exam 7

What is the only known risk factor for brain tumors?

Correct response: Ionizing radiation Explanation: Ionizing radiation is the only known risk factor for brain tumors. Head trauma, use of hair dyes, and the use of cellular phones are possible causes that have been investigated.

The nurse is caring for a patient in the emergency department with an onset of pain related to trigeminal neuralgia. What subjective data stated by the patient does the nurse determine triggered the paroxysms of pain?

Correct response: "I was brushing my teeth." Explanation: Trigeminal neuralgia is a condition of the fifth cranial nerve that is characterized by paroxysms of sudden pain in the area innervated by any of the three branches of the nerve. Paroxysms can occur with any stimulation of the terminals of the affected nerve branches, such as washing the face, shaving, brushing the teeth, eating, and drinking.

A client with a malignant glioma is scheduled for surgery. The client demonstrates a need for additional teaching about the surgery when he states which of the following?

Correct response: "The surgeon will be able to remove all of the tumor." Explanation: For clients with malignant gliomas, complete removal of the tumor and cure are not possible but the rationale for resection includes relief of increased intracranial pressure, removal of any necrotic tissue, and reduction in the bulk of the tumor, which theoretically leaves behind fewer cells to become resistant to radiation or chemotherapy.

A client with Parkinson's disease asks the nurse what their treatment is supposed to do since the disease is progressive. What would be the nurse's best response?

Correct response: "Treatment aims at keeping you independent as long as possible." Explanation: Treatment aims at prolonging independence. Treatment does matter, it is not palliative, and it is not aimed at keeping you emotionally healthy.

A client's vision is assessed at 20/200. The client asks what that means. Which is the most appropriate response by the nurse?

Correct response: "You see an object from 20 feet away that a person with normal vision sees from 200 feet away." Explanation: The fraction 20/20 is considered the standard of normal vision. Most people, positioned 20 feet from an eye chart, can see the letters designated as 20/20 from a distance of 20 feet.

A homeless client presents to the ED. Upon assessment, the client is experiencing hypothermia. The nurse will plan to complete which priority intervention during the rewarming process?

Correct response: Attach a cardiac monitor Explanation: Continuous electrocardiograph (ECG) monitoring is performed during the rewarming process because cold-induced myocardial irritability leads to conduction disturbances, especially ventricular fibrillation. A urinary catheter should be inserted to monitor urinary output; however, ECG monitoring is the priority. There is no indication for endotracheal intubation. Inotropic medications are contraindicated because they can stimulate the heart and increase the risk for fatal dysrhythmias, such as ventricular fibrillation.

A client in the emergency department has bruising over the mastoid bone and rhinorrhea. The triage nurse suspects the client has which type of skull fracture?

Correct response: Basilar Explanation: An area of ecchymosis (bruising) may be seen over the mastoid (Battle sign) in a basilar skull fracture. Basilar skull fractures are also suspected when cerebrospinal fluid (CSF) escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea). A simple (linear) fracture is a break in bone continuity. A comminuted fracture refers to a splintered or multiple fracture line.

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?

Correct response: Because hypoxemia can create or worsen a neurologic deficit of the spinal cord Explanation: Oxygen is administered to maintain a high partial pressure of arterial oxygen (PaO2) because hypoxemia can create or worsen a neurologic deficit of the spinal cord.

A nurse instructs a client to refrain from blinking after administering eye drops based on which rationale?

Correct response: Blinking causes the eye drop to be expelled from the conjunctival sac. Explanation: Blinking expels an instilled eye drop from the conjunctival sac, which interferes with the efficacy of the medication. Blood-ocular barriers keep foreign substances from entering the eye. The size of the conjunctival sac does change with blinking. It can hold only 50 uL.

A nurse practitioner advised the mother of a 16-year-old girl, who was diagnosed with human papillomavirus (HPV), that the infection can cause cancer of the _______ in the future.

Correct response: Cervix Explanation: Certain types of HPV can cause cells of the cervix to become abnormal, contributing to 70% of cervical cancers.

A client was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first?

Correct response: Declining level of consciousness (LOC) Explanation: With a brain injury such as an epidural hematoma (a likely diagnosis, based on this client's symptoms), the initial sign of increasing ICP is a change in LOC. As neurologic deterioration progresses, manifestations involving pupillary symmetry, breathing patterns, and posturing will occur.

A nurse is caring for a client with deteriorating neurologic status. The nurse is performing an assessment at the beginning of the shift that reveals a falling blood pressure and heart rate, and the client makes no motor response to stimuli. Which documentation of neuromuscular status is most appropriate?

Correct response: Flaccidity Explanation: The nurse would document flaccidity when the client makes no motor response to stimuli. Abnormal posturing and weak motor tone would be documented specifically as the nurse would assess. Decorticate posturing is when a client is stiff with bent arms and clenched fists with legs straight out.

A client comes to the emergency department with a suspected airway obstruction. The emergency department team prepares to manage the client as if he has a complete airway obstruction based on which of the following?

Correct response: High-pitched noise on inhalation Explanation: A client who demonstrates a weak, ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis should be managed as if he or she has a complete airway obstruction. Forceful coughing, wheezing between coughs, and a refusal to lie flat suggest a partial airway obstruction that can be managed as such.

Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of demyelination in the brain and spinal cord?

Correct response: Multiple sclerosis Explanation: The cause of MS is not known, and the disease affects twice as many women as men. Parkinson disease is associated with decreased levels of dopamine caused by destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain. Huntington disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary dancelike movements and dementia. Creutzfeldt-Jakob disease is a rare, transmissible, progressive fatal disease of the CNS characterized by spongiform degeneration of the gray matter of the brain.

A nurse is assessing a newly admitted client with meningitis. Which of the following findings in this client is most likely?

Correct response: Positive Brudzinski's sign Explanation: A positive Brudzinski's sign is a common finding in the client with meningitis. When the client's neck is flexed, flexion of the knees and hips is produced. A positive Kernig's sign is usual with meningitis. The client will develop lethargy as the illness progresses, not increased intake or hyper-alertness.

The nurse is performing an initial assessment on a client admitted to rule out Guillain-Barre syndrome. On which of the following areas will the nurse focus most heavily?

Correct response: Respiratory Explanation: Because of its possible rapid progression and neuromuscular respiratory failure, Guillain-Barre syndrome is a medical emergency. After baseline values are identified, assessment of changes in muscle strength and respiratory function alert the team to the physical and respiratory needs of the client. The other three choices may become problem areas later, but respiratory issues are always a priority.

The emergency department nurse is caring for clients involved in a chlorine exposure accident at a local chemical plant. The nurse is aware that permanent damage can occur to which body systems?

Correct response: Respiratory Explanation: The consequences of exposure to chlorine and other respiratory toxins are related to the amount, route, and length of chemical exposure. Death occurs as fluid infiltrates the pulmonary air spaces and terminal bronchioles interfering with gas exchange. Following recovery from an acute event, victims may develop chronic bronchitis and emphysema.

Which condition occurs when blood collects between the dura mater and arachnoid membrane?

Correct response: Subdural hematoma Explanation: A subdural hematoma is a collection of blood between the dura mater and the brain, a space normally occupied by a thin cushion of fluid. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with displacement of surrounding structures. An epidural hematoma is bleeding between the inner skull and the dura, compressing the brain underneath. An extradural hematoma is another name for an epidural hematoma.

What is a common source of airway obstruction in an unconscious client?

Correct response: The tongue Explanation: In an unconscious client, the muscles controlling the tongue commonly relax, causing the tongue to obstruct the airway. When this situation occurs, the nurse should use the head-tilt, chin-lift maneuver to cause the tongue to fall back into place. If she suspects the client has a neck injury she must perform the jaw-thrust maneuver.

A patient diagnosed with an ischemic stroke should be treated within the first 3 hours of symptom onset with which of the following?

Correct response: Tissue plasminogen activator (tPA) Explanation: In 1996, the FDA approved the use of tissue plasminogen activator (tPA) for the treatment of acute ischemic stroke within the first 3 hours of symptom onset.

Which is defined as the potential of an agent to cause injury to the body?

Correct response: Toxicity Explanation: The median lethal dose (LD50) is the amount of the chemical that will cause death in 50% of those who are exposed. Persistence means that the chemical is less likely to vaporize and disperse. Volatility is the tendency for a chemical to become a vapor. Latency is the time from absorption to the appearance of symptoms.

Which term refers to surgical repair of the tympanic membrane?

Correct response: Tympanoplasty Explanation: Tympanoplasty may be necessary to repair a scarred eardrum. A tympanotomy, or myringotomy, are incisions into the tympanic membrane. An ossiculoplasty is a surgical reconstruction of the middle ear bones to restore hearing.

The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern? Select all that apply.

Correct response: Unequal pupils Pinpoint pupils Absence of pupillary response Explanation: Normal assessment findings includes that the pupils are equal and reactive to light. Pupils that are unequal, pinpoint in nature, or fail to respond indicate a neurologic impairment.

The nurse is talking with a patient diagnosed with Ménière's disease about the patient's symptoms. What symptom does the patient inform the nurse is the most troublesome?

Correct response: Vertigo Explanation: Vertigo is the misperception or illusion of motion of the person or the surroundings. Most people with vertigo describe a spinning sensation or say they feel as though objects are moving around them. Vertigo is usually the most troublesome complaint related to Ménière's disease.

A client is placed in isolation for suspected tuberculosis. Which action should the nurse take when entering the client's room?

Correct response: Wear an N95 respirator. Explanation: Tuberculosis is acquired via airborne transmission. With airborne precautions, the door of a negative-pressure room must remain shut to ensure effectiveness. All personnel entering the room should wear an N-95 respirator or similarly approved respirator. A simple face mask with an eye shield is not an effective barrier to stop transmission. There is no need to minimize verbal interactions with a client with tuberculosis.

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the health care provider in the emergency department. Which is the origin of the client's symptoms?

Correct response: impaired cerebral circulation Explanation: TIAs involve the same mechanism as in the ischemic cascade, but symptoms are transient (< 24 hours) and there is no evidence of cerebral tissue infarction. The ischemic cascade begins when cerebral blood flow decreases to less than 25 mL/100 g/min and neurons are no longer able to maintain aerobic respiration. Thus, a TIA results directly from impaired blood circulation in the brain. Atherosclerosis, cardiac disease, hypertension, or diabetes can be risk factors for a TIA but do not cause it.

When obtaining the health history from a client with retinal detachment, a nurse expects the client to report:

Correct response: light flashes and floaters in front of the eye. Explanation: The sudden appearance of light flashes and floaters in front of the affected eye is characteristic of retinal detachment. Difficulty seeing cars in another driving lane suggests gradual loss of peripheral vision, which may indicate glaucoma. Headache, nausea, and redness of the eyes are signs of acute (angle-closure) glaucoma. Double vision is common in clients with cataracts.

The parent of a young client with severe hearing loss is quite concerned about the child's future independence because of impaired hearing. Which type of hearing loss is usually irreversible?

Correct response: sensorineural Explanation: Sensorineural hearing loss usually is irreversible.

A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client

Correct response: vomits. Explanation: Vomiting is a sign of increasing intracranial pressure and should be reported immediately. In general, the finding of headache in a client with a concussion is an expected abnormal observation. However, a severe headache, weakness of one side of the body, and difficulty in waking the client should be reported or treated immediately.

The physician's office nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm?

Correct response: Cerebral angiography Explanation: The nurse would anticipate a cerebral angiography, which detects distortion of the cerebral arteries and veins . A myelogram detects abnormalities of the spinal canal. An electroencephalogram records electrical impulses of the brain. An echoencephalography is an ultrasound of the structures of the brain.

The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe?

Correct response: Diplopia and ptosis Explanation: The initial manifestation of myasthenia gravis involves the ocular muscles, such as diplopia and ptosis. The remaining choices relate to multiple sclerosis.

Which terms refers to the progressive hearing loss associated with aging?

Correct response: Presbycusis Explanation: Age-related changes of both the middle and inner ear result in hearing loss. Exostoses refer to small, hard, bony protrusions in the lower posterior bony portion of the ear canal. Otalgia refers to a sensation of fullness or pain in the ear. Sensorineural hearing loss is loss of hearing related to damage of the end organ for hearing and/or cranial nerve VIII.

A nurse is providing care to a client in the emergency department and walks into the hallway to get equipment. All of a sudden, gunshots are heard. Which of the following would be the nurse's priority?

Correct response: Protecting himself or herself Explanation: If gunfire occurs in the emergency department, self-protection is the priority. Security officers and police must gain control of the situation first and then care is provided to the injured.

A nurse who is working as part of a disaster response team is performing triage at a mass casualty incident. One of the victims has a sucking chest wound. The nurse would triage this client using which color-coded tag?

Correct response: Red Explanation: A client with a sucking chest wound is triaged as needing immediate care and would be tagged red. Clients with injuries that are significant and require immediate care but can wait hours without threat to life or limb would be tagged yellow. Clients with minor injuries would be tagged green. Clients with injuries that are extensive and whose chances of survival are unlikely even with definitive care are tagged black.

Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch?

Correct response: Spasticity Explanation: Spasticity is often associated with weakness, increased deep tendon reflexes, and diminished superficial reflexes. Akathisia refers to restlessness, an urgent need to move around, and agitation. Ataxia refers to impaired ability to coordinate movement. Myoclonus refers to spasm of a single muscle or group of muscles.

A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment? Correct response: Lack of deep tendon reflexes

Explanation: Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia. If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and lack of motivation. Damage to the lower motor neurons may cause decreased muscle tone, flaccid muscle paralysis, and a decrease in or loss of reflexes.

A nurse notices that a client's left upper eyelid is drooping. The nurse has observed: Correct response: ptosis

Explanation: Ptosis is drooping or falling of the upper or lower eyelid. Ptolemy is not a medical condition. Proptosis is the extended or protruded upper eyelid that delays closing or remains partially open. Nystagmus is uncontrolled oscillating movement of the eyeball.

Which is the earliest sign of increasing intracranial pressure?

You Selected: Vomiting Correct response: Change in level of consciousness Explanation: The earliest sign of increasing intracranial pressure (ICP) is a change in level of consciousness. Other manifestations of increasing ICP are vomiting, headache, and posturing.

The nurse is reviewing information from a recent disaster management training session. The nurse knows that all of the following activities are part of the preparedness phase of disaster management except for:

Correct response: Providing emergency care Explanation: The preparedness phase of disaster management is the phase of planning for saving lives. Preparedness would include conducting training and mock disaster response drills, as well as designating location of shelters and developing early warning systems and evacuation routes. Providing emergency care is an aspect of the response phase. The purpose of the response phase is to limit injuries and deaths as well as reduce property damage.

The nurse is caring for a patient with Huntington's disease in the long-term care facility. What does the nurse recognize as the most prominent symptom of the disease that the patient exhibits?

Correct response: Rapid, jerky, involuntary movements Explanation: The most prominent clinical features of the disease are chorea (rapid, jerky, involuntary, purposeless movements), impaired voluntary movement, intellectual decline, and often personality changes

A nurse is assessing a client who has been in a motor vehicle collision. The client directly and accurately answers questions. The nurse notes a contusion to the client's forehead; the client reports a headache. Assessing the client's pupils, what reaction would confirm increasing intracranial pressure?

Correct response: unequal response Explanation: In increased ICP, the pupil response is unequal. One pupil responds more sluggishly than the other or becomes fixed and dilated.

A client has been admitted with primary syphilis. Which signs or symptoms should the nurse expect to see with this diagnosis?

Correct response: A painless genital ulcer that appeared about 3 weeks after unprotected sex Explanation: A painless genital ulcer is a symptom of primary syphilis. Macules on the palms and soles after fever are indicative of secondary syphilis, as is patchy hair loss. Wart-like papules are indicative of genital warts.

Which term refers to the inability to recognize objects through a particular sensory system?

Correct response: Agnosia Explanation: Agnosia may be visual, auditory, or tactile. Dementia refers to organic loss of intellectual function. Ataxia refers to the inability to coordinate muscle movements. Aphasia refers to loss of the ability to express oneself or to understand language.

Which term refers to a state of microorganisms being present within a host without causing host interference or interaction? You

Correct response: Colonization Explanation: Understanding the principle of colonization facilitates interpretation of microbiologic reports. A susceptible host is one that does not possess immunity to a particular pathogen. An immune host is one that is not susceptible to a particular pathogen. Infection refers to host interaction with an organism.

A patient with a brain tumor is complaining of headaches that are worse in the morning. What does the nurse know could be the reason for the morning headaches?

Correct response: Increased intracranial pressure Explanation: Headache, although not always present, is most common in the early morning and is made worse by coughing, straining, or sudden movement. It is thought to be caused by the tumor invading, compressing, or distorting the pain-sensitive structures or by edema that accompanies the tumor, leading to increased intracranial pressure.

A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke?

Correct response: Severe headache Explanation: The patient with a hemorrhagic stroke can present with a wide variety of neurologic deficits, similar to the patient with ischemic stroke. The conscious patient most commonly reports a severe headache.

A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?

Correct response: Shivering Explanation: Shivering can increase intracranial pressure by increasing vasoconstriction and circulating catecholamines. Shivering also increases oxygen consumption. A capillary refill of 2 seconds, urine output of 100mL/hr, and cool, dry skin are expected findings.

A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with:

Correct response: body temperature control. Explanation: The body's thermostat is located in the hypothalamus; therefore, injury to that area can cause problems with body temperature control. Balance and equilibrium problems are related to cerebellar damage. Visual acuity problems would occur following occipital or optic nerve injury. Thinking and reasoning problems are the result of injury to the cerebrum.

An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to You Selected: control shivering.

Correct response: dehydrate the brain and reduce cerebral edema. Explanation: Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid. Antipyretics and a cooling blanket are used to control fever in the client with increased ICP. Chlorpromazine may be prescribed to control shivering in the client with increased ICP. Medications such as barbiturates are given to the client with increased ICP to reduce cellular metabolic demands.