PNE 111/Health & Disease/PrepU 37
The critical care nurse is caring for 25-year-old client admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this client? Monitoring neurologic status closely Promoting mobility Providing health education Maintaining the client's functional independence
Monitoring neurologic status closely Explanation: Vigilant neurologic monitoring is a key aspect of caring for a client who has a brain abscess. This supersedes education, ADLs, and mobility, even though these are all valid and important aspects of nursing care.
A patient had a small pituitary adenoma removed by the transsphenoidal approach and has developed diabetes insipidus. What pharmacologic therapy will the nurse be administering to this patient to control symptoms? Vasopressin Mannitol Phenobarbital Furosemide (Lasix)
Vasopressin Explanation: Manipulation of the posterior pituitary gland during surgery may produce transient diabetes insipidus of several days' duration (Hickey, 2009). It is treated with vasopressin but occasionally persists.
Myasthenia gravis occurs when antibodies attack which receptor sites? Gamma-aminobutyric acid Serotonin Dopamine Acetylcholine
Acetylcholine Explanation: In myasthenia gravis, antibodies directed at the acetylcholine receptor sites impair transmission of impulses across the myoneural junction. Serotonin, dopamine, and gamma-aminobutyric acid are not receptor sites that are attacked in myasthenia gravis.
The nurse is preparing to administer the recommended dose of intravenous gamma-globulin for a 60-kg male client. How many grams will the nurse administer? 15 g 30 g 90 g 60 g
30 g Explanation: The optimal dose is determined by the client's response. In most instances, an IV dose of 200-800 mg/kg of body weight is administered every 3-4 weeks to ensure adequate serum levels of immunoglobulin G (IgG)
The spouse of a client with terminal brain cancer asks the nurse about hospice. Which statement by the nurse best describes hospice care? "Clients and families are the focus of hospice care." "Hospice care uses a team approach and provides complete care." "All hospice clients die at home." "The physician coordinates all the care delivered."
"Clients and families are the focus of hospice care." Explanation: The most important component of hospice care is the focus that is placed on the care of the client as well as the family. Hospice does take a team approach and coordinates care through the hospice physician, but these are not the focus. Not all hospice clients wish to die at home.
A client with Parkinson disease is experiencing episodes of constipation that are becoming increasingly frequent and severe. The client reports that he has been achieving relief for the past few weeks by using over-the-counter laxatives. How should the nurse respond? "It's important to drink plenty of fluids while you're taking laxatives." "Make sure that you supplement your laxatives with a nutritious diet." "You should ideally be using herbal remedies rather than medications to promote bowel function." "Let's explore other options, because laxatives can have side effects and create dependency."
"Let's explore other options, because laxatives can have side effects and create dependency." Explanation: Laxatives should be avoided in clients with Parkinson disease due to the risk of adverse effects and dependence. Herbal bowel remedies are not necessarily less risky.
The nurse is caring for a client newly diagnosed with a primary brain tumor. The client asks the nurse where the tumor came from. What would be the nurse's best response? "Your tumor originated from cells within your brain itself." "Your tumor is from nerve tissue somewhere in your body." "Your tumor likely started out in one of your glands." "Your tumor originated from somewhere outside the CNS."
"Your tumor originated from cells within your brain itself." Explanation: Primary brain tumors originate from cells and structures within the brain. Secondary brain tumors are metastatic tumors that originate somewhere else in the body. The scenario does not indicate that the client's tumor is a pituitary tumor or a neuroma.
The clinic nurse caring for a patient with Parkinson's disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. What common side effects of Sinemet would the nurse assess this patient for? Lactose intolerance Dyskinesia Diarrhea Pruritus
Dyskinesia Explanation: Within 5 to 10 years of taking levodopa, most patients develop a response to the medication characterized by dyskinesia (abnormal involuntary movements). Another potential complication of long-term dopaminergic medication use is neuroleptic malignant syndrome, characterized by severe rigidity, stupor, and hyperthermia. Side effects of long-term Sinemet therapy are not pruritus, lactose intolerance, or diarrhea.
A client, brought to the clinic by the client's spouse and son, is diagnosed with Huntington disease. When providing anticipatory guidance, the nurse should address the future possibility of what effect of Huntington disease? Emotional and personality changes Metastasis Risk for stroke Pathologic bone fractures
Emotional and personality changes Explanation: Huntington disease causes profound changes to personality and behavior. It is a nonmalignant disease and stroke is not a central risk. The disease is not associated with pathologic bone fractures.
A home health nurse is caring for a client who has an immunodeficiency. What is the nurse's priority action to help ensure successful outcomes and a favorable prognosis? Encourage the client and family to manage the client's activity level and activities of daily living effectively. Encourage the client and family to be active partners in the management of the immunodeficiency. Make sure that the client and family understand the importance of monitoring fluid balance. Make sure that the client and family know how to adjust dosages of the medications used in treatment.
Encourage the client and family to be active partners in the management of the immunodeficiency. Explanation: Encouraging the client and family to be active partners in the management of the immunodeficiency is the key to successful outcomes and a favorable prognosis. This transcends the client's activity and functional status. Medications should not be adjusted without consultation from the primary provider. Fluid balance is not normally a central concern.
A client is diagnosed with a brain angioma. When teaching the client about the risks associated with this type of brain tumor, the nurse would educate about signs and symptoms associated with which condition? Visual loss Thyroid disorders Hearing loss Hemorrhagic stroke
Hemorrhagic stroke Explanation: Brain angiomas (masses composed largely of abnormal blood vessels) are found either in the brain or on its surface. Because the walls of the blood vessels in angiomas are thin, affected clients are at risk for hemorrhagic stroke. Pituitary adenomas that produce hormones can lead to endocrine disorders, such as thyroid disorders. In addition, they can exert pressure on the optic nerves and optic chiasm, leading to vision loss. Acoustic neuromas are associated with hearing loss.
The nurse is caring for a patient on the neurological unit who is in status epilepticus. What medication does the nurse anticipate being given to halt the seizure? IV phenobarbital IV lidocaine IV diazepam Oral phenytoin
IV diazepam Explanation: Status epilepticus (acute prolonged seizure activity) is a series of generalized seizures that occur without full recovery of consciousness between attacks. Medical management of status epilepticus includes IV diazepam (Valium) and IV lorazepam (Ativan), given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state.
A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate? Restrain the client to prevent injury. Open the client's jaws to insert an oral airway. Place client in high Fowler position. Loosen the client's restrictive clothing.
Loosen the client's restrictive clothing. Explanation: An appropriate nursing intervention would include loosening any restrictive clothing on the client. No attempt should be made to restrain the client during the seizure because muscular contractions are strong and restraint can produce injury. Do not attempt to pry open jaws that are clenched in a spasm to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. If possible, place the client on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus.
A client has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the client's ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following? Signs of internal bleeding Hemiplegia Loss of brain stem reflexes Dry mucous membranes
Loss of brain stem reflexes Explanation: Loss of brain stem reflexes, including pupillary, corneal, gag, and swallowing reflexes, is an ominous sign of approaching death. Dry mucous membranes, hemiplegia, and bleeding must be promptly addressed, but none of these is a common sign of impending death.
A client is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this client's care, the nurse would expect to administer what priority medication? Mannitol Spironlactone Hydrochlorothiazide Furosemide
Mannitol Explanation: The osmotic diuretic mannitol is given to dehydrate the brain tissue and reduce cerebral edema. This drug acts by reducing the volume of brain and extracellular fluid. Spironlactone, furosemide, and hydrochlorothiazide are diuretics that are not typically used in the treatment of increased ICP resulting from cerebral edema.
A client with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a client with this diagnosis? Numbness and tingling in the lower extremities Pain upon ankle dorsiflexion of the foot Neck flexion produces flexion of knees and hips Inability to stand with eyes closed and arms extended without swaying
Neck flexion produces flexion of knees and hips Explanation: Clinical manifestations of bacterial meningitis include a positive Brudzinski sign. Neck flexion producing flexion of knees and hips correlates with a positive Brudzinski sign. Positive Homan sign (pain upon dorsiflexion of the foot) and negative Romberg sign (inability to stand with eyes closed and arms extended) are not expected assessment findings for the client with bacterial meningitis. Peripheral neuropathy manifests as numbness and tingling in the lower extremities. Again, this would not be an initial assessment to rule out bacterial meningitis.
When educating a patient about the use of antiseizure medication, what should the nurse inform the patient is a result of long-term use of the medication in women? Osteoarthritis Anemia Obesity Osteoporosis
Osteoporosis Explanation: Because of bone loss associated with the long-term use of antiseizure medications, patients receiving antiseizure agents should be assessed for low bone mass and osteoporosis. They should be instructed about strategies to reduce their risks of osteoporosis (AANN, 2009).
A client presents to the clinic reporting a headache. The nurse notes that the client is guarding the neck and tells the nurse about stiffness in the neck area. The nurse suspects the client may have meningitis. What is another well-recognized sign of this infection? Sluggish pupil reaction Negative Brudzinski sign Hyperpatellar reflex Positive Kernig sign
Positive Kernig sign Explanation: Meningeal irritation results in a number of well-recognized signs commonly seen in meningitis, such as a positive Kernig sign, a positive Brudzinski sign, and photophobia. Hyperpatellar reflex and a sluggish pupil reaction are not commonly recognized signs of meningitis.
A client with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? Administering prescribed antipyretics Restricting fluid intake and hydration Maintaining adequate hydration Hyperoxygenation before and after tracheal suctioning
Restricting fluid intake and hydration Explanation: Fluid restriction may be necessary if the client develops cerebral edema and hypervolemia from SIADH. Antipyretics are administered to clients who develop hyperthermia. In addition, it is important to maintain adequate hydration in such clients. A client with neurologic infection should be given tracheal suctioning and hyperoxygenation only when the respiratory distress develops
A young adult has just been diagnosed with atonic seizures. The nurse practitioner explains to the patient that this type of seizure is characterized by: Sudden loss of muscle tone that results in a fall. Jerking movements involving muscles on both sides of the body. Short episodes of staring and loss of awareness. Bilateral muscle movements without loss of consciousness.
Sudden loss of muscle tone that results in a fall. Explanation: Atonic seizures are characterized by sudden loss of muscle tone, resulting in falls or a "drop" to the ground, with rapid recovery. Clonic seizures are characterized by jerking movements, which involve muscles on both sides of the body. Absence (petit mal) seizures refer to short episodes of staring and loss of awareness. Myoclonic seizures (bilaterally massive epileptic) are characterized by jerking movements of a muscle or muscle group, without loss of consciousness.
A 70-year-old woman is being treated at home for Parkinson's disease (PD), a health problem that she was diagnosed with 18 months ago. The nurse who is participating in the woman's care should be aware that her initial symptoms most likely consisted of: Tremors and muscle rigidity Fatigue and respiratory difficulties Visual disturbances and muscle weakness Increasing forgetfulness and confusion
Tremors and muscle rigidity Explanation: The cardinal signs of PD are tremor, rigidity, akinesia/bradykinesia, and postural disturbances.
A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient? Within 24 hours after exposure Therapy is not necessary prophylactically and should only be used if the person develops symptoms. Within 48 hours after exposure Within 72 hours after exposure
Within 24 hours after exposure Explanation: People in close contact with patients with meningococcal meningitis should be treated with antimicrobial chemoprophylaxis using rifampin (Rifadin), ciprofloxacin hydrochloride (Cipro), or ceftriaxone sodium (Rocephin). Therapy should be started within 24 hours after exposure because a delay in the initiation of therapy limits the effectiveness of the prophylaxis.
A nurse is aware of the important role that interferons (IFNs) perform in the normal function of the immune system. As well, the nurse has provided care for patients who have benefited from interferon therapy. IFN therapy is most likely to be effective in the treatment of which of the following patients? A 60-year-old man with motor and sensory deficits resulting from an ischemic stroke A 68-year-old woman who is being treated for chronic myeloid leukemia (CML) A 36-year-old woman who is in danger of developing sepsis after suffering full-thickness burns An 80-year-old man who is debilitated from Clostridium difficile-related diarrhea
A 68-year-old woman who is being treated for chronic myeloid leukemia (CML) Explanation: IFNs are cytokines. They have antiviral and antitumor properties and can consequently be used in the treatment of neoplasms such as CML. Bacterial infections and neurological deficits are not responsive to interferon therapy.
A school nurse is called to the playground where a 6-year-old girl has been found sitting unresponsive and "staring into space," according to the playground supervisor. How would the nurse document the girl's activity in her chart at school? Unclassified seizure Generalized seizure Focal seizure Absence seizure
Absence seizure Explanation: Staring episodes characterize an absence seizure, whereas focal seizures, generalized seizures, and unclassified seizures involve uncontrolled motor activity.
Which nursing intervention is most helpful when addressing the priority nursing diagnosis of Impaired Physical Mobility related to damage of brain tissue as evidenced by visual deficits and absence of portions of the visual field? Ensure a clutter-free walkway. Place patient in a room near the nursing station. Instruct on adaptive plates with rims. Announce yourself when approaching the client.
Ensure a clutter-free walkway. Explanation: The most helpful nursing intervention for the Impaired Physical Mobility nursing diagnosis is to ensure a clutter-free walkway. With the absence of the visual field, a clutter-free walkway is a safety issue. The other options could possibly be appropriate, but not the priority intervention.
Splints have been prescribed for a client who is at risk of developing foot drop following a spinal cord injury. When should the nurse remove and reapply the splints? Each morning and evening At the client's request Every 2 hours One hour prior to mobility exercises
Every 2 hours Explanation: The feet are prone to foot drop; therefore, various types of splints are used to prevent foot drop. When used, the splints are removed and reapplied every 2 hours
A 50-year-old client is exhibiting progressive signs of Huntington's disease. The client verbalizes a wish to die and has become withdrawn. Poor appetite is noted, sleep pattern is disturbed, and the choreiform movements are worsening. Which nursing diagnosis best reflects the needs of this client? Disturbed Sleep Pattern Hopelessness Altered Nutrition Impaired Home Maintenance
Hopelessness Explanation: Huntington's disease is an inherited disease that has progressive physical, emotional, and mental involvement. There is no cure or course of treatment to preserve or prevent disease progression. Death is eminent. This client feels hopeless and helpless and sees no alternatives or choices available and is unable or unwilling to move forward with living. Impaired Home Maintenance is not significant. Altered Nutrition and Disturbed Sleep Patterns are apparent, but unless the client is able to mobilize energy to move forward, these problems cannot be resolved.
A client with Parkinson disease is undergoing a swallowing assessment because the client has recently developed adventitious lung sounds. The client's nutritional needs should be met by what method? Provision of a low-residue diet Total parenteral nutrition (TPN) Semisolid food with thick liquids Minced foods and a fluid restriction
Semisolid food with thick liquids Explanation: A semisolid diet with thick liquids is easier for a client with swallowing difficulties to consume than is a solid diet. Low-residue foods and fluid restriction are unnecessary and counterproductive to the client's nutritional status. The client's status does not warrant TPN until all other options have been ruled out.
A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include: pupillary changes. decreasing blood pressure. diminished responsiveness. elevated temperature.
diminished responsiveness. Explanation: Usually, diminished responsiveness is the first sign of increasing ICP. Pupillary changes occur later. Increased ICP causes systolic blood pressure to rise. Temperature changes vary and may not occur even with a severe decrease in responsiveness.
The nurse teaches the client that corticosteroids will be used to treat his brain tumor to facilitate regeneration of neurons. reduce cerebral edema. identify the precise location of the tumor. prevent extension of the tumor.
reduce cerebral edema. Explanation: Corticosteroids may be used before and after treatment to reduce cerebral edema and to promote a smoother, more rapid recovery. Corticosteroids do not prevent extension of the tumor or facilitate regeneration of neurons. Stereotactic procedures identify the precise location of the tumor.
A client weighing 132 lb is brought to the emergency department in status epilepticus. The physician asks the nurse to prepare diazepam 0.25 mg/kg. How many milligrams will be given to this client? divide 132/2.2 and then multiple by 0.25
15 Explanation: Step 1: 2.2 lb / 1 kg = 132 lb / X kg 132 lb = 2.2 X 60 kg = X Step 2: 1 kg / 0.25 mg = 60 kg / X mg 15 mg = X
A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? 9 3 6 12
3 Explanation: LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response (Barlow, 2012). The patient's responses are rated on a scale from 3 to 15. A score of 3 indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response. A score of 15 indicates that the patient is fully responsive (see Chapter 68).
A client with a traumatic brain injury is showing early signs of increasing intracranial pressure (ICP). While planning care for this client, what would be the priority expected outcome? Attains desired fluid balance Displays no signs or symptoms of infection Maintains a patent airway Demonstrates optimal cerebral tissue perfusion
Maintains a patent airway Explanation: Maintenance of a patent airway is always a first priority. Loss of airway is a possible complication of increasing ICP, as well as aspiration from vomiting.
A community health nurse is performing a home visit to a patient with amyotrophic lateral sclerosis (ALS). The nurse should prioritize assessments related to which of the following? Potential skin breakdown Cardiac function Respiratory function Cognition
Respiratory function Explanation: Respiratory function is profoundly affected by ALS and would be prioritized over integumentary assessment. Cardiac function and cognition are not normally affected by the disease.
A patient with Bell's palsy says to the nurse, "It doesn't hurt anymore to touch my face. How am I going to get muscle tone back so I don't look like this anymore?" What interventions can the nurse suggest to the patient? Tell the patient to smile every 4 hours. Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. Suggest applying cool compresses on the face several times a day to tighten the muscles. Inform the patient that the muscle function will return as soon as the virus dissipates.
Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. Explanation: After the sensitivity of the nerve to touch decreases and the patient can tolerate touching the face, the nurse can suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. Facial exercises, such as wrinkling the forehead, blowing out the cheeks, and whistling, may be performed with the aid of a mirror to prevent muscle atrophy. Exposure of the face to cold and drafts is avoided.
A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP value? The CPP is within normal limits. The CPP reading is inaccurate. The CPP is high. The CPP is low.
The CPP is low. Explanation: The normal CPP is 70 to 100 mm Hg. Therefore, a CPP of 40 mm Hg is low. Changes in intracranial pressure (ICP) are closely linked with cerebral perfusion pressure (CPP). The CPP is calculated by subtracting the ICP from the mean arterial pressure (MAP). Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage.
Which client should the nurse assess for degenerative neurologic symptoms? The client with glioma. The client with osteomyelitis. The client with Paget disease. The client with Huntington disease.
The client with Huntington disease. Explanation: Huntington disease is a chronic, progressive, degenerative neurologic hereditary disease of the nervous system that results in progressive involuntary choreiform movement and dementia. Paget disease is a musculoskeletal disorder, characterized by localized rapid bone turnover, most commonly affecting the skull, femur, tibia, pelvic bones, and vertebrae. Osteomyelitis is an infection of the bone. Malignant glioma is the most common type of brain tumor.
A client is being treated for increased intracranial pressure (ICP). The nurse should ensure that the client does not develop hypothermia because: hypothermia can cause death to the client. shivering in hypothermia can increase ICP. hypothermia is indicative of malaria. hypothermia is indicative of severe meningitis.
shivering in hypothermia can increase ICP. Explanation: Care must be taken to avoid the development of hypothermia because hypothermia causes shivering. Shivering, in turn, can increase intracranial pressure.
The nurse responds to the call light of a client who has had a cervical discectomy earlier in the day. The client states that she is having severe pain that had a sudden onset. What is the nurse's most appropriate action? Palpate the surgical site. Administer a dose of an NSAID. Call the surgeon to report the client's pain. Remove the dressing to assess the surgical site.
Call the surgeon to report the client's pain. Explanation: If the client experiences a sudden increase in pain, extrusion of the graft may have occurred, requiring reoperation. A sudden increase in pain should be promptly reported to the surgeon. Administration of an NSAID would be an insufficient response and the dressing should not be removed without an order. Palpation could cause further damage.
A client has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize? Generalized seizure Absence seizure Focal seizure Unclassified seizure
Generalized seizure Explanation: Generalized seizures often involve both hemispheres of the brain, causing both sides of the body to react. Intense rigidity of the entire body may occur, followed by alternating muscle relaxation and contraction (generalized tonic-clonic contraction). This pattern of rigidity does not occur in clients who experience unclassified, absence, or focal seizures.
The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning? Decreased pulse rate, abdominal breathing Increased pulse rate, adventitious breath sounds Increased pulse rate, respirations of 16 breaths/minute Decreased pulse rate, respirations of 20 breaths/minute
Increased pulse rate, adventitious breath sounds Explanation: An increased pulse rate above baseline with adventitious breath sounds indicate compromised respirations and signal a need for airway clearance. A decrease in pulse rate is not indicative of airway obstruction. An increase of pulse rate with slight elevation of respirations (16 breaths/minute) is not significant for suctioning unless findings suggest otherwise.
What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? Bradycardia A bounding pulse Lethargy and stupor Hypertension
Lethargy and stupor Explanation: As ICP increases, the patient becomes stuporous, reacting only to loud or painful stimuli. At this stage, serious impairment of brain circulation is probably taking place, and immediate intervention is required.
The nurse is participating in the care of a client with increased ICP. What diagnostic test is contraindicated in this client's treatment? Lumbar puncture Magnetic resonance imaging (MRI) Venous Doppler studies Computed tomography (CT) scan
Lumbar puncture Explanation: A lumbar puncture in a client with increased ICP may cause the brain to herniate from the withdrawal of fluid and change in pressure during the lumbar puncture. Herniation of the brain is a dire and frequently fatal event. CT, MRI, and venous Doppler are considered noninvasive procedures and they would not affect the ICP itself.
A client with increased intracranial pressure (ICP) has a ventriculostomy for monitoring ICP. The nurse's most recent assessment reveals that the client is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication? Meningitis Encephalitis Catheter occlusion Cerebral spinal fluid leak
Meningitis Explanation: Complications of a ventriculostomy include ventricular infectious meningitis and problems with the monitoring system. Nuchal rigidity and photophobia are clinical manifestations of meningitis, but are not suggestive of encephalitis, a cerebral spinal fluid (CSF) leak, or an occluded catheter.
A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention? Capillary refill of 2 seconds Cool, dry skin Shivering Urine output of 100 mL/hr
Shivering Explanation: Shivering can increase intracranial pressure by increasing vasoconstriction and circulating catecholamines. Shivering also increases oxygen consumption. A capillary refill of 2 seconds, urine output of 100mL/hr, and cool, dry skin are expected findings.
A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)? Administering a stool softener as ordered Encouraging oral fluid intake Suctioning the client once each shift Elevating the head of the bed 90 degrees
Administering a stool softener as ordered Explanation: To prevent the client from straining at stool, which may cause a Valsalva maneuver that increases ICP, the nurse should institute a regular bowel program that includes use of a stool softener. For a client at risk for increased ICP, the nurse should prevent, not encourage, oral fluid intake and should elevate the head of the bed only 30 degrees. Suctioning, indicated for a client with lung congestion, isn't necessary for this client. Reference:
A nurse is reviewing the immune system before planning an immunocompromised client's care. How should the nurse characterize the humoral immune response? Lymphocytes are stimulated to become cells that attack microbes directly. T lymphocytes are assisted by cytokines to fight infection. Specialized cells recognize and ingest cells that are recognized as foreign. Antibodies are made by B lymphocytes in response to a specific antigen.
Antibodies are made by B lymphocytes in response to a specific antigen. Explanation: The humoral response is characterized by the production of antibodies by B lymphocytes in response to a specific antigen. Phagocytosis and direct attack on microbes occur in the context of the cellular immune response.
A middle-aged client has sought care from the primary provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the client to seek care? Personality changes Cognitive declines Difficulty in coordination Contractures
Difficulty in coordination Explanation: The symptoms of MS most commonly reported are fatigue, depression, weakness, numbness, difficulty in coordination, loss of balance, spasticity, and pain. Cognitive changes and contractures usually occur later in the disease.
The nurse is performing an assessment for a patient in the clinic with Parkinson's disease. The nurse determines that the patient's voice has changed since the last visit and is now more difficult to understand. How should the nurse document this finding? Micrographia Dysphonia Dysphagia Hypokinesia
Dysphonia Explanation: Dysphonia (voice impairment or altered voice production) may occur as a result of weakness and incoordination of the muscles responsible for speech.
The nurse is writing a care plan for a client with brain metastases. The nurse decides that an appropriate nursing diagnosis is "anxiety related to lack of control over the health circumstances." In establishing this plan of care for the client, the nurse should include which intervention? Intensive therapy with the goal of distraction Antianxiety medications every 4 hours Encouragement to verbalize concerns related to the disease and its treatment Family instruction on planning the client's care
Encouragement to verbalize concerns related to the disease and its treatment Explanation: Clients need the opportunity to exercise some control over their situation. A sense of mastery can be gained as they learn to understand the disease and its treatment and how to deal with their feelings. Distraction and administering medications will not allow the client to gain control over anxiety. Delegating planning to the family will not help the client gain a sense of control and autonomy.
A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure? Sensory Jacksonian Generalized Absence
Generalized Explanation: A generalized seizure causes generalized electrical abnormality in the brain. The client typically falls to the ground, losing consciousness. The body stiffens (tonic phase) and then alternates between episodes of muscle spasm and relaxation (clonic phase). Tongue biting, incontinence, labored breathing, apnea, and cyanosis may also occur. A Jacksonian seizure begins as a localized motor seizure. The client experiences a stiffening or jerking in one extremity, accompanied by a tingling sensation in the same area. Absence seizures occur most commonly in children. They usually begin with a brief change in the level of consciousness, signaled by blinking or rolling of the eyes, a blank stare, and slight mouth movements. Symptoms of a sensory seizure include hallucinations, flashing lights, tingling sensations, vertigo, déjà vu, and smelling a foul odor.
A client with amyotrophic lateral sclerosis (ALS) has a nasal sound to speech. Which intervention will the nurse add to the client's plan of care? Give oral fluids with assistance. Maintain oxygen 2 liters per nasal canula. Suction the oropharynx as needed. Instruct to tuck the chin when swallowing.
Give oral fluids with assistance. Explanation: Clinical manifestations of amyotrophic lateral sclerosis (ALS) depend upon the location of the affected motor neurons. If the client has weakness in the muscles supplied by the cranial nerves, difficulty swallowing will occur. When the client ingests liquids, the soft palate and upper esophageal weakness cause the liquid to be regurgitated through the nose. It is necessary, therefore, for oral fluids to be given with assistance. Oropharyngeal suctioning is not indicated. Oxygen therapy would not be used because of the change in the speech tone. Tucking the chin when swallowing is not an intervention to help the client with ALS.
The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient? Restricts protein to 10% of daily caloric intake Low in fat High in protein and low in carbohydrate At least 50% carbohydrate
High in protein and low in carbohydrate Explanation: A dietary intervention, referred to as the ketogenic diet, may be helpful for control of seizures in some patients. This high-protein, low-carbohydrate, high-fat diet is most effective in children whose seizures have not been controlled with two antiseizure medications, but it is sometimes used for adults who have had poor seizure control (Mosek, Natour, Neufeld, et al., 2009).
The nurse is caring for a client who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to prevent seizures in this client? Phenytoin Cafergot Dexamethasone Prednisone
Phenytoin Explanation: Anticonvulsant medication (phenytoin, levetiracetam) is often prescribed prophylactically for clients who have undergone supratentorial craniotomy because of the high risk of seizures after this procedure. Prednisone and dexamethasone are steroids and do not prevent seizures. Cafergot is used in the treatment of migraines.
A middle-aged man has presented for care to a nurse practitioner because his seasonal allergies are detracting from his quality of life. What should the nurse teach this patient about allergic rhinitis? Allergic rhinitis is a risk factor for chronic obstructive pulmonary disease (COPD). Allergic rhinitis develops as a result of prolonged exposure to unhygienic conditions. Immunotherapy may have the potential to provide long-term relief from symptoms. A diagnosis is based on signs and symptoms because no objective diagnostic tests exist.
Immunotherapy may have the potential to provide long-term relief from symptoms. Explanation: Immunotherapy can be an effective treatment for many patients with allergic rhinitis. Unhygienic conditions can exacerbate the problem, but these are not implicated in the etiology of allergic rhinitis. Diagnostic testing is widely available, and allergic rhinitis is not a risk factor for COPD.
What specific drug group has both antiviral and anti-proliferative actions? Interferons Interleukins Monoclonal antibodies Hematopoietic growth factors
Interferons Explanation: Interferons are chemicals that are secreted by cells that have been invaded by viruses and possibly by other stimuli. The interferons prevent viral replication and also suppress malignant cell replication and tumor growth. Therefore Options B, C, and D are incorrect.
During the examination of an unconscious client, the nurse observes that the client's pupils are fixed and dilated. What is the most plausible clinical significance of the nurse's finding? It suggests onset of metabolic problems. It indicates paralysis on the right side of the body. It indicates an injury at the midbrain level. It indicates paralysis of cranial nerve X (CN X).
It indicates an injury at the midbrain level. Explanation: Pupils that are fixed and dilated indicate injury at the midbrain level. This finding is not suggestive of unilateral paralysis, metabolic deficits, or damage to CN X.
The nurse is caring for a client who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of "deficient fluid volume related to fluid restriction and osmotic diuretic use." What is the nurse's most appropriate intervention for this diagnosis? Maintain NPO status. Change the client's position as indicated. Monitor arterial blood gas (ABG) values. Monitor serum electrolytes.
Monitor serum electrolytes. Explanation: The postoperative fluid regimen depends on the type of neurosurgical procedure and is determined on an individual basis. The volume and composition of fluids are adjusted based on daily serum electrolyte values, along with fluid intake and output. Fluids may have to be restricted in clients with cerebral edema. Changing the client's position, maintaining an NPO status, and monitoring ABG values do not relate to the nursing diagnosis of deficient fluid volume.
A health care provider is taking post-exposure prophylaxis (PEP) medications for exposure to a client with human immunodeficiency virus (HIV). Which topics will the health care provider need to understand regarding PEP administration prior to beginning this regimen? Select all that apply. Potential drug toxicities Needed dietary changes Sleep pattern disturbances Potential drug interactions Adherence requirements
Potential drug toxicities Potential drug interactions Adherence requirements Explanation: The health care provider will need to understand potential drug toxicities, such as rashes and hypersensitivity reactions, which could imitate acute HIV seroconversion and require monitoring. The health care provider will also need to understand potential drug interactions, such as with supplements and vitamins, which could change the effectiveness of PEP. The health care provider will also need to understand adherence requirements, as adherence to the daily use of the PEP is paramount to its effectiveness. Typically, for most of PEP, there are no specific dietary changes needed. Sleep pattern disturbances generally do not happen with administration of these medications.
The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The care plan for this client reflects the client's problem eating due to jaw pain. To assist the client in meeting the adequate nutritional needs, what should the nurse suggest? Increase the intake of calcium and proteins. Take small meals of nutrient and calorie-dense food. Include additional servings of fruits and raw vegetables. Include fish, liver, and chicken in diet.
Take small meals of nutrient and calorie-dense food. Explanation: To help a client with trigeminal neuralgia who suffers pain in the jaws meet his or her nutritional needs, the nurse should offer small meals of soft consistency. Foods may be pureed to minimize jaw movements when eating. There is no need for the client to increase the intake of fruits and raw vegetables, calcium, or proteins during trigeminal neuralgia. In addition, an increased intake of fruits and raw vegetables requires excessive chewing, potentially increasing the incidence of jaw pain. The nurse should avoid offering meat and fish in the diet because they also require excessive chewing by the client.
A client newly diagnosed with multiple sclerosis (MS) asks about a cure for her disease process. The nurse gives which of the following information? There is no cure for MS. Medications do not assist with relief of signs and symptoms. If recommendations for symptom relief are followed, the disease will be cured. Life expectancy for clients with MS is dramatically different from that of those without MS.
There is no cure for MS. Explanation: No cure exists for MS. Life expectancy for clients with MS is not dramatically different from that of clients without MS. Medications are available for symptom management of clients with MS.