Exam 1 (Unit 2, Module 2 - Ch. 36 - Coordinating Care for Patients with Disorders of the Brain 2

The nurse is caring for a client diagnosed with septic meningitis. The unlicensed assistive personnel (UAP) reports the temperature at 101.6 F, pulse 128, respirations 32, and BP 96/46. Which action should the nurse implement first? 1. Notify the healthcare provider 2. Assess the client immediately 3. Prepare to administer acetaminophen (Tylenol) 4. Check the chart for the culture and sensitivity report

ANSWER: 2 RATIONALE: Whenever another healthcare team member reports information to the nurse, assessment should be completed to confirm the data. Then the nurse should notify the healthcare provider, administer Tylenol to decrease the fever, and check the chart, but the nurse must first realize that this is potential septic shock, and the client should be assessed. Application Safe, Effective Care Environment: Management of Care

Why would the nurse need to conduct a swallow screen for a client following a stroke? 1. To assess the oral, pharyngeal, and esophageal phases of swallowing 2. To determine if it is safe for this client to take medications, fluids, or food by mouth 3. To determine if a barium-swallow examination is required 4. To detect silent aspiration

ANSWER: 2 RATIONALE: A client with a stroke must pass a swallow screen, or evaluation, prior to taking medications, fluids, or food by mouth. This screen is a minimally invasive procedure that helps identify clients that might need further evaluation by a speech-language-pathologist or provider specialist. Based on the recommendations of these specialists, a barium swallow may be ordered. Screening will not detect aspiration that has occurred. Additional testing is required to determine the phase of swallowing affected. Application Physiological Integrity: Reduction of Risk Potential

A client recalls smelling an unpleasant odor before a seizure. How would the nurse interpret this information? 1. Atonic seizure 2. Seizure with aura 3. Icterus 4. Postictal experience

ANSWER: 2 RATIONALE: An aura occurs in some clients as a warning before a seizure. The client may experience a certain smell, a vision such as flashing lights, or a sensation. Atonic seizure or drop attack refers to an abrupt loss of muscle tone. Icterus refers to jaundice. Postictal experience occurs after a seizure, during which the client may be confused, somnolent, and fatigued. Application Physiological Integrity: Physiological Adaptation

A client has had a moderate to larger hemispheric stroke and has facial weakness. What would an assessment of this client reveal? 1. Complete upper and lower facial weakness on the affected side 2. Facial weakness with sparing of the forehead on the side of the paralysis 3. Client's smile is symmetric 4. Inability to open the client's closed eyes

ANSWER: 2 RATIONALE: Hemispheric stroke is a result of damage to the upper motor neurons in the brain. This type of facial weakness is known as facial paralysis. Because the muscles of the forehead receive input from both cerebral hemispheres, the forehead is spared on the side of the paralysis when the lesion is central. Full facial weakness is seen with direct injury to cranial nerve VII, such as in Bell's palsy. In both a central and peripheral palsy, the smile will be asymmetrical. Application Physiological Integrity: Physiological Adaptation

Which nursing intervention is important while caring for a client who has expressive aphasia? 1. Place the client in a busy room 2. Include detailed instructions about all procedures 3. Avoid yes or no questions 4. Encourage the client to use hand gestures, or other alternate methods to communicate

ANSWER: 4 RATIONALE: A client with aphasia should be encouraged to use alternate ways to communicate, such as pointing, picture boards, hand gestures, and drawing. Clients with aphasia should be placed in a quiet room without a lot or noise or distractions. Ask questions in a way that the client can answer with a "yes" or "no". Don't burden this client with excessive information. Application Physiological Integrity: Management of Care

The 18-year-old client is admitted to the medical floor with a diagnosis of meningitis. Which priority intervention should the nurse assess? 1. Assess the client's neurovascular status 2. Assess the client's cranial nerve IX function 3. Assess the client's brachioradialis reflex 4. Assess the client's neurological status

ANSWER: 4 RATIONALE: Meningitis directly affects the client's brain; therefore, assessing the neurological status would have priority for this client. Neurovascular assessment involves peripheral nerves and changes such as paralysis and skin temperature. Application Safe, Effective Care Environment: Management of Care

In assessing a patient with encephalitis, the nurse notes that when the patient's neck is flexed, the legs flex. The nurse documents this as which of the following? A. Positive Kernig's sign B. Positive Brudzinski's sign C. Nuchal rigidity D. Clonus

Answer: B Rationale: In the patient with a positive Brudzinski's sign, there is involuntary flexion of hips in response to passive flexion of the neck with the patient in a supine position. A positive Kernig's sign is charac- terized by pain behind the knee when the patient's hip and knee are flexed at a 90° angle, and then the knee is slowly extended. Nuchal rigidity is characterized by stiffening of the neck as a result of meningeal irritation. Clonus is manifests itself as a series of involuntary, rhythmic, muscular contractions and relaxations.

A patient with a history of complex partial seizures has a phenytoin (Dilantin) level (free) of 3.1 mcg/mL. The nurse calls the patient and instructs the patient to take which action? A. Stop the medication and make an appointment for the following week with the provider. B. Continue the medication and make an appointment right away with the health-care provider. C. Take an extra dose now and continue with the current regimen. D. Skip the next dose and make an appointment right away with the health-care provider.

Answer: B Rationale: The free level is high and the patient needs to be evaluated by their provider. The patient should not stop the medication or skip doses without approval of the provider. An extra

The nurse monitors which diagnostic results in the patient with bacterial encephalitis? (Select all that apply.) A. Isolation of CSF via polymerase chain reaction B. Gram stain and culture of CSF C. CT D. MRI E. EMG

Answer: B, C, and D Rationale: Cultures of the CSF will be completed for identification of the invading organism, and antibiotics will be aimed at eliminating the pathogen. A CT or MRI is performed to assess for signs of the infectious process as well as increased intracranial pressure. Isolation of CSF via PCR is used to diagnose a herpes infection. An EMG is indicated for the diagnosis of neuromuscular disorders.

Which symptoms are included in a diagnosis of Parkinson's disease? (Select all that apply.) A. Flaccidity B. Total resistance to movement C. Bradykinesia D. Tremors E. Photophobia

Answer: B, C, and D Rationale: Diagnosis of Parkinson's disease is made when two or more cardinal symptoms with asymmetri- cal presentation are observed. The four signs include bradykinesia, resting tremor, rigidity, and postural instability and are observed in the absence of other causes.

What interdisciplinary team members are involved in the management of the patient with Parkinson's disease? (Select all that apply.) A. Oncologist B. Speech therapist C. Occupational therapist D. Interventional radiologist E. Physical therapist

Answer: B, C, and E Rationale: Physical therapists provide exercises and activities that maximize strength, flexibility, and move- ment. The occupational therapist provides strategies to promote independence as well as to offer accommoda- tions that may need to be made in the home to promote safety and maximize independence in ADLs. The speech therapist completes a swallowing evaluation and makes suggestions to promote safe oral intake. They may also have strategies to promote verbal communication.

Which assessment data does the nurse recognize as the most sensitive indicator of increased ICP? A. Pupillary B. Respiratory C. Level of consciousness D. Cranial nerves

Answer: C Rationale: Change in level of consciousness is the earli- est sign of increased intracranial and should be reported immediately to the health-care provider. There may be changes in pupillary reflexes, cranial nerve function, and respiratory status, but they are all later signs.

The nurse recognizes that supplementation with which vitamin has been found to help with symptoms of Alzheimer's disease? A. Vitamin A B. Vitamin C C. Vitamin D D. Vitamin E

Answer: D Rationale: Vitamin E, an antioxidant, may help with symptoms of Alzheimer's disease by decreasing the damage caused by free radicals in the brain.

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The laboratory has just notified the nurse that a client on the unit has a phenytoin level of 32 mg/dL. Which symptoms should the nurse anticipate from this client? 1. Ataxia and confusion 2. Sodium depletion 3. Tonic-clonic seizure 4. Urinary incontinence

ANSWER: 1 RATIONALE: A level of 32 mg/dL indicates phenytoin toxicity. Symptoms of toxicity include confusion and ataxia. Phenytoin doesn't cause hyponatremia, seizure, or urinary incontinence. Incontinence may occur during or after a seizure. Application Physiological Integrity: Pharmacological and Parenteral Therapies

A client is admitted to the emergency department with new onset of stroke-like symptoms. Prioritize the following nursing interventions. 1. Assess airway, breathing, and circulation 2. State CT scan as ordered 3. Screen the client for ability to swallow 4. Administer atenolol to lower BP of 180/106 mmHg 5. Administer alteplase per protocol

ANSWER: 1, 2, 5, 4, 3 Ordered Response: 1. Assess airway, breathing, and circulation 2. State CT scan as ordered 5. Administer alteplase per protocol 4. Administer atenolol to lower BP of 180/106 mmHg 3. Screen the client for ability to swallow Application Physiological Integrity: Reduction of Risk Potential

Which nursing interventions are appropriate for a client experiencing status epilepticus? Select all that apply. 1. Protect the client from harm 2. Insert a padded tongue blade in the mouth 3. Assess for hypoglycemia 4. Administer lorazepam per health care provider's order 5. Place in prone position 6. Remain with client and give verbal reassurance

ANSWERS: 1, 3, 4, 6 RATIONALE: Status epilepticus is a medical emergency. Stay with the client, protecting them from harm, and call for help. Ensure that the airway is open and provide supplemental oxygen. Do not force an airway with a tongue blade. It is important to assess cardiac and respiratory function. Blood glucose should be checked to rule out hypoglycemia. Secure an IV and prepare to give lorazepam or a similar first-line agent. When the seizure ceases, turn the client on their side to protect the airway. Stay with the client during the postictal stage, and give verbal reassurance as the client may be confused. Application Safe, Effective Care Environment: Management of Care

The nurse recognizes which as the probable cause of Alzheimer's disease? A. Exposure to environmental toxins B. CNS trauma C. Unknown D. Chronic hypertension

Answer: C Rationale: Conclusive evidence as to the causes of Alzheimer's does not exist. The actual diagnosis of Alzheimer's is made only at autopsy. Neither long- standing hypertension or injury to the brain have been proven to cause Alzheimer's disease.

The nurse recognizes that the patient with Parkinson's disease is at risk for which complication? A. Excessive dry mouth due to autonomic dysfunction B. Facial twitching secondary to seizure activity C. Orthostatic hypotension due to involvement of the sympathetic nervous system D. Flaccid extremities related to the increased levels of dopamine

Answer: C Rationale: PD leads to reduced sympathetic nervous influences on the heart and blood vessels leading to orthostatic hypotension. Dry mouth is associated with the side effects of Levodopa medications. The patient with PD demonstrates tremors, not seizure activity. The patient with PD presents with rigidity, not flaccidity secondary to imbalance between dopamine and acetylcholine.

The nurse correlates increased intracranial pressure in the patient with meningitis to which pathophysiologic process? A. Increased production of cerebrospinal fluid B. Decreased reabsorption of cerebrospinal fluid C. Increased turbidity of cerebrospinal fluid D. Decreased protein levels in cerebrospinal fluid

Answer: C Rationale: The inflammatory process within the meninges leads to increased turbidity of cerebrospinal fluid causing sluggish flow of CSF. Protein levels tend to be elevated in patient with meningitis.

A patient is admitted for evaluation and treatment of generalized tonic-clonic seizures. Which clinical manifestations does the nurse assess for in this type of seizure disorder? A. Persistent jerking movement of one half of the body B. Unilateral jerking movement of one extremity C. Muscle flaccidity followed by tremors of all extremities D. Stiffening of muscles of arms and legs, followed by jerking movements

Answer: D Rationale: Tonic-clonic seizures are characterized by loss of consciousness, a tonic phase marked by rigidity, followed by rhythmic jerking of all extremi- ties that reflect the clonic phase. Unilateral jerking is characteristic of myoclonic seizures. Muscle flaccidity is associated with absence seizures.

A client, who has just started taking phenytoin, asks the nurse if there are any adverse effects of this medication. What is the nurse's best response? 1. Dry mouth 2. Furry tongue 3. Somnolence 4. Tachycardia

ANSWER: 3 RATIONALE: Adverse effects of phenytoin include sedation, somnolence, gingival hyperplasia, blood dyscrasia, and toxicity. The other symptoms aren't adverse effects of phenytoin. Application Physiological Integrity: Pharmacological and Parenteral Therapies

What is the nurse's most important intervention for a client having a tonic-clonic seizure? 1. Protect the client from further injury 2. Time the duration of the seizure 3. Note the origin of seizure activity 4. Insert a padded tongue blade to prevent the client from biting his tongue

ANSWER: 1 RATIONALE: The priority during and after a seizure is to protect the person from injury by keeping them from falling to the floor. Furniture or other objects that may be a source of injury during the seizure should be moved out of the client's way. Timing the seizure, and noting the origin of the seizure are important, but are not the priority. Nothing should be placed in the client's mouth during a seizure because teeth may be dislodged or the tongue pushed further back, further obstructing the airway. Application Safe, Effective Care Environment: Management of Care

What is used to diagnose a seizure disorder? (Select all that apply.) A. Electroencephalogram B. Lumbar puncture C. Metabolic panel D. Coagulation studies E. Electromyogram

Answer: A, B, and C Rationale: Diagnosis of seizures is made via imaging (CT, MRI) and laboratory work-up to ruleout causes (lesions, tumors, metabolic and other disorders) and through diagnostics via EEG monitoring for abnormal electrical activity. Coagulation studies are used to assess clotting, and the electromyogram is used to diagnose neuromuscular disorders such as multiple sclerosis and myasthenia gravis.

What is the priority nursing intervention for a client who has developed left arm swelling after a thromboembolic right hemispheric stroke? 1. Apply an arm splint to prevent a contracture 2. Elevate the arm to improve venous return 3. Notify the provider of a potential brachial vein thrombosis 4. Obtain a physical therapy consult due to the client's decreased muscle strength

ANSWER: 2 RATIONALE: In clients with hemiplegia or hemiparesis, loss of muscle contraction may decrease venous return resulting in swelling of the affected extremity. Elevating the extremity will help facilitate venous return and decrease swelling. Contracture may occur with a stroke, but don't typically present with swelling alone. Deep vein thrombosis may develop in clients with a stroke but are more likely to occur in the lower extremities. All clients with a stroke should have PT consult, especially in the presence of hemiparesis. Application Physiological Integrity: Physiological Adaptation

The nurse anticipates that stool softeners will be given to a client prior to repair of a cerebral aneurysm. Why would stool softeners be given to this client? 1. To stimulate the bowel due to loss of nerve innervation 2. To prevent straining, which increases intracranial pressure (ICP) 3. To prevent the Valsalva maneuver that can result in a reflex bradycardia 4. To prevent constipation due to osmotic diuretics

ANSWER: 2 RATIONALE: Straining when having a bowel movement, sneezing, coughing, and suctioning may lead to increased ICP and should be avoided when the potential for increased ICP exists. Stool softeners don't stimulate the bowel and aren't used in combination with osmotic diuretics. Although the Valsalva maneuver may lead to an increase in ICP, it does not prevent reflex bradycardia. Application Physiological Integrity: Reduction of Risk Potential

The nurse prepares the client for a lumbar puncture to rule out a subarachnoid hemorrhage. Which assessment finding would require intervention before the procedure? 1. Severe vomiting 2. Suspected increased intracranial pressure (ICP) 3. Client requires mechanical ventilation 4. Blood in the cerebrospinal fluid (CSF)

ANSWER: 2 RATIONALE: Sudden removal of CSF result in a lowered pressure in the lumbar area than in the brain which can cause brain herniation, especially in the presence of increased ICP. Therefore a LP is contraindicated when increased ICP is suspected. Vomiting may be caused by reasons other than increased ICP; therefore, LP isn't strictly contraindicated. A LP may be performed on clients requiring mechanical ventilation. Blood in the CSF is diagnostic for subarachnoid hemorrhage. Application Physiological Integrity: Physiological Adaptation

What information should the nurse include when providing discharge teaching for a client with a hemorrhagic stroke? 1. Share the facts about the occurrence of coronary artery disease 2. Emphasize the importance of follow-up with their regular provider for new, or worsening stroke symptoms 3. Explain the relationship between hypertension and their stroke 4. Explain the need to take a daily aspirin or other anti-platelet medication

ANSWER: 3 RATIONALE: Clients need to be educated about how to decrease their specific risk factor for recurrent stroke, such as better blood pressure management, and the need to contact emergency medical services promptly for new stroke symptoms. Unlike controlled hypertension, coronary artery disease is not a major risk factor for hemorrhagic stroke. Daily aspirin and anti-platelet medication are routine medications in clients with ischemic, not hemorrhagic strokes. Understanding Physiological Integrity: Reduction of Risk Potential

The nurse asks the unlicensed assistive personnel (UAP) to help admit the client diagnosed with bacterial meningitis. Which nursing task is priority? 1. Take the client's vital signs 2. Obtain the client's height and weight 3. Prepare the room for respiratory isolation 4. Pull the drapes and make sure the room is dim

ANSWER: 3 RATIONALE: Equipment needed for the staff to enter the client's room safely is the priority nursing task that can be delegated. All other tasks could be safely delegated to the UAP, but they are not priority. Application Safe, Effective Care Environment: Management of Care

An 87-year-old client is admitted following a stroke. During the admission interview and assessment the client's speech is slow, non-fluent, and labored. How should the nurse document this finding? 1. Receptive aphasia 2. Wernicke's aphasia 3. Expressive aphasia 4. Global aphasia

ANSWER: 3 RATIONALE: Expressive aphasia results from damage to Broca's area, located in the frontal lobe of the brain's dominant hemisphere. Typically, the client with expressive aphasia has difficulty expressing himself and his speech is slow, non-fluent, and labored; however, comprehension of written and verbal communication is intact. With receptive aphasia the client can't comprehend written or verbal communication. His speech is normal, but he conveys information poorly. With global aphasia, a combination of receptive and expressive aphasia, most of the brain's communication system is damaged. Global aphasia results from extensive damage to Broca's and Wernicke's areas. Application Physiological Integrity: Physiological Adaptation

When assessing vital signs in a client with new onset of seizures, which assessment is most important? 1. Checking for a pulse deficit 2. Checking for pulse paradoxus 3. Obtaining an accurate temperature 4. Checking the blood pressure for an auscultatory gap

ANSWER: 3 RATIONALE: High temperature can induce seizures. It is important to obtain an accurate temperature in a safe manner. Pulse deficit occurs in an arrhythmia. Pulse paradoxus may occur with cardiac tamponade. An auscultatory gap occurs with hypertension . Application Physiological Integrity: Reduction of Risk Potential

The registered nurse (RN), an LPN, and a UAP are caring for clients on a neurological unit. Which task would be appropriate for the nurse to assign/delegate? 1. Instruct the LPN to complete the client's admission assessment 2. Request the UAP to change the central line dressing 3. Assign the LPN to administer routine medications 4. Tell the UAP to complete the Glasgow Coma Scale

ANSWER: 3 RATIONALE: The LPN can administer routine medications. The RN should not assign/delegate assessment to an LPN or a UAP. The central line dressing is a sterile dressing that should not be delegated to a UAP. Application Safe, Effective Care Environment: Management of Care

The nurse and a UAP (unlicensed assistive personnel) are caring for a client with right-sided paralysis secondary to a stroke. Which action by the UAP requires the nurse to intervene? 1. The UAP encourages the client to perform range-of-motion exercises 2. The UAP places the client on a side with a pillow between the legs 3. The UAP leaves a urinal full of urine at the client's bedside 4. The UAP praises the client for attempting to get dressed alone

ANSWER: 3 RATIONALE: The UAP should be instructed to keep all urinals and bedpans clean when at the bedside. Application Safe, Effective Care Environment: Management of Care

A patient with a history of seizures experiences lip smacking and daydreams during a seizure with no loss of consciousness. The nurse recognizes these clinical manifestations as associated with which type of seizure? A. Absence seizure B. Complex partial seizure C. Atonic seizure D. Myoclonic seizure

Answer: A Rationale: Absence seizures are characterized may go unnoticed as the patient appears to be inattentive or daydreaming. They usually last 5 to 10 seconds and there is minimal, if any, loss of muscle tone. The patient may exhibit automatisms like lip smacking or excessive swallowing. Myoclonic seizures present with no loss of consciousness and include brief contractures of muscles that may be symmetrical or asymmetrical. Patients with atonic seizures may or may not lose consciousness and exhibit sudden momentary loss of motor tone. Complex partial seizures always include loss of consciousness and often are preceded by an aura. Patients may also demonstrate automatisms.

A patient with a brain tumor has been admitted to the hospital due to changes in level of consciousness. The nurse correlates the action of which medication to the treatment of suspected increasing cerebral edema? A. Dexamethasone (Decadron) B. Phenytoin (Dilantin) C. Carbamazepine (Tegretol) D. Furosemide (Lasix)

Answer: A Rationale: Dexamethasone is used to treat and pre- vent local cerebral edema, as it has been shown to stabilize cell membranes to prevent the occurrence of cerebral edema. Phenytoin and Carbamazepine are anti-epileptic medications. Furosemide is a loop diuretic to increase urine output.

The nurse correlates which clinical manifestation to a secondary headache? A. Sudden severe onset B. Tense neck muscles C. Nausea D. Tingling scalp sensation

Answer: A Rationale: Secondary headaches are caused by an underlying pathology such as infection, neoplasms (tumor), vascular (blood vessel) abnormalities, drug induced disorders, or idiopathic cause, and typically present with a sudden onset of severe pain.

Prior to the start of the semester, what type of meningitis can college-aged students be vaccinated against? A. Bacterial meningitis B. Viral meningitis C. Aseptic meningitis D. Fungal meningitis

Answer: A Rationale: The incidence of meningitis is increased in settings where people live in close proximity, including college dormitories, military barracks, and prisons. In the United States rates of bacterial meningitis have markedly declined, presently 0.6 to 4 cases/100,000 yearly due to the institution of vaccines such as HiB (Haemophilus influenza type B).

The nurse assess for which cardinal clinical manifestations in the patient with Parkinson's disease? (Select all that apply.) A. Rigidity B. Disorientation C. Tremor D. Bradykinesia E. Dementia F. Postural changes

Answer: A, B, C, and E Rationale: The four cardinal signs include bradyki- nesia, tremor, rigidity, and postural stability, and result as an imbalance between dopamine and acetylcholine.

When educating a patient with migraine headaches, the nurse should include which interventions? (Select all that apply.) A. Practice a healthy lifestyle (cease smoking, alcohol in moderation, exercise). B. Avoid triggers. C. Use techniques like relaxation and stress reduction. D. Stop taking medications if symptoms subside in order to decrease tolerance. E. Eliminate all salt and caffeine from the diet.

Answer: A, B, and C Rationale: Because smoking is associated with headaches, smoking cessation is indicated for patients with headaches. Additionally, alcohol moderation and decreasing stress through exercise and other non- pharmacological measures may be helpful in decreasing the intensity or frequency of headaches. Medications should not be abruptly withdrawn. While salt intake may lead to retaining water, there is no need to eliminate salt. If caffeine is a trigger, the patient may consider decreasing intake.