Pot of Questions: Chapter 36, 37 (Neuro A&P, CNS and PNS Disorders)
What is one of the earliest signs of increased ICP? a. decreased level of consciousness (LOC) b. headache c. Cushing's triad d. coma
a
Which finding is considered a positive finding of the Romberg test? a. Loss of balance b. Hoarseness in the voice c. Deviation of the tongue d. Tearing of the eye
a
The Glasgow Coma Scale is a common screening tool used for patients with a head injury. During the physical exam, the nurse documents that the patient is able to spontaneously open her eyes, obey verbal commands, and is oriented. The nurse records the highest score of: a. 20 b. 15 c. 10 d. 5
b
Which cerebral lobes is the largest and controls abstract thought? a. Temporal b. Frontal c. Parietal d. Occipital
b
A patient is scheduled for an electroencephalogram (EEG) in the morning. What food on the patient's tray should the nurse remove prior to the test? a. Orange juice b. Toast c. Coffee d. Eggs
c
Which term describes the fibrous connective tissues that cover the brain and spinal cord? a. Meninges b. Dura mater c. Arachnoid mater d. Pia mater
a
A client with a new diagnosis of amyotrophic lateral sclerosis (ALS) is overwhelmed by his diagnosis and the known complications of the disease. How can the client best make known his wishes for care as his disease progresses? a. Prepare an advance directive. b. Designate a most responsible health care provider (MRP) early in the course of the disease. c. Collaborate with representatives from the Amyotrophic Lateral Sclerosis Association. d. Ensure that witnesses are present when he provides instruction.
a
A hospital client has experienced a seizure. In the immediate recovery period, what action best protects the client's safety? a. Place the client in a side-lying position. b. Pad the client's bed rails. c. Administer antianxiety medications as prescribed. d. Reassure the client and family members.
a
A client falls to the floor in a generalized seizure with tonic-clonic movements. Which is the first action taken by the nurse? a. Insert an airway or bite block. b. Manually restrain the extremities. c. Turn client to side-lying position. d. Monitor vital signs.
c
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? a. Unclassified seizure b. Absence seizure c. Generalized seizure d. Focal seizure
c
What is the function of cerebrospinal fluid (CSF)? a. It cushions the brain and spinal cord. b. It acts as an insulator to maintain a constant spinal fluid temperature. c. It acts as a barrier to bacteria. d. It produces cerebral neurotransmitters.
a
When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first? a. Check the equipment. b. Contact the physician to review the care plan. c. Continue the assessment because no actions are indicated at this time. d. Document the reading because it reflects that the treatment has been effective.
a
Which client should the nurse assess for degenerative neurologic symptoms? a. The client with Huntington disease. b. The client with Paget disease. c. The client with osteomyelitis. d. The client with glioma.
a
What safety actions does the nurse need to take for a client receiving oxygen therapy who is undergoing magnetic resonance imaging (MRI)? a. Securely fasten the client's portable oxygen tank to the bottom of the MRI table after the client has been positioned on the top of the MRI table b. Check the client's oxygen saturation level using a pulse oximeter after the client has been placed on the MRI table c. Note that no special safety actions need to be taken d. Ensure that no client care equipment containing metal enters the room where the MRI is located.
d
Which is a late sign of increased intracranial pressure (ICP)? a. Irritability b. Slow speech c. Altered respiratory patterns d. Headache
c
The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began? a. Shortness of breath b. Sensitivity to bright light c. Muscle spasms d. Drooping eyelids
d
A client exhibiting an uncoordinated gait has presented at the clinic. Which of the following is the most plausible cause of this client's health problem? a. Cerebellar dysfunction b. A lesion in the pons c. Dysfunction of the medulla d. A hemorrhage in the midbrain
a
A nurse caring for a patient with head trauma will be monitoring the patient for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply. a. Bradycardia b. Bradypnea c. Hypertension d. Tachycardia e. Pupillary constriction
a,b,c
Which signs are manifestations of the Cushing triad? Select all that apply. a. Bradycardia b. Hypertension c. Bradypnea d. Tachycardia
a,b,c
Which is the earliest sign of increasing intracranial pressure? a. Vomiting b. Change in level of consciousness c. Headache d. Posturing
b
A 30-year-old was diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse? a. "I will have progressive muscle weakness." b. "I will lose strength in my arms." c. "My children are at greater risk to develop this disease." d. "I need to remain active for as long as possible."
c
A nurse is preparing a client for a computed tomography (CT) scan that requires infusion of radiopaque dye. Which question is the most important for the nurse to ask? a. "When did you last have something to eat or drink?" b. "When did you last take any medication?" c. "Are you allergic to seafood or iodine?" d. "How much do you weigh?"
c
A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate? a. Restrain the client to prevent injury. b. Open the client's jaws to insert an oral airway. c. Place client in high Fowler position. d. Loosen the client's restrictive clothing.
d
A nurse assesses the patient's level of consciousness using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? a. 3 b. 6 c. 9 d. 15
a
A patient with generalized seizure disorder has just had a seizure. The nurse would assess for what characteristic associated with the postictal state? a. Epileptic cry b. Confusion c. Urinary incontinence d. Body rigidity
b
Which lobe of the brain is responsible for concentration and abstract thought? a. Frontal b. Parietal c. Temporal d. Occipital
a
A patient is admitted to the intensive care unit with a subarachnoid bleed. Vital signs are: blood pressure 120/74 mm Hg, pulse 70 beats/min, and respirations 16 breaths/min. Several hours later, the patient has become belligerent, angry, threatening to the staff which is a change from his initial demeanor. Vital signs are now blood pressure (BP) 160/60 mm Hg, pulse 48 beats/min, and respirations 12 breaths/min. Most likely, what is going on with this patient? a. Hypertensive crisis b. Increasing intracranial pressure c. Impending seizure d. Ischemic stroke
b
A client is receiving baclofen for management of symptoms associated with multiple sclerosis. The nurse evaluates the effectiveness of this medication by assessing which of the following? a. Sleep pattern b. Mood and affect c. Appetite d. Muscle spasms
d
A client fell at home and sustained a head injury. The client exhibits signs and symptoms of head trauma with indications of increased ICP. What is the normal ventricular ICP? a. 5 to 15 mm Hg b. 16 to 20 mm Hg c. 21 to 30 mm Hg d. 31 to 40 mm Hg
a
To meet the sensory needs of a client with viral meningitis, the nurse should: a. minimize exposure to bright lights and noise. b. promote an active range of motion. c. increase environmental stimuli. d. avoid physical contact between the client and family members.
a
A client diagnosed with Huntington's disease has developed severe depression. What would be most important for the nurse to assess for? a. Loss of bowel and bladder control b. Choreiform movements c. Suicidal ideations d. Emotional apathy
c
What is the main purpose of the drugs used to treat Parkinson's disease? a. Substitute monoamine oxidase inhibitors for dopamine agonists b. Increase the actions of acetylcholine in the brain c. Make the COMT inhibitors work better d. Help adjust the balance of neurotransmitters
d
A client is being treated for increased intracranial pressure (ICP). The nurse should ensure that the client does not develop hypothermia because: a. shivering in hypothermia can increase ICP. b. hypothermia is indicative of severe meningitis. c. hypothermia is indicative of malaria. d. hypothermia can cause death to the client.
a
The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern? Select all that apply. a. Unequal pupils b. Pupil reaction quick c. Pinpoint pupils d. Absence of pupillary response e. Pupil reacts to light
a,c,d
A client with meningitis has a history of seizures. Which should the nurse do to safely manage the client during a seizure? Select all that apply. a. Turn the client to the side. b. Physically restrain the client's movements. c. Inspect the oral cavity and teeth. d. Provide verbal reassurance.
a,d
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? a. Hydrochlorothiazide b. Furosemide c. Mannitol d. Spirolactone
c
A client the nurse is caring for experiences a seizure. What would be a priority nursing action? a. Restrain the client during the seizure. b. Insert a tongue blade between the teeth. c. Protect the client from injury. d. Suction the mouth during the convulsion.
c
As part of a start-of-shift nursing assessment, the nurse is documenting a patient's neurological status according to the Glasgow Coma Scale (GCS). What responses will the nurse assess to determine the patient's GCS score? Select all that apply. a. Best sensory response b. Best judgment c. Best eye opening d. Best verbal response e. Best motor response
c,d,e
A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first? a. Elevate the head of the bed. b. Complete a head-to-toe assessment. c. Administer morning dose of anticonvulsant. d. Administer Percocet as ordered.
a
The nurse is assessing the client's pupils following a sports injury. Which assessment findings indicate a neurologic concern? Select all that apply. a. unequal pupils b. quick pupil reaction c. pinpoint pupils d. absence of pupillary response e. pupil reacts to light
a,c,d
A client scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the client for the MRI should prioritize what action? a. Withholding stimulants 24 to 48 hours prior to exam b. Removing all metal-containing objects c. Instructing the patient to void prior to the MRI d. Initiating an IV line for administration of contrast
b
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? a. Jacksonian b. Absence c. Generalized d. Sensory
c
A client is ordered to undergo CT of the brain with IV contrast. Before the test, the nurse should complete which action first? a. Maintain the client NPO for 6 hours before the test. b. Obtain a blood sample to evaluate BUN and creatinine concentrations. c. Assess the client for medication allergies. d. Obtain two large-bore IV lines.
c
A client with meningitis has a history of seizures. Which action by the nurse is appropriate while the client is actively seizing? a. Place a cooling blanket on the client b. Administer mannitol c. Turn the client to the side d. Insert oral airway
c
A client is diagnosed with a brain tumor. As the nurse assists the client from the bed to a chair, the client begins having a generalized seizure. Which action should the nurse take first? a. Initiate the code team response. b. Put a padded tongue blade into the client's mouth and restrain his extremities. c. Record the type of seizure and the time that it occurred. d. Assist the client to the floor, in a side-lying position, and protect him with linens.
d
A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? a. Dextrose 5% in water (D5W) b. Half-normal saline (0.45% NSS) c. One-third normal saline (0.33% NSS) d. Mannitol
d
A client with a traumatic brain injury has already displayed early signs of increasing intracranial pressure (ICP). Which of the following would be considered late signs of increasing ICP? a. Decerebrate posturing and loss of corneal reflex b. Loss of gag reflex and mental confusion c. Complaints of headache and lack of pupillary response d. Mental confusion and pupillary changes
a
A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis? a. chewing b. swallowing c. smelling d. tasting
a
Mr. Marks, age 52, is being treated for Parkinson disease. You are aware that Parkinson disease results in muscle rigidity, tremor at rest, and postural instability. What occurs in the neurons that causes these symptoms? a. There is an imbalance between dopamine and acetylcholine. b. There is an increase in dopamine in the terminal nerve endings. c. There is a decrease in stimulation of the nigrostriatal neural tracts. d. There is an increased level of GABA at the striatum.
a
The nurse is caring for a client with an inoperable brain tumor. What is a major threat to this client? a. Increased intracranial pressure b. Decreased intracranial pressure c. Hypervolemia d. Hypovolemia
a
A nurse is providing care to a client with a brain tumor. The client has experienced seizures as a result of the tumor. Which area would be a priority for this client? a. Safety b. Self-care c. Skin care d. Activity
a
Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event? a. Seizure began at 1300 hours. b. The client cried out before the seizure began. c. Seizure was 1 minute in duration including tonic-clonic activity. d. Sleeping quietly after the seizure
c
A patient diagnosed with multiple sclerosis (MS) has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen (Lioresal). What would be the expected outcome of this medication? a. Reduction in the appearance of new lesions on magnetic resonance imaging (MRI) b. Decreased muscle spasms in the lower extremities c. Increased muscle strength in the upper extremities d. Promotion of urinary continence
b
While completing a health history on a client who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state? a. Epileptic cry b. Confusion c. Urinary incontinence d. Body rigidity
b
A client who has been on long-term phenytoin therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the client's plan of care? a. Monitoring of pulse oximetry b. Administration of a low-protein diet c. Administration of thorough oral hygiene d. Fluid restriction as prescribed
c
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? a. Prednisone b. Dexamethasone c. Cafergot d. Phenytoin
d
Which topic is most important for the nurse to include in the teaching plan for a client newly diagnosed with Parkinson's disease? a. Involvement with diversion activities b. Enhancement of the immune system c. Establishing balanced nutrition d. Maintaining a safe environment
d
A patient who has suffered a stroke is unable to maintain respiration and is intubated and placed on mechanical ventilator support. What portion of the brain is most likely responsible for the inability to breathe? a. Frontal lobe b. Occipital lobe c. Parietal lobe d. Brain stem
d
A client is having a tonic-clonic seizure. What should the nurse do first? a. Elevate the head of the bed. b. Restrain the client's arms and legs. c. Place a tongue blade in the client's mouth. d. Take measures to prevent injury.
d
A patient has been taking phenytoin (Dilantin) for a seizure disorder. He has recently run out of his medication and has not obtained a refill. What is the patient at risk for developing? a. Depression b. Status epilepticus c. Hypotension d. Migraine headaches
b
The expected outcome for a patient taking levodopa as drug therapy for Parkinson's disease would be what? a. Decrease in sweating b. Decrease in rigidity c. Decrease in diarrhea d. Decrease in muscle twitching
b
The nurse is assisting the physician in completing a lumbar puncture. Which would the nurse note as a concern? a. Physician maintains aseptic procedure. b. Cerebrospinal fluid is cloudy in nature. c. Client reports a piercing feeling. d. Client reports pressure relief in the head.
b
The nurse is caring for a client hospitalized with a severe exacerbation of myasthenia gravis. When administering medications to this client, what is a priority nursing action? a. Assess client's reaction to new medication schedule. b. Administer medications at exact intervals ordered. c. Document medication given and dose. d. Give client plenty of fluids with medications.
b
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? a. IV phenobarbital b. IV diazepam c. IV lidocaine d. Oral phenytoin
b
The nurse is participating in the care of a client with increased ICP. What diagnostic test is contraindicated in this client's treatment? a. Computed tomography (CT) scan b. Lumbar puncture c. Magnetic resonance imaging (MRI) d. Venous Doppler studies
b
The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority? a. Maintaining accurate records of intake and output b. Maintaining a patent airway c. Inserting a nasogastric (NG) tube as prescribed d. Providing appropriate pain control
b
A nurse is caring for a patient who has just been diagnosed with Parkinson disease. The patient does not understand how the medication ordered, carbidopa-levodopa, is going to help her condition. Which of the following is the correct response by the nurse? a. "This drug will change the immune processes in your body to help decrease the tissue damage." b. "Carbidopa-levodopa will delay the loss of muscle strength and limb function for several months." c. "Carbidopa-levodopa increases the activity of dopamine in your body, which will decrease your symptoms." d. "Your drug therapy will reduce excessive reflex activity causing your muscle spasms and will allow for muscle relaxation."
c
A patient with Parkinson's disease is undergoing a swallowing assessment because she is experiencing difficulties when swallowing. What consistency is most appropriate for this patient, to reduce the risk of aspiration? a. Solid food with thin liquids b. Pureed food with water c. Semisolid food with thick liquids d. Thin liquids only
c
Which is a sympathetic effect of the nervous system? a. Decreased blood pressure b. Increased peristalsis c. Dilated pupils d. Decreased respiratory rate
c
The nurse is caring for a patient with an altered LOC. What is the first priority of treatment for this patient? a. Assessment of pupillary light reflexes b. Determination of the cause c. Positioning to prevent complications d. Maintenance of a patent airway
d
A client with an inoperable brain tumor says to the nurse, "I'm so afraid that I'm going to die alone." What is the nurse's best response? a. "You sound frightened." b. "You are not going to die." c. "There is nothing to be afraid of." d. "It won't be as bad as you think."
a
A nurse is caring for a client who experiences debilitating cluster headaches. The client should be taught to take appropriate medications at what point in the course of the onset of a new headache? a. As soon as the client's pain becomes unbearable b. As soon as the client senses the onset of symptoms c. Twenty to 30 minutes after the onset of symptoms d. When the client senses his or her symptoms peaking
b
A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include: a. pupillary changes. b. diminished responsiveness. c. decreasing blood pressure. d. elevated temperature.
b
A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following actions would be the first priority? a. Positioning to prevent complications b. Maintenance of a patent airway c. Assessment of pupillary light reflexes d. Determination of the cause
b
Which of the following teaching points is a priority in the management of symptoms for a client with Bell's palsy? a. Avoid stimuli that trigger pain. b. Use ophthalmic lubricant and protect the eye. c. Encourage semiannual dental exams. d. Complete the course of antibiotics as prescribed.
b
You are assessing a patient who was prescribed levodopa 1 week ago. What would you assess for? a. Improvement in handwriting b. Drug-drug interactions with dopaminergic agents c. Stable mood d. Psoriasis
a
Which term refers to the inability to coordinate muscle movements, resulting in difficulty walking? a. Agnosia b. Ataxia c. Spasticity d. Rigidity
b
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? a. Respiratory function b. Potential skin breakdown c. Cardiac function d. Cognition
a
A patient is admitted to the hospital for management of an extrapyramidal disorder. Included in the physician's admitting orders are the medications levodopa, benztropine, and selegiline. The nurse knows that most likely, the client has a diagnosis of: a. Parkinson's disease. b. Huntington's disease. c. seizure disorder. d. multiple sclerosis.
a
A typical spinal cord functions as a "highway" for sensory and descending motor neurons, providing conduction of impulses to and from the brain. The spinal cord is surrounded and protected by bony vertebrae, and ends between the: a. first and second lumbar vertebrae. b. first and second cervical vertebrae. c. first and second thoracic vertebrae. d. fourth and fifth thoracic vertebrae.
a
The nurse has created a plan of care for a client who is at risk for increased ICP. The client's care plan should specify monitoring for what early sign of increased ICP? a. Disorientation and restlessness b. Decreased pulse and respirations c. Projectile vomiting d. Loss of corneal reflex
a
The nurse is caring for a client who has been admitted with a head injury and continually assesses for signs of increasing intracranial pressure (ICP). The earliest sign of increasing ICP is a. Change in level of consciousness b. Widening pulse pressure c. Slowing of heart rate d. Elevation of systolic blood pressure
a
The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring? a. Increased ICP b. Exacerbation of uncontrolled hypertension c. Infection d. Increase in cerebral perfusion pressure
a
The nurse is completing the physical assessment of a client suspected of a neurological disorder. The client reports having recently suffered a head trauma. In such a case, the nurse should: a. not move or manipulate the client's head while assessing for bleeding or swelling. b. explain the procedure of head assessment to the client before doing the assessment. c. only move the client's head with the help of an assistant. d. make the client sit in a chair and then assess his or her head for bleeding or swelling.
a
A client has undergone a lumbar puncture for a neurological assessment. The client is put under the post-procedure care of a nurse. Which important post-procedure nursing interventions should be performed to ensure maximum comfort for the client? Select all that apply. a. Position the client flat for at least three hours or as directed by the physician. b. Encourage a liberal fluid intake for the client. c. Shampoo the client's hair with warm water. d. Keep the room brightly lit and play soothing music in the background.
a,b
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: a. Increasing forgetfulness and confusion b. Tremors and muscle rigidity c. Visual disturbances and muscle weakness d. Fatigue and respiratory difficulties
b
A client experiences a seizure while hospitalized for appendicitis. During the postictal phase, the client is yelling and swings a closed fist at the nurse. Which is the appropriate action by the nurse? a. Place the client in wrist restraints. b. Reorient the client while gently holding their arms. c. Administer lorazepam per orders. d. Apply oxygen via nasal cannula.
b
A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain? a. Frontal b. Occipital c. Temporal d. Parietal
b
A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention? a. Capillary refill of 2 seconds b. Shivering c. Cool, dry skin d. Urine output of 100 mL/hr
b
A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to: a. hold the client's arm still to keep him from hitting anything. b. carefully move the client to a flat surface and turn him on his side. c. allow the client to remain in the chair but move all objects out of his way. d. place an oral airway in the client's mouth to maintain an open airway.
b
A nurse has been invited to speak to a support group for persons with movement disorders and their families. Which of the following statements by the nurse addresses the chronic nature of these diseases and the relevant drug therapies? a. "Drug therapy can consist of one or more drugs to eliminate the symptoms of these diseases." b. "Drugs do not cure these disorders; they instead enhance quality of life." c. "Persons of all cultures are treated similarly and respond in similar ways to treatment." d. "Drugs used to treat these disorders always pose a risk of severe liver and kidney dysfunction."
b
A nurse and nursing student are caring for a client recovering from a lumbar puncture yesterday. The client reports a headache despite being on bedrest overnight. The physician plans an epidural blood patch this morning. The student asks how this will help the headache. The correct reply from the nurse is which of the following? a. "The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid." b. "The blood will replace the cerebral spinal fluid that has leaked out." c. "The blood can repair damage to the spinal cord that occurred with the procedure." d. "The blood provides moisture at the site, which encourages healing."
a
A nurse enters a client's room just as a visitor falls from a chair and begins to have a seizure. Which of the following nursing interventions would the nurse implement? a. Protect the person's head. b. Cover the person with a warm blanket. c. Offer the visitor room-temperature fluids. d. Insert something into the visitor's mouth to prevent injury to the tongue.
a
A nurse is assessing a client who has been in a motor vehicle collision. The client directly and accurately answers questions. The nurse notes a contusion to the client's forehead; the client reports a headache. Assessing the client's pupils, what reaction would confirm increasing intracranial pressure? a. unequal response b. equal response c. rapid response d. constricted response
a
A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis? a. Risk for aspiration b. Risk for falls c. Risk for impaired skin integrity d. Decreased intracranial adaptive capacity
a
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? a. Take small meals of nutrient and calorie-dense food. b. Increase the intake of calcium and proteins. c. Include additional servings of fruits and raw vegetables. d. Include fish, liver, and chicken in diet.
a
The school nurse notes a 6-year-old running across the playground with his friends. The child stops in midstride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child? a. An absence seizure b. A myoclonic seizure c. A partial seizure d. A tonic-clonic seizure
a
A client adopted at birth recently discovers that Huntington's disease is prevalent in the biological family history. How can the nurse best assist the client in dealing with personal fears? a. Provide information of the progression of the disease. b. Encourage client to verbalize fears. c. Explain that inherited risk is 50%. d. Offer genetic testing.
b
A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the ED. The nurse should gauge the client's LOC on the results of what diagnostic tool? a. Monro-Kellie hypothesis b. Glasgow Coma scale c. Cranial nerve function d. Mental status examination
b
A client with a suspected brain tumor is scheduled for a computed tomography (CT) scan. What should the nurse do when preparing the client for this test? a. Immobilize the neck before the client is moved onto a stretcher. b. Determine whether the client is allergic to iodine, contrast dyes, or shellfish. c. Place a cap over the client's head. d. Administer a sedative as ordered.
b
A patient is admitted with a fractured femur and possible head injury. Vital signs on admission were blood pressure (BP) 128/72 mmHg, pulse (P) 90/min, respirations (R) 16/min. Four hours after admission, the nurse is checking vital signs as part of her hourly assessment. Which of the following vital signs most likely indicate the presence of increased intracranial pressure? a. BP 160/90, P 112, R 16 b. BP 172/68, P 42, R 10 c. BP 100/70, P 120, R 30 d. BP 130/72, P 50, R 24
b
A trauma client in the ICU has been declared brain dead. What diagnostic test is used in making the determination of brain death? a. Magnetic resonance imaging (MRI) b. Electroencephalography (EEG) c. Electromyelography (EMG) d. Computed tomography (CT)
b
After a seizure, the nurse should place the patient in which of the following positions to prevent complications? a. High Fowler's, to prevent aspiration b. Side-lying, to facilitate drainage of oral secretions c. Supine, to rest the muscles of the extremities d. Semi-Fowler's, to promote breathing
b
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? a. Pruritus b. Dyskinesia c. Lactose intolerance d. Diarrhea
b
The neurologic ICU nurse is admitting a client with increased intracranial pressure. How should the nurse best position the client? a. Position the client supine. b. Maintain head of bed (HOB) elevated at 30 to 45 degrees. c. Position client in prone position. d. Maintain bed in Trendelenburg position.
b
The nurse has admitted a new client to the unit. One of the client's admitting orders is for an adrenergic medication. The nurse knows that this medication will have what effect on the circulatory system? a. Thin, watery saliva b. Increased heart rate c. Decreased BP d. Constricted bronchioles
b
The nurse is caring for a client who is in status epilepticus. What medication should the nurse anticipated administering to halt the seizure immediately? a. Intravenous phenobarbital b. Intravenous diazepam c. Oral lorazepam d. Oral phenytoin
b
The nurse is caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the potential complications of the disorder, what should the nurse keep always ready at the bedside? a. Nebulizer and thermometer b. Intubation tray and suction apparatus c. Blood pressure apparatus d. Incentive spirometer
b
The nurse is caring for a client with a significant allergy history to various medications and shellfish. Because the client needs to have a diagnostic study with contrast, which medication classification is anticipated? a. Bronchodilator b. Antihistamine c. Cardio tonic d. Antibiotic
b
A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP? a. Encourage coughing and deep breathing. b. Position the client with the head turned toward the side of the brain tumor. c. Administer stool softeners. d. Provide sensory stimulation.
c
A patient has a left temporal brain tumor. He smells an odor of ammonia prior to experiencing rapid rhythmic jerking movements. What is the odor of ammonia? a. The metastatic process of tumor growth b. The inhibition of serotonin and acetylcholine c. An aura prior to the seizure activity d. Chemical agent evoked by the tumor
c
The nurse is assisting with a lumbar puncture and observes that when the physician obtains CSF, it is clear and colorless. What does this finding indicate? a. A subarachnoid hemorrhage b. An overwhelming infection c. A normal finding; the fluid will be sent for testing to determine other factors d. Local trauma from the insertion of the needle
c
The nurse is caring for a patient with increased ICP. As the pressure rises, what osmotic diuretic does the nurse prepare to administer? a. Glycerin b. Isosorbide c. Mannitol d. Urea
c
A client is scheduled for an EEG. The client asks about any diet-related prerequisites before the EEG. Which diet-related advice should the nurse provide to the client? a. Avoid eating food at least 8 hours before the test. b. Include an increased amount of minerals in the diet. c. Decrease the amount of minerals in the diet. d. Avoid taking sedative drugs or drinks that contain caffeine for at least 8 hours before the test.
d
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)? a. Encouraging oral fluid intake b. Suctioning the client once each shift c. Elevating the head of the bed 90 degrees d. Administering a stool softener as ordered
d
A client was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first? a. Pupillary asymmetry b. Irregular breathing pattern c. Involuntary posturing d. Declining level of consciousness (LOC)
d
A client with epilepsy is having a seizure. During the active seizure phase, the nurse should: a. place the client on his back, remove dangerous objects, and insert a bite block. b. place the client on his side, remove dangerous objects, and insert a bite block. c. place the client on his back, remove dangerous objects, and hold down his arms. d. place the client on his side, remove dangerous objects, and protect his head.
d
A nurse conducts the Romberg test on a client by asking the client to stand with the feet close together and the eyes closed. As a result of this posture, the client suddenly sways to one side and is about to fall when the nurse intervenes and saves the client from being injured. How should the nurse interpret the client's result? a. Positive Romberg test, indicating a problem with level of consciousness b. Negative Romberg test, indicating a problem with body mass c. Negative Romberg test, indicating a problem with vision d. Positive Romberg test, indicating a problem with equilibrium
d
