MedSurgFinal

Secondary prevention: Risk factor modification (4)

1. smoking cessation 2. diabetes control 3. aggressive cholesterol lowering 4. hypertension control

Management of the patient with bacterial meningitis includes: 1.Administering antibiotics immediately after collection of specimens for culture. 2.Waiting for results of a CSF culture to identify an organism before initiating treatment. 3.Providing symptomatic and supportive treatment because drug therapy is not effective in treatment. 4.Obtaining skull x-rays and CT scans to determine the extent of the disease before treatment is started.

1.Administering antibiotics immediately after collection of specimens for culture. Rationale: Bacterial meningitis is a medical emergency. Rapid diagnosis based on history and physical examination is crucial because the patient is usually in a critical state when health care is sought. When meningitis is suspected, antibiotic therapy is instituted after collection of specimens for cultures, even before the diagnosis is confirmed.

absence seizure

staring, a brief loss of consciousness

a state of continuous seizure activity or a condition in which seizures recur in rapid succession without return to consciousness between seizures

status epilepticus

myoclonic seizure

sudden jerk of the body or extremities

After teaching a patient about management of migraine headaches, the nurse determines that the teaching has been effective when the patient says

"I will try to lie down someplace dark and quiet when the headaches begin." Rational: It is recommended that the patient with a migraine rest in a dark, quiet area.

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?

"MS symptoms may be worse after the pregnancy." Rational: During the postpartum period, women with MS are at greater risk for exacerbation of symptoms, thought 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.

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?

"Most patients with epilepsy are well controlled with antiseizure medications." Rational: The nurse should inform the patient that most patients with seizure disorders are controlled with medication.

4 major causes of hemorrhagic stroke

1) deep hypertensive intracerebral hemorrhages 2) ruptured saccular aneurysms 3) arteriovenous malformation 4) spontaneous lobar hemorrhages

Secondary prevention of stroke (3)

1. Anticoagulants 2. Antiplatelets 3. Surgery

A patient with a stroke has dysphagia. Before allowing the patient to eat, which of the following actions should the nurse take first? 1. Check the patient's gag reflex. 2. Request a soft diet with no liquids. 3. Place the patient in high-Fowler's position. 4. Test the patient's ability to swallow with a small amount of water.

1. Check the patient's gag reflex. Rationale: Before initiation of feeding, assess the gag reflex by gently stimulating the back of the throat with a tongue blade. If a gag reflex is present, the patient will gag spontaneously. If it is absent, defer the feeding, and begin exercises to stimulate swallowing. To assess swallowing ability, elevate the head of the bed to an upright position (unless contraindicated), and give the patient a small amount of crushed ice or ice water to swallow.

Arterial sources of stroke (3)

1. Intracranial vascular disease 2. Carotid vascular disease 3. Aortic arch

A 69-year-old patient is admitted to the hospital with a urinary infection and possible bacterial sepsis. The patient is disoriented and has a disturbed sleep-wake cycle. The nurse administers the Confusion Assessment Method (CAM) tool to differentiate among various cognitive disorders, primarily because: 1.Delirium can be reversed by treating the underlying causes. 2.Depression is a common cause of dementia in older adults. 3.Nursing care should be based on the cause of the cognitive impairment. 4.Drug therapy with antipsychotic agents is indicated in the treatment of dementia.

1.Delirium can be reversed by treating the underlying causes. Rationale: Delirium, a state of temporary but acute mental confusion, is a common, life-threatening, and possibly preventable syndrome in older adults. Clinically, delirium is rarely caused by a single factor. It is often the result of the interaction of the patient's underlying condition with a precipitating event.

Vigorous control of fever in the patient with meningitis is required to prevent complications. Identify four undesirable effects of fever in the patient with meningitis

1.increased seizures 2. increased ICP 3. dehydration 4. direct neurologic damage

A patient with Alzheimer's disease has a nursing diagnosis of impaired memory related to effects of dementia. An appropriate nursing intervention for the patient is to: 1.Let the patient know what behavior is socially appropriate. 2.Assist the patient with all self-care to maintain self-esteem. 3.Maintain familiar routines of sleep, meals, drug administration, and activities. 4.At every encounter with the patient, ask the day, time, and place to promote orientation.

3.Maintain familiar routines of sleep, meals, drug administration, and activities. Rationale: The nurse should maintain familiar routines by identifying usual patterns of behavior for activities such as sleep, medication use, elimination, food intake, and self-care.

A patient with right-sided paresthesias and hemiparesis is hospitalized and diagnosed with a thrombotic stroke. Over the next 72 hours, the nurse plans care with the knowledge that the patient: 1.Is ready for aggressive rehabilitation. 2.Will show gradual improvement of the initial neurologic deficits. 3.May show signs of deteriorating neurologic function as cerebral edema increases. 4.Should not be turned or exercised to prevent extension of the thrombus and increased neurologic deficits.

3.May show signs of deteriorating neurologic function as cerebral edema increases. Rationale: Ischemic stroke symptoms may progress in the first 72 hours as infarction and cerebral edema increase.

A patient experiencing TIAs is scheduled for a carotid endarterectomy. The nurse explains that this procedure is done to 1.Decrease cerebral edema 2.Reduce the brain damage that occurs during a stroke in evolution 3.Prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow 4.Provide a circulatory bypass around thrombotic plaques obstructing cranial circulation

3.Prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow Rationale: This is completed to prevent impending cerebral infarction. Atherosclerotic plaques are removed.

Normal ICP ranges from:

5 to 15 mm Hg

Cerebral ischemia and neuronal death occur when CPP is less than _________ mm Hg. A CPP less than __________ mm Hg is incompatible with life.

50 mm Hg; 30 mm Hg

Autoregulation to maintain constant blood flow to the brain becomes ineffective when the MAP is below ___ mm Hg, and the brain becomes ________. Autoregulation also becomes ineffective when MAP is greater than ___ mm Hg because the vessels are maximally _________

50, ischemic, 150, constricted

The nurse is monitoring a patient for increased ICP following a head injury. Which of the following manifestations indicate an increased ICP (select all that apply) a. fever b. oriented to name only c. narrowing pulse pressure d. dilated right pupil > left pupil e. decorticate posturing to painful stimulus

A, B, D, E- The first sign of increased ICP is a change in LOC. Other manifestations are dilated ipsilateral pupil, changes in motor response such as posturing, and fever, which may indicate pressure on the hypothalamus. Changes in vital signs would be an increased systolic BP with widened pulse pressure and bradycardia

A patient has ICP monitoring with an intraventricular catheter. A priority nursing intervention for the patient is a. aseptic technique to prevent infection b. constant monitoring of ICP waveforms c. removal of CSF to maintain normal ICP d. sampling CSF to determine abnormalities

A. Aseptic technique to prevent infection- An intraventricular catheter is a fluid coupled system that can provide direct access for microorganisms to enter the ventricles of the brain, and aseptic technique is a very high nursing priority to decrease the risk for infection. Constant monitoring of ICP waveforms is not usually necessary, and removal of CSF for sampling or to maintain normal ICP is done only when specifically ordered

A patient has a nursing diagnosis of risk for ineffective cerebral tissue perfusion related to cerebral edema. An appropriate nursing intervention for the patient is a. avoiding positioning the patient with neck and hip flexion b. maintaining hyperventilation to a PaCO2 of 15 to 20 mm Hg c. clustering nursing activities to provide periods of uninterrupted rest d. routine suctioning to prevent accumulation of respiratory secretions

A. Avoiding positioning the patient with neck and hip flexion- Nursing care activities that increase ICP include hip and neck flexion, suctioning, clustering care activities, and noxious stimuli; they should be avoided or performed as little as possible in the patient with increased ICP. Lowering the PaCO2 below 20 mm Hg can cause ischemia and worsening of ICP; the PaCO2 should be maintained at 30 to 35 mm Hg.

Match the common causes of cerebral edema with their related types a. Destructive lesions or trauma b. Increased permeability of blood-brain barrier c. Local disruption of cell membranes d. Ingested toxins e. Hydrocephalus

A. Cytotoxic B. Vasogenic C. Cytotoxic D. Vasogenic E. Interstitial

Indicate whether the following factors increase or decrease cerebral blood flow a. Pa Co2 of 30 mm Hg b. Pa O2 of 45 mm Hg c. Decreased MAP d. Increased ICP e. Arterial blood pH of 7. 3

A. Decrease B. Increase C. Decrease D. Decrease E. Increase

For the patient undergoing a craniotomy, the nurse provides information about the use of wigs and hairpieces or other methods to disguise hair loss a. during pre operative teaching b. in the patient asks about their use c. in the immediate postoperative period d. when the patient expresses negative feelings about his or her appearance

A. During pre operative teaching- The prevent undue concern and anxiety about hair loss and postoperative self-esteem disturbances, a patient undergoing cranial surgery should be informed pre operatively that the head is usually shaved in surgery while the patient is anesthetized and that methods can be used after the dressings are removed postoperatively to disguise the hair loss. In the immediate postoperative period, the patient is very ill, and the focus is on maintaining neurologic function, bur preoperatively the nurse should anticipate the patient's postoperative need for self-esteem and maintenance of appearance.

When a patient is admitted to the emergency department following a head injury, the nurse's first priority in management of the patient once a patent airway is confirmed is a. maintaining cervical spine precautions b. determining the presence of increased ICP c. monitoring for changes in neurologic status d. establishing IV access with a large-bore catheter

A. In addition to monitoring for a patent airway during emergency care of the patient with a head injury, the nurse must always assume that a patient with a head injury may have a cervical spine injury. Maintaining cervical spine precautions in all assessment and treatment activities with the patient is essential to prevent additional neurologic damage.

A patient with a suspected closed head injury has bloody nasal drainage. The nurse suspects that this patient has a cerebrospinal fluid (CSF) leak when observing which of the following? a. A halo sign on the nasal drip pad b. Decreased blood pressure and urinary output c. A positive reading for glucose on a Test-tape strip d. Clear nasal drainage along with bloody discharge

A. When drainage containing both CSF and blood is allowed to drip onto a white pad, within a few minutes the blood will coalesce into the center, and a yellowish ring of CSF will encircle the blood, giving a halo effect.

A patient is admitted to the hospital with a left hemiplegia. To determine the size and location and to ascertain whether a stroke is ischemic or hemorrhagic, the nurse anticipates that the health care provider will request a a. CT scan b. lumbar puncture c. cerebral arteriogram d. positron emission tomography (PET)

A: CT scan- A CT scan is the most commonly used diagnostic test to determine the size and location of the lesion and to differentiate a thrombotic stroke from a hemorrhagic stroke. Positron emission tomography (PET) will show the metabolic activity of the brain and provide a depiction of the extent of tissue damage after a stroke. Lumbar punctures are not performed routinely because of the chance of increased intracranial pressure causing herniation. Cerebral arteriograms are invasive and may dislodge an embolism or cause further hemorrhage; they are performed only when no other test can provide the needed information.

During the acute phase of a stroke, the nurse assesses the patient's vital signs and neurologic status every 4 hours. A cardiovascular sign that the nurse would see as the body attempts to increase cerebral blood flow is a. hypertension b. fluid overload c. cardiac dysrhythmias d. S3 and S4 heart sounds

A: Hypertension- The body responds to the vasopasm and a decreased circulation to the brain that occurs with a stroke by increasing the BP, frequently resulting in hypertension. The other options are important cardiovascular factors to assess, but they do not result from impaired cerebral blood flow.

A newly admitted patient who has suffered a right sided brain stroke has a nursing diagnosis of disturbed visual sensory perception related to homonymous hemianopsia. Early in the care of the patient, the nurse should a. place objects on the right side within the patient's field of vision b. approach the patient from the left side to encourage the patient to turn the head c. place objects on the patient's left side to assess the patient's ability to compensate d. patch the affected eye to encourage the patient to turn the head to scan the environment

A: Place objects on the right side within the patient's field of vision- the presence of homonymous hemianopia in a patient with right-hemisphere brain damage causes a loss of vision in the left field. Early in the care of the patient, objects should be placed on the right side of the patient in the field of vision, and the nurse should approach the patient from the right side. Later in treatment, patients should be taught to turn the head and scan the environment and should be approached from the affected side to encourage head turning. Eye patches are used if patients have diplopia (double vision).

Four days following a stroke, a patient is to start oral fluids and feedings. Before feeding the patient, the nurse should first a. check the patient's gag reflex b. order a soft diet for the patient c. raise the head of the bed to sitting position d. evaluate the patient's ability to swallow small sips of ice water

A: check the patient's gag reflex- the first step in providing oral feedings for a patient with a stroke is ensuring that the patient has an intact gag reflex because oral feedings will not be provided if gag reflex is impaired. The nurse should then evaluate the patient's ability to swallow ice chips or ice water after placing the patient in an upright position

What is the high and low score of a Glasgow Coma Scale indicate? Above 15 = 8 or less = 3 or less =

Above 15 = Non-neurological impaired 8 or less = Coma 3 or less is = likely brain death

Manifestations of left brain damage

Aphasia, inability to remember words

A patient seen at the health clinic with a severe migraine headache tells the nurse about having four similar headaches in the last 3 months. Which initial action should the nurse take?

Ask the patient to keep a headache diary. Rational: The initial nursing action should be further assessment of the precipitating causes of the headaches, quality, and location of pain, etc. Stress reduction, muscle relaxation, and the triptan drugs may be helpful, but more assessment is needed first.

Permissive hypertension

If you drop blood pressure, more green tissue (ischemic) turns red (infarcted), (only treat BP if >200)

A patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?

Assist with active range of motion. Rational: 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 patient's ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations.

A patient with an intracranial problem does not open his eyes to any stimulus, has no verbal response except moaning and muttering when stimulated, and flexes his arm in response to painful stimuli. The nurse records the patients GCS score as a. 6 b. 7 c. 9 d. 11

B. 7- no opening of eyes = 1; incomprehensible words= 2, flexion withdrawal = 4 Total = 7

The nurse is caring for a patient admitted with a subdural hematoma following a motor vehicle accident. Which of the following changes in vital signs would the nurse interpret as a manifestation of increased intracranial pressure? a. Tachypnea b. Bradycardia c. Hypotension d. Narrowing pulse pressure

B. Changes in vital signs indicative of increased intracranial pressure are known as Cushing's triad, which consists of increasing systolic pressure with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations.

The nurse recognizes the presence of Cushing's triad in the patient with a. Increased pulse, irregular respiration, increased BP b. decreased pulse, irregular respiration, increased pulse pressure c. increased pulse, decreased respiration, increased pulse pressure d. decreased pulse, increased respiration, decreased systolic BP

B. Cushing's triad consists of three vital sign measures that reflect ICP and its effect on the medulla, the hypothalamus, the pons, and the thalamus. Because these structures are very deep, Cushing's triad is usually a late sign of ICP. The signs include an increasing systolic BP with a widening pulse pressure, a bradycardia with a full and bounding pulse, and irregular respirations.

Assisting the family to understand what is happening to the patient is an especially important role of the nurse when the patient has a tumor of the a. ventricles b. frontal lobe c. parietal lobe d. occipital lobe

B. Frontal lobe- frontal lobe tumors often lead to loss of emotional control, confusion, memory loss, disorientation, and personality changes that are very disturbing and frightening to the family. Physical symptoms, such as blindness, disturbances in sensation and perception, and even seizures, that occur with other tumors are more likely to be understood and accepted by the family

Classic symptoms of bacterial meningitis include a. papilledema and psychomotor seizures b. high fever, nuchal rigidity, and severe headache c. behavioral changes with memory loss and lethargy d. positive Kernig's and Brudzinski's signs and hemiparesis

B. High fever, severe headache, nuchal rigidity, and positive Brudzinski's and Kernig's signs are such classic symptoms of meningitis that they are usually considered diagnostic for meningitis. Other symptoms, such as papilledema, generalized seizures, hemiparesis, and decreased LOC, may occur as complications of increased ICP and cranial nerve dysfunction.

A patient with a head injury has bloody drainage from the ear. To determine whether CSF is present in the drainage, the nurse a. examines the tympanic membrane for a tear b. tests the fluid for a halo sign on a white dressing c. tests the fluid with a glucose identifying strip or stick d. collects 5 mL of fluid in a test tube and sends it to the laboratory for analysis

B. Tests the fluid for a halo sing on a white dressing- Testing clear drainage for CSF in nasal or ear drainage may be done with a Dextrostik or Tes-Tape strip, but if blood is present, the glucose in the blood will produce and unreliable result. To test bloody drainage, the nurse should test the fluid for a halo or ring that occurs when a yellowish ring encircles blood dripped onto a white pad or towel

On physical examination of a patient with headache and fever, the nurse would suspect a brain abscess when the patient has a. seizures b. nuchal rigidity c. focal symptoms d. signs of increased ICP

C. The symptoms of brain abscess closely resemble those of meningitis and encephalitis, including fever, headache, and increased ICP, except the patient also usually has some focal symptoms that reflect the local are of the abscess.

A diagnosis of a ruptured cerebral aneurysm has been made in a patient with manifestations of a stroke. The nurse anticipates that treatment options that would be evaluated for the patient include a. hyperventilation therapy b. surgical clipping of the aneurysm c. administration of hyperosmotic agents d. administration of thrombolytic therapy

B: Surgical clipping of they aneurysm- Surgical management with clipping of an aneurysm to decrease re bleeding and vasospasm is an option for a stroke cause by rupture of a cerebral aneurysm. Placement of coils into the lumens of the aneurysm by intercentional radiologists is increasing in popularity. Hyperventilation therapy would increase vasodilation and the potential for hemorrhage. Thrombolytic therapy would be absolutely contraindicated, and if a vessel is patent, osmotic diuretics may leak into tissue, pulling fluid out of the vessel and increasing edema.

To promote communication during rehabilitation of the patient with aphasia, an appropriate nursing intervention is to a. use gestures, pictures, and music to stimulate patient responses b. talk about activities of daily living (ADLs) that are familiar to the patient c. structure statements so that patient does not have to respond verbally d. use flashcards with simple words and pictures to promote language recall

B: Talk about ADLs that are familiar to the patient- during rehabilitation, the patient with aphasia needs frequent, meaningful verbal stimulation that has relevance for him. Conversation by the nurse and family should address ADLs that are familiar to the patient. Gestures, pictures, and simple statements are more appropriate in the acute phase, when patients may be overwhelmed with verbal stimuli. Flashcards are often perceived by the patient as childish and meaningless.

Major Nursing Concern for Guillian-Barre syndrome (polyneuritis)

Breathing Problems

Cerebral contusion

Bruising of brain, often associated with coup-countercoup injury

Increased ICP in the left cerebral cortex, caused by intracranial bleeding causes displacement of brain tissue to the right hemisphere beneath the falx cerebri. The nurse knows that this is referred to as a. uncal herniation b. tentorial herniation c. cingulate herniation d. temporal lobe herniation

C. Cingulate herniation- the dural structures that separate the two hemispheres and the cerebral hemispheres from the cerebellum influence the patterns of cerebral herniation. A cingulated herniation occurs where there is lateral displacement of brain tissue beneath the falx cerebri.

The earliest signs of increased ICP the nurse should assess for include a. Cushing's triad b. unexpected vomiting c. decreasing level of consciousness (LOC) d. dilated pupil with sluggish response to light

C. One of the most sensitive signs of increased intracranial pressure (ICP) is a decreasing LOC. A decrease in LOC will occur before changes in vital signs, ocular signs, and projectile vomiting occur

An unconscious patient with increased ICP in on ventilatory support. The nurse notifies the health care provider when arterial blood gas measurement results reveal a a. pH of 7.43 b. SaO2 of 94% c. PaO2 of 50 mm Hg d. PaCO2 of 30 mm Hg

C. PaO2 of 50 mm Hg- A PaO2 of 50 mm Hg reflects a hypoxemia that may lead to further decreased cerebral perfusion and hypoxia and must be corrected. The pH of SaO2 are within normal range, and a PaCO2 of 30 mm Hg reflects acceptable value for the patient with increased ICP

While the nurse performs ROM on an unconscious patient with increased ICP, the patient experiences severe decerebrate posturing reflexes. The nurse should a. use restraints to protect the patient from injury b. administer CNS depressants to lightly sedate the patient c. perform the exercises less frequently because posturing can increase ICP d. continue the exercises because they are necessary to maintain musculoskeletal function

C. Perform the exercises less frequently because posturing can increase ICP- If reflex posturing occurs during ROM or positioning of the patient, these activities should be done less frequently until the patient's condition stabilizes, because posturing can case increases in ICP. Neither restraints nor CNS depressants would be indicated.

A 54-year old man is recovering from a skull fracture with a subacute subdural hematoma. He has return of motor control and orientation but appears apathetic and has reduced awareness of his environment. When planning discharge or the patient, the nurse explains to the patient and the family that a. continuous improvement in the patient's condition should occur until he has returned to pre trauma status b. the patient's complete recovery may take years, and the family should plan for his long term dependent care c. the patient is likely to have long term emotional and mental changes that may require continued professional help d. role changes in family members will be necessary because the patient will be dependent on his family for care and support

C. Residual mental and emotional changes of brain trauma with personality changes are often the most incapacitating problems following head injury and are common in patients who have been comatose longer than 6 hours. Families must be prepared for changes in the patient's behavior to avoid family-patient friction and maintain family functioning, and professional assistance may be required. There is no indication he will be dependent on others for care, but he likely will not return to pre trauma status

CN III originating in the midbrain is assessed by the nurse for an early indication of pressure on the brainstem by a. assessing for nystagmus b. testing the corneal reflex c. testing pupillary reaction to light d. testing for oculocephalic (doll's eye) reflex

C. Testing pupillary reaction to light- One of the functions of CN III, the oculomotor nerve, is pupillary constriction, and testing for pupillary constriction is important to identify patients at risk for brainstem herniation caused by increased ICP. The corneal reflex is used to assess the functions of CN V and VII, and the oculocephalic reflex tests all cranial nerves involved with eye movement. Nystagmus is commonly associatted with specific lesions or chemical toxicities and is not a definitive sign of ICP

Which intervention should the nurse delegate to the LPN when caring for a patient following an acute stroke? a. assess the patient's neurologic status b. assess the patient's gag reflex before beginning feeding c. administer ordered antihypertensives and platelet inhibitors d. teach the patient's caregivers strategies to minimize unilateral neglect

C: Administer ordered antihypertensives and platelet inhibitors- medication administration is within the scope of practice for an LPN. Assessment and teaching are within the scope of practice for the RN.

Which of the following is the best treatment for acute ischemic stroke? a. heparin b. LMWH c. Alteplase d. Eptifibatie e. Warfarin

C: Alteplase

The incidence of ischemic stroke in patients with TIAs and other risk factors is reduced with administration of a. furosemide (Lasix) b. lovastatin (Mevacor) c. daily low dose aspirin d. nimodipine (Nimotop)

C: Daily low dose aspirin- the administration of antiplatelet agents, such as aspirin, dipyridamole (Persantine), and ticlopdipine (Ticlid), reduces the incidence of stroke in those at risk. Anticoagulants are also used for prevention of embolic strokes but increase the risk for hemorrhage. Diuretics are not indicated for stroke prevention other than for their role in controlling BP, and antilipemic agents have bot been found to have a significant effect on stroke prevention. The calcium channel blocker nimodipine is used in patients with subarachnoid hemorrhage to decrease the effects of vasospasm and minimize tissue damage.

A patient with a stroke has a right sided hemiplegia. The nurse prepares family members to help control behavior changes seen with this type of stroke by teaching them to a. ignore undesirable behaviors manifested by the patient b. provide directions to the patient verbally in small steps c. distract the patient from inappropriate emotional responses d. supervise all activities before allowing the patient to pursue them independently

C: Distract the patient from inappropriate emotional responses- patients with left-sided brain damage from stroke often experience emotional lability, inappropriate emotional responses, mood swings, and uncontrolled tears or laughter disproportionate or out of context with the situation. The behavior is upsetting and embarrassing to both the patient and the family, and the patient should be distracted to minimize its presence. Patients with right-brain damage often have impulsive, rapid behavior that supervision and direction.

CN XII comes out of the temple and runs all the way down to the corner of the mouth. If there are problems with this nerve, what might we see?

Drooping of the corner of the mouth (Bell's Palsy)

A carotid endarterectomy is being considered as a treatment for a patient who has had several TIAs. The nurse explains to the patient that this surgery a. is used to restore blood to the brain following an obstruction of a cerebral artery b. involves intracranial surgery to join a superficial extracranial artery to an intracranial artery c. involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke d. is sued to open a stenosis in a carotid artery with a balloon and stent to restore cerebral circulation

C: Involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke- An endarterectomy is a removal of an atherosclerotic plaque, and plaque in the carotid artery may impair circulation enough to cause a stroke. A carotid endarterectomy is performed to prevent a cerebrovascular accident (CVA), as are most other surgical procedures. An extacranial-intracranial bypass involves cranial surgery to bypass a sclerotic intacranial artery. Percutaneous transluminal angioplasty uses a balloon to compress stenotic areas in the carotid and vertebrobasilar arteries and often includes inserting a stent to hold the artery open.

A patient with right hemisphere stroke has a nursing diagnosis of unilateral neglect related to sensory perceptual deficits. During the patient's rehabilitation, it is important for the nurse to a. avoid positioning the patient on the affected side b. place all objects for care on the patient's unaffected side c. teach the patient to care consciously for the affected side d. protect the affected side from injury with pillows and supports

C: Teach the patient to care consciously for the affected side- unilateral neglect, or neglect syndrome, occurs when the patient with a stroke is unaware of the affected side of the body, which puts the patient at risk for injury. During the acute phase, the affected side is cared for by the nurse with positioning and support, during rehabilitation the patient is taught to care consciously for and attend to the affected side of the body to protect it from injury. Patients may be positioned on the affected side for up to 30 minutes.

An appropriate food for a patient with a stroke who has mild dysphagia is a. fruit juices b. pureed meat c. scrambled eggs d. fortified milkshakes

C: scrambled eggs- soft foods that provide enough texture, flavor, and bulk to stimulate swallowing should be used for the patient with dysphasia. Thin liquids are difficult to swallow, and patients may not be able to control them in the mouth. Pureed foods are often too bland and to smooth, and milk products should be avoided because they tend to increase the viscosity of mucus and increase salivation.

A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved? CN X CN IX CN VII CN III

CN IX and CN VII

Orbital skull fracture

Causes periorbital ecchymoses

A lab result that may verify diagnosis of bacterial meningitis

Cloudy cerebrospinal fluid w/high protein and low glucose levels. R: A diagnosis of meningitis is made by testing cerebrospinal fluid obtained by lumbar puncture. In bacterial meningitis, findings usually include increased pressure, cloudy CSF, a high protein level, and a low glucose level.

Posterior fossa fracture

Cortical blindness or visual field defects

Successful achievement of patient outcomes for the patient with cranial surgery would be best indicated by the a. ability to return home in 6 days b. ability to meet all self-care needs c. acceptance of residual neurologic deficits d. absence of signs and symptoms of increased ICP

D. Absence of signs and symptoms of increased ICP- The primary goal after cranial surgery is prevention of increased ICP, and interventions to prevent ICP and infection postoperatively are nursing priorities. The residual deficits, rehabilitation potential, and ultimate function of the patient depend on the reason for surgery, the postoperative course, and the patient's general state of health

The nurse suspects the presence of an arterial epidural hematoma in the patient who experiences a. failure to regain consciousness following a head injury b. a rapid deterioration of neurologic function within 24 to 48 hours following a head injury c. nonspecific, nonlocalizing progression of alteration in LOC occurring over weeks or months d. unconsciousness at the time of a head injury with a brief period of consciousness followed by a decrease in LOC

D. An arterial epidural hematoma is the most acute neurologic emergency, and the typical symptoms include unconsciousness at the scene, with a brief lucid interval followed by a decrease in LOC. An acute subdural hematoma manifests signs within 48 hours of an injury; a chronic subdural hematoma develops over weeks or months

A patient is admitted to the hospital with possible bacterial meningitis. During the initial assessment, the nurse questions the patient about a recent history of a. mosquito or tick bites b. chickenpox or measles c. cold sores or fever blisters d. an upper respiratory infection

D. An upper respiratory infection- Meningitis is often a result of an upper respiratory infection or middle ear infection, where organisms gain entry to the CNS. Epidemic encephalitis is transmitted by ticks and mosquitoes, and nonepidemic encephalitis may occur as a complication of measles, chickenpox, or mumps. Encephalitis caused by the herpes simplex virus carries a high fatality rate

Metabolic and nutritional needs of the patient with increased ICP are best met with a. enteral feedings that are low in sodium b. the simple glucose available in D5W IV solutions c. a fluid restriction that promotes a moderate dehydration d. balanced, essential nutrition in a form that the patient can tolerate

D. Balanced, essential nutrition in a form that the patient can tolerate= A patient with increased ICP is in a hypermetabolic and hypercatabolic state and needs adequate glucose to maintain fuel for the brain and other nutrients to meet metabolic needs. Malnutrition promotes cerebral edema, and if a patient cannot take oral nutrition, other means of providing nutrition should be used, such as tube feedings or parenteral nutrition. Glucose alone is not adequate to meet nutritional requirements, and 5% dextrose solutions may increase cerebral edema by lowering serum osmolarity. Patients should remain in a normovolemic fluid state with close monitoring of clinical factors such as urine output, fluid intake, serum and urine osmolality, serum electrolytes, and insensible losses.

When assessing the body function of a patient with increased ICP, the nurse should initially assess a. corneal reflex testing b. extremity strength testing c. pupillary reaction to light d. circulatory and respiratory status

D. Circulatory and respiratory status- Of the body functions that should be assessed in an unconscious patient, cardiopulmonary status is the most vital function and gives priorities to the ABCs (airway, breathing, and circulation)

Skull radiographs and a computed tomography (CT) scan provide evidence of a depressed parietal fracture with a subdural hematoma in a patient admitted to the emergency department following an automobile accident. In planning care for the patient, the nurse anticipates that a. the patient will receive life-support measures until the condition stabilizes b. immediate burr holes will be made to rapidly decompress the intracranial activity c. the patient will be treated conservatively with close monitoring for changes in neurologic condition d. the patient will be taken to surgery for a craniotomy for evacuation of blood and decompression of the cranium

D. When there is a depressed fracture and fractures with loose fragments, a craniotomy is indicated to elevate the depressed bone and remove free fragments. A craniotomy is also indicated in cases of acute subdural and epidural hematomas to remove the blood and control the bleeding. Burr holes may be used in an extreme emergency for rapid decompression, but with a depressed fracture, surgery would be the treatment of choice

A nursing intervention is indicated for the patient with hemiplegia is a. the use of a footboard to prevent plantar flexion b. immobilization of the affected arm against the chest with a sling c. positioning the patient in bed with each joint lower than the joint proximal to it d. having the patient perform passive ROM of the affected limb with the unaffected limb

D: Having the patient perform passive ROM of the affected limb with the unaffected limb- active ROM should be initiated on the unaffected side as soon as possible, and passive ROM of the affected side should be started on the first day. Having the patient actively exercise the unaffected side provides the patient with active and passive ROM as needed. Use of footboards is controversial because they stimulate plantar flexion. The unaffected arm should be supported, but immobilization may precipitate a painful shoulder-hand syndrome. The patient should be positioned with each joint higher than the joint proximal to it to prevent dependent edema.

The nurse can assist the patient and the family in coping with the long term effects of a stroke by a. informing family members that the patient will need assistance with almost all ADLs b. explaining that the patient's prestroke behavior will return as improvement progresses c. encouraging the patient and family members to seek assistance from family therapy or stroke support groups d. helping the patient and family understand the significance of residual stroke damage to promote problem solving and planning

D: Helping the patient and family understand the significance of residual stroke damage to promote problem solving and planning- the patient and family need accurate and complete information about the effects of the stroke to problem solve and make plans for chronic care of the patient. It is uncommon for patients with major strokes to return completely to pre stroke function, behaviors, and role, and both the patient and family will mourn these losses. The patient's specific needs for care must be identified, and rehabilitation efforts should be continued at home. Family therapy and support groups may be helpful for some patients and families.

The priority intervention in the emergency department for the patient with a stroke is a. intravenous fluid replacement b. administration of osmotic diuretics to reduce cerebral edema c. initiation of hypothermia to decrease the oxygen needs of the brain d. maintenance of respiratory function with a patent airway and oxygen administration

D: Maintenance of respiratory function with a patent airway and oxygen administration- the first priority in acute management of the patient with a stroke is preservation of life. Because the patient with a stroke may be unconscious or have a reduced gag reflex, it is most important to maintain a patent airway for the patient and provide oxygen if respiratory effort is impaired. IV fluid replacement, treatment with osmotic diuretics, and perhaps hypothermia may be used for further treatment.

Craniectomy

Excision of cranial bone without replacementq

A patient's wife asks the nurse why her husband did not receive the clot busting medication (tPA) she has been reading about. Her husband is diagnosed with a hemorrhagic stroke. What should the nurse respond? a. He didn't arrive within the time frame for that therapy b. Not every is eligible for this drug. Has he had surgery lately? c. You should discuss the treatment of your husband with your doctor d. The medication you are talking about dissolves clots and could cause more bleeding in your husband's head

D: The medication you are talking about dissolves clots and could cause more bleeding in your husband's head- tPA dissolves clots and increases the risk for bleeding. It is not used with hemorrhagic strokes. If the patient had a thrombotic/embolic stroke the time frame would be important as well as a history of surgery. The nurse should answer the question as accurately as possible and then encourage the individual to talk with the primary care physician if he or she has further questions.

Compound skull fracture

Depressed skull fracture and scalp lacerations with communication to intracranial cavity

A patient tells the nurse about using acetaminophen (Tylenol) several times every day for recurrent bilateral headaches. Which action will the nurse plan to take first?

Discuss the need to stop taking the acetaminophen. Rational: The headache description suggests that the patient is experiencing medication overuse headache.

hemiplegia

total paralysis of the arm, leg, and trunk on the same side of the body

Which action will the nurse take when evaluating a patient who is taking phenytoin (Dilantin) for adverse effects of the medication?

Inspect the oral mucosa. Rational: Phenytoin can cause gingival hyperplasia.

Most common artery involved

Internal Carotid Artery

Depressed skull fracture

Inward indentation of the skull with possible pressure on brain

Characteristics of encephalitis

Is an inflammation of the brain, may be transmitted by insect vectors, almost always has a viral cause, cereral edema is a major problem

A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions?

Laceration of the middle meningeal artery

Manifestations of right brain damage

Left homonymous hemianopsia, agnosia, quick impulsive behavior, neglect of the left side of the body

Treat for hemorrhagic stroke

Lower BP

CPP = MAP - ICP Calculate the CPP of a patient whose BP is 106/52 and ICP is 14 mmg Hg.

MAP = DBP + 1/3 (SBP - DBP)= 52 + 18 = 70 CPP = 70 - 14 = 56

Parietal skull fracture

May cause deafness, loss of taste, and CSF otorrhea

Basilar skull fracture

May involve dural tear with CSF otorrhea, vertigo, and Battles' sign

Characteristics of meningitis

Most frequently caused by bacteria, CSF production increased, Involves an inflammation of pia matter and arachnoid layer, has a rapid onset of symptoms, exudate may impair normal CSF flow and absorption

Comminuted skull fracture

Multiple linear fracture with fragmentation of the bone

1st medical procedure planned when you suspect a stroke

Non-contrast CT scan (determines hemorrhagic vs ischemic)

A patient has a tonic-clonic seizure while the nurse is in the patient's room. Which action should the nurse take?

Note time, observe and record the details of the seizure and postictal state. Rational: 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 a seizure are contraindicated.

When the nurse is assessing a patient with myasthenia gravis, which action will be most important to take?

Observe respiratory effort. Rational: Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function.

Characteristics of embolic stroke

Onset unrelated to activity, quick onset and resolution, associated with endocardial disorders

Burr holes

Opening into cranium with a drill to remove blood and fluid

Craniotomy

Opening into cranium with removal of bone flap to open dura

Shunt procedures

Placement of tubes to redirect CSF from one area to another

Frontal lobe skull fracture

Possible pneumocranium, CSF rhinorrhea

The Glasgow Coma scale is a 15 point scale that is used to measure neurological status, what does it measure responses to?

Eyes Open, Verbal Response, Motor Response

Linear skull fracture

Fractured skull without alteration in fragment

Characteristics of subarachnoid hemorrhage

High initial mortality, symptoms of meningeal irritation, caused by rupture of intracranial aneurysm, associated with sudden, severe headache

A patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching about mediaction administration?

How to draw up and administer injections of the medication Rational: Copaxone is administered by self-injection.

Cranioplasty

Replacement of part of the cranium with an artificial plate

What is the PPE transmission precaution for meningococcal meningitis?

Respiratory Isolation = Droplet precautions: Gloves, Gown, Mask

Characteristics of intracerebral hemorrhage

Rupture of atherosclerotic vessels, carries the poorest prognosis, creates mass that compresses the brain

A patient with Parkinson's disease has a nursing diagnosis of impaired physical mobility related to bradykinesia. Which action will the nurse include in the plan of care?

Suggest that the patient rock from side to side to initiate leg movement. Rational: Rocking the body from side to side stimulates balance and improves mobility. The patient will be encouraged to continue exercising because this will maintain functional abilities. Maintaining a wide base of support will help with balance. The patient should lift the feet and avoid a shuffling gait.

A patient with multiple sclerosis (MS) has urinary retention caused by a flaccid bladder. Which action will the nurse plan to take?

Teach the patient how to use the Credé method. Rational: The Credé method can be used to improve bladder emptying.

Cerebral concussion

Temporary, minor injury with transient reduction in neural activity and LOC

Test used to diagnose MG and to differentiate between myasthenic crisis and cholinergic crisis.

Tensilon Test

A patient has a new prescription for bromocriptine (Parlodel) to control symptoms of Parkinson's disease. Which information obtained by the nurse may indicate a need for a decrease in the dose?

The patient's blood pressure is 90/46 mm Hg. Rational: Hypotension is an adverse effect of bromocriptine, and the nurse should check with the health care provider before giving the medication.

Sterotactic surgery

Three dimensional targeting of cranial tissue

When is a lumbar puncture indicated?

To determine if there is an infection in the spine (CNS) such as meningitis.

Characteristics of a thrombotic stroke

Type most often signaled by TIAs, commonly occurs during or after sleep, strong association with hypertension

When is a lumbar puncture not indicated?

When the patient has a possible brain tumor.

Brown-Séquard syndrome, also known as Brown-Séquard's hemiplegia and Brown-Séquard's paralysis

a loss of sensation and motor function (paralysis and ataxia) that is caused by the lateral hemisection (cutting) of the spinal cord

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 assess the patient for ...?

a possible head injury. Rational: 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.

most important method of diagnosing functional headaches is

a thorough history, assessing specific details of the headache

Which of the following interventions should the nurse perform in the acute care of a patient with autonomic dysreflexia? a. Urinary catheterization b. Administration of benzodiazepines c. Suctioning of the patient's upper airway d. Placement of patient in Trendelenburg position

a. Urinary catheterization

The Tonic phase of a seizure consists of? a. A state of muscle contraction in which there is excessive muscle tone b. A state of alternating contraction and relaxation of muscles c. The period immediately following the cessation of seizure activity d. None of the above choices

a. A state of muscle contraction in which there is excessive muscle tone

When assessing a patient with a traumatic brain injury, the nurse notes uncoordinated movement of the extremities. The nurse would document this as a. Ataxia. b. Apraxia. c. Anisocoria. d. Anosognosia.

a. Ataxia

__________ immediately precedes the onset of a seizure. a. Aura b. axonal force c. Prodroma d. All the above can occur

a. Aura

Which of the following clinical manifestations would the nurse interpret as representing neurogenic shock in a patient with acute spinal cord injury? a. Bradycardia b. Hypertension c. Neurogenic spasticity d. Bounding pedal pulses

a. Bradycardia, neurogenic shock is due to the loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia

Musculoskeletal assessment is an important component of care for patients on long-term therapy of a. Corticosteroids. b. Antiplatelet aggregators. c. b-Adrenergic blockers. d. Calcium-channel blockers.

a. Corticosteroids

You are assessing the mental status of a patient with Alzheimer disease. The type of memory loss you would expect to see is... a. Episodic b. Long term c. Short term d. Retrograde

a. Episodic

The nurse has given the client with Bell's Palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs additional information if the client states that he or she will: a. Expose the face to cold and drafts b. Massage the face with a gently upward motion c. Perform facial exercises d. Wrinkle the forehead, blow out the cheeks, and whistle.

a. Expose the face to cold and drafts

The end of spinal shock occurs when the spinal reflexes return within a few days to weeks, and all of the following characteristics occur when spinal shock resolves EXCEPT... a. Flaccid paralysis b. Spasticity c. Increased muscle tone d. Hyperactive reflexes

a. Flaccid paralysis

The client with a stroke has residual dysphagia. When the diet order is initiated, the nurse avoids doing which of the following? a. Giving the client thin liquids b. Thickening liquids to the consistency of oatmeal c. Placing food on the unaffected side of the mouth d. Allowing plenty of time for chewing and swallowing

a. Giving the client thin liquids Rationale: before the client with dyshagia is started on a diet, the gag and swallow reflexes must have returned. The client is assisted with meals as needed and is given ample time to chew and swallow. Food is placed on the unaffected side of the mouth. Liquids are thickened to avoid aspiration.

Which of the following signs and symptoms in a patient with a T4 spinal cord injury should alert the nurse to the possibility of autonomic dysreflexia? a. Headache and rising blood pressure b. Irregular respirations and shortness of breath c. Decreased level of consciousness or hallucinations d. Abdominal distention and absence of bowel sounds

a. Headache and rising blood pressure

The nurse is developing a care plan for a client with hepatic encephalopathy. Which of the following should the nurse include? a. Administering a lactulose enema as ordered. b. Encouraging a protein rich diet c. Adminis.tering sedatives as needed. d. Encouraging ambulation at least 4 times a day.

a. Hepatic encephalopathy is a degenerative disease of the brain that is a complication of cirrhosis. Rationale: For the client with hepatic encephalopathy, the nurse may administer the laxative lactulose to reduce ammonia levels in the colon. Protein intake is usually restricted to reduce serum ammonia levels until the client's mental status begins to improve. Sedatives are avoided because they can cause respiratory or circulatory failure. Bed rest is encouraged because physical activity increases metabolism, leading to an increased production of ammonia

A patient who has a neurologic disease that affects the pyramidal tract is likely to manifest which of the following signs? a. Impaired muscle movement b. Decreased deep tendon reflexes c. Decreased level of consciousness d. Impaired sensation of touch, pain, and temperature

a. Impaired muscle movement. Among the most important descending tracts are the corticobulbar and corticospinal tracts, collectively termed the pyramidal tract. These tracts carry volitional (voluntary) impulses from the cortex to the cranial and peripheral nerves.

Identify two ways the following three-volume components of intracranial pressure (ICP) can be changed to adapt to small increases in intracranial pressure. a. Cerebrospinal fluid (CSF) b. Brain Tissue c. Blood tissue

a. Increased absorption, decreased production, displacement into spinal canal b. herniation, lesion, edema, collapse of veins and dural sinuses, increased venous outflow and decreased blood flow c. distention of dura, slight compression of tissue

Which condition is exemplified by a patient who cannot communicate either through speech or through body movement, but is fully conscious, with intact cognitive function? a. Locked-in syndrome b. Akinetic mutism c. Minimally conscious state d. Vegetative state

a. Locked-in syndrome

Computed tomography of a 68-year-old male patient's head reveals that he has experienced a hemorrhagic stroke. Which of the following is a nursing priority intervention in the emergency department? a. Maintenance of the patient's airway b. Positioning to promote cerebral perfusion c. Control of fluid and electrolyte imbalances d. Administration of tissue plasminogen activator (tPA)

a. Maintenance of the patient's airway

Which of the following nursing actions should be implemented in the care of a patient who is experiencing increased intracranial pressure (ICP)? a. Monitor fluid and electrolyte status astutely. b. Position the patient in a high Fowler's position. c. Administer vasoconstrictors to maintain cerebral perfusion. d. Maintain physical restraints to prevent episodes of agitation.

a. Monitor fluid and electrolyte status astutely.

Which of following is a commonly occurring degenerative disorder of the basal ganglia involving the dopaminergic nigrostriatal pathway? a. Parkinson disease b. Huntington disease c. Hydrocephalus d. Paralysis

a. Parkinson disease

Nursing Process: Planning NCLEX: Physiological Integrity The nurse notes in the patient's medical history that the patient has a positive Romberg test. Which nursing diagnosis is appropriate? a. Risk for falls related to dizziness or weakness b. Disturbed tactile sensory perception related to spinal cord damage c. Ineffective thermoregulation related to decreased vasomotor response d. Acute pain related to hyperreflexia and spasm

a. Risk for falls related to dizziness or weakness Rationale: A positive Romberg test indicates that the patient has difficulty maintaining balance with the eyes closed. The Romberg does not test for tactile perception, thermoregulation, or hyperreflexia.

Magnetic resonance imaging (MRI) has revealed the presence of a brain tumor in a patient. The nurse would recognize the patient's likely need for which of the following treatment modalities? a. Surgery b. Chemotherapy c. Radiation therapy d. Pharmacologic treatment

a. Surgery

A patient is scheduled for a myelogram to confirm the presence of a herniated intervertebral disk. Which information obtained when admitting the patient is most important for the nurse to communicate to the health care provider before the procedure? a. The patient has an allergy to shellfish. b. The patient has back pain when lying flat for long periods. c. The patient had 4 ounces of apple juice 4 hours earlier. d. The patient is anxious about the test.

a. The patient has an allergy to shellfish. Rationale: Iodine containing contrast medium is injected into the subarachnoid space during a myelogram. The health care provider may need to modify the post-myelogram orders to prevent back pain, but this can be done after the procedure. Clear liquids are usually considered safe up to 4 hours before a diagnostic or surgical procedure. The patient's anxiety should be addressed, but this is not as important as the iodine allergy.

Which of the following measures should the nurse prioritize when providing care for a patient with a diagnosis of multiple sclerosis (MS)? a. Vigilant infection control and adherence to standard precautions b. Careful monitoring of neurologic vital signs and frequent reorientation c. Maintenance of a calorie count and hourly assessment of intake and output d. Assessment of blood pressure and monitoring for signs of orthostatic hypotension

a. Vigilant infection control and adherence to standard precautions. Infection control is a priority in the care of patients with MS, since infection is the most common precipitator of an exacerbation of the disease.

The nurse is caring for a patient admitted for evaluation and surgical removal of a brain tumor. The nurse will plan interventions for this patient based on knowledge that brain tumors can lead to which of the following complications (select all that apply)? a. Vision loss b. Cerebral edema c. Pituitary dysfunction d. Parathyroid dysfunction e. Focal neurologic deficits

a. Vision loss b. Cerebral edema c. Pituitary dysfunction e. Focal neurologic deficits

For a 65 year old woman who has lived with a T1 spinal cord injury for 20 years, which of the following health teaching instructions should the nurse emphasize? a. a mammogram needed every year b. bladder function tends to improve with age c. heart disease is not common in persons with spinal cord injury d. as a person ages the need to change body position is less important

a. a mammogram needed every year

A 50 year old man complains of recurring headaches. He describes these as sharp, stabbing, and located around his left eye. He also reports that his eye seems to swell and get teary when these headaches occur. Based on this history you suspect that he has a. cluster headaches b. tension headaches c. migraine headaches d. medication overuse headaches

a. cluster headaches

Social effects of a chronic neurologic disease include (select all that apply) a. divorce b. job loss c. depression d. role changes e. loss of self esteem

a. divorce b. job loss c. depression d. role changes e. loss of self esteem

In a patient who has a corticospinal tract lesion, the nurse should assess for a. extremity movement and strength. b. cranial nerve function. c. peripheral sensitivity to pain. d. level of consciousness (LOC).

a. extremity movement and strength. Rationale: The corticospinal tract carries impulses from the cortex to the peripheral nerves that control voluntary muscle movement. Cranial nerve function is affected by damage to the corticobulbar tract. Peripheral pain impulses are carried to the higher levels of the CNS by the spinothalamic tracts. LOC is not affected by the ascending or descending tracts.

A patient is suspected of having a cranial tumor. The signs and symptoms include memory deficits, visual disturbances, weakness of right upper and lower extremities, and personality changes. The nurse recognizes that the tumor is most likely located in the a. frontal lobe b. parietal lobe c. occipital lobe d. temporal lobe

a. frontal lobe

During assessment of the patient with trigeminal neuralgia, the nurse should (select all that apply) a. inspect all aspects of the mouth and teeth b. assess the gag reflex and respiratory rate and depth c. lightly palpate the affected side of the face for edema d. test for temperature and sensation perception n the face e. ask the patient to describe factors that initiate an episode

a. inspect all aspects of the mouth and teeth d. test for temperature and sensation perception n the face e. ask the patient to describe factors that initiate an episode

A patient suffering from an uncal herniation experiences ________ hemiplegia secondary to contralateral corticospinal tract compression. a. ipsilateral b. contralateral c. bilateral d. no

a. ipsilateral

A patient's eyes jerk while the patient looks to the left. You will record this finding as a. nystagmus b. CN VI palsy c. oculocephalia d. ophthalmic dyskinesia

a. nystagmus

During admission of a patient with a severe head injury to the emergency department, the nurse places the highest priority on assessment for a. patency of airway b. presence of a neck injury c. neurologic status with the glasgow coma scale d. cerebrospinal fluid leakage from the ears or nose

a. patency of airway

Which of the following is FALSE regarding status epilepticus? a. the patient is NO longer in a postictal state when the next seizure begins b. most often due to a abrupt discontinuation of antiseizure medications Incorrect c. IS a medical emergency d. continuous seizure >5 minutes or single seizure >30 minutes

a. the patient is NO longer in a postictal state when the next seizure begins

The nurse is called to the patient's room by the patient's spouse when the patient experiences a seizure. Upon finding the patient in a clonic reaction, the nurse should: a.Turn the patient to the side. b.Start oxygen by mask at 6 L/min. c.Restrain the patient's arms and legs to prevent injury. d.Record the time sequence of the patient's movements and responses as they occur.

a.Turn the patient to the side. During the seizure, the nurse should maintain a patent airway, protect the patient's head, turn the patient to the side, loosen constrictive clothing, and ease the patient to the floor, if seated. The patient should not be restrained, and no objects should be placed in the mouth. After the seizure, the patient may require repositioning to open and maintain the airway, suctioning, and oxygen. When a seizure occurs, the nurse should carefully observe and record details of the event because diagnosis and subsequent treatment often rest solely on the seizure description.

A hospitalized patient complains of a moderate bilateral headache that radiates from the base of the skull. Which PRN medication should the nurse administer initially?

acetaminophen (Tylenol) Rational: The patient's symptoms are consistent with a tension headache, and initial therapy usually involves a nonopioid analgesic such as acetaminophen, sometimes combined with a sedative or muscle relaxant.

A patient is seen in the health clinic with symptoms of a stooped posture, shuffling gait, and pill rolling-type tremor. The nurse will anticipate teaching the patient about

antiparkinsonian drugs. Rational: The diagnosis of Parkinson's is made when two of the three characteristic signs of tremor, rigidity, and bradykinesia are present. The confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered. This patient has symptoms of tremor and bradykinesia; the next anticipated step will be treatment with medications.

When obtaining a health history and physical assessment for a patient with possible multiple sclerosis (MS), the nurse should inquire about

any urinary tract problems. Rational: Urinary tract problems with incontinence or retention are common symptoms of MS.

What is the antidote for a cholenergic medication?

atropine

A nursing student is caring for a client with a stroke who is experiencing unilateral neglect. The nurse would intervene if the student plans to use which of the following strategies to help the client adapt to this deficit? a. Tells the client to scan the environment b. Approaches the client from the unaffected side c. Places the bedside articles on the affected side d. Moves the commode and chair to the affected side

b- Approaches the client from the unaffected side. Rationale: The nurse teaches the client to scan the environment to become aware of that half of the body and approaches the client form the affected side to increase awareness further.

When interviewing an acutely confused patient with a head injury, which of these questions will provide the most useful information? a. "Have you ever been hospitalized for a neurologic problem?" b. "Do you have any pain at the present time?" c. "What have you had to eat in the last 24 hours?" d. "Can you describe you usual pattern for coping with injury?"

b. "Do you have any pain at the present time?" Rationale: The acutely confused patient will be able to state whether there is pain currently. The patient may not be able to provide accurate information about history of hospitalization, 24-hour dietary recall, or usual coping patterns.

A female patient has left-sided hemiplegia following an ischemic stroke that she experienced 2 weeks earlier. How should the nurse best promote the health of the patient's integumentary system? a. Position the patient on her weak side the majority of the time. b. Alternate the patient's positioning between supine and side-lying. c. Avoid the use of pillows in order to promote independence in positioning. d. Establish a schedule for the massage of areas where skin breakdown emerges.

b. Alternate the patient's positioning between supine and side-lying.

How should the nurse most accurately assess the position sense of a patient with a recent traumatic brain injury? a. Ask the patient to close his or her eyes and slowly bring the tips of the index fingers together. b. Ask the patient to maintain balance while standing with his or her feet together and eyes closed. c. Ask the patient to close his or her eyes and identify the presence of a common object on the forearm. d. Place the two points of a calibrated compass on the tips of the fingers and toes and ask the patient to discriminate the points.

b. Ask the patient to maintain balance while standing with his or her feet together and eyes closed.

When assessing the accessory nerve, the nurse would a. Assess the gag reflex by stroking the posterior pharynx. b. Ask the patient to shrug the shoulders against resistance. c. Ask the patient to push the tongue to either side against resistance. d. Have the patient say "ah" while visualizing elevation of soft palate.

b. Ask the patient to shrug the shoulders against resistance.

Brief palpable jerks accompanied by tremor represent what type of rigidity in relation to Parkinson Disease? a. Parkinsonian rigidity b. Cogwheel rigidity c. Plastic rigidity

b. Cogwheel rigidity

The nurse is providing care for a patient admitted to the hospital with a head injury and who requires regular neurologic vital signs. Which of the following assessments will be components of the patient's score on the Glasgow Coma Scale (GCS) (select all that apply)? a. Judgment b. Eye opening c. Abstract reasoning d. Best verbal response e. Best motor response f. Cranial nerve function

b. Eye opening d. Best verbal response e. Best motor response

The nurse would expect to find which of the following clinical manifestations in a patient admitted with a left-brain stroke? a. Impulsivity b. Impaired speech c. Left-side neglect d. Short attention span

b. Impaired speech Clinical manifestations of left-sided brain damage include right hemiplegia, impaired speech/language aphasias, impaired right/left discrimination, and slow and cautious performance. The other options are all manifestations of right-sided brain damage.

The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain? a. Sternal rub b. Nail bed pressure c. Pressure on the orbital rim d. Squeezing of the sternocleidomastoid muscle

b. Nail bed pressure Rationale: Motor testing in the unconscious client can be done only by testing response painful stimuli. Nail bed pressure tests a basic peripheral pressure on the orbital rim, or squeezing the clavical or sternoleidomastoid muscle.

The patient has been receiving scheduled doses of phenytoin (Dilantin) and begins to experience diplopia. The nurse immediately assesses the patient for which of the following? a. An aura b. Nystagmus or confusion c. Abdominal pain or cramping d. Irregular pulse or palpitations

b. Nystagmus or confusion

The following orders are received for a patient who is unconscious after a head injury caused by an automobile accident. Which one should the nurse question? a. Perform neurologic checks every 15 minutes. b. Prepare the patient for lumbar puncture. c. Obtain x-rays of the skull and spine. d. Do computed tomography (CT) scan with and without contrast.

b. Prepare the patient for lumbar puncture. Rationale: After a head injury, the patient may be experiencing intracranial bleeding and increased intracranial pressure, which could lead to herniation of the brain with lumbar puncture. The other orders are appropriate.

The nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. Which of the following measures would the nurse avoid in planning for the client's safety? a. Padding the side rails of the bed b. Putting a padded tongue blade at the head of the bed c. Placing an airway, oxygen, and suction equipment at the bedside d. Having intravenous equipment ready for insertion of an intravenous catheter

b. Putting a padded tongue blade at the head of the bed. Seizure precautions may vary from agency to agency but the generally have some common features. Usually an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if anticonvulsant medications must be administered. The use of padded tongue blades is highly controversial, and they should not be kept at bedside. Forcing a tongue blade into the mouth during a seizure more likely will harm the client who bites down during seizure activity. Risks include blocking the airway from improper placement, chipping the client's teeth.

The nurse is caring for the client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated? a. Loosening restrictive clothing b. Restraining the client's limbs c. Removing the pillow and raising padded side rails d. Positioning the client to the side, if possible, with the head flexed forward

b. Restraining the client's limbs Rationale: Nursing Actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising the 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. Other aspects of care are as described for the client who is in bed.

The client with Parkinson's disease has a nursing diagnosis of falls, Risk for related to an abnormal gait documented in the nursing care plan. The nurse assesses the client, expecting to observe which type of gait? a. Unsteady and staggering b. Shuffling and propulsive c. Broad-based and waddling d. Accelerating with walking on the toes

b. Shuffling and propulsive

The nurse is caring for a patient admitted with a spinal cord injury following a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following? a. Central cord syndrome b. Spinal shock syndrome c. Anterior cord syndrome d. Brown-Séquard syndrome

b. Spinal shock syndrome

The nurse is assigned to care for a client with complete right-sided hemiparesis, the nurse plans care knowing that in this condition: a. The client has complete bilateral paralysis of the arms and legs b. The client has weakness on the right side of the body, including the face and tongue c. The client has lost the ability to move the right arm but is able to walk independently d. The client has lost the ability to feed and bathe self without assistance.

b. The client has weakness on the right side of the body, including the face and tongue Rationale: Hemiparesis is a weakness of one side of the body that may occur after a stroke. Complete hemiparesis is weakness of the face and tongue, arm and leg on one side. Complete bilateral paralysis does not occur in the condition. The client with right- sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing and ambulating.

Which of the following characteristics of a patient's recent seizure is congruent with a partial seizure? a. The patient lost consciousness during the seizure. b. The seizure involved lip smacking and repetitive movements. c. The patient fell to the ground and became stiff for 20 seconds. d. The etiology of the seizure involved both sides of the patient's brain.

b. The seizure involved lip smacking and repetitive movements.

Vasogenic cerebral edema increases intracranial pressure by a. shifting fluid in the gray matter b. altering the endothelial lining of cerebral capillaries c. leaking molecules from the intracellular fluid to the capillaries

b. altering the endothelial lining of cerebral capillaries

The most common early symptom of a spinal cord tumor is a. urinary incontinence b. back pain that worsens with activity c. paralysis below the level of involvement d. impaired sensation of pain, temperature, light touch

b. back pain that worsens with activity

A nursing measure that is indicated to reduce the potential for seizures and increased intracranial pressure in the patient with bacterial meningitis is a. administering codeine for relief of head and neck pain b. controlling fever with prescribed drugs and cooling techniques c. keeping the room darkened and quite to minimize environmental stimulation d. maintaining the patient on strict bed rest with the head of the bed slightly elevated

b. controlling fever with prescribed drugs and cooling techniques

The nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to a. keep the head of the bed flat b. elevate the head of the bed to 30 degrees c. maintain patient of the left side with the head supported on a pillow d. use a continuous rotation bed to continuously change patient position

b. elevate the head of the bed to 30 degrees

Goals of rehabilitation for the patient with an injury at the C6 level include (select all that apply) a. stand erect with leg brace b. feed self with hand devices c. drive an electric wheelchair d. assist with transfer activities e. drive adapted van from wheelchair

b. feed self with hand devices c. drive an electric wheelchair d. assist with transfer activities e. drive adapted van from wheelchair

A patient has a lesion that affects lower motor neurons. During assessment of the patient's lower extremities, the nurse expects to find a. spasticity. b. flaccidity. c. hyperactive reflexes. d. loss of sensation.

b. flaccidity. Rationale: Because the cell bodies of lower motor neurons are located in the spinal cord, damage to the neuron will decrease motor activity of the affected muscles. Spasticity and hyperactive reflexes are caused by upper motor neuron damage. Sensation is not impacted by motor neuron lesions.

To assess the functioning of the optic nerve (CN II), the nurse should a. apply a cotton wisp strand to the cornea. b. have the patient read a magazine. c. shine a bright light into the patient's pupil. d. check for equal opening of the eyelids.

b. have the patient read a magazine. Rationale: The optic nerve is responsible for visual fields and visual acuity. Trigeminal and facial nerve functions are tested by assessing the corneal reflex. Assessment of pupil response to light and ptosis are used to check function of the oculomotor nerve.

When caring for a patient with systemic sclerosis, the nurse knows it is important to instruct the patient related to (select all that apply) a. avoiding consumption of high purine foods b. strategies for good dental hygiene and mouth care c. protecting the extremities from hot and cold temperatures d. maintaining joint function and preserving muscle strength e. performing mouth excursion (yawning) exercises on a daily basis

b. strategies for good dental hygiene and mouth care c. protecting the extremities from hot and cold temperatures d. maintaining joint function and preserving muscle strength e. performing mouth excursion (yawning) exercises on a daily basis

When the nurse administers gabapentin (Neurontin), a drug that increases the level of gamma-aminobutyric acid (GABA) in the synapse, the effect the nurse would expect is a. widespread increases in nervous system activity. b. suppression of nervous system activity. c. increased patient alertness and arousal. d. excitation of the affected postsynaptic neurons.

b. suppression of nervous system activity. Rationale: GABA is a neurotransmitter that has inhibitory activity on action-potential generation and decreases nervous system activity. Because it has an inhibitory effect, the nurse will not expect increases in nervous system activity, increased alertness or arousal, or excitation of affected neurons.

One major goal of treatment for a patient with Huntington's Disease is a. disease cure b. symptomatic relief c. maintaining employment d. improving muscle strength

b. symptomatic relief

For a patient who is suspected of having a stroke, one of the most important pieces of information that the nurse can obtain is a. time of the patient's last meal b. time at which stroke symptoms first appeared c. patient's hypertension history and management d. family history of stroke and other cardiovascular diseases

b. time at which stroke symptoms first appeared

Neurologic testing of the patient by the nurse indicates impaired functioning of the left glossopharyngeal nerve (CN IX) and the vagus nerve (CN X). Based on these findings, the nurse plans to a. insert an oral airway. b. withhold oral fluid or foods. c. provide highly seasoned foods. d. apply artificial tears every hour.

b. withhold oral fluid or foods. Rationale: The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex; a patient with impaired function of these nerves is at risk for aspiration. An oral airway may be needed when a patient is unconscious and unable to maintain the airway, but it will not decrease aspiration risk. Taste and eye blink are controlled by the facial nerve.

An appropriate nursing diagnosis for a patient with advanced Parkinson's disease is a. Risk for injury related to limited vision. b. Risk for aspiration related to impaired swallowing. c. Urge incontinence related to effects of drug therapy. d. Ineffective breathing pattern related to diaphragm fatigue.

b.Risk for aspiration related to impaired swallowing. As swallowing becomes more difficult (dysphagia), malnutrition or aspiration may result.

The nurse has given suggestions to the client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs reinforcement of information if the client makes which of the following statements? a. "I will wash my face with cotton pads." b. "I'll have to start chewing on the unaffected side." c. "I'll try to eat my food either very warm or very cold." d. "I should rinse my mouth sometimes if toothbrushing is painful."

c. "I'll try to eat my food either very warm or very cold."

The nurse is evaluating the status of the client who had a craniotomy 3 days ago. The nurse would suspect that the client is developing meningitis as a complication of surgery if the client exhibits: a. A negative Kernig's sign b. Absence of nuchal rigidity c. A positive Brudzinski's sign d. A Glasgow Coma Scale score of 15

c. A positive Brudzinski's sign

Which of the following nursing diagnoses is likely to be a priority in the care of a patient with myasthenia gravis (MG)? a. Acute confusion b. Bowel incontinence c. Activity intolerance d. Disturbed sleep pattern

c. Activity intolerance, the primary feature of MG is fluctuating weakness of skeletal muscle.

The nurse is evaluation the respiratory outcomes for the client with Guillain-Barre syndrome. The nurse determines that which of the following is the least optimal outcome for the client? a. Spontaneous breathing b. Oxygen saturation of 98% c. Adventitious breath sounds d. Vital capacity within normal range

c. Adventitious breath sounds

Lower motor neuron syndromes originating in the anterior horn cells or the motor nuclei of the cranial nerves are called_________? a. Akinesia b. Distonia c. Amyotrophy d. Cogwheel Rigidity

c. Amyotrophy

A patient's sudden onset of hemiplegia has necessitated a computed tomography (CT) of her head. Which of the following assessments should the nurse complete prior to this diagnostic study? a. Assess the patient's immunization history. b. Screen the patient for any metal parts or a pacemaker. c. Assess the patient for allergies to shellfish, iodine, or dyes. d. Assess the patient's need for tranquilizers or antiseizure medications.

c. Assess the patient for allergies to shellfish, iodine, or dyes.

The factor related to cerebral blood flow that most often determines the extent of cerebral damage from a stroke is the a. amount of cardiac output b. oxygen content of the blood c. degree of collateral circulation d. level of carbon dioxide in the blood

c. degree of collateral circulation

You are working in the emergency department when a college freshman is brought in by his roommate. The freshman has a severe headache, stiff neck, subjective fever and his roommate had to pull over en route to the hospital to let the patient vomit. The lights of the ER triage area seem to bother his eyes. Which of the following is least helpful caring for this patient? a. Speaking to the client a slower rate b. Allowing plenty of time for the client to respond c. Completing the sentences that the client cannot finish d. Looking directly at the client during attempts at speech

c. Completing the sentences that the client cannot finish. Note that the question asks which is least helpful. These words indicate a negative event query and ask you to select an option that is and incorrect action. The patient should be placed on droplet precautions.

Which of the following is NOT a classic motor manifestation of Parkinson disease? a. Bradykinesia b. Tremor at rest c. Flexibility d. Hypoakinesia

c. Flexibility

Which diseased area of the brain will produce a deficit in of vigilance, detection and a working memory? a. Cortical Association Area b. Hippocampal Area c. Frontal Area d. Thalamus

c. Frontal Area

In promoting health maintenance for prevention of strokes, the nurse understands that the highest risk for the most common type of stroke is present in a. African Americans b. women who smoke c. individuals with hypertension and diabetes d. those who are obese with high dietary fat intake

c. Individuals with hypertension and diabetes- The highest risk factors for thrombotic stroke are hypertension and diabetes. African Americans have a higher risk for stroke than do white persons but probably because they have a greater incidence of hypertension. Factors such as obesity, diet high in saturated fats and cholesterol, cigarette smoking, and excessive alcohol use are also risk factors but carry less risk than hypertension.

Which motor neuron DIRECTLY influences the skeletal muscle? a. Upper motor neuron b. Astrocytes c. Lower motor neuron d. Third order neurons

c. Lower motor neuron

The client has experienced an episode of Myasthenic crisis. The nurse would assess whether the client has precipitating factors such as: a. Getting too little exercise b. Taking excess medication c. Omitting doses of medication d. Increasing intake of fatty foods

c. Omitting doses of medication

A male patient with a diagnosis of Parkinson's disease has been admitted recently to a long-term care facility. Which of the following actions should the health care team take in order to promote adequate nutrition for this patient? a. Provide multivitamins with each meal. b. Provide a diet that is low in complex carbohydrates and high in protein. c. Provide small, frequent meals throughout the day that are easy to chew and swallow. d. Provide the patient with a minced or pureed diet that is high in potassium and low in sodium.

c. Provide small, frequent meals throughout the day that are easy to chew and swallow.

The client with Guillian-Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which of the following strategies would the nurse incorporate in the plan of care to help the client cope with this illness? a. Giving client full control over care decisions and restricting visitors b. Providing positive feedback and encouraging active range of motion c. Providing information, giving positive feedback, and encouraging relaxation d. Providing intravenously administered sedatives, reducing distractions, and limiting visitors

c. Providing information, giving positive feedback, and encouraging relaxation

The nurse is providing care for a patient who has been diagnosed with Guillain-Barré syndrome. Which of the following assessments should the nurse prioritize? a. Pain assessment b. Glasgow Coma Scale c. Respiratory assessment d. Musculoskeletal assessment

c. Respiratory assessment

The nurse has given instructions to the client with Parkinson's disease about maintaining mobility. The nurse determines that the client understands the directions if the client sates that he or she will: a. Sit in soft, deep chairs b. Exercise in the evening to combat fatigue c. Rock back and forth to start movement with bradykinesia d. Buy clothes with many buttons to maintain finger dexterity

c. Rock back and forth to start movement with bradykinesia

Which of the following sensory-perceptual deficits is associated with left-brain stroke (right hemiplegia)? a. Overestimation of physical abilities b. Difficulty judging position and distance c. Slow and possibly fearful performance of tasks d. Impulsivity and impatience at performing tasks

c. Slow and possibly fearful performance of tasks, patients with a left-brain stroke (right hemiplegia) commonly are slower in organization and performance of tasks and may have a fearful, anxious response to a stroke.

The charge nurse is observing a new staff nurse who is assessing a patient with a possible spinal cord lesion for sensation. Which action indicates a need for further teaching about neurologic assessment? a. The new nurse tests for light touch before testing for pain. b. The new nurse has the patient close the eyes during testing. c. The new nurse tells the patient, "You may feel a pinprick now." d. The new nurse uses an irregular pattern to test for intact touch.

c. The new nurse tells the patient, "You may feel a pinprick now." Rationale: When performing a sensory assessment, the nurse should not provide verbal clues. The other actions by the new nurse are appropriate.

Which of the following nursing interventions is most appropriate when communicating with a patient suffering from aphasia poststroke? a. Present several thoughts at once so that the patient can connect the ideas. b. Ask open-ended questions to provide the patient the opportunity to speak. c. Use simple, short sentences accompanied by visual cues to enhance comprehension. d. Finish the patient's sentences so as to minimize frustration associated with slow speech.

c. Use simple, short sentences accompanied by visual cues to enhance comprehension.

Nursing management of a patient with a brain tumor includes (select all that apply) a. discussing with the patient methods to control inappropriate behavior b. using diversion techniques to keep the patient stimulated and motivated c. assisting and supporting the family in understanding any changes in behavior d. limiting self-care activities until the patient has regained maximum physical functioning e. plan for seizure precautions and teaching the patient and caregiver about antiseizure drugs

c. assisting and supporting the family in understanding any changes in behavior e. plan for seizure precautions and teaching the patient and caregiver about antiseizure drugs

The nurse is alerted to a possible acute subdural hematoma in the patient who a. has a linear skull fracture crossing a major artery b. has focal symptoms of brain damage with no recollection of a head injury c. develops decreased level of consciousness and a headache within 48 hours of a head injury d. has an immediate loss of consciousness with a brief lucid interval followed by decreasing level of consciousness

c. develops decreased level of consciousness and a headache within 48 hours of a head injury

When a 71-year-old patient who is being admitted to the hospital for minor surgery tells the nurse, "I haven't slept through the night for several years now," the nurse will plan to a. ask for an order for a mild nighttime sedative. b. teach the patient about electroencephalographic (EEG) testing. c. discuss sleep-pattern changes in older people. d. assess function of the cranial nerves.

c. discuss sleep-pattern changes in older people. Rationale: Normal changes in the reticular activating system and autonomic nervous system lead to more spontaneous awakening and less sleep time in older adults. For these normal changes, there is no indication for sedative use, EEG testing, or cranial nerve testing.

Which of the following are subdivisions of epilepsy? a. primary, secondary, idiopathic b. aura, prodroma, cortical c. idiopathic, symptomatic, cryptogenic d. metabolic disorders, genetic disorders, grand mal

c. idiopathic, symptomatic, cryptogenic

An obstruction of the anterior cerebral arteries will affect functions of a. visual imaging b. balance and coordination c. judgment, insight, and reasoning d. visual and auditory integration for language comprehension

c. judgment, insight, and reasoning

A patient with right sided hemiplegia and asphasia resulting from a stroke most likely has involvement of the a. brainstem b. vertebral artery c. left middle cerebral artery d. right middle cerebral artery

c. left middle cerebral artery

The nurse explains to the patient with a stroke who is scheduled for aniography that this test is used to determine a. presence of increased ICP b. site and size of the infarction c. patency of the cerebral blood vessels d. presence of blood in the cerebrospinal fluid

c. patency of the cerebral blood vessels

The nurse on the clinical unit is assigned to four patients. Which patient should she assess first? a. patient with a skull fracture whose nose is bleeding b. elderly patient with a stroke who is confused and whose daughter is present c. patient with meningitis who is suddenly agitated and reporting a headache of 10 on a zero to ten scale d. patient who had a craniotomy for a brain tumor who is now 3 days postoperative and has had continued emesis

c. patient with meningitis who is suddenly agitated and reporting a headache of 10 on a zero to ten scale

A patient experiencing TIAs is scheduled for a carotid endarterectomy. The nurse explains that this procedure is done to a. decreased cerebral edema b. reduce the brain damage that occurs during a stroke in evolution c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow d. provide a circulatory bypass around thrombotic plaques obstructing cranial circulation

c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow

When developing a plan of care for a patient with dysfunction of the cerebellum, the nurse will include interventions to a. improve short-term memory. b. stabilize mood. c. prevent falls. d. enhance the ability to swallow.

c. prevent falls. Rationale: Because functions of the cerebellum include coordination and balance, the patient with dysfunction is at risk for falls. The cerebellum does not impact on memory, mood, or swallowing ability.

A 65 year old woman was just diagnosed with Parkinson's disease. The priority nursing intervention is a. searching the internet for educational videos b. evaluating the home for environmental safety c. promoting physical exercise and a well balanced diet d. designing an exercise program to strengthen and stretch specific muscles

c. promoting physical exercise and a well balanced diet

A patient with a brainstem infarction is admitted to the nursing unit. The priority nursing assessment for the patient is a. level of consciousness. b. pupil reaction to light. c. respiratory rate and rhythm. d. reflex reaction time.

c. respiratory rate and rhythm. Rationale: Vital centers that control respiration are located in the medulla, and these are the priority assessments because changes in respiratory function may be life threatening. The other information will also be collected by the nurse, but it is not as urgent.

Propranolol (Inderal), an adrenergic blocking agent that inhibits sympathetic nervous system activity, is prescribed for a patient. The nurse monitors the patient for a. dry mouth. b. constipation. c. slowed pulse. d. urinary retention.

c. slowed pulse. Rationale: Inhibition of the fight or flight response leads to decreased heart rate. Dry mouth, constipation, and urinary retention are associated with PNS blockade.

A patient with a C7 spinal cord injury undergoing rehabilitation tells the nurse he must have the flu because he as had a bad headache and nausea. The initial action of the nurse is to a. call the physician b. check the patient's temperature c. take the patient's blood pressure d. elevate the head of the bed to 90 degrees

c. take the patient's blood pressure

When performing a focused assessment on a patient with a lesion of the left posterior temporal lobe, the nurse will assess for a. reasoning and problem-solving abilities. b. sensation on the left side of the body. c. understanding of written and oral language. d. voluntary movement on the right side.

c. understanding of written and oral language. Rationale: The posterior temporal lobe integrates the visual and auditory input for language comprehension. Reasoning and problem solving are functions of the anterior frontal lobe. Sensation on the left side of the body is located in the right postcentral gyrus. Voluntary movement on the right side is controlled in the left precentral gyrus.

A thrombus that develops in a cerebral artery does not always cause a loss of neurologic function because a. the body can dissolve the atherosclerotic plaques as they form b. some tissues of the brain do not require constant blood supply to prevent damage c. circulation through the circle of Willis may provide blood supply to the affected area of the brain d. neurologic deficits occur only when major arteries are occluded by thrombus formation around an atherosclerotic plaque

c: Circulation through the circle of Willis may provide blood supply to the affected area of the brain. The communication between cerebral arteries in the circle of Willis provides a collateral circulation, which may maintain circulation to an area of the brain if its original blood supply is obstructed. ALL areas of the brain require constant blood supply, and atherosclerotic plaques are not readily reversed. Neurologic deficits can result from ischemia cause by many factors.

The neurologic functions that are affected by a stroke are primarily related to a. the amount of tissue area involved b. the rapidity of onset of symptoms c. the brain area perfused by the affected artery d. the presence or absence of collateral circulation

c: The brain area perfused by the affected artery- clinical manifestation of altered neurologic function differ, depending primarily on the specific cerebral artery involved and the area of the brain that is perfused by the artery. The degree of impairment depends on rapidity of onset, the size of the lesion, and the presence of collateral circulation.

abrupt onset, 5-180 minutes, a ____ headache

cluster

alcohol, only dietary trigger in ____ headache

cluster

may be accompanied by unilateral ptosis or lacrimation, a ____ headache

cluster

recurs several times a day for several weeks, a ____ headache

cluster

severe, sharp penetrating head pain, a ____ headache

cluster

An increased lab level of ___ in a patient with MS indicates that the nurse should consult with the health care provider before giving the prescribed dose of fampridine (Ampyra).

creatinine Rational: Fampridine should not be given to patients with impaired renal function.

When obtaining a health history from a patient with a neurologic problem, which question by the nurse will elicit the most useful response from the patient? a. "Do you ever have any nausea or dizziness?" b. "Does the pain radiate from your back into your legs?" c. "Do you have any sensations of pins and needles in your feet?" d. "Can you describe the sensations you are having in your chest?"

d. "Can you describe the sensations you are having in your chest?" Rationale: The most useful and valid information is obtained through the use of open-ended questions that allow the patient to describe symptoms. The other questions encourage the use of "yes" or "no" responses and may cause the patient to omit useful additional data.

Which of the following statements are true about Hydrocephalus? a. Excess fluid built up within the cranial vault, subarachnoid space, or both b. Caused by interferences in CSF like decreased reabsorption, increased fluid production, and obstruction within the ventricular system c. Can be acute secondary to head injuries and may contribute to increased ICP (intracranial pressure) d. All of the above statements are true.

d. All of the above statements are true.

Concerning Dementia, mental abilities are impaired with a decrease in? a. Orienting b. Recent memory c. Remote memory d. All of the choices

d. All of the choices

Which of the following are risk factors for late onset sporadic Alzheimer disease? a. Increased BP and cholesterol b. ApoE gene c. Environmental triggers, toxins d. All of these are risk factors

d. All of these are risk factors

A patient admitted to the ICU for alcohol related accidental drowning after falling through the ice. His core temp is 32 C, does not respond to noxious stimuli, pupils are fixed and dilated. Which order would be inappropriate at this time? a. ETOH b. CBC, BMP, Mg, Phos, PT, PTT c. Neuro checks q 1 hr d. Brain death testing

d. Brain death testing

In teaching a patient with chronic fatigue syndrome (CFS) about this disorder, the nurse understands that a. palpating tender points is an indicator of CFS severity b. many symptoms are similar to fibromyalgia syndrome c. definitive treatment includes low dose hydrocortisone d. CFS is characterized by progressive memory impairment

d. CFS is characterized by progressive memory impairment.

Which is TRUE regarding Alzheimers Disease? a. The brain increases in volume b. The brain increase in weight c. Diagnosis is made upon angiogram d. Diagnosis is made by ruling out other causes of dementia by CT and blood tests

d. Diagnosis is made by ruling out other causes of dementia by CT and blood tests

Which of the following is NOT one of the three types of postural abnormalities that occur with Parkinson Disease? a. Disorders of postural fixation b. Disorders of equilibrium c. Disorders of righting d. Disorders of the diaphragm

d. Disorders of the diaphragm

The nurse is admitting a client with Guillian- Barre syndrome to the nursing unit. The client has an ascending paralysis to the level of the waist. Knowing the complication of the disorder, the nurse brings which of the following items into the client's room? a. Nebulizer and pulse oximeter b. Blood pressure and flashlight c. Flashlight and incentive spirometer d. Electrocardiographic monitoring electrodes and intubation tray

d. Electrocardiographic monitoring electrodes and intubation tray

All of the following describes decerebrate posturing, except: a. Opisthotonos (hyperextension of the vertebral column) b. Clenching of the teeth c. Extension, abduction, and hyperpronation of the arms d. Flexion of the lower extremities

d. Flexion of the lower extremities

When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is the highest priority? a. Risk for impairment of tissue integrity caused by paralysis b. Altered patterns of urinary elimination caused by quadriplegia c. Altered family and individual coping caused by the extent of trauma d. Ineffective airway clearance caused by high cervical spinal cord injury

d. Ineffective airway clearance caused by high cervical spinal cord injury

The nurse has instructed the family of a client with a stroke who has homonymous hemianopsia about measures to help the client overcome the deficit. The nurse determines that the family understands the measures to use if the state that they will: a. Place objects in the client's impaired field of vision b. Discourage the client from wearing eyeglasses. c. Approach the client from the impaired field of vision d. Remind the client to turn the head to scan the lost visual field.

d. Remind the client to turn the head to scan the lost visual field. Rationale: Homonymous hemianopsia is loss of half of the visual field. The client with Homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision: The nurse encourages the use of personal eye glasses, if they are available.

The nurse assesses a patient for signs of meningeal irritation and observes her for nuchal rigidity. Which of the following indicates the presence of this sign of meningeal irritation? a. Tonic spasms of the legs b. Curling in a fetal position c. Arching of the neck and back d. Resistance to flexion of the neck

d. Resistance to flexion of the neck

The client is admitted to the hospital with a diagnosis of Guillian-Barre syndrome. The nurse inquires during the nursing admission interview if the client has a history of: a. Seizures or trauma to the brain b. Meningitis during the last 5 years c. Back injury or trauma to the spinal cord d. Respiratory or gastrointestinal infection during the previous month

d. Respiratory or gastrointestinal infection during the previous month

The nurse is planning to test the function of the trigeminal nerve (cranial nerve V). The nurse would gather which of the following items to perform the test? a. Tuning fork and audiometer b. Snellen chart, ophthalmoscope c. Flashlight, pupil size chart or millimeter ruler d. Safety pin, hot and cold water in test tubes, cotton wisp

d. Safety pin, hot and cold water in test tubes, cotton wisp

All of the following are classified as posture disorders except: a. Dystonic posture b. Decerebrate posture c. Basal ganglion posture d. Spastic posture

d. Spastic posture

All of the following are manifestations of a supratentorial lesion compressing the diencephalon or brainstem except: a. Initial signs usually of focal cerebral dysfunction b. Signs of dysfunction progressing rostral to caudal c. Neurologic signs at any given time pointing to one anatomic area Incorrect d. Symmetric motor signs

d. Symmetric motor signs

The nurse is caring for a patient admitted 1 week ago with an acute spinal cord injury. Which of the following assessment findings would alert the nurse to the presence of autonomic dysreflexia? a. Tachycardia b. Hypotension c. Hot, dry skin d. Throbbing headache

d. Throbbing headache, autonomic dysreflexia is related to reflex stimulation of the sympathetic nervous system reflected by hypertension, bradycardia, throbbing headache, and diaphoresis.

Of the following patients, the nurse recognizes that the one with the highest risk for a stroke is a. an obese 45 year old native american b. a 35 year old asian american woman who smokes c. a 32 year old white woman taking oral contraceptives d. a 65 years old African American man with hypertension

d. a 65 years old African American man with hypertension

A patient with intracranial pressure monitoring has pressure of 12 mm Hg. The nurse understands that this pressure reflects a. a severe decrease in cerebral perfusion pressure b. an alteration in the production of cerebrospinal fluid c. the loss of autoregulatory control of intracranial pressure. d. a normal balance between brain tissue, blood, and cerebrospinal fluid

d. a normal balance between brain tissue, blood, and cerebrospinal fluid

The nurse assesses that a n 87 year old woman with alzheimers disease is continually rubbing, flexing, and kicking out her legs throughout the day. The night shift reports that this same behavior escalates at night, preventing her from obtaining her required sleep. The next step the nurse should take is to: a. ask the physician for a daytime sedative for the patient b. request soft restraints to prevent her from falling out of her bed c. ask the physician for a nighttime sleep medication for the patient d. assess the patient more closely, suspecting a disorder such as restless leg syndrome

d. assess the patient more closely, suspecting a disorder such as restless leg syndrome

When admitting a patient with acute confusion to the hospital, the nurse will interview the patient about health problems and health history primarily to a. determine the patient's motivation for self-care. b. include the patient in health care decisions. c. use the information given by the patient to guide care. d. assess the patient's baseline cognitive abilities.

d. assess the patient's baseline cognitive abilities. Rationale: Appropriateness of the patient's response and the patient's use of language will help the nurse to assess the baseline cognitive abilities of the patient. A confused patient may not be able to participate in self-care or make informed health care decisions. The health history given by a confused patient should not be used to guide decisions about care unless it can be verified by another source.

Drugs or diseases the impair the function of the extrapyramidal system may cause loss of a. sensations of pain and temperature b. regulation of the autonomic nervous system c. integration of somatic and special sensory inputs d. automatic movements associated with skeletal muscle activity

d. automatic movements associated with skeletal muscle activity

During the neurologic assessment, the patient cooperates with the nurse's directions to grip with the hands and to move the feet but does not respond to the nurse's questions. The nurse will suspect a. a temporal lobe lesion. b. injury to the cerebellum. c. a brainstem lesion. d. damage to the frontal lobe.

d. damage to the frontal lobe. Rationale: Expressive speech is controlled by Broca's area in the frontal lobe. The temporal lobe contains Wernicke's area, which is responsible for receptive speech. The cerebellum and brainstem do not affect higher cognitive functions such as speech.

When reviewing the results of a patient's cerebrospinal fluid analysis, the nurse will notify the health care provider about a. pH of 7.35. b. white blood cell count (WBC) of 4/ml (0.004/L). c. protein 30 mg/dl (0.30 g/L). d. glucose 30 mg/dl (1.7 mmol/L).

d. glucose 30 mg/dl (1.7 mmol/L). Rationale: The glucose level is low. The pH, WBCs, and protein values are normal.

A patient is scheduled for a lumbar puncture. The nurse will plan to a. administer a sedative medication 30 minutes before the procedure. b. transfer the patient to radiology just before the procedure. c. place the patient on NPO status for 4 hours before the procedure. d. help the patient lie on the side in the fetal position for the procedure.

d. help the patient lie on the side in the fetal position for the procedure. Rationale: For a lumbar puncture, the patient lies in the lateral recumbent position, with the knees drawn to the chest and the head flexed to the chest to separate the vertebrae. The procedure does not usually require a sedative, is done in the patient room, and has no risk for aspiration.

A patient is admitted to the ICU with a C7 spinal cord injury and diagnosed with brown-sequard syndrome. On physical examination, the nurse would most likely find a. upper extremity weakness only b. complete motor and sensory loss below C7 c. loss of position sense and vibration in both lower extremities d. ipsilateral motor loss and contralateral sensory loss below C7

d. ipsilateral motor loss and contralateral sensory loss below C7

A patient is admitted to the hospital with a C4 spinal cord injury after a motorcycle collision. The patient's BP is 83/49 mm Hg, and his pulse is 39 beats/min, and he remains orally intubated. The nurse identifies this pathophysiologic response as caused by a. increased vasomotor tone after injury b. a temporary loss of sensation and flaccid paralysis below the level of injury c.loss of parasympathetic nervous system innervation resulting in vasoconstriction d. loss of sympathetic nervous system innervation resulting in peripheral vasodilation

d. loss of sympathetic nervous system innervation resulting in peripheral vasodilation

During routine assessment of a patient with guillain-barre syndrome, the nurse finds the patient to be short of breath. The patient's respiratory distress is caused by a. elevated protein levels in the CSF b. immobility resulting from ascending paralysis c. degeneration of motor neurons in the brainstem and spinal cord d. paralysis ascending to the nerves that stimulate the thoracic area

d. paralysis ascending to the nerves that stimulate the thoracic area

When assessing motor function of a patient admitted with a stroke, the nurse notes mild weakness of the arm demonstrated by downward drifting of the arm. The nurse would most accurately document this finding as a. Athetosis. b. Hypotonia. c. Hemiparesis. d. Pronator drift.

d. pronator drift, downward drifting of the arm or pronation of the palm is identified as a pronator drift

Which is NOT a characteristic of the clonic phase in a grand-mal seizure? a. flexion spasm of whole body interrupted by muscular relaxation b. strenuous hyperventilation, and excessive salivation with froth of the mouth c. contorted face, and eyes rolled d. slow pulse e. rapid pulse

d. slow pulse

A patient with a deep, large laceration of the left forearm, which has damaged nerve fibers as well as other tissue, asks the nurse to explain what the effect of the nerve damage will be. The nurse should respond that a. nerve cells do not regenerate, and the loss of sensation and movement will be permanent. b. normal motor and sensory function will return once the peripheral nerve cells regenerate. c. weak sensation and movement will come back because peripheral nerve cells are capable of partial regeneration. d. some sensory and motor function may return because peripheral nerve fibers can regenerate if cell bodies have not been damaged.

d. some sensory and motor function may return because peripheral nerve fibers can regenerate if cell bodies have not been damaged. Rationale: In the peripheral nerve system (PNS), regeneration of injured nerve fibers is possible if the cell body is intact. The final result depends on the connections the axon sprouts make with end-organs and other nerves. Nerves of the central nervous system (CNS) do not regenerate, but peripheral nerves have some regenerative abilities. Return of normal or weak function is possible, but the nurse should not imply that either are guaranteed.

Information provided by the patient that would help differentiate a hemorrhagic stroke from a thrombotic stroke includes a. sensory disturbance b. a history of hypertension c. presence of motor weakness d. sudden onset of severe headache

d. sudden onset of severe headache

In teaching a patient with SLE about the disorder, the nurse knows that the pathophysiology of SLE includes a. circulating immune complexes formed from IgG autoantibodies reacting with IgG b. an autoimmune T cell reaction that results in destruction of the deep dermal skin layer c. immunologic dysfunction leading to chronic inflammation in the cartilage and muscles d. the production of a variety of autoantibodies directed against component of the cell nucleus

d. the production of a variety of autoantibodies directed against component of the cell nucleus

Interferon β-1b (Betaseron) has been prescribed for a young woman who has been diagnosed with relapsing-remitting multiple sclerosis. The nurse determines that additional teaching about the drug is needed when the patient says, a."I will need to rotate injection sites with each dose I inject." b."I should report any depression or suicidal thoughts that develop." c."I should avoid direct sunlight and use sunscreen and protective clothing when out of doors." d."Because this drug is a corticosteroid, I should reduce my sodium intake to prevent edema."

d."Because this drug is a corticosteroid, I should reduce my sodium intake to prevent edema." Interferon β-1b (Betaseron) is an immunomodulator drug (and not a corticosteroid). The drug is given subcutaneously every other day. Patient teaching should include the following: rotate injection sites with each dose; assess for depression and suicidal ideation; wear sunscreen and protective clothing while exposed to the sun; and know that flu-like symptoms are common following initiation of therapy.

Paralysis of lateral gaze indicates a lesion of cranial nerve a. II b. III c. IV d.VI

d.VI

In a patient with a disease that affects the myelin sheath of the nerves such as multiple sclerosis, the glial cells affected are the a.microglia b.astrocytes c.ependymal cells d.oligodendrocytes

d.oligodendrocytes

A patient comes to the emergency department immediately after experiencing numbness of the face and an inability to speak, but while the patient awaits examination, the symptoms disappear and the patient requests discharge. The nurse stresses that it is important for the patient to be evaluated primarily because a. the patient has probably experienced an asymptomatic lacunar stroke b. the symptoms are likely to return and progress to worsening neurologic deficit in the next 24 hours c. neurologic deficits that are transient occur most often as a result of small hemorrhages that clot off d. the patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebral vascular disease

d: The patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebral vascular disease- A TIA is a temporary focal loss of neurologic function caused by ischemia of an area of the brain, usually lasting only about 3 hours. TIAs may be due to microemboli from heart disease or carotid or cerebral thrombi and are a warning of progressive disease. Evaluation is necessary to determine the cause of the neurologic deficit and provide prophylactic treatment if possible.

What neurological symptoms of hypokalemia would be observed in a patient?

decreased reflexes

A patient seen in the outpatient clinic complains of restless legs syndrome. What common over-the-counter medications that the patient is taking routinely should the nurse discuss with the patient?

diphenhydramine (Benadryl) Rational: Antihistamines can aggravate restless legs syndrome.

An increase in intracranial pressure (ICP) may result from all of the following except: a. An intracranial tumor b. An intracranial bleed c. Edema d. Excess CSF e. A decrease in partial pressure of CO2

e. A decrease in partial pressure of CO2

Which of the following is NOT a type of Hypertonia: a. Spasticity b. Rigidity c. Dystonia d. Gegenhalten or paratonia e. All are correct

e. All are correct

When teaching a patient with myasthenia gravis (MG) about management of the disease, the nurse advises the patient to perform physically demanding activities when?

in the morning. Rational: Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then.

may be accompanied by nausea, vomiting or irritability, a ____ headache

migraine

may be preceded by prodrome, a ____ headache

migraine

strong family history in ____ headache

migraine

unilateral or bilateral throbbing pain, a ____ headache

migraine

hemiparesis

one half of the body has less marked weakness

Main "time" problem with IV-TPA

only 1-3% of patients arrive in time to receive it

The three criteria assess by the Glasgow Coma Scale (GCS) are:

open eyes best verbal response best motor response

Brudzinski's Sign

pain with resistance and involuntary flex of hip/knee when neck is flexed to chest when lying supine

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?

partial seizure Rational: The initial symptoms of a partial seizure involve clinical manifestations localized to a particular part of the body or brain.

atonic seizure

patient loses muscle tone and (typically) falls to the ground

Nursing care that can decrease ICP

positioning to prevent neck and hip flexion limiting suctioning space nursing care preventing isometric muscle contraction elevate HOB as ordered carefully regulate administration of IV fluids to prevent fluid volume excess

drug therapy for acute migraine and cluster headaches that appear to alter the pathophysiologic process are

specific serotonin receptor agonists (sumatriptan; Imitrex) cause vasoconstriction, useful in treatment

bilateral pressure or tightness in ____ headache

tension-type

chronic, dull, persisting intermittently over months or years, a ____ headache

tension-type

may occur with or between migraines, ____ headache

tension-type

A 42-year-old patient who was adopted at birth is diagnosed with early Huntington's disease (HD). When teaching the patient, spouse, and children about this disorder, the nurse will provide information about the availability of genetic testing to determine ...?

the HD risk for the patient's children. Rational: Genetic testing is available to determine whether an asymptomatic individual has the HD gene. The patient and family should be informed of the benefits and problems associated with genetic testing.

When a patient is experiencing a cluster headache, the nurse will plan to assess for

unilateral eyelid swelling Rational: Unilateral eye edema, tearing, and ptosis are characteristics of cluster headaches.