HIT 3 Test 3 Neuro Endocrine

A nurse and nursing student are caring for a client recovering from a lumbar puncture yesterday. The client reports a headache despite being on bedrest overnight. The physician plans an epidural blood patch this morning. The student asks how this will help the headache. The correct reply from the nurse is which of the following?

"The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid." Explanation: Loss of CSF causes the headache. Occasionally, if the headache persists, the epidural blood patch technique may be used. Blood is withdrawn from the antecubital vein and injected into the site of the previous puncture. The rationale is that the blood will act as a plug to seal the hole in the dura and preven further loss of CSF. The blood is not put into the subarachnoid space. The needle is inserted below the level of the spinal cord, which prevents damage to the cord. It is not a lack of moisture that prevents healing; it is more related to the size of the needle used for the puncture.

A 16-year-old patient newly diagnosed with type 1 diabetes has a very low body weight despite eating regular meals. The patient is upset because friends frequently state, "You look anorexic." Which of the following statements would be the best response by the nurse to help this patient understand the cause of weight loss due to this condition?

"Your body is using protein and fat for energy instead of glucose." Explanation: Persons with type 1 diabetes, particularly those in poor control of the condition, tend to be thin because when the body cannot effectively utilize glucose for energy (no insulin supply), it begins to break down protein and fat as an alternate energy source. Patients may be underweight at the onset of type 1 diabetes because of rapid weight loss from severe hyperglycemia. The goal initially may be to provide a higher-calorie diet to regain lost weight and blood glucose control. (less)

A female patient with diabetes who weighs 150 pounds has an ideal body weight of 118 pounds. She can lose 1 pound per week and drop her extra 32 pounds in approximately 8 months. To meet this goal, the nurse advises the patient to decrease her calories by:

3,500 per week. Explanation: A person needs to decrease caloric intake by 3,500 for each lb of weight that is lost. To lose 1 lb per week, a person would decrease his or her daily caloric intake by 500 calories (500 calories × 7 days = 3,500 calories = 1 lb).

A client with type 1 diabetes is scheduled to receive 30 units of 70/30 insulin. There is no 70/30 insulin available. As a substitution, the nurse may give the client:

9 units regular insulin and 21 units neutral protamine Hagedorn (NPH). Explanation: A 70/30 insulin preparation is 70% NPH and 30% regular insulin. Therefore, a correct substitution requires mixing 21 units of NPH and 9 units of regular insulin. The other choices are incorrect dosages for the ordered insulin

A nurse is caring for a client with an injury to the central nervous system. When caring for a client with a spinal cord insult slowing transmission of the motor neurons, which deficits are anticipated?

A delayed reaction in response due to the interrupted impulses from the central nervous system Explanation: The central nervous system is composed of the brain and the spinal cord. Motor neurons transmit impulses from the central nervous system. A deficit in slowing transmission in this area would slow the response of transmission leading to a delay in reaction. Sensory neurons transmit impulses from the environment to the central nervous system, allowing identification of a stimulus. Cognitive centers of the brain interpret the information.

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.

A female client is being treated for increased intracranial pressure (ICP). Why should the nurse ensure that the client does not develop hypothermia? Choose the correct option.

Because shivering in hypothermia can increase ICP Explanation: Care must be taken to avoid the development of hypothermia because hypothermia causes shivering. Shivering, in turn, can increase intracranial pressure. Hypothermia causes shivering, and shivering, in turn, can increase intracranial pressure. Hypothermia causes shivering, and shivering, in turn, can increase intracranial pressure. Hypothermia causes shivering, and shivering, in turn, can increase intracranial pressure.

A child is brought into the emergency department with vomiting, drowsiness, and blowing respirations. The father reports that the symptoms have been progressing throughout the day. The nurse suspects diabetic ketoacidosis (DKA). Which action should the nurse take first in the management of DKA?

Begin fluid replacements. Explanation: Management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the hypoglycemia with insulin.

A patient who has suffered a stroke is unable to maintain respiration and so is intubated and placed on mechanical ventilator support. What portion of the brain is most likely responsible for the inability to breathe?

Brain stem Explanation: The brain stem consists of the midbrain, pons, and medulla oblongata (see Fig. 65-2). Portions of the pons help regulate respiration. Motor fibers from the brain to the spinal cord and sensory fibers from the spinal cord to the brain are located in the medulla. Reflex centers for respiration, blood pressure, heart rate, coughing, vomiting, swallowing, and sneezing are located in the medulla.

Low levels of the neurotransmitter serotonin lead to which of the following disease processes?

Depression Explanation: A decrease of serotonin leads to depression. A decrease in the amount of acetylcholine causes myasthenia gravis. Parkinson's disease is caused by a depletion of dopamine. Decreased levels of GABA may cause seizures.

A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first?

Elevate the head of the bed. Explanation: The first action would be to elevate the head of the bed to promote venous drainage of blood and CSF. Then, a neurological assessment would be completed to determine if any other assessment findings are significant of increasing ICP. The administering of routine ordered drugs is not a priority, and narcotic analgesics would be avoided in clients with ICP issues.

Which of the following neurotransmitters inhibit pain transmission?

Enkephalin Explanation: Enkephalins are neurotransmitters that inhibit pain transmission. Acetylcholine is an excitatory transmitter. Serotonin is an inhibitory transmitter that helps control mood and sleep. Dopamine usually is inhibitory affecting behavior and fine movement.

What safety actions does the nurse need to take for a patient on oxygen therapy who is undergoing magnetic resonance imaging (MRI)?

Ensure that no patient care equipment containing metal enters the room where the MRI is located. Explanation: For patient safety the nurse must make sure no patient care equipment (eg, portable oxygen tanks) that contains metal or metal parts enters the room where the MRI is located. The magnetic field generated by the unit is so strong that any metal-containing items will be strongly attracted and can literally be pulled away with such great force that they can fly like projectiles towards the magnet.

Which of the following cerebral lobes is the largest and controls abstract thought?

Frontal Explanation: The frontal lobe also controls information storage or memory and motor function. The temporal lobe contains the auditory receptive area. The parietal lobe contains the primary sensory cortex, which analyzes sensory information and relays interpretation to the thalamus and other cortical areas. The occipital lobe is responsible for visual interpretation.

Which combination of adverse effects should a nurse monitor for when administering I.V. insulin to a client with diabetic ketoacidosis?

Hypokalemia and hypoglycemia Explanation: Blood glucose needs to be monitored in clients receiving I.V. insulin because of the risk of hyperglycemia or hypoglycemia. Hypoglycemia might occur if too much insulin is administered. Hypokalemia, not hyperkalemia, might occur because I.V. insulin forces potassium into cells, thereby lowering the plasma level of potassium. Calcium and sodium levels aren't affected by I.V. insulin administration.

The nurse is educating the diabetic client on setting up a sick plan to manage blood glucose control during times of minor illness such as influenza. Which is the most important teaching item to include?

Increase frequency of glucose self-monitoring. Explanation: Minor illnesses such as influenza can present a special challenge to a diabetic client. The body's need for insulin increases during illness. Therefore, the client should take the prescribed insulin dose, increase the frequency of glucose monitoring, and maintain adequate fluid intake to counteract the dehydrating effects of hyperglycemia. Clear liquids and juices are encouraged. Taking less than normal dose of insulin may lead to ketoacidosis.

The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring?

Increased ICP Explanation: Increased ICP and bleeding are life threatening to the patient who has undergone intracranial surgery. An increase in blood pressure and decrease in pulse with respiratory failure may indicate increased ICP.

A 60-year-old patient comes to the ED with complaints of weakness, vision problems, increased thirst, increased urination, and frequent infections that do not seem to heal easily. The physician suspects that the patient has diabetes. Which of the following classic symptoms should the nurse watch for to confirm the diagnosis of diabetes?

Increased hunger Explanation: The classic symptoms of diabetes are the three Ps: polyuria (increased urination), polydipsia (increased thirst), and polyphagia (increased hunger). Some of the other symptoms include tingling, numbness, and loss of sensation in the extremities and fatigue.

A nurse is teaching a patient recovering from diabetic ketoacidosis (DKA) about management of "sick days." The patient asks the nurse why it is important to monitor the urine for ketones. Which of the following statements is the nurse's best response?

Ketones accumulate in the blood and urine when fat breaks down. Ketones signal a deficiency of insulin that will cause the body to start to break down stored fat for energy. Explanation: Ketones (or ketone bodies) are byproducts of fat breakdown, and they accumulate in the blood and urine. Ketones in the urine signal a deficiency of insulin and control of type 1 diabetes is deteriorating. When almost no effective insulin is available, the body starts to break down stored fat for energy.

The nurse is caring for a patient with an altered LOC. What is the first priority of treatment for this patient?

Maintenance of a patent airway Explanation: The first priority of treatment for the patient with altered LOC is to obtain and maintain a patent airway.

A patient is admitted to the hospital for management of an extrapyramidal disorder. Included in the physician's admitting orders are the medications levodopa, Cogentin, and Eldepryl. The nurse knows that most likely, the client has a diagnosis of ________.

Parkinson's disease Explanation: These drugs are commonly used in the medical management of Parkinson's disease. Although antiparkinson drugs are used in some clients with Huntington's disease, these drugs are commonly used in the medical management of Parkinson's disease. The listed medications are not used to treat a seizure disorder. The listed medications are not used to treat MS.

A client who was diagnosed with type 1 diabetes 14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client's blood glucose level is 470 mg/dl. Which finding is most likely to accompany this blood glucose level?

Rapid, thready pulse Explanation: This client's abnormally high blood glucose level indicates hyperglycemia, which typically causes polyuria, polyphagia, and polydipsia. Because polyuria leads to fluid loss, the nurse should expect to assess signs of deficient fluid volume, such as a rapid, thready pulse; decreased blood pressure; and rapid respirations. Cool, moist skin and arm and leg trembling are associated with hypoglycemia. Rapid respirations — not slow, shallow ones — are associated with hyperglycemia.

A patient with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following is an important nursing action for this patient?

Restricting fluid intake and hydration Explanation: Fluid restriction may be necessary if the patient develops cerebral edema and hypervolemia from SIADH. Antipyretics are administered to patients who develop hyperthermia. In addition, it is important to maintain adequate hydration in such patients. A patient with neurological infection should be given tracheal suctioning and hyperoxygenation only when the patient develops respiratory distress.

A patient has been newly diagnosed with type 2 diabetes, and the nurse is assisting with the development of a meal plan. What step should be taken into consideration prior to making the meal plan?

Reviewing the patient's diet history to identify eating habits and lifestyle and cultural eating patterns Explanation: The first step in preparing a meal plan is a thorough review of the patient's diet history to identify eating habits and lifestyle and cultural eating patterns.

The diabetic client asks the nurse why shoes and socks are removed at each office visit. Which assessment finding is most significant in determining the protocol for inspection of feet?

Sensory neuropathy Explanation: Neuropathy results from poor glucose control and decreased circulation to nerve tissues. Neuropathy involving sensory nerves located in the periphery can lead to lack of sensitivity, which increases the potential for soft tissue injury without client awareness. The feet are inspected on each visit to insure no injury or pressure has occurred. Autonomic neuropathy, retinopathy, and nephropathy affect nerves to organs other than feet.

The nurse is instructing a community class when a student asks, "How does someone get super strength in an emergency?"The nurse is correct to instruct on the action of which system?

Sympathetic nervous system Explanation: The division of the autonomic nervous system called the sympathetic nervous system regulates the expenditure of energy. The neurotransmitters of the sympathetic nervous system are called catecholamines. During an emergency situation or an intensely stressful event, the body adjusts to deliver blood flow and oxygen to the brain, muscles, and lungs that need to react in the situation. The musculoskeletal system benefits from the sympathetic nervous system as the fight-or-flight effects pump blood to the muscles. The parasympathetic nervous system works to conserve body energy not expend it during an emergency. The endocrine system regulates metabolic processes.

A male client, aged 42 years, is diagnosed with diabetes mellitus. He visits the gym regularly and is a vegetarian. Which of the following factors is important when assessing the client?

The client's consumption of carbohydrates Explanation: While assessing a client, it is important to note the client's consumption of carbohydrates because he has high blood sugar. Although other factors such as the client's mental and emotional status, history of tests involving iodine, and exercise routine can be part of data collection, they are not as important to information related to the client's to be noted in a client with high blood sugar.

A hospitalized, insulin-dependent patient with diabetes has been experiencing morning hyperglycemia. The patient will be awakened once or twice during the night to test blood glucose levels. The health care provider suspects that the cause is related to the Somogyi effect. Which of the following indicators support this diagnosis? Select all that apply.

• Normal bedtime blood glucose • Increase in blood glucose from 3:00 AM until breakfast • Decrease in blood sugar to a hypoglycemic level between 2:00 to 3:00 AM • Elevated blood glucose at bedtime

A 6 months' pregnant patient was evaluated for gestational diabetes mellitus. The doctor considered prescribing insulin based on the serum glucose result of:

138 mg/dL, 2 hours postprandial. Explanation: The goals for a 2-hour, postprandial blood glucose level are less than 120 mg/dL in a patient who might develop gestational diabetes

A nurse is completing a neurological assessment and determines that the client has significant visual deficits. A brain tumor is considered. Considering the functions of the lobes of the brain, which area will most likely contain the neurologic deficit?

Occipital Explanation: The vision center is located in the occipital lobe. There is little other functioning that may interfere with the visual process in the other lobes of the brain.

The initial sign of increasing ICP includes

decreased level of consciousness. Explanation: The initial signs of increasing ICP include decreased level of consciousness and focal motor deficits. If ICP is not controlled, the uncus of the temporal lobe may be herniated through the tentorium, causing pressure on the brain stem. Vomiting and headache are not initial signs of increasing ICP.

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 nurse is preparing the daily care plan for a client with newly diagnosed diabetes mellitus. The priority nursing concern for this client should be:

providing client education at every opportunity. Explanation: The nurse should use routine care responsibilities as teaching opportunities with the intention of preparing the client to understand and eventually manage his disease. Monitoring blood glucose, checking for the presence of ketones, and administering insulin are important when caring for a client with diabetes, but they aren't the priority of care.

At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing's triad? Select all that apply.

• Bradypnea • Hypertension • Bradycardia

Which of the following medication classifications is utilized preoperatively to decrease the risk of postoperative seizures?

Anticonvulsants Explanation: Anticonvulsants are used to decrease the risk of postoperative seizures following cranial surgery. Diuretics, corticosteroids, and antianxiety medications may be used for the patient with increased ICP.

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?

Because hypoxemia can create or worsen a neurologic deficit of the spinal cord Explanation: Oxygen is administered to maintain a high partial pressure of arterial oxygen (PaO2), because hypoxemia can create or worsen a neurologic deficit of the spinal cord.

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 nurse is working in the neurologic intensive care unit and admits from the emergency department a patient with an inoperable brain tumor. Upon entering the room, the nurse observes that the patient is positioned like the person in part B of the accompanying image. Which posturing is the patient exhibiting?

Decerebrate Explanation: An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decerebrate. Decorticate posture is the flexion and internal rotation of forearms and hands. Decerebrate posture is extension and external rotation. Flaccidity is the absence of motor response; tonic clonic movements are seen with seizures.

If a patient has a lower motor neuron lesion, the nurse would expect which of the following upon physical assessment?

Decreased muscle tone Explanation: A patient with a lower motor neuron lesion would be expected to have decreased muscle tone. Those with upper motor neuron lesion would have hyperactive reflexes, no muscle atrophy, and muscle spasticity.

A nurse is teaching a diabetic support group about the causes of type 1 diabetes. The teaching is determined to be effective when the group is able to attribute which of the following factors as a cause of type 1 diabetes?

Presence of autoantibodies against islet cells Explanation: There is evidence of an autoimmune response in type 1 diabetes. This is an abnormal response in which antibodies are directed against normal tissues of the body, responding to these tissues as if they were foreign. Autoantibodies against islet cells and against endogenous (internal) insulin have been detected in people at the time of diagnosis and even several years before the development of clinical signs of type 1 diabetes.

The nurse is working in an outpatient studies unit administering neurological tests. The client is surprised that paste is used to secure an electroencephalogram and asks how it will be removed from the hair. The nurse is most correct to state which?

The paste is removed with standard shampoo. Explanation: Standard shampoo is used to remove the paste, which attached the electrodes to the head. Acetone is not used on the hair. There is no special soap needed. More than warm water is needed to lift and remove the paste.

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:

raccoon's eyes and Battle sign. Explanation: A basilar skull fracture commonly causes only periorbital ecchymosis (raccoon's eyes) and postmastoid ecchymosis (Battle sign); however, it sometimes also causes otorrhea, rhinorrhea, and loss of cranial nerve I (olfactory nerve) function. Nuchal rigidity and Kernig's sign are associated with meningitis. Motor loss in the legs that exceeds that in the arms suggests central cord syndrome. Pupillary changes are common in skull fractures with associated meningeal artery bleeding and uncal herniation.

The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern? Select all that apply.

• Unequal pupils • Pinpoint pupils • Absence of pupillary response

A client newly diagnosed with diabetes mellitus asks why he needs ketone testing when the disease affects his blood glucose levels. How should the nurse respond?

"Ketones will tell us if your body is using other tissues for energy." Explanation: The nurse should tell the client that ketones are a byproduct of fat metabolism and that ketone testing can determine whether the body is breaking down fat to use for energy. The spleen doesn't release ketones when the body can't use glucose. Although ketones can damage the eyes and kidneys and help the physician evaluate the severity of a client's diabetes, these responses by the nurse are incomplete.

Which instruction should a nurse give to a client with diabetes mellitus when teaching about "sick day rules"?

"Test your blood glucose every 4 hours." Explanation: The nurse should instruct a client with diabetes mellitus to check his blood glucose levels every 3 to 4 hours and take insulin or an oral antidiabetic agent as usual, even when he's sick. If the client's blood glucose level rises above 300 mg/dl, he should call his physician immediately. If the client is unable to follow the regular meal plan because of nausea, he should substitute soft foods, such as gelatin, soup, and custard.

A nurse is providing education about migraine headaches to a community group. The cause of migraines has not been clearly demonstrated, but is related to vascular disturbances. A member of the group asks about familial tendencies. The nurse's correct reply will be which of the following?

"There is a strong familial tendency." Explanation: Migraine headaches have a strong familial tendency. Migraines are primary headaches, not secondary headaches.

A nurse knows to assess a patient with type 1 diabetes for postprandial hyperglycemia. The nurse knows that glycosuria is present when the serum glucose level exceeds:

180 mg/dL Explanation: Glycosuria occurs when the renal threshold for sugar exceeds 180 mg/dL. Glycosuria leads to an excessive loss of water and electrolytes (osmotic diuresis).

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.

When administering insulin to a client with type 1 diabetes, which of the following would be most important for the nurse to keep in mind?

Accuracy of the dosage Explanation: The measurement of insulin is most important and must be accurate because clients may be sensitive to minute dose changes. The duration, area, and technique for injecting should also to be noted.

Which cranial nerve is tested by listening to a ticking watch?

Acoustic Explanation: The acoustic nerve (VIII) assesses hearing by rubbing the fingers, placing a ticking watch, or whispering near each ear. The facial nerve (VII) is assessed for symmetry of facial movement. The trigeminal nerve (V) is assessed for facial sensation, corneal reflex, and chewing or mastication. The vagus nerve (X) is assessed by swallowing and gag reflex.

A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as?

An intracerebral hematoma Explanation: Intracerebral hemorrhage (hematoma) is bleeding within the brain, into the parenchyma of the brain. It is commonly seen in head injuries when force is exerted to the head over a small area (e.g., missile injuries, bullet wounds, stab injuries). A subdural hematoma (SDH) is a collection of blood between the dura and the brain, a space normally occupied by a thin cushion of cerebrospinal fluid. After a head injury, blood may collect in the epidural (extradural) space between the skull and the dura.

Which of the following terms refers to the inability to coordinate muscle movements, resulting difficulty walking?

Ataxia Explanation: Ataxia is the inability to coordinate muscle movements, resulting in difficulty walking. Agnosia is the loss of ability to recognize objects through a particular sensory system.Spasticity is the sustained increase in tension of a muscle when it is passively lengthened or stretched

The nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse testing when using the chart?

CN II Explanation: The nurse assesses vision and thus the optic nerve (cranial nerve II) by use of a Snellen eye chart.

A patient is scheduled for an electroencephalogram (EEG) in the morning. What food on the patient's tray should the nurse remove prior to the test?

Coffee Explanation: Antiseizure agents, tranquilizers, stimulants, and depressants should be withheld 24 to 48 hours before an EEG, because these medications can alter the EEG wave patterns or mask the abnormal wave patterns of seizure disorders (Pagana & Pagana, 2009). Coffee, tea, chocolate, and cola drinks are omitted from the meal before the test because of their stimulating effect. However, the meal itself is not omitted, because an altered blood glucose level can cause changes in brain wave patterns.

Which of the following would be inconsistent as a cause of DKA?

Competency in injecting insulin Explanation: Being able to competently inject insulin is not a cause of DKA. Undiagnosed and untreated diabetes decreased or missed dose of insulin, and illness or infection are potential causes of DKA.

A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode?

Compliance with the prescribed medication regimen Explanation: The most common cause of status epilepticus is sudden withdraw of anticonvulsant therapy. The type of medication prescribed, the client's stress level, and weight change don't contribute to this condition.

A patient has a deficiency of the neurotransmitter serotonin. The nurse is aware that this deficiency can lead to:

Depression. Explanation: Serotonin helps control mood and sleep. A deficiency leads to depression.

Which of the following are sympathetic effects of the nervous system?

Dilated pupils Explanation: Dilated pupils are a sympathetic effect of the nervous system. Constricted pupils are a parasympathetic effect. Decreased blood pressure is a parasympathetic effect. Increased blood pressure is a sympathetic effect. Increased peristalsis is a parasympathetic effect. Decreased peristalsis is a sympathetic effect. Decreased respiratory rate is a parasympathetic effect. Increased respiratory rate is a sympathetic effect.

A patient is being tested for a gag reflex. When the nurse places the tongue blade to the back of the throat, there is no response elicited. What dysfunction does the nurse determine the patient has?

Dysfunction of the vagus nerve Explanation: The vagus nerve (cranial nerve X) controls the gag reflex and is tested by depressing the posterior tongue with a tongue blade. An absent gag reflex is a significant finding, indicating dysfunction of this nerve.

Which lobe of the brain is responsible for concentration and abstract thought?

Frontal Explanation: The major functions of the frontal lobe are concentration, abstract thought, information storage or memory, and motor function. The parietal lobe analyzes sensory information such as pressure, vibration, pain, and temperature. The occipital lobe is the primary visual cortex. The temporal lobe contains the auditory receptive areas located around the temples.

During assessment of a patient who has been taking Dilantin for seizure management for 3 years, the nurse notices one of the side effects that should be reported. What is that side effect?

Gingival hyperplasia Explanation: Side-effects of Dilantin include visual problems, hirsutism, gingival hyperplasia, arrhythmias, dysarthria, and nystagmus.

A nurse is caring for a client who requires intracranial pressure (ICP) monitoring. The nurse should be alert for what complication of ICP monitoring?

Infection Explanation: The catheter for measuring ICP is inserted through a burr hole into a lateral ventricle of the cerebrum, thereby creating a risk of infection. Coma, high blood pressure, and apnea are late signs of increased ICP, not complications.

The nurse is preparing a presentation for a group of adults at a local community center about diabetes. Which of the following would the nurse include as associated with type 2 diabetes?

Insufficient insulin production Explanation: Type 2 diabetes is characterized by insulin resistance or insufficient insulin production. It is more common in aging adults and now accounts for 20% of all newly diagnosed cases. Type 1 diabetes is more likely in childhood and adolescence; although, it can occur at any age. It accounts for approximately 5% to 10% of all diagnosed cases of diabetes. Prediabetes can lead to type 2 diabetes.

A patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit from the application of the halo device?

It allows for stabilization of the cervical spine along with early ambulation. Explanation: Halo devices provide immobilization of the cervical spine while allowing early ambulation.

The nurse is describing the action of insulin in the body to a client newly diagnosed with type 1 diabetes. Which of the following would the nurse explain as being the primary action?

It carries glucose into body cells. Explanation: Insulin carries glucose into body cells as their preferred source of energy. Besides, it promotes the liver's storage of glucose as glycogen and inhibits the breakdown of glycogen back into glucose. Insulin does not aid in gluconeogenesis but inhibits the breakdown of glycogen back into glucose. Insulin does not have an effect on the intestinal absorption of glucose.

A patient was admitted to a rehabilitation unit for treatment of a spinal cord injury. The admitting diagnosis is central cord syndrome. During an admissions physical, the nurse expects to find:

Loss of motor power and sensation in the upper extremities. Explanation: Characteristics of a central cord injury include motor deficits (in the upper extremities compared to the lower extremities; sensory loss varies but is more pronounced in the upper extremities); bowel/bladder dysfunction is variable, or function may be completely preserved.

Mildred McCarthy, an 89-year-old retired government clerk, is being admitted to your rehabilitation hospital as a result of the tetraplegia caused by stroke. Her condition is stable, and after admission, she will begin physical and psychological therapy. An important part of your nursing management is to reposition Mrs. McCarthy every 2 hours. What is the rationale behind this intervention?

Maintain sufficient integument capillary pressure Explanation: Changing position every 2 hours relieves pressure over bony prominences and maintains sufficient capillary pressure to promote intact skin integrity. The client is repositioned every 2 hours to relieve pressure over bony prominences and to maintain sufficient capillary pressure to promote intact skin integrity.

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.

To meet the sensory needs of a client with viral meningitis, which of the following should the nurse do?

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. Environmental stimuli may worsen symptoms; therefore, environmental stimuli should be reduced. Family members do not need to be avoided. People diagnosed with viral meningitis should be instructed to thoroughly wash hands frequently.

A patient who is diagnosed with type 1 diabetes would be expected to:

Need exogenous insulin. Explanation: Type 1 diabetes is characterized by the destruction of pancreatic beta cells that require exogenous insulin.

After a transsphenoidal adenohypophysectomy, a client is likely to undergo hormone replacement therapy. A transsphenoidal adenohypophysectomy is performed to treat which type of cancer?

Pituitary carcinoma Explanation: Pituitary carcinoma most commonly arises in the anterior pituitary (adenohypophysis) and must be removed by way of a transsphenoidal approach, using a bivalve speculum and rongeur. Surgery to treat esophageal carcinoma usually is palliative and involves esophagogastrectomy with jejunostomy. Laryngeal carcinoma may necessitate a laryngectomy. To treat colorectal cancer, the surgeon removes the tumor and any adjacent tissues and lymph nodes that contain cancer cells.

The nurse is caring for a patient immediately following supratentorial intracranial surgery. What action by the nurse is appropriate?

Place patient in supine position with head slightly elevated. Explanation: After surgery, the nurse should place the patient in either a supine position with the head slightly elevated or a side-lying position on the unaffected side. The dorsal recumbent position, the Trendelenburg position, and the prone position can increase intracranial pressure.

A discharge nurse in a rehabilitation facility is coordinating the discharge of Mr. Rigby, 47-year-old tetraplegic, married man with two children in high school. The client is being discharged to home and will require much assistance. Who would the discharge planner recognize as being the most important member of Mr. Rigby's care team?

Spouse Explanation: The client's spouse and family would need to be involved in the everyday care of Mr. Rigby; without their support, it is unlikely that Mr. Rigby would be able to manage at home. Although a very important component, the most important member of this team is the client's spouse.

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 Explanation: 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.

Lower motor neuron lesions cause

flaccid muscle paralysis. Explanation: Lower motor neuron lesions cause flaccid muscle paralysis, muscle atrophy, decreased muscle tone, and loss of voluntary control. Upper motor neuron lesions cause increased muscle tone. Upper motor neuron lesions cause no muscle atrophy. Upper motor neuron lesions cause hyperactive and abnormal reflexes.

Which of the following symptoms are indicative of a rapidly expanding acute subdural hematoma? Select all that apply.

• Hemiparesis • Decreased reactivity of the pupils • Bradycardia • Coma

Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply.

• Motor response • Eye opening • Verbal response

A mother brings her 6-year-old to the Emergency Department (ED) after the child fell off their bike. The physician diagnoses a concussion. The mother asks the nurse what a concussion is. What should the nurse's response be?

"A concussion is a blow to the head that jars the brain resulting in diffuse and microscopic injury to the brain." Explanation: A concussion results from a blow to the head that jars the brain. It usually is a consequence of falling, striking the head against a hard surface such as a windshield, colliding with another person (e.g., between athletes), battering during boxing, or being a victim of violence. A concussion results in diffuse and microscopic injury to the brain. Options A, B, and C are incorrect as they give incorrect information to the mother.

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP?

Lethargy and stupor Explanation: As ICP increases, the patient becomes stuporous, reacting only to loud or painful stimuli. At this stage, serious impairment of brain circulation is probably taking place, and immediate intervention is required.

A patient has difficulty interpreting his awareness of body position in space. Which lobe is most likely to be damaged?

Parietal Explanation: The parietal lobe is the primary sensory cortex. It is essential to a person's awareness of his body in space, as well as orientation in space and spatial relations.

A patient with increased ICP has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP?

The CPP is low. Explanation: The normal CPP is 70 to 100 mm Hg. A CPP of 40 mm Hg is low.

The client is waiting in a triage area to learn the medical status of his family following a motor vehicle accident. The client is pacing, taking deep breaths, and wringing the hands. Considering the effects in the body systems, what effects does the nurse anticipate in the liver?

The liver will 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.

A client preparing to undergo a lumbar puncture states he doesn't think he will be able to get comfortable with his knees drawn up to his abdomen and his chin touching his chest. He asks if he can lie on his left side. Which statement is the best response by the nurse?

"Although the required position may not be comfortable, it will make the procedure safer and easier to perform." Explanation: The nurse should explain that the knee-chest position is necessary to make the procedure safer and easier to perform. Lying on his left side won't make the procedure easy or safe to perform. The nurse shouldn't simply tell the client there is no other option because the client is entitled to understand the rationale for the required position. Reporting the client's concerns to the physician won't meet the client's needs in this situation.

The nurse is educating a patient about the benefits of fruit versus fruit juice in the diabetic diet. The patient states, "What difference does it make if you drink the juice or eat the fruit? It is all the same." What is the best response by the nurse?

"Eating the fruit instead of drinking juice decreases the glycemic index by slowing absorption." Explanation: Eating whole fruit instead of drinking juice decreases the glycemic index, because fiber in the fruit slows absorption.

The client with Guillain-Barré syndrome is scheduled for plasmapheresis and is questioning how this process works. Which of the following statements by the nurse best describes plasmapheresis in the management of this syndrome?

'Antibodies that triggered the autoimmune response are removed from your blood.' Explanation: Because GBS is believed to be an autoimmune disease, plasmapheresis (not blood transfusion) has emerged as a major treatment intervention. This process removes the blood, filters out the antibodies that trigger the autoimmune disease, and then returns the blood to the client. The blood removal is only a part of the process for filtering out antibodies and is not a dilution process.

The nurse is caring for a patient who was involved in a motor vehicle accident and sustained a head injury. When assessing deep tendon reflexes (DTR), the nurse observes diminished or hypoactive reflexes. How will the nurse document this finding?

1+ Explanation: Diminished or hypoactive DTRs are indicated by a score of 1+, no response by a score of 0, a normal response by a score of 2+, and an increased response by a score of 3+.

A health care provider prescribes short-acting insulin for a patient, instructing the patient to take the insulin 20 to 30 minutes before a meal. The nurse explains to the patient that Humulin-R, taken at 6:30 AM will reach peak effectiveness by:

8:30 AM. Explanation: Short-acting insulin reaches its peak effectiveness 2 to 3 hours after administration. See Table 30-3 in the text.

An unresponsive patient is brought to the ED by a family member. The family states, "We don't know what happened." Which of the following is the priority nursing intervention?

Assess for a patent airway. Explanation: A patient with altered LOC may be unable to protect his or her airway and therefore the priority nursing intervention should be to assess for a patent airway. The nurse should assess pupils, vital signs, and Glasgow Coma Scale, but only after ensuring the patient has a patent airway.

A patient recently noted difficulty maintaining his balance and controlling fine movements. The nurse explains that the provider will order diagnostic studies for the part of his brain known as the:

Cerebellum. Explanation: The cerebellum is largely responsible for coordination of all movement. It also controls fine movement, balance, position (postural) sense or proprioception (awareness of where each part of the body is), and integration of sensory input.

Which of the following is the earliest sign of increasing ICP?

Change in level of consciousness Explanation: The earliest sign of increasing ICP is a change in LOC. Other manifestations of increasing ICP are vomiting, headache, and posturing.

A nurse is caring for a client with deteriorating neurologic status. The nurse is performing an assessment at the beginning of the shift that reveals a falling blood pressure and heart rate, and the client makes no motor response to stimuli. Which documentation of neuromuscular status is most appropriate?

Flaccidity Explanation: The nurse would document flaccidity when the client makes no motor response to stimuli. Abnormal posturing and weak motor tone would be documented specifically as the nurse would assess. Decorticate posturing is when a client is stiff with bent arms and clenched fists with legs straight out.

Which assessment finding is most important in determining nursing care for a client with diabetes mellitus?

Fruity breath Explanation: The rising ketones and acetone in the blood can lead to acidosis and be detected as a fruity odor on the breath. Ketoacidosis needs to be treated to prevent further complications such as Kussmaul's respirations (fast, labored breathing) and renal shutdown. A blood sugar of 170 mg/dL is not ideal but will not result in glycosuria and/or trigger the classic symptoms of diabetes mellitus. Cloudy urine may indicate a UTI.

Cranial nerve IX is also known as which of the following?

Glossopharyngeal Explanation: Cranial nerve IX is the glossopharyngeal nerve. The vagus nerve is cranial nerve X. Cranial nerve XII is the hypoglossal nerve. The spinal accessory is the cranial nerve XI.

Which of the following is the most rapid acting insulin?

Humalog Explanation: The onset of action of rapid-acting Humalog is within 10 to 15 minutes. The onset of action of short-acting regular insulin is 30 minutes to 1 hour. The onset of action of intermediate acting NPH is 3 to 4 hours. The onset of action of long-acting Ultralente is 6 to 8 hours.

A client with diabetes is receiving an oral antidiabetic agent that acts to help the tissues use available insulin more efficiently. Which of the following agents would the nurse expect to administer?

Metformin Explanation: Metformin is a biguanide and along with the thiazolidinediones (rosiglitazone and pioglitazone) are categorized as insulin sensitizers; they help tissues use available insulin more efficiently. Glyburide and glipizide which are sulfonylureas, and repaglinide, a meglitinide, are described as being insulin releasers because they stimulate the pancreas to secrete more insulin.

A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care?

Monitoring is needed as rapid neurologic deterioration may occur. Explanation: The nurse identifies that the CT scan suggests an epidural hematoma. A key component in planning care is the understanding that rapid neurologic deterioration occurs. Symptoms evolve quickly. A crash cart may be kept nearby, but this is not the key information. An intracerebral hematoma is bleeding within the brain, which is a different area of bleeding.

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.

A client who has sustained a head injury to the parietal lobe cannot identify a familiar object by touch. The nurse knows that this deficit is which of the following?

Tactile agnosia Explanation: Tactile agnosia is the inability to identify a familiar object by touch. Visual agnosia is the loss of ability to recognize objects through sight. The Romberg test has to do with balance. Ataxia is defined as incoordination of voluntary muscle action.

A client has sustained a traumatic brain injury with involvement of the hypothalamus. The nurse is concerned about the development of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus?

Take daily weights. Explanation: A record of daily weights is maintained for the client with a traumatic brain injury, especially if the client has hypothalamic involvement and is at risk for the development of diabetes insipidus. A weight loss will alert the nurse to possible fluid imbalance early in the process.

A nurse is preparing to administer two types of insulin to a client with diabetes mellitus. Which of the following demonstrates that the nurse understands the correct procedure for preparing this medication?

The short-acting insulin is withdrawn before the intermediate-acting insulin. Explanation: When combining two types of insulin in the same syringe, the short-acting regular insulin is withdrawn into the syringe first and the intermediate-acting insulin is added next, a practice referred to as "clear to cloudy."

A client with diabetes mellitus develops sinusitis and otitis media accompanied by a temperature of 100.8° F (38.2° C). What effect do these findings have on his need for insulin?

They increase the need for insulin. Explanation: Insulin requirements increase in response to growth, pregnancy, increased food intake, stress, surgery, infection, illness, increased insulin antibodies, and some medications. Insulin requirements are decreased by hypothyroidism, decreased food intake, exercise, and some medications

An osmotic diuretic, such as mannitol, is given to the patient with increased intracranial pressure (IICP) for which of the following reasons?

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 patient with IICP. Chlorpromazine (Thorazine) may be prescribed to control shivering in the patient with IICP. Medications such as barbiturates are given to the patient with IICP to reduce cellular metabolic demands.

During a class on exercise for clients with diabetes mellitus, a client asks the nurse educator how often to exercise. To meet the goals of planned exercise, the nurse educator should advise the client to exercise:

at least three times per week. Explanation: Clients with diabetes must exercise at least three times per week to meet the goals of planned exercise — lowering the blood glucose level, reducing or maintaining the proper weight, increasing the serum high-density lipoprotein level, decreasing serum triglyceride levels, reducing blood pressure, and minimizing stress. Exercising once per week wouldn't achieve these goals. Exercising more than three times per week, although beneficial, would exceed the minimum requirement.

Clinical manifestations of neurogenic shock include which of the following? Select all that apply.

• Venous pooling in the extremities • Bradycardia • Warm skin

A patient is diagnosed with type 1 diabetes. What clinical characteristics does the nurse expect to see in this patient? (Select all that apply.)

• Younger than 30 years of age • Ketosis-prone • Little endogenous insulin

Which phase of a migraine headache usually lasts less than an hour?

Aura Explanation: The aura phase occurs in about 20% of patients who have migraines and may be characterized by focal neurological symptoms. The prodrome phase occurs hours to days before a migraine headache. The headache phase lasts from 4 to 72 hours. During the postheadache phase, patients may sleep for extended periods.

The nurse is assisting the physician in completing a lumbar puncture. Which would the nurse note as a concern?

Cerebrospinal fluid is cloudy in nature. Explanation: The nurse would note a concern as being the cerebrospinal fluid as cloudy in nature. Cloudy fluid is an indication of infection. The physician is correct to maintain aseptic procedure. A piercing feeling and pressure relief is a common feeling during and after the procedure.

The nurse is caring for a client experiencing autonomic dysreflexia. Which of the following does the nurse recognize as the source of symptoms?

Sympathetic nervous system Explanation: The nurse recognizes that autonomic dysreflexia is an exaggerated sympathetic nervous system response. Symptoms include severe hypertension, slow heart rate, pounding headache, etc. and can lead to seizures, stroke, and death. The autonomic nervous system regulates "feed and breed" functions. The central and peripheral nervous system is a component of the sympathetic nervous system

A client is scheduled for an EEG after having a seizure for the first time. Client preparation for this test should include which instruction?

"Avoid stimulants and alcohol for 24 to 48 hours before the test." Correct Explanation: For 24 to 48 hours before an EEG, the client should avoid coffee, cola, tea, alcohol, and cigarettes because these may interfere with the accuracy of test results. (For the same reason, the client also should avoid antidepressants, sedatives, and anticonvulsants.) To avoid a reduced serum glucose level, which may alter test results, the client should eat normal meals before the test. The hair should be washed before an EEG because the electrodes must be applied to a clean scalp. The client's thoughts don't affect the test results.

The nurse is preparing a client for a neurological examination by the physician and explains tests the physician will be doing, including the Romberg test. The client asks the purpose of this particular test. The correct reply by the nurse is which of the following?

"It is a test for balance." Explanation: The Romberg test screens for balance. The client stands with feet together and arms at the side, first with eyes open and then with both eyes closed for 20 to 30 seconds. Slight swaying is normal, but a loss of balance is abnormal and is considered a positive Romberg test.

You are a neuro trauma 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 of the following positions are employed 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.

A patient in the emergency room has bruising over the mastoid bone and rhinorrhea. These are indicative of which type of skull fracture?

Basilar Explanation: Bruising over the mastoid bone and rhinorrhea is indicative of a basilar skull fracture. A simple (linear) fracture is a break in the continuity of the bone. A comminuted fracture refers to a splintered or multiple fracture line.

The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for?

Burr holes Explanation: An epidural hematoma is considered an extreme emergency; marked neurologic deficit or even respiratory arrest can occur within minutes. Treatment consists of making openings through the skull (burr holes; see Fig. 66-8 in Chapter 66) to decrease intracranial pressure emergently, remove the clot, and control the bleeding.

Which of the following occurs when reflexes are hyperactive when the foot is abruptly dorsiflexed?

Clonus Explanation: Clonus occurs when the foot is abruptly dorsiflexed. It continues to "beat" two or three times before it settles into a position of rest. Sustained clonus always indicates the present of central nervous system disease and requires further evaluation. Ataxia is incoordination of voluntary muscle action. Rigidity is an increase in muscle tone at rest characterized by increased resistance to passive movement. Flaccid posturing is usually the result of lower brain stem dysfunction the patient has no motor function, is limp, and lacks motor tone.

The nurse is offering suggestions regarding reproductive options to a husband and paraplegic wife. Which option is most helpful?

Conception is not impaired; the birth process is determined with the physician. Explanation: The nurse's role is to provide facts without inserting personal opinions. The fact is that the woman can conceive and bear children. Suggesting adoption, a surrogate, and sterilization is not appropriate. Providing information on that suggestion is appropriate.

There are 12 pairs of cranial nerves. Only three are sensory. Select the cranial nerve that is affected with decreased visual fields.

Cranial nerve II Explanation: The three sensory cranial nerves are I, II and VIII. Cranial nerve II (optic) is affected with decreased visual fields and acuity.

Which of the following is a rare, transmissible, progressive fatal disease of the CNS characterized by spongiform degeneration of the gray matter of the brain?

Creutzfeldt-Jakob disease Explanation: Creutzfeldt-Jakob disease causes severe dementia and myoclonus. Multiple sclerosis is a chronic, degenerative, progressive disease of the CNS characterized by the occurrence of small patches of demyelination in the brain and spinal cord. Parkinson's 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. Huntington disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary dancelike movements and dementia.

The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?

Increased pulse rate, adventitious breath sounds Explanation: An increased pulse rate above baseline with adventitious breath sounds indicate compromised respirations and signal a need for airway clearance. A decrease in pulse rate is not indicative of airway obstruction. An increase of pulse rate with slight elevation of respirations (16 breaths/minute) is not significant for suctioning unless findings suggest otherwise.

When educating a patient about the use of antiseizure medication, what should the nurse inform the patient is a result of long-term use of the medication in women?

Osteoporosis Explanation: Because of bone loss associated with the long-term use of antiseizure medications, patients receiving antiseizure agents should be assessed for low bone mass and osteoporosis. They should be instructed about strategies to reduce their risks of osteoporosis (AANN, 2009).

The pre-nursing class is learning about the nervous system in their anatomy class. What part of the nervous system would the students learn is responsible for digesting food and eliminating body waste?

Parasympathetic Explanation: The parasympathetic division of the autonomic nervous system works to conserve body energy and is partly responsible for slowing heart rate, digesting food, and eliminating body wastes.

In your assessment of a 39-year-old victim of a motor vehicle collision, he directly and accurately answers your questions. Beginning at his head, you note a contusion to his forehead; the client reports a headache. As you assess his pupils, what reaction would confirm your suspicion of increasing intracranial pressure?

Unequal response Explanation: In increased ICP, the pupil response is unequal. One pupil responds more sluggishly than the other or becomes fixed and dilated. This is not a sign of increasing ICP. In increased ICP, the pupil response is unequal.

A patient with type 1 diabetes mellitus is being taught about self-injection of insulin. Which of the following facts about site rotation should the nurse include in the teaching?

Use all available injection sites within one area. Explanation: Systematic rotation of injection sites within an anatomic area is recommended to prevent localized changes in fatty tissue. To promote consistency in insulin absorption, the patient should be encouraged to use all available injection sites within one area rather than randomly rotating sites from area to area.

A nurse is performing a neurologic assessment on the client and notes a positive Romberg test. This test for balance is related to which of the following cranial nerves?

VIII Explanation: CN VIII is the acoustic nerve. It has to do with hearing, air and bone conduction, and balance. CN X is the vagus nerve and has to do with the gag reflex, laryngeal hoarseness, swallowing ability, and the symmetrical rise of the uvula and soft palate. CN III is the oculomotor and has to do with pupillary response, conjugate movements, and nystagmus. CN VII is the facial nerve and has to do with symmetry of facial movements and the ability to discriminate between the taste of sugar and salt.

The nurse is caring for a patient following an SCI who has a halo device in place. The patient is preparing for discharge. Which of the following statements made by the patient indicates the need for further instruction?

"I can apply powder under the liner to help with sweating." Explanation: The areas around the four pin sites of a halo device are cleaned daily and observed for redness, drainage, and pain. The pins are observed for loosening, which may contribute to infection. If one of the pins becomes detached, the head is stabilized in a neutral position by one person while another notifies the neurosurgeon. The skin under the halo vest is inspected for excessive perspiration, redness, and skin blistering, especially on the bony prominences. The vest is opened at the sides to allow the torso to be washed. The liner of the vest should not become wet because dampness causes skin excoriation. The liner should be changed periodically to promote hygiene and good skin care. Powder is not used inside the vest because it may contribute to the development of pressure ulcers.

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.

A 65-year-old client was hit in the head with a ball and was knocked unconscious. Upon her arrival at the emergency department and subsequent diagnostic tests, it was determined that she suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would you expect her 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. This describes a client with an acute subdural hematoma.

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)?

Administering a stool softener as ordered Explanation: To prevent the client from straining at stool, which may cause a Valsalva maneuver that increases ICP, the nurse should institute a regular bowel program that includes use of a stool softener. For a client at risk for increased ICP, the nurse should prevent, not encourage, oral fluid intake and should elevate the head of the bed only 30 degrees. Suctioning, indicated for a client with lung congestion, isn't necessary for this client.

The school nurse notes a 6-year-old running across the playground with his friends. The child stops in midstride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child?

An absence seizure Explanation: Absence seizures, formerly referred to as petit mal seizures, are more common in children. They are characterized by a brief loss of consciousness during which physical activity ceases. The person stares blankly; the eyelids flutter; the lips move; and slight movement of the head, arms, and legs occurs. These seizures typically last for a few seconds, and the person seldom falls to the ground. Because of their brief duration and relative lack of prominent movements, these seizures often go unnoticed. People with absence seizures can have them many times a day. Partial, or focal, seizures begin in a specific area of the cerebral cortex. Both myoclonic and tonic-clonic seizures involve jerking movements.

A client is admitted for scheduled gamma-knife radiosurgery, in the treatment of a brain tumor. Which nursing measure is primary in the postsurgical care of this client?

Assess neurological findings. Explanation: Gamma-knife radiosurgery is a non-invasive alternative for treating tumors within the brain. The nurse would be responsible for completing a neurological assessment on the client and providing comfort measures as needed. There is no incision on the skull, and no risk for radiation exposure to the nurse. The procedure eliminates surgical and anesthesia complications and does not result in use of a ventilator or artificial airway maintenance.

While snowboarding, a 17-year-old client fell and struck his head, resulting in a loss of consciousness. Within an hour after his arrival via squad at the ED where you practice nursing, he regained consciousness. He was admitted for 24-hour observation and was discharged without neurologic impairment. What would you expect the neurologist's diagnosis to be?

Concussion Explanation: A concussion results from a blow to the head that jars the brain. It usually is a consequence of falling, striking the head against a hard surface such as a windshield, colliding with another person (e.g., between athletes), battering during boxing, or being a victim of violence. The force of the blow causes temporary neurologic impairment but no serious damage to cerebral tissue. There is generally complete recovery within a short time. The impairment described is a concussion.

A 24-year-old female rock climber is brought to the Emergency Department after a fall from the face of a rock. The young lady is admitted for observation after being diagnosed with a contusion to the brain. The client asks the nurse what having a contusion means. How should the nurse respond?

Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue. Explanation: Contusions result in bruising, and sometimes, hemorrhage of superficial cerebral tissue. When the head is struck directly, the injury to the brain is called a coup injury. Dual bruising can result if the force is strong enough to send the brain ricocheting to the opposite side of the skull, which is called a contrecoup injury. Edema develops at the site of or in areas opposite to the injury. A skull fracture can accompany a contusion.

A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which finding suggests that the client has developed hyperglycemia?

Increased urine output Explanation: Glucose supplies most of the calories in TPN; if the glucose infusion rate exceeds the client's rate of glucose metabolism, hyperglycemia arises. When the renal threshold for glucose reabsorption is exceeded, osmotic diuresis occurs, causing an increased urine output. A decreased appetite and diaphoresis suggest hypoglycemia, not hyperglycemia. Cheyne-Stokes respirations are characterized by a period of apnea lasting 10 to 60 seconds, followed by gradually increasing depth and frequency of respirations. Cheyne-Stokes respirations typically occur with cerebral depression or heart failure.

A client you are caring for experiences a seizure. What would be a priority nursing action?

Protect the client from injury. Explanation: The nursing action for a client experiencing a seizure should be to protect the client from being injured. To ensure this, the nurse should turn the client to one side and not restrain client's movements. Inserting a tongue blade between the teeth is not as important as protecting the client from injury. The mouth and the pharynx of the client should be suctioned only after the seizure.

Which statement about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome?

Administer 2 to 3 L of I.V. fluid rapidly. Explanation: Regardless of the client's medical history, rapid fluid resuscitation is critical for maintaining cardiovascular integrity. Profound intravascular depletion requires aggressive fluid replacement. A typical fluid resuscitation protocol is 6 L of fluid over the first 12 hours, with more fluid to follow over the next 24 hours. Various fluids can be used, depending on the degree of hypovolemia. Commonly ordered fluids include dextran (in cases of hypovolemic shock), isotonic normal saline solution and, when the client is stabilized, hypotonic half-normal saline solution.

Which neurotransmitter demonstrates inhibitory action, helps control mood and sleep, and inhibits pain pathways?

Serotonin Explanation: The sources of serotonin are the brain stem, hypothalamus, and dorsal horn of the spinal cord. 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.

After a seizure, the nurse should place the patient in which of the following positions to prevent complications?

Side-lying, to facilitate drainage of oral secretions Explanation: To prevent complications, the patient is placed in the side-lying position to facilitate drainage of oral secretions, and suctioning is performed, if needed, to maintain a patent airway and prevent aspiration.

Which of the following terms refers to muscular hypertonicity with increased resistance to stretch?

Spasticity Explanation: Spasticity is often associated with weakness, increased deep tendon reflexes, and diminished superficial reflexes. Akathisia refers to a restless, 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.

During a routine physical examination to assess a client's deep tendon reflexes, a nurse should make sure to:

support the joint where the tendon is being tested. Explanation: The nurse should support the joint where the tendon is being tested to prevent the attached muscle from contracting. The nurse should use the flat, not pointed, end of the reflex hammer when striking the Achilles tendon. (The pointed end is used to strike over small areas, such as the thumb placed over the biceps tendon.) Tapping the tendon slowly and softly wouldn't provoke a deep tendon reflex response. The nurse should hold the reflex hammer loosely, not tightly, between the thumb and fingers so it can swing in an arc.

A patient with diabetes mellitus is receiving an oral antidiabetic agent. The nurse observes for which of the following symptoms when caring for this patient?

Hypoglycemia Explanation: The nurse should observe the patient receiving an oral antidiabetic agent for the signs of hypoglycemia. The time when the reaction might occur is not predictable and could be from 30 to 60 minutes to several hours after the drug is ingested.

A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis?

Ineffective breathing pattern Explanation: Because a cervical spine injury can cause respiratory distress, the nurse should take immediate action to maintain a patent airway and provide adequate oxygenation. Impaired physical mobility, Disturbed sensory perception (tactile), and Dressing or grooming self-care deficit may be appropriate for a client with a spinal cord injury — particularly during the course of recovery — but they don't take precedence over a diagnosis of Ineffective breathing pattern.

Which is the priority nursing diagnosis when caring for a patient with increased ICP who has an intraventricular catheter?

Ineffective cerebral tissue perfusion Explanation: The brain must be adequately perfused to maintain function and prevent long-term disability due to lack of oxygenation. The patient is at risk for injury, but this is not first priority. The patient is at risk for fluid volume deficit due to a possible fluid restriction to maintain normovolemia, but this is not first priority. The patient is at risk for infection due to the placement of the intraventricular catheter, but again this is not first priority.

A patient with herpes simplex virus (HSV) encephalitis is receiving acyclovir (Zovirax). To ensure early intervention, the nurse monitors laboratory values and urine output for which of the following adverse reactions?

Renal Explanation: Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy. Complications with the integumentary system will can be observed by the nurse; it is not necessary to review laboratory results or urine output for integumentary reactions. Urine output is not monitored for musculoskeletal or hepatic adverse reactions.

A client diagnosed with Huntington's disease has developed severe depression. What would be most important for the nurse to assess for?

Suicidal ideations Explanation: Severe depression is common and can lead to suicide, so it is most important for the nurse to assess for suicidal ideations. Symptoms of Huntington's 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 symptoms is appropriate, but not as important as assessing for suicidal ideations.

Insulin is a hormone secreted by the Islets of Langerhans and is essential for the metabolism of carbohydrates, fats, and protein. The nurse understands the physiologic importance of gluconeogenesis, which refers to the:

Synthesis of glucose from noncarbohydrate sources. Explanation: Gluconeogenesis refers to the making of glucose from noncarbohydrates. This occurs mainly in the liver. Its purpose is to maintain the glucose level in the blood to meet the body's demands.

A client is admitted to the unit with diabetic keto acidosis (DKA). Which insulin would the nurse expect to administer intravenously?

Regular Explanation: Regular insulin is administered intravenously to treat DKA. It is added to an IV solution and infused continuously. Glargine, NPH, and Lente are only administered subcutaneously.

Nursing assessment findings reveal joint swelling and tenderness and a butterfly rash on the face. The nurse suspects which of the following?

Systemic lupus erythematous Explanation: The butterfly rash is a unique skin manifestation of systemic lupus erythematous. Other clinical manifestaftions include joint swelling and tenderness, pain on movement, and morning stiffness. The disease can affect all body systems

The nurse is evaluating the transmission of a report from a paramedic unit to the emergency room. The medic reports that a client is unconscious with edema of the head and face and Battle's sign. What clinical picture would the nurse anticipate?

Edema to the head with bruising of the mastoid process Explanation: Battle's sign is the presence of bruising of the mastoid process behind the ear. It is not related to periorbital bleeding, lacerations, or fixed pupils.

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 patient brought to the hospital after a skiing accident was unconscious for a brief period of time at the scene, then woke up disoriented and refused to go to the hospital for treatment. The patient became very agitated and restless, then quickly lost consciousness again. What type of TBI is suspected in this situation?

Epidural hematoma Explanation: Epidural hematomas are often characterized by a brief loss of consciousness followed by a lucid interval in which the patient is awake and conversant. The patient then becomes increasingly restless, agitated, and confused as the condition progresses to coma.

Bell's palsy is a disorder of which cranial nerve?

Facial (VII) Explanation: Bell's palsy is characterized by facial dysfunction, weakness, and paralysis. Trigeminal neuralgia is a disorder of the trigeminal nerve and causes facial pain. Mnire's syndrome is a disorder of the vestibulocochlear nerve. Guillain-Barr syndrome is a disorder of the vagus nerve.

While riding a bicycle in a race, a patient fell into a ditch and sustained a head injury. Another cyclist found the patient lying unconscious in the ditch and called 911. What type of concussion does the patient most likely have?

Grade 3 concussion Explanation: There are three grades of concussion or mild traumatic brain injury defined by the American Academy of Neurology when the injury is sports related (Ruff, Iverson, Barth, et al., 2009). A grade 1 concussion has symptoms of transient confusion, no loss of consciousness, and duration of mental status abnormalities on examination that resolve in less than 15 minutes. A grade 2 concussion also has symptoms of transient confusion and no loss of consciousness, but the concussion symptoms or mental status abnormalities on examination last more than 15 minutes. In a grade 3 concussion, there is any loss of consciousness lasting from seconds to minutes (Ruff et al., 2009).

The nurse working on a neurological unit is mentoring a nursing student. The student asks about a client who has sustained a primary and and secondary brain injury. The nurse correctly tells the student which of the following, related to the primary injury?

It results from initial damage to the brain from the traumatic event. Explanation: The primary injury results from the initial damage from the traumatic event. The secondary injury results from inadequate delivery of nutrients and oxygen to the cells, usually due to cerebral edema and increased intracranial pressure.

A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP?

Keep the client's neck in a neutral position (no flexing). Explanation: To assist in controlling ICP in clients with severe brain injury, the following are recommended: elevate the head of the bed as prescribed (gravity helps drain fluid), maintain head/neck in neutral alignment (no twisting or flexing), give sedation as ordered to prevent agitation, and avoid noxious stimuli (scatter procedures so that client does not become overtired).

A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following?

Monro-Kellie Explanation: The Monro-Kellie hypothesis states that, because of the limited space for expansion in the skull, an increase in any one of its components causes a change in the volume of the others. Cushing's response is seen when cerbral blood flow decreases significantly. Systolic blood pressure increases, pulse pressure widens, and heart rate slows. The Dawn phenomenon is related to high blood glucose levels in the morning in clients with diabetes. Hasimoto's disease is related to the thyroid gland.

Which of the following drugs may be used after a seizure to maintain a seizure-free state?

Phenobarbital Explanation: IV diazepam (Valium), lorazepam (Ativan), or fosphenytoin (Cerebyx) are administered slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are administered later to maintain a seizure-free state. In general, a single drug is used to control the seizures.

Which of the following cerebral lobes contains the auditory receptive areas?

Temporal Explanation: The temporal lobe plays the most dominant role of any area of the cortex in cerebration. The frontal lobe, the largest lobe, controls concentration, abstract thought, information storage or memory, and motor function. The parietal lobe contains the primary sensory cortex, which analyzes sensory information and relays interpretation to the thalamus and other cortical areas. The occipital lobe is responsible for visual interpretation.

The nurse received report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?

The client has cerebral spinal fluid (CSF) leaking from the ear. Explanation: Otorrhea means leakage of CSF from the ear. The client with a basilar skull fracture can create a pathway from the brain to the middle ear due to a tear in the dura. As a result, the client can have cerebral spinal fluid leak from the ear. The nurse may assess clear fluid in the ear canal. Ecchymosis and periorbital edema can be present as a manifestation of bruising from the head injury. An elevated temperature may occur from the head injury and is monitored closely. The client may have serous drainage from the nose especially immediately following the injury.

Which of the following factors would a nurse identify as a most likely cause of diabetic ketoacidosis (DKA) in a client with diabetes?

The client has eaten and has not taken or received insulin. Explanation: If the client has eaten and has not taken or received insulin, DKA is more likely to develop. Hypoglycemia is more likely to develop if the client has not consumed food and continues to take insulin or oral antidiabetic medications, if the client has not consumed sufficient calories, or if client has been exercising more than usual.

The nurse is performing a neurological assessment of a client who has sustained damage to the frontal cortex. Which of the following deficits will the nurse look for during assessment?

The inability to tell how a mouse and a cat are alike Explanation: The client with damage to the fronal cortex will display a deficit in intellectual functioning. Questions designed to assess this capacity might include the ability to recognize similarities: for example, how are a mouse and dog or pen and pencil alike? The Romberg test assesses balance, which has to do with the cerebellar and basal ganglia influence on the motor system. Absence of movement below the waist suggests a deficit with the spinal cord. Intentional tremors have to do with deficits of the motor system.

Which of the following diagnostic tests maybe performed to evaluate blood flow within intracranial blood vessels?

Transcranial Doppler Explanation: Transcranial Doppler flow studies are used to study a tumor's blood flow within intracranial blood vessels. Cerebral angiography may be used to study a tumor's blood supply or obtain information about vascular lesions. An MRI provides information similar to that of a CT scan with improved tissue contrast, resolution and anatomic definition, and examines the lesion in multiple planes.