Med Surg exam #2 CHAPTERS 41, 42, 43, 44, 45

In the emergency department (ED), which is the nursing priority in assessing the client with a spinal cord injury? A Patent airway B Indication of allergies C Level of consciousness D Loss of sensation

A Clients with injuries at or above T6 are at risk for respiratory complications. After assessment of cardiorespiratory status, the level of consciousness must be assessed using the Glasgow Coma Scale. In the ED, determining allergies or loss of sensation is not the first priority in assessing the client with spinal cord injury.

A client's spouse expresses concern that the client, who has Guillain-Barré syndrome, is becoming very depressed and will not leave the house. What is the nurse's best response? A "Contact the Guillain-Barré Syndrome Foundation International for resources." B "Try inviting several people over so the client won't have to go out." C "Let your spouse stay alone. Your spouse will get used to it." D "This behavior is normal."

A The Guillain-Barré Syndrome Foundation International (www.gbs-cidp.org) provides resources and information for clients and their families. The client and family should be referred to self-help and support groups for clients with chronic illness, if indicated. Inviting one close friend over is appropriate, but more than one might overwhelm the client. Although depression is expected initially, some action does need to be taken to prevent further deterioration.

A client has received contrast medium. Which teaching does the nurse provide to avoid any neurologic health problems after the procedure? A "Practice memory drills this afternoon." B "Drink at least 1000 to 1500 mL of water today." C "Avoid sunlight." D "Rest in bed for 24 hours."

B Drinking an adequate amount of water helps flush the contrast out of the body. Practicing memory drills and getting bedrest are not effective precautions after the use of contrast medium. Sunlight does not affect contrast medium.

The nurse is teaching a client newly diagnosed with migraines about trigger control. Which statement made by the client demonstrates good understanding of the teaching plan? A "I can still eat Chinese food." B "I must not miss meals." C "It is okay to drink a few wine coolers." D "I need to use fake sugar in my coffee."

B Missing meals is a trigger for many people suffering from migraines. The client should not skip any meals until the triggers are identified. Monosodium glutamate-containing foods, alcohol, and artificial sweeteners are triggers for many people suffering from migraines and should be eliminated until the triggers are identified.

Which cranial nerve allows a person to feel a light breeze on the face? A I (olfactory) B III (oculomotor) C V (trigeminal) D VII (facial)

C Cranial nerve V (trigeminal) is responsible for sensation from the skin of the face and scalp and the mucous membranes of the mouth and nose. Cranial nerve I (olfactory) is responsible for smell. Cranial nerve III (oculomotor) is responsible for eye movement. Cranial nerve VII (facial) is responsible for pain and temperature from the ear area, deep sensations from the face, and taste from the anterior two thirds of the tongue.

The nurse is caring for a client postoperatively after an anterior cervical diskectomy and fusion. Which assessment finding is of greatest concern to the nurse? A Neck pain is at a level 7 on a 0-to-10 scale. B The client is reporting difficulty swallowing secretions. C The client has numbness and tingling bilaterally down the arms. D Serosanguineous fluid oozes onto the neck dressing.

B Difficulty swallowing may indicate swelling in the neck and the potential for compromise of the client's airway. Experiencing neck pain and numbness and tingling bilaterally down the arms are expected findings after this surgery. Serosanguineous fluid oozing onto the neck dressing is also a normal finding after this surgery.

A client is being evaluated for signs associated with myasthenic crisis or cholinergic crisis. Which symptoms lead the nurse to suspect that the client is experiencing a cholinergic crisis? A Abdominal cramps, blurred vision, facial muscle twitching B Bowel and bladder incontinence, pallor, cyanosis C Increased pulse, anoxia, decreased urine output D Restlessness, increased salivation and tearing, dyspnea

A Abdominal cramps, blurred vision, and facial muscle twitching are signs of an acute exacerbation of muscle weakness symptoms of cholinergic crisis caused by overmedication with cholinergic (anticholinesterase) drugs. Bowel and bladder incontinence, pallor, cyanosis, increased pulse, anoxia, and decreased urine output are symptoms indicating a myasthenic crisis. Restlessness, increased salivation and tearing, and dyspnea are symptoms indicating a mixed myasthenic-cholinergic crisis.

The parents of a young child report that their child sometimes stares blankly into space for just a few seconds and then gets very tired. The nurse anticipates that the child will be assessed for which seizure disorder? A Absence B Myoclonic C Simple partial D Tonic

A Absence seizures are more common in children and consist of brief (often just seconds) periods of loss of consciousness and blank staring, as though he or she is daydreaming. Myoclonic seizures are characterized by brief jerking or stiffening of the extremities, which may occur singly or in groups. Partial seizures are most often seen in adults. Tonic seizures are characterized by an abrupt increase in muscle tone, loss of consciousness, and autonomic changes lasting from 30 seconds to several minutes.

A client with trigeminal neuralgia is admitted for a percutaneous stereotactic rhizotomy in the morning. The client currently reports pain. What does the nurse do next? A Administers pain medication as requested B Ensures that the client has nothing by mouth (NPO) C Ensures that the preoperative laboratory work is complete D Performs a preoperative assessment

A Addressing the client's pain is the priority nursing intervention because pain is the main symptom of trigeminal neuralgia. This client is not required to be NPO until after midnight. Percutaneous stereotactic rhizotomy can be performed in an ambulatory care setting under general anesthesia, which would not require preoperative testing (except clotting time if the client were on anticoagulant therapy). A preoperative assessment can be performed after the client's pain has been addressed.

A client newly diagnosed with Parkinson disease is being discharged. Which instruction is best for the nurse to provide to the client's spouse? A Administer medications promptly on schedule to maintain therapeutic drug levels. B Complete activities of daily living for the client. C Speak loudly for better understanding. D Provide high-calorie, high-carbohydrate foods to maintain the client's weight.

A Administering medications promptly on schedule is a correct statement. The client should be encouraged to do as much as possible on his own. Slow speech rather than loud speech, and small, frequent meals are more effective for the client with Parkinson disease.

A client has been diagnosed with Huntington disease (HD). The nurse is teaching the client and her parents about the genetic aspects of the disease. Which statement made by the parents demonstrates a good understanding of the nurse's teaching? A "If she has children, she'll pass the gene on to her kids." B "She could only have gotten the disease from both of us." C "Because she got the gene from her father, she'll live longer than others with HD." D "More testing should definitely be done to see if she's really got the gene."

A An autosomal dominant trait with high penetrance, such as HD, means that a person who inherits just one mutated allele has an almost 100% chance of developing the disease. Only one defective gene is needed to inherit HD. The client could have inherited it from her father or mother. If the client inherited the gene from her mother, she would live a longer life than other people with the disease. If she inherited the gene from her father, her life would be shorter. Additional testing is not necessary. If the client has HD, then the client has the gene.

A client with a migraine is lying in a darkened room with a wet cloth on the head after receiving analgesic drugs. What does the nurse do next? A Allow the client to remain undisturbed. B Assess the client's vital signs. C Remove the cloth because it can harbor microorganisms. D Turn on the lights for a neurologic assessment.

A At the beginning of a migraine attack, the client may be able to alleviate pain with analgesics and by lying down in a darkened room with a cool cloth on his or her forehead. If the client falls asleep, he or she should remain undisturbed until awakening. Assessing the client's vital signs will disturb the client unnecessarily. A cool cloth is helpful for the client with a migraine and does not present enough of a risk that it should be removed. Turning on the lights for a neurologic assessment is not appropriate because light can cause the migraine to worsen.

The nursing instructor asks a nursing student to compare and contrast Bell's palsy and trigeminal neuralgia. Which statement by the nursing student is correct? A "Difficulty chewing may occur in both disorders." B "Both are disorders of the autonomic nervous system." C "Facial twitching occurs in both disorders." D "Both disorders are caused by the herpes simplex virus, which inflames and irritates cranial nerve V."

A Both Bell's palsy and trigeminal neuralgia can affect cranial nerve V, which affects facial expressions and chewing. Both are disorders of the cranial nerves. Facial twitching can be a sign of trigeminal neuralgia, whereas Bell's palsy causes a unilateral facial paralysis. Bell's palsy is caused by the herpes simplex virus, unlike trigeminal neuralgia, which is thought to be caused by excessive firing of irritated nerve fibers in the trigeminal nerve.

Which statement correctly illustrates the commonality between Guillain-Barré syndrome (GBS) and myasthenia gravis (MG)? A The client's respiratory status and muscle function are affected by both diseases. B Both diseases are autoimmune diseases with ocular symptoms. C Both diseases exhibit exacerbations and remissions of their signs and symptoms. D Demyelination of neurons is a cause of both diseases.

A Both GBS and MG affect respiratory status and muscle function. Only MG is an autoimmune disease with ocular symptoms, and is characterized by exacerbations and remissions, whereas GBS has three acute stages. GBS causes demyelination of the peripheral neurons.

The nurse is reviewing the history of a client who has been prescribed topiramate (Topamax) for treatment of intractable partial seizures. The nurse plans to contact the health care provider if the client has which condition? A Bipolar disorder B Diabetes mellitus C Glaucoma D Hypothyroidism

A Cases of suicide have been associated with topiramate when it is used in larger doses of 400 mg daily, most often in clients with bipolar disorder. Topiramate is not contraindicated in clients with diabetes mellitus, glaucoma, or hypothyroidism.

The spouse of the client with Alzheimer's disease is listening to the hospice nurse explaining the client's drug regimen. Which statement by the spouse indicates an understanding of the nurse's instruction? A "Donepezil (Aricept) will treat the symptoms of Alzheimer's disease." B "Memantine (Namenda) is indicated for treatment of early symptoms of Alzheimer's disease. C "Rivastigmine (Exelon) is used to treat depression." D "Sertraline (Zoloft) will treat the symptoms of Alzheimer's disease."

A Cholinesterase inhibitors (e.g., donepezil) are approved for the symptomatic treatment of Alzheimer's disease. Memantine (Namenda) is indicated for advanced Alzheimer's disease. Rivastigmine (Exelon) is a cholinesterase inhibitor that is used to treat Alzheimer's symptoms. Selective serotonin reuptake inhibitors are antidepressants and may be used in Alzheimer's clients who develop depression. Some clients with Alzheimer's disease experience depression and may be treated with antidepressants such as sertraline.

Which client diagnosed with neurologic injury is typically at highest risk for depression? A Young man with a spinal cord injury B Older man with a spinal cord injury C Older man with a mild stroke D Young woman with a mild stroke

A Clients who experience a loss of independent movement are more likely to experience depression. A young male who experiences a significant life-changing event, such as a spinal cord injury, is at a higher risk for depression. The older man with a spinal cord injury and the older man and young woman with mild strokes are at a somewhat lower risk.

The nurse is teaching a client about the risk factors of restless legs syndrome. Which statement by the client indicates a correct understanding of the nurse's instruction? A "Cigarettes and alcohol should be avoided." B "I should exercise my legs before bedtime." C "It is important to stay off my feet." D "Over-the-counter drugs should not be taken."

A Clients with restless legs syndrome should avoid as many risk factors as possible or make lifestyle modifications. Examples include avoiding caffeine and alcohol, quitting smoking, losing weight, and exercising. These clients should not engage in strenuous activity within 2 to 3 hours before bedtime, but general exercise is recommended. Use of over-the-counter drugs is not contraindicated for clients with restless legs syndrome.

Which change in the cerebrospinal fluid (CSF) indicates to the nurse that a client may have bacterial meningitis? A Cloudy, turbid CSF B Decreased white blood cells C Decreased protein D Increased glucose

A Cloudy, turbid CSF is a sign of bacterial meningitis. Clear fluid is a sign of viral meningitis. Increased white blood cells, increased protein, and decreased glucose are signs of bacterial meningitis.

A client has just returned from cerebral angiography. Which symptom does the client display that causes the nurse to act immediately? A Bleeding B Increased temperature C Severe headache D Urge to void

A If bleeding is present in the client who has had cerebral angiography, maintain manual pressure on the site and notify the health care provider immediately. Increased temperature or the urge to void are not typical complications of cerebral angiography. Severe headache is a typical complication of a lumbar puncture, but not of cerebral angiography.

In addition to frequent re-positioning, the nurse anticipates a consultation request for which special pressure relief device to help prevent pressure ulcers in the client with a spinal cord injury? A Chair pad B Thromboembolism-deterrent (TED) hose C Trapeze D Water bottle

A In addition to regular turning and re-positioning, special pressure-relief devices such as chair pads may be used in the wheelchair to prevent pressure ulcers in the client with spinal cord injury. TED hose help prevent thrombus, not pressure ulcers. A trapeze helps the client reposition him- or herself; it is not a pressure-relief device. A water bottle is not indicated for the client with spinal cord injury.

A client with Parkinson disease is being discharged home with his wife. To ensure success with the management plan, which discharge action is most effective? A Involving the client and his wife in developing a plan of care B Setting up visitations by a home health nurse C Telling his wife what the client needs D Writing up a detailed plan of care according to standards

A Involving the client and spouse in developing a plan of care is the best way to ensure success with the management plan. Home health nurse visitations are generally helpful, but may not be needed for this client. Instructing the spouse about the client's needs and providing the spouse with a written plan of care do not reinforce the spouse's involvement and buy-in with the management plan.

A client with amyotrophic lateral sclerosis is degenerating rapidly and will soon need respiratory support. What does the nurse plan to review with this client? A Advance directives B How to use the ventilator C Funeral plans D Nutritional support

A Mechanical ventilation enables the client to breathe and prolongs survival, but it will not alter progression of the disease. For this reason, many clients elect not to be placed on a mechanical ventilator, according to their wishes or advance directives. Ventilator operation and nutrition are not the priority issues to review with this client. Reviewing funeral plans with the client is inappropriate and is not the responsibility of the nurse.

The nurse is performing a neurologic assessment on an 81-year-old client. Which physiologic change does the nurse expect to find because of the client's age? A Decreased coordination B Increased sleeping during the night C Increased touch sensation D Stability in pain perception

A Older adults experience decreased coordination as a result of the aging process. They also experience decreased sleeping during the night, decreased touch sensation, and instability in pain perception as a result of aging.

The wife of a client with Alzheimer's disease mentions to the home health nurse that, although she loves him, she is exhausted caring for her husband. What does the nurse do to alleviate caregiver stress? A Arranges for respite care B Provides positive reinforcement and support to the wife C Restrains the client for a short time each day, to allow the wife to rest D Teaches the client improved self-care

A Respite care can give the wife some time to re-energize and will provide a social outlet for the client. Providing positive reinforcement and support is encouraging, but does not help the wife's situation. Restraints are almost never appropriate and are used only as an absolute last resort. The client with Alzheimer's disease typically is unable to learn improved self-care.

A client with a spinal cord tumor and a poor prognosis has lost bladder control. The client asks the nurse whether the suggested surgery will be "worth it." What is the nurse's best response? A "It should help return bladder control." B "Let me call the surgeon so you can ask the rest of your questions." C "What do you think?" D "What does your family think?"

A Surgical decompression may be performed to maintain bladder, bowel, or motor function and to preserve quality of life, even with a poor prognosis. The nurse should ascertain what was explained in the informed consent and then should clarify the information already given by the health care provider. The client must make the decision for surgery, but the nurse should provide additional information to the client, especially if the client asks. The family should not make the decision for surgery, the client should.

The nurse has just received report on a group of clients on the neurosurgical unit. Which client is the nurse's first priority? A Young adult whose Glasgow Coma Scale (GCS) score has changed from 15 to 10 B Adult whose deep tendon reflexes have become hyperactive C Middle-aged adult who displays plantar flexion when the bottom of the foot is stroked D Older adult who consistently demonstrates decortication when stimulated

A The change in the young client's GCS score indicates a significant change in neurologic status that should be immediately assessed further and reported to the health care provider. The client with hyperactive reflexes, the client displaying plantar flexion when the bottom of the foot is stroked, and the client with decortication upon stimulation will need to be assessed, but the changes in their conditions do not require immediate attention.

A client is admitted with bacterial meningitis. Which nursing intervention is the highest priority for this client? A Assessing neurologic status at least every 2 to 4 hours B Decreasing environmental stimuli C Managing pain through drug and nondrug methods D Strict monitoring of hourly intake and output

A The most important nursing intervention for clients with meningitis is the accurate monitoring and recording of their neurologic status, vital signs, and vascular assessment. The client's neurologic status and vital signs should be assessed at least every 4 hours, or more often if clinically indicated. The priority for care is to monitor for early neurologic changes that may indicate increased intracranial pressure, such as decreased level of consciousness. Decreasing environmental stimuli is helpful for the client with bacterial meningitis, but is not the highest priority. Clients with bacterial meningitis report severe headaches requiring pain management, but this is the second-highest priority. Assessing fluid balance while preventing overload is not the highest priority.

The nurse's friend fears that his mother is getting old, saying that she is becoming extremely forgetful and disoriented and is beginning to wander. What is the nurse's best response? A "Have you taken her for a check-up?" B "She has Alzheimer's disease." C "That is a normal part of aging." D "You should look into respite care."

A The mother's symptoms indicate possible Alzheimer's disease or some other physiologic imbalance, and she should be assessed further by a health care provider. The nurse cannot diagnose Alzheimer's disease. The mother's behavior is not normal age-related behavior. Respite care is for caregivers, not for clients.

A client with early-stage Alzheimer's disease is admitted to the surgical unit for a biopsy. Which client problem is the priority? A Potential for injury related to chronic confusion and physical deficits B Risk for reduced mobility related to progression of disability C Potential for skin breakdown related to immobility and/or impaired nutritional status D Lack of social contact related to personality and behavior changes

A The priority for interdisciplinary care is safety. Chronic confusion and physical deficits place the client with Alzheimer's disease at high risk for injury. The rest of the problems are usually the result of long-term care and not a priority for a short hospital stay.

The nurse is caring for a client in the emergency department whose spinal cord was injured at the level of C7 1 hour ago. Which assessment finding requires the most rapid action? A Electrocardiographic monitoring shows a sinus bradycardia at a rate of 50 beats/min. B The client demonstrates flaccid paralysis below the level of injury. C The client's chest moves very little with each respiration. D After two fluid boluses, the client's systolic blood pressure remains 80 mm Hg.

C Airway and breathing are always of major concern in a spinal cord injury, especially in an injury near C3 to C5, where the spinal nerves control the diaphragm. Symptoms often worsen after injury because of swelling. Bradycardia is consistent with spinal shock and will need to be addressed, but this is not the nurse's first priority. Flaccid paralysis below the level of injury will need to be addressed, but this is not compromising the client's cardiopulmonary status. Systolic blood pressure remaining at 80 mm Hg is consistent with spinal shock and will need to be addressed, but this is not the first priority.

Which client does the neurologic unit charge nurse assign to a registered nurse who has floated from the labor/delivery unit for the shift? A Older adult client who was just admitted with a stroke and needs an admission assessment B Young adult client who has had a lumbar puncture and reports, "Light hurts my eyes." C Adult client who has just returned from having a cerebral arteriogram and needs vital sign checks every 15 minutes D Middle-aged client who has a possible brain tumor and has questions about the scheduled magnetic resonance imaging

C An RN with experience in labor and delivery would be able to check vital signs and limbs for this client and would recognize signs of bleeding. The older adult admitted with a stroke, the young adult post lumbar puncture, and the middle-aged client with a possible brain tumor all require a nurse with more experience with neurologic diagnoses and diagnostic procedures; these clients should be assigned to a nurse with experience on the neurologic unit.

Which information is most important for the nurse to communicate to the health care provider about a client who is scheduled for cerebral angiography? A Allergy to penicillin B History of bacterial meningitis C Poor skin turgor and dry mucous membranes D The client's dose of metformin (Glucophage) held today

C An assessment of poor skin turgor and dry mucous membranes indicates dehydration; to prevent contrast-induced nephropathy, angiography should not be done until the client is hydrated. Allergy to penicillin, history of bacterial meningitis, and withheld metformin will need to be reported, but none indicates the need to intervene before the surgery.

The nurse is assessing a client with a traumatic brain injury after a skateboarding accident. Which symptom is the nurse most concerned about? A Amnesia B Head laceration C Asymmetric pupils D Restlessness

C Asymmetric (uneven) pupils, loss of light reaction, or unilateral or bilateral dilated pupils are a sign of a severe traumatic brain injury. Pupil changes are treated as herniation of the brain from increased intracranial pressure (ICP) until proven differently. The nurse should report and document any changes in pupil size, shape, and reactivity to the health care provider immediately because they could indicate an increase in ICP. Amnesia, a head laceration, and restlessness can be symptoms of mild traumatic brain injuries.

The nursing instructor asks the student nurse caring for a client with Alzheimer's disease who has been prescribed donepezil (Aricept) how the drug works. Which response by the nursing student best explains the action of donepezil? A "The reuptake of serotonin is blocked." B "Donepezil prevents the increase in the protein beta amyloid." C "It delays the destruction of acetylcholine by acetylcholinesterase." D "Dopamine levels are increased."

C By delaying the destruction of acetylcholine, donepezil improves cholinergic neurotransmission in the central nervous system, thus delaying the onset of cognitive decline in some clients. Donepezil is not a serotonin reuptake inhibitor. It is a cholinesterase inhibitor and does not work on the protein beta amyloid, nor does it work on dopamine receptors.

The nurse is teaching a client newly diagnosed with multiple sclerosis (MS). Which statement by the client indicates a correct understanding of the pathophysiology of the disease? A "I will die early." B "I will have gradual deterioration with no healthy times." C "Parts of my nervous system have plaques." D "This was caused by getting too many x-rays as a child."

C MS is characterized by an inflammatory response that results in diffuse random or patchy areas of plaque in the white matter of the central nervous system. The client with MS has no decrease in life expectancy. Frequent times of remission are common in clients with MS. There is no known cause for MS.

The nurse is teaching a client and her husband about sexuality issues after a spinal cord injury. Which comment by the client indicates a correct understanding of the nurse's instruction? A "I can no longer become pregnant." B "If I become pregnant, I cannot give birth." C "I may still be able to get pregnant." D "My children will be paralyzed."

C Many women with spinal cord injury go on to get pregnant and give birth to healthy children. Spinal cord injury is not a disorder that can be inherited.

Which nursing intervention is best for preventing complications of immobility when caring for a client with spinal cord problems? A Frequent ambulation B Encouraging nutrition C Regular turning and re-positioning D Special pressure-relief devices

C Regular turning and re-positioning are the best way to prevent complications of immobility in clients with spinal cord problems. Frequent ambulation may not be possible for these clients. A registered dietitian may be consulted to encourage nutrition to optimize diet for general health and to reduce osteoporosis. Use of special pressure-relief devices is important, but is not the best way to prevent immobility complications in clients with spinal cord problems.

A client arrives in the emergency department with new-onset ptosis, diplopia, and dysphagia. The nurse anticipates that the client will be tested for which neurologic disease? A Bell's palsy B Guillain-Barré syndrome (GBS) C Myasthenia gravis (MG) D Trigeminal neuralgia

C Sudden-onset ptosis, diplopia, and dysphagia are classic symptoms of MG. Laboratory studies and a cholinesterase inhibitor test (e.g., Tensilon challenge test) most likely will be done to confirm the diagnosis. Symptoms of Bell's palsy include facial paralysis; the face appears masklike and sags. Symptoms of GBS typically begin in the legs and spread to the arms and upper body. Trigeminal neuralgia is a chronic pain syndrome; this client's symptoms were of sudden onset.

A client with a T6 spinal cord injury who is on the rehabilitation unit suddenly develops facial flushing and reports a severe headache. Blood pressure is elevated, and the heart rate is slow. Which action does the nurse take first? A Check for fecal impaction. B Insert a straight catheter. C Help the client sit up. D Loosen the client's clothing.

C The client is experiencing autonomic dysreflexia, which can produce severe and rapidly occurring hypertension. Getting the client to sit upright is the easiest and quickest action to take and has the most immediate chance of lowering blood pressure to the brain. Checking for fecal impaction, inserting a straight catheter, and loosening the clothing are important, but will not immediately reduce blood pressure.

A client is admitted into the emergency department with frontal-temporal pain, preceded by a visual disturbance. The client is upset and thinks it is a stroke. What does the nurse suspect may be occurring? A Stroke B Tension headache C Classic migraine D Cluster headache

C The client's symptoms match those of a classic migraine. Symptoms of a stroke include sudden, severe headache with unknown cause, facial drooping, sudden confusion, and sudden difficulty walking or standing. A tension headache is characterized by neck and shoulder muscle tenderness and bilateral pain at the base of the skull and in the forehead. Symptoms of a cluster headache include intense, unilateral pain occurring in the fall or spring and lasting 30 minutes to 2 hours.

A client with dementia and Alzheimer's disease is discharged to home. The client's daughter says, "He wanders so much, I am afraid he'll slip away from me." What resource does the nurse suggest? A Alzheimer's Wandering Association B National Alzheimer's Group C Safe Return Program D Lost Family Members Tracking Association

C The family should enroll the client in the Safe Return Program, a national, government-funded program of the Alzheimer's Association that assists in the identification and safe, timely return of those with dementia who wander off and become lost. The Alzheimer's Wandering Association, National Alzheimer's Group, and Lost Family Members Tracking Association do not exist.

A client with myasthenia gravis is admitted with generalized fatigue, a weak voice, and dysphagia. Which client problem has the highest priority? A Inability to tolerate everyday activities related to severe fatigue B Inability to communicate verbally related to vocal weakness C Potential for aspiration related to difficulty with swallowing D Inability to care for self related to muscle weakness

C The potential for aspiration is the highest priority client problem because the client's ability to maintain airway patency is compromised. Although important, an inability to tolerate everyday activities, an inability to communicate verbally related to vocal weakness, and an inability to care for oneself related to muscle weakness are not the nurse's highest priority.

A client admitted with cerebral edema suddenly begins to have a seizure while the nurse is in the room. What does the nurse do first? A Administer phenytoin (Dilantin). B Draw the client's blood. C Assess the need for additional support. D Start an intravenous (IV) line.

C The primary goal is to assess the client for the need of additional support during the seizure. Interventions to protect the client from injury, turning the client on the side, and monitoring the client are indicated. After a quick assessment by the nurse, the health care provider must be notified immediately, and intubation by an anesthesiologist, nurse anesthetist, or respiratory therapist may be necessary. Phenytoin (Dilantin) is administered to prevent the recurrence of seizures, not to treat a seizure already underway. Drawing blood or starting an IV is not the priority in this situation.

The nurse is assessing a client with a neurologic condition who is reporting difficulty chewing when eating. The nurse suspects that which cranial nerve has been affected? A Abducens B Facial C Trigeminal D Trochlear

C The trigeminal nerve affects the muscles of mastication. The abducens nerve affects eye movement via lateral rectus muscles. The facial nerve affects pain and temperature from the ear area, deep sensations in the face, and taste in the anterior two thirds of the tongue. The trochlear nerve affects eye movement via superior oblique muscles.

The home health nurse is checking in on a client with dementia and the client's spouse. The spouse confides to the nurse, "I am so tired and worn out." What is the nurse's best response? A "Can't you take care of your spouse?" B "Establishing goals and a daily plan can help." C "Make sure you take some time off and take care of yourself too." D "That's not a very nice thing to say."

C This response is supportive and reminds the spouse that he or she cannot care for the client when exhausted. Of course, further assessment and planning will be necessary. Questioning the spouse's ability to provide care is not supportive and may offend the spouse. Establishing goals and a daily plan is not a helpful response. A better response would be, "Take one day at a time." Suggesting that the spouse's comment was not nice is judgmental and inappropriate.

The nurse is developing a teaching plan for a client with a history of low back pain. Which instructions does the nurse plan to include in teaching the client about preventing low back pain and injury? (Select all that apply.) A "Standing for long periods of time will help to prevent low back pain." B "Keep weight within 50% of ideal body weight." C "Begin a regular exercise program." D "When lifting something, the back should be straight and the knees bent." E "Do not wear high-heeled shoes."

C,D,E Beginning a regular exercise program will help to promote back strengthening. Keeping the back straight while bending the knees is the proper way to lift objects; this method will help prevent back injury. Wearing high-heeled shoes can increase back strain. The client should avoid standing or sitting for long periods of time because this can cause further strain on the back. Weight should be kept within 10% of ideal body weight.

A client was admitted this morning with an incomplete cervical spinal cord injury and is placed in a halo fixator. Halo fixation is used to reduce motion of the cervical spine. Which assessment finding will the nurse report immediately to the health care provider? A. A new-onset heart rate of 48 beats/min B. Mean arterial pressure of 90 mm Hg C. Pain level of 2 on a 0-to-10 pain scale D. Oxygen saturation of 95% on room air

Answer: A Rationale: Bradycardia is a sign of spinal shock. This symptom is a result of the interruption of sympathetic nervous system stimulation associated with the cervical spinal neurons. A mean arterial pressure of 90 mm Hg and oxygen saturation of 95% indicate normal physiology and no concerning changes in airway or circulation. A pain level of 2 indicates pain that is well controlled at a value less than 4 on a 0 to 10 scale.

A client with possible Parkinson's disease is scheduled to have magnetic resonance imaging (MRI). The daughter asks the nurse how this test is different from a computed tomography (CT) scan. What is the nurse's best response? A. "The MRI scan provides better contrast between normal tissue and pathologic tissue." B. "They are not different; both use ionizing radiation." C. "The MRI will not require contrast material." D. "The CT scan does not provide a view of deep brain structures like the region where Parkinson's originates.

Answer: A Rationale: MRI is based on how hydrogen atoms behave in a magnetic field. These atoms differ in normal versus diseased tissue, providing better visualization of small or deep structures in the body. Although both CT and MRI images can be enhanced with contrast material and both provide views of deep brain structures, only CT uses ionizing radiation.

The nurse is preparing a teaching plan for a client with migraine headaches. Which of these foods or food additives may trigger a migraine headache? A. Salt B. Sugar C. Tyramine D. Glutamine

Answer: C Rationale: Only tyramine has been consistently linked to the onset and severity of migraines. Its action is related to altering the vasoreactivity of cerebral blood vessels. Salt intake may cause fluid retention and a headache, but it is not associated with migraines. Sugar has not been demonstrated to cause migraines. Glutamine is used as a nutrition supplement and has no association with migraines.

A client with moderate dementia asks the nurse to find her brother who is deceased. What is the nurse's best response? A. "Your brother died over 20 years ago." B. "We can call him in a little while if you want." C. "What did your brother look like?" D. "I'll ask your daughter to find him for you when she comes in."

Answer: C Rationale: This response is congruent with the goal of promoting communication and illustrates the use of validation therapy in the client with dementia. Reality orientation (option A) often increases agitation. Reinforcing an invalid belief (options B and C) is not therapeutic in this client population.

A client has had a traumatic brain injury and is mechanically ventilated. Which technique does the nurse use to prevent increasing intracranial pressure (ICP)? A Assessing for Turner's sign B Maintaining PaCO2 levels at 35 mm Hg C Placing the client in the Trendelenburg position D Suctioning the client frequently

B After the first 24 hours when a client is mechanically ventilated, keeping the PaCO2 levels at 35 mm Hg prevents vasodilation, which could increase ICP. CO2 is a powerful vasodilator. Turner's sign is a bluish gray discoloration in the flank region caused by acute pancreatitis. The head of the bed should be at 30 degrees; the Trendelenburg position will cause the client's ICP to increase. Although some suctioning is necessary, frequent suctioning should be avoided because it increases ICP.

A client newly diagnosed with myasthenia gravis (MG) is being discharged, and the nurse is teaching about proper medication administration. Which statement by the client demonstrates a need for further teaching? A "It is important to post my medicine schedule at home, so my family knows my schedule." B "I can continue to take over-the-counter drugs." C "An extra supply of medicine should be kept in my car." D "Wearing a watch with an alarm will remind me to take my medicine."

B Clients with MG should not take any over-the-counter medications without checking with their health care provider. The client's medication schedule may be posted in the home for the benefit of family members. An extra supply of medication should be kept in the client's car or workplace to maintain therapeutic levels in case a dose was missed. The client may wear a watch with an alarm as a medication reminder to maintain therapeutic levels.

The nurse admits a client with suspected myasthenia gravis (MG). The nurse anticipates that the health care provider will request which medication to aid in the diagnosis of MG? A Atropine B Edrophonium chloride (Tensilon) C Methylprednisolone (Solu-Medrol) D Morphine sulfate

B Edrophonium chloride (Tensilon) and neostigmine bromide (Prostigmin) may be used for testing for MG. Tensilon is used most often because of its rapid onset and brief duration of action. This drug inhibits the breakdown of acetylcholine (ACh) at the postsynaptic membrane, which increases the availability of ACh for excitation of postsynaptic receptors. Atropine has parasympatholytic effects and is the antidote for edrophonium chloride. Methylprednisolone (Solu-Medrol) is a glucocorticoid that is used to treat inflammatory disorders. Morphine is an opioid analgesic and is not used in the diagnosis of MG.

A client has returned to the unit after peripheral nerve repair surgery following a traumatic injury to the right hand. Which nursing intervention is done first in the postoperative period? A Applying lanolin to dry skin B Assessing skin for tightness, warmth, and color C Loosening the splint if it is too tight D Teaching the client how to avoid temperature extremes

B Frequent neurovascular assessments should be performed, including checking the skin around splints and casts (initially every hour) for tightness, warmth, and color. If the skin is dry, lanolin or cocoa butter may be used as a lubricant; however, this is not the first priority in the postoperative period. If the client reports discomfort, tingling, or coolness, or if the color is blanched, the cast or splint may be too tight (constricted), and the health care provider should be notified immediately about constriction. Because sensation may be absent or inhibited, the client should be taught to protect involved areas from temperature extremes and other sources of potential trauma; however, this is not the first priority in the postoperative period.

Which is the most effective way for a college student to minimize the risk for bacterial meningitis? A Avoid large crowds. B Get the meningococcal vaccine. C Take a daily vitamin. D Take prophylactic antibiotics.

B Individuals ages 16 to 21 years have the highest rates of meningococcal infection and should be immunized against the virus. Adults are advised to get an initial or booster vaccine if living in a shared residence (residence hall, military barracks, group home), traveling or residing in countries in which the disease is common, or immunocompromised due to a damaged or surgically removed spleen or a serum complement deficiency. Avoiding large crowds is helpful, but is not practical for a college student. Taking a daily vitamin is helpful, but is not the best way to safeguard against bacterial meningitis. Taking prophylactic antibiotics is inappropriate because it leads to antibiotic-resistant strains of microorganisms.

The nurse is caring for a client who is scheduled to have a brain biopsy. The nurse anticipates that the health care provider will request which test before the brain biopsy is performed? A Lumbar puncture (LP) B Magnetic resonance imaging (MRI) C Skull x-ray D Transcranial Doppler ultrasonography (TCD)

B MRI or computed tomography is done before a brain biopsy to assist with identification and visualization of the affected area, because the procedure involves drilling a hole through the skull and inserting a hollow needle to the site of the lesion. An LP is a diagnostic test that may be indicated to obtain cerebrospinal fluid or to inject contrast medium or medications. A skull x-ray does not show the detailed visualization needed for the provider to perform a brain biopsy. TCD is used to evaluate intracranial hemodynamics.

The nurse is caring for a client with advanced Alzheimer's disease. Which communication technique is best to use with this client? A Providing the client with several options to choose from B Assuming that the client is not totally confused C Waiting for the client to express a need D Writing down instructions for the client

B Never assume that the client with Alzheimer's is totally confused and cannot understand what is being communicated. Choices should be limited; too many choices cause frustration and increased confusion in the client. Rather than waiting for the client to express a need, try to anticipate the client's needs and interpret nonverbal communication. Rather than writing down instructions, provide the client instructions with pictures, and put them in a highly visible place

The nurse is caring for a client with a spinal cord injury resulting from a diving accident, who has a halo fixator and an indwelling urinary catheter in place. The nurse notes that the blood pressure is elevated and that the client is reporting a severe headache. The nurse anticipates that the health care provider will prescribe which medication? A Dopamine hydrochloride (Inotropin) B Nifedipine (Procardia) C Methylprednisolone (Solu-Medrol) D Ziconotide (Prialt)

B This client is experiencing autonomic dysreflexia, which is a neurologic medical emergency that causes severe hypertension and bradycardia; nifedipine (Procardia) is given to treat the elevated blood pressure. Dopamine hydrochloride (Inotropin) is an inotropic agent used to treat severe hypotension. Methylprednisolone (Solu-Medrol) is a glucocorticoid and is not indicated because it may further increase blood pressure. Ziconotide (Prialt) is an N-type calcium channel blocker that is used to treat severe chronic back pain and failed back surgery syndrome and is also used for clients with cancer, AIDS, and unremitting pain from other nervous system disorders.

The nurse is caring for a client diagnosed with partial seizures after encephalitis, who is to receive carbamazepine (Tegretol). The nurse plans to monitor the client for which adverse effects? (Select all that apply.) A Alopecia B Headaches C Dizziness D Diplopia E Increased blood glucose

B, C, D Headaches, dizziness, and diplopia are adverse effects of carbamazepine because this drug affects the central nervous system. Carbamazepine does not cause alopecia and does not increase blood glucose; divalproex (Depakote) and valproic acid (Depakene) may cause alopecia.

A client has received preoperative teaching from the nurse for a microdiskectomy. Which statement by the client indicates a correct understanding of the nurse's instruction? A "I can go home the day of the procedure." B "I can go home 48 hours after the procedure." C "I'll have a drain in place after the procedure." D "I'll need to wear special stockings after the procedure."

A The client who undergoes a microdiskectomy typically can return home the same day. The client who undergoes a traditional open laminectomy typically can return home 48 hours after the procedure, will have a drain in place after the procedure, and will need to wear special stockings after the procedure.

A client with severe muscle spasticity has been prescribed tizanidine (Zanaflex, Sirdalud). The nurse instructs the client about which adverse effect of tizanidine? A Drowsiness B Hirsutism C Hypertension D Tachycardia

A Tizanidine (Zanaflex, Sirdalud) is a centrally acting skeletal muscle relaxant, and drowsiness and sedation are common adverse effects. Tizanidine may cause alopecia (not hirsutism), hypotension (not hypertension), and bradycardia (not tachycardia).

A client has undergone single-photon emission computed tomography (SPECT). Which instruction does the nurse give the client? A "Continue to use the ice pack." B "Call me if you have any itching." C "Keep the head of the bed flat." D "Return to your usual activity."

D Clients who have undergone SPECT can return to their usual activities immediately after the test. Ice packs may be used by clients who have undergone cerebral angiography. Asking clients to call if they have itching may be a typical instruction for a contact allergy, but not for this situation. The head of the bed should be kept flat for clients who have undergone a lumbar puncture.

A client has Parkinson disease (PD). Which nursing intervention best protects the client from injury? A Discouraging the client from activity B Encouraging the client to watch the feet when walking C Suggesting that the client obtain assistance in performing activities of daily living (ADLs) D Monitoring the client's sleep patterns

D Clients with PD tend to not sleep well at night because of drug therapy and the disease itself. Some clients nap for short periods during the day and may not be aware that they have done so. This sleep misperception could put the client at risk for injury (e.g., falling asleep while driving). Active and passive range-of-motion exercises, muscle stretching, and activity are important to keep the client with PD mobile and flexible. The client with PD should avoid watching his or her feet when walking to prevent falls and should be encouraged to participate as much as possible in self-management, including ADLs. Occupational and physical therapists can provide training in ADLs and the use of adaptive devices, as needed, to facilitate independence.

The nurse is instructing a client for whom a positron emission tomography (PET) scan has been requested. Which statement indicates to the nurse that the client understands the instructions? A "It's okay to have a cup of coffee before the test." B "Because I am diabetic, I will take my insulin just before the test." C "I can continue to smoke cigarettes up to 4 hours before the test." D "I will drink plenty of fluids after the test."

D Fluid intake should be increased after the test because this helps to remove the radioisotope more quickly. Caffeine should be avoided for 24 hours before the test. The client is NPO for 4 to 12 hours before the test, and insulin is not given to diabetic clients before a PET scan. Tobacco should be withheld for 24 hours before PET.

The nurse is providing instructions to a client with a spinal cord injury about caring for the halo device. The nurse plans to include which instructions? A "Begin driving 1 week after discharge." B "Avoid using a pillow under the head while sleeping." C "Swimming is recommended to keep active." D "Keep straws available for drinking fluids."

D Keeping straws available makes it easier to drink fluids because the device makes it difficult to bring a cup or a glass to the mouth. Driving should be avoided because vision is impaired with the device. The head should be supported with a small pillow when sleeping to prevent unnecessary pressure and discomfort. Swimming should be avoided to prevent the risk for infection.

A client who has just undergone spinal surgery must be moved. How does the nurse plan to move this client? A Getting the client up in a chair B Keeping the client in the Trendelenburg position C Lifting the client in unison with other health care personnel D Log rolling the client

D Log rolling the client who has undergone spinal surgery is the best way to keep the spine in alignment. The client who has undergone spinal surgery must remain straight. The Trendelenburg position is not indicated for the client who has undergone spinal surgery, nor should the client be lifted or encouraged to get up in a chair.

A client with new-onset Bell's palsy is being discharged. Which statement made by the client demonstrates a need for further discharge teaching by the nurse? A "I'll need artificial tears at least four times a day." B "I will eat a soft diet." C "My eye must be taped or patched at bedtime." D "Narcotics will be needed for pain relief."

D Mild analgesics, not narcotics, are used for pain associated with Bell's palsy. Artificial tears and taping the affected eye at night protect the cornea from drying out and potentially ulcerating because of the eye's inability to close. Mastication is often impaired with Bell's palsy, so soft foods are indicated.

The nurse prepares to assess a client with diabetes mellitus for sensory loss. Which equipment does the nurse use to perform this assessment? A Glucometer B Hammer C Nothing; the client is asked to walk D Cotton-tipped applicator

D Pain sensation is assessed with any sharp or dull object, such as a cotton-tipped applicator. The client indicates whether the touch is sharp or dull. The sharp and dull ends should be interchanged at random, so that the client does not anticipate the next type of sensation. A glucometer tests blood sugar. A hammer tests tendon reflexes. Asking the client to walk tests the client's gait and equilibrium.

The nurse is reviewing the medication history of a client diagnosed with myasthenia gravis (MG) who has been prescribed a cholinesterase (ChE) inhibitor. The nurse contacts the health care provider if the client is taking which medication? A Acetaminophen (Tylenol) B Furosemide (Lasix) C Ibuprofen (Motrin) D Procainamide (Pronestyl)

D Procainamide (Pronestyl) should be avoided because it may increase the client's weakness. Acetaminophen (Tylenol) does not interact with ChE inhibitors. Furosemide (Lasix) is a diuretic and does not interact with ChE inhibitors. Ibuprofen (Motrin) is a nonsteroidal analgesic and does not interact with ChE inhibitors.

The results of a client's lumbar puncture indicate that the client's protein level is 150 mg/dL. The nurse suspects that the client may have which condition? A Guillain-Barré syndrome B Meningismus C Paraventricular tumor D Viral infection Correct

D Protein levels of 50 to 200 mg/dL are indicative of a viral infection. A protein level greater than 500 mg/dL is indicative of a bacterial infection or Guillain-Barré syndrome. A protein level less than 15 mg/dL is indicative of meningismus. Protein levels of 45 to 100 mg/dL are indicative of a paraventricular tumor.

The nurse is performing a rapid neurologic assessment on a trauma client. Which assessment finding is normal? A Decerebrate posturing B Increased lethargy C Minimal response to stimulation D Constriction of pupils

D Pupil constriction is a function of cranial nerve III. Pupils should be equal in size and round and regular in shape, and should react to light and accommodation (PERRLA). Decerebrate or decorticate posturing, as well as pinpoint or dilated and nonreactive pupils, is a late sign of mental deterioration. Minimal response to stimulation and increased lethargy are not normal findings.

A family member of a client with a recent spinal cord injury asks the nurse, "Can you please tell me what the real prognosis for recovery is? I don't feel like I'm getting a straight answer." What is the nurse's best response? A "Every injury is different, and it is too soon to have any real answers right now." B "Only time will tell." C "The Health Insurance Portability and Accountability Act requires that I obtain the client's permission first." D "Please request a meeting with the health care provider."

D Questions concerning prognosis and potential for recovery should be referred to the health care provider. The timing and extent of recovery are different for each client, but it is not the nurse's role to inform the client and family members of the client's prognosis. Telling the family that "only time will tell" is too vague and minimizes the family's concern. The client was informed of Health Insurance Portability and Accountability Act (HIPAA) rights on admission or when consciousness was established, so permission has already been granted by the client.

The nurse is providing medication instructions to a client diagnosed with amyotrophic lateral sclerosis who has been prescribed riluzole (Rilutek). Which statement indicates to the nurse that the client understands the instructions? A "Riluzole should be taken with food." B "I plan to take riluzole once daily." C "I will call the health care provider if my pulse goes below 50." D "I will need frequent checks of my liver enzymes."

D Riluzole (Rilutek) may cause liver toxicity, and liver enzymes will need to be checked frequently. This drug should be taken twice a day without food and when the stomach is empty. Riluzole may cause tachycardia, not bradycardia.

A client is being discharged with paraplegia secondary to a motor vehicle crash and expresses concern over the ability to cope in the home setting after the injury. Which is the best resource for the nurse to provide for the client? A Hospital library B Internet C Provider's office D National Spinal Cord Injury Association

D The National Spinal Cord Injury Association will inform the client of support groups in the area and will assist in answering questions regarding adjustment in the home setting. The hospital library is not typically consumer-oriented; most information available there is targeted to health care professionals. The Internet is not the best resource simply because of the unlimited volume of information available and its questionable quality. The health care provider's office typically does not provide information about spinal cord injury support groups.

The nurse is administering the intake assessment for a newly admitted client with a history of seizures. The client suddenly begins to seize. What does the nurse do next? A Documents the length and time of the seizure. B Forces a tongue blade in the mouth. C Restrains the client. D Positions the client on the side.

D Turning the client on the side during a generalized tonic-clonic or complex partial seizure is indicated because he or she may lose consciousness. Documenting the length and time of seizures is important, but not the first priority intervention. Forcing a tongue blade in the mouth can cause damage. Restraining the client can cause injury.

A client with myasthenia gravis (MG) is receiving cholinesterase inhibitor drugs to improve muscle strength. The nurse is educating the family about this therapy. Which statement by a family member indicates a correct understanding of the nurse's instruction? A "I should call 911 if a sudden increase in weakness occurs." B "I should increase the dose if a sudden increase in weakness occurs." C "The medication should be taken with a large meal." D "The medication should be taken on an empty stomach." Cholinesterase inhibitors should be taken with a small amount of food to help alleviate GI side effects.

A A potential adverse effect of cholinesterase inhibitors is cholinergic crisis. Sudden increases in weakness and the inability to clear secretions, swallow, or breathe adequately indicate that the client is experiencing crisis. The family member should call 911 for emergency assistance. The dose of cholinesterase inhibitors should never be increased without provider supervision. The client should eat meals 45 to 60 minutes after taking cholinesterase inhibitors to avoid aspiration.

The nurse encourages a ventilated client with advanced Guillain-Barré syndrome (GBS) to communicate by which simple technique? A Blinking for "yes" or "no" B Moving lips to speak C Using sign language D Using a laptop to write

A A simple technique involving eye blinking or moving a finger to indicate "yes" and "no" is the best way for the ventilated client with GBS to communicate. Moving the lips is difficult to do around an endotracheal tube and is exhausting for the client. Sign language is very time-consuming to learn, unless the client and family already know it. Use of a laptop may prove too challenging for the client in advanced stages of GBS.

The nurse is about to administer a contrast medium to the client undergoing diagnostic testing. Which question does the nurse first ask the client? A "Are you taking ibuprofen daily?" B "Are you in pain?" C "Are you wearing any metal?" D "Do you know what this test is for?"

A The client should be asked about allergies to contrast agents, and conditions that may compromise kidney function should be explored. Ask the client about the use of drugs that may compromise renal perfusion, such as metformin and nonsteroidal anti-inflammatory drugs (NSAIDs). Ibuprofen is an NSAID, and daily use may place the client's renal function at risk for complications with contrast medium administration. Asking whether the client is in pain is not a priority in this situation. Asking the client whether she or he is wearing any metal is important for magnetic resonance imaging, but not for a contrast injection. The client should be asked well before this point whether he or she knows why the test is being performed.

A client with a history of seizures is placed on seizure precautions. What emergency equipment will the nurse provide at the bedside? Select all that apply. A. Oropharyngeal airway B. Oxygen C. Nasogastric tube D. Suction setup E. Padded tongue blade

Answer: A, B, D An oropharyngeal airway, oxygen, and suction setup are provided to help manage hypoxia that occurs during repeated muscle contraction as well as the potential compromised airway from oral injury or emesis during a seizure. Do not force implements such as a tongue blade or nasogastric tube into a client's mouth or nose during a seizure because these devices are more likely to cause injury with no client benefit.

A client is admitted to the critical care unit with possible Guillain-Barré syndrome. Which symptom of neurologic impairment will require priority nursing interventions? Select all that apply. A. New adventitious breath sounds B. A respiratory rate of 12 C. Rapid, shallow breathing pattern D. A peripheral oxygen saturation (SpO2) of 90% E. New-onset nausea following a position change

Answer: A, C, D Rationale: New adventitious breath sounds, a rapid and shallow breathing pattern, and a peripheral SpO2 of 90% indicate an adverse change in airway and breathing common to the ascending pattern of neurologic impairment associated with GBS. A respiratory rate of 12 breaths/min is normal; unless this value represents a sudden decrease in a rapid rate, it is not concerning. A new onset of nausea indicates a need for additional assessment to determine the cause, such as a full stomach or upright positioning that occurred too quickly.

During a client's neurologic assessment, the nurse finds that he is arousable after light touch combined with a loud voice. How does the nurse document this client's level of consciousness? A. "Stuporous" B. "Lethargic" C. "Comatose" D. "Drowsy"

Answer: B Rationale: Coma means unarousable, and alert is a normal response. Drowsy generally indicates arousal by voice. Lethargy indicates that voice and light touch are used to obtain a client response. Stuporous is a deeper level of unresponsiveness that responds to more vigorous touch or tactile stimulation. Comatose indicates no response to painful or noxious stimuli.

The nurse is caring for a client with Bell's palsy. Which potential problem requires assessment by the nurse to ensure client safety? A. Risk for falls from balance impairment B. Risk for communication difficulties from impaired hearing C. Risk for eye ulceration or abrasion from inability to close eyelid D. Risk for adverse drug effects from pain management therapy

Answer: C Rationale: Bell's palsy is an acute paralysis of the cranial nerve (VII) that affects all facial muscles on one side. Because the client cannot close the eyelid, the risk for eye injury is high. Although hearing is impaired from tinnitus, the risk for significant communication impairment is low. Balance is not affected, and pain is not a feature of Bell's palsy.

When providing discharge teaching to a client after a lumbar laminectomy, the nurse teaches the client to engage in which activities? A. Evening showers with hot water B. Vigorous stair climbing C. Return to work within 1-2 weeks D. Daily walking

Answer: D Rationale: Daily, low-intensity activity promotes recovery after back surgery. Stair climbing is avoided initially because of the physical stress on trunk muscles. Showers are avoided initially until the surgical incision is closed. A return to work needs additional consideration to evaluate risks to recovery, particularly related to limitations in static positions or lifting.

The nurse is caring for a client with dementia. Which nursing intervention is most appropriate when caring for this client? A. Provide a large clock and calendar at the nurses' station. B. Use removable restraints like a roll-waist belt to prevent wandering. C. Use incontinence pads or absorbent underwear to prevent complications from incontinence. D. Place the patient in a room close to the nurses' station for frequent observation.

Answer: D Rationale: A client with memory impairment benefits from a structured and consistent environment. Location near the nurses' station can provide frequent observation and timely interventions as well as safety for falls and wandering prevention. The clock and calendar need to be in the client's room for effectiveness. Restraints contribute to agitation stimuli. Incontinence pads and absorbent underwear should never be a first-line intervention for an incontinent client.

The nurse has just received report on a group of clients. Which client does the nurse assess first? A Young adult who was in a car accident and has a Glasgow Coma Scale score of 13 B Adult who had a cerebral arteriogram and has a cool, pale right leg C Middle-aged adult who has a headache after undergoing a lumbar puncture D Older adult who has expressive aphasia after a left-sided stroke

B A cool, pale leg after an arteriogram could indicate clot formation at the catheter insertion site and loss of blood flow to the extremity. The client with a 13 GCS score, the client with a headache following a lumbar puncture, and the older adult with expressive aphasia should be assessed as soon as possible, but the data do not indicate any serious complications.

A client returns to the neuromedicine floor after undergoing an anterior cervical diskectomy and fusion (ACDF). What is the nurse's first action? A Administer pain medication. B Assess airway and breathing. C Assist with ambulation. D Check the client's ability to void.

B Assessment in the immediate postoperative period after an ACDF is maintaining an airway and ensuring that the client has no problem with breathing. Swelling from the surgery can narrow the trachea, causing a partial obstruction. Ambulation, administration of pain medication, and assessing the client's ability to void are important, but are not the highest priority.

A female client with newly diagnosed migraines is being discharged with a prescription for sumatriptan (Imitrex). Which comment by the client indicates an understanding of the nurse's discharge instructions? A "Sumatriptan should be taken as a last resort." B "I must report any chest pain right away." C "Birth control is not needed while taking sumatriptan." D "St. John's wort can also be taken to help my symptoms."

B Chest pain must be reported immediately with the use of sumatriptan. Sumatriptan must be taken as soon as migraine symptoms appear. Remind the client to use contraception (birth control) while taking the drug because it may not be safe for women who are pregnant. Triptans should not be taken with selective serotonin reuptake inhibitors or St. John's wort, an herb used commonly for depression.

The nurse admits a client with suspected Eaton-Lambert syndrome. The nurse anticipates that the health care provider will request which test to confirm the diagnosis? A Doppler study B Electromyography (EMG) C Magnetic resonance imaging (MRI) D Tensilon test

B EMG is used to confirm the diagnosis of Eaton-Lambert syndrome, which is a form of myasthenia gravis (MG) that is often seen with small cell carcinoma of the lung. Doppler study is used frequently in the diagnosis of vascular disorders; Eaton-Lambert syndrome is a neurologic disorder. MRI is not used to confirm the diagnosis of Eaton-Lambert syndrome. The Tensilon test is used as a diagnostic test in MG, but it is not used to confirm the diagnosis of Eaton-Lambert syndrome.

The nurse has received report on a group of clients. Which client requires the nurse's attention first? A Adult who is lethargic after a generalized tonic-clonic seizure B Young adult who has experienced four tonic-clonic seizures within the past 30 minutes C Middle-aged adult with absence seizures who is staring at a wall and does not respond to questions D Older adult with a seizure disorder who has a temperature of 101.9° F (38.8° C)

B The young adult client who is experiencing repeated seizures over the course of 30 minutes is in status epilepticus, which is a medical emergency and requires immediate intervention. The adult client who is lethargic and the middle-aged adult client with absence seizures do not require immediate attention; these are not medical emergencies. A fever of 101.9° F (38.8° C) is not a medical emergency and does not require immediate attention.

Which task does the nurse plan to delegate to the nursing assistant caring for a group of clients in the neurosurgical unit? A Prepare a client who is going to radiology for a cerebral arteriogram B Attend to the care needs of a client who has had a transcranial Doppler study C Assist the health care provider in performing a lumbar puncture on a confused client D Educate a client about what to expect during an electroencephalogram (EEG)

B Transcranial Doppler studies are noninvasive and do not require any postprocedure monitoring or care; the nursing assistant can attend to this client. Preparing a client for a cerebral arteriogram and assisting the health care provider in performing a lumbar puncture require assessment and intervention that should be done by licensed nursing staff. Client teaching should be provided by licensed nursing staff.

A client has been admitted with new-onset status epilepticus. Which seizure precautions does the nurse put in place? (Select all that apply.) A Bite block at the bedside B Intravenous access C Continuous sedation D Suction equipment at the bedside E Siderails up

B, D, E Intravenous access is needed to administer medications. Suctioning equipment should be available to suction secretions and facilitate an open airway during a seizure. Raised, padded siderails may be used to protect the client from falling out of bed during a seizure. Bite blocks or padded tongue blades should not be used because the client's jaw may clench, causing teeth to break and possibly obstructing the airway. Continuous sedation is a medical intervention and not a seizure precaution.

In assessing a client with back pain, the nurse uses a paper clip bilaterally on each limb. What is the nurse assessing? A Gait B Mobility C Sensation D Strength

C Both extremities may be checked for sensation by using a pin or paper clip and a cotton ball for comparison of light and deep touch. The client may feel sensation in both limbs but may experience a stronger sensation on the unaffected side. Gait is assessed by having the client walk. Mobility is assessed by determining the client's level of self-care. Strength is measured by having the client perform bilateral grips.

The nurse has just received change-of-shift report about a group of clients on the neurosurgical unit. Which client does the nurse attend to first? A Young adult client involved in a motor vehicle crash (MVC) who is yelling obscenities at the nursing staff B Adult postoperative left craniotomy client whose hand grips are weaker on the right C Middle-aged adult client who had a cerebral aneurysm clipping and is increasingly stuporous D Older adult client who had a carotid endarterectomy and is unable to state the day of the week

C A change in level of consciousness is an early indication that central neurologic function has declined; the neurologic status of this client should be assessed and the health care provider notified about the change in status. The other clients are not the nurse's first priority. The young adult who is post-MVC does need to be assessed, but the client's behavior does not indicate a decline in neurologic function. The postoperative left craniotomy client and the older adult do need to be assessed, but these clients' neurologic assessment indicates better function.

The nurse is caring for a client with Guillain-Barré syndrome (GBS) who is receiving intravenous immunoglobulin (IVIG). Which assessment finding warrants immediate evaluation? A Chills B Generalized malaise C Headache with stiff neck D Temperature of 99° F (37° C)

C A headache with a stiff neck may be a sign of aseptic meningitis, a possible serious complication of IVIG therapy. Chills, generalized malaise, and a low-grade fever are minor adverse effects of IVIG therapy and do not indicate that the therapy should be stopped.

A client is admitted with an exacerbation of Guillain-Barré syndrome (GBS), presenting with dyspnea. Which intervention does the nurse perform first? A Calls the Rapid Response Team to intubate B Instructs the client on how to cough effectively C Raises the head of the bed to 45 degrees D Suctions the client

C The head of the client's bed should be raised to 45 degrees because this allows for increased lung expansion, which improves the client's ability to breathe. Intubation is indicated only if dyspnea is severe or oxygen saturation does not respond to oxygen therapy. Close monitoring of respiratory status is indicated because of the acute stages of GBS. Instructing the client on how to cough effectively is not the priority in this case. The client should be suctioned only if needed to avoid vagal stimulation.

To prevent the leading cause of death for clients with spinal cord injury, collaboration with which component of the health care team is a nursing priority? A Nutritional therapy B Occupational therapy C Physical therapy D Respiratory therapy

D A client with a cervical spinal cord injury is at risk for breathing problems resulting from an interruption of spinal innervation to the respiratory muscles. In collaboration with the respiratory therapist, the nurse should perform a complete respiratory assessment, including pulse oximetry for arterial oxygen saturation every 8 to 12 hours to prevent respiratory complications such as pneumonia, pulmonary emboli, and atelectasis. Collaboration with nutritional therapy, occupational therapy, and physical therapy does not help prevent the leading cause of death in clients with spinal cord injury.

A client is admitted with a spinal cord injury at the seventh cervical vertebra secondary to a gunshot wound. Which nursing intervention is the priority for this client's care? A Auscultating bowel sounds every 2 hours B Beginning a bladder retraining program C Monitoring nutritional status D Positioning the client to maximize ventilation potential

D Airway management is the priority for the client with a spinal cord injury. The client with a cervical spinal cord injury is at high risk for respiratory compromise because the cervical spinal nerves (C3-C5) innervate the phrenic nerve, controlling the diaphragm. Although assessing bowel sounds is important as a sign of neurogenic shock, this is not the priority intervention on admission. Bladder retraining begins as necessary after evaluation of urinary function; a catheter is initially inserted. Monitoring nutritional status is essential only after stabilization from the acute injury.

A client has returned to the unit after a thymectomy and is extubated. The client begins to report chest pain. What does the nurse do next? A Calls the Rapid Response Team for immediate intubation B Gives sublingual nitroglycerin (Nitrostat) C Increases the intravenous (IV) rate D Informs the surgeon immediately

D The client's chest pain is a symptom of a hemothorax or pneumothorax and must be reported to the surgeon immediately. Intubation is indicated only with severe respiratory distress. The cause of chest pain is noncardiac in nature, so nitroglycerin is not warranted. An increase in the IV rate is not indicated for this client.

A client is admitted with a brain abscess. Which diagnostic assessment intervention does the nurse question as nonspecific to the diagnosis? A Bone scan B Electroencephalogram (EEG) C Throat culture D Sinus x-rays

A A bone scan is done to determine new areas of bone growth, areas of metastatic lesions, and osteoporosis. An EEG is obtained to localize the lesion. Throat, ear, nose, and blood (aerobic and anaerobic) cultures are done to determine the primary source of infection. Sinus and mastoid x-rays are requested to see if they are the primary source of the infection causing the brain abscess.

A client with a traumatic brain injury from a motor vehicle crash is monitored for signs of increased intracranial pressure (ICP). Which sign does the nurse monitor for? A Changes in breathing pattern B Dizziness C Increasing level of consciousness D Reactive pupils

A Changes in breathing pattern may cause hypoxia and hypercapnia, which can increase ICP. Dizziness is indicative of brain injury. Increasing level of consciousness and reactive pupils are desired outcomes for this client.

The nurse is teaching a client and family about home care after a stroke. Which statement made by the client's spouse indicates a need for further teaching? A "I should spend all my time with my husband in case I'm needed." B "My husband may get depressed." C "My husband must take his medicine every day to prevent another stroke." D "The physical therapist will show us how to use the equipment so my husband can climb the stairs and get into and out of bed."

A Family members can start to feel socially isolated when caring for a loved one. The family may need to plan for regular respite care in a structured day-care respite program or through relief provided by a friend or neighbor. The life changes associated with stroke often cause a change in the client's self-esteem. The client who has had a stroke should maintain a regular medication regimen, such as anticoagulant therapy, to prevent another stroke. Once the home health nurse has assessed the home environment, he or she will notify the health care provider of the need for ancillary services, such as a physical therapist. The physical therapist will identify adaptive equipment needs, will request them, and then will instruct the client about their use, along with developing an exercise program.

A client hospitalized for hypertension presses the call light and reports "feeling funny." When the nurse gets to the room, the client is slurring words and has right-sided weakness. What does the nurse do first? A Assesses airway, breathing, and circulation B Calls the provider C Performs a neurologic check D Assists the client to a sitting position

A The client must be evaluated within 10 minutes of having a stroke. The priority is assessment of the "ABCs"—airway, breathing, and circulation. Calling the Rapid Response Team, not the provider, after assessing ABCs would be appropriate. A neurologic check may be performed later, but is not the priority in this situation. A sitting position is used for hyperreflexia in the client with spinal cord injury to assist in lowering blood pressure.

The nurse is evaluating the collaborative care of a client with traumatic brain injury (TBI). What is the most important goal for this client? A Achieving the highest level of functioning B Increasing cerebral perfusion C Preventing further injury D Preventing respiratory distress

A The nurse's goal for the client with TBI is to help him or her achieve the highest level of functioning possible. The nurse assesses cerebral perfusion, such as oxygenation status, but cannot increase cerebral perfusion. Prevention of injury from falls, infection, or further impairment of cerebral perfusion is part of a larger goal for this client. Prevention of respiratory distress is also part of a larger goal for this client.

A client receiving sumatriptan (Imitrex) for migraine headaches is experiencing adverse effects after taking the drug. Which adverse effect is of greatest concern to the nurse? A Chest tightness B Skin flushing C Tingling feelings D Warm sensation

A Triptan drugs are contraindicated in clients with coronary artery disease because they can cause arterial narrowing. Clients taking triptan drugs should report angina or chest discomfort to prevent cardiac injury associated with myocardial ischemia. Skin flushing, tingling feelings, and a warm sensation are common adverse effects with triptan medications and are not indications to avoid using this group of drugs.

A client is being discharged to home with progressing stage I Alzheimer's disease. The family expresses concern to the nurse about caring for their parent. What is the priority for best continuity of care? A Assigning a case manager B Ensuring that all family questions are answered before discharge C Providing a safe environment D Referring the family to the Alzheimer's Association

A Whenever possible, the client and family should be assigned a case manager who can assess their needs for health care resources and facilitate appropriate placement throughout the continuum of care. Ensuring all questions are answered and providing a safe environment are necessary for family support, but are not relevant for continuity of care. Referring the family to the Alzheimer's Association is necessary for appropriate resource referral, but is not relevant for continuity of care.

Which are risk factors for stroke? (Select all that apply.) A High blood pressure B Previous stroke or transient ischemic attack (TIA) C Smoking D Use of oral contraceptives E Female gender

A,B,C,D Common modifiable risk factors for developing a stroke include smoking and the use of oral contraceptives, specifically in women over the age of 35 and in women over the age of 30 who smoke. Other risk factors include high blood pressure and history of a previous TIA. Gender is not a known risk factor for stroke; however, the female client is at risk for delayed recognition of early stroke symptoms.

Which statements by a client or family member about preventing stroke indicate a need for further teaching by the nurse? Select all that apply. A. "I will adjust my aspirin drug dose depending on whether I have pain." B. "I have cut down on smoking to only a half-pack daily." C. "I need to walk at least 30 minutes most days of the week." D. "I need to consider salt content in the foods I eat at restaurants." E. "I don't need to worry about fat calories in what I eat—my heart is fine!"

Answer: A, B, E Rationale: Aspirin is prescribed in a fixed, low dose to prevent platelet activation and thrombus formation (ischemic stroke), not pain. Although decreasing smoking is helpful, the goal is smoking cessation. Stroke and cardiac risk are intertwined; fat calories contribute to atherosclerosis and stroke risk. Reducing salt intake and completing 30 minutes of walking daily decrease the risk for stroke.

A client begins to have severe epistaxis after completing a dose of alteplase. In order of priority, what are the nurse's actions? A. Obtain vital signs. B. Assess the airway, and set up suction at bedside. C. Draw blood for anticoagulation studies. D. Call the health care provider.

Answer: B, A, D, C Epistasis is a severe nosebleed, and blood can block the oropharynx. The first priority is ensuring that airway and breathing are maintained. Next determine whether adequate circulation (VS) is present. Obtaining assistance from the rapid response team or health care provider to provide timely interventions (these may include oxygen, nasal packing, or imaging tests) to prevent complications follows immediate assessment of the airway, breathing, and circulation (ABCs). Drawing blood for anticoagulation studies will guide therapy, but it is not the immediate action required to avoid a life-threatening compromise to the respiratory system.

A client returns from the postanesthesia care unit (PACU) after a craniotomy for removal of a left parietal lobe tumor. How will the nurse position the client after surgery? A. Flex the client's knees to decrease intra-abdominal pressure and cerebral hypertension. B. Keep the client on the left side to prevent surgical site bleeding or cerebrospinal fluid leakage. C. Elevate the client's head to at least 30 degrees to promote cerebral venous drainage. D. Hyperextend the client's neck to maintain the airway and prevent aspiration regardless of supine or side-lying positioning.

Answer: C Rationale: Elevation of the backrest allows both CSF and cerebral venous blood to drain out of the cranium. Avoid placing a client who has undergone a craniotomy on the operative side. Avoid hip and knee flexion because this increases intracranial pressure, and increased intracranial pressure from edema is common in clients after cranial surgery. Hyperextension of the neck will reduce CSF and venous outflow from the cranium.

A client with a confirmed acute ischemic stroke is comatose but breathing spontaneously. The client has an advance directive requesting limited resuscitation and is not a candidate for fibrinolytic therapy. What is the nurse's priority action on admission? A. Ask for palliative care consultation to assist with end-of-life decision making. B. Consult with the speech-language pathologist about alternative strategies for communication. C. Evaluate swallowing ability with an institution-specific, evidence-based protocol. D. Assess vital signs and determine if the advance directives need to be communicated to the health care provider.

Answer: D Rationale: Client values and preferences must be incorporated into high-quality care. Assessing VS will provide essential information about the urgency of obtaining an order for "Do not resuscitate" or variation provided by institutional policy. Communication with the health care provider is essential to ensure all health care team members share the client's preference about limited resuscitation and that those wishes are reflected in the medical record. Comatose clients are unresponsive; an alternate form of communication is not feasible. Palliative care can assist with managing symptoms and may be needed in subsequent days, but the end-of-life decisions have been made and are in the advanced directive.

An alert and oriented person is admitted to the emergency department with a GCS of 10, indicating a moderate brain injury. Which assessment finding will the nurse report immediately to the health care provider? A. Photophobia accompanied by headache B. New onset of dizziness when lying quietly in bed C. A brisk pupillary reaction to light D. New difficulty in responsiveness or sudden drowsiness

Answer: D Rationale: The change in level of consciousness is the most sensitive indicator of new or worsening brain damage and must be communicated urgently to the health care provider. Any deterioration in alertness or responsiveness in a client with new brain injury is an emergency. Although photophobia and dizziness are concerning, they are not emergencies. A brisk pupillary response is normal.

A client recovering from a stroke reports double vision that is preventing the client from effectively completing activities of daily living. How does the nurse help the client compensate? A Approaches the client on the affected side B Covers the affected eye C Encourages turning the head from side to side D Places objects in the client's field of vision

B Covering the client's eye with a patch prevents diplopia. The client who is recovering from a stroke should always be approached on the unaffected side. The nurse may encourage side-to-side head turning for clients with hemianopsia (blindness in half of the visual field). Objects should be placed in the field of vision for the client with a decreased visual field.

A client has been admitted with a diagnosis of stroke (brain attack). The nurse suspects that the client has had a right hemisphere stroke because the client exhibits which symptoms? A Aphasia and cautiousness B Impulsiveness and smiling C Inability to discriminate words D Quick to anger and frustration

B Impulsiveness and smiling are symptoms indicative of a right hemisphere stroke. Aphasia, cautiousness, the inability to discriminate words, quick to anger, and frustration are symptoms indicative of a left hemisphere stroke.

A client with a history of atrial fibrillation is receiving sodium heparin 24 hours after receiving thrombolytic therapy for a stroke. Which emergency drug does the nurse ensure is on the floor? A Narcan B Protamine sulfate C Vitamin K D Physostigmine

B Protamine sulfate is used to reverse the effects of heparin in case of adverse effects. Narcan (naloxone) is used to reverse the effects of a narcotic overdose. Vitamin K is used to reverse the effects of warfarin. Physostigmine is an acetylcholinesterase inhibitor used to treat myasthenia gravis.

A client has Guillain-Barré syndrome. Which interdisciplinary health care team members does the nurse plan to collaborate with to help prevent pressure ulcers related to immobility in this client? (Select all that apply.) A Certified hospital chaplain B Family members C Dietitian D Occupational therapist (OT) E Social worker

B, C, D The nurse should collaborate with the client's family to develop interventions to prevent complications such as pressure ulcers. The family will mostly likely be directly involved in the client's care and should be included. Malnutrition puts the client at greater risk for pressure ulcers, so the dietitian should be included as well. The OT can provide assistive devices that will help prevent ulcers. The certified hospital chaplain and the social worker can assist with providing additional psychosocial support, but would not be involved with direction prevention of ulcers.

A client is considering treatments for a malignant brain tumor. Which statement by the client indicates a need for further instruction by the nurse? A "A combination of treatments might be necessary." B "In a craniotomy, holes are cut in the skull to access the tumor." C "Antibiotics will help minimize the size of the tumor." D "The goal is to decrease tumor size and improve survival time."

C Antibiotics are used to treat a brain abscess, not a malignant tumor. Chemotherapy, radiation, and surgery are often used in conjunction with each other to treat malignancies. For a craniotomy, several burr holes are drilled into the skull, and a saw is used to remove a piece of bone (bone flap) to expose the tumor area. The goals of treatment of brain tumor are to decrease tumor size, improve quality of life, and improve survival time.

The nurse is providing medication instructions for a client for whom phenytoin (Dilantin) has been ordered for treatment of epilepsy. The nurse instructs the client to avoid which beverage? A Apple juice B Grape juice C Grapefruit juice D Milk

C Grapefruit juice can interfere with the metabolism of phenytoin. Apple juice, grape juice, and milk do not interact with phenytoin.

The nurse is monitoring a postoperative craniotomy client with increased intracranial pressure (ICP). Which pharmacologic agent does the nurse expect to be requested to maintain the ICP within a specified range? A Dexamethasone (Decadron) B Hydrochlorothiazide (HydroDIURIL) C Mannitol (Osmitrol) D Phenytoin (Dilantin)

C Mannitol is an osmotic diuretic used specifically to treat cerebral edema. Glucocorticoids have no demonstrated benefit in reducing ICP. Hydrochlorothiazide is only a mild diuretic; a loop diuretic such as furosemide (Lasix) is commonly used along with mannitol to reduce ICP. Dilantin is used to treat seizure activity caused by increased ICP.

The daughter of a client who has had a stroke asks the nurse for additional resources. What is the nurse's best response? A "Call hospice." B "Check the Internet." C "Go to the National Stroke Association website." D "The charge nurse at the desk has all of the information."

C The National Stroke Association is a specific and reliable resource that can be recommended. Hospice applies only to the client who will be requiring palliative end-of-life care. The Internet is too broad; unless the nurse recommends a specific website, the client's daughter may not find quality information. The nurse caring for the client is responsible for obtaining information that is readily available or for procuring a request from the health care provider for a consultation with the social worker.

A client in the emergency department (ED) has slurred speech, confusion, and visual problems, and has been having intermittent episodes of worsening symptoms. The symptoms have a gradual onset. The client also has a history of hypertension and atherosclerosis. What does the nurse suspect that the client is probably experiencing? A Embolic stroke B Hemorrhagic stroke C Thrombotic stroke D Transient ischemic attack

C The client's symptoms fit the description of a thrombotic stroke. Symptoms of embolic stroke have a sudden onset, unlike this client's symptoms. The client would be in a coma if a hemorrhagic stroke had occurred. Intermittent episodes of slurred speech, confusion, and visual problems are transient ischemic attacks, which often are warning signs of an impending ischemic stroke.

The nurse is teaching the spouse and client who has had a brain attack about rehabilitation. Which statement by the spouse demonstrates understanding of the nurse's instruction? A "My spouse will no longer need to take blood pressure medication." B "Rehabilitation and physical therapy are the same thing." C "The rehabilitation therapist will help identify changes needed at home." D "Frequent stimulation will help with the rehabilitation process."

C The rehabilitation therapist and home health professionals assist the client and family in adapting the home environment to the client's needs and assess the client's need for therapy. Any medication regimen for the client must be maintained. Rehabilitation is much more comprehensive than physical therapy. The family should develop a home routine that provides structure, repetition, and consistency.

A client is admitted with a stroke (brain attack). Which tool does the nurse use to facilitate a focused neurologic assessment of the client? A Mini-Mental State Examination (MMSE; mini-mental status examination) B Intracranial pressure monitor C Reflex hammer D National Institutes of Health Stroke Scale (NIHSS)

D Health care providers and nurses at primary stroke centers use a specialized stroke scale such as the NIHSS to assess clients. The MMSE is used primarily to differentiate among dementia, psychosis, and affective disorders. An intracranial pressure monitor would be requested by the health care specialist if signs and symptoms indicated increased intracranial pressure. A reflex hammer is used to assess deep tendon reflex response.

A client is being discharged home after surgery for brain cancer. Which statement by the client's spouse indicates a correct understanding of the nurse's discharge teaching? A "I will have to quit my job to care for my spouse." B "Life will be back to normal soon." C "The case manager will provide home care." D "We can find a support group through the local American Cancer Society."

D The American Cancer Society is a good community resource for clients with malignant tumors and their families. It is not a requirement that the client's spouse quit his or her job; resources are available for in-home client care. Although life need not be completely altered, it will never revert back to normal, as it was before the client's cancer occurred. The case manager helps coordinate care and teaching, but does not provide home care.

The nurse is monitoring a client after supratentorial surgery. Which sign does the nurse report immediately to the provider? A Periorbital edema B Bilateral ecchymoses of both eyes C Moderate amount of serosanguineous drainage on the head dressing D Decorticate positioning

D The major complications of supratentorial surgery are increased intracranial pressure from cerebral edema or hydrocephalus and hemorrhage. Decorticate positioning indicates damage to the pathway between the brain and the spinal cord. The client usually is rigid with flexion of arms, clenched fists, and extended rigid legs. Periorbital edema and a small-to-moderate amount of serosanguineous drainage are expected after a craniotomy. Ecchymoses in the facial region, especially around the eyes, are expected after a craniotomy.

A client is eating a soft diet while recovering from a stroke. The client reports food accumulating in the cheek of the affected side. What is the nurse's best response? A "Next time you eat, try lifting your chin when you swallow." B "Let's advance your diet to solid food." C "Let's see if the dietitian can help." D "Let's see if the speech-language pathologist can help."

D The speech-language pathologist identifies strategies to prevent food from accumulating in the cheek of the affected side of a client recovering from a stroke. The correct technique to improve swallowing is the chin-tuck method; however, the speech pathologist will assist the client with tongue exercises that will help move the food bolus to the unaffected side. Solid food is not appropriate for the client with chewing and swallowing challenges. The dietitian consults with the health care team if the client has had weight loss problems, or if abnormal laboratory results indicate a nutritional deficit.