Final

Which of these prescribed interventions will the nurse implement first for a hospitalized patient who is experiencing continuous tonic-clonic seizures? a. Give phenytoin (Dilantin) 100 mg IV. b. Monitor level of consciousness (LOC). c. Obtain computed tomography (CT) scan. d. Administer lorazepam (Ativan) 4 mg IV.

ANS: D To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary. Phenytoin also will be administered, but it is not rapidly acting. Patients who are experiencing tonic-clonic seizures are nonresponsive, although the nurse should assess LOC after the seizure.

The nurse anticipates that drug therapy for an acute severe attack of multiple sclerosis (MS) will be: a. intravenous methylprednisolone. b. intramuscular injections of interferon beta-1b. c. massive doses of antibiotics. d. muscle relaxants and opioids.

ANS: A IV methylprednisolone is the standard treatment for the severe acute attack of MS. Interferon is used to prevent attacks.

The nurse is assessing a patient diagnosed with myasthenia gravis. Which symptom would the nurse expect to assess? a. Ptosis b. Tremors of the hands during voluntary movement c. Dizziness on sudden movement of the head d. Postural hypotension

ANS: A Ptosis is a sign of myasthenia gravis.

The home health nurse caring for a patient with multiple sclerosis (MS) is planning an exercise program with the patient. Which is the best type of exercise for this patient? a. Swimming b. Progressive walking c. Weight training d. Isometric exercises

ANS: A Swimming is less tiring than other forms of exercise.

When preparing to admit a patient who has been treated for status epilepticus in the emergency department, which equipment should the nurse have available in the room (select all that apply)? a. Siderail pads b. Tongue blade c. Oxygen mask d. Suction tubing e. Nasogastric tube

ANS: A, C, D The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The beds side rails should be padded to minimize the risk for patient injury during a seizure. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. Use of tongue blades during a seizure is contraindicated.

When the home health RN is planning care for a patient with a seizure disorder, which nursing action can be delegated to an LPN/LVN? a. Make referrals to appropriate community agencies. b. Place medications in the home medication organizer. c. Teach the patient and family how to manage seizures. d. Assess for use of medications that may precipitate seizures.

ANS: B LPN/LVN education includes administration of medications. The other activities require RN education and scope of practice. DIF: Cognitive Level: Application REF: 1502

Which action will the nurse take when evaluating a patient who is taking phenytoin (Dilantin) for adverse effects of the medication? a. Inspect the oral mucosa. b. Listen to the lung sounds. c. Auscultate the bowel tones. d. Check pupil reaction to light.

ANS: A Phenytoin can cause gingival hyperplasia, but does not affect bowel tones, lung sounds, or pupil reaction to light.

The nurse outlines nutritional needs for the patient with multiple sclerosis (MS). What interventions should be emphasized for inclusion in the dietary intake? (Select all that apply.) a. Intake of at least 1500 mL of fluid daily b. Inclusion of high-fiber foods c. A high carbohydrate level in the diet d. Adding calcium and vitamin D e. Ensuring a high fat content

ANS: A, B, D High levels of carbohydrates and fats are not emphasized in the diet for an MS patient. Fluids and high fiber in the diet will prevent constipation, and calcium and vitamin D will help in preventing osteoporosis.

Following a thymectomy, a patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first? a. Auscultate the patients bowel sounds. b. Notify the patients health care provider. c. Administer the prescribed PRN antiemetic drug. d. Give the scheduled dose of prednisone (Deltasone).

ANS: B The patients history and symptoms indicate a possible cholinergic crisis. The health care provider should be notified immediately, and it is likely that atropine will be prescribed. The other actions will be appropriate if the patient is not experiencing a cholinergic crisis.

The nurse documents all the signs of epidural hematoma in a patient with a closed head injury, which are: (Select all that apply.) a. mottling of extremities. b. periorbital ecchymosis. c. Battles sign. d. nausea and vomiting. e. PERRLA.

ANS: B, C, D Raccoon eyes (periorbital ecchymosis), bruising behind the ears, and nausea and vomiting are some of the typical signs of epidural hematoma.

The nurse caring for a patient with an epidural hematoma suspects diabetes insipidus when the patient exhibits increased: a. lethargy. b. pulse pressure. c. urinary output. d. blood glucose levels.

NS: C A large increase in urinary output of pale urine with a low specific gravity is the clue to the development of diabetes insipidus related to edema of the posterior pituitary. Lethargy and increased pulse pressure are not typical signs of diabetes insipidus. Increased serum glucose levels is a sign of diabetes mellitus.

The nurse is preparing a community education program on the prevention of spinal cord injuries. Which of the following individuals would most likely benefit from this education? 1. Adolescent female who plays golf 2. Adolescent male who rides horses 3. Thirty-year-old female housewife 4. Fifty-year-old male who is a computer technician

ANS: 2 Most spinal cord injuries are caused by motor vehicle accidents; however, falls from horses and bicycles are common causes of these types of injuries. The average age of spinal cord injuries has risen to 40.2 in 2009. The adolescent female who plays golf is at a lower risk of sustaining a spinal cord injury than the adolescent male who rides horses. The 30-year-old female housewife and 50-year-old male computer technician are also at lower risk for experiencing this type of injury.

A client is recovering from a spinal cord injury at level T12. Once spinal shock has resolved and the clients status has stabilized, the client will need which of the following types of care going forward? 1. Medical 2. Nursing 3. Physical therapy 4. Spiritual

ANS: 2 Spinal cord injuries create a very intensive nursing situation for clients. It is one of the few conditions in which the need for nursing care is generally much greater than the need for medical care after the acute phase of recovery. Medical care is, of course, needed more during the acute phase of recovering from the injury. Physical therapy is one aspect of care that the client will need going forward; however, it is not as intensive as the nursing care required. Spiritual care may be needed once the client realizes that the ability to walk or function without assistance will not occur.

A client diagnosed with a spinal cord injury has been experiencing spinal shock. Which of the following assessment findings would indicate that this shock is resolving? 1. Blood pressure 80/55 mmHg 2. Heart rate 48 beats per minute 3. Reflexive emptying of the bladder 4. Body temperature 97F

ANS: 3 Resolution of spinal shock is indicated by return of reflexes, replacement of flaccidity with hyperreflexes, and reflexive emptying of the bladder. Low blood pressure, low heart rate, and low body temperature are all indications of neurogenic shock, which is an aspect of spinal shock.

assessing the patient with a significant right-sided closed head injury, the nurse would anticipate the patient to demonstrate which sign? a. Left-sided motor deficit with sluggish right pupil response b. Right-sided motor deficit with brisk right pupil response c. Bilateral motor deficit with bilaterally sluggish pupil response d. Left-sided motor deficit and bilateral PERRLA

ANS: A A right-sided injury will cause contralateral (opposite side) motor deficit and ipsilateral (same side) pupillary respons

An elementary teacher who has just been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, I cannot teach anymore, it will be too upsetting if I have a seizure at work. Which response by the nurse is best? a. You may want to contact the Epilepsy Foundation for assistance. b. You might benefit from some psychologic counseling at this time. c. The Department of Vocational Rehabilitation can help with work retraining. d. Most patients with epilepsy are well controlled with antiseizure medications.

ANS: D The nurse should inform the patient that most patients with seizure disorders are controlled with medication. The other information may be necessary if the patient seizures persist after treatment with antiseizure medications is implemented.

The nurse realizes that most spinal cord injuries are caused by: (Select all that apply.) 1. falls. 2. motor vehicle crashes. 3. sports injuries. 4. gunshot wounds. 5. walking. 6. gardening.

NS: 1, 2, 3, 4 Most spinal cord injuries are caused by motor vehicle accidents. Falls, gunshot wounds, and sports-related accidents also cause a significant number of these types of injuries. Spinal cord injuries are not caused by walking or gardening

nurse assesses the level of consciousness (LOC) of a patient with a neurologic injury as mildly disoriented to surroundings and time, but awake and needs additional verbal cues to stimulate response to commands. Which documentation is the most accurate in regard to LOC? a. Alert b. Confused c. Lethargic d. Obtunded

NS: B The confused patient is awake, but slightly confused and needs coaching to respond to commands. Alert indicates appropriate response to questions and commands with little stimulation. Lethargic is described as the patient being drowsy, but easily aroused. Obtunded patients are more difficult to arouse and respond slowly to stimulation.

13. The patient who suffered a spinal cord injury (SCI) 3 days ago resulting in flaccid paralysis begins to flex his arm. The concerned family is instructed that this muscle activity may be related to: a. increased intracranial pressure. b. increased edema of the cord. c. return of voluntary motor activity. d. muscle spasms.

NS: D Muscle spasms occur several days after the spinal cord injury and are spinal recovery indicators. Concerned family should be reminded that spasms are not necessarily an indication of the return of motor function.

.The nurse is caring for a client with a spinal cord injury located at T5. Which of the following should be included in this clients plan of care? 1. Use mechanical ventilation. 2. Assess blood glucose level for onset of diabetes. 3. Assist with removal of pulmonary secretions. 4. Provide assistive devices for ambulation.

ANS: 3 Because of the interruption in chest muscle innervation with spinal cord injuries located at level T7 and above, patients often need assistance with removal of secretions and have difficulty with inspiration and expiration. Mechanical ventilation is not needed for a spinal cord injury at level T5. A spinal cord injury does not precipitate the onset of diabetes. A client with a spinal cord injury at level T5 will not be able to use an assistive device to ambulate.

A client being treated for a spinal cord injury needs immediate ventilatory support. The nurse realizes that this clients level of injury is most likely: 1. C3. 2. C6. 3. T3. 4. L3.

ANS: 4 Because of greater movement, the cervical area is the most unstable area of the spinal cord and is the most vulnerable area for injury. The thoracic, lumbar, and coccygeal regions of the spinal cord are more stable and less vulnerable areas for injury.

7.The nurse, planning care for a client diagnosed with a spinal cord injury, would include interventions to address autonomic dysreflexia because the clients spinal cord injury is at which of the following levels? 1. L5 2. T12 3. S1 4. T4

ANS: 4 Clients with spinal cord injuries above the level of T6 are at the greatest risk for complications associated with autonomic dysreflexia. This complication is not common with injuries at L5, T12, or S1.

A client receiving care for a spinal cord injury complains of a pounding headache, blurred vision, and has a blood pressure of 200/100 mmHg. What is the first action the nurse should take? 1. Administer pain medication. 2. Position the client on the left side. 3. Turn off the lights and decrease the noise in the room. 4. Check the bladder for distension.

ANS: 4 The symptoms suggest autonomic hyperreflexia, a medical emergency. The client should be checked for a distended bladder and be prepared for catheterization. Pain medication, positioning, or reducing environmental stimuli will not treat the underlying cause of autonomic hyperreflexia.

A patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care? a. Assist with active range of motion. b. Observe for agitation and paranoia. c. Give muscle relaxants as needed to reduce spasms. d. Use simple words and phrases to explain procedures.

ANS: A ALS causes progressive muscle weakness, but assisting the patient to perform active ROM will help to maintain strength as long as possible. Psychotic symptoms such as agitation and paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the patients ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations.

In the event of autonomic dysreflexia (AD) in the patient with a spinal cord injury, the initial intervention should be to: a. elevate the head of the bed to lower blood pressure. b. notify the charge nurse to get assistance. c. increase IV fluid rate to ensure adequate circulating volume. d. administer anti-hypertensive medication.

ANS: A Autonomic dysreflexia (hyperreflexia) response is potentially dangerous to the patient, because it can produce vasoconstriction of the arterioles with an immediate elevation of blood pressure. Elevating the head of bed is the initial intervention to decrease the rising blood pressure. Notifying the charge nurse can be done after initial interventions. Increasing the IV fluid rate may further increase the blood pressure. The cause of AD should be addressed before administering any hypertensive medication.

A 28-year-old woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which response by the nurse is accurate? a. MS symptoms may be worse after the pregnancy. b. Women with MS frequently have premature labor. c. Symptoms of MS are likely to become worse during pregnancy. d. MS is associated with a slightly increased risk for congenital defects.

ANS: A During the postpartum period, women with MS are at greater risk for exacerbation of symptoms. There is no increased risk for congenital defects in infants born of mothers with MS. Symptoms of MS may improve during pregnancy. Onset of labor is not affected by MS

he patient presents in the health clinic with low back pain that radiates into the buttocks and below the knee. The nurse suspects which condition? a. Herniated disk b. Muscle spasm in lower back c. Spinal cord injury d. Sciatica

ANS: A Herniated disks typically cause compression on the sciatic nerve and allow the pain to radiate into the buttocks and leg. Muscle spasm in the lower back will result in back pain. There is no indication of spinal cord injury. Pain from sciatica does not involve back pain.

When teaching a patient with myasthenia gravis (MG) about management of the disease, the nurse advises the patient to a. perform physically demanding activities in the morning. b. anticipate the need for weekly plasmapheresis treatments. c. do frequent weight-bearing exercise to prevent muscle atrophy. d. protect the extremities from injury due to poor sensory perception.

ANS: A Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then. Plasmapheresis is not routinely scheduled but is used for myasthenia crisis or for situations in which corticosteroid therapy should be discontinued. There is no decrease in sensation with MG, and muscle atrophy does not occur because muscles are used during part of the day.

A patient with multiple sclerosis (MS) has urinary retention caused by a flaccid bladder. Which action will the nurse plan to take? a. Teach the patient how to use the Cred method. b. Decrease the patients fluid intake in the evening. c. Suggest the use of incontinence briefs for nighttime use only. d. Assist the patient to the commode every 2 hours during the day.

ANS: A The Cred method can be used to improve bladder emptying. Decreasing fluid intake will not improve bladder emptying and may increase risk for urinary tract infection (UTI) and dehydration. The use of incontinence briefs and frequent toileting will not improve bladder emptying.

The nurse explains that multiple sclerosis (MS) is most likely caused by: a. environmental factors and genetic predisposition. b. allergic response to antiviral medications. c. autoimmune reaction attacking the myelin. d. bacterial infection of the myelin.

ANS: A The actual cause of MS is unknown, but it is believed to be related to environmental factors, such as bacteria, a virus, or a chemical and genetic predisposition.

ollowing a craniotomy to relieve increased intracranial pressure (ICP), the nurse will implement which intervention? a. Elevate the head of the bed 30 to 45 degrees. b. Place drip pad or cotton to absorb cerebrospinal fluid drainage from the nose or ears. c. Keep the patient stimulated to better assess changing level of consciousness. d. Allow the patient to change positions frequently for comfort.

ANS: A The head of bed is elevated to aid in reduction of ICP. Drip pads, patient stimulation, and changing positions frequently may increase ICP.

A patient found in a tonic-clonic seizure reports afterward that the seizure was preceded by numbness and tingling of the arm. The nurse knows that this finding indicates what type of seizure? a. Atonic b. Partial c. Absence d. Myoclonic

ANS: A The initial symptoms of a partial seizure involve clinical manifestations that are localized to a particular part of the body or brain. Symptoms of an absence seizure are staring and a brief loss of consciousness. In an atonic seizure, the patient loses muscle tone and (typically) falls to the ground. Myoclonic seizures are characterized by a sudden jerk of the body or extremities.

The nurse witnesses a patient with a seizure disorder as the patient suddenly jerks the arms and legs, falls to the floor, and regains consciousness immediately. It will be most important for the nurse to a. assess the patient for a possible head injury. b. give the scheduled dose of divalproex (Depakote). c. document the timing and description of the seizure. d. notify the patients health care provider about the seizure.

ANS: A The patient who has had a myoclonic seizure and fall is at risk for head injury and should be evaluated and treated for this possible complication first. Documentation of the seizure, notification of the seizure, and administration of antiseizure medications also are appropriate actions, but the initial action should be assessment for injury.

To avoid stimulation of painful muscle spasms, the nurse will: a. grasp the muscle firmly when moving the patient. b. use palms of hands to support joints when moving the patient. c. log roll the patient as a unit. d. perform passive range of motion (ROM).

ANS: B Using the palms of the hands and not grasping the muscle will reduce the incidence of spasm. Log rolling and ROM may initiate spasms.

When turning the patient who is in Crutchfield tongs traction, the nurse will: a. turn the patient as a unit by log rolling. b. release the weights to prevent injury while turning. c. turn quickly to avoid muscle spasms. d. advise the patient to hold his breath and bear down during turning.

ANS: A Turning the patient as a unit by log rolling with the weights in place immobilizes the affected vertebrae and maintains alignment. Releasing the weights or turning quickly will affect vertebrae and alignment. Deep breathing will decrease muscle tension.

he anxious mother of an adolescent who sustained a spinal injury yesterday and has paralysis of the lower limbs asks if the paralysis is permanent. Which response by the nurse is most helpful? a. Motor function sometimes returns after the edema of the spinal cord has subsided. b. Motor function may improve, but there will always be a deficit. c. In all likelihood the paralysis will be permanent. d. The physician is the best source for that information.

ANS: A Until spinal cord edema has subsided, the extent or the permanency of the paralysis cannot be evaluated. It would be incorrect to indicate that there will definitely be a deficit or paralysis. Not addressing the question and suggesting only to talk to the physician will likely frighten the parent.

After an older adult falls, the nurse suspects the development of a subdural hematoma based on which assessment findings? (Select all that apply.) a. Increasing irritability b. Complaint of a dull headache c. Frequent nodding off in chair during the day d. Focal seizures e. Staggering gait

ANS: A, B, C Increasing irritability and complaint of headache as well as changing level of consciousness are signs of increasing intracranial pressure. Seizures and staggering gait are not specifically indicative of subdural hematoma.

e nurse is caring for a patient who has a complete transection of the cord at C7. The patient asks the nurse what functions he will be able to perform. The nurse responds that the patient will most likely be able to perform which activities? (Select all that apply.) a. Transferring himself b. Dressing himself c. Using a wheelchair with standard hand rims d. Feeding himself e. Effectively typing using all digits

ANS: A, B, C, D The patient with an injury at C7 does not have full control of all digits. The third finger is the most functional. With physical and occupational therapy, the patient may be able to perform all other functions listed.

The nurse caring for a patient with autonomic dysreflexia assesses the patient for which conditions or situations? (Select all that apply.) a. Distended bladder b. Constipation c. Increased fluid intake d. Wrinkles in bed linens e. Abrupt environmental temperature changes

ANS: A, B, D, E Bladder distention, constipation, wrinkled bed linens, and temperature changes are potential triggers for autonomic dysreflexia (AD) that the nurse should assess for. This condition causes a rapid increase in blood pressure.

The student nurse is researching relapsing progressive forms of multiple sclerosis. What characteristics would the student discover as typical of this form of the disease? (Select all that apply.) a. Steady worsening b. Partial remissions c. Clear acute relapses d. Temporary minor improvements e. Long plateau periods

ANS: A, C Steady worsening and clear acute relapses are the principle characteristics of relapsing progressive multiple sclerosis.

he patient with myasthenia gravis asks the nurse if she will be able to use the computer for her job. Which symptom will most affect the patients ability to use the computer? a. Ptosis b. Diplopia c. Dysphagia d. Aphasia

ANS: B Ptosis, dysphagia, and aphasia are all symptoms associated with myasthenia gravis, but diplopia, or double vision, will cause the patient the most difficulty with using a computer.

The patient with a suspected subdural hematoma is on an IV drip of mannitol infusing at 50 mL/hr. The nurse explains that the slow infusion rate is essential for what purpose? a. Ensure effectiveness of the drug. b. Avoid fluid overload. c. Maintain electrolyte balance. d. Maintain adequate blood pressure.

ANS: B The slow infusion rate will not cause fluid overload, which would add to the possibility of increased intracranial pressure.

hen obtaining a health history and physical assessment for a patient with possible multiple sclerosis (MS), the nurse should a. assess for the presence of chest pain. b. inquire about any urinary tract problems. c. inspect the skin for rashes or discoloration. d. question the patient about any increase in libido

ANS: B Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS.

The nurse is aware that an epidural hematoma warrants immediate intervention based on which criteria? (Select all that apply.) a. An epidural hematoma is related to bleeding from arterial venous source. b. An epidural hematoma can increase intracranial pressure quickly. c. An epidural hematoma changes overall condition quickly. d. An epidural hematoma can cause death. e. An epidural hematoma can cause irreversible brain damage.

ANS: B, C, D, E Bleeding is related to an arterial source. All other options are the complications of an epidural hematoma. An epidural hematoma is a medical emergency.

The nurse uses a visual aid to demonstrate how a coup-contrecoup injures the brain by: (Select all that apply.) a. allowing the brain to twist on the brainstem. b. moving forward to strike the anterior interior skull. c. allowing the brain to compress on itself. d. striking the bony area opposite the site of impact. e. losing small amounts of cerebrospinal fluid.

ANS: B, D In a coup-contrecoup injury, the brain moves forward, striking the anterior interior wall of the cranium, and moves back, striking the bony area opposite the site of the impact, causing two areas of injury.

he nurse describes a concussion as a closed head injury in which: a. the brain tissue is bruised. b. no loss of consciousness occurs. c. there is amnesia related to the incident. d. there are no subsequent symptoms.

ANS: C A concussion is a closed head injury in which there is a brief disruption of consciousness, amnesia, and subsequent headaches that may last for several weeks.

When the nurse is assessing a patient with myasthenia gravis, which action will be most important to take? a. Check pupillary size. b. Monitor grip strength. c. Observe respiratory effort. d. Assess level of consciousness.

ANS: C Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical.

A patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching? a. Recommendation to drink at least 3 to 4 L daily b. Need to avoid driving or operating heavy machinery c. How to draw up and administer injections of the medication d. Use of contraceptive methods other than oral contraceptives

ANS: C Copaxone is administered by self-injection. Oral contraceptives are an appropriate choice for birth control. There is no need to avoid driving or drink large fluid volumes when taking glatiramer.

Which information about a patient with MS indicates that the nurse should consult with the health care provider before giving the prescribed dose of fampridine (Ampyra)? a. The patient has relapsing-remitting MS. b. The patient enjoys walking for relaxation. c. The patient has an increased creatinine level. d. The patient complains of pain with neck flexion.

ANS: C Fampridine should not be given to patients with impaired renal function. The other information will not impact on whether the fampridine should be administered.

The student nurse is planning care for a patient with a recent spinal cord injury. Which intervention indicates the need for further instruction regarding care of the patient with a spinal cord injury? a. Keep the halo jacket fastened unless the patient is in a supine position. b. Monitor the bladder every 4 hours for signs of bladder distention. c. Instruct unlicensed assistive personnel (UAP) to turn and reposition the patient every 2 hours. d. Assess compression stockings for proper fit.

ANS: C Moving or positioning the patient with neurologic injury or surgery should not be delegated to unlicensed personnel. Following proper instruction, the UAP can assist the nurse with moving or repositioning the patient. Halo jackets must be kept fastened unless the patient is in a supine position in order to prevent sudden head movement. Bladder distention should be avoided to prevent infection or autonomic dysreflexia. Compression stockings are used to prevent deep vein thrombosis.

The home care nurse is visiting a patient in the late stages of amyotrophic lateral sclerosis (ALS). Which statement by the patient indicates the acceptance of grief from the condition and prognosis? a. The patient often cries about his incapacity. b. The patient makes jokes about this approaching death. c. The patient talks with his family about his desires for his funeral. d. The patient begins to sleep for longer periods of time during the day.

ANS: C Planning with family signals acceptance. Crying, joking, and sleeping are efforts at denial.

A patient with multiple sclerosis is seen by the home health nurse and complains of severe fatigue. What is the best suggestion by the nurse to help diminish the effects of fatigue? a. Relaxing in a warm bath b. Performing deep-breathing exercises c. Scheduling rest periods during the day d. Including daily-dose multivitamins

ANS: C Scheduling and observing rest periods during the day will reduce fatigue. Heat increases sense of fatigue. Muscular problems are associated with ineffective impulse transmission rather than muscle weakness related to nutritional deficiency.

The emergency room nurse assessing clear drainage from the nose of a newly admitted patient with a head injury should perform which intervention? a. Document the presence of rhinorrhea. b. Inform the physician of the assessment. c. Test fluid with a glucose Accu-Chek or Dextrostix. d. Tape a drip pad under the nose.

ANS: C The presence of glucose in the fluid from the nose confirms that the fluid is cerebrospinal fluid. Documentation and informing the physician should occur after confirmation of the character of the fluid.

The older adult who is admitted to the hospital following a closed head injury that resulted in a 5-minute period of unconsciousness will be observed for which change? a. Increasing respiratory rate b. Decreasing heart rate c. Decreasing pulse pressure d. Decreasing level of consciousness (LOC)

ANS: D Assessment of level of consciousness provides the greatest amount of information about neurologic condition. A reduction in level of consciousness may signal the onset of complications in the patient who has had a head injury.

A patient has a tonic-clonic seizure while the nurse is in the patients room. Which action should the nurse take? a. Insert an oral airway during the seizure to maintain a patent airway. b. Restrain the patients arms and legs to prevent injury during the seizure. c. Avoid touching the patient to prevent further nervous system stimulation. d. Time and observe and record the details of the seizure and postictal state.

ANS: D Because diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure.

The nurse is aware that the diagnosis of multiple sclerosis (MS) is based on: a. blood tests revealing identifiable MS markers. b. lumbar puncture results revealing inflammatory response. c. muscle biopsies revealing characteristic lesions. d. signs and symptoms assessed and reported by the patient.

ANS: D Diagnosis is almost completely reliant on signs and symptoms demonstrated by the patient. Other diagnostic tests will likely be performed in order to confirm the diagnosis.

The most beneficial and safe positioning of an unconscious patient who has a right-sided closed head injury is: a. high Fowlers. b. right side-lying. c. flat with small pillow under head. d. head of bed 30 to 45 degrees.

ANS: D Keeping the head of the bed 30 to 45 degrees with the body in good alignment will help reduce intracranial pressure and keep the airway patent.

The unconscious patient with a closed head injury is on mechanical ventilation. To improve brain perfusion through increased blood pressure, the CO2 level is maintained at _____ mm Hg. a. 10 to 15 b. 15 to 20 c. 20 to 25 d. 25 to 30

ANS: D The carbon dioxide level is set to be maintained at 25 to 30 mm Hg to create vascular constriction, raise blood pressure, and perfuse the cerebrum.

The nurse is educating the family of a patient in the late stages of amyotrophic lateral sclerosis (ALS). What teaching point is most important for the nurse to include? a. The patients ability to move the upper limbs may be affected. b. The patients cognitive and mental capacity will most likely remain intact throughout the disease progression. c. The patients breathing should not be affected by the disease. d. The patients ability to swallow will remain intact.

NS: B Whereas the ability to move the upper limbs will likely be affected by the disease, it is important for families to remember that the patients cognitive and mental capacity stays intact as the motor activity rapidly declines. Breathing and swallowing are often significantly affected by ALS.