CH 54 CARE OF THE PATIENT WITH A NEUROLOGIC DISORDER

Involuntary rhythmic movement of the eyes, with oscillations that may be horizontal, vertical, or mixed movements, is called ___________________.

ANS: nystagmus Nystagmus is a rhythmic movement of the eyes, which may be horizontal, vertical, or mixed in directional movement. The eye movement cannot be controlled by the patient.

The nurse explains that the triad of signs of Parkinson disease is: _______, rigidity, and bradykinesia.

ANS: tremor Tremor, rigidity, and bradykinesia are the triad that make up the signs of Parkinson disease.

The nurse is aware that the drug t-PA (Activase), a tissue plasminogen activator, must be given in hours of the onset of symptoms to have maximum benefit. a. 3 hours b. 4 hours c. 6 hours d. 8 hours

ANS: A t-PA must be given within 3 hours of the onset of symptoms to be beneficial.

A postoperative client has been receiving morphine sulfate every 3 to 4 hours for patient should be sure to implement which measure to reduce risk of adverse effects from medication a. monitor the clients temperature b. encourage fluids c. maintain the client in a supine position d. encourage coughing and deep breathing

ANS : D encourage coughing and deep breathing

How would a nurse record the behavior when a patient with Alzheimer disease attempts to eat using a napkin rather than a fork? a.Apraxia b.Agnosia c.Aphasia d.Dysphagia

ANS: B Agnosia is a total or partial loss of the ability to recognize familiar objects or people through sensory stimuli as a result of organic brain damage

An 83-year-old patient has had a stroke. He is right-handed and has a history of hypertension and "little" strokes. He presents with right hemiplegia. To afford him the best visual field, the nurse should approach him a. from the right side. b. from the left side. c. from the center. d. from either side.

ANS: B Another perceptual problem is hemianopia, which is characterized by defective vision or blindness in half of the visual field. If the patient has hemianopia, which is common, the patient should be approached from the nonparalyzed side for care.

A ___________ is a diagnostic procedure used to identify lesions by observing the flow of radiopaque dye through the subarachnoid space.

ANS: myelogram Preparation for this procedure is the same as for lumbar puncture.

What are surgical navigational systems? a. Computerized devices that guide the surgeon b. A set of detailed anatomic maps pinpointing specific areas of the brain c. A written set of progressive processes for the resection of small brain tumors d. The use of radioactive materials to pinpoint small tumors of the brain

ANS: A Surgical navigational systems are computerized devices that guide the surgeon and make possible the resection of tumors that were once thought to be inoperable.

A family member of a patient who has just suffered a tonic-clonic seizure is concerned about the patient's deep sleep. What is this behavior called? a.Convalescent period b.Neural recovery period c.Sombulant period d.Postictal period

ANS: D Seizures are followed by a rest period of variable length, called a postictal period

The waxy substance that covers the neuron fibers and increases the rate of transmission of impulses is the ________.

ANS: myelin Myelin is the waxy substance that covers the neuron fibers (axons and dendrites) and increases the rate of transmission of impulses.

What is the first sign of Bell's palsy? a. Inability to wrinkle forehead and pucker lips on affected side b. Sudden pain in nostril on affected side c. Excessive salivation on the affected side d. Excessive mucus running from nostril on affected side

ANS: A Unilateral weakness of the facial muscles usually occurs, resulting in a flaccidity of the affected side of the face with inability to wrinkle the forehead, close the eyelid, pucker the lips, smile, frown, whistle, or retract the mouth on that side. The face appears asymmetric.

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. DIF: Cognitive Level: Apply (application) REF: 1339-1340 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

The nurse is caring for a home health patient who had a spinal cord injury at C5 3 years ago. The nurse bases the plan of care on the knowledge that the patient will be able to: a. feed self with setup and adaptive equipment. b. transfer self to wheelchair. c. stand erect with full leg braces. d. sit with good balance.

ANS: A A cord injury at C5 allows for ability to drive an electric wheelchair with mobile hand supports and feed self with adaptive equipment

The nurse assures an anxious family member of a 92-year-old patient who is demonstrating signs of dementia that many causes of dementia are reversible and preventable. What is one example?a.Hypotension b.Alzheimer disease c.Diabetes d.Parkinson disease

ANS: A Some forms of dementia are reversible. Dementia caused by hypotension, anemia, drug toxicity, metabolic disturbance, and malnutrition can all be corrected to abolish the dementia

When caring for a patient who has had a head injury, which assessment information requires the most rapid action by the nurse? a. The patient is more difficult to arouse. b. The patient's pulse is slightly irregular. c. The patient's blood pressure increases from 120/54 to 136/62 mm Hg. d. The patient complains of a headache at pain level 5 of a 10-point scale.

ANS: A 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 is not unusual in a patient after a head injury. A slightly irregular apical pulse is not unusual

When admitting an acutely confused 20-year-old patient with a head injury, which action should the nurse take? a. Ask family members about the patient's health history. b. Ask leading questions to assist in obtaining health data. c. Wait until the patient is better oriented to ask questions. d. Obtain only the physiologic neurologic assessment data.

ANS: A When admitting a patient who is likely to be a poor historian, the nurse should obtain health history information from others who have knowledge about the patient's health. Waiting until the patient is oriented or obtaining only physiologic data will result in incomplete assessment data, which could adversely affect decision making about treatment. Asking leading questions may result in inaccurate or incomplete information. DIF: Cognitive Level: Apply (application) REF: 1343 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A client with Bell's palsy exhibits facial asymmetry and cannot close the eye completely on one side. The client is also drooling and has loss of tearing in one eye. The nurse documents that the client displays symptoms of involvement of which cranial nerves(CNs)? A. CN VI B. CN VII C. CN III D. CN V

ANS: B

A patient is in which stage of Alzheimer's disease when she demonstrates "sundowning"? a. Early stage b. Second stage c. Third stage d. Final stage

ANS: B "Sundowning" is seen in the AD patient in the second stage of the disease.

A frantic family member is distressed about the flaccid paralysis of her son following a spinal cord injury several hours ago. What does the nurse know about this condition? a. It is an ominous indicator of permanent paralysis. b. It is possibly a temporary condition and will clear. c. It degenerates into a spastic paralysis. d. It will progress up the cord to cause seizures.

ANS: B A period of flaccid paralysis following a cord injury is called areflexia, or spinal shock, and may be temporary.

The nurse explains that the two divisions of the autonomic nervous system work to maintain homeostasis. Which is the first autonomic event? a. Parasympathetic nervous system dominates b. Extremely stressful or frightening event c. Blood pressure, heart rate, and adrenaline output decrease d. Sympathetic nervous system dominates e. Heart rate and blood pressure rise, secretion of adrenaline

ANS: B In the event of a frightening event, the sympathetic nervous system dominates and increases the blood pressure, heart rate, and adrenaline output in the "fight or flight" mechanism. The body is calmed by the parasympathetic nervous system dominating and reducing the heart rate, blood pressure, and adrenaline output.

What should the nurse do when the child arrives on the floor with the diagnosis of bacterial meningitis? a. Arrange for humidified oxygen per mask. b. Place the child in respiratory isolation. c. Inquire about drug allergy. d. Hold NPO until orders arrive.

ANS: B Persons with bacterial meningitis are placed in respiratory isolation until the pathogen can no longer be cultured, usually 24 hours.

As the result of a stroke, a patient has difficulty discerning the position of his body without looking at it. In the nurse's documentation, which would best describe the patient's inability to assess spatial position of his body? a. Agnosia b. Proprioception c. Apraxia d. Sensation

ANS: B Patients may experience a loss of proprioception with a stroke. This may include apraxia and agnosia (a total or partial loss of the ability to recognize familiar objects or people)

What are the effects of normal aging on the nervous system? (Select all that apply.) a. Small vessel occlusion b. Loss of neurons c. Calcification of cerebrum d. Reduction of cerebral blood flow e. Lipofuscin f. Decrease in oxygen use

ANS: B, D, E, F As the person ages, normal age-related changes occur such as loss of neurons, reduction of cerebral blood flow, appearance of lipofuscin, a decrease in oxygen use and brain metabolism, and a decline in velocity of nerve impulses.

What is the purpose of a "drug holiday" in the treatment of Parkinson disease? a. Change all drugs. b. Allow the natural dopamine levels to rise. c. Restart drugs at a lower dosage with favorable results. d. Reduce the extrapyramidal symptoms.

ANS: C A "drug holiday" is a period when all drugs are withdrawn from the person with Parkinson disease. The drugs are then restarted at a lower dose with favorable results.

Which question is likely to elicit the most valid response from the patient who is being interviewed about a neurologic problem? a. "Do you have any sensations of pins and needles in your feet?" b. "Does the pain radiate from your back into your legs?" c. "Can you describe the sensations you are having?" d. "Do you ever have any nausea or dizziness?"

ANS: C For patients with suspected neurologic conditions, the presence of many symptoms or subjective data may be significant. Offering leading questions is not beneficial and may allow the patient to give misinformation. Questions should be specific about symptoms.

Why is the patient with suspected Guillain-Barre Syndrome (GBS) hospitalized immediately? a. The infection needs to be treated with IV antibiotics to prevent paralysis b. The brain may swell quickly causing seizures c. The disease can rapidly progress into respiratory failure d. IV hydration is needed to prevent possible fatal hypotension

ANS: C Hospitalization is necessary for GBS patients because the disease progresses very quickly and respiratory failure may occur.

What is the basic problem that prompts most of the early signs of Alzheimer' disease? a. changes in mood b. misplacing things c. memory loss that disrupts daily life d. problem with words in speaking

ANS: C Memory loss that disrupts daily life is the basic problem that prompts most of the early signs of AD.

How would the nurse instruct a patient with Parkinson disease to improve activity level? a. To use a soft mattress to relax the spine. b. To walk with a shuffling gait to avoid tripping. c. To walk with hands clasped behind back to help balance. d. To sit in hard chair with arms for posture control.

ANS: C The patient with Parkinson disease can improve the activity level by sleeping on a firm mattress without a pillow to prevent spinal curvature, hold hands clasped behind to keep better balance, and keep the arms from hanging stiffly at the side. Walk with a lifting of the feet to avoid tripping and "freezing."

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take? a. Insert an oral airway during the seizure to maintain a patent airway. b. Restrain the patient's arms and legs to prevent injury during the seizure. c. Time and observe and record the details of the seizure and postictal state. d. Avoid touching the patient to prevent further nervous system stimulation.

ANS: C Because the diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure. DIF: Cognitive Level: Apply (application) REF: 1422 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which question is likely to elicit the most valid response from the patient who is being interviewed about a neurologic problem? a."Do you have any sensations of pins and needles in your feet?" b."Does the pain radiate from your back into your legs?" c."Can you describe the sensations you are having?" d."Do you ever have any nausea or dizziness?"

ANS: C For patients with suspected neurologic conditions, the presence of many symptoms or subjective data may be significant. Offering leading questions is not beneficial and may allow the patient to give misinformation. Questions should be specific about symptoms.DIF:Cognitive Level: ApplicationREF:Page 677OBJ:8TOP:AssessmentKEY: Nursing Process Step: AssessmentMSC: NCLEX: Physiological Integrity

The nurse is aware that when assessing a patient by the FOUR score coma scale, the patient is assessed in four categories: eye response, brainstem reflexes, motor response, and respiration. How are these results reported? a. As a sum of the scores of the four categories b. As part of the Glasgow Coma Scale c. As individual scores in each category d. As progressive scores during a 24-hour period

ANS: C The FOUR score coma scale assesses the patient in four categories: eye response, brainstem reflexes, motor response, and respiration. The scores are reported as individual scores in each category. It is frequently done in conjunction with or as an alternative to the Glasgow Coma Scale, not part of it.

at the health clinic with a severe migraine headache tells the nurse about having other similar headaches recently. Which initial action should the nurse take? a. Teach about the use of triptan drugs. b. Refer the patient for stress counseling. c. Ask the patient to keep a headache diary. d. Suggest the use of muscle-relaxation techniques.

ANS: C The initial nursing action should be further assessment of the precipitating causes of the headaches, quality, and location of pain, etc. Stress reduction, muscle relaxation, and the triptan drugs may be helpful, but more assessment is needed first. DIF: Cognitive Level: Apply (application) REF: 1419 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

What are the three signs of Cushing response? (Select all that apply.) a. Increased pulse rate b. Increased blood pressure c. Widened pulse pressure d. Bradycardia e. Increased systolic blood pressure f. Uncontrolled thermoregulation

ANS: C, D, E A widened pulse pressure, increased systolic blood pressure, and bradycardia are together called Cushing response. It is considered an important diagnostic sign of late-stage brain herniation.

Which of the following techniques are necessary for safely feeding a hemiplegic patient? (Select all that apply.) a. Mixing liquids and solid foods together b. Taking the patient's dentures out to prevent choking c. Checking the affected side of mouth for food accumulation d. Offering small bites of food e. Elevating the patient to no more than 30 degrees f. Adding a thickening agent to liquids

ANS: C, D, F Important nursing measures include avoiding foods that cause choking, checking the affected side of the mouth for accumulation of food and resultant poor hygiene, not mixing liquids and solid foods, and encouraging the patient to take small bites.

What is the cardinal sign of increased intracranial pressure in a brain injured patient? a. Pupil changes b. Ipsilateral paralysis c. Vomiting d. Decrease in the level of consciousness

ANS: D Collection of objective data includes a change in level of consciousness. A change in the level of consciousness is the earliest sign of increased intracranial pressure.

What is the nurse assessing when asking the patient, "Who is the president of the United States?" during a level of consciousness assessment? a. Orientation b. Memory c. Calculation d. Fund of knowledge

ANS: D Fund of knowledge is tested by questions such as "Who is the president?" or asking about current events

The nurse is developing a plan of care for a client with a stroke (brain attack) who has right homonymous hemianopsia. Which should the nurse include in the plan of care for the client? a.Place an eye patch on the left eye. b.Place personal articles on the client's right side. c.Approach the client from the right field of vision. d.Instruct the client to turn the head to scan the right visual field

ANS: D Homonymous hemianopsia is a loss of half of the visual field. The nurse instructs the client to scan the environment and stands within the client's intact field of vision. The nurse should not patch the eye because the client does not have double vision. The client should have objects placed in the intact fields of vision, and the nurse should approach the client from the intact side. * Focus on the subject, a visual problem, and recall the definition of homonymous hemianopsia. Recalling that the client loses half of the visual field will assist in directing you to the correct option.

When assessing a patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider? a. The patient has a positive Kernig's sign. b. The patient complains of having a stiff neck. c. The patient's temperature is 101° F (38.3° C). d. The patient's blood pressure is 86/42 mm Hg

ANS: D Shock is a serious complication of meningitis, and the patient's low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig's sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the hypotension. DIF: Cognitive Level: Application REF: 1452-1453

What are the two divisions of the nervous system? a.Somatic and the autonomic b.Cerebellum and the brainstem c.Medulla oblongata and the diencephalon d.Central and the peripheral

ANS: D The central and the peripheral are the two divisions of the nervous system. The autonomic and the somatic are the division of the peripheral nervous system.

what does the nurse know about the stroke patient who has expressive aphasia a. has difficulty comprehending spoken and written communication b. cannot make any vocal sounds c. Has total loss and comprehension of language d.can understand the spoken word, but cannot speak

ANS: D The patient with expressive aphasia has difficulty articulating words but can understand the written and spoken word.

What is the cranial nerve that supplies most of the organs in the thoracic and abdominal cavities and also carries motor fibers to glands that produce digestive juices and other secretions? a. Somatic motor nerve b. Visceral sensory nerve c. Abducens nerve d. Vagus nerve

ANS: D The vagus nerve extends from the throat, larynx, and organs in the thoracic and abdominal cavities. It is responsible for sensations and will accelerate peristalsis when stimulated.

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. DIF: Cognitive Level: Apply (application) REF: 1339 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A 31-year-old woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which response by the nurse is accurate? a. "MS symptoms may be worse after the pregnancy." b. "Women with MS frequently have premature labor." c. "MS is associated with an increased risk for congenital defects." d. "Symptoms of MS are likely to become worse during pregnancy."

ANS: A During the postpartum period, women with MS are at greater risk for exacerbation of symptoms. There is no increased risk for congenital defects in infants born of mothers with MS. Symptoms of MS may improve during pregnancy. Onset of labor is not affected by MS. DIF: Cognitive Level: Understand (comprehension) REF: 1429 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

A patient has been taking phenytoin (Dilantin) for 2 years. Which action will the nurse take when evaluating for adverse effects of the medication? a. Inspect the oral mucosa. b. Listen to the lung sounds. c. Auscultate the bowel tones. d. Check pupil reaction to light.

ANS: A Phenytoin can cause gingival hyperplasia, but does not affect bowel tones, lung sounds, or pupil reaction to light. DIF: Cognitive Level: Apply (application) REF: 1424 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

The newly admitted patient to the emergency room 30 minutes ago after a fall off a ladder has gradually decreased in consciousness and has slowly reacting pupils, a widening pulse pressure, and verbal responses that are slow and unintelligible. What is the most appropriate position for the patient? a.Neck placed in a neutral position b.Head raised slightly with hips flexed c.Supine in gravity neutral position d.Turn on right side with head elevated

ANS: A Place the neck in a neutral position (not flexed or extended) to promote venous drainage

_________________ is/are responsible for the transmission of impulses between synapses

ANS: Neurotransmitters Neurotransmitters (acetylcholine, norepinephrine, dopamine, and serotonin) function to conduct transmission between the synapses.

Which symptom is specific to migraine headaches? a. Tachycardia b. They become worse in the evening c. They involve the entire head d. They are preceded by an aura

ANS: D Migraine headaches are unusual in that signs and symptoms occur before the acute attack

Why are the drugs neostigmine (Prostigmin) and pyridostigmine (Mestinon) helpful to the person with myasthenia gravis? a. imposes speech b. improves visual disturbance c. reduces pain d. promotes nerve impulse transmission

ANS: D Prostigmine and Mestinon improve the nerve impulses and alleviate the symptoms.

What is the reticular activating system (RAS) essential to? (Select all that apply.) a. Concentration b. Wakefulness c. Speech d. Attention e. Memory f. Introspection

ANS: A, B, D, F The RAS, located on the brainstem, is essential to wakefulness, attention, concentration, and introspection.

The nurse assures an anxious family member of a 92-year-old patient who is demonstrating signs of dementia that many causes of dementia are reversible and preventable. What is one example? a. Hypotension b. Alzheimer's disease c. Diabetes d. Parkinson disease

ANS: A Some forms of dementia are reversible. Dementia caused by hypotension, anemia, drug toxicity, metabolic disturbance, and malnutrition can all be corrected to abolish the dementia

A patient, age 45, is to have a myelogram to confirm the presence of a herniated intervertebral disk. Which nursing action should be planned with respect to this diagnostic test? a. Obtain an allergy history before the test. b. Ambulate the patient when returned to the room after the test. c. Use heated blanket to keep patient warm after procedure. d. Keep NPO for 6 to 8 hours after the test.

ANS: A Before the dye is injected, patients must be asked whether they have any allergies, specifically whether they have had any anaphylactic or hypotensive episodes from other dyes.

Which foods should the person who suffers from migraine headaches avoid? (Select all that apply.) a. Yogurt b. Caffeine c. Beef d. Pears e. Marinated foods f. Milk

ANS: A, B, E Some foods may cause or worsen headaches. Foods that may provoke headaches include vinegar, chocolate, yogurt, alcohol, fermented or marinated foods, ripened cheese, cured sandwich meat, caffeine, and pork

A patient has recently suffered a stroke with left-sided weakness and has problems with choking, especially when drinking thin liquids. What nursing interventions would be most helpful in assisting this patient to swallow safely? a. Use a straw. b. Tuck chin when swallowing. c. Take a sip of liquid with each bite. d. Turn head to the left.

ANS: B The patient should sit at a 90-degree angle with the head up and chin slightly tucked.

The nurse is aware that the characteristic gait of the person with Parkinson disease is a propulsive gait, which causes the patient to: a. stagger and need support of a walker. b. shuffle with arms flexed. c. fall over to one wide when walking. d. take small steps balanced on the toes.

ANS: B The propulsive gait causes the patient to shuffle with his arms flexed and with a loss of postural reflexes.

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. DIF: Cognitive Level: Apply (application) REF: 1349 | 1352 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A client who recently began medication therapy with levodopa (Larodopa) for Parkinson's disease complains of nausea. The nurse reminds the client to do which action to manage this problem? A. Take the medication with three glasses of water B. Eat a snack before taking the Medication. C. Take an antiemetic at the same time as the levodopa D. Lie down and rest after taking the dose

ANS: B Eat a snack before taking the Medication.

What is the nurse aware of when assessing a person with a craniocerebral injury? a. Most injuries of this type are irreversible b. Open injuries are always more serious than closed injuries c. Signs and symptoms may not occur until several days after the trauma d. Trauma to the frontal lobe is more significant than to any other area

ANS: C If a patient who has been conscious for several days after head injury loses consciousness or develops neurologic signs and symptoms, a subdural hematoma should be suspected

The newly admitted patient to the emergency room after a motorcycle accident has serosanguineous drainage coming from the nose. What is the most appropriate nursing response to this assessment? a. Cleanse nose with a soft cotton-tipped swab. b. Gently suction the nasal cavity. c. Gently wipe nose with absorbent gauze. d. Ask patient to blow his nose.

ANS: C The patient's ear and nose are checked carefully for signs of blood and serous drainage, which indicate that the meninges are torn and spinal fluid is escaping. No attempt should be made to clean out the orifice or to blow the nose. The drainage can be wiped away. The drainage can be tested for the presence of glucose, which would confirm that the fluid is spinal fluid and not mucus.

The nurse determines that teaching about management of migraine headaches has been effective when the patient says which of the following? a. "I can take the (Topamax) as soon as a headache starts." b. "A glass of wine might help me relax and prevent a headache." c. "I will lie down someplace dark and quiet when the headaches begin." d. "I should avoid taking aspirin and sumatriptan (Imitrex) at the same time."

ANS: C It is recommended that the patient with a migraine rest in a dark, quiet area. Topiramate (Topamax) is used to prevent migraines and must be taken for several months to determine effectiveness. Aspirin or other nonsteroidal antiinflammatory medications can be taken with the triptans. Alcohol may precipitate migraine headaches. DIF: Cognitive Level: Apply (application) REF: 1416 | 1419 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

What Glasgow Coma Scale rating would a patient receive who opens the eyes spontaneously, but has incomprehensible speech and obeys commands for movement? a. 8 b. 10 c. 11 d. 12

ANS: D The Glasgow Coma Scale was developed in 1974, and it consists of three parts of the neurologic assessment: eye opening, best motor response, and best verbal response. This patient gets a 4 for eye opening, a 2 for incomprehensible speech, and a 6 for moving on demand

The nurse witnesses a patient with a seizure disorder as the patient suddenly jerks the arms and legs, falls to the floor, and regains consciousness immediately. It will be most important for the nurse to a. assess the patient for a possible head injury. b. give the scheduled dose of divalproex (Depakote). c. document the timing and description of the seizure. d. notify the patient's health care provider about the seizure

ANS: A Rationale: The patient who has had a myoclonic seizure and fall is at risk for head injury and should be evaluated and treated for this possible complication first. Documentation of the seizure, notification of the seizure, and administration of antiseizure medications are also appropriate actions, but the initial action should be assessment for injury.

Following a myelogram the nurse should include in the postprocedure care assessment for: a. elevation of blood pressure. b. urine retention. c. sensation in lower extremities. d. slurred speech.

ANS: C Postmyelogram care includes the assessment to ensure there is no leakage of CSF, sensation and strength of the lower extremities, or headache. To avoid a headache, the patient should be flat for a few hours.

A patient with a spinal cord injury at T1 complains of stuffiness of the nose and a headache. The nurse notes a flushing of the neck and "goose flesh." What should be the primary nursing intervention based on these assessments? a Place patient in flat position and check temperature. b. Administer oxygen and check oxygen saturation. c. Place on side and check for leg swelling. d. Sit upright and check blood pressure.

ANS: D These are indicators of autonomic dysreflexia or hyperreflexia. It is a medical emergency. The patient should be placed in an upright position to decrease blood pressure and the blood pressure should be checked. Assessments for impaction, full bladder, or a urine infection can help to evaluate this condition

A 76-year-old patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease. Which information is most important for the nurse to report to the health care provider? a. Shuffling gait b. Tremor at rest c. Cogwheel rigidity of limbs d. Uncontrolled head movement

ANS: D Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other findings are typical with Parkinson's disease.

A patient with suspected meningitis is scheduled for a lumbar puncture. Before the procedure, the nurse will plan to a. enforce NPO status for 4 hours. b. transfer the patient to radiology. c. administer a sedative medication. d. help the patient to a lateral position.

ANS: D For a lumbar puncture, the patient lies in the lateral recumbent position. The procedure does not usually require a sedative, is done in the patient room, and has no risk for aspiration. DIF: Cognitive Level: Apply (application) REF: 1352 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse plan to take? a. Administer IV furosemide (Lasix). b. Initiate high-dose barbiturate therapy. c. Type and crossmatch for blood transfusion. d. Prepare the patient for immediate craniotomy.

ANS: D The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If intracranial pressure (ICP) is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but these will not be of benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries, and transfusion is usually not necessary.

A client is suspected of having myasthenia gravis. Edrophonium (Tensilon) 2 mg IV administered to determine the diagnosis. Which of the following indicates that the client has myasthenia gravis? a) an increase in muscle strength within 1 to 3 minutes following administration of the medication b) a decrease in muscle strength within 1 to 3 minutes following administration of the medication c) joint pain swelling following administration of the medication next 15 mins d) feelings of faintness, dizziness, hypotension, and signs of flushing in the client

ANS:A an increase in muscle strength within 1 to 3 minutes following administration of the medication

The client with myasthenia gravis becomes increasingly weaker. The physician injects a dose of edrophonium (Tensilon) to determine whether the client is experiencing a myasthenic crisis or a cholinergic crisis. The nurse expects that the client will have which of the following reactions if the client is in cholinergic crisis? A. No change in the condition B. Complaints of muscle spasms C. An improvement of the weakness D. A temporary worsening of the condition

ANS:D Rationale: An edrophonium (Tensilon) injection makes the client in cholinergic crisis temporarily worse. An improvement of the condition ("an improvement of the weakness") indicates myasthenic crisis. The other two options are unrelated to the test.

A patient with right-sided weakness that started 1 hour ago is admitted to the emergency department and all these diagnostic tests are ordered. Which order should the nurse act on first? a. Noncontrast computed tomography (CT) scan b. Chest radiograph c. Complete blood count (CBC) d. Electrocardiogram (ECG)

Correct Answer: A Rationale: Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 3 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the smaller the area of brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.

1. The nurse obtains all of the following information about a 65-year-old patient in the clinic. When developing a plan to decrease stroke risk, which risk factor is most important for the nurse to address? a. The patient smokes a pack of cigarettes daily. b. The patient's blood pressure (BP) is chronically between 150/80 to 180/90 mm Hg. c. The patient works at a desk and relaxes by watching television. d. The patient is 25 pounds above the ideal weight.

Correct Answer: B Rationale: Hypertension is the most important modifiable risk factor. Smoking, physical inactivity, and obesity all contribute to stroke risk but not so much as hypertension.

A patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Obtain the Glasgow Coma Scale score. b. Check the respiratory rate. c. Monitor the blood pressure. d. Send the patient for a CT scan.

Correct Answer: B Rationale: The initial nursing action should be to assess the airway and take any needed actions to assure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, circulation) are completed.