Nursing 406 Unit 3 Nclex

A patient is being given a medication that stimulates her parasympathetic system. Following administration of this medication, the nurse should anticipate what effect? A) Constricted pupils B) Dilated bronchioles C) Decreased peristaltic movement D) Relaxed muscular walls of the urinary bladder

Ans: A Feedback: Parasympathetic stimulation results in constricted pupils, constricted bronchioles, increased peristaltic movement, and contracted muscular walls of the urinary bladder

A patient is scheduled for a myelogram and the nurse explains to the patient that this is an invasive procedure, which assesses for any lesions in the spinal cord. The nurse should explain that the preparation is similar to which of the following neurologic tests? A) Lumbar puncture B) MRI C) Cerebral angiography D) EEG

Ans: A Feedback: A myelogram is an x-ray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture. Patient preparation for a myelogram would be similar to that for lumbar puncture. The other listed diagnostic tests do not involve lumbar puncture

A patient with lower back pain is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should prioritize what action? A) Positioning the patient with the head of the bed elevated 45 degrees B) Administering IV morphine sulfate to prevent headache C) Limiting fluids for the next 12 hours D) Helping the patient perform deep breathing and coughing exercises

Ans: A Feedback: After myelography, the patient lies in bed with the head of the bed elevated 30 to 45 degrees. The patient is advised to remain in bed in the recommended position for 3 hours or as prescribed. Drinking liberal amounts of fluid for rehydration and replacement of CSF may decrease the incidence of postlumbar puncture headache. Deep breathing and coughing exercises are not normally necessary since there is no consequent risk of atelectasis

The nurse is caring for a patient whose recent health history includes an altered LOC. What should be the nurses first action when assessing this patient? A) Assessing the patients verbal response B) Assessing the patients ability to follow complex commands C) Assessing the patients judgment D) Assessing the patients response to pain

Ans: A Feedback: Assessment of the patient with an altered LOC often starts with assessing the verbal response through determining the patients orientation to time, person, and place. In most cases, this assessment will precede each of the other listed assessments, even though each may be indicated.

A patient diagnosed with Bells palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions? A) Applying a protective eye shield at night B) Chewing on the affected side to prevent unilateral neglect C) Avoiding the use of analgesics whenever possible D) Avoiding brushing the teeth

Ans: A Feedback: Corneal irritation and ulceration may occur if the eye is unprotected. While paralysis lasts, the involved eye must be protected. The patient should be encouraged to eat on the unaffected side, due to swallowing difficulties. Analgesics are used to control the facial pain. The patient should continue to provide self-care including oral hygiene.

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

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

The nurse has created a plan of care for a patient who is at risk for increased ICP. The patients care plan should specify monitoring for what early sign of increased ICP? A) Disorientation and restlessness B) Decreased pulse and respirations C) Projectile vomiting D) Loss of corneal reflex

Ans: A Feedback: Early indicators of ICP include disorientation and restlessness. Later signs include decreased pulse and respirations, projectile vomiting, and loss of brain stem reflexes, such as the corneal reflex.

The nurse is caring for a patient who sustained a moderate head injury following a bicycle accident. The nurses most recent assessment reveals that the patients respiratory effort has increased. What is the nurses most appropriate response? A) Inform the care team and assess for further signs of possible increased ICP. B) Administer bronchodilators as ordered and monitor the patients LOC. C) Increase the patients bed height and reassess in 30 minutes. D) Administer a bolus of normal saline as ordered

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

The nurse is working with a patient who is newly diagnosed with MS. What basic information should the nurse provide to the patient? A) MS is a progressive demyelinating disease of the nervous system. B) MS usually occurs more frequently in men. C) MS typically has an acute onset. D) MS is sometimes caused by a bacterial infection.

Ans: A Feedback: MS is a chronic, degenerative, progressive disease of the central nervous system, characterized by the occurrence of small patches of demyelination in the brain and spinal cord. The cause of MS is not known, and the disease affects twice as many women as men.

A gerontologic nurse educator is providing practice guidelines to unlicensed care providers. Because reaction to painful stimuli is sometimes blunted in older adults, what must be used with caution? A) Hot or cold packs B) Analgesics C) Anti-inflammatory medications D) Whirlpool baths

Ans: A Feedback: Reaction to painful stimuli may be decreased with age. Because pain is an important warning signal, caution must be used when hot or cold packs are used. The older patient may be burned or suffer frostbite before being aware of any discomfort. Any medication is used with caution in the elderly, but not because of the decreased sense of heat or cold. Whirlpool baths are generally not a routine treatment ordered for the elderly

. A patient is postoperative day 1 following intracranial surgery. The nurses assessment reveals that the patients LOC is slightly decreased compared with the day of surgery. What is the nurses best response to this assessment finding? A) Recognize that this may represent the peak of post-surgical cerebral edema. B) Alert the surgeon to the possibility of an intracranial hemorrhage. C) Understand that the surgery may have been unsuccessful. D) Recognize the need to refer the patient to the palliative care team.

Ans: A Feedback: Some degree of cerebral edema occurs after brain surgery; it tends to peak 24 to 36 hours after surgery, producing decreased responsiveness on the second postoperative day. As such, there is not necessarily any need to deem the surgery unsuccessful or to refer the patient to palliative care. A decrease in LOC is not evidence of an intracranial hemorrhage.

A patient exhibiting an uncoordinated gait has presented at the clinic. Which of the following is the most plausible cause of this patients health problem? A) Cerebellar dysfunction B) A lesion in the pons C) Dysfunction of the medulla D) A hemorrhage in the midbrain

Ans: A Feedback: The cerebellum controls fine movement, balance, position sense, and integration of sensory input. Portions of the pons control the heart, respiration, and blood pressure. Cranial nerves IX through XII connect to the brain in the medulla. Cranial nerves III and IV originate in the midbrain.

A patient is admitted to the medical unit with an exacerbation of multiple sclerosis. When assessing this patient, the nurse has the patient stick out her tongue and move it back and forth. What is the nurse assessing? A) Function of the hypoglossal nerve B) Function of the vagus nerve C) Function of the spinal nerve D) Function of the trochlear nerve

Ans: A Feedback: The hypoglossal nerve is the 12th cranial nerve. It is responsible for movement of the tongue. None of the other listed nerves affects motor function in the tongue.

The patient in the ED has just had a diagnostic lumbar puncture. To reduce the incidence of a postlumbar puncture headache, what is the nurses most appropriate action? A) Position the patient prone. B) Position the patient supine with the head of bed flat. C) Position the patient left side-lying. D) Administer acetaminophen as ordered

Ans: A Feedback: The lumbar puncture headache may be avoided if a small-gauge needle is used and if the patient remains prone after the procedure. Acetaminophen is not administered as a preventative measure for post-lumbar puncture headaches.

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

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

The nurse is caring for a patient with permanent neurologic impairments resulting from a traumatic head injury. When working with this patient and family, what mutual goal should be prioritized? A) Achieve as high a level of function as possible. B) Enhance the quantity of the patients life. C) Teach the family proper care of the patient. D) Provide community assistance.

Ans: A Feedback: The overarching goals of care are to achieve as high a level of function as possible and to enhance the quality of life for the patient with neurologic impairment and his or her family. This goal encompasses family and community participation.

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

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

A hospital patient has experienced a seizure. In the immediate recovery period, what action best protects the patients safety? A) Place the patient in a side-lying position. B) Pad the patients bed rails. C) Administer antianxiety medications as ordered. D) Reassure the patient and family members.

Ans: A Feedback: To prevent complications, the patient is placed in the side-lying position to facilitate drainage of oral secretions. Suctioning is performed, if needed, to maintain a patent airway and prevent aspiration. None of the other listed actions promotes safety during the immediate recovery period.

The nurse is planning discharge education for a patient with trigeminal neuralgia. The nurse knows to include information about factors that precipitate an attack. What would the nurse be correct in teaching the patient to avoid? A) Washing his face B) Exposing his skin to sunlight C) Using artificial tears D) Drinking large amounts of fluids

Ans: A Feedback: Washing the face should be avoided if possible because this activity can trigger an attack of pain in a patient with trigeminal neuralgia. Using artificial tears would be an appropriate behavior. Exposing the skin to sunlight would not be harmful to this patient. Temperature extremes in beverages should be avoided.

The nurse is admitting a patient to the unit who is scheduled for removal of an intracranial mass. What diagnostic procedures might be included in this patients admission orders? Select all that apply. A) Transcranial Doppler flow study B) Cerebral angiography C) MRI D) Cranial radiography E) Electromyelography (EMG)

Ans: A, B, C Feedback: Preoperative diagnostic procedures may include a CT scan to demonstrate the lesion and show the degree of surrounding brain edema, the ventricular size, and the displacement. An MRI scan provides information similar to that of a CT scan with improved tissue contrast, resolution, and anatomic definition. Cerebral angiography may be used to study a tumors blood supply or to obtain information about vascular lesions. Transcranial Doppler flow studies are used to evaluate the blood flow within intracranial blood vessels. Regular x-rays of the skull would not be diagnostic for an intracranial mass. An EMG would not be ordered prior to intracranial surgery to remove a mass.

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

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

The nurse caring for a patient in a persistent vegetative state is regularly assessing for potential complications. Complications of neurologic dysfunction for which the nurse should assess include which of the following? Select all that apply. A) Contractures B) Hemorrhage C) Pressure ulcers D) Venous thromboembolism E) Pneumonia

Ans: A, C, D, E Feedback: Based on the assessment data, potential complications may include respiratory distress or failure, pneumonia, aspiration, pressure ulcer, deep vein thrombosis (DVT), and contractures. The pathophysiology of decreased LOC does not normally create a heightened risk for hemorrhage.

A male patient presents to the clinic complaining of a headache. The nurse notes that the patient is guarding his neck and tells the nurse that he has stiffness in the neck area. The nurse suspects the patient may have meningitis. What is another well-recognized sign of this infection? A) Negative Brudzinskis sign B) Positive Kernigs sign C) Hyperpatellar reflex D) Sluggish pupil reaction

Ans: B Feedback: Meningeal irritation results in a number of well-recognized signs commonly seen in meningitis, such as a positive Kernigs sign, a positive Brudzinskis sign, and photophobia. Hyperpatellar reflex and a sluggish pupil reaction are not commonly recognized signs of meningitis.

A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, agerelated changes. Of what phenomenon should the nurse be aware? A) Hyperactive deep tendon reflexes B) Reduction in cerebral blood flow C) Increased cerebral metabolism D) Hypersensitivity to painful stimuli

Ans: B Feedback: Reduction in cerebral blood flow (CBF) is a change that occurs in the normal aging process. Deep tendon reflexes can be decreased or, in some cases, absent. Cerebral metabolism decreases as the patient advances in age. Reaction to painful stimuli may be decreased with age. Because pain is an important warning signal, caution must be used when hot or cold packs are used

The nurse is participating in the care of a patient with increased ICP. What diagnostic test is contraindicated in this patients treatment? A) Computed tomography (CT) scan B) Lumbar puncture C) Magnetic resonance imaging (MRI) D) Venous Doppler studies

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

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

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

The nurse is caring for a patient who exhibits abnormal results of the Weber test and Rinne test. The nurse should suspect dysfunction involving what cranial nerve? A) Trigeminal B) Acoustic C) Hypoglossal D) Trochlear

Ans: B Feedback: Abnormal hearing can correlate with damage to cranial nerve VIII (acoustic). The acoustic nerve functions in hearing and equilibrium. The trigeminal nerve functions in facial sensation, corneal reflex, and chewing. The hypoglossal nerve moves the tongue. The trochlear nerve controls muscles that move the eye

A patient with herpes simplex virus encephalitis (HSV) has been admitted to the ICU. What medication would the nurse expect the physician to order for the treatment of this disease process? A) Cyclosporine (Neoral) B) Acyclovir (Zovirax) C) Cyclobenzaprine (Flexeril) D) Ampicillin (Prinicpen)

Ans: B Feedback: Acyclovir (Zovirax) or ganciclovir (Cytovene), antiviral agents, are the medications of choice in the treatment of HSV. The mode of action is the inhibition of viral DNA replication. To prevent relapse, treatment would continue for up to 3 weeks. Cyclosporine is an immunosuppressant and antirheumatic. Cyclobenzaprine is a centrally acting skeletal muscle relaxant. Ampicillin, an antibiotic, is ineffective against viruses.

A clinic nurse is caring for a patient diagnosed with migraine headaches. During the patient teaching session, the patient questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the patient about the effects of alcohol? A) Alcohol causes hormone fluctuations. B) Alcohol causes vasodilation of the blood vessels. C) Alcohol has an excitatory effect on the CNS. D) Alcohol diminishes endorphins in the brain

Ans: B Feedback: Alcohol causes vasodilation of the blood vessels and may exacerbate migraine headaches. Alcohol has a depressant effect on the CNS. Alcohol does not cause hormone fluctuations, nor does it decrease endorphins (morphine-like substances produced by the body) in the brain.

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

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

A patient with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a patient with this diagnosis? A) Pain upon ankle dorsiflexion of the foot B) Neck flexion produces flexion of knees and hips C) Inability to stand with eyes closed and arms extended without swaying D) Numbness and tingling in the lower extremities

Ans: B Feedback: Clinical manifestations of bacterial meningitis include a positive Brudzinskis sign. Neck flexion producing flexion of knees and hips correlates with a positive Brudzinskis sign. Positive Homans sign (pain upon dorsiflexion of the foot) and negative Rombergs sign (inability to stand with eyes closed and arms extended) are not expected assessment findings for the patient with bacterial meningitis. Peripheral neuropathy manifests as numbness and tingling in the lower extremities. Again, this would not be an initial assessment to rule out bacterial meningitis.

The nurse is doing an initial assessment on a patient newly admitted to the unit with a diagnosis of cerebrovascular accident (CVA). The patient has difficulty copying a figure that the nurse has drawn and is diagnosed with visual-receptive aphasia. What brain region is primarily involved in this deficit? A) Temporal lobe B) Parietal-occipital area C) Inferior posterior frontal areas D) Posterior frontal area

Ans: B Feedback: Difficulty copying a figure that the nurse has drawn would be considered visual-receptive aphasia, which involves the parietal-occipital area. Expressive aphasia, the inability to express oneself, is often associated with damage to the frontal area. Receptive aphasia, the inability to understand what someone else is saying, is often associated with damage to the temporal lobe area.

The nurse is caring for a patient with multiple sclerosis (MS). The patient tells the nurse the hardest thing to deal with is the fatigue. When teaching the patient how to reduce fatigue, what action should the nurse suggest? A) Taking a hot bath at least once daily B) Resting in an air-conditioned room whenever possible C) Increasing the dose of muscle relaxants D) Avoiding naps during the day

Ans: B Feedback: Fatigue is a common symptom of patients with MS. Lowering the body temperature by resting in an airconditioned 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 patient with MS include treating depression, using occupational therapy to learn energy conservation techniques, and reducing spasticity.

The nurse is performing a neurologic assessment of a patient whose injuries have rendered her unable to follow verbal commands. How should the nurse proceed with assessing the patients level of consciousness (LOC)? A) Assess the patients vital signs and correlate these with the patients baselines. B) Assess the patients eye opening and response to stimuli. C) Document that the patient currently lacks a level of consciousness. D) Facilitate diagnostic testing in an effort to obtain objective data

Ans: B Feedback: If the patient is not alert or able to follow commands, the examiner observes for eye opening; verbal response and motor response to stimuli, if any; and the type of stimuli needed to obtain a response. Vital signs and diagnostic testing are appropriate, but neither will allow the nurse to gauge the patients LOC. Inability to follow commands does not necessarily denote an absolute lack of consciousness.

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

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

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

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

The nurse is providing care for a patient who is unconscious. What nursing intervention takes highest priority? A) Maintaining accurate records of intake and output B) Maintaining a patent airway C) Inserting a nasogastric (NG) tube as ordered D) Providing appropriate pain control

Ans: B Feedback: Maintaining a patent airway always takes top priority, even though each of the other listed actions is necessary and appropriate.

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

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

In the course of a focused neurologic assessment, the nurse is palpating the patients major muscle groups at rest and during passive movement. Data gleaned from this assessment will allow the nurse to describe which of the following aspects of neurologic function? A) Muscle dexterity B) Muscle tone C) Motor symmetry D) Deep tendon reflexes

Ans: B Feedback: Muscle tone (the tension present in a muscle at rest) is evaluated by palpating various muscle groups at rest and during passive movement. Data from this assessment do not allow the nurse to ascertain the patients dexterity, reflexes, or motor symmetry.

The nurse is planning the care of a patient with Parkinsons disease. The nurse should be aware that treatment will focus on what pathophysiological phenomenon? A) Premature degradation of acetylcholine B) Decreased availability of dopamine C) Insufficient synthesis of epinephrine D) Delayed reuptake of serotonin

Ans: B Feedback: Parkinsons disease develops from decreased availability of dopamine, not acetylcholine, epinephrine, or serotonin.

A patient scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the patient for the MRI should prioritize which of the following actions? A) Withholding stimulants 24 to 48 hours prior to exam B) Removing all metal-containing objects C) Instructing the patient to void prior to the MRI D) Initiating an IV line for administration of contrast

Ans: B Feedback: Patient preparation for an MRI consists of removing all metal-containing objects prior to the examination. Withholding stimulants would not affect an MRI; this relates to an electroencephalography (EEG). Instructing the patient to void is patient preparation for a lumbar puncture. Initiating an IV line for administration of contrast would be done if the patient was having a CT scan with contrast.

The physician has ordered a somatosensory evoked responses (SERs) test for a patient for whom the nurse is caring. The nurse is justified in suspecting that this patient may have a history of what type of neurologic disorder? A) Hypothalamic disorder B) Demyelinating disease C) Brainstem deficit D) Diabetic neuropathy

Ans: B Feedback: SERs are used to detect deficits in the spinal cord or peripheral nerve conduction and to monitor spinal cord function during surgical procedures. The test is also useful in the diagnosis of demyelinating diseases, such as multiple sclerosis and polyneuropathies, where nerve conduction is slowed. The test is not done to diagnose hypothalamic disorders, brainstem deficits, or diabetic neuropathies.

To alleviate pain associated with trigeminal neuralgia, a patient is taking Tegretol (carbamazepine). What health education should the nurse provide to the patient before initiating this treatment? A) Concurrent use of calcium supplements is contraindicated. B) Blood levels of the drug must be monitored. C) The drug is likely to cause hyperactivity and agitation D) Tegretol can cause tinnitus during the first few days of treatment.

Ans: B Feedback: Side effects of Tegretol include nausea, dizziness, drowsiness, and aplastic anemia. The patient must also be monitored for bone marrow depression during long-term therapy. Skin discoloration, insomnia, and tinnitus are not side effects of Tegretol.

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

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

A trauma patient in the ICU has been declared brain dead. What diagnostic test is used in making the determination of brain death? A) Magnetic resonance imaging (MRI) B) Electroencephalography (EEG) C) Electromyelography (EMG) D) Computed tomography (CT)

Ans: B Feedback: The EEG can be used in determining brain death. MRI, CT, and EMG are not normally used in determining brain death.

A patient with metastatic cancer has developed trigeminal neuralgia and is taking carbamazepine (Tegretol) for pain relief. What principle applies to the administration of this medication? A) Tegretol is not known to have serious adverse effects. B) The patient should be monitored for bone marrow depression. C) Side effects of the medication include renal dysfunction. D) The medication should be first taken in the maximum dosage form to be effective.

Ans: B Feedback: The anticonvulsant agents carbamazepine (Tegretol) and phenytoin (Dilantin) relieve pain in most patients diagnosed with trigeminal neuralgia by reducing the transmission of impulses at certain nerve terminals. Side effects include nausea, dizziness, drowsiness, and aplastic anemia. Carbamazepine should be gradually increased until pain relief is obtained.

The neurologic ICU nurse is admitting a patient following a craniotomy using the supratentorial approach. How should the nurse best position the patient? A) Position the patient supine. B) Maintain head of bed (HOB) elevated at 30 to 45 degrees. C) Position patient in prone position. D) Maintain bed in Trendelenberg position.

Ans: B Feedback: The patient undergoing a craniotomy with a supratentorial (above the tentorium) approach should be placed with the HOB elevated 30 to 45 degrees, with the neck in neutral alignment. Each of the other listed positions would cause a dangerous elevation in ICP.

A patient is brought to the ER following a motor vehicle accident in which he sustained head trauma. Preliminary assessment reveals a vision deficit in the patients left eye. The nurse should associate this abnormal finding with trauma to which of the following cerebral lobes? A) Temporal B) Occipital C) Parietal D) Frontal

Ans: B Feedback: The posterior lobe of the cerebral hemisphere is responsible for visual interpretation. The temporal lobe contains the auditory receptive areas. The parietal lobe contains the primary sensory cortex, and is essential to an individuals awareness of the body in space, as well as orientation in space and spatial relations. The frontal lobe functions in concentration, abstract thought, information storage or memory, and motor function.

The nurse is caring for a patient who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of deficient fluid volume related to fluid restriction and osmotic diuretic use. What would be an appropriate intervention for this diagnosis? A) Change the patients position as indicated. B) Monitor serum electrolytes. C) Maintain NPO status. D) Monitor arterial blood gas (ABG) values.

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

The nurse has admitted a new patient to the unit. One of the patients admitting orders is for an adrenergic medication. The nurse knows that this medication will have what effect on the circulatory system? A) Thin, watery saliva B) Increased heart rate C) Decreased BP D) Constricted bronchioles

Ans: B Feedback: The term adrenergic refers to the sympathetic nervous system. Sympathetic effects include an increased rate and force of the heartbeat. Cholinergic effects, which correspond to the parasympathetic division of the autonomic nervous system, include thin, watery saliva, decreased rate and force of heartbeat, and decreased BP.

The nurse educator is reviewing the assessment of cranial nerves. What should the educator identify as the specific instances when cranial nerves should be assessed? Select all that apply. A) When a neurogenic bladder develops B) When level of consciousness is decreased C) With brain stem pathology D) In the presence of peripheral nervous system disease E) When a spinal reflex is interrupted

Ans: B, C, D Feedback: Cranial nerves are assessed when level of consciousness is decreased, with brain stem pathology, or in the presence of peripheral nervous system disease. Abnormalities in muscle tone and involuntary movements are less likely to prompt the assessment of cranial nerves, since these nerves do not directly mediate most aspects of muscle tone and movement.

Assessment is crucial to the care of patients with neurologic dysfunction. What does accurate and appropriate assessment require? Select all that apply. A) The ability to select mediations for the neurologic dysfunction B) Understanding of the tests used to diagnose neurologic disorders C) Knowledge of nursing interventions related to assessment and diagnostic testing D) Knowledge of the anatomy of the nervous system

Ans: B, C, D Feedback: Assessment requires knowledge of the anatomy and physiology of the nervous system and an understanding of the array of tests and procedures used to diagnose neurologic disorders. Knowledge about the nursing implications and interventions related to assessment and diagnostic testing is also essential. Selecting medications and interpreting diagnostic tests are beyond the normal scope of the nurse.

A patient is being admitted to the neurologic ICU following an acute head injury that has resulted incerebral edema. When planning this patients care, the nurse would expect to administer what prioritymedication? A)Hydrochlorothiazide (HydroDIURIL) B)Furosemide (Lasix) C)Mannitol (Osmitrol) D)Spirolactone (Aldactone)

Ans: C Feedback:The osmotic diuretic mannitol is given to dehydrate the brain tissue and reduce cerebral edema. Thisdrug acts by reducing the volume of brain and extracellular fluid. Spirolactone, furosemide, andhydrochlorothiazide are diuretics that are not typically used in the treatment of increased ICP resultingfrom cerebral edema

Following a traumatic brain injury, a patient has been in a coma for several days. Which of the following statements is true of this patients current LOC? A) The patient occasionally makes incomprehensible sounds. B) The patients current LOC will likely become a permanent state. C) The patient may occasionally make nonpurposeful movements. D) The patient is incapable of spontaneous respirations

Ans: C Feedback: Coma is a clinical state of unarousable unresponsiveness in which no purposeful responses to internal or external stimuli occur, although nonpurposeful responses to painful stimuli and brain stem reflexes may be present. Verbal sounds, however, are atypical. Ventilator support may or may not be necessary. Comas are not permanent states.

A patient with increased ICP has a ventriculostomy for monitoring ICP. The nurses most recent assessment reveals that the patient is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication? A) Encephalitis B) CSF leak C) Meningitis D) Catheter occlusion

Ans: C Feedback: Complications of a ventriculostomy include ventricular infectious meningitis and problems with the monitoring system. Nuchal rigidity and photophobia are clinical manifestations of meningitis, but are not suggestive of encephalitis, a CSF leak, or an occluded catheter.

A patient had a lumbar puncture performed at the outpatient clinic and the nurse has phoned the patient and family that evening. What does this phone call enable the nurse to determine? A) What are the patients and familys expectations of the test B) Whether the patients family had any questions about why the test was necessary C) Whether the patient has had any complications of the test D) Whether the patient understood accurately why the test was done

Ans: C Feedback: Contacting the patient and family after diagnostic testing enables the nurse to determine whether they have any questions about the procedure or whether the patient had any untoward results. The other listed information should have been elicited from the patient and family prior to the test.

When caring for a patient with an altered level of consciousness, the nurse is preparing to test cranial nerve VII. What assessment technique would the nurse use to elicit a response from cranial nerve VII? A) Palpate trapezius muscle while patient shrugs should against resistance. B) Administer the whisper or watch-tick test. C) Observe for facial movement symmetry, such as a smile. D) Note any hoarseness in the patients voice

Ans: C Feedback: Cranial nerve VII is the facial nerve. An appropriate assessment technique for this cranial nerve would include observing for symmetry while the patient performs facial movements: smiles, whistles, elevates eyebrows, and frowns. Palpating and noting strength of the trapezius muscle while the patient shrugs shoulders against resistance would be completed to assess cranial nerve XI (spinal accessory). Assessing cranial nerve VIII (acoustic) would involve using the whisper or watch-tick test to evaluate hearing. Noting any hoarseness in the patients voice would involve assessment of cranial nerve X (vagus).

A patient with Guillain-Barr syndrome has experienced a sharp decline in vital capacity. What is the nurses most appropriate action? A) Administer bronchodilators as ordered. B) Remind the patient of the importance of deep breathing and coughing exercises. C) Prepare to assist with intubation. D) Administer supplementary oxygen by nasal cannula.

Ans: C Feedback: For the patient with Guillain-Barr syndrome, mechanical ventilation is required if the vital capacity falls, making spontaneous breathing impossible and tissue oxygenation inadequate. Each of the other listed actions is likely insufficient to meet the patients oxygenation needs.

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

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

A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the patients plan of care? A) Monitoring of pulse oximetry B) Administration of a low-protein diet C) Administration of thorough oral hygiene D) Fluid restriction as ordered

Ans: C Feedback: Gingival hyperplasia (swollen and tender gums) can be associated with long-term phenytoin (Dilantin) use. Thorough oral hygiene should be provided consistently and encouraged after discharge. Fluid and protein restriction are contraindicated and there is no particular need for constant oxygen saturation monitoring.

The nurse is caring for a patient with a brain tumor. What drug would the nurse expect to be ordered to reduce the edema surrounding the tumor? A) Solumedrol B) Dextromethorphan C) Dexamethasone D) Furosemide

Ans: C Feedback: If a brain tumor is the cause of the increased ICP, corticosteroids (e.g., dexamethasone) help reduce the edema surrounding the tumor. Solumedrol, a steroid, and furosemide, a loop diuretic, are not the drugs of choice in this instance. Dextromethorphan is used in cough medicines.

A patient is scheduled for CT scanning of the head because of a recent onset of neurologic deficits. What should the nurse tell the patient in preparation for this test? A) No metal objects can enter the procedure room. B) You need to fast for 8 hours prior to the test. C) You will need to lie still throughout the procedure. D) There will be a lot of noise during the test

Ans: C Feedback: Preparation for CT scanning includes teaching the patient about the need to lie quietly throughout the procedure. If the patient were having an MRI, metal and noise would be appropriate teaching topics. There is no need to fast prior to a CT scan of the brain

During the performance of the Romberg test, the nurse observes that the patient sways slightly. What is the nurses most appropriate action? A) Facilitate a referral to a neurologist. B) Reposition the patient supine to ensure safety. C) Document successful completion of the assessment. D) Follow up by having the patient perform the Rinne test

Ans: C Feedback: Slight swaying during the Romberg test is normal, but a loss of balance is abnormal and is considered a positive Romberg test. Slight swaying is not a significant threat to the patients safety. The Rinne test assesses hearing, not balance

A patient is having a fight or flight response after receiving bad news about his prognosis. What affect will this have on the patients sympathetic nervous system? A) Constriction of blood vessels in the heart muscle B) Constriction of bronchioles C) Increase in the secretion of sweat D) Constriction of pupils

Ans: C Feedback: Sympathetic nervous system stimulation results in dilated blood vessels in the heart and skeletal muscle, dilated bronchioles, increased secretion of sweat, and dilated pupils.

A trauma patient was admitted to the ICU with a brain injury. The patient had a change in level of consciousness, increased vital signs, and became diaphoretic and agitated. The nurse should recognize which of the following syndromes as the most plausible cause of these symptoms? A) Adrenal crisis B) Hypothalamic collapse C) Sympathetic storm D) Cranial nerve deficit

Ans: C Feedback: Sympathetic storm is a syndrome associated with changes in level of consciousness, altered vital signs, diaphoresis, and agitation that may result from hypothalamic stimulation of the sympathetic nervous system following traumatic brain injury. Alterations in cranial nerve or adrenal function would not have this result.

The nurse caring for an 80 year-old patient knows that she has a pre-existing history of dulled tactile sensation. The nurse should first consider what possible cause for this patients diminished tactile sensation? A) Damage to cranial nerve VIII B) Adverse medication effects C) Age-related neurologic changes D) An undiagnosed cerebrovascular accident in early adulthood

Ans: C Feedback: Tactile sensation is dulled in the elderly person due to a decrease in the number of sensory receptors. While thorough assessment is necessary, it is possible that this change is unrelated to pathophysiological processes.

The nurse is caring for a patient in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the patients mean arterial pressure (MAP) is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurses most appropriate action? A) Position the patient in the high Fowlers position as tolerated. B) Administer osmotic diuretics as ordered. C) Participate in interventions to increase cerebral perfusion pressure. D) Prepare the patient for craniotomy.

Ans: C Feedback: The cerebral perfusion pressure (CPP) is 55 mm Hg, which is considered low. The normal CPP is 70 to 100 mm Hg. Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage. As a result, interventions are necessary. A craniotomy is not directly indicated. Diuretics and increased height of bed would exacerbate the patients condition.

A patient in the OR goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows that the area of the brain that regulates body temperature is which of the following? A) Cerebellum B) Thalamus C) Hypothalamus D) Midbrain

Ans: C Feedback: The hypothalamus plays an important role in the endocrine system because it regulates the pituitary secretion of hormones that influence metabolism, reproduction, stress response, and urine production. It works with the pituitary to maintain fluid balance through hormonal release and maintains temperature regulation by promoting vasoconstriction or vasodilatation. The cerebellum, thalamus, and midbrain and not directly involved in temperature regulation

A patient is recovering from intracranial surgery that was performed using the transsphenoidal approach. The nurse should be aware that the patient may have required surgery on what neurologic structure? A) Cerebellum B) Hypothalamus C) Pituitary gland D) Pineal gland

Ans: C Feedback: The transsphenoidal approach (through the mouth and nasal sinuses) is often used to gain access to the pituitary gland. This surgical approach would not allow for access to the pineal gland, cerebellum, or hypothalamus.

A neurologic nurse is reviewing seizures with a group of staff nurses. How should this nurse best describe the cause of a seizure? A) Sudden electrolyte changes throughout the brain B) A dysrhythmia in the peripheral nervous system C) A dysrhythmia in the nerve cells in one section of the brain D) Sudden disruptions in the blood flow throughout the brain

Ans: C Feedback: The underlying cause of a seizure is an electrical disturbance (dysrhythmia) in the nerve cells in one section of the brain; these cells emit abnormal, recurring, uncontrolled electrical discharges. Seizures are not caused by changes in blood flow or electrolytes.

A nurse is admitting a patient with a severe migraine headache and a history of acute coronary syndrome. What migraine medication would the nurse question for this patient? A) Rizatriptan (Maxalt) B) Naratriptan (Amerge) C) Sumatriptan succinate (Imitrex) D) Zolmitriptan (Zomig)

Ans: C Feedback: Triptans can cause chest pain and are contraindicated in patients with ischemic heart disease. Maxalt, Amerge, and Zomig are triptans used in routine clinical use for the treatment of migraine headaches.

The nurse is caring for a patient with an upper motor neuron lesion. What clinical manifestations should the nurse anticipate when planning the patients neurologic assessment? A) Decreased muscle tone B) Flaccid paralysis C) Loss of voluntary control of movement D) Slow reflexes

Ans: C Feedback: Upper motor neuron lesions do not cause muscle atrophy, flaccid paralysis, or slow reflexes. However, upper motor neuron lesions normally cause loss of voluntary control.

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

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

A nurse is assessing reflexes in a patient with hyperactive reflexes. When the patients foot is abruptly dorsiflexed, it continues to beat two to three times before settling into a resting position. How would the nurse document this finding? A) Rigidity B) Flaccidity C) Clonus D) Ataxia

Ans: C Feedback: When reflexes are very hyperactive, a phenomenon called clonus may be elicited. If the foot is abruptly dorsiflexed, it may continue to beat two to three times before it settles into a position of rest. Rigidity is an increase in muscle tone at rest characterized by increased resistance to passive stretch. Flaccidity is lack of muscle tone. Ataxia is the inability to coordinate muscle movements, resulting in difficulty walking, talking, and performing self-care activities.

The nurse is caring for a patient who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to prevent seizures in this patient? A) Prednisone B) Dexamethasone C) Cafergot D) Phenytoin

Ans: D Feedback: Antiseizure medication (phenytoin, diazepam) is often prescribed prophylactically for patients who have undergone supratentorial craniotomy because of the high risk of seizures after this procedure. Prednisone and dexamethasone are steroids and do not prevent seizures. Cafergot is used in the treatment of migraines

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

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

The nurse is admitting a patient to the unit who is diagnosed with a lower motor neuron lesion. What entry in the patients electronic record is most consistent with this diagnosis? A) Patient exhibits increased muscle tone. B) Patient demonstrates normal muscle structure with no evidence of atrophy. C) Patient demonstrates hyperactive deep tendon reflexes. D) Patient demonstrates an absence of deep tendon reflexes.

Ans: D Feedback: Lower motor neuron lesions cause flaccid muscle paralysis, muscle atrophy, decreased muscle tone, and loss of voluntary control

The nurse is preparing to provide care for a patient diagnosed with myasthenia gravis. The nurse should know that the signs and symptoms of the disease are the result of what? A) Genetic dysfunction B) Upper and lower motor neuron lesions C) Decreased conduction of impulses in an upper motor neuron lesion D) A lower motor neuron lesion

Ans: D Feedback: Myasthenia gravis is characterized by a weakness of muscles, especially in the face and throat, caused by a lower neuron lesion at the myoneural junction. It is not a genetic disorder. A combined upper and lower neuron lesion generally occurs as a result of spinal injuries. A lesion involving cranial nerves and their axons in the spinal cord would cause decreased conduction of impulses at an upper motor neuron.

The nurse is creating a plan of care for a patient who has a recent diagnosis of MS. Which of the following should the nurse include in the patients care plan? A) Encourage patient to void every hour. B) Order a low-residue diet. C) Provide total assistance with all ADLs. D) Instruct the patient on daily muscle stretching.

Ans: D Feedback: A patient diagnosed with MS should be encouraged to increase the fiber in his or her diet and void 30 minutes after drinking to help train the bladder. The patient should participate in daily muscle stretching to help alleviate and relax muscle spasms

A 72-year-old man has been brought to his primary care provider by his daughter, who claims that he has been experiencing uncharacteristic lapses in memory. What principle should underlie the nurses assessment and management of this patient? A) Loss of short-term memory is normal in older adults, but loss of long-term memory is pathologic. B) Lapses in memory in older adults are considered benign unless they have negative consequences. C) Gradual increases in confusion accompany the aging process. D) Thorough assessment is necessary because changes in cognition are always considered to be pathologic.

Ans: D Feedback: Although mental processing time decreases with age, memory, language, and judgment capacities remain intact. Change in mental status should never be assumed to be a normal part of aging.

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

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

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

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

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

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

The neurologic nurse is testing the function of a patients cerebellum and basal ganglia. What action will most accurately test these structures? A) Have the patient identify the location of a cotton swab on his or her skin with the eyes closed. B) Elicit the patients response to a hypothetical problem. C) Ask the patient to close his or her eyes and discern between hot and cold stimuli. D) Guide the patient through the performance of rapid, alternating movements.

Ans: D Feedback: Cerebellar and basal ganglia influence on the motor system is reflected in balance control and coordination. Coordination in the hands and upper extremities is tested by having the patient perform rapid, alternating movements and point-to-point testing. The cerebellum and basal ganglia do not mediate cutaneous sensation or judgment.

A nurse is caring for a patient diagnosed with Mnires disease. While completing a neurologic examination on the patient, the nurse assesses cranial nerve VIII. The nurse would be correct in identifying the function of this nerve as what? A) Movement of the tongue B) Visual acuity C) Sense of smell D) Hearing and equilibrium

Ans: D Feedback: Cranial nerve VIII (acoustic) is responsible for hearing and equilibrium. Cranial nerve XII (hypoglossal) is responsible for movement of the tongue. Cranial nerve II (optic) is responsible for visual acuity and visual fields. Cranial nerve I (olfactory) functions in sense of smell.

The nursing students are learning how to assess function of cranial nerve VIII. To assess the function of cranial nerve VIII the students would be correct in completing which of the following assessment techniques? A) Have the patient identify familiar odors with the eyes closed. B) Assess papillary reflex. C) Utilize the Snellen chart. D) Test for air and bone conduction (Rinne test)

Ans: D Feedback: Cranial nerve VIII is the acoustic nerve. It functions in hearing and equilibrium. When assessing this nerve, the nurse would test for air and bone conduction (Rinne) with a tuning fork. Assessment of papillary reflex would be completed for cranial nerves III (oculomotor), IV (trochlear), and VI (abducens). The Snellen chart would be used to assess cranial nerve II (optic).

The nurse caring for a patient diagnosed with Guillain-Barr syndrome is planning care with regard to the clinical manifestations associated this syndrome. The nurses communication with the patient should reflect the possibility of what sign or symptom of the disease? A) Intermittent hearing loss B) Tinnitus C) Tongue enlargement D) Vocal paralysis

Ans: D Feedback: Guillain-Barr syndrome is a disorder of the vagus nerve. Clinical manifestations include vocal paralysis, dysphagia, and voice changes (temporary or permanent hoarseness). Hearing deficits, tinnitus, and tongue enlargement are not associated with the disease.

A patient for whom the nurse is caring has positron emission tomography (PET) scheduled. In preparation, what should the nurse explain to the patient? A) The test will temporarily limit blood flow through the brain. B) An allergy to iodine precludes getting the radio-opaque dye. C) The patient will need to endure loud noises during the test. D) The test may result in dizziness or lightheadedness.

Ans: D Feedback: Key nursing interventions for PET scan include explaining the test and teaching the patient about inhalation techniques and the sensations (e.g., dizziness, light-headedness, and headache) that may occur. A PET scan does not impede blood flow through the brain. An allergy to iodine precludes the dye for an MRI, and loud noise is heard in an MRI.

A patient has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the patients ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following? A) Hemiplegia B) Dry mucous membranes C) Signs of internal bleeding D) Loss of brain stem reflexes

Ans: D Feedback: Loss of brain stem reflexes, including pupillary, corneal, gag, and swallowing reflexes, is an ominous sign of approaching death. Dry mucous membranes, hemiplegia, and bleeding must be promptly addressed, but none of these is a common sign of impending death.

During the examination of an unconscious patient, the nurse observes that the patients pupils are fixed and dilated. What is the most plausible clinical significance of the nurses finding? A) It suggests onset of metabolic problems. B) It indicates paralysis on the right side of the body. C) It indicates paralysis of cranial nerve X. D) It indicates an injury at the midbrain level.

Ans: D Feedback: Pupils that are fixed and dilated indicate injury at the midbrain level. This finding is not suggestive of unilateral paralysis, metabolic deficits, or damage to CN X.

A patient with suspected Creutzfeldt-Jakob disease (CJD) is being admitted to the unit. The nurse would expect what diagnostic test to be ordered for this patient? A) Cerebral angiography B) ABG analysis C) CT D) EEG

Ans: D Feedback: The EEG reveals a characteristic pattern over the duration of CJD. A CT scan may be used to rule out disorders that may mimic the symptoms of CJD. ABGs would not be necessary until the later stages of CJD; they would not be utilized as a diagnostic test. Cerebral angiography is not used to diagnose CJD.

The nurse is conducting a focused neurologic assessment. When assessing the patients cranial nerve function, the nurse would include which of the following assessments? A) Assessment of hand grip B) Assessment of orientation to person, time, and place C) Assessment of arm drift D) Assessment of gag reflex

Ans: D Feedback: The gag reflex is governed by the glossopharyngeal nerve, one of the cranial nerves. Hand grip and arm drifting are part of motor function assessment. Orientation is an assessment parameter related to a mental status examination

A patient is currently being stimulated by the parasympathetic nervous system. What effect will this nervous stimulation have on the patients bladder? A) The parasympathetic nervous system causes urinary retention. B) The parasympathetic nervous system causes bladder spasms. C) The parasympathetic nervous system causes urge incontinence. D) The parasympathetic nervous system makes the bladder contract.

Ans: D Feedback: The parasympathetic division of the nervous system causes contraction (stimulation) of the urinary bladder muscles and a decrease (inhibition) in heart rate, whereas the sympathetic division produces relaxation (inhibition) of the urinary bladder and an increase (stimulation) in the rate and force of the heartbeat.

An elderly patient is being discharged home. The patient lives alone and has atrophy of his olfactory organs. The nurse tells the patients family that it is essential that the patient have what installed in the home? A) Grab bars B) Nonslip mats C) Baseboard heaters D) A smoke detector

Ans: D Feedback: The sense of smell deteriorates with age. The olfactory organs are responsible for smell. This may present a safety hazard for the patient because he or she may not smell smoke or gas leaks. Smoke detectors are universally necessary, but especially for this patient.

What term is used to describe the fibrous connective tissue that hugs the brain closely and extends into every fold of the brains surface? A) Dura mater B) Arachnoid C) Fascia D) Pia mater

Ans: D Feedback: The term meninges describes the fibrous connective tissue that covers the brain and spinal cord. The meninges have three layers, the dura mater, arachnoid, and pia mater. The pia mater is the innermost membrane that hugs the brain closely and extends into every fold of the brains surface. The dura mater, the outermost layer, covers the brain and spinal cord. The arachnoid, the middle membrane, is responsible for the production of cerebrospinal fluid.

End: Chapter 65: Assessment of Neurologic Function

End: Chapter 65: Assessment of Neurologic Function

End: Chapter 66: Management of Patients with Neurologic Dysfunction

End: Chapter 66: Management of Patients with Neurologic Dysfunction

Start: Chapter 65: Assessment of Neurologic Function

Start: Chapter 65: Assessment of Neurologic Function

Start: Chapter 66: Management of Patients with Neurologic Dysfunction

Start: Chapter 66: Management of Patients with Neurologic Dysfunction

Start: Chapter 69: Management of Patients with Neurologic Infections, Autoimmune Disorders, and Neuropathies

Start: Chapter 69: Management of Patients with Neurologic Infections, Autoimmune Disorders, and Neuropathies