Neurological Disorders Comprehensive Examination

Which intervention has the highest priority for the client who is in the ED after a motorcycle collision with an automobile and who has a fractured left leg? 1. Assessing the neurological status. 2. Immobilizing the fractured leg. 3. Monitoring the client's output. 4. Starting an 18-gauge saline lock.

Answer: 1 1. Assessment is the first step in the nursing process, and a client in a motorcycle accident must be assessed for a head injury. 2. Neurological assessment is a priority over a fractured leg. 3. The client's urinary output is not a priority over an assessment. 4. An 18-gauge IV access should be started in case the client has to go to surgery, but it is not a priority over an assessment.

The client diagnosed with Parkinson's disease is prescribed carbidopa and levodopa. Which intervention should the nurse implement before administering the medication? 1. Discuss how to prevent orthostatic hypotension. 2. Take the client's apical pulse for one (1) full minute. 3. Inform the client that this medication is for short-term use. 4. Tell the client to take the medication on an empty stomach.

Answer: 1 1. Because carbidopa and levodopa (Sinemet) have been linked to hypotension, teaching a client given the medication ways to help prevent a drop in BP when standing—orthostatic hypotension—decreases the risks associated with hypotension and falling. 2. The medication will not cause the heart rate to change, so taking the client's apical pulse for 1 minute is not a priority. 3. Carbidopa and levodopa (Sinemet) is prescribed for the client for life unless the medication stops working or the client experiences adverse side effects. 4. The medication should be administered with food to help prevent gastrointestinal distress.

The client comes to the clinic and reports a sudden drooping of the left side of the face and reports pain in that area. The nurse notes that the client cannot wrinkle the forehead, close the left eye, and has excessive tearing in the left eye. Which condition should the nurse suspect? 1. Bell's palsy. 2. Left-sided stroke. 3. Tetany. 4. Mononeuropathy.

Answer: 1 1. Bell's palsy, called facial paralysis, is a disorder of the seventh cranial nerve (facial nerve) characterized by unilateral paralysis of facial muscles. 2. A left-sided stroke would see clinical manifestations on the right side of the body. Pain is not an immediate symptom of a stroke but can develop in the muscles and joints. 3. Tetany is due to low calcium levels. In this disorder, the face twitches when touched; this is known as a positive Chvostek's sign. 4. Mononeuropathy is limited to a single peripheral nerve and its branches and occurs because the trunk of the nerve is compressed, such as in carpal tunnel syndrome.

The client is scheduled for an MRI of the brain to confirm a diagnosis of Creutzfeldt-Jakob disease. Which intervention should the nurse implement before the procedure? 1. Determine if the client has claustrophobia. 2. Obtain a signed informed consent form. 3. Determine if the client is allergic to egg yolks. 4. Start an intravenous line in both hands.

Answer: 1 1. For an MRI scan, the client is placed in a very narrow tube. If claustrophobic, the client may need medication, or an open MRI machine may need to be considered. 2. An MRI scan is not an invasive procedure; therefore, informed consent is not needed. 3. The nurse would need to determine allergies to shellfish or iodine, not to egg yolks. 4. The client will need one saline lock, not two intravenous lines. Often the MRI tech is the person inserting the IV line.

The client with a history of migraine headaches comes to the ED reporting a migraine headache. Which collaborative treatment should the nurse anticipate? 1. Administer an injection of sumatriptan. 2. Prepare for CT of the head. 3. Place the client in a quiet room with the lights off. 4. Administer propranolol.

Answer: 1 1. Sumatriptan (Imitrex), a triptan, is a medication of choice for migraine headaches. It constricts blood vessels and reduces inflammation. The nurse administering the medication is part of a collaborative effort because the nurse must act on the order or prescription of a physician or other HCP with prescriptive authority. 2. This is a collaborative intervention, but it is not routinely ordered because the client reports having a history of migraine headaches. 3. This is an appropriate independent nursing intervention. 4. Propranolol (Inderal), a beta blocker, is not used for acute migraine headaches; it is prescribed for long-term prophylaxis of migraines, so the nurse should not anticipate its use in this situation.

The UAP is caring for a client having a seizure. Which action by the UAP would warrant immediate intervention by the RN? 1. The assistant attempts to insert an oral airway. 2. The assistant turns the client on the right side. 3. The assistant has all the side rails padded and up. 4. The assistant does not leave the client's bedside.

Answer: 1 1. The nurse must intervene to stop the UAP because the client's jaws are clenched. Attempting to insert anything into the mouth could cause injury to the client or to the UAP. 2. Side-lying positions help to prevent aspiration and are an appropriate intervention. 3. The client's safety is a priority, and this will help protect the client from injury. 4. Staying with the client is appropriate behavior that would not warrant intervention by the nurse.

The charge nurse is making client assignments for a neuro-medical floor. Which client should be assigned to the most experienced nurse? 1. The 80-year-old client diagnosed with a stroke in evolution. 2. The client diagnosed with a TIA 48 hours ago. 3. The client diagnosed with Guillain-Barré syndrome reporting leg pain. 4. The client diagnosed with Alzheimer's disease wandering in the halls.

Answer: 1 1. This client is experiencing a progressing stroke, is at risk for dying, and should be cared for by the most experienced nurse. 2. A TIA, by definition, lasts less than 24 hours, so this client should be stable at this time. 3. Pain is expected in clients diagnosed with Guillain-Barré syndrome, and symptoms are on the lower half of the body, which does not affect the airway. Therefore, a less experienced nurse could care for this client. 4. The charge nurse could delegate much of the care of this client to a UAP.

The nurse is preparing the male client for an electroencephalogram (EEG). Which intervention should the nurse implement? 1. Explain that this procedure is not painful. 2. Premedicate the client with a benzodiazepine drug. 3. Instruct the client to shave all facial hair. 4. Tell the client it will cause him to see "floaters."

Answer: 1 1. This procedure is not painful, although electrodes are attached to the scalp. The client will need to wash the hair after the procedure. 2. An antianxiety medication would make the client drowsy and could cause a false EEG reading. 3. There is no reason for facial hair to be shaved. 4. This procedure measures the electrical conductivity in the brain and does not cause the client to see "floaters" (spots before the eyes). Flashing bright lights may be used in an attempt to evoke a seizure.

The client is diagnosed with Huntington's disease. Which interventions should the nurse implement with the family? Select all that apply. 1. Refer to the Huntington's Disease Foundation. 2. Explain the need for the client to wear safety padding. 3. Discuss how to cope with the client's messiness. 4. Provide three meals a day and no between-meal snacks. 5. Teach the family how to perform chest percussion.

Answer: 1, 2, 3 1. Foundations offer the family and client information about the disease, support groups, and up-to-date information on current research. 2. The use of padding will help prevent injury from the constant movement that occurs with this disease. 3. The constant movement causes the client to be messy when eating, dressing, or performing ADLs. 4. The constant movements expend more calories; therefore, the client should have three (3) meals plus between-meal snacks. 5. The client is at risk for choking; therefore, teaching the Heimlich maneuver is appropriate, but teaching chest percussion is not.

Which assessment data would make the nurse suspect that the client diagnosed with a C7 SCI is experiencing autonomic dysreflexia? Select all that apply. 1. Abnormal diaphoresis. 2. A severe throbbing headache. 3. Sudden loss of motor function. 4. Spastic skeletal muscle movement. 5. Hypertension.

Answer: 1, 2, 5 1. Diaphoresis (sweating) is a sign of autonomic dysreflexia. 2. A throbbing headache is the classic sign of autonomic dysreflexia, which is caused by a stimulus such as a full bladder. 3. Sudden loss of motor function occurs with the original injury. Autonomic dysreflexia does not occur until spinal shock has resolved; it usually occurs in the rehabilitation phase. 4. Spastic skeletal muscle movement could be secondary to the reflex arc in lower motor neuron injuries. 5. Hypertension and bradycardia are signs of autonomic dysreflexia.

The intensive care nurse is caring for the client after intracranial surgery. Which interventions should the nurse implement? Select all that apply. 1. Assess for DVT. 2. Administer IV anticoagulant. 3. Monitor intake and output strictly. 4. Apply warm compresses to the eyes. 5. Perform passive ROM exercises.

Answer: 1, 3, 5 1. Assessing for DVT, which is a complication of immobility, would be appropriate for this client. 2. Anticoagulants may cause bleeding; therefore, the client after surgery would not be prescribed this medication. 3. Monitoring of intake and output helps to detect possible complications of the pituitary gland, which include diabetes insipidus and SIADH. 4. The nurse should apply cool compresses to alleviate periocular edema. 5. The nurse does not want the client to be active and possibly increase ICP; therefore, the nurse should perform passive ROM for the client.

The ambulance brings the client diagnosed with a head injury to the ED. The client responds to painful stimuli by opening the eyes, muttering, and pulling away from the nurse. How would the nurse rate this client on the GCS? 1. 3 2. 9 3. 10 4. 15

Answer: 2 1. A score of 3 is the lowest score and indicates a deep coma and impending brain death. 2. A score of 9 indicates moderate increased ICP, but with appropriate care, the client may survive. The nurse would rate the client at an 8: 2 for opening the eyes; 3 for verbal response; and 4 for motor response. 3. A score of 10 indicates moderately increased ICP. 4. A score of 15 is the highest score a client can receive, indicating normal function.

The nurse writes the nursing diagnosis "altered body temperature related to damaged temperature regulating mechanism" for a client diagnosed with a head injury. Which would be the most appropriate goal? 1. Administer acetaminophen for elevated temperature. 2. The client's temperature will remain less than 100°F. 3. Maintain the hypothermia blanket at 99°F for 24 hours. 4. The basal metabolic temperature will fluctuate no more than 2 degrees.

Answer: 2 1. Administering acetaminophen (Tylenol) is an intervention, which is not a goal. 2. This is an appropriate goal. It addresses the client, addresses the problem (temperature elevation), and is measurable. 3. Maintaining the blanket temperature is a nursing intervention, which should eliminate this as a possible answer. 4. The basal metabolic temperature is evaluated for a woman trying to get pregnant; it helps indicate ovulation.

The client has glossopharyngeal nerve (cranial nerve IX) paralysis secondary to a stroke. Which referral would be most appropriate for this client? 1. Hospice nurse. 2. Speech therapist. 3. Physical therapist. 4. Occupational therapist.

Answer: 2 1. Clients are referred to hospice when there is a life expectancy of less than 6 months. This client has difficulty swallowing, which is not life-threatening. 2. Speech therapists address the needs of clients having difficulty with the innervations and musculature of the face and neck. This includes the swallowing reflex. 3. The PT assists the client to ambulate and transfer (e.g., from bed to chair) and with muscle strength training. 4. The OT focuses on cognitive disability and ADL.

A family member brings the client to the ED reporting that the 78-year-old father has suddenly become very confused and thinks he is living in 1942, that he has to go to war, and that someone is trying to poison him. Which question should the nurse ask the family member? 1. "Has your father been diagnosed with dementia?" 2. "What medication has your father taken today?" 3. "What have you given him that makes him think it's poison?" 4. "Does your father like to watch old movies on television?"

Answer: 2 1. Dementia involves behavior changes that are irreversible and occur over time. Delirium, however, occurs suddenly (as in this man's symptom onset), is caused by an acute event, and is reversible. 2. Drug toxicity and interactions are common causes of delirium in older persons. 3. This is blaming the family member for the client's paranoid ideation. 4. Watching old movies on television will not cause delirium.

Which assessment data indicate that the client diagnosed with a TBI exhibiting decorticate posturing on admission is responding effectively to treatment? 1. The client has flaccid paralysis. 2. The client has purposeful movement. 3. The client has decerebrate posturing with painful stimuli. 4. The client does not move the extremities.

Answer: 2 1. Flaccid paralysis indicates a worsening of the increased ICP. 2. Purposeful movement indicates the client is getting better and is responding to the treatment. 3. Decerebrate positioning indicates a worsening of the increased ICP. 4. This is the same as flaccid paralysis and indicates a worsening of the increased ICP.

Which finding is considered to be one of the warning signs of developing Alzheimer's disease? 1. Difficulty performing familiar tasks. 2. Problems with orientation to date, time, and place. 3. Having problems focusing on a task. 4. Atherosclerotic changes in the vessels.

Answer: 2 1. The client may experience minor difficulty in work or social activities but has adequate cognitive ability to hide the loss and continue to function independently. 2. Disorientation to time and place is a warning sign. 3. Not being able to focus on a task is more likely a sign of attention deficit-hyperactivity disorder. 4. Atherosclerotic changes are not warning signs of Alzheimer's disease. Amyloid protein plaques do appear to have something to do with the disease, but they are not found until autopsy.

The client with a history of migraine headaches comes to the clinic and reports that a migraine is coming because the client is experiencing bright spots before the eyes. Which phase of migraine headaches is the client experiencing? 1. Premonitory phase. 2. Aura phase. 3. Headache phase. 4. Postdromal phase.

Answer: 2 1. The premonitory phase occurs hours to days before the migraine headache. 2. This is the aura phase, which is characterized by focal neurological symptoms. 3. The headache phase occurs when vasodilation occurs in the brain, along with a decline in serotonin levels, causing a throbbing headache. 4. The postdromal phase is when the pain begins to subside gradually.

Which assessment data should the nurse expect to observe for the client diagnosed with Parkinson's disease? 1. Ascending paralysis and pain. 2. Masklike face and pill rolling. 3. Diplopia and ptosis. 4. Dysphagia and dysarthria.

Answer: 2 1. The spread of pain and paralysis are clinical manifestations of Guillain-Barré syndrome. 2. Masklike face and pill rolling are clinical manifestations of Parkinson's disease, along with cogwheeling, postural instability, and stooped and shuffling gait. 3. Diplopia and ptosis are clinical manifestations of myasthenia gravis. 4. Dysphagia and dysarthria are clinical manifestations of myasthenia gravis.

The public health nurse is discussing St. Louis encephalitis with a group in the community. Which instruction should the nurse provide to help prevent an outbreak? 1. Yearly vaccinations for the disease. 2. Advise that the city should spray for mosquitoes. 3. The use of gloves when gardening. 4. Not going out at night.

Answer: 2 1. There is no vaccine for preventing encephalitis. 2. Mosquitoes are the vectors that spread the disease, and spraying to kill mosquito larvae will help prevent an outbreak in the community. 3. Gloves will not protect a person from being bitten by a mosquito. 4. Mosquitoes are more prevalent at night, but this is an unrealistic intervention and will not help prevent an outbreak.

The client diagnosed with a brain abscess has become lethargic and difficult to arouse. Which intervention should the nurse implement first? 1. Implement seizure precautions. 2. Assess the client's neurological status. 3. Close the drapes and darken the room. 4. Prepare to administer an IV steroid.

Answer: 2 1. This is an appropriate intervention, but it is not the first. 2. Remember, assessment is the first step of the nursing process and should be implemented first whenever there is a change in the client's behavior. 3. This helps prevent stimulation that could initiate a seizure, but it is not the first intervention. 4. Steroids may be administered to clients diagnosed with brain abscesses to decrease inflammation, but an assessment is the first intervention.

The client asks the nurse, "What causes Creutzfeldt-Jakob disease?" Which statement would be the nurse's best response? 1. "The person must have been exposed to an infected prion." 2. "It is mad cow disease, and eating contaminated meat is the cause." 3. "This disease is caused by a virus that is in stagnant water." 4. "A fungal spore from the lungs infects the brain tissue."

Answer: 2 1. Would a layperson know what a prion is? This is using medical jargon, which is not the nurse's best response. 2. This is the cause of this disease and would be the best response. 3. A virus is not the cause of Creutzfeldt-Jakob disease. 4. Fungal spores do not cause this disease.

The client is diagnosed with a brain abscess. Which clinical manifestations are present with this diagnosis? Select all that apply. 1. Projectile vomiting. 2. Disoriented behavior. 3. Headache. 4. Seizure activity. 5. Fever.

Answer: 2, 3, 4, 5 1. Nausea and vomiting may occur, but it is not projectile. 2. Disoriented behavior and confusion occur in 65% of brain abscesses. 3. The most common and prevalent symptom of a brain abscess is a headache. 4. The client diagnosed with a brain abscess may have seizure activity. 5. Fever is present in over half of the clients diagnosed with a brain abscess.

Which information should be shared with the client diagnosed with mild to moderate Alzheimer's disease prescribed donepezil? Select all that apply. 1. The client must continue taking this medication forever to maintain function. 2. The drug may delay the progression of the disease, but it does not cure it. 3. A serum drug level must be obtained monthly to evaluate for toxicity. 4. If the client develops any muscle aches, the HCP should be notified. 5. The drug may cause bradycardia and dizziness.

Answer: 2, 5 1. This is not a true statement. The client will no longer be prescribed this medication as the disease progresses and it becomes ineffective. 2. Donepezil (Aricept), a cholinesterase inhibitor, does not cure Alzheimer's disease, and at some point, it will become ineffective as the disease progresses. 3. There is no monthly drug level to be monitored. Toxicity includes jaundice and gastrointestinal distress. 4. Muscle aches are an adverse effect of the lipid-lowering medications, not of donepezil (Aricept), a cholinesterase inhibitor. 5. Donepezil (Aricept) can cause bradycardia and dizziness. The client should be instructed to take medication as directed and not to take higher doses because it will not increase the effects, only the side effects.

The client is undergoing post-thrombolytic therapy for a stroke. The HCP has ordered heparin to be infused at 1,000 units per hour. The solution comes as 25,000 units of heparin in 500 mL of D5W. At what rate will the nurse set the pump?

Answer: 20 mL/hr To arrive at the answer, the test taker must divide 25,000 units by 500 mL = 50 units in 1 mL. Divide 1,000 units by 50 units = 20 mL/hr.

Which assessment data would make the nurse suspect that the client has ALS? 1. History of a cold or gastrointestinal upset in the last month. 2. Reports of double vision and drooping eyelids. 3. Fatigue, progressive muscle weakness, and twitching. 4. Loss of sensation below the level of the umbilicus.

Answer: 3 1. A history of a cold or gastrointestinal upset in the last month would be assessment data that would make the nurse suspect Guillain-Barré syndrome. 2. Reports of double vision and drooping eyelids would make the nurse suspect myasthenia gravis. 3. Fatigue, progressive muscle weakness, and twitching are clinical manifestations of ALS, a progressive neurological disease in which there is a loss of motor neurons. There is no cure, but recently a medication to slow the deterioration of the motor neurons has been found. 4. Loss of sensation would make the nurse suspect some type of SCI.

The nurse writes the problem "high risk for impaired skin integrity" for the client diagnosed with an L5-6 SCI. Which intervention should the nurse include in the plan of care? 1. Perform active ROM exercise. 2. Massage the legs and trochanters every shift. 3. Arrange for a pressure relief cushion in the wheelchair. 4. Apply petroleum-based lotion to the extremities.

Answer: 3 1. A patient with an L5-6 SCI is paralyzed and cannot perform active ROM exercises. 2. Massaging bony prominences can cause trauma to the underlying blood vessels and will increase the risk of skin breakdown. 3. The nurse must realize that the client is at risk for skin breakdown even when sitting in the chair. A pressure relief cushion (Roho®) is an air-filled cushion that provides reduced pressure on the ischium. 4. Lotion will not prevent skin breakdown and should be water based, not petroleum based.

The client is diagnosed with Creutzfeldt-Jakob disease. Which referral would be the most appropriate? 1. Alzheimer's Association. 2. Creutzfeldt-Jakob Disease Foundation. 3. Hospice care. 4. A neurosurgeon.

Answer: 3 1. Creutzfeldt-Jakob disease is not Alzheimer's disease, although the presenting symptoms may mimic Alzheimer's disease. 2. There is no foundation for Creutzfeldt-Jakob disease, but if there were, the significant other would not be referred to this organization because the disease progresses so rapidly that the client would not get any benefit from the organization. 3. This disease is usually fatal within a year, and the symptoms progress rapidly to dementia. 4. The nurse does not refer the client to a neurosurgeon, and the primary HCP would not refer to a neurosurgeon because there is no surgical or medical treatment for this disease.

Which potential pituitary complication should the nurse assess for in the client diagnosed with a TBI? 1. Diabetes mellitus type 2 (DM 2). 2. Seizure activity. 3. Syndrome of inappropriate antidiuretic hormone (SIADH). 4. Cushing's disease.

Answer: 3 1. Diabetes mellitus type 2 is a pancreatic disease that has nothing to do with the pituitary gland or head injury. 2. Seizure activity is a possible complication of TBI, but it is not a pituitary complication. 3. The pituitary gland produces vasopressin, the ADH, and any injury that causes increased ICP will exert pressure on the pituitary gland and can cause SIADH. 4. Cushing's disease is caused by an excess production of glucocorticoids and mineralocorticoids from the adrenal gland.

The spouse of a recently retired man tells the nurse, "All my husband does is sit around and watch television all day long. He is so irritable and moody. I don't want to be around him." Which action should the nurse implement? 1. Encourage the spouse to leave the client alone. 2. Tell the spouse that he is probably developing Alzheimer's disease. 3. Recommend that the client see an HCP for antidepressant medication. 4. Instruct the spouse to buy him some arts and crafts supplies.

Answer: 3 1. If the wife could leave the client alone, she would not be sharing her concerns with the nurse. The nurse needs to address the wife's concerns as well as the husband's. 2. These are not the typical clinical manifestations of stage I Alzheimer's disease. 3. This behavior indicates the client is depressed and should be treated with antidepressants. A major lifestyle change has occurred, and he may need short-term medication therapy, depending on how the client adjusts to retirement. 4. The client may not want to participate in arts and crafts.

The client is admitted with a diagnosis of trigeminal neuralgia. Which assessment data would the nurse expect to find in this client? 1. Joint pain of the neck and jaw. 2. Unconscious grinding of the teeth during sleep. 3. Sudden severe shocklike facial pain. 4. A progressive loss of calcium in the nasal septum.

Answer: 3 1. Joint pain is usually associated with some type of arthritis. 2. Unconscious grinding of the teeth during sleep is usually associated with temporomandibular joint (TMJ) disorder. 3. Trigeminal neuralgia affects the 5th cranial nerve and is a form of neuropathic pain characterized by sudden, extreme shocklike facial pain that lasts from a few seconds to a few minutes per episode and can have frequent episodes in quick succession. The disorder is also known as tic douloureux. 4. The nasal structure is not made up of bone.

Which client should the nurse assess first after receiving the shift report? 1. The client diagnosed with a stroke and right-sided paralysis. 2. The client diagnosed with meningitis, reporting photosensitivity. 3. The client diagnosed with a brain tumor having projectile vomiting. 4. The client diagnosed with epilepsy reporting tender gums.

Answer: 3 1. Paralysis is an expected occurrence with a client diagnosed with a stroke. 2. Photosensitivity is an expected sign of meningitis. 3. Projectile vomiting indicates that increased ICP is exerting pressure on the vomiting center of the brain. 4. Tender gums could be secondary to medication given for epilepsy. The client may need to see a dentist, but this client does not need to be assessed first.

Which intervention should the nurse take with the client recently diagnosed with ALS (Lou Gehrig's disease)? 1. Discuss a percutaneous gastrostomy tube. 2. Explain how a fistula is accessed. 3. Provide an advance directive. 4. Refer to a PT for leg braces.

Answer: 3 1. The client was diagnosed recently and at some point may need a percutaneous endoscopic gastrostomy (PEG) tube, but it is too early for this discussion. 2. A fistula is used for hemodialysis, and ALS does not cause renal dysfunction. 3. It is never too early to discuss advance directives with a client diagnosed with a terminal illness. 4. A client diagnosed with ALS does not have leg braces as part of the therapeutic regimen.

The nurse stops at the scene of a motor vehicle accident and provides emergency first aid at the scene. Which law protects the nurse as a first responder? 1. The First Aid Act. 2. Ombudsman Act. 3. Good Samaritan Law. 4. First Responder Law.

Answer: 3 1. There is no such law known as the First Aid Act. 2. The Ombudsman Act addresses many areas, such as advance directives, elderly advocacy, and several other areas. 3. The Good Samaritan Law protects nurses from a judgment against them when responding in an emergency situation in which the nurse is not receiving compensation for the skills and expertise rendered. The nurse must act as any reasonable and prudent nurse would in the same situation (West & Varacallo, 2019). 4. There is no such law known as the First Responder Law.

The husband of a client with alcoholism tells the nurse, "I don't know what to do. I don't know how to deal with my wife's problem." Which response would be most appropriate by the nurse? 1. "It must be difficult. Maybe you should think about leaving." 2. "I think you should attend Alcoholics Anonymous." 3. "I think that Alanon might be very helpful for you." 4. "You should not enable your wife's alcoholism."

Answer: 3 1. This advice might be appropriate at some point from a professional counselor but not from the nurse. 2. Alcoholics Anonymous is the support group that people with alcoholism—in this case, the wife, not the husband—should attend. 3. Alanon is the support group for significant others of individuals with alcoholism. Al-A-Teen is for teenage children of individuals with alcoholism. 4. This statement is making a judgment that is not given in the stem and is not applicable to all husbands of wives who have alcoholism.

The nurse arrives at the scene of a motor vehicle accident, and the car is leaking gasoline. The client is in the driver's seat of the car and reports not being able to move the legs. Which actions should the nurse implement? Rank in order of priority. 1. Move the client safely out of the car. 2. Assess the client for other injuries. 3. Stabilize the client's neck. 4. Notify the emergency medical system. 5. Place the client in a functional anatomical position.

Answer: 3, 2, 1, 5, 4 3. Stabilizing the client's neck is a priority action to prevent further injury to the client, and it must be done before moving the client. 2. The nurse should assess for any other injuries before moving the client from the vehicle. 1. Because the vehicle is leaking fuel and there is potential for an explosion or fire, the client should be moved to an area of safety. 5. Placing the client in a functional anatomical position is an attempt to prevent further SCI. 4. Because the vehicle is leaking fuel, the priority is to remove the client and then obtain emergency medical assistance.

Which behavior is a risk factor for developing and spreading bacterial meningitis? 1. An upper respiratory infection (URI). 2. Unprotected sexual intercourse. 3. Chronic alcohol consumption. 4. Use of tobacco products.

Answer: 4 1. A URI is not a behavior. The question asked which behavior was a risk factor, so this option can be ruled out. However, a URI is a risk factor for developing and spreading bacterial meningitis because of increased droplet production. 2. Unprotected sexual intercourse is a risk factor for sexually transmitted diseases (STIs) but not for meningitis. 3. Chronic alcohol consumption can cause pancreatitis or hepatitis but not meningitis. 4. Tobacco use increases respiratory secretions and droplet production and thus is a risk factor for developing and spreading bacterial meningitis.

The nurse is caring for clients in a medical unit. Which client would be most at risk for experiencing a stroke? 1. A 92-year-old client with alcoholism. 2. A 54-year-old client diagnosed with hepatitis. 3. A 60-year-old client with a Greenfield filter. 4. A 68-year-old client diagnosed with chronic atrial fibrillation.

Answer: 4 1. An individual with alcoholism is not at risk of having a stroke any more than someone in the general population. 2. A client diagnosed with hepatitis is not at risk of having a stroke any more than someone in the general population. 3. A Greenfield filter is positioned in the inferior vena cava to prevent an embolism resulting from DVT; these filters prevent strokes and pulmonary emboli. 4. A client diagnosed with atrial fibrillation is at high risk of having a stroke and is usually given oral anticoagulants to prevent a stroke.

The client is diagnosed with arboviral encephalitis. Which priority intervention should the nurse implement? 1. Place the client in strict isolation. 2. Administer IV antibiotics. 3. Keep the client in the supine position. 4. Institute seizure precautions.

Answer: 4 1. Arboviral encephalitis is a viral infection transmitted by mosquito bites, and isolation is not required. 2. Antibiotics are prescribed for bacterial infections, not viral infections. There is no antiviral medication to treat this disease. 3. Keeping the client supine would increase ICP, which is a concern when caring for clients diagnosed with brain diseases. 4. Seizure precautions should be instituted because any inflammation of the brain tissue will put the client at risk for seizures.

The nurse is discussing seizure prevention with a female client just diagnosed with epilepsy. Which statement indicates the client needs more teaching? 1. "I will take calcium supplements daily and drink milk." 2. "I will see my HCP to have my blood levels drawn regularly." 3. "I should not drink any type of alcohol while taking the medication." 4. "I am glad that my periods will not affect my epilepsy."

Answer: 4 1. Because of bone loss associated with long-term use of anticonvulsants, the client should increase calcium intake to reduce the risk of osteoporosis. 2. Anticonvulsant medications have a narrow range of therapeutic value, and the levels should be checked regularly. 3. Alcohol interferes with anticonvulsant medication and should be avoided. 4. Women with epilepsy note an increase in the frequency of seizures during menses. This is thought to be linked to the increase in sex hormones that alter the excitability of the neurons in the brain.

The nurse is discussing psychosocial implications of Huntington's disease with the adult child of a client diagnosed with the disease. Which psychosocial intervention should the nurse implement? 1. Refer the adult child for genetic counseling as soon as possible. 2. Teach the adult child to use a warming tray under the food during meals. 3. Discuss the importance of not abandoning the parent. 4. Allow the adult child to talk about the fear of getting the disease.

Answer: 4 1. Referring the adult child is not a psychosocial intervention. The gene that determines if a client has Huntington's disease has been identified, and genetic counseling could rule out or confirm that the client's child will develop Huntington's disease. 2. This is an appropriate intervention, but it is not a psychosocial intervention. (Read the stem closely.) 3. This is placing a lot of responsibility on the child concerning the parent's debilitating, chronic, and devastating disease. The client may need to be in a long-term care facility, and the child should not feel guilty if this is necessary. 4. The adult child would develop this disease if the gene was inherited by the adult child. It can be frightening for children to watch a parent progress through this disease and understand that they too may get it.

The client is brought to the ED by the police for public disorderliness. The client reports feeling no pain and is unconcerned that the police have arrested him. The nurse notes the client has epistaxis and nasal congestion. Which substance should the nurse suspect the client has abused? 1. Marijuana. 2. Heroin. 3. Ecstasy. 4. Cocaine.

Answer: 4 1. Symptoms of marijuana use are apathy, delayed time, and not wanting to eat. 2. Heroin symptoms include pupil changes and respiratory depression. 3. Ecstasy is a hallucinogen that is an "upper." 4. Disorderly behavior and the symptoms of epistaxis and nasal congestion would make the nurse suspect cocaine abuse.

The client recently has been diagnosed with trigeminal neuralgia. Which intervention is the priority for the nurse to implement with the client? 1. Assess the client's sense of smell and taste. 2. Teach the client how to care for the eyes. 3. Instruct the client to have carbamazepine levels monitored regularly. 4. Assist the client to identify factors that trigger an attack.

Answer: 4 1. The client's sense of smell and taste are not affected. 2. The cornea is at risk for abrasions because of the twitching, which causes irritation. Therefore, the nurse must teach the client how to care for the eye, but the most important intervention is to prevent the attacks. 3. Carbamazepine (Tegretol) is a treatment for trigeminal neuralgia, but it is not the most important intervention when the client is first diagnosed with this condition. 4. Stimulating specific areas of the face, called trigger zones, many initiate the onset of pain. Therefore, the nurse should help the client identify situations that exacerbate the condition, such as chewing gum, eating, brushing the teeth, or being exposed to a draft of cold air.

The nurse is preparing to administer acetaminophen to a client diagnosed with a stroke and reporting a headache. Which intervention should the nurse implement first? 1. Administer the medication in pudding. 2. Check the client's armband. 3. Crush the tablet and dissolve in juice. 4. Have the client sip some water.

Answer: 4 1. The medication acetaminophen (Tylenol) can be administered in pudding, but it is not the first intervention. 2. The armband should be checked but not before determining if the client can swallow. 3. Acetaminophen (Tylenol) comes in liquid form, and the nurse should request this before crushing a very bitter tablet. 4. Asking the client to sip some water assesses the client's ability to swallow, which is a priority when placing anything in the mouth of the client diagnosed with a stroke.

The nurse in a long-term care facility has noticed a change in the behavior of one of the clients. The client no longer participates in activities and prefers to stay in his room. Which intervention should the nurse implement first? 1. Insist that the client go to the dining room for meals. 2. Notify the family of the change in behavior. 3. Determine if the client wants another roommate. 4. Complete a Geriatric Depression Scale.

Answer: 4 1. The nurse cannot insist that the client do anything. The nurse can encourage but, remember, this is the client's home. 2. The family may need to be notified, but the nurse should first assess what is happening that is causing this change in behavior. 3. There is nothing that indicates the client is unhappy with the roommate. In fact, the client wants to stay in the room, which does not indicate a need for a room change. 4. A change in behavior may indicate depression. The GDS measures satisfaction with life's accomplishments. Older persons should be in Erikson's generativity versus stagnation stage of life.

The client is reporting neck pain, fever, and a headache. The nurse elicits a positive Kernig's sign. Which diagnostic test procedure should the RN anticipate the HCP ordering to confirm a diagnosis? 1. A computed tomography (CT). 2. Blood cultures times 2. 3. Electromyogram (EMG). 4. Lumbar puncture (LP).

Answer: 4 1. The symptoms and a positive Kernig's sign suggest meningitis, but a CT scan is not diagnostic of meningitis. 2. Blood cultures determine septicemia or infections of the bloodstream, not meningitis. 3. An EMG evaluates electrical conductivity through the muscle. 4. The client's symptoms, along with a positive Kernig's sign, should make the nurse suspect meningitis. The definitive diagnostic test for meningitis is a LP to obtain cerebrospinal fluid for culture.

The male client diagnosed with Parkinson's disease has undergone a minor surgical procedure and is receiving cefazolin IV piggyback every six (6) hours. Which laboratory data should the nurse report to the HCP? 1. - RBCs: 6 - Hemoglobin: 16.6 - Hematocrit: 48 - Platelet: 140 - WBCs: 10.3 2. - Potassium: 4.2 - Sodium: 137 - Chloride: 103 - CO2: 30 3. - Glucose: 115 - A1C: 6.2 4. - Surgical wound culture: MRSA - Intravenous line culture: Negative

Answer: 4 1. These values are within the normal range for a male client. 2. These values are within the normal range. 3. These values are slightly above range for the client but not alarmingly so. 4. The wound has methicillin-resistant Staphylococcus aureus (MRSA) in it, and the client is receiving cefazolin (Ancef), an antibiotic that the MRSA is resistant to; the nurse should notify the HCP for a medication change to vancomycin.

The student nurse asks the RN, "Why do you ask the client to identify how many fingers you have up when the client hit the front of the head, not the back of the head?" The RN would base the response on which scientific rationale? 1. This is part of the routine neurological examination. 2. This is done to determine if the client has diplopia. 3. This assesses the amount of brain damage. 4. This is done to indicate if there is a rebound effect on the brain.

Answer: 4 1. This is part of the neurological examination, but this is not the scientific rationale for why it is done. The nurse must understand what is being assessed to interpret the data. 2. Diplopia, double vision, is a sign of head injury, but it is not the scientific rationale. 3. The procedure does assess brain damage, but this answer does not explain why. 4. When the client hits the front of the head, there is a rebound effect known as "coup-contrecoup," in which the brain hits the back of the skull. The occipital lobe is in the back of the head, and an injury to it may be manifested by seeing double.

Which should be the nurse's first intervention with the client diagnosed with Bell's palsy? 1. Explain that this disorder will resolve within a month. 2. Tell the client to apply heat to the involved side of the face. 3. Encourage the client to eat a soft diet. 4. Teach the client to protect the affected eye from injury.

Answer: 4 1. This is the correct information, but it is not a priority when discussing Bell's palsy. 2. Heat will help promote comfort and increase blood flow to the muscles, but the safety of the client's eye is a priority. 3. The client may have difficulty chewing on the affected side, so a soft diet should be encouraged, but it is not a priority teaching. 4. Teaching the client to protect the eye is a priority because the eye does not close completely, and the blink reflex is diminished, making the eye vulnerable to injury. The client should wear an eye patch at night and wraparound sunglasses or goggles during the day; the client may also need lubricating eye drops.

The client comes to the clinic for the treatment of a dog bite. Which intervention should the clinic nurse implement first? 1. Prepare the client for a series of rabies injections. 2. Notify the local animal control department. 3. Administer a tetanus toxoid in the deltoid. 4. Determine if the animal has had its vaccinations.

Answer: 4 1. This may be needed if it is determined the dog has not had its shots or if the dog cannot be found, but it is not the first intervention. 2. This is an appropriate action if the client does not know the dog owner, then the dog can be found and quarantined. 3. If the client has not had a tetanus booster in the last 10 years, one must be administered, but it is usually the last action taken before the client is discharged from the clinic. 4. This is a priority because if the dog has had its vaccinations, the client will not have to undergo a series of very painful injections. The nurse must obtain information about the dog, which is an assessment of the situation.

The client diagnosed with ALS (Lou Gehrig's disease) is prescribed medications that require intravenous access. The HCP has ordered a primarry intravenous line at a keep-vein-open (KVO) rate at 25 mL/hr. The drop factor is 10 gtts/mL. At what rate should the nurse set the IV tubing?

Answer: 4 gtts/min The nurse must know the formula for regulating IV drips: the amount to infuse (25 mL/hr) times the drop factor (10 gtts/mL) divided by the minutes. Thus, 25 × 10 = 250 ÷ 60 = 4.11 or 4 gtts/min.