Neurological Q's

The nurse in the outpatient clinic assesses a client diagnosed with trigéminas neuralgia. The nurse intervenes if the client makes which statement? A. "I drink hot coffee with breakfast and after dinner." B. "I like to eat creamed soups at room temperature." C. "I can't wait to eat my spouse's homemade applesauce." D. "I drink tomato juice during my afternoon break."

A. "I drink hot coffee with breakfast and after dinner." The trigeminal nerve carries sensation from the face to the brain. Hot foods can trigger a pain episode. Instruct the client to avoid foods that are too hot or too cold. Eating soft foods and foods at room temperature decreases an exacerbation of a pain episode for this condition. Even mild stimulation of the face may trigger excruciating pain. Tomato juice is an acceptable drink.

The nurse in the emergency department is assigned to a client who reports weakness and numbness of the right hand and arm, a severe HA, dizziness, and blurred vision. Sx began very suddenly about 20 min ago. Nurse's notes at 0900: Client lying on stretcher, head elevated at 45 degrees, awake and alert, speech slurred, difficult to understand. States name and "in hospital" correctly when asked name and location. Moves self on stretcher and moves legs well, but doesn't move right arm or hand. Client reports vision is blurry. Lungs clear, heart sounds irregular with clear S1 and S2. Abdomen soft with positive hypoactive bowel sounds all 4 quadrants. Skin warm and dry. Capillary refill < 2 sec. Client is married; spouse has been contacted and on way to ED. VS at 0900: HR: 112 beats/min, irregular BP: 152/92 mm Hg RR: 18 breaths/min, regular Temp (axillary): 97.8 F (36.4 C) SpO2: 98% on RA Height: 63 in (160 cm) Weight: 176 lb (79.83 kg) BMI: 31.2 kg/m^2 Lab results: Sodium: 146 mEq/L Potassium: 4.3 mEq/L Chloride: 102 mEq/L Glucose: 186 mg/dL BUN: 14 mg/dL Creatinine: 0.9 mg/dL Hemoglobin A1C: 7.4% WBC: 6,500 cells/ mm^3 Platelets: 380,000 cells/mm^3 Hematocrit: 42% Hemoglobin: 15 g/dL PT: 10 sec aPTT: 30 sec Total cholesterol: 262 mg/dL Tests: 12-lead ECG: a fib with ventricular rate of 90-110 CT scan of brain: no hemorrhage noted. Ischemic stroke left middle cerebral artery. Following the completion of fibrinolytic therapy, the nurse assesses the client. For each of the following findings, determine if it marks an improvement, decline, or no change in the patient. Assessment findings: - right and left hand grasp bilaterally - client aphasic - HR 114, irregular - RR 26 breaths/min, 10 sec period of apnea - sleepy, difficult to arouse

Assessment findings: - right and left hand grasp bilaterally - improvement - client aphasic - decline - HR 114, irregular - no change - RR 26 breaths/min, 10 sec period of apnea - decline - sleepy, difficult to arouse - decline Following fibrinolytic therapy, the goal is that the client's neurologic status is improved. Successful tx will result in the client being awake no alert with improvement of any deficits, and stable vitals. If the client has equal hand strength, therapy has been successful. Findings like aphasia, the client being more difficult to aroused, unequal or fixed pupils, or periods of apnea would be serious signs of worsening neurologic impairment.

A client is diagnosed with tonic-clonic seizures. The nurse tries to identify the client's aura. Which statement accurately describes an aura? A. A state of consciousness during the seizure B. Unusual sensations prior to the seizure C. Emotional status of the client after the seizure D. Uncomfortable feeling as the seizure begins to subside

B. Unusual sensations prior to the seizure This is a knowledge question. An aura can be described as a series of unusual sensations that occur as a prodrome to the seizure (prior to). Prodomal sx occur in about 50% of all seizure clients and usually include a change in sensation or in affect. The exact character of the aura varies from person to person, but may include numbness, flashing lights, dizziness, smells, and spots before the eyes. None of the other statements describe what an aura is. For future reference - a person can be un/conscious during a seizure, that's why you see if the person is responsive to their name or to touch. Unconsciousness occurs during generalized motor seizures and complex focal seizures due to excessive discharge of electrical activity within the brain. Postictal phase is after the seizure. Take the client's vitals, perform neurological checks, position the client on the side, and allow the client to sleep or rest. When the client awakens, reorient them to their surroundings.

A client is diagnosed with typical absence seizures. It is most important for the nurse to take which action? A. Place the client on complete bedrest B. Pad the side rails of the client's bed C. Observe for autonomic, purposeless motions with intense emotional experiences D. Monitor the client for brief interruptions of consciousness

D. Monitor the client for brief interruptions of consciousness Typical absence seizures are characterized by a momentary episode of loss of consciousness. The client may have a blank stare for a few seconds, or may stop talking in the middle of a sentence. After the seizure, the client is usually unaware that consciousness has been lost. There's no reason to put the client on bedrest because clients return to baseline after losing consciousness with this type of seizure. Padded side rails aren't recommended for this type of seizure because there's no motor activity that could cause harm to the client. Clients appear to be daydreaming and are unaware of the seizure. In a complex focal seizure, the client may have unilateral movement of an extremity, experience unusual sensations, or may have autonomic sx such as a change in HR, skin flushing, and epigastic discomfort.

The nurse in the emergency department is assigned to a client who reports weakness and numbness of the right hand and arm, a severe HA, dizziness, and blurred vision. Sx began very suddenly about 20 min ago. Nurse's notes at 0900: Client lying on stretcher, head elevated at 45 degrees, awake and alert, speech slurred, difficult to understand. States name and "in hospital" correctly when asked name and location. Moves self on stretcher and moves legs well, but doesn't move right arm or hand. Client reports vision is blurry. Lungs clear, heart sounds irregular with clear S1 and S2. Abdomen soft with positive hypoactive bowel sounds all 4 quadrants. Skin warm and dry. Capillary refill < 2 sec. Client is married; spouse has been contacted and on way to ED. VS at 0900: HR: 112 beats/min, irregular BP: 152/92 mm Hg RR: 18 breaths/min, regular Temp (axillary): 97.8 F (36.4 C) SpO2: 98% on RA Height: 63 in (160 cm) Weight: 176 lb (79.83 kg) BMI: 31.2 kg/m^2 Lab results: Sodium: 146 mEq/L Potassium: 4.3 mEq/L Chloride: 102 mEq/L Glucose: 186 mg/dL BUN: 14 mg/dL Creatinine: 0.9 mg/dL Hemoglobin A1C: 7.4% WBC: 6,500 cells/ mm^3 Platelets: 380,000 cells/mm^3 Hematocrit: 42% Hemoglobin: 15 g/dL PT: 10 sec aPTT: 30 sec Total cholesterol: 262 mg/dL Tests: 12-lead ECG: a fib with ventricular rate of 90-110 CT scan of brain: no hemorrhage noted. Ischemic stroke left middle cerebral artery. While the client is receiving IV fibrinolytic therapy, which assessment finding indicates the nurse must contact the health care provider immediately? Select all that apply. A. Epistaxis B. BP 140/90 mm Hg C. Client reports HA pain 10/10 D. Client awake, speech slurred E. Client begins to vomit F. HR 110, irregular G. Client unable to wiggle toes of the right foot H. Client states name and birthday I. Urine clear, pale yellow J. Abdomen soft with hyperactive bowel sounds

Report the following immediately if your patient's getting fibrinolytic therapy: A. Epistaxis C. Client reports HA pain 10/10 E. Client begins to vomit G. Client unable to wiggle toes of the right foot During fibrinolytic therapy, the nurse should be most concerned if the patient develops bleeding or signs of hemorrhage, signs of worsening neurologic status, or signs of increased ICP. Epistaxis, increasing HA, n/v, and loss of the ability to move the lower extremities should be reported to the provider immediately. The other assessment findings are either unchanged from baseline or are normal findings.

The nurse in the emergency department is assigned to a client who reports weakness and numbness of the right hand and arm, a severe HA, dizziness, and blurred vision. Sx began very suddenly about 20 min ago. Nurse's notes at 0900: Client lying on stretcher, head elevated at 45 degrees, awake and alert, speech slurred, difficult to understand. States name and "in hospital" correctly when asked name and location. Moves self on stretcher and moves legs well, but doesn't move right arm or hand. Client reports vision is blurry. Lungs clear, heart sounds irregular with clear S1 and S2. Abdomen soft with positive hypoactive bowel sounds all 4 quadrants. Skin warm and dry. Capillary refill < 2 sec. Client is married; spouse has been contacted and on way to ED. VS at 0900: HR: 112 beats/min, irregular BP: 152/92 mm Hg RR: 18 breaths/min, regular Temp (axillary): 97.8 F (36.4 C) SpO2: 98% on RA Height: 63 in (160 cm) Weight: 176 lb (79.83 kg) BMI: 31.2 kg/m^2 The nurse obtains the client's vital signs as well as height and weight, noting that the client is an obese, African American. While the client is being further assessed, the client's spouse arrives at the hospital and is able to provide more information. The client is 48 y/o, has no allergies, takes a multivitamin, and doesn't have an established health care provider. The client also smokes a pack of cigarettes a day, but doesn't drink alcohol or use illicit drugs. The client's a manager of a large office supply store and works 50-60 hours a week. Select all the assessment findings that place the client at risk of stroke: VS: A. HR 112 B. HR irregular C. BP 152/92 D. RR 18, irregular E. SpO2 98 RA F. Temp 97.8 F (36.4 C) Psychosocial: G. Married H. Age 48 I. African American J. Smokes cigarettes K. No health care provider L. Works 50-60 hrs/wk. M. No alcohol use, no illicit drug use. Metabolic: N. BMI 31.2 O. 176 lb

A. HR 112 B. HR irregular C. BP 152/92 H. Age 48 I. African American J. Smokes cigarettes K. No health care provider L. Works 50-60 hrs/wk. N. BMI 31.2 A fast HR alone isn't a risk factor for stroke, but when combined with irregularity, that can be a sign of a fib, which is a significant risk factor for embolic stroke. High BP is a RF for both ischemic and hemorrhagic stroke. Middle aged African Americans are at high risk for both ischemic and hemorrhagic stroke. No primary provider means that the person isn't regularly being assessed and screened for health care issues. Working excessive hours or working a high stress job is a RF for CVD, and also likely indicates that the client doesn't have time for regular exercise of physical activity. BMI of 31.2 is within range of obesity and is a risk factor for ischemic and hemorrhagic stroke, but weight alone isn't a risk factor. None of the other factors increase risk of stroke or are related to stroke.

The nurse in the emergency department is assigned to a client who reports weakness and numbness of the right hand and arm, a severe HA, dizziness, and blurred vision. Sx began very suddenly about 20 min ago. Nurse's notes at 0900: Client lying on stretcher, head elevated at 45 degrees, awake and alert, speech slurred, difficult to understand. States name and "in hospital" correctly when asked name and location. Moves self on stretcher and moves legs well, but doesn't move right arm or hand. Client reports vision is blurry. Lungs clear, heart sounds irregular with clear S1 and S2. Abdomen soft with positive hypoactive bowel sounds all 4 quadrants. Skin warm and dry. Capillary refill < 2 sec. Client is married; spouse has been contacted and on way to ED. VS at 0900: HR: 112 beats/min, irregular BP: 152/92 mm Hg RR: 18 breaths/min, regular Temp (axillary): 97.8 F (36.4 C) SpO2: 98% on RA Height: 63 in (160 cm) Weight: 176 lb (79.83 kg) BMI: 31.2 kg/m^2 Lab results: Sodium: 146 mEq/L Potassium: 4.3 mEq/L Chloride: 102 mEq/L Glucose: 186 mg/dL BUN: 14 mg/dL Creatinine: 0.9 mg/dL Hemoglobin A1C: 7.4% WBC: 6,500 cells/ mm^3 Platelets: 380,000 cells/mm^3 Hematocrit: 42% Hemoglobin: 15 g/dL PT: 10 sec aPTT: 30 sec Total cholesterol: 262 mg/dL Tests: 12-lead ECG: a fib with ventricular rate of 90-110 CT scan of brain: no hemorrhage noted. Ischemic stroke left middle cerebral artery. At 0920, the nurse receives health care provider's orders to obtain a 12 lead ECG, draw labs, and prepare the client for a CT of the brain with and without contrast. At 1015, the nurse reviews the results of the client's diagnostic tests as given above. The three priority nursing actions in the tx of this client are... A. Monitoring the client's level of consciousness B. Providing education about administration of warfarin C. Immediate administration of IV fibrinolytic therapy D. Obtaining and recording hourly blood glucose levels E. Teaching the client about a low cholesterol diet F. Monitoring the client's blood pressure

A. Monitoring the client's level of consciousness C. Immediate administration of IV fibrinolytic therapy F. Monitoring the client's blood pressure The results of the head CT indicate that the patient is experiencing an ischemic stroke. Because this is the case, they should get a fibrinolytic to dissolve the clot and reestablish cerebral blood flow within 3 hours of the start of sx. Monitoring LOC and doing hourly neuro checks are interventions that help you monitor cerebral perfusion and catch any increased ICP. It's also imperative that you monitor BP because it must be maintained in a narrow range to provide adequate cerebral perfusion but not place them at risk of hemorrhage. Elevated blood glucose and A1C are secondary concerns to stroke. Before discharge, they should receive education about monitoring blood glucose, anticoagulation for a fib, and making dietary changes to reduce cholesterol as part of the tx plan, but again, these aren't immediate concerns that have to be addressed.

The nurse identifies which medication is used for the treatment of Parkinson disease? A. Trihexyphenidyl B. Meclizine C. Fexofenadine D. Donepezil

A. Trihexyphenidyl None of the other medications are used to treat Parkinson's. Meclizine is an antiemetic that's used to treat vertigo and motion sickness. Fexofenadine is an antihistamine used for treating rhinitis, allergy symptoms, and chronic urticaria. Donezepil is a neurological medication used to stabilize or relieve symptoms of mild to moderate dementia. Trihexyphenidyl is an anticholinergic medication that can be used in conjunction with L-dopa to help counteract the spastic effects of Parkinson. Adverse effects include dry mouth, blurred vision, constipation, urinary hesitancy, and decreased mental acuity.

Which clinical manifestation does the nurse anticipate when caring for a client with a history of multiple sclerosis? A. Urinary retention B. Decrease in the level of consciousness C. Hyperreflexia of the extremities D. Intestinal obstruction E. Ataxia F. Decreased concentration

A. Urinary retention C. Hyperreflexia of the extremities E. Ataxia F. Decreased concentration The progressive demyelination of the spinal cord that occurs in myasthenia gravis impairs normal bodily processes in many ways. Altered innervation of the bladder and urinary tract happens, which leads to urinary retention. It also causes hyperreflexia of the extremities, which manifests as intention tremors, muscle weakness, spasticity, and paresthesia. Ataxia, or impaired coordination of movement, occurs because of damage/dysfunction to the cerebellum or basal ganglia. Decreased concentration can occur due to frontal or parietal lobe involvement. That can also lead to other cognitive changes like memory loss, impaired judgment, and decreased ability to problem solve. MS can cause constipation, but not intestinal obstruction. It does cause some aforementioned cognitive changes, but not decreased LOC.

The nurse in the emergency department is assigned to a client who reports weakness and numbness of the right hand and arm, a severe HA, dizziness, and blurred vision. Sx began very suddenly about 20 min ago. Nurse's notes at 0900: Client lying on stretcher, head elevated at 45 degrees, awake and alert, speech slurred, difficult to understand. States name and "in hospital" correctly when asked name and location. Moves self on stretcher and moves legs well, but doesn't move right arm or hand. Client reports vision is blurry. Lungs clear, heart sounds irregular with clear S1 and S2. Abdomen soft with positive hypoactive bowel sounds all 4 quadrants. Skin warm and dry. Capillary refill < 2 sec. Client is married; spouse has been contacted and on way to ED. VS at 0900: HR: 112 beats/min, irregular BP: 152/92 mm Hg RR: 18 breaths/min, regular Temp (axillary): 97.8 F (36.4 C) SpO2: 98% on RA Height: 63 in (160 cm) Weight: 176 lb (79.83 kg) BMI: 31.2 kg/m^2 For each body system below, select all the appropriate nursing interventions for this client. Cardiovascular: A. Obtain a 12 lead ECG B. Administer anti-hypertensive medication C. Establish IV access Respiratory: D. Place oxygen at 2 L nasal cannula E. Have the client breathe in a paper bag F. Plan for immediate intubation Neurological: G. Assess pupils for size and reaction H. Prepare the client for a CT of the brain I. Obtain neurologic checks every shift

Appropriate interventions for... Cardiovascular: A. Obtain a 12 lead ECG C. Establish IV access Respiratory: D. Place oxygen at 2 L nasal cannula Neurological: G. Assess pupils for size and reaction H. Prepare the client for a CT of the brain Getting an ECG is important because it'll allow you to determine if the client is in a fib, which is a major RF for stroke. Establishing IV access is important here because the client should have lab work done and if there is an ischemic stroke dx, you'll need to give IV anticoags like heparin. Even though there's no sign of respiratory distress, a stroke patient would be placed on low flow oxygen just as a precaution to help maintain oxygen saturation. Neurologic checks should be done hourly and should include assessments of LOC, pupils, speech, and movement of extremities. Getting a head CT is imperative here to help visualize whether a stroke is occurring and what type of stroke is occurring if there is one. Tx is based on type of stroke, so you can't tx the patient if you aren't sure what type of stroke they're having. If the client is having a stroke, you wouldn't give an antihypertensive because the high BP makes sure that the brain stays perfused during this major event. Breathing into a paper bag is a measure that helps you retain CO2 or help correct hyperventilation, neither of which are indicated in this scenario. There's no indication for intubation either since again, no respiratory distress is occurring and the client is breathing spontaneously. Neurologic checks should be done hourly, not once a shift (the answer given wasn't frequent enough).

The nurse provides care for a client suspected of having a seizure disorder. The client tells the nurse, "I smelled oranges today and there wasn't one on my tray." Which response by the nurse is best? A. "If you would like an orange I'll get you one from the kitchen." B. "Have you experienced this sensation before?" C. "Why do you think you're thinking about oranges?" D. "Isn't that strange? Maybe it's someone's cologne."

B. "Have you experienced this sensation before?" The nurse should suspect the client is describing an olfactory aura and explore any details about the occurrence. Although uncommon, olfactory auras are associated with temporal lobe epilepsy. The aura represents the local signature of the attack, and is the result of abnormal stimulation of the cortical area. This first statement assumes the client wants to eat an orange and indicates the nurse is not considering the relationship between the client describing an olfactory aura and the client's possible seizure disorder. The nurse would not ask the client why the aura is occurring but try to elicit information from the client to determine if this is an isolated experience or if it be client has had more episodes. The last statement indicates the nurse doesn't realize the relationship between the client's statement and the suspected seizure disorder.

The nurse cares for clients in the rehabilitation unit. The client reports having trouble focusing the eyes when trying to read. The nurse learns the client has not had a problem in the past. The nurse notes the client has been receiving phenobarbital for more than a year. It is most important for the nurse to take which action? A. Assess for drowsiness B. Obtain an order for a blood specimen C. Explain to the client a tolerance to the medication has developed D. Recommend the client have a vision test

B. Obtain an order for a blood specimen Phenobarbital is a barbiturate used as an anticonvulsant and sedative hypnotic for the treatment of seizures or when sedation is required. Drowsiness is a side effect that diminishes after the initial first couple weeks of therapy. Since it has been a year that the client has been taking this medication, the client is way past the period in which assessing for drowsiness would be necessary. Patients can develop a tolerance to phenobarbital, in which case you should gradually decrease the dose while simultaneously starting a replacement anticonvulsant when it comes to treating seizures. Nystagmus is an early sign of phenobarbital toxicity. Obtaining an order for a blood specimen can help providers determine if toxic levels have been reached in the patient. A vision test would follow if the vision issues are deemed not to be related to the phenobarbital levels, but not before the order for blood specimen is placed.

A client has a history of migraine headaches. The nurse recognizes which medication is used to treat the client's migraine headaches? A. Azithromycin B. Zolmitriptan C. Methylphenidate D. Methocarbamol

B. Zolmitriptan Zolmitriptan is a neurological medication used to treat acute migraines with or without aura. It does not prevent headaches. Adverse effects include dizziness, drowsiness, dry mouth, and dyspepsia. Azithromycin is an anti-infective agent used to treat infections of the respiratory and urinary tracts. Methylphenidate is a neurological medication used to manage ADHD, narcolepsy, and depression in older adults. Methocarbamol is a skeletal muscle relaxant used to relieve spasms from acute injuries.

The nurse visits the family with three small children who live in a three bedroom home built in 1952. The nurse counsels the family how to avoid lead poisoning. The nurse determines the teaching is effective if the parent makes which statement? A. "I plan to scrape paint off the walls after the children go to bed tonight." B. "My children eat meals whenever they are hungry." C. "I wet mop all of my floors and wash all of the window sills weekly." D. "I'm going to leave that patch of dirt uncovered so the children will have somewhere to dig."

C. "I wet mop all of my floors and wash all of the window sills weekly." Children should not live in homes with lead based paints. Scraping paint off the wall increases the free lead particles in the air that can contaminate and harm a person. Eating meals whenever hungry means that there isn't a regular schedule for eating. The children should eat regular meals with adequate intake of calcium and iron. More lead is absorbed on an empty stomach. It's wrong to let children dig around. Lead can be found in dirt, plant grass, or other ground cover. Homes with lead paint should be cleaned weekly by wet cleaning, like with a mop, all hard surfaces to remove dust that may contain lead. Do not dry sweep.

Which method does the nurse use to test a client's gag reflex? A. Request the client to speak a sentence. B. Ask the client to stick out the tongue and move it from side to side. C. Touch the back of the throat with a cotton-tipped applicator. D. Give the client a small amount of water to drink.

C. Touch the back of the throat with a cotton-tipped applicator. This is the only option that actually tests that function - it's a knowledge question. This test assess CN IX. To protect the airway, don't check gag reflex if the client doesn't have an intact cough or swallow reflex. Speaking a sentence assesses CN X. Sticking out the tongue and moving it side to side assesses CN XII. You shouldn't let your patient swallow fluids until you've assessed them fully and determined that their cough, gag, and swallow reflexes are all intact. They could aspirate if a gag reflex isn't present and fluids are given.

A client diagnosed with Alzheimer disease is confused and not able to remember the simple activities of daily living. The client has been living in a long-term care facility for the past six months. The family expresses concerns to the nurse about the client's confusion and memory loss. Which response by the nurse best addresses the family's concerns about memory loss? A. "Don't worry. We have instituted many safety measures for your loved one." B. "It would be helpful for you to remind your loved one to take care of basic needs." C. "This must be frustrating for you but I am sure you expected this to happen." D. "Memory loss will continue to make tasks difficult for your loved one."

D. "Memory loss will continue to make tasks difficult for your loved one." Memory loss is expected with AD, and it progressively gets worse until the patient dies bc there's no cure for it. So while the family is concerned about it and it is hard to see, txs for it are band aid type solutions rather than curative. Approach this situation as a time to discuss the care plan for the patient and to educate. The first option is dismissive of the family's concerns, which you should never do. You could remind the patient about tasks they need to complete, but that doesn't mean they'll understand and respond well to it. The third option is wrong bc although empathetic communication is important, the nurse also made a judgment and assumption here that may block further discussions.

The client with attention deficit hyperactive disorder (ADHD) is taking methylphenidate. The nurse knows that methylphenidate is prescribed for this child for which effect? A. Central nervous system depressant B. Antianxiety C. Sedative D. Central nervous system stimulant

D. Central nervous system stimulant This is a knowledge question. Methylphenidate's a CNS stimulant. These kinds of meds improve concentration and adaptive bx in people w ADHD. Examples of CNS depressants are pentobarbital, secobarbital, flurazepam, lorazepam. Examples of antianxiety meds are chlordiazepoxide, clorazepate, dipotassium, and diazepam.

A client with a diagnosis of ovarian cancer experiences severe pain. Which principle does the nurse remember when caring for this client? A. Caution must be used to prevent narcotic addiction B. Cancer pain is mostly psychological and is unable to be completely controlled C. Pain medication should be given when the client exhibits physical signs of pain D. Pain medication is more effective if given before pain becomes severe

D. Pain medication is more effective if given before pain becomes severe It's right to want to prevent addiction to narcotics, but you shouldn't let that caution prevent you from providing adequate pain control, which is the most important goal here. Cancer pain is not psychological. Typically, it's nociceptive, resulting from damage to normal tissue. Pain is a subjective experience, and not every patient will exhibit outward signs of pain when they're experiencing it. Thus, it is wrong to only administer pain medication when outward expressions of pain are seen. It is true that pain medication is more effective if given before the pain becomes severe. A preventive approach to medication administration incorporates regular dosing of pain medication on a schedule and providing PRN dosing for any breakthrough pain. This approach results in smaller doses of medication needed to relieve pain and improved pain control for the client.

The nurse provides education to the family member of a client diagnosed with Parkinson disease. Which statement by the family member reflects a need for further education? A. "I will buy lots of broth and soup for my parent." B. "I am teaching my parent posture exercises." C. "My parent is going to do the ROM exercises 3 times a day." D. "The bath bars will be installed before my parent comes home."

A. "I will buy lots of broth and soup for my parent." This indicates the family member doesn't understand the disease process. The client with a diagnosis of Parkinson disease may have difficulty with the sequence of swallowing and be at high risk for choking. The family member should offer a diet of semi-solids with thickened liquids. The client should sit in upright position when eating and be encouraged to think through the sequence involved in swallowing. The other statements are appropriate and reflect correct knowledge of the disease process. Posture exercises are important because the patient has a tendency for the head and neck to be down and forward. They should work with physical and occupational therapists to remain as mobile and independent as possible. ROM exercises will help increase joint flexibility. The family member should also encourage walking, riding a stationery bicycle, swimming, and gardening. The client is at a high fall risk and should be educated about fall precautions when engaging in activities. Bath bars contribute to the client's safety and independence. Other fall prevention include using an assistive device while ambulating, removing area rugs from floors, and ensuring walk ways are free of clutter.

Which statement, made to the nurse by the parent of an 8 month old client, indicates a possible delay in growth and development? A. "My child has almost doubled the birth weight." B. "My child smiles at me when I walk in the room." C. "My child cries and refuses to be held by the grandparents." D. "My child cannot say 'mama' yet."

A. "My child has almost doubled the birth weight." Each of the other findings are normal. Babies are usually scared of strangers and family members they don't see on a regular basis around 8 months. Babies usually don't say words like mama and dada until about 10 months. An infant's birth weight should double by 5 to 6 months. Since this baby is 8 months old, the fact that they haven't met this developmental landmark may indicate a possible delay in growth and development.

The nurse provides care for a client being evaluated for Guillain-Barré Syndrome. Which sign is most suggestive of Guillain-Barré Syndrome? A. Ascending paralysis B. Numbness and tingling of the fingers C. Hyperactive reflexes D. Tinnitus

A. Ascending paralysis Although paresthesias are present in several forms of GBS, they don't affect isolated extremities. In either the ascending or descending (less common) form, the fingers would not be the only site of numbness and tingling. Deep tendon reflexes are usually decreased or absent in clients with GBS. Neither hyperactive reflexes nor tinnitus are seen in GBS. Ascending paralysis is a classic finding associated with GBS. Weakness and paresthesia typically begin in the lower extremities and move upward to the arms and trunk with potential respiratory failure.

An unconscious client arrives in the emergency department following a fall that resulted in a severe head injury. Which action does the nurse take first? A. Assess the patency of the airway B. Check the client's pupils for size and reaction to light C. Establish the client's level of consciousness D. Evaluate the client's motor response

A. Assess the patency of the airway The first priority of nursing management here is to ensure patency and protection of the airway. An effective method of prioritization is utilizing airway, breathing, and circulation. Assessment and interventions must be completed for each category before proceeding to the next sequence. The unconscious client has lost the ability to protect the airway. Indications of head injury include changes in vital signs, confusion, disturbances of consciousness, sudden onset of neurological deficits, pupillary abnormalities, sensory dysfunction, visual and/or hearing impairment, vertigo, headache, spasticity, movement disorders, seizures, and hypovolemic shock. It's only after you've ensured there's a patent airway that you should do a neurological assessment. All of the other options are part of this.

An older adult is in a long term care facility. The client says, "I know my children visited me today, but they deny it. What's going on? I'm so mixed up." The nurse suspects this is due to sensory alterations. Which action by the nurse is best? A. Encourage the client to discuss the "mixed up" feelings B. Explain to the client the children did not visit C. Encourage the client's to visit more frequently D. Explain that being "mixed up" doesn't matter

A. Encourage the client to discuss the "mixed up" feelings Sensory deprivation occurs in institutionalized clients because of an inadequate quality or quantity of stimulation. The nurse should help a person in this situation realize that it's a temporary problem that's being experienced, caused by sensory deprivation. Don't argue with the client but reorient them but explain the location, identity, and time of day. It's important to encourage family involvement, but it's more important to allow the client to verbalize frustrations and help understand what's happening. Saying it doesn't matter negates the feelings the client is expressing and isn't helpful.

The nurse discovers a client diagnosed with Ménière disease leaning over the sink in the room and clutching it with both hands. After determining the client is having an acute attack, which action does the nurse take first? A. Helps the client back to bed and places a pillow on either side of the client's head B. Lays the client on the floor by the sink and obtains vitals and assesses pupillary response to light C. Gives the client to an emesis basin and massages the neck over the area of the carotid arteries D. Notifies the health care provider and prepares to administer atropine subcutaneously

A. Helps the client back to bed and places a pillow on either side of the client's head An acute attack of vertigo for a client diagnosed with Ménière disease feels like the room is violently spinning. Vertigo and dizziness may cause the client to fall. Lying down will prevent injury and placing pillows on either side of the head will prevent movement of the head, which aggravates vertigo. There's no reason to check vitals or pupils here. Vertigo doesn't alter pupillary reaction and the dizziness doesn't happen here because of hypotension. The client with vertigo may have episodes of n/v, but massaging neck, especially over the carotid arteries wouldn't be an appropriate action. Meds used to tx sx of this condition include diuretics, antihistamines, antiemetics, and tranquilizers. Atropine's not indicated or useful here.

A client is scheduled for an electroencephalogram (EEG). The nurse instructs the client to omit which food from the diet before the test? A. Hot chocolate B. Orange juice C. Lemon sherbet D. Tomato soup

A. Hot chocolate Hot chocolate contains caffeine; beverages that contain caffeine or stimulants are usually restricted prior to an EEG for 12-24 hrs. This includes coffee, tea, energy drinks. Also avoid sedatives before the test. Each of the other items listed are acceptable.

The nurse assesses a client with a diagnosis of meningitis. The nurse notes that when the client flexes the head, the client also flexes the hip and knee. Which nursing action is the best? A. Immediately report the finding to the provider. B. Document the finding and continue with the nursing assessment. C. Give 10 mg of morphine sulfate for pain. D. Place the client in high Fowler position and start oxygen at 2 L.

A. Immediately report the finding to the provider. Simultaneous flexion of the hip and knee when flexing one's neck is the Brudzinski sign, which indicates increased tension in the spinal cord r/t meningitis. Other s/s of meningitis include HA, fever, photophobia, changes in LOC, and nuchal rigidity. Kernig sign is another bedside test used to indicate meningeal irritation. Positive Kernig sign is exhibited when the client's hip is flexed to 90 degrees and complete extension of the client's knee is restricted and painful. Because this is a high priority/emergent finding, you wouldn't just proceed with the assessment. Pain management would come secondary to reporting this finding in this circumstance. Because the problem here is meningitis, the patient needs to get antibiotics. High Fowler wouldn't help the patient in this situation, and oxygen isn't necessary for the Brudzinski sign.

A client diagnosed with bacterial meningitis has an oral temperature of 104 F (40 C). Which intervention is essential for the nurse to carry out when the client is on the hypothermia blanket? A. Observe the client for shivering B. Monitor the client's oral temperature every hour C. Sponge the client with tepid water D. Place the client directly on the cooling blanket

A. Observe the client for shivering Shivering causes an increased energy expenditure and should be avoided by setting the cooling blanket at 75 F (23.9 C). Shivering can also raise core body temp which is the opposite of what you want in someone whose fever is already so high. It's not ideal to assess oral temp while a patient's using a cooling blanket - use rectal temp instead and check it q15min. Using tepid water increases risk of frostbite and skin injury for patients on cooling blankets. Never place a cooling blanket directly on a patient - a bath blanket should be btwn them to avoid skin injury.

The nurse in the emergency department is assigned to a client who reports weakness and numbness of the right hand and arm, a severe HA, dizziness, and blurred vision. Sx began very suddenly about 20 min ago. Nurse's notes at 0900: Client lying on stretcher, head elevated at 45 degrees, awake and alert, speech slurred, difficult to understand. States name and "in hospital" correctly when asked name and location. Moves self on stretcher and moves legs well, but doesn't move right arm or hand. Client reports vision is blurry. Lungs clear, heart sounds irregular with clear S1 and S2. Abdomen soft with positive hypoactive bowel sounds all 4 quadrants. Skin warm and dry. Capillary refill < 2 sec. Client is married; spouse has been contacted and on way to ED. Select the top 4 findings that require further assessment by the nurse. A. Speech slurred, difficult to understand B. Doesn't move right arm or hand C. Head elevated 45 degrees. D. Lungs clear E. Vision blurry F. Clear S1 and S2 G. Hypoactive bowel sounds H. Heart sounds irregular I. Skin warm, dry J. Capillary refill < 2 sec

A. Speech slurred, difficult to understand B. Doesn't move right arm or hand E. Vision blurry H. Heart sounds irregular This question is just about picking which assessment findings are abnormal vs normal. The ones above are abnormal, and all the rest are WNL. further assessments should focus on the neurological and cardiovascular systems.

The nurse provides care for a client admitted to the medical/surgical unit with a diagnosis of stroke. The nurse plans care for prevent the client from experiencing sensory overload. The nurse determines which plan is most effective? A. The nurse obtains vital signs and assists the client with morning care in one visit B. The nurse obtains viral signs, and completes morning care two hours later C. The nurse completes morning care and schedules physical therapy to follow immediately D. The nurse instructs the family to visit the client every other day

A. The nurse obtains vital signs and assists the client with morning care in one visit The nurse should combine activities in one visit to prevent the client from becoming overly fatigued. They should also try to give the patient uninterrupted time for rest and quiet. The second option is more disruptive for the client. Morning care and physical therapy cause fatigue, so they should be scheduled farther apart from each other to allow rest between. Visits every other day would mean decreased stimulation and likely sensory deprivation for the patient. They should visit more but still be informed about their loved one's need for rest.

The nurse provides care for a client with a diagnosis of traumatic brain injury. The client has a score of 7 on the GCS. The nurse identifies it is important to give eye care to this client for which reason? A. To prevent corneal irritation B. To suppress inflammation of the conjunctiva C. To promote lacrimal drainage D. To inhibit bacterial growth

A. To prevent corneal irritation The GCS is a 15 point scale which measures motor response, verbal response, and eye opening. A score of 7 or less on the GCS indicates severe TBI with coma. When the client is comatose, the eyes may stay partially open causing the corneas to dry out and become irritated. Preventive care involves keeping the corneas moist by using artificial tears. If the corneal reflex is absent, a protective shield should be put over the eyes to prevent abrasion to the corneas. None of the other options are the purpose of eye care for patients with this GCS score.

The nurse provides care for a client scheduled for an electroencephalogram (EEG). To prepare the client for the test, it is most important for the nurse to make which statement? A. "The test lasts approximately 2-3 minutes." B. "The procedure is not painful but you must lie still." C. "The wires cause brief electric shocks." D. "After the test, you should stay in bed for 8 hours."

B. "The procedure is not painful but you must lie still." Even though EEGs are painless, the client has to remain still for the duration of the test. The client should also be instructed to bathe the entire body and wash the hair prior to the procedure. The client should not use gels, lotions, oils, or hairsprays. An EEG takes 40-60 min. Electrodes detect electrical activity in the brain and don't cause a shock. Also, shocks are painful, and EEGs are, again, painless. EEGs are done on an outpatient basis. If the client is deprived of sleep prior to the test, the client may want a nap.

An older adult client is admitted with a diagnosis of acute pulmonary edema. Which is the best intervention for the nurse to include to prevent sensory deprivation? A. Determine the client's hobbies B. Assess the family support system C. Ensure the client can operate the television D. List the client's activities of daily living

B. Assess the family support system Institutionalized patients often get isolated, lonely, and experience sensory deprivation, which is why one concern for you as the nurse is to prevent sensory deprivation. Assessing the family support system is appropriate in this situation, as would be scheduling consistent staff contact and encouraging visitors to decrease isolation and enhance sensory stimulation. Though hobbies and television can be stimulating, social interaction is the primary concern when considering sensory stimulation. The client also should know what their ADLs are, but this isn't a related concern to sensory stimulation.

The nurse in the outpatient clinic provides care for a client diagnosed with Bell palsy. Which action does the nurse take first? A. Administers fentanyl as prescribed B. Assesses the client's pain experience C. Administers hygienic measures D. Orders an appropriate diet

B. Assesses the client's pain experience Assessment is the most important task in providing accurate, effective care. Pain behind the ear or on the face may occur hours or even days before the paralysis. Medications typically prescribed include corticosteroids and antiviral medications. The other options are wrong because they skip to implementing an intervention before completing an assessment. But for future reference - And though mild analgesics are used for pain management in those with Bell palsy, fentanyl wouldn't be prescribed because it's a really strong opiate that's not indicated for the average pain level associated with this condition. Nursing care is directed to address the neurological deficits, prevent injury, and provide emotional support. The client may not be able to close the eye on the affected side. The nurse would teach the client to manually close the affected eye and instill eye drops to protect the cornea. The client may have difficulty chewing or sipping fluids through a straw on the affected side. A soft diet may be better tolerated than a regular one in these patients.

The nurse provides care for a client that has been given spinal anesthesia. Which nursing consideration is most appropriate for this client? A. Partial paralysis is a serious but frequent complication. B. Clients must be protected from injury since sensation is impaired. C. Clients should try to ambulate as soon as possible. D. Spinal headache may be prevented by restricting intake of oral and intravenous fluids.

B. Clients must be protected from injury since sensation is impaired. You, of course, lose sensation or feeling when you're under anesthesia (local or general), and this means that you could have an injury you don't feel bc of that. Nurses should frequently assess sensation and voluntary movement, and protect the client from injury until their sensation comes back. Other adverse effects of spinal anesthesia include hypotension and headache. Anesthesia doesn't cause paralysis. Don't ambulate ASAP - clients should lie flat for 12 hrs until sensation has returned. Don't restrict fluid intake for patients to prevent spinal HA - instead, you should be encouraging your patients to have fluids while assessing their vitals as they recover from anesthesia.

Which symptoms does the nurse expect a client diagnosed with Ménière disease to exhibit? A. Continuous dizziness, nausea, and vomiting B. Episodic vertigo and fluctuating hearing loss C. Constant pain, vertigo, and tinnitus D. Sudden bilateral ear fullness and complete hearing loss

B. Episodic vertigo and fluctuating hearing loss Ménière disease causes people to have episodes of incapacitating vertigo which may last from minutes to hours. The vertigo may cause the client to have nausea and vomiting, but those symptoms will subside when the vertigo diminishes. Symptoms are episodic, not constant or continuous. Fluctuating attacks of hearing loss in the affected ear is a symptom of this condition, not complete hearing loss (which is constant). Ear fullness might occur in the affected ear right before an episode, doesn't necessarily happen bilaterally. It is right that Ménière disease causes episodic vertigo and fluctuating hearing loss. This is related to the dilation of the endolymphatic system. Other signs and symptoms include tinnitus, unilateral sensorineural hearing loss, and ear fullness.

The nurse provides care for an adolescent client after a skateboard accident that resulted in a brief episode of unconsciousness. The client's scalp and facial lacerations were treated and dressed in the emergency department. Which nursing care measure is the highest priority? A. Change the head wound dressings. B. Perform neurological checks frequently. C. Administer antiemetic medications. D. Manage the client's report of a headache.

B. Perform neurological checks frequently. Closed head trauma can be dangerous bc of increased ICP. Pressure within the cranial cavity from bleeding or swelling can be minor or can escalate rapidly and lead to death. The client must be carefully and closely monitored for deterioration in neurologic status. The client's LOC as well as pupillary reaction and motor ability should be assessed frequently and changes reported immediately to the provider. Changing head wound dressings while also inspecting the facial and scalp wounds is appropriate, but is a secondary priority to neuro checks. Many clients w head injuries have n/v and need antiemetics, but this is again a secondary priority r/t neuro checks. HA is often reported after head trauma. Assessment of HA pain and admin of ordered analgesics is again an appropriate intervention, but still secondary to neuro checks.

A client diagnosed with a traumatic brain injury develops a temperature of 104*F (40*C). Which intervention does the nurse implement first? A. Obtain blood cultures to rule out infection B. Place the client on an automatic cooling blanket C. Notify the health care provider and set up for a lumbar puncture D. Assess the family's ability to cope with the client's injury

B. Place the client on an automatic cooling blanket Ruling out infection as the cause of temperature is important, but getting blood cultures isn't the best answer of what you should do first in the list given. Lumbar puncture not indicated. Assessing family's coping process with the TBI of their loved is not a priority in addressing this issue of fever here. Hyperthermia increases metabolic rate and cerebral oxygen demand. Using an automatic cooling blanket reduces temperature and subsequently decreases cerebral metabolism.

The nurse provides care for a client diagnosed with tuberculosis. The client asks, "Why do I have to take vitamin B6 (pyridoxine)?" What explanation does the nurse provide? A. Promotes the absorption of isoniazid B. Prevents neuritis C. Alleviates gastrointestinal symptoms D. Prevents kidney damage

B. Prevents neuritis Vitamin B6 doesn't do any of the options listed except for preventing neuritis. Neuritis is inflammation of a nerve or the general inflammation of the peripheral nervous system. Neuritis is a potential complication of the isoniazid tuberculosis treatment. Vitamin B6 is given along with it in order to help prevent neuritis.

The nurse provides care for a client diagnosed with right-sided hemiplegia due to a stroke. The nurse observes the client has an inability to eat without total assistance. Which intervention is most appropriate to improve the client's nutrition? A. Assist the client to eat with the left hand B. Provide a pureed diet C. Stroke the client's throat D. Provide a wide variety of food choices on the meal tray

B. Provide a pureed diet Pureed, soft, or semisoft foods are easier to swallow than liquid foods. The nurse should position the client in an upright position with head and neck positioned slightly forward and flexed. The nurse should also allow ample time for the client to eat and should minimize any distractions while the client is trying to eat. A client with right-sided hemiplegia following a CVA may have significant difficulty with chewing and swallowing in addition to being unable to maneuver food to the mouth. It's more important to offer the client foods that can be safely swallowed. The client may need to learn to use the unaffected hand for feeding, but this isn't the priority intervention. Offering foods the client likes is important, but the consistency of the foods is more so. You don't want the patient to choke.

The nurse provides care for a client diagnosed with a stroke resulting in right hemiplegia. Which is the correct technique for the nurse to use when transferring the client from the bed to a chair? A. Assist the client from a sitting to a standing position by pulling up on the affected side B. Support the standing client for a minute before pivoting towards the chair C. Ask the client to roll to the right side of the bed and assist the client from the right side D. Instruct the client to place arms around the nurse's neck to move from a standing position to the chair

B. Support the standing client for a minute before pivoting towards the chair The nurse should assist the client by moving them into a sitting position. The nurse should stand directly in front of the client, have the client place the unaffected hand on the nurse's shoulder, bend at the knees, and allow the client to stand. The client should pivot on the unaffected leg (left) toward the chair. Before pivoting, the nurse should allow the client to pause for a moment when going from lying to sitting, then sitting to standing because they are at risk of orthostatic hypotension. This pause is necessary for the nurse to evaluate the client's ability to remain steady and complete the pivot to the chair. The client shouldn't roll to the right side, but to their left. They should lead with the unaffected side when pivoting to the chair, which should be at a 45 degree angle to the head of the bed. Placing the client's arms around the nurse's neck puts the nurse at risk of injury. Instead, the client's arms should be placed around the nurse's shoulders so that the weight is distributed more evenly.

Which should the nurse include in the plan of care for a client diagnosed with increased intracranial pressure (ICP)? A. Frequently suction the airway B. Teach the client to avoid the Valsalva maneuver C. Position the client supine in a dark room D. Withhold sedatives when the ICP is greater than 20 mm Hg

B. Teach the client to avoid the Valsalva maneuver Suctioning causes increased agitation, coughing, gagging, and subsequently increases intracranial pressure, so this doesn't solve the issue. The nurse should only suction as needed and should encourage deep breathing. A supine position does not promote venous flow from the head and increases ICP. Instead, the client should be position with the HOB at thirty degrees. The head should be maintained in midline position to promote venous flow. Client agitation or combativeness can cause sudden intracranial hypertension and increases ICP. It is appropriate to use sedatives in this situation so as to keep ICP down. Nursing actions should focus on reducing or eliminating a further increase in ICP. Valsalva maneuver is bearing down or forcibly expiring against a closed glottis. This action raises intrathoracic pressure, which reduces cranial venous outflow. Bearing down with defecation, holding the breath while turning, pulling or lifting, sneezing, or gagging will increase ICP. The nurse should administer stool softeners, instruct the client to breath out while turning or moving in bed, and avoid activities which cause the client to gag and cough.

The nurse cares for a client hospitalized for treatment of an abdominal gunshot wound. History reveals the client has been enrolled in a methadone maintenance clinic for the past two years. The nurse notes the client has no orders for continuation of the methadone. The nurse anticipates which activity may occur? A. The client will be less concerned about pain relief since the client has been on a regular dose of a long-acting opioid analgesic. B. The client will experience nausea, vomiting, and abdominal cramps. C. The health care provider will order a nonopioid analgesic. D. The client will use the hospital experience to change the lifestyle and become medication-free.

B. The client will experience nausea, vomiting, and abdominal cramps. Methadone is a synthetic narcotic used for severe pain and to suppress withdrawal sx during detox and maintenance from heroin. Withdrawal sx include n/v, abdominal cramps, chills, sweating. Nursing considerations include obtaining daily urine to monitor for other medication abuse while on methadone. Bc they've been on methadone for a while already, they'd have built up a tolerance to normal doses of the med and need higher than normal doses to achieve therapeutic effect. This is something they'd likely be more, not less, concerned about r/t pain relief. Gunshot wounds are really painful and nonopioid analgesics might be used in combo w other opiates for pain management, but unless the client refuses them, you wouldn't withhold needed medication from a patient. Dcing the med is also partially the patient's choice. What the question is saying is that the patient has been going to a methadone maintenance clinic for the past two years DESPITE not having any orders for it, so they don't need to be going there - it's their choice to do so. Given this fact, it's probably unlikely they'll want to come clean during their hospital stay, so it's not something you'd anticipate first per se. However, if the client decides to dc methadone use, it's better to gradually reduce the dose so they don't experience sx that could interfere with the rest needed for proper wound healing.

The nurse identifies which manifestation as most characteristic of myasthenia gravis? A. Lack of automatism B. Tiredness with slight exertion C. Paresthesia of the lower extremities D. Propulsive gait

B. Tiredness with slight exertion Clients with myasthenia gravis have an acetylcholine deficiency so the transmission of nerve impulses is limited. Therefore, it is difficult to stimulate or initiate muscular movement. As a result, the client will experience tiredness with the slightest amount of exertion. Sx of this condition include poor posture, difficulty swallowing or chewing, diplopia (double vision) and ptosis (drooping of the upper eyelid). Automatism (involuntary behaviors), paresthesia of the LE, and propulsive gait aren't sx of myasthenia gravis. It causes weakness, not numbness, of the skeletal muscles associated with breathing and moving, so LE can be affected but not in that way. Propulsive gait is seen with Parkinson dz, and it means that people affected by it walk with their head and neck pushed forward.

The nurse identifies which manifestation as most characteristic of myasthenia gravis? A. Lack of automatism B. Tiredness with slight exertion C. Paresthesia of the lower extremities D. Propulsive gait

B. Tiredness with slight exertion None of the other options are seen in myasthenia gravis. Myasthenia gravis is a chronic autoimmune neuromuscular disease that causes progressive weaknesss in the skeletal muscles (responsible for breathing and moving). Clients with this condition have an acetylcholine deficiency so the transmission of nerve impulses is limited. Therefore, it's difficult to stimulate or initiate muscular movement. As a result, the client will experience tiredness with the slightest amount of exertion. Other symptoms of myasthenia gravis include poor posture, difficulty swallowing or chewing, diplopia (double vision) and ptosis (drooping of upper eyelid).

A client diagnosed with Parkinson disease has tremors of both upper arms. The nurse observes that the tremors disappear as the client unbuttons the shirt. Which statement indicates the most accurate understanding of the tremors? A. Tremors are psychological and can be controlled at will B. Tremors decrease in severity when attention is diverted by activity C. Tremors are unexplainable and may increase with medication D. Tremors disappear with rest and increase with any activity

B. Tremors decrease in severity when attention is diverted by activity Clients dx with Parkinson disease usually only exhibit tremors at rest. If the client is given an activity to perform, the tremors seem to go away as the client pursues the purposeful activity due to the diversion. Parkinson tremors are physiological, not psychological, meaning they can't be controlled. A dopamine deficit creates an imbalance between dopamine and acetylcholine, allowing the excitatory effects of acetylcholine to be unopposed at receptor sites, which is why the tremors happen. The tremors are explainable (like we understand why they happen) and will decrease, not increase, with medications like anticholinergics and dopaminergics. Tremors may disappear when the client is asleep, but when awake, the tremors happen more at rest. They'll instead decrease with activity.

The nurse understands which cranial nerve is affected in tic douloureux? A. Optic B. Trigeminal C. Facial D. Vagus

B. Trigeminal The trigeminal nerve is cranial nerve V and controls jaw movement and sensation of the face and neck. Tic douloureux (trigeminal neuralgia) usually causes sudden, usually unilateral, severe, stabbing and recurrent episodes of facial pain. It occurs approximately twice as often in women as in men and mostly in people over 50 years of age. Optic nerve (II) controls vision. Facial nerve (VII) controls facial muscle movement and taste on the anterior two-thirds of the tongue. Vagus nerve (X) controls swallowing and speaking, along with parasympathetic innervation to the heart, lungs, and most of the digestive system.

The nurse provides care for a client diagnosed with Ménière disease. The nurse expects the client to exhibit which symptoms? A. Dizziness, irritability, weight loss B. Vertigo, hearing loss, tinnitus C. Ringing in the ears, ear pain, insomnia D. Nausea, vomiting, hypotension

B. Vertigo, hearing loss, tinnitus Ménière disease is an inner ear disorder characterized by vertigo, tinnitus, and fluctuating hearing loss. Sx include sudden, severe attacks of vertigo along with n/v, sweating, pallor. Attacks may be preceded by a sense of fullness in the ear and muffled hearing, and they may describe a sensation of being pulled to the ground. Attacks may last hours to days. Usually only one ear is affected. Severe HAs may also happen. Weight loss, insomnia, ear pain, and hypotension aren't characteristic of this dz.

The nurse instructs a client diagnosed with Bell palsy. It is most important for the nurse to make which statement about nighttime care? A. "Place a warm compress on the affected side." B. "Perform facial isometrics before you go to bed." C. "Apply an eye shield over the affected eye." D. "Massage your face with an oil-based lotion."

C. "Apply an eye shield over the affected eye." This question is specifically asking about nighttime care. Warm compresses can be used several times a day at any point for better comfort, so this wouldn't be the right answer here. Performing facial exercises is appropriate after muscle tone improves, not while it's weak, so it shouldn't be done as soon as the condition is diagnosed and it's not the priority when discussing nighttime care here. Massaging the face is an appropriate action for Bell palsy, but is less of a priority compared to decreasing the potential for injury. In Bell palsy, the client may be unable to close the eye on the affected side of the face. Corneal abrasion can occur and can cause pain and blindness. Teaching the client to apply an eye shield over the affected eye at night will prevent this occurrence.

The nurse assesses a client diagnosed with a transient ischemic attack (TIA). The nurse anticipates the client will report which symptom? A. Inability to speak for 7-10 days B. Intermittent sharp, stabbing pain on one side of the head C. Acute right lower extremity weakness that lasts about 15 minutes. D. Bilateral upper extremity weakness that progresses downward

C. Acute right lower extremity weakness that lasts about 15 minutes. TIAs usually cause unilateral neurologic sx like paresthesia, muscle weakness, aphasia, dizziness. They can last several minutes to several hours. The first option is wrong bc the inability to speak for several days is indicative of a stroke. The second option is wrong bc sharp, stabbing pain that's intermittent on one side of the head is a/w an impending HA or stroke. The last option is wrong bc sx of stroke and TIA are unilateral, not bilateral.

A client diagnosed with a complete C6 transection of the spinal cord has regained some gross motor activities in the upper extremities, but is still concerned about returning to the community after discharge. Which nursing intervention will best facilitate the client's adjustment back to the community? A. Encourage the client's family to remind the client about personal strengths B. Visit the community with the client and evaluate obstacles the client may encounter C. Arrange for a visit from another client with a similar spinal cord injury who is functioning well at home D. Encourage the client to continue rehabilitation to facilitate the return of fine motor coordination of the upper extremities

C. Arrange for a visit from another client with a similar spinal cord injury who is functioning well at home It is important for the client to have the support of family here, but just hearing about personal strengths might not be enough to help the client readjust to living back home. A community visit might even be discouraging for them, because if you're evaluating obstacles to their living at home, you're just reinforcing to them that their worries are true, and you're not helping alleviate them. Since the injury caused a complete transection, the client will not be able to regain fine motor activities. They should still continue rehab to achieve maximal potential function, while still being realistic that certain activities they might perform are self-propelling a lightweight wheelchair, may feed self with devices, can write and care for self, and can transfer from chair to bed. Arranging for a visit from another client with a similar spinal cord injury who's functioning well at home gives the client the opportunity to have a role model and talk about their worries with someone who has been in the same position. Role modeling provides the client with practical information and develops a reference group to facilitate networking in the community. The best way to facilitate the client's adjustment is to provide the client with a role model who has had experiences to which the client can relate.

A client is admitted to the hospital with a diagnosis of myasthenia gravis. When caring for this client, the nurse gives priority to which nursing goal? A. Provide meticulous personal hygiene B. Maintain balance between activity and rest C. Maintain respiratory function D. Promote adequate hydration

C. Maintain respiratory function Per the pathophysiology of myasthenia gravis, the acetylcholine deficiency limits or completely blocks the conduction of nerve impulses at the myoneural junction. This results in easy fatigue and muscle weakness, especially with muscles engaging in repetitive action. Breathing is a constant, repetitive activity; weakness of the respiratory muscles can lead to respiratory arrest if untreated. Being diligent about hygiene and balancing activity with rest are appropriate interventions for myasthenia gravis. However, they're not as much of a priority as maintaining respiratory function. If you can't breathe, you won't even get the chance to do these other things. Still, patients with myasthenia gravis might need lots of help with personal hygiene because they're prone to get easily fatigued. As far as activity and rest goes, you should make sure that the client's activity occurs early in the day or during the energizing period that happens right after they take their medication. Hydration is a lesser priority. Patients with myasthenia gravis, of course, still need it, but meeting proper hydration usually isn't a problem. However, if they become too fatigued, they might not drink enough. Medication education and management is more of a priority for these patients.

The nurse provides care for a client diagnosed with a stroke resulting in right hemiplegia, sensory loss, and cognitive dysfunction. During the client's first 72 hrs of hospitalization, which is the priority nursing action? A. Teach the client how to transfer from bed to chair. B. Use a picture board to help the client communicate. C. Perform neurological assessments every 2 hours. D. Assist the client to comb hair and brush teeth.

C. Perform neurological assessments every 2 hours. You have to be careful with patients who've recently had strokes bc they're at risk of that same stroke progressing and worsening or increased ICP within the first 72 hrs following its start. D/t the physical and chemical damages inflicted by strokes on the brain, damage can continue to occur for several days. A continued loss of brain function occurs w brain cell death. The nurse must be alert for changes in LOC and other signs of impaired cerebral tissue perfusion caused by increased ICP. Stroke is a sudden disruption in blood supply to the brain, resulting in a sudden loss of brain function that may be temporary or permanent. It's caused by thrombosis, embolism, ischemia, or hemorrhage. Assessing the client's current mobility level and facilitating physical activity is an appropriate but secondary concern to risk of further brain damage/injury. Communication and speech should also be assessed further, but should be done after that 72 hr period, after the patient has restabilized and the risk of brain damage/injury is addressed. ADLs - same as physical activity above.

The clinic nurse performs a neurological assessment on a new client. When the right leg is tapped for the patellar reflex, there is no movement. Which action does the nurse take first? A. Ask the client what is causing the lack of reaction B. Tell the client to take several quick breaths and then tap the tendon again C. Tap the tendon again while the client is pulling against interlaced, locked fingers D. Tap the tendon again using more force with the pointed end of the reflex hammer

C. Tap the tendon again while the client is pulling against interlaced, locked fingers Asking the client about what's causing the lack of reaction gives them the message that lack of response is a problem. Plus, reflexes are automatic, not under direct conscious influence, so the patient is not really likely to know what the problem is. Taking quick breaths is not advised because quick breaths create more muscle tension, further blocking the elicitation of any reflex reaction. Muscles have to be relaxed for a reflex to be seen. It's improper to use force and the more pointed end here. Tendons should be tapped with a quick, consistent briskness without too much force. The flat end of the reflex hammer should be used for striking larger areas like the patellar area. Interlocking fingers and trying to pull them apart while the tendon is tapped is a reinforcement technique or maneuver for the lower extremities. It involves isometric contraction of other muscles which could increase the generalized reflex response. This may also work by distraction and subsequent relaxation of the area to be tested.

The nurse supervises the family caring for the child diagnosed with cerebral palsy. The nurse intervenes if which finding is observed? A. The parent allows the child to rest prior to a physical therapy session B. The child wears a helmet when ambulating in the house C. The older sibling places a toy in the child's hands D. The parents offer high calorie snacks to the child

C. The older sibling places a toy in the child's hands Cerebral palsy is a neuromuscular disability in which the voluntary muscles are poorly controlled because of brain damage. This question is asking you to identify which of the four options is wrong here. Allowing rest before physical therapy is appropriate because patients with cerebral palsy are less successful with motor activities when fatigued. Wearing a helmet while ambulating is appropriate too because it prevents the child from hitting their head on hard objects during a fall. Offering a high calorie diet is needed to help meet the extra energy demands required to accomplish ADLs. The nurse should intervene if they see the older sibling place a toy in the child's hands. It's important to give patients with this condition incentives to move, so instead, the older sibling should hold up the toy for the sibling to come retrieve from them or place it out of their reach so that they'll have to move in order to get it.

The nurse assesses a client diagnosed with a traumatic brain injury and notes the client's arms are stiffly extended, abducted, and hyperpronated, and the client's legs are hyperextended with plantar flexion of the feet. Which is the nurse's best interpretation of the client's position? A. The client is having a tonic-clonic seizure due to the brain injury. B. This position indicates rigidity of the muscles in the arms and legs due to prolonged immobility. C. This is decerebrate posturing and results from disruption of motor fibers in the midbrain and brainstem. D. The client is displaying decorticate posturing which indicates a poor prognosis.

C. This is decerebrate posturing and results from disruption of motor fibers in the midbrain and brainstem. Decerebrate posturing indicates serious damage d/t a lesion of the midbrain. It results in exaggerated extensor posturing in the extremities, including the neck along w lower limb hyperreflexia. The prognosis for a client displaying decerebrate posturing is poor. Trauma is the most common cause of midbrain lesions. Subdural and epidural hematomas and edema can lead to herniation and compression on the brain sterm. On the GCS, the client would get a 2. Decerebrate posturing is more serious than decorticate posturing (a step higher in terms of level of problematicness). Still, decorticate posturing also indicates that there's been a disruption of motor fibers in the midbrain and brainstem. The difference in the two types of posturing is the position of the arms and feet. While the client in a decerebrate posture rigidly extends and hyperpronates the arms and plantar flexes the feet, the client in decorticate posturing adducts and flexes the arms and closes and flexes the hands. The legs will be rotated internally and feet will be dorsiflexed. Though people with TBIs are at risk of seizures during recovery, and the movements/findings described could POSSIBLY be a tonic clonic seizure, you can't assume it's a seizure w/o more info so posturing would be your answer. This specific rigidity and positioning of the legs is decerebrate posturing, not muscle rigidity from immobility. That can manifest in other ways, but posturing is a very specific position that you look out for.

A client delivers a healthy 8 lb, 2 oz infant. The client mentions to the nurse that the baby's "soft spot" bulges out when the baby cries. Which statement made by the nurse is most appropriate? A. "The anterior fontanel should close within 1 month." B. "The baby could be brain damaged if the soft spot is injured." C. "The baby's posterior fontanel should close after 1 year." D. "The anterior fontanel will normally bulge out when the baby coughs or cries."

D. "The anterior fontanel will normally bulge out when the baby coughs or cries." The soft spot refers to the anterior fontanel. The first answer doesn't properly address the client's question of the area bulging out. The anterior fontanel also takes 12 to 18 months to fully close, not 1 month. The second answer also doesn't address the question here and could unnecessarily alarm the client. While true, injury to the soft spot is uncommon. The third answer is wrong because the anterior fontanel is what's being discussed here. It also contains misinformation — the posterior fontanel closes at around 2 months. The fontanels should feel flat, firm, and well demarcated when the baby is at rest. Coughing or crying may cause the anterior fontanel to bulge.

The nurse provides care for a client at risk for an intracranial hemorrhage. Which of the following are risk factors for intracranial hemorrhage? A. Atherosclerosis and hypertension B. Anemia and kidney disease C. Hypothyroidism and glaucoma D. Arteriosclerosis and hypertension

D. Arteriosclerosis and hypertension Atherosclerosis is the depositing of fatty plaques in the arteries. This is more often associated with a thrombosis. Anemia, kidney disease, hypothyroidism, and glaucoma are not risk factors for intracranial hemorrhage. Arteriosclerosis is the thickening and sclerosis of the arterioles. This and hypertension are most often associated with intracranial bleed. A stroke is a sudden disruption in blood supply to the brain, resulting in a sudden loss of brain function that may be temporary or permanent. This is caused by thrombosis, embolism, ischemia, or hemorrhage. Indications include loss of movement, thought, memory, speech, or sensation. Nursing responsibilities include encouraging the client to attain maximum independence, stimulating multiple senses, repeating directions, and breaking down tasks into components, facing the client and speaking clearly and slowly, giving the client time to respond, maintaining skin integrity, providing exercises (ROM and facial), self-care activities, and teaching.

The nurse provides care for a client diagnosed with a spinal cord injury at the level of T3. The client reports a pounding headache and nasal congestion. The nurse notes the client has profuse sweating from the forehead and piloerection. Which action does the nurse take first? A. Administers an analgesic to relieve the headache B. Places the client in Trendelenburg position C. Administers a prescribed stool softener D. Checks the indwelling urinary catheter and tubing for kinks

D. Checks the indwelling urinary catheter and tubing for kinks Presence of an indwelling urinary catheter can cause stimulation of the bladder and trigger autonomic dysreflexia (AD) for the client with a high level spinal cord injury. If no indwelling urinary catheter is present, the nurse should check for bladder distention and catheterize immediately. Urinary tract infection may also precipitate an episode of AD. The client's sx, profuse sweating and piloerection, indicate AD, which is a life-threatening hypertensive crisis. The nurse should immediately assess for any noxious visceral or cutaneous stimuli that could be causing the reflex sympathetic activity. The nurse should contact the health care provider. Patients experiencing AD should be placed in high Fowler's, not Trendelenburg. The client is at risk for hemorrhagic stroke. The nurse should assess the client for tight, restrictive clothing and ensure the client's skin is not in contact with a sharp or hard object. AD is usually caused by GI, urologic, gynecologic, or vascular stimulation. The nurse must remove the stimulus if possible. An impaction or constipation can be a cause; the nurse would check for fecal impaction and if present, remove.

While the nurse ambulates a client to the bathroom, the client begins to a have a seizure. Which action does the nurse take first? A. Notes the time the seizure began B. Carries the client to the nearest bed C. Calls for a wheelchair D. Eases the client to the floor

D. Eases the client to the floor The client should be eased to the floor at the onset of the seizure. One of the primary goals of a nurse caring for a client who is having a seizure is to protect the client from injury. The client should never be left alone while seizing. If the client is in an upright position when a generalized seizure begins, the client should be lowered to the floor, and adjacent articles and equipment should be moved to prevent injury. Noting the time that the seizure started is an appropriate action but is secondary to patient safety. Moving the patient's position either to the bed or a wheelchair isn't safe because it puts the patient and the nurse at risk for injury. Additionally, a person is hard to carry when they're having a seizure.