MedSurg2 Exam 2 Part 3

Which of the following medication classifications is utilized preoperatively to decrease risk of postop seizures? a. Anticonvulsants b. Diuretics c. Corticosteroids d. Antianxiety

A Anticonvulsants are used to decrease the risk of postoperative seizures following cranial surgery. Diuretics, corticosteroids, and antianxiety medications may be used for the patient with increased intracranial pressure.

What is one of the earliest signs of increased ICP? a. decreased level of consciousness (LOC) b. headache c. Cushing's triad d. coma

A Headache is a symptom of increased ICP, but decreasing LOC is one of the earliest signs of increased ICP. Cushing's triad occurs late in increased ICP. If untreated, increasing ICP will lead to coma.

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? a. unequal response b. equal response c. rapid response d. constricted response

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

A client with an inoperable brain tumor says to the nurse, "I'm so afraid that I'm going to die alone." What is the nurse's best response?a. "You sound frightened." b. "You are not going to die." c. "There is nothing to be afraid of." d. "It won't be as bad as you think."

A In this scenario, the nurse stating "You sound frightened" is an example of reflective technique; it focuses on the client's feelings and encourages verbalization. The other statements deny the client's feelings.

Which nursing interventions might need to be considered in a care plan for a client with advanced multiple sclerosis? Select all that apply. a. Ensure access to a language board when communicating with the client. b. Obtain daily weights to monitor weight gain. c. Establish a voiding time schedule. d. Encourage the client to walk with feet wide apart.

A,C,D Language assistive devices may be needed if communication is severely affected. Occasional bladder incontinence may lead to total incontinence. A voiding time schedule will allow the client greater independence. If motor dysfunction causes problems of incoordination and clumsiness, the patient is at risk for falling. As the disease progresses, nutritional deficiencies may develop. Weight should be assessed to ensure that there is no significant weight loss. Weight gain should not be an issue.

A nurse is caring for a patient admitted with cluster headaches. The nurse knows that in the early phase of a cluster headache what is required? A) Dim lighting B) Abortive medication therapy C) Quiet D) Rest

ANS: B A migraine or a cluster headache in the early phase requires abortive medication therapy instituted as soon as possible. Dim lighting, quiet, and rest are necessary for migraines; they are not required in the early phase of a cluster headache.

A school nurse is called to the playground where a 6-year-old girl has fallen off the slide. When the nurse gets to the playground the girl is exhibiting jerking motions in her left arm and leg. The girl is unconscious. How would the nurse document the girl's activity in her chart at school? A) Simple partial seizure B) Complex partial seizure C) Complex generalized seizure D) Simple generalized seizure

ANS: B In a simple partial seizure, consciousness remains intact, whereas in a complex partial seizure, consciousness is impaired.

During their pathophysiology class the nursing students study seizures. How might the instructor best describe the cause of a seizure? A) Uncontrolled normal electrical charges throughout the brain B) A dysrhythmia in the motor strip of the brain C) A dysrhythmia in the nerve cells in one section of the brain D) Abnormal, recurring, controlled electrical charges in the brain

ANS: C The underlying cause of a seizure is an electrical disturbance (dysrhythmia) in the nerve cells in one section of the brain; these cells emit abnormal, recurring, uncontrolled electrical discharges. Seizures are not caused by normal electrical charges throughout the brain or controlled electrical charges in the brain. Option B could be correct, but not all seizures arise in the motor strip of the brain.

You are discharging a patient home after supratentorial removal of a pituitary mass. What medication would you expect to have ordered prophylactically for this patient? A) Prednisone B) Dexamethasone C) Cafergot D) Phentoin

ANS: D Antiseizure medication (phenytoin, diazepam) is often prescribed prophylactically for patients who have undergone supratentorial craniotomy because of the high risk of seizures after these procedures. Prednisone and dexamethasone are steroids. Cafergot is used in the treatment of migraines.

The causes of acquired seizures include what? (Mark all that apply.) A) Cerebrovascular disease B) Metabolic and toxic conditions C) Hypernatremia D) Brain tumor E) Drug and alcohol addiction

ANS: D The specific causes of seizures are varied and can be categorized as idiopathic (genetic, developmental defects) and acquired. Causes of acquired seizures include cerebrovascular disease; hypoxemia of any cause, including vascular insufficiency; fever (childhood); head injury; hypertension; central nervous system infections; metabolic and toxic conditions (eg, renal failure, hyponatremia, hypocalcemia, hypoglycemia, pesticide exposure); brain tumor; drug and alcohol withdrawal; and allergies.

A patient has developed diabetes insipidus after having increased ICP following head trauma. What nursing assessment best addresses this complication? A) Vigilant monitoring of fluid balance B) Continuous BP monitoring C) Serial arterial blood gases (ABGs) D) Monitoring of the patient's airway for patency

Ans: A Feedback:Diabetes insipidus requires fluid and electrolyte replacement, along with the administration of vasopressin, to replace and slow the urine output. Because of these alterations in fluid balance, careful monitoring is necessary. None of the other listed assessments directly addresses the major manifestations of diabetes insipidus.

A nurse is caring for a patient who experiences debilitating cluster headaches. The patient should be taught to take appropriate medications at what point in the course of the onset of a new headache? A)As soon as the patient's pain becomes unbearable B)As soon as the patient senses the onset of symptoms C) Twenty to 30 minutes after the onset of symptoms D) When the patient senses his or her symptoms peaking

Ans: B Feedback:A migraine or a cluster headache in the early phase requires abortive medication therapy instituted as soon as possible. Delaying medication administration would lead to unnecessary pain.

A patient with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate?A)Restrain the patient to prevent injury. B)Open the patient's jaws to insert an oral airway. C)Place patient in high Fowler's position. D)Loosen the patient's restrictive clothing.

Ans:D Feedback:An appropriate nursing intervention would include loosening any restrictive clothing on the patient. No attempt should be made to restrain the patient during the seizure because muscular contractions are strong and restraint can produce injury. Do not attempt to pry open jaws that are clenched in a spasm to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus.

The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing diagnosis of "ineffective cerebral tissue perfusion." What would be an expected outcome that the nurse would document for this diagnosis? A)Copes with sensory deprivation. B)Registers normal body temperature. C)Pays attention to grooming. D)Obeys commands with appropriate motor responses.

Ans:D Feedback:An expected outcome of the diagnosis of ineffective cerebral tissue perfusion in a patient with increased intracranial pressure (ICP) would include obeying commands with appropriate motor responses. Vitals signs and neurologic status are assessed every 15 minutes to every hour. Coping with sensory deprivation would relate to the nursing diagnosis of "disturbed sensory perception." The outcome of "registers normal body temperature" relates to the diagnosis of "potential for ineffective thermoregulation." Body image disturbance would have a potential outcome of "pays attention to grooming."

The nurse is participating in the care of a client with increased ICP. What diagnostic test is contraindicated in this client's treatment? a. Computed tomography (CT) scan b. Lumbar puncture c. Magnetic resonance imaging (MRI) d. Venous Doppler studies

B A lumbar puncture in a client with increased ICP may cause the brain to herniate from the withdrawal of fluid and change in pressure during the lumbar puncture. Herniation of the brain is a dire and frequently fatal event. CT, MRI, and venous Doppler are considered noninvasive procedures and they would not affect the ICP itself.

While completing a health history on a client who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state? a. Epileptic cry b. Confusion c. Urinary incontinence d. Body rigidity

B In the postictal state (after the seizure), the client is often confused and hard to arouse and may sleep for hours. The epileptic cry occurs from the simultaneous contractions of the diaphragm and chest muscles that occur during the seizure. Urinary incontinence and intense rigidity of the entire body are followed by alternating muscle relaxation and contraction (generalized tonic-clonic contraction) during the seizure.

The neurologic ICU nurse is admitting a client with increased intracranial pressure. How should the nurse best position the client? a. Position the client supine. b. Maintain head of bed (HOB) elevated at 30 to 45 degrees. c. Position client in prone position. d. Maintain bed in Trendelenburg position.

B The client with increased ICP should be placed with the HOB elevated 30 to 45 degrees, with the neck in neutral alignment. Each of the other listed positions would cause a dangerous elevation in ICP.

The nurse is caring for a client who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of "deficient fluid volume related to fluid restriction and osmotic diuretic use." What is the nurse's most appropriate intervention for this diagnosis? a. Change the client's position as indicated. b. Monitor serum electrolytes. c. Maintain NPO status. d. Monitor arterial blood gas (ABG) values.

B The postoperative fluid regimen depends on the type of neurosurgical procedure and is determined on an individual basis. The volume and composition of fluids are adjusted based on daily serum electrolyte values, along with fluid intake and output. Fluids may have to be restricted in clients with cerebral edema. Changing the client's position, maintaining an NPO status, and monitoring ABG values do not relate to the nursing diagnosis of deficient fluid volume.

A patient with Parkinson's disease is undergoing a swallowing assessment because she is experiencing difficulties when swallowing. What consistency is most appropriate for this patient, to reduce the risk of aspiration? a. Solid food with thin liquids b. Pureed food with water c. Semisolid food with thick liquids d. Thin liquids only

C A semisolid diet with thick liquids is easier to swallow for a patient with swallowing difficulties than a solid diet. Thin liquids should be avoided. Pureed foods with water are not indicated for this patient.

A nurse is collaborating with the interdisciplinary team to help manage a patient's recurrent headaches. What aspect of the patient's health history should the nurse identify as a potential contributor to the patient's headaches? A) The patient leads a sedentary lifestyle. B) The patient takes vitamin D and calcium supplements. C) The patient takes vasodilators for the treatment of angina. D) The patient has a pattern of weight loss followed by weight gain.

C Feedback:Vasodilators are known to contribute to headaches. Weight fluctuations, sedentary lifestyle, and vitamin supplements are not known to have this effect.

A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? a. Maintaining adequate hydration b. Administering prescribed antipyretics c. Restricting fluid intake and hydration d. Hyperoxygenation before and after tracheal suctioning

C Fluid restriction may be necessary if the client develops cerebral edema and hypervolemia from SIADH. Antipyretics are administered to clients who develop hyperthermia. In addition, it is important to maintain adequate hydration in such clients. A client with neurological infection should be given tracheal suctioning and hyperoxygenation only when respiratory distress develops.

The nurse is caring for a client who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the client's respiratory effort has increased. What is the nurse's most appropriate response? a. Inform the care team and assess for further signs of possible increased ICP. b. Administer bronchodilators as prescribed and monitor the client's LOC. c. Increase the client's bed height and reassess in 30 minutes. d. Administer a bolus of normal saline as prescribed.

A Increased respiratory effort can be suggestive of increasing ICP, and the care team should be promptly informed. A bolus of IV fluid will not address the problem. Repositioning the client and administering bronchodilators are insufficient responses, even though these actions may later be prescribed.

A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? a. 3 b. 6 c. 9 d. 12

A LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response (Barlow, 2012). The patient's responses are rated on a scale from 3 to 15. A score of 3 indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response. A score of 15 indicates that the patient is fully responsive (see Chapter 68).

While caring for a client with a seizure disorder, the nurse observes a sudden, brief jerking of the client's left arm. Most likely, the client has which type of seizure disorder? a. myoclonic seizure b. tonic-clonic seizure c. partial seizure d. absence seizure

A Myoclonic seizures are characterized by sudden, excessive jerking of the arms, legs, or entire body. The seizures are brief.

The nurse is liaising with the physical therapist and occupational therapist to create an activity management plan for a patient who has multiple sclerosis. What principle should be integrated into guidelines for exercise and activity that the team will provide to this patient in anticipation of discharge? a. The patient should perform frequent physical activity but avoid becoming fatigued. b. The patient should perform exercises that are brief but high-intensity. c. The patient should prioritize energy conservation and remain on bed rest if possible. d. The patient should attempt to maintain prediagnosis levels of activity and mobility.

A The patient is encouraged to work and exercise to a point just short of fatigue. Very strenuous physical exercise is not advisable because it raises the body temperature and may aggravate symptoms. The patient is advised to take frequent short rest periods, preferably lying down. Extreme fatigue may contribute to the exacerbation of symptoms. It is unrealistic to expect the patient to maintain prediagnosis levels of activity.

While completing a health history on a patient who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state? A)Epileptic cry B)Confusion C)Urinary incontinence D)Body rigidity

Ans: B Feedback:In the postictal state (after the seizure), the patient is often confused and hard to arouse and may sleep for hours. The epileptic cry occurs from the simultaneous contractions of the diaphragm and chest muscles that occur during the seizure. Urinary incontinence and intense rigidity of the entire body are followed by alternating muscle relaxation and contraction (generalized tonic-clonic contraction) during the seizure.

What should the nurse suspect when hourly assessment of urine output on a patient postcraniotomy exhibits a urine output from a catheter of 1,500 mL for two consecutive hours? A) Cushing syndrome B) Syndrome of inappropriate antidiuretic hormone (SIADH) C) Adrenal crisis D) Diabetes insipidus

Ans: D Feedback:Diabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in patients after brain surgery. Cushing syndrome is excessive glucocorticoid secretion resulting in sodium and water retention. SIADH is the result of increased secretion of ADH; the patient becomes volume-overloaded, urine output diminishes, and serum sodium concentration becomes dilute. Adrenal crisis is undersecretion of glucocorticoids resulting in profound hypoglycemia, hypovolemia, and hypotension.

When caring for a patient with increased ICP the nurse knows the importance of monitoring for possible secondary complications, including syndrome of inappropriate antidiuretic hormone (SIADH). What nursing interventions would the nurse most likely initiate if the patient developed SIADH? A)Fluid restriction B)Transfusion of platelets C)Transfusion of fresh frozen plasma (FFP) D)Electrolyte restriction

Ans:A Feedback: The nurse also assesses for complications of increased ICP, including diabetes insipidus, and SIADH. SIADH requires fluid restriction and monitoring of serum electrolyte levels. Transfusions are unnecessary.

A patient is recovering from intracranial surgery performed approximately 24 hours ago and is complaining of a headache that the patient rates at 8 on a 10-point pain scale. What nursing action is most appropriate? A)Administer morphine sulfate as ordered. B)Reposition the patient in a prone position. C)Apply a hot pack to the patient's scalp. D)Implement distraction techniques.

Ans:A Feedback: The patient usually has a headache after a craniotomy as a result of stretching and irritation of nerves in the scalp during surgery. Morphine sulfate may also be used in the management of postoperative pain in patients who have undergone a craniotomy. Prone positioning is contraindicated due to the consequent increase in ICP. Distraction would likely be inadequate to reduce pain and a hot pack may cause vasodilation and increased pain.

A patient with a new diagnosis of amyotrophic lateral sclerosis (ALS) is overwhelmed by his diagnosis and the known complications of the disease. How can the patient best make known his wishes for care as his disease progresses? A)Prepare an advance directive. B)Designate a most responsible physician (MRP) early in the course of the disease. C)Collaborate with representatives from the Amyotrophic Lateral Sclerosis Association. D)Ensure that witnesses are present when he provides instruction.

Ans:A Feedback:Patients with ALS are encouraged to complete an advance directive or "living will" to preserve their autonomy in decision making. None of the other listed actions constitutes a legally binding statement of end-of-life care.

An adult patient has sought care for the treatment of headaches that have become increasingly severe and frequent over the past several months. Which of the following questions addresses potential etiological factors? Select all that apply? A) "Are you exposed to any toxins or chemicals at work?" B) "How would you describe your ability to cope with stress?" C) "What medications are you currently taking?" D) "When was the last time you were hospitalized?" E) "Does anyone else in your family struggle with headaches?"

Ans:A, B, C, E Feedback:Headaches are multifactorial, and may involve medications, exposure to toxins, family history, and stress. Hospitalization is an unlikely contributor to headaches.

The nurse is developing a plan of care for a patient newly diagnosed with Bell's palsy. The nurse's plan of care should address what characteristic manifestation of this disease? A)Tinnitus B)Facial paralysis C)Pain at the base of the tongue D)Diplopia

Ans:B Feedback:Bell's palsy is characterized by facial dysfunction, weakness, and paralysis. It does not result in diplopia, pain at the base of the tongue, or tinnitus.

A patient exhibiting an altered level of consciousness (LOC) due to blunt-force trauma to the head is admitted to the ED. The physician determines the patient's injury is causing increased intracranial pressure (ICP). The nurse should gauge the patient's LOC on the results of what diagnostic tool? A)Monro-Kellie hypothesis B)Glasgow Coma Scale C)Cranial nerve function D)Mental status examination

Ans:B Feedback:LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response. The Monro-Kellie hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the components (blood, brain tissue, cerebrospinal fluid) causes a change in the volume of the others. Cranial nerve function and the mental status examination would be part of the neurologic examination for this patient, but would not be the priority in evaluating LOC.

The nurse is caring for a patient who is in status epilepticus. What medication does the nurse know may be given to halt the seizure immediately? A)Intravenous phenobarbital (Luminal) B)Intravenous diazepam (Valium) COral lorazepam (Ativan) D)Oral phenytoin (Dilantin)

Ans:B Feedback:Medical management of status epilepticus includes IV diazepam (Valium) and IV lorazepam (Ativan) given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state. Oral medications are not given during status epilepticus.

A school nurse is called to the playground where a 6-year-old girl has been found unresponsive and "staring into space," according to the playground supervisor. How would the nurse document the girl's activity in her chart at school? A)Generalized seizure B)Absence seizure C)Focal seizure D)Unclassified seizure

Ans:B Feedback:Staring episodes characterize an absence seizure, whereas focal seizures, generalized seizures, and unclassified seizures involve uncontrolled motor activity.

A patient with Parkinson's disease is undergoing a swallowing assessment because she has recently developed adventitious lung sounds. The patient's nutritional needs should be met by what method? A)Total parenteral nutrition (TPN) B)Provision of a low-residue diet C)Semisolid food with thick liquids D)Minced foods and a fluid restriction

Ans:C Feedback:A semisolid diet with thick liquids is easier for a patient with swallowing difficulties to consume than is a solid diet. Low-residue foods and fluid restriction are unnecessary and counterproductive to the patient's nutritional status. The patient's status does not warrant TPN.

A patient has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize? A)Unclassified seizure B)Absence seizure C)Generalized seizure D)Focal seizure

Ans:C Feedback:Generalized seizures often involve both hemispheres of the brain, causing both sides of the body to react. Intense rigidity of the entire body may occur, followed by alternating muscle relaxation and contraction (generalized tonic-clonic contraction). This pattern of rigidity does not occur in patients who experience unclassified, absence, or focal seizures.

A patient with Parkinson's disease is experiencing episodes of constipation that are becoming increasingly frequent and severe. The patient states that he has been achieving relief for the past few weeks by using OTC laxatives. How should the nurse respond? A)"It's important to drink plenty of fluids while you're taking laxatives." B)"Make sure that you supplement your laxatives with a nutritious diet." C)"Let's explore other options, because laxatives can have side effects and create dependency." D)"You should ideally be using herbal remedies rather than medications to promote bowel function."

Ans:C Feedback:Laxatives should be avoided in patients with Parkinson's disease due to the risk of adverse effects and dependence. Herbal bowel remedies are not necessarily less risky.

The nurse is providing care for a patient who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the patient has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following? A)The ability of the patient to follow instructions during the seizure. B)The success or failure of the care team to physically restrain the patient. C)The patient's ability to explain his seizure during the postictal period. D)The patient's activities immediately prior to the seizure.

Ans:D Feedback:Before and during a seizure, the nurse observes the circumstances before the seizure, including visual, auditory, or olfactory stimuli; tactile stimuli; emotional or psychological disturbances; sleep; and hyperventilation. Communication with the patient is not possible during a seizure and physical restraint is not attempted. The patient's ability to explain the seizure is not clinically relevant.

A patient has just been diagnosed with Parkinson's disease and the nurse is planning the patient's subsequent care for the home setting. What nursing diagnosis should the nurse address when educating the patient's family? A)Risk for infection B)Impaired spontaneous ventilation C)Unilateral neglect D)Risk for injury

Ans:D Feedback:Individuals with Parkinson's disease face a significant risk for injury related to the effects of dyskinesia. Unilateral neglect is not characteristic of the disease, which affects both sides of the body. Parkinson's disease does not directly constitute a risk for infection or impaired respiration.

An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to a. control fever. b. control shivering. c. dehydrate the brain and reduce cerebral edema. d. reduce cellular metabolic demand.

C 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.

A client is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this client's care, the nurse would expect to administer what priority medication? a. Hydrochlorothiazide b. Furosemide c. Mannitol d. Spironlactone

C The osmotic diuretic mannitol is given to dehydrate the brain tissue and reduce cerebral edema. This drug acts by reducing the volume of brain and extracellular fluid. Spironlactone, furosemide, and hydrochlorothiazide are diuretics that are not typically used in the treatment of increased ICP resulting from cerebral edema.

A nurse is collaborating with the interdisciplinary team to help manage a client's recurrent headaches. What aspect of the client's health history should the nurse identify as a potential contributor to the client's headaches? a. The client leads a sedentary lifestyle. b. The client takes vitamin D and calcium supplements. c. The client takes vasodilators for the treatment of angina. d. The client has a pattern of weight loss followed by weight gain.

C Vasodilators are known to contribute to headaches. Weight fluctuations, sedentary lifestyle, and vitamin supplements are not known to have this effect.

A patient 3 days postoperative from a craniotomy informs the nurse, "I feel something trickling down the back of my throat and I taste something salty." What priority intervention does the nurse initiate? a. Give the patient some mouthwash to gargle with. b. Request an antihistamine for the postnasal drip. c. Ask the patient to cough to observe the sputum color and consistency. d. Notify the physician of a possible cerebrospinal fluid leak.

D Any sudden discharge of fluid from a cranial incision is reported at once, because a large leak requires surgical repair. Attention should be paid to the patient who complains of a salty taste or "postnasal drip," because this can be caused by cerebrospinal fluid trickling down the throat.