Chronic Neurological Problems

The nurse is providing instructions to a client who will be taking phenytoin. Which statement, if made by the client, would indicate an understanding of the information about this medication? a. "I need to perform good oral hygiene, including flossing and brushing my teeth." b. "I should try to avoid alcohol, but if I'm not able to, I can drink alcohol in moderation." c. "I should take my medication before coming to the laboratory to have a blood level drawn." d. "I should monitor for side effects and adjust my medication dose depending on how severe the side effects are."

a. "I need to perform good oral hygiene, including flossing and brushing my teeth." Phenytoin is an anticonvulsant used to treat seizure disorders. The client also should see a dentist at regularly scheduled times because gingival hyperplasia is a side effect of this medication. The client should perform good oral hygiene, including flossing and brushing the teeth. The client should avoid alcohol while taking this medication. The client should also be instructed that follow-up serum blood levels are important and that, on the day of the scheduled laboratory test, the client should avoid taking the medication before the specimen is drawn. The client should not adjust medication dosages.

A client with recent-onset Bell's palsy is upset and crying about the change in facial appearance. The nurse plans to support the client emotionally by making which statement to the client? a. "This is not a stroke, and many clients recover in 3 to 5 weeks." b. "This is caused by a small tumor, which can be removed easily." c. "This is similar to a stroke, but all symptoms will reverse without treatment." d. "This is a temporary problem, with treatment similar to that for migraine headaches."

a. "This is not a stroke, and many clients recover in 3 to 5 weeks." Clients with Bell's palsy should be reassured that they have not experienced stroke a (brain attack) and that symptoms often disappear spontaneously in 3 to 5 weeks. The client is given supportive treatment for symptoms. Bell's palsy usually is not caused by a tumor, and the treatment is not similar to that for migraine headaches.

A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and suspects the presence of which problem? a. Altered breathing pattern b. Increased likelihood of injury c. Ineffective oxygen consumption d. Increased susceptibility to aspiration

a. Altered breathing pattern Altered breathing pattern indicates that the respiratory rate, depth, rhythm, timing, or chest wall movements are insufficient for optimal ventilation of the client. This is a risk for clients with spinal cord injury in the lower cervical area. Ineffective oxygen consumption occurs when oxygenation or carbon dioxide elimination is altered at the alveolar-capillary membrane. Increased susceptibility to aspiration and increased likelihood of injury are unrelated to the subject of the question.

The nurse observes a patient ambulating in the hospital hall when the patient's arms and legs suddenly jerk and the patient falls to the floor. The nurse will first 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 patients HCP about the seizure.

a. Assess the patient for a possible head injury The patient who has had a myoclonic seizure and fall is at risk for head injury and should first be evaluated and treated for this possible complication.

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 patients health care provider about the seizure.

a. Assess the patient for a possible head injury. 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 also are appropriate actions, but the initial action should be assessment for injury.

A patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care? a. Assist with active range of motion. b. Observe for agitation and paranoia. c. Give muscle relaxants as needed to reduce spasms. d. Use simple words and phrases to explain procedures.

a. Assist with active range of motion ALS causes progressive muscle weakness, but assisting the patient to perform active ROM will help to maintain strength as long as possible. Psychotic symptoms such as agitation and paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the patients ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations.

A 64 yr old patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care? a. Assist with active range of motion (ROM) b. Observe for agitation and paranoia c. Give muscle relaxants as needed to reduce spasms d. Use simple words and phrases to explain procedures

a. Assist with active range of motion (ROM) ALS causes progressive muscle weakness, but assisting the patient to perform active ROM will help maintain strength as long as possible.

A patient found in a tonic-clonic seizure reports afterward that the seizure was preceded by numbness and tingling of the arm. The nurse knows that this finding indicates what type of seizure? a. Atonic b. Partial c. Absence d. Myoclonic

a. Atonic The initial symptoms of a partial seizure involve clinical manifestations that are localized to a particular part of the body or brain. Symptoms of an absence seizure are staring and a brief loss of consciousness. In an atonic seizure, the patient loses muscle tone and (typically) falls to the ground. Myoclonic seizures are characterized by a sudden jerk of the body or extremities.

A client with myasthenia gravis arrives at the hospital emergency department in suspected crisis. The health care provider plans to administer edrophonium to differentiate between myasthenic and cholinergic crisis. The nurse ensures that which medication is available in the event that the client is in cholinergic crisis? a. Atropine sulfate b. Morphine sulfate c. Protamine sulfate d. Pyridostigmine bromide

a. Atropine sulfate Clients with cholinergic crisis have experienced overdosage of medication. Edrophonium will exacerbate symptoms in cholinergic crisis to the point at which the client may need intubation and mechanical ventilation. Intravenous atropine sulfate is used to reverse the effects of these anticholinesterase medications. Morphine sulfate and pyridostigmine bromide would worsen the symptoms of cholinergic crisis. Protamine sulfate is the antidote for heparin.

he home health nurse is visiting a client with myasthenia gravis and is discussing methods to minimize the risk of aspiration during meals related to decreased muscle strength. Which suggestions should the nurse give to the client? Select all that apply. a. Chew food thoroughly. b. Cut food into very small pieces. c. Sit straight up in the chair while eating. d. Lift the head while swallowing liquids. e. Swallow when the chin is tipped slightly downward to the chest.

a. Chew food thoroughly. b. Cut food into very small pieces. c. Sit straight up in the chair while eating. e. Swallow when the chin is tipped slightly downward to the chest. The client avoids swallowing any type of food or drink with the head lifted upward, which could actually cause aspiration by opening the glottis. The client should be advised to sit upright while eating, not to talk with food in the mouth (talking requires opening the glottis), cut food into very small pieces, chew thoroughly, and tip the chin downward to swallow.

A patient tells the nurse about using acetaminophen (Tylenol) several times every day for recurrent bilateral headaches. Which action will the nurse plan to take first? a. Discuss the need to stop taking the acetaminophen. b. Suggest the use of biofeedback for headache control. c. Teach the patient about magnetic resonance imaging (MRI). d. Describe the use of botulism toxin (BOTOX) for headaches.

a. Discuss the need to stop taking the acetaminophen. The headache description suggests that the patient is experiencing medication overuse headache. The initial action will be withdrawal of the medication. The other actions may be needed if headaches persist.

The nurse is caring for a client who sustained a spinal cord injury. During administration of morning care, the client begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action should the nurse take? a. Elevate the head of the bed. b. Examine the rectum digitally. c. Assess the client's blood pressure. d. Place the client in the prone position.

a. Elevate the head of the bed. Autonomic dysreflexia is a serious complication that can occur in the spinal cord-injured client. Once the syndrome is identified, the nurse elevates the head of the client's bed and then examines the client for the source of noxious stimuli. The nurse also assesses the client's blood pressure, but the initial action would be to elevate the head of the bed. The client would not be placed in the prone position; lying flat will increase the client's blood pressure.

The nurse is performing a neurological assessment on a client and is assessing the function of cranial nerves III, IV, and VI. Assessment of which aspect of function will yield the best information about these cranial nerves? a. Eye movements b. Response to verbal stimuli c. Affect, feelings, or emotions d. Insight, judgment, and planning

a. Eye movements Eye movements are under the control of cranial nerves III, IV, and VI. Level of consciousness (response to verbal stimuli) is controlled by the reticular activating system and both cerebral hemispheres. Feelings are part of the role of the limbic system and involve both hemispheres. Insight, judgment, and planning are part of the function of the frontal lobe in conjunction with association fibers that connect to other areas of the cerebrum.

The nurse is performing an assessment on a client with a diagnosis of Bell's palsy. The nurse should expect to observe which finding in the client? a. Facial drooping b. Periorbital edema c. Ptosis of the eyelid d. Twitching on the affected side of the face

a. Facial drooping Bell's palsy is a one-sided facial paralysis caused by the compression of the facial nerve (cranial nerve VII). Assessment findings include facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and speech or chewing difficulty. The remaining options are not associated findings in Bell's palsy.

A patient reports feeling numbness and tingling of the left arm before experiencing a tonic-clonic seizure. The nurse determines that this history is consistent with what type of seizure. a. Focal b. Atonic c. Absence d. Myoclonic

a. Focal The initial symptoms of a focal seizure involve clinical manifestations that are localized to a particular part of the body or brain.

When preparing to admit a patient who has been treated for status epilepticus in the emergency department, which equipment should the nurse have available in the room? Select all that apply. a. Siderail pads b. Tongue blade c. Oxygen mask d. Suction tubing e. Nasogastric tube

a. Siderail pads c. Oxygen mask d. Suction tubing The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The beds side rails should be padded to minimize the risk for patient injury during a seizure. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. Use of tongue blades during a seizure is contraindicated.

A client with a neurological problem is experiencing hyperthermia. Which measures would be appropriate for the nurse to use in trying to lower the client's body temperature? Select all that apply. a. Giving tepid sponge baths b. Applying a hypothermia blanket c. Covering the client with blankets d. Administering acetaminophen per protocol e. Placing ice packs over the client's abdomen and in the axilla and groin

a. Giving tepid sponge baths b. Applying a hypothermia blanket d. Administering acetaminophen per protocol Standard measures to lower body temperature include removing bed covers, providing cool sponge baths, using an electric fan in the room, administering acetaminophen, and placing a hypothermia blanket under the client. Ice packs are not used because they could cause shivering, which increases cellular oxygen demands, with the potential for increased intracranial pressure.

Which action will the nurse take when evaluating a patient who is taking phenytoin (Dilantin) 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.

a. Inspect the oral mucosa Phenytoin can cause gingival hyperplasia, but does not affect bowel tones, lung sounds, or pupil reaction to light.

The nurse has determined that a client with a neurological disorder also has difficulty breathing. Which activities would be appropriate components of the care plan for this client? Select all that apply. a. Keep suction equipment at the bedside. b. Elevate the head of the bed 30 degrees. c. Keep the client lying in a supine position. d. Keep the head and neck in good alignment. e. Administer prescribed respiratory treatments as needed.

a. Keep suction equipment at the bedside. b. Elevate the head of the bed 30 degrees. d. Keep the head and neck in good alignment. e. Administer prescribed respiratory treatments as needed. The nurse maintains a patent airway for the client with difficulty breathing by keeping the head and neck in good alignment and elevating the head of the bed 30 degrees unless contraindicated. Suction equipment is kept at the bedside if secretions need to be cleared. The client should be kept in a side-lying position whenever possible to minimize the risk of aspiration.

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. a. Keeping the linens wrinkle-free under the client b. Preventing unnecessary pressure on the lower limbs c. Limiting bladder catheterization to once every 12 hours d. Turning and repositioning the client at least every 2 hours e. Ensuring that the client has a bowel movement at least once a week

a. Keeping the linens wrinkle-free under the client b. Preventing unnecessary pressure on the lower limbs d. Turning and repositioning the client at least every 2 hours The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too infrequent), and urinary catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Ensuring a bowel movement once a week is much too infrequent. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply. a. Loosening restrictive clothing b. Restraining the client's limbs c. Removing the pillow and raising padded side rails d. Positioning the client to the side, if possible, with the head flexed forward e. Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist

a. Loosening restrictive clothing c. Removing the pillow and raising padded side rails d. Positioning the client to the side, if possible, with the head flexed forward Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising padded side rails in the bed, and placing the client on one side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible; protects the head from injury; and moves furniture that may injure the client.

A 28-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. Symptoms of MS are likely to become worse during pregnancy. d. MS is associated with a slightly increased risk for congenital defects.

a. MS symptoms may be worse after the pregnancy 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.

A thymectomy accomplished via a median sternotomy approach is performed in a client with a diagnosis of myasthenia gravis. The nurse creates a postoperative plan of care for the client that should include which intervention? a. Monitor the chest tube drainage. b. Restrict visitors for 24 hours postoperatively. c. Maintain intravenous infusion of lactated Ringer's solution. d. Avoid administering pain medication to prevent respiratory depression.

a. Monitor the chest tube drainage. The thymus has played a role in the development of myasthenia gravis. A thymectomy is the surgical removal of the thymus gland and may be used for management of clients with myasthenia gravis to improve weakness. The procedure is performed through a median sternotomy or a transcervical approach. Postoperatively the client will have a chest tube in the mediastinum. Lactated intravenous solutions usually are avoided because they can increase weakness. Pain medication is administered as needed, but the client is monitored closely for respiratory depression. There is no reason to restrict visitors.

A hospitalized 24-year-old patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first? a. Start the ordered PRN oxygen at 6 L/min. b. Put a moist hot pack on the patients neck. c. Give the ordered PRN acetaminophen (Tylenol). d. Notify the patients health care provider immediately.

a. Start the ordered PRN oxygen at 6 L/min Acute treatment for cluster headache is administration of 100% oxygen at 6 to 8 L/min. If the patient obtains relief with the oxygen, there is no immediate need to notify the health care provider. Cluster headaches last only 60 to 90 minutes, so oral pain medications have minimal effect. Hot packs are helpful for tension headaches but are not as likely to reduce pain associated with a cluster headache.

A client with multiple sclerosis tells a home health care nurse that she is having increasing difficulty in transferring from the bed to a chair. What is the initial nursing action? a. Observe the client demonstrating the transfer technique. b. Start a restorative nursing program before an injury occurs. c. Seize the opportunity to discuss potential nursing home placement. d. Determine the number of falls that the client has had in recent weeks.

a. Observe the client demonstrating the transfer technique. Observation of the client's transfer technique is the initial intervention. Starting a restorative program is important but not unless an assessment has been completed first. Discussing nursing home placement would be inappropriate in view of the information provided in the question. Determining the number of falls is another important intervention, but observing the transfer technique should be done first.

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. a. Padding the side rails of the bed b. Placing an airway at the bedside c. Placing the bed in the high position d. Putting a padded tongue blade at the head of the bed e. Placing oxygen and suction equipment at the bedside f. Flushing the intravenous catheter to ensure that the site is patent

a. Padding the side rails of the bed b. Placing an airway at the bedside e. Placing oxygen and suction equipment at the bedside f. Flushing the intravenous catheter to ensure that the site is patent Seizure precautions may vary from agency to agency, but they generally have some common features. Usually, an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if antiseizure medications must be administered, and as part of the routine assessment the nurse should be checking patency of the catheter. The use of padded tongue blades is highly controversial, and they should not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure more likely will harm the client who bites down during seizure activity. Risks include blocking the airway from improper placement, chipping the client's teeth, and subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begins.

After change of shift report, which patient should the nurse assess first? a. Patient with myasthenia gravis who is reporting increased muscle weakness b. Patient with a bilateral headache described as "like a band around my head" c. Patient with seizures who is scheduled to receive a dose of phenytoin (Dilantin) d. Patient with Parkinson's disease who has developed cogwheel rigidity of the arms

a. Patient with myasthenia gravis who is reporting increased muscle weakness. Because increased muscle weakness may indicate the onset of a myasthenic crisis, the nurse should assess this patient first.

The nurse advises a patient with myasthenia gravis (MG) to a. Perform physically demanding activities early in the day b. Anticipate the need for weekly plasmapheresis treatments c. Do frequent weight bearing exercise to prevent muscle atrophy d. Protect the extremities from injury due to poor sensory perception

a. Perform physically demanding activities early in the day Muscles are generally strongest in the morning, and activity involving muscle activity should be scheduled then.

When teaching a patient with myasthenia gravis (MG) about management of the disease, the nurse advises the patient to a. Perform physically demanding activities in the morning. b. Anticipate the need for weekly plasmapheresis treatments. c. Do frequent weight-bearing exercise to prevent muscle atrophy. d. Protect the extremities from injury due to poor sensory perception.

a. Perform physically demanding activities in the morning Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then. Plasmapheresis is not routinely scheduled but is used for myasthenia crisis or for situations in which corticosteroid therapy should be discontinued. There is no decrease in sensation with MG, and muscle atrophy does not occur because muscles are used during part of the day.

The nurse is assessing a client who is experiencing seizure activity. The nurse understands that it is necessary to determine information about which items as part of routine assessment of seizures? Select all that apply. a. Postictal status b. Duration of the seizure c. Changes in pupil size or eye deviation d. Seizure progression and type of movements e. What the client ate in the 2 hours preceding seizure activity

a. Postictal status b. Duration of the seizure c. Changes in pupil size or eye deviation d. Seizure progression and type of movements Typically seizure assessment includes the time the seizure began, parts of the body affected, type of movements and progression of the seizure, change in pupil size or eye deviation or nystagmus, client condition during the seizure, and postictal status. Determining what the client ate 2 hours prior to the seizure is not a component of seizure assessment.

The nurse is preparing a plan of care for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On assessment, the nurse notes that the client is severely dysphagic. Which intervention should be included in the care plan for this client? Select all that apply. a. Provide oral hygiene after each meal. b. Assess swallowing ability frequently. c. Allow the client sufficient time to eat. d. Maintain a suction machine at the bedside. e. Provide a full liquid diet for ease in swallowing.

a. Provide oral hygiene after each meal. b. Assess swallowing ability frequently. c. Allow the client sufficient time to eat. d. Maintain a suction machine at the bedside. A client who is severely dysphagic is at risk for aspiration. Swallowing is assessed frequently. The client should be given a sufficient amount of time to eat. Semi-soft foods are easiest to swallow and require less chewing. Oral hygiene is necessary after each meal. Suctioning should be available for clients who experience dysphagia and are at risk for aspiration.

The nurse is planning care for a client who displays confusion secondary to a neurological problem. Which approaches by the nurse would be helpful in assisting this client? Select all that apply. a. Providing sensory cues b. Giving simple, clear directions c. Providing a stable environment d. Keeping family pictures at the bedside e. Encouraging family members to visit at the same time

a. Providing sensory cues b. Giving simple, clear directions c. Providing a stable environment d. Keeping family pictures at the bedside Clients with cognitive impairment from neurological dysfunction respond best to a stable environment that is limited in amount and type of sensory input. The nurse can provide sensory cues and give clear, simple directions in a positive manner. Confusion can be minimized by reducing environmental stimuli (such as television or multiple visitors) and by keeping familiar personal articles (such as family pictures) at the bedside.

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crisis. Which client activity suggests that teaching is most effective? a. Taking medications as scheduled b. Eating large, well-balanced meals c. Doing muscle-strengthening exercises d. Doing all chores early in the day while less fatigued

a. Taking medications as scheduled Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is important. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional stress.

A patient with multiple sclerosis (MS) has urinary retention caused by a flaccid bladder. Which action will the nurse plan to take? a. Teach the patient how to use the Cred method. b. Decrease the patients fluid intake in the evening. c. Suggest the use of incontinence briefs for nighttime use only. d. Assist the patient to the commode every 2 hours during the day.

a. Teach the patient how to use the Credit method. The Cred method can be used to improve bladder emptying. Decreasing fluid intake will not improve bladder emptying and may increase risk for urinary tract infection (UTI) and dehydration. The use of incontinence briefs and frequent toileting will not improve bladder emptying.

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. a. The client is aphasic. b. The client has weakness on the right side of the body. c. The client has complete bilateral paralysis of the arms and legs. d. The client has weakness on the right side of the face and tongue. e. The client has lost the ability to move the right arm but is able to walk independently. f. The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance.

a. The client is aphasic. b. The client has weakness on the right side of the body. d. The client has weakness on the right side of the face and tongue. Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic: unable to discriminate words and letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.

A patient with Parkinson's disease is admitted to the hospital for treatment of pneumonia. Which nursing interventions will be included in the plan of care? Select all that apply. a. Use an elevated toilet seat b. Cut patients food into small pieces c. Provide high protein foods at each meal d. Place an armchair at the patient's bedside e. Observe for sudden exacerbation of symptoms.

a. Use an elevated toilet seat b. Cut patients food into small pieces d. Place an armchair at the patient's bedside. Because the patient with Parkinson's has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair.

A patient with Parkinson's disease is admitted to the hospital for treatment of an acute infection. Which nursing interventions will be included in the plan of care? Select all that apply. a. Use an elevated toilet seat. b. Cut patients food into small pieces. c. Provide high protein foods at each meal. d. Place an arm chair at the patient's bedside. e. Observe for sudden exacerbation of symptoms.

a. Use an elevated toilet seat. b. Cut patients food into small pieces. d. Place an arm chair at the patient's bedside. Since the patient with Parkinson's has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High protein foods will decrease the effectiveness of L-dopa. Parkinson's is a steadily progressive disease without acute exacerbations.

A high school teacher who has just been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse "I cannot teach anymore, it will be too upsetting if I have a seizure at work." Which response by the nurse is best a. "You might benefit from some psychological counseling." b. "Epilepsy usually can be well controlled with medications." c. "You will want to contact the epilepsy foundation for assistance." d. "The department of vocational rehabilitation can help with work retaining."

b. "Epilepsy usually can be well controlled with medications." The nurse should inform the patient that most patients with seizure disorders are controlled with medication.

A hospitalized patient complains of a moderate bilateral headache that radiates from the base of the skull. Which of these prescribed PRN medications should the nurse administer initially? a. Lorazepam (Ativan) b. Acetaminophen (Tylenol) c. Morphine sulfate (Roxanol) d. Butalbital and aspirin (Fiorinal)

b. Acetaminophen (Tylenol) The patients symptoms are consistent with a tension headache, and initial therapy usually involves a nonopioid analgesic such as acetaminophen, sometimes combined with a sedative or muscle relaxant. Lorazepam may be used in conjunction with acetaminophen but would not be appropriate as the initial monotherapy. Morphine sulfate and butalbital and aspirin would be more appropriate for a headache that did not respond to a nonopioid analgesic.

An older client in an acute state of disorientation is brought to the hospital emergency department by the client's daughter. The daughter states that the client was "clear as a bell this morning." The nurse determines from this piece of information that which is an unlikely cause of the disorientation? a. Hypoglycemia b. Alzheimer's disease c. Medication dosage d. Impaired circulation to the brain

b. Alzheimer's disease Alzheimer's disease is a chronic disease with progression of memory deficits over time. The situation presented in the question represents an acute problem. Evaluation is necessary to determine whether hypoglycemia, medication use, or impaired cerebral circulation has had a role in causing the client's current symptoms.

A client with myasthenia gravis is having difficulty with airway clearance and difficulty with maintaining an effective breathing pattern. The nurse should keep which most important items available at the client's bedside? a. Oxygen and metered-dose inhaler b. Ambu bag and suction equipment c. Pulse oximeter and cardiac monitor d. Incentive spirometer and cough pillow

b. Ambu bag and suction equipment The client with myasthenia gravis may experience episodes of respiratory distress if excessively fatigued or with development of myasthenic or cholinergic crisis. For this reason, an Ambu bag, intubation tray, and suction equipment should be available at the bedside.

A patient is seen in the health clinic with symptoms of a stooped posture, shuffling gait, and pill rollingtype tremor. The nurse will anticipate teaching the patient about a. Oral corticosteroids. b. Antiparkinsonian drugs. c. The purpose of electroencephalogram (EEG) testing. d. Preparation for magnetic resonance imaging (MRI).

b. Antiparkinsonian drugs The diagnosis of Parkinson's is made when two of the three characteristic signs of tremor, rigidity, and bradykinesia are present. The confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered. This patient has symptoms of tremor and bradykinesia; the next anticipated step will be treatment with medications. MRI and EEG are not useful in diagnosing Parkinsons disease, and corticosteroid therapy is not used to treat it.

When a 74-year-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling-type tremor, the nurse will anticipate teaching the patient about a. Oral corticosteroids. b. Antiparkinsonian drugs. c. Magnetic resonance imaging (MRI). d. Electroencephalogram (EEG) testing.

b. Antiparkinsonian drugs. The diagnosis of Parkinson's is made when two of the three characteristic manifestations of tremor, rigidity, and bradykinesia are present. The confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered. This patient has symptoms of tremor and bradykinesia. The next anticipated step will be treatment with medications. MRI and EEG are not useful in diagnosing Parkinson's disease, and corticosteroid therapy is not used to treat it.

A patient seen at the health clinic with a severe migraine headache tells the nurse about having four similar headaches in the last 3 months. Which initial action should the nurse take? a. Refer the patient for stress counseling. b. Ask the patient to keep a headache diary. c. Suggest the use of muscle-relaxation techniques. d. Teach about the effectiveness of the triptan drugs.

b. Ask the patient to keep a headache diary 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.

The nurse is assessing the client's gait and notes it is unsteady and staggering. Which description should the nurse use when documenting the assessment finding? a. Spastic b. Ataxic c. Festinating d. Dystrophic or broad-based

b. Ataxic An ataxic gait is characterized by unsteadiness and staggering. A spastic gait is characterized by stiff, short steps with the legs held together, hip and knees flexed, and toes that catch and drag. A festinating gait is best described as walking on the toes with an accelerating pace. A dystrophic or broad-based gait is seen as waddling, with the weight shifting from side to side and the legs far apart.

The nurse is assessing the function of cranial nerve XII in a client who sustained a stroke. To assess function of this nerve, which action should the nurse ask the client to perform? a. Extend the arms. b. Extend the tongue. c. Turn the head toward the nurse's arm. d. Focus the eyes on the object held by the nurse.

b. Extend the tongue. Impairment of cranial nerve XII can occur with a stroke. To assess the function of cranial nerve XII (the hypoglossal nerve), the nurse would assess the client's ability to extend the tongue. The maneuvers noted in the remaining options do not test the function of cranial nerve XII.

The nurse is providing discharge education to a client diagnosed with trigeminal neuralgia. Which medication will likely be prescribed upon discharge for this condition? a. Lorazepam b. Gabapentin c. Carisoprodol d. Chlordiazepoxide

b. Gabapentin Trigeminal neuralgia is characterized by spasms of pain that start suddenly and last from seconds to minutes. The pain often is described as either stabbing or similar to an electric shock. It is accompanied by spasms of the facial muscles that cause twitching of parts of the face or mouth, or closure of the eye. It is treated by giving antiseizure medications, such as gabapentin, and sometimes tricyclic antidepressants. These medications work by stabilizing the neuronal membrane and blocking the nerve.

The home care nurse is visiting a client with a diagnosis of Parkinson's disease. The client is taking benztropine mesylate orally daily. The nurse provides information to the spouse regarding the side effects of this medication and should tell the spouse to report which side effect if it occurs? a. Shuffling gait b. Inability to urinate c. Decreased appetite d. Irregular bowel movements

b. Inability to urinate Benztropine mesylate is an anticholinergic, which causes urinary retention as a side effect. The nurse would instruct the client or spouse about the need to monitor for difficulty with urinating, a distended abdomen, infrequent voiding in small amounts, and overflow incontinence. The remaining options are unrelated to the use of this medication.

The nurse assigned to the care of an unconscious client is making initial daily rounds. On entering the client's room, the nurse observes that the client is lying supine in bed, with the head of the bed elevated approximately 5 degrees. The nasogastric tube feeding is running at 70 mL/hr, as prescribed. The nurse assesses the client and auscultates adventitious breath sounds. Which judgment should the nurse formulate for the client? a. Impaired nutritional intake b. Increased risk for aspiration c. Increased likelihood for injury d. Susceptibility to fluid volume deficit

b. Increased risk for aspiration Increased risk for aspiration is a condition in which an individual is at risk for entry of gastrointestinal (GI) secretions, oropharyngeal secretions, or solids or fluids into tracheobronchial passages. Conditions that place the client at risk for aspiration include reduced level of consciousness, depressed cough and gag reflexes, and feeding via a GI tube. There is no information in the question indicating that the remaining options are a concern.

A client is admitted with an exacerbation of multiple sclerosis. The nurse is assessing the client for possible precipitating risk factors. Which factor, if reported by the client, should the nurse identify as being unrelated to the exacerbation? a. Annual influenza vaccination b. Ingestion of increased fruits and vegetables c. An established routine of walking 2 miles each evening d. A recent period of extreme outside ambient temperatures

b. Ingestion of increased fruits and vegetables The onset or exacerbation of multiple sclerosis can be preceded by a number of different factors, including physical stress (e.g., vaccination, excessive exercise), emotional stress, fatigue, infection, physical injury, pregnancy, extremes in environmental temperature, and high humidity. No methods of primary prevention are known. Intake of fruits and vegetables is a healthy and an unrelated item.

When obtaining a health history and physical assessment for a patient with possible multiple sclerosis (MS), the nurse should a. Assess for the presence of chest pain. b. Inquire about any urinary tract problems. c. Inspect the skin for rashes or discoloration. d. Question the patient about any increase in libido.

b. Inquire about any urinary tract problems Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS.

When obtaining a health history and physical assessment for a 36 yr old female patient with possible multiple sclerosis (MS), the nurse should a. Assess for the presence of chest pain b. Inquire about urinary tract problems c. Inspect the skin for rashes or discoloration d. Ask the patient about any increase in libido

b. Inquire about urinary tract problems Urinary tract problems with incontinence or retention are common symptoms of MS.

The home care nurse is making a visit to a client who requires use of a wheelchair after a spinal cord injury sustained 4 months earlier. Just before leaving the home, the nurse ensures that which intervention has been done to prevent an episode of autonomic dysreflexia (hyperreflexia)? a. Updating the home safety sheet b. Leaving the client in an unchilled area of the room c. Noting a bowel movement on the client progress note d. Recording the amount of urine obtained with catheterization

b. Leaving the client in an unchilled area of the room The most common cause of autonomic dysreflexia is visceral stimuli, such as with blockage of urinary drainage or with constipation. Barring these, other causes include noxious mechanical and thermal stimuli, particularly pressure and overchilling. For this reason, the nurse ensures that the client is positioned with no pinching or pressure on paralyzed body parts and that the client will be sufficiently warm.

A client admitted to the nursing unit from the hospital emergency department has a C4 spinal cord injury. In conducting the admission assessment, what is the nurse's priority action? a. Take the temperature. b. Listen to breath sounds. c. Observe for dyskinesias. d. Assess extremity muscle strength.

b. Listen to breath sounds. Because compromise of respiration is a leading cause of death in cervical cord injury, respiratory assessment is the highest priority. Assessment of temperature and strength can be done after adequate oxygenation is ensured. Because dyskinesias occur in cerebellar disorders, this is not as important a concern as in cord-injured clients unless head injury is suspected.

The nurse in the health care clinic is providing medication instructions to a client with a seizure disorder who will be taking divalproex sodium. The nurse should instruct the client about the importance of returning to the clinic for monitoring of which laboratory study? a. Electrolyte panel b. Liver function studies c. Renal function studies d. Blood glucose level determination

b. Liver function studies Divalproex sodium, an anticonvulsant, can cause fatal hepatotoxicity. The nurse should instruct the client about the importance of monitoring the results of liver function studies and ammonia level determinations. The studies in the remaining options are not required with the use of this medication.

The nurse is performing an assessment on a client with Guillain-Barré syndrome. The nurse determines that which finding would be of most concern? a. Difficulty articulating words b. Lung vital capacity of 10 mL/kg c. Paralysis progressing from the toes to the waist d. A blood pressure (BP) decrease from 110/78 mm Hg to 102/70 mm Hg

b. Lung vital capacity of 10 mL/kg Respiratory compromise is a major concern in clients with Guillain-Barré syndrome. Clients often are intubated and mechanically ventilated when the vital capacity is less than 15 mL/kg. Difficulty articulating words and paralysis progressing from the toes to the waist are expected, depending on the degree of paralysis that occurs. Although orthostatic hypotension is a problem with these clients, the BP drop in option 4 is less than 10 mm Hg and is not significant.

The nurse is reviewing the record for a client seen in the health care clinic and notes that the health care provider has documented a diagnosis of amyotrophic lateral sclerosis (ALS). Which initial clinical manifestation of this disorder should the nurse expect to see documented in the record? a. Muscle wasting b. Mild clumsiness c. Altered mentation d. Diminished gag reflex

b. Mild clumsiness The initial symptom of ALS is a mild clumsiness, usually noted in the distal portion of one extremity. The client may complain of tripping and drag one leg when the lower extremities are involved. Mentation and intellectual function usually are normal. Diminished gag reflex and muscle wasting are not initial clinical manifestations.

The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use which technique to test the client's peripheral response to pain? a. Sternal rub b. Nail bed pressure c. Pressure on the orbital rim d. Squeezing of the sternocleidomastoid muscle

b. Nail bed pressure Nail bed pressure tests a basic motor and sensory peripheral response. Cerebral responses to pain are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

Following a thymectomy, a 62 year old male patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first? a. Auscultate the patients bowel sounds b. Notify the patients HCP c. Administer the prescribed PRN antiemetic drug d. Give the scheduled dose of prednisone (Deltasone)

b. Notify the patients HCP The patient's history and symptoms indicate a possible cholinergic crisis. The HCP should be notified immediately and it is likely atropine will be prescribed.

Following a thymectomy, a patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first? a. Auscultate the patients bowel sounds. b. Notify the patients health care provider. c. Administer the prescribed PRN antiemetic drug. d. Give the scheduled dose of prednisone (Deltasone).

b. Notify the patients health care provider The patient's history and symptoms indicate a possible cholinergic crisis. The health care provider should be notified immediately, and it is likely that atropine will be prescribed. The other actions will be appropriate if the patient is not experiencing a cholinergic crisis.

The clinic nurse is reviewing the record of a client scheduled to be seen in the clinic. The nurse notes that the client is taking selegiline hydrochloride. The nurse suspects that the client has which disorder? a. Diabetes mellitus b. Parkinson's disease c. Alzheimer's disease d. Coronary artery disease

b. Parkinson's disease Selegiline hydrochloride is an antiparkinsonian medication. The medication increases dopaminergic action, assisting in the reduction of tremor, akinesia, and the rigidity of parkinsonism. This medication is not used to treat diabetes mellitus, Alzheimer's disease, or coronary artery disease.

When the home health RN is planning care for a patient with a seizure disorder, which nursing action can be delegated to an LPN/LVN? a. Make referrals to appropriate community agencies. b. Place medications in the home medication organizer. c. Teach the patient and family how to manage seizures. d. Assess for use of medications that may precipitate seizures.

b. Place medications in the home medication organizer LPN/LVN education includes administration of medications. The other activities require RN education and scope of practice.

The student nurse develops a plan of care for a client after a lumbar puncture. The nursing instructor corrects the student if the student documents which incorrect intervention in the plan? a. Maintain the client in a flat position. b. Restrict fluid intake for a period of 2 hours. c. Assess the client's ability to void and move the extremities. d. Inspect the puncture site for swelling, redness, and drainage.

b. Restrict fluid intake for a period of 2 hours. After the lumbar puncture the client remains flat in bed for at least 2 hours, depending on the health care provider's prescriptions. A liberal fluid intake is encouraged to replace the cerebrospinal fluid removed during the procedure, unless contraindicated by the client's condition. The nurse checks the puncture site for redness and drainage and assesses the client's ability to void and move the extremities.

The nurse is documenting nursing observations in the record of a client who experienced a tonic-clonic seizure. Which clinical manifestation did the nurse most likely note in the clonic phase of the seizure? a. Body stiffening b. Spasms of the entire body c. Sudden loss of consciousness d. Brief flexion of the extremities

b. Spasms of the entire body The clonic phase of a seizure is characterized by alternating spasms and momentary muscular relaxation of the entire body, accompanied by strenuous hyperventilation. The face is contorted and the eyes roll. Excessive salivation results in frothing from the mouth. The tongue may be bitten, the client sweats profusely, and the pulse is rapid. The clonic jerking subsides by slowing in frequency and losing strength of contractions over a period of 30 seconds. Body stiffening, sudden loss of consciousness, and brief flexion of the extremities are associated with the tonic phase of a seizure.

A 73-year-old patient with Parkinson's disease has a nursing diagnosis of impaired physical mobility related to bradykinesia. Which action will the nurse include in the plan of care? a. Instruct the patient in activities that can be done while lying or sitting. b. Suggest that the patient rock from side to side to initiate leg movement. c. Have the patient take small steps in a straight line directly in front of the feet. d. Teach the patient to keep the feet in contact with the floor and slide them forward.

b. Suggest that the patient rock from side to side to initiate leg movement. Rocking the body from side to side stimulates balance and improves mobility. The patient will be encouraged to continue exercising because this will maintain functional abilities. Maintaining a wide base of support will help with balance. The patient should lift the feet and avoid a shuffling gait.

The HCP is considering the use of sumatriptan (Imitrex) for a 54 yr old male patient with migraine headaches. Which information obtained by the nurse is most important to report to the HCP? a. The patient drinks 1 to 2 cups of coffee daily. b. The patient had a recent acute myocardial infarction c. The patient has had migraine headaches for 30 yrs d. The patient has taken topiramate (Topamax) for 2 months.

b. The patient had a recent acute myocardial infarction The triptans cause coronary artery vasoconstriction and should be avoided in patients with coronary artery disease.

The nurse is testing the spinal reflexes of a client during neurological assessment. Which assessment by the nurse would help to determine the adequacy of the spinal reflex? a. Cough reflex b. Withdrawal reflex c. Munro-Kellie reflex d. Accommodation reflex

b. Withdrawal reflex The withdrawal reflex is one of the spinal reflexes. It is an abrupt withdrawal of a body part in response to painful or injurious stimuli. The cough reflex is a brainstem-associated reflex. Accommodation reflex is associated with cranial nerve III and is part of the ocular motor system. Munro-Kellie is not a reflex; it is a doctrine or a hypothesis addressing the cerebral volume relationships among the brain, the cerebrospinal fluid, and intracranial blood and their cumulative impact on intracranial pressure.

A patient with Parkinsons disease has a nursing diagnosis of impaired physical mobility related to bradykinesia. Which action will the nurse include in the plan of care? a. Instruct the patient in activities that can be done while lying or sitting. b. Suggest that the patient rock from side to side to initiate leg movement. c. Have the patient take small steps in a straight line directly in front of the feet. d. Teach the patient to keep the feet in contact with the floor and slide them forward.

b. suggest that the patient rock from side to side to initiate leg movement Rocking the body from side to side stimulates balance and improves mobility. The patient will be encouraged to continue exercising because this will maintain functional abilities. Maintaining a wide base of support will help with balance. The patient should lift the feet and avoid a shuffling gait.

The home health nurse is visiting a client with a diagnosis of multiple sclerosis. The client has been taking oxybutynin. The nurse evaluates the effectiveness of the medication by asking the client which assessment question? a. "Are you constantly fatigued?" b. "Are you having muscle spasms?" c. "Are you getting up at night to urinate?" d. "Are you having normal bowel movements?"

c. "Are you getting up at night to urinate?" Oxybutynin is an antispasmodic used to relieve symptoms of urinary urgency, frequency, nocturia, and incontinence in clients with uninhibited or reflex neurogenic bladder. Expected effects include improved urinary control and decreased urinary frequency, incontinence, and nocturia. The questions in the remaining options are unrelated to the use of this medication.

The home care nurse is performing an assessment on a client with a diagnosis of Bell's palsy. Which assessment question will elicit specific information regarding this client's disorder? a. "Do your eyes feel dry?" b. "Do you have any spasms in your throat?" c. "Are you having any difficulty chewing food?" d. "Do you have any tingling sensations around your mouth?"

c. "Are you having any difficulty chewing food?" Bell's palsy is a one-sided facial paralysis caused by compression of the facial nerve. Manifestations include facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and speech or chewing difficulties.

The nurse has instructed a client with myasthenia gravis about strategies for self-management at home. The nurse determines a need for further teaching if the client makes which statement? a. "Here's the MedicAlert bracelet I obtained." b. "I should take my medications an hour before mealtime." c. "Going to the beach will be a nice, relaxing form of activity." d. "I've made arrangements to get a portable resuscitation bag and home suction equipment."

c. "Going to the beach will be a nice, relaxing form of activity." Most ongoing treatment for myasthenia gravis is done in outpatient settings, and the client must be aware of the lifestyle changes needed to maintain independence. The client should carry medical identification about the presence of the condition. Taking medications an hour before mealtime gives greater muscle strength for chewing and is indicated. The client should have portable suction equipment and a portable resuscitation bag available in case of respiratory distress. The client should avoid situations and other factors, including stress, infection, heat, surgery, and alcohol, that could worsen the symptoms.

The nurse has provided instructions to a client with a diagnosis of myasthenia gravis about home care measures. Which client statement indicates the need for further teaching? a. "I will rest each afternoon after my walk." b. "I should cough and deep breathe many times during the day." c. "I can change the time of my medication on the mornings when I feel strong." d. "If I get abdominal cramps and diarrhea, I should call my healthcare provider."

c. "I can change the time of my medication on the mornings when I feel strong." The client with myasthenia gravis and the family should be taught information about the disease and its treatment. They should be aware of the side and adverse effects of anticholinesterase medications and corticosteroids and should be taught that timing of anticholinesterase medication is critical. It is important to instruct the client to administer the medication on time to maintain a chemical balance at the neuromuscular junction. If it is not given on time, the client may become too weak to even swallow. Resting after a walk, coughing and deep-breathing many times during the day, and calling the health care provider when experiencing abdominal cramps and diarrhea indicate a correct understanding of home care instructions to maintain health with this neurological degenerative disease.

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 headache signs begin d. I should avoid taking aspirin and sumatriptan (Imitrex) at the same time

c. I will lie down someplace dark and quiet when the headaches begin It is recommended that the patient with a migraine rest in a dark, quiet area.

The nurse is assisting the neurologist in performing an assessment on a client who is unconscious after sustaining a head injury. The nurse understands that the neurologist would avoid performing the oculocephalic response (doll's eyes maneuver) if which condition is present in the client? a. Dilated pupils b. Lumbar trauma c. A cervical cord injury d. Altered level of consciousness

c. A cervical cord injury In an unconscious client, eye movements are an indication of brainstem activity and are tested by the oculocephalic response. When the doll's eyes maneuver is intact, the eyes move in the opposite direction when the head is turned. Abnormal responses include movement of the eyes in the same direction as that for the head and maintenance of a midline position of the eyes when the head is turned. An abnormal response indicates a disruption in the processing of information through the brainstem. Contraindications to performing this test include cervical-level spinal cord injuries and severely increased intracranial pressure.

A client has dysfunction of the cochlear division of the vestibulocochlear nerve (cranial nerve VIII). The nurse should determine that the client is adequately adapting to this problem if he or she states a plan to obtain which item? a. A walker b. Eyeglasses c. A hearing aid d. A bath thermometer

c. A hearing aid The cochlear division of cranial nerve VIII is responsible for hearing. Clients with hearing difficulty may benefit from the use of a hearing aid. The vestibular portion of this nerve controls equilibrium; difficulty with balance caused by dysfunction of this division could be addressed with use of a walker. Eyeglasses would correct visual problems (cranial nerve II); a bath thermometer would be of use to clients with sensory deficits of peripheral nerves, such as with diabetic neuropathy.

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? a. A negative Kernig's sign b. Absence of nuchal rigidity c. A positive Brudzinski's sign d. A Glasgow Coma Scale score of 15

c. A positive Brudzinski's sign Signs of meningeal irritation compatible with meningitis include nuchal rigidity, a positive Brudzinski's sign, and positive Kernig's sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is flexed. Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the leg is fully flexed at the knee and hip. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glasgow Coma Scale score of 15 is a perfect score and indicates that the client is awake and alert, with no neurological deficits.

A 22 yr old patient seen 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 headache diary d. Suggest the use of muscle-relaxation techniques.

c. Ask the patient to keep a headache diary. The initial nursing action should be further assessment of the precipitating causes of the headaches, quality, and location of pain.

A client with a neurological impairment experiences urinary incontinence. Which nursing action would be most helpful in assisting the client to adapt to this alteration? a. Using adult diapers b. Inserting a Foley catheter c. Establishing a toileting schedule d. Padding the bed with an absorbent cotton pad

c. Establishing a toileting schedule A bladder retraining program, such as use of a toileting schedule, may be helpful to clients experiencing urinary incontinence. A Foley catheter should be used only when necessary because of the associated risk of infection. Use of diapers or pads is the least acceptable alternative because of the risk of skin breakdown.

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? a. Hyperreflexia b. Positive reflexes c. Flaccid paralysis d. Reflex emptying of the bladder

c. Flaccid paralysis Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, and reflex emptying of the bladder.

A client brought to the emergency department had a seizure 1 hour ago. Family members were present during the episode and reported that the client's jaw was moving as though grinding food. In helping to determine the origin of this seizure, what should the nurse include in the client's assessment? a. Loss of consciousness b. Presence of diaphoresis c. History of prior trauma d. Rotating eye movements

c. History of prior trauma Seizures that originate with specific motor phenomena are considered focal and are indicative of a focal structural lesion in the brain, often caused by trauma, infection, or medication consumption. The remaining options address signs, rather than an origin of the seizure.

A 49-year-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching? a. Recommendation to drink at least 4 L of fluid daily b. Need to avoid driving or operating heavy machinery c. How to draw up and administer injections of the medication d. Use of contraceptive methods other than oral contraceptives

c. How to draw up and administer injections of the medication Copaxone is administered by self-injection. Oral contraceptives are an appropriate choice for birth control. There is no need to avoid driving or drink large fluid volumes when taking glatiramer.

A patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching? a. Recommendation to drink at least 3 to 4 L daily b. Need to avoid driving or operating heavy machinery c. How to draw up and administer injections of the medication d. Use of contraceptive methods other than oral contraceptives

c. How to draw up and administer injections of the medication Copaxone is administered by self-injection. Oral contraceptives are an appropriate choice for birth control. There is no need to avoid driving or drink large fluid volumes when taking glatiramer.

After teaching a patient about management of migraine headaches, the nurse determines that the teaching has been effective when the patient says a. I will take the (Topamax) as soon as any headaches start. b. I should avoid taking aspirin and sumatriptan (Imitrex) at the same time. c. I will try to lie down someplace dark and quiet when the headaches begin. d. A glass of wine might help me relax and prevent headaches from developing.

c. I will try to lie down someplace dark and quiet when the headaches begin 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 anti-inflammatory medications can be taken with the triptans. Alcohol may precipitate migraine headaches.

A client with multiple sclerosis is experiencing muscle weakness, spasticity, and an ataxic gait. On the basis of this information, the nurse should include which client problem in the plan of care? a. Inability to care for self b. Interruption in skin integrity c. Interruption in physical mobility d. Inability to perform daily activities

c. Interruption in physical mobility Multiple sclerosis is a chronic, nonprogressive, noncontagious degenerative disease of the central nervous system characterized by demyelination of the neurons. Interruption in physical mobility is most appropriate for the client with multiple sclerosis experiencing muscle weakness, spasticity, and ataxic gait. The remaining options are not related to the data in the question.

The nurse is monitoring a client who has returned to the nursing unit after a myelogram. Which client complaint would indicate the need to notify the health care provider (HCP)? a. Backache b. Headache c. Neck stiffness d. Feelings of fatigue

c. Neck stiffness Headache is relatively common after the procedure, but neck stiffness, especially on flexion, and pain should be reported because they signal meningeal irritation. The client also is monitored for evidence of allergic reactions to the dye such as confusion, dizziness, tremors, and hallucinations. Feelings of fatigue may be normal, and back discomfort may occur because of the positions required for the procedure.

The nurse is caring for a client diagnosed with Alzheimer's disease. The nurse should anticipate that the client has changes in which component of the nervous system? a. Glia b. Peripheral nerves c. Neuronal dendrites d. Monoamine oxidase

c. Neuronal dendrites Alzheimer's disease is characterized by changes in the dendrites of the neurons. The decrease in the number and composition of the dendrites is responsible for the symptoms of the disease. The components in the other options are not related to the pathology of Alzheimer's disease.

When the nurse is assessing a patient with myasthenia gravis, which action will be most important to take? a. Check pupillary size. b. Monitor grip strength. c. Observe respiratory effort. d. Assess level of consciousness.

c. Observe respiratory effort Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical.

A client with a history of myasthenia gravis presents at a clinic with bilateral ptosis and is drooling, and myasthenic crisis is suspected. The nurse assesses the client for which precipitating factor? a. Getting too little exercise b. Taking excess medication c. Omitting doses of medication d. Increasing intake of fatty foods

c. Omitting doses of medication Myasthenic crisis often is caused by undermedication and responds to the administration of cholinergic medications. Cholinergic crisis (the opposite problem) is caused by excess medication and responds to withholding of medications. Too little exercise and excessive fatty food intake are incorrect. Overexertion and overeating possibly could trigger myasthenic crisis.

A 40 yr old patient is diagnosed with early Huntingtons disease (HD). When teaching the patient, spouse, and children about this disorder, the nurse will provide information about the a. Use of levodopa-carbidopa (Sinemet) to help reduce HD symptoms b. Prophylactic antibiotics to decrease the risk for aspiration pneumonia c. Option of genetic testing for the patients children to determine their own HD risks d. Lifestyle changes of improved nutrition and exercise that delay disease progression.

c. Option of genetic testing for the patient children to determine their own HD risks.

The nurse is preparing for the admission to the unit of a client with a diagnosis of seizures and asks the nursing student to institute full seizure precautions. Which item if noted in the client's room would need to be removed and warrants the need to review seizure precautions with the student? a. Oxygen source b. Suction machine c. Padded tongue blade d. Padding for the side rails

c. Padded tongue blade Full seizure precautions include bed rest with padded side rails in a raised position, a suction machine at the bedside, having diazepam or lorazepam available, and providing an oxygen source. Objects such as tongue blades are contraindicated and should never be placed in the client's mouth during a seizure.

The nurse is preparing to care for a client after a lumbar puncture. The nurse should plan to place the client in which best position following the procedure? a. Prone in semi Fowler's position b. Supine in semi Fowler's position c. Prone with a small pillow under the abdomen d. Lateral with the head slightly lower than the rest of the body

c. Prone with a small pillow under the abdomen After the procedure, the client assumes a flat position. If the client is able, a prone position with a pillow under the abdomen is the best position. This position helps reduce cerebrospinal fluid leakage and decreases the likelihood of post-lumbar puncture headache. The remaining options are incorrect.

A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness? a. Giving client full control over care decisions and restricting visitors b. Providing positive feedback and encouraging active range of motion c. Providing information, giving positive feedback, and encouraging relaxation d. Providing intravenously administered sedatives, reducing distractions, and limiting visitors

c. Providing information, giving positive feedback, and encouraging relaxation The client with Guillain-Barré syndrome experiences fear and anxiety from the ascending paralysis and sudden onset of the disorder. The nurse can alleviate these fears by providing accurate information about the client's condition, giving expert care and positive feedback to the client, and encouraging relaxation and distraction. The family can become involved with selected care activities and provide diversion for the client as well.

The nurse is caring for a client with Parkinson's disease. Which finding about gait should the nurse expect to note in the client? a. Walking on the toes b. Unsteady and staggering c. Shuffling and propulsive d. Broad-based and waddling

c. Shuffling and propulsive The parkinsonian gait is characterized by short, accelerating, shuffling steps. The client leans forward with the head, hips, and knees flexed and has difficulty starting and stopping. An ataxic gait is unsteady and staggering. A dystrophic gait is broad-based and waddling. Walking on the toes can occur from shortened Achilles tendons.

The health care provider is considering the use of sumatriptan (Imitrex) for a patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider? a. The patient has at least 1 to 2 cups of coffee daily. b. The patient has had migraine headaches for 30 years. c. The patient has a history of a recent acute myocardial infarction. d. The patient has been taking topiramate (Topamax) for 2 months.

c. The patient has a history of a recent acute myocardial infarction. The triptans cause coronary artery vasoconstriction and should be avoided in patients with coronary artery disease. The other information will be reported to the health care provider, but none of it is an indication that sumatriptan would be an inappropriate treatment.

Which information about a patient with MS indicates that the nurse should consult with the health care provider before giving the prescribed dose of fampridine (Ampyra)? a. The patient has relapsing-remitting MS. b. The patient enjoys walking for relaxation. c. The patient has an increased creatinine level. d. The patient complains of pain with neck flexion.

c. The patient has an increased creatinine level Fampridine should not be given to patients with impaired renal function. The other information will not impact on whether the fampridine should be administere

Which information about a patient with MS indicates that the nurse should consult with the health care provider before giving the prescribed dose of dalfampridine (Ampyra)? a. The patient has relapsing-remitting MS. b. The patient enjoys walking for relaxation. c. The patient has an increased creatinine level. d. The patient complains of pain with neck flexion.

c. The patient has an increased creatinine level. Dalfampridine should not be given to patients with impaired renal function. The other information will not impact on whether the dalfampridine should be administered.

When a patient is experiencing a cluster headache, the nurse will plan to assess for a. nuchal rigidity. b. projectile vomiting. c. unilateral eyelid swelling. d. throbbing, bilateral facial pain.

c. unilateral eyelid swelling Unilateral eye edema, tearing, and ptosis are characteristic of cluster headaches. Nuchal rigidity suggests meningeal irritation, such as occurs with meningitis. Although nausea and vomiting may occur with migraine headaches, projectile vomiting is more consistent with increases in intracranial pressure (ICP). Unilateral sharp, stabbing pain, rather than throbbing pain, is characteristic of cluster headaches.

The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching? a. "I can sit down to put on my pants and shoes." b. "I try to exercise every day and rest when I'm tired." c. "My son removed all loose rugs from my bedroom." d. "I don't need to use my walker to get to the bathroom."

d. "I don't need to use my walker to get to the bathroom." The client with Parkinson's disease should be instructed regarding safety measures in the home. The client should use his or her walker as support to get to the bathroom because of bradykinesia. The client should sit down to put on pants and shoes to prevent falling. The client should exercise every day in the morning when energy levels are highest. The client should have all loose rugs in the home removed to prevent falling.

The nurse is providing diet instructions to a client with Ménière's disease who is being discharged from the hospital after admission for an acute attack. Which statement, if made by the client, indicates an understanding of the dietary measures to take to help prevent further attacks? a. "I need to restrict my carbohydrate intake." b. "I need to drink at least 3 L of fluid per day." c. "I need to maintain a low-fat and low-cholesterol diet." d. "I need to be sure to consume foods that are low in sodium."

d. "I need to be sure to consume foods that are low in sodium." Dietary changes, such as salt and fluid restrictions, that reduce the amount of endolymphatic fluid are sometimes prescribed for the client with Ménière's disease. The client should be instructed to consume a low-sodium diet and restrict fluids as prescribed. Although helpful to treat other disorders, low-fat, low-carbohydrate, and low-cholesterol diets are not specifically prescribed for the client with Ménière's disease.

The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement? a. "I will wash my face with cotton pads." b. "I'll have to start chewing on my unaffected side." c. "I should rinse my mouth if toothbrushing is painful." d. "I'll try to eat my food either very warm or very cold."

d. "I'll try to eat my food either very warm or very cold." Facial pain can be minimized by using cotton pads to wash the face and using room temperature water. The client should chew on the unaffected side of the mouth, eat a soft diet, and take in foods and beverages at room temperature. If brushing the teeth triggers pain, an oral rinse after meals may be helpful instead.

The home care nurse is preparing to visit a client with a diagnosis of trigeminal neuralgia (tic douloureux). When performing the assessment, the nurse should plan to ask the client which question to elicit the most specific information regarding this disorder? a. "Do you have any visual problems?" b. "Are you having any problems hearing?" c. "Do you have any tingling in the face region?" d. "Is the pain experienced a stabbing type of pain?"

d. "Is the pain experienced a stabbing type of pain?" Trigeminal neuralgia is characterized by spasms of pain that start suddenly and last for seconds to minutes. The pain often is characterized as stabbing or as similar to an electric shock. It is accompanied by spasms of facial muscles that cause twitching of parts of the face or mouth, or closure of the eye. The remaining options do not elicit data specifically related to this disorder.

The nurse is caring for a client diagnosed with trigeminal neuralgia. The client asks the nurse, "Why do I have so much pain?" Which is the appropriate response by the nurse? a. "It's a local reaction to nasal stuffiness." b. "It's due to a hypoglycemic effect on the cranial nerve." c. "Release of catecholamines with infection or stress leads to the pain." d. "Pain is due to stimulation of the affected nerve by pressure and temperature.

d. "Pain is due to stimulation of the affected nerve by pressure and temperature. The paroxysms of pain that accompany this neuralgia are triggered by stimulation of the terminal branches of the trigeminal nerve. Symptoms can be triggered by pressure from washing the face, brushing the teeth, shaving, eating, or drinking. Symptoms also can be triggered by thermal stimuli, such as a draft of cold air. The remaining options are incorrect.

The nurse is planning care for the client with a neurogenic bladder caused by multiple sclerosis. The nurse plans for fluid administration of at least 2000 mL/day. Which plan would be most helpful to this client? a. 400 to 500 mL with each meal and 500 to 600 mL in the evening before bedtime b. 400 to 500 mL with each meal and additional fluids in the morning but not after midday c. 400 to 500 mL with each meal, with all extra fluid concentrated in the afternoon and evening d. 400 to 500 mL with each meal and 200 to 250 mL at mid morning, mid afternoon, and late afternoon

d. 400 to 500 mL with each meal and 200 to 250 mL at mid morning, mid afternoon, and late afternoon Spacing fluid intake over the day helps the client with a neurogenic bladder to establish regular times for successful voiding. Omitting intake after the evening meal minimizes incontinence or the need to empty the bladder during the night.

A client with a spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. The nurse should perform which action? a. Ask the family to deliver the care. b. Leave the client alone until ready to participate. c. Advise the client that rehabilitation progresses more quickly with cooperation. d. Acknowledge the client's anger and continue to encourage participation in care.

d. Acknowledge the client's anger and continue to encourage participation in care. Adjusting to paralysis is physically and psychosocially difficult for the client and family. The nurse recognizes that the client goes through the grieving process in adjusting to the loss and may move back and forth among the stages of grief. The nurse acknowledges the client's feelings while continuing to meet the client's physical needs and encouraging independence. The family also is in crisis and needs the nurse's support and should not be relied on to provide care. The nurse cannot simply neglect the client until the client is ready to participate. Option 3 represents a factual but noncaring approach to the client and is not therapeutic.

Which of these prescribed interventions will the nurse implement first for a hospitalized patient who is experiencing continuous tonic-clonic seizures? a. Give phenytoin (Dilantin) 100 mg IV. b. Monitor level of consciousness (LOC). c. Obtain computed tomography (CT) scan. d. Administer lorazepam (Ativan) 4 mg IV.

d. Administer lorazepam (Ativan) 4 mg IV. To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary. Phenytoin also will be administered, but it is not rapidly acting. Patients who are experiencing tonic-clonic seizures are non responsive, although the nurse should assess LOC after the seizure.

A client who has a spinal cord injury that resulted in paraplegia experiences a sudden onset of severe headache and nausea. The client is diaphoretic with piloerection and has flushing of the skin. The client's systolic blood pressure (BP) is 210 mm Hg. What should the nurse immediately suspect? a. Return of spinal shock b. Malignant hypertension c. Impending brain attack (stroke) d. Autonomic dysreflexia (hyperreflexia)

d. Autonomic dysreflexia (hyperreflexia) Autonomic dysreflexia (hyperreflexia) results from sudden strong discharge of the sympathetic nervous system in response to a noxious stimulus. Signs and symptoms include pounding headache, nausea, nasal stuffiness, flushed skin, piloerection, and diaphoresis. Severe hypertension can occur, with a systolic BP rising potentially as high as 300 mm Hg. It often is triggered by thermal or mechanical events such as a kinking of catheter tubing, constipation, urinary tract infection, or any variety of cutaneous stimuli. The nurse must recognize this situation immediately and take corrective action to remove the stimulus. If untreated, this medical emergency could result in stroke, status epilepticus, or possibly death.

A 42-year-old patient who was adopted at birth is diagnosed with early Huntingtons disease (HD). When teaching the patient, spouse, and children about this disorder, the nurse will provide information about the a. Use of levodopa-carbidopa (Sinemet) to help reduce HD symptoms. b. Need to take prophylactic antibiotics to decrease the risk for pneumonia. c. Lifestyle changes such as increased exercise that delay disease progression. d. Availability of genetic testing to determine the HD risk for the patients children.

d. Availability of genetic testing to determine the HD risk for the patients children. Genetic testing is available to determine whether an asymptomatic individual has the HD gene. The patient and family should be informed of the benefits and problems associated with genetic testing. Sinemet will increase symptoms of HD given that HD involves an increase in dopamine. Antibiotic therapy will not reduce the risk for aspiration. There are no effective treatments or lifestyle changes that delay the progression of symptoms in HD.

The nurse is providing instructions to the client with trigeminal neuralgia regarding measures to take to prevent the episodes of pain. Which should the nurse instruct the client to do? a. Prevent stressful situations. b. Avoid activities that may cause fatigue. c. Avoid contact with people with an infection. d. Avoid activities that may cause pressure near the face.

d. Avoid activities that may cause pressure near the face. The pain that accompanies trigeminal neuralgia is triggered by stimulation of the trigeminal nerve. Symptoms can be triggered by pressure such as from washing the face, brushing the teeth, shaving, eating, or drinking. Symptoms also can be triggered by stimulation by a draft or cold air. The remaining options are not associated with triggering episodes of pain.

The nurse is reviewing the record of a client with a suspected diagnosis of Huntington's disease. The nurse should expect to note documentation of which early symptom of this disease? a. Aphasia b. Agnosia c. Difficulty with swallowing d. Balance and coordination problems

d. Balance and coordination problems Early symptoms of Huntington's disease include restlessness, forgetfulness, clumsiness, falls, balance and coordination problems, altered speech, and altered handwriting. Difficulty with swallowing occurs in the later stages. Aphasia and agnosia do not occur.

The nurse is preparing for the admission of a client with a suspected diagnosis of Guillain-Barré syndrome. When the client arrives at the nursing unit, the nurse reviews the health care provider's documentation. The nurse expects to note documentation of which hallmark clinical manifestation of this syndrome? a. Multifocal seizures b. Altered level of consciousness c. Abrupt onset of a fever and headache d. Development of progressive muscle weakness

d. Development of progressive muscle weakness A hallmark clinical manifestation of Guillain-Barré syndrome is progressive muscle weakness that develops rapidly. Seizures are not normally associated with this disorder. The client does not have symptoms such as a fever or headache. Cerebral function, level of consciousness, and pupillary responses are normal.

A patient who is seen in the outpatient clinic complains of restless legs syndrome. Which of the following over-the-counter medications that the patient is taking routinely should the nurse discuss with the patient? a. Multivitamin (Stresstabs) b. Acetaminophen (Tylenol) c. Ibuprofen (Motrin, Advil) d. Diphenhydramine (Benadryl)

d. Diphenhydramine (Benadryl) Antihistamines can aggravate restless legs syndrome. The other medications will not contribute to the restless legs syndrome.

The nurse is teaching a client hospitalized with a seizure disorder and the client's spouse about safety precautions after discharge. The nurse determines that the client needs further teaching if the client states an intention to take which action? a. Refrain from smoking alone. b. Take all prescribed medications on time. c. Have the spouse nearby when showering. d. Drink alcohol in small amounts and only on weekends.

d. Drink alcohol in small amounts and only on weekends. The client should avoid the intake of alcohol. Alcohol could interact with the client's seizure medications, or it could precipitate seizure activity. The client should take all medications on time to avoid decreases in therapeutic medication levels, which could precipitate seizures. The client should not bathe in the shower or tub without someone nearby and should not smoke alone, to minimize the risk of injury if a seizure occurs.

The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which most essential items into the client's room? a. Nebulizer and pulse oximeter b. Blood pressure cuff and flashlight c. Flashlight and incentive spirometer d. Electrocardiographic monitoring electrodes and intubation tray

d. Electrocardiographic monitoring electrodes and intubation tray The client with Guillain-Barré syndrome is at risk for respiratory failure because of ascending paralysis. An intubation tray should be available for use. Another complication of this syndrome is cardiac dysrhythmias, which necessitates the use of electrocardiographic monitoring. Because the client is immobilized, the nurse should assess for deep vein thrombosis and pulmonary embolism routinely. Although items in the incorrect options may be used in care, they are not the most essential items from the options provided.

A patient with Parkinsons disease has decreased tongue mobility and an inability to move the facial muscles. Which nursing diagnosis is of highest priority? a. Activity intolerance b. Self-care deficit: toileting c. Ineffective self-health management d. Imbalanced nutrition: less than body requirements

d. Imbalanced nutrition:less than body requirements The data about the patient indicate that poor nutrition will be a concern because of decreased swallowing. The other diagnoses also may be appropriate for a patient with Parkinsons disease, but the data do not indicate they are current problems for this patient.

The home health nurse has been discussing interventions to prevent constipation in a client with multiple sclerosis. The nurse determines that the client is using the information most effectively if the client reports which action? a. Drinking a total of 1000 mL/day b. Giving herself an enema every morning before breakfast c. Taking stool softeners daily and a glycerin suppository once a week d. Initiating a bowel movement every other day, 45 minutes after the largest meal of the day

d. Initiating a bowel movement every other day, 45 minutes after the largest meal of the day To manage constipation, the client should take in a high-fiber diet, bulk formers, and stool softeners. A fluid intake of 2000 mL/day is recommended. The client should initiate a bowel movement on an every-other-day basis and should sit on the toilet or commode. This should be done approximately 45 minutes after the largest meal of the day to take advantage of the gastrocolic reflex. A glycerin suppository, bisacodyl suppository, or digital stimulation may be used to initiate the process. Laxatives and enemas should be avoided whenever possible because they lead to dependence.

The nurse in the neurological unit is caring for a client with a supratentorial lesion. The nurse assesses which measurement as the most critical index of central nervous system (CNS) dysfunction? a. Temperature b. Blood pressure c. Ability to speak d. Level of consciousness

d. Level of consciousness Level of consciousness is the most critical index of CNS dysfunction. Changes in level of consciousness can indicate clinical improvement or deterioration. Although blood pressure, temperature, and ability to speak may be components of the assessment, the client's level of consciousness is the most critical index of CNS dysfunction.

A client with a spinal cord injury expresses little interest in food and is very particular about the choice of meals that are actually eaten. How should the nurse interpret this information? a. Anorexia is a sign of clinical depression, and a referral to a psychologist is needed. b. The client has compulsive habits that should be ignored as long as they are not harmful. c. The client probably has a naturally slow metabolism, and the decreased nutritional intake will not matter. d. Meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable.

d. Meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable. Depression frequently may be seen in the client with spinal cord injury and may be exhibited as a loss of appetite. However, the client should be allowed to choose the types of food eaten and when they are eaten as much as is feasible because it is one of the few areas of control that the client has left. There is no information in the question that would indicate that the client is anorexic or obsessive-compulsive or has a slow metabolism.

An elementary teacher who has just been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, I cannot teach anymore, it will be too upsetting if I have a seizure at work. Which response by the nurse is best? a. You may want to contact the Epilepsy Foundation for assistance. b. You might benefit from some psychologic counseling at this time. c. The Department of Vocational Rehabilitation can help with work retraining. d. Most patients with epilepsy are well controlled with antiseizure medications.

d. Most patients with epilepsy are well controlled with anti seizure medications The nurse should inform the patient that most patients with seizure disorders are controlled with medication. The other information may be necessary if the patient seizures persist after treatment with antiseizure medications is implemented.

The nurse is caring for a client who is brought to the hospital emergency department with a spinal cord injury. The nurse minimizes the risk of compounding the injury by performing which action? a. Keeping the client on a stretcher b. Logrolling the client onto a soft mattress c. Logrolling the client onto a firm mattress d. Placing the client on a bed that provides spinal immobilization

d. Placing the client on a bed that provides spinal immobilization Spinal immobilization is necessary after spinal cord injury to prevent further damage and insult to the spinal cord. Whenever possible, the client is placed on a special bed, such as a Stryker frame, which allows the nurse to turn the client to prevent complications of immobility while maintaining alignment of the spine. If a Stryker frame is not available, a firm mattress with a bed board under it should be used. The remaining options are incorrect and potentially harmful interventions.

The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client most at risk for this disease? a. Meningitis or encephalitis during the last 5 years b. Seizures or trauma to the brain within the last year c. Back injury or trauma to the spinal cord during the last 2 years d. Respiratory or gastrointestinal infection during the previous month

d. Respiratory or gastrointestinal infection during the previous month Guillain-Barré syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits. On occasion, the syndrome can be triggered by vaccination or surgery.

Which information about a 60-year-old patient with MS indicates that the nurse should consult with the health care provider before giving the prescribed dose of dalfampridine (Ampyra)? a. The patient has relapsing-remitting MS. b. The patient walks a mile a day for exercise. c. The patient complains of pain with neck flexion. d. The patient has an increased serum creatinine level.

d. The patient has an increased serum creatinine level. Dalfampridine should not be given to patients with impaired renal function. The other information will not impact whether the dalfampridine should be administered.

A patient has a new prescription for bromocriptine (Parlodel) to control symptoms of Parkinson's disease. Which information obtained by the nurse may indicate a need for a decrease in the dose? a. The patient has a chronic dry cough. b. The patient has four loose stools in a day. c. The patient develops a deep vein thrombosis. d. The patients blood pressure is 90/46 mm Hg.

d. The patients blood pressure is 90/46mmHg Hypotension is an adverse effect of bromocriptine, and the nurse should check with the health care provider before giving the medication. Diarrhea, cough, and deep vein thrombosis are not associated with bromocriptine use.

A patient has a tonic-clonic seizure while the nurse is in the patients room. Which action should the nurse take? a. Insert an oral airway during the seizure to maintain a patent airway. b. Restrain the patients arms and legs to prevent injury during the seizure. c. Avoid touching the patient to prevent further nervous system stimulation. d. Time and observe and record the details of the seizure and postictal state.

d. Time and observe and record the details of the seizure and postictal state Because 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.

Which information about a patient who is being treated with carbidopa/levodopa (Sinemet) for Parkinsons disease 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

d. Uncontrolled head movement 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 Parkinsons disease.