Neuro Practice Quiz

A client has a diagnosis of trigeminal neuralgia. When assessing the client's trigeminal nerve function, which should the nurse evaluate? A. Corneal sensation B. Facial expressions C. Ocular muscle movement D. Shrugging of the shoulders

A Rationale The afferent sensory branch of the trigeminal nerve (cranial nerve V) innervates the cornea. Facial expressions (e.g., smiling, frowning) reflect the functioning of cranial nerve VII. The ocular muscle movement tests the function of cranial nerves III, IV, and VI. Shrugging of the shoulders tests the function of cranial nerve XI.

A nurse is counseling a client with amyotrophic lateral sclerosis (ALS) about management of this disorder. What important suggestion should the nurse make to the client? A. "Eye surgery may improve your vision." B. "Activities should be spaced throughout the day." C. "Opioids may be necessary for the pains in your legs." D. "Leg restraints will decrease the chance of physical injury."

B Rationale ALS is a disease of the motor neurons characterized by muscle wasting and weakness. Conserving the energy and spacing activities throughout the day are useful strategies. The senses, such as vision, are not affected with ALS. Opioids generally are not a part of the treatment for ALS because they can contribute to inhibition of the client's respirations. The use of leg restraints is not a part of treatment for ALS; however, leg braces or a walker may maximize independence by promoting ambulation.

A nurse completes an admission assessment on a client who is diagnosed with myasthenia gravis. Which clinical finding is the nurse most likely to identify? A. Problems with cognition B. Difficulty swallowing saliva C. Intention tremors of the hands D. Nonintention tremors of the extremities

B Rationale Facial muscles innervated by the cranial nerves often are affected; dysphagia, ptosis, and diplopia are present. Myasthenia gravis is a neuromuscular disease with altered neuromuscular junction and receptors, not central nervous system symptoms (problems with cognition). Intention tremors of the hands are associated with multiple sclerosis. Nonintention tremors of the extremities are associated with Parkinson disease.

A client manifests right-sided hemianopsia as a result of a brain attack (cerebrovascular accident, CVA). Which goal does the nurse include in the plan of care? A. Correct the client's misuse of equipment. B. Instruct the client to scan surroundings. C. Teach the client to look at the position of the left extremities. D. Provide the client with tactile stimulation to the affected extremities.

B Rationale The client has lost vision from the right visual field[1][2]; scanning compensates for this loss. Correcting the client's misuse of equipment is used for clients with apraxia (inability to manipulate objects). Teaching the client to look at the position of the left extremities increases neglect of the affected side. Providing the client with tactile stimulation to the affected extremities is used for denial of the right side (unilateral neglect).

A client is admitted with a head injury. The nurse identifies that the client's urinary catheter is draining large amounts of clear, colorless urine. What does the nurse identify as the most likely cause? A. Increased serum glucose B. Deficient renal perfusion C. Inadequate antidiuretic hormone (ADH) secretion D. Excess amounts of intravenous (IV) fluid

C Rationale Deficient ADH from the posterior pituitary results in diabetes insipidus. This can be caused by head trauma; water is not conserved by the body, and excess amounts of urine are produced. Although increased serum glucose may cause polyuria, it is associated with diabetes mellitus, not diabetes insipidus. Ineffective renal perfusion will cause decreased urine production. While excess amounts of IV fluids may cause dilute urine, it is unlikely that a client with head trauma will be receiving excess fluid because of the danger of increased intracranial pressure.

A client with myasthenia gravis has increased difficulty swallowing. Which action will the nurse take to prevent the aspiration of food? A. Offer three large meals a day. B. Assess the client's respiratory status before and after meals. C. Seek a change in the diet prescription from soft foods to clear liquids. D. Schedule meals with the peak effect of an anticholinesterase muscle stimulant.

D Rationale Dysphagia should be minimized during the peak effect of an anticholinesterase muscle stimulant such as pyridostigmine, thereby decreasing the probability of aspiration. Three large meals a day will tire the client with myasthenia gravis. Assessing the client's respiratory status before and after meals will not prevent aspiration, although it is vital that respiratory function be monitored. Data are insufficient to determine whether changing the diet to clear liquids is appropriate because liquids also may be aspirated; liquids are more difficult to manage than are foods with the consistency of pudding.

A 50-year-old male client has difficulty communicating because of expressive aphasia after a cerebrovascular accident (CVA, also known as a "brain attack"). When the nurse asks the client how he is feeling, his wife answers for him. How should the nurse address this behavior? A. Ask the wife how she knows how the client feels. B. Instruct the wife to let the client answer for himself. C. When the wife leaves return to speak with the client. D. Acknowledge the wife but look at the client for a response.

D Rationale The opportunity must be provided for the client to practice language skills; family participation must be accepted and recognized. The spouse should be included and involved in the client's care. Asking the wife how she knows how the client feels, instructing the wife to let the client answer for himself, and returning to speak with the client when the wife leaves demean the spouse and cut off communication.

Which health problem does the nurse identify from an older client's history that increases the client's risk factors for a cerebrovascular accident (CVA, also known as "brain attack")? A. Glaucoma B. Hypothyroidism C. Continuous nervousness D. Transient ischemic attacks (TIAs)

D Rationale TIAs are temporary neurologic deficits related to cerebral hypoxia; about one third of the people who have TIAs will have a brain attack (CVA) within 2 to 5 years. Glaucoma, hypothyroidism, and continuous nervousness are not risk factors associated with a CVA.

When helping a client with Parkinson disease to ambulate, what instructions should the nurse give the client? A. Avoid leaning forward. B. Hesitate between steps. C. Rest when tremors are experienced. D. Keep arms close to the center of gravity.

A Rationale The client with Parkinson disease often has a stooped posture[1][2][3] because of the tendency of the head and neck to be drawn down; this shift away from the center of gravity causes instability. Hesitation is part of the disease; clients may use a marching rhythm to help maintain a more fluid gait. The tremors of Parkinson disease occur at rest (resting tremors). The client must consciously attempt to maintain a natural arm swing for balance.

A client has a diagnosis of myasthenia gravis. What does the nurse recall are associated clinical manifestations? A. Blurred vision along with episodes of vertigo B. Tremors of the hands when attempting to lift objects C. Partial improvement of muscle strength with mild exercise D. Involvement of the distal muscles rather than the proximal muscles

A Rationale Blurred vision and episodes of vertigo are symptoms of myasthenia gravis and are aggravated by physical activity. Intentional tremors are associated with multiple sclerosis. Exercise decreases muscle strength. The proximal muscles are more involved than the distal muscles.

A client is admitted to the emergency department with head trauma resulting from an accident. The client opens both eyes to painful stimuli, makes incomprehensible sounds, and flexes to pain. Using the Glasgow Coma Scale, which score will the nurse document in the client's medical record? A. 8 B. 9 C. 12 D. 15

A Rationale The score is 8. The Glasgow Coma Scale[1][2] is a three-part neurologic assessment measuring eye opening, response to auditory stimuli, and motor response; the lower the score, the deeper the coma. A score of 8 or less indicates coma. Nine and 12 are too high a rating for the behaviors exhibited by the client. A rating of 15 indicates that the client is opening the eyes spontaneously, obeying commands, and fully oriented.

Which manifestations may indicate a client has systemic lupus erythematosus (SLE)? Select all that apply. A. Pericarditis B. Esophagitis C. Fibrotic skin D. Discoid lesions E. Pleural effusions

A, D, E Rationale SLE is a chronic, progressive inflammatory connective tissue disorder that can cause major organs and systems to fail. Pericarditis is a cardiovascular manifestation of SLE. Discoid lesion is a skin manifestation that is a key indicator of the presence of SLE. Pleural effusion, a pulmonary manifestation, is a key indicator of the presence of SLE. Esophagitis is one of the gastrointestinal manifestations of systemic sclerosis. Fibrotic skin is one of the skin manifestations of systemic sclerosis.

During a seizure, a client had sudden loss of muscle tone that lasted for a few seconds followed by confusion. Which statement about this type of seizures is true? Select all that apply. A. These seizures are associated with amnesia. B. These seizures increase the risk of injuries due to fall. C. These seizures are most resistant to drug therapy. D. These seizures are preceded by perception of an offensive smell. E. These seizures cause one sided movement of extremities in the client.

B, C Rationale Atonic (akinetic) seizures are characterized by a sudden loss of muscle tone lasting for seconds followed by postictal confusion. These seizures cause the client to fall because of the decreased muscle tone, which may result in injury. This type of seizure tends to be most resistant to drug therapy. Amnesia is associated with complex partial seizures. In simple partial seizures, the client reports an aura and perception of unusual sensations, such as an offensive smell and sudden onset of pain. Simple partial seizures are also associated with one-sided movement of the extremities.

A nurse is assessing a client with Parkinson disease. Which assessment finding indicates the presence of bradykinesia? A. Intention tremor B. Muscle flaccidity C. Paralysis of the limbs D. Lack of spontaneous movement

D Rationale Bradykinesia is a slowing down in the initiation and execution of movement. Tremors are more prominent at rest and are known as nonintention, not intention, tremors. Cogwheel rigidity, not flaccidity, occurs because the disorder causes sustained muscle contractions. The limbs are rigid and move with a jerky quality; the limbs are not paralyzed.

During an exacerbation of multiple sclerosis a client reports urinary urgency and frequency. What is the most appropriate initial nursing action? A. Begin teaching self-catheterization. B. Develop a plan to ensure high fluid intake. C. Palpate the suprapubic area of the abdomen. D. Initiate a regimen to monitor urinary output.

C Rationale Assessment is the priority; the nurse should determine whether clinical manifestations are caused by a full bladder. Teaching self-catheterization may be necessary eventually, but it is not the initial action. Ensuring an increase in fluid intake may be done to reduce urinary bacterial count and stone formation, but it is not the initial action. Initiating a regimen to monitor urinary output should be done, but it is not the initial action.

A client experiences expressive aphasia as a result of a brain attack (cerebrovascular accident, CVA). The client's spouse asks whether the client's speech will ever return. What is the best response by the nurse? A. "It should return in several months." B. "You will have to ask the primary healthcare provider." C. "It is hard to say how much improvement will occur." D. "Unfortunately, your spouse will no longer be able to speak."

C Rationale Recovery from aphasia[1][2] is a continuous process; the amount of recovery cannot be predicted. The response "It should return in several months" gives false reassurance; it may take a year or longer or may never return. The response "You will have to ask the primary healthcare provider" abdicates the nurse's responsibility; the healthcare provider cannot predict return of function. Speech return is a continuous process; it may take a year or longer or may never return.

A client is at risk for increased intracranial pressure (ICP). Which assessment finding reflects an increase in ICP? A. Unequal pupil size B. Decreasing systolic blood pressure C. Tachycardia D. Decreasing body temperature

A Rationale Increased ICP causes unequal pupils as a result of pressure on the third cranial nerve. It causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. ICP increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.

An older client is diagnosed with Alzheimer disease. For which clinical manifestations should the nurse assess the client? Select all that apply. A. Loss of recent memory B. Focused attention span C. Perceptual disturbances D. Willingness to accept change E. Difficulty learning something new

A, C, E Rationale Neurofibrillary tangles attack the hippocampus, impairing recent memory. As dementia progresses sensory-perceptual alterations occur, such as hallucinations. Alzheimer disease is associated with a global intellectual impairment that affects learning, thinking, and language. Progressive deterioration of the regions of the brain results in cognitive deficits, such as a decreased, not focused, attention span. Clients with Alzheimer disease are easily confused or disoriented. They require familiar routines that provide a sense of security.

A healthcare provider determines that a client has myasthenia gravis. Which clinical findings does the nurse expect when completing a health history and physical assessment? Select all that apply. Select all that apply A. Double vision B. Problems with cognition C. Difficulty swallowing saliva D. Intention tremors of the hands E. Drooping of the upper eyelids E. Nonintention tremors of the extremities

A, C, E Rationale Double vision occurs as a result of cranial nerve dysfunction. Facial muscles innervated by the cranial nerves often are affected; difficulty with swallowing (dysphagia) is a common clinical finding. Drooping of the upper eyelids (ptosis) occurs because of cranial nerve III (oculomotor) dysfunction. Myasthenia gravis is a neuromuscular disease with lower motor neuron characteristics, not central nervous system symptoms. Intention tremors of the hands are associated with multiple sclerosis. Nonintention tremors of the extremities are associated with Parkinson disease.

A home care nurse is counseling a client with amyotrophic lateral sclerosis (ALS). What information should the nurse include in the discussion? Select all that apply. Select all that apply A. Space activities throughout the day. B. Engage in social interactions with large groups. C. Request an opioid if leg pain becomes excessive. D. Anticipate the use of alternate ways to communicate. E. Use leg restraints to decrease the risk of physical injury.

A, D Rationale Spacing activities throughout the day is a strategy to help conserve the client's energy. Alternate ways to communicate (e.g., writing, electronic devices) should be used when speech becomes difficult because of muscle weakness. Large groups should be avoided to limit the risk of infection; respiratory complications are the leading cause of death. Opioids are not used because they may depress respirations. Lower-extremity pain usually is not a problem associated with ALS. Braces and splints, not restraints, may be used.

Which autoimmune disease is directly related to the client's central nervous system? A. Rheumatic fever B. Multiple sclerosis C. Myasthenia gravis D. Goodpasture syndrome

B Rationale Multiple sclerosis is a central nervous system-specific autoimmune disease. Rheumatic fever is related to the heart. Myasthenia gravis is a muscle-related autoimmune disease. Goodpasture syndrome is a kidney-related autoimmune disease.

While walking in the hall, a hospitalized client has a tonic-clonic seizure. To protect the client during the seizure, what should the nurse do? A. Hold the client's extremities firmly. B. Protect the client's head from injury. C. Insert an airway between the client's teeth. D. Have several staff members move the client to a soft surface.

B Rationale Rhythmic contraction and relaxation associated with a tonic-clonic seizure can cause repeated banging of the head. Holding extremities firmly is contraindicated because it can cause broken bones. Inserting an airway between the client's teeth is contraindicated because damage to the teeth can occur if force is used to insert an airway. Moving during a seizure can result in physical injuries; the client should be moved after the seizure.

A client who had a brain attack (cerebrovascular accident, CVA) frequently cries when family members visit, and they obviously are upset by the crying. What explanation for the client's behavior does the nurse provide the family members? A. Having difficulty controlling emotions B. Demonstrating a premorbid personality C. Mourning the loss of functional abilities D. Conveying unhappiness about the situation

A Rationale A common complication of a brain attack is an inability to control emotional affect; clients may be depressed or apathetic and have a lability of mood. There are no data to support the conclusion that the client is demonstrating a premorbid personality. There are no data to support the conclusion that the client is mourning the loss of functional abilities. There are no data to support the conclusion that the client is conveying unhappiness about the situation.

Three days after admission to the hospital for a brain attack (cerebrovascular accident, CVA), a client has a nasogastric tube inserted and is receiving continuous tube feedings. Which action should the nurse take to best evaluate whether the feeding is being absorbed? A. Aspirate for a residual volume B. Evaluate the intake in relation to the output C. Instill air into the client's stomach while auscultating D. Compare the client's body weight with the baseline data

A Rationale A gastric residual of over 200 mL or as specified by the primary healthcare provider or facility will alert the nurse that the feeding is not being absorbed; conversely, a residual of less than 200 mL indicates the feeding is being absorbed. Evaluation of intake to output gauges fluid balance, not whether feeding is absorbed. Instilling air into the client's stomach is not advocated and does not determine if the feeding is absorbed. Comparing the body weight to the baseline is a fluid issue and is performed on a daily basis, or it is a weight gain/loss issue. Since weight can fluctuate based on fluid, the aspirate is the better choice for absorption.

What action should the nurse take when caring for a client who has a possible skull fracture as a result of trauma? A. Monitor the client for signs of brain injury. B. Check for hemorrhaging from the oral and nasal cavities. C. Elevate the foot of the bed if the client develops symptoms of shock. D. Observe for clinical indicators of decreased intracranial pressure and temperature.

A Rationale Head injuries can cause trauma to the brain, and the client should be monitored for symptoms of increased intracranial pressure (e.g., headache, dizziness, and visual disturbances). Checking for hemorrhaging from the oral and nasal cavities is not indicated in this situation. Elevating the lower extremities should be avoided because it will increase intracranial pressure. The intracranial pressure may increase after trauma because of bleeding and edema. The temperature may increase because of injury to or pressure on the hypothalamus.

A client goes to the primary healthcare provider because of fatigue, double vision, and muscle weakness. A diagnosis of myasthenia gravis is suspected. When collecting a health history, the nurse expects the client to report which information? A. Muscle weakness improving after a period of rest B. Symptoms worse in the morning upon awakening C. Periods of hyperactivity D. Slow, insidious onset of muscle weakness

A Rationale Increased activity and stress precipitate exacerbation of symptoms because nerve impulses fail to pass to muscles at the myoneural junction with myasthenia gravis; theories include inadequate acetylcholine, excessive cholinesterase, or a nonresponse of the muscle fibers to acetylcholine. Symptoms improve after rest or a good night's sleep. Hyperactivity is not associated with myasthenia gravis. Muscle weakness and fatigue come on quickly and disappear rapidly with rest in the initial stages of myasthenia gravis. Rest promotes a decrease in symptoms associated with myasthenia gravis because the demand for muscle contraction is reduced.

A client is diagnosed with a brain attack (cerebrovascular accident, CVA). The baseline vital signs are a pulse rate of 78 bpm and a blood pressure (BP) of 120/80 mm Hg. The nurse continues to monitor the vital signs and recognizes that which changes in vital signs indicate increased intracranial pressure (ICP)? A. Pulse 50 bpm and BP 140/60 mm Hg B. Pulse 56 bpm and BP 130/110 mm Hg C. Pulse 60 bpm and BP 126/96 mm Hg D. Pulse 120 bpm and BP 80/60 mm Hg

A Rationale Increasing intracranial pressure is evidenced by widening of pulse pressure and a decreased pulse rate. Pulse 56 bpm and BP 130/110 mm Hg, pulse 60 bpm and BP 126/96 mm Hg, and pulse 120 bpm and BP 80/60 mm Hg do not meet these criteria.

A client has a mean arterial blood pressure (MAP) of 97 mmHg and an intracranial pressure (ICP) of 12 mmHg. What is the cerebral perfusion pressure (CPP) for this client? Record your answer using a whole number. ____ mmHg

85 mmHG Rationale The cerebral perfusion pressure (CPP) can be calculated by the following equation: CPP=MAP - ICP. If the mean arterial blood pressure (MAP) is 97 mmHg and intracranial pressure (ICP) is 12 mmHg, the CPP is 85 mmHg.

An older client experiences a cerebral vascular accident (CVA) and has right-sided hemiplegia and expressive aphasia. The client's children ask the nurse which functions will be impaired. Which abilities does the nurse explain will be affected? A. Stating wishes verbally B. Recognizing familiar objects C. Comprehending written words D. Understanding verbal communication

A Rationale Impaired ability to state wishes verbally is a characteristic of expressive aphasia[1][2] from damage to Broca area in the dominant hemisphere of the brain. Not recognizing familiar objects is known as agnosia; it is not related to expressive aphasia. Not comprehending written words is known as alexia or dyslexia, a type of receptive aphasia. Not understanding verbal communication is related to receptive aphasia.

A client has a history of progressive carotid and cerebral atherosclerosis and experiences transient ischemic attacks (TIAs). How does the nurse explain TIAs to the client? A. Temporary episodes of neurologic dysfunction B. Intermittent attacks caused by multiple small clots C. Ischemic attacks that result in progressive neurologic deterioration D. Exacerbations of neurologic dysfunction alternating with remissions

A Rationale Narrowing of arteries supplying the brain causes temporary neurologic deficits that last for a short period. Between attacks, neurologic functioning is normal. Emboli result in a brain attack (CVA); with a CVA the damage is usually permanent, not intermittent. Ischemic attacks that result in progressive neurologic deterioration occur with multiple small brain attacks; TIAs do not result in permanent damage. Exacerbations of neurologic dysfunction alternating with remission are not the description of a TIA; remissions and exacerbations occur with progressive degenerative neurologic disorders.

Which nursing action is specific to the plan of care for a client with trigeminal neuralgia? A. Be alert to prevent dehydration or starvation. B. Initiate exercises of the jaw and facial muscles. C. Apply ice compresses to the affected body area. D. Emphasize the importance of brushing the teeth.

A Rationale Pain may prevent the client from ingesting anything by mouth. Facial exercises may precipitate an attack. Hot or cold foods or compresses should be avoided because they may trigger a painful attack. Brushing the teeth may initiate an acute attack of trigeminal neuralgia[1][2]; often clients must limit oral hygiene to rinsing the mouth.

A client is admitted to the hospital with a tentative diagnosis of Guillain-Barré syndrome. Which question by the nurse will bestelicit information that supports this diagnosis? A. "Have you experienced an infection recently?" B. "Is there a history of this disorder in your family?" C. "Did you receive a head injury during the past year?" D. "What medications have you taken in the last several months?"

A Rationale Symptoms usually appear one to three weeks after an acute infection; this syndrome is linked to diseases such as viral hepatitis, the Epstein-Barr virus, and infectious mononucleosis. There is no known familial tendency that exists in the development of Guillain-Barré syndrome. This syndrome is unrelated to head trauma. Drug therapy is not implicated as a contributing factor in Guillain-Barré syndrome.

A client is admitted to the hospital after having a tonic-clonic seizure and is diagnosed with a seizure disorder. Which is mostimportant for the nurse to include in a teaching program? A. Explain ways to prevent physical trauma from occurring during a seizure. B. Teach that anticonvulsant medications should be taken on an empty stomach. C. Teach the client that the symptoms and treatment of seizure disorders are similar, regardless of the cause. D. Explain to the client that it is not necessary to tell others of the illness because medication will control seizures.

A Rationale The client may become injured in many ways during a seizure, and trauma prevention is a priority. Anticonvulsants can cause gastrointestinal disturbances, especially early in therapy, and should be taken with food. Seizures and seizure disorders are not similar; they vary greatly. Others should understand the condition and be taught how to help in case of a seizure.

A client is admitted with a closed head injury sustained in a motor vehicle accident (MVA). The nursing assessment indicates increased intracranial pressure (ICP). Which intervention should the nurse perform first? A. Place the head and neck in alignment. B. Administer 1 gram mannitol intravenously (IV) as prescribed. C. Increase the ventilator's respiratory rate to 20 breaths/minute. D. Administer 100 mg of pentobarbital IV as prescribed.

A Rationale The nurse should first attempt nursing interventions such as placing the head and neck in alignment (neutral position) to facilitate venous return and thereby decrease ICP. If nursing measures prove ineffective, notify the healthcare provider, who may prescribe mannitol. The nurse would notify the healthcare provider for hyperventilation therapy or for pentobarbital. Hyperventilation is used only when all other interventions have been ineffective in decreasing ICP.

A client exhibits blurred and double vision and muscular weakness, and diagnostic tests are prescribed. The client is informed that a diagnosis of multiple sclerosis (MS) has been made. The client becomes visibly upset. How should the nurse respond? A. "That must have really shocked you. Tell me what the healthcare provider told you about it." B. "You should see a psychiatrist who will help you cope with this overwhelming news." C. "Don't worry; early treatment often alleviates symptoms of the disease." D. "You should be glad that we caught it early so it can be cured."

A Rationale The response "That must have really shocked you. Tell me what the healthcare provider told you about it" acknowledges the effect of the diagnosis on the client and explores what is known. There is no evidence of ineffective coping, so a referral to a psychiatrist is not necessary. The statement "Don't worry; early treatment often alleviates symptoms of the disease" provides false reassurance. The statement "You should be glad we caught it early so it can be cured" does not address the client's current emotional state, and it is inaccurate; MS is a chronic autoimmune disease.

A client recently diagnosed with multiple sclerosis says, "I had planned to get married before the end of the year. After this diagnosis, I might not be ready. Maybe I should call off the wedding." Which is the best response by the nurse? A. "You don't feel able to make a decision at this time?" B. "Have you spoken to your fiancé about your feelings?" C. "Your fiancé loves you and I'm sure still wants to marry you." D. "These are your feelings now, but don't decide until you feel better and can cope."

A Rationale The response "You don't feel able to make a decision at this time?" reflects the client's concern and provides an opportunity for further verbalization while indicating the nurse's understanding. The response "Have you spoken to your fiancé about your feelings?" changes the emphasis to the fiancé's opinion and asks a direct question, which closes off communication. The response "Your fiancé loves you and I'm sure still wants to marry you" is false reassurance that belittles the client's concerns. The response "These are your feelings now, but don't decide until you feel better and can cope" gives advice and cuts off further exploration of the client's feelings.

Which clinical findings does the nurse anticipate a client with an exacerbation of multiple sclerosis will experience? Select all that apply. Select all that apply A. Double vision B. Resting tremors C. Flaccid paralysis D. Scanning speech E. Mental retardation

A, D Rationale Diplopia (double vision) and nystagmus[1][2] (involuntary, rapid, rhythmic eye movements) are experienced by clients with multiple sclerosis as a result of demyelination. Scanning (clipped) speech occurs with multiple sclerosis as a result of demyelination. These clients exhibit the Charcot triad: intention tremor, nystagmus, and scanning speech. Clients experience intention, not resting, tremors. Clients experience spastic paralysis because upper motoneurons are involved. Although emotional affect and speech are affected, intelligence remains intact.

A client is admitted to the hospital with a diagnosis of Parkinson disease. Which common signs of Parkinson disease does the nurse expect to identify when completing a nursing admission history and physical? Select all that apply. Select all that apply A. Muscle rigidity B. Blank facial expression C. Leaning toward the affected side D. Intention tremors with movement E. Hyperextension of the affected extremity

A, B Rationale With Parkinson disease muscle rigidity occurs as a result of an imbalance between excitatory and inhibitory messages in the basal ganglia. With Parkinson disease there is a lack of neural control of fine-motor movements, resulting in a characteristic masklike face. Leaning toward an affected side is unrelated to Parkinson disease; this often is associated with a brain attack (CVA). Movement usually abolishes tremors; these are known as nonintention tremors. Hyperextension of the affected extremities does not occur with Parkinson disease; both arms fall rigidly to the sides and do not swing with a regular rhythm when walking, producing a shuffling gait.

The nurse is supporting cognitive ability in clients with Alzheimer disease. Which actions will the nurse take? Select all that apply. A. Encouraging caregivers to support safe independence B. Using calendars, clocks, and pictures to support memory C. Providing a limited number of choices to support decision-making D. Quizzing the client regularly to assess orientation to person, place, and time E. Administering prescribed rivastigmine to the client with severe Alzheimer dementia

A, B, C Rationale Strategies that assist orientation without challenging the client and that encourage safe independence and decision-making support cognitive function in Alzheimer disease, such as clocks, calendars, limited number of choices, and allowing safe independence. Interactions that quiz or challenge the client are not well tolerated and do not support cognitive functioning. Alzheimer dementia is characterized by cerebral atrophy and by the presence of neurofibrillary tangles and amyloid plaques. Rivastigmine is a cholinesterase inhibitor that provides a modest short-term cognitive benefit for some people with mild to moderate Alzheimer dementia. It works by increasing acetylcholine at cholinergic synapses. It is not approved for people with severe disease.

The nurse is caring for a client who was just admitted to the hospital with the diagnosis of head trauma. Which clinical indicators should the nurse consider as evidence of increasing intracranial pressure? Select all that apply. A. Vomiting B. Irritability C. Hypotension D. Increased respirations E. Decreased level of consciousness

A, B, E Rationale Anorexia, nausea, and vomiting occur because of pressure on the brain. Increasing pressure on the vital centers in the brain and irritation of cerebral tissue result in irritability and seizures. Increased intracranial pressure disrupts neurons and neurotransmitters, resulting in faulty impulse transmission and an altered level of consciousness. The blood pressure will be increased, not decreased, because of pressure on the vital centers in the brain. Also, the pulse pressure increases. Pressure on the respiratory center in the medulla results in a decreased, not increased, respiratory rate. As the intracranial pressure increases, the client may exhibit Cheyne-Stokes respirations.

A nurse is caring for a client with Parkinson disease. Which clinical indicators does the nurse expect to find upon assessment? Select all that apply. A. Resting tremors B. Flattened affect C. Muscle flaccidity D. Tonic-clonic seizures E. Slow voluntary movements

A, B, E Rationale Resting (nonintention) tremors, commonly accompanied by pill-rolling movements of the thumb against the fingers, are associated with destruction of the neurons of the basal ganglia and substantia nigra. Destruction of the neurons of the basal ganglia and substantia nigra results in decreased muscle tone. The masklike appearance, unblinking eyes, and monotonous speech patterns can be interpreted as a flat affect. Slow voluntary movements (bradykinesia) are associated with this disorder. Muscle flaccidity is not associated with Parkinson disease. Rigidity is caused by sustained muscle contractions. Movement is jerky in quality (cogwheel rigidity). Tonic-clonic seizures are not associated with Parkinson disease.

A nurse is performing the history and physical examination of a client with Parkinson disease. Which assessments identified by the nurse support this diagnosis? Select all that apply. A. Nonintention tremors B. Frequent bouts of diarrhea C. Masklike facial expression D. Hyperextension of the neck E. Rigidity to passive movement

A, C, E Rationale Nonintention tremors associated with Parkinson disease result from degeneration of the dopaminergic pathways and excess cholinergic activity in the feedback circuit. A masklike facial expression results from nigral and basal ganglial depletion of dopamine, an inhibitory neurotransmitter. Cogwheel rigidity is increased resistance to passive motion and is a classic sign of Parkinson. Constipation, not diarrhea, is a common problem because of a weakness of muscles used in defecation. The tendency is for the head and neck to be drawn forward, not hyperextended, because of loss of basal ganglial control.

A nurse is teaching a client with multiple sclerosis (MS) about how to manage urinary retention. Which instructions should the nurse include in the teaching session? Select all that apply. A. Using Credé maneuver B. Using an indwelling catheter C. Using anticholinergic medications D. Monitoring and restricting fluid intake to 800 mL daily E. Monitoring for and reporting signs of urinary tract infection

A, E Rationale Credé maneuver is the use of manual pressure over the suprapubic area to compress the bladder and promote emptying. Urinary retention is a risk factor for urinary tract infection. Physical stressors, such as infections, can trigger exacerbations in clients with multiple sclerosis. Early recognition and treatment of infection is important to decrease the risk of exacerbation in the client with multiple sclerosis. Use of an indwelling urinary catheter puts the client at risk for urinary tract infection. Some clients with urinary retention are taught intermittent self-catheterization. Risk of urinary tract infection is lower with intermittent catheterization than with the use of an indwelling urinary catheter. Acetylcholine is the primary neurotransmitter of the parasympathetic nervous system. Stimulation of the parasympathetic nervous system causes the detrusor muscle to contract, which promotes bladder emptying. Anticholinergic medications inhibit the cholinergic response and lead to urinary retention. Oral fluids should be encouraged in the client with voiding difficulties as concentrated urine increases the risk of urinary tract infection.

A client has inflammation of the facial nerve, causing facial paralysis on one side. Which diagnosis will the nurse most likely observe written in the medical record? A. Botulism B. Bell palsy C. Trigeminal neuralgia D. Guillain-Barré syndrome

B Rationale Bell palsy is a cranial nerve disorder characterized by inflammation of the facial nerve on one side of the face. Botulism is a type of polyneuropathy caused by food poisoning due to Clostridium botulinum that can be fatal. Trigeminal neuralgia is a cranial nerve disorder characterized by pain in the distribution of the trigeminal nerve. Guillain-Barré syndrome is an acute, rapidly progressing, potentially fatal polyneuritis.

Which information should be included in the teaching plan for the client diagnosed with epilepsy? A. Antiseizure medication must be taken for life. B. People taking phenytoin must floss regularly. C. People with epilepsy can never be issued a driver's license. D. Loss of consciousness during a seizure requires emergency evaluation.

B Rationale Gingival hyperplasia is a common side effect of phenytoin. Regular brushing and flossing decrease gingival hyperplasia. While lifelong treatment with antiseizure medication often is required, some people are able to be weaned from antiseizure medication after they have been seizure free for a period of several years (generally 3 to 5) and have a normal EEG and neurologic examination. Driving laws for people with epilepsy vary from state to state. For example, some states require a seizure-free period of several months, and some states require a seizure-free period of up to a year before a driver's license can be issued or reinstated. It is not necessary for the person who has experienced a single seizure to be taken to the hospital unless it is a first-time seizure, the seizure is prolonged, or the seizure results in bodily harm.

A client has surgery for the creation of burr holes after sustaining head trauma. Which early clinical manifestation of meningeal irritation does the nurse assess in the client? A. Sunset eyes B. Kernig sign C. Plantar reflex D. Homans sign

B Rationale Kernig sign, which is an inability to completely extend the legs, is the classic sign of meningeal irritation. "Sunset eyes" is associated with hydrocephalus; it occurs when the eyelid falls above the iris, allowing the sclera to show. It occurs only in infants whose cranial bones have not yet fused. Plantar reflex, a spinal cord reflex, is unrelated to meningeal irritation. Homans sign indicates the presence of thrombophlebitis; pain is experienced when the foot is dorsiflexed because of vascular irritability.

When making rounds, a nurse observes a client who is experiencing a seizure. What should the nurse do? A. Hyperextend the client's neck B. Move obstacles away from the client C. Restrain the client's body movements D. Attempt to place an airway in the client's mouth

B Rationale Moving obstacles away from the client helps the client avoid hitting objects and thus prevents trauma during the tonic-clonic phase of the seizure[1][2]. Hyperextending the neck is contraindicated; it may injure the client. Restraining the client's body movements is contraindicated; it may injure the client. Attempting to place an airway in the client's mouth during the tonic-clonic phase of the seizure can cause injury.

A client is admitted to the hospital with numbness of the hands and feet, which has progressed upward and now involves the arms, legs, and lower trunk. The client tells the nurse that approximately two weeks ago, the client experienced 48 hours of chills, fever, and upper respiratory congestion. A tentative diagnosis of Guillain-Barré syndrome is made. The nurse assesses for what major clinical manifestations of the syndrome? A. Ptosis and dysphagia B. Paresthesias and paralysis C. Atrophy and fasciculations D. Muscle weakness and drooling

B Rationale Paresthesias and paralysis result from patchy demyelinization of the peripheral nerves, nerve roots, root ganglia, and spinal cord and are related to a diagnosis of Guillain-Barré syndrome. Ptosis and dysphagia are related to myasthenia gravis. Atrophy and fasciculations are related to amyotrophic lateral sclerosis. Muscle weakness and drooling are related to Parkinson disease.

A recently hospitalized client with multiple sclerosis is concerned about generalized weakness and fluctuating physical status. What is the prioritynursing intervention for this client? A. Encourage bed rest. B. Space activities throughout the day. C. Teach the limitations imposed by the disease. D. Have one of the client's relatives stay at the bedside.

B Rationale Spacing activities will encourage maximum functioning within the limits of strength and fatigue. Bed rest and limited activity may lead to muscle atrophy and calcium depletion. Strengths, rather than limitations, should be stressed. Having one of the client's relatives stay at the bedside is unnecessary. It is the nurse's responsibility to maintain client safety and meet client needs.

A client with multiple sclerosis is in remission. Which diversional activity should the nurse encourage that best meets the client's needs while in remission? A. Hiking B. Swimming C. Sewing classes D. Watching television

B Rationale Swimming helps keep the muscles supple, without requiring fine-motor activity. Hiking might prove too rigorous for the client. Sewing requires fine-motor activity and will be difficult for the client. Sedentary activities are not helpful in maintaining muscle tone.

How should a nurse assess a client's trigeminal nerve function? A. Observing pupil constriction B. Identifying corneal sensation C. Determining the ability to smell D. Determining the ability to shrug the shoulders

B Rationale The afferent sensory branch of the trigeminal nerve ( cranial nerve V[1][2]) innervates the cornea. Observing pupil constriction tests the function of cranial nerve III. Determining the ability to smell tests cranial nerve I. Determining the ability to shrug the shoulders tests the function of cranial nerve XI.

The nurse is caring for a client with Parkinson disease. Which is a priority nursing concern? A. Decreased physical mobility related to stooped posture B. Risk for injury related to gait disturbances C. Impaired skin related to drooling D. Pain related to headache

B Rationale The client with Parkinson disease may fall because of gait disturbances. Decreased mobility and impaired skin are problems but not the priority. Pain is usually not a manifestation of Parkinson disease.

A client is admitted to the hospital after having a tonic-clonic seizure. The client has a two-year history of a seizure disorder, but the seizures have been well controlled by phenytoin for the last six months. The client says to the nurse, "I am so upset. I didn't think I was going to have more seizures." Which is the best response by the nurse? A. "Did you forget to take your medication?" B. "You are worried about having more seizures?" C. "You must be under a lot of stress right now." D. "Don't be too concerned because your medication needs to be increased."

B Rationale The response "You are worried about having more seizures?" addresses the client's feelings and encourages communication. The question "Did you forget to take your medication?" sounds accusatory; it ignores the client's feelings and discourages communication. Although the statement "You must be under a lot of stress right now" may be true, it does not encourage further communication concerning the seizure. The statement "Don't be too concerned because your medication needs to be increased" negates the client's feelings and discourages communication.

While hospitalized, a client has a hypertensive crisis and a brain attack (cerebrovascular accident, CVA). Initially, the nurse should place the client in which position? A. Supine B. Side-lying C. Orthopneic D. Trendelenburg

B Rationale The side-lying position will neither raise intracranial pressure nor interfere with respirations and will permit oral secretions to drain from the mouth by gravity. The supine position can compromise the airway by permitting the tongue to fall to the posterior pharynx and obstruct the airway. Orthopneic may place pressure on the brainstem. The Trendelenburg position is contraindicated because it may increase intracranial pressure.

A nurse identifies that a client exhibits the characteristic gait associated with Parkinson disease. When recording on the client's record, what term does the nurse use to document this gait? A. Ataxic B. Shuffling C. Scissoring D. Asymmetric

B Rationale With a shuffling gait[1][2][3] the steps are short and dragging; this is seen with basal ganglia defects. Ataxia is a staggering gait often associated with cerebellar damage. Scissoring is associated with bilateral spastic paresis of the legs. An asymmetric gait is associated with weakness of or pain in one lower extremity.

A client is admitted to the hospital with a diagnosis of myasthenia gravis. For which common early clinical finding should the nurse assess the client? A. Tearing B. Diplopia C. Nystagmus D. Exophthalmos

B Rationale With myasthenia gravis, the sensitivity of the end plates at the postsynaptic junction to acetylcholine is reduced, thus interfering with muscle contraction. Inadequate contraction of the ocular muscles results in double vision (diplopia). Tearing is not a clinical manifestation associated with myasthenia gravis. Nystagmus is not a clinical manifestation associated with myasthenia gravis; it is associated with multiple sclerosis. Exophthalmos is associated with hyperthyroidism.

A client is newly diagnosed with multiple sclerosis. The client is obviously upset with the diagnosis and asks, "Am I going to die?" Which is the nurse's best response? A. "Most individuals with your disease live a normal life span." B. "Is your family here? I would like to explain your disease to all of you." C. "The prognosis is variable; most individuals experience remissions and exacerbations." D. "Why don't you speak with your healthcare provider? You probably can get more details about your disease."

C Rationale "The prognosis is variable; most individuals experience remissions and exacerbations" is a truthful answer that provides some realistic hope. The response "Most individuals with your disease live a normal life span" provides false reassurance; repeated exacerbations may reduce the life span. The response "Is your family here? I would like to explain your disease to all of you" avoids the client's question; the family did not ask the question. The response "Why don't you speak with your healthcare provider? You probably can get more details about your disease" avoids the client's question and transfers responsibility to the practitioner.

A nurse is caring for a group of clients with myasthenia gravis, Guillain-Barré syndrome, and amyotrophic lateral sclerosis (ALS). Which information should the nurse consider when planning care for this group of clients? A. Progressive deterioration until death B. Deficiencies of essential neurotransmitters C. Increased risk for respiratory complications D. Involuntary twitching of small muscle groups

C Rationale All three share increased risk for respiratory complications. As a result of muscle weakness, the vital capacity is reduced, leading to increased risk of respiratory complications; impaired swallowing can also lead to aspiration. Although ALS is progressive, clients with myasthenia gravis may be stable with treatment, and clients with Guillain-Barré syndrome may experience a complete recovery. None of these diseases are caused by a lack of neurotransmitters; only myasthenia gravis is associated with a decreased number of receptor sites. Twitching is not expected with myasthenia gravis or Guillain-Barré syndrome.

A nurse is caring for a client with Bell palsy. Which goal is priority? A. Promoting ambulation B. Managing incontinence C. Preventing corneal damage D. Maintaining seizure precautions

C Rationale Bell palsy unilaterally affects the seventh cranial nerve, which innervates the face; the blink reflex is diminished, so corneal damage must be prevented. Managing incontinence, promoting ambulation, and maintaining seizure precautions are not necessary because Bell palsy involves the seventh cranial nerve, which innervates the facial muscles.

The laboratory reports of a client who underwent a hypophysectomy show an intracranial pressure (ICP) of 20 mmHg. Which action made by the client is responsible for this condition? A. Drinking lots of water B. Eating high-fiber foods C. Bending over at the waist D. Bending knees when lowering body

C Rationale Bending over at the waist should be avoided as this position increases intracranial pressure in clients who underwent hypophysectomy. Drinking lots of water and eating high-fiber foods reduce the risk of constipation, so this should not cause increased intracranial pressure. The client should bend the knees then lowering their body to reduce the risk of intracranial pressure.

A client who had a cerebrovascular accident (CVA, "brain attack") is starting to eat lunch. Which client behavior indicates to the nurse that the client may be experiencing left hemianopsia? A. Asks to have food moved to the left side of the tray B. Drops the coffee cup when trying to use the right hand C. Ignores the food on the left side of the tray when eating D. Reports not being able to use the right arm to help eat meals

C Rationale Clients with hemianopsia affecting the left field of vision cannot see whatever is in the left field of vision. Asking to have food moved to the left side of the tray may occur if the client has right hemianopsia and wishes to see better when eating. Dropping the coffee cup when trying to use the right hand may occur with right hemiparesis, not with hemianopsia. Reporting about not being able to use the right arm to help eat indicates hemiplegia, not hemianopsia.

The nurse is caring for a client two days after the client had a brain attack (cerebrovascular accident, CVA). To prevent the development of plantar flexion, which action should the nurse take? A. Place a pillow under the thighs. B. Elevate the knee gatch of the bed. C. Encourage active range of motion. D. Maintain the feet at right angles to the legs.

D Rationale Maintaining the feet at right angles to the legs produces dorsiflexion of the feet and prevents the tendons from shortening, preventing footdrop. Placing a pillow under the thighs and elevating the knee gatch of the bed will not prevent plantar flexion; it can promote hip and knee flexion contractures. The client will not have the ability or strength to perform range-of-motion exercises unassisted at this time.

A nurse is caring for two clients. One has Parkinson disease, and the other has myasthenia gravis. For which common complication associated with both disorders should the nurse assess these clients? A. Cogwheel gait B. Impaired cognition C. Difficulty swallowing D. Nonintention tremors

C Rationale Difficulty swallowing (dysphagia) is a manifestation of both neurologic disorders. With Parkinson disease there is a progressive loss of spontaneity of movement, including swallowing, related to degeneration of the dopamine-producing neurons in the substantia nigra of the midbrain. With myasthenia gravis there is a decreased number of acetylcholine (Ach) receptor sites at the neuromuscular junction, which interferes with muscle contraction, impairing muscles involved in chewing, swallowing, speaking, and breathing. A cogwheel gait is associated with Parkinson disease, not myasthenia gravis. Impaired cognition is associated with Parkinson disease, not myasthenia gravis. Nonintention tremors are associated with Parkinson disease, not myasthenia gravis. The nonintention tremors associated with Parkinson disease result from the loss of the inhibitory influence of dopamine in the basal ganglia, which interferes with the feedback circuit within the cerebral cortex.

Family members of a client who had a brain attack (cerebrovascular accident, CVA) ask why the client cries easily and without provocation. How does the nurse explain the client's behavior? A. Is making an attempt to get attention B. Has selective memory from the past, especially the sad events C. Has little control over this behavior D. Feels guilty about the demands being made on the family

C Rationale Emotional instability usually is caused by lesions affecting the thalamic area (the part of the neural system most responsible for emotions). Crying easily is not attention-getting behavior; lability of mood is a physiological response to the CVA. The client may have remote memory, but there is no selective process of what events are remembered. There are inadequate data to come to the conclusion that the client feels guilt. Lability of mood is a physiological response to the CVA.

A client is admitted to the hospital with weakness in the right extremities, and speech that is slightly slurred. A diagnosis of brain attack (cerebrovascular accident, CVA) is suspected. During the first 24 hours after symptom onset, which action is priority? A. Assess the temperature B. Monitor bowel sounds C. Evaluate motor status D. Obtain a urinalysis

C Rationale Evaluating the client's motor status will reveal whether there is a progression of symptoms. These data will assist the practitioner in determining a diagnosis. An elevation in temperature is not an early sign of an extension of a CVA. Monitoring bowel sounds is not the priority; motor ability takes precedence over peristalsis. Obtaining the client's urine for a urinalysis is not the priority assessment.

A client with myasthenia gravis asks the nurse why the disease has occurred. Which pathology underlies the nurse's reply? A. A genetic defect in the production of acetylcholine (ACh) B. An inefficient use of the neurotransmitter acetylcholine C. A decreased number of functioning acetylcholine receptor (AChR) sites D. An inhibition of the enzyme acetylcholinesterase (AChE), leaving the end plates folded

C Rationale One of the pathologic changes is fewer AChR sites; also, antibodies cause destruction and blockade at the AChR sites. There is no genetic defect in the production of ACh; rather than a genetic cause, it is thought that myasthenia gravis has an autoimmune etiology. Although the defect is at the neuromuscular junction, it is not an inefficiency in the use of ACh but a decrease in the number of receptor sites for ACh. AChE is inhibited by anticholinesterase drugs used to treat myasthenia gravis, leaving more ACh available to the damaged or decreased ACh receptors.

After a mild brain attack (cerebrovascular accident, CVA) a client has difficulty grasping objects with the dominant hand. To increase hand mobility and strength, what specific range-of-motion exercise should the nurse teach the client? A. Eversion B. Supination C. Opposition D. Circumduction

C Rationale Opposition occurs when the thumb, a saddle joint, sequentially touches the tip of each finger of the same hand; the thumb joint movements involved are abduction, rotation, and flexion. Strengthening the thumb facilitates grasping and holding objects in the hand. Eversion involves turning the sole of the foot outward by moving the ankle joint, which is a gliding joint. Supination involves moving the bones of the forearm so that the palm of the hand faces upward when held in front of the body. Circumduction involves movement of the distal part of the bone in a circle while the proximal end remains fixed; circumduction is used with ball-and-socket joints, such as the shoulder and hip.

A client is suspected of having myasthenia gravis. What are the most significant initial nursing assessments that should be performed? A. Ability to chew and speak distinctly B. Capacity to smile and close the eyelids C. Effectiveness of respiratory exchange and ability to swallow D. Degree of anxiety and concern about the suspected diagnosis

C Rationale Respiratory failure will require emergency intervention, and inability to swallow may lead to aspiration. Difficulty with chewing and speaking are signs of myasthenia gravis that may occur but are not life threatening. Ocular palsies and an inability to smile are signs of myasthenia gravis that may occur but are not life threatening. Although the client's level of anxiety and concerns about the diagnosis are important, they are not the most significant assessments.

A client has a diagnosis of multiple sclerosis and is currently in remission. The client is a parent of two active preschoolers. What should the nurse encourage the client to do? A. Plan a schedule of specific times each day that will be set aside for playtime with the children. B. While in remission, provide support to other people with multiple sclerosis who also have young children. C. Develop a flexible schedule for completion of routine daily activities. D. Meet with a self-help group for people with the diagnosis of multiple sclerosis.

C Rationale The client must be flexible and adjust activities to provide for rest when necessary; activity should cease before the point of fatigue. Although quality time with children is important, it must be done on a flexible schedule to prevent fatigue. Although laudable, providing support to other people with multiple sclerosis who also have young children cannot be done if the client is in need of support or if it overtaxes physical resources. Meeting with a self-help group for people with the diagnosis of multiple sclerosis may not be a need at this time; prevention of fatigue always is important.

A client diagnosed with Bell palsy has many questions about the course of the disorder. Which information should the nurse share with the client? A. Cool compresses decrease facial involvement. B. Pain occurs with transient ischemic attacks (TIAs). C. Most clients recover from the effects in several weeks. D. Body changes should be expected with residual effects.

C Rationale The client should be assured that the symptoms are not caused by a stroke; the majority of clients recover in a few weeks. Moist heat, not a cool compress, increases blood circulation to the nerve. Bell palsy is not caused by a TIA. Paresis or paralysis of cranial nerve VII occurs; pain is usually present. The majority of clients recover without residual effects; occasionally some clients are left with evidence of Bell palsy. Exercises may help to maintain muscle tone; also, surgery may be necessary.

Which is the priority assessment for the client with Guillain-Barré syndrome with rapidly ascending paralysis? A. Monitoring urinary output B. Assessing nutritional status C. Monitoring respiratory status D. Assessing communication needs

C Rationale The most serious complication of Guillain-Barré syndrome is respiratory failure caused by respiratory muscle paralysis. Urinary retention is common in Guillain-Barré, but monitoring urinary output is of lower priority than monitoring respiratory status. If ascending paralysis impairs the gag reflex, clients may require tube feedings or parenteral nutrition. Assessing nutritional status, however, is of lower priority than monitoring respiratory status. If ascending paralysis impairs cranial nerve functioning, or if the client is intubated, verbal communication abilities are lost.

A client newly diagnosed with multiple sclerosis asks the nurse if it will be painful. Which response should the nurse give the client first? A. "Tell me more about your fears regarding pain." B. "Medications will be prescribed to help control pain." C. "Pain is a common symptom of this condition." D. "Let's list your questions for the healthcare provider."

C Rationale The response "Pain is a common symptom of this condition" is a truthful answer for the client. Reassuring the client that "medications will be prescribed to help control pain" when the client experiences it is the next helpful response from the nurse. After being truthful about pain and reassuring the client about its medical management, asking the client to "tell more about...fears regarding pain" opens the conversation to discuss it and offers an opportunity for emotional release, which can decrease anxiety. The response "Let's list your questions for the healthcare provider" is a helpful final conversation during this encounter because it teaches the client how to make the most of their visit with the healthcare provider.

A client with multiple sclerosis is informed that this is a chronic, progressive neurologic condition. The client asks the nurse, "Will I experience unbearable pain?" What is the nurse's best response? A. "Tell me about your fears regarding pain." B. "Analgesics will be prescribed to control the pain." C. "Some clients report feeling a tingling or burning sensation but not unbearable pain." D. "Let's make a list of the things you need to ask your healthcare provider."

C Rationale The response, "Some clients report feeling a tingling or burning sensation[1][2], but not unbearable pain," is a truthful answer that provides hope for the client. Although neuropathic pain may sometimes occur, it does not occur in all clients. These clients more typically have diminished sensitivity to pain and paresthesias (e.g., tingling, burning, crawling sensations). The response, "Tell me about your fears regarding pain," avoids the client's question and may increase anxiety. Analgesics are not commonly prescribed unless pain results from some other condition. The response, "Let's make a list of the things you need to ask your healthcare provider," avoids the client's question and abdicates the nurse's responsibility.

A client with a history of hypertension is admitted to the hospital immediately after a brain attack (cerebrovascular accident, CVA). The client is unconscious, and the vital signs are temperature 98° F (36.7° C), pulse 78 beats per minute, respiration 16 breaths per minute, and blood pressure 120/80 mm Hg. Which nursing concern is a priority for this client? A. Injury B. Constipation C. Respiratory distress D. Decreased fluid volume

C Rationale The risk for an obstructed airway is the priority when a client is unconscious; reduced oxygen intake may lead to serious complications. Although protecting the client from injury is important, it is not as life threatening as an obstructed airway. Although important, constipation is not as life threatening as an obstructed airway. Although maintaining fluid balance is important, it is not as critical as maintaining a patent airway.

A client is experiencing diplopia, ptosis, and mild dysphagia. Myasthenia gravis is diagnosed, and an anticholinergic medication is prescribed. The nurse is planning care with the client and spouse. What instruction is the priority? A. Eat foods that are pureed. B. Perform range-of-motion exercises. C. Take a stool softener daily. D. Take the medication according to a specific schedule.

D Rationale A priority of care for a client with myasthenia gravis[1][2] is to take medication according to a specific schedule; for example, the anticholinergic medication should be taken before meals because it enhances chewing and swallowing. Dysphagia usually is not an initial problem with myasthenia gravis. A variety of foods in texture and taste should be encouraged. Mechanical soft foods or chopped foods should be eaten until the dysphagia progresses to the point that pureed foods are necessary. Although movement and mobility are important, range-of-motion exercises prevent joint contractures rather than promote muscle strength. Anticholinergic medications taken for myasthenia gravis cause relaxation of smooth muscle, resulting in diarrhea rather than constipation.

A client who had a brain attack (cerebrovascular accident, CVA) has left-sided hemiparesis but is able to ambulate with assistance. When getting up from a lying position, the client reports feeling lightheaded and dizzy. The nurse explains that these clinical manifestations are a result of which condition? A. Inflamed peripheral nerves B. Loss of blood and blood volume C. Demyelination of peripheral nerves D. Blood pooling in the lower extremities

D Rationale Dilation of blood vessels causes dependent pooling when the client moves to an upright position, resulting in orthostatic (postural) hypotension. The client can limit feelings of lightheadedness and dizziness by moving gradually when changing positions. Inflammation of peripheral nerves is not the cause of the clinical manifestations. Inflamed peripheral nerves can cause neuropathies. Loss of blood and blood volume causes hypovolemia, leading to shock. Demyelination of peripheral nerves leads to multiple sclerosis.

A client who recently experienced a brain attack (cerebrovascular accident, CVA) and who has limited mobility reports constipation. What is mostimportant for the nurse to determine when collecting information about the constipation? A. Presence of distention B. Extent of weight gained C. Amount of high-fiber food consumed D. Length of time this problem has existed

D Rationale First, the nurse should establish when the client last defecated because the client may have perceived constipation. Abdominal distention may or may not be observed with constipation. Weight gain has no relationship to constipation. Although lack of bulk in the diet can lead to constipation, particularly in clients with limited activity or an inadequate fluid intake, the lack of bulk in the diet is not the most significant information to obtain at this time.

A client has a tonic-clonic seizure at work and is admitted to the emergency department. Which question is most useful when planning nursing care related to the client's seizure? A. "Is your job demanding or stressful most of the time?" B. "Do you participate in any strenuous sports activities on a regular basis?" C. "Does anyone in your family have a history of central nervous system problems?" D. "Were you aware of anything different or unusual just before your seizure began?"

D Rationale Identification of a sensation that occurs before each seizure[1][2] (aura) is helpful in identifying the cause of the seizure and planning how to identify and avoid a future seizure. Although the response "Is your job demanding or stressful most of the time?" may provide some information, it is not the most inclusive question the nurse can ask; also, it limits the client's reply. Although the response "Do you participate in any strenuous sports activities on a regular basis?" may provide some information, it is not the most inclusive question the nurse can ask; also, it limits the client's reply. Although the response "Does anyone in your family have a history of central nervous system problems?" may provide some information, it is not the most inclusive question the nurse can ask; also, it limits the client's reply.

A client with dementia and chronic confusion is suspected to have Alzheimer disease. Which imaging technique is specific for Alzheimer disease? A. Diffusion imaging (DI) B. Magnetic resonance imaging (MRI) C. Magnetic resonance angiography (MRA) D. Magnetic resonance spectroscopy (MRS)

D Rationale In diseases such as Alzheimer disease, stroke, and epilepsy, the biochemical process in the brain is altered. Abnormalities in biochemical processes of the brain are diagnosed with magnetic resonance spectroscopy (MRS). Diffusion imaging (DI) is used to evaluate ischemia in the brain to determine the location and severity of a stroke. Magnetic resonance imaging (MRI) involves taking multiple sets of images to determine normal and abnormal anatomy. Magnetic resonance angiography (MRA) is used to evaluate blood flow and blood vessel abnormalities, such as arterial blockage, intracranial aneurysms, and arteriovenous malformations in the brain.

A client with the diagnosis of multiple sclerosis (MS) develops hand tremors. When performing a history and physical assessment, which finding should the nurse expect the client to report? A.The tremors increase when I fall asleep. B. The tremors increase when I feel fatigued. C. The tremors increase when I become nervous. D. The tremors increase when I perform an activity.

D Rationale Multiple foci of demyelination cause interruption or distortion of the impulse, resulting in intention tremors (tremor when performing an activity). There are no tremors when the client is asleep. Fatigue will exacerbate the signs and symptoms of multiple sclerosis, but it will not precipitate intention tremors. Intention tremors are associated with muscle contraction, not feelings; however, stress can exacerbate the signs and symptoms of multiple sclerosis.

A client with parkinsonism is taking an anticholinergic medication for morning stiffness and tremors in the right arm. During a visit to the clinic, the client complains of some numbness in the left hand. What is the nurse's priority intervention? A. Refer the client to the primary healthcare provider only if other neurologic deficits are present. B. Ask the primary healthcare provider to increase the client's dosage of the anticholinergic medication. C. Stress the importance of having the client call the primary healthcare provider as soon as possible. D. Make arrangements immediately for further medical evaluation by the client's primary healthcare provider.

D Rationale Numbness, a sensory deficit, is inconsistent with parkinsonism; further medical evaluation is necessary. Numbness, even in the absence of other problems, may be indicative of an impending brain attack (cerebrovascular accident, CVA). This symptom is not caused by parkinsonism; increasing the dosage of the anticholinergic medication will not be helpful. Stressing the importance of having the client call the primary healthcare provider as soon as possible can cause a delay in the client's receiving immediate medical attention.

A client with the diagnosis of multiple sclerosis experiences a sudden loss of vision and asks the nurse what caused it to happen. The nurse considers the common clinical findings associated with multiple sclerosis before responding. Which is the most probable cause of the client's sudden loss of vision? A. Virus-induced iritis B. Intracranial pressure C. Closed-angle glaucoma D. Optic nerve inflammation

D Rationale Optic nerve inflammation is a common early effect of multiple sclerosis caused by lesions in the optic nerves or their connections (demyelization). This effect may resolve during periods of remission. At present there is no evidence of viral infection of the eyes in multiple sclerosis. Tumors of the brain and cerebral edema, not multiple sclerosis, cause increased intracranial pressure because the skull cannot expand. Closed-angle glaucoma causes blindness as a result of increased intraocular pressure, not inflammation of the optic nerve, which is commonly associated with multiple sclerosis. Closed-angle glaucoma is unrelated to multiple sclerosis.

A client is diagnosed with Parkinson disease and asks the nurse what causes the disease. On which underlying pathology does the nurse base a response? A. Disintegration of the myelin sheath B. Breakdown of upper and lower neurons C. Reduced acetylcholine receptors at synapses D. Degeneration of the neurons of the basal ganglia

D Rationale Parkinson disease involves destruction of the neurons of the substantia nigra, reducing dopamine. The cause of this destruction is unknown. Disintegration of the myelin sheath is associated with multiple sclerosis. Breakdown of upper and lower motor neurons is associated with Lou Gehrig disease or amyotrophic lateral sclerosis. Reduced acetylcholine receptors at synapses are associated with myasthenia gravis.

A client is having a tonic-clonic seizure. Which is a priority nursing action? A. Elevating the head of the bed B. Restraining the client's arms and legs C. Placing a tongue blade in the client's mouth D. Taking measures to prevent injury

D Rationale Protecting the client from injury is the immediate priority during a seizure[1][2]. Elevating the head of the bed would have no effect on the client's condition or safety. Restraining the client's arms and legs could cause injury. Placing a tongue blade or other object in the client's mouth could damage the teeth.

A client has a tonic-clonic seizure. Which is the priority nursing intervention during the tonic-clonic stage of the seizure? A. Go for additional help B. Establish a patent airway C. Turn the client on the side D. Protect the client from injury

D Rationale Protecting the client from injury, together with observation and documentation of the seizure activity, is the primary nursing care for a client with a tonic-clonic seizure. The client should not be left unattended. Establishing a patent airway is done after the seizure; the mouth should not be pried open to insert an airway during a seizure because injury may occur. Turning the client on the side will assist with establishing an airway after the seizure, but it is an unsafe action during a seizure.

What should the nurse instruct the client to do to limit triggering the pain associated with trigeminal neuralgia? A. Drink iced liquids. B. Avoid oral hygiene. C. Apply warm compresses. D. Chew on the unaffected side.

D Rationale The client may avoid stimulating the involved trigeminal nerve and thus prevent pain by chewing on the unaffected side. Food and fluids that are too hot or too cold can precipitate pain. Although oral hygiene may initiate pain, it cannot be avoided. It can be modified to include rinsing the mouth or using a soft swab instead of a toothbrush. Warm compresses may precipitate pain.

After sustaining a head trauma, a client reports hearing ringing noises. Which area should the nurse assess further? A. Frontal lobe B. Occipital lobe C. Sixth cranial nerve (abducens) D. Eighth cranial nerve (vestibulocochlear)

D Rationale The eighth cranial nerve has two parts: the vestibular nerve and the cochlear nerve[1][2][3]. Sensations of hearing are conducted by the cochlear nerve. The frontal lobe is concerned with thinking and emotions. The occipital lobe is concerned with sight, particularly shape and color. Cranial nerve VI (abducens) is concerned with abduction of the eye.

A client is admitted to the hospital with a diagnosis of acute Guillain-Barré syndrome. Which assessment is priority? A. Urinary output B. Sensation to touch C. Neurologic status D. Respiratory exchange

D Rationale The respiratory center in the medulla oblongata can be affected with acute Guillain-Barré syndrome because the ascending paralysis can reach the diaphragm, leading to death from respiratory failure. Although urinary output, sensation to touch, and neurologic status are important, none of them are the priority.

A client who has a history of seizures is scheduled for an arteriogram at 10:00 AM and is to have nothing by mouth before the test. The client is scheduled to receive an anticonvulsant medication at 9:00 AM. What should the nurse do? A. Omit the 9:00 AM dose of the drug. B. Give the same dosage of the drug rectally. C. Administer the drug with 30 mL of water at 9:00 AM. D. Ask the healthcare provider to prescribe an alternate route of administration.

D Rationale To achieve the anticonvulsant effect, therapeutic blood levels must be maintained. If the client is not able to take the prescribed oral preparation, the healthcare provider should be questioned about alternate routes of administration. Omission will result in lowered blood levels, possibly to less than the necessary therapeutic level to prevent a seizure. The route of administration cannot be altered without healthcare provider approval. The client is being kept nothing by mouth.