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26. A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client? A) Complaint of headache off and on for past month B) No bowel movement since yesterday C) Nausea D) Frequent voiding

26. A client is admitted for evaluation of cerebral aneurysm. Which assessment finding is of greatest importance in prioritizing nursing care to this client? A) Complaint of headache off and on for past month B) No bowel movement since yesterday C) Nausea D) Frequent voiding

32. The nurse is caring for a client with a herniation of C4. What item does the nurse anticipate to use if conservative therapy is used? A) A cervical collar B) Bandages and tape C) A firm mattress D) Traction equipment

Ans: A Feedback: A C4 injury is in the cervical spine region. A herniated cervical disk is treated conservatively (not surgically) by immobilizing the cervical spine with a cervical collar. Dressing supplies are not needed unless there is a wound. A firm mattress is appropriate for a lumbar herniation. Traction equipment is not used on cervical vertebrae.

2. A client has just been diagnosed with a cerebral aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client? A) Avoid heavy lifting. B) Avoid fiber in the diet. C) Take an antacid frequently. D) Take an herbal form of feverfew.

Ans: A Feedback: A client with an aneurysm should be advised to avoid heavy lifting, extreme emotional situations, or straining of stools because these activities increase intracranial pressure and thereby headaches and potential rupture of aneurysm. Avoidance of fiber may lead to constipation and straining with stools and would not be recommended. There would not be a recommendation for antacids or feverfew in the discharge teaching.

32. A client is admitted to the intensive care unit (ICU) with a diagnosis of cerebrovascular accident (CVA). Which assessment by the nurse provides the most significant finding in differentiating between ischemic and hemorrhagic strokes? A) A unit of fresh frozen plasma is infusing. B) Neurological checks are ordered every 2 hours. C) Keppra is ordered for treatment of focal seizures. D) Oropharyngeal suctioning as needed.

Ans: A Feedback: FFP is used in the treatment of clotting deficiencies as seen with over dose of anticoagulants and would indicate a hemorrhagic stroke. Neuro checks ordered every 2 hours does not differentiate between types of strokes. Focal seizures can occur with any stroke and would not differentiate. Suctioning is a nursing action taken to maintain airway and does not indicate a specific type of stroke.

6. A client diagnosed with migraine headaches asks the nurse what he can do to help control the headaches and minimize the number of attacks he is having. What instructions should the nurse give this client? A) Identify and avoid factors that precipitate or intensify an attack. B) Keep a record of activities following an attack. C) When an attack occurs, stay in a brightly lit area. D) Write down any adverse drug effects.

Ans: A Feedback: The nurse includes the following instructions: Follow the indications and dosage regimen for medication and notify the physician of any adverse drug effects. Identify and avoid factors that precipitate or intensify an attack. Keeping a food diary may help identify foods that trigger attacks. Keep a record of the attacks, including activities before the attack and environmental or emotional circumstances that appear to bring on the attack. Lie down in a darkened room and avoid noise and movement when an attack occurs, if that is possible.

18. A client with a cerebrovascular accident (CVA) is having difficulty with eating food on the plate. Which is the best nursing action to be taken? A) Perform a vision field assessment. B) Reposition the tray and plate. C) Assist the client with feeding. D) Know this is a normal finding for CVA.

Ans: A Feedback: The nurse should perform a vision field assessment to evaluate the client for hemianopia. This finding could indicate damage to the visual area of the brain as a result of evolving CVA. Repositioning the tray and assisting with feeding would not be the best nursing action until new finding has been evaluated. Hemianopia can be associated with a CVA but, when presenting as a new finding, should be evaluated and reported immediately.

11. The nurse is completing an assessment on a client with a history of migraines. The nurse would identify which of the following factors as a possible trigger for a migraine headache? Select all that apply. A) Red wine B) Nausea C) Menstruation D) Exposure to bright light E) Change in environmental temperature F) Prolonged positioning

Ans: A, C Feedback: Research on the cause of migraines is ongoing; however, changes in reproductive hormones (menstruation) and particular food/beverages can be a trigger for some clients. Nausea is a symptom of a migraine. Exposure to bright light and changes in environmental temperature are not triggers for migraine headaches. Prolonged positioning can cause muscle fatigue and strain that trigger tension headaches.

12. A client who complains of recurring headaches, accompanied by increased irritability, photophobia, and fatigue is asked to track the headache symptoms and occurrence on a calendar log. Which is the best nursing rationale for this action? A) Cluster headaches can cause severe debilitating pain. B) Migraines often coincide with menstrual cycle. C) Tension headaches are easier to treat. D) Headaches are the most common type of reported pain.

Ans: B Feedback: Changes in reproductive hormones as found during menstrual cycle can be a trigger for migraine headaches and may assist in the management of the symptoms. Cluster headaches can cause severe pain but is not the reason for tracking. Tension headaches can be managed but is not associated with a monthly calendar. Headaches are common but not the reason for tracking.

30. An elderly client, who has fallen several times at home, is admitted for possible transient ischemic attack (TIA). Which assessment finding is most significant in determining care for this client? A) Becomes confused during the night B) Drooling from side of mouth C) Bruit heard over carotids D) Irregular heart rhythm

Ans: B Feedback: Facial droop and drooling from the side of the mouth can indicate progression of symptoms or evolving CVA. It is not unusual for elderly clients to become confused when placed in a new environment and would indicate a need for further assessment. Bruits over the carotids may indicate altered blood flow to the brain but may not be a new finding for this client. Irregular heart rate can be indicative of atrial fibrillation or other cardiac disorders.

23. The nurse is working in the rehabilitative setting caring for tetraplegia and paraplegia clients. When instructing family members on the difference between the sites of impairment, which location differentiates the two disorders? A) The second cervical vertebrae B) The first thoracic vertebrae C) The seventh thoracic vertebrae D) The first lumbar vertebrae

Ans: B Feedback: Tetraplegia is the impairment of all extremities and the trunk when there is a spinal injury at or above the first thoracic vertebrae. Paraplegia is the impairment of all extremities below the first thoracic vertebrae.

3. You are caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury? A) Radiography B) Myelography C) Neurologic examination D) Computed tomography (CT) scan

Ans: C Feedback: A neurologic examination reveals the level of spinal cord injury. Radiography, myelography, and a CT scan show the evidence of fracture or compression of one or

8. While making your initial rounds after coming on shift, you find a client thrashing about in bed complaining of a severe headache. The client tells you the pain is behind his right eye, which is red and tearing. What type of headache would you suspect this client of having? A) Migraine B) Tension C) Cluster D) Sinus

Ans: C Feedback: A person with a cluster headache has pain on one side of the head, usually behind the eye, accompanied by nasal congestion, rhinorrhea (watery discharge from the nose), and tearing and redness of the eye. The pain is so severe that the person is not likely to lie still; rather he or she paces or thrashes about. The symptoms in the scenario do not describe a sinus headache.

25. A video fluoroscopy has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include honey thickened liquids. Which of the following is the priority nursing diagnosis for this client? A) Risk for Fluid Volume Deficit B) Risk for Aspiration C) Impaired Swallowing D) Altered Nutrition: Less Than Body Requirements

Ans: C Feedback: Impaired Swallowing was evident on the video fluoroscopy. Risk for Aspiration, Altered Nutrition, and Fluid Volume Deficit can occur but are not the primary diagnosis at this point in time.

21. The nurse is evaluating the transmission of a report from a paramedic unit to the emergency room. The medic reports that a client is unconscious with edema of the head and face and Battle's sign. What clinical picture would the nurse anticipate? A) Edema to the head and a blackened eye B) Edema to the head with a large scalp laceration C) Edema to the head with fixed pupils D) Edema to the head with bruising of the mastoid process

Ans: D Feedback: Battle's sign is the presence of bruising of the mastoid process behind the ear. It is not related to periorbital bleeding, lacerations, or fixed pupils.

14. A client who has experienced an initial transient ischemic attack (TIA) states: "I'm glad it wasn't anything serious." Which is the best nursing response to this statement? A) "I sense that you are happy it was not a stroke." B) "People who experience a TIA will develop a stroke." C) "TIA symptoms are short lived and resolve within 24 hours." D) "TIA is a warning sign. Let's talk about lowering your risks."

Ans: D Feedback: TIA is a warning sign and can be used to empower clients to make life changes to lower the risks. Sensing the client is happy is a psychotherapeutic response but does not lead to teaching and learning for health promotion. TIAs can lead to a stroke for approximately one third of the clients but is not a definitive result and presents as a frightening statement without empowering change. TIA symptoms are short lived, but this is a factual statement that does not provide additional information to the client.

For which type of stroke does a postmyocardial infarction (MI) client experiencing atrial fibrillation most at risk? A) Hemorrhagic stroke B) Embolic stroke C) Thrombotic stroke D) Cerebral aneurysm

B) Embolic stroke Rationale: In atrial fibrillation, the blood is not ejected normally, and small clots may develop in the atria. If these clots are ejected into the circulation as emboli and travel to the brain, an embolic stroke occurs.

29. A client is prescribed sumatriptan (Imitrex) for the treatment of migraine headache. Which client statement would indicate a need for additional teaching from the nurse? A) "I use this to prevent migraines." B) "I take this when I get a headache." C) "It constricts the blood vessels in my head." D) "It alleviates my sensitivity to light and sound."

Ans: A Feedback: Imitrex is a serotonin receptor agonist that stimulates serotonin receptors in the brain and causes vasoconstriction of the cerebral arteries and reduce/eliminate headaches and other symptoms associated with migraines. Imitrex is used during an attack and is not

7. You are caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke do you know this client has? A) Ischemic B) Hemorrhagic C) Right-sided D) Left-sided

Ans: A Feedback: Ischemic strokes occur when a thrombus or embolus obstructs an artery carrying blood to the brain; about 80% of strokes are the ischemic variety. Options B, C, and D are incorrect.

20. The nurse received report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate? A) The client has cerebral spinal fluid (CSF) leaking from the ear. B) The client has ecchymosis in the periorbital region. C) The client has an elevated temperature. D) The client has serous drainage from the nose.

Ans: A Feedback: Otorrhea means leakage of CSF from the ear. The client with a basilar skull fracture can create a pathway from the brain to the middle ear due to a tear in the dura. As a result, the client can have cerebral spinal fluid leak from the ear. The nurse may assess clear fluid in the ear canal. Ecchymosis and periorbital edema can be present as a manifestation of bruising from the head injury. An elevated temperature may occur from the head injury and is monitored closely. The client may have serous drainage from the nose especially immediately following the injury.

23. Which of the following goals is the priority in the care planning of a client with cerebrovascular accident (CVA) who is being transferred to a rehabilitation unit? A) To prevent contractures and joint deformities B) To decrease risk for ineffective cerebral tissue perfusion C) To develop appropriate coping mechanisms D) To increase activity tolerance

Ans: A Feedback: The long-term outcome for rehabilitation is directed toward maintaining musculoskeletal functioning. The risk for ineffective cerebral tissue perfusion is of most concern during the acute phase rather than rehab phase of care. Developing appropriate coping mechanisms in dealing with loss of body function or image is important but not as significant as musculoskeletal integrity. Activity tolerance should increase during rehab but not a primary concern.

28. The nurse is caring for a client who requires spine surgery to remove bone fragments and fuse the vertebrae with bone from which location? A) Iliac crest B) Floating rib C) Femur D) Mandible

Ans: A Feedback: To fuse the vertebrae during surgery, the physician uses bone from the iliac crest. The other options are incorrect.

34. The nurse is working on a neurosurgical unit. Which of the following nursing interventions are included in the plan of care following spinal surgery? Select all that apply. A) Monitor vital signs B) Intake and output C) Coughing and deep breathing D) PEARLA E) Neurovascular assessment of the lower extremity F) Dressing assessment

Ans: A, B, C, E, F Feedback: All of the following nursing interventions would be included in the plan of care except for PEARLA. Assessment of the pupils is informative for a client with neurologic symptoms resulting from a head injury.

26. The nurse is caring for a client with a spinal cord injury leaving paralysis. When planning care related to the musculoskeletal system, which considerations are important? Select all that apply. A) Bone demineralization B) Contractures C) Weight bearing D) Spasticity E) Limited range of motion

Ans: A, B, D, E Feedback: When planning care for clients with a spinal cord injury, the nurse is correct to recognize the physiologic effects of limited mobility associated with having a spinal cord injury. Bone demineralization occurs due to limited physical activity. Contractures occur due to limited range of motion. Spasticity occurs from the misfiring of neurons. Planning regarding weight bearing is not as important at this time.

7. You suspect that a newly admitted client is in spinal shock. What are the symptoms of spinal shock? Select all that apply. A) Bladder distention B) Poikilothermia C) Loss of hunger sensation D) Circulatory failure E) No perspiration below the level of the injury

Ans: A, B, E Feedback: In addition to paralysis, manifestations include pronounced hypotension, bradycardia, and warm, dry skin. If the level of injury is in the cervical or upper thoracic region, respiratory failure can occur. Bowel and bladder distention develop. The client does not perspire below the level of injury, which impairs temperature control. The client manifests with poikilothermia, body temperature of the environment. Symptoms of spinal shock do not include loss of hunger sensation or circulatory failure.

8. The nursing instructor is teaching about hematomas to a pre-nursing pathophysiology class. What would the nursing instructor describe as an arterial bleed with rapid neurologic deterioration? A) Extradural hematoma B) Epidural hematoma C) Subdural hematoma D) Intracranial hematoma

Ans: B Feedback: An epidural hematoma stems from arterial bleeding, usually from the middle meningeal artery, and blood accumulation above the dura. It is characterized by rapidly progressive neurologic deterioration.

24. Which nursing assessment finding is most indicative of a hemorrhagic stroke? A) Client history of atrial fibrillation B) Sudden onset of breathing alterations C) Symptoms evolving over 24 to 48 hours D) Client history of hyperlipidemia

Ans: B Feedback: Hemorrhagic strokes are less common than ischemic strokes and usually present with sudden onset and have the most impact on breathing, blood pressure, and heart rate. Client history of atrial fibrillation and hyperlipidemia are most significant with ischemic strokes caused by embolus or plaque. Ischemic strokes tend to evolve over 24 to 48 hours until symptoms complete.

13. The nurse is working on the neurologic unit at a local hospital. The nurse has four clients assigned who sustained head injuries as a result of an industrial accident. Which client would the nurse anticipate the physician sending for specialized care? A) The client with history of seizures B) The client who was in a bike accident last summer C) The client who played soccer in college D) The client whose father has Parkinson's disease

Ans: C Feedback: The client who has history of playing many years of a physical sport such as soccer and use the head to redirect the ball may have had years of injury to the brain. When concussions occur repetitively, even though they may have not shown injury at that time, chronic traumatic encephalopathy may result. Chronic traumatic encephalopathy, which can produce neurodegeneration, will need specialized care. The client who has a history of seizures may have no brain injury. The client who was in a previous accident may have had injury, but it is not of a repetitive nature. The client with a father who has Parkinson's disease will have regular follow-up care.

6. A mother brings her 6-year-old to the emergency department (ED) after the child fell off the bike. The physician diagnoses a concussion. The mother asks the nurse what a concussion is. What should the nurse's response be? A) "A concussion is a blow to the head that bruises the brain." B) "A concussion is a blow to the head that is hard enough for the brain to bounce off the other side of the skull." C) "A concussion is a blow to the head that is minor and has no real consequences." D) "A concussion is a blow to the head that jars the brain, resulting in diffuse and microscopic injury to the brain."

Ans: D Feedback: A concussion results from a blow to the head that jars the brain. It usually is a consequence of falling, striking the head against a hard surface such as a windshield, colliding with another person (e.g., between athletes), battering during boxing, or being a victim of violence. A concussion results in diffuse and microscopic injury to the brain. Options A, B, and C are incorrect because they give incorrect information to the mother.

Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura? A) Epidural B) Subdural C) Intracerebral D) Cerebral

Ans: B Feedback: A subdural hematoma results from venous bleeding, with blood gradually accumulating in the space below the dura. An epidural hematoma stems from arterial bleeding, usually from the middle meningeal artery, and blood accumulation above the dura. An intracerebral hematoma is bleeding within the brain that results from an open or closed head injury or from a cerebrovascular condition such as a ruptured cerebral aneurysm. A cerebral hematoma is bleeding within the skull.

11. The nurse is caring for a client who was discovering unconscious after falling off a ladder. The client is diagnosed with a concussion. All testing is normal, and discharge instructions are compiled. Which instructions have been compiled for the spouse? A) Tylenol may be administered for aches. B) Observe for any signs of behavioral changes. C) A light meal may be eaten if desired. D) Follow up with regular physician is encouraged.

Ans: B Feedback: All of the options are typical for a client being discharged with a concussion. The instruction that is emphasized is to observe for any signs of behavior changes, which may indicate an increase in the client's intracranial pressure. A concussion results in

31. A client with atrial fibrillation is placed on Coumadin to reduce the potential of developing a cerebrovascular accident (CVA). The international normalized ratio (INR) is 1.5. What does this finding indicate to the nurse? A) Therapeutic range is achieved. B) Coumadin will be increased. C) Coumadin will be decreased. D) INR is too high.

Ans: B Feedback: Ideally, the INR will be therapeutic at 2.0 to 3.0. Because the level is low, the nurse can anticipate the increase in Coumadin dosage.

22. The nurse is orienting a new nurse to the neurologic unit. When instructing on the typical care provided to a client with head injuries, which type of medications are frequently administered? Select all that apply. A) Loop diuretics B) Anticonvulsants C) Corticosteroids D) Analgesics E) Antibiotics F) Antidepressants

Ans: B, D, E Feedback: The nurse working on this specialty unit needs to be knowledgeable of the medication classifications, side effects, and therapeutic outcomes. Osmotic diuretics such as mannitol are commonly administered to decrease intracranial swelling. Anticonvulsants are administered to prevent seizure activity. Corticosteroids are less frequently used since new research data shows poor outcomes. Analgesics are administered for pain relief follow traumas. Antibiotics are administered to prevent infection. Antidepressants are not a typical medication related to this injury.

28. A client is brought into the emergency department with a diagnosis of ruptured cerebral aneurysm. Which assessment data provides the most important information in preparing for the nursing care of this client? A) Blood pressure 180/98 mm Hg B) Alert and oriented times three C) Grade V on the Hunt-Hess Scale D) Complaint of severe splitting headache

Ans: C Feedback: The Hunt-Hess Scale is used for grading a client with a cerebral aneurysm and provides the most accurate assessment as listed. An elevated blood pressure is anticipated with a cerebral aneurysm. Being alert and oriented provides little assessment value without additional neurologic data. Complaint of severe headache is subjective and not as significant as the Hunt-Hess Scale.

34. A client has experienced a transient ischemic attack (TIA) and presents with carotid bruits. Which is the priority action to be taken by the nurse, following a bilateral carotid endarterectomy? A) Encourage deep breathing and coughing. B) Observe for facial swelling. C) Anticipate need for endotracheal intubation. D) Resume antilipemic drugs.

Ans: C Feedback: Surgical approach to the neck area can result in swelling and blockage of the airway. This is especially significant with bilateral carotid endarterectomy. The nurse needs to be observant and prepared for immediate intubation if the airway becomes obstructed. Encouraging deep breathing and coughing is not significant because general anesthesia is not routine. Resuming drugs for hyperlipidemia is not a priority in the acute postoperative period.

29. A nurse is caring for a client with a spinal cord injury from a motorcycle accident. The nurse is instructing on the benefits of cell transplantation therapy. Which early outcome of treatment is anticipated? A) Cell transplantation therapy produced a reduction in swelling and pain. B) Cell transplantation therapy allowed organs to be brought from one person to another. C) Cell transplantation therapy improves the growth of new neurologic connections. D) Cell transplantation therapy allows the replacement of nerve cells that are damaged.

Ans: D Feedback: Nerve cells in the central nervous system lose the ability to regenerate when injured. Consequently, there is a focus on finding cells that, when transplanted, can replace the nerve cells that have been damaged. The early outcome of transplantation is the replacement. A later outcome of the transplantation is that nerve transmission improves and muscle functions improve or there is a reduction in symptoms.

5. A client with impaired physical mobility has been hospitalized. What nursing intervention helps reduce the potential for formation of thrombi and renal calculi in a client with impaired physical mobility? A) Provide a well-balanced diet. B) Position the client. C) Keep the client hydrated. D) Help the client perform exercises.

Ans: C Feedback: The nurse should keep the client hydrated. Adequate hydration reduces the potential for the formation of thrombi and renal calculi. A well-balanced diet provides nutrients and elements necessary for energy and to sustain cellular growth and repair. Positioning the client helps avoid joint contractures and foot drop. Active and passive exercise maintains joint flexibility and reduces muscle atrophy and atony.

The nurse is instructing the client on management and prevention of migraine headaches. Which of the following statements indicate the client requiring further instruction? A) "I will lie down in a darkened room and avoid noise and movement when an attack occurs." B) "Keeping a record of attacks will help identify factors that bring on a migraine." C) "A back massage will promote muscle relaxation." D) "I will administer sumatriptan (Imitrex) for headaches before symptoms of migraines appear."

D) "I will administer sumatriptan (Imitrex) for headaches before symptoms of migraines appear." Rationale: This medication is given any time after symptoms appear; oral doses can be repeated in 2 hours; a second injection can be repeated in 1 hour if headache is unrelieved or reoccurs.

13. When providing teaching to a client who reports tension headaches, which of the following instructions would be most beneficial to prevent onset of symptoms? A) Apply cool or warm cloth to head or eyes. B) Eliminate use of bright lights when working. C) Avoid certain foods. D) Perform stretching exercises and frequent position change.

Ans: D Feedback: Tension headaches are often associated with prolonged tensed muscles. Application of cool or warm cloths and avoidance of bright lights may help to reduce the headache after occurrence. Avoiding certain foods may prevent migraine headaches, but it is not likely to prevent tension headaches.

25. The nurse is caring for a client experiencing autonomic dysreflexia. Which of the following does the nurse recognize as the source of symptoms? A) Autonomic nervous system B) Central nervous system C) Peripheral nervous system D) Sympathetic nervous system

Ans: D Feedback: The nurse recognizes that autonomic dysreflexia is an exaggerated sympathetic nervous system response. Symptoms include severe hypertension, slow heart rate, pounding headache, etc. and can lead to seizures, stroke, and death. The autonomic nervous system regulates "feed and breed" functions. The central and peripheral nervous system is a component of the sympathetic nervous system.

15. A client is being assessed for a possible transient ischemic attack (TIA). Which of the following assessment findings suggests to the nurse that the client is experiencing a TIA? A) Unilateral ptosis B) Respiratory distress C) Severe headache D) Nausea and vomiting

Ans: A Feedback: A client with a TIA may experience impaired muscle coordination or paralysis on one side. Respiratory distress and severe headache are not associated with TIA. Nausea and vomiting is not a usual symptom of TIA.

9. A family member comes to the clinic to talk to the nurse about a client who has had a stroke on the right side of the brain. The family member is concerned because of the deficits the client is exhibiting. The nurse knows that when a client experiences a stroke on the right side of the brain, common deficits include what? Select all that apply. A) Left-sided hemiplegia B) Tendency to distractibility C) Impairment of long-term memory D) Hyperaware of deficits E) Neglect of objects and people on the left side

Ans: A, B, E Feedback: Left-sided hemiplegia (stroke on right side of brain) may have the following neurologic deficits: spatial-perceptual defects; disregard for the deficits of the affected side require special safety considerations; tendency to distractibility; impulsive behavior, unaware of deficits; poor judgment; defects in left visual fields; misjudge distances; difficulty distinguishing upside down and right side up; impairment of short-term memory; and neglect left side of body, objects and people on left side.

10. A 76-year-old male client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain? Select all that apply. A) Balloon angioplasty of the carotid artery followed by stent placement B) Removal of the carotid artery C) Percutaneous transluminal coronary artery angioplasty D) Carotid endarterectomy

Ans: A, D Feedback: If narrowing of the carotid artery by atherosclerotic plaques is the cause of the TIAs, a carotid endarterectomy (surgical removal of atherosclerotic plaque) could be performed. A balloon angioplasty of the carotid artery, a procedure similar to a percutaneous transluminal coronary artery angioplasty, may be performed alternatively to dilate the carotid artery and increase blood flow to the brain, followed by stent placement. Options B and C are not options to increase blood flow through the carotid artery to the brain.

20. The nurse is assisting a client, with a right-sided brain infarction, to transfer from the wheelchair to the bed. Which is the best placement of the wheelchair to facilitate this transfer? A) Wheelchair placed so client leads with his left side B) Wheelchair placed on the right side of the bed facing the foot C) Wheelchair placed on the left side of the bed facing the head D) Wheelchair placed on the right side of the bed facing the head

Ans: B Feedback: A right-sided brain infarct can result in left-sided weakness or paralysis. The wheelchair should be positioned to allow the client to lead with the right side of the body.

19. The intensive care unit has four clients received from a violent motor vehicle accident. When assessing the clients, which client would the nurse assess first? A) The client with an open head injury B) The client with a basilar fracture C) The client with a concussion D) The client with a coup injury

Ans: B Feedback: Of the four clients, the client whom the nurse would assess first would be the client with a basilar fracture due to location of the fracture being at the base of the skull. This location is especially dangerous because it can cause edema of the brain near the spinal cord and can interfere with circulation of cerebral spinal fluid. An open head injury causes a potential for infection but are less likely to have an increased intracranial pressure. A concussion is a blow to the head that jars the brain. A coup injury occurs when the brain is struck directly.

30. A 58-year-old client has scheduled a sick visit to the physician's office, stating symptoms of lower back pain with exacerbation upon movement. The nurse draws a picture of the components of the spinal cord and surrounding structures and identified potential causes of the pain. Which area of the drawing would the nurse emphasize? A) Spinal cord pathway B) Nucleus pulposus C) Bony vertebrae D) Associated musculature

Ans: B Feedback: Pressure on the spinal nerve roots result from trauma, herniated disks, and tumors. The nurse would emphasize the nucleus pulposus as a common area of problem. Stress caused by poor body mechanics, age, or disease weakens an area in the vertebra, causing the spongy center of the vertebra, the nucleus pulposus, to swell and herniate. The spinal cord pathway can cause symptoms of numbness and tingling. The bony vertebrae can present symptoms when fractures and bony fragments occur. Associated musculature pulling can place the vertebrae out of alignment causing symptoms.

18. The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician? A) The client has periorbital edema and ecchymosis. B) The client's vital signs are temperature, 100.9° F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg. C) The client's level of consciousness has improved. D) The client prefers to rest in the semi-Fowler's position.

Ans: B Feedback: The assessment finding promptly reported to the physician is the information which may cause complications. It is important to report the elevation in client temperature (100.9° F) because hyperthermia increases brain metabolism, increasing the potential for brain damage. It is not unusual for the client to experience periorbital edema and ecchymosis secondary to the head injury and surgery. Improved level of consciousness is a positive outcome of the treatment provided. There is no complication related to semi-Fowler's position.

15. A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care? A) Symptoms will evolve over a period of 1 week. B) Monitoring is needed as rapid neurologic deterioration may occur. C) The crash cart with defibrillator is kept nearby. D) Bleeding continues into the intracerebral area.

Ans: B Feedback: The nurse identifies that the CT scan suggests an epidural hematoma. A key component in planning care is the understanding that rapid neurologic deterioration occurs. Symptoms evolve quickly. A crash cart may be kept nearby, but this is not the key information. An intracerebral hematoma is bleeding within the brain, which is a different area of bleeding.

14. A client has sustained a head injury and is unconscious in the emergency room. A family member of the client arrives and is providing details of the client's medical history. Which information is of most concern to the nurse? A) The client is a heart transplant recipient. B) The client's medications include warfarin (Coumadin). C) The client is HIV positive. D) The client has a history of concussions from playing hockey.

Ans: B Feedback: The nurse is most concerned that the client is prescribed warfarin (Coumadin) because this is a blood thinner. Due to the action of the medication, the client is at a high risk for intracranial bleeding. The cardiovascular system will be assessed, but that is not the area of greatest concern at this time. The nurse will care for the HIV positive client using standard precautions. A history of concussions may indicate past brain damage, but the potential for active bleeding is the highest concern.

27. The nurse is offering suggestions regarding reproductive options to a husband and paraplegic wife. Which option is most helpful? A) Adoption is an option to complete your family but not put your life in jeopardy. B) Conception is not impaired; the birth process is determined with the physician. C) Birth via surrogate is best because your baby can be implanted in another woman. D) Sterilization is best; it would be difficult to care for a baby in your condition.

Ans: B Feedback: The nurse's role is to provide facts without inserting personal opinions. The fact is that the woman can conceive and bear children. Suggesting adoption, a surrogate, and sterilization is not appropriate. Providing information on that suggestion is appropriate.

33. A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings? A) Transient ischemic attack (TIA) B) Left-sided cerebrovascular accident (CVA) C) Right-sided cerebrovascular accident (CVA) D) Completed Stroke

Ans: B Feedback: When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete.

19. A client has been found unresponsive at home for an undetermined period of time. A cerebrovascular accident (CVA) is suspected, and the family is demanding a clot buster be used to restore functioning. The nurse knows that successful use of TPA in a client with CVA requires which of the following? Select all that apply. A) The symptoms are no longer evolving. B) Presence of an ischemic stroke C) Used concurrently with heparin therapy D) Administer intramuscular for faster response. E) Administer within 3 hours of onset of symptoms. F) Administer for hemorrhagic strokes.

Ans: B, E Feedback: TPA is a thrombolytic agent that can limit neurologic deficits if given IV within 3 hours of onset of an ischemic CVA. Waiting for symptoms to stabilize (no longer evolve) may take days and would not be appropriate for the use of TPA. TPA is not used in conjunction with other anticoagulants and would never be used to treat a hemorrhagic stroke (promotes more bleeding).

4. The nurse is caring for a client with a cerebral aneurysm. Why does the nurse limit the interaction of visitors or family members with the client with an aneurysm? A) The interaction may cause the client to become violent. B) The interaction may cause migraine in the client. C) The stimulation can increase intracranial pressure (ICP) or trigger a seizure. D) The client may become emotional and lose interest in the treatment.

Ans: C Feedback: Although visitors' and family members' desire to interact with the client are well intentioned, the stimulation can increase ICP or trigger a seizure. The nurse can suggest that they take turns and stay briefly. Interactions are not likely to make the client violent or emotional, which may cause the client to lose interest in the treatment. The interactions also may not cause migraine in the client.

17. A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment? A) Prothrombin level B) Chest x-ray C) Brain CT scan or MRI D) Lumbar puncture

Ans: C Feedback: CT scan or MRI differentiates CVA from other disorders and can differentiate between ischemic or hemorrhagic strokes. PT level would be done if the client is receiving anticoagulant therapy. Chest x-ray may be performed if respiratory concerns are indicated. Lumbar puncture would be done if subarachnoid bleeding is suspected.

22. The client with hemiplegia is at risk for impaired walking. Which nursing intervention would best assist this client in preventing complications associated with lower extremity impairment? A) Occupational therapy daily B) Use of walker for ambulation C) Use of high-top tennis shoes throughout the day D) Whirlpool tub baths and massage therapy

Ans: C Feedback: Hemiplegic clients are at risk for the development of plantar flexion, which would impede ambulation. High-top tennis shoes act as splints, providing support to the ankle/foot, and prevent plantar flexion contractures by maintaining the extremity in proper anatomic position. Occupational therapy is an important factor in rehabilitation after a stroke but not significant in preventing complications with walking. Whirlpool tub baths and massage therapy are soothing and assist in reducing muscle tension but not significant in prevention of walking impairment. The client must have strength in both upper extremities to be able to use a walker safely.

3. A client has tension headaches. The nurse recommends massage as a treatment for tension headaches. How does massage help clients with tension headaches? A) Reduces hypotension B) Increases appetite C) Relaxes muscles D) Relieves migraines

Ans: C Feedback: Massaging relaxes tense muscles, causes local dilation of blood vessels, and relieves headache. However, this approach is not likely to help a client with migraine or cluster headaches. Massage is not offered to clients with tension headaches to increase their

24. The nurse is caring for a client immediately after a spinal cord injury. Which assessment finding is essential when caring for a client in spinal shock with injury in the lower thoracic region? A) Numbness and tingling B) Respiratory pattern C) Pulse and blood pressure D) Pain level

Ans: C Feedback: Spinal shock is a loss of sympathetic reflex activity below the level of the injury within 30 to 60 minutes after insult. In addition to the paralysis, manifestations include pronounced hypotension, bradycardia, and warm, dry skin. Numbness and tingling and pain are not as high of a concern at this time due to the cord injury. Because the level of impairment is below the first thoracic vertebrae, respiratory failure is not a concern

17. The nurse is caring for a client following intracranial surgery. In the plan of care, the nurse states to remove antiembolism stockings. What would the nurse do to accurately complete this intervention? A) Remove the antiembolism stockings nightly and reapply by 8 AM. B) Place the antiembolism stockings on the lower extremities as tolerated. C) Remove the antiembolism stockings briefly every 8 hours. D) Apply the antiembolism stocking prior to ambulation daily.

Ans: C Feedback: The nurse is correct to identify time frames on nursing interventions. When caring for a client using antiembolism stockings following surgery, the correct intervention is to remove antiembolism stockings briefly every 8 hours. Antiembolism stockings promote circulation and decrease the risk of a thrombus or embolus.

33. The nurse is employed in the neurosurgeon's office assisting the physician in teaching. The nurse is instructing a client who is very anxious stating, "What will happen if the conservative treatment for the degenerative changes in my spine does not help my lumbar pain." The nurse is most correct to turn the teaching to which surgical procedure? A) A diskectomy B) A laminectomy C) A spinal fusion D) Aggressive traction

Ans: C Feedback: The nurse is most correct to provide teaching on a spinal fusion aimed to stabilize the vertebrae weakened by degenerative joint changes such as osteoarthritis and by a laminectomy. A diskectomy provides pain relief by the removal of a ruptured disk. A laminectomy is the removal of the posterior arch of a vertebra to expose the spinal cord. From this point, the surgeon can remove a herniated disk, tumor, bone fragments, etc. Aggressive traction is not a surgical option.

The nurse is caring for a client with a head injury after a fall from a hayloft. Which of the following indicates the presence of/or leaking of cerebral spinal fluid? A) Change in the level of consciousness (LOC) B) Signs of increased intracranial pressure (IICP) C) Halo sign D) Swelling

Ans: C Feedback: To detect any CSF drainage, the nurse looks for a halo sign. If drainage is present, the nurse allows it to flow freely onto porous gauze and avoids tightly plugging the orifice. Change in the LOC and signs of IICP are part of the neurologic assessment and do not assist in detecting any CSF drainage. The presence of swelling does not assist in detecting CSF drainage.

4. The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury? A) Cervical collar B) Cast C) Traction with weights and pulleys D) Turning frame

Ans: C Feedback: Traction with weights and pulleys is applied to provide correct vertebral alignment and to increase the space between the vertebrae. A cast and a cervical collar are used to immobilize the injured portion of the spine. A turning frame is used to change the client's position without altering the alignment of the spine.

16. The nurse is caring for a client who continues to have increasingly high intracranial pressure. Which complication is expected unless intracranial pressure is resolved? A) Additional inflammation occurs in the brain. B) Blood vessels dilate circulating blood. C) Herniation occurs through the foramen magnum. D) Venous congestion occurs causing peripheral edema.

Ans: C Feedback: Unless intracranial pressure is resolved, the brain will shift to the lateral side or herniate downward through the foramen magnum. Inflammation occurs from damage to the brain but will reach a maximum. Blood vessels do not dilate as a result of intracranial pressure. Peripheral edema is not a concern.

31. A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report? A) Sciatic nerve pain B) Herniation C) Paresthesia D) Paralysis

Ans: C Feedback: When a client reports numbness and tingling in an area, he is reporting a paresthesia. The nurse would document the experience as such or place the client's words in parenthesis. The nurse would not make a medical diagnosis of sciatic nerve pain or herniation. The symptoms are not consistent with paralysis.

A client presents to the walk-in clinic complaining of a migraine. The client is prescribed a neuronal stabilizer. What should the nurse suggest to the client? A) Avoid crowds. B) Take drugs only after meals at night. C) Avoid caffeine and alcohol. D) Use caution while driving or performing hazardous activities.

Ans: D Feedback: A client who is prescribed a neuronal stabilizer needs to exercise caution while driving and avoid performing hazardous activities. A client taking nonsteroidal anti-inflammatory drugs should be advised against taking caffeine and alcohol. The client need not take the drug only at night after meals or be instructed to avoid crowds.

5. A client is prescribed warfarin. Client teaching has included instructions to avoid a diet rich in foods that contain vitamin K. What sources of food should the nurse instruct the client to avoid? A) Fish, meats, and vegetable oils B) Citrus fruits C) Milk and dairy products D) Cereals, soybeans, and spinach

Ans: D Feedback: Clients who take warfarin (Coumadin) must be informed that they should avoid foods rich in vitamin K. Examples of food sources of vitamin K include cabbage, cauliflower, spinach, and other green leafy vegetables; cereals; and soybeans. Other food groups are not known to contain vitamin K. Milk and dairy products are good sources of calcium, whereas citrus fruits are sources of vitamin C. Fish, meats, and oils are sources of proteins and fats.

10. You are caring for a client who has had intracranial surgery and is being discharged home. What instructions would you give the client besides instructions on the medication? A) Understand that headaches are uncommon. B) You can cover the incision with your hair. C) You can expect swelling above the incision. D) Expect sensory changes, such as hearing a clicking sound, around the bone flap.

Ans: D Feedback: In addition, the nurse must provide the following verbal and written instructions: Watch for signs of intracranial bleeding and infection (expect swelling around the eye and below the incision). Expect sensory changes such as hearing a "clicking" sound around the bone flap, which will disappear as healing takes place. Understand that headaches also are common, but notify the surgeon if a mild analgesic such as acetaminophen (Tylenol) fails to relieve them. Care for the surgical site as directed by the physician. Some recommendations include keeping the incision clean, avoiding scrubbing the incision, securing remaining hair away from the incision, resuming shampooing the hair when the staples or sutures are removed, and wearing a hat when outside to avoid sunburn until hair growth resumes. Maintain safety precautions at home, including ambulating only with assistance and ensuring well-lit and clutter-free rooms. Do not drive until the risk of seizures has been eliminated. Engage in exercises that promote strength and endurance. Use techniques to ensure bowel and bladder elimination. Follow feeding and/or nutritional suggestions. Keep follow-up appointments for measuring anticonvulsant blood levels, electroencephalograms, and continued medical care and evaluation. This information is usually given to the client on a take-home instruction sheet.

9. When caring for a client who is post-intracranial surgery what is the most important parameter to monitor? A) Extreme thirst B) Intake and output C) Nutritional status D) Body temperature

Ans: D Feedback: It is important to monitor the client's body temperature closely because hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures. Options A, B, and C are not the most important parameters to monitor.

27. The client with a cerebral aneurysm asks the nurse, "What's the big fuss over a headache?" Which is the best response from the nurse regarding to a cerebral aneurysm? A) "Don't worry. The aneurysm has probably been there since birth." B) "The headache can be an indication that the aneurysm is growing." C) "A headache means your aneurysm is leaking blood into the brain." D) "Your physician wants to evaluate the location and condition of the aneurysm."

Ans: D Feedback: Keeping the client calm and quiet is an important aspect of care. Explaining the need for further evaluation is factual. The nurse should avoid saying "don't worry" or telling a client how to feel—this is not a therapeutic response. The aneurysm is growing or leaking are both inappropriate responses from a nurse and can lead to increased concern and anxiety for the client.

12. The nurse and physician are viewing a brain scan, which indicates bleeding at the point of impact to the skull and edema on the opposite side. The client is sleeping but can be aroused. The client has no memory of accident. The nurse provides all details to the next shift and is most accurate to report which type of injury? A) Coup injury B) Contusion C) Head injury D) Contrecoup injury

Ans: D Feedback: The nurse most accurately reports a contrecoup injury because the client has this type of dual brain injury. The client has experienced not only a direct strike to the brain but the brain ricochets in the skull to the opposite side causing damage and inflammation at that location as well. The client experienced a head injury, which is a general term. The injury is a contusion because it is more serious than a concussion and leads to structural injury to the brain. It is inaccurate to report a coup injury because this reveals injury to the brain itself from a direct strike to the head.

21. Following the use of a thrombolytic agent in the management of cerebrovascular accident (CVA) client, which is the priority nursing assessment? A) Pulse B) Respirations C) Airway D) Blood pressure

Ans: D Feedback: The use of tissue plasminogen activator (TPA), a thrombolytic agent, has been found to limit the neurologic deficits when given within 3 hours after onset of an ischemic CVA. Blood pressure is a critical assessment factor during the first 24 hours to determine intracerebral hemorrhage, which is a major complication associated with thrombolytic use. Airway is always a priority but not significant with thrombolytic use. Pulse and respirations can also indicate signs of hypovolemic shock resulting from hemorrhage.