Unit 5

A nurse is assessing a child with suspected autism. At what age does the nurse determine that the signs of autism initially may be evident? 1. 2 years of age 2. 6 years of age 3. 6 months of age 4. 1 to 3 months of age

2 years of age

An older adult is being admitted to a nursing home with the diagnosis of dementia. The history reveals confusion, difficulty recognizing family members, and nighttime wandering. What should the nurse include in the client's plan of care? 1. Ordering a vest restraint for the client to be applied at night 2. Obtaining a prescription for a sedative so the client will sleep better at night 3. Requesting that the family provide a companion to stay with the client at night 4. Assigning the client to a room near the nurses' station for closer supervision at night

4. Assigning the client to a room near the nurses' station for closer supervision at night

While caring for an older adult client, what symptom requires an immediate reassessment of the client's needs and plan of care? 1 Memory loss or confusion 2 Neglect of self-care 3 Increased daily fatigue 4 Withdrawal from usual activities

ANS - 1 Memory loss or confusion All are common signs of depression due to the aging process, however, memory loss or confusion may require immediate intervention. The development of confusion indicates that the client's ability to maintain equilibrium has not been achieved and that further disequilibrium is occurring, setting the client up for safety issues. Confusion may also be related to more serious physical conditions that can occur which require medical intervention.

What is the most appropriate nursing intervention for clients who exhibit mild cognitive impairment? 1 Reality orientation 2 Behavioral confrontation 3 Reflective communication 4 Reminiscence group therapy

ANS - 1 Reality orientation Reality orientation is generally helpful for clients exhibiting mild cognitive impairment; these clients are aware of their impairment, and orientation then reduces anxiety. Behavioral confrontation is not therapeutic because it may cause frustration and increase psychomotor agitation in a client with cognitive impairment. Reflective communication is a technique in which the nurse restates or repeats the client's statements; it can be used to clarify thoughts but may also lead to frustration when the approach is overdone. Reminiscence group therapy is helpful with severely confused, disorganized clients because it reinforces identity, acknowledges what was significant, and often compensates for the dullness of the present.

Which period of Piaget's theory describes the idea of object permanence? 1 Sensorimotor period 2 Preoperational period 3 Formal operations period 4 Concrete operations period

ANS - 1 Sensorimotor period There are four periods of Piaget's theory of cognitive development. The first period is the sensorimotor period; this period describes object permanence. During the ages of birth to 2 years old, the child understands that objects continue to exist even when they are not visible. The second period is the preoperational period, which is observed in children between the ages of 2 and 7 years. During this time, children learn to think about the use of symbols and have mental images. The third period is the concrete operations period, which is observed between the ages of 7 and 11 years. During this period, the child thinks about an action before performing it. The formal operations period is the fourth period, which is observed in children from the ages of 11 years old throughout adulthood. During this period, there is a prevalence of egocentric thought.

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply. 1. Loosen restrictive clothing 2. Restraining the clients limbs 3. Removing the pillow and raising padded side rails. 4. Positioning the client to the side, if possible, with the head flexed foward 5. Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist.

ANS - 1, 3, 4 - Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising padded side rails in bed, and placing the client on 1 side with the head flexed forward.

The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? 1.Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2.Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressureA client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? 3.Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4.Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

ANS - 2 Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur.

The nurse has completed discharge instructions for a client with application of a halo device. Which statement indicates that the client NEEDS FURTHER CLARIFICATION. of the instructions? 1. I will use a straw for drinking 2. I will drive only during the daytime 3. I will be careful because the device alerts balance 4. I will wash the skin daily under the lamb's wool liner of the vest.

ANS - 2 The halo device alters balance and can cause fatigue because its weight. the client should cleanse the skin daily under the vest to protect the skin from ulceration and should avoid the use of powder or lotions. The liner should be changed if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. The client cannot drive at all because the device impairs the range of vision.

The nurse is caring for a client who is at risk for increased intracranial pressure (ICP) after a stroke. Which activities performed by the nurse will assist with preventing increases in ICP? (Select all that apply) .1.Clustering nursing activities 2.Hyperoxygenating before suctioning 3.Maintaining 20 degree flexion of the knees 4.Maintaining the head and neck in midline position 5.Maintaining the head of the bed (HOB) at 30 degrees elevation

ANS - 2,4,5Measures aimed at preventing increased ICP in the poststroke client include hyperoxgenating before suctioning to avoid transient hypoxemia and resultant ICP elevation from dilation of cerebral arteries; maintaining the head in a midline, neutral position to help promote venous drainage from the brain; and keeping the HOB elevated to between 25 and 30 degrees to prevent a decreased blood flow to the brain. Clustering activities can be stressful for the client and increase ICP. Maintaining 20 degree flexion of the knees increases intraabdominal pressure and consequently ICP.

A client with a history of chronic alcoholism is admitted to the mental health unit. What does the nurse identify as the cause of a client's use of confabulation? 1 Ideas of grandeur 2 Need to get attention 3 Marked loss of memory 4 Difficulty accepting the truth

ANS - 3 Marked loss of memory. Alcoholic clients have loss of memory and adapt to this by unconsciously filling in with false information areas that cannot be remembered. Ideas of grandeur do not occur in this disease. A need to get attention is unrelated to confabulation. These individuals are not purposely lying but instead are trying to cover memory losses.

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? 1.Fluid is clear and tests negative for glucose. 2.Fluid is grossly bloody in appearance and has a pH of 6. 3.Fluid clumps together on the dressing and has a pH of 7. 4.Fluid separates into concentric rings and tests positive for glucose.

ANS - 4 Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.

A client with paralysis of the legs is found to have somatoform disorder, conversion type. What must the nurse consider when formulating a plan of care for this client? 1. The illness is very real to the client and requires appropriate nursing care. 2 Although the client believes that there is an illness, there is no cause for concern. 3 There is no physiological basis for the illness; therefore only emotional care is needed. 4 Nursing intervention is needed even though the nurse understands that the client is not ill.

ANS: 1 - Individuals who have somatoform disorders are really ill; they need care in a nonthreatening environment. The client requires physiological and emotional care for treatment of motor or sensory functional deficits.

Which drug most commonly causes extrapyramidal side effects (EPS)? 1. Clozapine 2. Haloperidol 3. Risperidone 4. Aripiprazole

ANS: 2. - Haloperidol is a typical antipsychotic that commonly causes extrapyramidal side effects. Clozapine is an atypical antipsychotic that has a low risk of causing extrapyramidal side effects. Risperidone and aripiprazole have a low risk of causing extrapyramidal side effects.

When answering questions from the family of a client with Alzheimer disease, how does the nurse describe the disease? 1. Emerges in the fourth decade of life 2. Is a slow, relentless deterioration of the mind 3. Is functional in origin and occurs in the later years 4. Is diagnosed through laboratory and psychological tests

ANS: 2. Is a slow, relentless deterioration of the mind. Alzheimer disease [1] [2] [3] is a slow and relentless deterioration of the mind; clients become progressively worse over time. The disease usually appears in people 60 years of age and older. Alzheimer disease is an organic, not a functional, disorder. At this time there are no diagnostic tools other than autopsy that can provide a definite confirmation of Alzheimer disease.

A 65-year-old man is admitted to a mental health facility with a diagnosis of substance-induced persisting dementia resulting from chronic alcoholism. When conducting the admitting interview, the nurse determines that the client is using confabulation. What does the nurse recall precipitates the client's use of confabulation? 1. deas of grandeur 2 Need for attention 3. Marked memory loss 4. Difficulty in accepting the diagnosis

ANS: 3 - A client with this disorder has a loss of memory and adapts by filling in areas that cannot be remembered with made-up information. Ideas of grandeur do not occur with this type of dementia. The use of confabulation is not attention-seeking behavior; the individual is attempting to mask memory loss. This person is not coping with the diagnosis; when confabulating, the individual is attempting to mask memory loss.STUDY TIP: A word of warning: do not expect to achieve the maximum benefits of this review tool by cramming a few days before the examination. It doesn't work! Instead, organize planned study sessions in an environment that you find relaxing, free of stress, and supportive of the learning process.

Which drug may lead to bruxism? 1. Vilazodone 2. Isocarboxazid 3. Clomipramine 4. Levomilnacipran

ANS: 4 Serotonin reuptake inhibitors and serotonin/epinephrine reuptake inhibitors may lead to bruxism. Levomilnacipran is a serotonin/epinephrine reuptake inhibitor that may cause bruxism. Vilazodone is an atypical antidepressant that does not cause bruxism. Isocarboxazid is a monoamine oxidase inhibitor that does not cause bruxism. Clomipramine is a tricyclic antidepressant that does not cause bruxism.

While assessing an older adult in the emergency department the nurse notes that the client is upset. The nurse asks what is wrong, and the client describes the current situation and then offers information that goes further and further off the topic. What pattern of communication does this conversation reflect? 1 Perseveration 2 Thought blocking 3 Overcompensation 4 Tangential thinking

ANS: 4 Tangential thinking In tangential thinking the person never answers the question or returns to the central point of the conversation. It often is seen in people with dementia. Perseveration is the repetitive expression of a single idea in response to different questions; it is found most often in clients with cognitive impairments and those experiencing catatonia. Thought blocking is a sudden stoppage of the spontaneous flow of speaking for no apparent external reason; it is seen most often in clients who are experiencing auditory hallucinations. Overcompensation, also known as reaction formation, is a defense mechanism, not a pattern of communication.

A nurse is caring for a client after a total knee replacement who is requesting hydrocodone/acetaminophen in addition to the patient-controlled analgesia (PCA). The client reports having taken two hydrocodone/acetaminophen tablets every 4 hours for several weeks before surgery. If each tablet contains 500 mg of acetaminophen, how much acetaminophen had the client been ingesting per day? Record your answer using a whole number with no punctuation. ___ mg

ANS: 6000mg. Two tablets every 4 hours over 24 hours equals a total of 12 tablets daily. Because each tablet has 500 mg, then 500 × 12 = 6000 mg. This is more than the recommended maximum dose of 4000 mg/24 hr for short-term use.Test-Taking Tip: When taking the NCLEX exam, an on-screen calculator will be available for you to determine your response, which you will then type in the provided space.

9. A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question should the nurse ask? a. "Do you live in a crowded residence?" b. "When was your last tetanus vaccination?" c. "Have you had any viral infections recently?" d. "Have you traveled out of the country in the last month?"

ANS: A Meningococcal meningitis tends to occur in multiple outbreaks. It is most likely to occur in areas of high-density population, such as college dormitories, prisons, and military barracks. A tetanus vaccination would not place the client at increased risk for meningitis or protect the client from meningitis. A viral infection would not lead to bacterial meningitis but could lead to viral meningitis. Simply knowing if the client traveled out of the country does not provide enough information. The nurse should ask about travel to specific countries in which the disease is common, for example, sub-Saharan Africa.

14. A nurse witnesses a client with late-stage Alzheimer's disease eat breakfast. Afterward the client states, "I am hungry and want breakfast." How should the nurse respond? a. "I see you are still hungry. I will get you some toast." b. "You ate your breakfast 30 minutes ago." c. "It appears you are confused this morning." d. "Your family will be here soon. Let's get you dressed."

ANS: A Use of validation therapy with clients who have Alzheimer's disease involves acknowledgment of the client's feelings and concerns. This technique has proved more effective in later stages of the disease, when using reality orientation only increases agitation. Telling the client that he or she already ate breakfast may agitate the client. The other statements do not validate the client's concerns.

A nurse assesses clients on a medical-surigcal unit. Which clients should the nurse identify as at risk for secondary seizures? (Select all that apply). a. A 26yr old women with a left temporal brain tumor. b. A 38yr old male client in an alcohol withdrawal program. c. A 42yr old football player with a traumatic brain injury. d. A 66yr old female client with multiple sclerosis e. A 72yr old man with chronic obstructive pulmonary disease.

ANS: A, B, C - Clients at risk for secondary seizures include those with a brain lesion from a tumor or trauma, and those who are experiencing a metabolic disorder, acute alcohol withdrawal, electrolyte disturbances, and high fever. Clients with a history of stroke, heart disease, and substance abuse are also at risk. Clients with multiple sclerosis or chronic obstructive pulmonary disease are not at risk for secondary seizures.

3. A nurse evaluates the results of diagnostic tests on a clients cerebrospinal fluid (CSF). Which fluid results alerts the nurse to possible viral meningitis?(Select all that apply.) a. Clear b. Cloudy c. Increased protein level d. Normal glucose level e. Bacterial organisms present f. Increased white blood cells

ANS: A, C, D - In viral meningitis, CSF fluid is clear, protein levels are slightly increased, and glucose levels are normal. Viral meningitis does not cause cloudiness or increased turbidity of CSF. In bacterial meningitis, the presence of bacteria and white blood cells causes the fluid to be cloudy.

A nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions should the nurse include in this clients plan of care? (Select all that apply) a. Have suction equipment at the bedside b. Place a padded tongue blade at the bedside. c. Permit only oral fluids. d. Keep bed rails up at all times. e. Maintain the client on strict bedrest f. Ensure that the client has IV access.

ANS: A, D, F -Oxygen and suction equipment with an airway must be readily available. Bed rails should be up at all times while the client is in bed to prevent injury from a fail if the client is in the bed to prevent injury from a fall if the client has a seizure.

A nurse is caring for a client with meningitis. Which laboratory values should the nurse monitor to identify potential complications of this disorder? (Select all that apply) a. Sodium level b. Liver enzymes c. Clotting factors d. Cardiac enzymes e. Creatinine level

ANS: A. C - Inflammation associated with meningitis can stimulate the hypothalamus and result in excessive production of antidiurectic hormone. The nurse should monitor sodium levels for early identification of syndrome of inappropriate antidiuretic hormone. A systemic inflammatory response (SIR) can also occur with meningitis. A SIR can result in a coagulopathy that leads to disseminated intravascular coagulation. The nurse should monitor clotting factors to identify this complication. The other laboratory values are not specific to complications of meningitis.

15. A nurse assesses a client after administering prescribed levetiracetam (Keppra). Which laboratory tests should the nurse monitor for potential adverse effects of this medication? a. Serum electrolyte levels b. Kidney function tests c. Complete blood cell count d. Antinuclear antibodies

ANS: B Adverse effects of levetiracetam include coordination problems and renal toxicity. The other laboratory tests are not affected by levetiracetam.

A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication should the nurse prepare to administer? a. Atenolol (Tenormin) b. Lorazepam (Ativan) c. Phenytoin (Dilantin) d. Lisinopril (Prinivil)

ANS: B Initially, intravenous lorazepam is administered to stop motor movements. This is followed by the administration of phenytoin. Atenolol, a beta blocker, and lisinopril, an angiotensin-converting enzyme inhibitor, are not administered for seizure activity. These medications are typically administered for hypertension and heart failure

A nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How should the nurse document this activity? a. Atonic seizure b. Tonic-clonic seizure c. Myoclonic seizure d. Absence seizure

ANS: B Seizure activity that begins with stiffening of the arms and legs, followed by loss of consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure. An atonic seizure presents as a sudden loss of muscle tone followed by postictal confusion. A myoclonic seizure presents with a brief jerking or stiffening of extremities that may occur singly or in groups. Absence seizures present with automatisms, and the client is unaware of his or her environment.

A nurse cares for a client with advanced Alzheimer's disease. The client's caregiver states, "She is always wandering off. What can I do to manage this restless behavior?" How should the nurse respond? a. "This is a sign of fatigue. The client would benefit from a daily nap." b. "Engage the client in scheduled activities throughout the day." c. "It sounds like this is difficult for you. I will consult the social worker." d. "The provider can prescribe a mild sedative for restlessness."

ANS: B Several strategies may be used to cope with restlessness and wandering. One strategy is to engage the client in structured activities. Another is to take the client for frequent walks. Daily naps and a mild sedative will not be as effective in the management of restless behavior. Consulting the social worker does not address the caregiver's concern.

A nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. Which action should the nurse take? a. Start fluids via a large-bore catheter. b. Turn the client's head to the side. c. Administer IV push diazepam. d. Prepare to intubate the client.

ANS: B The nurse should turn the client's head to the side to prevent aspiration and allow drainage of secretions. Anticonvulsants are administered on a routine basis if a seizure is sustained. If the seizure is sustained (status epilepticus), the client must be intubated and should be administered oxygen, 0.9% sodium chloride, and IV push lorazepam or diazepam.

A nurse assesses a client who has encephalitis. Which manifestations should the nurse recognize as signs of increased intracranial pressure (ICP), a complication of encephalitis? (Select all that apply) a. Photophobia b. Dilated pupils c. Headache d. Widen pulse pressure e. Bradycardia

ANS: B, D, E - Increased ICP is a complication of encephalitis. The nurse should monitor for signs of increased ICP, including dilated pupils, widened pulse pressure, bradycardia, irregular respirations, and less responsive pupils. Photophobia and headache are not related to increased ICP.

A nurse assess a client who is experiencing an absence seizure. For which clinical manifestations should the nurse assess? (Select all that apply). a. Internmittent rigidity b. Lip smacking c. Sudden loss of muscle tone d. Brief jerking of the extremities e. Picking at the clothing f. Patting of the hand on the leg

ANS: B, E, F - Automatisms are characteristic of absence seizures. These behaviors consist of lip smacking, picking at clothing, and patting. Rigidity of muscles is associated with the tonic phase of a seizure, and jerking of the extremities is associated with the clonic phase of a seizure. Loss of muscle tone occurs with atomic seizures.

13. A nurse assesses a client with Alzheimer's disease who is recently admitted to the hospital. Which psychosocial assessment should the nurse complete? a. Assess religious and spiritual needs while in the hospital. b. Identify the client's ability to perform self-care activities. c. Evaluate the client's reaction to a change of environment. d. Ask the client about relationships with family members.

ANS: C As Alzheimer's disease progresses, the client experiences changes in emotional and behavioral affect. The nurse should be alert to the client's reaction to a change in environment, such as being hospitalized, because the client may exhibit an exaggerated response, such as aggression, to the event. The other assessments should be completed but are not as important as assessing the client's reaction to environmental change.

A nurse delegates care for a client with early-stage Alzheimers disease to unlicensed assistive personnel (UAP) Which statement should the nurse include when delegating this clients care? a. If she is confused, play along and pretend that everything is okay. b. Remove the clock from her room so that she dosent get confused. c. Reorient the client to the day, time, and environment with each contact. d. Use validation therapy to recognize and acknowledge the clients concerns.

ANS: C Clients who have early-stage Alzheimers disease should be reoriented frequently to person, place, and time. The UAP should reorient the client and not encourage the clients delusions. The room should have a clock and white board with the current date written on it. Validation therapy is used with late-stage Alzheimers disease.

17. A nurse prepares to discharge a client with Alzheimer's disease. Which statement should the nurse include in the discharge teaching for this client's caregiver? a. "Allow the client to rest most of the day." b. "Place a padded throw rug at the bedside." c. "Install deadbolt locks on all outside doors." d. "Provide a high-calorie and high-protein diet."

ANS: C Clients with Alzheimer's disease have a tendency to wander, especially at night. If possible, alarms should be installed on all outside doors to alert family members if the client leaves. At a minimum, all outside doors should have deadbolt locks installed to prevent the client from going outdoors unsupervised. The client should be allowed to exercise within his or her limits. Throw rugs are a slip and fall hazard and should be removed. The client should eat a well-balanced diet. There is no need for a high-calorie or high-protein diet.

A nurse is teaching the daughter of a client who has Alzheimer's disease. The daughter asks, "Will the medication my mother is taking improve her dementia?" How should the nurse respond? a. "It will allow your mother to live independently for several more years." b. "It is used to halt the advancement of Alzheimer's disease but will not cure it." c. "It will not improve her dementia but can help control emotional responses." d. "It is used to improve short-term memory but will not improve problem solving."

ANS: C Drug therapy is not effective for treating dementia or halting the advancement of Alzheimer's disease. However, certain drugs may help suppress emotional disturbances and psychiatric manifestations. Medication therapy may not allow the client to safely live independently.

A nurse assesses a client who is recovering from the implantation of a vagal nerve stimulation device. For which clinical manisfestations should the nurse assess as common complications of this procedure? (Select all that apply.) a. Bleeding b. Infection c. Hoarseness d. Dysphagia e. Seizures

ANS: C, D - Complications of surgery to implant a vagal nerve stimulation device include hoarseness (most common), dyspnea, neck pain, and dysphagia. The device is tunneled under the skin with an electrode connected to the vagus nerve to control simple or complex partial seizures. Bleeding is not common complication of this procedure, and infection would not occur during the recovery period.

After teaching a client who is diagnosed with new-onset status epilepticus and prescribed phenytoin (Dilantin), the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching? a. "To prevent complications, I will drink at least 2 liters of water daily." b. "This medication will stop me from getting an aura before a seizure." c. "I will not drive a motor vehicle while taking this medication." d. "Even when my seizures stop, I will continue to take this drug."

ANS: D Discontinuing antiepileptic drugs can lead to the recurrence of seizures or status epilepticus. The client does not need to drink more water and can drive while taking this medication. The medication will not stop an aura before a seizure.

After teaching a client newly diagnosed with epilepsy, the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching? a. "I will wear my medical alert bracelet at all times." b. "While taking my epilepsy medications, I will not drink any alcoholic beverages." c. "I will tell my doctor about my prescription and over-the-counter medications." d. "If I am nauseated, I will not take my epilepsy medication."

ANS: D The nurse must emphasize that antiepileptic drugs must be taken even if the client is nauseous. Discontinuing the medication can predispose the client to seizure activity and status epilepticus. The client should not drink alcohol while taking seizure medications. The client should wear a medical alert bracelet and should make the doctor aware of all medications to prevent complications of polypharmacy.

A nurse prepares to provide perineal care to a client with meningococcal meningitis. Which personal protective equipement should the nurse wear? (Select all that apply) a. Particulate respirator b. Isolation gown c. Shoe covers d. Surgical mask e. Gloves

ANS: D, E - Meningeal meningitis is spread via saliva and droplets, and droplet precautions are necessary. Caregivers should wear a surgical mask when within 6 feet of the client and should continue to use Standard Precautions, including gloves. A particulate respirator, an isolation gown, and shoe covers are not necessary for Droplet Precautions. DIF: Applying/Application REF: 869

The nurse is caring for a client with Alzheimer disease who exhibits behaviors associated with hyperorality. To meet the client's need for a safe milieu, what instructions will the nurse give the staff to monitor the client? 1 At meals to help prevent choking 2 For the presence of mouth ulcers 3 To prevent injury caused by hot foods 4 For attempts at eating inedible objects

Ans: 4 For attempts at eating inedible objects Hyperorality is the compulsive need to taste and chew inedible objects. Hyperorality is not related to choking, a tendency to mouth ulcers, or the inability to perceive temperature properly.

Which assessment finding would be the earliest and most sensitive indicator that there is an alteration in intracranial regulation? a. Change in level of consciousness b. Inability to focus visually c. Loss of primitive reflexes d. Unequal pupil size.

Ans: A - A change in level of consciousness is the earliest and most sensitive indication of a change in intracranial processing. This is assessed with the Glasgow coma Scale (GCS). which assess eye opening and verbal and motor response.

The nurse preparing to care for a patient after a suspected stroke would question which order? a. Anti-hypertensive b. Anti-pyretic c. Osmotic diuretic d. Sedative

Ans: A - Anti-hypertensive medications may be detrimental because the mean arterial pressure must be adequate to maintain cerebral blood flow and limit secondary injury. Fever can worsen the outcome after a stroke, and antipyretics can promote normothermia.

When caring for a patient after a head injury, the nurse would be MOST concerned with assessment findings which included respiratory changes along with what other findings? a. Hypertension and bradycardia b. Hypertension and tachycardia c. Hypotension and bradycardia d. Hypotension and tachycardia

Ans: A - Hypertension with widening pulse pressure, bradycardia, and respiratory changes are the ominous late signs of increased intracranial pressure and indications of impending herniation (Cushing's triad). It is bradycardia not tachycardia, which is the component of this ominous triad.

A neonate is admitted to the unit with a diagnosis of bacterial meningitis. The nurse is aware that the priority assessment will include which of the following? a. Hypothermia, irritability, and poor feeding b. Positive babinski's reflex, mottling, and pallor c. Headache, nuchal rigidity, and developmental delays d. Positive Moro's embrace reflex, hyperthermia, and sunken fontanel.

Ans: A - Hypothermia, irritability, and poor feeding - The clinical appearance of a neonate with meningitis is different from that or a child or an adult. Neonates may be hyper or hypothermic. The irritation of the meninges causes the neonates to be irritable and to have a decreased appetite. They may be pale and mottled with a bulging, full fontanel. Older children and adults with meningitis have headaches, nuchial rigidity, and hyperthermia as clinical manifestations. Normal neonates have Babinski's and Moro's embrace.

15.. A nurse is teaching a client who experiences migraine headaches and is prescribed a beta blocker. Which statement should the nurse include in this clients teaching? a. Take this drug only when you have prodromal symptoms indicating the onset of a migraine headache. b. Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches. c. This drug will relieve the pain during the aura phase soon after a headache has started. d. This medication will have no effect on your heart rate or blood pressure because you are taking it for migraines.

Ans: B - Beta blockers are prescribed as prophylactic treatment to prevent the vascular changes that initiate migraine headaches. Heart rate and blood pressure will also be affected, and the client should monitor these side effects. The other responses do not discuss appropriate uses of the medication.

The nurse is caring for a patient with increased intracranial pressure. Which action is considered unsafe? a. Aligning the neck with the body b. Clustering many nursing activities c. Elevating the head of bed 30 degrees d. Providing stool softeners or laxatives as ordered

Ans: B - It is important to minimize stress and activities that could increase intracranial pressure. Combing many nursing activities could increase oxygen demand and intracranial pressure. This would not be safe. Interventions which can promote venous outflow can help decrease intracranial pressure. The stress of constipation or bowel movements can increase intracranial pressure; stool softeners or laxatives can minimize this.

In caring for a 9-year old child immediately after a head injury, a nurse notes a blood pressure of 110/60 mm/hg, a heart rate of 78 BPM, dilated and nonreactive pupils, minimal response to pain, and slow response to name. Which symptom should cause the nurse the most concern? a. Vital signs b. nonreactive pupils c. slow response to name d. Minimal response to pain

Ans: B - Nonreactive pupils - dilated and nonreactive pupils indicate that anoxia or ischemia of the brain has occurred. If the pupils are also fixed, then herniation of the brain stem has occurred. The vital signs are normal. Slow response to name can be normal after a head injury. Minimal response to pain is an indication of the child's LOC.

The nurse is caring for a child following a shunt insertion on the right side of the head to relieve hydrocephalus. What is the priority intervention for the nurse to include in the plan of care? a. Place the child flat in the bed on the right side. b. Place the child flat in the bed on the left side. c. Place the child in a semi-fowler's position. d. Place the child in an upright position.

Ans: B - The child should be flat in the bed to avoid rapid decompression of the CSF and on the left side or on his back to avoid occlusion of the shunt and blockage of the drainage of CSF.

After shunt procedure, the nurse would monitor the patient's neurologic status by using the a. electroencephalogram. b. GCS. c. National Institutes of Health Stroke Scale. d. Monro-Kellie doctrine.

Ans: B The GCS gives a standard numeric score of the neurologic patient assessment.

A neonate has been brought to the ER by his mother. The nurse assess the child and suspects that the child may have hydrocephalus. Which observations by the nurse would indicate this condition? a. Bulging fontanel, low-pitched cry b. Depressed fontanel, low-pitched cry c. Bulging fontanel, eyes rotated downward d. Depressed fontanel, eyes rotated downard

Ans: C - As the CNS increases, the fontanel bulges, causing an increase in ICP. This pressure causes the neonate's eyes to deviate downward and the neonate's cry becomes high pitched.

A 2-year old child is admitted to the pediatric unit with the diagnosis of bacterial meningitis. Which intervention would be appropriate for a nurse to perform first? a. Obtain a urine specimen b. Draw ordered laboratory tests. c. Place the toddler in respiratory isolation d. Explain the treatment plan to the parents.

Ans: C - Nurses should take necessary precautions to protect themselves and others from possible infection from the bacterial organism causing meningitis. The affected child should immediately be placed in respiratory isolation; then the parents can be informed about the treatment plan. This should be done before laboratory tests are performed.

After a pathogen compromises the blood-brain and blood-cerebrospinal fluid (CSF) barriers, infection will spread to the meninges for which reason? a. The spinal fluid has a rich erythrocyte content. b. Glucose content of the spinal fluid is relatively high. c. There's a build-up of infectious exudate within the ventricular system. d. CFS is devoid of the body's major defense systems.

Ans: D - CSF is devoid of the body's major defense systems. After an organism compromises the natural barriers, the CSF provides an ideal medium for growth. All of the body's typical major defense systems are essentially absent in normal CSF.

Components of the Glasgow Coma Scale (GCS) the nurse would use to assess a patient after a head injury include which assessment? a. Blood pressure b. Cranial nerve function c. Head circumference d. Verbal responsiveness

Ans: D - Components of the GCS include eye opening, motor responsiveness, and verbal responsiveness. The nurse would want to assess the blood pressure, but this is not a component of the coma scale.

A mother brings her infant to the emergency department and says he had a seizure. While a nurse is obtaining a history, the mother says she was running out of formula so she stretched the formula by adding 3 times the normal amount of water. Electrolytes and blood glucose levels are drawn on the infant. The nurse should expect which laboratory value? a. Blood glucose 120mg/dL b. Chloride 104 mmol/L c. Potassium 4 mmo/L d. Sodium 125 mmol/L

Ans: D - Diluting formula can alter an infant's fluid and electrolytes. Normal serum sodium for an infant is 135 to 145 mmol/L. When formula is diluted, the infant's sodium is also diluted and will decrease. Hyponatremia is one of the causes of seizures in an infant. The other lab values are normal.

The nurse should teach a patient that which is a primary prevention strategy to reduce the occurrence of head injuries? a. blood pressure control b. Smoking cessation c. Maintaining a healthy weight d. violence prevention

Ans: D - violence prevention measures such a wearing a seat belt, helmet use, firearm safety, and violence prevention programs reduce the risk of traumatic brain injuries. Blood pressure control and exercising can decrease the risk of vascular disease, impacting the cerebral arteries, rather than head injuries.

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. 1.Padding the side rails of the bed 2.Placing an airway at the bedside 3.Placing the bed in the high position 4.Putting a padded tongue blade at the head of the bed 5.Placing oxygen and suction equipment at the bedside 6.Flushing the intravenous catheter to ensure that the site is patent

ans - 1,2,5,6 Seizure precautions may vary from agency to agency, but they generally have some common features. Usually, an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if antiseizure medications must be administered, and as part of the routine assessment the nurse should be checking patency of the catheter. The use of padded tongue blades is highly controversial, and they should not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure more likely will harm the client who bites down during seizure activity. Risks include blocking the airway from improper placement, chipping the client's teeth, and subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begins.

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? 1. A negative Kernig's sign 2. Absence of nuchal rigidity 3 A positive Brudzinski's sign 4. A Glasgow Coma Scale score of 15

ans - 3 Signs of meningeal irritation compatible with meningitis include nuchal rigidity, a positive Brudzinski's sign, and positive Kernig's sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is flexed. Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the leg is fully flexed at the knee and hip. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glasgow Coma Scale score of 15 is a perfect score and indicates that the client is awake and alert, with no neurological deficits.

What should the nurse include in the plan of care for a client with dementia of the Alzheimer type, stage 2 (moderate dementia)? 1 Discuss recent current events. 2 Teach the client new social skills. 3 Maintain a daily routine of living. 4 Encourage the client to talk about past experiences.

ans: 3 Maintain a daily routine of living. The client with this disorder will be most comfortable with a familiar and repetitive daily routine because it will produce less anxiety. Cognitive changes probably make a discussion of current events unrealistic. It probably is beyond the client's capability to develop new social skills. Memory impairment may make talking about past events impossible.

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? 1. Blowing the nose 2.Isometric exercises 3.Coughing vigorously 4.Exhaling during repositioning

ans: 4 Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure. Some of these activities include isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising.