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Neurology NCLEX | VERIFIED SOLUTION
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Neurology NCLEX | VERIFIED SOLUTION 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...

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  • February 7, 2023
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  • 2022/2023
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  • neurology nclex | verified solution 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

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Neurology NCLEX | VERIFIED SOLUTION

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

10. 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

,11. 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.
12. 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

13. 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).

14. 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

15. 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.

16. 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

17. 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

18. 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.

19. 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

20. A client is diagnosed with glaucoma. Which data gathered by the nurse
indicate a risk factor associated with glaucoma?
Answer: Cardiovascular disease

21. 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

22. 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.

23. 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.

24. 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.

25. 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.

26. 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.

28. 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)

29. 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

30. 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."

31. 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.

32. 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

33. 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

34. 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

35. 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

36. 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.

37. 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

38. 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

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