Nclex Review: intracranial class quiz questions

Which of the following is an initial sign of Parkinson's disease? 1. Rigidity. 2. Tremor. 3. Bradykinesia. 4. Akinesia.

2. The first sign of Parkinson's disease is usually tremors. The client commonly is the first to notice this sign because the tremors may be minimal at first. Rigidity is the second sign, and brady-kinesia is the third sign. Akinesia is a later stage of bradykinesia.

The nurse observes that a client's upper arm tremors disappear as he unbuttons his shirt. Which statement best guides the nurse's analysis of this observation about the client's tremors? 1. The tremors are probably psychological and can be controlled at will. 2. The tremors sometimes disappear with purposeful and voluntary movements. 3. The tremors disappear when the client's attention is diverted by some activity. 4. There is no explanation for the observation; it is probably a chance occurrence.

2. Voluntary and purposeful movements often temporarily decrease or stop the tremors associated with Parkinson's disease. In some clients, however, tremors may increase with voluntary effort. Tremors associated with Parkinson's disease are not psychogenic but are related to an imbalance between dopamine and acetylcholine. Tremors cannot be reduced by distracting the client.

A client with Parkinson's disease asks the nurse to explain to his nephew "what the doctor said the pallidotomy would do." The nurse's best response includes stating that the main goal for the client after pallidotomy is improved: 1. Functional ability. 2. Emotional stress. 3. Alertness. 4. Appetite.

1

Which of the following should the nurse include in the discharge plan for a client with multiple sclerosis who has an impaired peripheral sensation? Select all that apply. 1. Carefully test the temperature of bath water. 2. Avoid kitchen activities because of the risk of injury. 3. Avoid hot water bottles and heating pads. 4. Inspect the skin daily for injury or pressure points. 5. Wear warm clothing when outside in cold temperatures.

1,3,4,5

A 20-year-old who hit his head while playing football has a tonic-clonic seizure. Upon awakening from the seizure, the client asks the nurse, "What caused me to have a seizure? I've never had one before." Which cause should the nurse include in the response as a primary cause of tonic-clonic seizures in adults older than age 20? 1. Head trauma. 2. Electrolyte imbalance. 3. Congenital defect. 4. Epilepsy.

1. Trauma is one of the primary causes of brain damage and seizure activity in adults. Other common causes of seizure activity in adults include neoplasms, withdrawal from drugs and alcohol, and vascular disease. Given the history of head injury, electrolyte imbalance is not the cause of the seizure. There is no information to indicate that the seizure is related to a congenital defect. Epilepsy is usually diagnosed in younger clients.

A client with multiple sclerosis (MS) lives with her daughter and 3-year-old granddaughter. The daughter asks the nurse what she can do at home to help her mother. Which of the following measures would be most beneficial? 1. Psychotherapy. 2. Regular exercise. 3. Day care for the granddaughter. 4. Weekly visits by another person with MS.

2

When preparing to teach a client about phenytoin sodium (Dilantin) therapy, the nurse should urge the client not to stop the drug suddenly because: 1. Physical dependency on the drug develops over time. 2. Status epilepticus may develop. 3. A hypoglycemic reaction develops. 4. Heart block is likely to develop.

2. Anticonvulsant drug therapy should never be stopped suddenly; doing so can lead to life-threatening status epilepticus. Phenytoin sodium does not carry a risk of physical dependency or lead to hypoglycemia. Phenytoin has antiarrhythmic properties, and discontinuation does not cause heart block.

A client with Parkinson's disease is prescribed levodopa (l-dopa) therapy. Improvement in which of the following indicates effective therapy? 1. Mood. 2. Muscle rigidity. 3. Appetite. 4. Alertness.

2. Levodopa is prescribed to decrease severe muscle rigidity. Levodopa does not improve mood, appetite, or alertness in a client with Parkinson's disease.

A client is being switched from levodopa (l-dopa) to carbidopa-levodopa (Sinemet). The nurse should monitor for which of the following possible complications during medication changes and dosage adjustment? 1. Euphoria. 2. Jaundice. 3. Vital sign fluctuation. 4. Signs and symptoms of diabetes.

3

A client with multiple sclerosis (MS) is receiving baclofen (Lioresal). The nurse determines that the drug is effective when it achieves which of the following? 1. Induces sleep. 2. Stimulates the client's appetite. 3. Relieves muscular spasticity. 4. Reduces the urine bacterial count.

3

A new medication regimen is ordered for a client with Parkinson's disease. At which time should the nurse make certain that the medication is taken? 1. At bedtime. 2. All at one time. 3. Two hours before mealtime. 4. At the time scheduled.

4

What nursing assessments should be documented at the beginning of the ictal phase of a seizure? 1. Heart rate, respirations, pulse oximeter, and blood pressure. 2. Last dose of anticonvulsant and circumstances at the time. 3. Type of visual, auditory, and olfactory aura the client experienced. 4. Movement of the head and eyes and muscle rigidity.

4. During a seizure, the nurse should note movement of the client's head and eyes and muscle rigidity, especially when the seizure first begins, to obtain clues about the location of the trigger focus in the brain. Other important assessments would include noting the progression and duration of the seizure, respiratory status, loss of consciousness, pupil size, and incontinence of urine and stool. It is typically not possible to assess the client's pulse and blood pressure during a tonic-clonic seizure because the muscle contractions make assessment difficult to impossible. The last dose of anticonvulsant medication can be evaluated later. The nurse should focus on maintaining an open airway, preventing injury to the client, and assessing the onset and progression of the seizure to determine the type of brain activity involved. The type of aura should be assessed in the preictal phase of the seizure.

A client states that she is afraid she will not be able to drive again because of her seizures. Which response by the nurse would be best? 1. A person with a history of seizures can drive only during daytime hours. 2. A person with evidence that the seizures are under medical control can drive. 3. A person with evidence that seizures occur no more often than every 12 months can drive. 4. A person with a history of seizures can drive if he carries a medical identification card.

2. Specific motor vehicle regulations and restrictions for people who experience seizures vary locally. Most commonly, evidence that the seizures are under medical control is required before the person is given permission to drive. Time of day is not a consideration when determining driving restrictions related to seizures. The amount of time a person has been seizure-free is a consideration for lifting driving restrictions; however, the time frame is usually 2 years. It is recommended, not required, that a person who is subject to seizures carry a card or wear an identification bracelet describing the illness to facilitate quick identification in the event of an emergency.

Which of the following is contraindicated for a client with seizure precautions? 1. Encouraging him to perform his own personal hygiene. 2. Allowing him to wear his own clothing. 3. Assessing oral temperature with a glass thermometer. 4. Encouraging him to be out of bed.

3. Temperatures are not assessed orally with a glass thermometer because the thermometer could break and cause injury if a seizure occurred. The client can perform personal hygiene. There is no clinical reason to discourage the client from wearing his own clothes. As long as there are no other limitations, the client should be encouraged to be out of bed.

65. Which goal is the most realistic and appropriate for a client diagnosed with Parkinson's disease? 1. To cure the disease. 2. To stop progression of the disease. 3. To begin preparations for terminal care. 4. To maintain optimal body function.

4. Helping the client function at his or her best is most appropriate and realistic. There is no known cure for Parkinson's disease. Parkinson's disease progresses in severity, and there is no known way to stop its progression. Many clients live for years with the disease, however, and it would not be appropriate to start planning terminal care at this time.

It is the night before a client is to have a computed tomography (CT) scan of the head without contrast. The nurse should tell the client? 1. "You must shampoo your hair tonight to remove all oil and dirt." 2. "You may drink fluids until midnight, but after that drink nothing until the scan is completed." 3. "You will have some hair shaved to attach the small electrode to your scalp." 4. "You will need to hold your head very still during the examination."

4. The client will be asked to hold the head very still during the examination, which lasts about 30 to 60 minutes. In some instances, food and fluids may be withheld for 4 to 6 hours before the procedure if a contrast medium is used because the radiopaque substance sometimes causes nausea. There is no special preparation for a CT scan, so a shampoo the night before is not required. The client may drink fluids until 4 hours before the scan is scheduled. Electrodes are not used for a CT scan, nor is the head shaved.

Which statement by a client with a seizure disorder taking topiramate (Topamax) indicates the client has understood the nurse's instruction? 1. "I will take the medicine before going to bed." 2. "I will drink 6 to 8 glasses of water a day." 3. "I will eat plenty of fresh fruits." 4. "I will take the medicine with a meal or snack."

2. Toxic effects of topiramate (Topamax) include nephrolithiasis, and clients are encouraged to drink 6 to 8 glasses of water a day to dilute the urine and flush the renal tubules to avoid stone formation. Topiramate is taken in divided doses because it produces drowsiness. Although eating fresh fruits is desirable from a nutritional standpoint, this is not related to the topiramate. The drug does not have to be taken with meals.

A client is experiencing mood swings after a stroke and often has episodes of tearfulness that are distressing to the family. Which is the best technique for the nurse to instruct family members to try when the client experiences a crying episode? 1. Sit quietly with the client until the episode is over. 2. Ignore the behavior. 3. Attempt to divert the client's attention. 4. Tell the client that this behavior is unacceptable.

3. A client who has brain damage may be emotionally labile and may cry or laugh for no explainable reason. Crying is best dealt with by attempting to divert the client's attention. Ignoring the behavior will not affect the mood swing or the crying and may increase the client's sense of isolation. Telling the client to stop is inappropriate.

Which clinical manifestation is a typical reaction to long-term phenytoin sodium (Dilantin) therapy? 1. Weight gain. 2. Insomnia. 3. Excessive growth of gum tissue. 4. Deteriorating eyesight.

3. A common adverse effect of long-term phenytoin therapy is an overgrowth of gingival tissues. Problems may be minimized with good oral hygiene, but in some cases, overgrown tissues must be removed surgically. Phenytoin does not cause weight gain, insomnia, or deteriorating eyesight.

What is the priority nursing intervention in the postictal phase of a seizure? 1. Reorient the client to time, person, and place. 2. Determine the client's level of sleepiness. 3. Assess the client's breathing pattern. 4. Position the client comfortably.

3. A priority for the client in the postictal phase (after a seizure) is to assess the client's breathing pattern for effective rate, rhythm, and depth. The nurse should apply oxygen and ventilation to the client as appropriate. Other interventions, to be completed after the airway has been established, include reorientation of the client to time, person, and place. Determining the client's level of sleepiness is useful, but it is not a priority. Positioning the client comfortably promotes rest but is of less importance than ascertaining that the airway is patent.

During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's: 1. Pulse. 2. Respirations. 3. Blood pressure. 4. Temperature.

3. Control of blood pressure is critical during the first 24 hours after treatment because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Vital signs are monitored, and blood pressure is maintained as identified by the physician and specific to the client's ischemic tissue needs and risk of bleeding from treatment. The other vital signs are important, but the priority is to monitor blood pressure.

A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. The nurse should first: 1. Ask what medications the client is taking. 2. Complete a history and health assessment. 3. Identify the time of onset of the stroke. 4. Determine if the client is scheduled for any surgical procedures.

3. Studies show that clients who receive recombinant t-PA treatment within 3 hours after the onset of a stroke have better outcomes. The time from the onset of a stroke to t-PA treatment is critical. A complete health assessment and history is not possible when a client is receiving emergency care. Upcoming surgical procedures may need to be delayed because of the administration of t-PA, which is a priority in the immediate treatment of the current stroke. While the nurse should identify which medications the client is taking, it is more important to know the time of the onset of the stroke to determine the course of action for administering t-PA.

Which of the following will the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure? 1. Jerking in one extremity that spreads gradually to adjacent areas. 2. Vacant staring and abruptly ceasing all activity. 3. Facial grimaces, patting motions, and lip smacking. 4. Loss of consciousness, body stiffening, and violent muscle contractions.

4. A generalized tonic-clonic seizure involves both a tonic phase and a clonic phase. The tonic phase consists of loss of consciousness, dilated pupils, and muscular stiffening or contraction, which lasts about 20 to 30 seconds. The clonic phase involves repetitive movements. The seizure ends with confusion, drowsiness, and resumption of respiration. A partial seizure starts in one region of the cortex and may stay focused or spread (e.g., jerking in the extremity spreading to other areas of the body). An absence seizure usually occurs in children and involves a vacant stare with a brief loss of consciousness that often goes unnoticed. A complex partial seizure involves facial grimacing with patting and smacking.

At what time of day should the nurse encourage a client with Parkinson's disease to schedule the most demanding physical activities to minimize the effects of hypokinesia? 1. Early in the morning, when the client's energy level is high. 2. To coincide with the peak action of drug therapy. 3. Immediately after a rest period. 4. When family members will be available.

.2. Demanding physical activity should be performed during the peak action of drug therapy. Clients should be encouraged to maintain independence in self-care activities to the greatest extent possible. Although some clients may have more energy in the morning or after rest, tremors are managed with drug therapy.

The nurse is reviewing the care plan of a client with Multiple Sclerosis. Which of the following nursing diagnoses should receive further validation? 1. Impaired mobility related to spasticity and fatigue. 2. Risk for falls related to muscle weakness and sensory loss. 3. Risk for seizures related to muscle tremors and loss of myelin. 4. Impaired skin integrity related bowel and bladder incontinence.

3

Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence? 1. Limit fluid intake to 1,000 mL/ day. 2. Insert an indwelling urinary catheter. 3. Establish a regular voiding schedule. 4. Administer prophylactic antibiotics, as ordered.

3

Which of the following is not a realistic outcome to establish with a client who has multiple sclerosis (MS)? The client will: 1. Develop joint mobility. 2. Develop muscle strength. 3. Develop cognition. 4. Develop mood elevation.

3

A 21-year-old female client takes clonazepam (Klonopin). What should the nurse ask this client about? Select all that apply. 1. Seizure activity. 2. Pregnancy status. 3. Alcohol use. 4. Cigarette smoking. 5. Intake of caffeine and sugary drinks.

1, 2, 3. The nurse should assess the number and type of seizures the client has experienced since starting clonazepam monotherapy for seizure control. The nurse should also determine if the client might be pregnant because clonazepam crosses the placental barrier. The nurse should also ask about the client's use of alcohol because alcohol potentiates the action of clonazepam. Although the nurse may want to check on the client's diet or use of cigarettes for health maintenance and promotion, such information is not specifically related to clonazepam therapy.

Regular oral hygiene is essential for the client who has had a stroke. Which of the following nursing measures is not appropriate when providing oral hygiene? 1. Placing the client on the back with a small pillow under the head. 2. Keeping portable suctioning equipment at the bedside. 3. Opening the client's mouth with a padded tongue blade. 4. Cleaning the client's mouth and teeth with a toothbrush.

1. A helpless client should be positioned on the side, not on the back, with the head on a small pillow. A lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration. It may be necessary to suction the client if he aspirates. Suction equipment should be nearby. It is safe to use a padded tongue blade, and the client should receive oral care, including brushing with a toothbrush.

In planning care for the client who has had a stroke, the nurse should obtain a history of the client's functional status before the stroke because? 1. The rehabilitation plan will be guided by it. 2. Functional status before the stroke will help predict outcomes. 3. It will help the client recognize his physical limitations. 4. The client can be expected to regain much of his functioning.

1. The primary reason for the nursing assessment of a client's functional status before and after a stroke is to guide the plan. The assessment does not help to predict how far the rehabilitation team can help the client to recover from the residual effects of the stroke, only what plans can help a client who has moved from one functional level to another. The nursing assessment of the client's functional status is not a motivating factor.

A client has had multiple sclerosis (MS) for 15 years and has received various drug therapies. What is the primary reason why the nurse has found it difficult to evaluate the effectiveness of the drugs that the client has used? 1. The client exhibits intolerance to many drugs. 2. The client experiences spontaneous remissions from time to time. 3. The client requires multiple drugs simultaneously. 4. The client endures long periods of exacerbation before the illness responds to a particular drug.

2

The nurse is preparing a client with multiple sclerosis (MS) for discharge from the hospital to home. The nurse should tell the client: 1. "You will need to accept the necessity for a quiet and inactive lifestyle." 2. "Keep active, use stress reduction strategies, and avoid fatigue." 3. "Follow good health habits to change the course of the disease." 4. "Practice using the mechanical aids that you will need when future disabilities arise."

2

Which of the following is not a typical clinical manifestation of multiple sclerosis (MS)? 1. Double vision. 2. Sudden bursts of energy. 3. Weakness in the extremities. 4. Muscle tremors.

2

The nurse is teaching a client about taking prophylactic warfarin sodium (Coumadin). Which statement indicates that the client understands how to take the drug? Select all that apply. 1. "The drug's action peaks in 2 hours." 2. "Maximum dosage is not achieved until 3 to 4 days after starting the medication." 3. "Effects of the drug continue for 4 to 5 days after discontinuing the medication." 4. "Protamine sulfate is the antidote for warfarin." 5. "I should have my blood levels tested periodically."

2, 3, 5. The maximum dosage of warfarin sodium (Coumadin) is not achieved until 3 to 4 days after starting the medication, and the effects of the drug continue for 4 to 5 days after discontinuing the medication. The client should have his blood levels tested periodically to make sure that the desired level is maintained. Warfarin has a peak action of 9 hours. Vitamin K is the antidote for warfarin; protamine sulfate is the antidote for heparin.

The nurse is teaching a client with bladder dysfunction from multiple sclerosis (MS) about bladder training at home. Which instructions should the nurse include in the teaching plan? Select all that apply. 1. Restrict fluids to 1,000 mL/ 24 hours. 2. Drink 400 to 500 mL with each meal. 3. Drink fluids midmorning, midafternoon, and late afternoon. 4. Attempt to void at least every 2 hours. 5. Use intermittent catheterization as needed.

2,3,4,5

. The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which of the following strategies is not appropriate? 1. Maintaining an upright position. 2. Restricting the diet to liquids until swallowing improves. 3. Introducing foods on the unaffected side of the mouth. 4. Keeping distractions to a minimum.

2. A client with dysphagia (difficulty swallowing) commonly has the most difficulty ingesting thin liquids, which are easily aspirated. Liquids should be thickened to avoid aspiration. Maintaining an upright position while eating is appropriate because it minimizes the risk of aspiration. Introducing foods on the unaffected side allows the client to have better control over the food bolus. The client should concentrate on chewing and swallowing; therefore, distractions should be avoided.

For breakfast on the morning a client is to have an electroencephalogram (EEG), the client is served a soft-boiled egg, toast with butter and marmalade, orange juice, and coffee. Which of the following should the nurse do? 1. Remove all the food. 2. Remove the coffee. 3. Remove the toast, butter, and marmalade only. 4. Substitute vegetable juice for the orange juice.

2. Beverages containing caffeine, such as coffee, tea, and cola drinks, are withheld before an EEG because of the stimulating effects of the caffeine on the brain waves. A meal should not be omitted before an EEG because low blood sugar could alter brain wave patterns; the client can have the entire meal except for the coffee.

For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication? 1. Speaking loudly. 2. Using a picture board. 3. Writing directions so client can read them. 4. Speaking in short sentences.

2. Expressive aphasia is a condition in which the client understands what is heard or written but cannot say what he or she wants to say. A communication or picture board helps the client communicate with others in that the client can point to objects or activities that he or she desires.

A health care provider has ordered carbidopa-levodopa (Sinemet) four times per day for a client with Parkinson's disease. The client states that he wants "to end it all now that the Parkinson's disease has progressed." What should the nurse do? Select all that apply. 1. Explain that the new prescription for Sinemet will treat his depression. 2. Encourage the client to discuss his feelings as the Sinemet is being administered. 3. Contact the health care provider before administering the Sinemet. 4. Determine if the client is on antidepressants or monoamine oxidase (MAO) inhibitors. 5. Determine if the client is at risk for suicide.

3, 4, 5. The nurse should contact the health care provider before administering Sinemet because this medication can cause further symptoms of depression. Suicide threats in clients with chronic illness should be taken seriously. The nurse should also determine if the client is on an MAO inhibitor because concurrent use with Sinemet can cause a hypertensive crisis. Sinemet is not a treatment for depression. Having the client discuss his feelings is appropriate when the prescription is finalized.

The nurse sees a client walking in the hallway who begins to have a seizure. The nurse should do which of the following in priority order? 1. Maintain patent airway 2.record the seizure activity observed 3.ease the client to the floor 4. Obtain vital signs

3,1,4,2

What is the expected outcome of thrombolytic drug therapy for stroke? 1. Increased vascular permeability. 2. Vasoconstriction. 3. Dissolved emboli. 4. Prevention of hemorrhage.

3. Thrombolytic enzyme agents are used for clients with a thrombotic stroke to dissolve emboli, thus reestablishing cerebral perfusion. They do not increase vascular permeability, cause vasoconstriction, or prevent further hemorrhage.

A client with a hemorrhagic stroke is slightly agitated, heart rate is 118, respirations are 22, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/ 88, and oral secretions are noted. What order of interventions should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion? 1. Suction the airway 2.hyperoxygenate 3.suction the mouth 4. Provide sedation

4,2,1,3

Which intervention is most effective in minimizing the risk of seizure activity in a client who is undergoing diagnostic studies after having experienced several episodes of seizures? 1. Maintain the client on bed rest. 2. Administer butabarbital sodium (phenobarbital) 30 mg P.O., three times per day. 3. Close the door to the room to minimize stimulation. 4. Administer carbamazepine (Tegretol) 200 mg P.O., twice per day.

4. Carbamazepine (Tegretol) is an anticonvulsant that helps prevent further seizures. Bed rest, sedation (phenobarbital), and providing privacy do not minimize the risk of seizures.

What is the primary goal collaboratively established by the client with Parkinson's disease, nurse, and physical therapist? 1. To maintain joint flexibility. 2. To build muscle strength. 3. To improve muscle endurance. 4. To reduce ataxia.

1. The primary goal of physical therapy and nursing interventions is to maintain joint flexibility and muscle strength. Parkinson's disease involves a degeneration of dopamine-producing neurons; therefore, it would be an unrealistic goal to attempt to build muscles or increase endurance. The decrease in dopamine neurotransmitters results in ataxia secondary to extrapyramidal motor system effects. Attempts to reduce ataxia through physical therapy would not be effective.

A client with Parkinson's disease needs a long time to complete her morning hygiene, but she becomes annoyed when the nurse offers assistance and refuses all help. Which action is the nurse's best initial response in this situation? 1. Tell the client firmly that she needs assistance and help her with her care. 2. Praise the client for her desire to be independent and give her extra time and encouragement. 3. Tell the client that she is being unrealistic about her abilities and must accept the fact that she needs help. 4. Suggest to the client that if she insists on self-care, she should at least modify her routine.

2

Which of the following should the nurse include in the teaching plan for a client with seizures who is going home with a prescription for gabapentin (Neurontin)? 1. Take all the medication until it is gone. 2. Notify the physician if vision changes occur. 3. Store gabapentin in the refrigerator. 4. Take gabapentin with an antacid to protect against ulcers.

2. Gabapentin (Neurontin) may impair vision. Changes in vision, concentration, or coordination should be reported to the physician. Gabapentin should not be stopped abruptly because of the potential for status epilepticus; this is a medication that must be tapered off. Gabapentin is to be stored at room temperature and out of direct light. It should not be taken with antacids.

Which food-related behaviors are expected in a client who has had a stroke that has left him with homonymous hemianopia? 1. Increased preference for foods high in salt. 2. Eating food on only half of the plate. 3. Forgetting the names of foods. 4. Inability to swallow liquids.

2. Homonymous hemianopia is blindness in half of the visual field; therefore, the client would see only half of his plate. Eating only the food on half of the plate results from an inability to coordinate visual images and spatial relationships. There may be an increased preference for foods high in salt after a stroke, but this would not be related to homonymous hemianopia. Forgetting the names of foods would be aphasia, which involves a cerebral cortex lesion. Being unable to swallow liquids is dysphagia, which involves motor pathways of cranial nerves IX and X, including the lower brain stem.

What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? 1. Cholesterol level. 2. Pupil size and pupillary response. 3. Bowel sounds. 4. Echocardiogram.

2. It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. The cholesterol level is not a priority assessment, although it may be an assessment to be addressed for long-term healthy lifestyle rehabilitation. Bowel sounds need to be assessed because an ileus or constipation can develop, but this is not a priority in the first 24 hours, when the primary concerns are cerebral hemorrhage and increased intracranial pressure. An echocardiogram is not needed for the client with a thrombotic stroke without heart problems.

When communicating with a client who has aphasia, which of the following nursing interventions is not appropriate? 1. Present one thought at a time. 2. Encourage the client not to write messages. 3. Speak with normal volume. 4. Make use of gestures.

2. The nurse should encourage the client to write messages or use alternative forms of communication to avoid frustration. Presenting one thought at a time decreases stimuli that may distract the client, as does speaking in a normal volume and tone. The nurse should ask the client to "show me" and should encourage the use of gestures to assist in getting the message across with minimal frustration and exhaustion for the client.

The nurse is teaching a client to recognize an aura. The nurse should instruct the client to note: 1. A postictal state of amnesia. 2. An hallucination that occurs during a seizure. 3. A symptom that occurs just before a seizure. 4. A feeling of relaxation as the seizure begins to subside.

3. An aura is a premonition of an impending seizure. Auras usually are of a sensory nature (e.g., an olfactory, visual, gustatory, or auditory sensation); some may be of a psychic nature. Evaluating an aura may help identify the area of the brain from which the seizure originates. Auras occur before a seizure, not during or after (postictal). They are not similar to hallucinations or amnesia or related to relaxation.

The nurse develops a teaching plan for a client newly diagnosed with Parkinson's disease. Which of the following topics that the nurse plans to discuss is the most important? 1. Maintaining a balanced nutritional diet. 2. Enhancing the immune system. 3. Maintaining a safe environment. 4. Engaging in diversional activity.

3. The primary focus is on maintaining a safe environment because the client with Parkinson's disease usually has a propulsive gait, characterized by a tendency to take increasingly quicker steps while walking. This type of gait commonly causes the client to fall or to have trouble stopping. The client should maintain a balanced diet, enhance the immune system, and enjoy diversional activities;

A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining program. Which strategy is inappropriate? 1. Eating a diet high in fiber. 2. Setting a regular time for elimination. 3. Using an elevated toilet seat. 4. Limiting fluid intake to 1,000 mL/ day.

4

The right hand of a client with multiple sclerosis trembles severely whenever she attempts a voluntary action. She spills her coffee twice at lunch and cannot get her dress fastened securely. Which is the best legal documentation in nurses' notes of the chart for this client assessment? 1. "Has an intention tremor of the right hand." 2. "Right-hand tremor worsens with purposeful acts." 3. "Needs assistance with dressing and eating due to severe trembling and clumsiness." 4. "Slight shaking of right hand increases to severe tremor when client tries to button her clothes or drink from a cup."

4

When the nurse talks with a client with multiple sclerosis who has slurred speech, which nursing intervention is contraindicated? 1. Encouraging the client to speak slowly. 2. Encouraging the client to speak distinctly. 3. Asking the client to repeat indistinguishable words. 4. Asking the client to speak louder when tired.

4

The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm and hand. Which of the following positions are appropriate? 1. Placing a pillow in the axilla so the arm is away from the body. 2. Inserting a pillow under the slightly flexed arm so the hand is higher than the elbow. 3. Immobilizing the extremity in a sling. 4. Positioning a hand cone in the hand so the fingers are barely flexed. 5. Keeping the arm at the side using a pillow.

1, 2, 4. Placing a pillow in the axilla so the arm is away from the body keeps the arm abducted and prevents skin from touching skin to avoid skin breakdown. Placing a pillow under the slightly flexed arm so the hand is higher than the elbow prevents dependent edema. Positioning a hand cone (not a rolled washcloth) in the hand prevents hand contractures. Immobilization of the extremity may cause a painful shoulder-hand syndrome. Flexion contractures of the hand, wrist, and elbow can result from immobility of the weak or paralyzed extremity. It is better to extend the arms to prevent contractures

The nurse is assessing a client in the postictal phase of generalized tonic-clonic seizure. The nurse should determine if the client has? 1. Drowsiness. 2. Inability to move. 3. Paresthesia. 4. Hypotension.

1. The nurse should expect a client in the postictal phase to experience drowsiness to somnolence because exhaustion results from the abnormal spontaneous neuron firing and tonic-clonic motor response. An inability to move a muscle part is not expected after a tonic-clonic seizure because a lack of motor function would be related to a complication, such as a lesion, tumor, or stroke, in the correlating brain tissue. A change in sensation would not be expected because this would indicate a complication such as an injury to the peripheral nerve pathway to the corresponding part from the central nervous system. Hypotension is not typically a problem after a seizure.

Which of the following techniques does the nurse avoid when changing a client's position in bed if the client has hemiparalysis? 1. Rolling the client onto the side. 2. Sliding the client to move up in bed. 3. Lifting the client when moving the client up in bed. 4. Having the client help lift off the bed using a trapeze.

2. Sliding a client on a sheet causes friction and is to be avoided. Friction injures skin and predisposes to pressure ulcer formation. Rolling the client is an acceptable method to use when changing positions as long as the client is maintained in anatomically neutral positions and her limbs are properly supported. The client may be lifted as long as the nurse has assistance and uses proper body mechanics to avoid injury to himself or herself or the client. Having the client help lift herself off the bed with a trapeze is an acceptable means to move a client without causing friction burns or skin breakdown.

Which nursing intervention has been found to be the most effective means of preventing plantar flexion in a client who has had a stroke with residual paralysis? 1. Place the client's feet against a firm footboard. 2. Reposition the client every 2 hours. 3. Have the client wear ankle-high tennis shoes at intervals throughout the day. 4. Massage the client's feet and ankles regularly.

3. The use of ankle-high tennis shoes has been found to be most effective in preventing plantar flexion (footdrop) because they add support to the foot and keep it in the correct anatomic position. Footboards stimulate spasms and are not routinely recommended. Regular repositioning and range-of-motion exercises are important interventions, but the client's foot needs to be in the correct anatomic position to prevent overextension of the muscle and tendon. Massaging does not prevent plantar flexion and, if rigorous, could release emboli.

The client who has had a stroke with residual physical handicaps becomes discouraged by his physical appearance. What approach to the client is best for the nurse to use to help the client overcome his negative self-concept? Select all that apply. 1. Helpfulness. 2. Charity. 3. Firmness. 4. Encouragement. 5. Patience.

4, 5. When offering emotional support to a client who is discouraged and has a negative self-concept because of physical handicaps, the nurse should approach the client with encouragement and patience. The client should be praised when he or she shows progress in efforts to overcome handicaps. An attitude of helpfulness and sympathy allows the client to assume a role of someone not ordinary, someone who is not like others. Regardless of the handicap, the client still feels the same on the inside and has the same innate needs for his or her growth and developmental age-group. An attitude of charity tends to make the client feel like a "charity case" or like someone who is given something free because of his "condition." The client feels unequal to his peers or unable to fulfill the role relationships that were obtained before the stroke. An approach using firmness is inappropriate because it implies that the client can do better if he just tries harder and leaves no room for softness in the approach to overcoming a negative self-concept.

A nurse is teaching a client who had a stroke about ways to adapt to a visual disability. Which does the nurse identify as the primary safety precaution to use? 1. Wear a patch over one eye. 2. Place personal items on the sighted side. 3. Lie in bed with the unaffected side toward the door. 4. Turn the head from side to side when walking.

4. To expand the visual field, the partially sighted client should be taught to turn the head from side to side when walking. Neglecting to do so may result in accidents. This technique helps maximize the use of remaining sight. Covering an eye with a patch will limit the field of vision. Personal items can be placed within sight and reach, but most accidents occur from tripping over items that cannot be seen. It may help the client to see the door, but walking presents the primary safety hazard.