Patho II Exam 3 (in progress)

A 68-year-old male patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by his spouse. Which action will the nurse take first? a.Check oxygen saturation. b.Assess pupil reaction to light. c.Verify Glasgow Coma Scale (GCS) score. d.Palpate the head for hematoma or bony irregularities.

ANS: A Airway patency and breathing are the most vital functions, and should be assessed first. The neurologic assessments should be accomplished next and additional assessment after that.

After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a.A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed b.A 50-year-old patient who has atrial fibrillation and a new order for warfarin (Coumadin) c.A 40-year-old patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due d.A 30-year-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled

ANS: A tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury. The other medications should also be given as quickly as possible, but timing of the medications is not as critical.

When caring for a patient who experienced a T2 spinal cord transection 24 hours ago, which collaborative and nursing actions will the nurse include in the plan of care (select all that apply)? a.Urinary catheter care b.Nasogastric (NG) tube feeding c.Continuous cardiac monitoring d. Maintain a warm room temperature e.Administration of H2 receptor blockers

ANS: A, C, D, E The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature. Gastrointestinal (GI) motility is decreased initially and NG suctioning is indicated. To avoid bladder distention, a urinary retention catheter is used during this acute phase. Stress ulcers are a common complication, but can be avoided through the use of the H2 receptor blockers such as famotidine.

An unconscious male patient has just arrived in the emergency department after a head injury caused by a motorcycle crash. Which order should the nurse question? a.Obtain x-rays of the skull and spine. b.Prepare the patient for lumbar puncture. c.Send for computed tomography (CT) scan. d.Perform neurologic checks every 15 minutes.

ANS: B After a head injury, the patient may be experiencing intracranial bleeding and increased intracranial pressure, which could lead to herniation of the brain if a lumbar puncture is performed. The other orders are appropriate.

Which finding would the nurse expect when assessing the legs of a patient who has a lower motor neuron lesion? a.Spasticity b.Flaccidity c.No sensation d.Hyperactive reflexes

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

Which statement by a 40-year-old patient who is being discharged from the emergency department (ED) after a concussion indicates a need for intervention by the nurse? a.I will return if I feel dizzy or nauseated. b.I am going to drive home and go to bed. c.I do not even remember being in an accident. d.I can take acetaminophen (Tylenol) for my headache.

ANS: B Following a head injury, the patient should avoid driving and operating heavy machinery. Retrograde amnesia is common after a concussion. The patient can take acetaminophen for headache and should return if symptoms of increased intracranial pressure such as dizziness or nausea occur.

Which action will the nurse take when caring for a 46-year-old patient who develops tetanus from an injectable substance use? a.Avoid use of sedatives. b.Provide a quiet environment. c.Check pupil reaction to light every 4 hours. d.Provide range-of-motion exercises several times daily.

ANS: B In patients with tetanus, painful seizures can be precipitated by jarring, loud noises, or bright lights, so the nurse will minimize noise and avoid shining light into the patients eyes. Range-of-motion exercises may also stimulate the patient and cause seizures. Although the patient has a history of injectable drug use, sedative medications will be needed to decrease spasms.

Which assessments will the nurse make to monitor a patients cerebellar function (select all that apply)? a.Assess for graphesthesia. b.Observe arm swing with gait. c.Perform the finger-to-nose test. d.Check ability to push against resistance. e.Determine ability to sense heat and cold.

ANS: B, C The cerebellum is responsible for coordination and is assessed by looking at the patients gait and the finger-to-nose test. The other assessments will be used for other parts of the neurologic assessment.

A 68-year-old patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin? a.The patient has dysphasia. b.The patient has atrial fibrillation. c.The patient reports that symptoms began with a severe headache. d.The patient has a history of brief episodes of right-sided hemiplegia.

ANS: C A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer the aspirin.

The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a left-handed patient with left-sided hemiplegia. Which intervention should be included in the plan of care? a.Provide a wide variety of food choices. b.Provide oral care before and after meals. c.Assist the patient to eat with the right hand. d.Teach the patient the chin-tuck technique.

ANS: C Because the nursing diagnosis indicates that the patients imbalanced nutrition is related to the left-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use the right hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition.

Which finding in a patient with a spinal cord tumor is most important for the nurse to report to the health care provider? a.Back pain that increases with coughing b.Depression about the diagnosis of a tumor c.Decreasing sensation and ability to move the legs d.Anxiety about scheduled surgery to remove the tumor

ANS: C Decreasing sensation and leg movement indicates spinal cord compression, an emergency that will require rapid action (such as surgery) to prevent paralysis. The other findings will also require nursing action but are not emergencies.

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, the nurse reports the response as a.flexion withdrawal. b.localization of pain. c.decorticate posturing. d.decerebrate posturing.

ANS: C Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal.

The nurse is admitting a patient with a neck fracture at the C6 level to the intensive care unit. Which assessment finding(s) indicate(s) neurogenic shock? a.Hyperactive reflex activity below the level of injury b.Involuntary, spastic movements of the arms and legs c.Hypotension, bradycardia, and warm, pink extremities d.Lack of sensation or movement below the level of injury

ANS: C Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement and sensation indicate spinal cord injury, but not neurogenic shock.

Which of these nursing actions for a 64-year-old patient with Guillain-Barr syndrome is most appropriate for the nurse to delegate to an experienced unlicensed assistive personnel (UAP)? a.Nasogastric tube feeding q4hr b.Artificial tear administration q2hr c.Assessment for bladder distention q2hr d.Passive range of motion to extremities q4hr

ANS: D Assisting a patient with movement is included in UAP education and scope of practice. Administration of tube feedings, administration of ordered medications, and assessment are skills requiring more education and scope of practice, and the RN should perform these skills.

A 68-year-old patient hospitalized with a new diagnosis of Guillain-Barr syndrome has numbness and weakness of both feet. The nurse will anticipate teaching the patient about a.intubation and mechanical ventilation. b.administration of corticosteroid drugs. c.insertion of a nasogastric (NG) feeding tube. d.infusion of immunoglobulin (Sandoglobulin).

ANS: D Because the Guillain-Barr syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and tube feedings may be used later in the progression of the syndrome but are not needed now. Corticosteroid use is not helpful in reducing the duration or symptoms of the syndrome.

A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action? a.The bedrails at the head and foot of the bed are both elevated. b.The patient receives a regular diet from the dietary department. c.The lights in the patients room are turned off and the blinds are shut. d.Unlicensed assistive personnel enter the patients room without a mask.

ANS: D Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions. Because the patient may be confused and weak, bedrails should be elevated at both the foot and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an important aspect of care in a patient with meningitis.

A patient who uses a fentanyl (Duragesic) patch for chronic cancer pain suddenly complains of rapid onset pain at a level 9 (0 to 10 scale) and requests something for pain that will work now. How will the nurse document the type of pain reported by this patient? a.Somatic pain b.Referred pain c.Neuropathic pain d.Breakthrough pain

ANS: D Pain that occurs beyond the chronic pain already being treated by appropriate analgesics is termed breakthrough pain. Neuropathic pain is caused by damage to peripheral nerves or the central nervous system (CNS). Somatic pain is localized and arises from bone, joint, muscle, skin, or connective tissue. Referred pain is pain that is localized in uninjured tissue.

The nurse is admitting the client for rule-out encephalitis. Which interventions should the nurse assess to support the diagnosis of encephalitis? Select all that apply. 1. Determine if the client has recently received any immunizations. 2. Ask the client if he or she has had a cold in the last week. 3. Check to see if the client has active herpes simplex 1. 4. Find out if the client has traveled to the Great Lakes region. 5. Assess for exposure to soil with fungal spores.

1. A complication of immunizations for measles, mumps, and rubella can be encephalitis. 2. Upper respiratory tract illnesses can be a precursor to encephalitis. 3. The herpes simplex virus, specifically type 1, can lead to encephalitis.

Which is an expected outcome for a client diagnosed with encephalitis? 1. The client will regain as much neurological function as possible. 2. The client will have no short-term memory loss. 3. The client will have improved renal function. 4. The client will apply hydrocortisone cream daily.

1. Clients diagnosed with encephalitis have neurological deficits while the inflammation is present. The thera- peutic plan is to treat the disease process, decrease the edema, and re- turn the client to an optimal level of wellness.

Which intervention should the nurse implement when caring for the client diagnosed with encephalitis? Select all that apply. 1. Turn the client every two (2) hours. 2. Encourage the client to increase fluids. 3. Keep the client in the supine position. 4. Assess for deep vein thrombosis. 5. Assess for any alterations in elimination.

1. Clients with encephalitis should be treated for the disease process and also to prevent complications of immobility. Turning the client will prevent skin breakdown. 2. Increasing fluids helps prevent urinary tract infections and mobilize secretions in the lungs. 4. Immobility causes clients to be at risk for deep vein thrombosis. Therefore, clients with encephalitis should be assessed for deep vein thrombosis. 5. Immobility causes the gastrointestinal tract to slow, resulting in constipa- tion. Clients can have difficulty emp- tying their bladders, which can because retention and urinary tract infections and stones. Assessing these systems can identify problems early.

A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement? 1. Administer a stool softener b.i.d. 2. Encourage the client to cough hourly. 3. Monitor neurological status every shift. 4. Maintain the dopamine drip to keep BP at 160/90.

1. The client is at risk for increased intracranial pressure whenever performing the Valsalva maneuver, which will occur when straining during defecation. Therefore, stool softeners would be appropriate.

The client is diagnosed with a closed head injury and is in a coma. The nurse writes the client problem as "high risk for immobility complications." Which intervention would be included in the plan of care? 1. Position the client with the head of the bed elevated at intervals. 2. Perform active range-of-motion exercises every four (4) hours. 3. Turn the client every shift and massage bony prominences. 4. Explain all procedures to the client before performing them.

1. The head of the client's bed should be elevated to help the lungs expand and prevent stasis of secretions that could lead to pneumonia, a complication of immobility.

The home health nurse is caring for a 28-year-old client with a T10 SCI who says, "I can't do anything. Why am I so worthless?" Which statement by the nurse would be the most therapeutic? 1. "This must be very hard for you. You're feeling worthless?" 2. "You shouldn't feel worthless—you are still alive." 3. "Why do you feel worthless? You still have the use of your arms." 4. "If you attended a work rehab program you wouldn't feel worthless."

1. Therapeutic communication addresses the client's feelings and attempts to allow the client to verbalize feelings; the nurse should be a therapeutic listener.

The client is being admitted to rule out a brain tumor. Which classic triad of symptoms supports a diagnosis of brain tumor? 1. Nervousness, metastasis to the lungs, and seizures. 2. Headache, vomiting, and papilledema. 3. Hypotension, tachycardia, and tachypnea. 4. Abrupt loss of motor function, diarrhea, and changes in taste.

2. The classic triad of symptoms suggesting a brain tumor includes a headache that is dull, unrelenting, and worse in the morning; vomiting unrelated to food intake; and edema of the optic nerve (papilledema), which occurs in 70% to 75% of clients diagnosed with brain tumors. Papilledema causes visual disturbances such as decreased visual acuity and diplopia.

The nurse is assessing a client experiencing motor loss as a result of a left-sided cere-brovascular accident (CVA). Which clinical manifestations would the nurse document? 1. Hemiparesis of the client's left arm and apraxia. 2. Paralysis of the right side of the body and ataxia. 3. Homonymous hemianopsia and diplopia. 4. Impulsive behavior and hostility toward family.

2. The most common motor dysfunction of a CVA is paralysis of one side of the body, hemiplegia; in this case with a left-sided CVA, the paralysis would affect the right side. Ataxia is an impaired ability to coordinate movement.

The resident in a long-term care facility fell during the previous shift and has a lacer- ation in the occipital area that has been closed with Steri-Strips. Which signs/ symptoms would warrant transferring the resident to the emergency department? 1. A 4-cm area of bright red drainage on the dressing. 2. A weak pulse, shallow respirations, and cool pale skin. 3. Pupils that are equal, react to light, and accommodate. 4. Complaints of a headache that resolves with medication.

2. These signs/symptoms—weak pulse, shallow respirations, cool pale skin— indicate increased intracranial pressure from cerebral edema secondary to the fall, and they require immediate attention.

The 29-year-old client who was employed as a forklift operator sustains a traumatic brain injury secondary to a motor-vehicle accident. The client is being discharged from the rehabilitation unit after three (3) months and has cognitive deficits. Which goal would be most realistic for this client? 1. The client will return to work within six (6) months. 2. The client is able to focus and stay on task for 10 minutes. 3. The client will be able to dress self without assistance. 4. The client will regain bowel and bladder control.

2. "Cognitive" pertains to mental processes of comprehension, judgment, memory, and reasoning. Therefore, an appropriate goal would be for the client to stay on task for 10 minutes.

The client diagnosed with a closed head injury is admitted to the rehabilitation department. Which medication order would the nurse question? 1. A subcutaneous anticoagulant. 2. An intravenous osmotic diuretic. 3. An oral anticonvulsant. 4. An oral proton pump inhibitor.

2. An osmotic diuretic would be ordered in the acute phase to help decrease cerebral edema, but this medication would not be expected to be ordered in a rehabilitation unit.

The nurse is caring for the client with encephalitis. Which intervention should the nurse implement first if the client is experiencing a complication? 1. Examine pupil reactions to light. 2. Assess level of consciousness. 3. Observe for seizure activity. 4. Monitor vital signs every shift.

2. This is the most important assess- ment data. A change in level of consciousness is usually the first sign of neurological deterioration.

A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? 1. Prepare to administer recombinant tissue plasminogen activator (rt-PA). 2. Discuss the precipitating factors that caused the symptoms. 3. Schedule for a STAT computed tomography (CT) scan of the head. 4. Notify the speech pathologist for an emergency consult.

3. A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. If a CVA is diagnosed, the CT scan can determine if it is a hemorrhagic or ischemic accident and guide treatment.

The wife of the client diagnosed with septic meningitis asks the nurse, "I am so scared. What is meningitis?" Which statement would be the most appropriate response by the nurse? 1. "There is bleeding into his brain causing irritation of the meninges." 2. "A virus has infected the brain and meninges, causing inflammation." 3. "This is a bacterial infection of the tissues that cover the brain and spinal cord." 4. "This is an inflammation of the brain parenchyma caused by a mosquito bite."

3. Septic meningitis refers to meningitis caused by bacteria; the most common form of bacterial meningitis is caused by the Neisseria meningitides bacteria.

The nurse is caring for the following clients. Which client would the nurse assess first after receiving the shift report? 1. The 22-year-old male client diagnosed with a concussion who is complaining someone is waking him up every two (2) hours. 2. The 36-year-old female client admitted with complaints of left-sided weakness who is scheduled for a magnetic resonance imaging (MRI) scan. 3. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale score of 6. 4. The 62-year-old client diagnosed with a cerebrovascular accident (CVA) who has expressive aphasia.

3. The Glasgow Coma Scale is used to determine a client's response to stimuli (eye-opening response, best verbal response, and best motor response) secondary to a neurological problem; scores range from 3 (deep coma) to 15 (intact neurological function). A client with a score of 6 should be assessed first by the nurse.

The client has sustained a severe closed head injury and the neurosurgeon is deter- mining if the client is "brain dead." Which data support that the client is brain dead? 1. When the client's head is turned to the right, the eyes turn to the right. 2. The electroencephalogram (EEG) has identifiable waveforms. 3. There is no eye activity when the cold caloric test is performed. 4. The client assumes decorticate posturing when painful stimuli are applied.

3. The cold caloric test, also called the oculovestibular test, is a test used to determine if the brain is intact or dead. No eye activity indicates brain death. If the client's eyes moved, that would indicate that the brainstem is intact.

The nurse arrives at the site of a one-car motor-vehicle accident and stops to render aid. The driver of the car is unconscious. After stabilizing the client's cervical spine, which action should the nurse take next? 1. Carefully remove the driver from the car. 2. Assess the client's pupils for reaction. 3. Assess the client's airway. 4. Attempt to wake the client up by shaking him.

3. The nurse must maintain a patent airway. Airway is the first step in resuscitation.

The client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first? 1. Notify the health-care provider immediately. 2. Prepare to administer an antihistamine. 3. Test the drainage for presence of glucose. 4. Place 2 × 2 gauze under the nose to collect drainage.

3. The presence of glucose in drainage from the nose or ears indicates cerebrospinal fluid, and the HCP should be notified immediately once this is determined.

The intensive care nurse is caring for a client with a T1 SCI. When the nurse elevates the head of the bed 30 degrees, the client complains of lightheadedness and dizziness. The client's vital signs are T 99.2 ̊F, P 98, R 24, and BP 84/40. Which action should the nurse implement? 1. Notify the health-care provider ASAP. 2. Calm the client down by talking therapeutically. 3. Increase the IV rate by 50 mL/hour. 4. Lower the head of the bed immediately.

4. For the first two (2) weeks after an SCI above T7, the blood pressure tends to be unstable and low; slight elevations of the head of the bed can cause profound hypotension; therefore, the nurse should lower the head of the bed immediately.

The client has been diagnosed with a brain tumor. Which presenting signs and symptoms help to localize the tumor position? 1. Widening pulse pressure and bounding pulse. 2. Diplopia and decreased visual acuity. 3. Bradykinesia and scanning speech. 4. Hemiparesis and personality changes.

4. Hemiparesis would localize a tumor to a motor area of the brain, and personality changes localize a tumor to the frontal lobe.

The client has been diagnosed with a cerebrovascular accident (stroke). The client's wife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge? 1. Obtain a rubber mat to place under the dinner plate. 2. Purchase a long-handled bath sponge for showering. 3. Purchase clothes with Velcro closure devices. 4. Obtain a raised toilet seat for the client's bathroom.

4. Raising the toilet seat is modifying the home and addresses the client's weakness in being able to sit down and get up without straining muscles or requiring lifting assistance from the wife.

The client diagnosed with a brain tumor was admitted to the intensive care unit with decorticate posturing. Which indicates that the client's condition is becoming worse? 1. The client has purposeful movement with painful stimuli. 2. The client has assumed adduction of the upper extremities. 3. The client is aimlessly thrashing in the bed. 4. The client has become flaccid and does not respond to stimuli.

4. The most severe neurological impairment result is flaccidity and no response to stimuli. This indicates that the client's condition has worsened.

The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first? 1. Administer a nonnarcotic analgesic. 2. Prepare for STAT magnetic resonance imaging (MRI). 3. Start an intravenous infusion with D5W at 100 mL/hr. 4. Complete a neurological assessment.

4. The nurse must complete a neurological assessment to help determine the cause of the headache before taking any further action.

A female patient who had a stroke 24 hours ago has expressive aphasia. The nurse identifies the nursing diagnosis of impaired verbal communication. An appropriate nursing intervention to help the patient communicate is to a.ask questions that the patient can answer with yes or no. b.develop a list of words that the patient can read and practice reciting. c.have the patient practice her facial and tongue exercises with a mirror. d.prevent embarrassing the patient by answering for her if she does not respond.

ANS: A Communication will be facilitated and less frustrating to the patient when questions that require a yes or no response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.

A 39-year-old patient is being evaluated for a possible spinal cord tumor. Which finding by the nurse requires the most immediate action? a.The patient has new onset weakness of both legs. b.The patient complains of chronic severe back pain. c.The patient starts to cry and says, I feel hopeless. d.The patient expresses anxiety about having surgery.

ANS: A The new onset of symptoms indicates cord compression, which is an emergency that requires rapid treatment to avoid permanent loss of function. The other patient assessments also indicate a need for nursing action but do not require intervention as rapidly as the new onset weakness.

A patient is admitted with possible botulism poisoning after eating home-canned green beans. Which intervention ordered by health care provider will the nurse question? a.Encourage oral fluids to 3 L/day b.Document neurologic symptoms c.Position patient lying on the side d.Observe respiratory status closely

ANS: A The patient should be maintained on NPO status because neuromuscular weakness increases risk for aspiration. Side-lying position is not contraindicated. Assessment of neurologic and respiratory status is appropriate.

A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action will the nurse include in the plan of care? a.Teach the patient the Cred method. b.Instruct the patient how to self-catheterize. c.Catheterize for residual urine after voiding. d.Assist the patient to the toilet every 2 hours.

ANS: B Because the patients bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Cred method is more appropriate for a bladder that is flaccid, such as occurs with areflexic neurogenic bladder. Catheterization after voiding will not resolve the patients incontinence.

A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? a.Document the BP and ICP in the patients record. b.Report the BP and ICP to the health care provider. c.Elevate the head of the patients bed to 60 degrees. d.Continue to monitor the patients vital signs and ICP.

ANS: B Calculate the cerebral perfusion pressure (CPP): (CPP = mean arterial pressure [MAP] ICP). MAP = DBP + 1/3 (systolic blood pressure [SBP] diastolic blood pressure [DBP]). Therefore the (MAP) is 70 and the CPP is 56 mm Hg, which is below the normal of 60 to 100 mm Hg and approaching the level of ischemia and neuronal death. Immediate changes in the patients therapy such as fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation will also be done, but they are not the first actions that the nurse should take.

A 20-year-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take? a.Have the patient gently blow the nose. b.Check the drainage for glucose content. c.Teach the patient that rhinorrhea is expected after a head injury. d.Obtain a specimen of the fluid to send for culture and sensitivity.

ANS: B Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage.

Which assessment data for a patient who has Guillain-Barr syndrome will require the nurses most immediate action? a.The patients triceps reflexes are absent. b.The patient is continuously drooling saliva. c.The patient complains of severe pain in the feet. d.The patients blood pressure (BP) is 150/82 mm Hg.

ANS: B Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, and the BP requires ongoing monitoring, but these actions are not as urgently needed as maintenance of respiratory function. Absence of the reflexes should be documented, but this is a common finding in Guillain-Barr syndrome.

Which nursing action has the highest priority for a patient who was admitted 16 hours previously with a C5 spinal cord injury? a.Cardiac monitoring for bradycardia b.Assessment of respiratory rate and effort c.Application of pneumatic compression devices to legs d.Administration of methylprednisolone (Solu-Medrol) infusion

ANS: B Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patients respiratory function. Methylprednisolone (Solu-Medrol) is no longer recommended for the treatment of spinal cord injuries. The other actions also are appropriate but are not as important as assessment of respiratory effort.

The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a.The pulse rate is 102 beats/min. b.The patient has difficulty speaking. c.The blood pressure is 144/86 mm Hg. d.There are fine crackles at the lung bases.

ANS: B Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual because of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure. The nurse should have the patient take some deep breaths.

The home health nurse is caring for an 81-year-old who had a stroke 2 months ago. Based on information shown in the accompanying figure from the history, physical assessment, and physical therapy/occupational therapy, which nursing diagnosis is the highest priority for this patient? a.Impaired transfer ability. b.Risk for caregiver role strain c.Ineffective health maintenance d.Risk for unstable blood glucose level

ANS: B The spouses household and patient care responsibilities, in combination with chronic illnesses, indicate a high risk for caregiver role strain. The nurse should further assess the situation and take appropriate actions. The data about the control of the patients diabetes indicates that ineffective health maintenance and risk for unstable blood glucose are not priority concerns at this time. Because the patient is able to ambulate with a cane, the nursing diagnosis of impaired transfer ability is not supported.

Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia at the T4 level in order to prevent autonomic dysreflexia? a.Support selection of a high-protein diet. b.Discuss options for sexuality and fertility. c.Assist in planning a prescribed bowel program. d.Use quad coughing to strengthen cough efforts.

ANS: C Fecal impaction is a common stimulus for autonomic dysreflexia. Dietary protein, coughing, and discussing sexuality/fertility should be included in the plan of care but will not reduce the risk for autonomic dysreflexia.

A patient admitted with dermal ulcers who has a history of a T3 spinal cord injury tells the nurse, I have a pounding headache and I feel sick to my stomach. Which action should the nurse take first? a.Check for a fecal impaction. b.Give the prescribed analgesic. c.Assess the blood pressure (BP). d.Notify the health care provider.

ANS: C The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is occurring. Notification of the patients health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. After checking the BP, the nurse may assess for a fecal impaction using lidocaine jelly to prevent further increased BP.

A 27-year-old patient is hospitalized with new onset of Guillain-Barr syndrome. The most essential assessment for the nurse to carry out is a.determining level of consciousness. b.checking strength of the extremities. c.observing respiratory rate and effort. d.monitoring the cardiac rate and rhythm.

ANS: C The most serious complication of Guillain-Barr syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments will also be included in nursing care, but they are not as important as respiratory assessment.

The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as being at risk for Bells palsy. Which information should the nurse include in teaching the patient? a.You may be able to prevent Bells palsy by doing facial exercises regularly. b.Prophylactic treatment of herpes with antiviral agents prevents Bells palsy. c.Medications to treat Bells palsy work only if started before paralysis onset. d.Call the doctor if you experience pain or develop herpes lesions near the ear.

ANS: D Pain or herpes lesions near the ear may indicate the onset of Bells palsy and rapid corticosteroid treatment may reduce the duration of Bells palsy symptoms. Antiviral therapy for herpes simplex does not reduce the risk for Bells palsy. Corticosteroid therapy will be most effective in reducing symptoms if started before paralysis is complete but will still be somewhat effective when started later. Facial exercises do not prevent Bells palsy.

The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding is most important to report to the health care provider? a.Complaint of severe headache b.Large contusion behind left ear c.Bilateral periorbital ecchymosis d.Temperature of 101.4 F (38.6 C)

ANS: D Patients who have basilar skull fractures are at risk for meningitis, so the elevated temperature should be reported to the health care provider. The other findings are typical of a patient with a basilar skull fracture.

The client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority? 1. Assess neurological status. 2. Monitor pulse, respiration, and blood pressure. 3. Initiate an intravenous access. 4. Maintain an adequate airway.

4. The most important nursing goal in the management of a client with a head injury is to establish and maintain an adequate airway.

The nurse in the neurointensive care unit is caring for a client with a new C6 SCI who is breathing independently. Which nursing interventions should be implemented? Select all that apply. 1. Monitor the pulse oximetry reading. 2. Provide pureed foods six (6) times a day. 3. Encourage coughing and deep breathing. 4. Assess for autonomic dysreflexia. 5. Administer intravenous corticosteroids.

1. Oxygen is administered initially to prevent hypoxemia, which can worsen the spinal cord injury; therefore, the nurse should determine how much oxygen is reaching the periphery. 3. Breathing exercises are supervised by the nurse to increase the strength and endurance of inspiratory muscles, especially those of the diaphragm. 5. Corticosteroids are administered to decrease inflammation, which will decrease edema, and help prevent edema from ascending up the spinal cord, causing breathing difficulties.

The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply. 1. Position the client to prevent shoulder adduction. 2. Turn and reposition the client every shift. 3. Encourage the client to move the affected side. 4. Perform quadriceps exercises three (3) times a day. 5. Instruct the client to hold the fingers in a fist.

1. Placing a small pillow under the shoulder will prevent the shoulder from adducting toward the chest and developing a contracture. 3. The client should not ignore the paralyzed side, and the nurse must encourage the client to move it as much as possible; a written schedule may assist the client in exercising.

The nurse is caring for a client diagnosed with meningitis. Which collaborative intervention should be included in the plan of care? 1. Administer antibiotics. 2. Obtain a sputum culture. 3. Monitor the pulse oximeter. 4. Assess intake and output.

1. A nurse administering antibiotics is a collaborative intervention because the HCP must write an order for the intervention; nurses cannot prescribe medications unless they have additional education and licensure and are nurse practitioners with prescriptive authority.

Which client would the nurse identify as being most at risk for experiencing a CVA? 1. A 55-year-old African American male. 2. An 84-year-old Japanese female. 3. A 67-year-old Caucasian male. 4. A 39-year-old pregnant female.

1. African Americans have twice the rate of CVAs as Caucasians and men have a higher incidence than women; African Americans suffer more extensive damage from a CVA than do people of other cul- tural groups.

The client diagnosed with a gunshot wound to the head assumes decorticate posturing when the nurse applies painful stimuli. Which assessment data obtained three (3) hours later would indicate the client is improving? 1. Purposeless movement in response to painful stimuli. 2. Flaccid paralysis in all four extremities. 3. Decerebrate posturing when painful stimuli are applied. 4. Pupils that are 6 mm in size and nonreactive on painful stimuli.

1. Purposeless movement indicates that the client's cerebral edema is decreasing. The best motor response is purposeful movement, but purposeless movement indicates an improvement over decorticate movement, which, in turn, is an improvement over decerebrate movement or flaccidity.

The client diagnosed with a mild concussion is being discharged from the emergency department. Which discharge instruction should the nurse teach the client's significant other? 1. Awaken the client every two (2) hours. 2. Monitor for increased intracranial pressure. 3. Observe frequently for hypervigilance. 4. Offer the client food every three (3) to four (4) hours.

1. Awakening the client every two (2) hours allows the identification of headache, dizziness, lethargy, irritabil- ity, and anxiety—all signs of postcon- cussion syndrome—that would warrant the significant other's taking the client back to the emergency department.

In assessing a client with a T12 SCI, which clinical manifestations would the nurse expect to find to support the diagnosis of spinal shock? 1. No reflex activity below the waist. 2. Inability to move upper extremities. 3. Complaints of a pounding headache. 4. Hypotension and bradycardia.

1. Spinal shock associated with SCI represents a sudden depression of reflex activity below the level of the injury. T12 is just above the waist; therefore, no reflex activity below the waist would be expected.

After evacuation of an epidural hematoma, a patients intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse is most important to communicate to the health care provider? a.Pulse 102 beats/min b.Temperature 101.6 F c.Intracranial pressure 15 mm Hg d.Mean arterial pressure 90 mm Hg

ANS: B Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters. The temperature indicates the need for antibiotics or removal of the monitor. The ICP, arterial pressure, and apical pulse are all borderline high but require only ongoing monitoring at this time.

The rehabilitation nurse caring for the client with an L1 SCI is developing the nursing care plan. Which intervention should the nurse implement? 1. Keep oxygen via nasal cannula on at all times. 2. Administer low-dose subcutaneous anticoagulants. 3. Perform active lower extremity ROM exercises. 4. Refer to a speech therapist for ventilator-assisted speech.

2. Deep vein thrombosis (DVT) is a potential complication of immobility, which can occur because the client cannot move the lower extremities as a result of the L1 SCI. Low-dose anticoagulation therapy (Lovenox) helps prevent blood from coagulating, thereby preventing DVTs.

The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care? 1. Potential for injury. 2. Powerlessness. 3. Disturbed thought processes. 4. Sexual dysfunction.

2. Expressive aphasia means that the client cannot communicate thoughts but understands what is being communicated; this leads to frustration, anger, depression, and the inability to verbalize needs, which, in turn, causes the client to have a lack of control and feel powerless.

The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply. 1. Maintain the head of the bed at 60 degrees of elevation. 2. Administer stool softeners daily. 3. Ensure that pulse oximeter reading is higher than 93%. 4. Perform deep nasal suction every two (2) hours. 5. Administer mild sedatives.

2. Stool softeners are initiated to prevent the Valsalva maneuver, which increases intracranial pressure. 3. Oxygen saturation higher than 93% ensures oxygenation of the brain tissues; decreasing oxygen levels increase cerebral edema. 5. Mild sedatives will reduce the client's agitation; strong narcotics would not be administered because they decrease the client's level of consciousness.

The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative intervention will be included in the plan of care? 1. Observe the client swallowing for possible aspiration. 2. Position the client in a semi-Fowler's position when sleeping. 3. Place a suction setup at the client's bedside during meals. 4. Refer the client to an occupational therapist for evaluation.

4. A collaborative intervention is an intervention in which another health-care discipline—in this case, occupational therapy—is used in the care of the client.

The nurse is assessing the client admitted with encephalitis. Which data require immediate nursing intervention? The client: 1. Has bilateral facial palsies. 2. Has a recurrent temperature of 100.6 ̊F. 3. Has a decreased complaint of headache. 4. Comments that the meal has no taste.

4. The absence of smell and taste indicates that the cranial nerves may be involved. The client's condition is becoming more serious.

The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? 1. The assistant places a gait belt around the client's waist prior to ambulating. 2. The assistant places the client on the back with the client's head to the side. 3. The assistant places a hand under the client's right axilla to move up in bed. 4. The assistant praises the client for attempting to perform ADLs independently.

3. This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; the client should be pulled up by placing the arm underneath the back or using a lift sheet.

The client with a C6 SCI is admitted to the emergency department complaining of a severe pounding headache and has a BP of 180/110. Which intervention should the emergency department nurse implement? 1. Keep the client flat in bed. 2. Dim the lights in the room. 3. Assess for bladder distention. 4. Administer a narcotic analgesic.

3. This is an acute emergency caused by exaggerated autonomic responses to stimuli and only occurs after spinal shock has resolved in the client with a spinal cord injury above T6. The most common cause is a full bladder.

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? 1. A blood glucose level of 480 mg/dL. 2. A right-sided carotid bruit. 3. A blood pressure of 220/120 mm Hg. 4. The presence of bronchogenic carcinoma.

3. Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured blood vessel inside the cranium.

The nurse is enjoying a day at the lake and witnesses a water skier hit the boat ramp. The water skier is in the water not responding to verbal stimuli. The nurse is the first health-care provider to respond to the accident. Which intervention should be implemented first? 1. Assess the client's level of consciousness. 2. Organize onlookers to remove the client from the lake. 3. Perform a head-to-toe assessment to determine injuries. 4. Stabilize the client's cervical spine.

4. The nurse should always assume that a client with traumatic head injury may have sustained spinal cord injury. Mov- ing the client could further injure the spinal cord and cause paralysis; there- fore, the nurse should stabilize the cer- vical spinal cord as best as possible prior to removing the client from the water.

Which patient is most at risk for respiratory depression related to opioid administration for pain relief? A. 82-year-old patient who had abdominal surgery 4 hours ago B. 24-year-old patient who had a vaginal delivery 12 hours ago C. 32-year-old patient with chronic neuropathic pain for 6 months D. 20-year-old patient with a closed reduction of a fractured right arm

A. 82-year-old patient who had abdominal surgery 4 hours ago Patients most at risk for respiratory depression include those who are older, have underlying lung disease, have a history of sleep apnea, or are receiving other central nervous system depressants. For postoperative patients the greatest risk is in the first 24 hours after surgery. Respiratory depression related to opioid administration is higher in hospitalized patients who are opioid naïve.

Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a registered nurse (RN) who has floated from the medical unit? a.A 45-year-old receiving IV antibiotics for meningococcal meningitis b.A 25-year-old admitted with a skull fracture and craniotomy the previous day c.A 55-year-old who has increased intracranial pressure (ICP) and is receiving hyperventilation therapy d.A 35-year-old with ICP monitoring after a head injury last week

ANS: A An RN who works on a medical unit will be familiar with administration of IV antibiotics and with meningitis. The postcraniotomy patient, patient with an ICP monitor, and the patient on a ventilator should be assigned to an RN familiar with the care of critically ill patients.

A 45-year-old patient has a dysfunction of the cerebellum. The nurse will plan interventions to a.prevent falls. b.stabilize mood. c.avoid aspiration. d.improve memory.

ANS: A Because functions of the cerebellum include coordination and balance, the patient with dysfunction is at risk for falls. The cerebellum does not affect memory, mood, or swallowing ability.

A college athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether a patient is developing postconcussion syndrome? a.Short-term memory b.Muscle coordination c.Glasgow Coma Scale d.Pupil reaction to light

ANS: A Decreased short-term memory is one indication of postconcussion syndrome. The other data may be assessed but are not indications of postconcussion syndrome.

Which action will the public health nurse take to reduce the incidence of epidemic encephalitis in a community? a.Encourage the use of effective insect repellents during mosquito season. b.Remind patients that most cases of viral encephalitis can be cared for at home. c.Teach about the importance of prophylactic antibiotics after exposure to encephalitis. d.Arrange for screening of school-age children for West Nile virus during the school year.

ANS: A Epidemic encephalitis is usually spread by mosquitoes and ticks. Use of insect repellent is effective in reducing risk. Encephalitis frequently requires that the patient be hospitalized in an intensive care unit during the initial stages. Antibiotic prophylaxis is not used to prevent encephalitis because most encephalitis is viral. West Nile virus is most common in adults over age 50 during the summer and early fall.

A 42-year-old patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care? a.Encourage family members to remain at the bedside. b.Apply soft restraints to protect the patient from injury. c.Keep the room well-lighted to improve patient orientation. d.Minimize contact with the patient to decrease sensory input.

ANS: A Patients with meningitis and disorientation will be calmed by the presence of someone familiar at the bedside. Restraints should be avoided because they increase agitation and anxiety. The patient requires frequent assessment for complications. The use of touch and a soothing voice will decrease anxiety for most patients. The patient will have photophobia, so the light should be dim.

Admission vital signs for a brain-injured patient are blood pressure 128/68, pulse 110, and respirations 26. Which set of vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a.Blood pressure 154/68, pulse 56, respirations 12 b.Blood pressure 134/72, pulse 90, respirations 32 c.Blood pressure 148/78, pulse 112, respirations 28 d.Blood pressure 110/70, pulse 120, respirations 30

ANS: A Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushings triad. These findings indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.

A 40-year-old patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan? a.Apply intermittent pneumatic compression stockings. b.Assist to dangle on edge of bed and assess for dizziness. c.Encourage patient to cough and deep breathe every 4 hours. d.Insert an oropharyngeal airway to prevent airway obstruction.

ANS: A The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboembolism (VTE). Activities such as coughing and sitting up that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.

For a patient who had a right hemisphere stroke the nurse establishes a nursing diagnosis of a.risk for injury related to denial of deficits and impulsiveness. b.impaired physical mobility related to right-sided hemiplegia. c.impaired verbal communication related to speech-language deficits. d.ineffective coping related to depression and distress about disability.

ANS: A The patient with right-sided brain damage typically denies any deficits and has poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability.

A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L) and a decreasing level of consciousness (LOC). He is now complaining of a headache. Which prescribed interventions should the nurse implement first? a.Administer IV 5% hypertonic saline. b.Draw blood for arterial blood gases (ABGs). c.Send patient for computed tomography (CT). d.Administer acetaminophen (Tylenol) 650 mg orally.

ANS: A The patients low sodium indicates that hyponatremia may be causing the cerebral edema. The nurses first action should be to correct the low sodium level. Acetaminophen (Tylenol) will have minimal effect on the headache because it is caused by cerebral edema and increased intracranial pressure (ICP). Drawing ABGs and obtaining a CT scan may provide some useful information, but the low sodium level may lead to seizures unless it is addressed quickly.

When admitting a 42-year-old patient with a possible brain injury after a car accident to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider? a.The patient takes warfarin (Coumadin) daily. b.The patients blood pressure is 162/94 mm Hg. c.The patient is unable to remember the accident. d.The patient complains of a severe dull headache.

ANS: A The use of anticoagulants increases the risk for intracranial hemorrhage and should be immediately reported. The other information would not be unusual in a patient with a head injury who had just arrived in the ED.

Several patients have been hospitalized for diagnosis of neurologic problems. Which patient will the nurse assess first? a.Patient with a transient ischemic attack (TIA) returning from carotid duplex studies b.Patient with a brain tumor who has just arrived on the unit after a cerebral angiogram c.Patient with a seizure disorder who has just completed an electroencephalogram (EEG) d.Patient prepared for a lumbar puncture whose health care provider is waiting for assistance

ANS: B Because cerebral angiograms require insertion of a catheter into the femoral artery, bleeding is a possible complication. The nurse will need to check the pulse, blood pressure, and the catheter insertion site in the groin as soon as the patient arrives. Carotid duplex studies and EEG are noninvasive. The nurse will need to assist with the lumbar puncture as soon as possible, but monitoring for hemorrhage after cerebral angiogram has a higher priority.

Which question asked by the nurse will give the most information about the patients metastatic bone cancer pain? a.How long have you had this pain? b.How would you describe your pain? c.How much medication do you take for the pain? d.How many times a day do you take medication for the pain?

ANS: B Because pain is a multidimensional experience, asking a question that addresses the patients experience with the pain will elicit more information than the more specific information asked in the other three responses. All of these questions are appropriate, but the response beginning How would you describe your pain? is the best initial question.

After endotracheal suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first? a.Document the increase in intracranial pressure. b.Ensure that the patients neck is in neutral position. c.Notify the health care provider about the change in pressure. d.Increase the rate of the prescribed propofol (Diprivan) infusion.

ANS: B Because suctioning will cause a transient increase in intracranial pressure, the nurse should initially check for other factors that might be contributing to the increase and observe the patient for a few minutes. Documentation is needed, but this is not the first action. There is no need to notify the health care provider about this expected reaction to suctioning. Propofol is used to control patient anxiety or agitation. There is no indication that anxiety has contributed to the increase in intracranial pressure.

To assess for functional deficits, which question will the nurse ask a patient who has been admitted for treatment of a benign occipital lobe tumor? a.Do you have difficulty in hearing? b.Are you experiencing visual problems? c.Are you having any trouble with your balance? d.Have you developed any weakness on one side?

ANS: B Because the occipital lobe is responsible for visual reception, the patient with a tumor in this area is likely to have problems with vision. The other questions will be better for assessing function of the temporal lobe, cerebellum, and frontal lobe.

A patient with second-degree burns has been receiving hydromorphone through patient-controlled analgesia (PCA) for a week. The patient wakes up frequently during the night complaining of pain. What action by the nurse ismost appropriate? a.Administer a dose of morphine every 1 to 2 hours from the PCA machine while the patient is sleeping. b.Consult with the health care provider about using a different treatment protocol to control the patients pain. c.Request that the health care provider order a bolus dose of morphine to be given when the patient awakens with pain. d.Teach the patient to push the button every 10 minutes for an hour before going to sleep, even if the pain is minimal.

ANS: B PCAs are best for controlling acute pain. This patients history indicates chronic pain and a need for a pain management plan that will provide adequate analgesia while the patient is sleeping. Administering a dose of morphine when the patient already has severe pain will not address the problem. Teaching the patient to administer unneeded medication before going to sleep can result in oversedation and respiratory depression. It is illegal for the nurse to administer the morphine for a patient through PCA.

The nurse admitting a patient who has a right frontal lobe tumor would expect the patient may have a.expressive aphasia. b.impaired judgment. c.right-sided weakness. d.difficulty swallowing.

ANS: B The frontal lobe controls intellectual activities such as judgment. Speech is controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumor. Swallowing is controlled by the brainstem.

A 46-year-old patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. The nurse records the patients Glasgow Coma Scale score as a.9. b.11. c.13. d.15.

ANS: B The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.

A patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider should the nurse question? a.Elevate the head of the bed 20 degrees. b.Restrict oral fluids to 1000 mL daily. c.Administer ceftriaxone (Rocephin) 1 g IV every 12 hours. d.Give ibuprofen (Motrin) 400 mg every 6 hours as needed for headache.

ANS: B The patient with meningitis has increased fluid needs, so oral fluids should be encouraged. The other actions are appropriate. Slight elevation of the head of the bed will decrease headache without causing leakage of cerebrospinal fluid from the lumbar puncture site. Antibiotics should be administered until bacterial meningitis is ruled out by the cerebrospinal fluid analysis.

Which cerebrospinal fluid analysis result will be most important for the nurse to communicate to the health care provider? a.Specific gravity 1.007 b.Protein 65 mg/dL (0.65 g/L) c.Glucose 45 mg/dL (1.7 mmol/L) d.White blood cell (WBC) count 4 cells/mL

ANS: B The protein level is high. The specific gravity, WBCs, and glucose values are normal.

Which information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the health care provider? a.The patient complains of having a stiff neck. b.The patients blood pressure (BP) is 90/50 mm Hg. c.The patient reports a severe and unrelenting headache. d.The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).

ANS: B To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider.

During the neurologic assessment, the patient is unable to respond verbally to the nurse but cooperates with the nurses directions to move his hands and feet. The nurse will suspect a.cerebellar injury. b.a brainstem lesion. c.frontal lobe damage. d.a temporal lobe lesion.

ANS: C Expressive speech is controlled by Brocas area in the frontal lobe. The temporal lobe contains Wernickes area, which is responsible for receptive speech. The cerebellum and brainstem do not affect higher cognitive functions such as speech.

The nurse teaches a student nurse about the action of ibuprofen. Which statement, if made by the student, indicates that teaching was effective? a.The drug decreases pain impulses in the spinal cord. b.The drug decreases sensitivity of the brain to painful stimuli. c.The drug decreases production of pain-sensitizing chemicals. d.The drug decreases the modulating effect of descending nerves.

ANS: C Nonsteroidal antiinflammatory drugs (NSAIDs) provide analgesic effects by decreasing the production of pain-sensitizing chemicals such as prostaglandins at the site of injury. Transmission of impulses through the spinal cord, brain sensitivity to pain, and the descending nerve pathways are not affected by NSAIDs.

The public health nurse is planning a program to decrease the incidence of meningitis in adolescents and young adults. Which action is most important? a.Encourage adolescents and young adults to avoid crowds in the winter. b.Vaccinate 11- and 12-year-old children against Haemophilus influenzae. c.Immunize adolescents and college freshman against Neisseria meningitides. d.Emphasize the importance of hand washing to prevent the spread of infection.

ANS: C The Neisseria meningitides vaccination is recommended for children ages 11 and 12, unvaccinated teens entering high school, and college freshmen. Hand washing may help decrease the spread of bacteria, but it is not as effective as immunization. Vaccination with Haemophilus influenzae is for infants and toddlers. Because adolescents and young adults are in school or the workplace, avoiding crowds is not realistic.

Which information about a 30-year-old patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse? a.Intracranial pressure of 15 mm Hg b.Cerebrospinal fluid (CSF) drainage of 25 mL/hour c.Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg d.Cardiac monitor shows sinus tachycardia at 128 beats/minute

ANS: C The PbtO2 should be 20 to 40 mm Hg. Lower levels indicate brain ischemia. An intracranial pressure (ICP) of 15 mm Hg is at the upper limit of normal. CSF is produced at a rate of 20 to 30 mL/hour. The reason for the sinus tachycardia should be investigated, but the elevated heart rate is not as concerning as the decrease in PbtO2.

The nurse is caring for a patient who has a head injury and fractured right arm after being assaulted. Which assessment information requires the most rapid action by the nurse? a.The apical pulse is slightly irregular. b.The patient complains of a headache. c.The patient is more difficult to arouse. d.The blood pressure (BP) increases to 140/62 mm Hg.

ANS: C The change in level of consciousness (LOC) is an indicator of increased intracranial pressure (ICP) and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache and a slightly irregular apical pulse are not unusual in a patient after a head injury.

When visiting a hospice patient, the nurse assesses that the patient has a respiratory rate of 11 breaths/minute and complains of severe pain. Which action is best for the nurse to take? a.Inform the patient that increasing the morphine will cause the respiratory drive to fail. b.Tell the patient that additional morphine can be administered when the respirations are 12. c.Titrate the prescribed morphine dose upward until the patient indicates adequate pain relief. d.Administer a nonopioid analgesic, such as a nonsteroidal antiinflammatory drug (NSAID), to improve patient pain control.

ANS: C The goal of opioid use in terminally ill patients is effective pain relief regardless of adverse effects such as respiratory depression. A nonopioid analgesic like ibuprofen would not provide adequate analgesia or be absorbed quickly. The rule of double effect provides ethical justification for administering an increased morphine dose to provide effective pain control even though the morphine may further decrease the patients respiratory rate.

A male patient who has right-sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activities. The nurse observes that when the patients wife is visiting, she feeds and dresses him. Which nursing diagnosis is most appropriate for the patient? a.Interrupted family processes related to effects of illness of a family member b.Situational low self-esteem related to increasing dependence on spouse for care c.Disabled family coping related to inadequate understanding by patients spouse d.Impaired nutrition: less than body requirements related to hemiplegia and aphasia

ANS: C The information supports the diagnosis of disabled family coping because the wife does not understand the rehabilitation program. There are no data supporting low self-esteem, and the patient is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. There is no indication that the patient has impaired nutrition.

14. A 47-year-old patient will attempt oral feedings for the first time since having a stroke. The nurse should assess the gag reflex and then a.order a varied pureed diet. b.assess the patients appetite. c.assist the patient into a chair. d.offer the patient a sip of juice.

ANS: C The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted regardless.

A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care? a.Encourage coughing and deep breathing. b.Position the patient with knees and hips flexed. c.Keep the head of the bed elevated to 30 degrees. d.Cluster nursing interventions to provide rest periods.

ANS: C The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP. Extreme flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP.

During the change of shift report a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have a.dysphasia. b.confusion. c.visual deficits. d.poor judgment.

ANS: C Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion.

The charge nurse is observing a new staff nurse who is assessing a patient with a traumatic spinal cord injury for sensation. Which action indicates a need for further teaching of the new nurse about neurologic assessment? a.The new nurse tests for light touch before testing for pain. b.The new nurse has the patient close the eyes during testing. c.The new nurse asks the patient if the instrument feels sharp. d.The new nurse uses an irregular pattern to test for intact touch.

ANS: C When performing a sensory assessment, the nurse should not provide verbal clues. The other actions by the new nurse are appropriate.

A patient being admitted with bacterial meningitis has a temperature of 102.5 F (39.2 C) and a severe headache. Which order for collaborative intervention should the nurse implement first? a.Administer ceftizoxime (Cefizox) 1 g IV. b.Give acetaminophen (Tylenol) 650 mg PO. c.Use a cooling blanket to lower temperature. d.Swab the nasopharyngeal mucosa for cultures.

ANS: D Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics are started. As soon as the cultures are done, the antibiotic should be started. Hypothermia therapy and acetaminophen administration are appropriate but can be started after the other actions are implemented.

A 58-year-old patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should a.use a calm voice to ask the patient to stop the crying behavior. b.explain to the family that depression is normal following a stroke. c.have the family members leave the patient alone for a few minutes. d.teach the family that emotional outbursts are common after strokes.

ANS: D Patients who have left-sided brain stroke are prone to emotional outbursts that are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patients outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patients control and asking the patient to stop will lead to embarrassment.

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness (LOC). Which nursing diagnosis do they determine has thehighest priority for the patient? a.Impaired physical mobility related to weakness b.Disturbed sensory perception related to brain injury c.Risk for impaired skin integrity related to immobility d.Risk for aspiration related to inability to protect airway

ANS: D Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses are also appropriate, but interventions to prevent aspiration are the priority at this time.

After having a craniectomy and left anterior fossae incision, a 64-year-old patient has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to a.cluster nursing activities to allow longer rest periods. b.turn and reposition the patient side to side every 2 hours. c.position the bed flat and log roll to reposition the patient. d.perform range-of-motion (ROM) exercises every 4 hours.

ANS: D ROM exercises will help prevent the complications of immobility. Patients with anterior craniotomies are positioned with the head elevated. The patient with a craniectomy should not be turned to the operative side. When the patient is weak, clustering nursing activities may lead to more fatigue and weakness.

A 73-year-old patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find? a.Impulsive behavior b.Right-sided neglect c.Hyperactive left-sided tendon reflexes d.Difficulty comprehending instructions

ANS: D Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side stroke.

When assessing a 53-year-old patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider? a.The patient exhibits nuchal rigidity. b.The patient has a positive Kernigs sign. c.The patients temperature is 101 F (38.3 C). d.The patients blood pressure is 88/42 mm Hg.

ANS: D Shock is a serious complication of meningitis, and the patients low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernigs sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the hypotension.

After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? a.A 20-year-old patient whose cranial x-ray shows a linear skull fracture b.A 30-year-old patient who has an initial Glasgow Coma Scale score of 13 c.A 40-year-old patient who lost consciousness for a few seconds after a fall d.A 50-year-old patient whose right pupil is 10 mm and unresponsive to light

ANS: D The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage and increased intracranial pressure. The other patients are not at immediate risk for complications such as herniation.

A patient with chronic neck pain is seen in the pain clinic for follow-up. In order to evaluate whether the pain management is effective, which question is best for the nurse to ask? a.Can you describe the quality of your pain? b.Has there been a change in the pain location? c.How would you rate your pain on a 0 to 10 scale? d.Does the pain keep you from doing things you enjoy?

ANS: D The goal for the treatment of chronic pain usually is to enhance function and quality of life. The other questions are also appropriate to ask, but information about patient function is more useful in evaluating effectiveness.

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

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

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a.The patients speech is difficult to understand. b.The patients blood pressure is 144/90 mm Hg. c.The patient takes a diuretic because of a history of hypertension. d.The patient has atrial fibrillation and takes warfarin (Coumadin).

ANS: D The use of warfarin probably contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patients care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.

The priority nursing assessment for a 72-year-old patient being admitted with a brainstem infarction is a.reflex reaction time. b.pupil reaction to light. c.level of consciousness. d.respiratory rate and rhythm.

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

The postoperative patient is receiving epidural fentanyl for pain relief. For which common side effects should the nurse monitor the patient (select all that apply)? A. Ataxia B. Itching C. Nausea D. Urinary retention E. Gastrointestinal bleeding

B, C, D. Common side effects of intraspinal opioids include nausea, itching, and urinary retention. Ataxia is a common side effect of intraspinal clonidine.