Neuro EAQ Review

The nurse performed a neurological assessment on a client, which included the Glasgow Coma Scale (GCS). Which components does the GCS assessment tool include? Select all that apply. One, some, or all responses may be correct. 1. Best verbal response 2. Best pupillary response 3. Best motor response 4. Best eye-opening response 5. Best cognitive response

Correct: 1. Best verbal response 3. Best motor response 4. Best eye-opening response The GCS is a common way of determining and documenting level of consciousness that scores verbal response, motor response, and eye-opening response. The lowest score is 3, which indicates a totally unresponsive client; a normal GCS score is 15. Pupillary and cognitive responses are not part of the GCS assessment.

Which actions will the nurse take to support cognitive ability in clients who have Alzheimer disease? Select all that apply. One, some, or all responses may be correct. 1. Encouraging caregivers to support safe independence 2. Using calendars, clocks, and pictures to support memory 3. Providing a limited number of choices to support decision-making 4. Quizzing the client regularly to assess orientation to person, place, and time 5. Administering prescribed rivastigmine to clients with severe dementia

Correct: 1. Encouraging caregivers to support safe independence 2. Using calendars, clocks, and pictures to support memory 3. Providing a limited number of choices to support decision-making Strategies that assist orientation without challenging the client and that encourage safe independence and decision-making support cognitive function in Alzheimer disease, such as clocks, calendars, limited number of choices, and allowing safe independence. Interactions that quiz or challenge the client are not well tolerated and do not support cognitive functioning. Alzheimer dementia is characterized by cerebral atrophy and by the presence of neurofibrillary tangles and amyloid plaques. Rivastigmine is a cholinesterase inhibitor that provides a modest short-term cognitive benefit for some people with mild to moderate Alzheimer dementia. It works by increasing acetylcholine at cholinergic synapses. It is not approved for people with severe disease.

Which factors can trigger a client's migraine attacks? Select all that apply. One, some, or all responses may be correct. 1. Fatigue 2. Vertigo 3. Aphasia 4. Sleep problems 5. Tingling sensations 6. Hormonal fluctuations

Correct: 1. Fatigue 4. Sleep problems 6. Hormonal fluctuations Fatigue tires the body and causes headaches. Sleep problems may increase the risk for disturbance to the brain. Hormonal fluctuations in different stages can trigger a migraine attack. Vertigo, aphasia, and tingling sensations are the symptoms of migraine headaches, not triggers.

For which clinical manifestations would the nurse assess the client diagnosed with Alzheimer disease? Select all that apply. One, some, or all responses may be correct. 1. Loss of recent memory 2. Focused attention span 3. Perceptual disturbances 4. Willingness to accept change 5. Difficulty learning something new

Correct: 1. Loss of recent memory 3. Perceptual disturbances 5. Difficulty learning something new Neurofibrillary tangles attack the hippocampus, impairing recent memory. As dementia progresses, sensory-perceptual alterations occur, such as hallucinations. Alzheimer disease is associated with a global intellectual impairment that affects learning, thinking, and language. Progressive deterioration of the regions of the brain results in cognitive deficits, such as a decreased, not focused, attention span. Clients with Alzheimer disease are easily confused or disoriented. They require familiar routines that provide a sense of security.

The nurse is taking care of a client who has chronic back pain. Which nursing considerations would be made when determining the client's plan of care? Select all that apply. One, some, or all responses may be correct. 1.Ask the client about the acceptable level of pain. 2. Eliminate all activities that precipitate the pain. 3. Administer the pain medications regularly around the clock. 4. Use a different pain scale each time to promote patient education. 5. Assess the client's pain every 15 minutes.

Correct: 1.Ask the client about the acceptable level of pain. 3. Administer the pain medications regularly around the clock. The nurse works together with the client to determine the tolerable level of pain. Considering that the client has chronic, not acute, pain, the goal of pain management is to decrease pain to a tolerable level instead of eliminating pain completely. Administration of pain medications around the clock will provide a stable level of pain medication in the blood and relieve the pain. Elimination of all activities that precipitate the client's pain is not possible even though the nurse will try to minimize such activities. The same pain scale should be used for assessment of the client's pain level because it helps ensure consistency and accuracy in the pain assessment. Only management of acute pain, such as postoperative pain, requires pain assessment at frequent intervals

Which clinical manifestations would the nurse expect to identify in a client experiencing spinal shock client immediately after sustaining a functional transection of the spinal cord at C7-C8? Select all that apply. One, some, or all responses may be correct. 1. Spasticity 2. Incontinence 3. Flaccid paralysis 4. Respiratory failure 5. Lack of reflexes below the injury

Correct: 3. Flaccid paralysis 5. Lack of reflexes below the injury Spinal shock (spinal shock syndrome) is immediate after a transection of the spinal cord; it results in flaccid paralysis of all skeletal muscles and usually lasts for 48 hours, but may persist for several weeks. Transection of the spinal cord caused the spinal shock and resulted in a loss of reflex activity below the level of the injury. Spasticity occurs after spinal shock has subsided. During the acute phase, retention of urine and feces occurs because of decreased tone of the bladder and bowel; thus incontinence is unusual. Respirations are labored, but spontaneous breathing continues, indicating the level of injury is below C4 and respirations are not affected.

A client with migraine headaches is scheduled for an electroencephalogram (EEG). Which statement by the client indicates to the nurse that preprocedure teaching has been effective? 1. "I will need to avoid beverages with caffeine." 2. "I will have a headache after the test." 3. "I will avoid drinking milk until the test is completed." 4. "I will take my sleeping pill before the test."

Correct: 1. "I will need to avoid beverages with caffeine." Caffeine products usually are avoided before an EEG because of their effect on brain activity. A headache is not a complication after an EEG. It is not necessary to avoid milk or other calcium-rich foods. Antianxiety and sleep medications usually are discontinued before the EEG because of their effect on brain activity.

When planning long-term care for a 2-year-old child with cerebral palsy (CP), which is important for the nurse to consider? 1. CP is not progressively degenerative. 2. The effects of CP are unpredictable. 3. The child probably has some degree of cognitive impairment (CI). 4. The child should have genetic counseling before planning a family.

Correct: 1. CP is not progressively degenerative. CP is a nonprogressive chronic condition and its effects are predictable. Although CI may be present in some children with CP, not all children with this disorder have CI. A variety of prenatal, perinatal, and postnatal factors contribute to the development of CP. It is estimated that the cause of CP is unknown in as many as 80% of people with the disorder.

The nurse would include which instruction to the parents of a child being treated with oral ampicillin for otitis media? 1. Complete the entire course of antibiotic therapy. 2. Herbal fever remedies are highly discouraged. 3. Administer the medication with meals. 4. Stop the antibiotic therapy when the child no longer has a fever.

Correct: 1. Complete the entire course of antibiotic therapy. Once antibiotic therapy is initiated, the antibiotics start to destroy specific bacterial infections that the health care provider is trying to treat. Antibiotic therapy takes a specific dose and number of days to completely eliminate the bacteria. If the caregivers start a dose and stop it before the course is complete, the remaining bacteria have a chance to grow again, become resistant to antibiotic treatment, and multiply. The nurse would not discourage use of herbal fever remedies; however, the herbal treatment would be reviewed to see if it is contraindicated. Ampicillin would be taken 1 to 2 hours after meals. Antibiotic therapy would be completed as prescribed.

A client arrives in the emergency department unconscious and exhibiting decerebrate posturing. Which positioning behaviors would the nurse expect to observe? 1. Hyperextension of both the upper and lower extremities 2. Spastic paralysis of both the upper and lower extremities 3. Hyperflexion of the upper extremities and hyperextension of the lower extremities 4. Flaccid paralysis of the upper extremities and spastic paralysis of the lower extremities

Correct: 1. Hyperextension of both the upper and lower extremities Limbs hyperextended and arms hyperpronated (extension posturing, decerebrate posturing) indicate upper brainstem damage; this is a grave sign. Spastic paralysis of both the upper and lower extremities is associated with an upper motor neuron disease or lesion. Hyperflexion of the upper extremities and hyperextension of the lower extremities is associated with flexion posturing (decorticate posturing), which indicates damage to the pyramidal motor tract above the brainstem. Flaccid paralysis of the upper extremities and spastic paralysis of the lower extremities is associated with a lower motor neuron disease or lesion.

Which clinical assessment would the nurse perform to evaluate the effectiveness of a shunt for an infant with hydrocephalus? 1. Palpating the anterior fontanel 2. Determining the frequency of voiding 3. Assessing the child for periorbital edema 4. Assessing the symmetry of the Moro reflex

Correct: 1. Palpating the anterior fontanel A bulging fontanel is the most significant sign of increased intracranial pressure in an infant. Periorbital edema, the frequency of voiding, and the symmetry of the Moro reflex are not indicators of increased intracranial pressure.

Which intervention would the nurse perform first for the client admitted with a closed head injury and increased intracranial pressure (ICP)? 1. Place the head and neck in neutral alignment. 2. Obtain a prescription for 100 mg of pentobarbital IV. 3. Administer 1 g mannitol intravenously (IV) as prescribed. 4. Increase the ventilator's respiratory rate to 20 breaths/minute.

Correct: 1. Place the head and neck in neutral alignment. The nurse would first attempt nursing interventions such as placing the head and neck in alignment (neutral position) to facilitate venous return and thereby decrease ICP. If nursing measures prove ineffective, notify the health care provider, who may prescribe mannitol. The nurse would notify the health care provider for hyperventilation therapy or for pentobarbital. Hyperventilation is used only when all other interventions have been ineffective in decreasing ICP.

Which finding would help confirm the nurse's suspicion that a client may have meningitis after surgery for a brain tumor? 1. Positive Kernig sign 2. Glasgow Coma Score: 10 3. Absence of nuchal rigidity 4. Negative Brudzinski sign

Correct: 1. Positive Kernig sign Meningitis may occur secondary to surgical procedures on the brain. It is highly probable when Kernig sign is positive. The Glasgow Coma Scale is used as a reliable way of recording the conscious state of the client, but it is not used to diagnose meningitis. A meningitis diagnosis is highly probable with a positive Brudzinski sign and the presence of nuchal rigidity (e.g., stiff neck).

Which clinical manifestations indicate a client who sustained head and chest injuries from a motor vehicle accident, responded to medical treatments, and is ready for transfer to a critical care unit? 1. Stabilized vital signs and complaints of pain 2. Pale and alert; remains restless 3. Increasing temperature and apprehension 4. Fluctuating vital signs and drowsy, but easily roused

Correct: 1. Stabilized vital signs and complaints of pain Stable vital signs is the major indicator predicting transfer will not jeopardize the client's condition. Although complaints of pain are a concern, they do not place the client in physiologic jeopardy. Restlessness and pallor may be early signs of shock; the client needs further assessment. An increasing temperature is a sign of increasing intracranial pressure; delay transfer of the client at this time. Fluctuating vital signs and drowsiness indicate an unstable client with potentially increasing intracranial pressures.

The nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral side of a client's foot is stroked. Which finding would the nurse document? 1. "Has intact plantar reflexes" 2. "Exhibits a positive Babinski sign" 3. "Demonstrates normal sensory function" 4. "Able to perform active range of motion"

Correct: 2. "Exhibits a positive Babinski sign" This is a positive Babinski sign; it is expected in infants but suggests upper motor neuron disease of the pyramidal tract in adults. The plantar reflex involves flexion of the toes and plantar flexion of the feet. "Demonstrates normal sensory function" is incorrect; positive Babinski is not an indication of normal sensation. "Able to perform active range of motion is inaccurate"; Babinski reflex is not caused by intentional movement. Active range of motion is a type of exercise, not a reflex.

Which instruction will the nurse give a client with migraine headaches who is starting triptan medication therapy? 1. "Check your pulse before and after administration." 2. "Report any chest discomfort to the health care provider." 3. "Wait for 1 hour after symptom onset to administer the medication." 4. "Stop taking the medication if you experience warm, flushing sensations."

Correct: 2. "Report any chest discomfort to the health care provider." Clients need to be instructed to report chest discomfort to the health care provider immediately. Clients taking triptan medications who experience chest discomfort must be investigated for myocardial ischemia. Clients on beta-blocker therapy for migraines, not triptan therapy, will be instructed to monitor pulse. Triptan medications are taken as soon as symptoms appear. Warm, flushing sensations are a common experience in clients taking triptan medication; the side effect generally subsides with continued use and does not indicate a need to stop the medication.

A client develops tinnitus. Which of the client's medications would the nurse suspect is the cause of this new development? 1. Digoxin 0.25 mg, one tablet daily 2. Aspirin 325 mg, two tablets every 4 hours 3. Captopril 25 mg, one tablet three times daily 4. Diphenhydramine 25 mg, one tablet every 4 to 8 hours prn

Correct: 2. Aspirin 325 mg, two tablets every 4 hours Aspirin is a salicylate. Extensive use of salicylates can cause salicylism. Tinnitus is a common manifestation of this condition. Tinnitus is not an adverse effect of digoxin, captopril, or diphenhydramine.

Which ophthalmic solution is contraindicated for clients with glaucoma? 1. Timolol 2. Atropine 3. Pilocarpine 4. Epinephrine

Correct: 2. Atropine Atropine, a mydriatic ophthalmic solution, is contraindicated for clients with glaucoma because it dilates the pupil, increasing intraocular pressure. Timolol, a beta blocker, decreases aqueous humor production; beta blockers are the preferred initial medications given to reduce intraocular pressure. Pilocarpine, a cholinergic, constricts the pupil, thereby increasing aqueous humor outflow. Epinephrine, an adrenergic agent, enhances aqueous humor outflow, thereby reducing intraocular pressure.

Which information would the nurse include in the teaching plan for a client diagnosed with epilepsy? 1. The client will take anticonvulsant medications for life. 2. Individuals taking phenytoin must floss their teeth regularly. 3. A diagnosis of epilepsy prevents individuals from ever obtaining a driver's license. 4. Loss of consciousness during a seizure requires emergency evaluation.

Correct: 2. Individuals taking phenytoin must floss their teeth regularly. Gingival hyperplasia is a common side effect of phenytoin. Clients may decrease or delay development of gingival hyperplasia by regular brushing and flossing of their teeth. Although lifelong treatment with antiseizure medication often is required, some people are able to wean from antiseizure medication after they have been seizure free for a period of several years (generally 3 to 5) and have a normal electroencephalogram and neurological examination. Driving laws for people with epilepsy vary from state to state. For example, some states require a seizure-free period of several months and some states require a seizure-free period of up to a year before reinstating or issuing a driver's license. The person who has experienced a single seizure may not need to go to the hospital, unless the event is a first-time seizure, the seizure is prolonged, or the seizure results in bodily harm

A client manifests right-sided hemianopsia as a result of a cerebrovascular accident (CVA, also known as a "brain attack"). Which goal would the nurse include in the client's plan of care? 1. Correct the client's misuse of equipment. 2. Instruct the client to scan surroundings. 3. Teach the client to look at the position of the left extremities. 4. Provide the client with tactile stimulation to the affected extremities.

Correct: 2. Instruct the client to scan surroundings. The client has lost vision from the right visual field; scanning compensates for this loss. Correct the client's misuse of equipment for clients with apraxia (inability to manipulate objects). When teaching the client to look at the position of the left extremities, neglect of the affected side increases. Provide the client with tactile stimulation to the affected extremities when the client experiences denial of the right side (unilateral neglect).

Which early sign of increased intracranial pressure (ICP) would the nurse monitor in a client who sustained a head injury while playing soccer? 1. Nausea 2. Lethargy 3. Sunset eyes 4. Hyperthermia

Correct: 2. Lethargy Lethargy is an early sign of a changing level of consciousness; a changing level of consciousness is one of the first signs of increased ICP. Nausea is a subjective symptom, not a sign, potentially present with increased ICP. Sunset eyes is a late sign of increased ICP that occurs in children with hydrocephalus. Hyperthermia is a late sign of increased ICP that occurs as compression of the brainstem increases.

Dexamethasone has been prescribed for a client after a craniotomy for a brain tumor. Which physiological response is responsible for this medication's therapeutic effect? 1. Reduced cell growth 2. Reduced cerebral edema 3. Increased renal reabsorption 4. Increased response to sedation

Correct: 2. Reduced cerebral edema Dexamethasone is a corticosteroid with anti-inflammatory effects, which will reduce cerebral edema. Dexamethasone will not keep the tumor from growing; it will reduce fluid content and therefore cell size, not the number of cells. Dexamethasone does not promote fluid reabsorption, which is undesirable because it increases fluid retention and therefore cerebral edema. Dexamethasone does not promote sedation; sedation is not desired because it may mask the client's adaptations to the craniotomy

The nurse teaches a client with multiple sclerosis methods to reduce fatigue. Which statement indicates an understanding of the education? 1. Take a hot bath on a daily basis. 2. Rest in an air-conditioned room. 3. Increase the dose of muscle relaxants. 4. Avoid naps during the day.

Correct: 2. Rest in an air-conditioned room. Fatigue is a common symptom in clients with multiple sclerosis. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, the client must avoid extreme cold. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness and fatigue. Planning frequent rest periods and naps can relieve fatigue.

The nurse is caring for a client who has a traumatic brain injury with increased intracranial pressure. Which health care provider prescription would the nurse question? 1. Continue anticonvulsants 2. Teach isometric exercises 3. Continue osmotic diuretics 4. Keep HOB at 30 degrees

Correct: 2. Teach isometric exercises The prescription for isometric exercises should be questioned; isometric exercises increase the basal metabolic rate and intracranial pressure. Anticonvulsants may be administered prophylactically after traumatic brain injury to limit the risk for seizures, which will further increase intracranial pressure. Osmotic diuretics may be used to draw fluid from the cerebral tissue into the vascular space to decrease cerebral edema and intracranial pressure. Elevation of the head of the bed helps reduce cerebral edema as the result of gravitational force on the fluid.

A client arrived in the emergency department with a posttraumatic brain injury and multiple fractures. The client's eyes remain closed, and there is no evidence of verbalization or movement when the nurse changes the client's position. Which score on the Glasgow Coma Scale (GCS) would the nurse document? Record your answer using a whole number. _______ Total GCS score

Correct: 3 The score is 3. The score on the GCS ranges from 3 to 15. The client's lack of response earns the minimum of 1 point in each of the categories: eye opening response, best verbal response, and best motor response.

A health care provider prescribed a diagnostic workup for a client who may have myasthenia gravis. Which initial objective would the nurse establish with the client? 1. "The client will adhere to the teaching plan." 2. "The client will achieve psychologic adjustment." 3. "The client will maintain present muscle strength." 4. "The client will prepare for a possible myasthenic crisis."

Correct: 3. "The client will maintain present muscle strength." Until confirming the diagnosis, the primary goal should be to maintain appropriate activity and prevent muscle atrophy. It is too early to develop a teaching plan; establishment of the diagnosis has not yet occurred. The response "achieve psychologic adjustment" is too early; the client cannot adjust with a confirmed diagnosis. The response "prepare for a possible myasthenic crisis" is an intervention, not an objective.

The company transported an unconscious construction worker, who fell off the roof of a two-story, to the hospital. Which clinical finding would the nurse report immediately? 1. Bilaterally reactive pupils 2. Depressed anterior fontanel 3. Bleeding from the ears 4. Increased body temperature

Correct: 3. Bleeding from the ears Bleeding from the ears occurs only with basal skull fractures; bleeding from the ears is an assessment that assists in diagnosing the location of the injury. Reactive pupils is a positive response; pupils should react to light bilaterally. An adult does not have fontanels; a depressed fontanel will occur in an infant in the presence of dehydration. Increasing body temperature occurs with increased intracranial pressure (ICP) and pressure on the brainstem; an increased ICP is an expected response, but not an immediate one

A newborn is admitted to the neonatal intensive care unit with a myelomeningocele located at the fourth lumbar vertebra (L4). Which is the priority nursing intervention while the infant is awaiting surgery? 1. Increasing nutritional intake 2. Promoting sensory stimulation 3. Providing meticulous skin care 4. Performing range-of-motion exercises

Correct: 3. Providing meticulous skin care Skin care is essential to prevent rupture of the sac and subsequent infection. There is no need to increase nutrition; there are no data to confirm that the infant is malnourished. Although sensory stimulation is important, it is not the priority. Exercises are not indicated at this time; they may be implemented after surgery

A client is diagnosed with Parkinson disease and receives a prescription for levodopa therapy. Which mechanism of action would the nurse identify for this medication? 1. Blocks the effects of acetylcholine 2. Increases the production of dopamine 3. Restores the dopamine levels in the brain 4. Promotes the production of acetylcholine

Correct: 3. Restores the dopamine levels in the brain Levodopa is a precursor of dopamine, a catecholamine neurotransmitter; it increases dopamine levels in the brain that are depleted in Parkinson disease. Blocking the effects of acetylcholine is accomplished by anticholinergic medications. Increasing the production of dopamine is ineffective because it is believed that the cells that produce dopamine have degenerated in Parkinson disease. Levodopa does not affect acetylcholine production.

A client with myasthenia gravis asks the nurse, "What is going to happen to me and to my family?" Which information about the anticipated disease process would the nurse incorporate when responding to the client's question? 1. There is a high cure rate with proper treatment for this disease. 2. This disease has a slow, progressive course, without remissions. 3. The disease is a chronic illness with exacerbations and remissions. 4. Myasthenia gravis has a poor prognosis, with death occurring in a few months.

Correct: 3. The disease is a chronic illness with exacerbations and remissions. Myasthenia gravis is a chronic disorder with remissions and exacerbations. Emotional stress, ingestion of alcohol, and physiological stress such as infection precipitate the exacerbations. There is no cure for myasthenia gravis, but it can be managed. Exacerbations and remissions characterize this disease. The disease is chronic. Death does not occur within a short period.

Which response reported by an older adult client would the nurse identify as consistent with the diagnosis of macular degeneration? 1. "My vision is best when I dim the lights." 2. "I always see halos around lights, especially at night." 3. "I can't see objects in my periphery vision." 4. "I can't see objects in the center of my vision field."

Correct: 4. "I can't see objects in the center of my vision field." The macula is the central vision area of the retina; therefore macular degeneration affects central vision and makes objects within direct, center vision difficult to see. Dim light will make vision more difficult for this client. Seeing halos around lights relates to glaucoma, rather than macular degeneration. An inability to see objects in the periphery relates to glaucoma, rather than macular degeneration.

A client diagnosed with a transient ischemic attack (TIA) related to hypertension is discharged with a prescription of hydrochlorothiazide. Which instruction would the nurse include when teaching about this medication? 1. "Resume regular eating habits." 2. "Drink a protein supplement daily." 3. "Avoid eating foods high in insoluble fiber." 4. "Increase the intake of potassium-rich foods."

Correct: 4. "Increase the intake of potassium-rich foods." The client must increase the dietary intake of potassium because of potassium loss associated with hydrochlorothiazide. The client should be taught about medication-induced deficiencies, which may necessitate a change in diet, and not just return to regular eating habits once home. Protein supplements are not necessary, and protein may be obtained from meat, fish, and dairy products in the diet or complementary vegetable and grain proteins. Foods high in insoluble fiber are part of the food pyramid and should be included in the diet.

For optimum nutrition, which intervention would the nurse implement when determining a client, who sustained a cerebrovascular accident (also known as a "brain attack"), needs assistance with eating? 1. Request that the client's food be pureed. 2. Feed the client to conserve the client's energy. 3. Have a family member assist the client with each meal. 4. Encourage the client to participate in the feeding process.

Correct: 4. Encourage the client to participate in the feeding process. As part of the rehabilitative process after a brain attack, clients should be encouraged to participate in their own care to the extent they are able and extend their abilities by establishing short-term goals. A client with a brain attack may or may not have dysphagia; altering the consistency of food without the need to do so may make it less palatable. Making the client feel helpless discourages independence. Having a family member assist the client with each meal is unrealistic; family members may not be available because of other responsibilities.

Which clinical indicator would the nurse expect to identify when assessing a client who has a brain tumor in the occipital lobe? 1. Hemiparesis 2. Receptive aphasia 3. Personality changes 4. Visual hallucinations

Correct: 4. Visual hallucinations The occipital lobe is involved with visual interpretation. Hemiparesis is not associated with the occipital lobe damage. Receptive aphasia is a function associated with the temporal lobe. Personality changes are functions associated with the frontal lobe.