1.The nurse is reinforcing home-care instructions to a client and family

Neurology NCLEX 1.The nurse is reinforcing home-care instructions to a client and family regarding care after cataract removal from the right eye. Which statement made by the client indicates an understanding of the instructions?

Answer: "I should not sleep on my right side."

2.The nurse is assisting with caring for a client after a craniotomy. Which is the best position for the client to be placed?

Answer: Semi-Fowler's position

3.The nurse is caring for a client following a supratentorial craniotomy, in which a large tumor was removed from the left side. In which position can the nurse safely place the client? Refer to Figures.

Answer: A

4.The nurse is preparing to communicate with an older client who is hearing impaired. Which intervention should be implemented initially?

Answer: Stand in front of the client.

5.Which intervention should be implemented for the older client with presbycusis who has a hearing loss?

Answer: Use low-pitched tones.

6.The nurse is preparing to reinforce a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures should the nurse include in the plan? Select all that apply.

Answer: To avoid activities that require bending over

To place an eye shield on the surgical eye at bedtime To contact the surgeon if a decrease in visual acuity occurs To take acetaminophen (Tylenol) for minor eye discomfort 7.The nurse is assisting in developing a teaching plan for the client with glaucoma. Which instruction should the nurse suggest to include in the plan of care?

Answer: Eye medications will need to be administered for the rest of

your life.

8.The nurse is assigned to care for a client with a detached retina. Which finding should the nurse expect to be documented in the client's record?

Answer: A sense of a curtain falling across the field of vision

9.The nurse is assigned to care for a client with a diagnosis of detached retina. Which finding would indicate that bleeding has occurred as a result of retinal detachment?

Answer: Complaints of a burst of black spots or floaters

• A client arrives in the emergency department after an automobile crash.

The client's forehead hit the steering wheel, and a hyphema has been diagnosed. Which position should the nurse prepare to position the client?

Answer: On bed rest in a semi-Fowler's position

• A client sustains a contusion of the eyeball after a traumatic injury with a

blunt object. The nurse should take which immediate action?

Answer: Apply ice to the affected eye.

• A client sustains a chemical eye injury from a splash of battery acid. The

nurse should prepare the client for which immediate measure?

Answer: Irrigating the eye with sterile normal saline

• The nurse is caring for a client after enucleation and notes the presence

of bright red drainage on the dressing. The nurse should take which appropriate action?

Answer: Report the finding to the registered nurse (RN).

• The nurse is preparing to administer eardrops to an adult client. The

nurse administers the eardrops by which technique?

Answer: Pulling the pinna up and back

• The nurse is caring for a client who is hearing-impaired and should take

which approach to facilitate communication?

Answer: Speak in a normal tone.

• A client arrives at the emergency department with a foreign body in the

left ear that has been determined to be an insect. Which initial intervention should the nurse anticipate to be prescribed?

Answer: Instillation of mineral oil or diluted alcohol

• The nurse notes that the health care provider has documented a

diagnosis of presbycusis on the client's chart. The nurse understands that this condition is accurately described as which?

Answer: A sensorineural hearing loss that occurs with aging

• A client with Ménière's disease is experiencing severe vertigo. The nurse

reinforces instructions to the client to do which to assist in controlling the vertigo?

Answer: Avoid sudden head movements.

• The nurse is assigned to care for a client hospitalized with Ménière's

disease. The nurse expects that which would most likely be prescribed for the client?

Answer: Low-sodium diet

• A client is diagnosed with glaucoma. Which data gathered by the nurse

indicate a risk factor associated with glaucoma?

Answer: Cardiovascular disease

• Betaxolol hydrochloride (Betoptic) eyedrops have been prescribed for the

client with glaucoma. Which nursing action is most appropriate related to monitoring for the side/adverse effects of this medication?

Answer: Monitoring blood pressure

• The nurse assists to prepare the client for ear irrigation as prescribed by

the health care provider. Which action should the nurse plan to take?

Answer: Warm the irrigating solution to 98° F.

• In preparation for cataract surgery, the nurse is to administer

cyclopentolate (Cyclogyl) eyedrops. The nurse administers the eyedrops knowing that the purpose of this medication is which?

Answer: Dilate the pupil of the operative eye.

• The nurse is providing instructions to a client who will be self-

administering eyedrops. To minimize the systemic effects that eyedrops can produce, the client is instructed to perform which?

Answer: Occlude the nasolacrimal duct with a finger over the

inner canthus for 30 to 60 seconds after instilling the drops.

• The client is receiving an eyedrop and an eye ointment to the right eye.

Which action should the nurse take?

Answer: Administer the eyedrop first, followed by the eye

ointment.

• The nurse is caring for a client with glaucoma. Which medication

prescribed for the client should the nurse question?

Answer: Atropine sulfate (Isopto Atropine)

27.The nurse is preparing to administer eyedrops. Which interventions should the nurse take to administer the drops? Select all that apply.

Answer: Wash hands.

Put on gloves.Place the drop in the conjunctival sac.Pull the lower lid down against the cheekbone.

• A client was just admitted to the hospital to rule out a gastrointestinal

(GI) bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication should the nurse determine to be the cause of the client's complaint?

Answer: Acetylsalicylic acid (aspirin)

• Pilocarpine hydrochloride (Isopto Carpine) is prescribed for the client with

glaucoma. Which medication should the nurse plan to have available in the event of systemic toxicity?

Answer: Atropine sulfate

• A miotic medication has been prescribed for the client with glaucoma.

The client asks the nurse about the purpose of the medication. The nurse should tell the client which?

Answer: "The medication causes the pupil to constrict and will

lower the pressure in the eye."

• A client with a seizure disorder is being admitted to the hospital. Which

should the nurse plan to implement for this client? Select all that apply.

Answer: Pad the bed's side rails.

Place an airway at the bedside.Place oxygen equipment at the bedside.Place suction equipment at the bedside.

• The nurse is caring for a client with increased intracranial pressure (ICP).

Which change in vital signs would occur if ICP is rising?

Answer: Increasing temperature, decreasing pulse, decreasing

respirations, increasing BP

• The nurse observes the unlicensed assistive personnel (UAP) positioning

the client with increased intracranial pressure (ICP). Which position would require intervention by the nurse?

Answer: Head turned to the side

• The client recovering from a head injury is arousable and participating in

care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure (ICP) if the nurse observes the client doing which activity?

Answer: Exhaling during repositioning

• The client has clear fluid leaking from the nose after a basilar skull

fracture. The nurse determines that this is cerebrospinal fluid (CSF) if the fluid meets which criteria?

Answer: Separates into concentric rings and tests positive for

glucose

• The client is admitted to the hospital for observation with a probable

minor head injury after an automobile crash. The nurse expects the cervical collar will remain in place until which time?

Answer: The health care provider reviews the x-ray results.

• The client was seen and treated in the emergency department (ED) for a

concussion. Before discharge, the nurse explains the signs/symptoms of a worsening condition. The nurse determines that the family needs further teaching if they state they will return to the ED if the client experiences which sign/symptom?

Answer: Minor headache

• The nurse is caring for a client who has undergone craniotomy with a

supratentorial incision. The nurse should plan to place the client in which position postoperatively?

Answer: Head of bed elevated 30 to 45 degrees, head and neck

midline