Neurologic Practice Prep Us

Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply. A Verbal response B Motor response C Eye opening D Muscle strength E Intelligence

A Verbal response B Motor response C Eye opening LOC can be assessed based on the criteria in the GCS, which include eye opening, verbal response, and motor response. The patient's responses are rated on a scale from 3 to 15. Intelligence and muscle strength are not measured in the GCS.

Which are characteristics of autonomic dysreflexia? A severe hypertension, slow heart rate, pounding headache, sweating B severe hypotension, tachycardia, nausea, flushed skin C severe hypotension, slow heart rate, anxiety, dry skin D severe hypertension, tachycardia, blurred vision, dry skin

A severe hypertension, slow heart rate, pounding headache, sweating

The nurse is caring for a client following a spinal cord injury who has a halo device in place. The client is preparing for discharge. Which statement by the client indicates the need for further instruction? A "If a pin becomes detached, I'll notify the surgeon." B "I can apply powder under the liner to help with sweating." C "I will change the vest liner periodically." D " I'll check under the liner for blisters and redness."

B "I can apply powder under the liner to help with sweating." Powder is not used inside the vest because it may contribute to the development of pressure ulcers. The areas around the four pin sites of a halo device are cleaned daily and observed for redness, drainage, and pain. The pins are observed for loosening, which may contribute to infection. If one of the pins becomes detached, the head is stabilized in a neutral position by one person while another notifies the neurosurgeon. The skin under the halo vest is inspected for excessive perspiration, redness, and skin blistering, especially on the bony prominences. The vest is opened at the sides to allow the torso to be washed. The liner of the vest should not become wet because dampness can cause skin excoriation. The liner should be changed periodically to promote hygiene and good skin care.

A patient with myasthenia gravis is in the hospital for treatment of pneumonia. The patient informs the nurse that it is very important to take pyridostigmine bromide on time. The nurse gets busy and does not administer the medication until after breakfast. What outcome will the patient have related to this late dose? A There should not be a problem, since the medication was only delayed by about 2 hours. B The muscles will become fatigued and the patient will not be able to chew food or swallow pills. C The patient will go into cardiac arrest. D The patient will require a double dose prior to lunch.

B The muscles will become fatigued and the patient will not be able to chew food or swallow pills. Maintenance of stable blood levels of anticholinesterase medications, such as pyridostigmine, is imperative to stabilize muscle strength. Therefore, the anticholinesterase medications must be administered on time. Any delay in administration of medications may exacerbate muscle weakness and make it impossible for the patient to take medications orally.

A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean him from sedation therapy. A nurse needs further assessment data to determine whether: A to continue IV administration of other scheduled medications. B she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube. C nutritional protocol will be effective after the client sedation therapy is tapered. D payment status will change if the client isn't sedated.

B she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube. When the client isn't sedated, he may make attempts to remove the ET tube without realizing what he's doing. The nurse needs to obtain information to determine whether it's necessary to request an order for restraints. The nurse doesn't need to obtain additional data to determine if the nutritional protocol will continue to reflect the client's needs because this aspect of care won't change. The client doesn't require additional assessments to continue I.V. administration of medications. I.V. medication clearly needs to continue because the client is intubated. The staff nurse doesn't need to monitor payment status because client sedation shouldn't affect payment status.

A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client A reports a headache. B vomits. C reports generalized weakness. D sleeps for short periods of time.

B vomits. Vomiting is a sign of increasing intracranial pressure and should be reported immediately. In general, the finding of headache in a client with a concussion is an expected abnormal observation. However, a severe headache, weakness of one side of the body, and difficulty in waking the client should be reported or treated immediately.

The earliest sign of serious impairment of brain circulation related to increased ICP is: A Bradycardia. B Hypertension. C A change in consciousness. D A bounding pulse.

C A change in consciousness. The earliest sign of increasing ICP is a change in the LOC. Any changes in LOC should be reported immediately.

A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as? A A subdural hematoma B An extradural hematoma C An intracerebral hematoma D An epidural hematoma

C An intracerebral hematoma Intracerebral hemorrhage (hematoma) is bleeding within the brain, into the parenchyma of the brain. It is commonly seen in head injuries when force is exerted to the head over a small area (e.g., missile injuries, bullet wounds, stab injuries). A subdural hematoma (SDH) is a collection of blood between the dura and the brain, a space normally occupied by a thin cushion of cerebrospinal fluid. After a head injury, blood may collect in the epidural (extradural) space between the skull and the dura.

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)? A So that the patient will not have a respiratory arrest B To increase cerebral perfusion pressure C Because hypoxemia can create or worsen a neurologic deficit of the spinal cord D To prevent secondary brain injury

C Because hypoxemia can create or worsen a neurologic deficit of the spinal cord Oxygen is administered to maintain a high partial pressure of arterial oxygen (PaO2) because hypoxemia can create or worsen a neurologic deficit of the spinal cord.

When assessing a client who has experienced a spinal injury, the nurse notes diaphragmatic breathing and loss of upper limb use and sensation. At what level does the nurse anticipate the injury has occurred? A C3 B T6 C C5 D L1

C C5 The nurse should anticipate that the injury has occurred at level C5. Injuries above C3 result in the loss of spontaneous respiratory function. Clients with injuries at T6 and L1 retain some degree of upper limb use and sensation.

A client is experiencing muscle weakness and an ataxic gait. The client has a diagnosis of multiple sclerosis (MS). Based on these symptoms, the nurse formulates "Impaired physical mobility" as one of the nursing diagnoses applicable to the client. What nursing intervention should be most appropriate to address the nursing diagnosis? A Use a footboard and trochanter rolls. B Use pressure-relieving devices when the client is in bed or in a wheelchair. C Help the client perform range-of-motion (ROM) exercises every 8 hours. D Change body position every 2 hours.

C Help the client perform range-of-motion (ROM) exercises every 8 hours. Helping the client perform ROM exercises every 8 hours helps in promoting joint flexibility and muscle tone in a client with muscle weakness. Measures such as using pressure-relieving devices or changing the body positions every 2 hours prevents skin breakdown. The nurse should use a footboard and trochanter rolls to promote a neutral body position that will keep the body in good alignment.

A client with a spinal cord injury has full head and neck control when the injury is at which level? A C1 B C2 to C3 C C4 D C5

D C5

A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client? A Disturbed thought processes related to brain injury B Ineffective cerebral tissue perfusion related to increased intracranial pressure C Deficient fluid balance related to decreased level of consciousness and hormonal dysfunction D Ineffective airway clearance related to brain injury

D Ineffective airway clearance related to brain injury Maintaining an airway is always the priority. All the other choices are appropriate nursing diagnoses for this client, but the priority is maintenance of the airway.

The diagnosis of multiple sclerosis is based on which test? A CSF electrophoresis B Neuropsychological testing C Evoked potential studies D Magnetic resonance imaging

D Magnetic resonance imaging The diagnosis of MS is based on the presence of multiple plaques in the central nervous system observed with magnetic resonance imaging. Electrophoresis of CSF identifies the presence of oligoclonal banding. Evoked potential studies can help define the extent of the disease process and monitor changes. Neuropsychological testing may be indicated to assess cognitive impairment.

The nurse is discussing spinal cord injury (SCI) at a health fair at a local high school. The nurse relays that the most common cause of SCI is A Motor vehicle crashes B Falls C Sports-related injuries D Acts of violence

A Motor vehicle crashes The most common causes of SCIs are motor vehicle crashes (46%), falls (22%), violence (16%), and sports (12%). Males account for 80% of clients with SCI. An estimated 50% to 70% of SCIs occur in those aged 15 to 35 years.

In a spinal cord injury, neurogenic shock develops due to loss of the autonomic nervous system functioning below the level of the lesion. Which of the following indicators of neurogenic shock would the nurse expect to find? Select all that apply. A Tachypnea B Hypotension C Tachycardia D Venous pooling E Diaphoresis F Hypothermia

A Tachypnea B Hypotension D Venous pooling F Hypothermia The vital organs are affected in a spinal cord injury, causing the blood pressure and heart rate to decrease. This loss of sympathetic innervation causes a variety of other clinical manifestations, including a decrease in cardiac output, venous pooling in the extremities, and peripheral vasodilation resulting in mild hypotension, bradycardia, and warm skin. In addition, the patient does not perspire on the paralyzed portions of the body because sympathetic activity is blocked; therefore, close observation is required for early detection of an abrupt onset of fever.

When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes? A Side-lying B 30-degree head elevation C Flat D Trendelenburg's

B 30-degree head elevation For clients with increased intracranial pressure (ICP), the head of the bed should be elevated to 30 degrees to promote venous outflow. Trendelenburg's position is contraindicated because it can raise ICP. Flat or neutral positioning is indicated when elevating the head of the bed would increase the risk of neck injury or airway obstruction. A side-lying position isn't specifically a therapeutic treatment for increased ICP.

You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides? A Tetraplegia B Autonomic dysreflexia C Areflexia D Paraplegia

B Autonomic dysreflexia Autonomic dysreflexia is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury, usually after the spinal shock subsides. Tetraplegia results in the paralysis of all extremities when there is a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Areflexia is a loss of sympathetic reflex activity below the level of injury within 30 to 60 minutes of a spinal injury.

The nurse is performing an initial nursing assessment on a client with possible Guillain-Barre syndrome. Which of the following findings would be most consistent with this diagnosis? A Hyporeflexia and skin rash B Muscle weakness and hyporeflexia of the lower extremities C Ptosis and muscle weakness of upper extremities D Fever and cough

B Muscle weakness and hyporeflexia of the lower extremities Guillain-Barre syndrome typically begins with muscle weakness and diminished reflexes of the lower extremities. Fever, skin rash, cough, and ptosis are not signs/symptoms associated with Guillain-Barre.

The nurse is caring for a client who has sustained a spinal cord injury (SCI) at C5 and has developed a paralytic ileus. The nurse will prepare the client for which of the following procedures? A Digital stimulation B Bowel surgery C Insertion of a nasogastric tube D A large volume enema

C Insertion of a nasogastric tube

The nurse is caring for a client with traumatic brain injury (TBI). Which clinical finding, observed during the reassessment of the client, causes the nurse the most concern? A Urinary output increase from 40 to 55 mL/hr B Pulse oximetry decrease from 99% to 97% room air C Temperature increase from 98.0°F to 99.6°F D Heart rate decrease from 100 to 90 bpm

C Temperature increase from 98.0°F to 99.6°F Fever in the client with a TBI can be the result of damage to the hypothalamus, cerebral irritation from hemorrhage, or infection. The nurse monitors the client's temperature every 2 to 4 hours. If the temperature increases, efforts are made to identify the cause and to control it using acetaminophen and cooling blankets to maintain normothermia. The other clinical findings are within normal limits.

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor? A Extreme thirst B Intake and output C Nutritional status D Body temperature

D Body temperature It is important to monitor the client's body temperature closely because hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures. Extreme thirst, intake and output, and nutritional status are not the most important parameters to monitor.

Pressure ulcers may begin within hours of an acute spinal cord injury (SCI) and may cause delay of rehabilitation, adding to the cost of hospitalization. The most effective approach is prevention. Which of the following nursing interventions will most protect the client against pressure ulcers? A Allowing the client to choose the position of comfort B Continuous use of an indwelling catheter C Avoidance of all lotions and lubricants D Meticulous cleanliness

D Meticulous cleanliness Meticulous cleanliness is the best choice for preventing pressure ulcers. A continuous indwelling catheter is not conducive to preventing pressure ulcers. Pressure-sensitive areas should be kept well lubricated with lotion. The client does not know the best positioning techniques for prevention of skin breakdown. The nurse and client together should decide how to best position the body.

The nurse is taking health history from a client admitted to rule out Guillain-Barre syndrome. An important question to ask related to the diagnosis is which of the following? A "Have you experienced any viral infections in the last month?" B "Have you developed any new allergies in the last year?" C "Have you had difficulty with urination in the last 6 weeks?" D "Have you experienced any ptosis in the last few weeks?"

A "Have you experienced any viral infections in the last month?" An antecedent event (most often a viral infection) precipitates clinical presentation. The antecedent event usually occurs about 2 weeks before the symptoms begin. Ptosis is a common symptom associated with myasthenia gravis. Urination and development of allergies are not associated with Guillain-Barre.

A client with quadriplegia is in spinal shock. What finding should the nurse expect? A Absence of reflexes along with flaccid extremities B Spasticity of all four extremities C Positive Babinski's reflex along with spastic extremities D Hyperreflexia along with spastic extremities

A Absence of reflexes along with flaccid extremities During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the client will demonstrate positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities.

A client is hospitalized with Guillain-Barré syndrome. Which nursing assessment finding is most significant? A Uneven, labored respirations B Urine output of 40 ml/hour C Warm, dry skin D Soft, nondistended abdomen

A Uneven, labored respirations A characteristic feature of Guillain-Barré syndrome is ascending weakness, which usually begins in the legs and progresses upward to the trunk, arms, and face. Respiratory muscle weakness, evidenced by uneven, labored respirations, is a particularly dangerous effect of this disease progression because it may lead to respiratory failure and death. Therefore, although warm, dry skin; urine output of 40 ml/hour; and a soft, nondistended abdomen are pertinent assessment data, those related to respiratory function and status are most significant.

A client with a T4 level spinal cord injury (SCI) is complaining of a severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect? A Orthostatic hypotension B Autonomic dysreflexia C Spinal shock D Thrombophlebitis

B Autonomic dysreflexia Autonomic dysreflexia occurs only after spinal shock has resolved. It is characterized by a severe, pounding headache, marked hypertension, diaphoresis, nausea, nasal congestion, and bradycardia. It occurs only with SCIs above T6 and is a hypertensive emergency. It is not related to thrombophlebitis.

The nurse is caring for a client who was discovered unconscious after falling off a ladder. The client is diagnosed with a concussion. All testing is normal, and discharge instructions are compiled. Which instructions have been compiled for the spouse? A Follow up with regular physician is encouraged. B Acetaminophen may be administered for aches. C Observe for any signs of behavioral changes. D A light meal may be eaten if desired.

C Observe for any signs of behavioral changes.

Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch? A Akathisia B Ataxia C Myoclonus D Spasticity

D Spasticity Spasticity is often associated with weakness, increased deep tendon reflexes, and diminished superficial reflexes. Akathisia refers to restlessness, an urgent need to move around, and agitation. Ataxia refers to impaired ability to coordinate movement. Myoclonus refers to spasm of a single muscle or group of muscles.

Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin? A Represents building block of nervous system B Carries message to the next nerve cell C Acts as chemical messenger D Speeds nerve impulse transmission

D Speeds nerve impulse transmission Myelin is a complex substance that covers nerves, providing insulation and speeding the conduction of impulses from the cell body to the dendrites. The axon carries the message to the next nerve cell. The neuron is the building block of the nervous system. A neurotransmitter is a chemical messenger

Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury? A Increased pulse B Increased respirations C Decreased body temperature D Widened pulse pressure

D Widened pulse pressure Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic blood pressure, and widening pulse pressure (Cushing reflex). As brain compression increases, respirations decrease or become erratic, blood pressure may decrease, and the pulse slows further. This is an ominous development, as is a rapid fluctuation of vital signs. Temperature is maintained at less than 38°C (100.4°F). Tachycardia and arterial hypotension may indicate that bleeding is occurring elsewhere in the body.

A nurse is providing education to a client with newly diagnosed multiple sclerosis (MS). Which of the following will the nurse include? A Avoid hot temperatures. B Take moderate amounts of alcohol. C Avoid analgesic medication. D Avoid physical activity.

A Avoid hot temperatures. Fatigue affects most people with MS. Avoidance of hot temperatures may help control fatigue. A balance of rest and activity is a good strategy, but avoidance of any physical activity is not recommended. Avoidance of all alcohol is a good strategy. Analgesics may be required for pain management.

The nurse is caring for a client who is scheduled for surgery to relieve pressure on a compressed nerve. The compression does not involve the spinal cord. What kind of spinal nerve root compression does the nurse know this is? A Extramedullary B Intramedullary C Spinal D Peripheral

A Extramedullary There are two basic types of spinal nerve root compression: intramedullary lesions that involve the spinal cord and extramedullary lesions that involve the tissues surrounding the spinal cord. Options B, C, and D are incorrect.

A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family? A Look for signs of increased intracranial pressure B Emphasize complete bed rest C Look for a halo sign D Have the client avoid physical exertion

A Look for signs of increased intracranial pressure The nurse informs the family to monitor the client closely for signs of increased intracranial pressure if findings are normal and the client does not require hospitalization. Signs of increased intracranial pressure include headache, blurred vision, vomiting, and lack of energy or sleepiness. The nurse looks for a halo sign to detect any cerebrospinal fluid drainage.

A client with tetraplegia cannot do his own skin care. The nurse is teaching the caregiver about the importance of maintaining skin integrity. Which of the following will the nurse most encourage the caregiver to do? A Maintain a diet for the client that is high in protein, vitamins, and calories. B Keep accurate intake and output. C Watch closely for signs of urinary tract infection. D Avoid range of motion exercises for the client because of spasms.

A Maintain a diet for the client that is high in protein, vitamins, and calories. To maintain healthy skin, the following interventions are necessary: regularly relieve pressure, protect from injury, keep clean and dry, avoid wrinkles in the bed, and maintain a diet high in protein, vitamins, and calories to ensure minimal wasting of muscles and healthy skin.

A patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit from the application of the halo device? A It is the only device that can be applied for stabilization of a spinal fracture. B It allows for stabilization of the cervical spine along with early ambulation. C The patient can remove it as needed. D It is less bulky and traumatizing for the patient to use.

B It allows for stabilization of the cervical spine along with early ambulation.

A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan? A Disturbed sensory perception (visual) B Impaired verbal communication C Risk for injury D Dressing or grooming self-care deficit

C Risk for injury Because the client is disoriented and restless, the most important nursing diagnosis is Risk for injury. Although Disturbed sensory perception (visual), Dressing or grooming self-care deficit, and Impaired verbal communication may all be appropriate, they're secondary because they don't immediately affect the client's health or safety.

A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as: A Mild TBI. B Brain death. C Severe TBI. D Moderate TBI.

C Severe TBI. A score of 13 to 15 is classified as mild TBI, 9 to 12 is moderate TBI, and 3 to 8 is severe TBI. A score of 3 indicates severe impairment of neurologic function, deep coma, brain death, or pharmacologic inhibition of the neurologic response; a score of 8 or less typically indicates an unconscious patient; a score of 15 indicates a fully alert and oriented patient.

The nurse has been educating a client newly diagnosed with MS. Which statement by the client indicates an understanding of the education? A "I should participate in non-weight-bearing exercises." B "I will take hot tub baths to decrease spasms." C "The exercises should be completed quickly to reduce fatigue." D "I will stretch daily as directed by the physical therapist."

D "I will stretch daily as directed by the physical therapist." A stretching routine should be established. Stretching can help prevent contractures and muscle spasticity. Hot baths are discouraged because of the risk of injury. Clients have sensory loss that may contribute to the risk of burns. In addition, hot temperatures may cause an increase in symptoms. Warm packs should be encouraged to provide relief. Progressive weight-bearing exercises are effective in managing muscle spasms. Clients should not hurry through the exercise activity because it may increase muscle spasticity.

Which of the following is the earliest and most significant sign of increasing intracranial pressure (ICP)? A Restlessness B Pupil changes C Seizures D Change in level of consciousness (LOC)

D Change in level of consciousness (LOC) The earliest sign of increasing ICP is a change in LOC. Any changes in LOC should be reported immediately. Seizures, restlessness, and pupil changes may occur, but these are not the earliest signs.

A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The physician suspects myasthenia gravis. Which drug will be used to test for this disease? A Pyridostigmine (Mestinon) B Ambenonium (Mytelase) C Carbachol (Carboptic) D Edrophonium (Tensilon)

D Edrophonium (Tensilon) Edrophonium temporarily blocks the breakdown of acetylcholine, thus increasing acetylcholine level in the blood, and relieves weakness. Because of its short duration of action, edrophonium is the drug of choice for diagnosing myasthenia gravis. It's also used to differentiate myasthenia gravis from cholinergic toxicity. Ambenonium is used as an antimyasthenic. Pyridostigmine serves primarily as an adjunct in treating severe anticholinergic toxicity; it's also an antiglaucoma agent and a miotic. Carbachol reduces intraocular pressure during ophthalmologic procedures; topical carbachol is used to treat open-angle and closed-angle glaucoma.

A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report? A Herniation B Sciatic nerve pain C Paralysis D Paresthesia

D Paresthesia When a client reports numbness and tingling in an area, the client is reporting a paresthesia. The nurse would document the experience as such or place the client's words in parentheses. The nurse would not make a medical diagnosis of sciatic nerve pain or herniation. The symptoms are not consistent with paralysis.

Which nursing intervention is the priority for a client in myasthenic crisis? A Ensuring adequate nutritional support B Assessing respiratory effort C Preparing for plasmapheresis D Administering intravenous immunoglobin (IVIG) per orders

B Assessing respiratory effort A client in myasthenic crisis has severe muscle weakness, including the muscles needed to support respiratory effort. Myasthenic crisis can lead to respiratory failure and death if not recognized early. Administering IVIG, preparing for plasmapheresis, and ensuring adequate nutritional support are important and appropriate interventions, but maintaining adequate respiratory status or support is the priority during the crisis.

The nurse working on a neurological unit is mentoring a nursing student. The student asks about a client who has sustained a primary and secondary brain injury. The nurse correctly tells the student which of the following, related to the primary injury? A It refers to the permanent deficits seen after the rehabilitation process. B It refers to the difficulties suffered by the client and family related to the changes in the client. C It results from initial damage to the brain from the traumatic event. D It results from inadequate delivery of nutrients and oxygen to the cells.

C It results from initial damage to the brain from the traumatic event. The primary injury results from the initial damage from the traumatic event. The secondary injury results from inadequate delivery of nutrients and oxygen to the cells, usually due to cerebral edema and increased intracranial pressure.

Which stimulus is known to trigger an episode of autonomic dysreflexia in the client who has suffered a spinal cord injury? A Voiding B Placing the client in a sitting position C Placing a blanket over the client D Diarrhea

C Placing a blanket over the client An object on the skin or skin pressure may precipitate autonomic dysreflexia. In general, constipation or fecal impaction triggers autonomic dysreflexia. When the client is observed to be demonstrating signs of autonomic dysreflexia, the nurse immediately places the client in a sitting position to lower blood pressure. The most common cause of autonomic dysreflexia is a distended bladder.

A client with respiratory complications of multiple sclerosis (MS) is admitted to the medical-surgical unit. Which equipment is most important for the nurse to keep at the client's bedside? A Nasal cannula and oxygen B Padded tongue blade C Suction machine with catheters D Sphygmomanometer

C Suction machine with catheters MS weakens the respiratory muscles and impairs swallowing, putting the client at risk for aspiration. To ensure a patent oral airway, the nurse should keep a suction machine and suction catheters at the bedside. A sphygmomanometer is no more important for this client than for any other. A padded tongue blade is an appropriate seizure precaution but shouldn't be used in this client because its large size could cause oral airway obstruction. A nasal cannula and oxygen would be ineffective to ensure adequate oxygen delivery; this client requires a mechanical ventilator.

The nurse is assisting with administering a Tensilon test to a patient with ptosis. If the test is positive for myasthenia gravis, what outcome does the nurse know will occur? A The patient will have recovery of symptoms for at least 24 hours after the administration of the Tensilon. B Eight hours after administration, the acetylcholinesterase begins to regenerate the available acetylcholine and will relieve symptoms. C After administration of the medication, there will be no change in the status of the ptosis or facial weakness. D Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes.

D Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes. Thirty seconds after injection, facial muscle weakness and ptosis should resolve for about 5 minutes (Hickey, 2009). Immediate improvement in muscle strength after administration of this agent represents a positive test and usually confirms the diagnosis.

A nurse is teaching a client who has facial muscle weakness and has recently been diagnosed with myasthenia gravis. The nurse should teach the client that myasthenia gravis is caused by: A upper and lower motor neuron lesions. B decreased conduction of impulses in an upper motor neuron lesion. C genetic dysfunction. D a lower motor neuron lesion.

D a lower motor neuron lesion. Myasthenia gravis is characterized by a weakness of muscles, especially in the face and throat, caused by a lower motor neuron lesion at the myoneural junction. It isn't a genetic disorder. A combined upper and lower motor neuron lesion generally occurs as a result of spinal injuries. A lesion involving cranial nerves and their axons in the spinal cord would cause decreased conduction of impulses at an upper motor neuron.

A client with Guillain-Barre syndrome cannot swallow and has a paralytic ileus; the nurse is administering parenteral nutrition intravenously. The nurse is careful to assess which of the following related to intake of nutrients? A Gag reflex and bowel sounds B Condition of skin C Respiratory status D Urinary output and capillary refill

A Gag reflex and bowel sounds Paralytic ileus may result from insufficient parasympathetic activity. The nurse may administer parenteral nutrition and IV fluids. The nurse carefully assesses for the return of the gag reflex and bowel sounds before resuming oral nutrition. The other three choices are important assessment items, but not necessarily related to the intake of nutrients.

A client is admitted to the hospital after sustaining a closed head injury in a skiing accident. The physician ordered neurologic assessments to be performed every 2 hours. The client's neurologic assessments have been unchanged since admission, and the client is complaining of a headache. Which intervention by the nurse is best? A Administer codeine 30 mg by mouth as ordered and continue neurologic assessments as ordered. B Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes. C Reassure the client that a headache is expected and will go away without treatment. D Notify the physician; a headache is an early sign of worsening neurologic status.

B Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes. Headache is common after a head injury. Therefore, the nurse should administer acetaminophen to try to manage the client's pain without causing sedation. The nurse should then reassess the client in 30 minutes to note the effectiveness of the pain medication. Administering codeine, an opioid, could cause sedation that may mask changes in the client's neurologic status. Although a headache is expected, the client should receive treatment to alleviate pain. The nurse should notify the physician if the client's neurologic status changes or if treatment doesn't relieve the headache.

A 24-year-old female rock climber is brought to the emergency department after a fall from the face of a rock. The young lady is admitted for observation after being diagnosed with a contusion to the brain. The client asks the nurse what having a contusion means. How should the nurse respond? A Contusions occur when the brain is jarred and bounces off the skull on the opposite side from the blow. B Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue. C Contusions are deep brain injuries. D Contusions are microscopic brain injuries.

B Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue. Contusions result in bruising, and sometimes, hemorrhage of superficial cerebral tissue. When the head is struck directly, the injury to the brain is called a coup injury. Dual bruising can result if the force is strong enough to send the brain ricocheting to the opposite side of the skull, which is called a contrecoup injury. Edema develops at the site of or in areas opposite to the injury. A skull fracture can accompany a contusion. Therefore the other options are incorrect.

The most important nursing priority of treatment for a patient with an altered LOC is to: A Stabilize the blood pressure and heart rate to ensure adequate perfusion of the brain. B Maintain a clear airway to ensure adequate ventilation. C Prevent dehydration and renal failure by inserting an IV line for fluids and medications. D Position the patient to prevent injury and ensure dignity.

B Maintain a clear airway to ensure adequate ventilation. The first priority of treatment for the patient with altered LOC is to obtain and maintain a patent airway. The patient may be orally or nasally intubated (unless basilar skull fracture or facial trauma is suspected), or a tracheostomy may be performed. Until the ability of the patient to breathe on his or her own is determined, a mechanical ventilator is used to maintain adequate oxygenation and ventilation.

The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)? A Administer enemas, as needed B Maintain cerebral perfusion pressure from 50 to 70 mm Hg C Restrain the client, as indicated D Position the client in the supine position

B Maintain cerebral perfusion pressure from 50 to 70 mm Hg The nurse should maintain cerebral perfusion pressure from 50 to 70 mm Hg to help control increased ICP. Other measures include elevating the head of the bed as prescribed, maintaining the client's head and neck in neutral alignment (no twisting or flexing the neck), initiating measures to prevent the Valsalva maneuver (e.g., stool softeners), maintaining body temperature within normal limits, administering O2 to maintain PaO2 greater than 90 mm Hg, maintaining fluid balance with normal saline solution, avoiding noxious stimuli (e.g., excessive suctioning, painful procedures), and administering sedation to reduce agitation.

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia? A Assessing laboratory test results as ordered B Monitoring the patency of an indwelling urinary catheter C Placing the client in Trendelenburg's position D Administering zolpidem tartrate (Ambien)

B Monitoring the patency of an indwelling urinary catheter A full bladder can precipitate autonomic dysreflexia, the nurse should monitor the patency of an indwelling urinary catheter to prevent its occlusion, which could result in a full bladder. Administering zolpidem tartrate, assessing laboratory values, and placing the client in Trendelenburg's position can't prevent autonomic dysreflexia.

Family members of a client with traumatic brain injury are extremely distressed about their loved one. How can the nurse best assist the family to cope during this acute phase? A Wait for the family members to approach with questions. B Provide factual information and emotional support. C Reassure them that progress will be made, but it takes time. D Allow family members distance and space to deal with the changes to the client.

B Provide factual information and emotional support. During the most acute phase of injury, family members need factual information and support from the health care team. Allowing distance and space can alienate the family, and make them feel like they are not involved with the client. The family may be unsure of approaching the nurse and may not know what questions to ask. The nurse should be available and offer information to start. He or she should not provide false reassurance; they need factual information at this time

A nursing assistant tells the nurse that a client with paraplegia has an area of skin breakdown on his left calf. When the nurse assesses the client, he is sitting on a cushion in a wheelchair and wearing specialty boots. The nurse notes a circular wound 2 cm × 2 cm × 0.25 cm on the posterior aspect of the calf. What most likely caused the client's skin breakdown? A Leg rest of the wheelchair B Specialty boots C Absence of sensation in the lower extremities and immobility D Sitting in the wheelchair for long periods of time

B Specialty boots The area of skin breakdown was most likely caused by the specialty boot — ordered to reduce pressure in the heels — rubbing against the skin. Although the wheelchair leg rest is located near the wound site, the wound described is likely to be caused by pressure, not a laceration caused by contact with the leg rest. Immobility and decreased sensation places the client at risk for skin breakdown, but these factors aren't the direct cause of this wound. A paraplegic is capable of sitting in a wheelchair for extended periods because he can shift his weight throughout the day.

Which of the following tests confirms the diagnosis of myasthenia gravis (MG)? A Electromyogram (EMG) B Tensilon test C Computed tomography (CT) scan D Serum studies

B Tensilon test Edrophonium chloride (Tensilon) is an acetylcholinesterase inhibitor that stops the breakdown of acetylcholine. The drug is used because it has a rapid onset of 30 seconds and a short duration of 5 minutes. Immediate improvement in muscle strength after administration of this agent represents a positive test and usually confirms the diagnosis. The presence of acetylcholine receptor antibodies is identified in serum. Repetitive nerve stimulation demonstrates a decrease in successive action potentials. The thymus gland may be enlarged in MG, and a T scan of the mediastinum is performed to detect thymoma or hyperplasia of the thymus. Reference: