Lewis Ch 58, Lewis Ch 55

A patient who is having an acute exacerbation of multiple sclerosis has a prescription for methylprednisolone (Solu-Medrol) 160 mg IV. The label on the vial reads: methylprednisolone 125 mg in 2 mL. How many mL will the nurse administer?

2.56. With a concentration of 125 mg/2 mL, the nurse will need to administer 2.56 mL to obtain 160 mg of methylprednisolone.

A patient with Parkinson's disease is admitted to the hospital for treatment of pneumonia. Which nursing interventions will be included in the plan of care (select all that apply)? a. Use an elevated toilet seat. b. Cut patient's food into small pieces. c. Provide high-protein foods at each meal. d. Place an armchair at the patient's bedside. e. Observe for sudden exacerbation of symptoms.

A, B, D a. Use an elevated toilet seat. b. Cut patient's food into small pieces. d. Place an armchair at the patient's bedside. Because the patient with Parkinson's has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High-protein foods will decrease the effectiveness of L-dopa. Parkinson's is a steadily progressive disease without acute exacerbations.

A 27-year-old patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room (select all that apply)? a. Side-rail pads b. Tongue blade c. Oxygen mask d. Suction tubing e. Urinary catheter f. Nasogastric tube

A, C, D a. Side-rail pads c. Oxygen mask d. Suction tubing The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The bed's side rails should be padded to minimize the risk for patient injury during a seizure. Use of tongue blades during a seizure is contraindicated. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. A urinary catheter is not required unless there is urinary retention.

In which patient would it be the most important for the nurse to assess the glossopharyngeal and vagus nerves? A. A 50-year-old woman with lethargy from a drug overdose B. A 40-year-old man with a complete lumbar spinal cord injury C. A 60-year-old man with severe pain from trigeminal neuralgia D. A 30-year-old woman with a high fever and bacterial meningitis

A. A 50-year-old woman with lethargy from a drug overdose The glossopharyngeal and vagus nerves innervate the pharynx and are tested by the gag reflex. It is important to assess the gag reflex in patients who have a decreased level of consciousness, a brainstem lesion, or a disease involving the throat musculature. If the reflex is weak or absent, the patient is in danger of aspirating food or secretions.

The nurse is completing a health assessment for an obese 62-year-old man who wants to begin a diet and exercise program. Which assessment should the nurse perform to determine the cognitive function of the patient during the physical examination? A. Ask the patient a question such as, "Who were the last three presidents?" B. Determine the level of consciousness, body posture, and facial expressions. C. Observe for signs of agitation, anger, or depression during the health check. D. Request that the patient mimic rapid, alternating movements with both hands.

A. Ask the patient a question such as, "Who were the last three presidents?" Cognition is one component of the mental status examination to determine cerebral functioning. Cognition is assessed by determining orientation, memory, general knowledge, insight, judgment, problem solving, and calculation. A question often used to determine cognition for adults living in the United States is, "Who were the last three presidents?" General appearance and behavior is another component and includes level of consciousness, body posture, and facial expressions. Mood and affect are assessed by observing for agitation, anger, or depression. Cerebellar function is determined by assessing balance and coordination and may include testing rapid alternating movements of the upper and lower extremities.

The nurse cares for a 34-year-old woman after a lumbar puncture. Which action by the nurse is most appropriate? A. Assess for drainage or bleeding from the puncture site. B. Monitor for bladder dysfunction and bowel incontinence. C. Maintain bed rest until lower extremities move normally. D. Check for loss of muscle strength in the upper extremities.

A. Assess for drainage or bleeding from the puncture site. After a lumbar puncture the nurse should monitor the puncture site for drainage or bleeding. Other assessments include headache intensity, meningeal irritation (nuchal rigidity), signs and symptoms of local trauma (e.g., hematoma, pain), neurologic signs, and vital signs. A lumbar puncture does not affect bowel or bladder function or upper extremity muscle strength. Bed rest until lower extremity movement returns is indicated for the patient after spinal anesthesia. Awarded 1.0 points out of 1.0 possible points.

When assessing a patient with a traumatic brain injury, the nurse notes uncoordinated movement of the extremities. How should the nurse document this assessment? A. Ataxia B. Apraxia C. Anisocoria D. Anosognosia

A. Ataxia Ataxia is a lack of coordination of movement, possibly caused by lesions of sensory or motor pathways, cerebellum disorders, or certain medications. Apraxia is the inability to perform learned movements despite having the desire and physical ability to perform them related to a cerebral cortex lesion. Anisocoria is inequality of pupil size from an optic nerve injury. Anosognosia is the inability to recognize a bodily defect or disease related to lesions in the right parietal cortex.

A patient who has a neurologic disease that affects the pyramidal tract is likely to manifest what sign? A. Impaired muscle movement B. Decreased deep tendon reflexes C. Decreased level of consciousness D. Impaired sensation of touch, pain, and temperature

A. Impaired muscle movement Among the most important descending tracts are the corticobulbar and corticospinal tracts, collectively termed the pyramidal tract. These tracts carry volitional (voluntary) impulses from the cortex to the cranial and peripheral nerves. Dysfunction of the pyramidal tract is likely to manifest as impaired movement because of hypertonicity. Diseases affecting the pyramidal tract do not result in changes in LOC, impaired reflexes, or decreased sensation.

Data regarding mobility, strength, coordination and activity tolerance are important for the nurse to obtain because? A. Many neurologic diseases affect one or more of these areas B. Patients are less able to identify other neurologic impairments C. These are the first functions to be affected by neurologic diseases D. Aspects of movement are the most important function of the nervous system

A. Many neurologic diseases affect one or more of these areas Rationale: Many neurologic disorders affect the patient's mobility, strength, and coordination. These problems can alter the patient's usual activity and exercise patterns.

A patient's eyes jerk while the patient looks to the left. You will record this finding as? A. Nystagmus B. CN VI palsy C. Oculocephalia D. Ophthalmic dyskenesia

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

A patient with heart failure and type 1 diabetes mellitus is scheduled for a positron emission tomography (PET) of the brain. Which medication prescribed by the health care provider should the nurse expect to administer before the diagnostic study? A. Regular insulin 6 units (SQ) B. Furosemide (Lasix) 20 mg (IV) C. Alprazolam (Xanax) 0.5 mg (PO) D. Ciprofloxacin (Cipro) 500 mg (PO)

A. Regular insulin 6 units (SQ) Patients with type 1 diabetes mellitus must have insulin administered the day of the PET study if glucose metabolism is the focus of the PET. Diuretics should not be administered before the PET scan unless a urinary catheter is inserted. The patient must remain still during the procedure (1 to 2 hours). Sedatives and tranquilizers (e.g., alprazolam) should not be administered before a PET study of the brain because the patient may need to perform mental activities and these medications may affect glucose metabolism. Prophylactic antibiotics are not necessary. Patients are NPO before a PET study of the brain and should not receive oral medications (alprazolam and ciprofloxacin)

Which assessments will the nurse make to test a patient's cerebellar function (select all that apply)? a. Assess for graphesthesia. b. Perform the finger-to-nose test. c. Observe arm movement with gait. d. Check ability to push against resistance. e. Determine ability to sense heat and cold.

B C b. Perform the finger-to-nose test. c. Observe arm movement with gait. The cerebellum is responsible for coordination and is assessed by looking at the patient's gait and the finger-to-nose test. The other assessments will be used for other parts of the neurological assessment. DIF: Cognitive Level: Analysis REF: 1417-1418

Which normal nervous system changes of aging put the geriatric person at higher risk of falls (select all that apply)? A. Memory deficit B. Sensory deficit C. Motor function deficit D. Cranial and spinal nerves E. Reticular activation system F. Central nervous system changes

B,C,F B. Sensory deficit C. Motor function deficit F. Central nervous system changes An older person is at a higher risk for falls because the changes in the nervous system decrease the sensory function that leads to poor ability to maintain balance and a widened gait. The motor function deficit decreases muscle strength and agility. The central nervous system changes in the brain lead to a diminished kinesthetic sense or position sense. Memory deficits, normal changes of cranial and spinal nerves, and the reticular activation system do not contribute to the increased risk of falls.

When assessing the accessory nerve, what should the nurse do? A. Assess the gag reflex by stroking the posterior pharynx. B. Ask the patient to shrug the shoulders against resistance. C. Ask the patient to push the tongue to either side against resistance. D. Have the patient say "ah" while visualizing elevation of soft palate.

B. Ask the patient to shrug the shoulders against resistance. The spinal accessory nerve is tested by asking the patient to shrug the shoulders against resistance and to turn the head to either side against resistance while observing the sternocleidomastoid muscles and the trapezius muscles. Assessing the gag reflex and saying "ah" are used to assess the glossopharyngeal and vagus nerves. Asking the patient to push the tongue to either side against resistance and to stick out the tongue are used to assess the hypoglossal nerve

How should the nurse most accurately assess the position sense of a patient with a recent traumatic brain injury? A. Ask the patient to close his or her eyes and slowly bring the tips of the index fingers together. B. Ask the patient to stand with the feet together and eyes closed and observe for balance maintenance. C. Ask the patient to close his or her eyes and identify the presence of a common object on the forearm. D. Place the two points of a calibrated compass on the tips of the fingers and toes and ask the patient to discriminate the points.

B. Ask the patient to stand with the feet together and eyes closed and observe for balance maintenance. The Romberg test is an assessment of position sense in which the patient stands with the feet together and then closes his or her eyes while attempting to maintain balance. The other cited tests of neurologic function do not directly assess position sense.

A patient has been taking phenytoin (Dilantin) for 2 years. Which action will the nurse take when evaluating for adverse effects of the medication? a. Inspect the oral mucosa. b. Listen to the lung sounds. c. Auscultate the bowel tones. d. Check pupil reaction to light.

a. Inspect the oral mucosa. Phenytoin can cause gingival hyperplasia, but does not affect bowel tones, lung sounds, or pupil reaction to light.

10. The nurse is caring for a patient with peripheral neuropathy who is going to have EMG studies tomorrow morning. The nurse should? A. Ensure the patient has an empty bladder B. Instruct the patient that there is no risk of electric shock C. Ensure the patient has no metallic jewelry or metal fragments D. Instruct the patient that she or he may experience pain during the study

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

A patient's sudden onset of hemiplegia has necessitated a computed tomography (CT) of her head. Which assessment should the nurse complete prior to this diagnostic study? A. Assess the patient's immunization history. B. Screen the patient for any metal parts or a pacemaker. C. Assess the patient for allergies to shellfish, iodine, or dyes. D. Assess the patient's need for tranquilizers or antiseizure medications.

C. Assess the patient for allergies to shellfish, iodine, or dyes. Allergies to shellfish, iodine, or dyes contraindicate the use of contrast media in CT. The patient's immunization history is not a central consideration, and the presence of metal in the body does not preclude the use of CT as a diagnostic tool. The need to assess for allergies supersedes the need for tranquilizers or antiseizure medications in the majority of patients.

The new patient has a diagnosis of frontal lobe dementia. What functional difficulties should the nurse expect in this patient? A. The lack of reflexes B. Endocrine problems C. Higher cognitive function abnormalities D. Respiratory, vasomotor, and cardiac dysfunction

C. Higher cognitive function abnormalities Because the frontal lobe is responsible for higher cognitive function, this patient may have difficulty with memory retention, voluntary eye movements, voluntary motor movement, and expressive speech. The lack of reflexes would occur if the patient had problems with the reflex arcs in the spinal cord. Endocrine problems would be evident if the hypothalamus or pituitary gland were affected. Respiratory, vasomotor, and cardiac dysfunction would occur if there were a problem in the medulla.

An obstruction of the anterior cerebral arteries will affect functions of? A. Visual imaging B. balane and coordination C. Judgment, insight, and reasoning D. Visual and auditory integration for language comprehension

C. Judgment, insight, and reasoning Rationale: The anterior cerebral artery feeds the medial and anterior portions of the frontal lobes. The anterior portion of the frontal lobe controls higher order processes such as judgment and reasoning.

The nurse is caring for a group of well older people at a community day center. Which neurologic finding associated with aging would the nurse expect to find in older adults? A. Longer reaction time B. Improved sense of taste C. Orthostatic hypotension D. Hyperactive deep tendon reflexes

C. Orthostatic hypotension Older adults are more likely to experience orthostatic hypotension related to altered coordination of neuromuscular activity. Other neurologic changes in the older adult include atrophy of taste buds with decreased sense of taste, below average reflex score (and diminished deep tendon reflexes), and slowed reaction times.

During neurologic testing, the patient is able to perceive pain elicited by pinprick based on this finding the nurse may omit testing for? A. Position sense B. Patellar reflexes C. Temperature perception D. Heel-to- shin movements

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

The nurse is preparing the patient for an electromyography (EMG). What should the nurse include in teaching the patient before the test? A.The patient will be tilted on a table during the test. B. It is noninvasive, and there is no risk of electric shock. C.The pain that occurs is from the insertion of the needles. D.The passive sensor does not make contact with the patient.

C.The pain that occurs is from the insertion of the needles. With an EMG, pain may occur when needles are inserted to record the electrical activity of nerve and skeletal muscle. The patient is tilted on a table during a myelogram. The electroencephalography (EEG) is noninvasive without a danger of electric shock. The magnetoencephalography (MEG) is done with a passive sensor that does not make contact with the patient.

A result of stimulation of the parasympathetic nervous system is (select all that apply) A. constriction of the bronchi B. Dilation of skin blood vessels C. increased secreation of insulin D. increased blood glucose levels E. relaxation of the urinary sphincters

Correct answers: a, b, c, e A. constriction of the bronchi B. Dilation of skin blood vessels C. increased secreation of insulin E. relaxation of the urinary sphincters Rationale: Stimulation of the parasympathetic nervous system results in constriction of the bronchi, dilation of blood vessels to the skin, increased secretion of insulin, and relaxation of the urinary sphincter. Stimulation of the sympathetic nervous system results in increased blood glucose levels.

Assessment of muscle strength of older adults cannot be compared with that of younger adults because? A. Stroke is more common in older adults B. Nutritional status is better in younger adults C. Most young people exercise more than older people D. Aging leads to a decrease in muscle bulk and strength

D. Aging leads to a decrease in muscle bulk and strength Rationale: Changes associated with aging include decreases in muscle strength and agility in relation to decreased muscle bulk.

A patient is having a transsphenoidal hypophysectomy. The nurse should provide preoperative patient teaching about what potential deficit as a result of the surgery? A. Increased heart rate B. Loss of coordination C. Impaired swallowing D. Altered sense of smell

D. Altered sense of smell Using a transsphenoidal approach to remove the pituitary gland includes a risk of damage to the olfactory cranial nerve because the cell bodies of the olfactory nerve are located in the nasal epithelium. With damage to this nerve, the sense of smell would be altered. Increased heart rate, loss of coordination, and impaired swallowing will not be potential deficits from this surgery.

Drugs or disease that impair the function of the extrapyramidal system may cause loss of? A. sensations of pain and temperature B. regulation of the automonic nervous system C. integration of somatic and special sensory inputs D. Automatic movements asociated with skeletal muscle activity

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

In a patient with a disease that affects the myelin sheath of nerves, such as multiple sclerosis the glial cells affected are the? A. microglia b. Astrocytes. C. ependymal cells D. Oligodendrocytes

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

When assessing motor function of a patient admitted with a stroke, the nurse notes mild weakness of the arm demonstrated by downward drifting of the arm. How should the nurse most accurately document this finding? A. Athetosis B. Hypotonia C. Hemiparesis D. Pronator drift

D. Pronator drift Downward drifting of the arm or pronation of the palm is identified as a pronator drift. Athetosis is a slow, writhing, involuntary movement of the extremities. Hypotonia is flaccid muscle tone, and hemiparesis is weakness of one side of the body.

Paralysis of lateral gaze indicates a lesion of cranial nerve A. II B. III C. IV D. VI

D. VI Rationale: Cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) are responsible for eye movement. The lateral rectus eye muscle is innervated by cranial nerve VI, and it is the primary muscle that is responsible for lateral eye movement.

A 31-year-old woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which response by the nurse is accurate? a. "MS symptoms may be worse after the pregnancy." b. "Women with MS frequently have premature labor." c. "MS is associated with an increased risk for congenital defects." d. "Symptoms of MS are likely to become worse during pregnancy."

a. "MS symptoms may be worse after the pregnancy." During the postpartum period, women with MS are at greater risk for exacerbation of symptoms. There is no increased risk for congenital defects in infants born of mothers with MS. Symptoms of MS may improve during pregnancy. Onset of labor is not affected by MS.

When admitting an acutely confused patient with a head injury, which action should the nurse take? a. Ask family members about the patient's health history. b. Ask leading questions to assist in obtaining health data. c. Wait until the patient is better oriented to ask questions. d. Obtain only the physiologic neurologic assessment data.

a. Ask family members about the patient's health history. When admitting a patient who is likely to be a poor historian, the nurse should obtain health history information from others who have knowledge about the patient's health. Waiting until the patient is oriented or obtaining only physiologic data will result in incomplete assessment data; this could adversely affect decision-making about treatment. Asking leading questions may result in inaccurate or incomplete information. DIF: Cognitive Level: Application REF: 1412-1413

A 64-year-old patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care? a. Assist with active range of motion (ROM). b. Observe for agitation and paranoia. c. Give muscle relaxants as needed to reduce spasms. d. Use simple words and phrases to explain procedures.

a. Assist with active range of motion (ROM). ALS causes progressive muscle weakness, but assisting the patient to perform active ROM will help maintain strength as long as possible. Psychotic manifestations such as agitation and paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the patient's ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations.

A 46-year-old patient tells the nurse about using acetaminophen (Tylenol) several times every day for recurrent bilateral headaches. Which action will the nurse plan to take first? a. Discuss the need to stop taking the acetaminophen. b. Suggest the use of biofeedback for headache control. c. Describe the use of botulism toxin (Botox) for headaches. d. Teach the patient about magnetic resonance imaging (MRI).

a. Discuss the need to stop taking the acetaminophen. The headache description suggests that the patient is experiencing medication overuse headache. The initial action will be withdrawal of the medication. The other actions may be needed if the headaches persist.

A patient reports feeling numbness and tingling of the left arm before experiencing a tonic-clonic seizure. The nurse determines that this history is consistent with what type of seizure? a. Focal b. Atonic c. Absence d. Myoclonic

a. Focal The initial symptoms of a focal seizure involve clinical manifestations that are localized to a particular part of the body or brain. Symptoms of an absence seizure are staring and a brief loss of consciousness. In an atonic seizure, the patient loses muscle tone and (typically) falls to the ground. Myoclonic seizures are characterized by a sudden jerk of the body or extremities.

After change-of-shift report, which patient should the nurse assess first? a. Patient with myasthenia gravis who is reporting increased muscle weakness b. Patient with a bilateral headache described as "like a band around my head" c. Patient with seizures who is scheduled to receive a dose of phenytoin (Dilantin) d. Patient with Parkinson's disease who has developed cogwheel rigidity of the arms

a. Patient with myasthenia gravis who is reporting increased muscle weakness Because increased muscle weakness may indicate the onset of a myasthenic crisis, the nurse should assess this patient first. The other patients should also be assessed, but do not appear to need immediate nursing assessments or actions to prevent life-threatening complications.

A hospitalized 31-year-old patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first? a. Start the ordered PRN oxygen at 6 L/min. b. Put a moist hot pack on the patient's neck. c. Give the ordered PRN acetaminophen (Tylenol). d. Notify the patient's health care provider immediately.

a. Start the ordered PRN oxygen at 6 L/min. Acute treatment for cluster headache is administration of 100% oxygen at 6 to 8 L/min. If the patient obtains relief with the oxygen, there is no immediate need to notify the health care provider. Cluster headaches last only 60 to 90 minutes, so oral pain medications have minimal effect. Hot packs are helpful for tension headaches but are not as likely to reduce pain associated with a cluster headache.

charge nurse is observing a new staff nurse who is assessing a patient with a possible spinal cord lesion for sensation. Which action indicates a need for further teaching about neurologic assessment? a. The new nurse asks the patient, "Does this feel sharp?" b. The new nurse tests for light touch before testing for pain. c. The new nurse has the patient close the eyes during testing. d. The new nurse uses an irregular pattern to test for intact touch.

a. The new nurse asks the patient, "Does this feel sharp?" When performing a sensory assessment, the nurse should not provide verbal clues. The other actions by the new nurse are appropriate. DIF: Cognitive Level: Application REF: 1417-1418

Which equipment will the nurse obtain to assess vibration sense in a patient who has peripheral nerve dysfunction? a. Sharp pin b. Tuning fork c. Reflex hammer d. Calibrated compass

b. Tuning fork Vibration sense is testing by touching the patient with a vibrating tuning fork. The other equipment is needed for testing of pain sensation, reflexes, and two-point discrimination. DIF: Cognitive Level: Comprehension REF: 1417-1419

To assess the functioning of the trigeminal and facial nerves (CN V and VII), the nurse should a. apply a cotton wisp strand to the cornea. b. have the patient read a magazine or book. c. shine a bright light into the patient's pupil. d. check for unilateral drooping of the eyelids.

a. apply a cotton wisp strand to the cornea The trigeminal and facial nerves are responsible for the corneal reflex. The optic nerve is tested by having the patient read a Snellen chart or a newspaper. Assessment of pupil response to light and ptosis are used to check function of the oculomotor nerve. DIF: Cognitive Level: Comprehension REF: 1416-1417

The nurse observes a patient ambulating in the hospital hall when the patient's arms and legs suddenly jerk and the patient falls to the floor. The nurse will first a. assess the patient for a possible head injury. b. give the scheduled dose of divalproex (Depakote). c. document the timing and description of the seizure. d. notify the patient's health care provider about the seizure.

a. assess the patient for a possible head injury. The patient who has had a myoclonic seizure and fall is at risk for head injury and should first be evaluated and treated for this possible complication. Documentation of the seizure, notification of the seizure, and administration of antiseizure medications are also appropriate actions, but the initial action should be assessment for injury.

The nurse advises a patient with myasthenia gravis (MG) to a. perform physically demanding activities early in the day. b. anticipate the need for weekly plasmapheresis treatments. c. do frequent weight-bearing exercise to prevent muscle atrophy. d. protect the extremities from injury due to poor sensory perception.

a. perform physically demanding activities early in the day. Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then. Plasmapheresis is not routinely scheduled, but is used for myasthenia crisis or for situations in which corticosteroid therapy must be avoided. There is no decrease in sensation with MG, and muscle atrophy does not occur because although there is muscle weakness, they are still used.

When developing a plan of care for a patient with dysfunction of the cerebellum, the nurse will include interventions to a. prevent falls. b. stabilize mood. c. enhance swallowing ability. d. improve short-term memory.

a. prevent falls. Because functions of the cerebellum include coordination and balance, the patient with dysfunction is at risk for falls. The cerebellum does not affect memory, mood, or swallowing ability. DIF: Cognitive Level: Application REF: 1410

A high school teacher who has just been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, "I cannot teach anymore, it will be too upsetting if I have a seizure at work." Which response by the nurse is best? a. "You might benefit from some psychologic counseling." b. "Epilepsy usually can be well controlled with medications." c. "You will want to contact the Epilepsy Foundation for assistance." d. "The Department of Vocational Rehabilitation can help with work retraining."

b. "Epilepsy usually can be well controlled with medications." The nurse should inform the patient that most patients with seizure disorders are controlled with medication. The other information may be necessary if the seizures persist after treatment with antiseizure medications is implemented.

A hospitalized patient complains of a bilateral headache, 4/10 on the pain scale, that radiates from the base of the skull. Which prescribed PRN medications should the nurse administer initially? a. Lorazepam (Ativan) b. Acetaminophen (Tylenol) c. Morphine sulfate (Roxanol) d. Butalbital and aspirin (Fiorinal)

b. Acetaminophen (Tylenol) The patient's symptoms are consistent with a tension headache, and initial therapy usually involves a nonopioid analgesic such as acetaminophen, which is sometimes combined with a sedative or muscle relaxant. Lorazepam may be used in conjunction with acetaminophen but would not be appropriate as the initial monotherapy. Morphine sulfate and butalbital and aspirin would be more appropriate for a headache that did not respond to a nonopioid analgesic.

Following a thymectomy, a 62-year-old male patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first? a. Auscultate the patient's bowel sounds. b. Notify the patient's health care provider. c. Administer the prescribed PRN antiemetic drug. d. Give the scheduled dose of prednisone (Deltasone).

b. Notify the patient's health care provider. The patient's history and symptoms indicate a possible cholinergic crisis. The health care provider should be notified immediately, and it is likely that atropine will be prescribed. The other actions will be appropriate if the patient is not experiencing a cholinergic crisis.

The home health registered nurse (RN) is planning care for a patient with a seizure disorder related to a recent head injury. Which nursing action can be delegated to a licensed practical/vocational nurse (LPN/LVN)? a. Make referrals to appropriate community agencies. b. Place medications in the home medication organizer. c. Teach the patient and family how to manage seizures. d. Assess for use of medications that may precipitate seizures.

b. Place medications in the home medication organizer. LPN/LVN education includes administration of medications. The other activities require RN education and scope of practice.

The following orders are received for an unconscious patient who has just arrived in the emergency department after a head injury caused by an automobile accident. Which one should the nurse question? a. Obtain x-rays of the skull and spine. b. Prepare the patient for lumbar puncture. c. Send for computed tomography (CT) scan. d. Perform neurologic checks every 15 minutes.

b. Prepare the patient for lumbar puncture. After a head injury, the patient may be experiencing intracranial bleeding and increased intracranial pressure, which could lead to herniation of the brain with lumbar puncture. The other orders are appropriate. DIF: Cognitive Level: Application REF: 1418-1419

Which information about a 71-year-old patient is most important for the admitting nurse to report to the patient's health care provider? a. Triceps reflex response graded at 1/5 b. Recent unintended weight loss of 20 pounds c. Patient complaint of chronic difficulty in falling asleep d. Orthostatic drop in systolic blood pressure of 10 mm Hg

b. Recent unintended weight loss of 20 pounds Although changes in appetite are normal with aging, a 20-pound weight loss requires further investigation. Orthostatic drops in blood pressure, changes in sleep patterns, and slowing of reflexes are normal changes in aging. DIF: Cognitive Level: Application REF: 1412-1413 | 1414

A 73-year-old patient with Parkinson's disease has a nursing diagnosis of impaired physical mobility related to bradykinesia. Which action will the nurse include in the plan of care? a. Instruct the patient in activities that can be done while lying or sitting. b. Suggest that the patient rock from side to side to initiate leg movement. c. Have the patient take small steps in a straight line directly in front of the feet. d. Teach the patient to keep the feet in contact with the floor and slide them forward.

b. Suggest that the patient rock from side to side to initiate leg movement. Rocking the body from side to side stimulates balance and improves mobility. The patient will be encouraged to continue exercising because this will maintain functional abilities. Maintaining a wide base of support will help with balance. The patient should lift the feet and avoid a shuffling gait.

The nurse notes in the patient's medical history that the patient has a positive Romberg test. Which nursing diagnosis is appropriate? a. Acute pain related to hyperreflexia and spasm b. Risk for falls related to dizziness or weakness c. Disturbed tactile sensory perception related to spinal cord damage d. Ineffective thermoregulation related to decreased vasomotor response

b. Risk for falls related to dizziness or weakness A positive Romberg test indicates that the patient has difficulty maintaining balance with the eyes closed. The Romberg does not test for tactile perception, thermoregulation, or hyperreflexia. DIF: Cognitive Level: Application REF: 1417-1418

Which intervention will the nurse include in the plan of care for a patient with primary restless legs syndrome (RLS) who is having difficulty sleeping? a. Teach about the use of antihistamines to improve sleep. b. Suggest that the patient exercise regularly during the day. c. Make a referral to a massage therapist for deep massage of the legs. d. Assure the patient that the problem is transient and likely to resolve.

b. Suggest that the patient exercise regularly during the day. Nondrug interventions such as getting regular exercise are initially suggested to improve sleep quality in patients with RLS. Antihistamines may aggravate RLS. Massage does not alleviate RLS symptoms and RLS is likely to progress in most patients.

Which action will the nurse plan to take for a 40-year-old patient with multiple sclerosis (MS) who has urinary retention caused by a flaccid bladder? a. Decrease the patient's evening fluid intake. b. Teach the patient how to use the Credé method. c. Suggest the use of adult incontinence briefs for nighttime only. d. Assist the patient to the commode every 2 hours during the day.

b. Teach the patient how to use the Credé method. The Credé method can be used to improve bladder emptying. Decreasing fluid intake will not improve bladder emptying and may increase risk for urinary tract infection (UTI) and dehydration. The use of incontinence briefs and frequent toileting will not improve bladder emptying.

The health care provider is considering the use of sumatriptan (Imitrex) for a 54-year-old male patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider? a. The patient drinks 1 to 2 cups of coffee daily. b. The patient had a recent acute myocardial infarction. c. The patient has had migraine headaches for 30 years. d. The patient has taken topiramate (Topamax) for 2 months.

b. The patient had a recent acute myocardial infarction. The triptans cause coronary artery vasoconstriction and should be avoided in patients with coronary artery disease. The other information will be reported to the health care provider, but none of it indicates that sumatriptan would be an inappropriate treatment.

A patient is scheduled for a myelogram to confirm the presence of a herniated intervertebral disk. Which information obtained when admitting the patient is most important for the nurse to communicate to the health care provider before the procedure? a. The patient is anxious about the test. b. The patient has an allergy to shellfish. c. The patient had 4 ounces of apple juice 4 hours earlier. d. The patient has back pain when lying flat for long periods.

b. The patient has an allergy to shellfish. Iodine-containing contrast medium is injected into the subarachnoid space during a myelogram. The health care provider may need to modify the postmyelogram orders to prevent back pain, but this can be done after the procedure. Clear liquids are usually considered safe up to 4 hours before a diagnostic or surgical procedure. The patient's anxiety should be addressed, but this is not as important as the iodine allergy. DIF: Cognitive Level: Application REF: 1421-1422

Neurologic testing of the patient indicates impaired functioning of the left glossopharyngeal nerve (CN IX) and the vagus nerve (CN X). Which action will the nurse include in the plan of care? a. Insert an oral airway. b. Withhold oral fluid or foods. c. Provide highly seasoned foods. d. Apply artificial tears every hour.

b. Withhold oral fluid or foods The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex; a patient with impaired function of these nerves is at risk for aspiration. An oral airway may be needed when a patient is unconscious and unable to maintain the airway, but it will not decrease aspiration risk. Taste and eye blink are controlled by the facial nerve. DIF: Cognitive Level: Application REF: 1417

When a 74-year-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling-type tremor, the nurse will anticipate teaching the patient about a. oral corticosteroids. b. antiparkinsonian drugs. c. magnetic resonance imaging (MRI). d. electroencephalogram (EEG) testing.

b. antiparkinsonian drugs. The diagnosis of Parkinson's is made when two of the three characteristic manifestations of tremor, rigidity, and bradykinesia are present. The confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered. This patient has symptoms of tremor and bradykinesia. The next anticipated step will be treatment with medications. MRI and EEG are not useful in diagnosing Parkinson's disease, and corticosteroid therapy is not used to treat it.

A patient has a lesion that affects lower motor neurons. During assessment of the patient's lower extremities, the nurse expects to find a. spasticity. b. flaccidity. c. loss of sensation. d. hyperactive reflexes.

b. flaccidity. Because the cell bodies of lower motor neurons are located in the spinal cord, damage to the neuron will decrease motor activity of the affected muscles. Spasticity and hyperactive reflexes are caused by upper motor neuron damage. Sensation is not impacted by motor neuron lesions. DIF: Cognitive Level: Comprehension REF: 1408-1409

A patient is scheduled for a lumbar puncture. The nurse will plan to a. transfer the patient to radiology just before the procedure. b. help the patient to a side lying position before the procedure. c. place the patient on NPO status for 4 hours before the procedure. d. administer a sedative medication 30 minutes before the procedure.

b. help the patient to a side lying position before the procedure. For a lumbar puncture, the patient lies in the lateral recumbent position. The procedure does not usually require a sedative, is done in the patient room, and has no risk for aspiration. DIF: Cognitive Level: Application REF: 1418-1419

When obtaining a health history and physical assessment for a 36-year-old female patient with possible multiple sclerosis (MS), the nurse should a. assess for the presence of chest pain. b. inquire about urinary tract problems. c. inspect the skin for rashes or discoloration. d. ask the patient about any increase in libido.

b. inquire about urinary tract problems. Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS.

The nurse will assess a 67-year-old patient who is experiencing a cluster headache for a. nuchal rigidity. b. unilateral ptosis. c. projectile vomiting. d. throbbing, bilateral facial pain.

b. unilateral ptosis. Unilateral eye edema, tearing, and ptosis are characteristic of cluster headaches. Nuchal rigidity suggests meningeal irritation, such as occurs with meningitis. Although nausea and vomiting may occur with migraine headaches, projectile vomiting is more consistent with increased intracranial pressure (ICP). Unilateral sharp, stabbing pain, rather than throbbing pain, is characteristic of cluster headaches.

The nurse determines that teaching about management of migraine headaches has been effective when the patient says which of the following? a. "I can take the (Topamax) as soon as a headache starts." b. "A glass of wine might help me relax and prevent a headache." c. "I will lie down someplace dark and quiet when the headaches begin." d. "I should avoid taking aspirin and sumatriptan (Imitrex) at the same time."

c. "I will lie down someplace dark and quiet when the headaches begin." It is recommended that the patient with a migraine rest in a dark, quiet area. Topiramate (Topamax) is used to prevent migraines and must be taken for several months to determine effectiveness. Aspirin or other nonsteroidal antiinflammatory medications can be taken with the triptans. Alcohol may precipitate migraine headaches.

A 22-year-old patient seen at the health clinic with a severe migraine headache tells the nurse about having other similar headaches recently. Which initial action should the nurse take? a. Teach about the use of triptan drugs. b. Refer the patient for stress counseling. c. Ask the patient to keep a headache diary. d. Suggest the use of muscle-relaxation techniques.

c. Ask the patient to keep a headache diary. The initial nursing action should be further assessment of the precipitating causes of the headaches, quality, and location of pain, etc. Stress reduction, muscle relaxation, and the triptan drugs may be helpful, but more assessment is needed first.

When caring for a patient who has had cerebral angiography, which nursing action will be included in the plan of care? a. Ask about headache and photophobia. b. Keep patient NPO until gag reflex returns. c. Check pulse and blood pressure frequently. d. Assess orientation to person, place, and time.

c. Check pulse and blood pressure frequently. Since a catheter is inserted into an artery (such as the femoral artery) during cerebral angiography, the nurse should assess for bleeding after this procedure. The other nursing assessments are not necessary after angiography. DIF: Cognitive Level: Application REF: 1418-1419

A 49-year-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching? a. Recommendation to drink at least 4 L of fluid daily b. Need to avoid driving or operating heavy machinery c. How to draw up and administer injections of the medication d. Use of contraceptive methods other than oral contraceptives

c. How to draw up and administer injections of the medication Copaxone is administered by self-injection. Oral contraceptives are an appropriate choice for birth control. There is no need to avoid driving or drink large fluid volumes when taking glatiramer.

Which assessment is most important for the nurse to make regarding a patient with myasthenia gravis? a. Pupil size b. Grip strength c. Respiratory effort d. Level of consciousness

c. Respiratory effort Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical.

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take? a. Insert an oral airway during the seizure to maintain a patent airway. b. Restrain the patient's arms and legs to prevent injury during the seizure. c. Time and observe and record the details of the seizure and postictal state. d. Avoid touching the patient to prevent further nervous system stimulation.

c. Time and observe and record the details of the seizure and postictal state. Because the diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure.

A 40-year-old patient is diagnosed with early Huntington's disease (HD). When teaching the patient, spouse, and children about this disorder, the nurse will provide information about the a. use of levodopa-carbidopa (Sinemet) to help reduce HD symptoms. b. prophylactic antibiotics to decrease the risk for aspiration pneumonia. c. option of genetic testing for the patient's children to determine their own HD risks. d. lifestyle changes of improved nutrition and exercise that delay disease progression.

c. option of genetic testing for the patient's children to determine their own HD risks. Genetic testing is available to determine whether an asymptomatic individual has the HD gene. The patient and family should be informed of the benefits and problems associated with genetic testing. Sinemet will increase symptoms of HD because HD involves an increase in dopamine. Antibiotic therapy will not reduce the risk for aspiration. There are no effective treatments or lifestyle changes that delay the progression of symptoms in HD.

Propranolol (Inderal), a β-adrenergic blocker that inhibits sympathetic nervous system activity, is prescribed for a patient. The nurse monitors the patient for a. dry mouth. b. constipation. c. slowed pulse. d. urinary retention.

c. slowed pulse. Inhibition of the fight or flight response leads to decreased heart rate. Dry mouth, constipation, and urinary retention are associated with peripheral nervous system blockade. DIF: Cognitive Level: Comprehension REF: 1407

Which prescribed intervention will the nurse implement first for a patient in the emergency department who is experiencing continuous tonic-clonic seizures? a. Give phenytoin (Dilantin) 100 mg IV. b. Monitor level of consciousness (LOC). c. Obtain computed tomography (CT) scan. d. Administer lorazepam (Ativan) 4 mg IV.

d. Administer lorazepam (Ativan) 4 mg IV To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary. Phenytoin will also be administered, but it is not rapidly acting. Patients who are experiencing tonic-clonic seizures are nonresponsive, although the nurse should assess LOC after the seizure.

Which medication taken by a patient with restless legs syndrome should the nurse discuss with the patient? a. Multivitamin (Stresstabs) b. Acetaminophen (Tylenol) c. Ibuprofen (Motrin, Advil) d. Diphenhydramine (Benadryl)

d. Diphenhydramine (Benadryl) Antihistamines can aggravate restless legs syndrome. The other medications will not contribute to restless legs syndrome.

A patient is hospitalized with a possible seizure disorder. To determine the cause of the patient's symptoms, the nurse will anticipate the need to teach the patient about which of these tests? a. Cerebral angiography b. Evoked potential studies c. Electromyography (EMG) d. Electroencephalography (EEG)

d. Electroencephalography (EEG) Seizure disorders are usually studied using EEG testing. Evoked potential is used for diagnosing problems with the visual or auditory systems. Cerebral angiography is used to diagnose vascular problems. EMG is used to evaluate electrical innervation to skeletal muscle. DIF: Cognitive Level: Comprehension REF: 1419-1423

After reviewing a patient's cerebrospinal fluid analysis, which result will be most important for the nurse to communicate to the health care provider? a. Specific gravity 1.007 b. Protein 65 mg/dL (0.30 g/L) c. White blood cell (WBC) count 4/μL d. Glucose 45 mg/dL (1.7 mmol/L)

d. Glucose 45 mg/dL (1.7 mmol/L) The protein level is high. The pH, WBCs, and glucose values are normal. DIF: Cognitive Level: Comprehension REF: 1422

Which nursing diagnosis is of highest priority for a patient with Parkinson's disease who is unable to move the facial muscles? a. Activity intolerance b. Self-care deficit: toileting c. Ineffective self-health management d. Imbalanced nutrition: less than body requirements

d. Imbalanced nutrition: less than body requirements The data about the patient indicate that poor nutrition will be a concern because of decreased swallowing. The other diagnoses may also be appropriate for a patient with Parkinson's disease, but the data do not indicate that they are current problems for this patient.

Which information about a 72-year-old patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consult with the health care provider before administration of the medication? a. Patient has generalized tonic-clonic seizures. b. Patient experiences an aura before seizures. c. Patient's most recent blood pressure is 156/92 mm Hg. d. Patient has minor elevations in the liver function tests.

d. Patient has minor elevations in the liver function tests. Many older patients (especially with compromised liver function) may not be able to metabolize phenytoin. The health care provider may need to choose another antiseizure medication. Phenytoin is an appropriate medication for patients with tonic-clonic seizures, with or without an aura. Hypertension is not a contraindication for phenytoin therapy.

Which information about a 60-year-old patient with MS indicates that the nurse should consult with the health care provider before giving the prescribed dose of dalfampridine (Ampyra)? a. The patient has relapsing-remitting MS. b. The patient walks a mile a day for exercise. c. The patient complains of pain with neck flexion. d. The patient has an increased serum creatinine level.

d. The patient has an increased serum creatinine level. Dalfampridine should not be given to patients with impaired renal function. The other information will not impact whether the dalfampridine should be administered.

A 62-year-old patient who has Parkinson's disease is taking bromocriptine (Parlodel). Which information obtained by the nurse may indicate a need for a decrease in the dose? a. The patient has a chronic dry cough. b. The patient has four loose stools in a day. c. The patient develops a deep vein thrombosis. d. The patient's blood pressure is 92/52 mm Hg.

d. The patient's blood pressure is 92/52 mm Hg. Hypotension is an adverse effect of bromocriptine, and the nurse should check with the health care provider before giving the medication. Diarrhea, cough, and deep vein thrombosis are not associated with bromocriptine use.

A 76-year-old patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease. Which information is most important for the nurse to report to the health care provider? a. Shuffling gait b. Tremor at rest c. Cogwheel rigidity of limbs d. Uncontrolled head movement

d. Uncontrolled head movement Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other findings are typical with Parkinson's disease.

During the neurologic assessment, the patient cooperates with the nurse's directions to grip with the hands and to move the feet but is unable to respond orally to the nurse's questions. The nurse will suspect a. a brainstem lesion. b. a temporal lobe lesion. c. injury to the cerebellum. d. damage to the frontal lobe.

d. damage to the frontal lobe. Expressive speech is controlled by Broca's area in the frontal lobe. The temporal lobe contains Wernicke's area, which is responsible for receptive speech. The cerebellum and brainstem do not affect higher cognitive functions such as speech. DIF: Cognitive Level: Application REF: 1408-1409

A patient with a brainstem infarction is admitted to the nursing unit. The priority nursing assessment for the patient is a. reflex reaction time. b. pupil reaction to light. c. level of consciousness. d. respiratory rate and rhythm.

d. respiratory rate and rhythm. Vital centers that control respiration are located in the medulla, and these are the priority assessments because changes in respiratory function may be life threatening. The other information also will be collected by the nurse, but it is not as urgent. DIF: Cognitive Level: Application REF: 1410

When performing a focused assessment on a patient with a lesion of the left posterior temporal lobe, the nurse will assess for a. sensation on the left side of the body. b. voluntary movement on the right side. c. reasoning and problem-solving abilities. d. understanding of written and oral language.

d. understanding of written and oral language. The posterior temporal lobe integrates the visual and auditory input for language comprehension. Reasoning and problem solving are functions of the anterior frontal lobe. Sensation on the left side of the body is located in the right postcentral gyrus. Voluntary movement on the right side is controlled in the left precentral gyrus. DIF: Cognitive Level: Application REF: 1409