A client has a neurological deficit involving the limbic system. On assessment, which finding is specific to this type of deficit?

• Is disoriented to person, place, and time

• Affect is flat, with periods of emotional lability

• Cannot recall what was eaten for breakfast today

• Demonstrates inability to add and subtract; does not know who is the president of the U.S.

Answer explanation

The limbic system is responsible for feelings (affect) and emotions. Calculation ability and knowledge of current events relate to function of the frontal lobe. The cerebral hemispheres, with specific regional functions, control orientation. Recall of recent events is controlled by the hippocampus.

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions would the nurse take? Select all that apply.

• Loosening restrictive clothing

• Restraining the client's limbs

• Removing the pillow and raising padded side rails

• Positioning the client to the side, if possible, with the head flexed forward

• Keeping the curtain around the client and the room door open so that help can act quickly upon arriving

Answer explanation

Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising padded side rails in the bed, and placing the client on one side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible; protects the head from injury; and moves furniture that may injure the client.

The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching?

• "I can sit down to put on my pants and shoes."

• "My family removed all loose rugs from my bedroom."

• "I try to exercise every day and rest when I'm tired."

• "I don't need to use my walker to get to the bathroom."

Answer explanation

The client with Parkinson's disease would be instructed regarding safety measures in the home. The client needs to use a walker as support to get to the bathroom because of bradykinesia. The client needs to sit down to put on pants and shoes to prevent falling. The client needs to exercise every day in the morning when energy levels are highest. The client needs to have all loose rugs in the home removed to prevent falling.

The nurse assesses a client who is diagnosed with a stroke (brain attack). On assessment, the client is unable to understand the nurse's commands. Which condition would the nurse document?

• Occipital lobe impairment

• Damage to the auditory association areas

• Frontal lobe and optic nerve tracts damage

• Difficulty with concept formation and abstraction areas

Answer explanation

Auditory association and storage areas are located in the temporal lobe and relate to understanding spoken language. The occipital lobe contains areas related to vision. The frontal lobe controls voluntary muscle activity, including speech, and an impairment can result in expressive aphasia. The parietal lobe contains association areas for concept formation, abstraction, spatial orientation, body and object size and shape, and tactile sensation.

The nurse is caring for a client with a head injury who has an intracranial pressure (ICP) monitoring device. The nurse would become most concerned if the ICP readings drifted to and stayed in the vicinity of which finding?

• 5 mm Hg

• 8 mm Hg

• 14 mm Hg

• 22 mm Hg

Answer explanation

Normal ICP readings range from 5 to 15 mm Hg pressure. Pressures greater than 20 mm Hg are considered to represent increased ICP, which seriously impairs cerebral perfusion.