Chapter 60, 61, 62, 64, 65: Neurological Function/Dysfunction REVIEW QUESTIONS

An adult client has sought care for the treatment of headaches that have become increasingly severe and frequent over the past several months. Which of the following questions addresses potential etiologic factors? Select all that apply. A. "Are you exposed to any toxins or chemicals at work?" B. "How would you describe your ability to cope with stress?" C. "What medications are you currently taking?" D. "When was the last time you were hospitalized?" E. "Does anyone else in your family struggle with headaches?"

A. "Are you exposed to any toxins or chemicals at work?" B. "How would you describe your ability to cope with stress?" C. "What medications are you currently taking? E. "Does anyone else in your family struggle with headaches?" Rationale: Headaches are multifactorial, and may involve medications, exposure to toxins, family history, and stress. Hospitalization is an unlikely contributor to headaches.

A client is recovering from intracranial surgery performed approximately 24 hours ago and is reporting a headache that the client rates at 8 on a 10-point pain scale. What nursing action is most appropriate? A. Administer morphine sulfate as prescribed. B. Reposition the client in a prone position. C. Apply a hot pack to the client's scalp. D. Implement distraction techniques.

A. Administer morphine sulfate as prescribed. Rationale: The client usually has a headache after a craniotomy as a result of stretching and irritation of nerves in the scalp during surgery. Morphine sulfate may also be used in the management of postoperative pain in clients who have undergone a craniotomy. Prone positioning is contraindicated due to the consequent increase in ICP. Distraction would likely be inadequate to reduce pain and a hot pack may cause vasodilation and increased pain

The nurse is caring for a client whose recent health history includes an altered LOC. What should be the nurse's first action when assessing this client? A. Assessing the client's verbal response B. Assessing the client's ability to follow complex commands C. Assessing the client's judgment D. Assessing the client's response to pain

A. Assessing the client's verbal response Rationale: Assessment of the client with an altered LOC often starts with assessing the verbal response through determining the client's orientation to time, person, and place. In most cases, this assessment will precede each of the other listed assessments, even though each may be indicated.

A client is being given a medication that stimulates the parasympathetic system. Following administration of this medication, the nurse should anticipate what effect? A. Constricted pupils B. Dilated bronchioles C. Decreased peristaltic movement D. Relaxed muscular walls of the urinary bladder

A. Constricted pupils Rationale: Parasympathetic stimulation results in constricted pupils, constricted bronchioles, increased peristaltic movement, and contracted muscular walls of the urinary bladder.

The nurse caring for a client in a persistent vegetative state is regularly assessing for potential complications. The nurse should assess for which complications? Select all that apply. A. Contractures B. Hemorrhage C. Pressure ulcers D. Venous thromboembolism E. Pneumonia

A. Contractures C. Pressure ulcers D. Venous thromboembolism E. Pneumonia Rationale: Based on the assessment data, potential complications (partially based on immobility) may include respiratory distress or failure, pneumonia, aspiration, pressure ulcer, deep vein thrombosis (DVT), and contractures. A persistent vegetative state does not directly create a heightened risk for hemorrhage.. A persistent vegetative state condition is when the client is wakeful but devoid of conscious content, without cognitive or affective mental function

The nurse has created a plan of care for a client who is at risk for increased ICP. The client's care plan should specify monitoring for what early sign of increased ICP? A. Disorientation and restlessness B. Decreased pulse and respirations C. Projectile vomiting D. Loss of corneal reflex

A. Disorientation and restlessness Rationale: Early indicators of ICP include disorientation and restlessness. Later signs include decreased pulse and respirations, projectile vomiting, and loss of brain stem reflexes, such as the corneal reflex.

The nurse is caring for a client with a brain tumor and is aware that the normal compensation measures to keep ICP (intracranial pressure) within normal limits may no longer be effective. What are the normal compensation measures for the brain? Select all that apply. A. Displacing or shifting cerebral spinal fluid (CSF) B. Decreasing cerebral perfusion C. Increasing the absorption of CSF D. Shifting brain tissue E. Decreasing cerebral blood volume

A. Displacing or shifting cerebral spinal fluid (CSF) C. Increasing the absorption of CSF E. Decreasing cerebral blood volume Rationale: The Monro-Kellie hypothesis explains the dynamic equilibrium of cranial contents. This hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the components causes a change in the volume of the others. The brain typically compensates for these changes by displacing or shifting CSF, increasing the absorption or diminishing the production of CSF, or decreasing cerebral blood volume. Without such changes, ICP begins to rise. A decrease in cerebral perfusion and shifting brain tissue are not normal compensatory events. An increase in ICP can occur because of a brain tumor. Increased ICP from any cause would result in a decrease in cerebral perfusion which stimulates further edema and may shift brain tissue. A shift in brain tissue results in herniation which is a dire and frequently fatal event.

A client is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what? A. Evidence of hemorrhagic stroke B. Blood pressure of 180/110 mm Hg C. Evidence of stroke evolution D. Previous thrombolytic therapy within the past 12 months

A. Evidence of hemorrhagic stroke Rationale: Thrombolytic therapy would exacerbate a hemorrhagic stroke with potentially fatal consequences. Stroke evolution, high BP, or previous thrombolytic therapy does not contraindicate its safe and effective use

The nurse is assessing a client with a suspected stroke. What assessment finding is most suggestive of a stroke? A. Facial droop B. Dysrhythmias C. Periorbital edema D. Projectile vomiting

A. Facial droop Rationale: Facial drooping or asymmetry is a classic abnormal finding on a physical assessment that may be associated with a stroke. Periorbital edema (swelling around the eyes) is not suggestive of a stroke, and clients less commonly experience dysrhythmias or vomiting.

The nurse is caring for a client who has developed SIADH. What intervention is most appropriate? A. Fluid restriction B. Transfusion of platelets C. Transfusion of fresh frozen plasma (FFP) D. Electrolyte restriction

A. Fluid restriction Rationale: The nurse also assesses for complications of increased ICP, including diabetes insipidus, and SIADH. SIADH requires fluid restriction and monitoring of serum electrolyte levels. Transfusions are unnecessary.

A client is admitted to the medical unit with an exacerbation of multiple sclerosis. When assessing this client, the nurse has the client stick out the tongue and move it back and forth. What is the nurse assessing? A. Function of the hypoglossal nerve B. Function of the vagus nerve C. Function of the spinal nerve D. Function of the trochlear nerve

A. Function of the hypoglossal nerve Rationale: The hypoglossal nerve is the 12th cranial nerve. It is responsible for movement of the tongue. None of the other listed nerves affects motor function in the tongue.

What neurologic assessment should the nurse perform to gauge the client's function of cranial nerve I? A. Have the client identify familiar odors with the eyes closed. B. Assess papillary reflex. C. Utilize the Snellen chart. D. Test for air and bone conduction (Rinne test).

A. Have the client identify familiar odors with the eyes closed. Rationale: Cranial nerve I is the olfactory nerve. The client's sense of smell could be assessed by asking him or her to identify common odors. Assessment of papillary reflex does not address the olfactory function of cranial nerve I. The Snellen chart would be used to assess cranial nerve II (optic).

A gerontologic nurse educator is providing practice guidelines to unlicensed care providers. Because reaction to painful stimuli is sometimes blunted in older adults, what must be used with caution? A. Hot or cold packs B. Analgesics C. Anti-inflammatory medications D. Whirlpool baths

A. Hot or cold packs Rationale: Reaction to painful stimuli may be decreased with age. Because pain is an important warning signal, caution must be used when hot or cold packs are used. The older client may be burned or suffer frostbite before being aware of any discomfort. Any medication is used with caution in older adults, but not because of the decreased sense of heat or cold. Whirlpool baths are generally not a routine treatment prescribed for older adults.

The nurse is caring for a client who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the client's respiratory effort has increased. What is the nurse's most appropriate action? A. Inform the care team and assess for further signs of possible increased ICP. B. Administer bronchodilators as prescribed and monitor the client's LOC. C. Increase the client's bed height and reassess in 30 minutes. D. Administer a bolus of normal saline as prescribed.

A. Inform the care team and assess for further signs of possible increased ICP. Rationale: Increased respiratory effort can be suggestive of increasing ICP, and the care team should be promptly informed. A bolus of IV fluid will not address the problem. Repositioning the client and administering bronchodilators are insufficient responses, even though these actions may later be prescribed

A client is scheduled for a myelogram, and the nurse explains to the client that this is an invasive procedure, which assesses for any lesions in the spinal cord. The nurse should explain that the preparation is similar to which of the following neurologic tests? A. Lumbar puncture B. MRI C. Cerebral angiography D. EEG

A. Lumbar puncture Rationale: A myelogram is an x-ray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture. Client preparation for a myelogram would be similar to that for lumbar puncture. The other listed diagnostic tests do not involve lumbar puncture.

When assessing a 36-year-old male, the nurse gently strokes the client's right palm using a cotton applicator. As the nurse strokes the client's palm the nurse then checks to see if the client will begin to grasp the applicator. This assessment is associated with which of the following reflexes? A. Pathologic B. Superficial C. Deep tendon D. Brachioradialis

A. Pathologic Rationale: Reflexes are classified either as pathological, superficial, or deep tendon. Pathological reflexes often represent the emergence of earlier reflexes that disappeared with the maturity of the nervous system. The palmar reflex is associated with assessing for a pathologic reflex. Superficial and deep tendon reflexes are not assessed using this type of test. Brachioradialis is a type of deep tendon reflex. Reflex tests are performed as a part of neurological assessment to quickly determine an intact spinal cord

A hospital client has experienced a seizure. In the immediate recovery period, what action best protects the client's safety? A. Place the client in a side-lying position. B. Pad the client's bed rails. C. Administer antianxiety medications as prescribed. D. Reassure the client and family members.

A. Place the client in a side-lying position. Rationale: To prevent complications, the client is placed in the side-lying position to facilitate drainage of oral secretions. Suctioning is performed, if needed, to maintain a patent airway and prevent aspiration. None of the other listed actions promotes safety during the immediate recovery period

The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication? A. Provide a board of commonly used needs and phrases. B. Have the client speak to loved ones on the phone daily. C. Help the client complete his or her sentences as needed. D. Speak in a loud and deliberate voice to the client.

A. Provide a board of commonly used needs and phrases. Rationale: The inability to talk on the telephone or answer a question or exclusion from conversation causes anger, frustration, fear of the future, and hopelessness. A common pitfall is for the nurse or other health care team member to complete the thoughts or sentences of the client. This should be avoided because it may cause the client to feel more frustrated at not being allowed to speak and may deter efforts to practice putting thoughts together and completing a sentence. The client may also benefit from a communication board, which has pictures of commonly requested needs and phrases. The board may be translated into several languages

A client is postoperative day 1 following intracranial surgery. The nurse's assessment reveals that the client's level of consciousness (LOC) is slightly decreased compared with the day of surgery. What is the nurse's best response to this assessment finding? A. Recognize that this may represent the peak of postsurgical cerebral edema. B. Alert the surgeon to the possibility of an intracranial hemorrhage. C. Understand that the surgery may have been unsuccessful. D. Recognize the need to refer the client to the palliative care team.

A. Recognize that this may represent the peak of postsurgical cerebral edema. Rationale: Some degree of cerebral edema occurs after brain surgery; it tends to peak 24 to 36 hours after surgery, producing decreased responsiveness on the second postoperative day. As such, there is not necessarily any need to deem the surgery unsuccessful or to refer the client to palliative care. A decrease in LOC is not evidence of an intracranial hemorrhage. Any change in the client's LOC should be reported to the healthcare provider.

The nurse is educating a group of students about complications of an aneurysm. Which is a complication of aneurysm? A. Seizure B. Hypernatremia C. Airway collapse D. Pneumothorax

A. Seizure Rationale: Due to increased intracranial pressure, there is a risk for the client developing seizures. Hyponatremia, not hypernatremia, can occur. Airway collapse and pneumothorax do not occur as a complication of an aneurysm.

A client who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this client? A. The client should be approached on the side where visual perception is intact. B. Attention to the affected side should be minimized in order to decrease anxiety. C. The client should avoid turning in the direction of the defective visual field to minimize shoulder subluxation. D. The client should be approached on the opposite side of where the visual perception is intact to promote recovery.

A. The client should be approached on the side where visual perception is intact. Rationale: Clients with decreased field of vision should first be approached on the side where visual perception is intact. All visual stimuli should be placed on this side. The client can and should be taught to turn the head in the direction of the defective visual field to compensate for this loss. The nurse should constantly remind the client of the other side of the body and should later stand at a position that encourages the client to move or turn to visualize who and what is in the room.

A health care provider has prescribed a standard electroencephalogram (EEG) test for the client. What general instructions should the nurse provide to the client? Select all that apply A. The procedure generally takes 45 to 60 minutes. B. Please remove all jewelry and any metal objects prior to the procedure C. This procedure uses a water-soluble lubricant for electrode contact which can be easily wiped off and removed using shampoo D. If you feel nervous about the test I can provide you a light sedative medication to ease your anxiety E. Please refrain from drinking coffee and any caffeinated beverages the morning prior to the procedure F. It is required that you withhold taking your anticonvulsant medication 72 hours before the procedure.

A. The procedure generally takes 45 to 60 minutes. C. This procedure uses a water-soluble lubricant for electrode contact which can be easily wiped off and removed using shampoo E. Please refrain from drinking coffee and any caffeinated beverages the morning prior to the procedure Rationale: A standard EEG usually takes 45 to 60 minutes. Typically, a water-soluble lubricant is used to aid electrode contact. This lubricant is easily removed with shampoo. Coffee, tea, chocolate, and cola drinks are omitted from the meal before the test because of their stimulating effect. Sedation is not considered because it may lower the seizure threshold in clients and it may alter brain activity. Stimulants, tranquilizers, anticonvulsants, and depressants are advised to be held 24 to 48 hours, not 72 hours, prior to the procedure because these medications can alter the EEG wave patterns or mask the abnormal wave patterns of seizure disorders. The client is instructed to eat before the test because keeping the client NPO (nothing by mouth) can alter blood glucose levels and cause changes in brain wave patterns. The client can wear jewelry during the test, although some facilities will request that earrings be removed.

The nurse is admitting a client to the unit who is scheduled for removal of an intracranial mass. What diagnostic procedures might be included in this client's admission orders? Select all that apply. A. Transcranial Doppler flow study B. Cerebral angiography C. MRI D. Cranial radiography E. Electromyography (EMG)

A. Transcranial Doppler flow study B. Cerebral angiography C. MRI Rationale: Preoperative diagnostic procedures may include a CT scan to demonstrate the lesion and show the degree of surrounding brain edema, the ventricular size, and the displacement. An MRI scan provides information similar to that of a CT scan with improved tissue contrast, resolution, and anatomic definition. Cerebral angiography may be used to study a tumor's blood supply or to obtain information about vascular lesions. Transcranial Doppler flow studies are used to evaluate the blood flow within intracranial blood vessels. Regular x-rays of the skull would not be diagnostic for an intracranial mass. An EMG would not be ordered prior to intracranial surgery to remove a mass.

A client has developed diabetes insipidus after having increased ICP following head trauma. What nursing assessment best addresses this complication? A. Vigilant monitoring of fluid balance B. Continuous BP monitoring C. Serial arterial blood gases (ABGs) D. Monitoring of the client's airway for patency

A. Vigilant monitoring of fluid balance Rationale: Diabetes insipidus requires fluid and electrolyte replacement, along with the administration of vasopressin, to replace and slow the urine output. Because of these alterations in fluid balance, careful monitoring is necessary. None of the other listed assessments directly addresses the major manifestations of diabetes insipidus.

A nurse is performing a complex neurological assessment on a client recently diagnosed with Alzheimer disease. What question should the nurse anticipate to ask when assessing the client's language ability? A. "How are a pencil and pen alike?" B. "Can you write your name on this blank sheet of paper?" C. "Can you tell me what year it is?" D. "What is the name of the president of the United States?"

B. "Can you write your name on this blank sheet of paper?" Rationale: When assessing written and spoken language ability, clients are usually asked to read a newspaper article and explain the meaning. Clients are also asked to write their name or copy a simple figure drawn by the examiner. Comparison questions are associated with assessing a client's intellectual function. Asking about the year and current name of the president are associated with assessing a client's mental status.

A school nurse is called to the playground where a 6-year-old girl has been found sitting unresponsive and "staring into space," according to the playground supervisor. How would the nurse document the girl's activity in her chart at school? A. Generalized seizure B. Absence seizure C. Focal seizure D. Unclassified seizure

B. Absence seizure Rationale: Staring episodes characterize an absence seizure, whereas focal seizures, generalized seizures, and unclassified seizures involve uncontrolled motor activity.

A clinic nurse is caring for a client diagnosed with migraine headaches. During the client teaching session, the client questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the client about the effects of alcohol? A. Alcohol causes hormone fluctuations. B. Alcohol causes vasodilation of the blood vessels. C. Alcohol has an excitatory effect on the CNS. D. Alcohol diminishes endorphins in the brain.

B. Alcohol causes vasodilation of the blood vessels. Rationale: Alcohol causes vasodilation of the blood vessels and may exacerbate migraine headaches. Alcohol has a depressant effect on the CNS. Alcohol does not cause hormone fluctuations, nor does it decrease endorphins (morphine-like substances produced by the body) in the brain

The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration? A. Generalized pain B. Alteration in level of consciousness (LOC) C. Tonic-clonic seizures D. Shortness of breath

B. Alteration in level of consciousness (LOC) Rationale: Alteration in LOC is the earliest sign of deterioration in a client after a hemorrhagic stroke, such as mild drowsiness, slight slurring of speech, and sluggish papillary reaction. Sudden headache may occur, but generalized pain is less common. Seizures and shortness of breath are not identified as early signs of hemorrhagic stroke.

A nurse is caring for a client who experiences debilitating cluster headaches. The client should be taught to take appropriate medications at what point in the course of the onset of a new headache? A. As soon as the client's pain becomes unbearable B. As soon as the client senses the onset of symptoms C. Twenty to 30 minutes after the onset of symptoms D. When the client senses his or her symptoms peaking

B. As soon as the client senses the onset of symptoms Rationale: A migraine or a cluster headache in the early phase requires abortive medication therapy instituted as soon as possible. Delaying medication administration would lead to unnecessary pain.

The nurse is performing a neurologic assessment of a client whose injuries have rendered the client unable to follow verbal commands. How should the nurse proceed with assessing the client's level of consciousness (LOC)? A. Assess the client's vital signs and correlate these with the client's baselines. B. Assess the client's eye opening and response to stimuli. C. Document that the client currently lacks a level of consciousness. D. Facilitate diagnostic testing in an effort to obtain objective data.

B. Assess the client's eye opening and response to stimuli. Rationale: If the client is not alert or able to follow commands, the examiner observes for eye opening; verbal response and motor response to stimuli, if any; and the type of stimuli needed to obtain a response. Vital signs and diagnostic testing are appropriate, but neither will allow the nurse to gauge the client's LOC. Inability to follow commands does not necessarily denote an absolute lack of consciousness.

A client recently had a stroke. Now the client has spasms in his/her hands, which is preventing a favorite hobby of knitting. The client is looking for a permanent solution to this problem. Which therapies would the nurse recommend? A. Botulinum toxin type A and heat B. Baclofen and stretching C. Amitriptyline and splinting D. Corticosteroids and acupuncture

B. Baclofen and stretching Rationale: Treatments for spasticity may include stretching, splinting (in select clients), and oral medications such as baclofen and tizanidine. Studies concerning splitting debate the effectiveness of this treatment. Botulinum toxin type A injected intramuscularly into wrist and finger muscles has been shown to be effective in reducing this spasticity but the effect is temporary, typically lasting 2 to 4 months. Amitriptyline is more effective for post-stroke pain and depression. Corticosteroids, heat therapy, and acupuncture are recommended for shoulder pain after a client has a stroke.

The nurse is planning the care of a client with Parkinson disease. The nurse should be aware that treatment will focus on what pathophysiologic phenomenon? A. Premature degradation of acetylcholine B. Decreased availability of dopamine C. Insufficient synthesis of epinephrine D. Delayed reuptake of serotonin

B. Decreased availability of dopamine Rationale: Parkinson disease develops from decreased availability of dopamine, not acetylcholine, epinephrine, or serotonin

The health care provider has prescribed a somatosensory evoked responses (SERs) test for a client for whom the nurse is caring. The nurse is justified in suspecting that this client may have a history of what type of neurologic disorder? A. Hypothalamic disorder B. Demyelinating disease C. Brainstem deficit D. Diabetic neuropathy

B. Demyelinating disease Rationale: SERs are used to detect deficits in the spinal cord or peripheral nerve conduction and to monitor spinal cord function during surgical procedures. The test is also useful in the diagnosis of demyelinating diseases, such as multiple sclerosis and polyneuropathies, where nerve conduction is slowed. The test is not done to diagnose hypothalamic disorders, brainstem deficits, or diabetic neuropathies.

A trauma client in the ICU has been declared brain dead. What diagnostic test is used in making the best determination that the brain's electrical activity has ceased? A. Magnetic resonance imaging (MRI) B. Electroencephalography (EEG) C. Electromyography (EMG) D. Computed tomography (CT)

B. Electroencephalography (EEG) Rationale: The EEG can be used to determine that brain activity has ceased.. MRI and CT scans have been used to declare brain death by showing an absence of blood flow, but this is not the best way to determine that brain activity has ceased. EMG is not normally used to determine brain death.

When caring for a client who has had a stroke, a priority is reduction of ICP. What client position is most consistent with this goal? A. Head turned slightly to the right side B. Elevation of the head of the bed C. Position changes every 15 minutes while awake D. Extension of the neck

B. Elevation of the head of the bed Rationale: Elevation of the head of the bed promotes venous drainage and lowers ICP; the nurse should avoid flexing or extending the neck or turning the head side to side. The head should be in a neutral midline position. Excessively frequent position changes are unnecessary.

A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the emergency department (ED). The nurse should first gauge the client's LOC on the results of what diagnostic tool? A. Monro-Kellie hypothesis B. Glasgow Coma scale C. Cranial nerve function D. Mental status examination

B. Glasgow Coma scale Rationale: LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma scale: eye opening, verbal response, and motor response. The Monro-Kellie hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the components (blood, brain tissue, cerebrospinal fluid) causes a change in the volume of the others. Cranial nerve function and the mental status examination would be part of the neurologic examination for this client, but would not be the priority in evaluating LOC. Glasgow coma scale can be done quickly and establishes a baseline of neurologic function.

The nurse is caring for a client who is in status epilepticus. What medication should the nurse anticipate administering to halt the seizure immediately? A. Intravenous phenobarbital B. Intravenous diazepam C. Oral lorazepam D. Oral phenytoin

B. Intravenous diazepam Rationale: Medical management of status epilepticus includes IV diazepam and IV lorazepam given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state. Oral medications are not given during status epilepticus.

The nurse is participating in the care of a client with increased ICP. What diagnostic test is contraindicated in this client's treatment? A. Computed tomography (CT) scan B. Lumbar puncture C. Magnetic resonance imaging (MRI) D. Venous Doppler studies

B. Lumbar puncture Rationale: A lumbar puncture in a client with increased ICP may cause the brain to herniate from the withdrawal of fluid and change in pressure during the lumbar puncture. Herniation of the brain is a dire and frequently fatal event. CT, MRI, and venous Doppler are considered noninvasive procedures and they would not affect the ICP itself

A nurse is caring for a client diagnosed with a hemorrhagic stroke. When creating this client's plan of care, what goal should be prioritized? A. Prevent complications of immobility. B. Maintain and improve cerebral tissue perfusion. C. Relieve anxiety and pain. D. Relieve sensory deprivation.

B. Maintain and improve cerebral tissue perfusion. Rationale: Each of the listed goals is appropriate in the care of a client recovering from a stroke. However, promoting cerebral perfusion is a priority physiologic need, on which the client's survival depends.

The neurologic ICU nurse is admitting a client with increased intracranial pressure. How should the nurse best position the client? A. Position the client supine. B. Maintain head of bed (HOB) elevated at 30 to 45 degrees. C. Position client in prone position. D. Maintain bed in Trendelenburg position.

B. Maintain head of bed (HOB) elevated at 30 to 45 degrees. Rationale: The client with increased ICP should be placed with the HOB elevated 30 to 45 degrees, with the neck in neutral alignment. Each of the other listed positions would cause a dangerous elevation in ICP

The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority? A. Maintaining accurate records of intake and output B. Maintaining a patent airway C. Inserting a nasogastric (NG) tube as prescribed D. Providing appropriate pain control

B. Maintaining a patent airway Rationale: Maintaining a patent airway always takes top priority, even though each of the other listed actions is necessary and appropriate.

The nurse is caring for a client who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of "deficient fluid volume related to fluid restriction and osmotic diuretic use." What is the nurse's most appropriate intervention for this diagnosis? A. Change the client's position as indicated. B. Monitor serum electrolytes. C. Maintain NPO status. D. Monitor arterial blood gas (ABG) values.

B. Monitor serum electrolytes. Rationale: The postoperative fluid regimen depends on the type of neurosurgical procedure and is determined on an individual basis. The volume and composition of fluids are adjusted based on daily serum electrolyte values, along with fluid intake and output. Fluids may have to be restricted in clients with cerebral edema. Changing the client's position, maintaining an NPO status, and monitoring ABG values do not relate to the nursing diagnosis of deficient fluid volume.

In the course of a focused neurologic assessment, the nurse is palpating the client's major muscle groups at rest and during passive movement. Data gleaned from this assessment will allow the nurse to describe which of the following aspects of neurologic function? A. Muscle dexterity B. Muscle tone C. Motor symmetry D. Deep tendon reflexes

B. Muscle tone Rationale: Muscle tone (the tension present in a muscle at rest) is evaluated by palpating various muscle groups at rest and during passive movement. Data from this assessment do not allow the nurse to ascertain the client's dexterity, reflexes, or motor symmetry.

The nurse is doing an initial assessment on a client newly admitted to the unit with a diagnosis of cerebrovascular disease. The client has difficulty copying a figure that the nurse has drawn and is diagnosed with visual receptive aphasia. What brain region is primarily involved in this client's deficit? A. Temporal lobe B. Parietal-occipital area C. Inferior-posterior frontal areas D. Posterior frontal area

B. Parietal-occipital area Rationale: Difficulty copying a figure that the nurse has drawn would be considered visual receptive aphasia, which involves the parietal-occipital area. Expressive aphasia, the inability to express oneself, is often associated with damage to the frontal area. Receptive aphasia, the inability to understand what someone else is saying, is often associated with damage to the temporal lobe area.

A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, age-related changes that may influence the assessment results. Of what phenomenon should the nurse be aware? A. Hyperactive deep tendon reflexes B. Reduction in cerebral blood flow C. Increased cerebral metabolism D. Hypersensitivity to painful stimuli

B. Reduction in cerebral blood flow Rationale: Reduction in cerebral blood flow (CBF) is a change that occurs in the normal aging process. Deep tendon reflexes can be decreased or, in some cases, absent. Cerebral metabolism decreases as the client advances in age. Reaction to painful stimuli may be decreased with age. Because pain is an important warning signal, caution must be used when hot or cold packs are used.

A client scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the client for the MRI should prioritize what action? A. Withholding stimulants 24 to 48 hours prior to exam B. Removing all metal-containing objects C. Instructing the client to void prior to the MRI D. Initiating an IV line for administration of contrast

B. Removing all metal-containing objects Rationale: Client preparation for an MRI consists of removing all metal-containing objects prior to the examination. Withholding stimulants would not affect an MRI; this relates to an electroencephalography (EEG). Instructing the client to void is client preparation for a lumbar puncture. Initiating an IV line for administration of contrast would be done if the client was having a CT scan with contrast.

A client with a recent stroke history is admitted to a rehabilitation unit and placed on high fall risk precautions. The client is impulsive, easily distracted, frequently forgets his/her cane when walking, and the location of his/her room. What stroke conditions do these signs best indicate? A. Ischemic stroke B. Right hemispheric stroke C. Hemorrhagic stroke D. Left hemispheric stroke

B. Right hemispheric stroke Rationale. In right hemispheric stroke, signs include a client that is easily distracted and has impulsive behavior and poor judgment. The client can be unaware of deficits like motor weakness, as demonstrated by the client forgetting the cane. Clients can also have spatial or perceptual deficits. This means they can get lost in familiar and unfamiliar places. This client was unable to find his/her room. The client who has a right hemisphere stroke demonstrates weakness on the left side of the body. The client with left hemispheric stroke has signs such as paralysis or weakness in the right side of the body, right-sided visual deficits, and slow cautious behaviors. Ischemic and hemorrhagic strokes describe what caused the stroke rather than what side of the brain was affected. Signs and symptoms differ for each type of stroke. Ischemic strokes can include numbness to one side of the face. Headache, decreased level of consciousness, and seizures typically are signs of a hemorrhagic stroke

A rapid response and stroke alert/code has been called for a client with deep vein thrombosis (DVT) of the left leg being treated with intravenous heparin. The client's international normalized ratio (INR) is 2.1 and vital signs are: Temperature 100.1°F (37.8°C), heart rate 102, blood pressure 190/100, respirations 14, and saturation 89% on room air. What are priority interventions for a client who is currently on anticoagulant therapy and having an ischemic stroke? A. Immediate intubation and urinary catheter placement B. Supplemental oxygen and monitoring blood glucose levels C. Antipyretics in order to keep the client in a state of hypothermia D. Antihypertensive medications and vital signs every two hours

B. Supplemental oxygen and monitoring blood glucose levels Rationale: Careful maintenance of cerebral hemodynamics to maintain cerebral perfusion is extremely important after a stroke. Interventions during this period include measures to reduce ICP. Other treatment measures include: Providing supplemental oxygen if saturation is below 95% and monitoring of blood glucose and management. Intubation is used only if necessary to establish a patent airway. For this client, a more expedient and less invasive measure would be supplemental oxygen. Urinary catheter placement is not a priority measure for this client. It is important to monitor for febrile events, but there is no protocol in place to keep the client hypothermic. Antihypertensive medication goals for blood pressure in the first 24 hours after a stroke remain controversial for a client who has not received thrombolytic therapy; antihypertensive treatment may be given to lower the blood pressure by 15% if the systolic blood pressure exceeds 220 mm Hg or the diastolic blood pressure exceeds 120 mm Hg. Vital signs for this client would be monitored closely and continuously until stable.

The nurse is preparing to assess a client with neurologic dysfunction. What does accurate and appropriate assessment require? Select all that apply. A. The ability to select basic medications for the neurologic dysfunction B. Understanding of the tests used to diagnose neurologic disorders C. Knowledge of nursing interventions related to assessment and diagnostic testing D. Knowledge of the anatomy of the nervous system E. The ability to interpret the results of diagnostic tests

B. Understanding of the tests used to diagnose neurologic disorders C. Knowledge of nursing interventions related to assessment and diagnostic testing D. Knowledge of the anatomy of the nervous system Rationale: Assessment requires knowledge of the anatomy and physiology of the nervous system and an understanding of the array of tests and procedures used to diagnose neurologic disorders. Knowledge about the nursing implications and interventions related to assessment and diagnostic testing is also essential. Selecting medications and interpreting diagnostic tests are beyond the normal scope of the nurse.

In which specific instances should the nurse assess the client's cranial nerves? Select all that apply. A. When a neurogenic bladder develops B. When level of consciousness is decreased C. With brain stem pathology D. In the presence of peripheral nervous system disease E. When a spinal reflex is interrupted

B. When level of consciousness is decreased C. With brain stem pathology D. In the presence of peripheral nervous system disease Rationale: Cranial nerves are assessed when level of consciousness is decreased, with brain stem pathology, or in the presence of peripheral nervous system disease. Abnormalities in muscle tone and involuntary movements are less likely to prompt the assessment of cranial nerves, since these nerves do not directly mediate most aspects of muscle tone and movement

A client is scheduled for CT scanning of the head because of a recent onset of neurologic deficits. What should the nurse tell the client in preparation for this test? A. "No metal objects can enter the procedure room." B. "You need to fast for 8 hours prior to the test." C. "You will need to lie still throughout the procedure." D. "There will be a lot of noise during the test."

C. "You will need to lie still throughout the procedure." Rationale: Preparation for CT scanning includes teaching the client about the need to lie quietly throughout the procedure. If the client were having an MRI, metal and noise would be appropriate teaching topics. There is no need to fast prior to a CT scan of the brain.

A client who has been on long-term phenytoin therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the client's plan of care? A. Monitoring of pulse oximetry B. Administration of a low-protein diet C. Administration of thorough oral hygiene D. Fluid restriction as prescribed

C. Administration of thorough oral hygiene Rationale: Gingival hyperplasia (swollen and tender gums) can be associated with long-term phenytoin use. Thorough oral hygiene should be provided consistently and encouraged after discharge. Fluid and protein restriction are contraindicated and there is no particular need for constant oxygen saturation monitoring.

The nurse caring for an 80-year-old client knows that the client has a preexisting history of dulled tactile sensation. The nurse should first consider what possible cause for this client's diminished tactile sensation? A. Damage to cranial nerve VIII B. Adverse medication effects C. Age-related neurologic changes D. An undiagnosed cerebrovascular disease in early adulthood

C. Age-related neurologic changes Rationale: Tactile sensation is dulled in the older adult client due to a decrease in the number of sensory receptors. While thorough assessment is necessary, it is possible that this change is unrelated to pathophysiologic processes.

A nurse is assisting a client who had a recent stroke with getting dressed for physical therapy. The client looks at each piece of clothing before putting it on the body. The client states, "This is how I know what item I am holding." What impairment is this client likely experiencing? A. Homonymous hemianopsia B. Receptive aphasia C. Agnosia D. Hemiplegia

C. Agnosia Rationale: Agnosia is the loss of the ability to recognize objects through a particular sensory system; it may be visual, auditory, or tactile. The client was able to see what was being held but was not recognizing specific garments by just touching them. Because the client was able to see homonymous hemianopsia, which is blindness in half of the visual field in one or both eyes, is unlikely. Receptive aphasia is an inability to understand language. Hemiplegia is a motor/ambulatory dysfunction. The presented scenario did not support these findings.

A client with a history of epilepsy is admitted preoperatively for a surgical procedure and dies overnight. The health care provider suspects sudden unexpected death in epilepsy (SUDEP). Which condition is most likely related to SUDEP? A. Brain aneurysm B. Undiagnosed sepsis C. Cardiac abnormalities D. Seizure medication overdose

C. Cardiac abnormalities Rationale: Cardiac and respiratory abnormalities have been implicated in SUDEP deaths. SUDEP may or may not be related to a seizure event. There have been studies that suggest that clients have an irregular heart rhythm after seizure which causes the death. The client is preoperative, thus there is a low likelihood of undiagnosed sepsis. Clients with epilepsy, especially when their medications are no longer preventing seizures, are at serious risk for SUDEP. SUDEP is defined as nontraumatic, nondrowning unexpected death of a client with epilepsy. These events may be witnessed or unwitnessed and postmortem examination reveals no anatomical or toxicological cause of death.

A nurse is assessing reflexes in a client with hyperactive reflexes. When the client's foot is abruptly dorsiflexed, it continues to "beat" two to three times before settling into a resting position. How should the nurse document this finding? A. Rigidity B. Flaccidity C. Clonus D. Ataxia

C. Clonus Rationale: When reflexes are very hyperactive, a phenomenon called clonus may be elicited. If the foot is abruptly dorsiflexed, it may continue to "beat" two to three times before it settles into a position of rest. Rigidity is an increase in muscle tone at rest characterized by increased resistance to passive stretch. Flaccidity is lack of muscle tone. Ataxia is the inability to coordinate muscle movements, resulting in difficulty walking, talking, and performing self-care activities.

The nurse is discharging home a client who had a stroke. The client has a flaccid right arm and leg and is experiencing urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common client response to a change in body image? A. Confusion B. Uncertainty C. Depression D. Disassociation

C. Depression Rationale: Depression is a common and serious problem in the client who has had a stroke. It can result from a profound disruption in his or her life and changes in total function, leaving the client with a loss of independence. The nurse needs to encourage the client to verbalize feelings to assess the effect of the stroke on self-esteem. Confusion, uncertainty, and disassociation are not the most common client response to a change in body image, although each can occur in some clients.

The nurse is caring for a client with a brain tumor. What drug would the nurse expect to be prescribed to reduce the edema surrounding the tumor? A. Solumedrol B. Dextromethorphan C. Dexamethasone D. Furosemide

C. Dexamethasone Rationale: If a brain tumor is the cause of the increased ICP, corticosteroids (e.g., dexamethasone) help reduce the edema surrounding the tumor. Solumedrol, a steroid, and furosemide, a loop diuretic, are not the drugs of choice in this instance. Dextromethorphan is used in cough medicines.

During the performance of the Romberg test, the nurse observes that the client sways slightly. What is the nurse's most appropriate action? A. Facilitate a referral to a neurologist. B. Reposition the client supine to ensure safety. C. Document successful completion of the assessment. D. Follow up by having the client perform the Rinne test.

C. Document successful completion of the assessment. Rationale: Slight swaying during the Romberg test is normal, but a loss of balance is abnormal and is considered a positive Romberg test. Slight swaying is not a significant threat to the client's safety. The Rinne test assesses hearing, not balance.

A nurse is performing a neurological assessment on a client at home. During the assessment, the nurse notices that the client has a flat affect. Which lobe of the brain is responsible for a person's affect? A. Parietal lobe B. Temporal lobe C. Frontal lobe D. Occipital lobe

C. Frontal lobe Rationale: The frontal lobe is the largest lobe located in front of the brain. It is responsible in large part for a person's affect, judgment, personality, and inhibitions. The parietal lobe is essential to a person's awareness of body position in space, size and shape discrimination, and right-left orientation. The temporal lobe plays a role in memory of sound and understanding of language and music. The occipital lobe is responsible for visual interpretation and memory

A client has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize? A. Unclassified seizure B. Absence seizure C. Generalized seizure D. Focal seizure

C. Generalized seizure Rationale: Generalized seizures often involve both hemispheres of the brain, causing both sides of the body to react. Intense rigidity of the entire body may occur, followed by alternating muscle relaxation and contraction (generalized tonic-clonic contraction). This pattern of rigidity does not occur in clients who experience unclassified, absence, or focal seizures.

The nurse is providing information to a client about neurological disorders associated with genetic defects. The nurse knows which disease is considered an autosomal dominant disorder? A. Duchenne muscular dystrophy B. Parkinson disease C. Huntington disease D. Fragile X syndrome

C. Huntington disease Rationale: Several neurologic disorders are associated with genetic abnormalities. These diseases can have distinct inheritance patterns including: autosomal dominant, Autosomal recessive, or X-linked. Autosomal dominant diseases include: familial Alzheimer disease, myotonic dystrophies, Von Hippel-Lindau syndrome, Huntington disease, neurofibromatosis, and cerebral arteriopathy. Duchenne muscular dystrophy and fragile X syndrome are X-linked disorders. Parkinson disease does not have a distinct inheritance pattern.

A client in the OR goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows the brain regulates body temperature in which of the following areas? A. Cerebellum B. Thalamus C. Hypothalamus D. Midbrain

C. Hypothalamus Rationale: The hypothalamus plays an important role in the endocrine system because it regulates the pituitary secretion of hormones that influence metabolism, reproduction, stress response, and urine production. It works with the pituitary to maintain fluid balance through hormonal release and maintains temperature regulation by promoting vasoconstriction or vasodilatation. The cerebellum, thalamus, and midbrain are not directly involved in temperature regulation

A client has been recently diagnosed with myasthenia gravis. Which is indicative of a person diagnosed with myasthenia gravis? A. Excessive serotonin activity in the brain B. Decreased dopamine activity in the brain C. Impairment of acetylcholine binding to muscle cells D. Defects in the expression of acetylcholine receptors

C. Impairment of acetylcholine binding to muscle cells Rationale: In myasthenia gravis, acetylcholine binding to muscle cells is impaired. A breakdown essentially occurs in the communication between nerves and muscles. This results in weakness of extremities and difficulties with speech and chewing. Many neurologic disorders are due, at least in part, to an imbalance in neurotransmitters. Decreased dopamine activity in the brain is suggestive of Parkinson. Excessive or too much serotonin activity in the brain can cause a variety of mild to severe symptoms.Some of these include high blood pressure, shivering, confusion and/or high fever. Defects in the expression of acetylcholine receptors is more indicative of amyotrophic lateral sclerosis (ALS). ALS affects motor neurons directly.

A client is having a "fight or flight response" after receiving a bad disease prognosis. What affect will this have on the client's sympathetic nervous system? A. Constriction of blood vessels in the heart muscle B. Constriction of bronchioles C. Increase in the secretion of sweat D. Constriction of pupils

C. Increase in the secretion of sweat Rationale: Sympathetic nervous system stimulation results in dilated blood vessels in the heart and skeletal muscle, dilated bronchioles, increased secretion of sweat, and dilated pupils.

The nurse is caring for a client with an upper motor neuron lesion. What clinical manifestations should the nurse anticipate when planning the client's neurologic assessment? A. Decreased muscle tone B. Flaccid paralysis C. Loss of voluntary control of movement D. Slow reflexes

C. Loss of voluntary control of movement Rationale: Upper motor neuron lesions do not cause muscle atrophy, flaccid paralysis, or slow reflexes. However, upper motor neuron lesions normally cause loss of voluntary control.

A client is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this client's care, the nurse would expect to administer what priority medication? A. Hydrochlorothiazide B. Furosemide C. Mannitol D. Spironlactone

C. Mannitol Rationale: The osmotic diuretic mannitol is given to dehydrate the brain tissue and reduce cerebral edema. This drug acts by reducing the volume of brain and extracellular fluid. Spironlactone, furosemide, and hydrochlorothiazide are diuretics that are not typically used in the treatment of increased ICP resulting from cerebral edema.

A client with increased intracranial pressure (ICP) has a ventriculostomy for monitoring ICP. The nurse's most recent assessment reveals that the client is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication? A. Encephalitis B. Cerebral spinal fluid leak C. Meningitis D. Catheter occlusion

C. Meningitis Rationale: Complications of a ventriculostomy include ventricular infectious meningitis and problems with the monitoring system. Nuchal rigidity and photophobia are clinical manifestations of meningitis, but are not suggestive of encephalitis, a cerebral spinal fluid (CSF) leak, or an occluded catheter

When caring for a client with an altered level of consciousness, the nurse is preparing to test cranial nerve VII. What assessment technique would most likely elicit a response from cranial nerve VII? A. Palpate trapezius muscle while client shrugs shoulders against resistance. B. Administer the whisper or watch tick test. C. Observe for facial movement symmetry, such as a smile. D. Note any hoarseness in the client's voice.

C. Observe for facial movement symmetry, such as a smile. Rationale: Cranial nerve VII is the facial nerve. An appropriate assessment technique for this cranial nerve would include observing for symmetry while the client performs facial movements: smiles, whistles, elevates eyebrows, and frowns. Cranial nerve XI (spinal accessory) does not affect the muscles of the face. Assessing cranial nerve VIII (acoustic) would involve evaluating hearing. Cranial nerve X (vagus) does not affect the face.

The nurse is caring for a client in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the client's mean arterial pressure (MAP) is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurse's most appropriate action? A. Position the client the high Fowler position as tolerated. B. Administer osmotic diuretics as prescribed. C. Participate in interventions to increase cerebral perfusion pressure (CPP). D. Prepare the client for craniotomy.

C. Participate in interventions to increase cerebral perfusion pressure (CPP) Rationale: The CPP is 55 mm Hg, which is considered low. The normal CPP is 70 to 100 mm Hg. Clients with a CPP of less than 50 mm Hg experience irreversible neurologic damage. As a result, interventions are necessary. A craniotomy is not directly indicated. Diuretics and increased height of bed would exacerbate the client's condition

A client is recovering from intracranial surgery that was performed using the transsphenoidal approach. The nurse should be aware that the client may have required surgery on what neurologic structure? A. Cerebellum B. Hypothalamus C. Pituitary gland D. Pineal gland

C. Pituitary gland Rationale: The transsphenoidal approach (through the mouth and nasal sinuses) is often used to gain access to the pituitary gland. This surgical approach would not allow for access to the pineal gland, cerebellum, or hypothalamus.

A 35-year-old client with a history of traumatic brain injury has been admitted to the emergency department for a recent change in cognition. The client is steadily walking across the room, intermittently laughing loudly, and crying hysterically. What is the most likely condition associated with these signs? A. Dementia B. Status epilepticus C. Pseudobulbar affect D. Absence seizure

C. Pseudobulbar affect Rationale: The condition known as pseudobulbar affect involves inappropriate or exaggerated emotional expression, usually episodes of laughing or crying. It is associated with brain injury (e.g., stroke, traumatic brain injury, multiple sclerosis [MS], amyotrophic lateral sclerosis [ALS], AD, and Parkinson disease). The client's age, gait, and new onset of symptoms make dementia an unlikely choice. Even new onset dementia typically occurs in a client over the age of 40 with a progressive /slow onset of symptoms which could impair their gait. Status epilepticus (acute prolonged seizure activity) can be defined as a seizure lasting 5 minutes or longer or serial seizures occurring without full recovery of consciousness between attacks. The client's symptoms do not support this finding. Absence seizures usually involve staring episodes.

A trauma client was admitted to the intensive care unit (ICU) with a brain injury that resulted in a change in level of consciousness and altered vital signs. The client subsequently became diaphoretic and agitated. The nurse should recognize which of the following syndromes as the most plausible cause of these symptoms? A. Adrenal crisis B. Hypothalamic collapse C. Sympathetic storm D. Cranial nerve deficit

C. Sympathetic storm Rationale: Sympathetic storm is a syndrome associated with changes in level of consciousness, altered vital signs, diaphoresis, and agitation that may result from hypothalamic stimulation of the sympathetic nervous system following traumatic brain injury. Alterations in cranial nerve or adrenal function would not have this result.

The nurse is preparing health education for a client who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education? A. Mild, intermittent seizures can be expected. B. Take ibuprofen for a serious headache. C. Take antihypertensive medication as prescribed. D. Drowsiness is normal for the first week after discharge.

C. Take antihypertensive medication as prescribed. Rationale: The client and family are provided with information that will enable them to cooperate with the care and restrictions required during the acute phase of hemorrhagic stroke and to prepare the client to return home. Client and family teaching includes information about the causes of hemorrhagic stroke and its possible consequences. Symptoms of hydrocephalus include gradual onset of drowsiness and behavioral changes. Hypertension is the most serious risk factor, suggesting that appropriate antihypertensive treatment is essential for a client being discharged. Seizure activity is not normal; reports of a serious headache should be reported to the health care provider before any medication is taken. Drowsiness is not normal or expected.

The nurse is caring for a client diagnosed with an ischemic stroke and knows that effective positioning of the client is important. Which of the following should be integrated into the client's plan of care? A. The client's hip joint should be maintained in a flexed position. B. The client should be in a supine position unless ambulating. C. The client should be placed in a prone position for 15 to 30 minutes several times a day. D. The client should be placed in a Trendelenburg position two to three times daily to promote cerebral perfusion.

C. The client should be placed in a prone position for 15 to 30 minutes several times a day. Rationale: If possible, the clients placed in a prone position for 15 to 30 minutes several times a day. A small pillow or a support is placed under the pelvis, extending from the level of the umbilicus to the upper third of the thigh. This helps to promote hyperextension of the hip joints, which is essential for normal gait, and helps prevent knee and hip flexion contractures. The hip joints should not be maintained in flexion and the Trendelenburg position is not indicated.

A client with a left hemispheric stroke is having difficulty with their normal speech patterns. The nurse is not sure whether the client has expressive aphasia or apraxia. Which statement would most likely be reflective of apraxia? A. The nurse gives direction to get out of bed but the client does not understand. B. The client points and gestures to an object needed on the overhead table. C. The client starts by saying "good morning" but finishes with saying "good day" to the nurse. D. The client sits up and turns to one side to see the object and states what is needed

C. The client starts by saying "good morning" but finishes with saying "good day" to the nurse. Rationale: Apraxia is an inability to perform a previously learned action as may be seen when a client makes verbal substitutions for desired syllables or words. The client changed "good morning" to "good day," which is suggestive of this condition. Aphasia which can be expressive aphasia (inability to express oneself) or receptive aphasia (inability to understand language) is more likely represented with the client being unable to understand directions to get out of bed and by pointing and gesturing to an object needed rather than speaking. The client turning to one side so he/she can see the object may be more indicative of blindness to one side (homonymous hemianopsia)

A client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for which purpose? A. To decrease cerebral edema B. To prevent seizure activity that is common following a TIA C. To remove atherosclerotic plaques blocking cerebral flow D. To determine the cause of the TIA

C. To remove atherosclerotic plaques blocking cerebral flow Rationale: The main surgical procedure for select clients with TIAs is carotid endarterectomy, the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in clients with occlusive disease of the extracranial arteries. An endarterectomy does not decrease cerebral edema, prevent seizure activity, or determine the cause of a TIA

A client had a lumbar puncture performed at the outpatient clinic and the nurse phoned the client and family that evening. What does this phone call enable the nurse to determine? Select all that apply. A. What the client's and family's expectations of the test are. B. Whether the client's family had any questions about why the test was necessary. C. Whether the client has had any complications from the test. D. Whether the client understood accurately why the test was done. E. The necessary steps for the client and family to take should complications arise.

C. Whether the client has had any complications from the test. E. The necessary steps for the client and family to take should complications arise. Rationale: Contacting the client and family after diagnostic testing enables the nurse to determine whether they have any questions about the procedure, whether the client had any untoward results, and what to do should complications arise. Since the test was done as an outpatient; monitoring and care are being provided by the family. The health of the client becomes a team effort so any communication by the nurse should include both parties. The other listed information should have been elicited from the client and family prior to the test.

The nurse is admitting a client to the unit who is diagnosed with a lower motor neuron lesion. What entry in the client's electronic record is most consistent with this diagnosis? A. "Client exhibits increased muscle tone." B. "Client demonstrates normal muscle structure with no evidence of atrophy." C. "Client demonstrates hyperactive deep tendon reflexes." D. "Client demonstrates an absence of deep tendon reflexes."

D. "Client demonstrates an absence of deep tendon reflexes." Rationale: Lower motor neuron lesions cause flaccid muscle paralysis, muscle atrophy, decreased muscle tone, and loss of voluntary control

A 26-year-old female client, who is breastfeeding a newborn, is due to undergo a computed tomography (CT) scan with dye contrast. What instruction should the nurse provide to the client based on this procedure? A. "Do not breastfeed your baby for two weeks after the procedure as recommended by your provider." B. "Limit your intake of water and alcohol following the procedure." C. "Do not eat or cook any shellfish prior to the procedure." D. "Stop breastfeeding for the time frame given by the provider within the nuclear medicine department."

D. "Stop breastfeeding for the time frame given by the provider within the nuclear medicine department." Rationale: Breastfeeding women are instructed by the nuclear medicine department to stop for a certain time period when undergoing nuclear medicine/CT scan treatment. Clients are assessed to see if an allergy to shellfish/iodine exists prior to the procedure. Clients are encouraged to drink plenty of fluids after the procedure to help the kidneys clear the dye out of the body

A client for whom the nurse is caring has positron emission tomography (PET) scheduled. In preparation, what should the nurse explain to the client? A. "The test will temporarily limit blood flow through the brain." B. "An allergy to iodine precludes getting the radio-opaque dye." C. "The client will need to endure loud noises during the test." D. "The test may result in dizziness or lightheadedness."

D. "The test may result in dizziness or lightheadedness." Rationale: Key nursing interventions for PET scan include explaining the test and teaching the client about inhalation techniques and the sensations (e.g., dizziness, lightheadedness, and headache) that may occur. A PET scan does not impede blood flow through the brain. An allergy to iodine precludes the dye for an MRI, and loud noise is heard in an MRI.

An older adult client is being discharged home. The client lives alone and has atrophy of the olfactory organs. The nurse tells the client's family that it is essential that the client have what installed in the home? A. Grab bars B. Nonslip mats C. Baseboard heaters D. A smoke detector

D. A smoke detector Rationale: The sense of smell deteriorates with age. The olfactory organs are responsible for smell. This may present a safety hazard for the client because he or she may not smell smoke or gas leaks. Smoke detectors are universally necessary, but especially for this client.

A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this client? A. Passive range-of-motion exercises to prevent contractures B. Supine positioning C. Early initiation of physical therapy D. Absolute bed rest in a quiet, non stimulating environment

D. Absolute bed rest in a quiet, non stimulating environment Rationale: The client is placed on immediate and absolute bed rest in a quiet, nonstressful environment because activity, pain, and anxiety elevate BP, which increases the risk for bleeding. Visitors are restricted. The nurse administers all personal care. The client is fed and bathed to prevent any exertion that might raise BP. Clients with increased ICP are normally positioned with the HOB elevated

A client is currently being stimulated by the parasympathetic nervous system. What effect will this nervous stimulation have on the client's bladder? A. Urinary retention B. Bladder spasms C. Urge incontinence D. Bladder contract

D. Bladder contract Rationale: The parasympathetic division of the nervous system causes contraction (stimulation) of the urinary bladder muscles whereas the sympathetic division produces relaxation (inhibition) of the urinary bladder

A client diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse? A. Sit with the client for a few minutes. B. Administer an analgesic. C. Inform the nurse manager. D. Call the health care provider immediately.

D. Call the health care provider immediately. Rationale: A headache may be an indication that the aneurysm is leaking. The nurse should notify the health care provider immediately. The health care provider will decide whether administration of an analgesic is indicated. Informing the nurse manager is not necessary. Sitting with the client is appropriate, once the health care provider has been notified of the change in the client's condition

What should the nurse suspect when hourly assessment of urine output on a client post craniotomy exhibits a urine output from a catheter of 1,500 mL for two consecutive hours? A. Cushing syndrome B. Syndrome of inappropriate antidiuretic hormone (SIADH) C. Adrenal crisis D. Diabetes insipidus

D. Diabetes insipidus Rationale: Diabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in clients after brain surgery. Cushing syndrome is excessive glucocorticoid secretion resulting in sodium and water retention. SIADH is the result of increased secretion of ADH; the client becomes volume-overloaded, urine output diminishes, and serum sodium concentration becomes dilute. Adrenal crisis is undersecretion of glucocorticoids resulting in profound hypoglycemia, hypovolemia, and hypotension

What should be included in the client's care plan when establishing an exercise program for a client affected by a stroke? A. Schedule passive range of motion every other day B. Keep activity limited, as the client may be overstimulated. C. Have the client perform active range-of-motion (ROM) exercises once a day. D. Exercise the affected extremities passively four or five times a day.

D. Exercise the affected extremities passively four or five times a day. Rationale: The affected extremities are exercised passively and put through a full ROM four or five times a day to maintain joint mobility, regain motor control, prevent development of a contracture in the paralyzed extremity, prevent further deterioration of the neuromuscular system, and enhance circulation. Active ROM exercises should ideally be performed more than once per day.

The neurologic nurse is testing the function of a client's cerebellum and basal ganglia. What action will most accurately test these structures? A. Have the client identify the location of a cotton swab on his or her skin with the eyes closed. B. Elicit the client's response to a hypothetical problem. C. Ask the client to close his or her eyes and discern between hot and cold stimuli. D. Guide the client through the performance of rapid, alternating movements.

D. Guide the client through the performance of rapid, alternating movements. Rationale: Cerebellar and basal ganglia influence on the motor system is reflected in balance control and coordination. Coordination in the hands and upper extremities is tested by having the client perform rapid, alternating movements and point-to-point testing. The cerebellum and basal ganglia do not mediate cutaneous sensation or judgment.

During the examination of an unconscious client, the nurse observes that the client's pupils are fixed and dilated. What is the most plausible clinical significance of the nurse's finding? A. It suggests onset of metabolic problems. B. It indicates paralysis on the right side of the body. C. It indicates paralysis of cranial nerve X (CN X). D. It indicates an injury at the midbrain level.

D. It indicates an injury at the midbrain level. Rationale: Pupils that are fixed and dilated indicate injury at the midbrain level. This finding is not suggestive of unilateral paralysis, metabolic deficits, or damage to CN X.

The nurse is conducting a focused neurologic assessment and is assessing the client's gag reflex. How should the nurse best perform this aspect of the assessment? A. Depress the client's tongue with a sterile tongue depressor. B. Ask the client to swallow a small quantity of any soft food. C. Observe the client swallowing a small mouthful of water. D. Lightly touch the client's pharynx with a cotton swab.

D. Lightly touch the client's pharynx with a cotton swab. Rationale: The gag reflex is elicited by gently touching the back of the pharynx with a cotton-tipped applicator, first on one side of the uvula and then the other. The gag reflex is not assessed by having the client swallow or by depressing the tongue.

A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate? A. Restrain the client to prevent injury. B. Open the client's jaws to insert an oral airway. C. Place client in high Fowler position. D. Loosen the client's restrictive clothing.

D. Loosen the client's restrictive clothing. Rationale: An appropriate nursing intervention would include loosening any restrictive clothing on the client. No attempt should be made to restrain the client during the seizure because muscular contractions are strong and restraint can produce injury. Do not attempt to pry open jaws that are clenched in a spasm to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. If possible, place the client on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus

A client has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the client's ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following? A. Hemiplegia B. Dry mucous membranes C. Signs of internal bleeding D. Loss of brain stem reflexes

D. Loss of brain stem reflexes Rationale: Loss of brain stem reflexes, including pupillary, corneal, gag, and swallowing reflexes, is an ominous sign of approaching death. Dry mucous membranes, hemiplegia, and bleeding must be promptly addressed, but none of these is a common sign of impending death.

A client with an ischemic stroke has been brought to the emergency room. The health care provider institutes measures to restore cerebral blood flow. What area of the brain would most likely benefit from this immediate intervention? A. Cerebral cortex B. Temporal lobe C. Central sulcus D. Penumbra region

D. Penumbra region Rationale: In an ischemic stroke, there is disruption of the cerebral blood flow due to obstruction of a blood vessel. This disruption in blood flow initiates a complex series of cellular metabolic events referred to as the ischemic cascade. Early in the cascade, an area of low cerebral blood flow, referred to as the penumbra region, exists around the area of infarction. The penumbra region is ischemic brain tissue that may be salvaged with timely intervention. The cerebral cortex, temporal lobe, and central sulcus are all different areas of the brain. Since the specific area was not identified in the scenario; the area that would most benefit from immediate interventions would be the area surrounding the infarct called the penumbra region.

The nurse is caring for a client who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to prevent seizures in this client? A. Prednisone B. Dexamethasone C. Cafergot D. Phenytoin

D. Phenytoin

What term is used to describe the fibrous connective tissue that hugs the brain closely and extends into every fold of the brain's surface? A. Dura mater B. Arachnoid C. Fascia D. Pia mater

D. Pia mater Rationale: The term "meninges" describes the fibrous connective tissue that covers the brain and spinal cord. The meninges have three layers: the dura mater, arachnoid, and pia mater. The pia mater is the innermost membrane that hugs the brain closely and extends into every fold of the brain's surface. The dura mater, the outermost layer, covers the brain and spinal cord. The arachnoid, the middle membrane, is responsible for the production of cerebrospinal fluid. This is not known as "fascia."

A client is diagnosed with a right-sided stroke. The client is now experiencing hemianopsia. How might the nurse help the client manage the potential sensory and perceptional difficulties? A. Keep the lighting in the client's room low. B. Place the client's clock on the affected side. C. Approach the client on the side where vision is impaired. D. Place the client's extremities where the client can see them.

D. Place the client's extremities where the client can see them.

A 50-year-old female client reports a new onset, moderate headache after a lumbar puncture. What is the most likely condition that the client is experiencing? A. Cranial arteritis B. Cluster headache C. Paroxysmal hemi-cranias D. Secondary headache

D. Secondary headache Rationale: A secondary headache is a symptom associated with other causes, such as a brain tumor, an aneurysm, or lumbar puncture. Cranial arteritis is a cause of headache in the older population, reaching its greatest incidence in those older than 70 years of age. Inflammation of the cranial arteries is characterized by a severe headache localized in the region of the temporal arteries. A cluster headache is usually chronic and occurs more frequently in the male population. Paroxysmal hemicrania is a rare form of a primary headache that usually begins as an adult. It is usually severe, sudden, and can be linked to women with conditions like head trauma or a tumor on the pituitary gland

A client recovering from a stroke has severe shoulder pain from subluxation of the shoulder. To prevent further injury and pain, the nurse caring for this client is aware of what principle of care? A. The client should be fitted with a cast because use of a sling should be avoided due to adduction of the affected shoulder. B. Elevation of the arm and hand can lead to further complications associated with edema. C. Passively exercising the affected extremity is avoided in order to minimize pain. D. The client should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder.

D. The client should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder. Rationale: To prevent shoulder pain, the nurse should never lift a client by the flaccid shoulder or pull on the affected arm or shoulder. The client is taught how to move and exercise the affected arm/shoulder through proper movement and positioning. The client is instructed to interlace the fingers, place the palms together, and push the clasped hands slowly forward to bring the scapulae forward; he or she then raises both hands above the head. This is repeated throughout the day. The use of a properly worn sling when the client is out of bed prevents the paralyzed upper extremity from dangling without support. Range-of-motion exercises are still vitally important in preventing a frozen shoulder and ultimately atrophy of subcutaneous tissues, which can cause more pain. Elevation of the arm and hand is also important in preventing dependent edema of the hand.

The nurse is providing care for a client who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the client has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following? A. The ability of the client to follow instructions during the seizure. B. The success or failure of the care team to physically restrain the client. C. The client's ability to explain his seizure during the postictal period. D. The client's activities immediately prior to the seizure.

D. The client's activities immediately prior to the seizure. Rationale: Before and during a seizure, the nurse observes the circumstances before the seizure, including visual, auditory, or olfactory stimuli; tactile stimuli; emotional or psychological disturbances; sleep; and hyperventilation. Communication with the client is not possible during a seizure and physical restraint is not attempted. The client's ability to explain the seizure may not be accurate since the client is often still confused during the postictal period.

A 72-year-old man has been brought to his primary care provider by the client's daughter, who claims that the client has been experiencing uncharacteristic lapses in memory. What principle should underlie the nurse's assessment and management of this client? A. Loss of short-term memory is normal in older adults, but loss of long-term memory is pathologic. B. Lapses in memory in older adults are considered benign unless they have negative consequences. C. Gradual increases in confusion accompany the aging process. D. Thorough assessment is necessary because changes in cognition are always considered to be pathologic.

D. Thorough assessment is necessary because changes in cognition are always considered to be pathologic. Rationale: Although mental processing time decreases with age, memory, language, and judgment capacities remain intact. Change in mental status should never be assumed to be a normal part of aging.