EXAM 2 NURSE 315

For the patient with a seizure disorder and a history of diabetes mellitus, which statements indicate understanding of safety measures taught by the nurse? Select all that apply.

"I will refrain from drinking alcohol." "I will wear a helmet while riding a bike." "I will maintain adequate sleep and rest schedules."

A patient's surgical therapy for trigeminal neuralgia resulted in an altered corneal reflex. After the nurse provides education about long-term management of the reflex, which statement made by the patient indicates the need for further teaching?

"I'm glad I won't need to put drops in my eyes anymore."

In which order would the nurse anticipate a patient's seizure activity to occur?

1. The phase with signs preceding a seizure Correct2.The phase with a sensory warning of a seizure Correct3.The phase with a full seizure Correct4.The phase with recovery period after a seizure

A patient presents with an open wound. The nurse reviews the patient's history and determines that a tetanus booster is not necessary. This determination was made because the patient was immunized against tetanus within the past how many years? Record the answer as a whole number. _______ years

5

The nurse finds that the patient is unable to recognize familiar objects after a stroke. Which term would the nurse chart in the patient's medical record?

Agnosia

About which food item would the nurse teach a patient as being a potential trigger for cluster headaches?

Alcohol

The patient with Parkinson's disease lost 35 pounds (15.9 kg) over the last two months, and a swallow study indicates ability to swallow without aspiration. Which intervention would the nurse discuss with the patient and spouse to improve nutritional intake?

Allow adequate time for the patient to eat each of six small meals.

In which order would the nurse explain the neuropathologic changes occurring in patients with multiple sclerosis?

An environmental factor or virus triggers the activation of T cells in genetically susceptible individuals. The activated T cells in the systemic circulation migrate to the central nervous system (CNS), disrupting the blood-brain barrier. The antigen-antibody reaction within the CNS activates the inflammatory response, causing demyelination of axons. The ongoing inflammation affects the nearby oligodendrocytes, and the myelin loses the ability to regenerate. The underlying axon gets damaged, disrupting transmission of nerve impulses and loss of nerve function The inflammation subsides, and the glial scar tissue replaces the damaged tissue, forming hard, sclerotic plaques.

Which factor improves cerebral blood flow?

An increase in hydrogen ion concentration

Which parameter would the nurse assess when examining a patient with a history of tension-type headaches (TTHs)?

Auscultate carotid artery sounds

Which information would the nurse include in a teaching plan about the onset of embolic stroke?

Embolic stroke occurs rapidly.

A patient with a spinal cord injury is paralyzed below the waist. The patient is completely dependent for all care, is withdrawn, and sleeps excessively. The patient tells the nurse, "I can't believe this is happening to me." How does the nurse respond? Select all that apply.

Encourage the patient to set daily goals. Encourage the patient to participate in care. Teach the patient what to expect during the rehabilitation period.

the nurse provides postoperative care for a patient after a cervical spine stabilization surgery. The nurse recognizes that which interventions will help stabilize the spine? Select all that apply.

Ensure that the patient's body is correctly aligned. Use a sternal-occipital-mandibular immobilizer brace. Turn the patient as a unit.

Which assessment finding would cause the nurse to suspect trigeminal neuralgia in a patient who reports severe burning of the face?

Facial twitching

Which health promotion activity has the greatest impact in the prevention of spinal cord injury (SCI) in adults 65 years and older?

Fall prevention strategies

Which seizure disorder would the patient have when medication therapy failed, and the patient had a resection of epileptogenic tissue?

Focal seizures

Which diagnosis is supported by the symptom of areflexia?

Guillain-Barré syndrome

Which issue would the nurse prioritize when planning care for a patient in the acute phase of an ischemic stroke?

Impaired breathing

Which clinical manifestation is associated with a stroke on the right side of the brain?

Impulsiveness

The nurse prepares a dietary teaching plan for a patient with a spinal cord injury and includes which information? Select all that apply.

Include two servings from the milk group. Eat three well-balanced meals each day. Include two or more servings from the meat group.

A patient with a new cervical spinal cord injury is hospitalized. The nurse identifies that which interventions are appropriate to include in the patient's nutrition plan? Select all that apply.

Insert a nasogastric tube. Evaluate swallowing before starting oral feeding. If oral feeding is not possible, enteral nutrition must be provided.

Which diagnostic test would the nurse anticipate for a patient with progressive weakness suspected of having multiple sclerosis?

Magnetic resonance imaging (MRI)

During the acute phase of stroke management, which nursing intervention is most important to decrease risk of aspiration?

Maintaining NPO status

Which food would be included in the diet for a patient who had a stroke and has dysphagia?

Mashed potatoes

A decreased number of acetylcholine receptors in the neuromuscular junction is a characteristic of which autoimmune disease?

Myasthenia gravis

Which clinical manifestations would the nurse expect to identify during data collection and assessment of a patient admitted to an acute care facility with Willis-Ekbom disease? Select all that apply.

Numbness and tingling in the legs Leg pain localized to the calf muscles Sensation like bugs creeping on the legs

Which specific patient assessments would the nurse perform immediately after a status epilepticus event subsides? Select all that apply.

Oxygenation Oral body temperature Respiratory rate and pattern

Which diagnostic findings would the nurse associate with a patient's diagnosis of multiple sclerosis (MS)? Select all that apply.

Presence of visual and auditory evoked potential Presence of increased immunoglobin G (IgG) antibodies in the cerebrospinal fluid Presence of inflammation, tissue breakdown, and atrophy of the spinal cord in the MRI scan

Which instruction would be given to a patient who is diagnosed with Bell's palsy?

Prevent corneal drying by instillation of ointment at night with an eye shield.

Which intervention would the nurse implement when a patient's adult child becomes emotionally upset upon hearing the patient's diagnosis of Huntington's disease?

Provide emotional and psychologic support

When providing care for a patient with advanced Huntington's disease (HD), which interventions would the nurse implement?

Provide palliative care as the collaborative approach

Regarding the patient with Parkinson's disease (PD) who recently entered a long-term care facility, which action would the health care team implement to promote adequate nutrition for this patient?

Provide small, frequent meals throughout the day that are easy to chew and swallow

For the patient with Parkinson's disease who has difficulty swallowing, which intervention would the nurse initially include in the patient's plan of care?

Provide the patient with semisolid or soft foods

Which staff would be included in the care team at a certified stroke center? Select all that apply.

Radiologist Neurologist Registered nurse Radiologic technician

Which information is an important part of the health history for a patient with a new diagnosis of Guillain-Barré syndrome (GBS)?

Recent viral infection

Which instructions would the nurse provide the patient who has a history of focal seizures, controlled with phenytoin (Dilantin), and mild gingival hyperplasia? Select all that apply.

Regular tooth brushing can limit hyperplasia Regular flossing can control gingival tissue growth.

The nurse is planning psychosocial support for a patient who suffered a stroke and the family. Which factor most likely will have the greatest impact on positive family coping with the situation?

Rehabilitation potential of the patient

Which action would be beneficial to a patient with a right-brain stroke?

Remove clutter and obstacles

Which assessment is a priority when caring for a patient who has been diagnosed with Guillain-Barré syndrome?

Respiratory assessment

For which major complication would the nurse monitor development in a patient experiencing a myasthenic crisis?

Respiratory insufficiency

When a patient presents with hypertension and reports paresthesia, tingling, and a pins-and-needles sensation, which disorder would the nurse associate the health care provider's prescription for gabapentin (Neurontin)?

Restless legs syndrome (RLS)

The respiratory status of a patient with Guillain-Barré syndrome is deteriorating. Which nursing interventions would be performed for this patient? Select all that apply.

Send a sputum culture if patient is febrile. Keep necessary equipment ready for mechanical ventilation and tracheostomy. Monitor vital capacity and arterial blood gases (ABGs

The nurse reviews the medical record of a patient with poikilothermia. The nurse identifies that which history finding likely caused this condition?

Spinal cord injury

A patient with a spinal cord injury (SCI) at the C7 level experiences autonomic dysreflexia. Which signs and symptoms occur with this condition? Select all that apply.

Sudden onset of severe headache Sweating above the level of the SCI

Arrange the steps of vagal nerve stimulation chronologically.

Surgical implantation of an electrode Activation of the electrode by a magnet Delivery of an electrical impulse from the electrode Prevention of a seizure occurrence

The nurse provides a group of nursing students with education about Bell's palsy and includes which information?

it can affect any age group

Which information would be given to the patient with a history of transient ischemic attacks and has been prescribed aspirin? Select all that apply.

it is pain medication and an antiplatelet agent. It may cause bleeding, which should be reported immediately.

Which disorder would the nurse associate with a patient's clinical manifestations of a throbbing headache and photophobia occurring prior to the headache's onset, as well as a history of this type of headache?

A migraine headache

A patient develops Bell's palsy weeks after being diagnosed with a middle ear infection. Which explanation would the nurse give when asked about the cause of the condition?

A virus causes inflammation, which leads to paralysis of the facial nerve

The nurse provides care for a patient with a C3 level of spinal injury. Which is the patient's potential for rehabilitation?

Ability to drive an electric wheelchair

Which medication would the nurse associate with the treatment of rebound headaches?

Amitriptyline (Elavil)

The nurse identifies that a patient is at risk for failure of the diaphragm when the patient experiences which level of spinal cord injury?

C3-C5

Which prescription would the nurse question for a patient who is admitted with a hemorrhagic stroke?

Clopidogrel 75 mg PO once daily

Which clinical manifestations would the nurse assess in a patient with Bell's palsy? Select all that apply.

Inability to smile Flaccidity of the affected side of the face Drooping of the mouth accompanied by drooling

Which nursing intervention would be included in the plan of care for a patient with a stroke who has a decreased level of consciousness and an altered swallowing reflex?

Providing small amounts of food

For patients with amyotrophic lateral sclerosis (ALS), which treatment goal focuses on preventing a common cause of death in patients with ALS?

Reduced risk of aspiration

Which deficit associated with the anterior cerebral artery would the nurse expect to find in a patient who had a stroke?

Rooting reflex

Which expected outcome would be included in the plan of care for a patient who had a stroke and is experiencing residual expressive aphasia?

The patient will demonstrate alternative communication techniques.

The RN is teaching a student nurse about the proper way to communicate with a patient who has aphasia due to a stroke. Which statement made by the student nurse indicates a need for further learning?

"I will try to force communication with the patient if the patient is upset."

When teaching the clinical manifestations of cluster headaches to a group, which statement would the nurse include?

"The pain experienced in cluster headaches is unilateral."

Which points would the nurse teach a patient with trigeminal neuralgia who is scheduled for microvascular decompression of the trigeminal nerve? Select all that apply.

"It will be performed by making a small hole behind your ear. "It involves displacement of the blood vessels pressing on the nerve.

Which cranial nerve is associated with Bell's palsy?

VII

A nurse is measuring the BP of a hypertensive obese patient who has been admitted to the hospital for increased blood glucose levels. While he or she is speaking, the nurse notes that the patient has suddenly started mumbling and is unable to articulate words. Which action would the nurse take?

treat this as an emergency and call the health care provider.

Which is an example of blunt trauma that can result in a spinal cord injury?

Diving accident

Which are primary methods of preventing a stroke? Select all that apply.

Healthy diet Regular exercise Management of BP

When a patient has a new prescription of phenytoin (Dilantin) for seizures, the nurse would provide information for which common side effects of the medication? Select all that apply.

Hirsutism Gingival hyperplasia

For the treatment of a patient's tension-type headache (TTH), about which newly prescribed medication would the nurse prepare information for the patient?

Mirtazapine (Remeron)

Which deficit is associated with left-hemispheric stroke?

Slow and possibly fearful performance of tasks

An experienced nurse is teaching a novice nurse about interventions for a patient with a stroke. Which statement by the novice nurse indicates a need for further teaching?

"I should refrain from distracting the patient during a sudden emotional outburst."

If blood flow to the brain is interrupted, how quickly does cellular death occur?

5 minutes

At which rate must blood flow in the brain be maintained for normal functioning?

750 to 1000 mL/min

When planning for venous thromboembolism (VTE) prevention, what should the nurse place as the highest priority ?

Active and passive range-of-motion (ROM) exercises

Which topics would the nurse include in a teaching plan about self-care for a patient who is diagnosed with Bell's palsy? Select all that apply.

Administration of corticosteroid medications Dark glasses and artificial tears to protect the eyes

A patient diagnosed with Guillain-Barré syndrome who has a weak gag reflex would be at risk for which complication?

Aspiration of food into the airways

Place in chronologic order the events in fibrinolytic therapy.

Binding of tissue plasminogen activator to the fibrin Conversion of plasminogen to plasmin Digestion of fibrin and fibrinogen Lysis of the clot

After a fall at home, a patient is hospitalized and diagnosed with conus medullaris syndrome. The nurse expects which assessment findings? Select all that apply.

Bowel incontinence Urinary incontinence Hypotonicity of the lower limbs

Which clinical manifestation does the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury?

Bradycardia

Which prescribed first-line drug would the nurse prepare to administer to a patient with trigeminal neuralgia?

Carbamazepine

the nurse is caring for a patient with a spinal cord injury who demonstrates motor paralysis and a loss of pain and temperature sensation below the level of injury. The nurse suspects which causative factor of this condition?

Damage to the anterior spinal artery

Which prescribed IV injection would the nurse administer first for the patient experiencing status epilepticus?

Diazepam (Valium) IV

Which nursing intervention would the nurse include in the plan of care for a patient with hemorrhagic stroke who is having neuromuscular and cognitive impairment?

Encouraging independent exercise

Which lobe of the brain is affected if a patient has Broca's aphasia?

Frontal lobe

Which extracranial condition would the nurse associate with a patient's seizures?

Hypertension

Which modifiable risk factor for stroke would be most important for the nurse to include when planning a community education program?

Hypertension

Which neurologic factor would the nurse assess and record for a patient who had a stroke?

Level of consciousness

A patient with Parkinson's disease taking a dopamine agonist medication reported nausea and vomiting. The patient lost consciousness from a sudden drop in BP after receiving an IV antiemetic. Which antiemetic medication interaction would nurse associate with the patient's response?

Ondansetron (Zofran) and apomorphine (Apokyn)

Which medication may cause a rebound headache effect and requires dose tapering before discontinuing the medication?

Opioids (Oxycodone)

Which intervention would the nurse delegate to the experienced unlicensed assistive personnel (UAP) when working with a patient who had a stroke?

Perform passive range-of-motion exercises to flaccid extremities

Which risk factors would the nurse include in a teaching plan when instructing a patient about modifiable risk factors for stroke?

Smoking

A nurse is planning a community-based stroke awareness/prevention health fair. Which activities would be most helpful to include? Select all that apply.

Smoking cessation Cholesterol screening BP screening Early warning signs of a stroke

Which is a priority nonoperative treatment following a spinal cord injury?

Stabilization

For the patient taken to the hospital after a seizure, which characteristic pattern reported by the patient's caregiver would the nurse associate with those of a tonic-clonic seizure?

Stiffening of the body for 20 seconds, followed by jerking of the extremities for 40 seconds

Upon review of a patient's medical history, which question would the nurse ask the patient with a history of restless legs syndrome (RLS)?

"Are you able to sleep well and feel rested?

Which questions would the nurse ask a patient with multiple sclerosis prior to administering the newly prescribed medication, dalfampridine (Ampyra)? Select all that apply.

"Do you have kidney disease?" "Do you have a history of any seizure disorder?"

For the patient with multiple sclerosis (MS), who has a new prescription for diazepam (Valium), which teaching points would the nurse provide? Select all that apply.

Do not stop the medication abruptly Avoid driving while on the medication. Avoid alcohol intake with the medication

Which instructions would the nurse provide the patient prescribed carbamazepine (Tegretol) for seizures? Select all that apply.

Do not stop using the medication abruptly. Do not consume grapefruit juice while on this medication. Notify the health care provider about any vision problems

The patient with a spinal cord injury (SCI) is admitted to the intensive care unit. The nurse recalls which information about medications used to treat SCI?

Dopamine has more complications than phenylephrine in SCI

When performing a physical examination of a patient with Parkinson's disease, which associated clinical manifestations would the nurse likely identify? Select all that apply.

Drooling of saliva Decreased arm swing Shuffling, propulsive gait

Which tests would be of greatest benefit to obtain information about cerebral blood flow in a patient who had a stroke? Select all that apply.

Duplex scanning Digital subtraction angiography Transcranial Doppler ultrasonography

Which clinical manifestations of Guillain-Barré syndrome (GBS) are related to cranial nerve involvement? Select all that apply.

Dysphagia facial weakness

Which symptoms are related to autonomic dysfunction in a patient with Guillain-Barré syndrome? Select all that apply.

Dysrhythmias Bradycardia Orthostatic hypotension

The nurse is preparing educational materials about the differences between Bell's palsy and trigeminal neuralgia. Which information would the nurse include about Bell's palsy?

It affects the seventh cranial nerve, whereas trigeminal neuralgia affects the fifth.

A patient with trigeminal neuralgia asks the nurse about how antiseizure drugs would prevent painful episodes. Which explanation would the nurse give in order to explain the mechanism of action of the drug?

It blocks the transmission of nerve impulses from the trigeminal nerve

A nurse advises a patient with Bell's palsy to use a facial sling. Which benefits would the nurse teach the patient to encourage the use of the facial sling? Select all that apply.

It facilitates eating. It supports facial muscles. It improves mouth alignment.

Which information would be included when explaining to the relatives of a patient suspected of having a stroke about the importance of undergoing MRI? Select all that apply.

It is helpful in identifying the likely causes of stroke It helps to differentiate between a stroke and any other brain lesion.

Which information will a transcranial Doppler (TCD) ultrasonography provide?

It measures the velocity of blood flow.

Which clinical manifestation would the nurse associate with a cluster headache?

Lacrimation

The nurse is providing teaching to a group of nursing students about the actions of the primary medications used to treat trigeminal neuralgia. Which points would the nurse include in the education? Select all that apply.

Lamotrigine blocks the nerve firing Nortriptyline can be used to treat constant burning

Which diagnostic study is used to assess soft tissue injury and neurologic changes?

MRI

The nurse assists with prehospital care of a patient with a suspected C7 spinal cord injury. Which is the most important nursing intervention during this acute stage of care?

Maintaining a patent airway

A male patient with a T7 complete spinal cord injury (SCI) asks the nurse about sexual problems that he may experience. The nurse recalls which information related to sexual function that is associated with SCIs? Select all that apply.

Men with complete injuries are less likely to have psychogenic erections. Most men with SCI can have a reflex erection with physical stimulation if the S2-S4 nerve pathways are not damaged. Signals from the brain about sexual thoughts are sent through the nerves of the spinal cord to the T10-L2 levels. The signals are then relayed to the penis and trigger an erection. Phosphodiesterase inhibitors have become the first-line treatment in men with SCI between T6 and L5

The nurse is assessing a patient with a T2 level spinal cord injury (SCI). The nurse notes that there is a kink in the catheter, the bladder is distended, and the BP is 220/100 mm Hg. Which interventions does the nurse implement? Select all that apply.

Monitor BP regularly Notify the primary health care provider. Check for the presence of bowel impaction. Remove the kink in the catheter and drain the bladder.

Administration of which drugs would be part of the treatment plan for a patient diagnosed with tetanus infection? Select all that apply.

Opioid analgesics Sedatives and muscle relaxants Tetanus toxoid and immune globulin

Which neurodegenerative disorder has the characteristics of rigidity and bradykinesia?

Parkinson's disease

Which intervention does the nurse perform in the acute care of a patient with autonomic dysreflexia?

Urinary catheterization

Which interventions does the nurse include in the teaching plan for a patient with paraplegia who is being discharged from a rehabilitation facility? Select all that apply.

Use pressure-relief devices while sitting. Change bed positions at least every two hours Dress warmly in cold weather to prevent frostbite.

Which discharge instruction would the nurse provide to a patient with trigeminal neuralgia?

"Eat a diet that is high in protein."

Which instructions would the nurse give to a patient recently diagnosed with Bell's palsy who is being discharged to home? Select all that apply.

"It is important to do good oral hygiene after each meal." "Full recovery generally occurs in three to six months." "Dark glasses will help protect your eyes and help to cover up the paralysis."

A nurse is admitting a patient with a thrombotic stroke. The patient is NPO but is requesting a drink of water. Which response by a nurse is appropriate?

"It is not safe to allow you to have anything by mouth until a swallow assessment can be performed."

Which patient statements, made during the nurse's neurologic assessment, support the health care provider's diagnosis of cluster headache? Select all that apply.

"My cheeks also ache during the headache." "My skin appears pale during the headache." "I don't feel like sitting in one place during the headache."

How many years apart are tetanus and diphtheria toxoid boosters given? Record the answer using a whole number. __________ years

10

the nurse is providing care to a patient with a spinal cord injury (SCI). The patient's assessment findings include varying control of legs and pelvis, instability of the lower back, and good sitting balance. The patient has full use of the wheelchair and can ambulate with long leg braces. Which level of spinal cord injury would have caused this manifestation?

L1

For the patient with multiple sclerosis, which action would the nurse classify as a priority intervention when developing the patient's plan of care?

Assist the patient in identifying the factors that precipitate exacerbations

"Drop attacks" are a characteristic of which type of seizure?

Atonic seizure

Which degenerative neurologic disorder is an example of a genetically transmitted, autosomal dominant disorder?

Huntington's disease

Which finding supports the nurse's suspicion of a drug-associated side effect from the administration of topiramate (Topamax) therapy to a patient?

Hypoglycemia

Which clinical manifestation is associated with a left-hemispheric stroke?

Impaired speech

For the patient reporting difficulty with eye and eyelid movement, chewing, swallowing, speaking, and breathing, which diagnostic findings would the nurse associate with myasthenia gravis? Select all that apply.

Improved muscle contractibility during the Tensilon test Decreased response to repeated stimulation of hand muscles during electromyography (EMG) test

Which behavior would be exhibited by a patient who has suffered a right-brain stroke?

Impulsive and impatient

A patient with a known history of hypertension presents to the emergency department with the complaint of sudden severe headache with no known cause. Which intervention would the nurse do first?

Obtain orders and send the patient for a CT scan.

A patient experiences a spinal cord injury as a result of a motor vehicle accident. The patient exhibits a loss of deep tendon and sphincter reflexes, loss of sensation, and flaccid paralysis below the level of injury. The nurse identifies that the findings are consistent with which condition?

Spinal shock

Which criteria are used to determine whether plasmapheresis is effective in a patient who is diagnosed with Guillain-Barré syndrome? Select all that apply

Stabilization of BP and pulse rate. Symptoms of paralysis stop progressing and abate. Lung vital capacity and arterial blood gases are stable

Which disorder would the nurse associate with a patient's seizure lasting longer than five minutes and occurring in rapid succession without a return to consciousness between seizures?

Status epilepticus

Which assessment finding is associated with initial manifestations of tetanus?

Stiffness in the jaw

For the patient who sustained a head trauma, which type of seizure might he or she experience while on a ventilator and receiving sedation medications in the intensive care unit?

Subclinical seizure

Which medication would the nurse anticipate administering as a first-line therapy in treatment of severe migraines?

Sumatriptan (Imitrex)

A patient with paraplegia experiences convulsive movements of the lower limbs. Which information does the nurse provide to the patient and the caregivers about the spasms? Select all that apply.

The spasms can occur as a result of a variety of stimuli. Such reflexes could be positively used for bowel and bladder retraining. Medications such as baclofen or dantrolene may be prescribed to help to control the spasms

Which concepts about the pathology of botulism would the nurse teach the patient who is newly diagnosed with the disease? Select all that apply.

The spores of the organism are difficult to destroy this neurotoxin inhibits nerve impulses from reaching the muscle. The neurotoxin produced by the bacteria is absorbed in the gastrointestinal (GI) tract.

A patient who has been admitted to the hospital with a spinal cord injury at the upper thoracic level experiences neurogenic shock. How does the nurse explain the condition to the patient's family? Select all that apply.

There is loss of nervous control of the blood vessels. The amount of blood pumped out of the heart is reduced. There is pooling of blood in the veins of the extremities

For the family members of a patient with Huntington's disease (HD), which inferences would the nurse associate with a positive genetic test result for the patient's son? Select all that apply.

There is no cure for Huntington's disease The son will develop a progressive, degenerative brain disorder. The onset of disease usually occurs between 30 and 50 years of age

While assessing a patient who had a stroke, the nurse notes adventitious breath sounds and the accumulation of sputum. Why would the nurse encourage the patient to take slow, deep breaths and to cough frequently?

To increase airway clearance

Which term would the nurse use to document a patient who suddenly lost consciousness, stiffened for about 15 seconds, and then developed a jerking motion of the extremities?

Tonic-clonic seizure

If taken daily, which prescribed medication prevents the development of a migraine attack?

Topiramate (Topamax)

Which statement would the nurse include when teaching a patient about the medication classification of triptans, of which a newly prescribed medication belongs?

Triptans are most effective when taken during an aura

Which diagnostic criterion would the nurse include for migraine headaches when explaining the difference between a migraine headache and a tension-type headache (TTH)?

Unilateral pain

Which finding is consistent with a left-hemispheric stroke?

Unilateral weakness of the right extremities

Which statement is accurate about Guillain-Barré syndrome (GBS)?

Weakness of the limbs is acute and symmetrical.

A patient injured at work with an open cut asks the occupational health nurse whether a "tetanus shot" is needed. The nurse would base the response on which fact?

When the patient last received a tetanus toxoid booster

Which medical condition places a patient at a higher risk for an embolic stroke?

Atrial fibrillation

A patient is hospitalized with a new T2 level spinal cord injury. The nurse notes abnormal cardiovascular assessment findings. The nurse anticipates prescriptions for which medications? Select all that apply.

Atropine Vasopressor drugs

A patient with a history of headaches asks the nurse what cluster headaches are. Which responses by the nurse are most appropriate? Select all that apply.

Alcohol is the only known dietary trigger for cluster headaches Cluster headaches occur regularly and frequently at the same time each day. Cluster headaches can occur for weeks to months at a time, followed by remission periods.

Which nursing interventions would assist a patient who had a stroke and is frustrated by mobility problems? Select all that apply.

Allow family and friends to visit the patient more often. Speak to the patient in a calm, caring manner to reduce frustration. Help the family understand that frustration is common in the first year after a stroke.

he nurse is providing care to a patient with a spinal cord injury as the result of a motor vehicle accident. The nurse notes that the patient feels no pain in the leg on the side opposite the injury. Which spinal cord syndrome does the nurse suspect?

Brown-Séquard syndrome

Which clinical manifestations of Guillain-Barré syndrome (GBS) are related to cranial nerve involvement? Select all that apply

Dysphagia Facial weakness

For the patient with myasthenia gravis, which factors experienced in the patient's current life led to development of respiratory failure and a myasthenic crisis, requiring admission? Select all that apply.

Attended the funeral of a family member earlier in week Took an antibiotic prescribed for a urinary tract infection Was diagnosed with urinary tract infection previous week Omitted pyridostigmine (Mestinon) on the previous day

Which diagnostic study is the most reliable to identify the source of a subarachnoid hemorrhage?

Cerebral angiography

Which interventions for treatment of a seizure disorder may contribute to the patient's development of depression? Select all that apply.

Chronic disease diagnosis Darkened room to decrease stimuli Ineffective coping skills/strategies Prescribed antiseizure medications

Which type of seizure would the nurse suspect when family members report that the patient suddenly lost consciousness and fell, and the patient's left leg exhibited jerky movements for a few seconds?

Clonic seizure

For which condition would the nurse administer 100% oxygen immediately?

Cluster headache

Which identified clinical manifestation would the nurse associate with those exhibited with a cluster headache?

Conjunctivitis

Which prescribed intervention would the nurse anticipate implementing when the patient with a history of cluster headaches reports not having any pain relief from the administered analgesics?

Deep brain stimulation

After receiving a local anesthesia during surgery, which intervention would the nurse implement for the patient with a history of epilepsy who experiences a tonic-clonic seizure lasting two minutes in the postanesthesia care unit (PACU)?

Ensure that the patient has a patent airway.

Which assessment would the nurse teach a patient to report as part of the warning signs of stroke, using the mnemonic FAST?

Facial drooping

When performing a physical assessment on a patient with amyotrophic lateral sclerosis (ALS), which clinical manifestations would the nurse identify? Select all that apply.

Limb weakness Difficulty swallowing Difficulty articulating words

Which patient actions would be responsible for a reported decrease in headache events at a follow-up clinic visit? Select all that apply.

Meditating in the evenings Performing yoga in the mornings Taking sumatriptan (Imitrex) once a day

When teaching a patient with cluster headaches, which factor would the nurse include as a potential trigger?

Napping

For the patient with an aggressive form of multiple sclerosis who is not responding to teriflunomide (Aubagio) and dalfampridine (Ampyra), the prescriber changed the medications to natalizumab (Tysabri) and mitoxantrone (Novantrone). Later, when the patient developed progressive multifocal leukoencephalopathy, which prescribed medication might be responsible?

Natalizumab

A degeneration of dopamine-producing neurons and decreased levels of dopamine are characteristics of which disease?

Parkinson's disease

For the patient with myasthenia reporting concern about the potential need for a thymectomy, the nurse explains which patients are candidates for this surgical procedure? Select all that apply.

Patients with thymoma Patients with purely ocular myasthenia gravis Patients between the ages of puberty and about 65 years

Which clinical manifestation would the nurse associate with a tension-type headache (TTH)?

Phonophobia

For the patient diagnosed with myasthenia gravis, which instructions would the nurse include in the patient's discharge teaching plan? Select all that apply.

Plan activities with periods of rest Eat a balanced diet promoting easily chewed items Schedule medications so their peak effect is at mealtime.

Which surgical treatment would the health care provider discuss with the patient whose seizure activity failed to respond to medication therapy and who reports unusual sensations and hallucinations?

Resection of epileptogenic tissue

Which information would the nurse give a patient who had a transient ischemic attack (TIA) and is being discharged home? Select all that apply.

Smoking cessation decreases risk of a stroke. Hypertension is the most important modifiable stroke risk factor. Diabetes increases the risk of stroke.

For the patient with recent seizure activity, which characteristic would the nurse associate with a focal seizure?

The seizure involved lip smacking and repetitive movements

Which artery would be obstructed if a patient sustained a stroke and is experiencing cranial nerve deficits?

Vertebral artery

A patient was brought to the emergency department with a sudden onset of a severe headache different from any other headache previously experienced. Which type of stroke is most likely occurring based on these symptoms?

hemorrhagic stroke

Which medications are considered to be first-line drugs for treatment of trigeminal neuralgia? Select all that apply.

phenytoin Topiramate Gabapentin Clonazepam Carbamazepine

Which points would the nurse include in a teaching plan about Bell's palsy and the reason why oral hygiene and nutrition are affected in this condition? Select all that apply.

the taste sensation is impaired There is accumulation of food on one side of the mouth. There is pain around the jaw, which prevents the proper chewing of food.

In which order does Guillain-Barré syndrome (GBS) develop and resolve?

1. The myelin layer of the affected nerves is lost. Correct2.The transmission of nerve impulses is slowed or stopped. Correct3.The muscle innervated by the damaged nerve undergoes denervation and atrophy. Correct4.The nerve undergoes slow remyelination. Correct5.The neurologic function returns in a proximal-to-distal pattern.

A patient with a T4 injury develops signs of neurogenic shock. The nurse expects which assessment findings? Select all that apply.

BP < 90 mm Hg Temperature dysregulation Peripheral vasodilation Venous pooling

Which nerve also has the label of cranial nerve (CN) V?

Trigeminal nerve

The nurse caring for a patient with Bell's palsy expects to find which key symptom on assessment?

Unilateral lower motor facial weakness

the nurse is caring for a patient who has sustained a spinal cord injury. To prevent autonomic dysreflexia, the nurse instructs the patient to avoid which occurrence?

Urine retention

A patient with a T1 level spinal cord injury (SCI) is scheduled to be discharged from the hospital. The nurse creates a neurogenic bowel management plan and includes which information? Select all that apply.

Use of stool softeners Dietary choices for a high-fiber diet Use of suppositories for evacuation Instructions for how to perform digital stimulation of the rectum

Which nursing interventions optimize musculoskeletal function of a patient with a stroke? Select all that apply.

Using a lapboard Placing a trochanter roll by the hip Using posterior leg splints

When assessing a patient for the presence of petit mal, or absence, seizures, which classic sign would the nurse associate with this disorder?

Vacant facial expression

For the patient with multiple sclerosis, which interventions would the nurse teach about the new prescription for teriflunomide (Aubagio)? Select all that apply.

We need to monitor your liver function implement and maintain practices to avoid pregnancy.

Which instructions would the nurse give to a patient with Bell's palsy regarding preventive measures for complications related to the eye? Select all that apply.

Wear dark glasses. Tape eyelids at night Instill artificial tears frequently

After receiving information as to how metabolic disturbances cause seizures, which statements indicate effective learning? Select all that apply.

"Seizures can be caused by a decrease in oxygen levels." "Seizures can be caused by a decrease in pH of the blood." "Seizures can be caused by a decrease in blood glucose levels."

Which response would the nurse use when a patient's caregiver inquires as to why the patient developed tonic-clonic seizures without a prior history of epilepsy? Select all that apply.

"Stroke is an intracranial cause of tonic-clonic seizure." "Brain tumor is an intracranial cause of tonic-clonic seizure." "Hypertensive crisis is an intracranial cause of tonic-clonic seizure."

A lumbar puncture is to be performed for a patient with suspected subarachnoid hemorrhage. Which explanation would the nurse give about why this procedure was ordered to help with diagnosis? Select all that apply.

"The lumbar puncture will assess for the presence of red blood cells in the cerebrospinal fluid." "The lumbar puncture is a follow-up study because your CT scan does not show hemorrhage."

The nurse finds the wife of a patient who experienced a stroke one week ago crying in the hallway. The wife tells the nurse, "I do not know if I can deal with this. He cries about everything and gets so moody with me." Which response by the nurse is most appropriate?

"This must be very frustrating for you."

When visiting a patient prescribed phenytoin (Dilantin) for seizures, which instruction would the nurse provide the patient to prevent precipitation of seizures?

Do not stop the drug abruptly without consulting the health care provider.

Which food items would be included in the diet plan for a patient being discharged from the hospital after recovering from a stroke? Select all that apply.

Grilled chicken Vegetable soups

While the patient with Parkinson's disease, who is unresponsive to drug therapy, considers the surgical options presented by the health care provider, which procedures would the nurse anticipate providing as additional resources? Select all that apply.

Ablation Transplantation Deep-brain stimulation

Which prescribed medication would the nurse anticipate administering to the patient complaining of a severe headache, neck stiffness, and intensified pain upon exposure to sound?

Acetaminophen (Tylenol)

Which complementary pain management measures would be included in the plan of care for a patient with trigeminal neuralgia? Select all that apply.

Acupuncture Yoga Biofeedback

For the patient with hypoglycemia who has experienced a suspected seizure, which IV intervention would the nurse implement immediately?

Administer IV 0.9% sodium chloride and 5% glucose (Dextrose)

Which treatment option would the nurse associate with the patient who was received in the emergency department in an unconscious state, who has a routine prescription of gabapentin (Neurontin) for a history of epilepsy, and who is experiencing recurring seizures in rapid succession?

Administer diazepam (Valium) IV

Which intervention would the nurse take for a patient who has been prescribed nimodipine?

Administer if heart rate is greater than 60 beats/min

A patient has had three episodes of trigeminal neuralgia and has stopped eating food, fearing that chewing would trigger pain. Which instruction would the nurse give that would help to maintain a proper nutritional status of this patient? Select all that apply.

Advise the patient to consume food that is easy to chew. Advise the patient to eat small quantities of food more frequently. Advise the patient to eat food that is rich in carbohydrates and proteins.

A patient who is hospitalized with a spinal cord injury experiences poor dietary intake. Which measures does the nurse take to improve the patient's nutritional status? Select all that apply.

Allow adequate time to eat. Encourage intake of dietary fiber. Keep a calorie count of the food taken. Provide a pleasant eating environment. Encourage the family to bring in special foods.

Which aspects of the medical history of a female patient are risk factors for stroke? Select all that apply.

Current use of high-dose oral contraceptives History of migraine headaches with aura

The nurse assists with the prehospital care of a patient who experienced a 15-foot fall. Which action by the nurse will limit the damage if a spinal cord injury (SCI) has occurred?

Applying a rigid cervical collar and using a backboard to transport the patient

The nurse provides information for a new graduate who is working in an intensive care unit about mechanical ventilation in patients with a spinal cord injury (SCI). The nurse lists which patient conditions that warrant intubation? Select all that apply.

Arterial blood gases (ABGs) showing inadequate oxygenation A pCO2 > 20 mm Hg above baseline A patient with decreased vital capacity A patient who experiences severe dyspnea

The nurse is caring for a patient with paraplegia who is at risk for developing venous thromboembolism (VTE). The nurse expects that the patient's care plan will include which interventions? Select all that apply.

Assess thighs and calves for signs of VTE. Administer prophylactic low-dose low-molecular-weight heparin. Regularly perform range-of-motion (ROM) exercises and stretching. Continue VTE prophylaxis for three months after injury.

A patient has undergone a percutaneous radiofrequency rhizotomy procedure for trigeminal neuralgia and has facial numbness and trigeminal motor weakness on the affected side. Which instructions would the nurse give this patient? Select all that apply.

Avoid eating hot food or beverages. Protect the face from extreme temperatures. Check oral cavity after eating food for any residual food particles.

Which potential medications would the nurse anticipate administering to a patient with myasthenia gravis who reports difficulty with swallowing, chewing, eye movement, and facial mobility? Select all that apply.

Azathioprine (Imuran) Prednisone (Deltasone) Pyridostigmine (Mestinon)

Which treatment helps to control a patient's spasms that are caused by tetanus?

Barbiturates

The nurse is providing care to a patient with a penetrating spinal cord injury. The patient experiences ipsilateral loss of motor function and position and vibratory sense vasomotor paralysis. Which syndrome does the nurse document in this patient?

Brown-Séquard syndrome

Which diagnostic test determines cerebral blood flow?

Cerebral angiography

Which mechanism protects the brain and promotes its functioning?

Cerebral autoregulation

Which diagnostic tests are a priority for a patient who had a stroke and needs a cardiac assessment? Select all that apply.

Chest x-ray Cardiac markers Electrocardiogram

When discharging a patient admitted with a transient ischemic attack (TIA), for which medications might the nurse expect to provide discharge instructions? Select all that apply.

Clopidogrel Enoxaparin Dipyridamole Enteric-coated aspirin

The patient recovering from a stroke who is confined to bed for most of the day is at risk for which condition?

Constipation

Upon review of a patient's admission orders for treatment of a migraine headache, the nurse notes that the medication list includes sumatriptan (Imitrex). During the admission assessment, which intervention would the nurse implement when the patient reports having experienced a stroke last month?

Contact the health care provider about the patient's history and prescribed sumatriptan.

When caring for a patient with Bell's palsy, the nurse would monitor for which complications? Select all that apply.

Corneal abrasions Psychologic withdrawal Mucous membrane trauma

Immediately following a stroke, the patient's BP is 80/60 mm Hg. Which actions would the nurse take based on this finding? Select all that apply.

Correct hypotension. Correct hypovolemia. Continue treatment for stroke.

Which type of food would the nurse feed the patient by mouth for the first time after a stroke?

Crushed ice

Which patient statements regarding Huntington's disease and related genetic testing indicate understanding of the disease? Select all that apply.

Currently, there is no effective treatment or cure for Huntington's disease. Positive genetic testing indicates that the patient will eventually develop the disease. Offspring of persons with Huntington's disease have a 50% risk of disease development.

Which action can the nurse delegate to the unlicensed assistive personnel (UAP) to reduce fatigue for a patient recovering from a stroke at mealtimes?

Cut up the meat for the patient.

Which information would the nurse include when teaching a patient with multiple sclerosis about the advantages of exercise during remission? Select all that apply.

Decreases spasticity Increases coordination Retrains unaffected muscles to substitute for impaired ones.

A patient suspected of having myasthenia gravis (MG) suffers injury and has related pain, infection, and inflammation. Which drugs must be used with caution? Select all that apply.

Diuretics Antibiotics Opioid analgesics

Which information would the nurse provide a patient with multiple sclerosis who begins treatment with β-interferon? Select all that apply

Do not drink grape juice or eat grapes. Know that flulike symptoms are common. Wear sunscreen while exposed to sunlight

A patient with a spinal cord injury experiences a neurogenic bowel. Beyond the use of bisacodyl suppositories and digital stimulation, which measures does the nurse teach the patient and the caregiver about to assist with bowel evacuation? Select all that apply.

Eat 20 to 30 g of fiber per day. Consume 2 to 3 liters of fluid per day.

Which prescribed diagnostic test, used to diagnose a tension-type headache (TTH), would the nurse anticipate explaining to the patient?

Electromyography

Which interventions would the nurse include in the care plan for a patient with chronic tension headaches? Select all that apply.

Encouraging the patient to perform yoga in the mornings Massaging the patient's shoulders with warm coconut oil Encouraging the patient to practice deep-breathing exercises

Which actions would the nurse implement for a patient who had a stroke and has a BP of 166/96 mm Hg? Select all that apply.

Ensure adequate fluid intake. Continue to monitor the BP

Which prescribed medication would the nurse anticipate providing additional information to the patient expressing fear of cluster headaches recurring during an upcoming flight?

Ergotamine (Ergomar)

Which intervention would be included in the plan of care for a patient who has experienced a right-brain stroke?

Evaluate body positioning during all transfers.

A patient with quadriplegia who has been hospitalized for one month is at a risk of developing pressure injury (PI). Which steps does the nurse take to prevent this complication? Select all that apply.

Evaluate the nutritional status of the patient. Monitor urinary incontinence Check bony prominences for signs of pressure sores.

For the older adult with a brain tumor, which medications would the nurse associate with the treatment of associated headache symptoms, confusion, and altered levels of consciousness reported by the family? Select all that apply.

Gabapentin (Neurontin) Levetiracetam (Keppra) Oxcarbazepine (Trileptal

Which noninvasive surgical procedure is often performed in patients with trigeminal neuralgia?

Gamma knife radiosurgery

Which seizure activity would the nurse associate with a patient's jerky muscle movements of the extremities, as well as bowel and bladder incontinence during the event?

Generalized seizures

Which surgical therapy for trigeminal neuralgia is a peripheral procedure?

Glycerol rhizotomy

Which adverse effect would the nurse monitor for the potential development of in a patient who received a botulinum A toxin (Botox) injection?

Headache

Which manifestations in a patient with a T4 spinal cord injury alerts the nurse to the possibility of autonomic dysreflexia?

Headache and increased BP

When feeding a patient with a stroke on the left side, in which position would the nurse place the patient?

High Fowler's position

After determining that the patient has a tension-type headache (TTH), which patient statement supports the nurse's finding?

I feel some pressure on my neck during the headache

Regarding a young adult driver with epilepsy who sustained trauma from a motor vehicle accident, which response would the nurse use when family members inquire about the incidence of epilepsy?

In younger patients, epilepsy is generally caused by some birth injury, infection, trauma, or genetic factor

he nurse is preparing educational materials about the differences between the facial characteristics of Bell's palsy and those of trigeminal neuralgia. Which characteristics of Bell's palsy would the nurse include? Select all that apply.

Inability to whistle Inability to wrinkle brow

Which type of stroke correlates with the clinical manifestations of a severe headache, hypertension, vomiting, dysarthria, and eye-movement disturbances?

Intracerebral hemorrhage

Which intervention would the nurse implement when a patient with a history of tension headaches complains of head pain, but the patient's vital signs and brief neurologic assessment are normal?

Obtain the patient's detailed past medical history.

The nurse provides care for a patient immediately after a spinal cord injury (SCI). The nurse identifies that which renal problems can occur because of the loss of autonomic and reflex control of the bladder? Select all that apply.

Overdistention of the bladder Renal failure Rupture of the bladder No sensation of bladder fullness

Which clinical manifestation would the nurse associate with those of a migraine?

Paralysisx

Which actions taken by a patient with a history of trigeminal neuralgia indicate that the patient is trying to avoid triggering another episode? Select all that apply.

Patient has stopped eating Patient covers the face with a cloth. Patient avoids interacting with people

A percutaneous radiofrequency rhizotomy procedure has been planned for a patient with trigeminal neuralgia. Which information would the nurse give to this patient about the procedure? Select all that apply.

Patient may experience facial numbness after the surgery. Patient may have difficulty with eye movements after the procedure. An ice pack will be placed on the jaw for three to five hours after the procedure.

The nurse creates a plan of care for an older male patient with a spinal cord injury who requires clean intermittent catheterization (CIC). Which interventions does the nurse include in the plan? Select all that apply.

Perform CIC four to six times daily If the urine becomes cloudy, then send a specimen for culture. The patient may have benign prostatic hyperplasia, which may interfere with the ability to complete CIC. Bladder distention may cause autonomic dysreflexia (AD)

A patient who is hospitalized with a T10 spinal cord injury experiences neurogenic bowel. Which intervention does the nurse include in the patient's bowel management program?

Plan bowel evacuation for 30 to 60 minutes after the first meal

Which criterion would the nurse associate with the health care provider's diagnosis of Parkinson's disease (PD)? Select all that apply.

Positive response to antiparkinsonian medications Presence of two of the three classic features: rigidity, bradykinesia, and tremor

Which seizure phase would the nurse identify when a patient with systemic lupus erythematosus presents to the emergency department with warm skin, pallor, lethargy, and an altered level of consciousness?

Postictal phase

When teaching a community group, which conditions would the nurse discuss as precipitating the development or intensity of restless legs syndrome (RLS)? Select all that apply.

Pregnancy Hypertension Iron deficiency

A patient presents to the emergency department reporting a sudden onset of headache described as "the worst headache ever." The patient also reports nausea and visual disturbances. Which collaborative intervention would be a priority for the nurse?

Prepare patient for transport to CT scan.

During an acute exacerbation of the patient's multiple sclerosis, which interventions would the nurse implement? Select all that apply.

Prevent the complication of pressure ulcers. Prevent the complication of urinary tract infections

Which intervention would the nurse take for a patient with trigeminal neuralgia whose oral intake is sharply reduced and is compromising his or her nutritional status?

Providing food through a nasogastric tube

Which surgery involves destruction of the sensory fibers of the trigeminal nerve using low-voltage current?

Radiofrequency thermal lesioning

The nurse reviews a patient's medical record and notes tic douloureux. Which assessment finding would the nurse expect?

Recurrent episodes of stabbing pain along the distribution of the trigeminal nerve

Which body system is the priority focus for nursing care of the patient with Guillain-Barré syndrome?

Respiratory

the nurse reviews the medical record of a patient with poikilothermia. The nurse identifies that which history finding likely caused this condition?

Spinal cord injury

Which condition is associated with trismus?

Tetanus