Final Practice Q's

A patient is admitted with amyotrophic lateral sclerosis (ALS). Which classic assessment findings will support the diagnosis of ALS? a. Progressive dementia b. Muscle weakness and atrophy c. Severe paresthesias d. Autonomic dysfunctions

ANS: B ALS is manifested by muscle weakness and atrophy. ALS is not manifested by dementia, but by muscle weakness and atrophy. ALS is not manifested by paresthesias, but by muscle weakness and atrophy. ALS is manifested by muscle weakness and atrophy.

A 10-year-old female was brought to the ER following a sudden onset of convulsions. The primary care provider thinks that she experienced an explosive, disorderly discharge of cerebral neurons referred to as: a. Reflex b. Seizure c. Inattentiveness d. Brain death

ANS: B An explosive disorderly discharge of neurons is a seizure. A reflex is an expected response. Inattentiveness is a form of neglect. Brain death is a cessation of function

Which information indicates the nurse understands assessment findings of an aneurysm? a. A headache is the most common symptom b. The majority are asymptomatic c. Nosebleeds are an early symptom d. Epidural hemorrhage occurs in over 80% of patients

ANS: B Aneurysms often are asymptomatic. A headache can occur, but is not the most common symptom. Nosebleeds do not occur. Subarachnoid hemorrhage is the first indication.

A 25-year-old female presents to her primary care provider reporting fever, headache, nuchal rigidity, and decreased consciousness. She was previously treated for sinusitis. Which of the following is the most likely diagnosis? a. Aseptic meningitis b. Bacterial meningitis c. Fungal meningitis d. Nonpurulent meningitis

ANS: B Bacterial meningitis can occur secondary to sinusitis and is manifested by fever, tachycardia, chills, and a petechial rash with a severe throbbing headache, severe photophobia, and nuchal rigidity. The clinical manifestations of aseptic meningitis are milder than bacterial meningitis and are not associated with a previous infection such as sinusitis. Fungal meningitis presents as dementia. Nonpurulent meningitis is the same as aseptic and is milder and not associated with conditions such as sinusitis.

While planning care for a patient with an extradural hematoma, which principle should the nurse remember? The main source of bleeding in extradural (epidural) hematomas is: a. Arterial b. Venous c. Capillary d. Sinus

A An artery is the source of bleeding in 85% of extradural hematomas. An artery, not a vein, is the source of bleeding in 85% of extradural hematomas. An artery, not a capillary, is the source of bleeding in 85% of extradural hematomas. The sinus is not the source of bleeding in extradural hematomas; it is arterial.

A 25-year-old male was in an automobile accident. At impact, his forehead struck the windshield. In this situation, a nurse recalls the coup injury would occur in the _____ region. a. Frontal b. Temporal c. Parietal d. Occipital

A Coup injuries move forward and affect the frontal region of the brain. Coup injuries affect the frontal region of the brain as the brain moves forward, not to the side or temporal region. Coup injuries affect the frontal region of the brain as the brain moves forward, not to the middle or parietal region. Contrecoup injuries affect the rear or occipital region.

Patients with myasthenia gravis often have tumors or pathologic changes in the: a. Brain b. Pancreas c. Thymus d. Lungs

ANS: C Patients with myasthenia gravis experience tumors in the thymus. Patients with myasthenia gravis experience tumors in the thymus, not the brain. Patients with myasthenia gravis experience tumors in the thymus, not the pancreas. Patients with myasthenia gravis experience tumors in the thymus, not the lungs.

A cause of hydrocephalus in subarachnoid hemorrhage is: a. Scarring of meninges and impairment of CSF resorption b. Choroid plexus injury c. Impairment of CSF flow through the ventricles d. Vasoconstriction related to carbon dioxide (CO2) changes in the cerebral circulation

ANS: A A primary cause of hydrocephalus is impairment of CSF resorption that allows fluid to accumulate. A primary cause of hydrocephalus is impairment of CSF resorption that allows fluid to accumulate, not injury to the choroid plexus. A primary cause of hydrocephalus is impairment of CSF resorption. Flow of fluid through the ventricles could be affected, but it is the lack of resorption that leads to hydrocephalus. Vasoconstriction could lead to increased ICP, but it is the impairment of CSF resorption that allows fluid to accumulate.

The patient is experiencing an increase in intracranial pressure. This increase results in: a. Brain tissue hypoxia b. Intracranial hypotension c. Ventricular swelling d. Expansion of the cranial vault

ANS: A Brain tissue hypoxia occurs as a result of increased intracranial pressure as it places pressure on the brain. Increased intracranial pressure leads to intracranial hypertension. Ventricular swelling may lead to increased intracranial pressure, but increased pressure does not lead to ventricular swelling. Expansion of the cranial vault may lead to increased intracranial pressure, but increased pressure does not lead to expansion of the vault.

The breathing pattern that reflects respirations based primarily on carbon dioxide (CO2) levels in the blood is: a. Cheyne-Stokes b. Ataxic c. Central neurogenic d. Normal

ANS: A Cheyne-Stokes respirations occur as a result of CO2 levels in the blood. Ataxic breathing occurs as a result of dysfunction of the medullary neurons. Central neurogenic patterns occur as a result of uncal herniation. Normal respirations are based on the levels of oxygen (O2) in the blood.

A 45-year-old male presents with seizures. An MRI reveals a meningioma most likely originating from the: a. Dura mater and arachnoid membrane b. Astrocytes c. Pia mater d. CNS neurons

ANS: A Meningiomas tumors usually originate from the arachnoidal (meningeal) cap cells in the dura mater. Astrocytes are found in the brain, but are not related to meningiomas. The pia mater is the location of the infection meningitis. Neurons are located throughout all regions of the brain.

A 20-year-old male is admitted to the neurological critical care unit with a severe closed head injury. When an intraventricular catheter is inserted, the ICP is recorded at 24 mm Hg. How should the nurse interpret this reading? This reading is: a. Higher than normal b. Lower than normal c. Normal d. Borderline

ANS: A Normal ICP is 5 to 15 mm Hg; at 24 mm Hg, the patients is higher than normal. Normal ICP is 5 to 15 mm Hg; at 24 mm Hg, the patients is higher than normal, not lower. Normal ICP is 5 to 15 mm Hg; the patients is higher than normal. Normal ICP is 5 to 15 mm Hg; at 24 mm Hg, the patients is higher than normal, not borderline.

Of the following groups, who are at highest risk for a cerebrovascular accident (CVA)? a. Blacks over 65 years of age b. Whites over 65 years of age c. Blacks under 65 years of age d. Whites under 65 years of age

ANS: A The individuals at highest risk for cerebrovascular accident would be blacks over 65. Blacks are at greater risks than whites. Older adults are at greater risk than younger adults. Older adults are at greater risks than younger adults, and blacks are at greater risks than whites.

A neurologist is teaching about brain injuries. Which information should the neurologist include? The most severe diffuse brain injury caused by rotational acceleration is most likely to be located _____ the brainstem. a. More peripheral to b. In the central portion of c. Throughout d. Distal to

ANS: A The most severe axonal injuries are located more peripheral to the brainstem. These injuries occur peripherally to the brainstem, not in the central portion. These injuries occur peripherally to the brainstem, not throughout the brainstem. These injuries occur peripherally to the brainstem, not distal to the stem.

A 15-month-old child from Pennsylvania was brought to the ER for fever, seizure activity, cranial palsies, and paralysis. Which of the following diagnosis will be documented in the chart? a. Eastern equine encephalitis b. Venezuelan encephalitis c. St. Louis encephalitis d. West Nile encephalitis

ANS: A The symptoms indicate encephalitis, and given the residence of the child and the symptoms, the diagnosis is Eastern equine encephalitis. Venezuelan occurs in Texas, Florida, and the South. St. Louis occurs in Canada and the Pacific coast. West Nile occurs throughout the United States, but primarily affects the elderly.

A 75-year-old male experienced a lacunar stroke. When looking through the history of the patients chart, which of the following would the nurse expect to find? a. An embolus b. Hypertension c. A hemorrhage d. An aneurysm

ANS: B A lacunar stroke is associated with hypertension. A lacunar stroke is associated with hypertension, not an embolus. A lacunar stroke is associated with hypertension, not hemorrhage. A lacunar stroke is associated with hypertension, not an aneurysm.

When a patient asks how bad the injuries will be from a spinal injury, what is the nurses best response? It is difficult to know the full extent of the injury because of: a. Incomplete transection of the spinal cord b. Swelling within the spinal cord c. Necrosis of the spinal cord d. Free radical injury and scarring of the glial cells

ANS: B Cord swelling increases the individuals degree of dysfunction, so it is hard to distinguish functions permanently lost from those temporarily impaired. It is swelling, not incomplete transection, that leads to the difficulty knowing the full extent of injury in the spinal column. It is swelling, not necrosis, that leads to the difficulty knowing the full extent of injury in the spinal column. It is swelling, not free radical injury and scarring, that leads to the difficulty knowing the full extent of injury in the spinal column.

A 15-year-old male suffered diffuse brain injury after wrecking an all-terrain vehicle. He had momentary confusion and retrograde amnesia after 5 to 10 minutes. His injury could be categorized as: a. Grade I b. Grade II c. Grade III d. A mild concussion

ANS: B Grade II is manifested as momentary confusion and retrograde amnesia after 5 to 10 minutes. Grade I is manifested by confusion and disorientation with momentary amnesia. Grade III is manifested by confusion and retrograde amnesia from impactalso anterograde amnesia. A mild concussion does not result in memory loss.

A 10-year-old male was climbing on a house and fell. He suffered a severe brain injury. His Glasgow Coma Scale (GCS) was 5 initially and 7 after 1 day. He remained unconscious for 2 weeks, then was confused and suffered from anterograde amnesia. Which of the following is he most likely experiencing? a. Mild diffuse brain injury b. Moderate diffuse brain injury c. Severe diffuse brain injury d. Postconcussive syndrome

ANS: B In moderate diffuse axonal injury, the score on the GCS is 4 to 8 initially and 6 to 8 by 24 hours and the person is confused and suffers a long period of posttraumatic anterograde and retrograde amnesia. Individuals who experience diffuse brain injury experience agitation, impulsiveness, blunted affect, social withdrawal, and depression. In severe diffuse axonal injury, the person experiences immediate autonomic dysfunction that disappears in a few weeks. Increased ICP appears 4 to 6 days after the injury. In postconcussive syndrome the individual experiences headache, nervousness or anxiety, irritability, insomnia, depression, inability to concentrate, forgetfulness, and fatigability.

A 39-year-old male suffers a severe brain injury when he falls off a building while working. CT scan reveals that he has a basilar skull fracture. Based upon his injuries, what major complication should the nurse observe for in this patient? a. Hematoma formation b. Meningeal infection c. Increased intracranial pressure (ICP) d. Cognitive deficits

ANS: B Individuals with basilar skull fractures should be observed for meningitis and other complications. Individuals with basilar skull fracture are at risk for meningitis due to the open fracture, not hematoma. Individuals with basilar skull fracture are at risk for meningitis due to the open fracture, not increased ICP. Individuals with basilar skull fracture are at risk for meningitis due to the open fracture, not cognitive deficits.

A neurologist is teaching about encephalitis. Which information should the neurologist include? Most causes of encephalitis are: a. Bacterial b. Viral c. Fungal d. Toxoid

ANS: B Most causes of encephalitis are viral. Most causes of encephalitis are viral, not bacterial. Most causes of encephalitis are viral, not fungal. Most causes of encephalitis are viral, not toxoid.

A 16-year-old male took a recreational drug that altered his level of arousal. Physical exam revealed a negative Babinski sign, equal and reactive pupils, and roving eye movements. Which of the following diagnosis will the nurse most likely see on the chart? a. Psychogenic arousal alteration b. Metabolically induced coma c. Structurally induced coma d. Structural arousal alteration

ANS: B Persons with metabolically induced coma generally retain ocular reflexes even when other signs of brainstem damage are present. Psychogenic arousal activation demonstrates a general psychiatric disorder. Structurally induced coma is manifested by asymmetric responses. Structural arousal alteration does not have drug use as its etiology.

A 25-year-old male died from a gunshot wound to the heart. Upon autopsy, abnormalities in the media of the arterial wall and degenerative changes were detected. Which of the following most likely accompanied this finding? a. Fusiform aneurysm b. Saccular aneurysm c. Arteriovenous malformation d. Thrombotic stroke

ANS: B Saccular aneurysms (berry aneurysms) occur frequently (in approximately 2% of the population) and likely result from congenital abnormalities in the media of the arterial wall and degenerative changes. Fusiform aneurysms (giant aneurysms) occur as a result of diffuse arteriosclerotic changes and are found most commonly in the basilar arteries or terminal portions of the internal carotid arteries. Arteriovenous malformation (AVM) is a tangled mass of dilated blood vessels creating abnormal channels between the arterial and venous systems. Thrombotic stroke would show signs of necrotic tissue, not degenerative changes.

A 51-year-old male is admitted to the neurological critical care unit with a severe closed head injury. All four extremities are in rigid extension, his forearm is hyperpronated, and his legs are in plantar extension. How should the nurse chart this condition? a. Decorticate posturing b. Decerebrate posturing c. Caloric posturing d. Excitation posturing

ANS: B The description is of a patient in decerebrate posturing. The patient is in decerebrate posturing, not decorticate. The patient is in decerebrate posturing, not caloric. The patient is in decerebrate posturing, not excitation.

The patient reports generalized muscle weakness. The health care provider orders administration of the medication edrophonium chloride (Tensilon). This medication is used in the diagnosis of: a. Amyotrophic lateral sclerosis b. Myasthenia gravis c. MS d. Autonomic hyperreflexia

ANS: B The diagnosis of myasthenia gravis is made on the basis of a response to edrophonium chloride (Tensilon). The diagnosis of myasthenia gravis, not amyotrophic lateral sclerosis, is made on the basis of a response to edrophonium chloride (Tensilon). The diagnosis of myasthenia gravis, not MS, is made on the basis of a response to edrophonium chloride (Tensilon). The diagnosis of myasthenia gravis, not autonomic hyperreflexia, is made on the basis of a response to edrophonium chloride (Tensilon).

A 23-year-old female begins having problems with tiredness, weakness, and visual changes. Her diagnosis is multiple sclerosis (MS). What is occurring in the patients body? a. Depletion of dopamine in the central nervous system (CNS) b. Demyelination of nerve fibers in the CNS c. The development of neurofibril webs in the CNS d. Reduced amounts of acetylcholine at the neuromuscular junction

ANS: B The pathophysiology of MS includes demyelination of nerve fibers. Depletion of dopamine is related to Parkinson disease. The development of neurofibrils is related to Alzheimer disease. Myasthenia gravis is due to decreased amounts of acetylcholine at the junction.

A 15-year-old male is brought to the ER for treatment of injuries received in a motor vehicle accident. An MRI reveals spinal cord injury, and his body temperature fluctuates markedly. The most accurate explanation of this phenomenon is that: a. He developed pneumonia. b. His sympathetic nervous system has been damaged and thermal control disturbed. c. He has a brain injury. d. He has septicemia from an unknown source.

ANS: B The patient experiences disturbed thermal control because the sympathetic nervous system is damaged. The hypothalamus cannot regulate body heat through vasoconstriction and increased metabolism; therefore, the individual assumes the temperature of the air. The patient may develop pneumonia, but the temperature fluctuation is due to disturbed thermal control because the sympathetic nervous system is damaged. The hypothalamus cannot regulate body heat through vasoconstriction and increased metabolism; therefore, the individual assumes the temperature of the air. The patient may have a brain injury, but thermal control is affected because the sympathetic nervous system is damaged. The hypothalamus cannot regulate body heat through vasoconstriction and increased metabolism; therefore, the individual assumes the temperature of the air. The patient exhibits disturbed thermal control, not because of septicemia, but because the sympathetic nervous system is damaged. The hypothalamus cannot regulate body heat through vasoconstriction and increased metabolism; therefore, the individual assumes the temperature of the air.

A 20-year-old male suffers a severe closed head injury in a motor vehicle accident. He remains in a vegetative state (VS) 1 month after the accident. Which of the following structures is most likely keeping him in a vegetative state? a. Cerebral cortex b. Brainstem c. Spinal cord d. Cerebellum

ANS: B When a person loses cerebral function, the reticular activating system and brainstem can maintain a crude waking state known as a VS. Cognitive cerebral functions, however, cannot occur without a functioning reticular activating system. A VS is associated with the brainstem, not the cerebral cortex. A VS is associated with the brainstem, not the spinal cord. A VS is associated with the brainstem, not the cerebellum.

A 48-year-old female presents at the ER reporting an acute severe headache, nausea, photophobia, and nuchal rigidity. What does the nurse suspect caused these signs and symptoms? a. Diffuse brain injury b. Subarachnoid hemorrhage c. Epidural hematoma d. Classic concussion

ANS: B With subarachnoid hemorrhage, meningeal irritation occurs, leading to nuchal rigidity. Diffuse brain injury is not associated with nuchal rigidity. Epidural hematoma is not associated with nuchal rigidity. Classic concussion is not associated with nuchal rigidity.

Which of the following would increase a patients risk for thrombotic stroke? a. Hyperthyroidism b. Hypertension c. Anemia d. Dehydration

ANS: D Dehydration is a risk factor because it increases blood viscosity and decreases cerebral perfusion. Hyperthyroidism would lead to increased blood pressure but does not place the patient at risk for thrombotic stroke. Hypotension, not hypertension is a risk factor for thrombotic stroke. Anemia would decrease a persons risk for thrombotic stroke.

A patient has memory loss of events that occurred before a head injury. What cognitive disorder does the nurse suspect the patient is experiencing? a. Selective memory deficit b. Anterograde amnesia c. Retrograde amnesia d. Executive memory deficit

ANS: C Retrograde amnesia is manifested by loss of memory of past personal history memories or past factual memories. In selective memory deficit, the person reports inability to focus attention and has failure to perceive objects and other stimuli. Anterograde amnesia is a loss of the ability to form new memories. Executive memory deficit involves the failure to stay alert and oriented to stimuli.

Which statement by the nurse indicates teaching was successful regarding CNS tumors in adults? The most common primary CNS tumors in adults are: a. Meningiomas b. Oligodendrogliomas c. Astrocytomas d. Ependymomas

ANS: C Astrocytomas are the most common primary tumors in the CNS, accounting for over 50%. Meningiomas tumors usually originate from the arachnoidal (meningeal) cap cells in the dura mater and account for 30% of tumors. Oligodendrogliomas account for about 2% of tumors. Ependymomas are more common in children.

A major contributing process in CVAs is the development of atheromatous plaques in cerebral circulation. These most commonly form: a. In the larger veins b. Near capillary sphincters c. In cerebral arteries d. In the venous sinuses

ANS: C Atheromatous plaques (stenotic lesion) form at branchings and curves in the cerebral circulation. Over 20 to 30 years, atheromatous plaques (stenotic lesion) form at branchings and curves in the cerebral circulation, primarily the arteries. Over 20 to 30 years, atheromatous plaques (stenotic lesion) form at branchings and curves in the cerebral circulation, not in the sphincters Over 20 to 30 years, atheromatous plaques (stenotic lesion) form at branchings and curves in the cerebral circulation, primarily in the arterial vessels.

A 33-year-old male is brought to the ER for treatment of injuries received in a motor vehicle accident. An MRI reveals an injury of the cervical cord. Cord swelling in this region may be life threatening because: a. Increased ICP may occur. b. Reflexes will be disrupted. c. Diaphragm function may be impaired. d. Bladder emptying will not occur.

ANS: C In the cervical region, cord swelling may be life threatening because it may impair the diaphragm function. Increased ICP does not occur with cord injury, but cord swelling may be life threatening because it may impair the diaphragm function. Reflexes may be disrupted, but the cord swelling may be life threatening because it may impair the diaphragm function. Bladder emptying may not occur, but the cord swelling may be life threatening because it may impair the diaphragm function.

A 65-year-old female loses her balance while walking in the woods, causing her to fall and hit her head. She loses consciousness and is in a coma for 5 days. She is diagnosed as having diffuse brain injury. Which of the following would most likely occur in this patient? a. Complete loss of vision b. Arrhythmia c. Blunted affect d. Meningitis infection

ANS: C Individuals who experience diffuse brain injury experience agitation, impulsiveness, blunted affect, social withdrawal, and depression. Individuals who experience diffuse brain injury may experience visual impairments, but do not experience loss of vision. Individuals who experience diffuse brain injury may experience paralysis, but do not experience arrhythmias. Individuals with basilar skull fractures experience meningitis, not those with diffuse brain injury.

Which assessment finding by the nurse characterizes a mild concussion? a. A brief loss of consciousness b. Significant behavioral changes c. Retrograde amnesia d. Permanent confusion

ANS: C Mild concussion is characterized by immediate but transitory confusion that lasts for one to several minutes, possibly with amnesia for events preceding the trauma. Individuals with extradural hematomas lose consciousness at injury; one-third then become lucid for a few minutes to a few days. Persons with diffuse brain injury demonstrate behavioral changes. Individuals with a mild concussion experience transient not permanent confusion.

When a patient asks, What is the cause of multiple sclerosis? how should the nurse reply? The cause of MS seems to be an interaction between: a. Vascular and metabolic factors b. Bacterial infection and the inflammatory response c. Autoimmunity and genetic susceptibility d. Neurotransmitters and inherited genes

ANS: C Multiple sclerosis is due to an interaction between the autoimmune response and genetics. Multiple sclerosis is an autoimmune disorder. Multiple sclerosis is an autoimmune disorder that is thought to have developed secondary to a viral infection, not bacterial. Multiple sclerosis is not related to a neurotransmitter dysfunction.

An initial assessment finding associated with acute spinal cord injury is _____ the injury. a. Pain below the level of b. Loss of autonomic reflexes above c. Loss of voluntary control below d. Hyperactive spinal reflexes below

ANS: C Normal activity of the spinal cord cells at and below the level of injury ceases because of loss of the continuous tonic discharge from the brain or brainstem and inhibition of suprasegmental impulses immediately after cord injury, thus causing spinal shock. Pain would not be present below the level of the injury because activity of the cells below the level of injury ceases. Autonomic reflexes above the injury remain intact. Activity of the cells below the level of injury cease; thus, hyperactive spinal reflexes below the injury will not occur.

A 50-year-old male presents with low back pain. He denies trauma and says he just woke up and it was hurting. An MRI reveals that the vertebra at L5 slid forward relative to those above and below it. Which of the following conditions will be documented on the chart? a. Degenerative disk disease b. Spondylolysis c. Spondylolisthesis d. Spinal stenosis

ANS: C Spondylolisthesis occurs when there is forward displacement of the deficient vertebra. Degenerative disk disease is a pathophysiological cause of spondylolisthesis, but is not the definition of forward displacement. Spondylolysis is a structural defect of the spine. Spinal stenosis is a narrowing of the spinal canal.

A 20-year-old female suffered from spinal cord injury that resulted from a motor vehicle accident. She had spinal shock lasting 15 days and is now experiencing an uncompensated cardiovascular response to sympathetic stimulation. What does the nurse suspect caused this condition? a. Toxic accumulation of free radicals below the level of the injury b. Pain stimulation above the level of the spinal cord lesion c. A distended bladder or rectum d. An abnormal vagal response

ANS: C The described symptoms indicate autonomic hyperreflexia and are due to a distended bladder or rectum. The described symptoms indicate autonomic hyperreflexia and are due to a distended bladder or rectum, not the accumulation of free radicals. The described symptoms indicate autonomic hyperreflexia and are due to a distended bladder or rectum, not pain stimulation. The described symptoms indicate autonomic hyperreflexia and are due to a distended bladder or rectum, not an abnormal vagal response.

A 30-year-old white male recently suffered a cerebrovascular accident. Which of the following is the most likely factor that contributed to his stroke? a. Age b. Gender c. Diabetes d. Race

ANS: C The most likely contributing factor to the patients stroke is that he has diabetes with a fourfold increase in stroke incidence and an eightfold increase in stroke mortality. Age greater than 65 years is contributing factor. Men are affected, but for the 30-year-old, his type 2 diabetes mellitus contributes to a fourfold increase in stroke incidence and an eightfold increase in stroke mortality. Blacks are affected more than whites, and it is this patients diabetes that places him at risk.

Six weeks ago a female patient suffered a T6 spinal cord injury. She then developed a blood pressure of 200/120, a severe headache, blurred vision, and bradycardia. What does the nurse suspect the patient is experiencing? a. Extreme spinal shock b. Acute anxiety c. Autonomic hyperreflexia d. Parasympathetic areflexia

ANS: C The patient is experiencing autonomic hyperreflexia, which is manifested by paroxysmal hypertension (up to 300 mm Hg, systolic), a pounding headache, blurred vision, sweating above the level of the lesion with flushing of the skin, nasal congestion, nausea, piloerection caused by pilomotor spasm, and bradycardia (30 to 40 beats/min). The patient in extreme spinal shock experiences paralysis and flaccidity in muscles, absence of sensation, loss of bladder and rectal control, transient drop in blood pressure, and poor venous circulation. The patient may experience acute anxiety, but the symptoms of elevated blood pressure with severe headache is due to autonomic hyperreflexia. It is autonomic hyperreflexia, not parasympathetic areflexia, that produces paroxysmal hypertension (up to 300 mm Hg, systolic), a pounding headache, blurred vision, sweating above the level of the lesion with flushing of the skin, nasal congestion, nausea, piloerection caused by pilomotor spasm, and bradycardia (30 to 40 beats/min).

A 60-year-old female with a recent history of head trauma and a long-term history of hypertension presents to the ER for changes in mental status. MRI reveals that she had a hemorrhagic stroke. What does the nurse suspect caused this type of stroke? a. Rheumatic heart disease b. Thrombi c. Aneurysm d. Hypotension

ANS: C The primary causative factor of a hemorrhagic stroke is an aneurysm. The primary causative factor of a hemorrhagic stroke is an aneurysm, not thrombi, which would lead to thrombotic stroke. A thrombi would lead to a CVA from blockage, but not to a hemorrhagic stroke. Hypertension, not hypotension, would lead to a hemorrhagic stroke.

A 72-year-old male demonstrates left-sided weakness of upper and lower extremities. The symptoms lasted 4 hours and resolved with no evidence of infarction. The patient most likely experienced a(n): a. Stroke in evolution b. Arteriovenous malformation c. Transient ischemic attack d. Cerebral hemorrhage

ANS: C When symptoms resolve with complete recovery, it is a transient ischemic attack. A stroke in evolution is an impending stroke, and symptoms would not resolve. An arteriovenous malformation is an abnormal arrangement of blood vessels that could lead to stroke, but is not a disorder in itself. Cerebral hemorrhage would not resolve.

A 65-year-old male suffers a subarachnoid hemorrhage secondary to uncontrolled hypertension. He appears drowsy and confused with pronounced focal neurologic deficits. This condition is grade: a. I b. II c. III d. IV

ANS: C With grade III, the patient experiences drowsiness and confusion with or without focal neurologic deficits and pronounced meningeal signs. With grade I, neurologic status is intact with mild headache and slight nuchal rigidity. With grade II, neurologic deficit is evidenced by cranial nerve involvement and moderate to severe headache with more pronounced meningeal signs (e.g., photophobia, nuchal rigidity). With grade IV, the patient is stuporous with pronounced neurologic deficits (e.g., hemiparesis, dysphasia) and nuchal rigidity.

A nurse is preparing to teach staff about the most common type of traumatic brain injury. Which type of traumatic brain injury should the nurse discuss? a. Penetrating trauma b. Diffuse axonal injury c. Focal brain injury d. Concussion

ANS: D A concussion is the most common type of traumatic brain injury. Penetrating trauma is due to such items as bullets and is not the most common type of brain injury. Diffuse axonal injury is due to rotation and is not as common as concussions. Focal brain injury is not as common as concussions.

As a portion of the assessment of the patient with meningitis, the health care provider flexes the patients neck to the chest. The patient responds with flexion of the legs and thighs. The name for this response is: a. Decorticate posturing b. Decerebrate posturing c. Kernigs sign d. Brudzinskis sign

ANS: D Brudzinskis sign is demonstrated by flexion of the legs and thighs with forceful flexion of the neck onto the chest. Decorticate posturing occurs when the arms are bent forward on the chest and the hands clenched. Decerebrate posturing occurs when the upper extremities extend. Kernigs sign occurs when the patient straightens the knee with the hip and knee in a flexed position.

_____ are most at risk of spinal cord injury from minor trauma. a. Infants b. Men c. Women d. The elderly

ANS: D Elderly people are particularly at risk from minor trauma that results in serious spinal cord injury because of preexisting degenerative vertebral disorders. It is the elderly, not infants, who are at risk for minor trauma that results in serious spinal cord injury because of preexisting degenerative vertebral disorders. Males are at greatest risk for major spinal cord injury. It is the elderly that are most at risk for injury with minor trauma. Males, not females, are at greatest risk for major spinal cord injury. It is the elderly that are most at risk for injury with minor trauma.

An adult has hydrocephalus. When the patient asks the nurse what caused this, how should the nurse respond? Hydrocephalus in adults is most often caused by: a. Overproduction of CSF b. Intercellular edema c. Elevated arterial blood pressure d. Defective CSF reabsorption

ANS: D Hydrocephalus occurs because of defective reabsorption of the fluid. Hydrocephalus can occur because of overproduction of CSF, but in adults it occurs most often because of defective reabsorption of the fluid. Hydrocephalus is not due to intercellular edema. Hydrocephalus does not occur due to elevated arterial blood pressure.

Which statement by a patient indicates teaching was successful regarding myasthenia gravis? Myasthenia gravis results from: a. Viral infection of skeletal muscle b. Atrophy of motor neurons in the spinal cord c. Demyelination of skeletal motor neurons d. Autoimmune injury at the neuromuscular junction

ANS: D Myasthenia gravis is a disorder resulting from autoimmune injury at the neuromuscular junction. Myasthenia gravis is a disorder resulting from autoimmune injury at the neuromuscular junction, not from a viral infection. Myasthenia gravis is a disorder resulting from autoimmune injury at the neuromuscular junction. It is not due to motor neuron atrophy, but a lack of acetylcholine. MS is due to demyelination of skeletal motor neurons, not myasthenia gravis.

An older adult is admitted to the ER following a fall. The patient complains of pain in the back. The patient has a history of osteoporosis. The nurse would expect the patients injury and subsequent pain is most likely due to: a. A fractured hip b. Spinal stenosis c. Herniation of a thoracic disk d. A spinal compression fracture

ANS: D Osteoporosis increases the risk of spinal compression fractures and may be why elderly women report more symptoms than men. A fracture of the hip could have occurred, but the patients pain is in the back and this would not cause pain in the back. Spinal stenosis is a narrowing of the spinal and is most often congenital and would not be due to a fall. Herniation of a thoracic disk could have occurred, but the most likely explanation is a compression fracture.

A teenage boy sustains a severe closed head injury following an all-terrain vehicle (ATV) accident. He is in a state of deep sleep that requires vigorous stimulation to elicit eye opening. How should the nurse document this in the chart? a. Confusion b. Coma c. Obtundation d. Stupor

ANS: D Stupor is a condition of deep sleep or unresponsiveness from which the person may be aroused or caused to open eyes only by vigorous and repeated stimulation. Confusion is the loss of the ability to think rapidly and clearly and is characterized by impaired judgment and decision making. Coma is a condition in which there is no verbal response to the external environment or to any stimuli; noxious stimuli such as deep pain or suctioning do not yield motor movement. Obtundation is a mild to moderate reduction in arousal (awakeness) with limited response to the environment.

The majority of intervertebral disk herniations occur between which vertebral levels (cervical, C; thoracic, T; lumbar, L; sacral, S)? a. C1 to C3 b. T1 to T4 c. T12 to L3 d. L4 to S1

ANS: D The most common discs affected by herniation are the lumbosacral disksthat is, L5-S1 and L4-L5. Cervical herniation can occur, but the most common discs affected by herniation are the lumbosacral disksthat is, L5-S1 and L4-L5. The most common discs affected by herniation are the lumbosacral disksthat is, L5-S1 and L4-L5. The most common discs affected by herniation are the lumbosacral disksthat is, L5-S1 and L4-L5.

The nursing student would correctly identify the most common symptom of brain abscess as: a. Nuchal rigidity b. Vomiting c. Drowsiness d. Headache

ANS: D The most common symptom of brain abscess is headache. The most common symptom of brain abscess is headache; nuchal rigidity occurs, but is not the most common. Vomiting does not occur with brain abscess. Drowsiness occurs, but headache is the most common.

A 20-year-old male is brought to the emergency room (ER) for treatment of injuries received in a motor vehicle accident. A spinal cord injury is suspected. What two regions should the nurse assess as they are most likely to be damaged? a. Cervical and thoracic regions b. Thoracic and lumbar regions c. Lumbar and sacral regions d. Cervical and lumbar regions

ANS: D Vertebral injuries in adults occur most often at cervical and lumbar regions as these are the most mobile portions of the vertebral column. Vertebral injuries in adults occur most often at cervical and lumbar regions, rather than the cervical and thoracic, as these are the most mobile portions of the vertebral column. Vertebral injuries in adults occur most often at cervical and lumbar regions, rather than the thoracic and lumbar, as these are the most mobile portions of the vertebral column. Vertebral injuries in adults occur most often at cervical and lumbar regions, rather than the lumbar and sacral, as these are the most mobile portions of the vertebral column.

A 69-year-old male with a history of alcohol abuse presents to the emergency room (ER) after a month-long episode of headaches and confusion. Based on his alcoholism, a likely cause of his neurologic symptoms is: a. Concussion b. Chronic subdural hematoma c. Epidural hematoma d. Subacute subdural hematoma

B Chronic subdural hematomas are commonly found in persons who abuse alcohol and develop over weeks to months. A concussion is more acute, and chronic subdural hematomas are more commonly found in persons who abuse alcohol. It is a chronic subdural hematoma that occurs in alcoholics, not an epidural. Subacute subdural hematomas present with confusion, but these occur sooner than the chronic subdural associated with alcoholism.

A 15-year-old male was struck by a motor vehicle and suffered a traumatic brain injury. Paramedics found him unconscious at the scene of the accident. During the ambulance ride, he regained consciousness and was able to maintain a conversation with the medical staff. Upon arrival to hospital, he was alert and oriented. Physical exam reveals confusion and impaired responsiveness. What is the probable nature of his brain injury based on this history? a. Mild concussion b. Subdural hematoma c. Extradural (epidural) hematoma d. Mild diffuse axonal injury

C Individuals with extradural hematomas lose consciousness at injury; one-third then become lucid for a few minutes to a few days. Mild concussion is characterized by immediate but transitory confusion that lasts for one to several minutes, possibly with amnesia for events preceding the trauma. Subdural hematomas begin with headache, drowsiness, restlessness or agitation, slowed cognition, and confusion. These symptoms worsen over time and progress to loss of consciousness, respiratory pattern changes, and pupillary dilation. Individuals with mild diffuse axonal injury display decerebrate or decorticate posturing and may experience prolonged periods of stupor or restlessness.