Chp 53 Nervous System Questions

17. A right-handed patient has right-sided hemiplegia and aphasia from a stroke. What is the most likely location of the lesion? 1. Left frontal lobe 2. Right brainstem 3. Motor areas of the right cerebrum 4. Medial superior area of the temporal lobe

1 (Check back of book if this doesn't make sense)

Scrambled Term 25. orientdisation

Disorientation d unable to follow simple commands; thinking slowed; inattentive; flat affect

Midbrain

E

Pons

F

21. Few patients with advanced HIV disease (AIDS) ever actually develop neurologic symptoms. (1950) True or false

False: Approximately 80% of patients with advanced HIV disease (AIDS) have neurologic symptoms that result from infection from HIV itself or from associated complications of the disease.

22. Most elderly people will eventually experience dementia. (1903) True or false

False: Dementia is not a normal consequence of aging, but may be a result of many reversible conditions, including anemia, fluid and electrolyte imbalance, malnutrition, hypothyroidism, metabolic disturbances, drug toxicity, a drug reaction or idiosyncrasy, and hypotension.

20. Seventy to eighty percent of people who become infected with the West Nile virus develop encephalitis or meningitis. (1949) True or false

False: Seventy to eighty percent of people who become infected with the West Nile virus do not have any type of illness.

Medulla Oblongata

G

15. _________________________ is a generalized impairment of intellect, awareness, and judgment. (1951)

Global cognitive dysfunction

Gyri (convolutions)

H

16. _________________________ disease is characterized by abnormal and excessive involuntary writhing and twisting movements of the face, limbs, and body. (1938)

Huntington's

Suci (fissures)

I

Ventricles

J

Cerebellum

K

Spinal Cord

L

Scrambled Term 27. tosecomasemi

Semicomatose b Is in impaired state of consciousness, characterized by obtundation and stupor, from which a patient can be aroused only by energetic stimulation

Scrambled Term 26. porstu

Stupor a Responds to verbal commands with moaning or groaning, if at all; seems unaware of surroundings

18. Pain receptors are not adaptable----- they are specific for pain only and pain impulses continue at the same rate as long as the stimulus is present. (1912) True or false

True

19. Amyotrophic lateral sclerosis usually results in death 2 to 6 years after diagnosis. Respiratory tract infection secondary to compromised respiratory function is usually the cause. (1937) True or false

True

III—oculomotor

a Eye movements, extraocular muscles, pupillary control (pupillary constriction)

VII—facial

g Sense of taste on anterior two-thirds of tongue; contraction of muscles of facial expression

IX—glossopharyngeal

h Sensations of throat, taste, swallowing movements, gag reflex, taste posterior one third of tongue, secretion of saliva

VI—abducens

i Lateral movement of eye

X—vagus

j Sensations of throat, larynx, and thoracic and abdominal organs; swallowing, voice production, slowing of heartbeat, acceleration of peristalsis

XII—hypoglossal

k Tongue movements

14. The cerebrum is the largest part of the brain and cotains five majors regions: (1959)

motor; sensory; visual; speech; auditory

12. When teaching a patient with Parkinson's disease, which response would indicate the need for further education? 1. "If I miss an occasional dose of the medication, it doesn't matter much." 2. "I need to exercise at least some every day." 3. "I need to be sitting straight up with my chin slightly tucked so I won't choke when I eat or drink." 4. "I should eat a diet high in fiber and roughage to decrease my constipation."

1 (Check back of book if this doesn't make sense)

15. During admission of a patient with a severe head injury to the emergency department, what is the highest priority assessment for the nurse? 1. Patency of airway 2. Presence of a neck injury 3. Neurologic status with the Glasgow Coma Scale 4. Cerebrospinal fluid leakage from the ears or nose

1 (Check back of book if this doesn't make sense)

5. The nursing assessment of an 80-year-old who has had a stroke found that she had difficulty swallowing. A videofluoroscopy with barium was performed to rule out aspiration. The rehabilitation team in the skilled nursing facility determined that she can eat a soft diet with one-to-one supervision. Which action is important to prevent aspiration? 1. Tipping the head toward the unaffected side while swallowing 2. Extending the head during swallowing 3. Mixing solids and liquids to facilitate swallowing 4. Encouraging the patient to drink with a straw to make swallowing easier

1 (Check back of book if this doesn't make sense)

8. A 76-year-old who has had Parkinson's disease for the past 6 years has now been admitted to a long-term care facility. The nurse doing the admission interview and assessment notices which characteristic sign of the disease? 1. Bradykinesia 2. Increased postural reflexes 3. Sensory loss 4. Intention tremor

1 (Check back of book if this doesn't make sense)

19. Which sign or symptom of late-stage increased intracranial pressure should the LPN/LVN be aware of? (Select all that apply.) 1. Increase in systolic blood pressure 2. Widening of pulse pressure 3. Bradycardia 4. Unequal pupils that react slowly to light 5. Tachycardia

1,2,3 (Check back of book if this doesn't make sense)

3. A nurse in the emergency department of her community hospital is teaching a group of high school students how to prevent head and spine injuries. What should the nurse include in the presentation? (Select all that apply.) 1. Use helmets for bicycles, motorcycles, and skateboarding. 2. Use helmets when participating in contact sports. 3. Never drive or ride with someone under the influence of alcohol or drugs. 4. Wear seatbelts and shoulder harnesses when driving or riding in a car. 5. Avoid diving in water less than 6 feet deep.

1,2,3,4,5 (Check back of book if this doesn't make sense)

2. A 35-year-old patient is being seen for complaints of headache, which she has experienced for the past month. Her health care provider wants to rule out a brain tumor. What diagnostic tests will be most helpful in formulating this diagnosis? (Select all that apply.) 1. Brain scan 2. PET scan 3. Lumbar puncture 4. Electroencephalography 5. MRI

1,2,4,5 (Check back of book if this doesn't make sense)

20. What nursing interventions should the nurse include in the plan of care for a patient who has had a stroke with right-sided hemiplegia and expressive aphasia? (Select all that apply.) 1. Allow the patient ample time to verbalize his needs. 2. Encourage self-help behaviors as much as possible, such as feeding. 3. Monitor the patient's neurologic status once a day. 4. Perform ROM to affected extremities every shift. 5. Implement the use of a communication board for the patient to use as needed.

1,2,4,5 (Check back of book if this doesn't make sense)

17. In untreated cases of brain abscess, the mortality rate approaches _______%. (1950)

100

14. The nursing care plan for a patient with increased intracranial pressure will include what as the most therapeutic position for the patient? 1. Keep the head of the bed flat. 2. Maintain the head of the bed at 30 degrees. 3. Increase the head of the bed's angle to 30 degrees with patient on left side. 4. Use a continuous-rotation bed to continuously change patient position.

2 (Check back of book if this doesn't make sense)

7. A patient was involved in a snowmobile accident. On admission to the emergency department, he is receiving oxygen and is intubated. His Glasgow Coma Scale score is 6. About 10 minutes after arrival, he is noted to have a widened pulse pressure, increased systolic blood pressure, and bradycardia. Which finding indicates to the nurse that late-stage increased ICP is present? 1. Anisocoria 2. Supratentorial shift 3. Cushing's response 4. Medullary reflex

2 (Check back of book if this doesn't make sense) (Answer should be 3, Brady cardia, widening pulse pressure and increase systolic pressure is Cushing 's response... NOT related to Cushing's disease, same Doctor discovered both)

What neurotransmitter primarily affects motor function and is involved in gross subconscious movements of the skeletal muscles? 1. Acetylcholine 2. Norepinephrine 3. Dopamine 4. Serotonin

3 The neurotransmitter that primarily affects motor function and is involved in gross subconscious movements of the skeletal muscles is known as dopamine. Dopamine also plays a role in emotional responses. In Parkinson disease, there is a deficiency of dopamine, and the patient suffers from tremors or involuntary trembling movements. Acetylcholine plays a role in nerve impulse transmission; it spills into the synapse area and speeds the transmission of the impulse. Norepinephrine has an impact on maintaining arousal, dreaming, and regulation of mood. Serotonin induces sleep, affects sensory perception, controls temperature, and has a role in the control of mood.REF: Page 1897

1. A patient is admitted to the hospital with a diagnosis of transient ischemic attack (TIA). The patient asks the nurse to explain to him what a TIA is. Which statement by the nurse is most accurate? 1. "A TIA is the result of permanent cerebrovascular insufficiency." 2. "An episode of a TIA may last up to 2 days." 3. "A TIA is often a precursor to a stroke." 4. "A TIA generally occurs once and never occurs again."

3 (Check back of book if this doesn't make sense)

10. A patient is diagnosed with Bell's palsy as indicated by a feeling of stiffness and a drawing sensation of the face. What is important to teach her about the disease? 1. There is a heightened awareness of taste, so foods must be bland. 2. There may be an increased sensitivity to sound. 3. The eye is susceptible to injury if the eyelid does not close. 4. Drooling from increased saliva on the affected side may occur.

3 (Check back of book if this doesn't make sense)

18. A patient experiencing TIAs is scheduled for a carotid endarterectomy. The patient asks the nurse what this procedure is. The nurse correctly responds with which response? 1. "This procedure promotes cerebral flow to decrease cerebral edema." 2. "This procedure reduces the brain damage that occurs during a stroke." 3. "This procedure helps prevent a stroke by removing atherosclerotic plaques obstructing cerebral blood flow." 4. "This procedure provides a circulatory bypass around thrombotic plaques obstructing cranial circulation."

3 (Check back of book if this doesn't make sense)

21. The nurse is caring for a patient with myasthenia gravis. The patient asks the nurse about the causes of the disease. Which response by the nurse is correct? 1. "Myelin sheath breakdown has caused your myasthenia gravis." 2. "Degeneration of the dopamine-producing neurons in the midbrain most commonly causes the disease." 3. "Antibodies attacking the acetylcholine receptors, damaging them, and reducing their number is the most likely cause of myasthenia gravis." 4. "Myasthenia gravis is usually caused by inflammation of cranial nerve VII."

3 (Check back of book if this doesn't make sense)

23. A patient has been diagnosed with Bell's palsy. This condition impacts which cranial nerve? 1. Cranial nerve V 2. Cranial nerve VI 3. Cranial nerve VII 4. Cranial nerve VIII

3 (Check back of book if this doesn't make sense)

25. What plan of care is considered beneficial for select patients who have experienced an ischemic stroke? 1. IV Tensilon in the first 3 hours 2. Anticholinesterase in the first 3 hours 3. Thrombolytic such as tPA in the first 3 hours 4. Intravenous immune globulin in the first 3 hours

3 (Check back of book if this doesn't make sense)

9. A 13-year-old student is admitted to the pediatric unit with possible meningitis. The nurse finds that the patient cannot extend her legs completely without experiencing extreme pain. The nurse correctly documents this as which sign? 1. Brudzinski's sign 2. Battle's sign 3. Kernig's sign 4. Cosgrow's sign

3 (Check back of book if this doesn't make sense)

13. The nurse is caring for a patient who suffered a cervical spinal cord injury. What injury can most likely be anticipated? 1. Tetraplegia 2. Hemiplegia 3. Paraplegia 4. Paresthesia

3 (Check back of book if this doesn't make sense) [C stands for cervical, book has all Ca under tetraplegia in the chart, answer should be 1]

A male patient has been recently diagnosed with Parkinson disease. His wife asks the nurse numerous questions about the disease. What information is correct in addressing this wife's questions? 1. Parkinson disease is more common in women. 2. The tremor from Parkinson disease is more prominent with movement. 3. Symptoms of Parkinson disease appear when there is either an increase in dopamine or a decrease in acetylcholine levels in the basal ganglia. 4. Parkinson disease is a syndrome of bradykinesia, rigidity, tremor, and impaired postural reflexes.

4 Parkinson disease is a syndrome of slowing down in the initiation of movement (bradykinesia), increased muscle tone (rigidity), tremor, and impaired postural reflexes. Parkinson disease is more common in men than in women by a ratio of 3:2. The tremor from Parkinson disease is more prominent at rest, and decreases with movement of the affected body part. There is normally a balance between the neurotransmitters acetylcholine and dopamine in the basal ganglia. Symptoms of Parkinson disease appear when either there is a decrease in dopamine or an increase in acetylcholine levels.REF: Page 1926

11. The nurse is caring for a patient with a spinal cord injury who displays symptoms of autonomic dysreflexia. What intervention should the nurse implement first? 1. Sit the patient upright, if permitted. 2. Check for bladder distention. 3. Give nitroprusside (Nipride) as ordered. 4. Assess vital signs.

4 (Check back of book if this doesn't make sense)

16. When caring for a patient who has undergone a craniotomy, what is the primary nursing intervention? 1. Preventing infection 2. Ensuring patient comfort 3. Avoiding need for secondary surgery 4. Preventing increased intracranial pressure

4 (Check back of book if this doesn't make sense)

22. A patient who has been experiencing recent seizure activity is preparing to have diagnostic testing performed. The health care provider has explained that the test will provide a graphic recording of the electrical conduction activities of the brain. The patient understands that which test will be performed? 1. ECG 2. MRI 3. PET 4. EEG

4 (Check back of book if this doesn't make sense)

24. When reviewing the medical plan of treatment for a patient with Guillain-Barré syndrome, what therapies are considered to be most therapeutic? 1. Avonex and Betaseron 2. Thymectomy and Zarontin 3. Depakote and Zarontin 4. Plasmapheresis and intravenous immune globulin

4 (Check back of book if this doesn't make sense)

4. A 70-year-old with back pain is scheduled to have a myelogram in the morning to rule out a pathologic condition of the spine. In preparing him for the procedure, what statement by the nurse is accurate? 1. "We will be assessing your mental status frequently after the procedure." 2. "You will need to lie completely supine and still during the procedure." 3. "You will be able to ambulate immediately after the test." 4. "We will ask you if you have any numbness or tingling in your legs after the procedure."

4 (Check back of book if this doesn't make sense)

6. A 12-year-old has a history of generalized tonic-clonic seizures. The nurse educates the patient and his family by including which teaching points? 1. Most people feel normal immediately after the seizure. 2. It is important to place a tongue blade in his mouth during the seizure. 3. The tonic phase of the seizure usually lasts for 3 to 4 minutes. 4. It is not uncommon to lose consciousness during this type of seizure.

4(Check back of book if this doesn't make sense)

Meninges

A

Scrambled Term 24. treal

Alert e Responds appropriately to auditory, tactile, and visual stimuli

29. What behavior(s) would be considered normal neurologic changes related to aging? (Select all that apply.) (1903) 1. Drives slower to compensate for slowed reaction time 2. Demonstrates slight tremor while holding teacup when tired 3. Takes a foreign language class, but can't keep up with classmates 4. Does needlework, but has more trouble with fine , small stitches 5. Rearranges items on countertop, but action serves no purpose 6. Frequently misplaces keys or eyeglasses, but can usually find them

Answer 1, 2, 3, 4, 6: Changes related to aging include slowed reaction time, slowed learning, slight tremors when fatigued, increased difficulty with fine motor movement, and short-term memory loss. Nonpurposeful action like shuffling items is associated with dementia. Ability to locate misplaced items demonstrates a retention of problem-solving ability, despite some forgetfulness.

46. The nurse hears in report that the 33-year-old patient with multiple sclerosis (MS) is with- drawn, depressed, and emotionally labile. The nurse knows that emotional changes are part of the disease. What other aspect(s) of the disease is/are likely to be contributing to the patient's emotional state? (Select all that apply.) (1925, 1926) 1. Exacerbations and remissions are continu- ous; deterioration progresses. 2. The symptoms are vague, insidious, and widely distributed. 3. No specific treatments exist, although many treatments have been tried. 4. Multiple body systems are affected and function is lost in every area. 5. If cured in the early stages, patient can maintain independence and self-care.

Answer 1, 2, 3, 4: Multiple sclerosis is a disease that more frequently develops in young women. The onset is insidious, the symptoms are vague, and there are bouts of exacerbation and remission, but with progressive deterioration. The patient will be discouraged, because many treatments will have been tried, some will give partial symptom relief, but there is no cure and the patient sees herself getting progressively worse to the point of being totally helpless.

44. Select the measures that may be implemented to reduce venous volume in a patient experi- encing increased intracranial pressure. (Select all that apply.) (1916) 1. Restrict fluid intake 2. Place head in flexed postion 3. Avoid flexion of the hips 4.Administer enemas as needed. 5. Administer oxygen.

Answer 1, 3, 5: Fluid is restricted to avoid adding fluid volume to the system. Flexion of the hips increases intraabdominal and intrathoracic pressure. Oxygen is given to support impaired brain tissue. Head should be in a neutral position. Enemas are not recommended.

42. What is an early sign of increased intracranial pressure? (1914) 1. Change in level of consciousness 2. Decreased or abnormal respirations 3. Increased systolic blood pressure 4. Increased or widening pulse pressure

Answer 1: Change in level of consciousness is an early sign. The others are late signs.

51. The patient comes to the clinic and is exhibit- ing stroke symptoms. The health care provider believes that the patient is a possible candidate for thrombolytic therapy. What are the most important actions for the clinic staff to per- form? (1942) 1. Rapid triage and transport to a stroke center 2. Draw blood for coagulation tests and establish IV 3. Obtain a CT or MRI to rule out hemorrhagic stroke 4. Explain the risks and benefits of therapy to the patient

Answer 1: For thrombolytic therapy, the timing is critical to the outcome. The clinic staff should work towards immediate transfer to a stroke center. If the patient were to suddenly become unresponsive, the clinic staff would stop to intervene; otherwise no action should delay transfer to a stroke center.

35. The nurse is caring for a patient who has uni- lateral neglect that includes the nondominant hand. For which task is the patient most likely to require assistance? (1906) 1. Putting on her blouse 2. Brushing her hair 3. Using the remote control 4. Writing a letter

Answer 1: In unilateral neglect, the patient is unaware or inattentive to one side of the body; thus, she is unlikely to be able to accomplish any task that requires two hands. It is possible that she would struggle to put on one sleeve.

57. A young man who sustained a serious head injury several years ago is a resident in a long- term care facility. After the injury, he demon- strated intermittent poor judgment and occa- sional physical aggression. Today, he is trying to leave the facility. What should the nurse do first? (1954) 1. Speak calmly and redirect him to another activity. 2. Obtain an order for a PRN antianxiety medication. 3. Allow him to wander around, but keep an eye on him. 4. Instruct a UAP to perform one-on-one ob- servation.

Answer 1: Redirection is the best first action, because it is possible that the nurse can get him to focus on something else. Medicating him is possible, but is not the first action to try, because it would be considered a chemical restraint. Allowing him to wander is a possibility, but his agitation could increase. Assigning a UAP is also possible if the nurse believes that the resident is a danger to himself.

47. A resident with Parkinson's disease lives at a long term care facility. The patient has a flat facial expression, hand tremors, and bradykinesia. Which instruction will the nurse give to the UAP to address the bradykinesia? (1929) 1.He has a shuffling gait and needs assistance to prevent bumping into objects. 2. He has trouble bending to tie his shoes because of muscle soreness and aches. 3. He has trouble eating soup or drinking coffee because of fine hand tremors. 4. He has resistance to motion, so he may seem stiff when you put on his shirt.

Answer 1: The classic triad of Parkinson's includes tremors, rigidity, and bradykinesia. Bradykinesia affects the gait and he may be propelled forward until an obstacle stops him. Stiffness in bending or moving the arms is a sign of rigidity. Tremors affect fine motor control.

52. In caring for a patient with trigeminal neural- gia, what instructions would the nurse give to the UAP about assisting with hygiene and meals? (1945) 1. Use gentle touch when assisting with shaving. 2. Encourage the patient to drink cold liquids. 3. Ask the patient if he prefers to do his own care. 4. Offer to cut the patient's food into bite-sized pieces.

Answer 3: The patient may prefer to do his own care, because the face is very painful and he may fear that the UAP will cause pain just by touching. Shaving, combing hair, and hygiene in general can be deferred until the pain is better controlled. Warm puréed foods are best. Cold liquids are likely to increase pain.

38. A 35-year-old man who suffers from tension headaches requests opioid medications for the debilitating pain. Why is the health care provider unlikely to grant the patient's request? (1911) 1. Opioids are avoided because of the risk of abuse. 2. Tension headache pain does not warrant opioid use. 3. Pain receptor sites will not respond to opioids. 4. Tension headaches are controlled by reducing stress.

Answer 1: The health care provider is likely to suggest acetaminophen, phenacetin, ibuprofen, and aspirin. Narcotics are avoided because these drugs are often subject to abuse; it is much better to counsel patients to develop other ways to relieve headaches. The nurse should suggest nonpharmaceutical measures such as relaxation techniques, regular exercise, adequate sleep, and avoidance of alcohol.

53. A patient who is diagnosed with Bell's palsy will need to know how to use which device? (1946) 1. Eating utensil with a universal cuff 2. Eyeshield to be applied at night 3. Footboard for the end of the bed 4. A volar wrist splint for extension

Answer 2: Bell's palsy is an inflammation of the facial nerve and the muscles of the face of the affected side become flaccid. This includes the eyelid. The purpose of the eye shield at night is to prevent corneal damage because the eyelid will not close.

48. What is an early subjective symptom that the patient may report that would be characteristic of myasthenia gravis? (1936) 1. Muscle weakness in the extremities 2. Eyelid drooping and double vision 3. Trouble swallowing 4. Weak, nasal-sounding voice

Answer 2: Eyelid drooping and double vision are considered early signs. The other signs will come later as the disease progresses.

56. What is considered a prominent early sign of a brain tumor? (1951) 1. Speech impairment 2. Morning headache 3. Change in personality 4. Memory loss

Answer 2: Headaches are the most prominent early sign. Patients often report that the headache is more severe in the morning.

43. The nurse is checking the pupils of a patient who sustained a serious head injury. Which pupil response is the most ominous? (1914) 1. Pupil reacts, but is sluggish. 2. Pupil is fixed and dilated 3. Pupil is dilated, but will slowly constrict. 4. Pupil on affected side is larger.

Answer 2: The fixed and dilated pupil is the most ominous sign, which warrants immediate notification of the health care provider. None of these reactions are considered normal and all should be pointed out to the health care provider.

40. In caring for a patient with a headache, which instruction will the nurse give to the UAP? (1911) 1. Assist the patient to turn every 2 hours. 2. Keep the room quiet and dark. 3. Refresh warm compress as needed. 4. Maintain NPO status for nausea.

Answer 2: The patient is likely to be more comfortable in a quiet, dark room. The patient can turn self. Warm compresses are not needed. Patient may refuse foods and liquids during the peak of nausea, but does not need to be kept on NPO status.

54. In caring for a patient who is diagnosed with Guillain-Barré syndrome (GBS), what is the priority assessment? (1948) 1. Paralysis in the legs 2. Respiratory function 3. Change of mental status 4. Loss of bowel control

Answer 2: The weakness and paralysis will start in the legs and move upwards. The primary concern is that rapid progression upwards will cause paralysis of the respiratory muscles.

55. The nurse is caring for a patient who is diagnosed with bacterial meningitis. For this patient, what is the rationale for keeping the room quiet and dark? (1949) 1. Light and noise increase the subjective experience of pain. 2. Patient needs extra rest and sleep to facilitate recovery. 3. Any increased sensory stimulation may cause a seizure. 4. Critically ill patients do better in quiet environments.

Answer 3: For this patient, the reduction of stimuli decreases the risk for seizures, which are a complication of meningitis. The other options are correct rationales for different patient conditions.

41. The nurse is reviewing the medication list for a patient who is diabetic and sees that gaba- pentin (Neurontin) is prescribed. Which pain assessment will the nurse make? (1913) 1. Low-back pain with movement 2. Dull or throbbing headache 3. Burning or tingling in lower legs 4. Stiffness in joints in the morning

Answer 3: Gabapentin (Neurontin) is a medication that is prescribed for neuropathic pain. Diabetics frequently have this type of pain in the lower part of the legs.

37. The nurse is caring for a patient who had cere- bral angiography and the vascular system was accessed through the carotid artery. In the im- mediate postprocedure assessment, what is the priority? (1909) 1. Watching for infection at the puncture site 2. Assessing for reaction to contrast media 3. Observing for respiratory diffculties 4. Assessing for nausea and vomiting

Answer 3: If the access is at the carotid, hematoma or swelling could cause an airway obstruction. Respiratory effort is the priority assessment. Infection is always a concern, but there are no signs immediately after the procedure. Delayed reaction to contrast medium is possible, but usually the chief concern for contrast media is immediately after administration. Nausea and vomiting might occur, but usually nausea will occur in response to the contrast medium and that sensation is generally mild and transient.

33. The nurse hears in report that the patient has motor aphasia. Which intervention will the nurse plan to use when communicating with this patient? (1905) 1. Talk slower, be patient, and enunciate very clearly. 2. Face the patient so that he can watch the lips move. 3. Obtain a set of picture cards and encourage gestures. 4. Be kind and caring, but limit verbal communication.

Answer 3: In motor aphasia, the patient can understand the nurse, but is unable to use the symbols of speech; thus, pointing at pictures or objects and developing a language of gestures will help the patient.

49. What is the single most important modifiable risk factor for stroke? (1938) 1. Cigarette smoking 2. Sedentary lifestyle 3. Hypertension 4. Obesity

Answer 3: Stroke risk can be reduced by up to 42% with appropriate treatment of hypertension. Controlling the other factors will also reduce risk.

32. The nurse is using the FOUR Score coma scale to assess a patient who suffered a stroke. Which assessment is an integral part of this scale? (1905) 1. Checking the blood pressure and pulse 2. Checking orientation to person, place, and time 3. Assessing the respiratory rate and pattern 4. Evaluating the ability to make good judgments

Answer 3: The FOUR Score coma scale includes eye response, brainstem reflexes, motor response, and respiration.

30. The nurse is assessing the "fund of knowl- edge" component of the patient's awareness. Which question would the nurse use to assess this component? (1904) 1. "What month is it? And what day of the week is it today?" 2. "What did you have for dinner last night?" 3. "If you had $3.00 and gave me half, what would you have?" 4. "Who was president before Obama took office."

Answer 4: Fund of knowledge is an assessment of the patient's retention of general knowledge that the average adult should know. The other components are orientation to time, person, and place; assessment of short-term memory; and ability to calculate.

45. The patient has residual hemiplegia following a stroke. Which instructions will the nurse give to the UAP? (1917) 1. Assist the patient to ambulate to the bathroom. 2. Put the unaffected arm through range of motion. 3. Place in a prone position if the patient can tolerate it. 4. Use pillows to keep the upper arm in abduction.

Answer 4: In hemiplegia, the upper arm will tend to fall forward, so the counter-position is abduction. It is unlikely that the patient can walk safely to the bathroom, even with assistance. The affected arm should be put through ROM exercises. The prone position would be good for the patient, but the nurse should make the determination if the patient can tolerate it, rather than expecting the UAP to make that decision.

39. Which food may cause or worsen a migraine headache? (1910) 1. Italian foods 2. Apples 3. Dairy products 4. Ripened cheese

Answer 4: Many foods may contribute to migraines: such as aged cheeses (cheddar and Swiss), cured meats, fermented cabbage (sauerkraut), and soy and fish sauces. Nitrites are present in curing substances used in the preparation of meats such as bologna, ham, hotdogs, and bacon. Other substances that may provoke headaches include vinegar, chocolate, yogurt, alcohol, fermented or marinated foods, and caffeine.

58. The UAP tells the nurse that a patient with a spinal cord injury has a systolic blood pres- sure of 190/100 mm Hg. The nurse observes that the patient is diaphoretic, restless, and has "gooseflesh" and a headache. What should the nurse do first ?(1955) 1. Recheck the blood pressure. 2. Check the bladder for distention. 3. Check the rectum for impaction. 4. Put the patient in a sitting position.

Answer 4: Putting the patient in a sitting position decreases the blood pressure, especially the pressure in the head. Bladder distention and fecal impaction are the most common causes, so the nurse would check these and try to resolve the issue. The nurse can direct the UAP to recheck the blood pressure. This is a medical emergency and if the pressure does not come down, the health care provider must be notified so that drug therapy can be started.

34. The nurse is checking the gag reflex prior to giving liquids to a patient who had a bronchos- copy earlier in the day. Which cranial nerve is the nurse testing? (1905, 1906) 1. Trochlear 2. Abducens 3. Trigeminal 4. Glossopharyngeal

Answer 4: The glossopharyngeal nerve is involved in the gag reflex and swallowing movements. The trochlear and abducens nerves are involved in eye movement and the trigeminal is involved in jaw strength, facial sensation, and corneal reflex.

50. The patient who had a stroke exhibits dysphagia. Which intervention will the nurse use? (1918) 1. Mix solid and liquid foods together to facilitate swallowing. 2. Assist the patient to drink water after every bite of food. 3. Offer the patient a drinking straw or a covered plastic cup. 4. Check mouth on the affected side for accumulation of food.

Answer 4: The nurse would check for unintentional pouching of food on the affected side of the mouth. The other options are incorrect, except use of covered cups is okay.

31. The nurse is assessing a patient who had a serious head injury. During the assessment, the patient spontaneously opens his eyes; is oriented to person, place, and time; and can follow the nurse's commands. How would the nurse document his Glasgow coma score? (1904) 1. GCS within normal limits 2. GCS insufficent 3. GCS3 4. GCS15

Answer 4: The patient is demonstrating the maximum possible score which is 15 total points.

36. The patient is scheduled to return from having a lumbar puncture. What instructions will the nurse give to the UAP about the care of this pa- tient? (1907) 1. Help the patient ambulate in the halls. 2. Keep the head of the bed at 30 degrees. 3. Patient needs to be NPO for several hours. 4. Report if the patient has numbness or tingling.

Answer 4: UAP is not expected to assess for numbness or tingling, but should be instructed to report any patient complaints of numbness, tingling, or pain. The patient should be flat in bed and fluids are usually encouraged. Both measures are to prevent headaches.

Skull

B

Cerebrum

C

Scrambled Term 28. esotamoc

Comatose c Unable to respond to stimuli; cornea and pupillary reflexes are absent; swallow or cough; is incontinent of urine and feces; electroencephalogram pattern demonstrates decreased or absent neuronal activity

Diencephalon

D

61. It is likely that you know or will know someone who has Alzheimer's disease. a.What are the warning signs? (1934, 1935) b. Discuss the effect that Alzheimer's disease has on family and society. (1934, 1935) c. What are things you can do and teach your patients to do that will help prevent Alzheimer's disease? (1934, 1935)

a. See Box 53-2, p. 1934 for the Warning Signs of Alzheimer's Disease. b. Currently no effective treatment is available to stop the progression of AD, which occurs at a variable rate. The course of the disease can span 5-20 years. The economic costs of AD in the United States is on average $56,800 annually. While portions of this cost are absorbed by insurance coverage, large costs are borne by the family (Ramnarace, 2010). Ultimately, most patients die from complications such as pneumonia, malnutrition, and dehydration. The burden on the individual, the family, caregivers, and society as a whole is staggering. c. Engage in activities that require information processing (e.g., reading, learning a new language, doing crossword puzzles). Participate in regular physical activity, leisure activities, and educational achievements throughout the lifespan. Antioxidant- containing foods such citrus fruits, dark-green vegetables, tomatoes, brown rice, and foods high in beta-carotene (sweet potatoes and carrots) are considered to lower the risk of the development of Alzheimer's disease.

The school nurse is accompanying a group of children on a field trip. One of the children suddenly reports feeling odd and then sits down on the ground. As the nurse eases her to a supine position, the child demonstrates tonic-clonic jerking movements of the body. The nurse notes secretions and drooling from the child's mouth and the lips are slightly cyanotic. The child is unable to respond to her name and her eyes are rolled back and upwards. (1921, 1924) a.Describe what the nurse should do. b. What information should the nurse record and report to the health care provider?

a. The nurse protects from aspiration and injury and observes the seizure activity. The nurse stays with the child and the area is cleared of dangerous objects if possible. The child's head is supported and protected and if possible, turned to the side to maintain the airway. Restrictive clothing around the neck is loosened. The child is not restrained and no objects are placed in the mouth. b. The nurse would note, record, and report events that preceded the seizure, presence of aura, when the seizure occurred, length of ictal phase and postictal phase, and what occurred during each phase.

60. A 58-year-old man reports he experienced numbness in his legs, a loss of sensation in his arms, and an inability to speak. Upon questioning, he reported that the entire event lasted only about 15 minutes. (1940) a. What condition/disorder has the patient experienced? b. Since this event was short in duration, is it of any long term significance? Why or why not? c. What is the most frequently prescribed antiplatelet agent for this condition?

a. Transient ischemic attack (TIA) b. Yes, TIAs are significant because at least one in three people who experience them will experience a cerebrovascular accident within 2-5 years. c. Aspirin

VIII—acoustic (vestibulocochlear)

b Hearing; sense of balance (equilibrium)

IV—trochlear

c Down and inward movement of eye

I—olfactory

e Sense of smell

Decerebrate

extension away from body, pronation of arms/legs

II—optic

f Vision

Decorticate

flexion into body

13. The two main structural divisions of the nervous system are the _________________________ nervous system and the _________________________ nervous system. (1959)

central; peripheral

XI—spinal accessory

d Shoulder movements (trapezius muscle) and turning movements of head (sternocleidomastoid muscles)