Neuro Saunders, EOC, ATI

A client has a cerebellar lesion. The nurse would plan to obtain which item for use by this client? 1.Walker 2.Slider board 3.Raised toilet seat 4.Adaptive eating utensils

1 The cerebellum is responsible for balance and coordination. A walker provides stability for the client during ambulation. A raised toilet seat is useful if the client has sufficient mobility or ability to flex the hips. A slider board is used in transferring a client with weak or paralyzed legs from a bed to stretcher or wheelchair. Adaptive eating utensils are beneficial if the client has partial paralysis of the hand.

The nurse is planning to perform an assessment of the client's level of consciousness using the Glasgow Coma Scale. Which assessments should the nurse include in order to calculate the score? Select all that apply. 1.Eye opening 2.Reflex response 3.Best verbal response 4.Best motor response 5.Pupil size and reaction

1,3,4 Assessment of pupil size and reaction and reflex response are not part of the Glasgow Coma Scale. The 3 categories included are eye opening, best verbal response, and best motor response. Pupil assessment and reflex response is a necessary part of a total assessment of the neurological status of a client but is not part of this particular scale.

A client has sustained damage to Wernicke's area from a stroke (brain attack). On assessment of the client, which sign or symptom would be noted? 1.Difficulty speaking 2.Problem with understanding language 3.Difficulty controlling voluntary motor activity 4.Problem with articulating events from the remote past

2 Wernicke's area consists of a small group of cells in the temporal lobe whose function is the understanding of language. Damage to Broca's area is responsible for aphasia. The motor cortex in the precentral gyrus controls voluntary motor activity. The hippocampus is responsible for the storage of memory.

At 8:00 a.m., a client who has had a stroke (brain attack) was awake and alert with vital signs of temperature 98º F (37.2º C) orally, pulse 80 beats/min, respirations 18 breaths/min, and blood pressure 138/80 mm Hg. At noon, the client is confused and only responsive to tactile stimuli, and vital signs are temperature 99º F (36.7º C) orally, pulse 62 beats/min, respirations 20 breaths/min, and blood pressure 166/72 mm Hg. The nurse should take which action? 1.Reorient the client. 2.Retake the vital signs. 3.Call the primary health care provider (PHCP). 4.Administer an antihypertensive PRN (as needed).

3 The important nursing action is to call the PHCP. The deterioration in neurological status, decreasing pulse, and increasing blood pressure with a widening pulse pressure all indicate that the client is experiencing increased intracranial pressure, which requires immediate treatment to prevent further complications and possible death. The nurse should retake the vital signs and reorient the client to surroundings. If the client's blood pressure falls within parameters for PRN antihypertensive medication, the medication also should be administered. However, options 1, 2, and 4 are secondary nursing actions.

A client is anxious about an upcoming diagnostic procedure. The client's pupils are dilated, and the respiratory rate, heart rate, and blood pressure are increased from baseline. The nurse determines that the client's clinical manifestations are due to what type of physiologic response? 1.Vagal 2.Peripheral nervous system 3.Sympathetic nervous system 4.Parasympathetic nervous system

3 The sympathetic nervous system is responsible for the so-called fight or flight response, which is characterized by dilated pupils, increases in heart rate and cardiac output, and increases in respiratory rate and blood pressure. The sympathetic nervous system response affects some type of change in most systems of the body. The responses stated in the other options do not produce these effects.

The nurse is caring for a patient with a closed head injury. The nurse evaluates that the prescribed hyperosmotic agents are having their intended effects when which assessment is made? (Select all that apply.) Body temperature decreases Patient is seizure-free Stools for occult blood are negative Urine output increases Intracranial pressure decreases

3. Correct answer: D, E Rationale: Hyperosmotic agents (osmotic diuretics) draw fluid out of brain cells by increasing the osmolality of the blood. This helps to decrease intracranial pressure. The fluid is drawn into the circulating blood volume and is excreted as urine. These medications excrete water and leave behind solutes. Osmotic diuretics are not used to treat hyperthermia, prevent seizures, or prevent gastrointestinal hemorrhages.

The nurse is reviewing the record of a client with a suspected diagnosis of Huntington's disease. The nurse should expect to note documentation of which early symptom of this disease? 1.Aphasia 2.Agnosia 3.Difficulty with swallowing 4.Balance and coordination problems

4 Early symptoms of Huntington's disease include restlessness, forgetfulness, clumsiness, falls, balance and coordination problems, altered speech, and altered handwriting. Difficulty with swallowing occurs in the later stages. Aphasia and agnosia do not occur.

The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement? 1."I will wash my face with cotton pads." 2."I'll have to start chewing on my unaffected side." 3."I should rinse my mouth if toothbrushing is painful." 4."I'll try to eat my food either very warm or very cold."

4 Facial pain can be minimized by using cotton pads to wash the face and using room temperature water. The client should chew on the unaffected side of the mouth, eat a soft diet, and take in foods and beverages at room temperature. If brushing the teeth triggers pain, an oral rinse after meals may be helpful instead.

The nurse is caring for a client with an intracranial pressure (ICP) monitoring device. The nurse should become most concerned if the ICP readings drifted to and stayed in the vicinity of which finding? 1.5 mm Hg 2.8 mm Hg 3.14 mm Hg 4.22 mm Hg

4 Normal ICP readings range from 5 to 15 mm Hg pressure. Pressures greater than 20 mm Hg are considered to represent increased ICP, which seriously impairs cerebral perfusion.

An older client is brought to the hospital emergency department by a neighbor who heard the client talking and found him wandering in the street at 3 a.m. The nurse should first determine which data about the client? 1.His insurance status 2.Blood toxicology levels 3.Whether he ate his evening meal 4.Whether this is a change in usual level of orientation

4 The nurse should first determine whether this behavior represents a change in the client's neurological status. The next item to determine is when the client last ate. Blood toxicology levels may or may not be needed, but the health care provider would likely prescribe these. Insurance information must be obtained at some point but is not the priority from a clinical care viewpoint.

A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and suspects the presence of which problem? 1.Altered breathing pattern 2.Increased likelihood of injury 3.Ineffective oxygen consumption 4.Increased susceptibility to aspiration

1 Altered breathing pattern indicates that the respiratory rate, depth, rhythm, timing, or chest wall movements are insufficient for optimal ventilation of the client. This is a risk for clients with spinal cord injury in the lower cervical area. Ineffective oxygen consumption occurs when oxygenation or carbon dioxide elimination is altered at the alveolar-capillary membrane. Increased susceptibility to aspiration and increased likelihood of injury are unrelated to the subject of the question.

The nurse is caring for a client who sustained a spinal cord injury. During administration of morning care, the client begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action should the nurse take? 1.Elevate the head of the bed. 2.Examine the rectum digitally. 3.Assess the client's blood pressure. 4.Place the client in the prone position.

1 Autonomic dysreflexia is a serious complication that can occur in the spinal cord-injured client. Once the syndrome is identified, the nurse elevates the head of the client's bed and then examines the client for the source of noxious stimuli. The nurse also assesses the client's blood pressure, but the initial action would be to elevate the head of the bed. The client would not be placed in the prone position; lying flat will increase the client's blood pressure.

The nurse is performing an assessment on a client with a diagnosis of Bell's palsy. The nurse should expect to observe which finding in the client? 1.Facial drooping 2.Periorbital edema 3.Ptosis of the eyelid 4.Twitching on the affected side of the face

1 Bell's palsy is a one-sided facial paralysis caused by the compression of the facial nerve (cranial nerve VII). Assessment findings include facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and speech or chewing difficulty. The remaining options are not associated findings in Bell's palsy.

A client has suffered damage to Broca's area of the brain. Which priority assessment should the nurse perform? 1.Speech 2.Hearing 3.Balance 4.Level of consciousness

1 Broca's area in the brain is responsible for the motor aspects of speech, through coordination of the muscular activity of the tongue, mouth, and larynx. The term assigned to damage in this area is aphasia. The items listed in the other options are not the responsibility of Broca's area.

A client with recent-onset Bell's palsy is upset and crying about the change in facial appearance. The nurse plans to support the client emotionally by making which statement to the client? 1."This is not a stroke, and many clients recover in 3 to 5 weeks." 2."This is caused by a small tumor, which can be removed easily." 3."This is similar to a stroke, but all symptoms will reverse without treatment." 4."This is a temporary problem, with treatment similar to that for migraine headaches."

1 Clients with Bell's palsy should be reassured that they have not experienced a stroke (brain attack) and that symptoms often disappear spontaneously in 3 to 5 weeks. The client is given supportive treatment for symptoms. Bell's palsy usually is not caused by a tumor, and the treatment is not similar to that for migraine headaches.

The nurse reviews the primary health care provider's (PHCP's) prescriptions for a client with Guillain-Barré syndrome. Which prescription written by the PHCP should the nurse question? 1.Clear liquid diet 2.Bilateral calf measure 3.Monitor vital signs frequently 4.Passive range-of-motion (ROM) exercises

1 Clients with Guillain-Barré syndrome have dysphagia. Clients with dysphagia are more likely to aspirate clear liquids than thick or semisolid foods. Passive ROM exercises can help prevent contractures, and assessing calf measurements can help detect deep vein thrombosis, for which these clients are at risk. Because clients with Guillain-Barré syndrome are at risk for hypotension or hypertension, bradycardia, and respiratory depression, frequent monitoring of vital signs is required.

A client with myasthenia gravis arrives at the hospital emergency department in suspected crisis. The primary health care provider plans to administer edrophonium to differentiate between myasthenic and cholinergic crises. The nurse ensures that which medication is available in the event that the client is in cholinergic crisis? 1.Atropine sulfate 2.Morphine sulfate 3.Protamine sulfate 4.Pyridostigmine bromide

1 Clients with cholinergic crisis have experienced an overdosage of medication. Edrophonium will exacerbate symptoms in cholinergic crisis to the point at which the client may need intubation and mechanical ventilation. Intravenous atropine sulfate is used to reverse the effects of these anticholinesterase medications. Morphine sulfate and pyridostigmine bromide would worsen the symptoms of cholinergic crisis. Protamine sulfate is the antidote for heparin.

The nurse in the neurological unit is monitoring a client with a head injury for signs of increased intracranial pressure (ICP). The nurse reviews the assessment findings for the client and notes documentation of the presence of Cushing's reflex. The nurse determines that the presence of this reflex is obtained by assessing which item? 1.Blood pressure 2.Motor response 3.Pupillary response 4.Level of consciousness

1 Cushing's reflex is a late sign of increased ICP and consists of a widening pulse pressure (systolic pressure rises faster than diastolic pressure) and bradycardia. The remaining options are unrelated to monitoring for Cushing's reflex.

The nurse is developing a plan of care for an older client that addresses interventions to prevent cold discomfort and the development of accidental hypothermia. The nurse should document which desired outcome in the plan of care? 1.The client's fingers and toes are warm to touch. 2.The client's body temperature is 98º F (36.7º C). 3.The client remains in a fetal position when in bed. 4.The client complains of coolness in the hands and feet only.

1 Desired outcomes for nursing interventions to prevent cold discomfort and the development of accidental hypothermia include the following: hands and limbs are warm; body is relaxed and not curled; body temperature is greater than 97º F (36.1º C); the client is not shivering; and the client has no complaints of feeling cold.

The nurse is caring for a client after a craniotomy and monitors the client for signs of increased intracranial pressure (ICP). Which finding, if noted in the client, would indicate an early sign of increased ICP? 1.Confusion 2.Bradycardia 3.Sluggish pupils 4.A widened pulse pressure

1 Early manifestations of increased ICP are subtle and often may be transient, lasting for only a few minutes in some cases. These early clinical manifestations include episodes of confusion, drowsiness, and slight pupillary and breathing changes. Later manifestations include a further decrease in the level of consciousness, a widened pulse pressure, and bradycardia. Cheyne-Stokes respiratory pattern, or a hyperventilation respiratory pattern, and pupillary sluggishness and dilatation appear in the late stages.

The nurse is performing a neurological assessment on a client and is assessing the function of cranial nerves III, IV, and VI. Assessment of which aspect of function will yield the best information about these cranial nerves? 1.Eye movements 2.Response to verbal stimuli 3.Affect, feelings, or emotions 4.Insight, judgment, and planning

1 Eye movements are under the control of cranial nerves III, IV, and VI. Level of consciousness (response to verbal stimuli) is controlled by the reticular activating system and both cerebral hemispheres. Feelings are part of the role of the limbic system and involve both hemispheres. Insight, judgment, and planning are part of the function of the frontal lobe in conjunction with association fibers that connect to other areas of the cerebrum.

A client who had a stroke (brain attack) has right-sided hemianopsia. What should the nurse plan to do to help the client adapt to this problem? 1.Teach the client to scan the environment. 2.Place all objects within the left visual field. 3.Place all objects within the right visual field. 4.Ensure that the family brings the client's eyeglasses to hospital.

1 Hemianopsia is blindness in half of the visual field. The client with hemianopsia is taught to scan the environment. This allows the client to take in the entirety of the visual field, which is necessary for proper functioning within the environment and helps to prevent injury to the client. Options 2 and 3 will not help the client adapt to this visual impairment. Eyeglasses are useful if the client already wears them, but they will not correct this visual field deficit.

The nurse is caring for a client diagnosed with bacterial meningitis. Which clinical manifestation should the nurse monitor for, indicating increased intracranial pressure? 1.Altered mental status 2.Decreased urinary output 3.Decreased peripheral sensation 4.Numbness and tingling in the fingers and toes

1 Meningitis is a bacterial infection of the meninges of the brain. A common complication of meningitis is increased intracranial pressure. Altered mental status can result from increased intracranial pressure. Decreased urinary output, decreased peripheral sensation, and numbness and tingling in the fingers and toes are not specifically associated with bacterial meningitis.

A client arrives in the hospital emergency department with a closed head injury to the right side of the head caused by an assault with a baseball bat. The nurse assesses the client neurologically, looking primarily for motor response deficits that involve which area? 1.The left side of the body 2.The right side of the body 3.Both sides of the body equally 4.Cranial nerves only, such as speech and pupillary response

1 Motor responses such as weakness and decreased movement will be seen on the side of the body that is opposite an area of head injury. Contralateral deficits result from compression of the cortex of the brain or the pyramidal tracts. Depending on the severity of the injury, the client may have a variety of neurological deficits.

The nurse is providing care to a client with increased intracranial pressure (ICP). Which approach is beneficial in controlling the client's ICP from an environmental viewpoint? 1.Reduce environmental noise. 2.Allow visitors as desired by the client and family. 3.Awaken the client every 2 to 3 hours to monitor mental status. 4.Cluster nursing activities to reduce the number of interruptions.

1 Nursing interventions to control ICP include maintaining a calm, quiet, and restful environment. Environmental noise should be kept at a minimum. Visiting should be monitored to avoid emotional stress and interruption of sleep. Interventions should be spaced out over the shift to minimize the risk of a sustained rise in ICP.

A client with multiple sclerosis tells a home health care nurse that she is having increasing difficulty in transferring from the bed to a chair. What is the initial nursing action? 1.Observe the client demonstrating the transfer technique. 2.Start a restorative nursing program before an injury occurs. 3.Seize the opportunity to discuss potential nursing home placement. 4.Determine the number of falls that the client has had in recent weeks.

1 Observation of the client's transfer technique is the initial intervention. Starting a restorative program is important but not unless an assessment has been completed first. Discussing nursing home placement would be inappropriate in view of the information provided in the question. Determining the number of falls is another important intervention, but observing the transfer technique should be done first.

The nurse is caring for a client who is in the chronic phase of stroke (brain attack) and has a right-sided hemiparesis. The nurse identifies that the client is unable to feed self. Which is the appropriate nursing intervention? 1.Assist the client to eat with the left hand to build strength. 2.Provide a pureed diet that is easy for the client to swallow. 3.Inform the client that a feeding tube will be placed if progress is not made. 4.Provide a variety of foods on the meal tray to stimulate the client's appetite.

1 Right-sided hemiparesis is weakness of the right arm and leg. The nurse should teach the client to use both sides of the body to increase strength and build endurance. Providing a pureed diet is incorrect. The question does not mention swallowing difficulty, so there is no need to puree the food. Informing the client that a feeding tube may need to be placed is incorrect. That information would come from the primary health care provider. Providing a variety of foods is also incorrect because the problem is not the food selection but the client's ability to eat the food independently.

Members of the family of an unconscious client with increased intracranial pressure are talking at the client's bedside. They are discussing the client's condition and wondering whether the client will ever recover. The nurse intervenes on the basis of which interpretation? 1.It is possible the client can hear the family. 2.The family needs immediate crisis intervention. 3.The client might have wanted a visit from the hospital chaplain. 4.The family could benefit from a conference with the primary health care provider.

1 Some clients who have awakened from an unconscious state have remembered hearing specific voices and conversations. Family and staff should assume that the client's sense of hearing is intact and act accordingly. In addition, positive outcomes are associated with coma stimulation-that is, speaking to and touching the client. The remaining options are incorrect interpretations.

Which intervention should the nurse include in a postoperative teaching plan for a client who underwent a spinal fusion and will be wearing a brace? 1.Tell the client to inspect the environment for safety hazards. 2.Inform the client about the importance of sitting as much as possible. 3.Inform the client that lotions and body powders can be used for skin breakdown. 4.Instruct the client to tighten the brace during meals and to loosen it for the first 30 minutes after each meal.

1 The client must inspect the environment for safety hazards. The client is instructed in the importance of avoiding prolonged sitting and standing. Powders and lotions should not be used because they may irritate the skin. The client should be taught to loosen the brace during meals and for 30 minutes after each meal. The client may have difficulty eating if the brace is too tight. Loosening the brace after each meal will allow adequate nutritional intake and promote comfort.

The nurse is caring for a client diagnosed with a hydrocephalus. Which should the nurse anticipate as being the cause of this disorder? 1.Closure of cranial sutures 2.Small aqueduct of Sylvius 3.Enlarged foramen of Monro 4.Increased number of arachnoid villi

1 The closure of cranial sutures during childhood prevents expansion of the cranial vault when hydrocephalus occurs in the adult. This leads to increased neurological changes with lesser degrees of hydrocephalus compared with hydrocephalus during early childhood. The other structures identified in the remaining options are associated with cerebrospinal fluid formation and circulation but are not responsible for hydrocephalus.

A client who had cranial surgery 5 days earlier to remove a brain tumor has a few cognitive deficits and does not seem to be progressing as quickly as the client or family had hoped. The nurse plans to implement which approach as most helpful to the client and family at this time? 1.Emphasize progress in a realistic manner. 2.Set high goals to give the client something to "aim for." 3.Tell the family to be extremely optimistic with the client. 4.Inform the client and family of standardized goals of care.

1 The most helpful approach by the nurse is to emphasize progress that is being made in a realistic manner. The nurse does not offer false hope but does provide factual information in a clear and positive manner. The nurse encourages the family to be realistic in their expectations and attitudes. The plan of care should be individualized for each client.

The nurse is caring for a client with a head injury. The client's intracranial pressure reading is 8 mm Hg. Which condition should the nurse document? 1.The intracranial pressure reading is normal. 2.The intracranial pressure reading is elevated. 3.The intracranial pressure reading is borderline. 4.An intracranial pressure reading of 8 mm Hg is low.

1 The normal intracranial pressure is 5 to 15 mm Hg. A pressure of 8 mm Hg is within normal range.

The nurse is reviewing a discharge teaching plan for a postcraniotomy client that was prepared by a nursing student. The nurse would intervene and provide teaching to the student if the student included which home care instruction? 1.Sounds will not be heard clearly unless they are loud. 2.Obtain assistance with ambulation if the client is lightheaded. 3.Tub bath or shower is permitted, but the scalp is kept dry until the sutures are removed. 4.Use a check-off system for administering anticonvulsant medications to avoid missing doses.

1 The postcraniotomy client typically is sensitive to loud noises and can find them excessively irritating. Control of environmental noise by others will be helpful for this client. Seizures are a potential complication that may occur for up to 1 year after surgery. For this reason, the client must diligently take anticonvulsant medications. The client and family are encouraged to keep track of the doses administered. The family should learn seizure precautions and should accompany the client during ambulation if dizziness or seizures tend to occur. The suture line is kept dry until sutures are removed to prevent infection.

A thymectomy accomplished via a median sternotomy approach is performed in a client with a diagnosis of myasthenia gravis. The nurse creates a postoperative plan of care for the client that should include which intervention? 1.Monitor the chest tube drainage. 2.Restrict visitors for 24 hours postoperatively. 3.Maintain intravenous infusion of lactated Ringer's solution. 4.Avoid administering pain medication to prevent respiratory depression.

1 The thymus has played a role in the development of myasthenia gravis. A thymectomy is the surgical removal of the thymus gland and may be used for management of clients with myasthenia gravis to improve weakness. The procedure is performed through a median sternotomy or a transcervical approach. Postoperatively the client will have a chest tube in the mediastinum. Lactated intravenous solutions usually are avoided because they can increase weakness. Pain medication is administered as needed, but the client is monitored closely for respiratory depression. There is no reason to restrict visitors.

A client who is experiencing an inferior wall myocardial infarction has had a drop in heart rate into the range of 50 to 56 beats/minute. The client also is complaining of nausea. On the basis of these findings, the nurse determines that the client is experiencing parasympathetic stimulation of which cranial nerve? 1.Vagus (CN X) 2.Hypoglossal (CN XII) 3.Spinal accessory (CN XI) 4.Glossopharyngeal (CN IX)

1 The vagus nerve is responsible for sensations in the thoracic and abdominal viscera. It also is responsible for the decrease in heart rate because approximately 75% of all parasympathetic stimulation is carried by the vagus nerve. CN XII is responsible for tongue movement. CN XI is responsible for neck and shoulder movement. CN IX is responsible for taste in the posterior two-thirds of the tongue, pharyngeal sensation, and swallowing.

A client who is experiencing an inferior wall myocardial infarction has had a drop in heart rate into the 50 to 56 beats/minute range. The client is also complaining of nausea. Which cranial nerve damage should the nurse expect that the client is experiencing? 1.Vagus (CN X) 2.Hypoglossal (CN XII) 3.Spinal accessory (CN XI) 4.Glossopharyngeal (CN IX)

1 The vagus nerve is responsible for sensations in the thoracic and abdominal viscera. It is also responsible for the decrease in heart rate because approximately 75% of all parasympathetic stimulation is carried by the vagus nerve. CN IX is responsible for taste in the posterior two-thirds of the tongue, pharyngeal sensation, and swallowing. CN XI is responsible for neck and shoulder movement. CN XII is responsible for tongue movement.

The nurse is teaching a client with paraplegia measures to maintain skin integrity. Which instruction will be most helpful to the client? 1.Shift weight every 2 hours while in a wheelchair. 2.Change bed sheets every other week to maintain cleanliness. 3.Place a pillow on the seat of the wheelchair to provide extra comfort. 4.Use a mirror to inspect for redness and skin breakdown twice a week.

1 To maintain skin integrity, the client should shift weight in the wheelchair every 2 hours and use a pressure relief pad. A pillow is not sufficient to relieve the pressure. While the client is in bed, the bottom sheet should be free of wrinkles and wetness. Sheets should be changed as needed and more frequently than every other week. The client should use a mirror to inspect the skin twice daily (morning and evening) to assess for redness, edema, and breakdown. General additional measures include a nutritious diet and meticulous skin care.

The nurse is caring for a client who is on bed rest as part of aneurysm precautions. The nurse should avoid doing which action when giving respiratory care to this client? 1.Encouraging hourly coughing 2.Assisting with incentive spirometer 3.Encouraging hourly deep breathing 4.Repositioning gently side to side every 2 hours

1 With aneurysm precautions, any activity that could raise the client's intracranial pressure (ICP) is avoided. For this reason, activities such as straining, coughing, blowing the nose, and even sneezing are avoided whenever possible. The other interventions (repositioning, deep breathing, and incentive spirometry) do not provide added risk of increasing ICP and are beneficial in reducing the respiratory complications of bed rest.

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific prescriptions, the nurse should safely place the client in which positions? Select all that apply. 1.Head midline 2.Neck in neutral position 3.Head of bed elevated 30 to 45 degrees 4.Head turned to the side when flat in bed 5.Neck and jaw flexed forward when opening the mouth

1,2,3

The nurse is preparing a plan of care for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On assessment, the nurse notes that the client is severely dysphagic. Which intervention should be included in the care plan for this client? Select all that apply. 1.Provide oral hygiene after each meal. 2.Assess swallowing ability frequently. 3.Allow the client sufficient time to eat. 4.Maintain a suction machine at the bedside. 5.Provide a full liquid diet for ease in swallowing.

1,2,3,4 A client who is severely dysphagic is at risk for aspiration. Swallowing is assessed frequently. The client should be given a sufficient amount of time to eat. Semisoft foods are easiest to swallow and require less chewing. Oral hygiene is necessary after each meal. Suctioning should be available for clients who experience dysphagia and are at risk for aspiration.

The nurse is planning care for a client who displays confusion secondary to a neurological problem. Which approaches by the nurse would be helpful in assisting this client? Select all that apply. 1.Providing sensory cues 2.Giving simple, clear directions 3.Providing a stable environment 4.Keeping family pictures at the bedside 5.Encouraging family members to visit at the same time

1,2,3,4 Clients with cognitive impairment from neurological dysfunction respond best to a stable environment that is limited in amount and type of sensory input. The nurse can provide sensory cues and give clear, simple directions in a positive manner. Confusion can be minimized by reducing environmental stimuli (such as television or multiple visitors) and by keeping familiar personal articles (such as family pictures) at the bedside.

The nurse is assessing a client who is experiencing seizure activity. The nurse understands that it is necessary to determine information about which items as part of routine assessment of seizures? Select all that apply. 1.Postictal status 2.Duration of the seizure 3.Changes in pupil size or eye deviation 4.Seizure progression and type of movements 5.What the client ate in the 2 hours preceding seizure activity

1,2,3,4 Typically seizure assessment includes the time the seizure began, parts of the body affected, type of movements and progression of the seizure, change in pupil size or eye deviation or nystagmus, client condition during the seizure, and postictal status. Determining what the client ate 2 hours prior to the seizure is not a component of seizure assessment.

The nurse is creating a plan of care for a client with dysphagia following a stroke (brain attack). Which should the nurse include in the plan? Select all that apply. 1.Thicken liquids. 2.Assist the client with eating. 3.Assess for the presence of a swallow reflex. 4.Place the food on the affected side of the mouth. 5.Provide ample time for the client to chew and swallow.

1,2,3,5 Liquids are thickened to prevent aspiration. The nurse should assist the client with eating and place food on the unaffected side of the mouth. The nurse should assess for gag and swallowing reflexes before the client with dysphagia is started on a diet. The client should be allowed ample time to chew and swallow to prevent choking.

The home health nurse is visiting a client with myasthenia gravis and is discussing methods to minimize the risk of aspiration during meals related to decreased muscle strength. Which suggestions should the nurse give to the client? Select all that apply. 1.Chew food thoroughly. 2.Cut food into very small pieces. 3.Sit straight up in the chair while eating. 4.Lift the head while swallowing liquids. 5.Swallow when the chin is tipped slightly downward to the chest.

1,2,3,5 The client avoids swallowing any type of food or drink with the head lifted upward, which could actually cause aspiration by opening the glottis. The client should be advised to sit upright while eating, not to talk with food in the mouth (talking requires opening the glottis), cut food into very small pieces, chew thoroughly, and tip the chin downward to swallow.

The nurse is trying to communicate with a client who had a stroke and has aphasia. Which actions by the nurse would be most helpful to the client? Select all that apply. 1.Speaking to the client at a slower rate 2.Allowing plenty of time for the client to respond 3.Completing the sentences that the client cannot finish 4.Looking directly at the client during attempts at speech 5.Shouting words if it seems as though the client has difficulty understanding

1,2,4 Clients with aphasia after brain attack often fatigue easily and have a short attention span. General guidelines when trying to communicate with the aphasic client include speaking more slowly and allowing adequate response time, listening to and watching attempts to communicate, and trying to put the client at ease with a caring and understanding manner. The nurse would avoid shouting (because the client is not deaf), appearing rushed for a response, and letting family members provide all responses for the client.

A client with a neurological problem is experiencing hyperthermia. Which measures would be appropriate for the nurse to use in trying to lower the client's body temperature? Select all that apply. 1.Giving tepid sponge baths 2.Applying a hypothermia blanket 3.Covering the client with blankets 4.Administering acetaminophen per protocol 5.Placing ice packs over the client's abdomen and in the axilla and groin

1,2,4 Standard measures to lower body temperature include removing bed covers, providing cool sponge baths, using an electric fan in the room, administering acetaminophen, and placing a hypothermia blanket under the client. Ice packs are not used because they could cause shivering, which increases cellular oxygen demands, with the potential for increased intracranial pressure.

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure (ICP). Pending specific primary health care provider prescriptions, the nurse should plan to place the client in which positions? Select all that apply. 1.Head midline 2.Neck in neutral position 3.Flat, with head turned to the side 4.Head of bed elevated 30 to 45 degrees 5.Head of bed elevated with the neck extended

1,2,4 The client who is at risk for or who has increased ICP should be positioned so that the head is in a neutral, midline position. The nurse should avoid flexing or extending the client's neck or turning the head from side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep ICP down.

The client with a cervical spine injury has cervical tongs applied in the emergency department. What should the nurse include when planning care for this client? Select all that apply. 1.Using a RotoRest bed 2.Ensuring that weights hang freely 3.Removing the weights to reposition the client 4.Assessing the integrity of the weights and pulleys 5.Comparing the amount of prescribed traction with the amount in use

1,2,4,5 Cervical tongs are applied after drilling holes in the client's skull under local anesthesia. Weights are attached to the tongs, which exert pulling pressure on the longitudinal axis of the cervical spine. Serial x-rays of the cervical spine are taken, with weights being added gradually until the x-ray reveals that the vertebral column is realigned. After that, weights may be reduced gradually to a point that maintains alignment. The client with cervical tongs is placed on a Stryker frame or RotoRest bed. The nurse ensures that weights hang freely and the amount of weight matches the current prescription. The nurse also inspects the integrity and position of the ropes and pulleys. The nurse does not remove the weights to administer care.

The nurse is evaluating the respiratory outcomes for a client with Guillain-Barré syndrome. The nurse determines that which are acceptable outcomes for the client? Select all that apply. 1.Spontaneous breathing 2.Oxygen saturation of 98% 3.Adventitious breath sounds 4.Normal arterial blood gas levels 5.Vital capacity within normal range

1,2,4,5 Satisfactory respiratory outcomes for a client with Guillain-Barré syndrome include clear breath sounds on auscultation, spontaneous breathing, normal vital capacity, normal arterial blood gas levels, and normal pulse oximetry. Adventitious breath sounds are an abnormal finding.

The nurse has determined that a client with a neurological disorder also has difficulty breathing. Which activities would be appropriate components of the care plan for this client? Select all that apply. 1.Keep suction equipment at the bedside. 2.Elevate the head of the bed 30 degrees. 3.Keep the client lying in a supine position. 4.Keep the head and neck in good alignment. 5.Administer prescribed respiratory treatments as needed.

1,2,4,5 The nurse maintains a patent airway for the client with difficulty breathing by keeping the head and neck in good alignment and elevating the head of the bed 30 degrees unless contraindicated. Suction equipment is kept at the bedside if secretions need to be cleared. The client should be kept in a side-lying position whenever possible to minimize the risk of aspiration.

The nurse is planning to put aneurysm precautions in place for a client with a cerebral aneurysm. Which nursing measures would be implemented? Select all that apply. 1.Provide physical aspects of care. 2.Prevent pushing or straining activities. 3.Limit caffeinated coffee to 1 cup per day. 4.Keeping the lights on in the client's room. 5.Maintain the head of the bed at 15 degrees.

1,2,5 Aneurysm precautions include placing the client on bed rest (as prescribed) in a quiet setting. Stimulants such as caffeine and nicotine are prohibited; decaffeinated coffee or tea may be used. Lights are kept dim to minimize environmental stimulation. Any activity that increases the blood pressure or impedes venous return from the brain is prohibited, such as pushing, pulling, sneezing, coughing, or straining. The nurse provides physical care to minimize increases in blood pressure. For the same reason, visitors, radio, television, and reading materials are prohibited or limited.

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. 1.Padding the side rails of the bed 2.Placing an airway at the bedside 3.Placing the bed in the high position 4.Putting a padded tongue blade at the head of the bed 5.Placing oxygen and suction equipment at the bedside 6.Flushing the intravenous catheter to ensure that the site is patent

1,2,5,6 Seizure precautions may vary from agency to agency, but they generally have some common features. Usually, airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if antiseizure medications must be administered, and as part of the routine assessment the nurse should be checking patency of the catheter. The use of padded tongue blades is highly controversial, and they should not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure more likely will harm the client who bites down during seizure activity. Risks include blocking the airway from improper placement, chipping the client's teeth, and subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begins.

The nurse is caring for a client with an intracranial aneurysm who has been alert. Which signs and symptoms are an early indication that the level of consciousness (LOC) is deteriorating? Select all that apply. 1.Mild drowsiness 2.Drooping eyelids 3.Ptosis of the left eyelid 4.Slight slurring of speech 5.Less frequent spontaneous speech

1,4,5 Early changes in LOC relate to orientation, alertness, and verbal responsiveness. Mild drowsiness, slight slurring of speech, and less frequent spontaneous speech are early signs of decreasing LOC. Ptosis (drooping) of the eyelid is caused by pressure on and dysfunction of cranial nerve III. Once ptosis occurs, it is ongoing; it does not relate to LOC.

A patient with a spinal cord injury is prescribed pantoprazole (Protonix). The nurse will explain which rationale for this administration? Prevents stress-related gastric ulcers. Encourages healing of gastric nerves. Promotes digestion of enteral feedings. Supports healthy bacteria in the gastrointestinal tract.

10. Correct answer: A Rationale: A proton-pump inhibitor, such as pantoprazole (Protonix), is often prescribed to prevent stress-related gastric ulcers. This medication is not prescribed to encourage healing of gastric nerves, promote digestion of enteral feedings, or support healthy bacteria in the gastrointestinal tract. Cognitive Level: Analyzing; Nursing Process: Planning; Client Need: Physiological Integrity

A client was seen and treated in the hospital emergency department for a concussion. The nurse determines that family members need further teaching if they verbalize to call the primary health care provider (PHCP) for which client sign or symptom? 1.Vomiting 2.Minor headache 3.Difficulty speaking 4.Difficulty awakening

2 A concussion after head injury is a temporary loss of consciousness (from a few seconds to a few minutes) without evidence of structural damage. After concussion, the family is taught to monitor the client and call the PHCP or return the client to the emergency department for signs and symptoms such as confusion, difficulty awakening or speaking, one-sided weakness, vomiting, and severe headache. Minor headache is expected.

The nurse is evaluating a function of the limbic system as a part of the neurological status of a client. What should the nurse assess? 1.Experience of pain 2.Affect or emotions 3.Response to verbal stimuli 4.Insight, judgment, and planning

2 Affect and emotions are part of the role of the limbic system and involve both hemispheres of the brain. Pain is a complex experience involving several areas of the central nervous system. The response to verbal stimuli is part of the level of consciousness, which is under the control of the reticular activating system and both cerebral hemispheres. Insight, judgment, and planning are part of the functions of the frontal lobes of the brain in conjunction with association fibers connecting to other areas of the cerebrum.

The nurse has made a judgment that a client who had a craniotomy is experiencing a problem with body image. The nurse develops goals for the client but determines that the client has not met the outcome criteria by discharge if the client performs which action? 1.Wears a turban to cover the incision 2.Indicates that facial puffiness will be a permanent problem 3.Verbalizes that periorbital bruising will disappear over time 4.States an intention to purchase a hairpiece until hair has grown back

2 After craniotomy, clients may experience difficulty with altered personal appearance. The nurse can help by listening to the client's concerns and by clarifying any misconceptions about facial edema, periorbital bruising, and hair loss (all of which are temporary). The nurse can encourage the client to participate in self-grooming and use personal articles of clothing. Finally, the nurse can suggest the use of a turban, followed by a hairpiece, to help the client adapt to the temporary change in appearance.

The student nurse develops a plan of care for a client after a lumbar puncture. The nursing instructor corrects the student if the student documents which incorrect intervention in the plan? 1.Maintain the client in a flat position. 2.Restrict fluid intake for a period of 2 hours. 3.Assess the client's ability to void and move the extremities. 4.Inspect the puncture site for swelling, redness, and drainage.

2 After the lumbar puncture the client remains flat in bed for at least 2 hours, depending on the primary health care provider's prescriptions. A liberal fluid intake is encouraged to replace the cerebrospinal fluid removed during the procedure, unless contraindicated by the client's condition. The nurse checks the puncture site for redness and drainage and assesses the client's ability to void and move the extremities.

An older client in an acute state of disorientation is brought to the hospital emergency department by the client's daughter. The daughter states that the client was "clear as a bell this morning." The nurse determines from this piece of information that which is an unlikely cause of the disorientation? 1.Hypoglycemia 2.Alzheimer's disease 3.Medication dosage error 4.Impaired circulation to the brain

2 Alzheimer's disease is a chronic disease with progression of memory deficits over time. The situation presented in the question represents an acute problem. Evaluation is necessary to determine whether hypoglycemia, medication use, or impaired cerebral circulation has had a role in causing the client's current symptoms.

The nurse is assessing the client's gait and notes it is unsteady and staggering. Which description should the nurse use when documenting the assessment finding? 1.Spastic 2.Ataxic 3.Festinating 4.Dystrophic or broad-based

2 An ataxic gait is characterized by unsteadiness and staggering. A spastic gait is characterized by stiff, short steps with the legs held together, hip and knees flexed, and toes that catch and drag. A festinating gait is best described as walking on the toes with an accelerating pace. A dystrophic or broad-based gait is seen as waddling, with the weight shifting from side to side and the legs far apart.

The nurse assesses a client who is diagnosed with a stroke (brain attack). On assessment, the client is unable to understand the nurse's commands. Which condition should the nurse document? 1.Occipital lobe impairment 2.Damage to the auditory association areas 3.Frontal lobe and optic nerve tracts damage 4.Difficulty with concept formation and abstraction areas

2 Auditory association and storage areas are located in the temporal lobe and relate to understanding spoken language. The occipital lobe contains areas related to vision. The frontal lobe controls voluntary muscle activity, including speech, and an impairment can result in expressive aphasia. The parietal lobe contains association areas for concept formation, abstraction, spatial orientation, body and object size and shape, and tactile sensation.

A client admitted to the nursing unit from the hospital emergency department has a C4 spinal cord injury. In conducting the admission assessment, what is the nurse's priority action? 1.Take the temperature. 2.Listen to breath sounds. 3.Observe for dyskinesias. 4.Assess extremity muscle strength.

2 Because compromise of respiration is a leading cause of death in cervical cord injury, respiratory assessment is the highest priority. Assessment of temperature and strength can be done after adequate oxygenation is ensured. Because dyskinesias occur in cerebellar disorders, this is not as important a concern as in cord-injured clients unless head injury is suspected.

The home care nurse is visiting a client with a diagnosis of Parkinson's disease. The client is taking benztropine mesylate orally daily. The nurse provides information to the spouse regarding the side effects of this medication and should tell the spouse to report which side effect if it occurs? 1.Shuffling gait 2.Inability to urinate 3.Decreased appetite 4.Irregular bowel movements

2 Benztropine mesylate is an anticholinergic, which causes urinary retention as a side effect. The nurse would instruct the client or spouse about the need to monitor for difficulty with urinating, a distended abdomen, infrequent voiding in small amounts, and overflow incontinence. The remaining options are unrelated to the use of this medication.

The nurse is performing an assessment on a client with the diagnosis of Brown-Séquard syndrome. The nurse would expect to note which assessment finding? 1.Bilateral loss of pain and temperature sensation 2.Ipsilateral paralysis and loss of touch and vibration 3.Contralateral paralysis and loss of touch, pressure, and vibration 4.Complete paraplegia or quadriplegia, depending on the level of injury

2 Brown-Séquard syndrome results from hemisection of the spinal cord, resulting in ipsilateral paralysis and loss of touch, pressure, vibration, and proprioception. Contralaterally, pain and temperature sensation are lost because these fibers decussate after entering the cord. The remaining options are not assessment findings in this syndrome.

A client has a high level of carbon dioxide (CO2) in the bloodstream, as measured by arterial blood gases. The nurse anticipates that which underlying pathophysiology can occur as a result of this elevated CO2? 1.It will cause arteriovenous shunting. 2.It will cause vasodilation of blood vessels in the brain. 3.It will cause blood vessels in the circle of Willis to collapse. 4.It will cause hyperresponsiveness of blood vessels in the brain.

2 CO2 is one of the metabolic end products that can alter the tone of the blood vessels in the brain. High CO2 levels cause vasodilation, which may cause headache, whereas low CO2 levels cause vasoconstriction, which may cause lightheadedness. The statements included in the other options are incorrect effects.

The home care nurse is making extended follow-up visits to a client discharged from the hospital after a moderately severe head injury. The family states that the client is behaving differently than before the accident. The client is more fatigued and irritable and has some memory problems. The client, who was previously very even tempered, is prone to outbursts of temper now. The nurse determines that these behaviors are indicative of which problem? 1.Intracranial pressure changes 2.A long-term sequela of the injury 3.A worsening of the original injury 4.A short-term problem that will resolve in about 1 month

2 Clients with moderate to severe head injury usually have residual physical and cognitive disabilities; these include personality changes, increased fatigue and irritability, mood alterations, and memory changes. The client also may require frequent to constant supervision. The nurse assesses the family's ability to cope and makes appropriate referrals to respite services, support groups, and state or local chapters of the National Head Injury Foundation.

The nurse in the health care clinic is providing medication instructions to a client with a seizure disorder who will be taking divalproex sodium. The nurse should instruct the client about the importance of returning to the clinic for monitoring of which laboratory study? 1.Electrolyte panel 2.Liver function studies 3.Renal function studies 4.Blood glucose level determination

2 Divalproex sodium, an anticonvulsant, can cause fatal hepatotoxicity. The nurse should instruct the client about the importance of monitoring the results of liver function studies and ammonia level determinations. The studies in the remaining options are not required with the use of this medication.

The nurse is admitting a client to the hospital emergency department from a nursing home. The client is unconscious with an apparent frontal head injury. A medical diagnosis of epidural hematoma is suspected. Which question is of the highest priority for the emergency department nurse to ask of the transferring nurse at the nursing home? 1."When did the injury occur?" 2."Was the client awake and talking right after the injury?" 3."What medications has the client received since the fall?" 4."What was the client's level of consciousness before the injury?"

2 Epidural hematomas frequently are characterized by a "lucid interval" that lasts for minutes to hours, during which the client is awake and talking. After this lucid interval, signs and symptoms progress rapidly, with potentially catastrophic intracranial pressure increase. Epidural hematomas are medical emergencies. It is important for the nurse to assist in the differentiation between epidural hematoma and other types of head injuries.

The nurse has given the client with Bell's palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs further teaching if the client makes which statements? 1."I will perform facial exercises." 2."I will expose my face to cold to decrease the pain." 3."I will massage my face with a gentle upward motion." 4."I will wrinkle my forehead, blow out my cheeks, and whistle frequently."

2 Exposure to cold or drafts is avoided in Bell's palsy because it can cause discomfort. Prevention of muscle atrophy with Bell's palsy is accomplished with facial massage, facial exercises, and electrical nerve stimulation. Local application of heat to the face may improve blood flow and provide comfort.

The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention should the nurse plan to incorporate into the care routine for the client and family? 1.Discouraging the family from touching the client 2.Explaining equipment and procedures on an ongoing basis 3.Ensuring adherence to visiting hours to ensure the client's rest 4.Encouraging the family not to "give in" to their feelings of grief

2 Families often need assistance to cope with the illness of a loved one. The nurse should explain all equipment, treatments, and procedures and should supplement or reinforce information given by the primary health care provider. Family members should be encouraged to touch and speak to the client and to become involved in the client's care to the extent they are comfortable. The nurse should allow the family to stay with the client to the extent possible and should encourage them to eat and sleep adequately to maintain strength. The nurse can help family members of an unconscious client by assisting them to work through their feelings of grief.

The nurse is assessing the function of cranial nerve XII in a client who sustained a stroke. To assess function of this nerve, which action should the nurse ask the client to perform? 1.Extend the arms. 2.Extend the tongue. 3.Turn the head toward the nurse's arm. 4.Focus the eyes on the object held by the nurse.

2 Impairment of cranial nerve XII can occur with a stroke. To assess the function of cranial nerve XII (the hypoglossal nerve), the nurse would assess the client's ability to extend the tongue. The maneuvers noted in the remaining options do not test the function of cranial nerve XII.

The nurse is performing the oculocephalic response (doll's eyes maneuver) on an unconscious client. The nurse turns the client's head and notes movement of the eyes in the same direction as the head. How should the nurse document these findings? 1.Normal 2.Abnormal 3.Insignificant 4.Inconclusive

2 In an unconscious client, eye movements are an indication of brainstem activity and are tested by the oculocephalic response. When the doll's eyes maneuver is intact, the eyes move in the opposite direction when the head is turned. Abnormal responses include movement of the eyes in the same direction as the head and maintenance of a midline position of the eyes when the head is turned. An abnormal response indicates a disruption in the processing of information through the brainstem.

The nurse is performing an assessment on a client with a head injury and notes that the client is assuming this posture. The nurse contacts the primary health care provider and reports that the client is exhibiting which posture? Refer to figure.View Figure 1.Opisthotonos 2.Decorticate rigidity 3.Decerebrate rigidity 4.Flaccid quadriplegia

2 In decorticate rigidity, the upper extremities (arms, wrists, and fingers) are flexed with adduction of the arms. The lower extremities are extended with internal rotation and plantar flexion. Decorticate rigidity indicates a hemispheric lesion of the cerebral cortex. Opisthotonos is prolonged arching of the back with the head and heels bent backward. Opisthotonos indicates meningeal irritation. In decerebrate rigidity, the upper extremities are stiffly extended and adducted with internal rotation and pronation of the palms. The lower extremities are stiffly extended with plantar flexion. The teeth are clenched, and the back is hyperextended. Decerebrate rigidity indicates a lesion in the brainstem at the midbrain or upper pons. Flaccid quadriplegia is complete loss of muscle tone and paralysis of all four extremities, indicating a completely nonfunctional brainstem.

The nurse assigned to the care of an unconscious client is making initial daily rounds. On entering the client's room, the nurse observes that the client is lying supine in bed, with the head of the bed elevated approximately 5 degrees. The nasogastric tube feeding is running at 70 mL/hr, as prescribed. The nurse assesses the client and auscultates adventitious breath sounds. Which judgment should the nurse formulate for the client? 1.Impaired nutritional intake 2.Increased risk for aspiration 3.Increased likelihood for injury 4.Susceptibility to fluid volume deficit

2 Increased risk for aspiration is a condition in which an individual is at risk for entry of gastrointestinal (GI) secretions, oropharyngeal secretions, or solids or fluids into tracheobronchial passages. Conditions that place the client at risk for aspiration include reduced level of consciousness, depressed cough and gag reflexes, and feeding via a GI tube. There is no information in the question indicating that the remaining options are a concern.

The nurse is assessing a client's muscle strength and notes that when asked, the client cannot maintain the hands in a supinated position with the arms extended and eyes closed. How should the nurse correctly document this finding on the medical record? 1.Client is demonstrating ataxia. 2.Client is exhibiting pronator drift. 3.Client appears to have nystagmus. 4.Client examination reveals hyperreflexia.

2 Pronator drift occurs when a client cannot maintain the hands in a supinated position with the arms extended and eyes closed. This assessment may be done to detect small changes in muscle strength that might not otherwise be noted. Ataxia is a disturbance in gait. Nystagmus is characterized by fine, involuntary eye movements. It can occur with neurological disease or as a side effect of selected medications. Hyperreflexia is an excessive reflex action.

A client with neck and upper extremity pain has been diagnosed with cervical radiculitis. What does the nurse anticipate as being the cause of these clinical manifestations? 1.Pressure on a spinous process 2.Pressure on a spinal nerve root 3.Pressure on a central spinal cord 4.Pressure on a posterior facet joints

2 Radiculitis is a term used to describe spinal nerve root compression at the intervertebral foramen. Radiculitis can be caused by a number of factors, such as whiplash or ruptured intervertebral disk. In many cases, it is caused by malalignment that occurs with degenerative disease or bone spur formation. Options 1, 3, and 4 are not associated with cervical radiculitis.

At the beginning of the work shift, the nurse assesses the status of the client wearing a halo device. The nurse determines that which assessment finding requires intervention? 1.Tightened screws 2.Red skin areas under the jacket 3.Clean and dry lamb's wool jacket lining 4.Finger-width space between the jacket and the skin

2 Red skin areas under the jacket indicate that the jacket is too tight. The resulting pressure could lead to altered skin integrity and needs to be relieved by loosening the jacket. The screws all should be properly tightened. A clean, dry lamb's wool lining should be in place underneath the jacket, and there should be a finger-width space between the jacket and the skin. In addition, the client should wear a clean white cotton T-shirt next to the skin to help prevent itching.

The nurse is performing an assessment on a client with Guillain-Barré syndrome. The nurse determines that which finding would be of most concern? 1.Difficulty articulating words 2.Lung vital capacity of 10 mL/kg 3.Paralysis progressing from the toes to the waist 4.A blood pressure (BP) decrease from 110/78 mm Hg to 102/70 mm Hg

2 Respiratory compromise is a major concern in clients with Guillain-Barré syndrome. Clients often are intubated and mechanically ventilated when the vital capacity is less than 15 mL/kg. Difficulty articulating words and paralysis progressing from the toes to the waist are expected, depending on the degree of paralysis that occurs. Although orthostatic hypotension is a problem with these clients, the BP drop in option 4 is less than 10 mm Hg and is not significant.

A client with a traumatic brain injury is able, with eyes closed, to identify a set of keys placed in his or her hands. On the basis of this assessment finding, the nurse determines that there is appropriate function of which lobe of the brain? 1.Frontal 2.Parietal 3.Occipital 4.Temporal

2 The ability to distinguish an object by touch is called stereognosis, which is a function of the right parietal area. The parietal lobe of the brain is responsible for spatial orientation and awareness of sizes and shapes. The left parietal area is responsible for mathematics and right-left orientation. The other lobes of the brain are not responsible for this function.

A client with myasthenia gravis is having difficulty with airway clearance and difficulty with maintaining an effective breathing pattern. The nurse should keep which most important items available at the client's bedside? 1.Oxygen and metered-dose inhaler 2.Ambu bag and suction equipment 3.Pulse oximeter and cardiac monitor 4.Incentive spirometer and cough pillow

2 The client with myasthenia gravis may experience episodes of respiratory distress if excessively fatigued or with development of myasthenic or cholinergic crisis. For this reason, an Ambu bag, intubation tray, and suction equipment should be available at the bedside.

t the end of the work shift, the nurse is reviewing the respiratory status of a client admitted with a stroke (brain attack) earlier in the day. The nurse determines that the client's airway is patent if which data are identified? 1.Respiratory rate 24 breaths/min, oxygen saturation 94%, breath sounds clear 2.Respiratory rate 18 breaths/min, oxygen saturation 98%, breath sounds clear 3.Respiratory rate 16 breaths/min, oxygen saturation 85%, wheezes bilaterally 4.Respiratory rate 20 breaths/min, oxygen saturation 92%, diminished breath sounds in lung bases

2 The client's airway is most protected if all of the respiratory parameters measured fall within normal limits. Therefore, the respiratory rate should ideally be 16 to 20 breaths/min, the oxygen saturation should be greater than 95%, and the breath sounds should be clear. The correct option is the only one that meets all 3 criteria.

The nurse is documenting nursing observations in the record of a client who experienced a tonic-clonic seizure. Which clinical manifestation did the nurse most likely note in the clonic phase of the seizure? 1.Body stiffening 2.Spasms of the entire body 3.Sudden loss of consciousness 4.Brief flexion of the extremities

2 The clonic phase of a seizure is characterized by alternating spasms and momentary muscular relaxation of the entire body, accompanied by strenuous hyperventilation. The face is contorted and the eyes roll. Excessive salivation results in frothing from the mouth. The tongue may be bitten, the client sweats profusely, and the pulse is rapid. The clonic jerking subsides by slowing in frequency and losing strength of contractions over a period of 30 seconds. Body stiffening, sudden loss of consciousness, and brief flexion of the extremities are associated with the tonic phase of a seizure.

A client is diagnosed with Bell's palsy. The nurse assessing the client expects to note which symptom? 1.A symmetrical smile 2.Difficulty closing the eyelid on the affected side 3.Narrowing of the palpebral fissure on the affected side 4.Paroxysms of excruciating pain in the lips and cheek on the affected side

2 The facial drooping associated with Bell's palsy makes it difficult for the client to close the eyelid on the affected side. A widening of the palpebral fissure (the opening between the eyelids) and an asymmetrical smile are seen with Bell's palsy. Paroxysms of excruciating pain are characteristic of trigeminal neuralgia.

The nurse is positioning a client who has increased intracranial pressure. Which position should the nurse avoid? 1.Head midline 2.Head turned to the side 3.Neck in neutral position 4.Head of bed elevated 30 to 45 degrees

2 The head of a client with increased intracranial pressure should be kept in a neutral midline position. The nurse should avoid flexing or extending the client's neck or turning the head from side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure down.

A client who suffered a stroke is prepared for discharge from the hospital. The primary health care provider has prescribed range-of-motion (ROM) exercises for the client's right side. What action should the nurse include in the client's plan of care? 1.Implement ROM exercises to the point of pain for the client. 2.Consider the use of active, passive, or active-assisted exercises in the home. 3.Encourage the client to be dependent on the home care nurse to complete the exercise program. 4.Develop a schedule of ROM exercises every 2 hours while awake even if the client is fatigued.

2 The home care nurse must consider all forms of ROM for the client. Even a client with hemiplegia can participate in some components of rehabilitative care. In addition, the goal in home care nursing is for the client to assume as much self-care and independence as possible. The nurse needs to teach home care measures so that the client becomes self-reliant. The options of performing ROM exercises to the point of pain and performing ROM exercises every 2 hours while the client is awake even if fatigued are incorrect from a physiological standpoint.

The nurse notes that a client who has suffered a brain injury has an adequate heart rate, blood pressure, fluid balance, and body temperature. Based on these clinical findings, the nurse determines that which brain area is functioning properly? 1.Thalamus 2.Hypothalamus 3.Limbic system 4.Reticular activating system

2 The hypothalamus is responsible for autonomic nervous system functions, such as heart rate, blood pressure, temperature, and fluid and electrolyte balance (among others). The thalamus acts as a relay station for sensory and motor information. The limbic system is responsible for emotions. The reticular activating system is responsible for the sleep-wake cycle.

The nurse is reviewing the record for a client seen in the health care clinic and notes that the primary health care provider has documented a diagnosis of amyotrophic lateral sclerosis (ALS). Which initial clinical manifestation of this disorder should the nurse expect to see documented in the record? 1.Muscle wasting 2.Mild clumsiness 3.Altered mentation 4.Diminished gag reflex

2 The initial symptom of ALS is a mild clumsiness, usually noted in the distal portion of 1 extremity. The client may complain of tripping and drag 1 leg when the lower extremities are involved. Mentation and intellectual function usually are normal. Diminished gag reflex and muscle wasting are not initial clinical manifestations.

The home care nurse is making a visit to a client who requires use of a wheelchair after a spinal cord injury sustained 4 months earlier. Just before leaving the home, the nurse ensures that which intervention has been done to prevent an episode of autonomic dysreflexia (hyperreflexia)? 1.Updating the home safety sheet 2.Leaving the client in an unchilled area of the room 3.Noting a bowel movement on the client progress note 4.Recording the amount of urine obtained with catheterization

2 The most common cause of autonomic dysreflexia is visceral stimuli, such as with blockage of urinary drainage or with constipation. Barring these, other causes include noxious mechanical and thermal stimuli, particularly pressure and overchilling. For this reason, the nurse ensures that the client is positioned with no pinching or pressure on paralyzed body parts and that the client will be sufficiently warm.

Which assessment finding should the nurse expect to note in the client hospitalized with a diagnosis of stroke who has difficulty chewing food? 1.Dysfunction of vagus nerve (cranial nerve X) 2.Dysfunction of trigeminal nerve (cranial nerve V) 3.Dysfunction of hypoglossal nerve (cranial nerve XII) 4.Dysfunction of spinal accessory nerve (cranial nerve XI)

2 The motor branch of cranial nerve V is responsible for the ability to chew food. The vagus nerve is active in parasympathetic functions of the autonomic nervous system. The hypoglossal nerve aids in swallowing. The spinal accessory nerve is responsible for shoulder movement, among other things.

A client is newly admitted to the hospital with a diagnosis of stroke (brain attack) manifested by complete hemiplegia. Which item in the medical history of the client should the nurse be most concerned about? 1.Glaucoma 2.Emphysema 3.Hypertension 4.Diabetes mellitus

2 The nurse should be most concerned about emphysema. The respiratory system is the priority in the acute phase of a stroke. The client with a stroke is vulnerable to respiratory complications such as atelectasis and pneumonia. Because the client has complete hemiplegia (is unable to move) and has emphysema, these risks are very significant. Although the other conditions of glaucoma, hypertension, and diabetes mellitus are important, they are not as significant as emphysema.

A client is admitted with an exacerbation of multiple sclerosis. The nurse is assessing the client for possible precipitating risk factors. Which factor, if reported by the client, should the nurse identify as being unrelated to the exacerbation? 1.Annual influenza vaccination 2.Ingestion of increased fruits and vegetables 3.An established routine of walking 2 miles each evening 4.A recent period of extreme outside ambient temperatures

2 The onset or exacerbation of multiple sclerosis can be preceded by a number of different factors, including physical stress (e.g., vaccination, excessive exercise), emotional stress, fatigue, infection, physical injury, pregnancy, extremes in environmental temperature, and high humidity. No methods of primary prevention are known. Intake of fruits and vegetables is a healthy and an unrelated item.

The nurse is testing the spinal reflexes of a client during neurological assessment. Which assessment by the nurse would help to determine the adequacy of the spinal reflex? 1.Cough reflex 2.Withdrawal reflex 3.Munro-Kellie reflex 4.Accommodation reflex

2 The withdrawal reflex is one of the spinal reflexes. It is an abrupt withdrawal of a body part in response to painful or injurious stimuli. The cough reflex is a brainstem-associated reflex. Accommodation reflex is associated with cranial nerve III and is part of the ocular motor system. Munro-Kellie is not a reflex; it is a doctrine or a hypothesis addressing the cerebral volume relationships among the brain, the cerebrospinal fluid, and intracranial blood and their cumulative impact on intracranial pressure.

The nurse is providing discharge education to a client diagnosed with trigeminal neuralgia. Which medication will likely be prescribed upon discharge for this condition? 1.Lorazepam 2.Gabapentin 3.Carisoprodol 4.Chlordiazepoxide

2 Trigeminal neuralgia is characterized by spasms of pain that start suddenly and last from seconds to minutes. The pain often is described as either stabbing or similar to an electric shock. It is accompanied by spasms of the facial muscles that cause twitching of parts of the face or mouth, or closure of the eye. It is treated by giving antiseizure medications, such as gabapentin, and sometimes tricyclic antidepressants. These medications work by stabilizing the neuronal membrane and blocking the nerve.

The nurse is caring for a client who was admitted for a stroke (brain attack) of the temporal lobe. Which clinical manifestations should the nurse expect to note in the client? 1.The client will be unable to recall past events. 2.The client will have difficulty understanding language. 3.The client will have difficulty moving 1 side of the body. 4.The client will demonstrate difficulty articulating words.

2 Wernicke's area consists of a small group of cells in the temporal lobe, the function of which is the understanding of language. The hippocampus is responsible for the storage of memory (the client will be unable to recall past events). Damage to Broca's area is responsible for aphasia (the client will demonstrate difficulty articulating words). The motor cortex in the precentral gyrus controls voluntary motor activity (the client will have difficulty moving one side of the body).

The nurse has applied a hypothermia blanket to a client with a fever. The nurse should inspect the skin frequently to detect which condition that is a complication of hypothermia blanket use? 1.Frostbite 2.Skin breakdown 3.Arterial insufficiency 4.Venous insufficiency

2 When a hypothermia blanket is used, the skin is inspected frequently for pressure points, which over time could lead to skin breakdown. The hypothermia blanket decreases the blood flow to pressure areas and can cause numbness, making it so that the client is not aware of damage to the skin. The temperature of the blanket is not cold enough to cause frostbite. Arterial insufficiency and venous insufficiency are not complications of hypothermia blanket use.

The nurse develops a plan of care for a client with a brain aneurysm who will be placed on aneurysm precautions. Which interventions should be included in the plan? Select all that apply. 1.Leave the lights on in the client's room at night. 2.Place a blood pressure cuff at the client's bedside. 3.Close the shades in the client's room during the day. 4.Allow the client to drink 1 cup of caffeinated coffee a day. 5.Allow the client to ambulate 4 times a day with assistance.

2,3 Aneurysm precautions include placing the client on bed rest in a quiet setting. The use of lights is kept to a minimum to prevent environmental stimulation. The nurse should monitor the blood pressure and note any changes that could indicate rupture. Any activity, such as pushing, pulling, sneezing, or straining, that increases the blood pressure or impedes venous return from the brain is prohibited. The nurse provides physical care to minimize increases in blood pressure. Visitors, radio, television, and reading materials are restricted or limited. Stimulants, such as nicotine and coffee and other caffeine-containing products, are prohibited. Decaffeinated coffee or tea may be used.

A client who has had a stroke (brain attack) has residual dysphagia. When a diet prescription is initiated, the nurse should take which actions? Select all that apply. 1.Giving the client thin liquids 2.Thickening liquids to the consistency of oatmeal 3.Placing food on the unaffected side of the mouth 4.Allowing plenty of time for chewing and swallowing 5.Leave the client alone so that the client will gain independence by feeding self

2,3,4 The client with dysphagia is started on a diet only after the gag and swallow reflexes have returned. The client is assisted with meals as needed and is given ample time to chew and swallow. Food is placed on the unaffected side of the mouth. Liquids are thickened to avoid aspiration. The client is not left alone because of the risk of aspiration.

The nurse is administering mouth care to an unconscious client. The nurse should perform which actions in the care of this person? Select all that apply. 1.Use products that contain alcohol. 2.Position the client on his or her side. 3.Brush the teeth with a small, soft toothbrush. 4.Cleanse the mucous membranes with soft sponges. 5.Use lemon glycerin swabs when performing mouth care.

2,3,4 The unconscious client is positioned on the side during mouth care to prevent aspiration. The teeth are brushed at least twice daily with a small toothbrush. The gums, tongue, roof of the mouth, and oral mucous membranes are cleansed with soft sponges to avoid encrustation and infection. The lips are coated with a water-soluble lubricant to prevent drying, cracking, and encrustation. The use of products with alcohol and lemon glycerin swabs should be avoided because they have a drying effect.

The nurse is caring for a client who is at risk for increased intracranial pressure (ICP) after a stroke. Which activities performed by the nurse will assist with preventing increases in ICP? Select all that apply. 1.Clustering nursing activities 2.Hyperoxygenating before suctioning 3.Maintaining 20 degree flexion of the knees 4.Maintaining the head and neck in midline position 5.Maintaining the head of the bed (HOB) at 30 degrees elevation

2,4,5 Measures aimed at preventing increased ICP in the poststroke client include hyperoxgenating before suctioning to avoid transient hypoxemia and resultant ICP elevation from dilation of cerebral arteries; maintaining the head in a midline, neutral position to help promote venous drainage from the brain; and keeping the HOB elevated to between 25 and 30 degrees to prevent a decreased blood flow to the brain. Clustering activities can be stressful for the client and increase ICP. Maintaining 20 degree flexion of the knees increases intra-abdominal pressure and consequently ICP.

2. A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? A. Teach the client to scan to the right to see objects on the right side of the body. B. Place the bedside table on the right side of the bed. C. Orient the client to the food on the plate using the clock method. D. Place the wheelchair on the client's left side.

2. A. A client who has left homonymous hemianopsia has lost the left visual field of both eyes. The client should be taught to turn the head to the left to visualize the entire field of vision. B. CORRECT: The client is unable to visualize to the left midline of their body. Placing the bedside table on the right side of the client's bed will permit visualization of items on the table. C. Using the clock method of food placement will be ineffective because only half of the plate can be seen. D. The wheelchair should be placed to the client's right or unaffected side.

2. A nurse is caring for a client who has a spinal cord injury who reports a severe headache and is sweating profusely. Vital signs include blood pressure 220/110 mm Hg and apical heart rate 54/min. Which of the following actions should the nurse take first? A. Examine skin for irritation or pressure. B. Sit the client upright in bed. C. Check the urinary catheter for blockage. D. Administer antihypertensive medication.

2. A. Examine the client's skin for areas of irritation, pressure, or broken skin to alleviate a triggering stimulus. However, another action is the priority. B. CORRECT: The greatest risk to the client is experiencing a cerebrovascular accident (stroke) secondary to elevated blood pressure caused by autonomic dysreflexia. The first action to take is to elevate the head of the bed until the client is in an upright position, which should lower the blood pressure secondary to postural hypotension. C. Check the client's catheter for blockage. However, another action is the priority. D. Administer an antihypertensive medication if indicated. However, another action is the priority.

The nurse assesses a depressed gag reflex in an unconscious patient. The nurse's priority interventions will relate to which patient problem? Increased risk of aspiration Ineffectiveness of breathing pattern Risk for increased intracranial pressure Risk for poor nutrition

2. Correct answer: A Rationale: The unconscious patient with a depressed or absent gag and swallowing reflex is at high risk for aspiration since saliva and any fluids taken by mouth could not be swallowed normally. There is no information to support that the patient has an ineffective breathing pattern. There is no information to support that the patient has increased intracranial pressure. There is also not enough information to support that the patient has imbalanced nutrition. In the absence of a gag reflex, nutrition can be provided through other, nonoral routes.

The nurse is planning care for a patient with an acute SCI. According to best practices, which medications should the nurse prepare during this patient's initial care? (Select all that apply.) Analgesics Antibiotics Vasopressors Antihistamines Corticosteroids

2. Correct answer: A, C Rationale: Analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) and narcotics are administered to reduce pain. Vasopressors are used in the immediate acute care phase to treat bradycardia or hypotension due to spinal and neurogenic shock. Antibiotics and antihistamines are not indicated in the acute care of a patient with a SCI. At this time, the use of corticosteroids is no longer part of the guidelines in initial treatment of SCI.

The nurse is assessing a patient with damage to the lower motor neurons. Which findings should the nurse expect to assess in this patient? (Select all that apply.) Loss of reflexes Increased muscle tone Decreased coordination Fasciculations Muscle atrophy

2. Correct answer: A,D,E Rationale: Damage to lower motor neurons causes decreased muscle tone, muscle atrophy, fasciculations, and loss of reflexes. Damage to upper motor neurons results in increased muscle tone, decreased muscle strength, decreased coordination, and hyperactive reflexes.

A patient is concerned about developing Alzheimer disease with aging. What manifestation should the nurse instruct as usually being the first indication of the disease? Inability to perform basic ADLs Mild and subtle memory deficits Inability to communicate verbally Wandering and changes in sleep patterns at night

2. Correct answer: B Rationale: Memory loss is usually the first sign of Alzheimer disease. Memory deficits are initially subtle and family members and friends may not suspect a problem until the disease progresses and manifestations become more noticeable. Inability to perform basic activities of daily living, loss of verbal communication, wandering, and changes in sleep patterns at night are later manifestations of the disease process.

A client with a neurological impairment experiences urinary incontinence. Which nursing action would be most helpful in assisting the client to adapt to this alteration? 1.Using adult diapers 2.Inserting a Foley catheter 3.Establishing a toileting schedule 4.Padding the bed with an absorbent cotton pad

3 A bladder retraining program, such as use of a toileting schedule, may be helpful to clients experiencing urinary incontinence. A Foley catheter should be used only when necessary because of the associated risk of infection. Use of diapers or pads is the least acceptable alternative because of the risk of skin breakdown.

A client has a difficulty with the ability to flex the hips. The nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which item? 1.Walker 2.Slider board 3.Raised toilet seat 4.Adaptive eating utensils

3 A raised toilet seat is useful if the client does not have the mobility or ability to flex the hips. The cerebellum is responsible for balance and coordination. A walker would provide stability for the client during ambulation. A slider board is used in transferring a client from a bed to a stretcher or wheelchair. Adaptive eating utensils may be beneficial if the client has partial paralysis of the hand.

The nurse is caring for a client who has undergone a craniotomy and has a supratentorial incision. The nurse should place the client in which position postoperatively? 1.Head of bed flat, head and neck midline 2.Head of bed flat, head turned to the nonoperative side 3.Head of bed elevated 30 to 45 degrees, head and neck midline 4.Head of bed elevated 30 to 45 degrees, head turned to the operative side

3 After supratentorial surgery, the head is kept at a 30- to 45-degree angle. The head and neck should not be angled either anteriorly or laterally but rather should be kept in a neutral (midline) position. This promotes venous return through the jugular veins, which will help prevent a rise in intracranial pressure.

The nurse is preparing to care for a client after a lumbar puncture. The nurse should plan to place the client in which best position following the procedure? 1.Prone in semi-Fowler's position 2.Supine in semi-Fowler's position 3.Prone with a small pillow under the abdomen 4.Lateral with the head slightly lower than the rest of the body

3 After the procedure, the client assumes a flat position. If the client is able, a prone position with a pillow under the abdomen is the best position. This position helps reduce cerebrospinal fluid leakage and decreases the likelihood of post-lumbar puncture headache. The remaining options are incorrect.

The nurse is caring for a client diagnosed with Alzheimer's disease. The nurse should anticipate that the client has changes in which component of the nervous system? 1.Glia 2.Peripheral nerves 3.Neuronal dendrites 4.Monoamine oxidase

3 Alzheimer's disease is characterized by changes in the dendrites of the neurons. The decrease in the number and composition of the dendrites is responsible for the symptoms of the disease. The components in the other options are not related to the pathology of Alzheimer's disease.

The nurse is assessing a client with a brainstem injury. In addition to obtaining the client's vital signs and determining the Glasgow Coma Scale score, what priority intervention should the nurse plan to implement? 1.Check cranial nerve functioning. 2.Determine the cause of the accident. 3.Draw blood for arterial blood gas analysis. 4.Perform a pulmonary wedge pressure measurement.

3 Assessment should be specific to the area of the brain involved. The respiratory center is located in the brainstem. Assessing the respiratory status is the priority for a client with a brainstem injury. The actions in the remaining options are not priorities, although they may be a component in the assessment process, depending on the injury and client condition.

The home care nurse is performing an assessment on a client with a diagnosis of Bell's palsy. Which assessment question will elicit specific information regarding this client's disorder? 1."Do your eyes feel dry?" 2."Do you have any spasms in your throat?" 3."Are you having any difficulty chewing food?" 4."Do you have any tingling sensations around your mouth?"

3 Bell's palsy is a one-sided facial paralysis caused by compression of the facial nerve. Manifestations include facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and speech or chewing difficulties.

The nurse in the neurological unit is caring for a client who was in a motor vehicle crash and sustained a blunt head injury. On assessment of the client, the nurse notes the presence of bloody drainage from the nose. Which nursing action is most appropriate? 1.Insert nasal packing. 2.Document the findings. 3.Contact the primary health care provider (PHCP). 4.Monitor the client's blood pressure and check for signs of increased intracranial pressure.

3 Bloody or clear drainage from either the nasal or the auditory canal after head trauma could indicate a cerebrospinal fluid leak. The appropriate nursing action is to notify the PHCP because this finding requires immediate intervention. The remaining options are inappropriate nursing actions in this situation.

The nurse is reviewing the medical records of a client admitted to the nursing unit with a diagnosis of a thrombotic brain attack (stroke). The nurse would expect to note that which is documented in the assessment data section of the record? 1.Sudden loss of consciousness occurred. 2.Signs and symptoms occurred suddenly. 3.The client experienced paresthesias a few days before admission to the hospital. 4.The client complained of a severe headache, which was followed by sudden onset of paralysis.

3 Cerebral thrombosis does not occur suddenly. In the few hours or days preceding a thrombotic brain attack (stroke), the client may experience a transient loss of speech, hemiplegia, or paresthesias on 1 side of the body. Signs and symptoms of thrombotic brain attack (stroke) vary but may include dizziness, cognitive changes, or seizures. Headache is rare, but some clients with stroke (brain attack) experience signs and symptoms similar to those of cerebral embolism or intracranial hemorrhage.

The nurse is assessing the nasal dressing on a client who had a transsphenoidal resection of the pituitary gland. The nurse notes a small amount of serosanguineous drainage that is surrounded by clear fluid on the nasal dressing. Which nursing action is most appropriate? 1.Document the findings. 2.Reinforce the dressing. 3.Notify the primary health care provider (PHCP). 4.Mark the area of drainage with a pen and monitor for further drainage.

3 Cerebrospinal fluid (CSF) leakage after cranial surgery may be detected by noting drainage that is serosanguineous surrounded by an area of straw-colored or pale drainage. The physical appearance of CSF drainage is that of a halo. If the nurse notes the presence of this type of drainage, the PHCP needs to be notified. The remaining options are inappropriate nursing actions.

The nurse has a prescription to administer a medication to a client who is experiencing shivering as a result of hyperthermia. Which medication should the nurse anticipate to be prescribed? 1.Buspirone 2.Fluphenazine 3.Chlorpromazine 4.Prochlorperazine

3 Chlorpromazine is used to control shivering in hyperthermic states. It is a phenothiazine and has antiemetic and antipsychotic uses, especially when psychosis is accompanied by increased psychomotor activity. Buspirone is an anxiolytic. Prochlorperazine is a phenothiazine that is an antiemetic and antipsychotic. Fluphenazine is a phenothiazine that is used as an antipsychotic.

The nurse is conducting home visits with a head-injured client with residual cognitive deficits. The client has problems with memory, has a shortened attention span, is easily distracted, and processes information slowly. The nurse plans to talk with the primary health care provider about referring the client to which professional? 1.A psychologist 2.A social worker 3.A neuropsychologist 4.A vocational rehabilitation specialist

3 Clients with cognitive deficits after head injury may benefit from referral to a neuropsychologist who specializes in evaluating and treating cognitive problems. The neuropsychologist plans an individual program of therapy and initiates counseling to help the client reach maximal potential. The neuropsychologist works in collaboration with other disciplines that are involved in the client's care and rehabilitation. The remaining options are incorrect because these health care workers do not specialize in evaluating and treating cognitive problems.

To promote optimal cerebral tissue perfusion in the postoperative phase following cranial surgery, the nurse should place the client with an incision in the anterior or middle fossa in which position? 1.15 degrees of Trendelenburg's 2.Side-lying with the head of the bed flat 3.With the head of the bed elevated at least 30 degrees 4.With the head of the bed elevated no more than 10 degrees

3 Correct positioning of the client following cranial surgery is important to avoid increased intracranial pressure and to promote optimal cerebral tissue perfusion. The surgeon's prescription for positioning is always followed. The client with an incision in the anterior or middle fossa should be positioned with the head of bed (HOB) elevated at least 30 degrees. If the incision is in the posterior fossa or burr holes have been made, the client is positioned flat or with the HOB elevated no more than 10 to 15 degrees. If a craniectomy (bone flap) is performed, the client should not be positioned to the operative side. Trendelenburg's position is contraindicated in the postoperative phase following cranial surgery.

The nurse is preparing for the admission to the unit of a client with a diagnosis of seizures and asks the nursing student to institute full seizure precautions. Which item if noted in the client's room would need to be removed and warrants the need to review seizure precautions with the student? 1.Oxygen source 2.Suction machine 3.Padded tongue blade 4.Padding for the side rails

3 Full seizure precautions include bed rest with padded side rails in a raised position, a suction machine at the bedside, having diazepam or lorazepam available, and providing an oxygen source. Objects such as tongue blades are contraindicated and should never be placed in the client's mouth during a seizure.

The nurse is monitoring a client who has returned to the nursing unit after a myelogram. Which client complaint would indicate the need to notify the primary health care provider (PHCP)? 1.Backache 2.Headache 3.Neck stiffness 4.Feelings of fatigue

3 Headache is relatively common after the procedure, but neck stiffness, especially on flexion, and pain should be reported because they signal meningeal irritation. The client also is monitored for evidence of allergic reactions to the dye such as confusion, dizziness, tremors, and hallucinations. Feelings of fatigue may be normal, and back discomfort may occur because of the positions required for the procedure.

The nurse is assisting the neurologist in performing an assessment on a client who is unconscious after sustaining a head injury. The nurse understands that the neurologist would avoid performing the oculocephalic response (doll's eyes maneuver) if which condition is present in the client? 1.Dilated pupils 2.Lumbar trauma 3.A cervical cord injury 4.Altered level of consciousness

3 In an unconscious client, eye movements are an indication of brainstem activity and are tested by the oculocephalic response. When the doll's eyes maneuver is intact, the eyes move in the opposite direction when the head is turned. Abnormal responses include movement of the eyes in the same direction as that for the head and maintenance of a midline position of the eyes when the head is turned. An abnormal response indicates a disruption in the processing of information through the brainstem. Contraindications to performing this test include cervical-level spinal cord injuries and severely increased intracranial pressure.

The nurse caring for a client following craniotomy who has a supratentorial incision understands that the client should most likely be maintained in which position? 1.Prone position 2.Supine position 3.Semi-Fowler's position 4.Dorsal recumbent position

3 In supratentorial surgery (surgery above the brain's tentorium), the client's head is usually elevated 30 degrees to promote venous outflow through the jugular veins. The client's head or the head of the bed is not lowered in the acute phase of care after supratentorial surgery. An exception to this is the client who has undergone evacuation of a chronic subdural hematoma, but a primary health care provider's (PHCP's) prescription is required for positions other than those involving head elevation. In addition, the PHCP's prescription regarding positioning is always checked and agency procedures are always followed.

The nurse has instructed a client with myasthenia gravis about strategies for self-management at home. The nurse determines a need for further teaching if the client makes which statement? 1."Here's the MedicAlert bracelet I obtained." 2."I should take my medications an hour before mealtime." 3."Going to the beach will be a nice, relaxing form of activity." 4."I've made arrangements to get a portable resuscitation bag and home suction equipment."

3 Most ongoing treatment for myasthenia gravis is done in outpatient settings, and the client must be aware of the lifestyle changes needed to maintain independence. The client should carry medical identification about the presence of the condition. Taking medications an hour before mealtime gives greater muscle strength for chewing and is indicated. The client should have portable suction equipment and a portable resuscitation bag available in case of respiratory distress. The client should avoid situations and other factors, including stress, infection, heat, surgery, and alcohol, that could worsen the symptoms.

A client with multiple sclerosis is experiencing muscle weakness, spasticity, and an ataxic gait. On the basis of this information, the nurse should include which client problem in the plan of care? 1.Inability to care for self 2.Interruption in skin integrity 3.Interruption in physical mobility 4.Inability to perform daily activities

3 Multiple sclerosis is a chronic, nonprogressive, noncontagious degenerative disease of the central nervous system characterized by demyelination of the neurons. Interruption in physical mobility is most appropriate for the client with multiple sclerosis experiencing muscle weakness, spasticity, and ataxic gait. The remaining options are not related to the data in the question.

A client with a history of myasthenia gravis presents at a clinic with bilateral ptosis and is drooling, and myasthenic crisis is suspected. The nurse assesses the client for which precipitating factor? 1.Getting too little exercise 2.Taking excess medication 3.Omitting doses of medication 4.Increasing intake of fatty foods

3 Myasthenic crisis often is caused by undermedication and responds to the administration of cholinergic medications. Cholinergic crisis (the opposite problem) is caused by excess medication and responds to withholding of medications. Too little exercise and excessive fatty food intake are incorrect. Overexertion and overeating possibly could trigger myasthenic crisis.

The home health nurse is visiting a client with a diagnosis of multiple sclerosis. The client has been taking oxybutynin. The nurse evaluates the effectiveness of the medication by asking the client which assessment question? 1."Are you consistently fatigued?" 2."Are you having muscle spasms?" 3."Are you getting up at night to urinate?" 4."Are you having normal bowel movements?"

3 Oxybutynin is an antispasmodic used to relieve symptoms of urinary urgency, frequency, nocturia, and incontinence in clients with uninhibited or reflex neurogenic bladder. Expected effects include improved urinary control and decreased urinary frequency, incontinence, and nocturia. The questions in the remaining options are unrelated to the use of this medication.

The nurse is caring for a client with a neurological deficit involving the hippocampus. On assessment of the client, which signs and symptoms would most likely be noted? 1.Disoriented to client, place, and time 2.Affect flat, with periods of emotional lability 3.Cannot recall what was eaten for breakfast today 4.Unable to add and subtract; does not know who is president

3 Recall of recent events and the storage of memories are controlled by the hippocampus, which is a limbic system structure. The cerebral hemispheres, with specific regional functions, control orientation. The limbic system, overall, is responsible for feelings, affect, and emotions. Calculation ability and knowledge of current events are under the control of the frontal lobes of the cerebrum.

A client brought to the emergency department had a seizure 1 hour ago. Family members were present during the episode and reported that the client's jaw was moving as though grinding food. In helping to determine the origin of this seizure, what should the nurse include in the client's assessment? 1.Loss of consciousness 2.Presence of diaphoresis 3.History of prior trauma 4.Rotating eye movements

3 Seizures that originate with specific motor phenomena are considered focal and are indicative of a focal structural lesion in the brain, often caused by trauma, infection, or medication consumption. The remaining options address signs, rather than an origin of the seizure.

The client with a head injury opens eyes to sound, has no verbal response, and localizes to painful stimuli when applied to each extremity. How should the nurse document the Glasgow Coma Scale (GCS) score? 1.GCS = 3 2.GCS = 6 3.GCS = 9 4.GCS = 11

3 The GCS is a method for assessing neurological status. The highest possible GCS score is 15. A score lower than 8 indicates that coma is present. Motor response points are as follows: Obeys a simple response = 6; Localizes painful stimuli = 5; Normal flexion (withdrawal) = 4; Abnormal flexion (decorticate posturing) = 3; Extensor response (decerebrate posturing) = 2; No motor response to pain = 1. Verbal response points are as follows: Oriented = 5; Confused conversation = 4; Inappropriate words = 3; Responds with incomprehensible sounds = 2; No verbal response = 1. Eye opening points are as follows: Spontaneous = 4; In response to sound = 3; In response to pain = 2; No response, even to painful stimuli = 1. Using the GCS, a score of 3 is given when the client opens the eyes to sound. Localization to pain is scored as 5. When there is no verbal response, the score is 1. The total score is then equal to 9.

A client is somewhat nervous about undergoing magnetic resonance imaging (MRI). Which statement by the nurse would provide the most reassurance to the client about the procedure? 1."The MRI machine is a long, narrow, hollow tube and may make you feel somewhat claustrophobic." 2."You will be able to eat before the procedure unless you get nauseated easily. If so, you should eat lightly." 3."Even though you are alone in the scanner, you will be in voice communication with the technologist at all times during the procedure." 4."It is necessary to remove any metal or metal-containing objects before having the MRI done to avoid the metal being drawn into the magnetic field."

3 The MRI scanner is a hollow tube that gives some clients a feeling of claustrophobia. Metal objects must be removed before the procedure so that they are not drawn into the magnetic field. The client may eat and may take all prescribed medications before the procedure. If a contrast medium is used, the client may wish to eat lightly if he or she has a tendency to become nauseated easily. The client lies supine on a padded table that moves into the imager. The client must lie still during the procedure. The imager makes tapping noises during the scanning. The client is alone in the imager, but the nurse can reassure the client that the technologist will be in voice communication with the client at all times during the procedure.

The client with a spinal cord injury at the level of T4 is experiencing a severe throbbing headache with a blood pressure of 180/100 mm Hg. What is the priority nursing intervention? 1.Notify the neurologist. 2.Loosen tight clothing on the client. 3.Place the client in a sitting position. 4.Check the urinary catheter tubing for kinks or obstruction.

3 The client is demonstrating clinical manifestations of autonomic dysreflexia, which is a neurological emergency. The first priority is to place the client in a sitting position to prevent hypertensive stroke. Loosening tight clothing and checking the urinary catheter can then be done, and the neurologist can be notified once initial interventions are done.

The nurse has provided instructions to a client with a diagnosis of myasthenia gravis about home care measures. Which client statement indicates the need for further teaching? 1."I will rest each afternoon after my walk." 2."I should cough and deep breathe many times during the day." 3."I can change the time of my medication on the mornings when I feel strong." 4."If I get abdominal cramps and diarrhea, I should call my health care provider."

3 The client with myasthenia gravis and the family should be taught information about the disease and its treatment. They should be aware of the side and adverse effects of anticholinesterase medications and corticosteroids and should be taught that timing of anticholinesterase medication is critical. It is important to instruct the client to administer the medication on time to maintain a chemical balance at the neuromuscular junction. If it is not given on time, the client may become too weak to even swallow. Resting after a walk, coughing and deep breathing many times during the day, and calling the primary health care provider when experiencing abdominal cramps and diarrhea indicate a correct understanding of home care instructions to maintain health with this neurological degenerative disease.

A client has dysfunction of the cochlear division of the vestibulocochlear nerve (cranial nerve VIII). The nurse should determine that the client is adequately adapting to this problem if he or she states a plan to obtain which item? 1.A walker 2.Eyeglasses 3.A hearing aid 4.A bath thermometer

3 The cochlear division of cranial nerve VIII is responsible for hearing. Clients with hearing difficulty may benefit from the use of a hearing aid. The vestibular portion of this nerve controls equilibrium; difficulty with balance caused by dysfunction of this division could be addressed with use of a walker. Eyeglasses would correct visual problems (cranial nerve II); a bath thermometer would be of use to clients with sensory deficits of peripheral nerves, such as with diabetic neuropathy.

A client has suffered a head injury affecting the occipital lobe of the brain. What is the focus of the nurse's immediate assessment? 1.Taste 2.Smell 3.Vision 4.Hearing

3 The occipital lobe is responsible for reception of vision and contains visual association areas. This area of the brain helps the individual to visually recognize and understand the surroundings. The other senses listed are not a function of the occipital lobe.

The nurse is caring for a client with Parkinson's disease. Which finding about gait should the nurse expect to note in the client? 1.Walking on the toes 2.Unsteady and staggering 3.Shuffling and propulsive 4.Broad-based and waddling

3 The parkinsonian gait is characterized by short, accelerating, shuffling steps. The client leans forward with the head, hips, and knees flexed and has difficulty starting and stopping. An ataxic gait is unsteady and staggering. A dystrophic gait is broad-based and waddling. Walking on the toes can occur from shortened Achilles tendons.

The nurse overhears a neurologist saying that a client has an aneurysm located in the circle of Willis. The nurse understands that which blood vessels are part of the circle of Willis? Select all that apply. 1.Basilar artery 2.Vertebral artery 3.Anterior cerebral artery 4.Internal carotid arteries 5.Posterior cerebral artery

3,4,5 The circle of Willis is a ring of blood vessels located at the base of the brain. It is referred to as the anterior circulation to the brain and is composed of the anterior and middle cerebral arteries, posterior cerebral arteries, posterior communicating arteries, internal carotid arteries, and anterior communicating branches. The basilar artery and vertebral artery are not part of the circle of Willis. Rather, they are part of the vertebral-basilar system, which is known as the posterior circulation to the brain. Other parts of the posterior circulation are the posterior inferior cerebellar artery and the spinal arteries.

A client with a traumatic closed head injury shows signs of secondary brain injury. What are some manifestations of secondary brain injury? Select all that apply. 1.Fever 2.Seizures 3.Hypoxia 4.Ischemia 5.Hypotension 6.Increased intracranial pressure (ICP)

3,4,5,6 Secondary brain injury can occur several hours to days after the initial brain injury and is a major concern when managing brain trauma. Nursing management of the client with an acute intracranial problem must include management of secondary injury. Manifestations of secondary injury include hypoxia, ischemia, hypotension, and increased ICP that follows primary injury. It does not include fever or seizures.

3. A nurse is caring for a client who has a C4 spinal cord injury. The nurse should recognize the client is at greatest risk for which of the following complications? A. Neurogenic shock B. Paralytic ileus C. Stress ulcer D. Respiratory compromise

3. A. Monitor for neurogenic shock, which is a response of the sympathetic nervous system of a client who has a SCI. However, another complication is the priority. B. Monitor for a paralytic ileus, which is a complication immediately following a SCI. However, another complication is the priority. C. Monitor for a stress ulcer, which is a response to changes caused from the SCI. However, another complication is the priority. D. CORRECT: When using the airway, breathing, and circulation (ABC) approach to client care, the priority complication is respiratory compromise secondary to involvement of the phrenic nerve. Maintenance of an airway and provision of ventilatory support as needed is the priority intervention.

The nurse is identifying interventions appropriate for a patient with multiple sclerosis. These interventions should focus on which patient goal that occurs in all patients with MS, regardless of type or severity? Preventing fatigue Relieving pain Reducing risk of aspiration Improving gas exchange

3. Correct answer: A Rationale: Fatigue is a major problem for almost all patients diagnosed with multiple sclerosis. The patient with multiple sclerosis does not experience acute pain and is not necessarily at risk for aspiration or impaired gas exchange.

The nurse is preparing a teaching session on the neurologic system for a group of nursing students. What should the nurse include about the purpose and function of cerebrospinal fluid? (Select all that apply.) Cushions the brain Helps nourish the brain Prevents glucose from entering brain cells Protects the brain and spinal cord from trauma Removes waste products of cellular metabolism

3. Correct answer: A, B, D, E Rationale: Cerebrospinal fluid (CSF) cushions the brain tissue and spinal cord, protects them from trauma, provides nourishment to the brain, and removes waste products. Glucose is needed in brain cells for normal cell and brain functioning.

A patient with a thoracic spinal cord injury is experiencing spinal shock. How should the nurse explain this pathophysiologic process to the patient? (Select all that apply.) There is damage to the lower motor neurons. There is an exaggerated sympathetic response. There is a loss of control of cardiovascular mechanisms. There is a temporary loss of reflex function below the level of injury. There is loss of sensation below the level of the injury that may be temporary.

3. Correct answer: D, E Rationale: Spinal shock is the response of the cord itself to injury. It involves temporary loss of reflex function below the level of injury at the cervical and upper thoracic spinal cord. There is loss of all sensations below the level of the injury. Spinal shock is not damage to the lower motor neurons. Spinal shock interrupts sympathetic nerve functioning. Spinal shock leads to a loss of sympathetic input to the blood vessels of the peripheral system and the heart, leading to unopposed vagal tone. Control of cardiovascular mechanisms is not lost but altered.

The nurse is preparing for the admission of a client with a suspected diagnosis of Guillain-Barré syndrome. When the client arrives at the nursing unit, the nurse reviews the primary health care provider's documentation. The nurse expects to note documentation of which hallmark clinical manifestation of this syndrome? 1.Multifocal seizures 2.Altered level of consciousness 3.Abrupt onset of a fever and headache 4.Development of progressive muscle weakness

4 A hallmark clinical manifestation of Guillain-Barré syndrome is progressive muscle weakness that develops rapidly. Seizures are not normally associated with this disorder. The client does not have symptoms such as a fever or headache. Cerebral function, level of consciousness, and pupillary responses are normal.

The nurse is caring for a client with bacterial meningitis. The nurse should anticipate that an antibiotic with which characteristics will be prescribed for the client? 1.One that has a long half-life 2.One that acts within minutes to hours 3.One that can be easily excreted in the urine 4.One that is able to cross the blood-brain barrier

4 A primary consideration regarding medications to treat bacterial meningitis is the ability of the medication to cross the blood-brain barrier. If the medication cannot cross, it will not be effective. The duration, onset, and excretion of the medication are also of general concern but apply to all medications and not specifically to those that are used to treat meningitis.

A client with a spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. The nurse should perform which action? 1.Ask the family to deliver the care. 2.Leave the client alone until ready to participate. 3.Advise the client that rehabilitation progresses more quickly with cooperation. 4.Acknowledge the client's anger and continue to encourage participation in care.

4 Adjusting to paralysis is physically and psychosocially difficult for the client and family. The nurse recognizes that the client goes through the grieving process in adjusting to the loss and may move back and forth among the stages of grief. The nurse acknowledges the client's feelings while continuing to meet the client's physical needs and encouraging independence. The family also is in crisis and needs the nurse's support and should not be relied on to provide care. The nurse cannot simply neglect the client until the client is ready to participate. Option 3 represents a factual but noncaring approach to the client and is not therapeutic.

The nurse is assessing fluid balance in a client who has undergone a craniotomy. The nurse should assess for which finding as a sign of overhydration, which would aggravate cerebral edema? 1.Unchanged weight 2.Shift intake 950 mL, output 900 mL 3.Blood urea nitrogen (BUN) 10 mg/dL (3.6 mmol/L) 4.Serum osmolality 280 mOsm/kg H2O (280 mmol/kg)

4 After craniotomy the goal is to keep the serum osmolality on the high side of normal to minimize excess body water and control cerebral edema. The normal serum osmolality is 285 to 295 mOsm/kg H2O (285 to 295 mmol/kg). A higher value indicates dehydration; a lower value indicates overhydration. Stable weight indicates that there is neither fluid excess nor fluid deficit. A difference of 50 mL in intake and output for an 8-hour shift is insignificant. The BUN of 10 mg/dL (3.6 mmol/L) is within normal range and does not indicate overhydration or underhydration.

The nurse cares for a client immediately following a lumbar laminectomy procedure. The client reports numbness and tingling down the left lateral thigh and knee. What is the next action for the nurse to take? 1.Document the assessment. 2.Contact the primary health care provider (PHCP). 3.Inform the client that this is to be expected. 4.Question the client about preoperative symptoms.

4 After spinal surgery the client requires frequent neurological assessments. Movement of the arms and the legs and assessment of sensation should be unchanged when compared with the preoperative status. Thus, the correct option is 4. Although the assessment finding should be documented, option 1 is incorrect, as that is not the next thing the nurse should do. Option 2 is incorrect, as more assessment data are needed before calling the PHCP. Option 3 is incorrect because this is an unexpected finding except if these findings were present before surgery; however, that preoperative information hasn't been gathered yet.

The nurse is preparing to care for a client who had a supratentorial craniotomy. The nurse should plan to place the client in which position? 1.Prone 2.Supine 3.Side-lying 4.Semi-Fowler's

4 After supratentorial surgery (surgery above the tentorium of the brain), the head of the client's bed usually is elevated 30 degrees to promote venous outflow through the jugular veins. Prone, supine, and side-lying denote incorrect positions after this surgery, and these positions could result in edema at the surgical site and increased intracranial pressure. The primary health care provider's prescriptions are always followed with regard to positioning the client.

A client with myasthenia gravis has become increasingly weaker. The primary health care provider prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium is administered. Which finding would indicate that the client is in cholinergic crisis? 1.No change in the condition 2.Complaints of muscle spasms 3.An improvement of the weakness 4.A temporary worsening of the condition

4 An edrophonium injection makes the client in cholinergic crisis temporarily worse. An improvement in the weakness indicates myasthenia crisis. Muscle spasms are not associated with this test.

A client who has a spinal cord injury that resulted in paraplegia experiences a sudden onset of severe headache and nausea. The client is diaphoretic with piloerection and has flushing of the skin. The client's systolic blood pressure (BP) is 210 mm Hg. What should the nurse immediately suspect? 1.Return of spinal shock 2.Malignant hypertension 3.Impending brain attack (stroke) 4.Autonomic dysreflexia (hyperreflexia)

4 Autonomic dysreflexia (hyperreflexia) results from sudden strong discharge of the sympathetic nervous system in response to a noxious stimulus. Signs and symptoms include pounding headache, nausea, nasal stuffiness, flushed skin, piloerection, and diaphoresis. Severe hypertension can occur, with a systolic BP rising potentially as high as 300 mm Hg. It often is triggered by thermal or mechanical events such as a kinking of catheter tubing, constipation, urinary tract infection, or any variety of cutaneous stimuli. The nurse must recognize this situation immediately and take corrective action to remove the stimulus. If untreated, this medical emergency could result in stroke, status epilepticus, or possibly death.

A postoperative craniotomy client who sustained a severe head injury is admitted to the neurological unit. What nursing intervention is necessary for this client? 1.Take and record vital signs every 4 to 8 hours. 2.Prophylactically hyperventilate during the first 24 hours. 3.Treat a central fever with the administration of antipyretic medications such as acetaminophen. 4.Keep the head of the bed elevated at least 30 degrees, and position the client to avoid extreme flexion or extension of the neck and head.

4 Avoiding extreme flexion and extension of the neck can enhance venous drainage and help prevent increased intracranial pressure. As a general rule, hyperventilation is avoided during the first 24 hours postoperatively because it may produce ischemia caused by cerebral vasoconstriction. Vital signs need to be taken and recorded at least every 1 to 2 hours. Central fevers caused by hypothalamic damage respond better to cooling (hypothermia blankets, sponge baths) than to the administration of antipyretic medications.

The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The client asks for a snack and something to drink. The nurse should offer which best snack to the client? 1.Cocoa with honey and toast 2.Hot herbal tea with graham crackers 3.Iced coffee and peanut butter and crackers 4.Vanilla wafers and room-temperature water

4 Because mild tactile stimulation of the face can trigger pain in trigeminal neuralgia, the client needs to eat or drink lukewarm, nutritious foods that are soft and easy to chew. Extremes of temperature will cause trigeminal nerve pain. Therefore, the options that include cocoa, hot herbal tea, and iced coffee are incorrect.

The nurse is caring for a client with intracranial pressure (ICP) monitoring. Which intervention is appropriate to include in the plan of care? 1.Place the client in the modified left lateral recumbent position. 2.Change the drainage tubing every 48 hours. 3.Level the transducer at the lowest point of the ear. 4.Use strict aseptic technique when touching the monitoring system.

4 Because there is a foreign body embedded in the client's brain, vigilant aseptic technique should be implemented. The modified left lateral recumbent position is a side-lying, flat position. With a client who has increased ICP, the head of the bed should be elevated at least 30 degrees to improve jugular outflow. The drainage tubing should not be routinely changed. It should remain for the duration of the monitoring. To obtain accurate ICP pressure readings, the transducer is zeroed at the level of the foramen of Monro, which is approximated by placing the transducer 1 inch above the level of the ear. Serial ICP readings should be done with the client's head in the same position.

A client had a transsphenoidal resection of the pituitary gland. The nurse notes drainage on the nasal dressing. Suspecting cerebrospinal fluid (CSF) leakage, the nurse should look for drainage that is of which characteristic? 1.Serosanguineous only 2.Bloody with very small clots 3.Sanguineous only with no clot formation 4.Serosanguineous, surrounded by clear to straw-colored fluid

4 CSF leakage after cranial surgery may be detected by noting drainage that is serosanguineous (from the surgery) and surrounded by an area of clear or straw-colored drainage. The typical appearance of CSF drainage is that of a "halo." The nurse also would further verify actual CSF drainage by testing the drainage for glucose, which would be positive.

The nurse is assisting with caloric testing of the oculovestibular reflex in an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left, followed by eye movement back to midline. The nurse understands that this finding indicates which situation? 1.Brain death 2.A cerebral lesion 3.A temporal lesion 4.An intact brainstem

4 Caloric testing provides information about differentiating between cerebellar and brainstem lesions. After determining patency of the ear canal, cold or warm water is injected into the auditory canal. A normal response that indicates intact function of cranial nerves III, VI, and VIII is conjugate eye movements toward the side being irrigated, followed by eye movement back to midline. Absent or dysconjugate eye movements indicate brainstem damage.

The nurse is performing an assessment on a client with a diagnosis of thrombotic stroke (brain attack). Which assessment question would elicit data specific to this type of stroke? 1."Have you had any headaches in the past few days?" 2."Have you recently been having difficulty with seeing at nighttime?" 3."Have you had any sudden episodes of passing out in the past few days?" 4."Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?"

4 Cerebral thrombosis (thrombotic stroke) does not occur suddenly. In the few days or hours preceding the thrombotic stroke, the client may experience a transient loss of speech, hemiparesis, or paresthesias on 1 side of the body. Signs and symptoms of this type of stroke vary but may also include dizziness, cognitive changes, or seizures. Headache is rare, but some clients with stroke experience signs and symptoms similar to those of cerebral embolism or intracranial hemorrhage. The client does not complain of difficulty with night vision as part of this clinical problem. In addition, most clients do not have repeated episodes of loss of consciousness.

The client has an impairment of cranial nerve II. Specific to this impairment, what should the nurse plan to do to ensure client safety? 1.Speak loudly to the client. 2.Test the temperature of the shower water. 3.Check the temperature of the food on the dietary tray. 4.Provide a clear path for ambulation without obstacles.

4 Cranial nerve II is the optic nerve, which governs vision. The nurse can provide safety for the visually impaired client by clearing the path of obstacles when ambulating. Speaking loudly may help overcome a deficit of cranial nerve VIII (vestibulocochlear). Testing the shower water temperature would be useful if there was an impairment of peripheral nerves. Cranial nerves VII (facial) and IX (glossopharyngeal) control taste from the anterior two-thirds and posterior third of the tongue, respectively.

A client with a spinal cord injury expresses little interest in food and is very particular about the choice of meals that are actually eaten. How should the nurse interpret this information? 1.Anorexia is a sign of clinical depression, and a referral to a psychologist is needed. 2.The client has compulsive habits that should be ignored as long as they are not harmful. 3.The client probably has a naturally slow metabolism, and the decreased nutritional intake will not matter. 4.Meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable.

4 Depression frequently may be seen in the client with spinal cord injury and may be exhibited as a loss of appetite. However, the client should be allowed to choose the types of food eaten and when they are eaten as much as is feasible because it is one of the few areas of control that the client has left. There is no information in the question that would indicate that the client is anorexic or obsessive-compulsive or has a slow metabolism.

The nurse is caring for the client who suffered a spinal cord injury 48 hours ago. What should the nurse assess for when monitoring for gastrointestinal complications? 1.A history of diarrhea 2.A flattened abdomen 3.Hyperactive bowel sounds 4.Hematest-positive nasogastric tube drainage

4 Development of a stress ulcer can occur after spinal cord injury and can be detected by Hematest-positive nasogastric tube aspirate or stool. The client is also at risk for paralytic ileus, which is characterized by the absence of bowel sounds and abdominal distention. A history of diarrhea is irrelevant.

The nurse has a prescription to begin aneurysm precautions for a client with a subarachnoid hemorrhage secondary to aneurysm rupture. The nurse would plan to incorporate which intervention in controlling the environment for this client? 1.Keep the window blinds open. 2.Turn on a small spotlight above the client's head. 3.Make sure the door to the room is open at all times. 4.Prohibit or limit the use of a radio or television and reading.

4 Environmental stimuli are kept to a minimum with subarachnoid precautions to prevent or minimize increases in intracranial pressure. For this reason, lighting is reduced by closing window blinds and keeping the door to the client's room shut. Overhead lighting also is avoided for the same reason. The nurse prohibits television, radio, and reading unless this is so stressful for the client that it would be counterproductive. In that instance, minimal amounts of stimuli by these means are allowed with approval of the primary health care provider.

The nurse is creating a plan of care for a client with a stroke (brain attack) who has global aphasia. The nurse should incorporate communication strategies into the plan of care because of which expected characteristic of the client's speech? 1.Intact 2.Rambling 3.Characterized by literal paraphasia 4.Associated with poor comprehension

4 Global aphasia is a condition in which the affected person has few language skills as a result of extensive damage to the left hemisphere. The speech is nonfluent and is associated with poor comprehension and limited ability to name objects or repeat words. The client with conduction aphasia has difficulty repeating words spoken by another, and speech is characterized by literal paraphasia with intact comprehension. The client with Wernicke's aphasia may exhibit a rambling type of speech.

The nurse is creating a plan of care for a client with a stroke (brain attack) who has right homonymous hemianopsia. Which should the nurse include in the plan of care for the client? 1.Place an eye patch on the left eye. 2.Place personal articles on the client's right side. 3.Approach the client from the right field of vision. 4.Instruct the client to turn the head to scan the right visual field.

4 Homonymous hemianopsia is a loss of half of the visual field. The nurse instructs the client to scan the environment and stands within the client's intact field of vision. The nurse should not patch the eye because the client does not have double vision. The client should have objects placed in the intact fields of vision, and the nurse should approach the client from the intact side.

The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? 1."We need to discourage him from wearing eyeglasses." 2."We need to place objects in his impaired field of vision." 3."We need to approach him from the impaired field of vision." 4."We need to remind him to turn his head to scan the lost visual field."

4 Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available.

The nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs of infection. On the basis of these findings the nurse suspects dysfunction in which area of the brain? 1.Cerebrum 2.Cerebellum 3.Hippocampus 4.Hypothalamus

4 Hypothalamic damage causes persistent hyperthermia, which also may be called central fever. It is characterized by a persistent high fever with no diurnal variation. Another characteristic feature is absence of sweating. Hyperthermia would not result from damage to the cerebrum, cerebellum, or hippocampus.

A new registered nurse (RN) is assigned to the care of a client hospitalized with a diagnosis of hypothermia. After consulting with an experienced RN, which statement by the new RN indicates understanding of likely assessment findings for this client? 1.Increased heart rate and increased blood pressure 2.Increased heart rate and decreased blood pressure 3.Decreased heart rate and increased blood pressure 4.Decreased heart rate and decreased blood pressure

4 Hypothermia decreases the heart rate and the blood pressure because the metabolic needs of the body are reduced in this condition. With fewer metabolic needs, the workload of the heart decreases, resulting in decreased heart rate and blood pressure. Therefore, the remaining options are incorrect.

The nurse is creating a plan of care for a client with a diagnosis of stroke (brain attack) with anosognosia. To meet the needs of the client with this deficit, the nurse should include activities that will achieve which outcome? 1.Encourage communication. 2.Provide a consistent daily routine. 3.Promote adequate bowel elimination. 4.Increase the client's awareness of the affected side.

4 In anosognosia, the client exhibits neglect of the affected side of the body. The nurse will plan care activities that remind the client to perform actions that require looking at the affected arm or leg, as well as activities that will increase the client's awareness of the affected side. The remaining options are not associated with this deficit.

The nurse is creating a plan of care for a client with a diagnosis of stroke (brain attack). On reviewing the client's record, the nurse notes an assessment finding of anosognosia. The nursing care plan should address which manifestation related to this finding? 1.The client will be easily fatigued. 2.The client will have difficulty speaking. 3.The client will have difficulty swallowing. 4.The client will exhibit neglect of the affected side.

4 In anosognosia, the client neglects the affected side of the body. The client either may ignore the presence of the affected side (often creating a safety hazard as a result of potential injuries) or may state that the involved arm or leg belongs to someone else. The remaining options are not associated with anosognosia.

The nurse is assessing the client's level of consciousness and documents that the client has delirium. On the basis of this documentation, the nurse should determine that there is damage to which area of the nervous system? 1.Temporal lobe and frontal lobe 2.Hippocampus and frontal lobe 3.Limbic system and cerebral hemispheres 4.Reticular activating system and cerebral hemispheres

4 Insomnia, agitation, mania, and delirium are caused by excessive arousal of the reticular activating system in conjunction with the cerebral hemispheres. The temporal lobe, hippocampus, and frontal lobe are responsible for memory. The limbic system is responsible for feelings and affect.

The nurse in the neurological unit is caring for a client with a supratentorial lesion. The nurse assesses which measurement as the most critical index of central nervous system (CNS) dysfunction? 1.Temperature 2.Blood pressure 3.Ability to speak 4.Level of consciousness

4 Level of consciousness is the most critical index of CNS dysfunction. Changes in level of consciousness can indicate clinical improvement or deterioration. Although blood pressure, temperature, and ability to speak may be components of the assessment, the client's level of consciousness is the most critical index of CNS dysfunction.

The nurse is planning care for the client with a neurogenic bladder caused by multiple sclerosis. The nurse plans for fluid administration of at least 2000 mL/day. Which plan would be most helpful to this client? 1.400 to 500 mL with each meal and 500 to 600 mL in the evening before bedtime 2.400 to 500 mL with each meal and additional fluids in the morning but not after midday 3.400 to 500 mL with each meal, with all extra fluid concentrated in the afternoon and evening 4.400 to 500 mL with each meal and 200 to 250 mL at midmorning, midafternoon, and late afternoon

4 Spacing fluid intake over the day helps the client with a neurogenic bladder to establish regular times for successful voiding. Omitting intake after the evening meal minimizes incontinence or the need to empty the bladder during the night.

The nurse is caring for a client who is brought to the hospital emergency department with a spinal cord injury. The nurse minimizes the risk of compounding the injury by performing which action? 1.Keeping the client on a stretcher 2.Logrolling the client onto a soft mattress 3.Logrolling the client onto a firm mattress 4.Placing the client on a bed that provides spinal immobilization

4 Spinal immobilization is necessary after spinal cord injury to prevent further damage and insult to the spinal cord. Whenever possible, the client is placed on a special bed, such as a Stryker frame, which allows the nurse to turn the client to prevent complications of immobility while maintaining alignment of the spine. If a Stryker frame is not available, a firm mattress with a bed board under it should be used. The remaining options are incorrect and potentially harmful interventions.

Transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with pain, and the nurse instructs the client about the purpose of the TENS unit. Which statement by the client indicates the need for further teaching? 1."The unit relieves pain." 2."Electrodes are attached to the skin." 3."The unit will reduce the need for analgesics." 4."Hospitalization is required because the unit is not portable."

4 The TENS unit is portable and the client controls the system for relieving pain and reducing the need for analgesics. It is attached to the skin of the body by electrodes. Hospitalization is not required.

The nurse has taught a client with a herniated lumbar disk about proper body mechanics and other items pertinent to low back care. The nurse determines that further teaching is needed if the client states the need to take which action? 1.Bend at the knees to pick up objects. 2.Increase fiber and fluid intake in the diet. 3.Strengthen the back muscles by swimming or walking. 4.Get out of bed by sitting straight up and swinging the legs over the side of the bed.

4 The client is taught to get out of bed by sliding near the edge of the mattress. The client then rolls onto 1 side and pushes up from the bed using 1 or both arms. The client keeps the back straight and swings the legs over the side. Proper body mechanics include bending at the knees, not the waist, to lift objects. Increasing fluid intake and dietary fiber helps prevent straining at stool, thereby preventing increases in intraspinal pressure. Walking and swimming are excellent exercises for strengthening lower back muscles.

The nurse is teaching a client hospitalized with a seizure disorder and the client's spouse about safety precautions after discharge. The nurse determines that the client needs further teaching if the client states an intention to take which action? 1.Refrain from smoking alone. 2.Take all prescribed medications on time. 3.Have the spouse nearby when showering. 4.Drink alcohol in small amounts and only on weekends.

4 The client should avoid the intake of alcohol. Alcohol could interact with the client's seizure medications, or it could precipitate seizure activity. The client should take all medications on time to avoid decreases in therapeutic medication levels, which could precipitate seizures. The client should not bathe in the shower or tub without someone nearby and should not smoke alone, to minimize the risk of injury if a seizure occurs.

The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which most essential items into the client's room? 1.Nebulizer and pulse oximeter 2.Blood pressure cuff and flashlight 3.Flashlight and incentive spirometer 4.Electrocardiographic monitoring electrodes and intubation tray

4 The client with Guillain-Barré syndrome is at risk for respiratory failure because of ascending paralysis. An intubation tray should be available for use. Another complication of this syndrome is cardiac dysrhythmias, which necessitates the use of electrocardiographic monitoring. Because the client is immobilized, the nurse should assess for deep vein thrombosis and pulmonary embolism routinely. Although items in the incorrect options may be used in care, they are not the most essential items from the options provided.

The nurse is caring for a client with a diagnosis of right (nondominant) hemispheric stroke. The nurse notes that the client is alert and oriented to time and place. On the basis of these assessment findings, the nurse should make which interpretation? 1.Had a very mild stroke 2.Most likely suffered a transient ischemic attack 3.May have difficulty with language abilities only 4.Is likely to have perceptual and spatial disabilities

4 The client with a right (nondominant) hemispheric stroke may be alert and oriented to time and place. These signs of apparent wellness often suggest that the client is less disabled than is the case. However, impulsivity and confusion in carrying out activities may be very real problems for these clients as a result of perceptual and spatial disabilities. The right hemisphere is considered specialized in sensory-perceptual and visual-spatial processing and awareness of body space. The left hemisphere is dominant for language abilities.

A client with a traumatic brain injury is on mechanical ventilation. The nurse promotes normal intracranial pressure (ICP) by ensuring that the client's arterial blood gas (ABG) results are within which ranges? 1.PaO2 60 to 100 mm Hg (60 to 100 mm Hg), PaCo2 25 to 30 mm Hg (25 to 30 mm Hg) 2.PaO2 60 to 100 mm Hg (60 to 100 mm Hg), PaCo2 30 to 35 mm Hg (30 to 35 mm Hg) 3.PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCo2 25 to 30 mm Hg (25 to 30 mm Hg) 4.PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCo2 35 to 38 mm Hg (35 to 38 mm Hg)

4 The goal is to maintain the partial pressure of arterial carbon dioxide (PaCo2) at 35 to 38 mm Hg (35 to 38 mm Hg). Carbon dioxide is a very potent vasodilator that can contribute to increases in ICP. The PaO2 is not allowed to fall below 80 mm Hg (80 mm Hg), to prevent cerebral vasodilation from hypoxemia, which can also result in an increase in ICP. Therefore, the remaining options are incorrect.

The nurse is providing instructions to the client with trigeminal neuralgia regarding measures to take to prevent the episodes of pain. Which should the nurse instruct the client to do? 1.Prevent stressful situations. 2.Avoid activities that may cause fatigue. 3.Avoid contact with people with an infection. 4.Avoid activities that may cause pressure near the face.

4 The pain that accompanies trigeminal neuralgia is triggered by stimulation of the trigeminal nerve. Symptoms can be triggered by pressure such as from washing the face, brushing the teeth, shaving, eating, or drinking. Symptoms also can be triggered by stimulation by a draft or cold air. The remaining options are not associated with triggering episodes of pain.

trigeminal neuralgia. The client asks the nurse, "Why do I have so much pain?" Which is the appropriate response by the nurse? 1."It's a local reaction to nasal stuffiness." 2."It's due to a hypoglycemic effect on the cranial nerve." 3."Release of catecholamines with infection or stress leads to the pain." 4."Pain is due to stimulation of the affected nerve by pressure and temperature."

4 The paroxysms of pain that accompany this neuralgia are triggered by stimulation of the terminal branches of the trigeminal nerve. Symptoms can be triggered by pressure from washing the face, brushing the teeth, shaving, eating, or drinking. Symptoms also can be triggered by thermal stimuli, such as a draft of cold air. The remaining options are incorrect.

The nurse is caring for a client who has just been admitted to the hospital with a diagnosis of a hemorrhagic stroke. The nurse should place the client in which position? 1.Prone 2.Supine 3.Semi-Fowler's with the hip and the neck flexed 4.Head of the bed elevated 30 degrees with the head in midline position

4 The primary health care provider's prescriptions are always followed with regard to positioning the client after stroke. Clients with hemorrhagic stroke usually have the head of the bed elevated to 30 degrees to reduce intracranial pressure that can occur from the hemorrhage. The head should be in a midline, neutral position to facilitate venous drainage from the brain. Extreme hip and neck flexion should be avoided to prevent an increase in intrathoracic pressure and to promote venous drainage from the brain. For clients with ischemic stroke, the head of the bed usually is kept flat to ensure adequate blood flow and thus oxygenation to the brain. Prone, supine, and hip and neck flexion are incorrect positions for clients with hemorrhagic stroke.

The home health nurse has been discussing interventions to prevent constipation in a client with multiple sclerosis. The nurse determines that the client is using the information most effectively if the client reports which action? 1.Drinking a total of 1000 mL/day 2.Giving herself an enema every morning before breakfast 3.Taking stool softeners daily and a glycerin suppository once a week 4.Initiating a bowel movement every other day, 45 minutes after the largest meal of the day

4 To manage constipation, the client should take in a high-fiber diet, bulk formers, and stool softeners. A fluid intake of 2000 mL/day is recommended. The client should initiate a bowel movement on an every-other-day basis and should sit on the toilet or commode. This should be done approximately 45 minutes after the largest meal of the day to take advantage of the gastrocolic reflex. A glycerin suppository, bisacodyl suppository, or digital stimulation may be used to initiate the process. Laxatives and enemas should be avoided whenever possible because they lead to dependence.

The home care nurse is preparing to visit a client with a diagnosis of trigeminal neuralgia (tic douloureux). When performing the assessment, the nurse should plan to ask the client which question to elicit the most specific information regarding this disorder? 1."Do you have any visual problems?" 2."Are you having any problems hearing?" 3."Do you have any tingling in the face region?" 4."Is the pain experienced a stabbing type of pain?"

4 Trigeminal neuralgia is characterized by spasms of pain that start suddenly and last for seconds to minutes. The pain often is characterized as stabbing or as similar to an electric shock. It is accompanied by spasms of facial muscles that cause twitching of parts of the face or mouth, or closure of the eye. The remaining options do not elicit data specifically related to this disorder.

A nurse is planning a seminar for city public health workers on ways to reduce the onset of West Nile encephalitis in the community. On which topic should the nurse focus in this seminar? Garbage pickup Sanitation services Mosquito spraying Washing fruits and vegetables

9. Correct answer: C Rationale: The best way to reduce the onset of West Nile disease is to control mosquitoes with repellants, insecticides, and protective clothing. Community programs such as spraying to destroy the insect larvae and eliminate breeding places, such as pools of stagnant water, should also be provided. Garbage pickup, sanitation services, and the washing of fruits and vegetables will not reduce the infestation of mosquitoes.

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective? 1.Taking medications as scheduled 2.Eating large, well-balanced meals 3.Doing muscle-strengthening exercises 4.Doing all chores early in the day while less fatigued

1 Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is important. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional stress.

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific primary health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply. 1.Head midline 2.Neck in neutral position 3.Head of bed elevated 30 to 45 degrees 4.Head turned to the side when flat in bed 5.Neck and jaw flexed forward when opening the mouth

1,2,3 Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure from elevating. The head of the client at risk for or with increased intracranial pressure should be positioned so that it is in a neutral, midline position. The head of the bed should be raised to 30 to 45 degrees. The nurse should avoid flexing or extending the client's neck or turning the client's head from side to side.

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. 1.The client is aphasic. 2.The client has weakness on the right side of the body. 3.The client has complete bilateral paralysis of the arms and legs. 4.The client has weakness on the right side of the face and tongue. 5.The client has lost the ability to move the right arm but is able to walk independently. 6.The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance.

1,2,4 Hemiparesis is a weakness of 1 side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on 1 side. These clients are also aphasic: unable to discriminate words and letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. 1.The client is aphasic. 2.The client has weakness on the right side of the body. 3.The client has complete bilateral paralysis of the arms and legs. 4.The client has weakness on the right side of the face and tongue. 5.The client has lost the ability to move the right arm but is able to walk independently. 6.The client has lost the ability to ambulate independently but is able to feed and bathe herself or himself without assistance.

1,2,4 Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic, unable to discriminate words and letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. 1.Keeping the linens wrinkle-free under the client 2.Preventing unnecessary pressure on the lower limbs 3.Limiting bladder catheterization to once every 12 hours 4.Turning and repositioning the client at least every 2 hours 5.Ensuring that the client has a bowel movement at least once a week

1,2,4 The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too infrequent), and urinary catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Ensuring a bowel movement once a week is much too infrequent. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. 1.Keeping the linens wrinkle-free under the client 2.Preventing unnecessary pressure on the lower limbs 3.Limiting bladder catheterization to once every 12 hours 4.Turning and repositioning the client at least every 2 hours 5.Ensuring that the client has a bowel movement at least once a week

1,2,4 The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too infrequent), and urinary catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Ensuring a bowel movement once a week is much too infrequent. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

1. A nurse is assessing a client who has a seizure disorder. The client tells the nurse, "I am about to have a seizure." Which of the following actions should the nurse implement? (Select all that apply.) A. Provide privacy. B. Ease the client to the floor if standing. C. Move furniture away from the client. D. Loosen the client's clothing. E. Protect the client's head with padding. F. Restrain the client.

1. A. CORRECT: The nurse should implement privacy to minimize the client's embarrassment. B. CORRECT: The nurse should ease the client to the floor to prevent falling and injury. C. CORRECT: The nurse should move the furniture away from the client to prevent injury. D. CORRECT: The nurse should loosen the client's clothing to minimize restriction of movement. E. CORRECT: The nurse should protect the client's head from injury by placing the client's head in her lap or using a pillow or blanket under the head during a seizure. F. The nurse should not restrain the client. Restraint can increase the client's risk for injury or more seizure activity

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. 1.Padding the side rails of the bed. 2.Placing an airway at the bedside. 3.Placing the bed in the high position. 4.Putting a padded tongue blade at the head of the bed. 5.Placing oxygen and suction equipment at the bedside. 6.Flushing the intravenous catheter to ensure that the site is patent.

1,2,5,6 Seizure precautions may vary from agency to agency, but they generally have some common features. Usually, an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if antiseizure medications must be administered, and as part of the routine assessment the nurse should be checking patency of the catheter. The use of padded tongue blades is highly controversial, and they should not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure more likely will harm the client who bites down during seizure activity. Risks include blocking the airway from improper placement, chipping the client's teeth, and subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begins.

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply. 1.Loosening restrictive clothing 2.Restraining the client's limbs 3.Removing the pillow and raising padded side rails 4.Positioning the client to the side, if possible, with the head flexed forward 5.Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist

1,3,4 Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising padded side rails in the bed, and placing the client on 1 side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible; protects the head from injury; and moves furniture that may injure the client.

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply. 1.Loosening restrictive clothing. 2.Restraining the client's limbs. 3.Removing the pillow and raising padded side rails. 4.Positioning the client to the side, if possible, with the head flexed forward. 5.Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist.

1,3,4 Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising padded side rails in the bed, and placing the client on 1 side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible; protects the head from injury; and moves furniture that may injure the client.

1. A nurse is caring for a client who has experienced a right-hemispheric stroke. The nurse should expect the client to have difficulty with which of the following? (Select all that apply.) A. Impulse control B. Moving the left side C. Depth perception D. Speaking E. Situational awareness

1. A. CORRECT: A client who has experienced a right-hemispheric stroke can exhibit impulse control difficulty, such as the urgency to use the restroom. B. CORRECT: A client who has experienced a right-hemispheric stroke can exhibit left-sided hemiplegia. C. CORRECT: A client who has experienced a right-hemispheric stroke can experience a loss in depth perception. D. A client who has experienced a left-hemispheric stroke can experience aphasia. E. CORRECT: A client who has experienced a right-hemispheric stroke can demonstrate a lack of awareness of surroundings.

1. A nurse is planning care for a client who has a spinal cord injury (SCI) involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should be the nurse's highest priority? A. Prevention of further damage to the spinal cord B. Prevention of contractures of the lower extremities C. Prevention of skin breakdown of areas that lack sensation D. Prevention of postural hypotension when placing the client in a wheelchair

1. A. CORRECT: The greatest risk to the client during the acute phase of an SCI is further damage to the spinal cord. When planning care, the priority intervention to take is to prevent further damage to the spinal cord by minimizing movement of the client until spinal stabilization is accomplished through either traction or surgery, and adequate oxygenation of the client to decrease ischemia of the spinal cord. B. Implement ROM exercise to prevent contractures. However, another action is the priority. C. Implement a turning schedule to prevent skin breakdown. However, another action is the priority. D. Slowly move the client to an upright position to prevent postural hypotension. However, another action is the priority.

1. A nurse is caring for a client who was recently admitted to the emergency department following a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and has a laceration on the forehead that is bleeding. Which of the following is the priority nursing action at this time? A. Keep neck stabilized. B. Insert nasogastric tube. C. Monitor pulse and blood pressure frequently. D. Establish IV access and start fluid replacement.

1. A. CORRECT: The greatest risk to the client is permanent damage to the spinal cord if a cervical injury does exist. The priority nursing intervention is to keep the neck immobile until damage to the cervical spine can be ruled out. B. Insertion of a nasogastric tube is not the priority nursing action at this time. C. Frequent monitoring of pulse and blood pressure is important but not the priority nursing action at this time. D. Establishing IV access for fluid replacement is important but not the priority nursing action at this time

1. A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect? A. Fluctuations in blood pressure B. Loss of cognitive function C. Ineffective cough D. Drooping eye lids

1. A. Fluctuations in blood pressure is a manifestation associated with amyotrophic lateral sclerosis. B. CORRECT: Loss of cognitive function is a manifestation associated with MS. C. Ineffective cough is a manifestation associated with amyotrophic lateral sclerosis. D. Drooping eyelids is a manifestation associated with myasthenia gravis.

1. A nurse is caring for a client who is postprocedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? (Select all that apply.) A. Use the Glasgow Coma Scale when assessing the client. B. Assist the client to a supine position. C. Administer an opioid medication. D. Encourage the client to increase fluid intake. E. Instruct the client to perform deep breathing and coughing exercises.

1. A. The Glasgow Coma Scale is used to assess a client's level of consciousness and is not necessary following a lumbar puncture. B. CORRECT: The nurse should assist the client to a supine position, which can relieve a headache following a lumbar puncture. C. CORRECT: The nurse should administer an opioid medication for a client's report of headache pain. D. CORRECT: The nurse should encourage an increased fluid intake to maintain a positive fluid balance, which can relieve a headache following a lumbar puncture. E. Coughing can increase ICP, which can result in an increase in the client's headache.

A patient has a systemic illness but demonstrates no signs of neurologic involvement. Which physiologic mechanism should the nurse recall that protects the brain from harmful substances? Blood-brain barrier Structure of neurons Large oxygen demand Circulation of cerebrospinal fluid

1. Correct answer: A Rationale: The blood-brain barrier controls the environment within by allowing oxygen, carbon dioxide, lipids, glucose, and water into the capillaries but preventing entry of urea, creatinine, toxins, proteins, and antibiotics. The structure of neurons and cerebrospinal fluid circulation do not protect the brain from harmful substances. The brain has a large oxygen demand to prevent cerebral cell damage.

The nurse is reviewing a patient's manifestations to determine if dementia is present. What information will help the nurse with this determination? (Select all that apply.) Dementia causes impaired short- and long-term memory. Dementia is an acute disorder, resulting from an injury to the brain. Dementia is the primary manifestation of Guillain-Barré syndrome. Dementia describes the cognitive and behavioral manifestations of Alzheimer disease. Dementia is a general term used to describe manifestations of damage or death of neurons.

1. Correct answer: A, D, E Rationale: Dementia is a general term used to describe the outcome of the death of neurons and the cognitive and behavioral manifestations of Alzheimer disease. The hallmark of dementia is impairment of both short- and long-term memory. Dementia is not an acute disorder and is not the primary manifestation of Guillain-Barre syndrome.

A patient is admitted to the ED with a cervical SCI following an automobile crash. What should the nurse explain to the family as the reason for the patient being placed on mechanical ventilation? The accident injured the patient's lungs. The nerves that control lung function have been injured. The patient is unable to breathe because of being unconscious. The ventilator is temporary to ensure the patient receives adequate oxygen until recovery.

1. Correct answer: B Rationale: SCI at the C1-C4 level produces respiratory paralysis and the patient will be unable to breathe on his or her own, so a ventilator will be necessary to maintain respiratory function. The nerves controlling lung function have been injured. The patient does not have a lung injury. The use of a ventilator is not because the patient is unconscious. The use of a ventilator will not be temporary.

The nurse is assessing the breathing pattern of a patient with a head injury who has a change in level of consciousness. Which pathophysiologic event causes an irregular respiratory pattern as level of consciousness decreases? Pressure on the meninges Reflexive motor responses Loss of the oculocephalic reflex Lower brainstem responses to changes in PaCO2

1. Correct answer: D Rationale: When there is damage to the reticular activating system or cerebral hemispheres, neural control of these centers is lost, and lower brainstem centers regulate breathing patterns by responding only to changes in PaCO2, resulting in irregular respiratory patterns. Blood in the ventricles or subarachnoid space irritates the meninges and brain tissue, causing an inflammatory reaction and impairing absorption and circulation of cerebrospinal fluid. Reflexive motor responses may occur as brain function declines. Loss of oculocephalic reflexes indicates a deterioration in brainstem functioning.

The nurse is preparing teaching for the family of a patient with myasthenia gravis. The nurse would teach the family to immediately report which manifestations that indicate possible myasthenic crisis? (Select all that apply.) Severe muscle tetany Fast heartbeat Increased difficulty speaking Incontinence of urine Depressed affect

10. Correct answer: A, B, C Rationale: Manifestations of myasthenic crisis are severe muscle weakness, fast heartbeat, restlessness, difficulty breathing, and increasing difficulty swallowing or speaking. Incontinence of urine and depressed affect are not manifestations of this disorder.

The nurse is documenting that a patient is demonstrating decorticate posturing. What does this statement indicate about the patient's physical posture? (Select all that apply.) Arms extended Fingers flexed Feet plantar flexed Legs internally rotated Wrists extended

10. Correct answer: B, C, D Rationale: In decorticate posturing the upper arms are close to the body; the elbows, wrists, and fingers are flexed; and the legs are extended with internal rotation. In decerebrate posturing the neck is extended, the arms are extended and pronated, and the feet are plantar flexed.

A patient has had a carotid endarterectomy. The nurse plans which care for this patient? (Select all that apply.) Position on the operative side. Support the head during position changes. Keep the head of bed elevated at least 45 degrees. Maintain head and neck alignment. Keep a tracheostomy tray at the bedside.

10. Correct answer: B, D, E Rationale: Supporting the head helps prevent stress on the operative site. Maintaining head and neck alignment prevents additional tension or pressure on the operative side. Respiratory distress may result from edema and hematoma formation, which may compress the trachea, making tracheostomy necessary. The patient should be positioned on the nonoperative side. The head of the bed should be flat or at 30 degrees.

The nurse is caring for the client with increased intracranial pressure as a result of a head injury? The nurse would note which trend in vital signs if the intracranial pressure is rising? 1.Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2.Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3.Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4.Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

2 A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur.

The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? 1.Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2.Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3.Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4.Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

2 A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur.

The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use which technique to test the client's peripheral response to pain? 1.Sternal rub 2.Nail bed pressure 3.Pressure on the orbital rim 4.Squeezing of the sternocleidomastoid muscle

2 Nail bed pressure tests a basic motor and sensory peripheral response. Cerebral responses to pain are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

The nurse is assessing the motor and sensory function of an unconscious client who sustained a head injury. The nurse should use which technique to test the client's peripheral response to pain? 1.Sternal rub 2.Nailbed pressure 3.Pressure on the orbital rim 4.Squeezing of the sternocleidomastoid muscle

2 Rationale:Nailbed pressure tests a basic motor and sensory peripheral response. Cerebral responses to pain are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

The nurse has completed discharge instructions for a client with application of a halo device who sustained a cervical spinal cord injury. Which statement indicates that the client needs further clarification of the instructions? 1."I will use a straw for drinking." 2."I will drive only during the daytime." 3."I will be careful because the device alters balance." 4.I will wash the skin daily under the lamb's wool liner of the vest."

2 The halo device alters balance and can cause fatigue because of its weight. The client should cleanse the skin daily under the vest to protect the skin from ulceration and should avoid the use of powder or lotions. The liner should be changed if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin care is done as instructed. The client cannot drive at all, because the device impairs the range of vision.

A client has a neurological deficit involving the limbic system. On assessment, which finding is specific to this type of deficit? 1.Is disoriented to person, place, and time 2.Affect is flat, with periods of emotional lability 3.Cannot recall what was eaten for breakfast today 4.Demonstrates inability to add and subtract; does not know who is the president of the United States

2 The limbic system is responsible for feelings (affect) and emotions. Calculation ability and knowledge of current events relate to function of the frontal lobe. The cerebral hemispheres, with specific regional functions, control orientation. Recall of recent events is controlled by the hippocampus.

A client has a neurological deficit involving the limbic system. On assessment, which finding is specific to this type of deficit? 1.Is disoriented to person, place, and time. 2.Affect is flat, with periods of emotional lability. 3.Cannot recall what was eaten for breakfast today. 4.Demonstrates inability to add and subtract; does not know who is the president of the United States.

2 The limbic system is responsible for feelings (affect) and emotions. Calculation ability and knowledge of current events relate to function of the frontal lobe. The cerebral hemispheres, with specific regional functions, control orientation. Recall of recent events is controlled by the hippocampus.

2. A nurse is beginning a physical assessment of a client who has a new diagnosis of multiple sclerosis. Which of the following findings should the nurse expect? (Select all that apply.) A. Areas of paresthesia B. Involuntary eye movements C. Alopecia D. Increased salivation E. Ataxia

2. A. CORRECT: Areas of loss of skin sensation are a finding in a client who has MS. B. CORRECT: Nystagmus is a finding in a client who has MS. C. Hair loss is not a finding in a client who has MS. D. Dysphagia, swallowing difficulty, is a finding in a client who has amyotrophic lateral sclerosis. E. CORRECT: Ataxia occurs in the client who has MS as muscle weakness develops and there is loss of coordination.

2. A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first? A. Keep the client in a side-lying position. B. Document the duration of the seizure. C. Reorient the client to the environment. D. Provide client hygiene.

2. A. CORRECT: The greatest risk to the client is aspiration during the postictal phase. Therefore, the priority intervention is to keep the client in a side-lying position so secretions can drain from the mouth keeping the airway patent. B. The nurse should document the duration of the seizure in the client's medical record, but there is another action that the nurse should take first. C. The nurse should reorient the client to the environment because the client can feel confused, but there is another action that the nurse should take first. D. The nurse should provide client hygiene if the client experienced incontinence during the seizure, but there is another action that the nurse should take first.

2. A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment? A. Glasgow Coma Scale B. Cranial nerve function C. Oxygen saturation D. Pupillary response

2. A. The Glasgow Coma Scale is important. However, another assessment is the priority. B. Assessment of cranial nerve function is important. However, another assessment is the priority. C. CORRECT: Using the airway, breathing, and circulation (ABC) priority-setting framework, assessment of oxygen saturation is the priority action. Brain tissue can only survive for 3 min before permanent damage occurs. D. Assessment of pupillary response is important. However, another assessment is the priority.

2. A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy? A. Headache B. Infection C. Aphasia D. Hypertension

2. A. The nurse should monitor a client who has increased ICP for a headache, but a headache does not indicate a complication directly related to the ventriculostomy. B. CORRECT: The nurse should monitor a client who has a ventriculostomy for infection, which is a complication. The nurse should use strict asepsis to avoid this life-threatening condition, which can result in meningitis. C. The nurse should monitor a client who has increased ICP for aphasia related to the head injury, but this not a complication directly related to the ventriculostomy. D. The nurse should monitor a client who has increased ICP for hypertension, but this is not a complication directly related to the ventriculostomy.

The nurse is preparing medication teaching for a patient with multiple sclerosis. Which medications should be included in this teaching? (Select all that apply.) Antibiotics Antihistamines Immunomodulators Dopamine precursors Adrenocorticosteroids

4. Correct answer: C, E Rationale: Immunomodulators are administered to patients with relapsing-remitting MS to prolong the time of onset to disability. Adrenocorticosteroids are used both to sustain a remission and to treat exacerbations of MS. Dopamine precursors are used in the treatment of Parkinson disease. Antibiotics and antihistamines are not used to treat multiple sclerosis.

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? 1.Hyperreflexia 2.Positive reflexes 3.Flaccid paralysis 4.Reflex emptying of the bladder

3 Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyper-reflexia rather than flaccidity, and reflex emptying of the bladder.

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? 1.A negative Kernig's sign 2.Absence of nuchal rigidity 3.A positive Brudzinski's sign 4.A Glasgow Coma Scale score of 15

3 Signs of meningeal irritation compatible with meningitis include nuchal rigidity, a positive Brudzinski's sign, and positive Kernig's sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is flexed. Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the leg is fully flexed at the knee and hip. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glasgow Coma Scale score of 15 is a perfect score and indicates that the client is awake and alert, with no neurological deficits.

A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness? 1.Giving client full control over care decisions and restricting visitors 2.Providing positive feedback and encouraging active range of motion 3.Providing information, giving positive feedback, and encouraging relaxation 4.Providing intravenously administered sedatives, reducing distractions, and limiting visitors

3 The client with Guillain-Barré syndrome experiences fear and anxiety from the ascending paralysis and sudden onset of the disorder. The nurse can alleviate these fears by providing accurate information about the client's condition, giving expert care and positive feedback to the client, and encouraging relaxation and distraction. The family can become involved with selected care activities and provide diversion for the client as well.

3. A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? (Select all that apply.) A. Have suction equipment available for use. B. Feed the client thickened liquids. C. Place food on the unaffected side of the client's mouth. D. Assign an assistive personnel to feed the client slowly. E. Teach the client to swallow with the neck flexed.

3. A. CORRECT: Suction equipment should be available in case of choking and aspiration. B. CORRECT: The client should be given liquids that are thicker than water to prevent aspiration. C. CORRECT: Placing food on the unaffected side of the client's mouth will allow them to have better control of the food and reduce the risk of aspiration. D. Due to the risk of aspiration, assistive personnel should not be assigned to feed the client because the client's swallowing ability should be assessed, and suctioning can be needed if choking occurs. E. CORRECT: The client should be taught to flex the neck, tucking the chin down and under to close the epiglottis during swallowing.

3. A nurse is teaching a client who has multiple sclerosis and a new prescription for baclofen. Which of the following statements should the nurse include in the teaching? A. "This medication will help you with your tremors." B. "This medication will help you with your bladder function." C. "This medication can cause your skin to bruise easily." D. "This medication can cause you to experience dizziness."

3. A. Propranolol is a beta blocker and clonazepam is a benzodiazepine given to clients who have MS to treat tremors. B. Propantheline is an anticholinergic medication that is given to clients who have MS to treat bladder dysfunction. C. Prednisone is a corticosteroid medication that is given to clients who have MS to treat inflammation. An adverse effect of this medication is bruising of the skin. D. CORRECT: Baclofen is an antispasmodic medication that is given to clients who have MS to treat muscle spasms. An adverse effect of this medication is drowsiness, as well as dizziness. Instruct the client to monitor for these findings, as they can lead to impaired safety. The client should be instructed not to discontinue baclofen abruptly.

3. A nursing is caring for a client who has a closed-head injury with ICP readings ranging from 16 to 22 mm Hg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? (Select all that apply.) A. Suction the endotracheal tube frequently. B. Decrease the noise level in the client's room. C. Elevate the client's head on two pillows. D. Administer a stool softener. E. Keep the client well hydrated.

3. A. Suctioning increases ICP and should be performed only when indicated. B. CORRECT: Decreasing the noise level and restricting the number of people in the client's room can help prevent increases in ICP. C. Hyperflexion of the client's neck with pillows carries the risk of increasing ICP and should be avoided. The head of the bed should be raised to at least 30°, but the head should be maintained in an upright, neutral position. D. CORRECT: Administration of a stool softener will decrease the need to bear down (Valsalva maneuver) during bowel movements, which can increase ICP. E. Overhydration carries the risk of increasing ICP and should be avoided. Monitor fluid and electrolyte levels closely for the client who has increased ICP.

3. A nurse is assessing a client for changes in the level of consciousness using the Glasgow Coma Scale (GCS). The client opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the following GCS scores should the nurse document? A. E2 + V3 + M5 = 10 B. E3 + V4 + M4 = 11 C. E4 + V5 + M6 = 15 D. E2 + V2 + M4 = 8

3. A. The calculation is incorrect. E2 represents eyes opening secondary to pain, V3 represents verbal response with words spoken inappropriately, and M5 represents motor response to pain with a local reaction. B. CORRECT: The client's score is calculated correctly, indicating moderate head injury. E3 represents opening eyes secondary to voice stimulation, V4 represents verbal conversation that is incoherent and disoriented, and M4 represents motor response as a general withdrawal to pain. C. The client's score is calculated incorrectly. E4 represents eyes opening spontaneously, V5 represents verbal conversation as coherent and oriented, and M6 indicates a client is able to follow commands. D. The client's score is calculated incorrectly. E2 represents eyes opening secondary to pain, V2 represents verbal response by the client making sounds but speaking no words, and M4 is a motor response with a general withdrawal to pain.

3. A nurse is providing discharge instructions to a client who has a prescription for phenytoin. Which of the following information should the nurse include? A. Consider taking an antacid when on this medication. B. Watch for receding gums when taking the medication. C. Take the medication at the same time every day. D. Provide a urine sample to determine therapeutic levels of the medication.

3. A. The nurse does not need to instruct the client to consider taking an antacid, because phenytoin does not cause any gastrointestinal adverse effects. B. The nurse should instruct the client that phenytoin causes overgrowth of the gums. C. CORRECT: The nurse should instruct the client to take phenytoin at the same time every day to enhance effectiveness. D. The nurse should instruct the client to have periodic blood tests to determine the therapeutic level of phenytoin.

The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully? 1.Gets angry with family if they interrupt a task 2.Experiences bouts of depression and irritability 3.Has difficulty with using modified feeding utensils 4.Consistently uses adaptive equipment in dressing self

4 Clients are evaluated as coping successfully with lifestyle changes after a stroke if they make appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions. Options 1 and 2 are not adaptive behaviors; option 3 indicates a not yet successful attempt to adapt.

The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client most at risk for this disease? 1.Meningitis or encephalitis during the last 5 years 2.Seizures or trauma to the brain within the last year 3.Back injury or trauma to the spinal cord during the last 2 years 4.Respiratory or gastrointestinal infection during the previous month

4 Guillain-Barré syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits. On occasion, the syndrome can be triggered by vaccination or surgery.

The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? 1."We need to discourage him from wearing eyeglasses." 2."We need to place objects in his impaired field of vision." 3."We need to approach him from the impaired field of vision." 4."We need to remind him to turn his head to scan the lost visual field."

4 Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available.

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? 1.Fluid is clear and tests negative for glucose. 2.Fluid is grossly bloody in appearance and has a pH of 6. 3.Fluid clumps together on the dressing and has a pH of 7. 4.Fluid separates into concentric rings and tests positive for glucose.

4 Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids, because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? 1.Blowing the nose 2.Isometric exercises 3.Coughing vigorously 4.Exhaling during repositioning

4 Rationale:Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure. Some of these activities include isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising.Client Needs: Physiological IntegrityCognitive Ability: EvaluatingContent Area: Adult Health: NeurologicalHealth Problem: Adult Health: Neurological: Head Injury/TraumaIntegrated Process: Nursing Process/EvaluationPriority Concepts: Client Education, Intracranial RegulationStrategy(ies): Subject

The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has complaints of inability to move both legs and reports a tingling sensation above the waistline. Knowing the complications of the disorder, the nurse should bring which most essential items into the client's room? 1.Nebulizer and pulse oximeter 2.Blood pressure cuff and flashlight 3.Nasal cannula and incentive spirometer 4.Electrocardiographic monitoring electrodes and intubation tray

4 The client with Guillain-Barré syndrome is at risk for respiratory failure because of ascending paralysis. An intubation tray should be available for use. Another complication of this syndrome is cardiac dysrhythmias, which necessitates the use of electrocardiographic monitoring. Because the client is immobilized, the nurse should assess for deep vein thrombosis and pulmonary embolism routinely. Although items in the incorrect options may be used in care, they are not the most essential items from the options provided.

The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching? 1."I can sit down to put on my pants and shoes." 2."I try to exercise every day and rest when I'm tired." 3."My son removed all loose rugs from my bedroom." 4."I don't need to use my walker to get to the bathroom."

4 The client with Parkinson's disease should be instructed regarding safety measures in the home. The client should use her or his walker as support to get to the bathroom because of bradykinesia. The client should sit down to put on pants and shoes to prevent falling. The client should exercise every day in the morning when energy levels are highest. The client should have all loose rugs in the home removed to prevent falling.

The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching? 1."I can sit down to put on my pants and shoes." 2."My son removed all loose rugs from my bedroom." 3."I try to exercise every day and rest when I'm tired." 4."I don't need to use my walker to get to the bathroom."

4 The client with Parkinson's disease should be instructed regarding safety measures in the home. The client should use his or her walker as support to get to the bathroom because of bradykinesia. The client should sit down to put on pants and shoes to prevent falling. The client should exercise every day in the morning when energy levels are highest. The client should have all loose rugs in the home removed to prevent falling.

A new registered nurse (RN) is assisting the RN in admitting a client who has a diagnosis of hypothermia. The RN provides education to the new RN on anticipated vital signs in the client with hypothermia. Which statement by the new RN indicates that the teaching has been effective? 1."The client will likely exhibit increased heart rate and increased blood pressure." 2."The client will likely exhibit increased heart rate and decreased blood pressure." 3."The client will likely exhibit decreased heart rate and increased blood pressure." 4."The client will likely exhibit decreased heart rate and decreased blood pressure."

4 The heart rate and blood pressure are decreased because the metabolic needs of the body are reduced with hypothermia. With fewer metabolic needs, the workload of the heart decreases. Therefore, the vital sign changes in the remaining options are incorrect.

4. A nurse is caring for a client who experienced a cervical spine injury 24 hr ago. Which of the following prescriptions should the nurse clarify with the provider? A. Anticoagulant B. Plasma expanders C. H2 antagonists D. Muscle relaxants

4. A. Administer an anticoagulant to decrease the risk of developing a VTE. B. Administer plasma expanders to treat hypotension caused by the SCI. C. Administer H2 antagonists to decrease the complication of developing a gastric ulcer from stress. D. CORRECT: Clarify with the provider the need for the client to receive muscle relaxants. The client will not experience muscle spasms until after the spinal shock has resolved, making muscle relaxants unnecessary at this time.

4. A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following should the nurse include in the client's plan of care? (Select all that apply.) A. Speak to the client at a slower rate. B. Assist the client to use cards with pictures. C. Speak to the client in a loud voice. D. Complete sentences that the client cannot finish. E. Give instructions one step at a time.

4. A. CORRECT: Clients who have global aphasia have difficulty with speaking and understanding speech. One strategy that can enhance client understanding is speaking to the client at a slower rate. B. CORRECT: One strategy that can enhance understanding is the use of alternative forms of communication, such as cards with pictures or a computer. C. For the client who has aphasia, speaking in a loud voice is unnecessary and can be interpreted as patronizing. D. Allow the client adequate time to finish sentences and not complete the sentences for them. E. CORRECT: One strategy that can enhance understanding is giving instructions one step at a time.

4. A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? (Select all that apply.) A. Headache B. Dilated pupils C. Tachycardia D. Decorticate posturing E. Hypotension

4. A. CORRECT: Headache is a finding associated with increased ICP. B. CORRECT: Dilated pupils is a finding associated with increased ICP. C. Bradycardia, not tachycardia, is a finding associated with increased ICP. D. CORRECT: Decorticate or decerebrate posturing is a finding associated with increased ICP. E. Hypertension, not hypotension, is a finding associated with increased ICP.

4. A nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosis of generalized seizures. Which of the following information should the nurse include in this review? (Select all that apply.) A. Avoid overwhelming fatigue. B. Remove caffeinated products from the diet. C. Limit looking at flashing lights. D. Perform aerobic exercise. E. Limit episodes of hypoventilation. F. Use of aerosol hairspray is recommended.

4. A. CORRECT: The nurse should instruct the client to avoid overwhelming fatigue, which can trigger a seizure by stimulating abnormal electrical neuron activity. B. CORRECT: The nurse should instruct the client to remove caffeinated products from the diet, which can trigger a seizure by stimulating abnormal electrical neuron activity. C. CORRECT: The nurse should instruct the client to refrain from looking at flashing lights, which can trigger a seizure by stimulating abnormal electrical neuron activity. D. The nurse should instruct the client to avoid vigorous physical activity, which can help to avoid triggering a seizure. E. The nurse should instruct the client to limit excess hyperventilation, which can trigger a seizure by stimulating abnormal electrical neuron activity. F. The nurse should instruct the client to avoid using aerosol hairspray, which can trigger a seizure by stimulating abnormal electrical neuron activity.

4. A nurse is developing a plan of care for a client who is scheduled for cerebral angiography with contrast media. Which of the following statements by the client should the nurse report to the provider? (Select all that apply.) A. "I think I might be pregnant." B. "I take warfarin." C. "I take antihypertensive medication." D. "I am allergic to shrimp." E. "I ate a light breakfast this morning."

4. A. CORRECT: The nurse should report the client's statement of possible pregnancy to the provider because the contrast media can place the fetus at risk. B. CORRECT: The nurse should report that the client is taking warfarin to the provider due to the potential for bleeding following angiography. C. There is no contraindication related to cerebral angiography for a client who is taking antihypertensive medication. D. CORRECT: The nurse should report a client's report of allergy to shrimp, which is a shellfish, to the provider due to a potential allergic reaction to the contrast media. E. CORRECT: The nurse should report a client's intake of food to the provider since the client should remain NPO for 4 to 6 hr prior to the procedure.

The nurse is monitoring the neurologic status of a patient in a coma. Which command should the nurse use to accurately identify changes in mental status? "Squeeze my hand." "Tell me your name." "Are you having trouble breathing?" "Look at this light when I shine it in your eyes."

4. Correct answer: A Rationale: The level of brain dysfunction and the side of the brain affected may be assessed by motor responses. These responses are the most accurate identifier of changes in mental status. In altered LOC, asking the patient to "squeeze my hand" would be used to determine mental status changes. Other questions such as "Tell me your name," "Are you having trouble breathing?" and "Look at the light while it is shined in your eyes" will not accurately determine mental status changes in the patient.

A patient is demonstrating manifestations of autonomic dysreflexia. What will the nurse most likely assess as the reason for this health problem? Diarrhea Distended bladder Elevated blood pressure Respiratory wheezes and stridor

4. Correct answer: B Rationale: Autonomic dysreflexia is triggered by stimuli that would normally cause abdominal discomfort, by stimulation of pain receptors, and by visceral contractions. The most common cause is from a full bladder resulting from a blocked urinary catheter. Diarrhea and respiratory problems do not cause autonomic dysreflexia. An elevated blood pressure is a manifestation of this disorder.

A patient's assessment reveals lack of movement of the left eye. The nurse will conduct additional assessment of which cranial nerves that control this movement? (Select all that apply.) Olfactory Optic Oculomotor Trochlear Trigeminal

4. Correct answer: C, D Rationale: Eyeball movement is controlled by the oculomotor and trochlear cranial nerves. The olfactory nerve controls sense of smell. The optic nerve is associated with vision. The trigeminal nerve controls sensation in several areas of the face and head and controls chewing.

5. A nurse is assessing a client. Which of the following findings indicates that the client has experienced a left-hemispheric stroke? A. Impulse control difficulty B. Poor judgment C. Inability to recognize familiar objects D. Loss of depth perception

5. A. A client who has experienced a right-hemispheric stroke will experience difficulty with impulse control. B. A client who has experienced a right-hemispheric stroke will experience poor judgment. C. CORRECT: A client who experienced a left-hemispheric stroke will demonstrate the inability to recognize familiar objects, known as agnosia. D. A client who experienced a right-hemispheric stroke will experience a loss of depth perception.

5. A nurse is caring for a client who experienced a cervical spine injury 3 months ago. The nurse should plan to implement which of the following types of bladder management methods? A. Condom catheter B. Intermittent urinary catheterization C. Credé's method D. Indwelling urinary catheter

5. A. CORRECT: Implement the noninvasive use of a condom catheter, because the bladder will empty on its own due to the client having an upper motor neuron injury, which is manifested by a spastic bladder. B. Implement the intermittent urinary catheterization method for a client who has a flaccid bladder. C. Implement the Credé's method for a client who has a flaccid bladder. D. An indwelling urinary catheter is an invasive procedure. Do not implement this bladder management method for the client.

5. A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor? A. Hyperglycemia B. Hyponatremia C. Hypervolemia D. Oliguria

5. A. Hyperglycemia is not an adverse effect of mannitol. B. CORRECT: Mannitol is a powerful osmotic diuretic. Adverse effects include electrolyte imbalances, such as hyponatremia. C. Hypovolemia is an adverse effect of mannitol and should be monitored. D. Polyuria is an adverse of mannitol and should be monitored.

5. A nurse is completing discharge teaching to a client who has seizures and received a vagal nerve stimulator to decrease seizure activity. Which of the following statements should the nurse include in the teaching? A. "It is safe to use microwaves that are 1,200 watts or less." . B. "You should avoid the use of CT scans with contrast.". C. "You should place a magnet over the implantable device when you feel an aura occurring." D. "It is recommended that you use ultrasound diathermy for pain management."

5. A. The nurse should instruct the client to avoid using a microwave, regardless of wattage, which can affect the function of the stimulator. B. The nurse should instruct the client to avoid MRIs, which can affect the function of the stimulator. C. CORRECT: The nurse should instruct the client to hold a magnet over the implantable device when an aura occurs so as to decrease seizure activity. D. The nurse should instruct the client to avoid the use of ultrasound diathermy for pain management because of its effect on the function of the stimulator.

5. A nurse is providing education to a client who is to undergo an electroencephalogram (EEG) the next day. Which of the following information should the nurse include in the teaching? A. "Do not wash your hair the morning of the procedure." B. "Try to stay awake most of the night prior to the procedure." C. "The procedure will take approximately 15 minutes." D. "You will need to lie flat for 4 hours after the procedure."

5. A. The nurse should teach the client to wash her hair on the morning of the procedure to remove oils, gels, and sprays, which can affect the EEG readings. B. CORRECT: The nurse should teach the client to remain awake most of the night to provide cranial stress and increase the possibility of abnormal electrical activity. C. The nurse should teach the client that the procedure will take approximately 1 hr. D. The nurse should teach the client that normal activity can resume immediately following the procedure.

The nurse is teaching a young adult patient with multiple sclerosis about the disease process. What information should the nurse include during this teaching? (Select all that apply.) Onset is usually between 20 and 40. The disease is treatable, but not curable. It is important to avoid extremes of heat and cold. Few drugs are available for the treatment of MS. Alternating relapses and remissions are a common disease pattern.

5. Correct answer: A, B, C, E Rationale: The onset of MS is usually between 20 and 40 years of age. There is no cure for the disease. The patient should be advised to avoid temperature extremes, such as hot showers or exposure to cold. Maintaining a relatively constant body temperature may prevent exacerbation of the disorder. Heat can delay impulse transmission across demyelinated nerves, which contributes to fatigue. Many people with MS experience a recurrent pattern of relapses and remissions. Many medications are available to aid in the treatment of this health problem.

An industrial nurse is conducting a class for manufacturing plant employees on methods to prevent back pain. What should the nurse include in this teaching? (Select all that apply.) Use large leg muscles to push when lifting. Bend from the waist to lift articles from the floor. Spread the feet apart to broaden the base of support. Avoid squatting while lifting. Always twist to the side while lifting.

5. Correct answer: A, C Rationale: In teaching prevention of back injuries, the nurse would incorporate principles of proper body mechanics, which include using large leg muscles to push when lifting and spreading the feet apart to widen the base of support. Bending from the waist to lift objects is dangerous; a squatting position should be used. Twisting should be avoided.

Laboratory tests are being prescribed for a patient with altered level of consciousness. Which tests should the nurse expect to be prescribed for this patient? (Select all that apply.) Blood glucose Urine for WBCs Serum electrolytes Liver function tests Blood and urine toxicology

5. Correct answer: A, C, D, E Rationale: A patient with an altered LOC would probably have blood glucose level checked for hypoglycemia, electrolytes checked for metabolic disturbances, liver function tests to evaluate hepatic function, and blood and urine toxicology studies to test for drug or alcohol toxicity. Urine white blood cell levels would not be indicated for the patient's health problem.

A patient reports narrowly missing having an automobile crash when merging onto the freeway. Which division of the autonomic nervous system should the nurse recall as causing body responses to stress? Adrenergic Cholinergic Sympathetic Parasympathetic

5. Correct answer: C Rationale: The sympathetic division of the ANS has the purpose of preparing the body to handle stressful events, such as almost being in an automobile crash, by increasing heart rate, force of contraction, vasodilation of coronary arteries, and increased mental alertness. The parasympathetic division of the ANS operates during nonstressful situations and causes pupil constriction, decreased heart rate, vasoconstriction of coronary arteries, constriction of the bronchioles, and increased peristalsis. Adrenergic is a term used to describe the effects of the neurotransmitter norepinephrine. Nerves that transmit impulses through the release of acetylcholine are called cholinergic.

The nurse is preparing to assess a patient's neurologic system. The nurse will prepare to use which assessment techniques in this assessment? (Select all that apply.) Palpation Percussion Inspection Auscultation History review

6. Correct answer: A, B, C, E Rationale: Assessment begins with history review. The skills of palpation, percussion, and inspection are used. Auscultation is not part of a typical neurologic system assessment.

A nurse is assessing a patient recovering from a posterior cervical laminectomy for manifestations of spinal cord compression. How should this assessment be conducted? (Select all that apply.) Ask the patient to wiggle his or her toes. Ask the patient to grip the nurse's hands. Use a stethoscope to auscultate heart sounds. Use a reflex hammer to assess Babinski's reflex. Assess the patient's ability to detect touch on hands.

6. Correct answer: B, E Rationale: To monitor for signs of nerve root compression after a cervical laminectomy, the nurse should assess hand grips, arm strength, the ability to move the fingers, and the ability to detect touch. Wiggling the toes would be used to assess for nerve compression after a lumbar laminectomy. Auscultation of heart sounds will not detect cervical root compression after a cervical laminectomy. A reflex hammer is not used to assess for a Babinski reflex.

The nurse is caring for a patient with altered level of consciousness. On which laboratory value should the nurse focus as the most accurate indicator of hydration status in the patient? CBC Urinalysis Blood culture Serum osmolality

6. Correct answer: D Rationale: Serum osmolality is an indicator of hydration status. The test measures the number of dissolved particles such as electrolytes, urea, and glucose in the serum. The complete blood count and urinalysis will not provide information about the patient's hydration status. Blood cultures are used to determine the presence of a bacterial infection in the blood.

The nurse is preparing to talk with the family of a patient newly diagnosed with Parkinson disease. How should the nurse explain the cause of this disorder? Genetic defect Effects of a neurotoxin Autoimmune responses to a viral infection Failure of dopamine to inhibit acetylcholine

6. Correct answer: D Rationale: The usual balance of dopamine (an inhibitory neurotransmitter) and acetylcholine (an excitatory neurotransmitter) in the brain is disrupted, and dopamine no longer inhibits acetylcholine. The failure to inhibit acetylcholine is the underlying basis for the manifestations of Parkinson's disease. The cause of the disease is still unknown, but is believed to be the result of environmental and genetic factors, with genetic mutations especially implicated in early-onset Parkinson disease. This disease does not develop as an autoimmune response to a viral infection.

The nurse is assessing a patient's cranial nerve function. What equipment should the nurse use to assess function of cranial nerve V, the trigeminal nerve? Cotton ball and safety pin Measuring tape and pencil Scents such as coffee and vanilla Stethoscope with bell and diaphragm

7. Correct answer: A Rationale: A cotton ball and a safety pin would be used to assess sensations of light, dull, and sharp on the face. If the safety pin is used to assess sharp touch, the pin is to be discarded as a sharp after use. A measuring tape and pencil might be used to assess cranial diameter. Various scents would be used to assess CN I olfactory nerve function. A stethoscope is not used when assessing the neurologic system.

The nurse is preparing instructions for the caregiver of a patient with Parkinson disease regarding care that will be needed at home. What information should the nurse provide to the caregiver? (Select all that apply.) Ways to prevent falls Interventions to maintain nutrition The need to avoid daily baths and showers Ways to prevent an overdose of medications How to prevent constipation

7. Correct answer: A, B, E Rationale: Parkinson disease is a common disorder in older adults, who are already at greater risk for falls resulting from orthostatic hypotension, osteoporosis, poor vision, and other problems causing disorientation and confusion. Tremors, altered gait, and impaired chewing and swallowing can cause nutritional problems and should be addressed. Constipation can also be an issue. There is no reason for the patient with Parkinson disease to avoid showers or baths. The skin is usually damp and oily, so bathing is needed. There is no reason to believe that the patient with Parkinson disease is at risk for medication overdose.

The nurse is concerned that a patient is experiencing a transient ischemic attack. What did the nurse most likely assess in this patient? (Select all that apply.) Sudden severe pain over the left eye Visual disturbance of one or both eyes Loss of sensation and reflexes in both legs Complete paralysis of the right arm and leg Numbness and tingling in the corner of the mouth

7. Correct answer: B, E Rationale: Neurologic manifestations of a TIA vary according to the location and size of the cerebral vessel involved and have a sudden onset. Commonly occurring deficits include contralateral numbness or weakness of the leg, hand, forearm, and corner of the mouth; aphasia; and visual disturbances such as blurring. The patient may also experience a fleeting blindness of one eye. Eye pain is associated with a stroke of the vertebral artery. Loss of reflexes is associated with a contusion. Loss of sensation in the legs can be associated with a brain injury. Complete paralysis of the right arm and leg would indicate a stroke within the left cerebral hemisphere.

A patient with a lumbar spinal cord tumor reports sudden onset of numbness in one leg. Which intervention is the nurse's priority? Ask the patient to rate the amount of numbness on a scale similar to the pain scale. Reposition the patient and recheck in 15 minutes. Discuss this report with the health care provider. Check the patient's indwelling catheter for kinking.

7. Correct answer: C Rationale: Sudden-onset numbness may indicate that spinal cord compression is occurring. Immediate action to relieve the compression may be necessary to prevent infarction and paralysis. Rating the numbness is not a primary intervention. Repositioning the patient may increase damage to the spinal cord. Waiting for 15 minutes to recheck the patient would delay definitive treatment. The numbness is not caused by a kinked indwelling catheter.

The nurse is preparing medication teaching for a patient with amyotrophic lateral sclerosis. On which drug classification should the nurse focus when providing these instructions? Antiglutamate Anticholinergic Dopamine agonist Anti-inflammatory

8. Correct answer: A Rationale: An antiglutamate was the first medication developed to treat ALS. It inhibits the presynaptic release of glutamic acid in the CNS and protects neurons against the excite-toxicity of glutamic acid. Anticholinergics and dopamine agonists are used to treat Parkinson disease. Anti-inflammatory medications may be used to treat Bell palsy.

The nurse is instructing a patient on ways to prevent a stroke. What should the nurse emphasize as being the greatest risks for a stroke? (Select all that apply.) Diabetes History of head trauma Heart disease Hypertension Hyperlipidemia

8. Correct answer: A, C, D, E Rationale: The most important treatable conditions that increase the risk of stroke include hypertension, heart disease, hyperlipidemia, and diabetes. Having history of head trauma is not a major factor in contributing to a stroke.

The nurse assesses decreased corneal reflex in a newly admitted patient. This reflex may normally be decreased due to which history? Over age 50 Wears contact lenses Takes diuretic medications Wears dentures

8. Correct answer: B Rationale: There may be a normal decrease or absence of corneal reflex in those who wear contact lenses. Being over 50, taking a diuretic, and wearing dentures are not reasons this decrease will occur.

A patient with meningitis is drowsy and confused. What should the nurse explain to the patient's family as being the cause for these mental status changes? Decreased intracranial pressure Bleeding in the central nervous system Elevated serum white blood cell count Sluggish flow of cerebrospinal fluid

8. Correct answer: D Rationale: Pathogen entry into the CNS initiates the inflammatory response in the meninges, CSF, and ventricles. Meningeal vessels become engorged and permeability increases. Phagocytic white blood cells migrate into the subarachnoid space, forming a purulent exudate that thickens and clouds the CSF and impairs its flow. Intracranial pressure can increase and not decrease with meningitis. Meningitis does not cause bleeding into the central nervous system. An elevated systemic white blood cell count does not affect the cognitive status.

The nurse is preparing a teaching plan for a patient with Bell palsy. What information should the nurse include? "One side of your face will not move normally." "The disease affects your muscles so you can't walk." "You will experience severe facial pain during attacks." "Be sure to boil all home-canned foods before eating them."

9. Correct answer: A Rationale: When teaching patients about Bell palsy, the nurse needs to tell the patient that one side of the face will not move normally since the affected nerve supplies the muscles that produce expression on one side of the face. The disease does not affect lower extremity muscles. Pain from the ear along the jaw may precede the facial paralysis. There is no reason for the patient to boil home-canned foods since Bell palsy is not caused by botulism.

The nurse is planning to assess a patient's gag reflex. What equipment should the nurse use to test this reflex? Safety pin Cotton ball Stethoscope Tongue depressor

9. Correct answer: D Rationale: The gag reflex is assessed by touching the back of the patient's throat with a tongue depressor. Safety pins, cotton balls, and stethoscopes are not used.

The nurse is providing care for a patient who has had an acute ischemic stroke of a left cerebral vessel. The medical record includes information that the patient has contralateral deficits. What does this information suggest to the nurse? Both sides of the body are involved. Deficits will be present below the level of the stroke. The patient will have neurologic deficits on the left side of the body. The patient will have neurologic deficits on the right side of the body.

9. Correct answer: D Rationale: The neurologic deficits that occur as a result of a stroke can often be used to identify its location. Because the motor pathways cross at the junction of the medulla and spinal cord, strokes lead to loss or impairment of sensorimotor functions on the side of the body opposite the side of the brain that is damaged. This effect, known as a contralateral deficit, means that a stroke in the right hemisphere of the brain is manifested by deficits in the left side of the body and vice versa. Contralateral does not mean that the effects of the stroke are evident on both sides of the body, below the level of the stroke, or on the same side of the embolic event.