ATI Medical-Surgical Neurosensory AI Exam

A nurse is reviewing the medical record of a client who is experiencing tinnitus in both ears. Which of the following pieces of information in the client's medical record should the nurse identify as a risk for tinnitus? - Sclerosis of the ossicles (otosclerosis) which is an overgrowth of the tissue of the bones in the middle ear A nurse is assessing a client who reports an acute visual disturbance that he describes as a "curtain" pulled over his visual field with occasional flashes of light. The nurse should notify the provider that this client might have which disorder? - Retinal Detachment A nurse asks a client to stand with her feet together and her eyes open. After a few seconds, the nurse asks the client to close her eyes. If the client begins to fall, the nurse should interpret this finding as a positive Romberg test, indicating what? - Cerebellar dysfunction A nurse is providing discharge teaching to a client who has had a TIA. Which of the following instructions should the nurse include? - Reduce dietary sodium. This can help control HTN and prevent future TIAs A nurse is caring for a client who begins to have a generalized tonic-clonic seizure while lying in bed. Which of the following actions should the nurse take? - Turn the client onto a side, this will protect the client from aspiration A nurse is caring for a client who has an impairment of CN II. Which of the following actions should the nurse perform to promote the client's safety? - Provide an obstacle-free path for ambulation. CN II is the optic nerve, therefore, the client has at least some visual challenges. A nurse is assessing a client who has Guillain-Barre syndrome. Which of the following findings should the nurse expect? - Weakness of the lower extremities. This syndrome is characterized by the rapid onset of ascending weakness and paralysis, starting at the lower extremities, and can advance to the upper extremities. A nurse is performing a neurological assessment for a client who has a brain tumor. Which of the following findings should indicate cranial nerve involvement? - Dysphagia. This can occur as a result of CN IX or X damage A nurse is assessing a client who recently experienced a head injury. Which of the following findings should the nurse identify as an indication of short-term memory impairment? - Inability to locate eyeglasses A nurse is caring for a client who has encephalitis due to West Nile virus. Which of the following actions should the nurse take? - Monitor vital signs Q2H Assess neurological status Q4H Keep the client's room darkened to decrease agitation During a neurological assessment, a nurse asks the client to name all of his children, their ages, and their birth dates. Which of the following types of memory is the nurse testing? - Remote (long-term memory) A nurse is caring for a client who has expressive aphasia following a stroke. The nurse should identify that the stroke affected which lobe of the brain? - Frontal A nurse is caring for a client during the first 72hrs following a CVA. Which of the following actions should the nurse take? - Elevate the HOB 25-30 degrees with the client in a neutral mid-line position to prevent an increase in ICP A charge nurse is observing a newly licensed nurse irrigate a client's ear, which is impacted with cerumen. Which of the following actions requires the charge nurse to intervene? - instilling 50mL of fluid with each irrigation. The nurse should use no more than 5-10mL of irrigating fluid at a time to decrease the chance of stimulating the vestibular nerve which would result in N/V or dizziness. A nurse is assessing an older adult client for physiological changes that can occur with age. Which of the following findings should the nurse expect? - Decreased sense of taste A nurse is assessing a client who has cataracts. Which of the following findings should the nurse expect? - Opacity visible behind the pupul A nurse is reviewing the medical history of a client who is scheduled for an MRI of the cervical vertebra. Which of the following pieces of information in the client's history is a contraindication to this procedure? - The client has a pacemaker A nurse is reviewing the lab results of a lumbar puncture (LP) for a client who has manifestations of bacterial meningitis. Which of the following findings should the nurse expect? - Elevated protein A nurse is caring for a client who has a closed traumatic brain injury and is experiencing increased ICP. This increase in ICP is due to which of the following? - Rigid skull containing cranial contents. An increase in edema and bleeding from the head injury against the rigid skull results in an increase in ICP A nurse is preparing a client for an electroencephalogram (EEG). Which of the following pieces of information should the nurse share with the client? - "You'll begin by lying still with your eyes closed." A nurse is assessing a client who has increased ICP and has received IV mannitol. Which of the following findings indicates a therapeutic effect of this medication? - Increased urine output. Mannitol is an osmotic diuretic used to reduce ICP by mobilizing intracranial fluid and inhibiting the re-absorption of water and electrolytes in the kidneys. A nurse is providing discharge teaching to a client who is post-op following cataract surgery and has an intraocular lens implant. Which of the following statements by the client indicates an understanding of the instructions? - "I will avoid bending over." This is to avoid an increase in intraocular pressure. They should also avoid lifting, bending, coughing, or performing the Valsalva maneuver. A nurse in an ED is assessing a client who sustained a fall off of a roof. Which of the following findings should the nurse identify as an indication of a basilar skull fracture? - Clear fluid coming from the nares. CSF manifests as a clear fluid coming from the nares or ears, indicating a basilar skull fracture A nurse is providing teaching to a client who is scheduled for an EEG in the morning. Which of the following pieces of information should the nurse share? - "Shampoo your hair before the procedure and don't use any styling products afterward." For the electrodes to adhere to the scalp, the client's hair has to be clean and free of oil and hair-care products A nurse is caring for a client who experienced a traumatic brain injury. Which of the following findings indicates the client is experiencing increased ICP? - Dilated pupils. This should be reported to the provider immediately. A nurse is caring for a client who has dementia and is experiencing anxiety. Which of the following action should the nurse take? - Redirect the client to a different activity with a small group of people. A nurse is caring for a client who is post-op following a frontal craniotomy. The nurse should place the client in which of the following positions? - Semi-Fowlers. This will prevent an increase in ICP. A nurse is planning care for a client following a stroke. Which of the following interventions should the nurse identify as the priority of the client's plan of care? - Monitor the client for ICP which is their greatest risk. A nurse in the emergency department has assessed a client's airway, breathing, and circulation (ABC) following a head injury from a fall at work. Which of the following actions is the priority for the nurse to perform next? - Immobilize the client's cervical spine A nurse is preparing an older client who had a TIA for discharge. The nurse should teach the client to monitor which of the following parameters at home? - Blood pressure. The most common causes of a TIA are atherosclerotic plaque in the carotid arteries and HTN; therefore, the client should track their BP regularly to promote HTN management and reduce the risk of another TIA or CVA A nurse is assessing a client with a closed head injury who has received mannitol for manifestations of increased ICP. Which of the following findings indicates that the medication is having a therapeutic effect? - The client's serum osmolarity is 310 mOsm/L A nurse is caring for a client who has a traumatic brain injury and assumes a decerbrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a blood sample? - The client extends his arms. A client who exhibits a decerebrate posture rigidly extends and prontates the 4 extremities and externally rotates the wrists. This indicates a severe brain stem injury and late neurological decline. A nurse is assessing a client who reports vision loss. The client describes the loss as beginning with a "flash" of light followed by a "curtain" across the field of vision. The nurse should identify that these manifestations indicate which of the following eye disorders? - Retinal detachment A nurse is triaging clients during a mass casualty event. Which of the following labels should the nurse assign to a client who has a head injury with fixed, dilated pupils? - Black tag, these are given to clients who are not expected to live and will be allowed to die naturally. A nurse in a rehabilitation center is performing an assessment for a client who is recovering from a left-hemisphere stroke. Which of the following findings should the nurse expect? - Difficulty with speech. The left hemisphere is usually the dominant side and is responsible for language. A nurse is providing teaching to a client who has a history of tonic-clonic seizures and is scheduled for a standard EEG. Which of the following instructions should the nurse include in the teaching? - Thoroughly shampoo her hair prior to the EEG A nurse is teaching a client who has a new diagnosis of simple partial seizures about auras. Which of the following statements by the client indicates an understanding of the teaching? - "An aura is a sensory warning that a seizure is imminent." The client reporting the aura may report hearing bells, seeing lights, or smelling an odor. A nurse is providing teaching to a class about TIAs. Which of the following pieces of information should the nurse include in the teaching? - A TIA can precede an ischemic stroke. TIAs are considered a manifestation of advanced atherosclerotic disease and often precede an ischemic stroke A nurse is providing teaching to a client who has a new diagnosis of MS. The client asks the nurse about the usual course of MS. Which of the following responses should the nurse make? - "Acute episodes are usually followed by remission, which can vary in duration." Can be caused by heat/cold/stressors A nurse is preparing a client for an EEG. When the client asks the nurse what this test does, which of the following responses should the nurse provide? - "An EEG records the electrical activity of your brain cells" A nurse is preparing to test the function of CN X. Which of the following assessment procedures should the nurse use? - Have the client open his mouth and say, "aah". The vagus nerve has both sensory and motor functions. With this test, the uvula should move upwards in response and the nurse should also assess the voice quality for hoarseness. A nurse is assessing a client who is unconscious. The client has a rhythmical breathing pattern of rapid deep respirations followed by rapid shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations? - Cheyne-Stokes A nurse is providing teaching to a client who has a new diagnosis of Meniere's disease. Which of the following instructions should the nurse include in the teaching? - Avoid sudden movements. This disease is of the inner ear and can affect balance and hearing. It is characterized by vertigo, hearing loss, and tinnitus. A nurse is caring for a client who is recovering from a recent stroke. Which of the following assessments is the nurse's priority? - The client's ability to clear oral secretions During a neurological assessment, a nurse asks how the client arrived at the appointment and with whom. Which of the following types of memory is the nurse testing? - Recall A nurse in the ED is caring for a group of clients who all have an odor of alcohol on their breath and multiple injuries to the head and extremities. Which of the following clients should the nurse assess first? - A client who is difficult to arouse and is unable to respond to questions. A nurse is providing discharge teaching to a client who is post-op following scleral buckling to repair a detached retina. Which of the following instructions should the nurse include in the teaching? - "You should avoid reading for 1 week." A nurse is reviewing the medical history of a client who has presbyopia. With which of the following activities should the nurse expect the client to have difficulty? - Reading the newspaper. With this disease, the lens is unable to change shape to focus on near objects. A nurse is caring for a client who has moderate Alzheimer's disease. Which of the following actions should the nurse take? - Add gestures when speaking with the client, this will increase their understanding of the communication. A nurse is caring for a client who has received sedation. When the nurse applies nailbed pressure, the client withdraws his hand. The nurse should document this response as indicating what? - Arrousal A nurse in an acute care facility is preparing to admit a client who has myashtenia gravis. Which of the following supplies should the nurse place at the client's bedside table. - Oral-nasal suction equipment. These clients are at risk of aspiration due to progressive weakness of the oropharyngeal muscles. A nurse is caring for a client who has receptive aphasia. Which of the following communication problems should the nurse expect when assessing the client? - The client is unable to understand words or sentences she hears. A nurse is caring for a client who has Meniere's disease. The nurse should identify that Meniere's disease affects which structure of the ear? - Cochlea