Adult Health II - Exam 4 - Endocrine and Neuro

25. Which question during the assessment of a diabetic patient will help the nurse identify autonomic neuropathy? a. "Do you feel bloated after eating?" b. "Have you seen any skin changes?" c. "Do you need to increase your insulin dosage when you are stressed?" d. "Have you noticed any painful new ulcerations or sores on your feet?"

ANS: A Autonomic neuropathy can cause delayed gastric emptying, which results in a bloated feeling for the patient. The other questions are also appropriate to ask but would not help in identifying autonomic neuropathy.

9. In order to assist an older diabetic patient to engage in moderate daily exercise, which action is most important for the nurse to take? a. Determine what type of activities the patient enjoys. b. Remind the patient that exercise will improve self-esteem. c. Teach the patient about the effects of exercise on glucose level. d. Give the patient a list of activities that are moderate in intensity.

ANS: A Because consistency with exercise is important, assessment for the types of exercise that the patient finds enjoyable is the most important action by the nurse in ensuring adherence to an exercise program. The other actions will also be implemented but are not the most important in improving compliance.

45. Which nursing action can the nurse delegate to unlicensed assistive personnel (UAP) who are working in the diabetic clinic? a. Measure the ankle-brachial index. b. Check for changes in skin pigmentation. c. Assess for unilateral or bilateral foot drop. d. Ask the patient about symptoms of depression.

ANS: A Checking systolic pressure at the ankle and brachial areas and calculating the ankle-brachial index is a procedure that can be done by UAP who have been trained in the procedure. The other assessments require more education and critical thinking and should be done by the registered nurse (RN).

34. A 27-year-old patient admitted with diabetic ketoacidosis (DKA) has a serum glucose level of 732 mg/dL and serum potassium level of 3.1 mEq/L. Which action prescribed by the health care provider should the nurse take first? a. Place the patient on a cardiac monitor. b. Administer IV potassium supplements. c. Obtain urine glucose and ketone levels. d. Start an insulin infusion at 0.1 units/kg/hr.

ANS: A Hypokalemia can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with electrocardiogram (ECG) monitoring. Because potassium must be infused over at least 1 hour, the nurse should initiate cardiac monitoring before infusion of potassium. Insulin should not be administered without cardiac monitoring because insulin infusion will further decrease potassium levels. Urine glucose and ketone levels are not urgently needed to manage the patient's care.

13. Which patient action indicates a good understanding of the nurse's teaching about the use of an insulin pump? a. The patient programs the pump for an insulin bolus after eating. b. The patient changes the location of the insertion site every week. c. The patient takes the pump off at bedtime and starts it again each morning. d. The patient plans for a diet that is less flexible when using the insulin pump.

ANS: A In addition to the basal rate of insulin infusion, the patient will adjust the pump to administer a bolus after each meal, with the dosage depending on the oral intake. The insertion site should be changed every 2 or 3 days. There is more flexibility in diet and exercise when an insulin pump is used. The pump will deliver a basal insulin rate 24 hours a day.

37. A female patient is scheduled for an oral glucose tolerance test. Which information from the patient's health history is most important for the nurse to communicate to the health care provider? a. The patient uses oral contraceptives. b. The patient runs several days a week. c. The patient has been pregnant three times. d. The patient has a family history of diabetes.

ANS: A Oral contraceptive use may falsely elevate oral glucose tolerance test (OGTT) values. Exercise and a family history of diabetes both can affect blood glucose but will not lead to misleading information from the OGTT. History of previous pregnancies may provide informational about gestational glucose tolerance, but will not lead to misleading information from the OGTT.

14. A 32-year-old patient with diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage? a. Lispro (Humalog) b. Glargine (Lantus) c. Detemir (Levemir) d. NPH (Humulin N)

ANS: A Rapid- or short-acting insulin is used for mealtime coverage for patients receiving intensive insulin therapy. NPH, glargine, or detemir will be used as the basal insulin.

10. Which statement by the patient indicates a need for additional instruction in administering insulin? a. "I need to rotate injection sites among my arms, legs, and abdomen each day." b. "I can buy the 0.5 mL syringes because the line markings will be easier to see." c. "I should draw up the regular insulin first after injecting air into the NPH bottle." d. "I do not need to aspirate the plunger to check for blood before injecting insulin."

ANS: A Rotating sites is no longer recommended because there is more consistent insulin absorption when the same site is used consistently. The other patient statements are accurate and indicate that no additional instruction is needed.

44. The nurse has administered 4 oz of orange juice to an alert patient whose blood glucose was 62 mg/dL. Fifteen minutes later, the blood glucose is 67 mg/dL. Which action should the nurse take next? a. Give the patient 4 to 6 oz more orange juice. b. Administer the PRN glucagon (Glucagon) 1 mg IM. c. Have the patient eat some peanut butter with crackers. d. Notify the health care provider about the hypoglycemia.

ANS: A The "rule of 15" indicates that administration of quickly acting carbohydrates should be done 2 to 3 times for a conscious patient whose glucose remains less than 70 mg/dL before notifying the health care provider. More complex carbohydrates and fats may be used once the glucose has stabilized. Glucagon should be used if the patient's level of consciousness decreases so that oral carbohydrates can no longer be given.

7. A 38-year-old patient who has type 1 diabetes plans to swim laps daily at 1:00 PM. The clinic nurse will plan to teach the patient to a. check glucose level before, during, and after swimming. b. delay eating the noon meal until after the swimming class. c. increase the morning dose of neutral protamine Hagedorn (NPH) insulin. d. time the morning insulin injection so that the peak occurs while swimming.

ANS: A The change in exercise will affect blood glucose, and the patient will need to monitor glucose carefully to determine the need for changes in diet and insulin administration. Because exercise tends to decrease blood glucose, patients are advised to eat before exercising. Increasing the morning NPH or timing the insulin to peak during exercise may lead to hypoglycemia, especially with the increased exercise.

6. A 55-year-old female patient with type 2 diabetes has a nursing diagnosis of imbalanced nutrition: more than body requirements. Which goal is most important for this patient? a. The patient will reach a glycosylated hemoglobin level of less than 7%. b. The patient will follow a diet and exercise plan that results in weight loss. c. The patient will choose a diet that distributes calories throughout the day. d. The patient will state the reasons for eliminating simple sugars in the diet.

ANS: A The complications of diabetes are related to elevated blood glucose, and the most important patient outcome is the reduction of glucose to near-normal levels. The other outcomes also are appropriate but are not as high in priority.

35. A 54-year-old patient is admitted with diabetic ketoacidosis. Which admission order should the nurse implement first? a. Infuse 1 liter of normal saline per hour. b. Give sodium bicarbonate 50 mEq IV push. c. Administer regular insulin 10 U by IV push. d. Start a regular insulin infusion at 0.1 units/kg/hr.

ANS: A The most urgent patient problem is the hypovolemia associated with diabetic ketoacidosis (DKA), and the priority is to infuse IV fluids. The other actions can be done after the infusion of normal saline is initiated.

26. Which information will the nurse include in teaching a female patient who has peripheral arterial disease, type 2 diabetes, and sensory neuropathy of the feet and legs? a. Choose flat-soled leather shoes. b. Set heating pads on a low temperature. c. Use callus remover for corns or calluses. d. Soak feet in warm water for an hour each day.

ANS: A The patient is taught to avoid high heels and that leather shoes are preferred. The feet should be washed, but not soaked, in warm water daily. Heating pad use should be avoided. Commercial callus and corn removers should be avoided. The patient should see a specialist to treat these problems

12. A patient receives aspart (NovoLog) insulin at 8:00 AM. Which time will it be most important for the nurse to monitor for symptoms of hypoglycemia? a. 10:00 AM b. 12:00 AM c. 2:00 PM d. 4:00 PM

ANS: A The rapid-acting insulins peak in 1 to 3 hours. The patient is not at a high risk for hypoglycemia at the other listed times, although hypoglycemia may occur.

41. A 34-year-old has a new diagnosis of type 2 diabetes. The nurse will discuss the need to schedule a dilated eye exam a. every 2 years. b. as soon as possible. c. when the patient is 39 years old. d. within the first year after diagnosis.

ANS: B Because many patients have some diabetic retinopathy when they are first diagnosed with type 2 diabetes, a dilated eye exam is recommended at the time of diagnosis and annually thereafter. Patients with type 1 diabetes should have dilated eye exams starting 5 years after they are diagnosed and then annually.

47. After change-of-shift report, which patient should the nurse assess first? a. 19-year-old with type 1 diabetes who has a hemoglobin A1C of 12% b. 23-year-old with type 1 diabetes who has a blood glucose of 40 mg/dL c. 40-year-old who is pregnant and whose oral glucose tolerance test is 202 mg/dL d. 50-year-old who uses exenatide (Byetta) and is complaining of acute abdominal pain

ANS: B Because the brain requires glucose to function, untreated hypoglycemia can cause unconsciousness, seizures, and death. The nurse will rapidly assess and treat the patient with low blood glucose. The other patients also have symptoms that require assessments and/or interventions, but they are not at immediate risk for life-threatening complications.

20. The nurse is preparing to teach a 43-year-old man who is newly diagnosed with type 2 diabetes about home management of the disease. Which action should the nurse take first? a. Ask the patient's family to participate in the diabetes education program. b. Assess the patient's perception of what it means to have diabetes mellitus. c. Demonstrate how to check glucose using capillary blood glucose monitoring. d. Discuss the need for the patient to actively participate in diabetes management.

ANS: B Before planning teaching, the nurse should assess the patient's interest in and ability to self-manage the diabetes. After assessing the patient, the other nursing actions may be appropriate, but planning needs to be individualized to each patient.

11. Which patient action indicates good understanding of the nurse's teaching about administration of aspart (NovoLog) insulin? a. The patient avoids injecting the insulin into the upper abdominal area. b. The patient cleans the skin with soap and water before insulin administration. c. The patient stores the insulin in the freezer after administering the prescribed dose. d. The patient pushes the plunger down while removing the syringe from the injection site.

ANS: B Cleaning the skin with soap and water or with alcohol is acceptable. Insulin should not be frozen. The patient should leave the syringe in place for about 5 seconds after injection to be sure that all the insulin has been injected. The upper abdominal area is one of the preferred areas for insulin injection.

21. An unresponsive patient with type 2 diabetes is brought to the emergency department and diagnosed with hyperosmolar hyperglycemic syndrome (HHS). The nurse will anticipate the need to a. give a bolus of 50% dextrose. b. insert a large-bore IV catheter. c. initiate oxygen by nasal cannula. d. administer glargine (Lantus) insulin.

ANS: B HHS is initially treated with large volumes of IV fluids to correct hypovolemia. Regular insulin is administered, not a long-acting insulin. There is no indication that the patient requires oxygen. Dextrose solutions will increase the patient's blood glucose and would be contraindicated.

33. The nurse is taking a health history from a 29-year-old pregnant patient at the first prenatal visit. The patient reports no personal history of diabetes but has a parent who is diabetic. Which action will the nurse plan to take first? a. Teach the patient about administering regular insulin. b. Schedule the patient for a fasting blood glucose level. c. Discuss an oral glucose tolerance test for the twenty-fourth week of pregnancy. d. Provide teaching about an increased risk for fetal problems with gestational diabetes.

ANS: B Patients at high risk for gestational diabetes should be screened for diabetes on the initial prenatal visit. An oral glucose tolerance test may also be used to check for diabetes, but it would be done before the twenty-fourth week. The other actions may also be needed (depending on whether the patient develops gestational diabetes), but they are not the first actions that the nurse should take.

24. Which action should the nurse take after a 36-year-old patient treated with intramuscular glucagon for hypoglycemia regains consciousness? a. Assess the patient for symptoms of hyperglycemia. b. Give the patient a snack of peanut butter and crackers. c. Have the patient drink a glass of orange juice or nonfat milk. d. Administer a continuous infusion of 5% dextrose for 24 hours.

ANS: B Rebound hypoglycemia can occur after glucagon administration, but having a meal containing complex carbohydrates plus protein and fat will help prevent hypoglycemia. Orange juice and nonfat milk will elevate blood glucose rapidly, but the cheese and crackers will stabilize blood glucose. Administration of IV glucose might be used in patients who were unable to take in nutrition orally. The patient should be assessed for symptoms of hypoglycemia after glucagon administration.

38. Which laboratory value reported to the nurse by the unlicensed assistive personnel (UAP) indicates the most urgent need for the nurse's assessment of the patient? a. Bedtime glucose of 140 mg/dL b. Noon blood glucose of 52 mg/dL c. Fasting blood glucose of 130 mg/dL d. 2-hr postprandial glucose of 220 mg/dL

ANS: B The nurse should assess the patient with a blood glucose level of 52 mg/dL for symptoms of hypoglycemia and give the patient a carbohydrate-containing beverage such as orange juice. The other values are within an acceptable range or not immediately dangerous for a diabetic patient.

19. The nurse identifies a need for additional teaching when the patient who is self-monitoring blood glucose a. washes the puncture site using warm water and soap. b. chooses a puncture site in the center of the finger pad. c. hangs the arm down for a minute before puncturing the site. d. says the result of 120 mg indicates good blood sugar control.

ANS: B The patient is taught to choose a puncture site at the side of the finger pad because there are fewer nerve endings along the side of the finger pad. The other patient actions indicate that teaching has been effective.

A patient who had a subtotal thyroidectomy earlier today develops laryngeal stridor and a cramp in the right hand upon returning to the surgical nursing unit. Which collaborative action will the nurse anticipate next? a. Suction the patient's airway. b. Administer IV calcium gluconate. c. Plan for emergency tracheostomy. d. Prepare for endotracheal intubation.

ANS: B The patient's clinical manifestations of stridor and cramping are consistent with tetany caused by hypocalcemia resulting from damage to the parathyroid glands during surgery. Endotracheal intubation or tracheostomy may be needed if the calcium does not resolve the stridor. Suctioning will not correct the stridor.

15. Which information will the nurse include when teaching a 50-year-old patient who has type 2 diabetes about glyburide (Micronase, DiaBeta, Glynase)? a. Glyburide decreases glucagon secretion from the pancreas. b. Glyburide stimulates insulin production and release from the pancreas. c. Glyburide should be taken even if the morning blood glucose level is low. d. Glyburide should not be used for 48 hours after receiving IV contrast media.

ANS: B The sulfonylureas stimulate the production and release of insulin from the pancreas. If the glucose level is low, the patient should contact the health care provider before taking the glyburide, because hypoglycemia can occur with this class of medication. Metformin should be held for 48 hours after administration of IV contrast media, but this is not necessary for glyburide. Glucagon secretion is not affected by glyburide.

40. An active 28-year-old male with type 1 diabetes is being seen in the endocrine clinic. Which finding may indicate the need for a change in therapy? a. Hemoglobin A1C level 6.2% b. Blood pressure 146/88 mmHg c. Heart rate at rest 58 beats/minute d. High density lipoprotein (HDL) level 65 mg/dL

ANS: B To decrease the incidence of macrovascular and microvascular problems in patients with diabetes, the goal blood pressure is usually 130/80. An A1C less than 6.5%, a low resting heart rate (consistent with regular aerobic exercise in a young adult), and an HDL level of 65 mg/dL all indicate that the patient's diabetes and risk factors for vascular disease are well controlled.

28. A diabetic patient who has reported burning foot pain at night receives a new prescription. Which information should the nurse teach the patient about amitriptyline (Elavil)? a. Amitriptyline decreases the depression caused by your foot pain. b. Amitriptyline helps prevent transmission of pain impulses to the brain. c. Amitriptyline corrects some of the blood vessel changes that cause pain. d. Amitriptyline improves sleep and makes you less aware of nighttime pain.

ANS: B Tricyclic antidepressants decrease the transmission of pain impulses to the spinal cord and brain. Tricyclic antidepressants also improve sleep quality and are used for depression, but that is not the major purpose for their use in diabetic neuropathy. The blood vessel changes that contribute to neuropathy are not affected by tricyclic antidepressants.

1. To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually (select all that apply)? a. Chest x-ray b. Blood pressure c. Serum creatinine d. Urine for microalbuminuria e. Complete blood count (CBC) f. Monofilament testing of the foot

ANS: B, C, D, F Blood pressure, serum creatinine, urine testing for microalbuminuria, and monofilament testing of the foot are recommended at least annually to screen for possible microvascular and macrovascular complications of diabetes. Chest x-ray and CBC might be ordered if the diabetic patient presents with symptoms of respiratory or infectious problems but are not routinely included in screening.

1. Which statement by a nurse to a patient newly diagnosed with type 2 diabetes is correct? a. Insulin is not used to control blood glucose in patients with type 2 diabetes. b. Complications of type 2 diabetes are less serious than those of type 1 diabetes. c. Changes in diet and exercise may control blood glucose levels in type 2 diabetes. d. Type 2 diabetes is usually diagnosed when the patient is admitted with a hyperglycemic coma.

ANS: C For some patients with type 2 diabetes, changes in lifestyle are sufficient to achieve blood glucose control. Insulin is frequently used for type 2 diabetes, complications are equally severe as for type 1 diabetes, and type 2 diabetes is usually diagnosed with routine laboratory testing or after a patient develops complications such as frequent yeast infections.

17. When a patient who takes metformin (Glucophage) to manage type 2 diabetes develops an allergic rash from an unknown cause, the health care provider prescribes prednisone (Deltasone). The nurse will anticipate that the patient may a. need a diet higher in calories while receiving prednisone. b. develop acute hypoglycemia while taking the prednisone. c. require administration of insulin while taking prednisone. d. have rashes caused by metformin-prednisone interactions.

ANS: C Glucose levels increase when patients are taking corticosteroids, and insulin may be required to control blood glucose. Hypoglycemia is not a side effect of prednisone. Rashes are not an adverse effect caused by taking metformin and prednisone simultaneously. The patient may have an increased appetite when taking prednisone, but will not need a diet that is higher in calories.

23. The health care provider suspects the Somogyi effect in a 50-year-old patient whose 6:00 AM blood glucose is 230 mg/dL. Which action will the nurse teach the patient to take? a. Avoid snacking at bedtime. b. Increase the rapid-acting insulin dose. c. Check the blood glucose during the night d. Administer a larger dose of long-acting insulin.

ANS: C If the Somogyi effect is causing the patient's increased morning glucose level, the patient will experience hypoglycemia between 2:00 and 4:00 AM. The dose of insulin will be reduced, rather than increased. A bedtime snack is used to prevent hypoglycemic episodes during the night.

22. A 26-year-old female with type 1 diabetes develops a sore throat and runny nose after caring for her sick toddler. The patient calls the clinic for advice about her symptoms and a blood glucose level of 210 mg/dL despite taking her usual glargine (Lantus) and lispro (Humalog) insulin. The nurse advises the patient to a. use only the lispro insulin until the symptoms are resolved. b. limit intake of calories until the glucose is less than 120 mg/dL. c. monitor blood glucose every 4 hours and notify the clinic if it continues to rise. d. decrease intake of carbohydrates until glycosylated hemoglobin is less than 7%.

ANS: C Infection and other stressors increase blood glucose levels and the patient will need to test blood glucose frequently, treat elevations appropriately with lispro insulin, and call the health care provider if glucose levels continue to be elevated. Discontinuing the glargine will contribute to hyperglycemia and may lead to diabetic ketoacidosis (DKA). Decreasing carbohydrate or caloric intake is not appropriate because the patient will need more calories when ill. Glycosylated hemoglobin testing is not used to evaluate short-term alterations in blood glucose.

39. When a patient with type 2 diabetes is admitted for a cholecystectomy, which nursing action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Communicate the blood glucose level and insulin dose to the circulating nurse in surgery. b. Discuss the reason for the use of insulin therapy during the immediate postoperative period. c. Administer the prescribed lispro (Humalog) insulin before transporting the patient to surgery. d. Plan strategies to minimize the risk for hypoglycemia or hyperglycemia during the postoperative period.

ANS: C LPN/LVN education and scope of practice includes administration of insulin. Communication about patient status with other departments, planning, and patient teaching are skills that require RN education and scope of practice.

Which information will the nurse teach a 48-year-old patient who has been newly diagnosed with Graves' disease? a. Exercise is contraindicated to avoid increasing metabolic rate. b. Restriction of iodine intake is needed to reduce thyroid activity. c. Antithyroid medications may take several months for full effect. d. Surgery will eventually be required to remove the thyroid gland.

ANS: C Medications used to block the synthesis of thyroid hormones may take 2 to 3 months before the full effect is seen. Large doses of iodine are used to inhibit the synthesis of thyroid hormones. Exercise using large muscle groups is encouraged to decrease the irritability and hyperactivity associated with high levels of thyroid hormones. Radioactive iodine is the most common treatment for Graves' disease although surgery may be used.

8. The nurse determines a need for additional instruction when the patient with newly diagnosed type 1 diabetes says which of the following? a. "I can have an occasional alcoholic drink if I include it in my meal plan." b. "I will need a bedtime snack because I take an evening dose of NPH insulin." c. "I can choose any foods, as long as I use enough insulin to cover the calories." d. "I will eat something at meal times to prevent hypoglycemia, even if I am not hungry."

ANS: C Most patients with type 1 diabetes need to plan diet choices very carefully. Patients who are using intensified insulin therapy have considerable flexibility in diet choices but still should restrict dietary intake of items such as fat, protein, and alcohol. The other patient statements are correct and indicate good understanding of the diet instruction.

31. A 26-year-old patient with diabetes rides a bicycle to and from work every day. Which site should the nurse teach the patient to administer the morning insulin? a. thigh. b. buttock. c. abdomen. d. upper arm.

ANS: C Patients should be taught not to administer insulin into a site that will be exercised because exercise will increase the rate of absorption. The thigh, buttock, and arm are all exercised by riding a bicycle.

42. After the nurse has finished teaching a patient who has a new prescription for exenatide (Byetta), which patient statement indicates that the teaching has been effective? a. "I may feel hungrier than usual when I take this medicine." b. "I will not need to worry about hypoglycemia with the Byetta." c. "I should take my daily aspirin at least an hour before the Byetta." d. "I will take the pill at the same time I eat breakfast in the morning."

ANS: C Since exenatide slows gastric emptying, oral medications should be taken at least an hour before the exenatide to avoid slowing absorption. Exenatide is injected and increases feelings of satiety. Hypoglycemia can occur with this medication.

43. A few weeks after an 82-year-old with a new diagnosis of type 2 diabetes has been placed on metformin (Glucophage) therapy and taught about appropriate diet and exercise, the home health nurse makes a visit. Which finding by the nurse is most important to discuss with the health care provider? a. Hemoglobin A1C level is 7.9%. b. Last eye exam was 18 months ago. c. Glomerular filtration rate is decreased. d. Patient has questions about the prescribed diet.

ANS: C The decrease in renal function may indicate a need to adjust the dose of metformin or change to a different medication. In older patients, the goal for A1C may be higher in order to avoid complications associated with hypoglycemia. The nurse will plan on scheduling the patient for an eye exam and addressing the questions about diet, but the biggest concern is the patient's decreased renal function.

36. A patient who was admitted with diabetic ketoacidosis secondary to a urinary tract infection has been weaned off an insulin drip 30 minutes ago. The patient reports feeling lightheaded and sweaty. Which action should the nurse take first? a. Infuse dextrose 50% by slow IV push. b. Administer 1 mg glucagon subcutaneously. c. Obtain a glucose reading using a finger stick. d. Have the patient drink 4 ounces of orange juice.

ANS: C The patient's clinical manifestations are consistent with hypoglycemia and the initial action should be to check the patient's glucose with a finger stick or order a stat blood glucose. If the glucose is low, the patient should ingest a rapid-acting carbohydrate, such as orange juice. Glucagon or dextrose 50% might be given if the patient's symptoms become worse or if the patient is unconscious.

46. After change-of-shift report, which patient will the nurse assess first? a. 19-year-old with type 1 diabetes who was admitted with possible dawn phenomenon b. 35-year-old with type 1 diabetes whose most recent blood glucose reading was 230 mg/dL c. 60-year-old with hyperosmolar hyperglycemic syndrome who has poor skin turgor and dry oral mucosa d. 68-year-old with type 2 diabetes who has severe peripheral neuropathy and complains of burning foot pain

ANS: C The patient's diagnosis of HHS and signs of dehydration indicate that the nurse should rapidly assess for signs of shock and determine whether increased fluid infusion is needed. The other patients also need assessment and intervention but do not have life-threatening complications.

2. A 48-year-old male patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL (6.7 mmol/L). The nurse will plan to teach the patient about a. self-monitoring of blood glucose. b. using low doses of regular insulin. c. lifestyle changes to lower blood glucose. d. effects of oral hypoglycemic medications.

ANS: C The patient's impaired fasting glucose indicates prediabetes, and the patient should be counseled about lifestyle changes to prevent the development of type 2 diabetes. The patient with prediabetes does not require insulin or oral hypoglycemics for glucose control and does not need to self-monitor blood glucose.

29. Which information is most important for the nurse to report to the health care provider before a patient with type 2 diabetes is prepared for a coronary angiogram? a. The patient's most recent HbA1C was 6.5%. b. The patient's admission blood glucose is 128 mg/dL. c. The patient took the prescribed metformin (Glucophage) today. d. The patient took the prescribed captopril (Capoten) this morning.

ANS: C To avoid lactic acidosis, metformin should be discontinued a day or 2 before the coronary arteriogram and should not be used for 48 hours after IV contrast media are administered. The other patient data will also be reported but do not indicate any need to reschedule the procedure.

4. The nurse is assessing a 22-year-old patient experiencing the onset of symptoms of type 1 diabetes. Which question is most appropriate for the nurse to ask? a. "Are you anorexic?" b. "Is your urine dark colored?" c. "Have you lost weight lately?" d. "Do you crave sugary drinks?"

ANS: C Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy. The patient is thirsty but does not necessarily crave sugar-containing fluids. Increased appetite is a classic symptom of type 1 diabetes. With the classic symptom of polyuria, urine will be very dilute.

18. A hospitalized diabetic patient received 38 U of NPH insulin at 7:00 AM. At 1:00 PM, the patient has been away from the nursing unit for 2 hours, missing the lunch delivery while awaiting a chest x-ray. To prevent hypoglycemia, the best action by the nurse is to a. save the lunch tray for the patient's later return to the unit. b. ask that diagnostic testing area staff to start a 5% dextrose IV. c. send a glass of milk or orange juice to the patient in the diagnostic testing area. d. request that if testing is further delayed, the patient be returned to the unit to eat.

ANS: D Consistency for mealtimes assists with regulation of blood glucose, so the best option is for the patient to have lunch at the usual time. Waiting to eat until after the procedure is likely to cause hypoglycemia. Administration of an IV solution is unnecessarily invasive for the patient. A glass of milk or juice will keep the patient from becoming hypoglycemic but will cause a rapid rise in blood glucose because of the rapid absorption of the simple carbohydrate in these items.

30. Which action by a patient indicates that the home health nurse's teaching about glargine and regular insulin has been successful? a. The patient administers the glargine 30 minutes before each meal. b. The patient's family prefills the syringes with the mix of insulins weekly. c. The patient draws up the regular insulin and then the glargine in the same syringe. d. The patient disposes of the open vials of glargine and regular insulin after 4 weeks.

ANS: D Insulin can be stored at room temperature for 4 weeks. Glargine should not be mixed with other insulins or prefilled and stored. Short-acting regular insulin is administered before meals, while glargine is given once daily.

32. The nurse is interviewing a new patient with diabetes who receives rosiglitazone (Avandia) through a restricted access medication program. What is most important for the nurse to report immediately to the health care provider? a. The patient's blood pressure is 154/92. b. The patient has a history of emphysema. c. The patient's blood glucose is 86 mg/dL. d. The patient has chest pressure when walking.

ANS: D Rosiglitazone can cause myocardial ischemia. The nurse should immediately notify the health care provider and expect orders to discontinue the medication. There is no urgent need to discuss the other data with the health care provider.

27. Which finding indicates a need to contact the health care provider before the nurse administers metformin (Glucophage)? a. The patient's blood glucose level is 174 mg/dL. b. The patient has gained 2 lb (0.9 kg) since yesterday. c. The patient is scheduled for a chest x-ray in an hour. d. The patient's blood urea nitrogen (BUN) level is 52 mg/dL.

ANS: D The BUN indicates possible renal failure, and metformin should not be used in patients with renal failure. The other findings are not contraindications to the use of metformin.

5. A patient with type 2 diabetes is scheduled for a follow-up visit in the clinic several months from now. Which test will the nurse schedule to evaluate the effectiveness of treatment for the patient? a. Urine dipstick for glucose b. Oral glucose tolerance test c. Fasting blood glucose level d. Glycosylated hemoglobin level

ANS: D The glycosylated hemoglobin (A1C or HbA1C) test shows the overall control of glucose over 90 to 120 days. A fasting blood level indicates only the glucose level at one time. Urine glucose testing is not an accurate reflection of blood glucose level and does not reflect the glucose over a prolonged time. Oral glucose tolerance testing is done to diagnose diabetes, but is not used for monitoring glucose control once diabetes has been diagnosed.

16. The nurse has been teaching a patient with type 2 diabetes about managing blood glucose levels and taking glipizide (Glucotrol). Which patient statement indicates a need for additional teaching? a. "If I overeat at a meal, I will still take the usual dose of medication." b. "Other medications besides the Glucotrol may affect my blood sugar." c. "When I am ill, I may have to take insulin to control my blood sugar." d. "My diabetes won't cause complications because I don't need insulin."

ANS: D The patient should understand that type 2 diabetes places the patient at risk for many complications and that good glucose control is as important when taking oral agents as when using insulin. The other statements are accurate and indicate good understanding of the use of glipizide.

3. A 28-year-old male patient with type 1 diabetes reports how he manages his exercise and glucose control. Which behavior indicates that the nurse should implement additional teaching? a. The patient always carries hard candies when engaging in exercise. b. The patient goes for a vigorous walk when his glucose is 200 mg/dL. c. The patient has a peanut butter sandwich before going for a bicycle ride. d. The patient increases daily exercise when ketones are present in the urine.

ANS: D When the patient is ketotic, exercise may result in an increase in blood glucose level. Type 1 diabetic patients should be taught to avoid exercise when ketosis is present. The other statements are correct.

For a 65-year-old woman who has lived with a T1 spinal cord injury for 20 years, which of the following health teaching instructions should the nurse emphasize? a. A mammogram is needed every year. b. Bladder function tends to improve with age. c. Heart disease is not common in people with spinal cord injury. d. As a person ages, the need to change body position is less important.

a. A mammogram is needed every year. Rationale: Health promotion and screening are important for an older patient with a spinal cord injury. Older adult women with spinal cord injuries should perform monthly breast examinations and undergo yearly mammography.

A patient is admitted with a headache, fever, and general malaise. The HCP has asked that the patient be prepared for a lumbar puncture. What is a priority nursing action to avoid complications? a. Ensure that CT scan is performed prior to lumbar puncture. b. Assess laboratory results for changes in the white cell count. c. Provide acetaminophen for the headache and fever before the procedure. d. Administer antibiotics before the procedure to treat the potential meningitis.

a. Ensure that CT scan is performed prior to lumbar puncture. Rationale: A CT scan must be performed prior to lumbar puncture in a patient with possible increased intracranial pressure to avoid potential downward herniation of the brain when cerebrospinal fluid is drawn from the lumbar cistern.

During rehabilitation, a patient with spinal cord injury begins to ambulate with long leg braces. Which level of injury does the nurse associate with this degree of recovery? a. L1-2 b. T6-7 c. T1-2 d. C7-8

a. L1-2 During rehabilitation, the patient with SCI at L1-2 is able to maintain good sitting balance and full use of a wheelchair. The patient ambulates with long leg braces. Patients with higher level injury are unable to attain this degree of ambulation.

A 50-year-old man complains of recurring headaches. He describes these as sharp, stabbing, and located around his left eye. He also reports that his left eye seems to swell and get teary when these headaches occur. Based on this history, you suspect that he has a. cluster headaches. b. tension headaches. c. migraine headaches. d. medication overuse headaches.

a. cluster headaches. Rationale: Cluster headaches involve repeated headaches that can occur for weeks to months, followed by periods of remission. The pain of cluster headache is sharp and stabbing; the intense pain lasts a few minutes to 3 hours. Cluster headaches can occur every other day and as often as eight times a day. The clusters occur with regularity, usually at the same time each day and during the same seasons of the year. Typically, a cluster lasts 2 weeks to 3 months, and the patient then goes into remission for months to years. The pain usually is located around the eye and radiates to the temple, forehead, cheek, nose, or gums. Other manifestations may include swelling around the eye, lacrimation (tearing), facial flushing or pallor, nasal congestion, and constriction of the pupil. During the headache, the patient is often agitated and restless, unable to sit still or relax.

Stimulation of the parasympathetic nervous system results in (select all that apply) a. constriction of the bronchi. b. dilation of skin blood vessels. c. increased secretion of insulin. d. increased blood glucose levels. e. relaxation of the urinary sphincter.

a. constriction of the bronchi. b. dilation of skin blood vessels. c. increased secretion of insulin. e. relaxation of the urinary sphincter. Rationale: Stimulation of the parasympathetic nervous system results in constriction of the bronchi, dilation of blood vessels to the skin, increased secretion of insulin, and relaxation of the urinary sphincter. Stimulation of the sympathetic nervous system results in increased blood glucose levels.

Common psychosocial reactions of the stroke patient to the stroke include (select all that apply) a. depression. b. disassociation. c. intellectualization. d. sleep disturbances. e. denial of severity of stroke.

a. depression. d. sleep disturbances. e. denial of severity of stroke. Rationale: The patient with a stroke may experience many losses, including sensory, intellectual, communicative, functional, role behavior, emotional, social, and vocational. Some patients experience long-term depression, manifesting symptoms such as anxiety, weight loss, fatigue, poor appetite, and sleep disturbances. The time and energy required to perform previously simple tasks can result in anger and frustration. Frustration and depression are common in the first year after a stroke. A stroke is usually a sudden, extremely stressful event for the patient, caregiver, family, and significant others. The family is often affected emotionally, socially, and financially as their roles and responsibilities change. Reactions vary considerably but may involve fear, apprehension, denial of the severity of stroke, depression, anger, and sorrow.

Social effects of a chronic neurologic disease include (select all that apply) a. divorce. b. job loss. c. depression. d. role changes. e. loss of self-esteem.

a. divorce. b. job loss. c. depression. d. role changes. e. loss of self-esteem. (Yep, all of them!) Rationale: Social problems related to chronic neurologic disease may include changes in roles and relationships (e.g., divorce, job loss, role changes); other psychologic problems (e.g., depression, loss of self-esteem) also may have social effects.

A patient is suspected of having a brain tumor. The signs and symptoms include memory deficits, visual disturbances, weakness of right upper and lower extremities, and personality changes. The nurse recognizes that the tumor is most likely located in the a. frontal lobe. b. parietal lobe. c. occipital lobe. d. temporal lobe.

a. frontal lobe. Rationale: A unilateral frontal lobe tumor may result in the following signs and symptoms: unilateral hemiplegia, seizures, memory deficit, personality and judgment changes, and visual disturbances. A bilateral frontal lobe tumor may cause symptoms associated with a unilateral frontal lobe tumor and an ataxic gait.

During assessment of the patient with trigeminal neuralgia, the nurse should (select all that apply) a. inspect all aspects of the mouth and teeth. b. assess the gag reflex and respiratory rate and depth. c. lightly palpate the affected side of the face for edema. d. test for temperature and sensation perception on the face. e. ask the patient to describe factors that initiate an episode.

a. inspect all aspects of the mouth and teeth. d. test for temperature and sensation perception on the face. e. ask the patient to describe factors that initiate an episode. Rationale: Assessment of the attacks, including the triggering factors, characteristics, frequency, and pain management techniques, helps the nurse plan for patient care. Painful episodes are usually triggered by light touch at a specific point (i.e., trigger zone) along the distribution of the nerve branches. Precipitating stimuli include chewing, tooth brushing, a hot or cold blast of air on the face, washing the face, yawning, or talking. Touch and tickle seem to predominate as causative triggers, rather than pain or changes in ambient temperature. The nursing assessment should include the patient's nutritional status, hygiene (especially oral), and behavior (including withdrawal). As a result of the attacks, the patient may eat improperly, neglect hygienic practices, wear a cloth over the face, and withdraw from interaction with others.

A priority goal of treatment for the patient with AD is to a. maintain patient safety. b. maintain or increase body weight. c. return to a higher level of self-care. d. enhance functional ability over time.

a. maintain patient safety. Rationale: The overall management goals are that the patient with AD will (1) maintain functional ability for as long as possible, (2) be maintained in a safe environment with a minimum of injuries, (3) have personal care needs met, and (4) have dignity maintained. The nurse should place emphasis on patient safety while planning and providing nursing care.

A patient's eyes jerk while the patient looks to the left. The nurse will record this finding as a. nystagmus. b. CN VI palsy. c. ophthalmic dyskinesia. d. oculocephalic response.

a. nystagmus. Rationale: Nystagmus is defined as fine, rapid jerking movements of the eyes.

During admission of a patient with a severe head injury to the emergency department, the nurse places the highest priority on assessment for a. patency of airway. b. presence of a neck injury. c. neurologic status with the Glascow Coma Scale. d. cerebrospinal fluid leakage from ears or nose.

a. patency of airway. Rationale: The nurse's initial priority in the emergency management of a patient with a severe head injury is to ensure that the patient has a patent airway.

A nurse is caring for a patient newly diagnosed with chronic inflammatory demyelinating polyneuropathy (CIDP). Which statement can the nurse accurately use to teach the patient about CIDP? a. "Corticosteroids have little effect on this disease." b. "Maintenance therapy will be needed to prevent relapse." c. "You will go into remission in approximately eight weeks." d. "You should be able to walk without help within three months."

b. "Maintenance therapy will be needed to prevent relapse." Rationale: Unlike GBS, CIDP does not automatically resolve or go into remission. Most patients with GBS can walk without help within three months. Corticosteroids are a standard therapy for CIDP. Patients with CIDP require maintenance therapy to prevent relapse or progression.

Which statement(s) accurately describe(s) mild cognitive impairment (select all that apply)? a. Always progresses to AD b. Caused by variety of factors and may progress to AD c. Should be aggressively treated with acetylcholinesterase drugs d. Caused by vascular infarcts that, if treated, will delay progression to AD e. Patient is usually not aware that there is a problem with his or her memory

b. Caused by variety of factors and may progress to AD Rationale: Although some individuals with mild cognitive impairment (MCI) revert to normal cognitive function or do not go on to develop Alzheimer's disease (AD), those with MCI are at high risk for AD. No drugs have been approved for the treatment of MCI. A person with MCI is often aware of a significant change in memory.

A patient with a T4 spinal cord injury experiences neurogenic shock as a result of sympathetic nervous system dysfunction. What would the nurse recognize as characteristic of this condition? a. Tachycardia b. Hypotension c. Increased cardiac output d. Peripheral vasoconstriction

b. Hypotension Rationale: Neurogenic shock results from loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic nervous system innervation causes peripheral vasodilation, venous pooling, and a decrease in cardiac output. These effects are usually associated with a cervical or high thoracic injury (T6 or higher).

A patient is seen in the emergency department after diving into the pool and hitting the bottom with a blow to the face that hyperextended the neck and scraped the skin off the nose. The patient also described "having double vision" when looking down. During the neurologic exam, the nurse finds the patient is unable to abduct either eye. The nurse recognizes this finding is related to a. a basal skull fracture. b. a stretch injury to bilateral CN VI. c. a stiff neck from the hyperextension injury. d. facial swelling from the scrape on the bottom of the pool.

b. a stretch injury to bilateral CN VI. Rationale: Cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) are responsible for eye movement. The lateral rectus eye muscle, the primary muscle responsible for lateral eye movement, is innervated by cranial nerve VI. The hyperextension injury, which can be experienced in diving accidents or rear-end motor vehicle crashes, can stretch these nerves bilaterally.

Vasogenic cerebral edema increases intracranial pressure by a. shifting fluid into the gray matter. b. altering the endothelial lining of cerebral capillaries. c. leaking molecules from the intracellular fluid to the capillaries. d. altering the osmotic gradient flow into the intravascular component.

b. altering the endothelial lining of cerebral capillaries. Rationale: Vasogenic cerebral edema occurs mainly in the white matter. It is caused by changes in the endothelial lining of cerebral capillaries.

The most common early symptom of a spinal cord tumor is a. urinary incontinence. b. back pain that worsens with activity. c. paralysis below the level of involvement. d. impaired sensation of pain, temperature, and light touch.

b. back pain that worsens with activity. Rationale: The most common early symptom of a spinal cord tumor is pain in the back, with radicular pain following the nerve(s) affected. The location of the pain depends on the level of compression. The pain worsens with activity, coughing, straining, and lying down.

A nursing measure that is indicated to reduce the potential for seizures and increased intracranial pressure in the patient with bacterial meningitis is a. administering codeine for relief of head and neck pain. b. controlling fever with prescribed drugs and cooling techniques. c. keeping the room darkened and quiet to minimize environmental stimulation. d. maintaining the patient on strict bed rest with the head of the bed slightly elevated.

b. controlling fever with prescribed drugs and cooling techniques. Rationale: Fever must be vigorously managed because it increases cerebral edema and the frequency of seizures. Neurologic damage may result from an extremely high temperature over a prolonged period. Acetaminophen or aspirin may be used to reduce fever; other measures, such as a cooling blanket or tepid sponge baths with water, may be effective in lowering the temperature.

A nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to a. keep the head of the bed flat. b. elevate the head of the bed to 30 degrees. c. maintain patient on the left side with the head supported on a pillow. d. use a continuous-rotation bed to continuously change patient position.

b. elevate the head of the bed to 30 degrees. Rationale: The nurse should maintain the patient with abnormal ICP in the head-up position. Elevation of the head of the bed to 30 degrees enhances respiratory exchange and aids in decreasing cerebral edema. The nurse should position the patient to prevent extreme neck flexion, which can cause venous obstruction and contribute to elevation in ICP. Elevation of the head of the bed also reduces sagittal sinus pressure, promotes drainage from the head through the valveless venous system and jugular veins, and decreases the vascular congestion that can produce cerebral edema. However, raising the head of the bed above 30 degrees may decrease the cerebral perfusion pressure (CPP) by lowering systemic BP. The effects of elevation of the head of the bed on the ICP and CPP must be evaluated carefully

During the admitting neurological examination, the nurse determines the patient has speech difficulties as well as weakness of the right arm and lower face. The nurse would expect a CT scan to show pathology in the distribution of the a. basilar artery. b. left middle cerebral artery. c. right anterior cerebral artery. d. left posterior communicating artery.

b. left middle cerebral artery. Rationale: The left middle cerebral artery feeds the lateral frontal lobes. The motor strip in this distribution controls the contralateral arm, lower half of the face, and motor speech.

The early stage of AD is characterized by a. no noticeable change in behavior. b. memory problems and mild confusion. c. increased time spent sleeping or in bed. d. incontinence, agitation, and wandering behavior.

b. memory problems and mild confusion. Rationale: An initial sign of AD is a subtle deterioration in memory.

The nurse is assessing the muscle strength of an older adult patient. The nurse knows the findings cannot be compared to those of a younger adult because a. nutritional status is better in young adults. b. muscle bulk and strength decrease in older adults. c. muscle strength should be the same for all adults. d. most young adults exercise more than older adults.

b. muscle bulk and strength decrease in older adults. Rationale: Changes associated with aging include decreases in muscle strength and agility in relation to decreased muscle bulk.

For a patient who is suspected of having a stroke, one of the most important pieces of information that the nurse can obtain is a. time of the patient's last meal. b. time at which stroke symptoms first appeared. c. patient's hypertension history and management. d. family history of stroke and other cardiovascular diseases.

b. time at which stroke symptoms first appeared. Rationale: During initial evaluation, the most important point in the patient's history is the time since onset of stroke symptoms. If the stroke is ischemic, recombinant tissue plasminogen activator (tPA) must be administered within 3 to 4½ hours of the onset of clinical signs of ischemic stroke; tPA reestablishes blood flow through a blocked artery and prevents brain cell death in patients with acute onset of ischemic stroke.

A patient with spinal cord injury is experiencing severe neurologic deficits. What is the most likely mechanism of injury for this patient? a. Compression b. Hyperextension c. Flexion-rotation d. Extension-rotation

c. Flexion-rotation Rationale: The major mechanisms of SCI are flexion, hyperextension, flexion-rotation, extension-rotation, and compression. The flexion-rotation injury is the most unstable because spinal ligaments are torn. This injury most often contributes to severe neurologic deficits.

The nurse on the clinical unit is assigned to four patients. Which patient should she assess first? a. Patient with a skull fracture whose nose is bleeding b. Older patient with a stroke who is confused and whose daughter is present c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0-to-10 scale d. Patient who had a craniotomy for a brain tumor and who is now 3 days postoperative and has had continued vomiting

c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0-to-10 scale (then d, a, & b is last) Rationale: The patient with meningitis should be seen first; patients with meningitis must be observed closely for manifestations of elevated ICP, which is thought to result from swelling around the dura and increased cerebrospinal fluid (CSF) volume. Sudden change in the level of consciousness or change in behavior along with a sudden severe headache may indicate an acute elevation of ICP. The patient who has undergone cranial surgery should be seen second; although nausea and vomiting are common after cranial surgery, it can result in elevations of ICP. Nausea and vomiting should be treated with antiemetics. The patient with a skull fracture needs to be evaluated for CSF leakage occurring with the nosebleed and should be seen third. Confusion after a stroke may be expected; the patient should have a family member present.

Nursing management of a patient with a brain tumor includes (select all that apply) a. discussing with the patient methods to control inappropriate behavior. b. using diversion techniques to keep the patient stimulated and motivated. c. assisting and supporting the family in understanding any changes in behavior. d. limiting self-care activities until the patient has regained maximal physical functioning. e. planning for seizure precautions and teaching the patient and the caregiver about antiseizure drugs.

c. assisting and supporting the family in understanding any changes in behavior. e. planning for seizure precautions and teaching the patient and the caregiver about antiseizure drugs. Rationale: Nursing interventions should be based on a realistic appraisal of the patient's condition and prognosis after cranial surgery. The nurse should provide support and education to the caregiver and family about the patient's behavioral changes. The nurse should be prepared to manage seizures and teach the caregiver and family about antiseizure medications and how to manage a seizure. An overall goal is to foster the patient's independence for as long as possible and to the highest degree possible. The nurse should decrease stimuli in the patient's environment to prevent increases in intracranial pressure.

Bladder training in a male patient who has urinary incontinence after a stroke includes a. limiting fluid intake. b. keeping a urinal in place at all times. c. assisting the patient to stand to void. d. catheterizing the patient every 4 hours.

c. assisting the patient to stand to void. Rationale: In the acute stage of stroke, the primary urinary problem is poor bladder control and incontinence. Nurses should promote normal bladder function and avoid the use of indwelling catheters. A bladder retraining program consists of (1) adequate fluid intake, with most fluids administered between 7:00 AM and 7:00 PM; (2) scheduled toileting every 2 hours with the use of a bedpan, commode, or bathroom; and (3) noting signs of restlessness, which may indicate the need for urination. Intermittent catheterization may be used for urinary retention (not urinary incontinence). During the rehabilitation phase after a stroke, nursing interventions focused on urinary continence include (1) assessing for bladder distention by palpation; (2) offering the bedpan, urinal, commode, or toilet every 2 hours during waking hours and every 3 to 4 hours at night; (3) using a direct command to help the patient focus on the need to urinate; (4) assisting with clothing and mobility; (5) scheduling most fluid intake between 7:00 AM and 7:00 PM; and (6) encouraging the usual position for urinating (i.e., standing for men and sitting for women).

Vascular dementia is associated with a. transient ischemic attacks. b. bacterial or viral infection of neuronal tissue. c. cognitive changes secondary to cerebral ischemia. d. abrupt changes in cognitive function that are irreversible.

c. cognitive changes secondary to cerebral ischemia. Rationale: Vascular dementia is the loss of cognitive function that results from ischemic, ischemic-hypoxic, or hemorrhagic brain lesions caused by cardiovascular disease. In this type of dementia, narrowing and blocking of arteries that supply the brain cause a decrease in blood supply.

The factor related to cerebral blood flow that most often determines the extent of cerebral damage from a stroke is the a. amount of cardiac output. b. O2 content of the blood. c. degree of collateral circulation. d. level of CO2 in the blood.

c. degree of collateral circulation. Rationale: The extent of the stroke depends on the rapidity of onset, size of the lesion, and presence of collateral circulation.

The nurse is alerted to a possible acute subdural hematoma in the patient who a. has a linear skull fracture crossing a major artery. b. has focal symptoms of brain damage with no recollection of a head injury. c. develops decreased level of consciousness and a headache within 48 hours of a head injury. d. has an immediate loss of consciousness with a brief lucid interval followed by decreasing level of consciousness.

c. develops decreased level of consciousness and a headache within 48 hours of a head injury. Rationale: An acute subdural hematoma manifests within 24 to 48 hours of the injury. The signs and symptoms are similar to those associated with brain tissue compression in elevated ICP and include decreasing level of consciousness and headache.

A patient is exhibiting word finding difficulty and weakness in his right arm. What area of the brain is most likely involved? a. brainstem. b. vertebral artery. c. left middle cerebral artery. d. right middle cerebral artery.

c. left middle cerebral artery. Rationale: If the middle cerebral artery is involved in a stroke, the expected clinical manifestations include aphasia, motor and sensory deficit, and hemianopsia on the dominant side and include neglect, motor and sensory deficit, and hemianopsia on the nondominant side.

Dementia with Lewy bodies (DLB) is characterized by a. remissions and exacerbations over many years. b. memory impairment, muscle jerks, and blindness. c. parkinsonian symptoms, including muscle rigidity. d. increased intracranial pressure secondary to decrease CSF drainage.

c. parkinsonian symptoms, including muscle rigidity. Rationale: Dementia with Lewy bodies (DLB) is characterized by features of dementia and Parkinson's disease. These patients typically have manifestations of parkinsonism, hallucinations, short-term memory loss, unpredictable cognitive shifts, and sleep disturbances.

The nurse explains to the patient with a stroke who is scheduled for angiography that this test is used to determine the a. presence of increased ICP. b. site and size of the infarction. c. patency of the cerebral blood vessels. d. presence of blood in the cerebrospinal fluid.

c. patency of the cerebral blood vessels. Rationale: Angiography provides visualization of cerebral blood vessels and can help estimate perfusion and detect filling defects in the cerebral arteries.

A patient experiencing TIAs is scheduled for a carotid endarterectomy. The nurse explains that this procedure is done to a. decrease cerebral edema. b. reduce the brain damage that occurs during a stroke in evolution. c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow. d. provide a circulatory bypass around thrombotic plaques obstructing cranial circulation.

c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow. Rationale: In a carotid endarterectomy, the atheromatous lesion is removed from the carotid artery to improve blood flow.

A 65-year-old woman was just diagnosed with Parkinson's disease. The priority nursing intervention is a. searching the Internet for educational videos. b. evaluating the home for environmental safety. c. promoting physical exercise and a well-balanced diet. d. designing an exercise program to strengthen and stretch specific muscles.

c. promoting physical exercise and a well-balanced diet. Rationale: Promotion of physical exercise and a well-balanced diet are major concerns of nursing care for patients with Parkinson's disease.

A patient with a C7 spinal cord injury undergoing rehabilitation tells the nurse he must have the flu because he has a bad headache and nausea. The nurse's first priority is to a. call the HCP b. check the patient's temperature c. take the patient's blood pressure d. elevate the head of the bed to 90 degrees

c. take the patient's blood pressure Rationale: Autonomic hyperreflexia is a massive, uncompensated cardiovascular reaction mediated by the sympathetic nervous system. Manifestations include hypertension (up to 300 mm Hg systolic), throbbing headache, marked diaphoresis above the level of the injury, bradycardia (30 to 40 beats/min), piloerection, flushing of the skin above the level of the injury, blurred vision or spots in the visual fields, nasal congestion, anxiety, and nausea. It is important to measure BP when a patient with a spinal cord injury complains of headache. Other nursing interventions in this serious emergency are elevation of the head of the bed 45 degrees or sitting the patient upright, notification of the physician, and assessment to determine the cause. Table 60-7 (p. 1431) lists the causes and symptoms of autonomic hyperreflexia. The nurse must monitor BP frequently during the episode. An α-adrenergic blocker or an arteriolar vasodilator may be administered.

During neurologic testing, the patient is able to perceive pain elicited by pinprick. Based on this finding, the nurse may omit testing for a. position sense. b. patellar reflexes. c. temperature perception. d. heel-to-shin movements.

c. temperature perception. Rationale: If pain sensation is intact, assessment of temperature sensation may be omitted because both sensations are transmitted by the same ascending pathways.

Of the following patients, the nurse recognizes that the one with the highest risk for a stroke is a(n) a. obese 45-yr-old Native American. b. 35-yr-old Asian American woman who smokes. c. 32-yr-old white woman taking oral contraceptives. d. 65-yr-old African American man with hypertension.

d. 65-yr-old African American man with hypertension. Rationale: Nonmodifiable risk factors for stroke include age (older than 65 years), male gender, ethnicity or race (incidence is highest in African Americans; next highest in Hispanics, Native Americans/Alaska Natives, and Asian Americans; and next highest in white people), and family history of stroke or personal history of a transient ischemic attack or stroke. Modifiable risk factors for stroke include hypertension (most important), heart disease (especially atrial fibrillation), smoking, excessive alcohol consumption (causes hypertension), abdominal obesity, sleep apnea, metabolic syndrome, lack of physical exercise, poor diet (high in saturated fat and low in fruits and vegetables), and drug abuse (especially cocaine). Other risk factors for stroke include a diagnosis of diabetes mellitus, increased serum levels of cholesterol, consumption of birth control pills (high levels of progestin and estrogen), history of migraine headaches, inflammatory conditions, hyperhomocysteinemia, and sickle cell disease.

Which patient is most at risk for developing delirium? a. A 50-yr-old woman with cholecystitis b. A 19-yr-old man with a fractured femur c. A 42-yr-old woman having an elective hysterectomy d. A 78-yr-old man admitted to the medical unit with complications related to heart failure

d. A 78-yr-old man admitted to the medical unit with complications related to heart failure Rationale: Risk factors that can precipitate delirium include age of 65 years or older, male gender, and severe acute illness (e.g., heart failure). The 78-year-old man has the most risk factors for delirium (Table 59-16).

A patient with intracranial pressure monitoring has a pressure of 12 mm Hg. The nurse understands that this pressure reflects a. a severe decrease in cerebral perfusion pressure. b. an alteration in the production of cerebrospinal fluid. c. the loss of autoregulatory control of intracranial pressure. d. a normal balance between brain tissue, blood, and cerebrospinal fluid.

d. a normal balance between brain tissue, blood, and cerebrospinal fluid. Rationale: Normal intracranial pressure (ICP) is 5 to 15 mm Hg. A sustained pressure above the upper limit is considered abnormal.

The nurse finds that an 87-year-old woman with Alzheimer's disease is continually rubbing, flexing, and kicking her legs throughout the day. The night shift reports that this same behavior escalates at night, preventing her from obtaining her required sleep. The next step the nurse should take is to a. ask the physician for a daytime sedative for the patient. b. request soft restraints to prevent her from falling out of her bed. c. ask the physician for a nighttime sleep medication for the patient. d. assess the patient more closely, suspecting a disorder such as restless legs syndrome.

d. assess the patient more closely, suspecting a disorder such as restless legs syndrome. Rationale: The severity of sensory symptoms of restless legs syndrome (RLS) ranges from infrequent, minor discomfort (paresthesias, including numbness, tingling, and "pins and needles" sensation) to severe pain. The discomfort occurs when the patient is sedentary and is most common in the evening or at night. The pain at night can disrupt sleep and is often relieved by physical activity, such as walking, stretching, rocking, or kicking. In the most severe cases, patients sleep only a few hours at night, leading to daytime fatigue and disruption of the daily routine. The motor abnormalities associated with RLS include of voluntary restlessness and stereotyped, periodic, involuntary movements. The involuntary movements usually occur during sleep. Symptoms are aggravated by fatigue.

Drugs or diseases that impair the function of the extrapyramidal system may cause loss of a. sensations of pain and temperature. b. regulation of the autonomic nervous system. c. integration of somatic and special sensory inputs. d. automatic movements associated with skeletal muscle activity.

d. automatic movements associated with skeletal muscle activity. Rationale: A group of descending motor tracts carries impulses from the extrapyramidal system, which includes all motor systems (except the pyramidal system) concerned with voluntary movement. It includes descending pathways originating in the brainstem, basal ganglia, and cerebellum. The motor output exits the spinal cord by way of the ventral roots of the spinal nerves.

The nurse is caring for a patient with peripheral neuropathy who is scheduled for EMG studies tomorrow morning. The nurse should a. ensure the patient has an empty bladder. b. instruct the patient about the risk of electric shock. c. ensure the patient has no metallic jewelry or metal fragments. d. instruct the patient that pain may be experienced during the study.

d. instruct the patient that pain may be experienced during the study. Rationale: Electromyography (EMG) is used to assess electrical activity associated with nerves and skeletal muscles. Activity is recorded by insertion of needle electrodes to detect muscle and peripheral nerve disease. The nurse should inform the patient that pain and discomfort are associated with insertion of needles. There is no risk of electric shock with this procedure.

In a patient with a disease that affects the myelin sheath of nerves, such as multiple sclerosis, the glial cells affected are the a. microglia. b. astrocytes. c. ependymal cells. d. oligodendrocytes.

d. oligodendrocytes. Rationale: Glial cell types include oligodendrocytes, astrocytes, ependymal cells, and microglia, and each has specific functions. Oligodendrocytes are specialized cells that produce the myelin sheath of nerve fibers in the central nervous system (CNS), and they are located primarily in the white matter of the CNS.

During routine assessment of a patient with Guillain-Barré syndrome, you find the patient is short of breath. The patient's respiratory distress is caused by a. elevated protein levels in the CSF. b. immobility resulting from ascending paralysis. c. degeneration of motor neurons in the brainstem and spinal cord. d. paralysis ascending to the nerves that stimulate the thoracic area.

d. paralysis ascending to the nerves that stimulate the thoracic area. Rationale: Guillain-Barré syndrome is characterized by ascending, symmetric paralysis that usually affects cranial nerves and the peripheral nervous system. The most serious complication of this syndrome is respiratory failure, which occurs as the paralysis progresses to the nerves that innervate the thoracic area.

The clinical diagnosis of dementia is based on a. CT or MRS. b. brain biopsy. c. electroencephalogram. d. patient history and cognitive assessment.

d. patient history and cognitive assessment. Rationale: The diagnosis of dementia depends on determining the cause. A thorough physical examination is performed to rule out other potential medical conditions. Cognitive testing (e.g., Mini-Mental State Examination) is focused on evaluating memory, ability to calculate, language, visual-spatial skills, and degree of alertness. Diagnosis of dementia related to vascular causes is based on the presence of cognitive loss, the presence of vascular brain lesions demonstrated by neuroimaging techniques, and the exclusion of other causes of dementia. Structural neuroimaging with CT scan or MRI is used in the evaluation of patients with dementia but does not provide a definitive diagnosis. A psychologic evaluation is also indicated to determine the presence of depression.

Information provided by the patient that would help differentiate a hemorrhagic stroke from a thrombotic stroke includes a. sensory disturbance. b. a history of hypertension. c. presence of motor weakness. d. sudden onset of severe headache.

d. sudden onset of severe headache. Rationale: A hemorrhagic stroke usually causes a sudden onset of symptoms, which include neurologic deficits, headache, nausea, vomiting, decreased level of consciousness, and hypertension. Ischemic stroke symptoms may progress in the first 72 hours as infarction and cerebral edema increase.

Dementia is defined as a a. syndrome that results only in memory loss. b. disease associated with abrupt changes in behavior. c. disease that is always due to reduced blood flow to the brain. d. syndrome characterized by cognitive dysfunction and loss of memory.

d. syndrome characterized by cognitive dysfunction and loss of memory. Rationale: Dementia is a syndrome characterized by dysfunction in or loss of memory, orientation, attention, language, judgment, and reasoning. Personality changes and behavioral problems such as agitation, delusions, and hallucinations may result.

The nurse is reinforcing teaching with a newly diagnosed patient with amyotrophic lateral sclerosis. Which statement would be appropriate to include in the teaching? a."ALS results from an excess chemical in the brain, and the symptoms can be controlled with medication." b."Even though the symptoms you are experiencing are severe, most people recover with treatment." c."You need to consider advance directives now, since you will lose cognitive function as the disease progresses." d."This is a progressing disease that eventually results in permanent paralysis, though you will not lose any cognitive function."

d."This is a progressing disease that eventually results in permanent paralysis, though you will not lose any cognitive function." Rationale: The disease results in destruction of the motor neurons in the brainstem and spinal cord, causing gradual paralysis. Cognitive function is maintained. Because no cure exists for amyotrophic lateral sclerosis (ALS), interprofessional care is palliative and based on symptom relief. Death often occurs within 2 to 5 years after diagnosis.