Nursing Med Surg 265- Week 7 EAQ

The registered nurse is teaching a student nurse about the proper way to communicate with a patient who has aphasia due to a stroke. Which statement made by the student nurse indicates a need for further learning?

"I will try to force communication with the patient if the patient is upset." Rationale Communication should not be forced if the patient is upset because anxiety worsens aphasia. Communication with the patient should be in a normal tone of voice because the patient should not feel as if they are spoken to like a child. Questions should be framed in a "Yes" or "No" format to make communication easier for the patient. The nurse should not pretend to understand the patient. Instead, the patient should be encouraged to use nonverbal modes of communication.Test-Taking Tip: Be alert with the stem of the question. Recollect the concepts and apply the appropriate ones; reread the options until you are strong enough to conclude the option to be the suitable one. p. 1361

What rate should blood flow in the brain in order to maintain normal function?

55 mL/100 g Rationale Blood flow must be maintained at 55 mL/100 g for optimal brain functioning. Blood flow of 15 mL/100 g or 25 mL/100 g is not sufficient for optimal brain functioning. Blood flow of 70 mL/100 g indicates an increased rate. p. 1346

A nurse is preparing for an unconscious client with a head injury to be transferred from the emergency department to a neurologic trauma unit. Which nursing action is the priority?

Checking that a bag-valve mask is available during the transfer

Which cranial nerve damage may lead to a decrease in the client's olfactory acuity?

Cranial Never 1

Which action can the nurse delegate to the unlicensed assistive personnel (UAP) to reduce fatigue for a patient recovering from a stroke at meal times?

Cut up the meat for the patient. Rationale The nurse should instruct the UAP to cut up the meat at meal times and to assist with eating as needed. The ability to drink water during the meal may be limited if the patient has problems swallowing, but this will not address fatigue. Placing the head of the bed at 30 degrees is not high enough for eating and will not reduce fatigue during the meal. Feeding this patient reduces independence and should be avoided as the first action. pp. 1360-1361

What therapeutic effect does the nurse expect to identify when mannitol is administered parenterally to a client with cerebral edema?

Decreased intracranial pressure

When completing a neurologic assessment, the nurse determines that a client has a positive Romberg test. Which finding supports the nurse's conclusion?

Inablility to stand

Which nursing action should be included in the plan of care for a child with acute poststreptococcal glomerulonephritis?

Monitoring for seizures Rationale Cerebral edema from hypertension or cerebral ischemia may occur, which may result in seizures. Increasing fluid intake may lead to an increase in blood pressure and edema. Measuring abdominal girth is appropriate for children with nephrotic syndrome, in which the child has hypoalbuminemia that causes fluid to shift from plasma to the abdominal cavity. Glomerulonephritis will not alter pupillary reactions.

After a cerebrovascular accident (also known as brain attack) a client is unable to differentiate between heat or cold and sharp or dull sensory stimulation. What lobe of the brain should the nurse conclude is likely affected?

Parietal

A child sitting on a chair in a playroom starts to have a tonic-clonic seizure with a clenched jaw. What is the best initial action by the nurse?

Placing the child on the floor Rationale Placing the child on the floor limits the danger of falling and striking the head. Attempting to open the jaw is unsafe; it may result in injury. Protecting the child is the priority; assistance at this time is futile. Placing a pillow under the child's head may cause airway occlusion by forcing the chin onto the neck.

Nurses working with clients who have a diagnosis of dementia should adopt a common approach of care, because these clients have a need to do what?

Rationale A consistent approach and consistent communication from all members of the health team help the client who has dementia remain more reality oriented. It is the staff members who need to be consistent. Clients who have this disorder do not attempt to manipulate the staff. Acceptance of controls that are concrete and fairly applied is not needed when working with clients who have this disorder; consistency is most important.

The nurse is caring for a client with Alzheimer disease who exhibits behaviors associated with hyperorality. To meet the client's need for a safe milieu, what instructions will the nurse give the staff to monitor the client?

Rationale Hyperorality is the compulsive need to taste and chew inedible objects. Hyperorality is not related to choking, a tendency to mouth ulcers, or the inability to perceive temperature properly.

What should a nurse who is caring for a hospitalized older client with dementia consider before planning care?

Routines provide stability for clients with dementia.

What is a clinical manifestation of hypernatremia in burns?

Seizures

The client is admitted to the emergency department after a fall from a roof. After determining that the client sustained a head injury, the nurse observes clear fluid coming from the client's left ear. What will the nurse do next?

Test the drainage from the client's ear with a glucose reagent strip

A client newly diagnosed with multiple sclerosis asks the nurse if it will be painful. Which response should the nurse give the client first?

"Pain is a common symptom of this condition." Rationale The response "Pain is a common symptom of this condition" is a truthful answer for the client. Reassuring the client that "medications will be prescribed to help control pain" when the client experiences it is the next helpful response from the nurse. After being truthful about pain and reassuring the client about its medical management, asking the client to "tell more about...fears regarding pain" opens the conversation to discuss it and offers an opportunity for emotional release, which can decrease anxiety. The response "Let's list your questions for the healthcare provider" is a helpful final conversation during this encounter because it teaches the client how to make the most of their visit with the healthcare provider.

A relative of a stroke patient who is unable to walk is not sure about the benefits of mirror therapy. How will the nurse assure the relative?

"Mirror therapy may improve the patient's ability to walk." "Mirror therapy is an additional intervention along with other treatments." Rationale Mirror therapy is an additional intervention that may, along with other treatments, improve the patient's ability to walk. It is not a complete treatment, and the patient may need to take medication for stroke. It does not make use of a prosthetic leg. Mirror therapy does not provide 100 percent relief; it is an additional therapy to be used with other treatment modalities. p. 1359

Which lobe of the cerebrum includes the client's Broca's speech center?

Frontal lobe Rationale Broca's speech center is located in the frontal lobe and is responsible for the formation of words into speech. The parietal lobe aids in processing of spatial awareness and receiving and processing information about temperature, taste, and touch. The primary visual center is in the occipital lobe. The auditory center for interpreting sound is present in the temporal lobe.

A nurse is interviewing a client with a tentative diagnosis of Parkinson disease. What should the nurse expect the client to report about how the onset of symptoms occurred?

Gradually Rationale The onset of this disease is not sudden, but insidious, with a prolonged course and gradual progression. The onset is slow and gradual. The onset is not irregular; there is a gradual, regular progression of symptoms.

A patient is being discharged from the hospital after recovering from stroke. What food items should be included in the diet plan?

Grilled chicken Vegetable soups Rationale A patient who has recovered from stroke should follow dietary restrictions. The diet should be low in fats; hence, grilled chicken is preferred to fried chicken. A diet that is high in fruits and vegetables reduces the risk for stroke. French fries, cheeseburgers, and pizzas are high in fat and should be avoided.Test-Taking Tip: Get a good night's sleep before an exam. Staying up all night to study before an exam rarely helps anyone. It usually interferes with the ability to concentrate. p. 1353

Family members of a client who had a brain attack (cerebrovascular accident, CVA) ask why the client cries easily and without provocation. How does the nurse explain the client's behavior?

Has little control over this behavior Rationale Emotional instability usually is caused by lesions affecting the thalamic area (the part of the neural system most responsible for emotions). Crying easily is not attention-getting behavior; lability of mood is a physiological response to the CVA. The client may have remote memory, but there is no selective process of what events are remembered. There are inadequate data to come to the conclusion that the client feels guilt. Lability of mood is a physiological response to the CVA.

During an annual physical assessment a client reports not being able to smell coffee and most foods. Which cranial nerve function should the nurse assess?

I Rationale Cranial nerve I is the olfactory nerve that concerns the sense of smell[1][2][3]; the ability to sense odors usually is affected when an intracranial lesion is present. Cranial nerve II is the optic nerve and is concerned with sight. Cranial nerve X is the vagus nerve and is concerned with the gag reflex, supplying parasympathetic fibers to body organs, and transmitting sensory impulses from the viscera. Cranial nerve VII is the facial nerve and is concerned with facial expressions, taste, and the salivary glands.

A nurse in the emergency department is caring for a 9-year-old child with a suspected spinal cord injury sustained while falling off a bicycle. What is the initial nursing action?

Immobilizing the child's spine to limit additional injury

What behavior is exhibited by a patient who has suffered a right-brain stroke?

Impulsive and impatient Rationale A patient who has suffered a stroke on the right side of the brain will behave impulsively and act impatiently. A left-brain stroke survivor is aware of the deficiency and failure in mental functioning, and is very cautious. After a stroke, a patient will be much slower while undertaking actions. Survivors of left-brain damage will experience communication problems and have difficulty with words. p. 1350

A client is admitted with a head injury. The nurse identifies that the client's urinary catheter is draining large amounts of clear, colorless urine. What does the nurse identify as the mostlikely cause?

Inadequate antidiuretic hormone (ADH) secretion Rationale Deficient ADH from the posterior pituitary results in diabetes insipidus. This can be caused by head trauma; water is not conserved by the body, and excess amounts of urine are produced. Although increased serum glucose may cause polyuria, it is associated with diabetes mellitus, not diabetes insipidus. Ineffective renal perfusion will cause decreased urine production. While excess amounts of IV fluids may cause dilute urine, it is unlikely that a client with head trauma will be receiving excess fluid because of the danger of increased intracranial pressure.

During the acute stage of a stroke, it is important for the nurse to include which intervention for a patient experiencing aphasia?

Ask simple yes and no questions. Rationale Asking questions that can be answered simply supports communication in the acute phase of a stroke. Verbal communication should not be limited but should be frequent and meaningful. Diverting eye contact is incorrect because it will increase embarrassment instead of reducing it. It is important to give the patient time to answer a question. Asking a second question before the patient has had time to answer the first one will increase frustration and decrease communication. p. 1361

A nurse is caring for a patient who has aphasia after suffering from a stroke. How will the nurse communicate with the patient?

Make use of gestures. Present only one thought at a time. Do not interrupt the patient if he or she is taking too long to communicate. Rationale Because the patient is aphasic, it is possible that the patient is depressed and is frustrated by the inability to speak. Hence, it is important to take care of the patient's emotional state of mind as well. Gestures will help the patient understand better, and presenting one thought at a time will avoid confusion. The patient should not be interrupted in between phrases or sentences, even if he or she is taking a long time to communicate. Encourage the patient to communicate, but do not force. The nurse should not pretend to understand the patient even if she does not understand the patient because this would increase the patient's level of frustration. p. 1361

A client with a brain attack (cerebrovascular accident) is admitted to the hospital. What is the priority nursing intervention for this client?

Monitoring for increased intracranial pressure Rationale Cerebral edema may occur with a brain attack, resulting in increased intracranial pressure. Although preventing pressure ulcers is important, it is not the priority. All vital signs are important, not just the pulse. Although maintaining joint mobility is important, it is not the priority; range-of-motion exercises may increase intracranial pressure and should be instituted in collaboration with the healthcare provider.

Hydrocephalus develops in an infant who was born with a meningomyelocele, and a ventriculoperitoneal shunt is inserted. What nursing intervention is most important in this infant's care during the first 24 hours after surgery?

Monitoring for increasing intracranial pressure

After a 4-year-old child undergoes craniotomy the nurse performs a neurologic assessment that includes level of consciousness, pupillary activity, and reflex activity. What else should the nurse include in this assessment?

Motor function

When making rounds, a nurse observes a client who is experiencing a seizure. What should the nurse do?

Move obstacles

A nurse is caring for an anxious, fearful client. Which client response indicates sympathetic nervous system control?

Skin pallor

Which sensory-perceptual deficit is associated with left-hemispheric stroke (right hemiplegia)?

Slow and possibly fearful performance of tasks Rationale Patients with a left-hemispheric stroke (right hemiplegia) commonly are slower in organization and performance of tasks and may have a fearful, anxious response to a stroke. Overconfidence, spatial disorientation, and impulsivity more commonly are associated with a right-hemispheric stroke.Test-Taking Tip: Read every word of each question and option before responding to the item. Glossing over the questions just to get through the examination quickly can cause you to misread or misinterpret the real intent of the question. p. 1350

Which type of seizure lasts longer than five minutes and occurs in rapid succession without return to consciousness between seizures?

Status epilepticus Status epilepticus is a state of continuous seizure activity or a condition in which seizures reoccur in rapid succession without return to consciousness between seizures. Epilepsy is marked by a continuing predisposition to seizures with neurobiologic, cognitive, psychologic, and social consequences. An absence seizure is characterized by a brief staring spell lasting less than 10 seconds. A tonic seizure involves a sudden increase in tone of the exterior muscles that contribute to sudden stiff movements lasting 20 seconds or less.

A novice nurse is developing a care plan for impaired swallowing in a patient after a stroke. Which outcome included by the nurse requires revision?

The patient is able to chew well. Rationale The treatment goal for impaired swallowing does not involve increasing the chewing ability of the patient. The treatment involves swallowing ability, ability to clear the oral cavity, and ability to handle oral secretions. pp. 1360-1361

A nurse is teaching a group of caregivers the warning signs of stroke. What type of assessment data obtained from the patients should the nurse teach the caregivers to consider as an emergency?

The patient suddenly has blurry vision. The patient suddenly has slurred speech. Rationale Blood vessels carry blood throughout the body. When a blood vessel in the brain becomes blocked for a short period of time, the blood flow to that area of the brain slows or stops. This lack of blood (and oxygen) often leads to temporary symptoms such as slurred speech or blurry vision. Insomnia, deafness, and loss of appetite are not associated with stroke. p. 1346

Initially after a stroke, a client's pupils are equal and reactive to light. Later, the nurse assesses that the right pupil is reacting more slowly than the left and that the systolic blood pressure is beginning to rise. What complication should the nurse consider that the client is developing?

Increasing intracranial pressure Rationale Increased intracranial pressure compresses vital brain tissue; this is manifested by a sluggish pupillary response and an increased systolic blood pressure. Spinal shock is manifested by decreased systolic blood pressure, with no pupillary changes. Hypovolemic shock is indicated by decreased systolic pressure and tachycardia, with no changes in pupillary reaction. Transtentorial herniation is manifested by dilated pupils and severe posturing.STUDY TIP: Focus your study time on the common health problems that nurses most frequently encounter.

A client undergoes removal of a pituitary tumor through a transsphenoidal approach. What should the nurse implement postoperatively?

Maintain the head of the bed at a 30-degree angle continuously Rationale Maintaining the head of the bed at a 30-degree angle continuously decreases pressure on the sella turcica and promotes venous return, thus limiting cerebral edema. Gentle oral hygiene is performed, excluding brushing of teeth, to prevent trauma to the surgical site. Although deep breathing is encouraged, initially coughing is discouraged to prevent increasing intracranial pressure. There is no need to limit oral fluids because of the presence of nasal packing.

A nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral side of a client's foot is stroked with an applicator stick during a neurologic examination. What should the nurse document in the client's medical record?

"Exhibits a positive Babinski sign" Rationale This is a positive Babinski sign[1][2][3]; it is expected in infants but suggests upper motor neuron disease of the pyramidal tract in adults. The plantar reflex involves flexion of the toes and plantar flexion of the feet. "Demonstrates normal sensory function" is incorrect; positive Babinski is not an indication of normal sensation. "Able to perform active range of motion is inaccurate"; a Babinski is not caused by intentional movement. Active range of motion is a type of exercise, not reflex.

The registered nurse is teaching a novice nurse about interventions for a patient with a stroke on the left side of the brain. Which statement by the novice nurse indicates a need for further teaching?

"I should refrain from distracting the patient during a sudden emotional outburst." Rationale Distraction during emotional outbursts is important to help the patient overcome the situation. A calm and relaxing environment should be maintained to prevent any atypical behavior. Scolding during emotional outbursts should be avoided because the patient is unable to control the feelings. After a stroke, it is important to educate the patient and the family members about emotional outbursts.Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect. pp. 1361-1362

The registered nurse is teaching a student nurse about airway management for a patient who is at risk of aspiration. Which statement made by the student nurse indicates effective learning?

"I will perform suctioning as needed." Rationale Suctioning helps to remove secretions and clear the airway. Coughing should be encouraged in the patient because it removes secretions and reduces the risk of aspiration. Slow, deep breaths should be encouraged to help in airway clearance. Before doing a swallow evaluation, the patient should be kept nil per os (NPO) to reduce the risk of aspiration. p.1358

A client has a tonic-clonic seizure at work and is admitted to the emergency department. Which question is most useful when planning nursing care related to the client's seizure?

"Were you aware of anything different or unusual just before your seizure began?" Rationale Identification of a sensation that occurs before each seizure[1][2] (aura) is helpful in identifying the cause of the seizure and planning how to identify and avoid a future seizure. Although the response "Is your job demanding or stressful most of the time?" may provide some information, it is not the most inclusive question the nurse can ask; also, it limits the client's reply. Although the response "Do you participate in any strenuous sports activities on a regular basis?" may provide some information, it is not the most inclusive question the nurse can ask; also, it limits the client's reply. Although the response "Does anyone in your family have a history of central nervous system problems?" may provide some information, it is not the most inclusive question the nurse can ask; also, it limits the client's reply.STUDY TIP: Answer every question. A question without an answer is the same as a wrong answer. Go ahead and guess. You have studied for the test, and you know the material well. You are not making a random guess based on no information. You are guessing based on what you have learned and your best assessment of the question.

A patient is admitted with stroke. After initial assessment, the health care provider finds that the patient has spatial-perceptual alteration. Which manifestations should the nurse expect to find in the patient?

- apraxia - agnosia - homonoymous hemianopsia Rationale Homonymous hemianopsia, agnosia, and apraxia are examples of spatial-perceptual alterations. Homonymous hemianopsia is characterized by blindness occurring in the same half of the visual fields of both eyes. Agnosia is the inability to recognize an object by sight, touch, or hearing. Apraxia is the inability to carry out learned sequential movements on command. Expressive aphasia is not a spatial-perceptual alteration and refers to the inability to produce language. Akinesia is a motor deficit characterized by loss of skilled voluntary movements. p. 1352

Phenytoin suspension 200 mg is prescribed for a client with epilepsy. The suspension contains 125 mg/5 mL. How much solution will the nurse administer? Record your answer using a whole number. mL

8

A 50-year-old male client has difficulty communicating because of expressive aphasia after a cerebrovascular accident (CVA, also known as a "brain attack"). When the nurse asks the client how he is feeling, his wife answers for him. How should the nurse address this behavior?

Acknowledge the wife but look at the client for a response.

A patient with epilepsy who has been taking oral gabapentin was admitted to the emergency department in an unconscious state. The patient is experiencing seizures that are reoccurring in rapid succession. Which treatment option would be beneficial in alleviating the symptoms of the patient?

Administer diazepam intravenously Rationale Seizures that reoccur in rapid succession without the patient regaining consciousness are a characteristic feature of status epilepticus. It is a serious complication of epilepsy and occurs with any type of seizure. The most commonly used drug to treat status epilepticus is diazepam. Saline is administered to patients with severe dehydration and electrolyte imbalance. Dextrose is given if the patient has seizures due to hypoglycemia. Gabapentin is given to treat generalized seizures. p. 1378

A nurse is caring for a client who sustained a transection of the spinal cord with no other injuries. The nurse continually monitors this client for which medical emergency?

Autonomic hyperreflexia Rationale Autonomic hyperreflexia, an uninhibited and exaggerated response of the autonomic nervous system to stimulation, results in a blood pressure greater than 200 mm Hg systolic; it is a medical emergency. While hemorrhage and hypovolemic shock could occur from the trauma, the scenario stated that no other injuries occurred. Although gastrointestinal atony can result from immobility, it is not a medical emergency.STUDY TIP: Record the information you find to be most difficult to remember on 3" × 5" cards and carry them with you in your pocket or purse. When you are waiting in traffic or for an appointment, just pull out the cards and review again. This "found" time may add to your test scores points that you have lost in the past.

A nurse uses a dull object to stroke the lateral side of the underside of a client's left foot and moves upward to the great toe. What reflex is the nurse testing?

Babinski Rationale This is the description of how to elicit the Babinski reflex. If it is present in adults it may indicate a lesion of the pyramidal tract. The Babinski reflex is expected in newborns and disappears after one year. The Moro (startle) reflex is expected in newborns. It disappears between the third and fourth months; if present after four months, neurologic disease is suspected. The stepping reflex is expected in newborns. It disappears at about three to four weeks after birth and is replaced by more deliberate action. The cremasteric is a superficial reflex that tests lumbar segments 1 and 2. Stimulation of this reflex is useful in initiating reflex emptying of the spastic bladder after a spinal cord disruption above the second, third, or fourth sacral segment.

A nurse is performing a neurologic assessment of an adolescent with a seizure disorder. How should the nurse test cranial nerve XI?

By telling the adolescent to shrug the shoulders Rationale The accessory nerve (cranial nerve XI) innervates the sternocleidomastoid and trapezius muscles; the nurse evaluates this nerve by asking the client to shrug the shoulders. The glossopharyngeal nerve (cranial nerve IX) is assessed by stimulating the pharynx with a tongue blade. The vagus nerve (cranial nerve X) controls muscles of the larynx and is assessed by asking the client to swallow. Stroking the plantar surface of the foot is a test for the presence or absence of the Babinski reflex; this test is not used for assessment of a cranial nerve.

A nurse is explaining methods to reduce the risk of stroke to a patient. What instructions should the nurse convey to the patient?

C. Limit consumption of alcohol to moderate levels. D. Eat a diet low in saturated fats. E. Maintain a normal blood pressure (BP). Rationale Alcoholics and people with hypertension are prone to strokes. Hence, alcohol consumption should be limited, a diet low in fat should be consumed, and BP should be maintained. Also, physical exercise and adequate fluid and fiber intake will decrease the risk of stroke and should be promoted. p. 1347

Which part of the client's brain primarily regulates muscle functioning and coordinates movement?

Cerebellum Rationale The cerebellum regulates motor movements resulting in smooth and balanced muscular activity. The cerebrum is associated with higher brain functions, such as thought and action. The epithalamus acts as a connection between the motor pathways and regulates emotions. The hypothalamus regulates the body temperature and secretions of the endocrine gland.

What does the nurse recognize is the highest priority intervention for a patient experiencing status epilepticus?

Diazepam IV Rationale Diazepam given in an IV push is one of the drugs of choice for a patient experiencing status epilepticus. It is a rapid-acting benzodiazepine, but its action is of short duration and so the drug must be followed with a longer-acting anticonvulsant medication. Vecuronium is a paralyzing agent and is not used to treat status epilepticus. Phenytoin is a long-acting anticonvulsant medication commonly administered after a rapid-acting benzodiazepine (such as diazepam) to help stop a seizure and prevent further seizures. A patient experiencing extended episodes of status epilepticus may be at risk for dehydration, but Lactated Ringer's IV fluids are not considered an immediate intervention. p. 1378

What would be the appropriate nursing intervention for optimizing musculoskeletal function of a patient with hemorrhagic stroke?

Discouraging pulling the patient's arm Rationale Shoulder displacement can occur if a patient's arm is pulled. Hemorrhagic stroke may lead to joint contractures and muscular atrophy. Therefore it is important to optimize musculoskeletal function. Lap boards prevent shoulder displacement, and the patient should be instructed to use them. Trochanter rolls keep the patient's hip in a neutral position and prevent external rotation. Posterior leg splints are advised to the patient to prevent footdrop. p. 1359

The nurse visits a patient who is being treated with phenytoin for seizures. Which instruction is important to prevent precipitation of seizures in this patient?

Do not stop the drug abruptly without consulting the health care provider. Rationale Phenytoin is an antiseizure drug. Abrupt withdrawal of the drug after long-term use may precipitate seizures; therefore, the patient should not stop the drug without consulting the health care provider. Unusual hair growth and gingival hyperplasia are side effects of antiseizure drugs and are not relevant in preventing precipitation of seizures. Maintaining a healthy lifestyle is a general measure to keep healthy and may not contribute to prevention of precipitation of seizures. p. 1378

A patient with known history of hypertension presents to the emergency department with the complaint of sudden severe headache with no known cause. What should the nurse do first?

Obtain a computed tomographic (CT) scan. Rationale A patient with a history of hypertension is at risk of stroke. Sudden severe headache with no known cause is one of the warning signs of stroke. Hence, a CT scan should be obtained. This test can show areas of abnormalities in the brain and can help to determine whether these areas are affected by insufficient blood flow (ischemic stroke), a ruptured blood vessel (hemorrhage), or a different kind of problem. An eye examination may show abnormal eye movements and changes in the back of the eye. The patient may have abnormal reflexes. However, these findings do not necessarily mean a person is having a brain hemorrhage and could be the result of another medical condition. The patient is a hypertensive; therefore, antihypertensives should be administered to reduce high BP. This intervention can be carried out once the patient has undergone CT scan. p. 1352

A patient with a history of epilepsy experienced gingival enlargement. Which drug may be causing it?

Phenytoin Phenytoin, gabapentin, clonazepam, valproic acid, and carbamazepine are the drugs used in treating epilepsy. Gingival enlargement is a common side effect of phenytoin; therefore, a patient with epilepsy who is using phenytoin may experience gingival enlargement. Gabapentin, clonazepam, and valproic acid do not cause gingival enlargement.

While walking in the hall, a hospitalized client has a tonic-clonic seizure. To protect the client during the seizure, what should the nurse do?

Protect the client's head from injury. Rationale Rhythmic contraction and relaxation associated with a tonic-clonic seizure can cause repeated banging of the head. Holding extremities firmly is contraindicated because it can cause broken bones. Inserting an airway between the client's teeth is contraindicated because damage to the teeth can occur if force is used to insert an airway. Moving during a seizure can result in physical injuries; the client should be moved after the seizure.

The nurse notes that a 3-year-old child in a crib has a clamped jaw and is having a tonic-clonic seizure. What is the priority nursing responsibility at this time?

Protecting the child from self-injury Rationale Because the child is in a crib, the nurse should remain, observe, and protect the child from injury to the head or extremities during seizure activity. An individual should never be restrained during a seizure; fractured bones or torn muscles and ligaments may result. Administering oxygen is useless until the seizure is over; the child is apneic during the seizure. Attempts at inserting an airway are futile and may damage the child's teeth and jaws.

The nurse uses the Glasgow Coma Scale to assess a client with a head injury. Which Glasgow Coma Scale score indicates that the client is in a coma?

Rationale A score of 8 or below indicates coma. The Glasgow Coma Scale is used to assess the extent of neurologic damage; it consists of three assessments: eye opening, response to auditory stimuli, and motor response. Consciousness exists on a continuum from full consciousness to coma. A score can be from 3 to 15; the lower the score the more indicative of coma. To achieve the ratings of 9, 12, or 15 the client must be exhibiting some meaningful responses.

A client who is receiving phenytoin to control a seizure disorder questions the nurse regarding this medication after discharge. How will the nurse respond?

Rationale Seizure disorders usually are associated with marked changes in the electrical activity of the cerebral cortex, requiring prolonged or lifelong therapy. Seizures may occur despite drug therapy; the dosage may need to be adjusted. A therapeutic blood level must be maintained through consistent administration of the drug irrespective of emotional stress. Absence of seizures will probably result from medication effectiveness rather than from correction of the pathophysiologic condition.

A nurse is measuring the blood pressure of a hypertensive obese patient who has been admitted to the hospital for increased blood glucose levels. While they are speaking, the nurse notes that the patient has suddenly started mumbling and is unable to articulate words. What is the nurse's priority action?

Treat this as an emergency and call the health care provider. Rationale Obesity, high blood pressure, and diabetes are all risk factors for stroke. Sudden fumbling of the patient or sudden slurred speech is considered a transient ischemic attack (TIA) and a warning sign of stroke. It should be considered an emergency, and the health care provider should be informed. TIAs may be caused by microemboli that temporarily block the blood flow. The signs and symptoms of a TIA depend on the blood vessel that is involved and the area of the brain that is ischemic. If the carotid system is involved, patients may have a temporary loss of vision in one eye, transient hemiparesis, numbness or loss of sensation, or a sudden inability to speak. Referral to a speech therapist may not help because it is not a speech disorder. The sudden inability to speak might not be caused the by patient's worry about his or her disease or by dysfunction of the hypoglossal nerve.Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect. p. 1347

To enhance communication with a patient who has aphasia following a stroke, which communication technique is best for the nurse to use?

Use gestures or demonstrations as indicated. Rationale Use of gestures or demonstration are acceptable forms of communication with a patient experiencing aphasia. Examples include "Point to where your pain is" or "Show me on this page what you need." Staff members should speak with normal volume and tone for the patient's sensory baseline. Staff should use simple or closed-ended questions, ones that would require a "Yes" or "No" response, to minimize patient frustration in trying to formulate and articulate long verbal responses. Patients should be given time to process information and generate a response before repeating question or formulating a response. p. 1361

Which action will help a nurse communicate better with a stroke patient with aphasia?

Utilizing touch Rationale Touching may be the only way a patient with aphasia can express feelings. Thus the nurse should hold or clasp the hand of the patient as much as possible while communicating with him or her. The patient should be treated like an adult at all times. The nurse should speak at a normal level and not raise his or her voice or speak firmly. If the nurse is unable to understand the patient, the nurse should not pretend to understand by nodding constantly. The nurse should clearly communicate to a patient about a lack of understanding. p. 1361

Which antiepileptic drug is used as the first-line treatment for absence seizures?

Valproic acid Rationale Valproic acid is used as the first-line treatment for absence seizures. Phenytoin is used to treat partial, secondary, and generalized tonic-clonic seizures. Diazepam is used to treat status epilepticus. Acetazolamide is used as an adjunct drug for the treatment of absence seizures.

A patient is admitted to the emergency department with right-sided facial drooping. When taking the patient's history, which information would be most significant?

When did the facial drooping begin?" Rationale The time of onset of symptoms determines which treatments can be given and is the most critical information the nurse should obtain in the history assessment. The family history, past incidence, and pain are all important but do not impact treatment to the same extent as time of symptom onset. p. 1354

The patient with epilepsy is due for a dose of carbamazepine. The serum carbamazepine level today is 18 mcg/mL. What is the priority nursing action?

Withhold the dose and telephone the health care provider with the result. Rationale The therapeutic range for the serum carbamazepine is 4 to 12 mcg /mL. The patient's result is higher than the normal range and places the patient at risk for toxicity. The nurse should hold the dose of medication and immediately notify the health care provider. There is no reason to repeat the drug level. p. 1378

Which color of cerebrospinal fluid (CSF) may indicate subarachnoid hemorrhage in the client?

Yellow Rationale The yellow color of CSF can be attributed to the hemolysis of the red blood cells (RBC), which leads to increased production of bilirubin. Other causes include subarachnoid hemorrhage, jaundice, increased CSF protein, hypercarotenemia, or hemoglobinemia. Hazy or unclear CSF is indicative of an elevated white blood cell count due to infections. If the CSF has a brown color it is indicative of the presence of methemoglobin, indicating a previous meningeal hemorrhage. A colorless color indicates a normal finding.