WEEK 1-3 QUIZ 1 MED SURG 2 PREP U

A nurse is providing education about migraine headaches to a community group. The cause of migraines has not been clearly demonstrated, but is related to vascular disturbances. A member of the group asks about familial tendencies. The nurse's correct reply will be which of the following?

"There is a strong familial tendency."

The nurse is caring for a client in the neurologic ICU who sustained head trauma in a physical altercation. What would the nurse know is the normal range of ICP for the client?

0 to 15 mm Hg

Which 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?

Multiple sclerosis

After a seizure, the nurse should place the patient in which of the following positions to prevent complications?

Side-lying, to facilitate drainage of oral secretions

Decerebrate

posture is extension and external rotation.

Decorticate

posture is the flexion and internal rotation of the forearms and hand

The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the

supine position with the head slightly elevated.

Myasthenia gravis occurs when antibodies attack which receptor sites?

Acetylcholine

During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do?

Administer atropine to control the side effects of edrophonium.

A client is suspected to have bacterial meningitis. What is the priority nursing intervention?

Administer prescribed antibiotics.

Which is a late sign of increased intracranial pressure (ICP)?

Altered respiratory patterns

A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop. The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment?

Neurovascular system

The nurse is assessing a newly admitted client with a diagnosis of meningitis. On assessment, the nurse expects to find which of the following?

Positive Kernig's sign

A client with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client?

Restricting fluid intake and hydration

A patient with myasthenia gravis is in the hospital for treatment of pneumonia. The patient informs the nurse that it is very important to take pyridostigmine bromide (Mestinon) on time. The nurse gets busy and does not administer the medication until after breakfast. What outcome will the patient have related to this late dose?

The muscles will become fatigued and the patient will not be able to chew food or swallow pills.

Decerebrate posturing indicates deeper and more severe dysfunction than does decorticate posturing. T or F

True

Which method is used to help reduce intracranial pressure?

Using a cervical collar

A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by:

a positive edrophonium (Tensilon) test.

The initial sign of increasing intracranial pressure (ICP) includes

decreased level of consciousness.

A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to:

rest in an air-conditioned room.

An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client?

Brain tumor

Which is the primary medical management of arthropod-borne virus (arboviral) encephalitis?

Controlling seizures and increased intracranial pressure

The nurse is caring for a patient in the emergency department with an onset of pain related to trigeminal neuralgia. What subjective data stated by the patient does the nurse determine triggered the paroxysms of pain?

"I was brushing my teeth."

A client with newly diagnosed seizures asks about stigma associated with epilepsy. The nurse will respond with which of the following statements?

"Many people with developmental disabilities resulting from neurologic damage also have epilepsy."

A client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize?

"You must avoid coughing, sneezing, and blowing your nose."

At what rate (in drops per minute) should a nurse start an IV infusion if the order is for 1 g of vancomycin (Vancocin) to be given in 180 ml of dextrose 5% in water over 60 minutes? The tubing delivers 15 drops/ml. Enter the correct number only.

45

The nurse is aware that burr holes may be used in neurosurgical procedures. Which of the following is a reason why a neurosurgeon may choose to create a burr hole in a patient?

Aspiration of a brain abscess

Which is the earliest sign of increasing intracranial pressure?

Change in level of consciousness

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?

Check the equipment.

A nurse is working in the neurologic intensive care unit and admits from the emergency department a patient with an inoperable brain tumor. Upon entering the room, the nurse observes that the patient is positioned like the person in part B of the accompanying image. Which posturing is the patient exhibiting?

Decerebrate

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP?

Lethargy and stupor

The diagnosis of multiple sclerosis is based on which test?

Magnetic resonance imaging

The nurse is educating a client with myasthenia gravis about medications. The nurse is sure to include which of the following?

Medications must be taken on time.

Which of the following is considered a central nervous system (CNS) disorder?

Multiple sclerosis

A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client?

Restricting fluid intake and hydration

When caring for a client with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP?

Rising blood pressure and bradycardia

The nurse is assisting with administering a Tensilon test to a patient with ptosis. If the test is positive for myasthenia gravis, what outcome does the nurse know will occur?

Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes.

A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient?

Within 24 hours after exposure

A nurse is teaching a client who was recently diagnosed with myasthenia gravis. Which statement should the nurse include in her teaching?

"This disease doesn't cause sensory impairment."

A client with myasthenia gravis is admitted with an exacerbation. The nurse is educating the client about plasmapheresis and explains this in which of the following statements?

Antibodies are removed from the plasma.

Which condition is a rare, transmissible, progressive fatal disease of the central nervous system characterized by spongiform degeneration of the gray matter of the brain?

Creutzfeldt-Jakob disease

A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head?

Elevated 30 degrees

When caring for a client with trigeminal neuralgia, which intervention has the highest priority?

Encouraging the client to bathe with care

A health care provider asks a nurse to assess a patient being evaluated for aseptic meningitis for a positive Brudzinski sign. Which of the following actions should the nurse take?

Help the patient flex his neck and observe for flexion of the hips and knees.

The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring?

Increased ICP

A client with a traumatic brain injury is showing early signs of increasing intracranial pressure (ICP). While planning care for this client, what would be the priority expected outcome?

Maintains a patent airway

Medical management of arthropod-borne virus (arboviral) encephalitis is aimed at

controlling seizures and increased intracranial pressure.

The client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. The nurse monitors blood chemistry test results and urinary output for

renal complications related to acyclovir therapy.

Vagus nerve demyelinization, which may occur in Guillain-Barré syndrome, would not be manifested by which of the following?

20/20 vision

A patient diagnosed with multiple sclerosis (MS) has ataxia. Which of the following medications could be used to treat this clinical manifestation?

Neurontin

A neurologic deficit is best defined as a deficit of the:

central and peripheral nervous systems with decreased, impaired, or absent functioning.

While caring for clients who have suffered neurologic deficits from causes such as cerebrovascular accident and closed head injury, an important nursing goal that motivates nurses to offer the best care possible is preventing:

complications

Cerebral edema peaks at which time point after intracranial surgery?

24 hours

A patient is admitted to the hospital with an ICP reading of 20 mm Hg and a mean arterial pressure of 90 mm Hg. What would the nurse calculate the CPP to be?

70 mm Hg

A client was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first?

Declining level of consciousness (LOC)

The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe?

Diplopia and ptosis

The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began?

Drooping eyelids (ptosis)

A client is undergoing testing to confirm a diagnosis of myasthenia gravis. The nurse explains that a diagnosis is made if muscle function improves after the client receives an IV injection of a medication. What is the medication the nurse tells the client he'll receive during this test?

Edrophonium (Tensilon)

Which of the following is an early sign of increasing intracranial pressure (ICP)?

Headache

A client is experiencing muscle weakness and an ataxic gait. The client has a diagnosis of multiple sclerosis (MS). Based on these symptoms, the nurse formulates "Impaired physical mobility" as one of the nursing diagnoses applicable to the client. What nursing intervention should be most appropriate to address the nursing diagnosis?

Help the client perform range-of-motion (ROM) exercises every 8 hours.

Which is the most common cause of acute encephalitis in the United States?

Herpes simplex virus

A nurse is working on a neurological unit with a nursing student who asks the difference between primary and secondary headaches. The nurse's correct response will include which of the following statements?

"A secondary headache is associated with an organic cause, such as a brain tumor."

A nurse assesses the patient's level of consciousness using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function?

3

A client is receiving intravenous (IV) mannitol to prevent increased intracranial pressure. The order is for mannitol 1.5 grams per kg of body weight IV now. The client weighs 143 lbs (65 kg). How many grams will the nurse administer to the client? Enter the correct number in tenths.

97.5

A client has a neurological defect and will be transferred to a nursing home because family members are unable to care for the client at home. While receiving a bed bath, the client yells at the nurse, "You don't know what you are doing!" What is the best reaction by the nurse?

Accept the patient's behavior and do not take it personally.

A 34-year-old patient is diagnosed with relapsing-remitting MS. The nurse explains to the patient's family that they should expect:

Acute attacks with full recovery or residual deficit upon recovery.

Which drug should be available to counteract the effect of edrophonium chloride?

Atropine

A nurse is providing education to a client with newly diagnosed multiple sclerosis (MS). Which of the following will the nurse include?

Avoid hot temperatures.

Which positions is used to help reduce intracranial pressure (ICP)?

Avoiding flexion of the neck with use of a cervical collar

The nurse recognizes that causes of acquired seizures include what? Select all that apply.

Cerebrovascular disease Metabolic and toxic conditions Hyponatremia Brain tumor Drug and alcohol withdrawal

A 58-year-old construction worker fell from a 25-foot scaffolding and incurred a closed head injury as a result. As his intracranial pressure continues to increase, the potential of herniation also increases. If the brain herniates, which of the following are potential consequences? Choose all correct options.

Death Permanent neurologic dysfunction Impaired cellular activity Seizures

The nurse is preparing the client for an acetylcholinesterase inhibitor test to rule out myasthenia gravis. Which is the priority nursing action?

Ensure atropine is readily available.

The nurse is caring for a client with an inoperable brain tumor. What teaching is important for the nurse to do with these clients?

Explaining hospice care and services

A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication?

Lamictal

The nurse is caring for a client with a traumatic brain injury who has developed increased intracranial pressure resulting in syndrome of inappropriate antidiuretic hormone (SIADH). While assessing this client, the nurse expects which of the following findings?

Oliguria and serum hyponatremia

When educating a patient about the use of antiseizure medication, what should the nurse inform the patient is a result of long-term use of the medication in women?

Osteoporosis

A nurse is assessing a newly admitted client with meningitis. Which of the following findings in this client is most likely?

Positive Brudzinski's sign

Which is a component of the nursing management of the client with new variant Creutzfeldt-Jakob disease (vCJD)?

Providing supportive care

A patient with Bell's palsy says to the nurse, "It doesn't hurt anymore to touch my face. How am I going to get muscle tone back so I don't look like this anymore?" What interventions can the nurse suggest to the patient?

Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone.

The client presents to the walk-in clinic with fever, nuchal rigidity, and headache. Which of the following assessment findings would be most significant in the diagnosis of this client?

Vector bites

A nurse is caring for a client with a history of severe migraines. The client has a medical history that includes asthma, gastroesophageal reflux disease, and three pregnancies. Which medication does the nurse anticipate the physician will order for the client's migraines?

Verapamil (Calan)

A primary headache is one for which no organic cause can be identified. These types include...

migraine, tension, and cluster headaches.

A client with fungal encephalitis receiving amphotericin B reports fever, chills, and body aches. The nurse knows that these symptoms

may be controlled by the administration of diphenhydramine and acetaminophen approximately 30 minutes before administration of the amphotericin.

For a client with suspected increased intracranial pressure (ICP), an appropriate respiratory goal is to:

promote carbon dioxide elimination.

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is most appropriate?

Alternatively patch one eye every 2 hours.

The school nurse notes a 6-year-old running across the playground with his friends. The child stops in midstride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child?

An absence seizure

The nurse is performing an initial assessment on a client with suspected Bell's palsy. Which of the following findings would the nurse be most focused on related to this medical diagnosis?

Facial distortion and pain

A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?

"The paralysis caused by this disease is temporary."

A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The physician suspects myasthenia gravis. Which drug will be used to test for this disease?

Edrophonium (Tensilon)

A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following nursing diagnoses would be the first priority for the plan of care?

Ineffective airway clearance related to altered LOC

The nurse is caring for a patient with an altered LOC. What is the first priority of treatment for this patient?

Maintenance of a patent airway

A client has been diagnosed with a frontal lobe brain abscess. Which nursing intervention is appropriate?

`Initiate seizure precautions.

When the nurse observes that the client has extension and external rotation of the arms and wrists and plantar flexion of the feet, the nurse records the client's posture as

decerebrate