When admitting an acutely confused 20-year-old patient with a head injury, which action should the nurse take?

Which finding would the nurse expect when assessing the legs of a patient who has a lower motor neuron lesion?

The nurse performing a focused assessment of left posterior temporal lobe functions will assess the patient for

Propranolol (Inderal), a b-adrenergic blocker that inhibits sympathetic nervous system activity, is prescribed for a patient who has extreme anxiety about public speaking. The nurse monitors the patient for

To assess the functioning of the trigeminal and facial nerves (CNs V and VII), the nurse should

Which action will the nurse include in the plan of care for a patient with impaired functioning of the left glossopharyngeal nerve (CN IX) and the vagus nerve (CN X)?

An unconscious male patient has just arrived in the emergency department after a head injury caused by a motorcycle crash. Which order should the nurse question?

A patient with suspected meningitis is scheduled for a lumbar puncture. Before the procedure, the nurse will plan to

During the neurologic assessment, the patient is unable to respond verbally to the nurse but cooperates with the nurses directions to move his hands and feet. The nurse will suspect

A 45-year-old patient has a dysfunction of the cerebellum. The nurse will plan interventions to

Which nursing diagnosis is expected to be appropriate for a patient who has a positive Romberg test?

The nurse will anticipate teaching a patient with a possible seizure disorder about which test?

Which nursing action will be included in the care for a patient who has had cerebral angiography?

Which equipment will the nurse obtain to assess vibration sense in a diabetic patient who has peripheral nerve dysfunction?

Which information about a 76-year-old patient is most important for the admitting nurse to report to the patients health care provider?

The charge nurse is observing a new staff nurse who is assessing a patient with a traumatic spinal cord injury for sensation. Which action indicates a need for further teaching of the new nurse about neurologic assessment?

Which cerebrospinal fluid analysis result will be most important for the nurse to communicate to the healthcare provider?

A 39-year-old patient with a suspected herniated intervertebral disc is scheduled for a myelogram. Which information is most important for the nurse to communicate to the health care provider before the procedure?

The priority nursing assessment for a 72-year-old patient being admitted with a brainstem infarction is

Several patients have been hospitalized for diagnosis of neurologic problems. Which patient will the nurse assess first?

Which assessments will the nurse make to monitor a patients cerebellar function (select all that apply)?

Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best?

Admission vital signs for a brain-injured patient are blood pressure 128/68, pulse 110, and respirations 26. Which set of vital signs, if taken 1 hour after admission, will be of most concern to the nurse?

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, the nurse reports the response as

The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medications effectiveness?

A 46-year-old patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. The nurse records the patients Glasgow Coma Scale score as

An unconscious 39-year-old male patient is admitted to the emergency department (ED) with a head injury. The patients spouse and teenage children stay at the patients side and ask many questions about the treatment being given. What action is best for the nurse to take?

A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care?

A 20-year-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take?

Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness?

A 23-year-old patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse plan to take?

The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patients nose. Which admission order should the nurse question?

A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether a patient is developing postconcussion syndrome?

The nurse admitting a patient who has a right frontal lobe tumor would expect the patient may have

Which statement by a 40-year-old patient who is being discharged from the emergency department (ED) after a concussion indicates a need for intervention by the nurse?

After having a craniectomy and left anterior fossae incision, a 64-year-old patient has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to

A 42-year-old patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care?

The public health nurse is planning a program to decrease the incidence of meningitis in adolescents and young adults. Which action is most important?

A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action?

When assessing a 53-year-old patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider?

A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first?

After endotracheal suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first?

Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a registered nurse (RN) who has floated from the medical unit?

A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L) and a decreasing level of consciousness (LOC). He is now complaining of a headache. Which prescribed interventions should the nurse implement first?

After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first?

The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding is most important to report to the health care provider?

After evacuation of an epidural hematoma, a patients intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse is most important to communicate to the health care provider?

The charge nurse observes an inexperienced staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene?

A 68-year-old male patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by his spouse. Which action will the nurse take first?

A patient has increased intracranial pressure and a ventriculostomy after a head injury. Which action can the nurse delegate to unlicensed assistive personnel (UAP) who regularly work in the intensive care unit?

Which information about a 30-year-old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse?

The nurse is caring for a patient who has a head injury and fractured right arm after being assaulted. Which assessment information requires the most rapid action by the nurse?

Which finding for a patient who has a head injury should the nurse reportimmediately to the health care provider?

When admitting a 42-year-old patient with a possible brain injury after a car accident to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider?

A patient being admitted with bacterial meningitis has a temperature of 102.5 F (39.2 C) and a severe headache. Which order for collaborative intervention should the nurse implement first?

A patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider should the nurse question?

Which action will the public health nurse take to reduce the incidence of epidemic encephalitis in a community?

To assess for functional deficits, which question will the nurse ask a patient who has been admitted for treatment of a benign occipital lobe tumor?

After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about

A 68-year-old patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin?

A 73-year-old patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find?

During the change of shift report a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have

When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral atherosclerosis

A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate?

A patient admitted with possible stroke has been aphasic for 3 hours and his current blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse question?

A 56-year-old patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for

A female patient who had a stroke 24 hours ago has expressive aphasia. The nurse identifies the nursing diagnosis of impaired verbal communication. An appropriate nursing intervention to help the patient communicate is to

For a patient who had a right hemisphere stroke the nurse establishes a nursing diagnosis of

When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care?

The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a left-handed patient with left-sided hemiplegia. Which intervention should be included in the plan of care?

A 40-year-old patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan?

A 47-year-old patient will attempt oral feedings for the first time since having a stroke. The nurse should assess the gag reflex and then

A male patient who has right-sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activities. The nurse observes that when the patients wife is visiting, she feeds and dresses him. Which nursing diagnosis is most appropriate for the patient?

Several weeks after a stroke, a 50-year-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention will be best to include in the initial plan for an effective bladder training program?

A 72-year-old patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, I dont need the aspirin today. I don’t have a fever. Which action should the nurse take?

A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. The nurse will anticipate teaching the patient about

A 58-year-old patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should

Which stroke risk factor for a 48-year-old male patient in the clinic is most important for the nurse to address?

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the healthcare provider?

A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first?

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness (LOC). Which nursing diagnosis do they determine has the highest priority for the patient?

Which information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the health care provider?

The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)?

After receiving change-of-shift report on the following four patients, which patient should the nurse see first?

The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse?

A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?

The home health nurse is caring for an 81-year-old who had a stroke 2 months ago. Based on information shown in the accompanying figure from the history, physical assessment, and physical therapy/occupational therapy, which nursing diagnosis is the highest priority for this patient?

The nurse determines that teaching about management of migraine headaches has been effective when the patient says which of the following?

The nurse will assess a 67-year-old patient who is experiencing a cluster headache for

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take?

A high school teacher who has just been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, I cannot teach anymore, it will be too upsetting if I have a seizure at work. Which response by the nurse is best?

A patient has been taking phenytoin (Dilantin) for 2 years. Which action will the nurse take when evaluating for adverse effects of the medication?

A patient reports feeling numbness and tingling of the left arm before experiencing a tonic-clonic seizure. The nurse determines that this history is consistent with what type of seizure?

When obtaining a health history and physical assessment for a 36-year-old female patient with possible multiple sclerosis (MS), the nurse should

A 31-year-old woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which response by the nurse is accurate?

A 49-year-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching?

Which information about a 60-year-old patient with MS indicates that the nurse should consult with the health care provider before giving the prescribed dose of dalfampridine (Ampyra)?

Which action will the nurse plan to take for a 40-year-old patient with multiple sclerosis (MS) who has urinary retention caused by a flaccid bladder?

A 73-year-old patient with Parkinsons disease has a nursing diagnosis of impaired physical mobility related to bradykinesia. Which action will the nurse include in the plan of care?

A 62-year-old patient who has Parkinsons disease is taking bromocriptine (Parlodel). Which information obtained by the nurse may indicate a need for a decrease in the dose?

The nurse advises a patient with myasthenia gravis (MG) to

Which medication taken by a patient with restless legs syndrome should the nurse discuss with the patient?

A 64-year-old patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?

A 40-year-old patient is diagnosed with early Huntingtons disease (HD). When teaching the patient, spouse, and children about this disorder, the nurse will provide information about the

When a 74-year-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling type tremor, the nurse will anticipate teaching the patient about

A 22-year-old patient seen at the health clinic with a severe migraine headache tells the nurse about having other similar headaches recently. Which initial action should the nurse take?

A hospitalized patient complains of a bilateral headache, 4/10 on the pain scale, that radiates from the base of the skull. Which prescribed PRN medications should the nurse administer initially?

A 46-year-old patient tells the nurse about using acetaminophen (Tylenol) several times every day for recurrent bilateral headaches. Which action will the nurse plan to take first?

The health care provider is considering the use of sumatriptan (Imitrex) for a 54-year-old male patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider?

The nurse observes a patient ambulating in the hospital hall when the patients arms and legs suddenly jerk and the patient falls to the floor. The nurse will first

Which prescribed intervention will the nurse implement first for a patient in the emergency department who is experiencing continuous tonic-clonic seizures?

The home health registered nurse (RN) is planning care for a patient with a seizure disorder related to a recent head injury. Which nursing action can be delegated to a licensed practical/vocational nurse (LPN/LVN)?

A 76-year-old patient is being treated with carbidopa/levodopa (Sinemet) for Parkinsons disease. Which information is most important for the nurse to report to the health care provider?

Which nursing diagnosis is of highest priority for a patient with Parkinsons disease who is unable to move the facial muscles?

Which assessment is most important for the nurse to make regarding a patient with myasthenia gravis?

Following a thymectomy, a 62-year-old male patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first?

A hospitalized 31-year-old patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first?

Which intervention will the nurse include in the plan of care for a patient with primary restless legs syndrome (RLS) who is having difficulty sleeping?

Which information about a 72-year-old patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consult with the health care provider before administration of the medication?

After change-of-shift report, which patient should the nurse assess first?

A 27-year-old patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patients assigned room (select all that apply)?

A patient with Parkinsons disease is admitted to the hospital for treatment of pneumonia. Which nursing interventions will be included in the plan of care (select all that apply)?