MS2- Neurologic- NCLEX

The nurse is caring for a client with myasthenia gravis who has received edrophonium by the intravenous route to test for myasthenic crisis. The client asks the nurse how long the improvement in muscle strength will last. Which response should the nurse make to the client? 1. "It will last for 4 to 5 minutes." 2. "It will last for about 30 minutes." 3. "It will last longer than 60 minutes." 4. "It will last approximately 10 minutes."

ANS: 1 "It will last for 4 to 5 minutes." Rationale: Edrophonium commonly is given to test for myasthenic crisis. If the client is in myasthenic crisis, muscle strength improves after administration of the medication. Within 30 to 60 seconds, most myasthenic clients show a marked improvement in muscle tone that lasts for 4 to 5 minutes. Options 2, 3 and 4 are incorrect.

The nurse is caring for a client who is in the chronic phase of stroke (brain attack) and has a right-sided hemiparesis. The nurse identifies that the client is unable to feed self. Which is the appropriate nursing intervention? 1. Assist the client to eat with the left hand to build strength. 2. Provide a pureed diet that is easy for the client to swallow. 3. Inform the client that a feeding tube will be placed if progress is not made. 4. Provide a variety of foods on the meal tray to stimulate the client's appetite.

ANS: 1 Assist the client to eat with the left hand to build strength. Rationale: Right-sided hemiparesis is weakness of the right arm and leg. The nurse should teach the client to use both sides of the body to increase strength and build endurance. Providing a pureed diet is incorrect. The question does not mention swallowing difficulty, so there is no need to puree the food. Informing the client that a feeding tube may need to be placed is incorrect. That information would come from the health care provider. Providing a variety of foods is also incorrect because the problem is not the food selection but the client's ability to eat the food independently.

The nurse who is caring for a client with myasthenia gravis has a prescription to perform an edrophonium test. After obtaining edrophonium the nurse should be certain that which also is available at the bedside? 1. Atropine sulfate 2. Protamine sulfate 3. Calcium gluconate 4. Magnesium sulfate

ANS: 1 Atropine sulfate Rationale: An edrophonium test is performed to distinguish between myasthenic and cholinergic crisis. After administration of the edrophonium, if symptoms intensify, the crisis is cholinergic. Because the symptoms of cholinergic crisis will worsen with the administration of edrophonium, atropine sulfate should be available because it is the antidote. Protamine sulfate is the antidote for heparin. Calcium gluconate is the antidote for magnesium sulfate toxicity.

A client with myasthenia gravis arrives at the hospital emergency department in suspected crisis. The health care provider plans to administer edrophonium to differentiate between myasthenic and cholinergic crises. The nurse ensures that which medication is available in the event that the client is in cholinergic crisis? 1. Atropine sulfate 2. Morphine sulfate 3. Protamine sulfate 4. Pyridostigmine bromide

ANS: 1 Atropine sulfate Rationale: Clients with cholinergic crisis have experienced overdosage of medication. Edrophonium will exacerbate symptoms in cholinergic crisis to the point at which the client may need intubation and mechanical ventilation. Intravenous atropine sulfate is used to reverse the effects of these anticholinesterase medications. Morphine sulfate and pyridostigmine bromide would worsen the symptoms of cholinergic crisis. Protamine sulfate is the antidote for heparin.

The nurse is caring for a client after a craniotomy and monitors the client for signs of increased intracranial pressure (ICP). Which finding, if noted in the client, would indicate an early sign of increased ICP? 1. Confusion 2. Bradycardia 3. Sluggish pupils 4. A widened pulse pressure

ANS: 1 Confusion Rationale: Early manifestations of increased ICP are subtle and often may be transient, lasting for only a few minutes in some cases. These early clinical manifestations include episodes of confusion, drowsiness, and slight pupillary and breathing changes. Later manifestations include a further decrease in the level of consciousness, a widened pulse pressure, and bradycardia. Cheyne-Stokes respiratory pattern, or a hyperventilation respiratory pattern, and pupillary sluggishness and dilatation appear in the late stages.

The nurse is performing a neurological assessment on a client and is assessing the function of cranial nerves III, IV, and VI. Assessment of which aspect of function will yield the best information about these cranial nerves? 1. Eye movements 2. Response to verbal stimuli 3. Affect, feelings, or emotions 4. Insight, judgment, and planning

ANS: 1 Eye movements Rationale: Eye movements are under the control of cranial nerves III, IV, and VI. Level of consciousness (response to verbal stimuli) is controlled by the reticular activating system and both cerebral hemispheres. Feelings are part of the role of the limbic system and involve both hemispheres. Insight, judgment, and planning are part of the function of the frontal lobe in conjunction with association fibers that connect to other areas of the cerebrum.

Members of the family of an unconscious client with increased intracranial pressure are talking at the client's bedside. They are discussing the client's condition and wondering whether the client will ever recover. The nurse intervenes on the basis of which interpretation? 1. It is possible the client can hear the family. 2. The family needs immediate crisis intervention. 3. The client might have wanted a visit from the hospital chaplain. 4. The family could benefit from a conference with the health care provider.

ANS: 1 It is possible the client can hear the family. Rationale: Some clients who have awakened from an unconscious state have remembered hearing specific voices and conversations. Family and staff should assume that the client's sense of hearing is intact and act accordingly. In addition, positive outcomes are associated with coma stimulation-that is, speaking to and touching the client. The remaining options are incorrect interpretations.

A client with myasthenia gravis who is taking neostigmine is experiencing frequent exacerbations of myasthenic crisis and cholinergic crisis. The nurse teaches the client that it is most important that this medication be taken in which manner? 1. On time 2. On an empty stomach 3. Double-dosed if 1 dose is missed 4. Titrated for dosage, depending on symptoms

ANS: 1 On time Rationale: The client should take neostigmine exactly on time. Taking the medication early or late could result in myasthenic or cholinergic crisis. Taking the medication on time is especially important for the client with dysphagia because the client may not be able to swallow the medication if it is given late. These clients are taught to set an alarm clock to remind them of dosage times. The medication should be administered with food or milk to minimize side and adverse effects. The client should never skip or double up on missed doses or titrate the dose, depending on symptoms. The client needs to take the medication exactly as prescribed

A client has suffered damage to Broca's area of the brain. Which priority assessment should the nurse perform? 1. Speech 2. Hearing 3. Balance 4. Level of consciousness

ANS: 1 Speech Rationale: Broca's area in the brain is responsible for the motor aspects of speech, through coordination of the muscular activity of the tongue, mouth, and larynx. The term assigned to damage in this area is aphasia. The items listed in the other options are not the responsibility of Broca's area.

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective? 1. Taking medications as scheduled 2. Eating large, well-balanced meals 3. Doing muscle-strengthening exercises 4. Doing all chores early in the day while less fatigued

ANS: 1 Taking medications as scheduled Rationale: Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is important. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional stress.

A client who had a stroke (brain attack) has right-sided hemianopsia. What should the nurse plan to do to help the client adapt to this problem? 1. Teach the client to scan the environment. 2. Place all objects within the left visual field. 3. Place all objects within the right visual field. 4. Ensure that the family brings the client's eyeglasses to hospital.

ANS: 1 Teach the client to scan the environment. Rationale: Hemianopsia is blindness in half of the visual field. The client with hemianopsia is taught to scan the environment. This allows the client to take in the entirety of the visual field, which is necessary for proper functioning within the environment and helps to prevent injury to the client. Options 2 and 3 will not help the client adapt to this visual impairment. Eyeglasses are useful if the client already wears them, but they will not correct this visual field deficit.

The nurse is preparing a plan of care for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On assessment, the nurse notes that the client is severely dysphagic. Which intervention should be included in the care plan for this client? Select all that apply. 1. Provide oral hygiene after each meal. 2. Assess swallowing ability frequently. 3. Allow the client sufficient time to eat. 4. Maintain a suction machine at the bedside. 5.

ANS: 1, 2, 3, 4 Rationale: A client who is severely dysphagic is at risk for aspiration. Swallowing is assessed frequently. The client should be given a sufficient amount of time to eat. Semisoft foods are easiest to swallow and require less chewing. Oral hygiene is necessary after each meal. Suctioning should be available for clients who experience dysphagia and are at risk for aspiration.

The nurse is creating a plan of care for a client with dysphagia following a stroke (brain attack). Which should the nurse include in the plan? Select all that apply. 1. Thicken liquids 2. Assist the client with eating. 3. Assess for the presence of a swallow reflex. 4. Place the food on the affected side of the mouth. 5. Provide ample time for the client to chew and swallow.

ANS: 1, 2, 3, 5 Rationale: Liquids are thickened to prevent aspiration. The nurse should assist the client with eating and place food on the unaffected side of the mouth. The nurse should assess for gag and swallowing reflexes before the client with dysphagia is started on a diet. The client should be allowed ample time to chew and swallow to prevent choking.

The home health nurse is visiting a client with myasthenia gravis and is discussing methods to minimize the risk of aspiration during meals related to decreased muscle strength. Which suggestions should the nurse give to the client? Select all that apply. 1. Chew food thoroughly. 2. Cut food into very small pieces. 3. Sit straight up in the chair while eating. 4. Lift the head while swallowing liquids. 5. Swallow when the chin is tipped slightly downward to the chest.

ANS: 1, 2, 3, 5 Rationale: The client avoids swallowing any type of food or drink with the head lifted upward, which could actually cause aspiration by opening the glottis. The client should be advised to sit upright while eating, not to talk with food in the mouth (talking requires opening the glottis), cut food into very small pieces, chew thoroughly, and tip the chin downward to swallow.

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. 1. The client is aphasic 2. The client has weakness on the right side of the body. 3. The client has complete bilateral paralysis of the arms and legs. 4. The client has weakness on the right side of the face and tongue. 5. The client has lost the ability to move the right arm but is able to walk independently. 6. The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance.

ANS: 1, 2, 4 1. The client is aphasic 2. The client has weakness on the right side of the body. 3. The client has weakness on the right side of the face and tongue. Rationale: Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic: unable to discriminate words and letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.

The nurse is trying to communicate with a client who had a stroke and has aphasia. Which actions by the nurse would be most helpful to the client? Select all that apply. 1. Speaking to the client at a slower rate 2. Allowing plenty of time for the client to respond 3. Completing the sentences that the client cannot finish 4. Looking directly at the client during attempts at speech 5. Shouting words if it seems as though the client has difficulty understanding.

ANS: 1, 2, 4 Rationale: Clients with aphasia after brain attack often fatigue easily and have a short attention span. General guidelines when trying to communicate with the aphasic client include speaking more slowly and allowing adequate response time, listening to and watching attempts to communicate, and trying to put the client at ease with a caring and understanding manner. The nurse would avoid shouting (because the client is not deaf), appearing rushed for a response, and letting family members provide all responses for the client.

A client with a neurological problem is experiencing hyperthermia. Which measures would be appropriate for the nurse to use in trying to lower the client's body temperature? Select all that apply. 1. Giving tepid sponge baths 2. Applying a hypothermia blanket 3. Covering the client with blankets 4. Administering acetaminophen per protocol 5. Placing ice packs over the client's abdomen and in the axilla and groin

ANS: 1, 2, 4 Rationale: Standard measures to lower body temperature include removing bed covers, providing cool sponge baths, using an electric fan in the room, administering acetaminophen, and placing a hypothermia blanket under the client. Ice packs are not used because they could cause shivering, which increases cellular oxygen demands, with the potential for increased intracranial pressure.

The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? 1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

ANS: 2 Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure Rationale: A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur.

The nurse is planning to perform an assessment of the client's level of consciousness using the Glasgow Coma Scale. Which assessments should the nurse include in order to calculate the score? Select all that apply. 1. Eye Opening 2. Reflex response 3. Best verbal response 4. Best motor response 5. Pupil size and reaction

ANS: 1, 3, 4 Rationale: HomeHistoryHelpCalculator Study Mode Question 195 of 277 QN: 2446 | ID: 4760 | file: Adult_Health_Neurology PreviousGoNextStopBookmarkRationaleStrategyReference(s)Submit The nurse is planning to perform an assessment of the client's level of consciousness using the Glasgow Coma Scale. Which assessments should the nurse include in order to calculate the score? Select all that apply. Rationale:Assessment of pupil size and reaction and reflex response are not part of the Glasgow Coma Scale. The 3 categories included are eye opening, best verbal response, and best motor response. Pupil assessment and reflex response is a necessary part of a total assessment of the neurological status of a client but is not part of this particular scale.

A client with myasthenia gravis is having difficulty with airway clearance and difficulty with maintaining an effective breathing pattern. The nurse should keep which most important items available at the client's bedside? 1. Oxygen and metered-dose inhaler 2. Ambu bag and suction equipment 3. Pulse oximeter and cardiac monitor 4. Incentive spirometer and cough pillow

ANS: 2 Ambu bag and suction equipment Rationale: The client with myasthenia gravis may experience episodes of respiratory distress if excessively fatigued or with development of myasthenic or cholinergic crisis. For this reason, an Ambu bag, intubation tray, and suction equipment should be available at the bedside.

The nurse is assessing the client's gait and notes it is unsteady and staggering. Which description should the nurse use when documenting the assessment finding? 1. Spastic 2. Ataxic 3. Festinating 4. Dystrophic or broad-based

ANS: 2 Ataxic Rationale: An ataxic gait is characterized by unsteadiness and staggering. A spastic gait is characterized by stiff, short steps with the legs held together, hip and knees flexed, and toes that catch and drag. A festinating gait is best described as walking on the toes with an accelerating pace. A dystrophic or broad-based gait is seen as waddling, with the weight shifting from side to side and the legs far apart.

A client who suffered a stroke is prepared for discharge from the hospital. The health care provider has prescribed range-of-motion (ROM) exercises for the client's right side. What action should the nurse include in the client's plan of care? 1. Implement ROM exercises to the point of pain for the client. 2. Consider the use of active, passive, or active-assisted exercises in the home. 3. Encourage the client to be dependent on the home care nurse to complete the exercise program. 4. Develop a schedule of ROM exercises every 2 hours while awake even if the client is fatigued.

ANS: 2 Consider the use of active, passive, or active-assisted exercises in the home. Rationale: The home care nurse must consider all forms of ROM for the client. Even a client with hemiplegia can participate in some components of rehabilitative care. In addition, the goal in home care nursing is for the client to assume as much self-care and independence as possible. The nurse needs to teach home care measures so that the client becomes self-reliant. The options of performing ROM exercises to the point of pain and performing ROM exercises every 2 hours while the client is awake even if fatigued are incorrect from a physiological standpoint.

The nurse assesses a client who is diagnosed with a stroke (brain attack). On assessment, the client is unable to understand the nurse's commands. Which condition should the nurse document? 1. Occipital lobe impairment 2. Damage to the auditory association areas 3. Frontal lobe and optic nerve tracts damage 4. Difficulty with concept formation and abstraction areas

ANS: 2 Damage to the auditory association areas Rationale: Auditory association and storage areas are located in the temporal lobe and relate to understanding spoken language. The occipital lobe contains areas related to vision. The frontal lobe controls voluntary muscle activity, including speech, and an impairment can result in expressive aphasia. The parietal lobe contains association areas for concept formation, abstraction, spatial orientation, body and object size and shape, and tactile sensation.

Which assessment finding should the nurse expect to note in the client hospitalized with a diagnosis of stroke who has difficulty chewing food? 1. Dysfunction of vagus nerve (cranial nerve X) 2. Dysfunction of trigeminal nerve (cranial nerve V) 3. Dysfunction of hypoglossal nerve (cranial nerve XII) 4. Dysfunction of spinal accessory nerve (cranial nerve XI)

ANS: 2 Dysfunction of trigeminal nerve (cranial nerve V) Rationale: The motor branch of cranial nerve V is responsible for the ability to chew food. The vagus nerve is active in parasympathetic functions of the autonomic nervous system. The hypoglossal nerve aids in swallowing. The spinal accessory nerve is responsible for shoulder movement, among other things.

A client is newly admitted to the hospital with a diagnosis of stroke (brain attack) manifested by complete hemiplegia. Which item in the medical history of the client should the nurse be most concerned about? 1. Glaucoma 2. Emphysema 3. Hypertension 4. Diabetes mellitus

ANS: 2 Emphysema Rationale: The nurse should be most concerned about emphysema. The respiratory system is the priority in the acute phase of a stroke. The client with a stroke is vulnerable to respiratory complications such as atelectasis and pneumonia. Because the client has complete hemiplegia (is unable to move) and has emphysema, these risks are very significant. Although the other conditions of glaucoma, hypertension, and diabetes mellitus are important, they are not as significant as emphysema.

The nurse is assessing the function of cranial nerve XII in a client who sustained a stroke. To assess function of this nerve, which action should the nurse ask the client to perform? 1. Extend the arms. 2. Extend the tongue. 3. Turn the head toward the nurse's arm. 4. Focus the eyes on the object held by the nurse.

ANS: 2 Extend the tongue. Rationale: Impairment of cranial nerve XII can occur with a stroke. To assess the function of cranial nerve XII (the hypoglossal nerve), the nurse would assess the client's ability to extend the tongue. The maneuvers noted in the remaining options do not test the function of cranial nerve XII.

A client has a high level of carbon dioxide (CO2) in the bloodstream, as measured by arterial blood gases. The nurse anticipates that which underlying pathophysiology can occur as a result of this elevated CO2? 1. It will cause arteriovenous shunting. 2. It will cause vasodilation of blood vessels in the brain. 3. It will cause blood vessels in the circle of Willis to collapse. 4. It will cause hyperresponsiveness of blood vessels in the brain.

ANS: 2 It will cause vasodilation of blood vessels in the brain. Rationale: CO2 is one of the metabolic end products that can alter the tone of the blood vessels in the brain. High CO2 levels cause vasodilation, which may cause headache, whereas low CO2 levels cause vasoconstriction, which may cause lightheadedness. The statements included in the other options are incorrect effects.

The nurse is reviewing the record for a client seen in the health care clinic and notes that the health care provider has documented a diagnosis of amyotrophic lateral sclerosis (ALS). Which initial clinical manifestation of this disorder should the nurse expect to see documented in the record? 1. Muscle wasting 2. Mild clumsiness 3. Altered mentation 4. Diminished gag reflex

ANS: 2 Mild clumsiness Rationale: The initial symptom of ALS is a mild clumsiness, usually noted in the distal portion of one extremity. The client may complain of tripping and drag one leg when the lower extremities are involved. Mentation and intellectual function usually are normal. Diminished gag reflex and muscle wasting are not initial clinical manifestations.

A client has sustained damage to Wernicke's area from a stroke (brain attack). On assessment of the client, which sign or symptom would be noted? 1. Difficulty speaking 2. Problem with understanding language 3. Difficulty controlling voluntary motor activity 4. Problem with articulating events from the remote past

ANS: 2 Problem with understanding language Rationale: Wernicke's area consists of a small group of cells in the temporal lobe whose function is the understanding of language. Damage to Broca's area is responsible for aphasia. The motor cortex in the precentral gyrus controls voluntary motor activity. The hippocampus is responsible for the storage of memory.

The nurse has applied a hypothermia blanket to a client with a fever. The nurse should inspect the skin frequently to detect which condition that is a complication of hypothermia blanket use? 1. Frostbite 2. Skin breakdown 3. Arterial insufficiency 4. Venous insufficiency

ANS: 2 Skin breakdown Rationale: When a hypothermia blanket is used, the skin is inspected frequently for pressure points, which over time could lead to skin breakdown. The hypothermia blanket decreases the blood flow to pressure areas and can cause numbness, making it so that the client is not aware of damage to the skin. The temperature of the blanket is not cold enough to cause frostbite. Arterial insufficiency and venous insufficiency are not complications of hypothermia blanket use.

The nurse is caring for a client who was admitted for a stroke (brain attack) of the temporal lobe. Which clinical manifestations should the nurse expect to note in the client? 1. The client will be unable to recall past events. 2. The client will have difficulty understanding language. 3. The client will demonstrate difficulty articulating words. 4. The client will have difficulty moving 1 side of the body.

ANS: 2 The client will have difficulty understanding language. Rationale: Wernicke's area consists of a small group of cells in the temporal lobe, the function of which is the understanding of language. The hippocampus is responsible for the storage of memory (the client will be unable to recall past events). Damage to Broca's area is responsible for aphasia (the client will demonstrate difficulty articulating words). The motor cortex in the precentral gyrus controls voluntary motor activity (the client will have difficulty moving one side of the body).

A client who has had a stroke (brain attack) has residual dysphagia. When a diet prescription is initiated, the nurse should take which actions? Select all that apply. 1. Giving the client thin liquids 2. Thickening liquids to the consistency of oatmeal 3. Placing food on the unaffected side of the mouth 4. Allowing plenty of time for chewing and swallowing 5. Leave the client alone so that the client will gain independence by feeding self

ANS: 2, 3, 4 Rationale: The client with dysphagia is started on a diet only after the gag and swallow reflexes have returned. The client is assisted with meals as needed and is given ample time to chew and swallow. Food is placed on the unaffected side of the mouth. Liquids are thickened to avoid aspiration. The client is not left alone because of the risk of aspiration.

The nurse is administering mouth care to an unconscious client. The nurse should perform which actions in the care of this person? Select all that apply. 1. Use products that contain alcohol. 2. Position the client on his or her side. 3. Brush the teeth with a small, soft toothbrush. 4. Cleanse the mucous membranes with soft sponges. 5. Use lemon glycerin swabs when performing mouth care.

ANS: 2, 3, 4 Rationale: The unconscious client is positioned on the side during mouth care to prevent aspiration. The teeth are brushed at least twice daily with a small toothbrush. The gums, tongue, roof of the mouth, and oral mucous membranes are cleansed with soft sponges to avoid encrustation and infection. The lips are coated with water-soluble lubricant to prevent drying, cracking, and encrustation. The use of products with alcohol and lemon glycerin swabs should be avoided because they have a drying effect.

The health care provider is preparing to administer edrophonium to the client with myasthenia gravis. In planning care, the nurse understands which about the administration of edrophonium? Select all that apply. 1. Edrophonium is a long-acting cholinesterase inhibitor. 2. Atropine is used to reverse the effects of edrophonium. 3. If symptoms worsen following administration of edrophonium, the crisis is cholinergic. 4. Edrophonium is used to distinguish between a myasthenic crisis and a cholinergic crisis. 5. An improvement in symptoms following administration of edrophonium indicates myasthenic crisis.

ANS: 2, 3, 4, 5 Rationale: Edrophonium is an ultra-short-acting reversible cholinesterase inhibitor that can be used to distinguish between a cholinergic and a myasthenic crisis. To distinguish between overtreatment (cholinergic crisis) and undertreatment (myasthenic crisis), edrophonium is administered; this is often referred to as a Tensilon test. Overtreatment of myasthenia gravis with reversible cholinesterase inhibitors results in a cholinergic crisis. Undertreatment can result in a myasthenic crisis. Both cholinergic and myasthenic crises result in increased muscle weakness or paralysis. If symptoms improve after the administration of edrophonium, the crisis is myasthenic; if symptoms worsen, the crisis is cholinergic. Atropine must be readily available so that edrophonium can be reversed if the symptoms worsen.

The nurse is caring for a client who is at risk for increased intracranial pressure (ICP) after a stroke. Which activities performed by the nurse will assist with preventing increases in ICP? Select all that apply. 1. Clustering nursing activities 2. Hyperoxygenating before suctioning 3. Maintaining 20 degree flexion of the knees 4. Maintaining the head and neck in midline position 5. Maintaining the head of the bed (HOB) at 30 degrees elevation

ANS: 2, 4, 5 Rationale: Measures aimed at preventing increased ICP in the poststroke client include hyperoxgenating before suctioning to avoid transient hypoxemia and resultant ICP elevation from dilation of cerebral arteries; maintaining the head in a midline, neutral position to help promote venous drainage from the brain; and keeping the HOB elevated to between 25 and 30 degrees to prevent a decreased blood flow to the brain. Clustering activities can be stressful for the client and increase ICP. Maintaining 20 degree flexion of the knees increases intraabdominal pressure and consequently ICP.

A client is somewhat nervous about undergoing magnetic resonance imaging (MRI). Which statement by the nurse would provide the most reassurance to the client about the procedure? 1. "The MRI machine is a long, narrow, hollow tube and may make you feel somewhat claustrophobic." 2. "You will be able to eat before the procedure unless you get nauseated easily. If so, you should eat lightly." 3. "Even though you are alone in the scanner, you will be in voice communication with the technologist at all times during the procedure." 4. "It is necessary to remove any metal or metal-containing objects before having the MRI done to avoid the metal being drawn into the magnetic field."

ANS: 3 "Even though you are alone in the scanner, you will be in voice communication with the technologist at all times during the procedure." Rationale: The MRI scanner is a hollow tube that gives some clients a feeling of claustrophobia. Metal objects must be removed before the procedure so that they are not drawn into the magnetic field. The client may eat and may take all prescribed medications before the procedure. If a contrast medium is used, the client may wish to eat lightly if he or she has a tendency to become nauseated easily. The client lies supine on a padded table that moves into the imager. The client must lie still during the procedure. The imager makes tapping noises during the scanning. The client is alone in the imager, but the nurse can reassure the client that the technologist will be in voice communication with the client at all times during the procedure.

The nurse has instructed a client with myasthenia gravis about strategies for self-management at home. The nurse determines a need for further teaching if the client makes which statement? 1. "Here's the MedicAlert bracelet I obtained." 2. "I should take my medications an hour before mealtime." 3. "Going to the beach will be a nice, relaxing form of activity." 4. "I've made arrangements to get a portable resuscitation bag and home suction equipment."

ANS: 3 "Going to the beach will be a nice, relaxing form of activity." Rationale: Most ongoing treatment for myasthenia gravis is done in outpatient settings, and the client must be aware of the lifestyle changes needed to maintain independence. The client should carry medical identification about the presence of the condition. Taking medications an hour before mealtime gives greater muscle strength for chewing and is indicated. The client should have portable suction equipment and a portable resuscitation bag available in case of respiratory distress. The client should avoid situations and other factors, including stress, infection, heat, surgery, and alcohol, that could worsen the symptoms.

The nurse has provided instructions to a client with a diagnosis of myasthenia gravis about home care measures. Which client statement indicates the need for further teaching? 1. "I will rest each afternoon after my walk." 2. "I should cough and deep breathe many times during the day." 3. "I can change the time of my medication on the mornings when I feel strong." 4. "If I get abdominal cramps and diarrhea, I should call my health care provider."

ANS: 3 "I can change the time of my medication on the mornings when I feel strong." Rationale: The client with myasthenia gravis and the family should be taught information about the disease and its treatment. They should be aware of the side and adverse effects of anticholinesterase medications and corticosteroids and should be taught that timing of anticholinesterase medication is critical. It is important to instruct the client to administer the medication on time to maintain a chemical balance at the neuromuscular junction. If it is not given on time, the client may become too weak to even swallow. Resting after a walk, coughing and deep-breathing many times during the day, and calling the health care provider when experiencing abdominal cramps and diarrhea indicate a correct understanding of home care instructions to maintain health with this neurological degenerative disease.

A client is experiencing impotence after taking guanfacine. The client states, "I would sooner have a stroke than keep living with the effects of this medication." What is the most appropriate response by the nurse? 1. "I can understand completely." 2. "You wouldn't really want to have a stroke." 3. "You are concerned about the effects of your medication." 4. "The health care provider should change your prescription."

ANS: 3 "You are concerned about the effects of your medication." Rationale: Reflection of the client's own comment lets the client know that the nurse hears the concern without judging. The nurse cannot understand what the client is experiencing. To tell the client "you wouldn't really want to have a stroke" is confrontational and unsupportive. The client's prescription may need to be changed, but from the options provided this is not the most appropriate response.

The nurse is assisting in the care of a client who is being evaluated for possible myasthenia gravis. The health care provider gives a test dose of edrophonium. Evaluation of the results indicates that the test is positive. Which would be the expected response noted by the nurse? 1. Joint pain for the next 15 minutes 2. An immediate increase in blood pressure 3. An increase in muscle strength within 1 to 3 minutes 4. Feelings of faintness or dizziness for 5 to 10 minutes.

ANS: 3 An increase in muscle strength within 1 to 3 minutes Rationale: Edrophonium is a short-acting acetylcholinesterase inhibitor used to diagnose myasthenia gravis. An increase in muscle strength should be seen in 1 to 3 minutes following the test dose if the client does have the disease. If no response occurs, another dose is given over the next 2 minutes and muscle strength is tested again. If no increase in muscle strength occurs with this higher dose, the muscle weakness is not caused by myasthenia gravis. Clients who receive injections of this medication commonly demonstrate a drop in blood pressure, feel faint and dizzy, and are flushed.

At 8:00 a.m., A client who has had a stroke (brain attack) was awake and alert with vital signs of temperature 98°F (37.2°C) orally, pulse 80 beats/min, respirations 18 breaths/min, and blood pressure 138/80 mm Hg. At noon, the client is confused and only responsive to tactile stimuli, and vital signs are temperature 99°F (36.7°C) orally, pulse 62 beats/min, respirations 20 breaths/min, and blood pressure 166/72 mm Hg. The nurse should take which action? 1. Reorient the client. 2. Retake the vital signs. 3. Call the health care provider (HCP). 4. Administer an antihypertensive PRN (as needed).

ANS: 3 Call the health care provider (HCP). Rationale: The important nursing action is to call the HCP. The deterioration in neurological status, decreasing pulse, and increasing blood pressure with a widening pulse pressure all indicate that the client is experiencing increased intracranial pressure, which requires immediate treatment to prevent further complications and possible death. The nurse should retake the vital signs and reorient the client to surroundings. If the client's blood pressure falls within parameters for PRN antihypertensive medication, the medication also should be administered. However, options 1, 2, and 4 are secondary nursing actions.

The nurse is assessing a client with a brainstem injury. In addition to obtaining the client's vital signs and determining the Glasgow Coma Scale score, what priority intervention should the nurse plan to implement? 1. Check cranial nerve functioning 2. Determine the cause of the accident. 3. Draw blood for arterial blood gas analysis. 4. Perform a pulmonary wedge pressure measurement.

ANS: 3 Draw blood for arterial blood gas analysis. Rationale: Assessment should be specific to the area of the brain involved. The respiratory center is located in the brainstem. Assessing the respiratory status is the priority for a client with a brainstem injury. The actions in the remaining options are not priorities, although they may be a component in the assessment process, depending on the injury and client condition.

The client with a head injury opens eyes to sound, has no verbal response, and localizes to painful stimuli when applied to each extremity. How should the nurse document the Glasgow Coma Scale (GCS) score? 1. GCS = 3 2. GCS = 6 3. GCS = 9 4. GCS = 11

ANS: 3 GCS = 9 Rationale: The GCS is a method for assessing neurological status. The highest possible GCS score is 15. A score lower than 8 indicates that coma is present. Motor response points are as follows: Obeys a simple response = 6; Localizes painful stimuli = 5; Normal flexion (withdrawal) = 4; Abnormal flexion (decorticate posturing) = 3; Extensor response (decerebrate posturing) = 2; No motor response to pain = 1. Verbal response points are as follows: Oriented = 5; Confused conversation = 4; Inappropriate words = 3; Responds with incomprehensible sounds = 2; No verbal response = 1. Eye opening points are as follows: Spontaneous = 4; In response to sound = 3; In response to pain = 2; No response, even to painful stimuli = 1. Using the GCS, a score of 3 is given when the client opens the eyes to sound. Localization to pain is scored as 5. When there is no verbal response the score is 1. The total score is then equal to 9.

A client with a history of myasthenia gravis presents at a clinic with bilateral ptosis and is drooling, and myasthenic crisis is suspected. The nurse assesses the client for which precipitating factor? 1. Getting too little exercise 2. Taking excess medication 3. Omitting doses of medication 4. Increasing intake of fatty foods

ANS: 3 Omitting doses of medication Rationale: Myasthenic crisis often is caused by undermedication and responds to the administration of cholinergic medications. Cholinergic crisis (the opposite problem) is caused by excess medication and responds to withholding of medications. Too little exercise and excessive fatty food intake are incorrect. Overexertion and overeating possibly could trigger myasthenic crisis.

A client has a difficulty with the ability to flex the hips. The nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which item? 1. Walker 2. Slider board 3. Raised toilet seat 4. Adaptive eating utensils

ANS: 3 Raised toilet seat Rationale: A raised toilet seat is useful if the client does not have the mobility or ability to flex the hips. The cerebellum is responsible for balance and coordination. A walker would provide stability for the client during ambulation. A slider board is used in transferring a client from a bed to a stretcher or wheelchair. Adaptive eating utensils may be beneficial if the client has partial paralysis of the hand.

A client has suffered a head injury affecting the occipital lobe of the brain. What is the focus of the nurse's immediate assessment? 1. Taste 2. Smell 3. Vision 4. Hearing

ANS: 3 Vision Rationale: The occipital lobe is responsible for reception of vision and contains visual association areas. This area of the brain helps the individual to visually recognize and understand the surroundings. The other senses listed are not a function of the occipital lobe.

The nurse is performing an assessment on a client with a diagnosis of thrombotic stroke (brain attack). Which assessment question would elicit data specific to this type of stroke? 1. "Have you had any headaches in the past few days?" 2. "Have you recently been having difficulty with seeing at nighttime?" 3. "Have you had any sudden episodes of passing out in the past few days?" 4. "Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?"

ANS: 4 "Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?" Rationale: Cerebral thrombosis (thrombotic stroke) does not occur suddenly. In the few days or hours preceding the thrombotic stroke, the client may experience a transient loss of speech, hemiparesis, or paresthesias on 1 side of the body. Signs and symptoms of this type of stroke vary but may also include dizziness, cognitive changes, or seizures. Headache is rare, but some clients with stroke experience signs and symptoms similar to those of cerebral embolism or intracranial hemorrhage. The client does not complain of difficulty with night vision as part of this clinical problem. In addition, most clients do not have repeated episodes of loss of consciousness.

The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? 1. "We need to discourage him from wearing sunglasses." 2. "We need to place objects in his impaired field of vision." 3. "We need to approach him from the impaired field of vision." 4. "We need to remind him to turn his head to scan the lost visual field."

ANS: 4 "We need to remind him to turn his head to scan the lost visual field." Rationale: Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available.

A client with myasthenia gravis has difficulty chewing and has received a prescription for pyridostigmine. The nurse should check to see that the client takes the medication at what time? 1. With meals 2. Between meals 3. Just after meals 4. 30 minutes before meals

ANS: 4 30 minutes before meals Rationale: Pyridostigmine is a cholinergic medication used to increase muscle strength in the client with myasthenia gravis. For the client who has difficulty chewing, the medication should be administered 30 minutes before meals to enhance the client's ability to eat. The times noted in the remaining options will not be helpful to the client.

A client with myasthenia gravis becomes increasingly weaker. The health care provider injects a dose of edrophonium to determine whether the client is experiencing a myasthenic crisis or a cholinergic crisis. The nurse expects that the client will have which reaction if in cholinergic crisis? 1. No change in the condition 2. Complaints of muscle spasms 3. An improvement of the weakness 4. A temporary worsening of the condition

ANS: 4 A temporary worsening of the condition

A client with myasthenia gravis has become increasingly weaker. The health care provider prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium is administered. Which finding would indicate that the client is in cholinergic crisis? 1. No change in the condition 2. Complaints of muscle spasms 3. An improvement of the weakness 4. A temporary worsening of the condition

ANS: 4 A temporary worsening of the condition Rationale: An edrophonium injection makes the client in cholinergic crisis temporarily worse. An improvement in the weakness indicates myasthenia crisis. Muscle spasms are not associated with this test.

A client is suspected of having myasthenia gravis. Edrophonium is administered intravenously to determine the diagnosis. Which indicates that the client may have myasthenia gravis? 1. Joint pain following administration of the medication 2.vFeelings of faintness, dizziness, hypotension, and signs of flushing in the client 3. A decrease in muscle strength within 30 to 60 seconds following administration of the medication 4. An increase in muscle strength within 30 to 60 seconds following administration of the medication

ANS: 4 An increase in muscle strength within 30 to 60 seconds following administration of the medication Rationale: Edrophonium is a short-acting acetylcholinesterase inhibitor used as a diagnostic agent. When a client has suspected myasthenia gravis, the health care provider will administer an edrophonium test. When a dose is administered intravenously, an increase in muscle strength should be seen in 30 to 60 seconds. If no response occurs, another dose of edrophonium is given over the next 2 minutes, and muscle strength is tested again. If no increase in muscle strength occurs with this higher dose, the muscle weakness is not caused by myasthenia gravis. Clients receiving injections of this medication commonly demonstrate a drop in blood pressure, feel faint and dizzy, and are flushed.

The nurse is creating a plan of care for a client with a stroke (brain attack) who has global aphasia. The nurse should incorporate communication strategies into the plan of care because of which expected characteristic of the client's speech? 1. Intact 2. Rambling 3. Characterized by literal paraphasia 4. Associated with poor comprehension

ANS: 4 Associated with poor comprehension Rationale: Global aphasia is a condition in which the affected person has few language skills as a result of extensive damage to the left hemisphere. The speech is nonfluent and is associated with poor comprehension and limited ability to name objects or repeat words. The client with conduction aphasia has difficulty repeating words spoken by another, and speech is characterized by literal paraphasia with intact comprehension. The client with Wernicke's aphasia may exhibit a rambling type of speech.

The nurse is reviewing the record of a client with a suspected diagnosis of Huntington's disease. The nurse should expect to note documentation of which early symptom of this disease? 1. Aphasia 2. Agnosia 3. Difficulty with swallowing 4. Balance and coordination problems

ANS: 4 Balance and coordination problems Rationale: Early symptoms of Huntington's disease include restlessness, forgetfulness, clumsiness, falls, balance and coordination problems, altered speech, and altered handwriting. Difficulty with swallowing occurs in the later stages. Aphasia and agnosia do not occur.

The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully? 1. Gets angry with family if they interrupt a task 2. Experiences bouts of depression and irritability 3. Has difficulty with using modified feeding utensils 4. Consistently uses adaptive equipment in dressing self

ANS: 4 Consistently uses adaptive equipment in dressing self Rationale: Clients are evaluated as coping successfully with lifestyle changes after a stroke if they make appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions. Options 1 and 2 are not adaptive behaviors; option 3 indicates a not yet successful attempt to adapt.

The nurse is caring for a client who has just been admitted to the hospital with a diagnosis of a hemorrhagic stroke. The nurse should place the client in which position? 1. Prone 2. Supine 3. Semi Fowler's with the hip and the neck flexed 4. Head of the bed elevated 30 degrees with the head in midline position.

ANS: 4 Head of the bed elevated 30 degrees with the head in midline position Rationale: The health care provider's prescriptions are always followed with regard to positioning the client after stroke. Clients with hemorrhagic stroke usually have the head of the bed elevated to 30 degrees to reduce intracranial pressure that can occur from the hemorrhage. The head should be in a midline, neutral position to facilitate venous drainage from the brain. Extreme hip and neck flexion should be avoided to prevent an increase in intrathoracic pressure and to promote venous drainage from the brain. For clients with ischemic stroke, the head of the bed usually is kept flat to ensure adequate blood flow and thus oxygenation to the brain. Prone, supine, and hip and neck flexion are incorrect positions for clients with hemorrhagic stroke.

The nurse is creating a plan of care for a client with a diagnosis of stroke (brain attack) with anosognosia. To meet the needs of the client with this deficit, the nurse should include activities that will achieve which outcome? 1. Encourage communication. 2. Provide a consistent daily routine. 3. Promote adequate bowel elimination. 4. Increase the client's awareness of the affected side.

ANS: 4 Increase the client's awareness of the affected side. Rationale: In anosognosia, the client exhibits neglect of the affected side of the body. The nurse will plan care activities that remind the client to perform actions that require looking at the affected arm or leg, as well as activities that will increase the client's awareness of the affected side. The remaining options are not associated with this deficit.

The nurse is creating a plan of care for a client with a stroke (brain attack) who has right homonymous hemianopsia. Which should the nurse include in the plan of care for the client? 1. Place an eye patch on the left eye. 2. Place personal articles on the client's right side. 3. Approach the client from the right field of vision. 4. Instruct the client to turn the head to scan the right visual field.

ANS: 4 Instruct the client to turn the head to scan the right visual field. Rationale: Homonymous hemianopsia is a loss of half of the visual field. The nurse instructs the client to scan the environment and stands within the client's intact field of vision. The nurse should not patch the eye because the client does not have double vision. The client should have objects placed in the intact fields of vision, and the nurse should approach the client from the intact side.

The nurse is caring for a client with a diagnosis of right (nondominant) hemispheric stroke. The nurse notes that the client is alert and oriented to time and place. On the basis of these assessment findings, the nurse should make which interpretation? 1. Had a very mild stroke 2. Most likely suffered a transient ischemic attack 3. May have difficulty with language abilities only 4. Is likely to have perceptual and spatial abilities

ANS: 4 Is likely to have perceptual and spatial disabilities Rationale: The client with a right (nondominant) hemispheric stroke may be alert and oriented to time and place. These signs of apparent wellness often suggest that the client is less disabled than is the case. However, impulsivity and confusion in carrying out activities may be very real problems for these clients as a result of perceptual and spatial disabilities. The right hemisphere is considered specialized in sensory-perceptual and visual-spatial processing and awareness of body space. The left hemisphere is dominant for language abilities.

The client has an impairment of cranial nerve II. Specific to this impairment, what should the nurse plan to do to ensure client safety? 1. Speak loudly to the client. 2. Test the temperature of the shower water. 3. Check the temperature of the food on the dietary tray. 4. Provide a clear path for ambulation without obstacles.

ANS: 4 Provide a clear path for ambulation without obstacles. Rationale: Cranial nerve II is the optic nerve, which governs vision. The nurse can provide safety for the visually impaired client by clearing the path of obstacles when ambulating. Speaking loudly may help overcome a deficit of cranial nerve VIII (vestibulocochlear). Testing the shower water temperature would be useful if there was an impairment of peripheral nerves. Cranial nerves VII (facial) and IX (glossopharyngeal) control taste from the anterior two thirds and posterior third of the tongue, respectively.

The nurse is creating a plan of care for a client with a diagnosis of stroke (brain attack). On reviewing the client's record, the nurse notes an assessment finding of anosognosia. The nursing care plan should address which manifestation related to this finding? 1. The client will be easily fatigued. 2. The client will have difficulty speaking. 3. The client will have difficulty swallowing. 4. The client will exhibit neglect of the affected side.

ANS: 4 The client will exhibit neglect of the affected side. Rationale: In anosognosia, the client neglects the affected side of the body. The client either may ignore the presence of the affected side (often creating a safety hazard as a result of potential injuries) or may state that the involved arm or leg belongs to someone else. The remaining options are not associated with anosognosia.

At the end of the work shift, the nurse is reviewing the respiratory status of a client admitted with a stroke (brain attack) earlier in the day. The nurse determines that the client's airway is patent if which data are identified? 1. Respiratory rate 24 breaths/min, oxygen saturation 94%, breath sounds clear 2. Respiratory rate 18 breaths/min, oxygen saturation 98%, breath sounds clear 3. Respiratory rate 16 breaths/min, oxygen saturation 85%, wheezes bilaterally 4. Respiratory rate 20 breaths/min, oxygen saturation 92%, diminished breath sounds in lung bases

ANS: B Respiratory rate 18 breaths/min, oxygen saturation 98%, breath sounds clear Rationale: The client's airway is most protected if all of the respiratory parameters measured fall within normal limits. Therefore, the respiratory rate should ideally be 16 to 20 breaths/min, the oxygen saturation should be greater than 95%, and the breath sounds should be clear. The correct option is the only one that meets all 3 criteria.