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If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse would anticipate that the client has problems with:
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Body temperature control.
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A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning?
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Lidocaine (Xylocaine)
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After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the emergency department. He’s unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client?
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Perform a lumbar puncture
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The nurse is performing a mental status examination on a male client diagnosed with subdural hematoma. This test assesses for:
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Cerebral function
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Emergency medical technicians transport a 27-year-old iron worker to the emergency department. They tell the nurse, “He fell from a two-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has a compound fracture of his left femur and he’s comatose. We intubated him and he’s maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual-resuscitation bag.” What intervention by the nurse has the highest priority?
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Assessing the left leg
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A female client is admitted to the facility for investigation of balance and coordination problems, including possible Ménière’s disease. When assessing this client, the nurse expects to note:
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Vertigo, tinnitus, and hearing loss.
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The nurse is monitoring a male client for adverse reactions to atropine sulfate (Atropine Care) eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction?
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Tachycardia
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A female client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client’s oculocephalic (doll’s eye) response by:
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Introducing ice water into the external auditory canal
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A female client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain?
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Midbrain
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The nurse is caring for a male client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?
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Call the physician immediately
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During recovery from a cerebrovascular accident (CVA), a female client is given nothing by mouth, to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client’s swallowing ability once each shift. This assessment evaluates:
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cranial nerves IX and X
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An elderly client is experiencing an alteration in his equilibrium and coordinated muscle movements. The nurse realizes that these functions are controlled by which area of the nervous system?
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Cerebellum
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The nurse wants to assess the function of a client’s accessory nerve (CN XI). Which of the following activities can be done to assess this nerve’s function?
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Ask the client to shrug his shoulders
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During an assessment of an adult client’s plantar reflex, the nurse notes a normal response. Which of the following would be considered normal for this client?
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Plantar flexion of the foot
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A client begins experiencing severe facial pain while chewing. The cranial nerve responsible for this pain is:
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Cranial Nerve V Trigeminal
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