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Med-Surg III: Neuro - Ch. 21: The Neurologic System, Ch. 22: Care of Patients with Head & Spinal Cord Injuries, Ch. 23: Care of Patients with Brain Disorders, & Ch. 24: Care of Patients with Peripheral Nerve & Degenerative Neurologic Disorders€12,20
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Med-Surg III: Neuro - Ch. 21: The Neurologic System, Ch. 22: Care of Patients with Head & Spinal Cord Injuries, Ch. 23: Care of Patients with Brain Disorders, & Ch. 24: Care of Patients with Peripheral Nerve & Degenerative Neurologic Disorders
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Med-Surg
Établissement
Med-Surg
Med-Surg III: Neuro - Ch. 21: The
Neurologic System, Ch. 22: Care of Patients
with Head & Spinal Cord Injuries, Ch. 23:
Care of Patients with Brain Disorders, & Ch.
24: Care of Patients with Peripheral Nerve &
Degenerative Neurologic Disorders
A nurse is caring for a client who is postprocedu...
Med-Surg III: Neuro - Ch. 21: The
Neurologic System, Ch. 22: Care of Patients
with Head & Spinal Cord Injuries, Ch. 23:
Care of Patients with Brain Disorders, & Ch.
24: Care of Patients with Peripheral Nerve &
Degenerative Neurologic Disorders
A nurse is caring for a client who is postprocedure following lumbar puncture & reports a
throbbing headache when sitting upright. Which of the following actions should the nurse take?
(SATA)
a. Use the Glasgow Coma Scale to evaluate the client.
b. Assist the client to a supine position.
c. Administer opioid medication
d. Encourage the client to increase fluid intake.
e. Remove the bandage on the client's puncture site. - answer✔✔• Place the patient in a supine
position
• Administer an opioid for pain
• Encourage the patient to increase fluid intake
Postprocedure: Appropriately label tubes with patient data & transport them to the laboratory
immediately. Keep patient flat in bed to reduce headache for 1 hour or longer after procedure &
encourage fluid intake unless contraindicated. Observe the site for signs of drainage &
inflammation.
Ch. 21, pg. 480 (Table 21-6)
a. Monitor for hypotension
b. Provide an emesis basin at the bedside
c. Administer antipyretic medication
d. Perform a skin assessment
e. Keep the head of the bed flat - answer✔✔• Provide an emesis basin at the bedside
• Administer antipyretic medication
• Perform a skin assessment
Med-Surg ATI: Ch. 5, pg. 32 & 33
A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the
following findings should the nurse expect? (SATA)
a. Impulse control difficulty
b. Left hemiplegia
c. Loss of depth perception
d. Aphasia
e. Lack of situational awareness - answer✔✔• Impulse control difficulty
• Left hemiplegia
• Loss of depth perception
• Lack of situational awareness
PHYSICAL FINDINGS:
Manifestations vary based on the area of the brain that is deprived of oxygenated blood:
*The LEFT cerebral hemisphere* is responsible for language, mathematics skills, & analytic
thinking.
• Expressive & receptive aphasia (inability to speak & understand language)
*The RIGHT cerebral hemisphere* is responsible for visual & spatial awareness &
propioception.
• Altered perception of deficits (overestimation of abilities)
• Loss of depth perception
• Poor impulse control & judgment
• Inability to solve problems
• Emotional lability
• Left hemiplegia, or hemiparesis
• Visual changes, such as hemianopsia
Med-Surg ATI: Ch. 9, pg. 54 & 58
A nurse is contributing to a plan of care for the nutritional needs of a client who has stage IV
Parkinson's Disease (PD). Which nursing actions should the nurse include in the plan of care?
(SATA)
a. Provide 3 large balanced meals daily.
b. Record diet & fluid intake only.
c. Document weight every other week.
d. Place the client in Fowler's position to eat.
e. Offer nutritional supplements between meals. - answer✔✔• Record diet & fluid intake daily.
• Offer nutritional supplements between meals.
NURSING CARE:
• Consult the dietician for appropriate diet, which often includes semisolid foods & thickened
liquids.
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