Quizlet Practice questions Neuro N3

In assessing the patient's neurologic status, the nurse notes the patient is able to move the eyes in all six directions. Which set of cranial nerves (CN) does the nurse document as intact? a)-CN I, II, and IV. b)-CN VII and IX. c)-CN III, IV, and VI. d)-CN V and X.

c)-CN III, IV, and VI.

What is the maximum amount of time the nurse should allow an older adult with a cerebrovascular accident (also known as "brain attack") to remain in one position? 1- 1 to 2 hours 2- 3 to 4 hours 3- 15 to 20 minutes 4- 30 to 40 minutes

1- 1 to 2 hours

A nurse is caring for a child with a diagnosis of meningitis. What clinical findings indicate an increase in intracranial pressure? Select all that apply. 1-Irritability 2-Bradycardia 3-Hyperalertness 4-Decreased pulse pressure 5-Decreased systolic blood pressure

1-Irritability 2-Bradycardia

A child with meningitis suddenly assumes an opisthotonic position. In what position should the nurse position the child? 1-Side-lying 2-Knee-chest 3-High-Fowler 4-Trendelenburg

1-Side-lying Maximal safety and comfort are ensured with the side-lying position because the child's neck and back are hyperextended. The knee-chest position is impossible because the child is in a rigid opisthotonic position, with the neck and back hyperextended. The high-Fowler is impossible because the child is in a rigid position with the neck and back hyperextended. The Trendelenburg position increases intracranial pressure and is contraindicated in meningitis.

A client at 36 weeks' gestation is admitted to the high-risk unit with the diagnosis of severe preeclampsia, and antiseizure therapy is instituted. A fetal monitor and an electronic blood pressure machine are applied. Which complication of severe preeclampsia requires diligent monitoring of the blood pressure? 1-Stroke 2-Hemorrhage 3-Precipitous labor 4-Disseminated intravascular coagulation

1-Stroke

When does a nurse caring for a client with eclampsia determine that the risk for another seizure has decreased? 1-After birth occurs 2-After labor begins 3-48 hours postpartum 4-24 hours postpartum

3-48 hours postpartum The danger of a seizure in a woman with eclampsia subsides when postpartum diuresis has occurred, usually 48 hours after birth; however, the risk for seizures may remain for as long as 2 weeks after delivery.

During a home visit, a nurse discovers that a child in the household has a disability and has been experiencing seizures. In addition, the child's parent is indifferent to the child's physical, emotional, or medical needs and seems to provoke seizure episodes by harsh verbal exchanges with the child. The nurse believes that an intervention by an appropriate community resource is indicated. Where should the nurse direct the referral? 1-Outpatient clinic 2-Hospital pediatric unit 3-Child Protective Services 4-Bureau of the handicapped

3-Child Protective Services

Which clinical indicators does the nurse identify that suggest a client is experiencing urinary retention and overflow after a cerebrovascular accident (also known as a "brain attack")? Select all that apply. 1-Edema 2-Oliguria 3-Frequent voidings 4-Suprapubic distention 5-Continual incontinence

3-Frequent voidings 4-Suprapubic distention

A lactating woman takes fluoxetine to treat depression. Her newborn developed tremors, seizures, and fever. Which drug-induced physiologic alterations may be responsible for the central nervous system effects of the drug on the neonate? 1-Increase in fat content 2-Increase in protein binding 3-Immature blood-brain barrier 4-Delayed first stooling

3-Immature blood-brain barrier

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? 1-Applying restraints 2-Administering oxygen 3-Protecting the child from self-injury 4-Inserting a plastic airway in the child's mouth

3-Protecting the child from self-injury

The spouse of a client who had a cerebrovascular accident (also known as a "brain attack") seems unable to accept the concept that the client must be encouraged to participate in self-care. What is the best response by the nurse? 1-Tell the spouse to let the client do things independently. 2-Allow the spouse to assume total responsibility for the client's care. 3-Explain that the nursing staff has full responsibility for the client's activities. 4-Ask the spouse for assistance in planning those activities most helpful to the client

4-Ask the spouse for assistance in planning those activities most helpful to the client

A nurse is performing a neurologic assessment of an adolescent with a seizure disorder. How should the nurse test cranial nerve XI? 1-By checking the gag reflex 2-By asking the adolescent to swallow 3-By stroking the plantar surface of the foot 4-By telling the adolescent to shrug the shoulders

4-By telling the adolescent to shrug the shoulders

After surgical clipping of a cerebral aneurysm, the client develops the syndrome of inappropriate secretion of antidiuretic hormone (ADH). Which outcome would the nurse anticipate? 1-Increased blood urea nitrogen (BUN) 2-Increased serum sodium level 3-Decreased specific gravity 4-Decreased urine output

4-Decreased urine output

A nurse may find that for optimum nutrition a client with a cerebrovascular accident (also known as "brain attack") needs assistance with eating. What should the nurse do? 1-Request that the client's food be pureed. 2-Feed the client to conserve the client's energy. 3-Have a family member assist the client with each meal. 4-Encourage the client to participate in the feeding process

4-Encourage the client to participate in the feeding process

A 2½-year-old toddler is admitted with a fever of 103° F (39.4° C), stiffness of the neck, and general malaise. The diagnosis is acute bacterial meningitis. What is the priority nursing intervention for this child? 1-Increasing fluids 2-Administering oxygen 3-Giving a tepid sponge bath 4-Instituting droplet precautions

4-Instituting droplet precautions Droplet precautions prevent the spread of infection to others; isolation is a priority and should be implemented immediately. There is no indication that the child is dehydrated; fluid maintenance is a continuing goal.

A client with severe preeclampsia develops eclampsia. After the seizure, the client has a temperature of 102° F (38.9° C). What does the nurse suspect as the cause of the elevated temperature? 1-Excessive muscular activity 2-Development of a systemic infection 3-Dehydration caused by rapid fluid loss 4-Irregularity in the cerebral thermal center

4-Irregularity in the cerebral thermal center

A nurse is performing range-of-motion exercises with a client who had a cerebrovascular accident (CVA). The nurse places the client's hand in the position exhibited in the picture. What is the term for this position?

Extension

The nurse is evaluating the collaborative care of a client with traumatic brain injury (TBI). What is the most important assessment finding for this client? a)Head laceration. b)Asymmetric pupils. c)Amnesia. d)Restlessness.

b)Asymmetric pupils.

A 4-year-old child is admitted to the pediatric neurologic service with a seizure disorder. Shortly after admission, while in bed, the child has a generalized seizure. What nursing actions are most appropriate? Select all that apply. 1-Assessing the seizure 2-Taking the child's vital signs 3-Turning the child on the side 4-Pulling the padded side rails up 5-Initiating oxygen administration

1-Assessing the seizure 3-Turning the child on the side 4-Pulling the padded side rails up

A client is admitted to the hospital with a suspected brain tumor. Based on the history of loss of equilibrium and coordination, where does the nurse suspect the tumor is located? 1-Cerebellum 2-Parietal lobe 3-Basal ganglia 4-Occipital lobe

1-Cerebellum

The family members of a client with the diagnosis of cerebrovascular accident (CVA, also known as "brain attack") express concern that the client often becomes uncontrollably tearful during their visits. What should the nurse include in a response? 1-Emotional lability is associated with brain trauma. 2-Their presence allows the client to express feelings. 3-The client is depressed about the loss of functional abilities. 4-Nonverbal expressions of feelings are more accurate than verbal ones.

1-Emotional lability is associated with brain trauma. Emotional lability is associated with brain trauma from ischemia or injury.

The nurse caring for a 3-year-old child with meningitis should be alert for which signs and symptoms of increased intracranial pressure? Select all that apply. 1-Vomiting 2-Headache 3-Irritability 4-Tachypnea 5-Hypotension

1-Vomiting 2-Headache 3-Irritability

he nurse is admitting an 8-month-old infant with suspected bacterial meningitis to the hospital. List in order of priority the nursing actions that should be taken. .Monitor for signs of increased intracranial pressure (ICP) -Institute respiratory isolation .Assist with a lumbar puncture .Insert an intravenous access device .Administer the prescribed antibiotics

1.Institute respiratory isolation 2.Insert an intravenous access device 3.Assist with a lumbar puncture 4.Administer the prescribed antibiotics 5.Monitor for signs of increased intracranial pressure (ICP)

What comprises the prehospital priority care delivered by a nurse for a heatstroke victim? 1-The nurse should provide cold compresses. 2-The nurse should not give food or liquid to the victim. 3-The nurse should stabilize the spine of the victim with a board. 4-The nurse should closely monitor the blood pressure and respiratory function

2-The nurse should not give food or liquid to the victim. The nurse should not give food or liquid to the victim as prehospital care for heatstroke because vomiting and aspiration are risks.

After surgical clipping of a cerebral aneurysm, the client develops the syndrome of inappropriate secretion of antidiuretic hormone (ADH). Which manifestations of excessive levels of ADH should the nurse identify when assessing the client? Select all that apply. 1-Polyuria 2-Weight gain 3-Hypotension 4-Hyponatremia 5-Decreased specific gravity

2-Weight gain 4-Hyponatremia

A client with a seizure disorder is receiving phenytoin and phenobarbital. What client statement indicates that the instructions regarding the medications are understood? 1-"I will not have any seizures with these medications." 2-"These medicines must be continued to prevent falls and injury." 3-"Stopping the drugs can cause continuous seizures and I may die." 4-"By my staying on the medicines I will prevent post-seizure confusion.

3-"Stopping the drugs can cause continuous seizures and I may die."

In the postoperative period, all of the following are normal findings, except Depressed gag, blink, or swallowing reflex. A comatose child. Decreased muscle strength. Presence of light yellow drainage on the dressing.

Presence of light yellow drainage on the dressing. The presence of colorless drainage is reported immediately because it most likely is cerebrospinal fluid from the incision area.

The nurse notes cerebrospinal fluid (CSF) leakage in a patient who has sustained a head injury. What medication is likely to benefit the patient? a)Anti-epileptics. b)Corticosteroids. c)Opioids. d)Antibiotics

d)Antibiotics The appropriate medication for managing CSF leakage is administration of antibiotic to prevent brain infection.

A nurse is caring for a client with a brain tumor in the occipital lobe. What clinical indicator does the nurse expect to identify when assessing the client? 1-Hemiparesis 2-Receptive aphasia 3-Personality changes 4-Visual hallucinations

4-Visual hallucinations

Initially after a brain attack (stroke, cerebrovascular accident), a client's pupils are equal and reactive to light. Four hours later the nurse identifies that one pupil reacts more slowly than the other. The client's systolic blood pressure is beginning to increase. On which condition should the nurse be prepared to focus care? 1-Spinal shock 2-Brain herniation 3-Hypovolemic shock 4-Increased intracranial pressure

4-Increased intracranial pressure Increased intracranial pressure is manifested by a sluggish pupillary reaction and elevation of the systolic

After a craniotomy to remove a brain tumor, the client develops the syndrome of inappropriate secretion of antidiuretic hormone (ADH). For which clinical indicators should the nurse monitor the client? Select all that apply. 1-Polyuria 2-Insomnia 3-Bradycardia 4-Increased weight 5-Decreased serum sodium 6-Decreased level of consciousness

4-Increased weight 5-Decreased serum sodium 6-Decreased level of consciousness

A preterm neonate admitted to the neonatal intensive care nursery exhibits muscle twitching; seizures; cyanosis; abnormal respirations; and a short, shrill cry. Which complication does the nurse suspect? 1-Tetany 2-Spina bifida 3-Hyperkalemia 4-Intracranial hemorrhage

4-Intracranial hemorrhage Intracranial bleeding may occur in the subdural, subarachnoid, or intraventricular spaces of the brain, causing pressure on vital centers; clinical signs are related to the area and degree of cerebral involvement

A client who had a cerebrovascular accident (also known as a "brain attack") becomes incontinent of feces. What is the most important nursing action to support the success of a bowel training program? 1-Using medication to induce elimination 2-Adhering to a definite time for attempted evacuations 3-Considering previous habits associated with defecation 4-Timing of elimination to take advantage of the gastrocolic reflex

2-Adhering to a definite time for attempted evacuations Bowel training is a program for the development of a conditioned reflex that controls regular emptying of the bowel. The key to success is adherence to a strict time for evacuation based on the client's individual schedule.

A 1-year-old infant has been admitted with a tentative diagnosis of bacterial meningitis. A lumbar puncture is performed to confirm the diagnosis. What laboratory report on the cerebrospinal fluid (CSF) supports this diagnosis? 1-Decreased cell count 2-Increased protein level 3-Increased glucose level 4-Low spinal fluid pressure

2-Increased protein level

When making rounds, a nurse observes a client who is experiencing a seizure. What should the nurse do? 1-Hyperextend the client's neck 2-Move obstacles away from the client 3-Restrain the client's body movements 4-Attempt to place an airway in the client's mouth

2-Move obstacles away from the client

A nurse is assisting with an electroconvulsive therapy (ECT) treatment. The healthcare provider administers the electrical shock, and a seizure of 60 seconds' duration results. Place in priority order the nursing actions that should be taken after the seizure ends. 1.Ensuring an open airway 2.Orienting the client to place and time 3.Checking vital signs 4.Providing nourishment because the client has been on nothing-by-mouth (NPO) status 5.Assessing the client for the presence of short-term memory loss

1, 3, 2, 5, 4. During the seizure the client is not breathing or swallowing, and mucous secretions collect in the oral cavity, so ensuring a patent airway is a priority. ECT and the anesthesia used during the treatment can cause significant temporary physiologic changes. Checking the client's vital signs is necessary to identify and address any complications quickly. Orienting the client to place and time as the anesthesia wears off will ease the client's anxiety. As the client becomes more alert, memory questions can be asked to determine the level of short-term memory loss. This is a common side effect of ECT, and its presence or absence should be documented. Finally, when the client is completely awake and oriented and the vital signs are stable, nutritional needs may be addressed.

A client develops a seizure disorder as a result of a traumatic fall. When the client returns to the clinic for a routine visit, the client states, "I have not had a seizure in 2 years. When can I stop taking my antiseizure medications?" What is the nurse's best response? 1-"A gradual reduction in seizure medication may be considered." 2-"You will require medication for the rest of your life." 3-"Enough time has passed since the last seizure. The medication probably will be discontinued at this visit." 4-"A minimum of 10 years without seizures is necessary before discontinuation of medications is considered.

1-"A gradual reduction in seizure medication may be considered."

A client with a bleeding disorder is taking intravenous coagulant medications. The client suddenly develops an embolic stroke as a result of drug overdose. Which actions by the hospital management does the Leapfrog Group suggest? Select all that apply. 1-Apologize to the client and family 2-Waive all costs directly related to the adverse effect 3-Report the adverse event to The Joint Commission 4-Include the details of the medical error in the client's case sheet 5-Share the client's details and condition with other health care facilities

1-Apologize to the client and family 2-Waive all costs directly related to the adverse effect 3-Report the adverse event to The Joint Commission

Three days after admission to the hospital for a brain attack (cerebrovascular accident, CVA), a client has a nasogastric tube inserted and is receiving continuous tube feedings. Which action should the nurse take to best evaluate whether the feeding is being absorbed? 1-Aspirate for a residual volume 2-Evaluate the intake in relation to the output 3-Instill air into the client's stomach while auscultating 4-Compare the client's body weight with the baseline data

1-Aspirate for a residual volume

The nurse is assessing the client with subdural hematoma after a fall. The client was admitted for observation with a normal neurologic assessment on admission. Upon entering the room the nurse finds the client exhibiting seizure activity. Which is the first action the nurse should take? 1-Assess the client's airway. 2-Place pads on the side rails. 3-Notify the healthcare provider. 4-Leave and obtain the crash cart

1-Assess the client's airway.

A male client with a brain attack (cerebrovascular accident) has regained control of bowel movements but still is incontinent of urine. To help reestablish bladder control, what should the nurse encourage the client to do? 1-Assume a standing position for voiding. 2-Void every four hours and attempt to hold urine between set times. 3-Attempt to void more frequently in the afternoon than in the morning. 4-Drink a minimum of 4 L of fluid daily and divide it equally among the hours while awake

1-Assume a standing position for voiding. Assuming a standing position for voiding reduces tension (physical and psychologic), facilitates the movement of urine into the lower portion of the bladder, and relaxes the external sphincter (increasing pressure and initiating the micturition reflex).

Which drug is contraindicated in clients with eating and seizure disorders? 1-Bupropion 2-Trazodone 3-Amitriptyline 4-Lithium citrate

1-Bupropion

A 12-year-old girl is admitted to the pediatric unit with a diagnosis of meningococcal meningitis. Three days after admission the child is afebrile and asymptomatic but appears sad and cries frequently. How should the nurse help the child verbalize her thoughts and feelings? 1-By telling the child that she seems sad and upset 2-By encouraging the parents to speak with their child 3-By showing the child some photos of hospitalized children and having the child tell stories about them 4-By having the child watch videotapes about sick children and answering any questions that the child might have

1-By telling the child that she seems sad and upset The child is old enough to respond when a direct question is asked or an open-ended statement of assessment is made. The parents may be too emotionally involved to effectively help their child communicate feelings

The nurse is providing postprocedure care for a client who had a central venous access device (CVAD) inserted. Before the CVAD is used, what procedure is performed to verify placement? 1-Chest x-ray 2-Flushing the line with heparin 3-Withdrawing blood to ensure patency 4-Chest fluoroscopy

1-Chest x-ray

A client on bupropion therapy for depression experiences seizures. Which actions of the primary healthcare provider are used to reduce the risk for seizures? Select all that apply. 1-Discouraging rapid dose titration 2-Maintaining the dose at 550 mg/day 3-Avoiding administration of the medication with paroxetine 4-Avoiding concomitant use of fluoxetine with the medication 5-Administering the medication with small doses of fluoxetine

1-Discouraging rapid dose titration 3-Avoiding administration of the medication with paroxetine 4-Avoiding concomitant use of fluoxetine with the medication

After a short hospitalization for an episode of a transient ischemic attack (TIA) related to hypertension, a client is discharged on a regimen that includes chlorothiazide. What will the nurse instruct the client to do regarding nutrition? Select all that apply. 1-Eat more dark green leafy vegetables such as spinach. 2-Eat more vitamin-enriched products. 3-Return to previous eating habits. 4-Increase intake of dairy products. 5-Increase intake of beans

1-Eat more dark green leafy vegetables such as spinach. 5-Increase intake of beans

A client is admitted to the hospital after having a tonic-clonic seizure and is diagnosed with a seizure disorder. Which is most important for the nurse to include in a teaching program? 1-Explain ways to prevent physical trauma from occurring during a seizure. 2-Teach that anticonvulsant medications should be taken on an empty stomach. 3-Teach the client that the symptoms and treatment of seizure disorders are similar, regardless of the cause. 4-Explain to the client that it is not necessary to tell others of the illness because medication will control seizures.

1-Explain ways to prevent physical trauma from occurring during a seizure.

An infant who underwent revision of a ventriculoperitoneal shunt is found to have meningitis, the result of an infected shunt. What clinical manifestations support this conclusion? Select all that apply. 1-Fever 2-Lethargy 3-Stiff neck 4-Poor feeding 5-Depressed fontanels

1-Fever 2-Lethargy 3-Stiff neck 4-Poor feeding

A client who had a brain attack (cerebrovascular accident, CVA) frequently cries when family members visit, and they obviously are upset by the crying. What explanation for the client's behavior does the nurse provide the family members? 1-Having difficulty controlling emotions 2-Demonstrating a premorbid personality 3-Mourning the loss of functional abilities 4-Conveying unhappiness about the situation

1-Having difficulty controlling emotions

After being hospitalized for a transient ischemic attack (TIA) related to hypertension, a client is discharged with a prescription of hydrochlorothiazide. What should the nurse instruct the client to do when taking this medication? 1-Increase the intake of potassium-rich foods. 2-Drink a protein supplement daily. 3-Avoid eating foods high in insoluble fiber. 4-Resume regular eating habits

1-Increase the intake of potassium-rich foods.

A child is admitted to the hospital with a tentative diagnosis of meningitis, and a lumbar puncture is performed to confirm the diagnosis. What finding from the spinal fluid report should lead the nurse to conclude that bacterial meningitis is present? 1-Increased protein 2-Increased glucose 3-Decreased specific gravity 4-Decreased white blood cell count

1-Increased protein

A nurse is caring for an infant with meningitis. When the nurse extends the baby's leg, the hamstring muscles go into spasm and the infant begins to cry. What sign or reflex is the infant exhibiting? 1-Kernig sign 2-Babinski reflex 3-Chvostek sign 4-Cremasteric reflex

1-Kernig sign

A client has a brain attack (stroke) that involves the right cerebral cortex and cranial nerves. Which areas of paralysis should the nurse find upon assessment? Select all that apply. 1-Left leg 2-Left arm 3-Right leg 4-Right arm 5-Left side of face

1-Left leg 2-Left arm 5-Left side of face

A healthcare provider prescribes phenobarbital sodium for a client who had a tonic-clonic seizure. The nurse assesses the client's knowledge after teaching about the adverse effects of this drug. What responses should the client identify as a reason for calling the healthcare provider? 1-Loss of appetite or persistent fatigue 2-Anal itching or dizziness when standing up 3-Diarrhea or a rash on the upper part of the body 4-Decreased tolerance to common foods or constipation

1-Loss of appetite or persistent fatigue Phenobarbital depresses the central nervous system, particularly the motor cortex, producing adverse effects such as lethargy, loss of appetite, depression, and vertigo. Anal itching, diarrhea, rashes, and decreased tolerance to common foods or constipation are not side effects of phenobarbital.

While in the playroom a school-aged child exhibits twitching of the right arm and leg that almost immediately progresses to a generalized tonic-clonic seizure with clenched jaws. What is the best action for the nurse to take after moving the child to the floor? 1-Moving objects away from the child 2-Taking the other children to their rooms 3-Inserting a plastic airway into the child's mouth 4-Positioning a large pillow under the child's head

1-Moving objects away from the child Safety is the priority during the seizure and objects should be moved away from the child. It is unsafe to leave the child during the seizure to take other children to their rooms

A client with a primary brain tumor has developed syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse will expect to see which clinical findings upon assessment? Select all that apply. 1-Nausea and vomiting 2-Hyperthermia 3-Bradycardia 4-Increased weight 5-Decreased serum sodium 6-Decreased level of consciousness

1-Nausea and vomiting 4-Increased weight 5-Decreased serum sodium 6-Decreased level of consciousness

Bed rest is prescribed after a client's cerebrovascular accident (CVA, "brain attack") results in right hemiplegia. Which exercises should the nurse incorporate into the client's plan of care 24 hours after the brain attack? 1-Passive range-of-motion exercises 2-Active exercises of the extremities 3-Light weight-lifting exercises of the right side 4-Isotonic exercises that will capitalize on returning muscle function

1-Passive range-of-motion exercises Passive range-of-motion exercises prevent the development of deformities (e.g., contractures) and do not require any energy expenditure by the client. Instituting range-of-motion exercises is an independent nursing function.

The nurse is caring for a client who had a brain attack (cerebrovascular accident) and who has varying moods. The moods range from anger to depression to concern about the aphasia, hemiparesis, and the gavage feedings. Which behavior best indicates the client's acceptance of physical limitations? 1-Performs tube feedings without assistance 2-Allows family members to assist with care 3-Smiles and becomes more extroverted 4-Walks in the hall and sits in the lounge

1-Performs tube feedings without assistance The best indicator of acceptance is when the client begins to participate in self-care (tube feedings). Allowing others to provide care does not indicate acceptance.

What nursing action is essential when a client experiences hemianopsia as the result of a left ischemic stroke? 1-Place objects within the visual field. 2-Teach passive range-of-motion exercises. 3-Instill artificial teardrops into the affected eye. 4-Reduce time client is positioned on the left side.

1-Place objects within the visual field. A stroke in the left hemisphere will lead to a loss of the right visual field of each eye; objects should be placed within the client's view. Passive range-of-motion exercises, artificial teardrops, and reducing time client is positioned on the left side are not related to hemianopsia.

The nurse is caring for a client who underwent surgery for a brain tumor. On assessment, the nurse suspects meningitis in the client. Which finding would help confirm the nurse's suspicion? 1-Positive Kernig sign 2-Glasgow coma score: 10 3-Absence of nuchal rigidity 4-Negative Brudzinski sign

1-Positive Kernig sign

A client is diagnosed with a brain attack (cerebrovascular accident, CVA). The baseline vital signs are a pulse rate of 78 bpm and a blood pressure (BP) of 120/80 mm Hg. The nurse continues to monitor the vital signs and recognizes that which changes in vital signs indicate increased intracranial pressure (ICP)? 1-Pulse 50 bpm and BP 140/60 mm Hg 2-Pulse 56 bpm and BP 130/110 mm Hg 3-Pulse 60 bpm and BP 126/96 mm Hg 4-Pulse 120 bpm and BP 80/60 mm Hg

1-Pulse 50 bpm and BP 140/60 mm Hg Increasing intracranial pressure is evidenced by widening of pulse pressure and a decreased pulse rate

A client is admitted to the emergency department in the midst of persistent tonic-clonic seizures (status epilepticus). Diazepam is to be administered immediately. In addition to decreasing central neuronal activity, what other effect does the nurse anticipate? 1-Relaxing peripheral muscles 2-Slowing cardiac contractions 3-Dilating tracheobronchial structures 4-Providing amnesia of the convulsive episode

1-Relaxing peripheral muscles Diazepam is a tranquilizer and anticonvulsant used to relax skeletal muscles during continuous seizures

A client hospitalized with heat stroke presents with a body temperature of 106° F and skin that is hot and dry. Which priority interventions should be provided to the client? Select all that apply. 1-Remove the client's clothing. 2-Immerse the client in cold water. 3-Keep the client from eating or drinking. 4-Transfer the client to the critical care unit. 5-Administer parenteral benzodiazepine to the client.

1-Remove the client's clothing 2-Immerse the client in cold water Immediate priority care for heat stroke is to provide rapid cooling by removing the clothing and immersing the client in cold water to bring down the temperature. Refraining from giving food or liquids to the client is done before surgical procedures

A nurse is caring for a 2-year-old child with meningitis. For which clinical manifestations of increasing intracranial pressure should the nurse assess the child? Select all that apply. 1-Seizures 2-Vomiting 3-Bulging fontanels 4-Subnormal temperature 5-Decreased respiratory rate

1-Seizures 2-Vomiting 5-Decreased respiratory rate

While caring for a client on antidepressant therapy, the nurse observes hyperthermia and seizures. Upon a further assessment, the nurse finds that the client's heart rate is 200 beats per minute. Which medication might be responsible for the condition? 1-Sertraline 2-Asenapine 3-Risperidone 4-Fluphenazine

1-Sertraline A heart rate of 200 beats per minute indicates cardiac dysrhythmias. Hyperthermia, seizures, and cardiac dysrhythmias in a client on antidepressant therapy indicate serotonin syndrome. Serotonin syndrome is an adverse effect of selective serotonin inhibitors such as sertraline.

A client who had a brain attack (stroke) is admitted to the hospital with right-sided hemiplegia. For what reason does the nurse recognize the importance of identifying restrictions of mobility or neuromuscular abnormalities? 1-Shortening and eventual atrophy of the muscles will occur. 2-Hypertrophy of the muscles eventually will result from disuse. 3-Rigid extension can occur, making therapy painful and difficult. 4-Decreased movement on the affected side predisposes the client to infection

1-Shortening and eventual atrophy of the muscles will occur.

A 7-year-old child who is taking medication to prevent seizures has been seizure free for 2 years. The child's parents ask a nurse, "How much longer will my child need to take the medication?" What is the best response by the nurse? 1-"Medications are continued for 3 years after the last seizure." 2-"It is important that the medications be gradually decreased." 3-"Medications are usually discontinued at the 2-year follow-up visit." 4-"Seizure disorders are lifelong problems that require ongoing medications."

2-"It is important that the medications be gradually decreased." A predesigned protocol is used to wean a child off anticonvulsants gradually because abrupt removal of the drug can result in a seizure. Anticonvulsants are discontinued gradually after a child is seizure free for 2, not 3, years and has an EEG within expected limits.

A client is admitted to the hospital after having a tonic-clonic seizure. The client has a two-year history of a seizure disorder, but the seizures have been well controlled by phenytoin for the last six months. The client says to the nurse, "I am so upset. I didn't think I was going to have more seizures." Which is the best response by the nurse? 1-"Did you forget to take your medication?" 2-"You are worried about having more seizures?" 3-"You must be under a lot of stress right now." 4-"Don't be too concerned because your medication needs to be increased."

2-"You are worried about having more seizures?"

The nurse is assessing four clients with ischemic stroke. Which client requires a medium priority of care according to the National Institutes of Health Stroke Scale (NIHSS) score? 1-A client with visual score of 3 2-A client with facial palsy score of 1 3-A client with level of consciousness score of 0 4-A client with motor and drift of each extremity score of 4

2-A client with facial palsy score of 1

A client with a history of atrial fibrillation has a stroke, and vascular dementia (multiinfarct dementia) is diagnosed. In a comparison of assessment findings in clients with vascular dementia and dementia of the Alzheimer type, which factor is unique to vascular dementia? 1-Memory impairment 2-Abrupt onset of symptoms 3-Difficulty making decisions 4-Inability to use words to communicate

2-Abrupt onset of symptoms

A preschool-aged child is about to be admitted to the pediatric intensive care unit after surgery for removal of a brain tumor. The nurse manager should intervene immediately when the child's nurse does what? 1-Places a hypothermia blanket at the bedside 2-Adjusts the bed to the Trendelenburg position 3-Obtains electronic equipment for monitoring of vital signs 4-Secures a pump to administer the ordered intravenous fluids

2-Adjusts the bed to the Trendelenburg position Raising the foot of the bed increases blood flow to the brain, thereby increasing intracranial pressure. An increase in temperature may occur after a craniotomy as a result of stimulation of the hypothalamus.

A client is taking phenytoin to treat clonic-tonic seizures. The client's phenytoin level is 16 mcg/L. Which action should the nurse take? 1-Hold the medication and notify the healthcare provider. 2-Administer the next dose of the medication as prescribed. 3-Hold the next dose and then resume administration as prescribed. 4-Call the healthcare provider to obtain a prescription with an increased dose

2-Administer the next dose of the medication as prescribed.

A client is admitted to a rehabilitation unit after a brain attack (cerebrovascular accident, CVA) with residual hemiparesis. To help achieve the goal of safe walking with a cane, what should the nurse teach the client to do? 1-Shorten the stride of the unaffected extremity. 2-Advance the cane and the affected extremity simultaneously. 3-Lean the body toward the side with the cane when ambulating. 4-Hold the cane on the same side as the affected extremity and increase the base of support

2-Advance the cane and the affected extremity simultaneously.

The nurse is planning care for an immobilized client who has suffered a stroke. The client has right-sided hemiparesis. Which activity takes priority for this client? 1-Assess the client lung sounds every 8 hours. 2-Assist the client in performing range-of-motion (ROM) exercises every 1 to 2 hours. 3-Allow the client to sit upright in the chair for as long as tolerated. 4-Have the nursing assistant turn and reposition the client every 2 to 3 hours

2-Assist the client in performing range-of-motion (ROM) exercises every 1 to 2 hours. ROM exercises should be performed often to prevent muscle atrophy and contractures. Assessing the client's lung sounds every 8 hours is the minimum the nurse should assess lung sounds, and it is important, but it is not a priority in planning care for immobilization

Which condition may cause the gradual occlusion of the internal or common carotid arteries, manifested by transient ischemic attacks? 1-Acquired valvular heart disease 2-Atherosclerosis of the vascular system 3-Emboli associated with atrial fibrillation 4-Developmental defects of the arterial wall

2-Atherosclerosis of the vascular system Gradual occlusion of the carotid arteries, manifested by the transient ischemia attacks, is caused almost exclusively by atherosclerotic thrombosis.

The healthcare provider makes the diagnosis of transient ischemic attacks (TIAs). The client asks the nurse, "What causes TIAs?" When preparing a response in language the client will understand, the nurse considers that TIAs are caused by which factor? 1-Genetic valvular heart disease 2-Atherosclerotic plaques within arteries 3-Developmental defects in arterial walls 4-Multiple emboli ascending from the lower extremities

2-Atherosclerotic plaques within arteries

A nurse is reviewing the report of a biopsy taken from a preschool child's brain tumor. The tumor is a cerebellar astrocytoma. The nurse determines that this tumor is what? 1-Fast growing and malignant 2-Benign and associated with a high rate of cure 3-Close to vital centers, with only a partial excision possible 4-Associated with pituitary and hypothalamic malfunction later in life

2-Benign and associated with a high rate of cure Cerebellar astrocytomas, unlike those in the cerebrum, are slow growing and benign, with a cure rate of 70% to 90% after surgery. Other infratentorial tumors, such as medulloblastomas, grow rapidly and are highly malignant.

The nurse is assessing a client with hemorrhagic stroke due to a motor bike accident. Which condition of the client requires immediate attention? 1-Glasgow Coma score of 10 2-Body temperature of 81.2°F 3-Oxygen saturation of 90 percent 4-Presence of carotid pulse with blood pressure of 80 mm Hg

2-Body temperature of 81.2°F Severe hypothermia such as body temperature of 81.2° F must be immediately corrected by infusing warm fluids and blood. This helps to prevent hypothermia-related complications. A Glasgow Coma score of 10 needs medium priority since it does indicate immediate danger to the client

A client who had a tonic-clonic seizure of unknown etiology is to begin taking phenytoin. What instructions will the nurse give to the client? 1-Take the medication on an empty stomach. 2-Brush the teeth and gums three times daily. 3-Stop taking the drug if abdominal pain occurs. 4-Note any change in pulse and respiratory rates

2-Brush the teeth and gums three times daily. Adequate dental hygiene is essential to control or prevent the common side effect of hypertrophy of the gums. The medication should be taken with food or milk to decrease gastrointestinal side effects.

A client has a tonic-clonic seizure that involves all extremities. The nurse anticipates that the healthcare provider will prescribe the intravenous administration of which drug? 1-Naloxone 2-Diazepam 3-Epinephrine 4-Atropine

2-Diazepam Parenterally administered diazepam is a benzodiazepine that has muscle relaxant and anticonvulsant effects that help limit massive muscular spasms. Naloxone does not limit seizures; it is an opioid antagonist and is used for morphine, meperidine, and methadone overdose.

A nurse is caring for a client who has urinary incontinence as the result of a cerebrovascular accident (also known as "brain attack"). What action should the nurse include in the plan of care to limit the occurrence of urinary incontinence? 1-Insert a urinary retention catheter. 2-Institute measures to prevent constipation. 3-Encourage an increase in the intake of caffeine. 4-Suggest that a carbonated beverage be ingested daily.

2-Institute measures to prevent constipation.

Status epilepticus develops in an adolescent with a seizure disorder who is taking antiseizure medication. What does the nurse identify as the most common reason for the development of status epilepticus? 1-The amount prescribed is insufficient to cover activities. 2-The prescribed antiseizure drug probably is not taken consistently. 3-The client is prescribed a drug that is ineffective in preventing seizures. 4-The provider failed to account for a growth spurt

2-The prescribed antiseizure drug probably is not taken consistently. Skipping doses of the medication is a form of denial that an adolescent client may engage in once the seizures are controlled; also, adolescents tend to feel invincible.

During a seizure, a client had sudden loss of muscle tone that lasted for a few seconds followed by confusion. Which statement about this type of seizures is true? Select all that apply. 1-These seizures are associated with amnesia. 2-These seizures increase the risk of injuries due to fall. 3-These seizures are most resistant to drug therapy. 4-These seizures are preceded by perception of an offensive smell. 5-These seizures cause one sided movement of extremities in the client

2-These seizures increase the risk of injuries due to fall. 3-These seizures are most resistant to drug therapy.

A nurse is caring for a 9-month-old infant who has been admitted to the pediatric unit with a tentative diagnosis of meningitis. A lumbar puncture is performed. What does the nurse explain to the parents is the primary reason this procedure is performed? 1-To identify the presence of blood 2-To determine the causative agent 3-To reduce the intracranial pressure 4-To measure the spinal fluid glucose leve

2-To determine the causative agent Organisms that cause meningitis are often harbored in the spinal fluid. The lumbar puncture helps determine whether meningitis is present and whether the causative agent is bacterial or viral.

A client experiences expressive aphasia as a result of a brain attack (cerebrovascular accident, CVA). The client's spouse asks whether the client's speech will ever return. What is the best response by the nurse? 1-"It should return in several months." 2-"You will have to ask the primary healthcare provider." 3-"It is hard to say how much improvement will occur." 4-"Unfortunately, your spouse will no longer be able to speak."

3-"It is hard to say how much improvement will occur."

An infant with a seizure disorder is receiving phenobarbital at home. The mother calls the pediatric clinic and states that the infant has become lethargic and sleeps for long periods. How should the nurse respond to ease the mother's anxiety? 1-"There's a drug that will prevent this problem." 2-"This means that your baby's dosage needs to be adjusted." 3-"This is a temporary response to the drug; it usually stops after a few weeks." 4-"Many infants experience the same problem, but your baby needs the medication."

3-"This is a temporary response to the drug; it usually stops after a few weeks." Drowsiness is frequently a side effect of barbiturate therapy because it depresses the central nervous system; the infant will adapt to this over time

A client with a recent history of sinusitis develops meningitis and demonstrates a positive Brudzinski sign. What is the priority nursing care? 1-Monitoring intracranial pressure 2-Adding pads to the side of the bed 3-Administering prescribed antibiotics 4-Hydrating the client with hypotonic saline

3-Administering prescribed antibiotics The Brudzinski sign (when the neck is flexed while in the supine position, flexion of the hips occurs) indicates bacterial meningitis, a complication of sinusitis; the client's greatest need is a regimen of antibiotics to which the causative agent is sensitive. Bacterial meningitis causes increased intracranial pressure and it is important for the nurse to monitor for manifestations of increased intracranial pressure; however, in this circumstance, it is not the priority because monitoring alone does not affect outcomes.

A client who sustains a stroke has a loss of proprioception and fine touch. Which artery does the nurse suspect is damaged? 1-Lateral cerebral 2-Middle cerebral 3-Anterior cerebral 4-Posterior cerebra

3-Anterior cerebral Damage to the anterior cerebral artery can lead to a loss of proprioception and fine touch. Damage to the vertebral artery can cause dysphagia and dysarthria. Injury to the middle cerebral artery can cause motor and sensory deficits. Posterior cerebral artery damage can cause visual hallucinations and hemianopsia. There is no artery called lateral cere

What is the priority nursing intervention for a client with stroke who is transitioned from ED to other settings? 1-Monitoring vital signs 2-Reassuring the client and family 3-Assessing the level of consciousness 4-Monitoring specific client manifestations of stroke

3-Assessing the level of consciousness Assessing the level of consciousness is the priority nursing action in the client with stroke and who is transitioned from ED to other settings. Monitoring the vital signs, reassuring the client and family, and monitoring specific client manifestations of stroke are ongoing nursing interventions

Which client should be treated first according to the National Institutes of Health Stroke Scale (NIHSS)? 1-Client with score of 0 for dysarthria 2-Client with score of 1 for limb ataxia 3-Client with score of 3 for facial palsy 4-Client with score of 0 for level of consciousness

3-Client with score of 3 for facial palsy The NIHSS helps in evaluating the effect of an acute stroke and assigns a score based on severity of condition. According to the NIHSS, the score of 3 for facial palsy is given to the client with complete paralysis of one or both sides of the face and, therefore, should be treated first to ensure safety. The client with an NIHSS score of 0 for dysarthria is normal and, therefore, can be treated last. The client with limb ataxia in the leg and a NIHSS score of 1 can be treated after treating the client with score 3 for facial palsy. The NIHSS score of 0 for level of consciousness is normal, and this client can be treated after treating the clients with complete facial paralysis and partial limb ataxia.

A client is admitted to the hospital with weakness in the right extremities, and speech that is slightly slurred. A diagnosis of brain attack (cerebrovascular accident, CVA) is suspected. During the first 24 hours after symptom onset, which action is priority? 1-Assess the temperature 2-Monitor bowel sounds 3-Evaluate motor status 4-Obtain a urinalysis

3-Evaluate motor status Evaluating the client's motor status will reveal whether there is a progression of symptoms. These data will assist the practitioner in determining a diagnosis.

The nurse is caring for a client who is recovering from a stroke. The primary health care provider has referred the client for rehabilitative care. Which interventions by the nurse help to make a successful referral process? Select all that apply. 1-Make the referral after the client is discharged. 2-Select a suitable rehabilitation center for the client. 3-Explain the need for referral to the client and family. 4-Provide the referral with adequate client information. 5-Determine what the referral recommends for client care

3-Explain the need for referral to the client and family. 4-Provide the referral with adequate client information. 5-Determine what the referral recommends for client care

After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What manifestations are exhibited with excessive levels of antidiuretic hormone? 1-Increased blood urea nitrogen (BUN) and hypotension 2-Hyperkalemia and poor skin turgor 3-Hyponatremia and decreased urine output 4-Polyuria and increased specific gravity of urine

3-Hyponatremia and decreased urine output

A client who had a cerebrovascular accident (CVA, "brain attack") is starting to eat lunch. Which client behavior indicates to the nurse that the client may be experiencing left hemianopsia? 1-Asks to have food moved to the left side of the tray 2-Drops the coffee cup when trying to use the right hand 3-Ignores the food on the left side of the tray when eating 4-Reports not being able to use the right arm to help eat meals

3-Ignores the food on the left side of the tray when eating

An infant is being admitted to a pediatric unit with bacterial meningitis. What is the priority nursing action? 1-Assessing the infant's neurologic status 2-Beginning intravenous fluids and antibiotics 3-Implementing respiratory isolation precautions 4-Teaching the parents the importance of maintaining a quiet environment

3-Implementing respiratory isolation precautions The infant's illness is contagious, and the nurse, as well as other clients, must first be protected with the implementation of respiratory isolation precautions. Assessment of neurologic status would be performed after implementing isolation. Parental teaching and implementation of prescribed fluids and antibiotics may be done after assessment. Also, antibiotics are usually not administered until after all cultures have been obtained. Topics

A 4-year-old girl with a brain tumor diagnosed as an astrocytoma is admitted to the pediatric unit. The nurse performs a physical assessment while the child is lying in the supine position. During the assessment the child states that her head hurts and begins to cry. What does the nurse suspect as the most likely cause of the headache? 1-Hunger from fasting until blood tests are completed 2-Separation anxiety that manifests in physical symptoms 3-Increased intracranial pressure caused by blood pooling in the head 4-Mutilation anxiety, which is most common in children of this age grou

3-Increased intracranial pressure caused by blood pooling in the head

A 13-month-old child is undergoing lumbar puncture for confirmation of a diagnosis of bacterial meningitis. During the procedure the nurse notes that the spinal fluid is cloudy. What does this finding indicate? 1-Healthy spinal fluid 2-Increased glucose level 3-Increased white blood cell (WBC) count 4-Rising number of red blood cells (RBCs)

3-Increased white blood cell (WBC) count A high WBC count causes spinal fluid to appear cloudy and possibly milky white; it is a sign of infection. Healthy spinal fluid is clear. An increased glucose level does not affect the color or clarity of the spinal fluid. RBCs give the spinal fluid a sanguineous, not cloudy, appearance.

After a mild brain attack (cerebrovascular accident, CVA) a client has difficulty grasping objects with the dominant hand. To increase hand mobility and strength, what specific range-of-motion exercise should the nurse teach the client? 1-Eversion 2-Supination 3-Opposition 4-Circumduction

3-Opposition Opposition occurs when the thumb, a saddle joint, sequentially touches the tip of each finger of the same hand; the thumb joint movements involved are abduction, rotation, and flexion.

A client has left hemiplegia because of a cerebrovascular accident (CVA, "brain attack"). What can the nurse do to contribute to the client's rehabilitation? 1-Begin active exercises. 2-Make a referral to the physical therapist. 3-Position the client to prevent contractures. 4-Avoid moving the affected extremities unless necessary

3-Position the client to prevent contractures. To prevent contractures after a brain attack, the client should be positioned in functional alignment, and passive range-of-motion exercises should be performed. Active exercises are impossible with paralyzed limbs.

A nurse is caring for a child with meningococcal meningitis. What clinical finding does the nurse expect to encounter during a physical assessment? 1-Severe glossitis 2-Low-grade fever 3-Purpuric skin rash 4-Tremors of the extremities

3-Purpuric skin rash

A client who is at risk for seizures as a result of severe preeclampsia is receiving an intravenous infusion of magnesium sulfate. What findings cause the nurse to determine that the client is showing signs of magnesium sulfate toxicity? Select all that apply. 1-Proteinuria 2-Epigastric pain 3-Respirations of 10 breaths/min 4-Loss of patellar reflexes 5-Urine output of 40 mL/hr

3-Respirations of 10 breaths/min 4-Loss of patellar reflexes A high level of magnesium sulfate may depress respirations; if respirations are fewer than 12 breaths/min, immediate treatment is warranted. Toxicity results in diminished reflexes or an absence of them; hypertonic (hyperactive) reflexes are related to preeclampsia.

A client with a history of hypertension is admitted to the hospital immediately after a brain attack (cerebrovascular accident, CVA). The client is unconscious, and the vital signs are temperature 98° F (36.7° C), pulse 78 beats per minute, respiration 16 breaths per minute, and blood pressure 120/80 mm Hg. Which nursing concern is a priority for this client? 1-Injury 2-Constipation 3-Respiratory distress 4-Decreased fluid volume

3-Respiratory distress

A nurse begins planning for the discharge of a client who had a brain attack (cerebrovascular accident, CVA) with residual hemiparesis and hemianopsia. Which information should the nurse include in the discharge teaching plan for this client? 1-Necessity for bed rest at home 2-Use of oxygen therapy at home 3-Significance of a safe environment 4-Need for decreased protein in the diet

3-Significance of a safe environment

Which clinical indicator is the nurse most likely to identify when assessing a client with a ruptured cerebral aneurysm? 1-Tonic-clonic seizures 2-Decerebrate posturing 3-Sudden severe headache 4-Narrowed pulse pressure

3-Sudden severe headache

A client is admitted with a brain attack (cerebrovascular accident, CVA) with left-sided paralysis. The client leans to the left when placed in a sitting position and fails to respond to stimuli in the left visual field. What should the client's plan of care include? 1-Approaching the client from the left side 2-Keeping the client's head turned to the right 3-Teaching the client to use head movements to scan the left field of vision 4-Arranging the furniture in the client's room so that the door is in the right visual field

3-Teaching the client to use head movements to scan the left field of vision

Which antiepileptic drug is used as the first-line treatment for absence seizures? 1-Phenytoin 2-Diazepam 3-Valproic acid 4-Acetazolamide

3-Valproic acid 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 client who has a history of seizures is scheduled for an arteriogram at 10:00 AM and is to have nothing by mouth before the test. The client is scheduled to receive an anticonvulsant medication at 9:00 AM. What should the nurse do? 1-Omit the 9:00 AM dose of the drug. 2-Give the same dosage of the drug rectally. 3-Administer the drug with 30 mL of water at 9:00 AM. 4-Ask the healthcare provider to prescribe an alternate route of administration

4-Ask the healthcare provider to prescribe an alternate route of administration To achieve the anticonvulsant effect, therapeutic blood levels must be maintained. If the client is not able to take the prescribed oral preparation, the healthcare provider should be questioned about alternate routes of administration. Omission will result in lowered blood levels, possibly to less than the necessary therapeutic level to prevent a seizure. The route of administration cannot be altered without healthcare provider approval. The client is being kept nothing by mouth.

A client develops hydrocephalus two weeks after cranial surgery for a ruptured cerebral aneurysm. The nurse concludes that the hydrocephalus probably is related to which physiologic response? 1-Vasospasm of adjacent cerebral arteries 2-Ischemic changes in the Broca speech center 3-Increased production of cerebrospinal fluid (CSF) 4-Blocked absorption of fluid from the arachnoid space

4-Blocked absorption of fluid from the arachnoid space Residual blood from the ruptured aneurysm may have blocked the arachnoid villi, interrupting the flow of CSF, resulting in hydrocephalus.

A client who had a brain attack (cerebrovascular accident, CVA) has left-sided hemiparesis but is able to ambulate with assistance. When getting up from a lying position, the client reports feeling lightheaded and dizzy. The nurse explains that these clinical manifestations are a result of which condition? 1-Inflamed peripheral nerves 2-Loss of blood and blood volume 3-Demyelination of peripheral nerves 4-Blood pooling in the lower extremities

4-Blood pooling in the lower extremities Dilation of blood vessels causes dependent pooling when the client moves to an upright position, resulting in orthostatic (postural) hypotension. The client can limit feelings of lightheadedness and dizziness by moving gradually when changing positions

Which antiseizure drugs are used to stabilize a client's mood by suppressing mania associated with bipolar disorder (BPD)? Select all that apply. 1-Lithium 2-Quetiapine 3-Ziprasidone 4-Carbamazepine 5-Divalproex sodium

4-Carbamazepine 5-Divalproex sodium

A nurse is caring for an infant with bacterial meningitis. The parents ask how their baby could have contracted the illness. What does the nurse consider as the most likely route of transmission to the central nervous system? 1-Genitourinary tract 2-Gastrointestinal tract 3-Skin or mucous membranes 4-Cranial apertures or sinuses

4-Cranial apertures or sinuses Infections of cranial structures can cause meningitis because bacteria travel by way of direct anatomic route to the meninges and cerebrospinal fluid (CSF). The other parts of the body do not come into contact with CSF.

A client is admitted to the hospital with the diagnosis of a right-sided brain attack (stroke). The client is right-handed. Which task will be most difficult for this client? 1-Eating meals 2-Writing letters 3-Combing the hair 4-Dressing every morning

4-Dressing every morning If the client is right-handed, there will be difficulty with dressing because it requires the use of two hands, and some clothing requires movement of both sides of the body when dressing.

A client with a cerebrovascular accident ("brain attack") has dysarthria. What should the nurse include in the plan of care to address this problem? 1-Routine hygiene 2-Liquid formula diet 3-Prevention of aspiration 4-Effective communication

4-Effective communication Clients with dysarthria have difficulty communicating verbally, and an alternate means of communication may be indicated. Routine hygiene, liquid formula diet, and prevention of aspiration are important aspects of care, but they are not related to dysarthria. Dysphagia can lead to aspiration.

An elderly client is admitted to the healthcare facility following a stroke. What should the nurse do when the client's relative who arrived much later asks to see the client's health record? 1-Confirm the client's relationship first. 2-Ask the client's primary healthcare provider. 3-Inform the nurse manager and show the records. 4-Explain that medical health records are confidential

4-Explain that medical health records are confidential

A client who has been receiving phenytoin therapy for seizures becomes pregnant. What is the most important need for client education at this time? 1-Providing a referral for immediate termination of the pregnancy 2-Stressing the need to decrease phenytoin to prevent fetal phenytoin toxicity 3-Discussing the need to increase protein requirements 4-Explaining why it is extremely important to take the prescribed folic acid supplements

4-Explaining why it is extremely important to take the prescribed folic acid supplements Phenytoin therapy interferes with folate absorption, which increases the risk of neural tube deformities in the developing fetus; therefore, it is a priority for this client to take folic acid supplements.

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? 1-Spinal shock 2-Hypovolemic shock 3-Transtentorial herniation 4-Increasing intracranial pressure

4-Increasing intracranial pressure

A child is admitted to the pediatric unit with a diagnosis of meningococcal meningitis. What does the nurse conclude about isolation? 1-It is unnecessary during the incubation period. 2-It is required for 7 to 10 days until the fever subsides. 3-It will be unnecessary after the diagnosis is confirmed. 4-It will be necessary for 24 to 72 hours after the initiation of antibiotic therapy

4-It will be necessary for 24 to 72 hours after the initiation of antibiotic therapy

A client had a craniotomy for excision of a brain tumor. After surgery, the nurse monitors the client for increased intracranial pressure. Which clinical finding supports an increase in intracranial pressure? 1-Thready, weak pulse 2-Narrowing pulse pressure 3-Regular, shallow breathing 4-Lowered level of consciousness

4-Lowered level of consciousness Altered consciousness is the first sign of increased intracranial pressure. An increase in intracranial pressure causes impaired cerebral blood flow affecting the cells of the cerebral cortex, which results in a decreased level of consciousness.

A client with a history of substance abuse is brought to the emergency department for possible overdose. The client is having seizures, is hypertensive, and has hyperthermia. What drug should the nurse consider that the client may have been abusing? 1-Alcohol 2-Fentanyl 3-Oxycodone 4-Methamphetamine

4-Methamphetamine Methamphetamine is a stimulant that increases the heart rate and blood pressure. It can cause hyperthermia, convulsions, and death.

A client has a tonic-clonic seizure caused by an overdose of aspirin. What is an appropriate nursing action? 1-Check reflexes every 2 hours. 2-Prepare a setup for a central venous pressure (CVP) line. 3-Insert a urinary retention catheter. 4-Monitor vital signs every 15 minutes

4-Monitor vital signs every 15 minutes

A school-aged child with a seizure disorder has been taking carbamazepine for three years. What nursing intervention is most important to undertake regularly? 1-Assessing the mouth for gingivitis 2-Checking the pupillary reaction to light 3-Keeping an accurate intake and output record 4-Monitoring the child's complete blood cell counts

4-Monitoring the child's complete blood cell counts

Phenytoin 75 mg twice daily is prescribed for a school-aged child with a seizure disorder. What instruction will the nurse include when teaching the parents about activities to limit the consequences of long-term phenytoin therapy? 1-Administer the medication between meals. 2-Watch for a reddish-brown discoloration of urine. 3-Supplement the diet with high-calorie foods and encourage fluids. 4-Provide oral hygiene, including gum massage and flossing of the teeth.

4-Provide oral hygiene, including gum massage and flossing of the teeth.

A nurse is monitoring a client with severe preeclampsia for the onset of eclampsia. What objective clinical finding indicates an impending seizure? 1-Persistent headache with blurred vision 2-Epigastric pain with nausea and vomiting 3-Spots and flashes of light before the eyes 4-Rolling of the eyes to one side with a fixed stare

4-Rolling of the eyes to one side with a fixed stare Rolling of the eyes to one side with a fixed stare is a sign of central nervous system involvement that the nurse can see without obtaining subjective data from the client. It is a sign of an impending seizure.

A client is having a tonic-clonic seizure. Which is a priority nursing action? 1-Elevating the head of the bed 2-Restraining the client's arms and legs 3-Placing a tongue blade in the client's mouth 4-Taking measures to prevent injury

4-Taking measures to prevent injury

The nurse is caring for a client who is suspected of having a brain tumor and is scheduled for a computed tomography (CT) scan. The nurse expects that the preprocedure plan of care will include which component? 1-Withholding routine medications 2-Administering the prescribed sedative 3-Explaining that all metal must be removed 4-Telling the client about what to expect during the examination

4-Telling the client about what to expect during the examination

After a preschooler undergoes craniotomy for the removal of a brain tumor, the nurse identifies an area of serosanguineous drainage about the size of a quarter on the child's dressing. What is the immediate response by the nurse? 1-Notifying the neurosurgeon 2-Circling the area with nonabsorbable ink 3-Reinforcing the dressing with gauze pads 4-Removing the dressing to check the sutures

2-Circling the area with nonabsorbable ink Progression of the discoloration beyond the markings shows that the drainage is increasing. It is not necessary to notify the neurosurgeon; it is not an emergency. Some drainage is expected.

A 10-year-old child is undergoing radiation therapy for a brain tumor. What should the nurse include in the skin care for this child? 1-Applying baby oil to the head 2-Cleansing the head with water 3-Washing the head with mild soap 4-Rinsing soap from the head under a shower

2-Cleansing the head with water A child undergoing radiation therapy usually has dry, sensitive skin; the nurse should use plain water to remove perspiration and cellular debris on the skin.

A nurse on the high-risk unit is caring for a client with severe preeclampsia. Which intervention is the most effective in preventing a seizure? 1-Providing a plastic airway 2-Controlling external stimuli 3-Having emergency equipment available 4-Keeping calcium gluconate at the bedside

2-Controlling external stimuli Reducing lights, noise, and stimulation minimizes central nervous system irritability, which can trigger a seizur

A woman with a seizure disorder is being treated with antiseizure drugs. She continues the drug therapy during pregnancy. Which nursing interventions would be beneficial to this client? Select all that apply. 1-Advise a termination of the pregnancy. 2-Determine when the drugs were taken. 3-Avoid ultrasound scans due to the risk of harm to the fetus. 4-Consult a gynecologist to determine the type of malformation expected. 5-Explain that the risk of malformation is minimal and can be corrected later

2-Determine when the drugs were taken. 4-Consult a gynecologist to determine the type of malformation expected. 5-Explain that the risk of malformation is minimal and can be corrected later

A client is to have a computed tomography (CT) scan with contrast to assess a potential brain tumor. The nurse should teach the client about which common expected responses to the contrast material? Select all that apply. 1-Visual disturbances 2-Flushing of the face 3-Sensation of warmth 4-Lemony taste in the mouth 5-Small petechiae on the arms

2-Flushing of the face 3-Sensation of warmth

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

2-Instruct the client to scan surroundings. The client has lost vision from the right visual field [1] [2]; scanning compensates for this loss.

A client experiences a cerebral vascular accident (CVA) and is admitted to the hospital in a coma. What is the priority nursing care for this client? 1-Monitor vital signs. 2-Maintain an open airway. 3-Maintain fluid and electrolytes. 4-Monitor pupil response and equality

2-Maintain an open airway.

A school-aged child is admitted to the pediatric unit with the diagnosis of a brain tumor. During breakfast the child vomits. What are the priority nursing interventions? Select all that apply. 1-Refeeding breakfast 2-Notifying the practitioner 3-Requesting a reevaluation 4-Administering the prescribed antiemetic 5-Increasing the intravenous infusion rate

2-Notifying the practitioner 3-Requesting a reevaluation When a child displays signs of increasing intracranial pressure, the healthcare provider must be notified and should conduct a repeat assessment. Refeeding breakfast is unsafe; the child should not be fed until the practitioner has reassessed the child

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? 1-Hold the client's extremities firmly. 2-Protect the client's head from injury. 3-Insert an airway between the client's teeth. 4-Have several staff members move the client to a soft surface.

2-Protect the client's head from injury.

Dexamethasone has been prescribed for a client after a craniotomy for a brain tumor. When evaluating the effectiveness of the medication, the nurse expects what physiologic response? 1-Reduced cell growth 2-Reduced cerebral edema 3-Increased renal reabsorption 4-Increased response to sedation

2-Reduced cerebral edema Dexamethasone is a corticosteroid with antiinflammatory effects, which will reduce cerebral edema. Dexamethasone will not keep the tumor from growing; it will reduce fluid content and therefore cell size, not the number of cells

A nurse is caring for a client who had a brain attack (cerebrovascular accident) two weeks ago. What should the nurse do to help the client develop independence? 1-Establish long-range goals for the client. 2-Reinforce success in tasks accomplished. 3-Point out errors in performance on which to focus. 4-Explain ways the client can regain independence in activities.

2-Reinforce success in tasks accomplished.

While hospitalized, a client has a hypertensive crisis and a brain attack (cerebrovascular accident, CVA). Initially, the nurse should place the client in which position? 1-Supine 2-Side-lying 3-Orthopneic 4-Trendelenburg

2-Side-lying

A school-aged child with a seizure disorder is to start taking divalproex. What will the nurse teach the parents about caring for their child in regard to this medication? 1-Crush the tablets and mix them with applesauce. 2-Take the child for regularly scheduled blood tests. 3-Stop the medication immediately if a rash develops. 4-Provide oral hygiene, especially gum massage and flossing.

2-Take the child for regularly scheduled blood tests. Adverse reactions to divalproex include thrombocytopenia, leukopenia, and lymphocytosis; blood studies must be performed on a regular basis. Tablets must be swallowed whole; they should not be broken, crushed, or chewed. If the medication is stopped suddenly a seizure may result; a rash should be reported to the healthcare provider. Meticulous oral hygiene is more important for a child who is taking phenytoin.

The survivors of an explosion develop heat stroke. Which intervention should be performed by the nurse on the disaster management team? 1-Start an intravenous infusion. 2-Assess the arterial blood gases. 3-Apply ice packs on the client's scalp. 4-Administer aspirin or any antipyretic drug

3-Apply ice packs on the client's scalp. The immediate intervention in a client with heat stroke is to remove the client from the hot environment and apply ice packs on the scalp to cool the body's temperature. An intravenous infusion is started after the client is admitted to the hospital. Arterial blood gases should be assessed to evaluate the lungs. Administration of aspirin or antipyretic drugs should be avoided in the client with heat stroke to prevent its worsening.

A 2-year-old child who has been restricted to bed rest because of a diagnosis of meningitis is now allowed out of bed. The nurse suggests going to the playroom. The child responds by shaking the head vigorously from side to side, screaming, "No! Won't!" However, the child is trying to climb out of the crib at the same time. In light of these behaviors, what is the most likely conclusion by the nurse? 1-The child is trying to assert independence. 2-The child is eager to resume regular play activities. 3-The child is unsure of the difference between yes and no. 4-The child is confused as a result of increased intracranial pressure

1-The child is trying to assert independence. The toddler is exhibiting typical behavior for this developmental level; most toddlers will say no as a means of asserting their independence. Although the child may be eager to resume playing, the behavior described is related to the child's assertion of autonomy.

A nurse places a school-aged child with bacterial meningitis in isolation with droplet precautions. What is the purpose of these precautions? 1-They keep the child away from uninfected people. 2-The infectious process is interrupted as quickly as possible. 3-The child is protected from contracting a secondary infection. 4-They prevent the development of a hospital-acquired infection.

1-They keep the child away from uninfected people.

A client is diagnosed as having a right-sided brain attack (cerebrovascular accident) and is admitted to the hospital. When preparing to care for this client, which intervention should the nurse perform? 1-Apply elastic stockings to prevent flaccid leg muscles. 2-Use a bed cradle to prevent dorsiflexion of the feet. 3-Implement passive range-of-motion (ROM) exercises to prevent muscle atrophy. 4-Use a hand roll while supporting the left upper extremity on a pillow to prevent contractures

4-Use a hand roll while supporting the left upper extremity on a pillow to prevent contractures

A client with a brain tumor develops a urine output of 300 mL/hr, dry skin, and dry mucous membranes. Which nursing intervention is the most appropriate to perform for this client? 1-Evaluate urine specific gravity. 2-Implement fluid restrictions. 3-Provide emollients to the skin to prevent breakdown. 4-Slow down the intravenous (IV) fluids and notify the primary healthcare provider.

1-Evaluate urine specific gravity. Urine output of 300 mL/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce antidiuretic hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration.

The nurse is caring for a client who reports dizziness, excessive thirst, and nausea. Which assessment parameter should make the nurse suspect this client may be suffering from heat stroke? 1-Skin that is hot and dry to the touch 2-Increased blood pressure 3-Decreased respiratory rate 4-Edema in bilateral lower extremities

1-Skin that is hot and dry to the touch Prolonged exposure to a high environmental temperature can overwhelm the body's heat-loss mechanisms. These conditions initially cause heat exhaustion which progresses to heat stroke if left untreated, which manifests as dizziness, excessive thirst, nausea, and skin that is hot and dry to the touch.

An older client experiences a cerebral vascular accident (CVA) and has right-sided hemiplegia and expressive aphasia. The client's children ask the nurse which functions will be impaired. Which abilities does the nurse explain will be affected? 1-Stating wishes verbally 2-Recognizing familiar objects 3-Comprehending written words 4-Understanding verbal communication

1-Stating wishes verbally Impaired ability to state wishes verbally is a characteristic of expressive aphasia [1] [2] from damage to Broca area in the dominant hemisphere of the brain

A client with severe abdominal pain is on meperidine treatment and later develops seizures. Which intervention is given highest priority? 1-Stop administration of meperidine. 2-Administer transdermal scopolamine. 3-Administer oxygen through facial mask. 4-Monitor respiratory status and sedation level

1-Stop administration of meperidine. Opioids such as meperidine are associated with neurotoxicity and seizures, which are caused by accumulation of its metabolite, normeperidine. Therefore the administration of the medication must be stopped immediately.

In assessing function of the cranial nerves (CN), the nurse offers the patient a garlic roll and the patient identifies it correctly by both taste and smell. How does the nurse document this finding? Select all that apply. A)CN II is functional. B)CN I is functional. C)CN IX is functional. D)CN X is functional. E)CN IV is functional.

A)CN I is functional. C)CN IX is functional.

The nurse is teaching a group of seniors about transient ischemic attacks (TIAs). What statement by one of the participants indicates a need for further teaching? "TIA leads to loss of central vision." "TIA is a warning sign for ischemic stroke." "Its symptoms last less than 24 hours." "A TIA of any kind is a medical emergency."

"TIA leads to loss of central vision."

A 6-year-old child who is sitting at a table in the playroom has a tonic-clonic seizure with clenched jaws. What is the best action for the nurse to take? 1-Lower the child to the floor. 2-Attempt to open the child's jaw. 3-Place a large pillow under the child's head. 4-Go to the nurse's station to request assistance

1-Lower the child to the floor. Lowering the child to the floor limits the risk that the child will fall and strike the head

A client had a cerebrovascular accident (also known as a "brain attack"), and bed rest is prescribed. What can the nurse use to best prevent footdrop in this client? 1-Splints 2-Blocks 3-Cradles 4-Sandbags

1-Splints Various types of splints or boots are available to keep the foot in a position of functional alignment

A client has had a recent brain attack (cerebrovascular accident/stroke). What does the nurse anticipate will be prescribed daily to prevent straining due to constipation? 1-Stimulant laxatives such as bisacodyl 2-Tap water enemas 3-Stool softener 4-Saline laxatives such as magnesium citrate

3-Stool softener

A client who recently experienced a brain attack (cerebrovascular accident, CVA) and who has limited mobility reports constipation. What is most important for the nurse to determine when collecting information about the constipation? 1-Presence of distention 2-Extent of weight gained 3-Amount of high-fiber food consumed 4-Length of time this problem has existed

4-Length of time this problem has existed

P 124/76, ICP 20. What is the cerebral perfusion pressure? a)36 b)81 c)72 d)45

72 MAP = 2(DBP) + SBP/3 CPP = MAP - ICP Is this normal CPP?? Yes Normal CPP is 70-100

A patient with history of cold sores is diagnosed with encephalitis. Which virus may be responsible for this condition? West Nile virus Echovirus Arbovirus Herpes simplex virus

Herpes simplex virus

Which assessment findings alert the nurse that a patient with a spinal cord injury is developing neurogenic shock? Select all that apply. Facial flushing Tachycardia Hypotension Warm, dry skin Pupillary dilation

Hypotension Warm, dry skin

A patient with a spinal cord injury is on medication to control severe muscle spasticity. After a few days of receiving the medication, the patient experiences sedation, fatigue, dizziness, and changes in mental status. Which medication does the nurse anticipate has contributed to these symptoms? Intrathecal baclofen Levetiracetam Lamotrigine Gabapentin

Intrathecal baclofen Intrathecal baclofen (ITB) may be prescribed to patients with spinal cord injury to control severe muscle spasticity. However, this drug has adverse effects such as sedation, fatigue, dizziness, and changes in mental status.

A patient with encephalitis is hospitalized. Which parameters should the nurse assess? Select all that apply. Fluid and electrolyte imbalance Motor dysfunction Changes in mental status Vascular dysfunction Focal neurologic defects

Motor dysfunction Changes in mental status Focal neurologic defects

Which clinical manifestations should the nurse assess in a patient who is hospitalized with meningitis? Select all that apply. Muscle aches Increased intraocular pressure Neck stiffness Light sensitivity Retina damage

Muscle aches Neck stiffness Light sensitivity

What clinical manifestations suggest increased intracranial pressure in an infant? Select all that apply. Poor feeding Drowsiness Nausea Tense, bulging fontanels Irritability and restlessness

Poor feeding Drowsiness Tense, bulging fontanels Irritability and restlessness

The nurse must be alert to complications in the patient who has suffered a ruptured intracranial aneurysm. The nurse should assess the patient for signs of which of the following? Select all that apply. Rebleeding Siff neck Hydrocephalus Vasospasm Headache

Rebleeding Hydrocephalus Vasospasm

A client has a heart rate of 72 beats/min and stroke volume of 70 mL. What is the client's cardiac output? Record your answer using a whole number. _____mL/min

The volume of blood pumped by the heart in 1 minute is the cardiac output. Cardiac output is the product of the heart rate and the stroke volume of the ventricle. Therefore cardiac output in the client with a heart rate of 72 beats/min and stroke volume of 70 mL is 5040 mL/min: 72 × 70 = 5040.

What parts of the brain will be damaged due to a diffuse axonal injury? Select all that apply. Upper brainstem. Cranial blood vessels. Cranial nerves. Midbrain. Cerebellum.

Upper brainstem. Midbrain. Cerebellum.

What nursing intervention is used to prevent increased intracranial pressure in an unconscious child? a)Focus on assessment and interventions to minimize pain. b)Frequent suctioning. c)Turning the head from side to side every hour. d)Providing the environmental stimulation.

a)Focus on assessment and interventions to minimize pain.

The nurse is preparing to administer prescribed mannitol (Osmitrol) to a client with a severe head injury. Which precaution does the nurse take before administering this medication? a)-Discontinue barbiturate-induced coma before drug administration. b)-Have injectable naloxone (Narcan) prepared and ready at bedside. c)-Prepare to hyperventilate the client before drug administration. d)-Draw up the medication using a filtered needle.

d)-Draw up the medication using a filtered needle. Mannitol (Osmitrol) must be drawn up using a filtered needle to eliminate microscopic crystals. Narcan does not reverse the effects of mannitol. Hyperventilation does not affect administration of this drug, and clients can be given mannitol while in a barbiturate-induced coma.

The mother of an infant with meningitis is concerned that if she stays with her infant at the hospital her toddler at home will feel neglected. How should the nurse respond? 1-"Has anything happened to make you feel this way?" 2-"It's so important to spend your time here with the baby." 3-"Try to divide your time evenly between the two children." 4-"Can you arrange with someone to stay here when you are at home?"

4-"Can you arrange with someone to stay here when you are at home?"

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? 1-Ask the wife how she knows how the client feels. 2-Instruct the wife to let the client answer for himself. 3-When the wife leaves return to speak with the client. 4-Acknowledge the wife but look at the client for a response

4-Acknowledge the wife but look at the client for a response

The nurse is evaluating the collaborative care of a client with traumatic brain injury (TBI). What is the most important goal for this client? a)Preventing further injury. b)Increasing cerebral perfusion. c)Achieving the highest level of functioning. d)Preventing respiratory distress.

c)Achieving the highest level of functioning.

A patient with a head injury was given IV Decadron (dexamethasone) after arriving in the emergency department. The patient also has a history of hypoglycemia. During the hospital stay, the nurse would expect to see which of the following? a)-Increased episodes of hypoglycemia. b)-Possible episodes of hyperglycemia. c)-No change in the patient's glycemic parameters. d)-Both hyper - and hypoglycemic episodes

b)-Possible episodes of hyperglycemia. Decadron may increase blood sugar by promoting gluconeogenesis.

A client has had a traumatic brain injury and is mechanically ventilated. Which technique does the nurse use to prevent increasing intracranial pressure (ICP)? a)Placing the client in Trendelenburg position. b)Maintaining PaCO2 levels at 35 mm Hg. c)Suctioning the client frequently. d)Assessing for Turner's sign.

b)Maintaining PaCO2 levels at 35 mm Hg.

An alert and oriented person is admitted to the emergency department with a GCS of 10, indicating a moderate brain injury. Which assessment finding will the nurse report immediately to the health care provider? a)New onset of dizziness when lying quietly in bed. b)New difficulty in responsiveness or sudden drowsiness. c)Photophobia accompanied by headache. d)A brisk reaction to light.

b)New difficulty in responsiveness or sudden drowsiness.

Which method is used to remove a section of the skull when the patient's intracranial pressure cannot be controlled? a)Placing an intraventricular catheter. b)Inducing barbiturate coma. c)Performing decompressive craniectomy. d)Performing therapeutic hyperthermia.

c)Performing decompressive craniectomy.

The nurse is examining a child who had a head injury. What assessment finding does the nurse recognize as a comminuted fracture? a)Presence of irregular fragments of broken bones. b)Presence of single fracture line and soft tissue swelling. c)Presence of bleeding around the eyes (raccoon eyes). d)Presence of multiple associated linear fractures.

d)Presence of multiple associated linear fractures.

A 9-year-old child is admitted to the pediatric unit with a tentative diagnosis of an infratentorial brain tumor. What presenting sign does the nurse anticipate when assessing the child? 1-Ataxia 2-Papilledema 3-Cranial enlargement 4-Generalized seizures

1-Ataxia An early sign of an infratentorial tumor is ataxia. The parents describe it as clumsiness that becomes progressively worse. Papilledema is a very late sign of tumor involvement.

The registered nurse is caring for a client with tonic-clonic seizures. Which action should the nurse perform immediately according to priority? 1-Ensuring patent airway 2-Administering intravenous fluids 3-Monitoring level of consciousness 4-Protecting the client from injury during seizures

1-Ensuring patent airway

A client is scheduled for a craniotomy to remove a brain tumor. To prevent the development of cerebral edema after surgery, the nurse anticipates the use of drugs from which class? 1-Steroids 2-Diuretics 3-Anticonvulsants 4-Antihypertensives

1-Steroids Glucocorticoids are used for their antiinflammatory action, which decreases the development of cerebral edema. Diuretics may be used in conjunction with steroids; they reduce edema after it is present

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? 1-Moro 2-Babinski 3-Stepping 4-Cremasteric

2-Babinski

A child is admitted to the pediatric intensive care unit with acute bacterial meningitis. What is the nurse's priority intervention? 1-Offering clear fluids whenever the child is awake 2-Checking the child's level of consciousness hourly 3-Assessing the child's blood pressure every four hours 4-Administering the prescribed oral antibiotic medication

2-Checking the child's level of consciousness hourly

A client is admitted to the hospital with a tentative diagnosis of a brain tumor. Which diagnostic test result will the nurse check for confirmation of this diagnosis? 1-Myelography 2-Lumbar puncture 3-Electromyography 4-Computed tomography

4-Computed tomography

A client has a tonic-clonic seizure. Which nursing action is appropriate for a patient during the tonic-clonic stage of a seizure? 1-Go for additional help 2-Establish a patent airway 3-Restrain the client to prevent injury 4-Protect the client's head

4-Protect the client's head Protecting the client's head from injury is an appropriate nursing action for a client experiencing a tonic-clonic seizure. The client should not be left unattended. Establishing a patent airway is done after the seizure; the mouth should not be pried open to insert an airway during a seizure because injury may occur. Restraining a client will increase the risk for injury so is an unsafe action during a seizure.

Which condition damages a patient's brain tissue and contributes to cerebral vasodilation and increased intracranial pressure (ICP)? a)-Cerebral edema. b)-Hematoma. c)-Hypotension. d)-Hypoxemia.

d)-Hypoxemia. Hypoxemia is an abnormally low concentration of oxygen in the blood; this condition can damage brain tissue and contribute to cerebral vasodilation and increased intracranial pressure.

A client is admitted with a closed head injury sustained in a motor vehicle accident (MVA). The nursing assessment indicates increased intracranial pressure (ICP). Which intervention should the nurse perform first? a)Administer 100 mg of Pentobarbital IV as prescribed. b)Increase the ventilator respiratory rate to 20 breaths per minute. c)Administer 1 gram Mannitol IV as prescribed. d)Place head and neck in alignment.

d)Place head and neck in alignment.

The nurse observed seizures in a client who is taking lithium for cycles of mania. Which laboratory parameters may lead to this condition? 1- 1 mEq/L (1 mmol/L) serum lithium levels 2- 3 mEq/L (3 mmol/L) serum lithium levels 3- 135 mEq/L (135 mmol/L) serum sodium levels 4- 140 mEq/L (140 mmol/L) serum sodium levels

2- 3 mEq/L (3 mmol/L) serum lithium levels Serum lithium levels exceeding 2.5 mEq/L (2.5 mmol/L) may cause seizures, gastrointestinal discomfort, tremors, confusion, and somnolence.

A child becomes cyanotic during a generalized tonic-clonic seizure. What is the most appropriate action by the nurse? 1-Inserting an oral airway 2-Administering oxygen by mask 3-Continuing to observe the seizure 4-Notifying the practitioner immediately

3-Continuing to observe the seizure

A nurse is about to perform a wound irrigation on a client who had a left hemispheric stroke 1 year ago. Which assessment is most important for the nurse to perform before beginning the irrigation? 1-Neurologic 2-Wound 3-Pain 4-Skin

3-Pain

Which type of brain tumor can originate from cells that form the myelin sheath around nerves? 1-Meningioma 2-Astrocytoma 3-Ependymoma 4-Acoustic neuroma

4-Acoustic neuroma

For how long should a nurse maintain isolation of a child with bacterial meningitis? 1-For 12 hours after admission 2-Until the cultures are negative 3-Until antibiotic therapy is completed 4-For 48 hours after antibiotic therapy begins

4-For 48 hours after antibiotic therapy begins

The nurse is caring for a client two days after the client had a brain attack (cerebrovascular accident, CVA). To prevent the development of plantar flexion, which action should the nurse take? 1-Place a pillow under the thighs. 2-Elevate the knee gatch of the bed. 3-Encourage active range of motion. 4-Maintain the feet at right angles to the legs

4-Maintain the feet at right angles to the legs

Which virus can cause encephalitis in adults and children? 1-Rubella virus 2-Parvovirus 3-Rotaviruses 4-West Nile virus

4-West Nile virus The West Nile virus causes encephaliti

What does a nurse recognize as the most serious complication of meningitis in young children? 1-Epilepsy 2-Blindness 3-Peripheral circulatory collapse 4-Communicating hydrocephalus

3-Peripheral circulatory collapse

Which client is most at risk of developing aseptic meningitis? 1-Client A Prescribed Drug: Muromonad CD-3 2-Client B Prescribed Drug: Antithymocyte glubolin-rabbit 3-Client C Prescribed Drug: Sirolimus 4-Client D Prescribed Drug: Cyclosporine

1-Client A Prescribed Drug: Muromonad CD-3 Muromonab-CD3 is effective for lessening transplant rejection, and its prolonged administration may lead to aseptic meningitis in a client. Therefore client A is at risk of developing aseptic meningitis.

When explaining the occurrence of febrile seizures to a parents' class, what information should the nurse include? 1-They may occur in minor illnesses. 2-The cause is usually readily identified. 3-They usually do not occur during the toddler years. 4-The frequency of occurrence is greater in females than males.

1-They may occur in minor illnesses.

A nurse is caring for a school-aged child who has had a tonic-clonic seizure. How should the nurse describe the clonic phase? 1-Generalized rigidity 2-Loss of consciousness 3-Spasmodic body jerking 4-Tremors of upper extremities

3-Spasmodic body jerking The clonic phase of a tonic-clonic seizure is associated with the rapid rhythmic extension and relaxation of muscle groups throughout the body. Rigidity occurs during the tonic phase of a seizure.

At 1 am a 28-month-old toddler is admitted to the pediatric unit with suspected meningitis. At 3 am, after the child is settled in, the mother tells the nurse, "I have to leave now, but whenever I try to go my child gets upset and then I start to cry." What is the best action by the nurse? 1-Walking the mother to the elevator 2-Encouraging the mother to spend the night 3-Staying with the child while the mother leaves 4-Telling the mother to wait until the child falls asleep

3-Staying with the child while the mother leaves

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? 1-Frontal 2-Parietal 3-Occipital 4-Temporal

2-Parietal

A client has a history of progressive carotid and cerebral atherosclerosis and experiences transient ischemic attacks (TIAs). How does the nurse explain TIAs to the client? 1-Temporary episodes of neurologic dysfunction 2-Intermittent attacks caused by multiple small clots 3-Ischemic attacks that result in progressive neurologic deterioration 4-Exacerbations of neurologic dysfunction alternating with remissions

1-Temporary episodes of neurologic dysfunction

The registered nurse is delegating tasks to the healthcare team. Which team member is most suitable for achieving an effective outcome in the care of a client who is bedridden for long periods with seizures? 1-Healthcare provider 2-Licensed practical nurse 3-Newly hired registered nurse 4-Unlicensed assistive personnel

2-Licensed practical nurse

A client with a history of seizures is admitted with a partial occlusion of the left common carotid artery. The client has been taking phenytoin for 10 years. When planning care for this client, what should the nurse do first? 1-Place an airway and restraints at the bedside. 2-Obtain a history of seizure type and incidence. 3-Ask the client to remove any dentures and eyeglasses. 4-Observe the client for increased restlessness and agitation

2-Obtain a history of seizure type and incidence.

A client who is receiving phenytoin to control a seizure disorder questions the nurse regarding this medication after discharge. How will the nurse respond? 1-"Antiseizure drugs will probably be continued for life." 2-"Phenytoin prevents any further occurrence of seizures." 3-"This drug needs to be taken during periods of emotional stress." 4-"Your antiseizure drug usually can be stopped after a year's absence of seizures."

1-"Antiseizure drugs will probably be continued for life." 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

The nurse was assessing an elderly client and recorded the pulse rate as 85. After assessment the nurse determined the cardiac output as 5950. What could be the approximate stroke volume? 1-70 mL 2-60 mL 3-50 mL 4-40 mL

1-70 mL Cardiac output is obtained by multiplying the heart rate and the stroke volume. Therefore to obtain the stroke volume, the cardiac output should be divided by pulse rate. Dividing 5950 by 85 yields a stroke volume of 70 mL.

A client who had a brain attack (cerebrovascular accident, CVA) two weeks ago is having problems communicating. The nurse shows the client a picture of a baseball and asks the client to identify it and its characteristics. The client describes its color, size, and purpose but cannot identify it as a ball. How will the nurse document this finding in the client's medical record? 1-Anomia 2-Apraxia 3-Dysarthria 4-Dysphagia

1-Anomia

The nurse is caring for a client with complete partial seizures. Put in priority order the care activities performed by the nurse 1.Maintaining airway 2-Assessing vital signs 3.Performing neurologic checks 4.Recording the time and duration of seizure

1-Maintaining the airway is the priority for a client with any type of seizure. 4-Then the nurse should record the time and duration of the seizure to determine the severity of the condition. 2-Then the nurse should assess the client's vital signs after completion of the seizure. 3-Then the nurse should assess the client's neurologic status.

A nurse is preparing to discharge a client who is partially paralyzed following a stroke. What should the nurse teach the client's family about recognizing caregiver role strain? Select all that apply. 1-The caregiver has disturbed sleep patterns. 2-The caregiver has reduced appetite and weight. 3-The caregiver is more concerned about personal appearance. 4-The caregiver engages in leisure activities as often as possible. 5-The caregiver is fearful about administering medications to the client

1-The caregiver has disturbed sleep patterns. 2-The caregiver has reduced appetite and weight. 5-The caregiver is fearful about administering medications to the client

A client at 24 weeks' gestation is admitted to the high-risk unit with a diagnosis of preeclampsia. She has a seizure. What is the nurse's priority action? 1-Turning the client's head to the side 2-Checking the client for an imminent birth 3-Inserting an airway into the client's mouth 4-Checking for bleeding from the client's vagina

1-Turning the client's head to the side Turning the client's head to the side will allow saliva to drain from the mouth by gravity, which will help maintain a patent airway. Although birth may be imminent, the priority is maintaining a patent airway.

The school nurse is teaching parents of school-aged children about the importance of immunizations for communicable diseases. Which preventable disease may have the complication of encephalitis? 1-Varicella 2-Scarlet fever 3-Poliomyelitis 4-Whooping cough

1-Varicella

The nurse is providing emergency care to a client suffering from heat stroke. What should be the order of nursing interventions in this scenario? 1.Remove the client from the hot environment. 2.Ensure a patent airway. 3.Remove the client's clothing. 4.Pour or spray cold water on the client's body and scalp. 5.Place ice in cloth or bags and position the packs on the client's scalp. 6.Fan the client with newspapers or whatever is available

2, 1, 3, 5, 6, 4. Emergency care should be provided to the client with heat stroke to restore thermoregulation. First the nurse should ensure a patent airway. Then the nurse should remove the client from the hot environment into air conditioning or shade and remove his or her clothing. Then the nurse should pour or spray cold water on the client's body and scalp. The client should be fanned with newspapers or whatever is available. This should be followed by placing ice in cloth or bags and positioning the packs on the client's scalp.

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? 1-"Has intact plantar reflexes" 2-"Exhibits a positive Babinski sign" 3-"Demonstrates normal sensory function" 4-"Able to perform active range of motion

2-"Exhibits a positive Babinski sign"

Warfarin is prescribed for the client who takes phenytoin for a seizure disorder. Why must the nurse observe the client closely during the initial days of treatment with warfarin? 1-Warfarin increases the metabolism of phenytoin. 2-Phenytoin decreases warfarin's anticoagulant effect. 3-Warfarin's action is greater in clients with seizure disorders. 4-Seizures increase the metabolic degradation rate of warfarin

2-Phenytoin decreases warfarin's anticoagulant effect. Concurrent administration of phenytoin and warfarin can decease the anticoagulant effects of the warfarin. This interaction is the result of phenytoin causing increased metabolism of the warfarin by the liver.

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? 1-Trying to open the jaw 2-Placing the child on the floor 3-Calling out for assistance from staff 4-Placing a pillow under the child's head

2-Placing the child on the floor

A 2-year-old toddler is admitted to the pediatric unit with a diagnosis of bacterial meningitis. What is the most important safety measure for the nurse to institute immediately after the child has a seizure? 1-Monitoring the child's vital signs 2-Padding the side rails of the toddler's crib 3-Placing the child in the side-lying position 4-Bringing suction equipment to the bedside

3-Placing the child in the side-lying position

The spouse of a client who had a brain attack (cerebrovascular accident) tells the home health nurse that the client cries easily and without provocation. The spouse asks why the client is so emotionally fragile. What is the nurse's best response? 1-This is a way of getting attention that should be ignored. 2-The client can remember only depressing events from the past. 3-The client feels guilty about the demands being placed on the family. 4-This behavior is a common response over which the client has very little control

4-This behavior is a common response over which the client has very little control. If the client exhibits emotional instability, this usually is caused by lesions that affect the thalamic area in the part of the neural system most responsible for emotions.

Which health problem does the nurse identify from an older client's history that increases the client's risk factors for a cerebrovascular accident (CVA, also known as "brain attack")? 1-Glaucoma 2-Hypothyroidism 3-Continuous nervousness 4-Transient ischemic attacks (TIAs)

4-Transient ischemic attacks (TIAs) TIAs are temporary neurologic deficits related to cerebral hypoxia; about one third of the people who have TIAs will have a brain attack (CVA) within 2 to 5 years. Glaucoma, hypothyroidism, and continuous nervousness are not risk factors associated with a CVA.

The parents of a young child report that their child sometimes stares blankly into space for just a few seconds and then gets very tired. The nurse anticipates that the child will be assessed for which seizure disorder? Myoclonic Tonic Absence Simple partial

Absence Absence seizures are more common in children and consist of brief (often just seconds) periods of loss of consciousness and blank staring, as though he or she is daydreaming.