AH2 Adaptive Quizzing
Where are the central thermoreceptors located in the human body? Select all that apply. a. Skin b. Spinal cord c. Hypothalamus d. Throughout the body e. Abdominal organs
1. Answer: B, C, D Central thermoreceptors in the body provide skin and core temperature information to the hypothalamus and are located in the spinal cord, hypothalamus, and abdominal organs. Central thermoreceptors are not present in the skin; peripheral thermoreceptors are present in the skin. Central thermoreceptors are not present throughout the body; multiple thermoreceptors are present throughout the body.
During the neurologic assessment of a client with a tentative diagnosis of Guillain-Barré syndrome, what does the nurse expect the client to manifest? a. Diminished visual acuity b. Increased muscular weakness c. Pronounced muscular atrophy d. Impairment in cognitive reasoning
Answer B Increased muscular weakness Muscular weakness with paralysis results from impaired nerve conduction because the motor nerves become demyelinated. Diminished visual acuity usually is not a problem; motor loss is greater than sensory loss, with paresthesia of the extremities being the most frequent sensory loss. Demyelination occurs rapidly early in the disease, and the muscles will not have had time to atrophy; this can occur later if rehabilitation is delayed. Only the peripheral nerves are involved; the central nervous system is unaffected.
A client who had a craniotomy is transferred to the intensive care unit from the postanesthesia care unit. Which nursing action is most important when caring for this client? a. Take axillary and oral temperatures. b. Encouraging coughing, but discourage deep breathing. c. Administer a prescribed opioid or sedative at the first sign of irritability. d. Report yellow or bloody drainage on the dressing to the healthcare provider immediately
Answer D Report yellow or bloody drainage on the dressing to the healthcare provider immediately. Yellow drainage may be cerebral spinal fluid, and bloody drainage is a sign of hemorrhage; either one should be reported to the healthcare provider immediately. Axillary temperatures are influenced by environmental conditions. Temperature evaluation must be accurate; therefore the rectal, not axillary, route is most appropriate. Oral temperatures are contraindicated for clients at risk for seizures. While deep breathing expands the lungs and mobilizes secretions to prevent respiratory complications, coughing can increase intracranial pressure and should be avoided. When necessary, secretions may be removed by suctioning because suctioning is less stressful than coughing and less likely to increase intracranial pressure. Administration of opioids and sedatives hinders accurate neurologic assessment because they depress the central nervous system.
Three days after admission to the hospital for a brain attack (cerebrovascular accident, CVA), a client has a nasogastric tube inserted and is receiving continuous tube feedings. Which action should the nurse take to best evaluate whether the feeding is being absorbed? a. Aspirate for a residual volume b. Evaluate the intake in relation to the output c. Instill air into the client's stomach while auscultating d. Compare the client's body weight with the baseline data
Answer: A A gastric residual of over 200 mL or as specified by the primary healthcare provider or facility will alert the nurse that the feeding is not being absorbed; conversely, a residual of less than 200 mL indicates the feeding is being absorbed. Evaluation of intake to output gauges fluid balance, not whether feeding is absorbed. Instilling air into the client's stomach is not advocated and does not determine if the feeding is absorbed. Comparing the body weight to the baseline is a fluid issue and is performed on a daily basis, or it is a weight gain/loss issue. Since weight can fluctuate based on fluid, the aspirate is the better choice for absorption.
A nurse is providing dietary instruction to a client with cardiovascular disease. Which dietary selection by the client indicates that the nurse needs to reeducate the client? a. Whole milk with oatmeal b. Garden salad with olive oil c. Tuna fish with a small apple d. Soluble fiber cereal with yogurt
Answer: A An overall heart healthy diet includes a variety of fruits and vegetables, whole grains, low-fat dairy products, skinless poultry and fish, nuts, legumes and non-tropical vegetable oils. Whole milk is high in saturated fat and should be avoided.
A client who is recuperating from a spinal cord injury at the T4 level wants to use a wheelchair. What should the nurse teach the client to do in preparation for this activity? a. Push-ups to strengthen arm muscles b. Leg lifts to prevent hip contractures c. Balancing exercises to promote equilibrium d. Quadriceps-setting exercises to maintain muscle tone
Answer: A Arm strength is necessary for transfers and activities of daily living and for use of crutches or a wheelchair, so the nurse should teach the client how to do wheelchair push-ups safely. Equilibrium is not a problem. The client does not have neurologic control of the other activities.
After a client is treated for a spinal cord injury, the healthcare provider informs the family that the client is a paraplegic. The family asks the nurse what this means. Which explanation should the nurse provide? a. Lower extremities are paralyzed. b. Upper extremities are paralyzed. c. One side of the body is paralyzed. d. Both lower and upper extremities are paralyzed.
Answer: A Both legs and generally the lower part of the body are paralyzed in paraplegia. There is no term to describe only upper extremities affected; all parts below an injury are affected. One side of the body paralyzed describes hemiplegia. The paralysis of both lower and upper extremities describes quadriplegia.
A client who had an infratentorial craniotomy is admitted to the intensive care unit after discharge from the postanesthesia care unit. Frequent assessments reveal that the client's intracranial pressure is increasing. What should the nurse do first? a. Notify the healthcare provider b. Elevate the head of the bed c. Reduce the flow rate of intravenous fluid d. Administer the next dose of osmotic diuretic early
Answer: A Immediate corrective therapy based on current assessments must be implemented. After an infratentorial craniotomy the client is positioned flat on one side with the head on a small, firm pillow unless otherwise instructed by the healthcare provider. Although reducing the flow rate of IV fluid is an appropriate action, it is not the priority until the healthcare provider is notified. Administering a medication is a dependent function of the nurse, and the prescription must be followed exactly.
A client has a discectomy and fusion for a herniated nucleus pulposus (HNP). When getting out of bed for the first time, the client reports feeling faint and lightheaded. Which instruction should the nurse provide to the client? a. "Sit upright on the edge of the bed." b. "Slide to the floor to prevent a fall and injury." c. "Bend forward to increase the blood flow to the brain." d. "Lie down immediately so a blood pressure can be obtained."
Answer: A Sitting maintains alignment of the back and allows the nurses to support the client until orthostatic hypotension subsides. Sliding to the floor so the client will not fall and get hurt will induce flexion of the vertebrae, which can traumatize the spinal cord. Because it will increase the blood flow to the brain, bending forward will induce flexion of the vertebrae, which can traumatize the spinal cord. Rapid movement can flex the vertebrae, which can traumatize the spinal cord; taking the blood pressure at this time is not necessary.
What action should the nurse take to prevent precipitating a painful attack in a client with tic douloureux? a. Avoid walking swiftly by the client. b. Keep the client in the prone position. c. Discontinue oral hygiene temporarily. d. Massage both sides of the face frequently.
Answer: A The nurse should avoid walking swiftly past the client because drafts or even slight air currents can initiate pain. The client may assume any position of comfort, but pressure on the face while in the prone position may trigger an attack. Although the procedure for oral hygiene may be modified, it is not discontinued. Massaging may trigger an attack and should be avoided.
A client who had a brain attack (cerebrovascular accident, CVA) two weeks ago is having problems communicating. The nurse shows the client a picture of a baseball and asks the client to identify it and its characteristics. The client describes its color, size, and purpose but cannot identify it as a ball. How will the nurse document this finding in the client's medical record? a. Anomia b. Apraxia c. Dysarthria d. Dyshagia
Answer: A Anomia Clients with anomia cannot remember names of objects. Clients with apraxia cannot use objects properly or complete sequential movement. Clients with dysarthria know what they want to say but cannot speak clearly because there is motor impairment caused by a central or peripheral nervous system injury. Clients with dysphagia have difficulty swallowing; they do not have speech problem.
A nurse is caring for four clients. Which client is at a risk of meningitis, hearing loss, and generalized paresis? a. Client A with gummas on the skin, nose, mouth, and bones b. Client B with painless, indurated, smooth weeping lesions on skin c. Client C with diffuse reddish-brown macules and papules 3 mm in size new the genitalia d. Client D with malaise, muscular aches, condylomata lata and moth-eaten appearance of the scalp
Answer: A Client A with gummas on the skin, nose, mouth, and bones Gummas on the skin, nose, mouth, and bones are associated with the third stage of syphilis. A client in the third stage of syphilis is at a higher risk for neurosyphilis, which may lead to central nervous system problems. Therefore Client A is more prone to meningitis, hearing loss, and generalized paresis. Client B (with painless, indurated, smooth, and weeping skin lesions) has a highly infectious primary stage of syphilis. Client C (with diffuse reddish-brown macules and papules 3 mm in size near the genitalia) may have secondary syphilis. Client D (with malaise, muscular aches, condylomata lata, and a moth-eaten appearance of the scalp) may have highly contagious secondary syphilis.
The nurse reviews the diagnostic reports of a client and discovers that the client has an injury to cranial nerve VII. What will the nurse observe upon assessment? a. Inhibition of tear production b. Inhibition of peripheral vision c. Impairment of eye movement d. Impairment of pupil constriction
Answer: A Inhibition of tear production Injury to cranial nerve VII mainly leads to inhibition of tear production, a condition called keratoconjunctivitis sicca or dry eye syndrome. Any impairment to cranial nerve II may affect peripheral and central vision. Cranial nerves III, IV and VI affect eye movement. Therefore any injury to these nerves may affect eye movement. The function of cranial nerve III is constriction of the pupil. Any injury to this nerve may lead to impairment of pupil constriction.
A client is admitted with a closed head injury sustained in a motor vehicle accident (MVA). The nursing assessment indicates increased intracranial pressure (ICP). Which intervention should the nurse perform first? a. Place the head and neck in alignment. b. Administer 1 gram mannitol intravenously (IV) as prescribed. c. Increase the ventilator's respiratory rate to 20 breaths/minute. d. Administer 100 mg of pentobarbital IV as prescribed.
Answer: A Place the head and neck in alignment The nurse should first attempt nursing interventions such as placing the head and neck in alignment (neutral position) to facilitate venous return and thereby decrease ICP. If nursing measures prove ineffective, notify the healthcare provider, who may prescribe mannitol. The nurse would notify the healthcare provider for hyperventilation therapy or for pentobarbital. Hyperventilation is used only when all other interventions have been ineffective in decreasing ICP
When two nurses are getting an older adult out of bed, the client reports feeling light-headed. The nurse identifies that the client's pulse is stable and the client's color has not changed. What should the nurses assist the client to do? a. Slide slowly to the floor to prevent a fall and injury. b. Sit on the edge of the bed while they hold the client upright. c. Bend forward because this will increase blood flow to the brain. d. Lie down quickly so the legs can be raised above the heart level.
Answer: B Sitting allows the nurses to support the client until orthostatic hypotension subsides. The client's stable pulse and color indicate that the situation does not warrant placing the client in the supine position. Sliding slowly to the floor to prevent a fall and injury, bending forward, or rapid movement will permit flexion of the vertebrae, which may traumatize the spinal cord. A light-headed feeling usually is transient until the body adapts to the upright position, so leg elevation is unnecessary.
The registered nurse (RN) is teaching a student nurse about taking a current history from a client who is suspected to have a neurologic disorder. Which statement made by the student nurse indicates the RN needs to follow up? Select all that apply. a. "I should ask the client about insomnia." b. "I should ask the client about diabetes mellitus." c. "I should ask the client about weakness and clumsiness." d. "I should ask the client about any difficulty in swallowing." e. "I should ask the client about numbness and tingling sensations."
Answer: A, B The nurse should ask a client about insomnia and diabetes mellitus while documenting that client's past medical history, not during the current history. Therefore the RN will follow up to correct this misconception. All the other statements are correct. While taking and documenting the current history of a client, the nurse should ask the client about any feeling of weakness and clumsiness in the body, swallowing difficulties, and numbness and tingling sensations. These may help the nurse to identify the client's current health problems.
What interventions should the nurse implement in caring for a client with diabetes insipidus (DI) following a head injury? Select all that apply a. Providing adequate fluids within easy reach b. Reporting an increasing urine specific gravity c. Administering prescribed erythromycin d. Assessing for and reporting changes in neurological status e. Monitoring for constipation, weight loss, hypotension, and tachycardia
Answer: A, D, E Diabetes insipidus is a condition resulting in underproduction of antidiuretic hormone. The focus of care is on maintaining fluids and electrolytes. Oral fluids must be easily accessible at the bedside to balance urinary losses and prevent severe dehydration. The nurse monitors for, and reports, changes in neurological status associated with hypernatremia and high serum osmolality. Constipation and weight loss indicate fluid volume deficit and must be reported. Hypotension and tachycardia are signs of impending shock. Massive polyuria results in dilute urine. Decreasing urine specific gravity must be reported. There is no indication that an antibiotic is required; therefore erythromycin would not be prescribed. The primary pharmacologic treatment for diabetes insipidus, then, is replacement of antidiuretic hormone (ADH) with an exogenous vasopressin, such as desmopressin acetate (DDAVP).
After interacting with a client, the nurse believes the client is in the prodromal phase of a migraine. Which statements made by the client led the nurse to reach this conclusion? Select all that apply. a. "I feel drowsy all the time." b. "I feel severe pain over my ear." c. "I feel a throbbing pain in my head." d. "I feel confused at this point in time." e. "I feel weakness in the left side of my body."
Answer: A, D, E The nurse concludes the client is in the prodromal phase by the client's statements of drowsiness, confused state, and weakness on one side of the body. A migraine is a clinical syndrome that is characterized by recurrent episodic attacks of head pain. The first phase of a migraine headache is called the prodromal phase. In the prodromal phase, a variety of neurologic changes are seen. These include drowsiness, acute confusion, vertigo, numbness and tingling of lips or tongue, aphasia, and unilateral weakness. Severe pain over the ear is pain in the templar region and is the second phase of a migraine headache. Throbbing pain in the head occurs in the third phase of a migraine.
A client with a primary brain tumor has developed syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse will expect to see which clinical findings upon assessment? Select all that apply a. Nausea and vomiting b. Hyperthermia c. Bradycardia d. Increased weight e. Decreased serum sodium f. Decreased level of consciousness
Answer: A, D, E, F Water retention and decreased urinary output occur because of excess secretion of antidiuretic hormone (ADH). Early manifestations are related to water retention and may include gastrointestinal (GI) disturbances such as loss of appetite, nausea, and vomiting. Weight gain occurs because of the water retention. Serum sodium levels are decreased because of fluid retention and sodium loss. Central nervous system changes include headaches, lethargy, and decreased level of consciousness, progressing to coma and seizures. Hypothermia also occurs because of central nervous system disturbance. The pulse is full and bounding because of the increased fluid volume.
The nurse is conducting a neurologic assessment on a client brought to the emergency room after a motor vehicle accident. While assessing the client's response to pain, the client pulls his arms upward and inward. The nurse recognizes that this response represents an injury to what part of the brain? a. Frontal lobe b. Midbrain c. Pons d. Brainstem
Answer: B Decorticate posturing is a sign of significant deterioration in a client's neurologic status and is manifested by rigid flexing of elbows and wrists. This can represent an injury to the midbrain. Damage to the frontal lobe would affect motor function, problem solving, spontaneity, memory, language, initiation, judgment, impulse control, and social and sexual behavior. The pons (which is part of the brainstem) and brainstem help control breathing and heart rate, vision, hearing, sweating, blood pressure, digestion, alertness, sleep, and sense of balance. Damage to this area would manifest itself as abnormal responses in the above listed areas.
A client has expressive aphasia. The client's family members ask how they can help the client regain as much speech function as possible. Which information should the nurse share with the family? a. Speak louder than usual during visits while looking directly at the client. b. Encourage the client to speak while allowing time to respond. c. Give positive reinforcement for correct communication. d. Tell the client to use the correct words when speaking.
Answer: B In addition to the extent of injury, a factor in relearning speech is the client's motivation and effort. The more the client attempts to talk, the more likely speech will progress to its optimum level; relearning is a slow process. Clients with aphasia are not deaf. Although the nurse should instruct the family to approve and support the client's efforts to communicate, this support should be for the effort, not for correct communication. Telling the client to use the correct words when speaking will create frustration and may anger the client.
A nurse enters the room of a client with myasthenia gravis and identifies that the client is experiencing increased dysphagia. What should the nurse do first? a. Administer oxygen b. Raise the head of the bed c. Perform tracheal suctioning d. Call the healthcare provider
Answer: B Raising the head of the bed allows gravity to assist in the swallowing of saliva, thus decreasing the risk for aspiration. Oxygen will not assist in the management of dysphagia or the prevention of aspiration. Performing tracheal suctioning may become necessary if the upright position does not allow the client to manage secretions. Alerting the healthcare provider to the problem is necessary, but only after client safety is ensured.
A recently hospitalized client with multiple sclerosis is concerned about generalized weakness and fluctuating physical status. What is the priority nursing intervention for this client? a. Encourage bed rest b. Space activities throughout the day c. Teach the limitations imposed by the disease d. Have one of the client's relatives stay at the bedside
Answer: B Spacing activities will encourage maximum functioning within the limits of strength and fatigue. Bed rest and limited activity may lead to muscle atrophy and calcium depletion. Strengths, rather than limitations, should be stressed. Having one of the client's relatives stay at the bedside is unnecessary. It is the nurse's responsibility to maintain client safety and meet client needs.
A client with multiple sclerosis is in remission. Which diversional activity should the nurse encourage that best meets the client's needs while in remission? a. Hiking b. Swimming c. Sewing classes d. Watching television
Answer: B Swimming helps keep the muscles supple, without requiring fine-motor activity. Hiking might prove too rigorous for the client. Sewing requires fine-motor activity and will be difficult for the client. Sedentary activities are not helpful in maintaining muscle tone.
After a cervical neck injury, a client is placed in a halo fixation device with a body cast. Which statement indicates the client's concern about body image has been resolved successfully? a. "I hate having everyone else do things for me." b. "I've gotten used to the brace. I may even miss it when it's gone." c. "I've been keeping my daily calories low in an attempt to lose weight." d. "I can't get to sleep. However, I make up for it in the morning by sleeping later."
Answer: B The client is demonstrating acceptance and is looking toward the future with the response "I've gotten used to but the brace. I may even miss it when it's gone." The response "I hate having everyone else do things for me" relates to low self-esteem, not body image disturbance. The response "I've been keeping my daily calories low in an attempt to lose weight" may indicate that the client may not accept the present body weight. Although the response "I can't get to sleep. However, I make up for it in the morning by sleeping later" may indicate adaptability; it is not related to body image
While caring for a client who sustained a severe head injury in a motor vehicle accident, the nurse observes that the client is constantly passing urine and is dehydrated. What does the nurse suspect as the cause for the client's condition? a. Decreased secretion of aldosterone b. Decreased secretion of antidiuretic hormone c. Decreased secretion of parathyroid hormone d. Decreased secretion of atrial natriuretic peptide
Answer: B The client sustained a head injury in the accident; therefore the nurse suspects that the cause of constant water loss through urine could be because of decreased antidiuretic hormone. Diabetes insipidus is a complication of traumatic brain injury where the posterior pituitary does not secrete antidiuretic hormone. In the absence of antidiuretic hormone, water is not reabsorbed from the tubules in the nephron and, therefore, gets eliminated as urine. Aldosterone is secreted by the adrenal cortex and mainly controls sodium-potassium levels. Parathyroid hormone helps regulate serum calcium levels in the body and is secreted by the parathyroid glands located in the neck. Atrial natriuretic peptide is secreted by the myocyte cells in the right atrium and work in opposition to aldosterone, causing increased urine output.
A nurse is teaching a client with multiple sclerosis about the disease. Which statement by the client indicates to the nurse that further teaching is needed? a. "I avoid use of a straw to drink liquids." b. "I will take a hot bath to relax my muscles." c. "I will plan to use an incontinence pad when I go out." d. "I may be having a rough time now, but I hope tomorrow will be better."
Answer: B The nurse needs to address the hot baths to correct this misconception. Hot baths tend to increase symptoms and may result in burns because of decreased sensation. All the rest are correct and do not require teaching. Using a straw gives the client less control of liquid intake, which may lead to aspiration. Although a bladder regimen to maintain control is preferable, the use of pads can avoid embarrassment. The disease does have periods of remission and exacerbation.
A nurse is working with an unlicensed assistive personnel (UAP) in caring for a group of clients. Which statement by the UAP indicates a correct understanding of the UAP's role? a. "I will turn off clients' IVs that have infiltrated." b. "I will take clients' vital signs after their procedures are over." c. "I will use unit written materials to teach clients before surgery." d. "I will help by giving medications to clients who are slow in taking pills."
Answer: B "I will take clients' vital signs after their procedures are over." Monitoring vital signs after procedures is within the scope of a UAP's role. Registered professional nurses or licensed practical nurses, not UAPs, should perform turning off clients' intravenous (IV) infusions that have infiltrated. Using unit written materials to teach clients before surgery should be performed by registered professional nurses or licensed practical nurses, not UAPs. Helping by giving medications to clients who are slow in taking pills should be performed by registered professional nurses or licensed practical nurses, not UAPs.
The family member of a client with newly diagnosed Guillain-Barré syndrome comes out to the nurse's station and informs the nurse that the client is having difficulty breathing. What is the first action the nurse should do? a. Notify the healthcare provider. b. Go with the family member to assess the client. c. Send the nursing assistive personnel to take vital signs. d. Assure the family member this is a normal response for this disease.
Answer: B Go with the family member to assess the client. The initial response for the nurse is to assess the client to ensure a patent airway. Guillain-Barré syndrome will exhibit ascending paralysis and can impede respiratory function. The healthcare provider will be notified after the nurse has assessed the client. The nurse needs to personally assess the client since this is a change in condition; the nurse should not send the nursing assistive personnel to assess the client. This is not a normal response to this disease, so it is not correct to assure the family member of this.
A client experiences a cerebral vascular accident (CVA) and is admitted to the hospital in a coma. What is the priority nursing care for this client? a. Monitor vital signs b. Maintain an open airway c. Maintain fluid and electrolytes d. Monitor pupil response and equality
Answer: B Maintain an open airway A patent airway is the priority because the airway may become occluded by the tongue in an unconscious client. Monitoring vital signs is not the priority, although it is an important nursing function. Monitoring pupil response and equality and maintaining fluid and electrolytes are not the priority, although they are important nursing functions.
The nurse is assessing a client's equilibrium to test his or her cerebellar function. The nurse finds that the client sways with his or her eyes closed. How should the nurse document this observation? a. Positive Kernig sign b. Positive Romberg sign c. Positive Babinski sign d. Positive Brudzinski sign
Answer: B Positive Romberg sign A positive Romberg sign indicates abnormal proprioception; clients with this condition are unable to maintain balance with their eyes closed. A positive Kernig sign and a positive Brudzinski sign indicate meningitis. A positive Babinski sign indicates the presence of central nervous system disease.
A man walks into the emergency room (ER) with sunglasses on and tells the nurse that he fell off a ladder and hit his head and was unconscious for a few minutes. What is the most appropriate next question the nurse should ask the client? a. "Did you pass out?" b. "Can you take off your sunglasses?" c. "Are you injured anywhere else?" d. "How many feet did you fall?"
Answer: B T he nurse cannot quickly assess the client for raccoon eyes unless the sunglasses are removed. Raccoon eyes is periorbital ecchymosis around the eyes. If bilateral, it is highly suggestive of basilar skull fracture. It is caused by rupture of the meninges causing the venous sinuses to bleed into the arachnoid villi and cranial sinuses, resulting in pooling of blood around the eyes. It most often is associated with fractures of the anterior cranial fossa and requires immediate attention. It is also important to assess for any loss of consciousness, other injuries, and the height of the fall. However, visually assessing the client comes first.
A client with a traumatic brain injury is demonstrating signs of increasing intracranial pressure, which may exert pressure on the medulla. What should the nurse assess to determine involvement of the medulla? Select all that apply. a. Taster b. Breathing c. Heart rate d. Fluid balance e. Voluntary movement
Answer: B, C The medulla, part of the brainstem just above the foramen magnum, is concerned with vital functions such as breathing. The medulla is concerned with vital functions such as heart rate. The opercular-insular area of the parietal cerebral lobe is concerned with taste sensations. The medulla is not concerned with fluid balance. Osmoreceptors of the hypothalamus cause increased or decreased antidiuretic hormone (ADH) secretion depending on serum osmolarity. Voluntary movements are mediated through the somatomotor area of the cerebral cortex.
When caring for a client with a head injury that may have involved the medulla, the nurse bases assessments on the knowledge that the medulla controls a variety of functions. Which functions will the nurse assess? Select all that apply a. Balance b. Breathing c. Pulse rate d. Fat metabolism e. Temperature regulation
Answer: B, C The medulla, part of the brainstem just above the foramen magnum, is concerned with vital functions such as respirations. The medulla is concerned with vital functions such as the heart rate. The cerebellum controls balance. Fat metabolism is not controlled by the central nervous system. Temperature regulation is controlled by the hypothalamus.
A nurse gave a client naloxone. To evaluate the effectiveness of the medication, what should the nurse assess for? a. Change in level of consciousness b. Increased pain c. Increased respiration d. Decreased heart rate
Answer: C Naloxone is given for decreased respirations caused by opioid overdose[1][2]. The amount given is determined by the respiratory status, not the level of consciousness. Undesirable side effects of naloxone are pain and rapid heart rate with dysrhythmias
A client experiences expressive aphasia as a result of a brain attack (cerebrovascular accident, CVA). The client's spouse asks whether the client's speech will ever return. What is the best response by the nurse? a. "It should return in several months." b. "You will have to ask the primary healthcare provider." c. "It is hard to say how much improvement will occur." d. "Unfortunately, your spouse will no longer be able to speak."
Answer: C Recovery from aphasia is a continuous process; the amount of recovery cannot be predicted. The response "It should return in several months" gives false reassurance; it may take a year or longer or may never return. The response "You will have to ask the primary healthcare provider" abdicates the nurse's responsibility; the healthcare provider cannot predict return of function. Speech return is a continuous process; it may take a year or longer or may never return.
A client has a supratentorial craniotomy for a tumor in the right frontal lobe of the cerebral cortex. Which position does the nurse recognize is the most appropriate for this client postoperatively? a. Semi-fowler with knee gatch elevated b. Flat on one side with the neck maintained in alignment with a small pillow c. Head of the bed elevated 30 to 45 degrees with neck in neutral alignment d. Head of the bed elevated 20 degrees with the head turned to the operative side
Answer: C The head of the bed elevated to 30 to 45 degrees with the neck in neutral alignment will not impede venous return. The semi-Fowler position with knee gatch elevated lessens the possibility of hemorrhage, provides for better circulation of cerebrospinal fluid, and promotes venous return. Gatching the knees is contraindicated because it can increase intracranial pressure. Flat on one side with the neck maintained in alignment with a small pillow is the appropriate position after infratentorial surgery. The head of the bed elevated 20 degrees with the head turned to the operative side impedes venous return, thus increasing intracranial pressure.
A nurse assesses a client for increasing intracranial pressure by monitoring the pulse pressure. What is the pulse pressure? a. Force exerted against an arterial wall b. Gap between the apical and radial rates c. Difference between systolic and diastolic readings d. Quality of ventricular contraction in relation to cardiac output
Answer: C The pulse pressure is obtained by subtracting the diastolic blood pressure reading from the systolic blood pressure reading; pulse pressure widens as intracranial pressure increases. The force exerted against an arterial wall is reflected in blood pressure readings and indicates cardiovascular function. The gap between the apical and radial rates is the definition of a pulse deficit. The quality of ventricular contraction in relation to cardiac output is determined by various diagnostic techniques used in cardiology; this is the role of the primary healthcare provider, not the nurse.
On the first postoperative evening after a lumbar laminectomy, a client states, "My feet are as numb as they were before the operation." Which is the nurse's best response? a. "Let me elevate your feet so the numbness will decrease more quickly." b. "That's important to know. I will inform your healthcare provider about the numbness." c. "Continue to let me know how you feel. It often takes time before this feeling subsides." d. "There is no cause for concern because the numbness will disappear as soon as the anesthesia wears off."
Answer: C The response "Continue to let me know how you feel. It often takes time before this feeling subsides" offers the realistic assurance that nothing is wrong and encourages the client to relate information to the nurse. The response "Let me elevate your feet so the numbness will decrease more quickly" will not decrease the numbness; nerve root irritation will lessen only with time. The response "That's important to know. I will inform your healthcare provider about the numbness" tells the client that there is a problem when, in reality, there is no reason to call the healthcare provider. The response "There is no cause for concern because the numbness will disappear as soon as the anesthesia wears off" provides false reassurance; nerve root numbness lessens only with time.
A nurse should plan to maintain a client who has experienced a subarachnoid hemorrhage in what position? a. Supine b. On the unaffected side c. In bed with the head of the bed elevated d. With sandbags on either side of the head
Answer: C With the head of the bed elevated, the force of gravity helps prevent additional intracranial pressure which will intensify the ischemic manifestations of hemorrhage. The supine position will not facilitate drainage of cerebral fluid; this position promotes accumulation of fluid, which increases intracranial pressure. Lying on the unaffected side will not facilitate drainage of cerebral fluid; this position promotes accumulation of fluid, which increases intracranial pressure. Vomiting can occur with increased intracranial pressure, and placing sandbags to immobilize the head can result in aspiration.
Postoperatively, a client complains about a variety of minor environmental factors, frequently changes positions, and avoids eye contact. The nurse responds to these observations by stating, "Let me get you some cold water and your pain pill, and you'll be much better." What does the nurse's response demonstrate? a. An empathic recognition of anxiety b. Addressing of the client's needs c. An inappropriate interpretation of the assessment findings d. Advanced problem solving and critical thinking skills
Answer: C An inappropriate interpretation of the assessment findings The nurse did not clarify whether the client was in pain; also the nurse's statement offers false reassurance. The nurse's response denies the client's anxiety; it identifies pain as the problem. The nurse's response denies the client's needs; the client needs to discuss concerns and feelings. The nurse inappropriately identified the problem and did not clarify the client's needs.
When caring for a client who has hyponatremia, the nurse would monitor for which symptom? a. Increased urine output b. Deep rapid respirations c. Change in level of consciousness d. Distended neck veins
Answer: C Change in level of consciousness A normal sodium level is between 135 and 145 mEq/L of sodium. As sodium levels drop below 140 mEq/L, symptoms reflect cellular over-hydration which results from water movement from the relatively hypotonic serum into cells. Symptoms affect primarily the central nervous system (CNS) and musculoskeletal systems. CNS effects range from headache, fatigue and anorexia to lethargy, confusion, disorientation, agitation, vomiting, seizures, and coma. Musculoskeletal symptoms may include cramps and weakness. Vital signs will reflect an increased, weak, thready pulse, shallow respirations, and a low urine output.
In caring for the client with burr holes for a subdural hematoma postoperatively on day 2, the nurse notes the client has an increased temperature to 101.3 F° (38.5° C). What does the nurse understand about this reaction? a. This is a normal assessment for the client with a subdural hematoma. b. This is a normal reaction day 2 postoperatively, and the nurse will administer acetaminophen as prescribed by the healthcare provider. c. Because the client has burr holes, this is not an accurate measurement. d. The client is exhibiting signs of an infection, and the healthcare provider needs to be notified
Answer: D Any client with a temperature day 2 postoperatively could be exhibiting signs and symptoms of an infection. The nurse should notify the healthcare provider and continue assessment of the client for signs and symptoms of infection. An increased temperature 2 days postoperatively is not normal for any client. The burr holes have nothing to do with whether or not the temperature is okay.
Initially after a stroke, a client's pupils are equal and reactive to light. Later, the nurse assesses that the right pupil is reacting more slowly than the left and that the systolic blood pressure is beginning to rise. What complication should the nurse consider that the client is developing? a. Spinal shock b. Hypovolemic shock c. Transtentorial herniation d. Increasing intracranial pressure
Answer: D Increased intracranial pressure compresses vital brain tissue; this is manifested by a sluggish pupillary response and an increased systolic blood pressure. Spinal shock is manifested by decreased systolic blood pressure, with no pupillary changes. Hypovolemic shock is indicated by decreased systolic pressure and tachycardia, with no changes in pupillary reaction. Transtentorial herniation is manifested by dilated pupils and severe posturing.
A client reports buzzing in the ear for the past 5 days and a decreased ability to hear sounds. After interacting with the client, the nurse finds that the client is receiving long-term aminoglycoside therapy. Which cranial nerve should the nurse suspect to be affected? a. CN III b. CN V c. CN VII d. CN VIII
Answer: D Is the vestibulocochlear nerve, a part of central auditory system. Medications such as aminoglycosides are ototoxic and can damage CN VIII and cause hearing loss, tinnitus (buzzing in ears), and vertigo. CN III is the oculomotor nerve that innervates the iris sphincter muscle. This muscle helps in pupil constriction. CN V is the trigeminal nerve that innervates the iris dilator muscle involved in the dilation of the pupil. CN VII is the facial nerve, which innervates the muscles that help open and close the eyelids.
A client who was a passenger in an automobile collision is admitted to the emergency department with rhinorrhea and bleeding from the ear. The healthcare provider determines that the client has a basilar head injury. What should the nurse anticipate is the initial focus of care for this client? a. Physical therapy b. Psychosocial support c. Nutritional management d. Antimicrobial administration
Answer: D Preventing infection through the use of prophylactic antibiotics is the priority. Tearing the meninges may have introduced infectious organisms. Physical therapy is premature; physical therapy begun too early can increase intracranial pressure. Although psychosocial support is important, it is not the priority. Nutrition is not the priority at this time.
The spouse of a client who had a cerebrovascular accident (also known as a "brain attack") seems unable to accept the concept that the client must be encouraged to participate in self-care. What is the best response by the nurse? a. Tell the spouse to let the client do things independently. b. Allow the spouse to assume total responsibility for the client's care. c. Explain that the nursing staff has full responsibility for the client's activities. d. Ask the spouse for assistance in planning those activities most helpful to the client.
Answer: D To foster communication and cooperation, family members should be involved in planning and implementing care. Telling the spouse to let the client do things independently does not focus on feelings or needs. The spouse may promote dependency in the client to satisfy a need to control. Although the nursing staff does have full responsibility for the client's activities, the family should be involved.
A client is diagnosed as having a right-sided brain attack (cerebrovascular accident) and is admitted to the hospital. When preparing to care for this client, which intervention should the nurse perform? a. Apply elastic stockings to prevent flaccid leg muscles b. Use a bed cradle to prevent dorsiflexion of the feet c. Implement passive range-of-motion exercises to prevent muscle atrophy d. Use a hand roll while supporting the left upper extremity on a pillow to prevent contractures
Answer: D Using a hand roll while supporting the left upper extremity on a pillow to prevent contractures will maintain the affected left arm in functional alignment; the left side of the body will be affected with a right-sided brain attack. Elastic stockings promote venous return rather than prevent flaccid muscles; also, these require a prescription. Plantar flexion (foot drop), not dorsiflexion, may occur with a brain attack; high-top sneakers or splints, not a bed cradle, more appropriately prevent plantar flexion contractures. Passive ROM exercises prevent contractures rather than muscle atrophy; the institution of ROM exercises should be discussed with the healthcare provider because activity during the acute phase can increase intracranial pressure and should be avoided.
The nurse teaches a nursing student about the discharge instructions to be given to a post-operative client. Which statement made by the nursing student indicates the nurse needs to intervene? a. "I should teach the client about using topical antibiotics." b. "I should teach the client about how to change wound dressings." c. "I should instruct the client about signs and symptoms of an infection." d. "I should instruct the client that the non-oozing wound should be cleaned with saline solution."
Answer: D "I should instruct the client that the non-oozing wound should be cleaned with saline solution." The nurse should intervene to instruct the nursing student to teach the client to clean his or her non-oozing wounds with normal soap and plain water. All the other statements are correct and do not require the nurse to intervene. The nursing student should teach the client about the use of topical antibiotics and how to change wound dressings. The nursing student should instruct the client about the signs and symptoms of infection.
A nurse determines that the client's apical pulse rate is higher than the radial pulse and documents the pulse deficit. What does the nurse consider is the primary reason for the pulse deficit? a. The client's heart may be beating faster temporarily. b. The nurse may not know how to take an accurate pulse. c. The radial pulse site may be surrounded by too much subcutaneous fat. d. The client may have atrial fibrillation.
Answer: D The client may have atrial fibrillation Clients who have atrial fibrillation have a pulse deficit caused by reduction of preload. An accelerated heart rate is known as tachycardia, not a pulse deficit. It is unlikely the nurse does not know how to take a pulse accurately; nurses are trained in assessment. If a pulse deficit identified at a pulse site is attributed to the presence of excessive subcutaneous fat, the nurse should obtain the peripheral pulse at a different site.