Neuro - Sem 3 Nclex
A resident in a LTC facility prepares to walk out into a rainstorm after saying, "My father is waiting to take me for a ride." Which of the following would be an appropriate response by the nurse?
"I'm glad you told me that. Let's have a cup of coffee & you can tell me about your father."
A nurse is assigned to care for an adult pt who had a brain attack (stroke) & is aphasic. Choose the appropriate interventions for communicating with the pt. Select all that apply.
- Give the pt directions using short phrases & simple terms - Face the pt when talking. - Speak slowly & maintain eye contact. - Use gestures when talking to enhance words
A nurse is planning to institute seizure precautions for a pt who's being admitted from the ER. Which of the following measures should the nurse AVOID in planning for the pts safety?
Putting a padded tongue blade at the HOB
A nurse reviews the HCPs tx plan for a pt with Guillain-Barré syndrome. Which rx, if noted in the pts record, should the nurse question?
Clear liquid diet * Rationale: Pts with Guillain-Barré syndrome have dysphagia. Pts with dysphagia are more likely to aspirate clear liquids than thick or semisolid foods. Pts with Guillain-Barré syndrome are at r/f hypotension or hypertension, bradycardia, & respiratory depression & require freq monitoring of VS. PROM exercises can help prevent contractures, & checking calf measurements can help detect DVT, for which pts are at risk
A client recovering from a head injury is arousable & participating in care. The nurse determines that the pt understands measures to prevent elevations in ICP if the nurse observes the pt doing which of the following activities?
Exhaling during repositioning
An adult pt had a cerebrospinal fluid (CSF) analysis after lumbar puncture. The nurse interprets that a negative value of which of the following is consistent with normal findings?
RBC * Rationale: The adult with normal CSF has no RBCs in the CSF. The pt may have small levels of WBCs (0-3 per mm3). Protein (15-45 mg/dL) & glucose (40 to 80 mg/dL) are normally present in CSF
A pt has a halo vest that was applied following a C6 spinal cord injury. The nurse performs which of the following to determine whether the pt is ready to begin sitting up?
Compares the pts pulse & BP when both flat & sitting * Rationale: Pts with cervical spinal cord injuries may lose control over peripheral vasoconstriction, causing postural (orthostatic) hypotension when upright. A drop of 15 mm Hg in the systolic pressure or 10 mm Hg in the diastolic pressure accompanied by an increase in HR when the head is elevated may indicate autonomic insufficiency that can cause dizziness or syncope in the upright position. The halo vest is not loosened by the nurse. The vest provides trunk stability for sitting
A nurse is trying to communicate with a brain attack (stroke) pt with aphasia. Which action by the nurse would be LEAST helpful to the pt?
Completing sentences the pt cannot finish
A nurse reinforces what info to a pt who is scheduled for an electromyogram (EMG)?
Electrodes will be injected into the skeletal muscles * Rationale: EMG involves insertion of needle electrodes into selected skeletal muscles to evaluate changes & electrical potential of the muscles & the nerves that lead to them. The test is useful in evaluating suspected lumbar or cervical disk disease, myasthenia gravis, muscular dystrophy, & other musculoskeletal diseases. The pt should be reassured that the needle will not electrocute them, & that they'll experience sensations comparable to an injection as the needles are inserted. An informed consent form is required, & no other special prep is required for this test
A nurse is caring for a pt who sustained a spinal cord injury. While admin am care, the pt developed s/s of autonomic dysreflexia. The initial nursing action is to?
Elevate the HOB * Rationale: Autonomic dysreflexia is a serious complication that can occur in the spinal cord of the injured pt. Once the syndrome is identified, the nurse elevates the HOB & then examines the pt for the source of noxious stimuli. The nurse also assesses the pts BP, but the initial action is to elevate the HOB. The pt should NOT be placed in the prone position
A pt with right leg hemiplegia is experiencing difficulty with mobility. The nurse determines that the family needs reinforcement of teaching if the nurse observes which of the following being done by the family?
Encourage the pt to stand unassisted on the leg
A pt with Guillain-Barré syndrome has been asking many questions about the condition, & the nursing staff feels that the pt is very discouraged about her condition. It is important for the nurse to include which of the following info in discussions with the pt?
Generally, a vast # of people recover from this condition * Rationale: The vast majority of pts with Guillain-Barré syndrome recover from the paralysis because it affects peripheral nerves that have the capacity to remyelinate. Maximum paralysis can take up to 4 wks to develop. Paralysis progresses distally to proximally. Rehab can take 6 months-2 years
A pt with a brain attack (stroke) has residual dysphagia. When a diet rx is initiated, the nurse avoids doing which of the following?
Giving the pt thin liquids * Rationale: Before the pt with dysphagia is started on a diet, the gag & swallow reflexes must have returned. The pt is assisted with meals as needed & is given ample time to chew & swallow. Food is placed on the unaffected side of the mouth. Liquids are thickened to avoid aspiration
A nurse is assisting in caring for a pt with a supratentorial lesion. The nurse monitors which of the following as the critical index of CNS dysfunction?
LOC * Rationale: LOC is the most critical index of CNS dysfunction. Changes in LOC can indicate clinical improvement or deterioration. Although BP, temp, & ability to speak may be components of the assessment, the pt LOC is the most critical index of CNS dysfunction
A nurse is assisting to care for a pt who has sustained a nasal fx. The nurse monitors for which priority finding specifically r/t this injury?
Leakage of clear fluid from the nose * Rationale: This could be cerebrospinal fluid (CSF), and may be indicative of cerebral injury. Any discharge of fluid from the nose should be tested to determine whether it is CSF. Hematoma formation around the eyes & edema around the nose & eyes are common manifestations of nasal fx
A nurse is turning a postop pt who had extensive back surgery yesterday. What turning intervention or position would be best for repositioning this pt?
Logrolling * Rationale: Logrolling is used to maintain neck & spinal alignment after injury or surgery. A minimum of 3-4 staff members is recommended to prevent injury to the pt, & a draw or pull sheet is also suggested
A nurse is collecting data on a pt suspected of having Alzheimer's disease. The priority data would focus on which of the following characteristic of this disease?
Recent memory loss * Rationale: Dementia is the hallmark of Alzheimer's disease. Recent memory loss is 1 characteristic. Others include problems with abstract thinking, problems with speech (not hearing), & difficulty in performing familiar tasks
A nurse is monitoring a pt with a spinal cord injury who is experiencing spinal shock. Which of the following will provide the nurse with the best info about recovery from the spinal shock?
Reflexes * Rationale: Areflexia characterizes spinal shock; therefore reflexes would provide the best info
A nurse is caring for a pt who begins to experience seizure activity while in bed. Which action by the nurse would be contraindicated?
Restrain the pts limbs
A nurse has applied a hypothermia blanket to a pt with a fever. The nurse should inspect the skin frequently to detect which complication of hypothermia blanket use?
Skin breakdown
A nurse is preparing to care for a pt with a dx of brain attack (stroke). The nurse notes in the pts record that the pt has anosognosia. The nurse plans care, knowing that the pt will:
Neglect the affected side
A pt is somewhat nervous about having MRI. Which statement by the nurse would provide reassurance to the pt about the procedure?
"Even though you are alone in the scanner, you will be in voice communication with the technologist during the procedure."
A nurse is collecting data on a pt with myasthenia gravis. The nurse determines that the pt may be developing myasthenic crisis if the pt states:
"I can't swallow very well today." * Rationale: Because dysphagia is a classic sx of myasthenia gravis exacerbation, observing how a pt is able to ingest food is an important assessment. Timing of this med is of paramount concern
A nurse is providing instructions to the pt who has just been fitted for a halo vest. Which statement by the pt indicates the need for further instructions?
"I will avoid driving at night because the vest limits the ability to turn the head." * Rationale: The pt wearing a halo vest should not drive at all because the device impairs head movement & the range of vision. The inability to turn the head without turning the torso would make driving contraindicated. The halo device does alter balance & can pose increased r/o falls for the pt. The pt should clean the skin daily under the vest to protect the skin from ulceration & should use powder or lotions sparingly or not at all. The pt should have food cut into small pieces to facilitate chewing & use straws for drinking, because the head immobilization makes eating & drinking harder
A nurse is preparing for the admission of a pt with a rx for seizure precautions. Which supplies will the nurse make available to this pt? Select all that apply
- Rx Diazepam (Valium) - Suction machine - O2 admin - Padding for the side rails
A nurse is preparing for the admission of a pt with a suspected dx of herpes simplex encephalitis. Which dx test will be rx to confirm this dx?
Brain biopsy * Rationale: The dx of herpes simplex encephalitis can be made by brain biopsy & is rarely made from the culture of CSF obtained from a lumbar puncture. The EEG is abnormal, in many cases, indicating temporal lobe abnormalities but will not confirm the diagndx osis. The CT scan is normal up to the first 5 days, with low-density lesions in the temporal lobe noted later
A pt who's paraplegic after spinal cord injury has been taught muscle-strengthening exercises for the upper body. The nurse determines that the pt will derive the least muscle-strengthening benefit from which activity?
Doing active ROM to finger joints * Rationale: ROM exercises of the finger joints prevent contractures but do not actively strengthen muscle groups needed for self-mobilization with paraplegia. Other activities that are more effective include push-ups from a prone position, sit-ups from a sitting position, extending the arms while holding wts, & squeezing rubber balls or crumpling newspaper
A pt with suspected Guillain-Barré syndrome has a lumbar puncture performed. The CSF protein is 750 mg/dL. The nurse analyzes these results as:
Higher than normal supporting the dx of Guillain-Barré * Rationale: 7-10 days following the onset of sx of Guillain-Barré, the spinal fluid protein levels become extremely high. Normal CSF protein is 15-45 mg/dL. A value of 750 mg/dL is higher than normal, supporting the dx of Guillain-Barré
A nurse is collecting neurological data on a post-stroke adult pt. Which of the following techniques will the nurse perform to adequately check proprioception?
Hold the sides of the pts great toe &, while moving it, ask what position it is in
A nurse is planning care for a pt with Bell's palsy. Which measure should be included in the plan?
Instill artificial tears & wear a patch over the affected eye at night * Rationale: Instilling artificial tears & patching the affected eye at night protects the eye from corneal abrasions. Warm packs, not cold, will alleviate discomfort. Wearing dark glasses are recommended, as is gentle massage of the affected side
A nurse is assisting in admitting a pt who experienced seizure activity in the ER. The nurse avoids doing which of the following when managing this pts environment?
Keeping the bed position raised to the nurse's waist level
A nurse observes that a pt with Parkinson's disease has very little facial expression. The nurse attributes this piece of data to which of the following?
Mask-like facies is a component of Parkinson's disease
A nurse working in a LTC facility is approached by the son of a resident, who wants his 78 yo father to have a heating pad, because "his feet are always cold at night." The nurse should incorporate which of the following concepts when formulating a response to the family member?
Older adults often have slower neurological response times & are therefore more at r/f burns
An older pt is at r/f falls. When developing an individualized POC for this pt, the nurse recalls that which concept is least relevant to maintenance of balance for the older pt?
Older pts cannot think quickly enough to respond to emergencies
A pt has just undergone lumbar puncture (LP). The nurse assists the pt into which most optimal position if tolerated by the pt?
Prone with a pillow under he abdomen * Rational: This position helps minimize or prevent continued leakage of CSF from the site by enlisting the aid of gravity. If the pt cannot tolerate this position, the pt should be positioned flat in bed & turned from side to side as necessary. It is important that the HOB remain flat to prevent CSF leakage & to prevent postprocedure headache
A pt seeking tx for an episode of hyperthermia is being d/c to home. The nurse determines that the pt needs clarification of d/c instructions if the pt stated that he/she will:
Resume full activity level immediately * Rationale: D/c instructions for the pt hospitalized for hyperthermia include prevention of heat-related d/o's, increased fluid intake for 24 hrs, self-monitoring of voiding, & the importance of staying in a cool environment & resting
A nurse has given instructions to the pt with Parkinson's disease about maintaining mobility. The nurse determines that the pt understands the directions if the pt states that he/she will:
Rock back & forth to start movement with bradykinesia * Rationale: The pt with Parkinson's disease should exercise in the am, when energy levels are highest. The pt should avoid sitting in soft, deep chairs because getting up from them can be difficult. The pt can rock back & forth to initiate movement. The pt should buy clothes with Velcro fasteners & slide-locking buckles to allow for easier dressing
A pt with quadriplegia complains bitterly about the nurse's slow response to the call light & the rigidity of the therapy schedule. Which interpretation of this behavior would serve as a basis for planning nursing care?
The pt is reacting to loss of control * Rationale: Pts who feel a sense of control over their situation will adapt to their limitations more readily that those who think that they have lost control. Both of the pts complaints indicate a need for greater control. Pts should be offered an opportunity for input into scheduling & planning for staff response to their needs
A nurse is admin mouth care to an unconscious pt. The nurse should avoid doing which of the following?
Using products with lemon or ETOH
A nurse is assisting with caring for a pt after a craniotomy. The nurse plans to position the pt in a:
Semi Fowler's position * Rationale: After a craniotomy, the HOB is elevated 30-45* (semi-Fowler's-Fowler's position), & the pts head is maintained in a midline, neutral position to facilitate venous drainage
A pt with a neurological impairment experiences urinary incontinence. Which nursing action should help the pt adapt to this alteration?
Establishing a toileting schedule * Rationale: A bladder retraining program, such as use of a toileting schedule, may be helpful to pts experiencing urinary incontinence. A Foley cath should be used only when necessary because of r/o infection. Use of diapers/pads is the least acceptable alternative because the r/o skin breakdown exists
A nurse is monitoring a pt with a spinal cord injury for sx of spinal shock. Which of the following is indicative of this complication of a spinal cord injury?
Areflexia below the level of injury * Rationale: Spinal shock represents a temp but profound disruption of spinal cord function, which occurs immed after injury & is clinically evident within 30-60 minutes. It is a state of areflexia characterized by the loss of all neurological function below the level of injury. Flaccid paralysis, bradycardia, & hypotension occur. The body is unable to use either shivering or perspiring as a means of controlling body temp
A pt in the ER is dx with Bell's palsy. The nurse collecting data on this pt EXPECTS to note which of the following?
A lag in closing the bottom eyelid * Rationale: The facial drooping associated with Bell's palsy makes it difficult for the pt to close the eye lid on the affected side. A widening of the palpebral fissure (the opening between the eyelids) & an asymmetrical smile are seen with Bell's palsy
A pt with spinal cord injury becomes angry & belligerent whenever the nurse tries to admin care. The nurse should:
Acknowledge the pts anger & continue to encourage participation in care
A pt with spinal cord injury has experienced more than 1 episode of autonomic dysreflexia. The nurse would AVOID which of the following that could trigger an episode of this complication?
Allowing the pts bladder to become distended * Rationale: Autonomic dysreflexia is triggered most freq by a distended bladder. To prevent this, straight cath is done q4-6 hrs, & Foley caths are checked freq to prevent kinks in the tubing. Constipation & fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse admins care to minimize risk in these areas
The nurse overhears the term "sundowning" used to describe the behavior of a pt newly admitted to the nursing unit during the previous evening shift. The nurse interprets that this pt most likely has a dx of:
Alzheimer's disease * Rationale: The term "sundowning" or "sundown syndrome" refers to a pattern of disorientation in which the pt is more oriented during the daytime hours & more disoriented at night. It is seen often in pts with Alzheimer's disease. It is not a characteristic of the conditions noted in the other options
Which of the following information will the nurse REINFORC to the pt scheduled for a lumbar puncture?
An informed consent is required * Rationale: Pt prep for lumbar puncture includes obtaining informed consent from the pt. No dietary or food restrictions are required before the test. The pt is told that the test will take approximately 15-60 minutes. The nurse needs to inform the pt about the need for bedrest following the test
A nurse is collecting data on a pt with Parkinson's disease. Which finding indicates a serious complication of this d/o?
Congested cough & coarse rhonchi heard on auscultation * Rationale: PTs with Parkinson's disease are at r/f aspiration. A congested cough & coarse rhonchi may be present after a pt aspirates. Although constipation is a problem for pts with Parkinson's disease, the concern is greater if the pt has not had a BM by the 3rd day. Resting & pill-rolling tremors & a shuffling, propulsive gait are characteristic findings in Parkinson's disease
A nurse is trying to help the family of an unconscious pt cope with the situation. Which intervention should the nurse plan to incorporate into the care routine for the pt?
Explaining equipment & procedures on an ongoing basis
A nurse is caring for a pt with a dx of brain attack (stroke) with anosognosia. To meet the needs of the pt with this deficit, the nurse plans activities that will:
Increase the client's awareness of the affected side * Rationale: In anosognosia, the pt neglects the affected side of the body. The nurse should plan care activities that encourage the pt to look at the affected arm or leg & that will increase the pts awareness of the affected side
A pt with spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should avoid which measure to minimize the r/o recurrence?
Limiting bladder catheterization to once q12 hours * Rationale: The most freq cause of autonomic dysreflexia is a distended bladder. Straight cath should be performed every 4-6 hrs, & Foley caths should be checked freq for kinks in the tubing. Constipation & fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse admins care to minimize risk in these areas
A nurse is suctioning an unconscious pt who has a tracheostomy. The nurse should avoid which action during this procedure?
Making sure not to suction for longer than 30 seconds * Rationale: Suction equipment should be kept at the bedside of an unconscious pt, regardless of whether an artificial airway is present. The nurse auscultates breath sounds every 2-4 hrs, or more freq if there is a need. The pt should be hyperoxygenated before, during, & after suctioning to minimize cerebral hypoxia. The pt should not be suctioned for longer than 10 seconds at one time to prevent cerebral hypoxia & an increase in ICP
A pt with a spinal cord injury expresses little interest in food, & is very particular about the choice of meals that are actually eaten. The nurse interprets that:
Meal choices represent an area of pt control & should be encouraged as much as is nutritionally reasonable
A pt with a brain attack (stroke) is experiencing residual dysphagia. The nurse would REMOVE which of the following food items that arrived on the pts meal tray from the dietary department?
Peas * Rationale: In general, flavorful, very warm, or well-chilled foods with texture stimulate the swallowing reflex. Moist pastas, casseroles, egg dishes, & potatoes are usually well tolerated. Raw vegetables, chunky vegetables such as diced beets, & stringy vegetables such as spinach, corn, & peas are commonly excluded from the diet of a pt with a poor swallowing reflex
A pt is having a lumbar puncture (LP) performed. The nurse would place the pt in which position for the procedure?
Side-lying, with legs pulled up & head bent down onto the chest * Rationale: The pt undergoing LP is positioned lying on the side, with the legs pulled up to the abdomen & the head bent down onto the chest. This position helps open the spaces between the vertebrae
A nurse reinforces home care instructions to the postcraniotomy pt. Which statement by the pt indicates the need for further instruction?
"I will not hear sounds clearly unless they are loud."
A nurse is monitoring a pt who sustained a head injury & suspects that the pt has a skull fx. This conclusion is based on which of the following findings? Select all that apply.
- Drainage from ear - Bruising around the eyes -Pink-tinged drainage from the nose * Rationale: Drainage from ear or nose (clear or pink-tinged) is an indicator of the presence of CSF, which could be leaking as a result of the skull fracture. Bruising around the eyes (raccoon sign) is also an indicator of basilar skull fx. Tachycardia, coughing, & lower back pain are not associated specifically with skull fx
An 84 yo pt in an acute state of disorientation was brought to the ER by the pts daughter. The daughter states that this is the 1st time that the pt experienced confusion. The nurse determines from this piece of info that which of the following is unlikely to be the cause of the pts disorientation?
Alzheimer's disease * Rationale: Alzheimer's disease is a chronic disease with progression of memory deficits over time. The situation presented in the question represents an acute problem. Med use, hypoglycemia, & impaired cerebral circulation require evaluation to determine if they play a role in causing the pts current sx
A nurse is monitoring a pt with a head injury & notes that the pt is assuming this posture. The nurse notifies the RN immed to report that the pt is exhibiting: Refer to figure:
Decorticate posturing * Rationale: In decorticate posturing, the upper extremities (arms, wrists, & fingers) are flexed with adduction of the arms. The lower extremities are extended with internal rotation & plantar flexion. Decorticate posturing indicates a hemispheric lesion of the cerebral cortex. In decerebrate posturing, the upper extremities are extended stiffly & adducted with internal rotation & pronation of the palms. The lower extremities are extended stiffly with plantar flexion. The teeth are clenched & the back is hyperextended. Decerebrate posturing indicates a lesion in the brainstem at the midbrain or upper pons. Flaccid quadriplegia is complete loss of muscle tone & paralysis of all 4 extremities, indicating a completely nonfunctional brainstem. Opisthotonos is prolonged arching of the back with the head & heels bent backward. Opisthotonos indicates meningeal irritation
A nurse is planning care for a pt who displays confusion secondary to a neurological problem. Which approach by the nurse would be least helpful in assisting this pt?
Encouraging multiple visitors at one time * Rationale: Pts with cognitive impairment from neurological dysfunction respond best to a stable environment, which is limited in the amounts & type of sensory input. The nurse can provide sensory cues & give clear, simple directions in a positive manner. Confusion & agitation can be minimized by reducing environmental stimuli (such as tv, multiple visitors) & keeping familiar personal articles (such as family pictures) at the bedside
A nurse is caring for a pt dx with Bell's palsy 1 week ago. Which of the following data would indicate a potential complication associated with Bell's palsy?
Excessive tearing * Rationale: Complications of Bell's palsy include abnormal return of nerve function; "crocodile tears" (autonomic fibers reconnect to the lacrimal duct instead of the salivary glands, so the pt develops excessive tearing while eating); abnormal facial movements because of reinnervation of inappropriate muscles; & spasms, atrophy, & contractures caused by incomplete motor fiber reinnervation. Partial facial paralysis is a factor indicating recovery. Negative outcomes on the electromyography performed 1 week after sx onset indicate that nerve function is present (a negative test indicates a positive prognostic outcome). Tasting food 1 week after sx onset indicates a good prognosis for recovery
A nurse is assisting the HCP in performing a lumbar puncture. The nurse prepares for the procedure by placing the pt in which position?
Fetal position * Rationale: The pt is assisted into a fetal position at the edge of the bed with the knees drawn up to the chest. This position allows full flexion of the spine & wider spaces between the vertebrae. The nurse should also place a pillow between the legs to prevent the upper leg from rolling forward & a small pillow under the head to support the spine in a horizontal position
A nurse is caring for a pt who has undergone craniotomy with a supratentorial incision. The nurse should plan to place the pt in which position postop?
HOB elevated 30 to 45 degrees, head & neck midline * Rationale: Following supratentorial surgery, the HOB is kept at a 30-45* angle. The head & neck should not be angled either anteriorly or laterally, but rather should be kept in a neutral (midline) position. This will promote venous return through the jugular veins, which will help prevent a rise in ICP
A nurse notices that a pt with trigeminal neuralgia has been w/d, is having frequent episodes of crying, & is sleeping excessively. The best way for the nurse to explore issues with the pt regarding this behavior is to:
Have the pt express the feelings in writing
A nurse is positioning the pt with increased ICP. Which position should the nurse avoid?
Head turned to the side * Rationale: The head of the pt with increased ICP should be positioned so that the head is in a neutral, midline position. The nurse should avoid flexing or extending the neck or turning the head side to side. The HOB should be raised to 30-45*. Use of proper positions promotes venous drainage from the cranium to keep ICP down
A nurse is collecting neurological data on a post-stroke adult pt. Which of the following techniques will the nurse perform to adequately check proprioception?
Hold the sides of the pts great toe &, while moving it, ask what position it's in
A nurse suspects neurogenic shock in a pt with complete transection of the spinal cord at the T3 (thoracic 3) level if which of the following CM are observed?
Hypotension & bradycardia * Rationale: Spinal cord transection at the T5 level or above may lead to neurogenic shock. This injury results in massive vasodilation without compensation because of the loss of sympathetic nervous system vasoconstrictor tone. As a result, hypotension & bradycardia will be manifested. HTN with either bradycardia or tachycardia would NOT be exhibited
A nurse is reinforcing instructions to a pt taking Divalproex sodium (Depakote). The nurse tells the pt to return to the clinic for follow-up lab studies r/t which test?
Liver function studies * Rationale: Divalproex sodium, an anticonvulsant, can cause hepatotoxicity, which is potentially fatal. The nurse instructs the pt to return to the clinic for follow-up liver function studies, such as lactate dehydrogenase (LDH), serum glutamic-oxaloacetic transaminase (SGOT), serum glutamate pyruvate transaminase (SGPT), & ammonia levels. This is especially indicated in the first 6 months of therapy
A nurse is assisting in caring for a pt with a suspected dx of meningitis. The nurse reinforces to the pt info regarding which dx test that is commonly used to confirm this dx?
Lumbar puncture * Rationale: Meningitis is an acute or chronic inflammation of the meningeal area & the CSF. The key dx test used in meningitis is the lumbar puncture. The remaining options may also be performed but will not confirm the dx
A nurse is caring for a pt with a dx of right (nondominant) hemispheric brain attack (stroke). The nurse notes that the pt is alert & oriented to time & place. Based on these findings, the nurse interprets that the pt:
May likely have perceptual & spatial disabilities * Rationale: The pt with a right (nondominant) hemispheric stroke may be alert & oriented to time & place. These sx of apparent wellness often result in interpretations that the pt is less disabled than is the case. However, impulsive actions & confusion in carrying out activities may be very much a problem for these pts, as a result of perceptual & spatial disabilities. The right hemisphere is considered specialized in sensory-perceptual & visuospatial processing & awareness of body space. The left hemisphere is dominant for language abilities
A nurse is reviewing the MR of a pt dx with amyotrophic lateral sclerosis (ALS). Which initial CM of this d/o supports this dx?
Mild clumsiness * Rationale: The initial manifestation of ALS is a mild clumsiness usually in the distal portion of 1 extremity. The pt may c/o tripping & may drag 1 leg when the lower extremities are involved. Mentation & intellectual function are usually normal. Diminished gag reflex & muscle wasting are not initial CMs
A nurse is preparing a POC to monitor for complications in a pt who will be returning from the OR following transsphenoidal resection of a pituitary adenoma. Which of the following does the nurse document in the plan as the priority NI for this pt?
Monitor urine output * Rationale: The most common complication of surgery on the pituitary gland is temporary diabetes insipidus. This results from deficiency in antidiuretic hormone (ADH) secretion as a result of surgical trauma. The nurse measures the pts urine output to determine whether this complication is occurring
A nurse is planning care for a pt in spinal shock. Which of the following actions would be LEAST helpful in minimizing the effects of vasodilation below the level of the injury?
Moving the pt quickly as one unit
A nurse is collecting data on a pt with a dx of meningitis & notes that the pt is assuming this posture. (Refer to figure.)
Opisthotonos * Rationale: Opisthotonos is a prolonged arching of the back with the head & heels bent backward. Opisthotonos indicates meningeal irritation. In decorticate rigidity, the upper extremities (arms, wrists, and fingers) are flexed with adduction of the arms. The lower extremities are extended with internal rotation & plantar flexion. Decorticate rigidity indicates a hemispheric lesion of the cerebral cortex. In decerebrate rigidity, the upper extremities are stiffly extended & adducted with internal rotation & pronation of the palms. The lower extremities are extended stiffly with plantar flexion. The teeth are clenched & the back is hyperextended. Decerebrate rigidity indicates a lesion in the brainstem at the midbrain or upper pons. Flaccid quadriplegia is complete loss of muscle tone & paralysis of all 4 extremities, indicating a completely nonfunctional brain stem
A pt c/o pain in the lower back & pain & spasms in the hamstrings when the nurse attempts to extend the client's leg. (Refer to figure.)
Positive Kernig's sign * Rationale: Both Kernig's & Brudzinski's sx are suggestive of meningeal irritation, which occurs in meningitis. A positive Kernig's sign is the inability to extend the leg from a 90* flexion at the hip. Attempts to extend the leg cause pain & spasms in the hamstring muscles. With positive Brudzinski's sign, passive flexion of the head & neck causes flexion of the thighs & legs. Positive Trousseau's sign is a carpopedal spasm observed in the hypocalcemic pt when a BP cuff is inflated on the arm above the systolic pressure. A Babinski's reflex is elicited when the nurse strokes along the sole of the foot
A nurse has instructed the family of a brain attack (stroke) pt who has homonymous hemianopsia about measures to help the pt overcome the deficit. The nurse determines that the family understands the measures to use if they state that they will:
Remind the pt to turn the head to scan the lost visual field * Rationale: Homonymous hemianopsia is loss of half of the visual field. The pt with homonymous hemianopsia should have objects placed in the intact field of vision, & the nurse should approach the pt from the intact side. The nurse instructs the pt to scan the environment to overcome the visual deficit & performs pt teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available
A pt with a cervical spine injury has Crutchfield tongs applied in the ER. The nurse should avoid which of the following when planning care for this pt?
Removing the wts to reposition the pt * Rationale: Crutchfield tongs are applied after drilling holes in the pts skull under local anesthesia. Wts are attached to the tongs, which exert pulling pressure on the longitudinal axis of the cervical spine. Serial x-rays of the cervical spine are taken, with wts being added gradually until radiography reveals that the vertebral column is realigned. Wts then may be gradually reduced to a point that maintains alignment. The pt with Crutchfield tongs is placed on a Stryker frame or Roto-Rest bed. The nurse ensures that wts hang freely & the amount of wt matches the current rx. The nurse also inspects the integrity & position of the ropes & pulleys. The nurse DOES NOT remove the Wts to admin care
A nurse is monitoring a pt with a C5 spinal cord injury for spinal shock. Which of the following findings would be associated with spinal shock in this pt? Select all that apply.
- Bowel sounds are absent - The pts abdomen is distended - Respiratory excursion is diminished - Accessory muscles of respiration are areflexic * Rationale: During the period of areflexia that characterizes spinal shock, the BP may fall when the pt sits up. The bowel & bladder often become flaccid, may become distended, & fail to empty spontaneously. Bowel sounds would be absent. Accessory muscles of respiration may become areflexic as well, diminishing respiratory excursion & oxygenation
A pt with myasthenia gravis is having difficulty speaking. The pts speech is dysarthric & has a nasal tone. The nurse should use which communication strategies when working with this pt? Select all that apply.
- Listening attentively - Asking yes & no questions when able - Using a communication board when necessary - Repeating what the pt said to verify the message * Rationale: The pt has speech that is nasal in tone & dysarthric because of cranial nerve involvement of the muscles governing speech. The nurse listens attentively & verbally, verifies what the pt has said, asks questions requiring a yes/no response, & develops alternative communication methods (e.g., letter board, picture board, pen & paper, flash cards). Encouraging the pt to speak quickly is an ineffective communication strategy & is counterproductive
A nurse develops a POC for a pt following a lumbar puncture. Which interventions should be included in the plan? Select all that apply.
- Monitor the pts ability to void - Maintain the pt in a flat position - Monitor the pts ability to move the extremities - Inspect the puncture site for swelling, redness, & drainage. * Rationale: Following a lumbar puncture, the pt remains flat in bed for 6-24 hrs, depending on the HCPs rx. A liberal fluid intake (not NPO status) is encouraged to replace CSF removed during the procedure, unless contraindicated by the pts condition. The nurse checks the puncture site for redness & drainage, & monitors the pts ability to void & move the extremities
A pt has experienced an episode of myasthenic crisis. The nurse collects data to determine whether the pt has precipitating factors such as:
Omitted doses of med * Rationale: Myasthenic crisis is often caused by undermedication & responds to admin of cholinergic meds such as Neostigmine (Prostigmin) and Pyridostigmine (Mestinon). Cholinergic crisis (the opposite problem) is caused by excess med & responds to withholding of meds. Overexertion & overeating could trigger myasthenic crisis
A nurse is collecting admission data on a pt with Parkinson's disease. The nurse asks the pt to stand with the feet together & the arms at the side & then to close the eyes. The nurse notes that the pt begins to fall when the eyes are closed. Based on this finding, the nurse documents which of the following in the pts record?
Positive Romberg's test * Rationale: Romberg's test checks for cerebellar functioning r/t balance. The pt stands with the feet together & the arms at the side & then closes the eyes. Slight swaying is normal, but loss of balance indicates a problem & a positive Romberg's test
A pt with Bell's palsy exhibits facial asymmetry & cannot close the eye completely on 1 side. The pt is also drooling & has loss of tearing in 1 eye. The nurse documents that the pt displays sx of involvement of which of the following cranial nerves (CNs)?
CN VII * Rationale: Bell's palsy is a common problem involving CN VII. In addition to the sx identified in the question, the pt may exhibit loss of the nasolabial fold, an inability to blink automatically, inability to swallow secretions, & possibly loss of taste on the anterior 2/3 of the tongue. Other conditions that can affect CN VII function include fx of the temporal bone & parotid lacerations or contusions
A pt with myasthenia gravis (MG) is experiencing prolonged periods of weakness. The MD orders a test dose of edrophonium (Tensilon), & the pt becomes weaker. The nurse interprets this test result as:
Cholinergic crisis * Rationale: Edrophonium is admin to differentiate OD of med (cholinergic crisis) from the need for increased med (myasthenic crisis).Worsening of the sx after edrophonium is admin indicates a cholinergic crisis (OD of the med) or a negative Tensilon test result
A nurse has provided d/c instructions to a pt with an application of a halo device. The nurse determines that the pt needs further clarification of the instructions if the pt states that he/she will:
Drive only during the daytime
A nurse is assisting in assessing the 12th cranial nerve in the pt who sustained a CVA. When assessing the 12th cranial nerve, the nurse understands that the pt should be asked to:
Extend the tongue * Rationale: To assess the function of the 12th cranial (hypoglossal) nerve, the nurse would assess the pts ability to extend the tongue. Impairment of the 12th cranial nerve can occur with a CVA
A nurse is caring for an unconscious pt who's experiencing persistent hyperthermia with no s/s of infection. The nurse understands that there may be damage to the pts thermoregulatory center in the:
Hypothalamus * Rationale: Hypothalamic damage causes hyperthermia, which may also be called "central fever." It is characterized by a persistent high fever with no diurnal variation. There is also an absence of sweating
A pt experiences an episode of Bell's palsy & complains about increasing clumsiness. The nurse should prepare the pt for which dx study (studies) to determine the cause of the complaints? Select all that apply.
- CT - Cerebral angiography - Lumbar puncture (LP) * Rationale: Bell's palsy can be caused by inflammation or a lesion of the facial nerve, & when the pt presents with both Bell's palsy & increasing clumsiness, the health care team suspects more diffuse CNS lesions. The most sensitive & specific tests that provide relevant dx info for these types of pathology are cerebral angiography, LP, & CT The imaging studies illustrate CNS lesions, & the LP enables the care provider to analyze CSF for immunoglobulins (antibodies) & other components
A nurse is providing care to a pt with increased ICP. Which approach(es) may be beneficial in controlling the pts ICP from an environmental viewpoint? Select all that apply
- Reducing environmental noise - Maintaining a calm atmosphere - Allowing the pt uninterrupted time for sleep * Rationale: NIs should be spaced out over the shift to minimize the risk of a rise in ICP. If possible, activities known to raise ICP should be avoided when possible. Other interventions to control the ICP include keeping the lighting in the room dim or off, maintaining a calm, quiet environment & avoiding emotional stress & interruption of sleep
A nursing student is collecting data on a pt recently dx with meningitis. The student expects to note which of the following s/s? Select all that apply.
- Tachycardia - Photophobia - Red, macular rash - Positive Kernig's sign * Rationale: Meningitis is an infection or inflammation of the membranes covering the brain & spinal cord. S/s can include a positive Kernig's sign, tachycardia (HR greater than 100 bpm), a red macular-type rash, & photophobia. Other manifestations include severe headache, stiffness of the neck, irritability, malaise, & restlessness
A pt with Parkinson's disease "freezes" while ambulating, increasing the r/f falls. Which suggestion should the nurse include in the pts POC to alleviate this problem?
Consciously think about walking over imaginary lines on the floor * Rationale: Pts with Parkinson's disease can develop bradykinesia (slow movement) or akinesia (freezing or no movement). Having these individuals imagine lines on the floor to step over can keep them moving forward. Although standing erect & using a cane can help prevent falls, these measures will not help a person with akinesia move forward. Pts with Parkinson's disease should walk with a wide gait, not with the feet close together. A w/c should be used only when the pt can no longer ambulate with assistive devices such as canes or walkers
A pt has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure pt safety?
Provide a clear path for ambulation without obstacles * Rationale: Cranial nerve II is the optic nerve, which governs vision. The nurse can provide safety for the visually impaired pt by clearing the path of obstacles when ambulating. Testing the shower water temp would be useful if there were impairment of peripheral nerves. Speaking loudly may help overcome a deficit of cranial nerve VIII (vestibulocochlear). Cranial nerves VII (facial) & IX (glossopharyngeal) control taste from the anterior 2/3 & posterior 1/3 of the tongue, respectively
A pt is scheduled for a digital subtraction angiography. The nurse supports the pts understanding that the test is directed toward which outcome?
Providing info about the blood vessels * Rationale: Digital subtraction angiography is a radiographic method to study the blood vessels. The nurse should explain to the pt that the test gives instant info about the blood vessels
A nursing instructor asks a nursing student about the points to document if the pt has had a seizure. The instructor determines that the student needs to read about seizures & related documentation points if the student stated that it is important to document:
Pts diet in the 2 hrs preceding seizure activity * Rationale: Typically, seizure assessment includes the time the seizure began, part(s) of the body affected, the type of movements & progression of the seizure, changes in pupil size, eye deviation or nystagmus, pt condition during the seizure, & postictal status
A pt has clear fluid leaking from the nose after a basilar skull fx. The nurse determines that this is CSF if the fluid:
Separates into concentric rings & tests positive for glucose * Rationale: Leakage of CSF from the ears or nose may accompany basilar skull fx. It can be distinguished from other body fluids because the drainage will separate into bloody & yellow concentric rings on dressing material, which is known as the halo sign. It also tests positive for glucose
A nurse is teaching the pt with myasthenia gravis about prevention of myasthenic & cholinergic crises. The nurse tells the pt that this is most effectively done by:
Taking meds on time to maintain therapeutic blood levels * Rationale: Pts with myasthenia gravis are taught to space out activities over the day to conserve energy & restore muscle strength. It is very important to take meds correctly to maintain blood levels that are not too low or too high. Muscle-strengthening exercises are not helpful & can fatigue the pt. Overeating is a cause of exacerbation of sx, as well as exposure to heat, crowds, erratic sleep habits, & emotional stress
A pt with a T4 spinal cord injury is to be monitored for autonomic dysreflexia (hyperreflexia). Which finding is indicative of this complication?
The pt c/o a headache & the BP is elevated * Rationale: Autonomic dysreflexia, also known as autonomic hyperreflexia, is a life-threatening syndrome. It is a cluster of CMs that results when multiple spinal cord autonomic responses d/c simultaneously. Exaggerated autonomic nervous system reactions to stimuli result in sudden hypertensive episodes with severe headache. The pt may sweat profusely above the level of the cord lesion & c/o a stuffy nose. The knee-jerk response is not affected. Pupils may be dilated. Although a distended bladder is often the precipitating event, it's not indicative of dysreflexia, & not all pts with bladder distention exhibit dysreflexia
A nurse is caring for a pt with a head injury & is monitoring the pt for sx of increased ICP. Which sx if noted in the pt would the nurse report immediately?
The pt vomits * Rationale: The pt with a closed head injury is at r/o developing increased ICP. This is evidenced by sx such as headache, dizziness, confusion, weakness, & vomiting
A pt who suffered a cervical spine injury had Crutchfield tongs applied in the ER. The nurse would avoid which of the following actions in the care of the pt?
Removing the wts when repositioning the pt * Rationale: Crutchfield tongs are a method of skeletal traction used with cervical spine injury. All of the principles of assessment & care that apply to the pt in traction apply to this pt. The nurse should not remove the wts to admin care; removing the wts will disrupt the traction applied. The nurse should ensure that wts hang freely & that the amount of wt matches the current rx. The nurse should inspect the integrity & position of the ropes & pulleys. The pt is placed on a Stryker frame or Roto-Rest bed while the Crutchfield tongs are in use
An ER nurse is assigned to assist in caring for a pt who has suffered a head injury following a MVA. The nurse understands that the initial data collection should focus on which of the following?
Respiratory status * Rationale: The initial data collection focuses on ensuring that the pt has an adequate airway & respiratory status. In rapid sequence, the pts circulatory status is evaluated, followed by evaluation of the neurological status. ROM is not a priority. In fact, the extent of the injuries should be well established before assessing ROM
A nurse is caring for a pt following craniotomy who has a supratentorial incision. The nurse reviews the pts POC, expecting to note that the pt should be maintained in which of the following positions?
Semi Fowlers position * Rationale: In supratentorial surgery (surgery above the brain's tentorium), the pts head usually is elevated 30* to promote venous outflow through the jugular veins. The pts head or the HOB is not lowered in the acute phase of care after supratentorial surgery. An exception to this position is the pt who has undergone evacuation of a chronic subdural hematoma, but a HCPs rx is required for positions other than those involving head elevation
A nurse is reviewing the record of a pt with a suspected dx of Huntington's disease. Which documented early sx supports this dx?
Vertigo * Rationale: Early sx of Huntington's disease include restlessness, forgetfulness, clumsiness, falls, balance & coordination problems, vertigo, & altered speech & handwriting. Difficulty with swallowing occurs in the later stages. Aphasia & agnosia DO NOT occur
A pt has a cerebellar lesion. The nurse determines that the pt is adapting successfully to this problem if the pt demonstrates proper use of which of the following items?
Walker * Rationale: The cerebellum is responsible for balance & coordination. A walker would provide stability for the pt during ambulation. Adaptive eating utensils may be beneficial when the pt has partial paralysis of the hand. A raised toilet seat is useful when the client does not have the mobility or ability to flex the hips. A slider board is used in transferring a pt from a bed-stretcher or w/c
