Neuro Review 3

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The gold standard therapy for Parkinson's disease, a degenerative disease caused by a depletion of dopamine, is amantadine hydrochloride (Levodopa). a. True b. False

The gold standard therapy for Parkinson's disease, a degenerative disease caused by a depletion of dopamine, is amantadine hydrochloride (Levodopa). (amantadine is an ANTIVIRAL and its brand name is Symmetral, not Levodopa) (amantadine is used in parkinsons, but MOA is not known) (Levodopa is the gold standard treatment) a. True (if it meant levodopa)

The nurse is caring for a client who suffered a spinal cord injury 48 hours ago. The nurse monitors for GI complications by assessing for: a. A flattened abdomen b. Hematest positive nasogastric tube drainage c. Hyperactive bowel sounds d. A history of diarrhea

The nurse is caring for a client who suffered a spinal cord injury 48 hours ago. The nurse monitors for GI complications by assessing for: b. Hematest positive nasogastric tube drainage After spinal cord injury, the client can develop paralytic ileus, which is characterized by the absence of bowel sounds and abdominal distention. Development of a stress ulcer can be detected by hematest positive NG tube aspirate or stool. A history of diarrhea is irrelevant.

Which group of drugs mimics parasympathetic activity? a. Cholinergic agents b. Anticholinergic agents c. Adrenergic agents d. Antiadrenergic agents

Which group of drugs mimics parasympathetic activity? a. Cholinergic agents Cholinergic drugs mimic the effects of the parasympathetic nervous system. Anticholinergic agents antagonize the parasympathetic nervous system. Adrenergic agents stimulate sympathetic nervous system. Antiadrenergic agents block the effect of the sympathetic nervous system.

Stages of Alzheimer's Disease 1

Mild memory lapses.

A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority in this client's plan of care? a. Disturbed sensory perception (visual) b. Self-care deficient: Dressing/grooming c. Impaired verbal communication d. Risk for injury

A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority in this client's plan of care? d. Risk for injury Because the client is disoriented and restless, the most important nursing diagnosis is risk for injury. Although the other options may be appropriate, they are secondary because they do not immediately affect the client's health or safety.

A male client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure client to ensure client safety? a. Speak loudly to the client b. Test the temperature of the shower water c. Check the temperature of the food on the delivery tray d. Provide a clear path for ambulation without obstacles

A male client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure client to ensure client safety? d. Provide a clear path for ambulation without obstacles Cranial nerve II is the optic nerve, which governs vision. The nurse can provide safety for the visually impaired client by clearing the path of obstacles when ambulating. Testing the shower water temperature would be useful if there were an impairment of peripheral nerves. Speaking loudly may help overcome a deficit of cranial nerve VIII (vestibulocochlear). Cranial nerve VII (facial) and IX (glossopharyngeal) control taste from the anterior two thirds and posterior third of the tongue, respectively.

A nurse is working with family members of a newly diagnosed client with Alzheimer's disease. Which of the following interventions is most helpful? a. Implementing a daily exercise routine b. Improving daily nutritional intake c. Teaching relaxation techniques d. Suggesting communication strategies

A nurse is working with family members of a newly diagnosed client with Alzheimer's disease. Which of the following interventions is most helpful? d. Suggesting communication strategies Since Alzheimer's disease is a progressive chronic illness that greatly challenges caregivers, the nurse can be of greatest assistance in helping family to identify language changes, and select verbal and nonverbal communication strategies to minimize aberrant behavior.

Dysphagia

Difficulty swallowing.

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? a. Laceration of the middle meningeal artery b. Rupture of the carotid artery c. Thromboembolism from a carotid artery d. Venous bleeding from the arachnoid space

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? a. Laceration of the middle meningeal artery Epidural hematoma or extradural hematoma is usually caused by laceration of the middle meningeal artery. An embolic stroke is a thromboembolism from a carotid artery that ruptures. Venous bleeding from the arachnoid space is usually observed with subdural hematoma.

A female client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain? b. Midbrain Decerebrate posturing, characterized by abnormal extension in response to painful stimuli, indicates damage to the midbrain. With damage to the diencephalon or cortex, abnormal flexion (decorticate posturing) occurs when a painful stimulus is applied. Damage to the medulla results in flaccidity.

A male client has a history of painful, continuous muscle spasms. He has taken several skeletal muscle relaxants without experiencing relief. His physician prescribes diazepam (Valium), 2 mg P.O. twice daily. In addition to being used to relieve painful muscle spasms, diazepam also is recommended for: a. Treatment of spasticity associated with spinal cord lesions In addition to relieving painful muscle spasms, diazepam also is recommended for treatment of spasticity associated with spinal cord lesions. Diazepam's use is limited by its central nervous system effects and the tolerance that develops with prolonged use. The parenteral form of diazepam can treat status epilepticus, but the drug's sedating properties make it an unsuitable choice for long-term management of epilepsy. Diazepam isn't an analgesic agent.

Aphasia

Abnormal neurologic condition in which language function is defective or absent.

Adrenocorticotropic Hormone (ACTH) is prescribed for clients diagnosed with MS for the following reason: a. To treat symptoms b. To cure MS before it gets too severe c. To suppress the immune system to prevent demyelination d. To increase appetite

Adrenocorticotropic Hormone (ACTH) is prescribed to clients diagnosed with MS for the following reason: a. To treat symptoms

The client with a C6 spinal injury would most likely have which of the following symptoms? a. Aphasia b. Hemiparesis c. Paraplegia d. Tetraplegia

The client with a C6 spinal injury would most likely have which of the following symptoms? d. Tetraplegia Tetraplegia occurs as a result of cervical spine injuries. Paraplegia occurs as a result of injury to the thoracic cord and below.

Which finding indicates a side effect associated with the use of latanoprost (Xalantan) eye drops? a. Brown iris pigmentation b. Elevated BP c. Irregular pulse d. Periorbital edema

Which finding indicates a side effect associated with the use of latanoprost (Xalantan) eye drops? a. Brown iris pigmentation Common side effects of Xalantan eye drops includes blurred vision, eye irritation, tearing, darkening of eyelid skin color, increase in brown color in colored part of the eye, longer, thicker, and darker lashes.

Drugs classified as centrally acting skeletal muscle relaxants are most effective in relieving: a. Spasm due to trauma or inflammation b. Chronic spasm due to old injury c. Pain from arthritis d. Surgical complications

Drugs classified as centrally acting skeletal muscle relaxants are most effective in relieving: a. Spasm due to trauma or inflammation Centrally acting skeletal muscle relaxants are most effective in relieving spasm due to trauma or inflammation.

During recovery from a cerebrovascular accident (CVA), a female client is given nothing by mouth, to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once each shift. This assessment evaluates: c. Cranial nerves IX and X Swallowing is a motor function of cranial nerves IX and X. Cranial nerves I, II, and VIII don't possess motor functions. The motor functions of cranial nerve III include extraocular eye movement, eyelid elevation, and pupil constriction. The motor function of cranial nerve V is chewing. Cranial nerve VI controls lateral eye movement.

Identify the antispasticity medications below (select all that apply). a. baclofen (Lioresal) b. pyridostigmine bromide (Mestinon) c. dantrolene (Dantrium) d. benztropine mesylate (Cogentin) e. diazepam (Valium)

Identify the antispasticity medications below (select all that apply). a. baclofen (Lioresal) c. dantrolene (Dantrium) e. diazepam (Valium) Baclofen is an antispasticity used in the TX of MS. Dantrolene is used to treat muscle spasticity caused by spinal cord injury, stroke, cerebral palsy, and MS. Diazepam is a benzodiazepine is used to treat anxiety disorders, alcohol withdrawal symptoms, or muscle spasms. Pyridostigmine bromide (Mestinon)is a central nervous system depressant, used to help muscle strength in clients with MG. Benztropine mesylate (Cogentin) is an anticholinergic used for certain movement problems due to Parkinson's disease.

If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse would anticipate that the client has problems with: a. Body temperature control The body's thermostat is located in the hypothalamus; therefore, injury to that area can cause problems of body temperature control. Balance and equilibrium problems are related to cerebellar damage. Visual acuity problems would occur following occipital or optic nerve injury. Thinking and reasoning problems are the result of injury to the cerebrum.

Ataxia

Impaired ability to coordinate movement.

Apraxia

Impairment of ability to perform purposeful actions; inability to use objects properly.

Nurse Oliver is monitoring a client for adverse reactions to dantrolene (Dantrium). Which adverse reaction is most common? a. Slurred speech b. Muscle weakness c. Urine retention d. Excessive tearing

Nurse Oliver is monitoring a client for adverse reactions to dantrolene (Dantrium). Which adverse reaction is most common? b. Muscle weakness The most common adverse reaction to dantrolene is muscle weakness. The drug also may depress liver function or cause idiosyncratic hepatitis. Muscle weakness is rarely severe enough to cause slurring of speech, drooling, and enuresis. Although excessive tearing and urine retention are adverse reactions associated with dantrolene use, they aren't as common as muscle weakness.

Parkinson's disease involves a neurotransmitter imbalance in the extrapyramidal system resulting in a decrease in dopamine and an increase in acetylcholine. a. True b. False

Parkinson's disease involves a neurotransmitter imbalance in the extrapyramidal system resulting in a decrease in dopamine and an increase in acetylcholine. a. True Parkinson's disease is a neurodegenerative disease with motor and non-motor symptoms. In Parkinson's disease, a neurotransmitter imbalance occurs in the extrapyramidal system with a dopamine and GABA deficiency and an acetylcholine and glutamate surplus.

Stages of Alzheimer's Disease 3

Severe mental and physical deterioration.

Stages of Alzheimer's Disease 4

Severe mental and physical deterioration.

Stages of Alzheimer's Disease 2

Short-term memory lapses and disoriented to time.

The majority of clients with MS have early remissions that may last for a year or more. a. True b. False

The majority of clients with MS have early remissions that may last for a year or more. a. True The onset of MS is often insidious and gradual, with vague symptoms that occur intermittently over months or years, and thus the disease may not be diagnosed until long after the onset of the first symptoms.

The medical management of Bell's Palsy includes all of the following except? (Select all that apply). a. Electrical stimulation b. carbamazepine (Tegretol) c. baclofen (Gablofen) d. prednisone e. Warm moist heat along the course of the nerve

The medical management of Bell's Palsy includes all of the following except? (Select all that apply). b. carbamazepine (Tegretol) c. baclofen (Gablofen) Carbamazepine (Tegretol) is an antiseizure medication used in the treatment of Trigeminal Neuralgia. Baclofen (Gablofen) is an antispasmodic used in the treatment of Trigeminal Neuralgia. Bell's Palsy is treated with electrical stimulation, warm moist heat along the course of the nerve, corticosteroids, especially prednisone (started immediately - before paralysis).

The nurse is assessing a 37-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find? a. Vision changes b. Flaccid muscles c. Absent deep tendon reflexes d. Tremors at rest

The nurse is assessing a 37-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find? a. Vision changes Vision changes, such as diplopia, nystagmus, and blurred vision, are symptoms of multiple sclerosis. Deep tendon reflexes may be increased or hyperactive — not absent. Babinski's sign may be positive. Tremors at rest aren't characteristic of multiple sclerosis; however, intentional tremors, or those occurring with purposeful voluntary movement, are common in clients with multiple sclerosis. Affected muscles are spastic, rather than flaccid.

The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? (Select all that apply) a. Ensure the pulse oximeter reading is higher than 93% b. Perform deep nasal suction every two hours c. Administer stool softeners daily d. Maintain the HOD at 60 degrees e. Administer mild sedatives

The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? (Select all that apply) a. Ensure the pulse oximeter reading is higher than 93% c. Administer stool softeners daily e. Administer mild sedatives Stool softeners are initiated to prevent the Valsalva maneuver, which increases ICP. Oxygen saturation higher than 93% ensures oxygenation of the brain tissues; decreasing oxygen levels increases cerebral edema. Mild sedatives will reduce the client's agitation; strong narcotics would not be administered because they decrease the client's level of consciousness. The head of the bed should be elevated no more than 30 degrees to help decrease cerebral edema by gravity. Noxious stimuli, such as suctioning, increase ICP and should be avoided.

The nurse is caring for a client who experienced a C5 spinal cord injury. The nurse understands that with a C5 injury, the client's rehabilitation potential includes: a. Ability to drive electric wheelchair with portable ventilator b. Ability to assist with transfer and perform some self-care c. Ability to transfer self to wheelchair d. Ability to drive electric wheelchair with mobile hand supports

The nurse is caring for a client who experienced a C5 spinal cord injury. The nurse understands that with a C5 injury, the client's rehabilitation potential includes: d. Ability to drive electric wheelchair with mobile hand supports Use of a portable ventilator is associated with a C1-C3 spinal cord injury. Ability to assist with transfer is associated with a C6 spinal cord injury. The ability to transfer self to a wheelchair is associated with a C7-C8 spinal cord injury. The rehabilitation potential in a client with a C4 spinal injury is the same as in the client with a C1-C3 spinal injury.

The nurse is caring for a client with meningitis, and sees the client flex her hips and knees when her neck is flexed. The nurse realizes the client's response is called: a. Kernig's sign b. Brogard's sign c. Brudzinski's sign d. Chaddock's sign

The nurse is caring for a client with meningitis, and sees the client flex her hips and knees when her neck is flexed. The nurse realizes the client's response is called: c. Brudzinski's sign Brudzinski's sign is flexion of the hip and knee when the is flexed. Kernig's sign is the inability to extend the legs completely without extreme pain, and is also seen in the client with meningitis. Brogard's sign is elicited to determine increased pain points in nerve root disease. Chaddock's sign is related to upper motor neuron loss, and indicates lesions of the corticospinal paths.

The nurse is performing a mental status examination on a male client diagnosed with subdural hematoma. This test assesses which of the following? a. Intellectual function b. Cerebellar function c. Cerebral function d. Sensory function

The nurse is performing a mental status examination on a male client diagnosed with subdural hematoma. This test assesses which of the following? c. Cerebral function The mental status examination assesses functions governed by the cerebrum. Some of these are orientation, attention span, judgment, and abstract reasoning. Intellectual functioning isn't the only cerebral activity. Cerebellar function testing assesses coordination, equilibrium, and fine motor movement. Sensory function testing involves assessment of pain, light-touch sensation, and temperature discrimination.

The primary symptoms of ALS include all of the following except... a. weakness of upper extremities b. dysarthria c. dysphagia d. muscle twitching e. ptosis

The primary symptoms of ALS include all of the following except... e. ptosis Primary ALS symptoms include weakness of upper extremities (the hands are affected first), dysarthria, dysphagia, and muscle twitching. However, weakness may begin in the legs. Ptosis is a clinical manifestation of MG.

Agnosia

Total or partial loss of ability to recognize familiar objects or people thru sensory stimuli

Triptans, such as sumatriptan, are used for the treatment of mild to moderate migraine headaches. a. True b. False

Triptans, such as sumatriptan (Imitrex), are used for the treatment of migraines and cluster headaches. a. False Triptans are Serotonin Receptor Agonists, and the first line of therapy for moderate to severe headaches. Triptans are thought to act on receptors in the extracerebral, intracranial vessels that become dilated during a migraine attack. Stimulating these receptors constricts cranial vessels, inhibits neuropeptide release, and reduces nerve impulse transmission along the trigeminal pain pathway.

What is the condition that occurs when the ICP increases, and pressure is transmitted to the eyes through the CSF and to the optic disk at the back of the eye, causing the optic disk to swell, and the retina to compress. d. Papilledema Papilledema is an objective sign of increased ICP. As the optic disk becomes edematous, the retina is also compressed. The damaged retina cannot detect light rays. Visual acuity is lessened as the blind spot enlarges. Papilledema is also called a choked disk.

What would the nurse expect to see in the client diagnosed with Huntington's disease? (Select all that apply). a. Decreased levels of dopamine b. Increased levels of dopamine c. Excessive involuntary movements (Chorea) d. Slowing down in the initiation and execution of movement (Bradykinesia)

What would the nurse expect to see in the client diagnosed with Huntington's disease? (Select all that apply). b. Increased levels of dopamine c. Excessive involuntary movements (Chorea) Huntington's disease causes an excess of dopamine, due to an overactivity of the dopamine pathway; and clinical manifestations are characterized by abnormal and excessive involuntary movements. Parkinson's disease results in the degeneration of dopamine-producing neurons resulting in decreased dopamine levels; and major signs and symptoms include tremors, muscle rigidity, slowed movements, and impaired balance and coordination.

Which nursing diagnosis takes highest priority for a client with Parkinson's crisis? a. Ineffective airway clearance b. Risk for injury c. Impaired urinary elimination d. Imbalanced nutrition: Less than body requirements

Which nursing diagnosis takes highest priority for a client with Parkinson's crisis? a. Ineffective airway clearance In Parkinson's crisis, dopamine-related symptoms are severely exacerbated, virtually immobilizing the client. A client confined to bed during such a crisis is at risk for aspiration and pneumonia. Also, excessive drooling increases the risk of airway obstruction. Because of these concerns, the nursing diagnosis of Ineffective airway clearance takes highest priority. Although the other options also are appropriate, they aren't immediately life-threatening.

Which of the following medications are used to lessen some of the dementia associated with Alzheimer's disease? (select all that apply). a. benztropine mesylate (Cogentin) b. tacrine hydrochloride (Cognex) c. donepezil (Aricept) d. selegiline hydrochloride (Eldepryl)

Which of the following medications are used to lessen some of the dementia associated with Alzheimer's disease? (select all that apply). b. tacrine hydrochloride (Cognex) c. donepezil (Aricept) Cognex acts as reversible cholinesterase inhibitor, used for treatment of mild to moderate dementia of Alzheimer's type. Aricept improves cholinergic function by inhibiting acetylcholinesterase, and may temporarily lessen some of the dementia associated with Alzheimer's disease. Cogentin is indicated in treatment of mild cases of Parkinson's disease. Eldepryl is used as treatment adjunct to levodopa and may slow Parkinson's disease.

Which of the following side effects would the nurse assess for in a client receiving haloperidol, an antipsychotic for the treatment of Huntington's disease. Select all that apply. a. Anxiety or agitation b. Constipation or diarrhea c. Decreased sexual ability d. Menstrual changes e. Nausea or vomiting f. Weight gain

a. Anxiety or agitation b. Constipation or diarrhea c. Decreased sexual ability d. Menstrual changes e. Nausea or vomiting f. Weight gain (take with grain of salt, wasnt very clear)

A client with a spinal cord injury is about to receive A.M. bowel care. What medication would the nurse expect to administer prior to the A.M. care? a. Baclofen b. Prednisone c. Acyclovir d. Bisacodyl

A client with a spinal cord injury is about to be given A.M. bowel care. What medication would the nurse expect to administer prior to the A.M. care? d. Bisacodyl

A client comes into the ER after hitting his head in a MVA. He is alert and oriented. Which of the following nursing interventions should be done first? a. Assess full ROM to determine extent of injuries b. Immobilize the client's head and neck c. Call for an immediate chest x-ray d. Open the airway with the head-tilt chin-lift maneuver

A client comes into the ER after hitting his head in a MVA. He is alert and oriented. Which of the following nursing interventions should be done first? b. Immobilize the client's head and neck All clients with a head injury are treated as if a cervical spine injury is present until x-rays confirm their absence. ROM would be contraindicated at this time. There is no indication that the client needs a chest x-ray. The airway doesn't need to be opened since the client appears alert and not in respiratory distress. In addition, the head-tilt chin-lift maneuver wouldn't be used until the cervical spine injury is ruled out.

A client has been pronounced brain dead. Which of the following would the nurse assess? Select all that apply. a. Decerebrate posturing b. Absent corneal reflexes c. Deep tendon reflexes d. Dilated nonreactive pupils

A client has been pronounced brain dead. Which of the following would the nurse assess? Select all that apply. b. Absent corneal reflexes c. Deep tendon reflexes (huh, doesn't make explanation) d. Dilated nonreactive pupils A client who is brain dead typically demonstrates nonreactive dilated pupils and nonreactive or absent corneal and gag reflexes. The client may still have spinal reflexes such as deep tendon and Babinski reflexes in brain death. Decerebrate or decorticate posturing would not be seen.

A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition? a. Widening pulse pressure b. Dilated, fixed pupils c. Decrease in LOC d. Decrease in pulse rate

A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition? c. Decrease in LOC A decrease in the client's LOC is an early indicator of deterioration of the client's neurological status. Changes in LOC, such as restlessness and irritability, may be subtle. Widening of the pulse pressure, decrease in the pulse rate, and dilated, fixed pupils occur later if the increased ICP is not treated.

A client is about to receive Mannitol, an osmotic diuretic. He asks the nurse, "How does this medication work." What is the best response by the nurse? a. "It increases absorption of water and electrolytes." b. "It just does what it is supposed to do." c. " It inhibits reabsorption of water and electrolytes." d. "I don't know, just take what the doctor ordered."

A client is about to receive Mannitol, an osmotic diuretic. He asks the nurse, "How does this medication work." What is the best response from the nurse? c. " It inhibits reabsorption of water and electrolytes."

A client is admitted with a spinal cord injury at the level of T12. He has limited movement of his upper extremities. Which of the following medications would be used to control edema of the spinal cord? a. Acetazolamide (Diamox) b. Furosemide (Lasix) c. Methylprednisolone (Solu-Medrol) d. Sodium bicarbonate

A client is admitted with a spinal cord injury at the level of T12. He has limited movement of his upper extremities. Which of the following medications would be used to control edema of the spinal cord? c. Methylprednisolone (Solu-Medrol) High doses of Solu-Medrol are used within 24 hours of spinal injury to reduce cord swelling and limit neurological deficit. The other drugs are not indicated in this circumstance.

A client is prescribed carbamazepine (Tegretol) for the treatment of bipolar disorder. Which of the following laboratory results indicates that the client is experiencing a side effect of this medication? a. Neutrophil count of 1,200/mm3 b. Platelet count of 160,000/mm3 c. Uric acid level of 4mg/dl d. SGPT (ALT) level 50 units per liter of serum

A client is prescribed with Carbamazepine (Tegretol) for the treatment of bipolar disorder. Which of the following laboratory results indicates that the client is experiencing a side effect of this medication? a. Neutrophil count of 1,200/mm3 Carbamazepine is used to treat seizures and nerve pain such as trigeminal neuralgia and diabetic neuropathy. It causes decreased platelet count, white blood cells, and neutrophil count. The normal range for neutrophil is 1,500 to 8,000/mm3. Options "b," "c," and "d" all have a normal value.

A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate? a. Call the physician to adjust the ventilator settings b. Check deep tendon reflexes to determine the best motor response c. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma Score d. Count the rate to be sure the ventilations are deep enough to be sufficient

A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate? c. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma Score Cluster breathing consists of clusters of irregular breaths followed by periods of apnea on an irregular basis. A lesion in the upper medulla or lower pons is usually the cause of cluster breathing. Because the client had a bleed in the occipital lobe, which is superior and posterior to the pons and medulla, clinical manifestations that indicate a new lesion are monitored very closely in case another bleed ensues. The physician is notified immediately so that treatment can begin before respirations cease. Another nurse needs to assess vital signs and score the client according to the GCS, but time is also of the essence. Checking deep tendon reflexes is one part of the GCS analysis.

A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage, which may be shown by which of the following signs? a. Bloody drainage from the ears b. Frequent swallowing c. Guaiac-positive stools d. Hematuria

A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage, which may be shown by which of the following signs? b. Frequent swallowing Frequent swallowing after brain surgery may indicate fluid or blood leaking from the sinuses into the oropharynx. Blood or fluid draining from the ear may indicate a basilar skull fracture.

A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP? a. Apply a wrist restraint to each arm b. Wrap her hands in soft "mitten" restraints c. Tuck her arms and hands under the draw sheet d. Place her in a jacket restraint

A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP? b. Wrap her hands in soft "mitten" restraints It is best for the client to wear mitts which help prevent the client from pulling on the IV without causing additional agitation. Using a jacket or wrist restraint or tucking the client's arms and hands under the draw sheet restrict movement and add to feelings of being confined, all of which would increase her agitation and increase ICP.

A client with Huntington's disease has been prescribed Fluoxetine. Which of the following statements should the nurse include when teaching the patient about this medication? Select all that apply. a. Fluoxetine belongs to a class of drugs known as selective serotonin reuptake inhibitors b. Some young people have thoughts about suicide when first taking an antidepressant. Stay alert to changes in your mood. c. You can drink alcohol while on this medication d. Fluoxetine is also used to treat allergic reactions

A client with Huntington's disease has been prescribed Fluoxetine. Which of the following statements should the nurse include when teaching the patient about this medication? Select all that apply. a. Fluoxetine belongs to a class of drugs known as selective serotonin reuptake inhibitors. b. Some young people have thoughts about suicide when first taking an antidepressant. Stay alert to changes in your mood.

A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower extremities. Which of the following conditions would most likely be suspected? c. Neurogenic shock Loss of sympathetic control and unopposed vagal stimulation below the level of injury typically cause hypotension, bradycardia, pallor, flaccid paralysis, and warm, dry skin in the client in neurogenic shock. Hypervolemia is indicated by rapid and bounding pulse and edema. Autonomic dysreflexia occurs after neurogenic shock abates. Signs of sepsis would include elevated temperature, increased heart rate, and increased respiratory rate.

A client with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons? a. To hasten would healing b. To immobilize the cervical spine c. To prevent autonomic dysreflexia d. To hold bony fragments of the skull together

A client with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons? b. To immobilize the cervical spine Gardner-Wells, Vinke, and Crutchfield tongs immobilize the spine until surgical stabilization is accomplished.

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? a. Strict adherence to a bowel retraining program b. Limiting bladder catheterization to once every 12 hours c. Keeping the linen wrinkle-free under the client d. Preventing unnecessary pressure on the lower limbs

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? b. Limiting bladder catheterization to once every 12 hours The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours, and Foley catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose? a. Therapeutic drug levels should be maintained between 20 to 30 mg/ml b. Rapid Dilantin administration can cause cardiac arrhythmias c. Dilantin should be mixed in dextrose and water before administration d. Dilantin should be administered through an IV catheter in the client's hand

A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose? b. Rapid Dilantin administration can cause cardiac arrhythmias Dilantin IV shouldn't be given at a rate exceeding 50 mg/minute. Rapid administration can depress the myocardium, causing arrhythmias. Therapeutic drug levels range from 10 to 20 mg/ml. Dilantin shouldn't be mixed in solution for administration. However, because it's compatible with normal saline solution, it can be injected through an IV line containing normal saline. When given through an IV catheter hand, Dilantin may cause purple glove syndrome.

A client with head trauma develops a urine output of 300ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially? a. Evaluate urine specific gravity b. Anticipate treatment for renal failure c. Provide emollients to the skin to prevent breakdown d. Slow down the IV fluids and notify the physician

A client with head trauma develops a urine output of 300ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially? a. Evaluate urine specific gravity Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce anti-diuretic hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration. There's no evidence that the client is experiencing renal failure. Providing emollients to prevent skin breakdown is important, but doesn't need to be performed immediately. Slowing the rate of IV fluid would contribute to dehydration when polyuria is present.

A client with myasthenia gravis has begun frequently complaining of weakness and fatigue. The physician plans to identify whether the client is responding to an overdose of the medication or a worsening of the disease. A tensilon test is performed. Which of the following would indicate that the client is experiencing an overdose of the medication? a. Temporarily worsening of the condition b. Improvement of the weakness and fatigue c. No change in the condition d. Complaints of muscle spasms

A client with myasthenia gravis has become frequently complaining of weakness and fatigue. The physician plans to identify whether the client is responding to an overdose of the medication or a worsening of the disease. A tensilon test is performed. Which of the following would indicate that the client is experiencing an overdose of the medication? a. Temporarily worsening of the condition Tensilon test/ injection of edrophonium is performed to diagnose cholinergic crisis (overdose with anticholinesterase) or myasthenia crisis (under medication). A tensilon injection makes the client in cholinergic crisis temporarily worse (negative tensilon test). An improvement in the weakness indicates myasthenia crisis.

A client with tonic-clonic seizures is receiving Phenobarbital (Luminal) and Valproic acid (Depakene). The nurse tells the client that: a. Valproic acid decreases phenobarbital metabolism b. Valproic acid increases phenobarbital metabolism c. There is no interaction between the two d. The combination will increase the dosage of the two medications

A client with tonic-clonic seizure is receiving Phenobarbital (Luminal) and Valproic acid (Depakene). The nurse tells the client that: a. Valproic acid decreases phenobarbital metabolism Valproic acid appears to decrease phenobarbital metabolism, thus there are increased levels of phenobarbital in the body. Therefore, phenobarbital blood levels should be monitored and appropriate dosage adjustments made as indicated.

A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid: a. Is clear and tests negative for glucose b. Is grossly bloody c. Clumps together on the dressing and has a pH of 7 d. Separates into concentric rings and tests positive for glucose

A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid: d. Separates into concentric rings and tests positive for glucose Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.

A female client who has a history of seizures went to a health care facility to ask the nurse regarding the use of birth control pills while on phenytoin therapy. The nurse correctly states to the client that: a. Taking phenytoin decreases the effectiveness of the birth control pills. b. Pregnancy is not allowed while taking phenytoin. c. There is no known interaction between these medicines so there is nothing to worry about. d. To discontinue phenytoin and proceed with the oral contraceptive.

A female client who has a history of seizure went to a health care facility to ask the nurse regarding the use of birth control pills while on phenytoin therapy. The nurse correctly states to the client that: a. Taking phenytoin decreases the effectiveness of the birth control pills. Clients taking oral contraceptives are known to suffer contraceptive failure while taking anticonvulsants such as phenobarbitone, phenytoin, and carbamazepine because they decrease the effectiveness of the birth control pills. Options "b," "c," and "d" are inappropriate instructions.

A female client who was found unconscious at home is brought to the hospital by a rescue squad. In the ICU, the nurse checks the client's oculocephalic (doll's eye) response by: a. Shining a bright light into the pupil b. Introducing ice water into the external auditory canal c. Turning the client's head suddenly while holding the eyelids open d. Touching the cornea with a wisp of cotton

A female client who was found unconscious at home is brought to the hospital by a rescue squad. In the ICU, the nurse checks the client's oculocephalic (doll's eye) response by: c. Turning the client's head suddenly while holding the eyelids open To elicit the oculocephalic response, which detects cranial nerve compression, the nurse turns the client's head suddenly while holding the eyelids open. Normally, the eyes move from side to side when the head is turned; in an abnormal response, the eyes remain fixed. The nurse introduces ice water into the external auditory canal when testing the oculovestibular response; normally, the client's eyes deviate to the side of ice water introduction. The nurse touches the client's cornea with a wisp of cotton to elicit the corneal reflex response, which reveals brain stem function; blinking is the normal response. Shining a bright light into the client's pupil helps evaluate brain stem and cranial nerve III functions; normally, the pupil responds by constricting

A female client with Guillain-Barre syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond? a. "You may have difficulty believing this, but the paralysis caused by this disease is temporary." b. "You'll have to accept the fact that you're permanently paralyzed. However, you won't have any sensory loss." c. "It must be hard to accept the permanency or your paralysis." d. "You'll first regain use of your legs and then your arms."

A female client with Guillain-Barre syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond? a. "You may have difficulty believing this, but the paralysis caused by this disease is temporary." The nurse should inform the client that the paralysis that accompanies Guillain-Barre syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs.

A female client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test? a. Immobilize the neck before the client is moved onto a stretcher. b. Determine whether the client is allergic to iodine, contrast dyes, or shellfish. c. Place a cap over the client's head. d. Administer a sedative as ordered.

A female client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test? b. Determine whether the client is allergic to iodine, contrast dyes, or shellfish. Because CT commonly involves use of a contrast agent, the nurse should determine whether the client is allergic to iodine, contrast dyes, or shellfish. Neck immobilization is necessary only if the client has a suspected spinal cord injury. Placing a cap over the client's head may lead to misinterpretation of test results; instead, the hair should be combed smoothly. The physician orders a sedative only if the client can not be expected to remain still during the CT scan.

A nurse is giving dietary instructions to a client receiving levodopa. Which of the following food items should be avoided by the client? a. Goat yogurt b. Whole grain cereal c. Asparagus d. Apples

A nurse is giving dietary instructions to a client receiving levodopa. Which of the following food items should be avoided by the client? b. Whole grain cereal When administering levodopa, the client should avoid excessive intake of foods rich in pyridoxine (vitamin B6) which has been found to reduce the effects of levodopa. Large amounts of pyridoxine are also contained in some foods such as bananas, egg yolks, lima beans, meats, peanuts, and whole grain cereals. Options "a," "c," and "d" are foods low in vitamin B6.

After falling 20 feet, a 36-year-old man sustains a C6 fracture with spinal cord transection. Which other findings should the nurse expect? a. Quadriplegia with gross arm movement and diaphragmatic breathing b. Quadriplegia and loss of respiratory function c. Paraplegia with intercostal muscle loss d. Loss of bowel and bladder control

After falling 20 feet, a 36-year-old man sustains a C6 fracture with spinal cord transection. Which other findings should the nurse expect? a. Quadriplegia with gross arm movement and diaphragmatic breathing A client with a spinal cord injury at levels C5 to C6 has quadriplegia with gross arm movement and diaphragmatic breathing. Injury levels C1 to C4 leads to quadriplegia with total loss of respiratory function. Paraplegia with intercostal muscle loss occurs with injuries at T1 to L2. Injuries below L2 cause paraplegia and loss of bowel and bladder control.

An 18-year-old client was hit in the head with a baseball during practice. When discharging him to the care of his mother, the nurse gives which of the following instructions? a. "Watch him for keyhole pupil the next 24 hours." b. "Expect profuse vomiting for 24 hours after the injury." c. "Wake him every hour and assess his orientation to person, time, and place." d. "Notify the physician immediately if he has a headache."

An 18-year-old client was hit in the head with a baseball during practice. When discharging him to the care of his mother, the nurse gives which of the following instructions? c. "Wake him every hour and assess his orientation to person, time, and place." Changes in LOC may indicate expanding lesions such as subdural hematoma; orientation and LOC are assessed frequently for 24 hours. A keyhole pupil is found after iridectomy. Profuse or projectile vomiting is a symptom of increased ICP and should be reported immediately. A slight headache may last for several days after concussion; severe or worsening headaches should be reported.

The client with a head injury has been urinating copious amounts of dilute urine through the Foley catheter. The client's urine output for the previous shift was 3000 ml. The nurse implements a new physician order to administer: a. Dexamethasone (Decadron) b. Mannitol (Osmitrol) c. Desmopressin (DDAVP, stimate) d. Ethacrynic acid (Edecrin)

The client with a head injury has been urinating copious amounts of dilute urine through the Foley catheter. The client's urine output for the previous shift was 3000 ml. The nurse implements a new physician order to administer: c. Desmopressin (DDAVP, stimate) A complication of a head injury is diabetes insipidus, which can occur with insult to the hypothalamus, the antidiuretic storage vesicles, or the posterior pituitary gland. Urine output that exceeds 9 L per day generally requires treatment with desmopressin. Dexamethasone, a glucocorticoid, is administered to treat cerebral edema. This medication may be ordered for the head injured patient. Ethacrynic acid and mannitol are diuretics, which would be contraindicated.

The client with myasthenia gravis is receiving pyridostigmine (Mestinon). The nurse monitors for signs and symptoms of cholinergic crisis caused by overdose of the medication. The nurse checks the medication supply to ensure that which medication is available for administration if a cholinergic crisis occurs? c. Atropine sulfate The antidote for cholinergic crisis is Atropine sulfate. Acetylcysteine is the antidote for acetaminophen (Tylenol) overdose. Vitamin K is the antidote for warfarin (Coumadin), and protamine sulfate is the antidote for heparin.

The nurse evaluates that carbidopa and levodopa (Sinemet) is therapeutically effective if the client has: a. Decreased GI responses b. Increased tolerance to pyridoxine c. Decreased tremors at rest d. Increased urinary output

The nurse evaluates that carbidopa and levodopa (Sinemet) is therapeutically effective if the client has: c. Decreased tremors at rest Carbidopa and levodopa help restore the balance between dopamine and acetylcholine, thereby controlling the responses of Parkinson's disease.

The nurse is caring for a client admitted with spinal cord injury. The nurse minimizes the risk of compounding the injury most effectively by: a. Keeping the client on a stretcher b. Logrolling the client on a firm mattress c. Logrolling the client on a soft mattress d. Placing the client on a Stryker frame

The nurse is caring for a client admitted with spinal cord injury. The nurse minimizes the risk of compounding the injury most effectively by: d. Placing the client on a Stryker frame Spinal immobilization is necessary after spinal cord injury to prevent further damage and insult to the spinal cord. Whenever possible, the client is placed on a Stryker frame, which allows the nurse to turn the client to prevent complications of immobility, while maintaining alignment of the spine. If a Stryker frame is not available, a firm mattress with a bed board should be used.

The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a BP of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply. a. Loosen constrictive clothing b. Administer antihypertensive medication d. Assess for bladder distention and bowel impaction e. Elevate the HOB to 90 degrees The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn't reduce the client's blood pressure, IV antihypertensives should be administered. A fan shouldn't be used because cold drafts may trigger autonomic dysreflexia.

The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing this is compatible with: b. Epidural hematoma The changes in neurological signs from an epidural hematoma begin with a loss of consciousness as arterial blood collects in the epidural space and exerts pressure. The client regains consciousness as the cerebral spinal fluid is reabsorbed rapidly to compensate for the rising intracranial pressure. As the compensatory mechanisms fail, even small amounts of additional blood can cause the intracranial pressure to rise rapidly, and the client's neurological status deteriorates quickly.

The nurse is caring for the male 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 side, if possible, with the head flexed forward

The nurse is caring for the male client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated? b. Restraining the client's limbs Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising 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 nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell the family members that the test measures which of the following conditions? a. Extent of intracranial bleeding b. Percent of functioning brain tissue c. Activity of the brain d. Sites of brain injury

The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell the family members that the test measures which of the following conditions? c. Activity of the brain An EEG measures the electrical activity of the brain. Extent of intracranial bleeding and location of the injury site would be determined by CT or MRI. Percent of functional brain tissue would be determined by a series of tests.

The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists? c. Inability to elicit a Babinski's reflex Resolution of spinal shock is occurring when there is a return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, reflex emptying of the bladder, and a positive Babinski's reflex.

The nurse is giving instructions to a client receiving phenytoin (Dilantin). The nurse concludes that the client has a sufficient knowledge of the medication if the client states: a. "Wearing a medical alert tag is not required." b. "Alcohol is permitted while taking this medication." c. "I can take the medication with milk." d. "You will check my serum phenytoin level before giving the medication."

The nurse is giving instructions to a client receiving Phenytoin (Dilantin). The nurse concludes that the client has a sufficient knowledge if the client states that: d. "You will check my serum phenytoin level before giving the medication." Taking the prescribed daily dosage to keep the blood level of the drug constant and having a sample drawn for serum drug level is completed before taking the morning dose. Option "a": Wearing a medical tag allows any medical care provider to know that the client is on seizure medication. Option "b": Alcohol use can increase the blood levels of phenytoin and may increase side effects. Option "c": Taking it with milk will impair the absorption.

The nurse is teaching a female client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to: a. Take a hot bath b. Rest in an air-conditioned room c. Increase the dose of muscle relaxants d. Avoid naps during the day

The nurse is teaching a female client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to: b. Rest in an air-conditioned room Fatigue is a common symptom in clients with multiple sclerosis. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness and fatigue. Planning for frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with multiple sclerosis include treating depression, using occupational therapy to learn energy conservation techniques, and reducing spasticity.

When administering IV phenytoin (Dilantin), the nurse should: a. Administer it at a rate of 100 mg/min b. Protect the drug from light exposure c. Mix the drug in dextrose solution d. Mix the drug in saline solution

When administering IV phenytoin (Dilantin), the nurse should: d. Mix the drug in saline solution Phenytoin must be mixed in saline solution only. Phenytoin should be administered at a rate of 50 mg/min. There is no need to protect phenytoin from light because it does not destabilize with light exposure. Phenytoin will precipitate when mixed with a dextrose solution.

When discharging a client from the ER after a head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best describes a lucid interval? a. An interval when the client's speech is garbled b. An interval when the client is alert but can't recall recent events c. An interval when the client is oriented but then becomes somnolent d. An interval when the client has a "warning" symptom, such as an odor or visual disturbance

When discharging a client from the ER after a head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best describes a lucid interval? c. An interval when the client is oriented but then becomes somnolent A lucid interval is described as a brief period of unconsciousness followed by alertness; after several hours, the client again loses consciousness. Garbled speech is known as dysarthria. An interval in which the client is alert but can't recall recent events is known as amnesia. Warning symptoms or auras typically occur before seizures.

When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result? a. Normal b. Appropriate; lowering CO2 reduces ICP c. Significant; the client has alveolar hypoventilation d. Emergent; the client is poorly oxygenated

When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result? b. Appropriate; lowering CO2 reduces ICP A normal PaCO2 value is 35 to 45 mm Hg. CO2 has vasodilating properties; therefore, lowering PaCO2 through hyperventilation will lower ICP caused by dilated cerebral vessels. Oxygenation is evaluated through PaO2 and oxygen saturation. Alveolar hypoventilation would be reflected in an increased PaCO2.

Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia? a. A client with a brain injury b. A client with a herniated nucleus pulposus c. A client with a high cervical spine injury d. A client with a stroke

Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia? c. A client with a high cervical spine injury Autonomic dysreflexia refers to uninhibited sympathetic outflow in clients with spinal cord injuries about the level of T10. The other clients are not prone to dysreflexia.

Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury? a. Insert an indwelling urinary catheter to straight drainage b. Schedule intermittent catheterization every 2 to 4 hours c. Perform a straight catheterization every 8 hours while awake d. Perform Crede's maneuver to the lower abdomen before the client voids

Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury? b. Schedule intermittent catheterization every 2 to 4 hours Intermittent catheterization should begin every 2 to 4 hours early in the treatment. When residual volume is less than 400 ml, the schedule may advance to every 4 to 6 hours. Indwelling catheters may predispose the client to infection and are removed as soon as possible. Crede's maneuver is not used on people with spinal cord injury.

Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg? a. Administer low-dose barbiturate b. Restrict fluids c. Encourage the client to hyperventilate d. Give the client a warming blanket

Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg? c. Encourage the client to hyperventilate Normal ICP is 15 mm Hg or less. Hyperventilation causes vasoconstriction, which reduces CSF and blood volume, two important factors for reducing a sustained ICP of 20 mm Hg. A cooling blanket is used to control the elevation of temperature because a fever increases the metabolic rate, which in turn increases ICP. High doses of barbiturates may be used to reduce the increased cellular metabolic demands. Fluid volume and inotropic drugs are used to maintain cerebral perfusion by supporting the cardiac output and keeping the cerebral perfusion pressure greater than 80 mm Hg.

Which one of the following drugs reduces transmission of impulses from spinal cord to skeletal muscles; is an antispasticity agent for the treatment of spinal spasticity resulting from multiple sclerosis or spinal cord injury? a. Baclofen (Lioresal) b. Hydrochloride (Levodopa) c. Phenytoin (Dilantin) d. Valproic acid (Depakene)

Which one of the following drugs reduces transmission of impulses from spinal cord to skeletal muscles; is an antispasticity agent for the treatment of spinal spasticity resulting from multiple sclerosis or spinal cord injury? a. Baclofen (Lioresal) Levodopa is not hydrochloride anything it is (dihydroxyphenylalanine and the immediate precursor of dopamine. )

While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions? a. Autonomic dysreflexia b. Hemorrhagic shock c. Neurogenic shock d. Pulmonary embolism

While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions? c. Neurogenic shock Symptoms of neurogenic shock include hypotension, bradycardia, and warm, dry skin due to the loss of adrenergic stimulation below the level of the lesion. Hypertension, bradycardia, flushing, and sweating of the skin are seen with autonomic dysreflexia. Hemorrhagic shock presents with anxiety, tachycardia, and hypotension; this wouldn't be suspected without an injury. Pulmonary embolism presents with chest pain, hypotension, hypoxemia, tachycardia, and hemoptysis; this may be a later complication of spinal cord injury due to immobility.

A 20-year-old client who fell approximately 30 feet is unresponsive and breathless. A cervical spine injury is suspected. How should the first-responder open the client's airway for rescue breathing? a. By performing a jaw-thrust maneuver b. By inserting a nasopharyngeal airway c. By inserting an oropharyngeal airway d. By performing the head-tilt, chin-lift maneuver

A 20-year-old client who fell approximately 30 feet is unresponsive and breathless. A cervical spine injury is suspected. How should the first-responder open the client's airway for rescue breathing? a. By performing a jaw-thrust maneuver If the client has a suspected cervical spine injury, a jaw-thrust maneuver should be used to open the airway. If the tongue or relaxed throat muscles are obstructing the airway, a nasopharyngeal or oropharyngeal airway can be inserted; however, the client must have spontaneous respirations when the airway is open. The head-tilt, chin-lift maneuver requires neck hyperextension, which can worsen the cervical spine injury.

A nurse is instructing a client regarding Carbidopa-levodopa (Sinemet) for the treatment of Parkinson's disease. The nurse tells the client that which of the following is a side effect of the medication? a. Difficulty performing a voluntary movement Dyskinesia (difficulty performing a voluntary movement) is one of the symptoms of a levodopa overdose. Other side effects include nausea, diarrhea, vomiting, hypotension, bradycardia, confusion and hallucinations.

After a hypophysectomy (surgical removal of the pituitary gland), vasopressin is given IM for which of the following reasons? a. To reduce cerebral edema and lower intracranial pressure b. To treat growth failure c. To replace antidiuretic hormone (ADH) normally secreted by the pituitary d. To prevent syndrome of inappropriate antidiuretic hormone (SIADH)

After a hypophysectomy, vasopressin is given IM for which of the following reasons? c. To replace antidiuretic hormone (ADH) normally secreted by the pituitary After hypophysectomy, or removal of the pituitary gland, the body can't synthesize ADH. Somatropin or growth hormone, not vasopressin is used to treat growth failure. SIADH results from excessive ADH secretion. Mannitol or corticosteroids are used to decrease cerebral edema.

An 18-year-old client is admitted with a closed head injury sustained in a MVA. His ICP shows an upward trend. Which intervention should the nurse perform first? a. Reposition the client to avoid neck flexion b. Administer 1 g Mannitol IV as ordered c. Administer 100 mg of Pentobarbital IV as ordered d. Increase the ventilator's respiratory rate to 20 breaths/minute

An 18-year-old client is admitted with a closed head injury sustained in a MVA. His ICP shows an upward trend. Which intervention should the nurse perform first? a. Reposition the client to avoid neck flexion The nurse should first attempt nursing interventions, such as repositioning the client to avoid neck flexion, which increases venous return and lowers ICP. If nursing measures prove ineffective, notify the physician, who may prescribe mannitol, pentobarbital, or hyperventilation therapy.

Before administering amantadine (Symadine), the nurse should investigate which of the following client statements? a. "My hands are always shaking." b. "I had to take Dilantin 6 months ago." c. "I take low-dose enteric aspirin each day." d. "Simple tasks seem to take so long to perform."

Before administering amantadine (Symadine), the nurse should investigate which of the following client statements? b. "I had to take Dilantin 6 months ago." Amantadine is used cautiously in clients with a history of seizures. "a" and "d" are clinical manifestations of Parkinson's disease. Amantadine does not interact negatively with aspirin.

Biperiden hydrochloride (Akineton) is added to a list of antiparkinsonian medications that an elderly client is taking. Which of the following instructions made by the nurse indicates a need for further learning? a. Avoid smoking, alcohol and caffeine b. Use ice chips, candy or gum for dry mouth c. Walk in the morning to get your daily source of sunlight d. Eat foods rich in fiber and increase fluid intake

Biperiden hydrochloride (Akineton) is added to a list of antiparkinsonian medications that an elderly client is taking. Which of the following instructions made by the nurse that needs further learning? c. Walk in the morning to get your daily source of sunlight Biperiden hydrochloride (Akineton) is an anticholinergic antiparkinsonian agent used to treat the stiffness, tremors, spasms, and poor muscle control of Parkinson's disease. Photophobia is one of the side effects of this medication so instruct the client to use sunglasses in direct sunlight. Options "a," "b," and "d" are correct instructions regarding the use of this medication.

Cushing's triad is a sign of increased ICP, and consists of... a. Widening pulse pressure, irregular respirations, bradycardia b. Widening pulse pressure, irregular respirations, tachycardia c. Narrowing pulse pressure, irregular respirations, bradycardia d. Narrowing pulse pressure, irregular respirations, tachycardia

Cushing's triad is a sign of increased ICP, and consists of... a. Widening pulse pressure, irregular respirations, bradycardia Cushing's Triad is an important, but late sign of raised intracranial pressure that doctors, paramedics and nurses must be on the look for with patients who have had a recent head injury, brain injury, neurosurgery, or anyone with a sudden altered level of consciousness.

During a routine physical examination to assess a male client's deep tendon reflexes, the nurse should make sure to: a. Use the pointed end of the reflex hammer when striking the Achilles tendon b. Support the joint where the tendon is being tested c. Tap the tendon slowly and softly d. Hold the reflex hammer tightly

During a routine physical examination to assess a male client's deep tendon reflexes, the nurse should make sure to: b. Support the joint where the tendon is being tested To prevent the attached muscle from contracting, the nurse should support the joint where the tendon is being tested. The nurse should use the flat, not pointed, end of the reflex hammer when striking the Achilles tendon. (The pointed end is used to strike over small areas, such as the thumb placed over the biceps tendon). Tapping the tendon slowly and softly wouldn't provoke a deep tendon reflex response. The nurse should hold the reflex hammer loosely, not tightly, between the thumb and fingers so it can swing in an arc.

For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to: a. Prevent respiratory alkalosis b. Lower arterial pH c. Promote carbon dioxide elimination d. Maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg

For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to: c. Promote carbon dioxide elimination The goal of treatment is to prevent acidemia by eliminating carbon dioxide. That is because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP. Preventing respiratory alkalosis and lowering arterial pH may bring about acidosis, an undesirable condition in this case. It isn't necessary to maintain a PaO2 as high as 80 mm Hg; 60 mm Hg will adequately oxygenate most clients.

For which of the following medical conditions would the nurse anticipate that an antianxiety agent would not be indicated? a. Seizure disorder b. Alcohol detoxification c. Parkinson's disease d. Panic disorder

For which of the following medical conditions would the nurse anticipate that an antianxiety agent would not be indicated? c. Parkinson's disease Benzodiazepines may exacerbate the symptoms of Parkinson's disease.

Identify appropriate teaching for a client taking phenytoin (Dilantin) for seizure control: a. Use a soft bristled toothbrush b. Keep the HOB at 45 degrees c. Skin reactions are common d. A sore throat is common

Identify the nursing intervention for a client taking phenytoin (Dilantin): a. Use a soft bristled toothbrush Phenytoin (Dilantin) is an anticonvulsant. Gingival hyperplasia, bleeding, swelling, and tenderness of the gums can occur with the use of this medication.

In a spinal cord injury, corticosteroids are contraindicated due to the increased risk of spinal cord edema. a. True b. False

In a spinal cord injury, corticosteroids are contraindicated due to the increased risk of spinal cord edema. b. False A spinal cord injury requires immediate treatment IOT address life-threatening complications and to decrease the risk of long-term problems. Corticosteroid drugs such as dexamethasone (Decadron) or methylprednisolone (Medrol) are used to reduce swelling.

In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when positioning the client? a. Keeping the client flat on one side or the other b. Elevating the head of the bed to 30 degrees c. Log rolling or turning as a unit when turning d. Keeping the head in neutral position

In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when positioning the client? b. Elevating the head of the bed to 30 degrees Elevating the HOB to 30 degrees is contraindicated for infratentorial craniotomies because it could cause herniation of the brain down onto the brainstem and spinal cord, resulting in sudden death. Elevation of the head of the bed to 30 degrees with the head turned to the side opposite of the incision, if not contraindicated by the ICP; is used for supratentorial craniotomies.

Mannitol (Osmitrol) is an osmotic diuretic which is contraindicated in which conditions? Select all that apply. a. Pulmonary edema b. Narrow-angle glaucoma c. Heart failure d. Chemotherapy e. Hyponatremia

Mannitol (Osmitrol) is an osmotic diuretic which is contraindicated in which conditions? Select all that apply. a. Pulmonary edema c. Heart failure e. Hyponatremia Too rapid infusion of large amounts of mannitol injection will cause a shift of intracellular water into the extracellular compartment resulting in cellular dehydration and overexpansion of the intravascular space with hyponatremia, congestive heart failure, and pulmonary edema. Option "b": Mannitol is used to decrease ICP in clients with narrow-angle glaucoma. Option "d": Mannitol is used with chemotherapy to induce diuresis.

Peripherally acting skeletal muscle relaxants are used: a. To treat neuromuscular diseases b. To treat spinal trauma c. To relieve spasms from trauma d. As adjuncts to general anesthesia

Peripherally acting skeletal muscle relaxants are used: d. As adjuncts to general anesthesia Peripherally acting skeletal muscle relaxants are used as an adjunct to general anesthesia.

Phenobarbital (Luminal) is given to a client for a short treatment of anxiety. Which of the following results would indicate a therapeutic serum range of the medication? a. 5-10 mcg/ml b. 15-40 mcg/ml c. 45-65 mcg/ml d. 50-90 mcg/ml

Phenobarbital (luminal) is given to a client for a short treatment of anxiety. Which of the following results would indicate a therapeutic serum range of the medication? b. 15-40 mcg/ml The therapeutic serum range of phenobarbital is 15-40 mcg/ml.

The client admitted to the hospital for observation with a probable head injury after an automobile accident. The nurse expects the cervical collar will remain in place until which time? a. The client is taken for spinal x-rays b. The family comes to visit after surgery c. The nurse needs to provide physical care d. The health care provider reviews the x-ray results

The client admitted to the hospital for observation with a probable head injury after an automobile accident. The nurse expects the cervical collar will remain in place until which time? d. The health care provider reviews the x-ray results There is a significant association between cervical spine injury and head injury. For this reason, the nurse leaves any form of spinal immobilization in place until lateral cervical spine x-rays rule out fracture or other damage and the results have been reviewed by the health care provider.

The client asks the nurse why he is taking bromocriptine (Parlodel). The nurse's reply is based on the understanding that bromocriptine mimics the effects of dopamine by: a. Decreasing dopamine levels in the brain b. Decreasing the storage of dopamine peripherally c. Activating dopamine receptors in the brain d. Inhibiting monoamine oxidase type B

The client asks the nurse why he is taking bromocriptine (Parlodel). The nurse's reply is based on the understanding that bromocriptine mimics the effects of dopamine by: c. Activating dopamine receptors in the brain Bromocriptine is a dopaminergic agent, and this response refers to its action. Choice "a" refers to the action of levodopa. Choice "b" refers to the action of carbidopa and levodopa. Choice "d" refers to the action of selegiline.

The nurse is teaching the client with MS about the use of corticosteroids. Which of the following statements by the patient indicates an understanding of the use of corticosteroids? a. "I should watch for side effects such as euphoria and insomnia while taking this medication." b. "This medication will need to be administered for at least 2 weeks before I begin to see improvement in my condition." c. "The corticosteroids will reduce my chances of relapsing in the future." d. "I could see flu-like symptoms while taking this medication."

Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia? a. Absence of pain sensation in chest b. Spasticity c. Spontaneous respirations d. Urinary continence

Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia? b. Spasticity Spasticity, the return of reflexes, is a sign of resolving shock. Spinal or neurogenic shock is characterized by hypotension, bradycardia, dry skin, flaccid paralysis, or the absence of reflexes below the level of injury. The absence of pain sensation in the chest doesn't apply to spinal shock. Spinal shock descends from the injury, and respiratory difficulties occur at C4 and above.

A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client's vital signs, list in order of priority, the nurse's actions (Number 1 being the first priority and number 5 being the last priority). a. Check for bladder distention b. Raise the head of the bed c. Contact the physician d. Loosen tight clothing on the client e. Administer an antihypertensive medication

b. Raise the head of the bed d. Loosen tight clothing on the client a. Check for bladder distention c. Contact the physician e. Administer an antihypertensive medication Autonomic dysreflexia is characterized by severe hypertension, bradycardia, severe headache, nasal stuffiness, and flushing. The cause is a noxious stimulus, most often a distended bladder or constipation. Autonomic dysreflexia is a neurological emergency and must be treated promptly to prevent a hypertensive stroke. Immediate nursing actions are to sit the client up in bed in a high-Fowler's position and remove the noxious stimulus. The nurse should loosen any tight clothing and then check for bladder distention. If the client has a Foley catheter, the nurse should check for kinks in the tubing. The nurse also would check for a fecal impaction and disimpact if necessary. The physician is contacted especially if these actions do not relieve the signs and symptoms. Antihypertensive medications may be prescribed by the physician to minimize cerebral hypertension.

During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which of the following interventions? a. Elevate the client's legs b. Put the client flat in bed c. Put the client in the Trendelenburg's position d. Put the client in the high-Fowler's position

d. Put the client in the high-Fowler's position Putting the client in the high-Fowler's position will decrease cerebral blood flow, decreasing hypertension. Elevating the client's legs, putting the client flat in bed, or putting the bed in the Trendelenburg's position places the client in positions that improve cerebral blood flow, worsening hypertension.

A child is experiencing febrile seizures. What medication would you expect the physician to prescribe? a. Gabapentin b. Phenobarbital c. Zofran d. Water

A child is experiencing febrile seizures. What medication would you expect the physician to prescribe? b. Phenobarbital

A client with bell's palsy tells the nurse that acetaminophen (Tylenol) is taken daily as prescribed by the physician. Which laboratory value would indicate a toxicity of the medication? a. Blood urea nitrogen of 60 mg/dl b. Total bilirubin of 1.5 mg/dl c. Alkaline phosphatase of 120 IU/L d. Direct bilirubin of 0.3 mg/dl

A client with bell's palsy tells the nurse that acetaminophen (Tylenol) is taken daily as prescribed by the physician. Which laboratory value would indicate a toxicity of the medication? a. Blood urea nitrogen of 60 mg/dl Acetaminophen is hepatotoxic. Among the choices, the blood urea nitrogen is elevated. The normal value of BUA is between 7 to 20 mg/dl (2.5 to 7.1 mmol/L). Options "b," "c," and "d" all have normal values.

A white female client is admitted to an acute care facility with a diagnosis of cerebrovascular accident (CVA). Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for CVA? c. Obesity Obesity is a risk factor for CVA. Other risk factors include a history of ischemic episodes, cardiovascular disease, diabetes mellitus, atherosclerosis of the cranial vessels, hypertension, polycythemia, smoking, hypercholesterolemia, oral contraceptive use, emotional stress, family history of CVA, and advancing age. The client's race, sex, and bronchial asthma aren't risk factors for CVA.

A male client is having a tonic-clonic seizure. What should the nurse do first? a. Elevate the HOB b. Restrain the client's arms and legs c. Place a tongue blade in the client's mouth d. Take measures to prevent injury

A male client is having a tonic-clonic seizure. What should the nurse do first? d. Take measures to prevent injury Protecting the client from injury is the immediate priority during a seizure. Elevating the head of the bed would have no effect on the client's condition or safety. Restraining the client's arms and legs could cause injury. Placing a tongue blade or other object in the client's mouth could damage the teeth.

A pediatric client went to the emergency room complaining of right upper quadrant abdominal pain, nausea, and vomiting. Upon the interview of the nurse to the mother, the client has been taking a long-term use of acetaminophen. An overdose of the medication is suspected. Which of the following medications should be readily available? a. Naltrexone (ReVia) b. Urea (Ureaphil) c. Acetylcysteine (Mucomyst) d. Valproic acid (Depakene)

A pediatric client went to the emergency room complaining of right upper quadrant abdominal pain, nausea, and vomiting. Upon the interview of the nurse to the mother, the client has been taking a long-term use of acetaminophen. An overdose of the medication is suspected. Which of the following medications should be readily available? c. Acetylcysteine (Mucomyst) Acetylcysteine (Mucomyst) is the antidote for acetaminophen toxicity. Option "a" is an opioid antagonist. Option "b" is an osmotic diuretic. Option "c" is a valproate.

The nurse is caring for a client with glaucoma who is receiving acetazolamide (Diamox Sequels), a carbonic anhydrase inhibitor. Which sign/symptom indicates to the nurse that the client is experiencing an adverse effect related to the medication? a. Diarrhea b. Irritability c. Low back pain and dysuria d. Lacrimation

The client diagnosed with ALS is prescribed an antiglutamate, riluzole (Rilutek). Which instruction should the nurse give the client? a. Take the medication with food b. Avoid eating green leafy vegetables c. Use SPF 30 when going out in the sun d. Report any febrile illness

The client diagnosed with ALS is prescribed an antiglutamate, riluzole (Rilutek). Which instruction should the nurse discuss with the client? d. Report any febrile illness Cases of severe neutropenia (absolute neutrophil count less than 500 per mm3) within the first 2 months of RILUTEK treatment have been reported. Advise patients to report febrile illnesses.

The client with myasthenia gravis is suspected of having cholinergic crisis. Which sign/symptom indicates a crisis is taking place? a. Ataxia b. Mouth sores c. Hypothermia d. Hypertension

The client with myasthenia gravis is suspected of having cholinergic crisis. Which sign/symptom indicates a crisis is taking place? d. Hypertension Cholinergic crisis occurs as a result of an overdose of medication. Indications of cholinergic crisis include gastrointestinal disturbances, nausea, vomiting, diarrhea, abdominal cramps, increased salivation and tearing, miosis, hypertension, sweating, and increased bronchial secretions.

Which neurotransmitter is responsible for may of the functions of the frontal lobe? a. Dopamine b. GABA c. Histamine d. Norepinephrine

Which neurotransmitter is responsible for may of the functions of the frontal lobe? a. Dopamine The frontal lobe primarily functions to regulate thinking, planning, and affect. Dopamine is known to circulate widely throughout this lobe, which is why it's such an important neurotransmitter in schizophrenia.

Which of the following respiratory patterns indicate increasing ICP in the brain stem? a. Asymmetric chest expansion b. Nasal flaring c. Slow, irregular respirations d. Rapid, shallow respirations

Which of the following respiratory patterns indicate increasing ICP in the brain stem? c. Slow, irregular respirations Neural control of respiration takes place in the brain stem. Deterioration and pressure produce irregular respiratory patterns. Rapid, shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic of respiratory distress or hypoxia.

A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor? a. Tachycardia b. Unequal pupil size c. Decreasing body temperature d. Decreasing systolic blood pressure

A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor? b. Unequal pupil size Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.

A 17-year-old client is taking phenytoin (Dilantin) for the treatment of seizures. The phenytoin blood level indicates 25 mcg/ml. Which of the following symptoms would be expected as a result of the laboratory finding? a. No symptoms, because the value is within normal range b. Hypoglycemia c. Tachycardia d. Nystagmus

A 17-year-old client is taking Phenytoin (Dilantin) for the treatment of seizures. The phenytoin blood level indicates 25 mcg/ml. Which of the following symptoms would be expected as a result of the laboratory finding? d. Nystagmus The therapeutic level of phenytoin is 10-20mcg/ml. Higher than 20mcg/ml results in nystagmus (involuntary eye movement).

A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first? a. Place client flat in bed b. Assess patency of the indwelling urinary catheter c. Give one SL nitroglycerin tablet d. Raise the HOB immediately to 90 degrees

A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first? d. Raise the HOB immediately to 90 degrees Anxiety, flushing above the level of the lesion, piloerection, hypertension, and bradycardia are symptoms of autonomic dysreflexia, typically caused by such noxious stimuli such as a full bladder, fecal impaction, or decubitus ulcer. Putting the client flat will cause the blood pressure to increase even more. The indwelling urinary catheter should be assessed immediately after the HOB is raised. Nitroglycerin is given to reduce chest pain and reduce preload; it isn't used for hypertension or dysreflexia.

A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first? a. Suction the nose to maintain airway patency b. Check the fluid for dextrose with a dipstick c. Insert nasal and ear packing with sterile gauze d. Position the client flat in bed

A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first? b. Check the fluid for dextrose with a dipstick Clear fluid from the nose or ear can be determined to be cerebral spinal fluid or mucous by the presence of dextrose. Placing the client flat in bed may increase ICP and promote pulmonary aspiration. The nose wouldn't be suctioned because of the risk for suctioning brain tissue through the sinuses. Nothing is inserted into the ears or nose of a client with a skull fracture because of the risk of infection.

A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority? a. Neurological deficit b. The client's feelings about the injury c. Bladder distension d. Pulse ox readings

A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority? d. Pulse ox readings After a spinal cord injury, ascending cord edema may cause a higher level of injury. The diaphragm is innervated at the level of C4, so assessment of adequate oxygenation and ventilation is necessary. Although the other options would be necessary at a later time, observation for respiratory failure is the priority.

A client has a cervical spine injury at the level of C5. Which of the following conditions would the nurse anticipate during the acute phase? a. Absent corneal reflex b. Decerebrate posturing c. Movement of only the right or left half of the body d. The need for mechanical ventilation

A client has a cervical spine injury at the level of C5. Which of the following conditions would the nurse anticipate during the acute phase? d. The need for mechanical ventilation

A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia? a. Lumbar spinal cord injury b. Headache c. Neurogenic shock d. Noxious stimuli

A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia? d. Noxious stimuli Noxious stimuli, such as a full bladder, fecal impaction, or a decub ulcer, may cause autonomic dysreflexia. A headache is a symptom of autonomic dysreflexia, not a cause. Autonomic dysreflexia is most commonly seen with injuries at T10 or above. Neurogenic shock isn't a cause of dysreflexia.

Carbidopa - Levodopa (Sinemet) is prescribed for the client with Parkinson's disease, and the nurse monitors the client for adverse effects of the medication. Which sign/symptom indicates the client is experiencing an adverse effect? d. Impaired voluntary movements Dyskinesia and impaired voluntary movement may occur with high levodopa dosages. Nausea, anorexia, dizziness, orthostatic hypotension, bradycardia, and akinesia (the temporary muscle weakness that lasts 1 minute to 1 hour) are frequent side effects of the medication.

When caring for a client who is receiving phenytoin and warfarin (Coumadin), the nurse would expect which of the following drug-drug interactions? a. Decreased effectiveness of warfarin b. Increased effectiveness of phenytoin c. Increased effectiveness of warfarin d. Decreased effectiveness of phenytoin

When caring for a client who is receiving phenytoin and warfarin (Coumadin), the nurse would expect which of the following drug-drug interactions? a. Decreased effectiveness of warfarin

A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which of the following symptoms would also be anticipated? a. Decreased urine output or oliguria b. Respiratory depression c. Hypertension and bradycardia d. Symptoms of shock

A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which of the following symptoms would also be anticipated? c. Hypertension and bradycardia Hypertension, bradycardia, anxiety, blurred vision, and flushing above the lesion occur with autonomic dysreflexia due to uninhibited sympathetic nervous system discharge. The other options are incorrect.

A 40-year-old paraplegic must perform intermittent catheterization of the bladder. Which of the following instructions should be given? a. "Clean the meatus with soap and water." Intermittent catheterization may be performed chronically with clean technique, using soap and water to clean the urinary meatus. The meatus is always cleaned from front to back in a woman, or in expanding circles working outward from the meatus in a man. It isn't necessary to measure the urine. The catheter doesn't need to be rotated during removal.

A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest? c. Epidural hematoma An epidural hematoma occurs when blood collects between the skull and the dura mater. In a subdural hematoma, venous blood collects between the dura mater and the arachnoid mater. In a subarachnoid hemorrhage, blood collects between the pia mater and arachnoid membrane. A contusion is a bruise on the brain's surface.

The priority nursing intervention for a client receiving amantadine is to teach the client to: a. Monitor the pulse rate for regularity b. Take the last dose of medication at bedtime c. Inspect the skin for erythematous rash d. Stop taking the drug if the mouth becomes dry

The priority nursing intervention for a client receiving amantadine is to teach the client to: a. Monitor the pulse rate for regularity Dopaminergic agents can cause heart rate changes and cardiac arrhythmias. Choice "b" is incorrect because amantadine can cause insomnia. Choice "c" is incorrect because an adverse effect of amantadine is a mottled discoloration of the skin. Choice "d" is incorrect because dry mouth is an expected side effect and not an indication to discontinue amantadine.

Which of the following describes decerebrate posturing? a. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers b. Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of the feet c. Supination of arms, dorsiflexion of feet d. Back arched; rigid extension of all four extremities

Which of the following describes decerebrate posturing? b. Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of the feet Decerebrate posturing occurs in patients with damage to the upper brain stem, midbrain, or pons and is demonstrated clinically by arching of the back, rigid extension of the extremities, pronation of the arms, and plantar flexion of the feet. Internal rotation and adduction of arms with flexion of the elbows, wrists, and fingers described decorticate posturing, which indicates damage to corticospinal tracts and cerebral hemispheres.

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