Exam 20: Advanced Neurologic Care

A nurse assesses a client's blood pressure to be 180/68 mm Hg. Earlier in the day, the client's blood pressure was 142/86 mm Hg. What action by the nurse is most appropriate?

A client has a seizure. What action does the nurse take first?

When the nurse places a stethoscope on an unconscious client's chest, the client reacts as shown. What does the nurse interpret from this observation?

Which of the following terms are correctly matched to the description? (Select all that apply.)

The nurse is conducting a BE-FAST exam on a client suspected of having a stroke. What does this assessment include? (Select all that apply.)

A student is teaching a client about risk factors for stroke. What information provided by the student demonstrates a need to review the information?

The nurse is assessing a client's intracranial pressure via an external ventricular drain (EVD). The reading is markedly different from the previous one. What action does the nurse take next?

The nurse is placing a client on seizure precautions. What actions does this entail? (Select all that apply.)

The nurse reads a client's medical record and the last assessment documented the client's pupils as having consensual pupillary reflex. What does the nurse understand this to mean?

An hour after a client has a lumbar puncture (LP), the client reports a headache. What action does the nurse take first?

A nurse is caring for a client with dysarthria. What assessment finding is consistent with this diagnosis?

Which assessment finding requires the nurse to conduct further assessments?

The nurse is assessing a client's motor responses and applies pressure to the client's nailbed. The client responds by reaching over with the other hand to brush the nurse away. How does the nurse chart this finding?

The nurse is caring for a client who is getting a lumbar puncture (LP). The client also has COPD. Which assessment takes priority for this client during the exam?

The nurse is caring for four clients. Which does the nurse assess first?

The nurse is caring for a client with increased intracranial pressure (ICP). What interventions does the nurse include in the client's plan of care? (Select all that apply.)

The nurse assesses a client's pupils to be 7 mm. What action by the nurse is best?

Which statement about intracranial pressure waves is correct?

The nurse is caring for a client who had a stroke and has damage to Broca's area of the brain. What intervention does the nurse use for this client?

A client has an external ventricular drain (EVD). What assessment findings indicate to the nurse that a priority outcome has been met?