Adult 3 exam
trigeminal neuralgia treatment
Carbamezapine (or Oxcarbazepine)
Which is the earliest sign of increasing intracranial pressure?
Change in level of consciousness Explanation: The earliest sign of increasing intracranial pressure (ICP) is a change in level of consciousness. Other manifestations of increasing ICP are vomiting, headache, and posturing.
halo traction
Halo type bar that encircles the head screws are inserted into the outer table of the skull. The halo is attached to bed or rods that is secured to a rest
Cervical disc herniation treatment
Rest and immobilize the area.
A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as:
Severe TBI. Explanation: A score of 13 to 15 is classified as mild TBI, 9 to 12 is moderate TBI, and 3 to 8 is severe TBI. A score of 3 indicates severe impairment of neurologic function, deep coma, brain death, or pharmacologic inhibition of the neurologic response; a score of 8 or less typically indicates an unconscious patient; a score of 15 indicates a fully alert and oriented patient.
Cranial Nerve IV Trochlear
eye movement
A nurse is working on a neurological unit with a nursing student who asks the difference between primary and secondary headaches. The nurse's correct response will include which of the following statements?
"A secondary headache is associated with an organic cause, such as a brain tumor." Explanation: A secondary headache is a symptom associated with an organic cause, such as a brain tumor or an aneurysm. A primary headache is one for which no organic cause can be identified. These types include migraine, tension, and cluster headaches. Secondary headaches can be located in all areas of the head.
The nurse is assessing a client with sudden bilateral lower extremity weakness and dyskinesia. The client reports accompanying numbness and tingling episodes. Which question will the nurse ask the client to help determine the reason for the client's symptoms?
"Have you had a recent illness?" Explanation: Guillain-Barré syndrome (GBS), also known as acute idiopathic polyneuritis, is an autoimmune attack on the peripheral nerve myelin. An antecedent event (most often a viral infection) precipitates clinical presentation in approximately 60% to 70% of cases. The client should be asked about having a recent illness. GBS is not caused by medication, alcohol, or other illnesses.
A patient arrives to have an MRI done in the outpatient department. What information provided by the patient warrants further assessment to prevent complications related to the MRI?
"I am trying to quit smoking and have a patch on." Explanation: Before the patient enters the room where the MRI is to be performed, all metal objects and credit cards (the magnetic field can erase them) must be removed. This includes medication patches that have a metal backing and metallic lead wires; these can cause burns if not removed (Bremner, 2005).
Huntington's disease treatment
- Genetic, psychological, and social counseling - Drugs - PT: maximize endurance, strength, balance, postural control, and functional mobility
Cranial Nerve I
Olfactory (smell)
Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels?
T6 Explanation: Any patient with a lesion above T6 segment is informed that autonomic dysreflexia can occur and that it may occur even years after the initial injury.
When communicating with a client who has sensory (receptive) aphasia, the nurse should:
use short, simple sentences. Explanation: Although sensory aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension. Allowing time for the client to respond might be helpful but is less important than simplifying the communication. Because the client's hearing isn't affected, speaking loudly isn't necessary. A writing pad is helpful for clients with expressive, not receptive, aphasia.
cervical disc herniation/discectomy
usually occurs at the C5-C6 or C6-C7 interspaces and compresses a unilateral nerve root
Which neurotransmitter inhibits pain transmission?
Enkephalin Explanation: Enkephalins are excitatory neurotransmitters that cause pleasurable sensations and inhibit pain transmission. Acetylcholine is an excitatory transmitter that sometimes has inhibitory parasympathetic effects. Serotonin is an inhibitory transmitter that helps control mood and sleep. Dopamine usually is inhibitory, affecting behavior and fine movement
A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication?
Lamictal Explanation: Lamictal is an antiseizure medication. Its packaging was recently changed in an attempt to reduce medication errors, because this medication has been confused with Lamisil (an antifungal), labetalol (an antihypertensive), and Lomotil (an antidiarrheal).
Cervical disc herniation symptoms
Pain and stiffness may occur in the neck, the top of the shoulders, and the region of the scapulae. Patients sometimes interpret these signs as symptoms of heart trouble or bursitis. Pain may also occur in the arm and hand, accompanied by paresthesia (numbness, tingling, or a "pins and needles" sensation) of the upper extremity.
Cranial Nerve V Trigeminal
chewing, smiling
Cranial Nerve VI: Abducens
innervates the lateral rectus muscle (abducts eye)
Cranial Nerve XII: Hypoglossal
movement of tongue
muscular dystrophy treatment
physical therapy, bracing, ambulatory devices, medications
Cranial Nerve II: Optic
sensory, vision
Cranial Nerve IX
Glossopharyngeal - taste & senses carotid blood pressure
The client with a cerebral aneurysm asks the nurse, "What's the big fuss over a headache?" Which is the best response from the nurse regarding to a cerebral aneurysm?
"Your physician wants to evaluate the location and condition of the aneurysm." Explanation: Keeping the client calm and quiet is an important aspect of care. Explaining the need for further evaluation is factual. The nurse should avoid saying "don't worry" or telling a client how to feel—this is not a therapeutic response. The aneurysm is growing or leaking are both inappropriate responses from a nurse and can lead to increased concern and anxiety for the client.
Cerebral edema peaks at which time point after intracranial surgery?
24 hours Explanation: Cerebral edema tends to peak 24 to 36 hours after surgery.
Huntington's disease
Genetic disorder that causes progressive deterioration of brain cells. caused by a dominant allele. symptoms do not appear until about the age of 30.
Which of the following areas of the brain are responsible for temperature regulation?
Hypothalamus Explanation: The hypothalamus also controls and regulates the autonomic nervous system and maintains temperature by promoting vasoconstriction or vasodilation. The thalamus acts primarily as a relay station for all sensation except smell. The medulla and pons are essential for respiratory function
When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke?
The day the patient has the stroke Explanation: Although rehabilitation begins on the day the patient has the stroke, the process is intensified during convalescence and requires a coordinated team effort.
trigeminal neuralgia
characterized by severe lightning-like pain due to an inflammation of the fifth cranial nerve
A client is prescribed sumatriptan for the treatment of migraine headache. Which client statement would indicate a need for additional teaching from the nurse?
"I use this to prevent migraines." Explanation: Sumatriptan is a serotonin receptor agonist that stimulates serotonin receptors in the brain and causes vasoconstriction of the cerebral arteries and reduce/eliminate headaches and other symptoms associated with migraines. Sumatriptan is used during an attack and is not indicated for preventative migraine therapy.
A client with newly diagnosed seizures asks about stigma associated with epilepsy. The nurse will respond with which of the following statements?
"Many people with developmental disabilities resulting from neurologic damage also have epilepsy." Explanation: Many people who have developmental disabilities because of serious neurologic damage also have epilepsy. Epilepsy is not associated with intellectual level. It is not synonymous with intellectual disability or mental illness.
A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?
"The paralysis caused by this disease is temporary." Explanation: The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs.
A nurse is preparing a client for a lumbar puncture and informs the client that the needle will be inserted into the subarachnoid space between L3 and L4 or L4 and L5. The client reports that she is worried about damage to her spinal cord. The appropriate response from the nurse is which of the following?
"The spinal cord ends at L1, so puncturing it is not possible." Explanation: The needle is usually inserted into the subarachnoid space between the 3rd and 4th or 4th and 5th lumbar vertebrae. Because the spinal cord ends at the 1st lumbar vertebra, insertion of the needle below the level of the 3rd lumbar vertebra prevents puncture of the spinal cord.
Which term refers to the inability to recognize objects through a particular sensory system?
Agnosia Explanation: Agnosia may be visual, auditory, or tactile. Dementia refers to organic loss of intellectual function. Ataxia refers to the inability to coordinate muscle movements. Aphasia refers to loss of the ability to express oneself or to understand language
A 37-year-old mother of three has just been diagnosed with a grade I meningioma. As part of patient education, the nurse tells the patient that:
Growth is slow and symptoms are caused by compression rather than tissue invasion. Explanation: A meningioma is benign, encapsulated, and slow-growing. Sometimes the patient has no symptoms because of the slow-growing nature of the tumor.
A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include thickened liquids. Which of the following is the priority nursing diagnosis for this client?
Impaired Swallowing Explanation: Impaired Swallowing was evident on the video fluoroscopy. Aspiration, Malnutrition, and Decreased Fluid Volume Risk can occur but are not the primary diagnosis at this point in time.
The nurse is caring for a client with traumatic brain injury (TBI). Which clinical finding, observed during the reassessment of the client, causes the nurse the most concern?
Temperature increase from 98.0°F to 99.6°F Explanation: Fever in the client with a TBI can be the result of damage to the hypothalamus, cerebral irritation from hemorrhage, or infection. The nurse monitors the client's temperature every 2 to 4 hours. If the temperature increases, efforts are made to identify the cause and to control it using acetaminophen and cooling blankets to maintain normothermia. The other clinical findings are within normal limits.
A client with Parkinson's disease asks the nurse what their treatment is supposed to do since the disease is progressive. What would be the nurse's best response?
"Treatment aims at keeping you independent as long as possible." Explanation: Treatment aims at prolonging independence. Treatment does matter, it is not palliative, and it is not aimed at keeping you emotionally healthy.
Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting?
The client will remain free of injury if a seizure does occur. Explanation: All of the goals are appropriate, but the most important goal is the long-term goal to remain free of injury if a seizure occurs. Nursing interventions associated can include notifying someone of not feeling well, lowering self to a safe position, protecting head, turning on a side, etc. Also, the client may be at a risk for injury because, once a seizure begins, the client cannot implement self-protective behaviors. An established plan is important in the care of a seizure client. The other options are acceptable goals for nursing care.
A client who has just been diagnosed with mixed muscular dystrophy asks the nurse about the usual course of this disease. How should the nurse respond?
"You may experience progressive deterioration in all voluntary muscles." Explanation: The nurse should tell the client that muscular dystrophy causes progressive, symmetrical wasting of skeletal muscles, without neural or sensory defects. The mixed form of the disease typically strikes between ages 30 and 50 and progresses rapidly, causing deterioration of all voluntary muscles. Because the client asked the nurse this question directly, the nurse should answer and not simply refer the client to the physician. Limb-girdle muscular dystrophy causes a gradual decrease in arm and pelvic muscle strength, resulting in slight disability. Facioscapulohumeral muscular dystrophy is a slowly progressive, relatively benign form of muscular dystrophy; it usually arises before age 10.
A client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize?
"You must avoid coughing, sneezing, and blowing your nose." Explanation: After a transsphenoidal hypophysectomy, the client must refrain from coughing, sneezing, and blowing the nose for several days to avoid disturbing the surgical graft used to close the wound. The head of the bed must be elevated, not kept flat, to prevent tension or pressure on the suture line. Within 24 hours after a hypophysectomy, transient diabetes insipidus commonly occurs; this calls for increased, not restricted, fluid intake. Visual, not auditory, changes are a potential complication of hypophysectomy.
Cranial Nerve X: Vagus
-Function: sensory/motor impulses for larynx and pharynx; parasympathetic motor fibers supply smooth muscles of abdominal organs; sensory impulses from viscera -Testing procedure: tested in conjunction with cranial nerve IX
A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include:
diminished responsiveness. Explanation: Usually, diminished responsiveness is the first sign of increasing ICP. Pupillary changes occur later. Increased ICP causes systolic blood pressure to rise. Temperature changes vary and may not occur even with a severe decrease in responsiveness.
A comatose client is being cared for by a critical care nurse who documents that the client responds only to very painful stimuli by fragmentary, delayed reflex withdrawal. The nurse knows that reflexes in the body are centered where?
In the spinal cord Explanation: The spinal cord functions as a passageway for ascending sensory and descending motor neurons. Its two main functions are to provide centers for reflex action and to serve as a pathway for impulses to and from the brain. Reflex centers are not in the pons, the medulla, or the midbrain.
Cranial Nerve VIII
Vestibulocochlear (hearing and balance)
frontal lobe
A region of the cerebral cortex that has specialized areas for movement, abstract thinking, planning, memory, and judgement
occipital lobe
A region of the cerebral cortex that processes visual information
parietal lobe
A region of the cerebral cortex whose functions include processing information about touch.
A client with quadriplegia is in spinal shock. What finding should the nurse expect?
Absence of reflexes along with flaccid extremities Explanation: During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the client will demonstrate positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities.
Which of the following neurotransmitters are deficient in myasthenia gravis?
Acetylcholine Explanation: A decrease in the amount of acetylcholine causes myasthenia gravis. A decrease of serotonin leads to depression. Parkinson's disease is caused by a depletion of dopamine. Decreased levels of GABA may cause seizures.
The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the priority nursing intervention?
Administer corticosteroids as ordered. Explanation: Cranial arteritis is caused by inflammation, which can lead to visual impairment or rupture of the vessel. Administering the corticosteroid as ordered can decrease the chance of losing vision or vessel rupture. The client should receive an analgesic (acetaminophen) for the pain, but the corticosteroid should help decrease the pain and prevent complications. The nurse should assess for weight loss, but that can be determined after the medication is administered. Signs and symptoms of inflammation should be documented by the nurse after measures have been taken to decrease complications.
A client is suspected to have bacterial meningitis. What is the priority nursing intervention?
Administer prescribed antibiotics. Explanation: A client with suspected bacterial meningitis should receive antibiotic therapy within 30 minutes of arrival. Outcomes are usually better with early administration of antibiotics. Although the nurse should assess the CSF laboratory test results, antibiotic therapy should not be delayed waiting for the results. Encouraging oral fluids and preparing for a CT scan are appropriate interventions depending on the client, but the priority intervention is the early administration of antibiotics.
Which of the following is a sympathetic nervous system effect?
Decreased peristalsis Explanation: Sympathetic effects of the nervous system include decreased peristalsis, increased blood pressure, dilated pupils, and dilated bronchioles.
Which term refers to the failure to recognize familiar objects perceived by the senses?
Agnosia Explanation: Auditory agnosia is failure to recognize significance of sounds. Agraphia refers to disturbances in writing intelligible words. Apraxia refers to an inability to perform previously learned purposeful motor acts on a voluntary basis. Perseveration is the continued and automatic repetition of an activity, word, or phrase that is no longer appropriate
The nurse enters the client's room and finds the client with an altered level of consciousness (LOC). Which is the nurse's priority concern?
Airway clearance Explanation: The most important consideration in managing the patient with altered LOC is to establish an adequate airway and ensure ventilation.
A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first?
Alteration in level of consciousness (LOC) Explanation: The first sign of possible subdural hematoma is a change in LOC. Speech may be affected later as the client experiences continued reduction in oxygenation. Bradycardia and a decreased heart rate occur later if the condition isn't treated.
A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is most appropriate?
Alternatively patch one eye every 2 hours. Explanation: Patching one eye at a time relieves diplopia (double vision). Closing the eyes and making the room dark aren't the most appropriate options because they deprive the client of sensory input. Artificial tears relieve eye dryness but don't treat diplopia.
The nurse is taking care of a client with a history of headaches. The nurse takes measures to reduce headaches and administer medications. Which appropriate nursing interventions may be provided by the nurse to such a client?
Apply warm or cool cloths to the forehead or back of the neck Explanation: Applying warm or cool cloths to the forehead or back of the neck and massaging the back relaxes muscles and provides warmth to promote vasodilation. These measures are aimed at reducing the occurrence of headaches in the client. A client with transient ischemic attacks is advised to maintain hydration and drink eight glasses of fluid a day. A Heimlich maneuver is performed to clear the airway if the client cannot speak or breathe after swallowing food. The nurse uses pressure-relieving pads or a similar type of mattress to maintain peripheral circulation in the client's body.
Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis?
Apraxia Explanation: Verbal apraxia refers to difficulty forming and organizing intelligible words although the musculature is intact. Agnosia is a failure to recognize familiar objects perceived by the senses. Agraphia refers to disturbances in writing intelligible words. Perseveration is the continued and automatic repetition of an activity or word or phrase that is no longer appropriate.
A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first?
Ask the client if he has trouble breathing. Explanation: The nurse should first assess the client's breathing. A complication of a carotid endarterectomy is an incisional hematoma, which could compress the trachea causing breathing difficulty for the client. Although the other measures are important actions, they aren't the nurse's top priority.
If warfarin is contraindicated as a treatment for stroke, which medication is the best option?
Aspirin Explanation: If warfarin is contraindicated, aspirin is the best option, although other medications may be used if both are contraindicated.
Which drug should be available to counteract the effect of edrophonium chloride?
Atropine Explanation: Atropine should be available to control the side effects of edrophonium chloride. Prednisone, azathioprine, and pyridostigmine bromide are not used to counteract these effects.
Lesions in the temporal lobe may result in which type of agnosia?
Auditory Explanation: Lesions in the temporal lobe (lateral and superior portions) may result in auditory agnosia. Lesions in the occipital lobe may result in visual agnosia. Lesions in the parietal lobe may result in tactile agnosia. Lesions in the parietal lobe (posteroinferior regions) may result in relationship and body part agnosia
You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides?
Autonomic dysreflexia Explanation: Autonomic dysreflexia is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury, usually after the spinal shock subsides. Tetraplegia results in the paralysis of all extremities when there is a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Areflexia is a loss of sympathetic reflex activity below the level of injury within 30 to 60 minutes of a spinal injury.
Which positions is used to help reduce intracranial pressure (ICP)?
Avoiding flexion of the neck with use of a cervical collar Explanation: Use of a cervical collar promotes venous drainage and prevents jugular vein distortion, which can increase ICP. Slight elevation of the head is maintained to aid in venous drainage unless otherwise prescribed. Extreme rotation of the neck is avoided because compression or distortion of the jugular veins increases ICP. Extreme hip flexion is avoided because this position causes an increase in intra-abdominal pressure and intrathoracic pressure, which can produce a rise in ICP
Which positions is used to help reduce intracranial pressure (ICP)?
Avoiding flexion of the neck with use of a cervical collar Explanation: Use of a cervical collar promotes venous drainage and prevents jugular vein distortion, which can increase ICP. Slight elevation of the head is maintained to aid in venous drainage unless otherwise prescribed. Extreme rotation of the neck is avoided because compression or distortion of the jugular veins increases ICP. Extreme hip flexion is avoided because this position causes an increase in intra-abdominal pressure and intrathoracic pressure, which can produce a rise in ICP.
Cranial Nerve VII: Facial
Both - Moves face, tastes, salivates, Sensory information from taste buds on anterior 2/3 of tongue Proprioceptive information from face and scalp Motor information for facial expression and closing the eye Autonomic information for crying and salivation
An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client?
Brain tumor Explanation: The incidence of brain tumor increases with age. Headache and papilledema are less common symptoms of a brain tumor in the older adult. Symptoms of epilepsy include fits and spasms, while symptoms of trigeminal neuralgia would be pain in the jaws or facial muscles. Hypostatic pneumonia develops due to immobility or prolonged bed rest in older clients.
At which of the following spinal cord injury levels does the patient have full head and neck control?
C5 Explanation: At the level of C5, the patient should have full head and neck control, shoulder strength, and elbow flexion. At C4 injury, the patient will have good head and neck sensation and motor control, some shoulder elevation, and diaphragm movement. At C2 to C3, the patient will have head and neck sensation, some neck control, and can be independent of mechanical ventilation for short periods of time.
The nurse is performing an assessment of cranial nerve function and asks the patient to cover one nostril at a time to see if the patient can smell coffee, alcohol, and mint. The patient is unable to smell any of the odors. The nurse is aware that the patient has a dysfunction of which cranial nerve?
CN I Explanation: Cranial nerve (CN) I is the olfactory nerve, which allows the sense of smell. Testing of CN I is done by having the patient identify familiar odors with eyes closed, testing each nostril separately. An inability to smell an odor is a significant finding, indicating dysfunction of this nerve.
A client comes to the clinic for evaluation because of complaints of dizziness and difficulty walking. Further assessment reveals a staggering gait, marked muscle incoordination, and nystagmus. A brain tumor is suspected. Based on the client's assessment findings, the nurse would suspect that the tumor is located in which area of the brain?
Cerebellum Explanation: Findings such as ataxic or staggering gait, dizziness, marked muscle incoordination, and nystagmus suggest a cerebellar tumor. A frontal lobe tumor frequently produces personality, emotional, and behavioral changes. A tumor in the motor cortex produces seizure-like movements localized on one side of the body. Occipital lobe tumors produce visual manifestations.
Which of the following diagnostic studies provides visualization of cerebral blood vessels?
Cerebral angiography Explanation: Cerebral angiography provides visualization of cerebral blood vessels and can localize most cerebral trauma. A PET scan measures the brain's activity and is useful in differentiating tumor from scar tissue or radiation necrosis. Cytologic studies of the cerebral spinal fluid (CSF) may be performed to detect malignant cells because central nervous system tumors can shed cells into the CSF. Computer-assisted stereotactic biopsy is being used to diagnose deep-seated brain tumors.
The physician's office nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm?
Cerebral angiography Explanation: The nurse would anticipate a cerebral angiography, which detects distortion of the cerebral arteries and veins . A myelogram detects abnormalities of the spinal canal. An electroencephalogram records electrical impulses of the brain. An echoencephalography is an ultrasound of the structures of the brain.
A nurse is working in a neurologist's office. The physician orders a Romberg test. What should the nurse instruct the client to do?
Close eyes and stand erect. Explanation: In the Romberg test, the client stands erect with the feet close together and eyes closed. If the client sways as if to fall, it is considered a positive Romberg test. All of the other options include components of neurologic tests, indicating neurologic deficits and balance.
A client is waiting in a triage area to learn the medical status of family members following a motor vehicle accident. The client is pacing, taking deep breaths, and handwringing. Considering the effects in the body systems, what does the nurse anticipate the liver will do?
Convert glycogen to glucose for immediate use. Explanation: When the body is under stress, the sympathetic nervous system is activated readying the body for action. The effect of the body is to mobilize stored glycogen to glucose to provide additional energy for body action
muscular dystrophy symptoms
Difficult walking, muscle weakness, frequent falls, delay in muscle skills, drooping eyelids (ptosis), drooling, intellectual retardation, contractures, and skeletal deformities.
Which is a sympathetic effect of the nervous system?
Dilated pupils Explanation: Dilated pupils are a sympathetic effect of the nervous system, whereas constricted pupils are a parasympathetic effect. Decreased blood pressure is a parasympathetic effect, whereas increased blood pressure is a sympathetic effect. Increased peristalsis is a parasympathetic effect, but decreased peristalsis is a sympathetic effect. Decreased respiratory rate is a parasympathetic effect, and increased respiratory rate is a sympathetic effect.
The nurse is caring for a client hospitalized after a motor vehicle accident. The client has a comorbidity of Parkinson's disease. Why should the nurse closely monitor the condition and the drug regimen of a client with Parkinson's disease?
Drugs administered may cause a wide variety of adverse effects. Explanation: Drugs administered for Parkinsonism may cause a wide variety of adverse effects, which requires careful observation of the client. Over time, clients may respond less and less to their standard drug therapy and have more frequent "off episodes" of hypomobility. As a result, the nurse should administer the drugs closely to the schedule. Generally, a single drug called levodopa is administered to clients with Parkinson's disease. It is also not true that drugs may not cause the requisite therapeutic effect or such clients do not adhere to the drug regimen.
A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head?
Elevated 30 degrees Explanation: After supratentorial surgery, the nurse should elevate the client's head 30 degrees to promote venous outflow through the jugular veins. The nurse would keep the client's head flat after infratentorial, not supratentorial, surgery. However, after supratentorial surgery to remove a chronic subdural hematoma, the neurosurgeon may order the nurse to keep the client's head flat; typically, the client with such a hematoma is older and has a less expandable brain. A client without a bone flap can't be positioned with the head turned onto the operative side because doing so may injure brain tissue. Elevating the head 10 degrees or less wouldn't promote venous outflow through the jugular veins.
A client has undergone a lumbar puncture as part of a neurological assessment. The client is put under the care of a nurse after the procedure. Which important postprocedure nursing intervention should be performed to ensure the client's maximum comfort?
Encourage the client to drink liberal amounts of fluids Explanation: The nurse should encourage the client to take liberal fluids and should inspect the injection site for swelling or hematoma. These measures help restore the volume of cerebrospinal fluid extracted. The client is administered antihistamines before a test only if he or she is allergic to contrast dye and contrast dye will be used. The room of the client who has undergone a lumbar puncture should be kept dark and quiet. The client should be encouraged to rest, because sensory stimulation tends to magnify discomfort.
How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)?
Every 15 minutes Explanation: Neurological assessment and vital signs (except temperature) should be taken every 15 minutes initially while the patient is receiving tPA infusion.
A client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. While assessing the client, the nurse expects which of the following findings?
Excessive urine output and decreased urine osmolality Explanation: Diabetes insipidus is the result of decreased secretion of antidiuretic hormone (ADH). The client has excessive urine output, decreased urine osmolality, and serum hyperosmolarity.
After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know whether the client has a cervical spinal injury. Until such an injury is ruled out, the nurse should restrict this client to which position?
Flat, except for logrolling as needed Explanation: When caring for the client with a possible cervical spinal injury who's wearing a cervical collar, the nurse must keep the client flat to decrease mobilization and prevent further injury to the spinal column. The client can be logrolled, if necessary, with the cervical collar on.
A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to do perform which action?
Form understandable words and comprehend spoken words Explanation: Global aphasia is a combination of expressive and receptive aphasia and presents a tremendous challenge to the nurse to communicate effectively with the client. In receptive and expressive aphasia, the client is unable to form words that are understandable. The client who is unable to speak at all is referred to as mute.
Which anatomic part supplies cerebrospinal fluid to the subarachnoid space and down the spinal cord on the dorsal surface?
Fourth ventricle Explanation: Cerebrospinal fluid (CSF), produced in the ventricles, is circulated around both the brain and the spinal cord by the ventricular system. The fourth ventricle supplies CSF to the subarachnoid space and down the spinal cord on the dorsal surface. The third and fourth ventricles connect via the aqueduct of Sylvius. The arachnoid villus is the area in the brain where CSF is absorbed.
A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?
Frontal Explanation: If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation.
A nurse is assisting with the clinical examination for determination of brain death for a client, related to potential organ donation. All 50 states in the United States recognize uniform criteria for brain death. The nurse is aware that the three cardinal signs of brain death on clinical examination are all of the following except:
Glasgow Coma Scale of 6 Explanation: The three cardinal signs of brain death on clinical examination are coma, absence of brain stem reflexes, and apnea. The Glasgow Coma Scale is a tool for determining the client's level of consciousness. A score of 3 indicates a deep coma, and a score of 15 is normal.
A nurse is caring for a client with lower back pain who is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should place the client in which position?
Head of the bed elevated 45 degrees Explanation: After a myelogram, positioning depends on the dye injected. When a water-soluble dye such as metrizamide is injected, the head of the bed is elevated to a 45-degree angle to slow the upward dispersion of the dye. The prone and supine positions are contraindicated when a water-soluble contrast dye is used. The client should be positioned supine with the head lower than the trunk after an air-contrast study.
A client is diagnosed with a brain angioma. When teaching the client about the risks associated with this type of brain tumor, the nurse would educate about signs and symptoms associated with which condition?
Hemorrhagic stroke Explanation: Brain angiomas (masses composed largely of abnormal blood vessels) are found either in the brain or on its surface. Because the walls of the blood vessels in angiomas are thin, affected clients are at risk for hemorrhagic stroke. Pituitary adenomas that produce hormones can lead to endocrine disorders, such as thyroid disorders. In addition, they can exert pressure on the optic nerves and optic chiasm, leading to vision loss. Acoustic neuromas are associated with hearing loss.
Which is the most common cause of acute encephalitis in the United States?
Herpes simplex virus (HSV) Explanation: HSV-1 ( herpes simplex virus) is the most common cause of acute encephalitis in the United States. Fungal infections of the central nervous system occur rarely in healthy people. The Western equine encephalitis virus is one of four types of arboviral encephalitis that occur in North America is one of several fungi that may cause fungal encephalitis. Lyme disease leads to flu like symptoms and starts as a local infection which can systematically spread causing organ issues, however the incidence is rate, HIV leads to autoimmune disorders.
Which disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive, involuntary dancelike movements and dementia?
Huntington disease Explanation: Because it is transmitted as an autosomal dominant genetic disorder, each child of a parent with Huntington disease has a 50% risk of inheriting the illness. Multiple sclerosis is a chronic, degenerative, progressive disease of the central nervous system (CNS) characterized by the occurrence of small patches of demyelination in the brain and spinal cord. Parkinson disease is associated with decreased levels of dopamine due to destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain. Creutzfeldt-Jakob disease is a rare, transmissible, progressive and fatal disease of the CNS characterized by spongiform degeneration of the gray matter of the brain.
A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To confirm that this drug is producing its therapeutic effect, the nurse should consider which finding most significant?
Increased urine output Explanation: The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.
An emergency department nurse is interviewing a client who is presenting with signs of an ischemic stroke that began 2 hours ago. The client reports a history of a cholecystectomy 6 weeks ago and is taking digoxin, warfarin, and labetalol. What factor poses a threat to the client for thrombolytic therapy?
International normalized ratio greater than 2 Explanation: The client is at risk for further bleeding if the international normalized ratio is greater than 2. Thrombolytic therapy must be initiated within 3 hours in clients with ischemic stroke. The client is not eligible for thrombolytic therapy if she has had surgery within 14 days. Digoxin and labetalol do not prohibit thrombolytic therapy.
A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention?
Keeping the client in one position to decrease bleeding Explanation: The student nurse shouldn't keep the client in one position. She should carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of rebleeding.
The nurse is providing postoperative care for a client who just underwent surgery to remove a metastatic intramedullary tumor. On postoperative day 3, the client states, "I am really looking forward to going running again, it had become too difficult because of the loss of feeling in my feet." Which should the nurse address in the client's care plan?
Knowledge deficit Explanation: Clients with extensive neurologic deficits before surgery usually do not make significant functional recovery, even after successful tumor removal. In this case, the client had already developed bilateral sensory loss in the lower extremities indicating the fairly progressed impact of the tumor on the client's functional ability. The client's statement reflects a knowledge deficit and it is a priority to provide information regarding the possibility that lower extremity sensation may not return. Although body image disturbance and anxiety may be identified and addressed. This would occur after the client demonstrates an accurate understanding of loss of functional capabilities as a result of the progressed tumor. Ensuring the client understands the extent of functional loss due to the impact of the tumor is a priority. The client does not demonstrate impaired cognition.
A client has experienced an ischemic stroke that has damaged the frontal lobe of his brain. Which of the following deficits does the nurse expect to observe during assessment?
Limited attention span and forgetfulness Explanation: Damage to the frontal lobe may impair learning capacity, memory, or other higher cortical intellectual functions. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation. Damage to the motor neurons may cause hemiparesis, hemiplegia, and a change in reflexes. Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia.
The patient with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?
Limiting bladder catheterization to once every 12 hours
A client was undergoing conservative treatment for a herniated nucleus pulposus, at L5 - S1, which was diagnosed by magnetic resonance imaging. Because of increasing neurologic symptoms, the client undergoes lumbar laminectomy. The nurse should take which step during the immediate postoperative period?
Logroll the client from side to side. Explanation: Logrolling the client maintains alignment of his hips and shoulders and eliminates twisting in his operative area. The nurse should encourage ROM exercises to maintain muscle strength. Because of pressure on the operative area, having the client sit up in a chair or with the head of the bed elevated should be allowed only for short durations.
The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)?
Maintain cerebral perfusion pressure from 50 to 70 mm Hg Explanation: The nurse should maintain cerebral perfusion pressure from 50 to 70 mm Hg to help control increased ICP. Other measures include elevating the head of the bed as prescribed, maintaining the client's head and neck in neutral alignment (no twisting or flexing the neck), initiating measures to prevent the Valsalva maneuver (e.g., stool softeners), maintaining body temperature within normal limits, administering O2 to maintain PaO2 greater than 90 mm Hg, maintaining fluid balance with normal saline solution, avoiding noxious stimuli (e.g., excessive suctioning, painful procedures), and administering sedation to reduce agitation.
A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following actions would be the first priority?
Maintenance of a patent airway Explanation: The most important consideration in managing the patient with altered LOC is to establish an adequate airway and ensure ventilation.
Which is the primary vector of arthropod-borne viral encephalitis in North America?
Mosquitoes Explanation: The primary vector in North America related to anthropoid-borne virus encephalitis is a mosquito. Birds are associated with the West Nile virus. Spiders and ticks are not vectors for arthropod-borne virus encephalitis.
The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly?
Moving the head and chin toward the chest Explanation: The neck is examined for stiffness or abnormal position. The presence of rigidity is assessed by moving the head and chin toward the chest. The nurse should not maneuver the neck if a head or neck injury is suspected or known. The neck should also not be maneuvered if trauma to any part of the body is evident. Moving the head toward the sides or pressing the bones on the neck will not help assess for neck rigidity correctly. While assessing for neck rigidity, sensation at the neck area is not to be assessed
Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of small patches of demyelination in the brain and spinal cord?
Multiple sclerosis Explanation: The cause of MS is not known, and the disease affects twice as many women as men. Parkinson disease is associated with decreased levels of dopamine caused by destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain. Huntington disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary dancelike movements and dementia. Creutzfeldt-Jakob disease is a rare, transmissible, progressive fatal disease of the central nervous system characterized by spongiform degeneration of the gray matter of the brain.
Which of the following is the initial diagnostic in suspected stroke?
Noncontrast computed tomography (CT) Explanation: An initial head CT scan will determine whether or not the patient is experiencing a hemorrhagic stroke. An ischemic infarction will not be readily visible on initial CT scan if it is performed within the first few hours after symptoms onset; however, evidence of bleeding will almost always be visible.
During assessment of a hospitalized client who is recovering from a cervical discectomy, the client reports sudden and severe pain. Which of the following interventions is the nurse's priority?
Notify the client's surgeon. Explanation: If a client recovering from cervical discectomy experiences sudden increased pain, the graft may have extruded, requiring reoperation. The nurse should report this finding promptly to the surgeon. The nurse would not change the bandage or give medicine without a surgeon's order.
A nurse is caring for a client with slight expressive aphasia. Which nursing technique(s) facilitates communication with the client? Select all that apply.
Offer a communication board. Allow time for the client to respond to questions. Guess words the client has difficulty saying and confirm understanding with the client. Explanation: The nurse should offer a communication board to the client, allow time for the client to respond to questions, and guess words the client has difficulty saying and confirm understanding with the client. Encouraging exercises such as whistling are appropriate for a client with dysarthria, not expressive aphasia. Providing sensory aids such as glasses is a technique appropriate for a client with receptive aphasia, not expressive aphasia.
Which of the following is a late symptom of spinal cord compression?
Paralysis Explanation: Later symptoms include evidence of motor weakness and sensory deficits progressing to paralysis. Early symptoms associated with spinal cord compression include bladder and bowel dysfunction (urinary incontinence or retention; fecal incontinence or constipation).
A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report?
Paresthesia Explanation: When a client reports numbness and tingling in an area, the client is reporting a paresthesia. The nurse would document the experience as such or place the client's words in parentheses. The nurse would not make a medical diagnosis of sciatic nerve pain or herniation. The symptoms are not consistent with paralysis.
A client newly diagnosed with Huntington diease asks for information concerning management of symptoms. Which action would the nurse first take to address this request?
Perform a focused assessment on the client's needs and capabilities. Explanation: Nurses must look beyond the disease to focus on the patient's needs and capabilities first. While the client will benefit from the expertise of a Huntington disease multidisciplinary team, it is important to first establish their goals and individual needs. Only after a full assessment should medications be recommended by anyone on a health care team. In clients who present with rigidity, some temporary benefit may be obtained from antiparkinson medications, such as levodopa. Establishing a client's willingness to adhere to treatments is premature until the treatment plan is established. Huntington disease is characterized by a triad of symptoms that include motor dysfunction (the most prominent being chorea), impaired cognition, and behavioral features such as a blunted affect. Huntington disease is a progressive and terminal illness at this time. The focus for this client is optimizing quality of life with available medications and supportive treatments.
A client with a T4-level spinal cord injury (SCI) reports severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp and suspects autonomic dysreflexia. What is the first thing the nurse will do?
Place the client in a sitting position. Explanation: The nurse immediately places the client in a sitting position to lower blood pressure. Next, the nurse will do a rapid assessment to identify and alleviate the cause, and then check the bladder and bowel. The nurse will examine skin for any places of irritation. If no cause can be found, the nurse will give an antihypertensive as ordered and continue to look for cause. He or she watches for rebound hypotension once cause is alleviated. Antiembolic stockings will not decrease the blood pressure.
The nurse is assessing a newly admitted client with a diagnosis of meningitis. On assessment, the nurse expects to find which of the following?
Positive Kernig's sign Explanation: A positive Kernig's sign is a common finding in the client with meningitis. When the client is lying with the thigh flexed on the abdomen, the leg cannot be completely extended. A positive Brudzinski's sign is usual with meningitis. The Romberg sign would not be tested in this client. The client will develop lethargy as the illness progresses, not hyper-alertness.
Which is a component of the nursing management of the client with new variant Creutzfeldt-Jakob disease (vCJD)?
Providing supportive care Explanation: vCJD is a progressive fatal disease, and no treatment is available. Because of the fatal outcome of vCJD, nursing care is primarily supportive and palliative. Prevention of disease transmission is an important part of providing nursing care. Although client isolation is not necessary, use of standard precautions is important. Institutional protocols are followed for blood and body fluid exposure and decontamination of equipment. Organ donation is not an option because of the risk for disease transmission. Amphotericin B is used in the treatment of fungal encephalitis; no treatment is available for vCJD.
The nurse is caring for a client immediately after a spinal cord injury. Which assessment finding is essential when caring for a client in spinal shock with injury in the lower thoracic region?
Pulse and blood pressure Explanation: Spinal shock is a loss of sympathetic reflex activity below the level of the injury within 30 to 60 minutes after insult. In addition to the paralysis, manifestations include pronounced hypotension, bradycardia, and warm, dry skin. Numbness and tingling and pain are not as high of a concern at this time due to the cord injury. Because the level of impairment is below the first thoracic vertebrae, respiratory failure is not a concern.
Which of the following is the first-line therapy for myasthenia gravis (MG)?
Pyridostigmine bromide (Mestinon) Explanation: Mestinon, an anticholinesterase medication, is the first-line therapy in MG. It provides symptomatic relief by inhibiting the breakdown of acetylcholine and increasing the relative concentration of available acetylcholine at the neuromuscular junction. If Mestinon does not improve muscle strength and control fatigue, the next agents used are immunosuppressant agents. Imuran is an immunosuppressive agent that inhibits T lymphocytes and reduces acetylcholine receptor antibody levels. Baclofen is used in the treatment of spasticity in MG.
The nurse is caring for a patient with Huntington's disease in the long-term care facility. What does the nurse recognize as the most prominent symptom of the disease that the patient exhibits?
Rapid, jerky, involuntary movements Explanation: The most prominent clinical features of the disease are chorea (rapid, jerky, involuntary, purposeless movements), impaired voluntary movement, intellectual decline, and often personality changes (Aubeeluck & Wilson, 2008).
A client on your unit is scheduled to have intracranial surgery in the morning. Which nursing intervention helps to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting?
Restrict fluids before surgery. Explanation: Before surgery, the nurse should restrict fluids to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting. The nurse administers prescribed medications such as an anticonvulsant phenytoin, like Dilantin, to reduce the risk of seizures before and after surgery, an osmotic diuretic, and corticosteroids. Preoperative sedation is omitted.
A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan?
Risk for injury Explanation: Because the client is disoriented and restless, the most important nursing diagnosis is Risk for injury. Although Disturbed sensory perception (visual), Dressing or grooming self-care deficit, and Impaired verbal communication may all be appropriate, they're secondary because they don't immediately affect the client's health or safety.
Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event?
Seizure was 1 minute in duration including tonic-clonic activity. Explanation: Describing the length and the progression of the seizure is a priority nursing responsibility. During this time, the client will experience respiratory spasms, and their skin will appear cyanotic, indicating a period of lack of tissue oxygenation. Noting when the seizure began and presence of an aura are also valuable pieces of information. Postictal behavior should be documented along with vital signs, oxygen saturation, and assessment of tongue and oral cavity.
The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient?
Semi-Fowler's Explanation: The head of the bed is elevated 15 to 30 degrees (semi-Fowler's position) to promote venous drainage and decrease intracranial pressure.
Which neurotransmitter demonstrates inhibitory action, helps control mood and sleep, and inhibits pain pathways?
Serotonin Explanation: The brain stem, hypothalamus, and dorsal horn of the spinal cord are sources of serotonin. Enkephalin is excitatory and associated with pleasurable sensations. Norepinephrine is usually excitatory and affects mood and overall activity. Acetylcholine is usually excitatory, but the parasympathetic effects are sometimes inhibitory.
A client has a herniated disk in the region of the third and fourth lumbar vertebrae. Which nursing assessment finding most supports this diagnosis?
Severe lower back pain Explanation: The most common finding in a client with a herniated lumbar disk is severe lower back pain, which radiates to the buttocks, legs, and feet - usually unilaterally. A herniated disk also may cause sensory and motor loss (such as foot drop) in the area innervated by the compressed spinal nerve root. During later stages, it may cause weakness and atrophy of leg muscles. The condition doesn't affect bowel sounds or the arms.
Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch?
Spasticity Explanation: Spasticity is often associated with weakness, increased deep tendon reflexes, and diminished superficial reflexes. Akathisia refers to restlessness, an urgent need to move around, and agitation. Ataxia refers to impaired ability to coordinate movement. Myoclonus refers to spasm of a single muscle or group of muscles.
The nurse is caring for a client immediately following a spinal cord injury (SCI). Which is an acute complication of SCI?
Spinal shock Explanation: Acute complications of SCI include spinal and neurogenic shock and deep vein thrombosis (DVT). The spinal shock associated with SCI reflects a sudden depression of reflex activity in the spinal cord (areflexia) below the level of injury. Cardiogenic shock is not associated with SCI. Tetraplegia is paralysis of all extremities after a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Autonomic dysreflexia is a long-term complication of SCI.
Which condition occurs when blood collects between the dura mater and arachnoid membrane?
Subdural hematoma Explanation: A subdural hematoma is a collection of blood between the dura mater and the brain, a space normally occupied by a thin cushion of fluid. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with displacement of surrounding structures. An epidural hematoma is bleeding between the inner skull and the dura, compressing the brain underneath. An extradural hematoma is another name for an epidural hematoma.
A patient with Bell's palsy says to the nurse, "It doesn't hurt anymore to touch my face. How am I going to get muscle tone back so I don't look like this anymore?" What interventions can the nurse suggest to the patient?
Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. Explanation: After the sensitivity of the nerve to touch decreases and the patient can tolerate touching the face, the nurse can suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. Facial exercises, such as wrinkling the forehead, blowing out the cheeks, and whistling, may be performed with the aid of a mirror to prevent muscle atrophy. Exposure of the face to cold and drafts is avoided.
A client who's paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis?
The client uses a mirror to inspect the skin. Explanation: The client demonstrates understanding of safety measures related to paralysis when he uses a mirror to inspect his skin. The mirror enables the client to inspect all areas of the skin for signs of breakdown without the help of staff or family members. The client should keep the side rails up to help with repositioning and to prevent falls. The paralyzed client should take responsibility for repositioning or for reminding the staff to assist with it, if needed. A client with left-side paralysis may not realize that the left arm is hanging over the side of the wheelchair. However, the nurse should call this position to the client's attention because the arm can get caught in the wheel spokes or develop impaired circulation from being in a dependent position for too long.
A client diagnosed with Parkinson's disease has developed slurred speech and drooling. The nurse knows that these symptoms indicate which of the following?
The disease has entered the late stages. Explanation: In late stages, the disease affects the jaw, tongue, and larynx; speech is slurred; and chewing and swallowing become difficult. Rigidity can lead to contractures. Salivation increases, accompanied by drooling. In a small percentage of clients, the eyes roll upward or downward and stay there involuntarily (oculogyric crises) for several hours or even a few days. Options A, B, and C are therefore incorrect.
Neurological level of spinal cord injury refers to which of the following?
The lowest level at which sensory and motor function is normal Explanation: "Neurologic level" refers to the lowest level at which sensory and motor functions are normal. It is not the level of spinal cord transection, the best possible level of recovery, or the highest level at which sensory and motor function is normal.
The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury?
Traction with weights and pulleys Explanation: Traction with weights and pulleys is applied to provide correct vertebral alignment and to increase the space between the vertebrae. A cast and a cervical collar are used to immobilize the injured portion of the spine. A turning frame is used to change the client's position without altering the alignment of the spine.
A client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what?
Transient ischemic attack Explanation: A transient ischemic attack (TIA) is a sudden, brief attack of neurologic impairment caused by a temporary interruption in cerebral blood flow. Symptoms may disappear within 1 hour; some continue for as long as 1 day. When the symptoms terminate, the client resumes his or her presymptomatic state. The symptoms do not describe a left- or right-sided stroke or a cerebral aneurysm.
A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. He reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder?
Trigeminal neuralgia, a painful disorder of one or more branches of cranial nerve V (trigeminal), produces paroxysmal attacks of excruciating facial pain. Attacks are precipitated by stimulation of a trigger zone on the face. Triggering events may include light touch to a hypersensitive area, a draft of air, exposure to heat or cold, eating, smiling, talking, or drinking hot or cold beverages. It occurs most commonly in people older than age 40. Bell's palsy is a disease of cranial nerve VII that produces unilateral or bilateral facial weakness or paralysis. Migraine headaches are throbbing vascular headaches that usually begin to occur in childhood or adolescence. Headache pain may emanate from the pain-sensitive structures of the skin, scalp, muscles, arteries, and veins; cranial nerves V, VII, IX, and X; or cervical nerves 1, 2, and 3. Occasionally, jaw pain may indicate angina pectoris.
A client diagnosed with Huntington disease is on a disease-modifying drug regimen and has a urinary catheter in place. Which potential complication is the highest priority for the nurse while monitoring the client?
Urinary tract infection Explanation: Because all disease-modifying drug regimens for Huntington disease can decrease immune cells and infection protection, it is most important for the nurse to assess for acquired infections such as urinary tract infections, especially if the client is catheterized. Severe depression is common and can lead to suicide. Symptoms of Huntington disease develop slowly and include mental apathy and emotional disturbances, choreiform movements (uncontrollable writhing and twisting of the body), grimacing, difficulty chewing and swallowing, speech difficulty, intellectual decline, and loss of bowel and bladder control. Assessing for these other conditions is appropriate but not as important as assessing for urinary tract infection in the client on a disease-modifying drug regimen with a urinary catheter in place.
A high school soccer player sustained five concussions before she was told that she should never play contact sports again. After her last injury, she began experiencing episodes of double vision. She was told that she had most likely incurred damage to which cranial nerve?
VI (Abducens) Explanation: The abducens cranial nerve supports movement of the eye laterally. Damage to the nerve can cause double vision.
The nurse who is employed in a neurologist's office is performing a history and assessment on a client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of which cranial nerve?
VIII Explanation: There are 12 pairs of cranial nerves. Cranial nerve VIII is the vestibulocochlear or auditory nerve responsible for hearing and balance. Cranial nerve II is the optic nerve. Cranial nerve VI is the abducens nerve responsible for eye movement. Cranial nerve XI is the accessory nerve and is involved with head and shoulder movement
Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury?
Widened pulse pressure Explanation: Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic blood pressure, and widening pulse pressure (Cushing reflex). As brain compression increases, respirations decrease or become erratic, blood pressure may decrease, and the pulse slows further. This is an ominous development, as is a rapid fluctuation of vital signs. Temperature is maintained at less than 38°C (100.4°F). Tachycardia and arterial hypotension may indicate that bleeding is occurring elsewhere in the body.
A client was hit in the head with a ball and knocked unconscious. Upon arrival at the emergency department and subsequent diagnostic tests, it was determined that the client suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would the nurse expect this subdural hematoma to be classified?
acute Explanation: Subdural hematomas are classified as acute, subacute, and chronic according to the rate of neurologic changes. Symptoms progressively worsen in a client with an acute subdural hematoma within the first 24 hours of the head injury.
A client diagnosed with a stroke is ordered to receive warfarin. Later, the nurse learns that the warfarin is contraindicated and the order is canceled. The nurse knows that the best alternative medication to give is
aspirin. Explanation: If warfarin is contraindicated, aspirin is the best option, although other medications may be used if both are contraindicated.
Medical management of arthropod-borne virus (arboviral) encephalitis is aimed at
controlling seizures and increased intracranial pressure. Explanation: There is no specific medication for arbovirus encephalitis; therefore symptom management is key. Medical management is aimed at controlling seizures and increased intracranial pressure.
What is one of the earliest signs of increased ICP?
decreased level of consciousness (LOC) Explanation: Headache is a symptom of increased ICP, but decreasing LOC is one of the earliest signs of increased ICP. Cushing's triad occurs late in increased ICP. If untreated, increasing ICP will lead to coma.
An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to
dehydrate the brain and reduce cerebral edema. Explanation: Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid. Antipyretics and a cooling blanket are used to control fever in the client with increased ICP. Chlorpromazine may be prescribed to control shivering in the client with increased ICP. Medications such as barbiturates are given to the client with increased ICP to reduce cellular metabolic demands.
Huntington's disease symptoms
depression, mood swings, limb movements problems, bruised from falling, and forget detail (dementia)
Cranial Nerve III: Oculomotor
eyelid elevation, pupil constriction and accommodation
muscular dystrophy
group of hereditary diseases characterized by degeneration of muscle and weakness
To meet the sensory needs of a client with viral meningitis, the nurse should:
minimize exposure to bright lights and noise. Explanation: Photophobia and hypersensitivity to environmental stimuli are the common clinical manifestations of meningeal irritation and infection. Therefore, the nurse should provide a calm environment with less stressful stimuli. Physical activity may worsen symptoms; therefore, physical activity should be reduced. Family members do not need to be avoided. People diagnosed with viral meningitis should be instructed to thoroughly wash hands frequently.
The nurse has completed evaluating the client's cranial nerves. The nurse documents impairment of the right cervical nerves (CN IX and CN X). Based on these findings, the nurse should instruct the client to
refrain from eating or drinking for now. Explanation: Significant findings of CN IX (glossopharyngeal) include difficulty swallowing (dysphagia) and impaired taste, and significant findings of CN X (vagus) include weak or absent gag reflex, difficulty swallowing, aspiration, hoarseness, and slurred speech (dysarthria). Based on these findings, the nurse should instruct the client to refrain from eating and drinking and should contact the health care provider. The other instructions are associated with abnormalities of CN II (optic) and CN VIII (acoustic)
Cranial Nerve XI: Accessory
shoulder movement and head rotation
trigeminal neuralgia symptoms
sudden onset of jabbing pain -can be caused by touching face, brushing, chewing, speaking unilateral more common in *women*
The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the
supine position with the head slightly elevated. Explanation: After surgery, the nurse should place the client in either a supine position with the head slightly elevated or a side-lying position on the unaffected side. The dorsal recumbent, Trendelenburg, and prone positions can increase intracranial pressure.
