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A 58-year-old homeless male is brought to the emergency department by the police after being found unconscious on the street. Following examination and evaluation of laboratory test results, a diagnosis of diabetic ketoacidosis is confi rmed. Which of the following information is most crucial to document on the client's chart? Select all that apply. ■ 1. Size of pupils and reaction of pupils to light. ■ 2. Response to verbal and painful stimuli. ■ 3. Skin condition and presence of any rashes, lesions, or ulcers. ■ 4. Blood pressure. ■ 5. Length of time the client has had diabetes. ■ 6. Hourly urine output

1, 2, 3, 4, 6. Diabetic ketoacidosis is a potentially life-threatening problem. The state of unconsciousness requires very astute monitoring of the neurologic condition. Frequent assessments of neurologic status (including the client's ability to respond to stimuli), blood pressure, and urinary output need to be documented. Assessment of skin condition for the presence of lesions, bruises, ulcers, or bumps is documented to assess for possible injuries, such as falls associated with head injury or internal injuries. Although it would be helpful to know how long the client has had diabetes, this information is not essential to document

40. A 21-year-old female client takes clonazepam (Klonopin). What should the nurse ask this client about? Select all that apply. ■ 1. Seizure activity. ■ 2. Pregnancy status. ■ 3. Alcohol use. ■ 4. Cigarette smoking. ■ 5. Intake of caffeine and sugary drinks.

1, 2, 3. The nurse should assess the number and type of seizures the client has experienced since starting clonazepam monotherapy for seizure control. The nurse should also determine if the client might be pregnant because clonazepam crosses the placental barrier. The nurse should also ask about the client's use of alcohol because alcohol potentiates the action of clonazepam. Although the nurse may want to check on the client's diet or use of cigarettes for health maintenance and promotion, such information is not specifi cally related to clonazepam therapy

51. The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm and hand. Which of the following positions are appropriate? Select all that apply. ■ 1. Placing a pillow in the axilla so the arm is away from the body. ■ 2. Inserting a pillow under the slightly flexed arm so the hand is higher than the elbow. ■ 3. Immobilizing the extremity in a sling. ■ 4. Positioning a hand cone in the hand so the fingers are barely flexed. ■ 5. Keeping the arm at the side using a pillow.

1, 2, 4. Placing a pillow in the axilla so the arm is away from the body keeps the arm abducted and prevents skin from touching skin to avoid skin breakdown. Placing a pillow under the slightly fl exed arm so the hand is higher than the elbow prevents dependent edema. Positioning a hand cone (not a rolled washcloth) in the hand prevents hand contractures. Immobilization of the extremity may cause a painful shoulder-hand syndrome. Flexion contractures of the hand, wrist, and elbow can result from immobility of the weak or paralyzed extremity. It is better to extend the arms to prevent contractures

2. The nurse is monitoring a client with increased intracranial pressure (ICP). What indicators are the most critical for the nurse to monitor? Select all that apply. ■ 1. Systolic blood pressure. ■ 2. Urine output. ■ 3. Breath sounds. ■ 4. Cerebral perfusion pressure. ■ 5. Level of pain

1, 4. The nurse must monitor the systolic and diastolic blood pressure to obtain the mean arterial pressure (MAP), which represents the pressure needed for each cardiac cycle to perfuse the brain. The nurse must also monitor the cerebral perfusion pressure (CPP), which is obtained from the ICP and the MAP. The nurse should also monitor urine output, respirations, and pain; however, crucial measurements needed to maintain CPP are ICP and MAP. When ICP equals MAP, there is no CPP.

92. When the nurse performs oral hygiene for an unconscious client, which nursing intervention is the priority? ■ 1. Keep a suction machine available. ■ 2. Place the client in a prone position. ■ 3. Wear sterile gloves while brushing the client's teeth. ■ 4. Use gauze wrapped around the fingers to clean the client's gums.

1. Maintaining a patent airway is the priority. Therefore, the nurse should keep suction equipment available to remove secretions. The client should be placed in a side-lying, not prone, position. Performing oral hygiene is a clean procedure; therefore, the nurse wears clean gloves, not sterile gloves. The nurse should never place any fingers in an unconscious client's mouth; the client may bite down. Padded tongue blades, swabs, or a toothbrush should be used instead; but maintaining the airway is the priority

43. Regular oral hygiene is essential for the client who has had a stroke. Which of the following nursing measures is not appropriate when providing oral hygiene? ■ 1. Placing the client on the back with a small pillow under the head. ■ 2. Keeping portable suctioning equipment at the bedside. ■ 3. Opening the client's mouth with a padded tongue blade. ■ 4. Cleaning the client's mouth and teeth with a toothbrush.

1. A helpless client should be positioned on the side, not on the back, with the head on a small pillow. A lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration. It may be necessary to suction the client if he aspirates. Suction equipment should be nearby. It is safe to use a padded tongue blade, and the client should receive oral care, including brushing with a toothbrush

Which client would the nurse identify as being most at risk for experiencing a cerebrovascular accident (CVA)? 1. A 55-year-old African American male. 2. An 84-year-old Japanese female. 3. A 67-year-old Caucasian male. 4. A 39-year-old pregnant female.

1. African Americans have twice the rate of CVAs as Caucasians and men have a higher incidence than women; African Americans also suffer more extensive damage from a CVA than do people of other cultural groups.

Which of the following indicates that the client with diabetes insipidus understands how to manage care? ■ 1. The client will maintain normal fluid and electrolyte balance. ■ 2. The client will select American Diabetes Association diet correctly. ■ 3. The client will state dietary restrictions. ■ 4. The client will exhibit serum glucose level within normal range

1. Because diabetes insipidus involves excretion of large amounts of fluid, maintaining normal fluid and electrolyte balance is a priority for this client. Special dietary programs or restrictions are not indicated in treatment of diabetes insipidus. Serum glucose levels are priorities in diabetes mellitus but not in diabetes insipidus

Ergotamine tartrate (Gynergen) is prescribed for a client's migraine headaches. The client's report of which of the following indicates effectiveness? ■ 1. Prevention of the migraine. ■ 2. Reduced severity of the developing migraine. ■ 3. Relief from the sleeplessness experienced in the past after a migraine. ■ 4. Relief from the vision problems experienced in the past after a migraine.

1. Ergotamine tartrate is used to help abort a migraine attack. It should be taken as soon as prodromal symptoms appear. Reduced migraine severity and relief from sleeplessness and vision problems address symptoms that occur after the migraine has occurred and are not effects of ergotamine.

97. Of the following nursing interventions for catheter care, which should have the highest priority? ■ 1. Cleaning the area around the urethral meatus. ■ 2. Clamping the catheter periodically to maintain muscle tone. ■ 3. Irrigating the catheter with several ounces of normal saline solution. ■ 4. Changing the location where the catheter is taped to the client's leg

1. Good catheter care, including meticulous cleaning of the area around the urethral meatus, is the highest priority for the client with an indwelling catheter. Clamping an indwelling catheter is not recommended. Irrigation of the catheter, which requires breaking the closed system, is not recommended. Manipulation of the catheter taped to the client's leg causes trauma to the urethral meatus, which can predispose the client to an infection and is also not recommended

A client with hydrocephalus reports having had a headache in the morning on arising for the last 3 days, but it disappears later in the day. The nurse should: ■ 1. Notify the physician. ■ 2. Tell the client that this is normal because intracranial pressure fluctuates throughout the day. ■ 3. Instruct the client to increase fluid intake prior to going to bed to prevent headache in the morning. ■ 4. Advise the client to request pain medication from the physician.

1. ICP is highest in the early morning, and the client with hydrocephalus may be experiencing signs of increased ICP that need to be treated. The increased ICP is not related to fl uid levels, and the nurse should not advise the client to increase fl uid intake. While ICP does fl uctuate during the day, it is highest in the morning and the nurse should notify the physician. Pain medication will not treat the potentially increasing ICP and may mask important signs of increasing ICP.

6. A client is at risk for increased intracranial pressure (ICP). Which of the following would be the priority for the nurse to monitor? ■ 1. Unequal pupil size. ■ 2. Decreasing systolic blood pressure. ■ 3. Tachycardia. ■ 4. Decreasing body temperature.

1. Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.

8. Which of the following respiratory patterns indicates increasing intracranial pressure in the brain stem? ■ 1. Slow, irregular respirations. ■ 2. Rapid, shallow respirations. ■ 3. Asymmetric chest excursion. ■ 4. Nasal flaring.

1. Neural control of respiration takes place in the brain stem. Deterioration and pressure produce irregular respiratory patterns. Rapid, shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic of respiratory distress or hypoxia.

11. The client has a sustained increased intracranial pressure (ICP) of 20 mm Hg. Which client position would be most appropriate? ■ 1. The head of the bed elevated 30 to 45 degrees. ■ 2. Trendelenburg's position. ■ 3. Left Sims position. ■ 4. The head elevated on two pillows.

1. The client's ICP is elevated, and the client should be positioned to avoid extreme neck flexion or extension. The head of the bed is usually elevated 30 to 45 degrees to drain the venous sinuses and thus decrease the ICP. Trendelenburg's position places the client's head lower than the body, which would increase ICP. The Sims position (side lying) and elevating the head on two pillows may extend or fl ex the neck, which increases ICP

34. The nurse is assessing a client in the postictal phase of generalized tonic-clonic seizure. The nurse should determine if the client has? ■ 1. Drowsiness. ■ 2. Inability to move. ■ 3. Paresthesia. ■ 4. Hypotension.

1. The nurse should expect a client in the postictal phase to experience drowsiness to somnolence because exhaustion results from the abnormal spontaneous neuron fi ring and tonic-clonic motor response. An inability to move a muscle part is not expected after a tonic-clonic seizure because a lack of motor function would be related to a complication, such as a lesion, tumor, or stroke, in the correlating brain tissue. A change in sensation would not be expected because this would indicate a complication such as an injury to the peripheral nerve pathway to the corresponding part from the central nervous system. Hypotension is not typically a problem after a seizure

29. A 20-year-old who hit his head while playing football has a tonic-clonic seizure. Upon awakening from the seizure, the client asks the nurse, "What caused me to have a seizure? I've never had one before." Which cause should the nurse include in the response as a primary cause of tonic-clonic seizures in adults older than age 20? ■ 1. Head trauma. ■ 2. Electrolyte imbalance. ■ 3. Congenital defect. ■ 4. Epilepsy.

1. Trauma is one of the primary causes of brain damage and seizure activity in adults. Other common causes of seizure activity in adults include neoplasms, withdrawal from drugs and alcohol, and vascular disease. Given the history of head injury, electrolyte imbalance is not the cause of the seizure. There is no information to indicate that the seizure is related to a congenital defect. Epilepsy is usually diagnosed in younger clients.

98. A client has been pronounced brain dead. Which findings should the nurse document? Select all that apply. ■ 1. Decerebrate posturing. ■ 2. Nonreactive dilated pupils. ■ 3. Deep tendon reflexes. ■ 4. Absent corneal reflex. ■ 5. Blink reflex

2, 3, 4. A client who is brain dead typically demonstrates nonreactive dilated pupils and nonreactive or absent corneal and gag reflexes. The client may still have spinal reflexes, such as deep tendon and Babinski reflexes, in brain death. Decerebrate or decorticate posturing would not be seen. Clients who are brain dead do not have a blink reflex

86. Which clinical manifestations should the nurse expect to assess in a client diagnosed with an overdose of a cholinergic agent? Select all that apply. ■ 1. Dry mucous membranes. ■ 2. Urinary incontinence. ■ 3. Central nervous system (CNS) depression. ■ 4. Seizures. ■ 5. Skin rash

2, 3, 4. An excess of cholinergic agents produce urinary and fecal incontinence, increased salivation, diarrhea, and diaphoresis. In a severe overdose, CNS depression, seizures and muscle fasciculations, bradycardia or tachycardia, weakness, and respiratory arrest due to respiratory muscle paralysis occur. Anticholinergics produce dry mucous membranes. Skin rash is not a sign of overdose with a cholinergic agent

Prior to administering plasminogen activator (t-PA) to a client admitted with a stroke, the nurse should verify that the client: Select all that apply. ■ 1. Is older than 65 years. ■ 2. Has had symptoms of the stroke less than 3 hours. ■ 3. Has a blood pressure within normal limits. ■ 4. Does not have active internal bleeding. ■ 5. Has not had an alcoholic beverage within the last 8 hours.

2, 3, 4. Contraindications for t-PA or alteplase recombinant therapy include current active internal bleeding, 3 hours or longer since the onset of symptoms of a stroke, and severe hypertension. Age greater than 65 years or having had an alcoholic beverage are not contraindications for the therapy

1. Following a craniotomy, a client has been admitted to the neurologic intensive care unit. The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range. What should the nurse do? Select all that apply. ■ 1. Encourage the client to cough and take deep breaths. ■ 2. Elevate the head of the bed 15 to 30 degrees. ■ 3. Contact the health care provider if ICP is greater than 20 mm Hg. ■ 4. Monitor neurologic status using the Glasgow Coma Scale. ■ 5. Stimulate the client with active range-of-motion exercises.

2, 3, 4. The nurse should maintain ICP by elevating the head of the bed and monitoring neurologic status. An ICP greater than 20 mm Hg indicates increased ICP, and the nurse should notify the health care provider. Coughing and range-of-motion exercises will increase ICP and should be avoided in the early postoperative stage.

15. Four days after surgery for internal fixation of a C3 to C4 fracture, a nurse is moving a client from the bed to the wheelchair. The nurse is checking the wheelchair for correct features for this client. Which of the following features of the wheelchair are appropriate for the needs of this client? Select all that apply. ■ 1. Back at the level of the client's scapula. ■ 2. Back and head that are high. ■ 3. Seat that is lower than normal. ■ 4. Seat with fi rm cushions. ■ 5. Chair controlled by the client's breath.

2, 3, 5. The client with a C3 to C4 fracture has neck control but may tire easily using sore muscles around the incision area to hold up his head. Therefore, the head and neck of his wheelchair should be high. The seat of the wheelchair should be lower than normal to facilitate transfer from the bed to the wheelchair. When a client can use his hands and arms to move the wheelchair, the placement of the back to the client's scapula is necessary. This client cannot use his arms and will need an electric chair with breath, chin, or voice control to manipulate movement of the chair. A fi rm or hard cushion adds pressure to bony prominences; the cushion should instead be padded to reduce the risk of pressure ulcers.

42. The nurse is teaching a client about taking prophylactic warfarin sodium (Coumadin). Which statement indicates that the client understands how to take the drug? Select all that apply. ■ 1. "The drug's action peaks in 2 hours." ■ 2. "Maximum dosage is not achieved until 3 to 4 days after starting the medication." ■ 3. "Effects of the drug continue for 4 to 5 days after discontinuing the medication." ■ 4. "Protamine sulfate is the antidote for warfarin." ■ 5. "I should have my blood levels tested periodically."

2, 3, 5. The maximum dosage of warfarin sodium (Coumadin) is not achieved until 3 to 4 days after starting the medication, and the effects of the drug continue for 4 to 5 days after discontinuing the medication. The client should have his blood levels tested periodically to make sure that the desired level is maintained. Warfarin has a peak action of 9 hours. Vitamin K is the antidote for warfarin; protamine sulfate is the antidote for heparin.

4. A client with a contusion has been admitted for observation following a motor vehicle accident when he was driving his wife to the hospital to deliver their child. The next morning, instead of asking about his wife and baby, he asked to see the football game on television that he thinks is starting in 5 minutes. He is agitated that the nurse will not turn on the television. What should the nurse do next? Select all that apply. ■ 1. Find a television so the client can view the football game. ■ 2. Determine if the client's pupils are equal and react to light. ■ 3. Ask the client if he has a headache. ■ 4. Arrange for the client to be with his wife and baby. ■ 5. Administer a sedative.

2, 3. The nurse should determine if the client's pupils are equal and react to light, and ask the client if he has a headache. Confusion, agitation, and restlessness are subtle clinical manifestations of increased intracranial pressure (ICP). At this time, it is not appropriate for the nurse to fi nd a television or arrange for the client to see his wife and baby. Administering a sedative at this time will obscure assessment of increased ICP

53. The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which of the following strategies is not appropriate? ■ 1. Maintaining an upright position. ■ 2. Restricting the diet to liquids until swallowing improves. ■ 3. Introducing foods on the unaffected side of the mouth. ■ 4. Keeping distractions to a minimum.

2. A client with dysphagia (difficulty swallowing) commonly has the most difficulty ingesting thin liquids, which are easily aspirated. Liquids should be thickened to avoid aspiration. Maintaining an upright position while eating is appropriate because it minimizes the risk of aspiration. Introducing foods on the unaffected side allows the client to have better control over the food bolus. The client should concentrate on chewing and swallowing; therefore, distractions should be avoided.

12. The nurse administers mannitol (Osmitrol) to the client with increased intracranial pressure. Which parameter requires close monitoring? ■ 1. Muscle relaxation. ■ 2. Intake and output. ■ 3. Widening of the pulse pressure. ■ 4. Pupil dilation.

2. After administering mannitol, the nurse closely monitors intake and output because mannitol promotes diuresis and is given primarily to pull water from the extracellular fluid of the edematous brain. Mannitol can cause hypokalemia and may lead to muscle contractions, not muscle relaxation. Signs and symptoms, such as widening pulse pressure and pupil dilation, should not occur because mannitol serves to decrease ICP.

35. When preparing to teach a client about phenytoin sodium (Dilantin) therapy, the nurse should urge the client not to stop the drug suddenly because: ■ 1. Physical dependency on the drug develops over time. ■ 2. Status epilepticus may develop. ■ 3. A hypoglycemic reaction develops. ■ 4. Heart block is likely to develop.

2. Anticonvulsant drug therapy should never be stopped suddenly; doing so can lead to life threatening status epilepticus. Phenytoin sodium does not carry a risk of physical dependency or lead to hypoglycemia. Phenytoin has antiarrhythmic properties, and discontinuation does not cause heart block.

For breakfast on the morning a client is to have an electroencephalogram (EEG), the client is served a soft-boiled egg, toast with butter and marmalade, orange juice, and coffee. Which of the following should the nurse do? ■ 1. Remove all the food. ■ 2. Remove the coffee. ■ 3. Remove the toast, butter, and marmalade only. ■ 4. Substitute vegetable juice for the orange juice.

2. Beverages containing caffeine, such as coffee, tea, and cola drinks, are withheld before an EEG because of the stimulating effects of the caffeine on the brain waves. A meal should not be omitted before an EEG because low blood sugar could alter brain wave patterns; the client can have the entire meal except for the coffee

22. A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. The nurse should: ■ 1. Count the rate to be sure that ventilations are deep enough to be sufficient. ■ 2. Notify the physician of the client's breathing pattern. ■ 3. Increase the rate of ventilations. ■ 4. Increase the tidal volume on the ventilator.

2. Cluster breathing consists of clusters of irregular breaths followed by periods of apnea on an irregular basis. A lesion in the upper medulla or lower pons is usually the cause of cluster breathing. Because the client had a bleed in the occipital lobe, which is just superior and posterior to the pons and medulla, clinical manifestations that indicate a new lesion are monitored very closely in case another bleed ensues. The nurse should notify the physician immediately so that treatment can begin before respirations cease. The client is not obtaining suffi cient oxygen and the depth of breathing is assisted by the ventilator. The health care provider will determine changes in the ventilator settings.

A 57-year-old with diabetes insipidus is hospitalized for care. Which finding should the nurse report to the physician? ■ 1. Urine output of 350 mL in 8 hours. ■ 2. Urine specific gravity of 1.001. ■ 3. Potassium of 4.0 mEq. ■ 4. Weight gain.

2. Diabetes insipidus is caused by a defi - ciency of antidiuretic hormone, which results in excretion of a large volume of dilute urine. Therefore, a urine specifi c gravity of less than 1.005 should be reported. Urine output should be 30 to 50 mL/hour; thus, 350 mL is a normal urinary output over 8 hours. The potassium level is normal. Weight loss, not weight gain, should be monitored as a sign of dehydration

19. Which of the following is most effective in assessing the client suspected of developing diabetes insipidus? ■ 1. Taking vital signs every 2 hours. ■ 2. Measuring urine output hourly. ■ 3. Assessing arterial blood gas values every other day. ■ 4. Checking blood glucose levels.

2. Diabetes insipidus results from defi ciency of antidiuretic hormone (ADH). The condition may occur in conjunction with head injuries as well as with other disorders. In ADH defi ciency, the client is extremely thirsty and excretes large amounts of highly diluted urine. Measuring the urine output to detect excess amount and checking the specifi c gravity of urine samples to determine urine concentration are appropriate measures to determine the onset of diabetes insipidus. The client may be tachycardic and hypotensive from fl uid defi cit; however, altered vital signs in a client with a head injury may occur for other reasons as well. Blood gas analysis and blood glucose levels will not reveal diabetes insipidus.

23. In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when positioning the client? ■ 1. Keeping the client fl at on one side or the other. ■ 2. Elevating the head of the bed to 30 degrees. ■ 3. Logrolling or turning as a unit when turning. ■ 4. Keeping the neck in a neutral position.

2. Elevating the head of the bed to 30 degrees is contraindicated for infratentorial craniotomies because it could cause herniation of the brain down onto the brain stem and spinal cord, resulting in sudden death. Elevation of the head of the bed to 30 degrees with the head turned to the side opposite the incision, if not contraindicated by the increased intracranial pressure, is used for supratentorial craniotomies.

52. For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication? ■ 1. Speaking loudly. ■ 2. Using a picture board. ■ 3. Writing directions so client can read them. ■ 4. Speaking in short sentences.

2. Expressive aphasia is a condition in which the client understands what is heard or written but cannot say what he or she wants to say. A communication or picture board helps the client communicate with others in that the client can point to objects or activities that he or she desires.

30. Which of the following should the nurse include in the teaching plan for a client with seizures who is going home with a prescription for gabapentin (Neurontin)? ■ 1. Take all the medication until it is gone. ■ 2. Notify the physician if vision changes occur. ■ 3. Store gabapentin in the refrigerator. ■ 4. Take gabapentin with an antacid to protect against ulcers.

2. Gabapentin (Neurontin) may impair vision. Changes in vision, concentration, or coordination should be reported to the physician. Gabapentin should not be stopped abruptly because of the potential for status epilepticus; this is a medication that must be tapered off. Gabapentin is to be stored at room temperature and out of direct light. It should not be taken with antacids.

54. Which food-related behaviors are expected in a client who has had a stroke that has left him with homonymous hemianopia? ■ 1. Increased preference for foods high in salt. ■ 2. Eating food on only half of the plate. ■ 3. Forgetting the names of foods. ■ 4. Inability to swallow liquids.

2. Homonymous hemianopia is blindness in half of the visual fi eld; therefore, the client would see only half of his plate. Eating only the food on half of the plate results from an inability to coordinate visual images and spatial relationships. There may be an increased preference for foods high in salt after a stroke, but this would not be related to homonymous hemianopia. Forgetting the names offoods would be aphasia, which involves a cerebral cortex lesion. Being unable to swallow liquids is dysphagia, which involves motor pathways of cranial nerves IX and X, including the lower brain stem.

Which of the following neurologic changes indicates that the client is in the progressive stage of shock? ■ 1. Restlessness. ■ 2. Confusion. ■ 3. Incoherent speech. ■ 4. Unconsciousness.

2. In the progressive stage of shock, the client can display listlessness or agitation, confusion, and slowed speech. Restlessness occurs in the compensatory stage. Incoherent speech and unconsciousness are clinical manifestations of the irreversible stage

17. A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the I.V. line. Which nursing intervention protects the client without increasing her increased intracranial pressure (ICP)? ■ 1. Place her in a jacket restraint. ■ 2. Wrap her hands in soft "mitten" restraints. ■ 3. Tuck her arms and hands under the drawsheet. ■ 4. Apply a wrist restraint to each arm.

2. It is best for the client to wear mitts, which help prevent the client from pulling on the I.V. without causing additional agitation. Using a jacket or wrist restraint or tucking the client's arms and hands under the drawsheet restrict movement and add to feelings of being confined, all of which would increase her agitation and increase ICP.

46. What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? ■ 1. Cholesterol level. ■ 2. Pupil size and pupillary response. ■ 3. Bowel sounds. ■ 4. Echocardiogram.

2. It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. The cholesterol level is not a priority assessment, although it may be an assessment to be addressed for long-term healthy lifestyle rehabilitation. Bowel sounds need to be assessed because an ileus or constipation can develop, but this is not a priority in the first 24 hours, when the primary concerns are cerebral hemorrhage and increased intracranial pressure. An echocardiogram is not needed for the client with a thrombotic stroke without heart problems

The nurse is administering propranolol (Inderal) to a client for control of migraine headaches. The client's pulse rate is 56 bpm. What should the nurse do next? ■ 1. Contact the physician immediately. ■ 2. Assess blood pressure. ■ 3. Administer oxygen. ■ 4. Ask for a relative to contact.

2. One of the actions of propranolol (Inderal), a drug used in the treatment of migraine headaches, is to decrease the heart rate. The nurse should assess the client's blood pressure to evaluate overall circulatory response to the medication. Until the blood pressure value is assessed, there is no immediate need to contact the physician. The nurse should complete the blood pressure assessment before administering the drug. There is no immediate need to administer oxygen or contact a relative because a slowed pulse rate is an expected action of propranolol

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should assess the client for which alteration in fluid and electrolyte balance? ■ 1. Increased osmolality of the plasma. ■ 2. Decreased serum sodium level. ■ 3. Increased urine output. ■ 4. Decreased blood pressure

2. SIADH is characterized by excess antidiuretic hormone (ADH, vasopressin) secretion, despite low plasma osmolality. Excess ADH causes water to be retained. As blood volume expands, plasma becomes diluted resulting in dilutional hyponatremia. Aldosterone is suppressed, resulting in increased renal sodium excretion. Water moves from the hypotonic plasma and the interstitial spaces into the cells.

49. Which of the following techniques does the nurse avoid when changing a client's position in bed if the client has hemiparalysis? ■ 1. Rolling the client onto the side. ■ 2. Sliding the client to move up in bed. ■ 3. Lifting the client when moving the client up in bed. ■ 4. Having the client help lift off the bed using a trapeze.

2. Sliding a client on a sheet causes friction and is to be avoided. Friction injures skin and predisposes to pressure ulcer formation. Rolling the client is an acceptable method to use when changing positions as long as the client is maintained in anatomically neutral positions and her limbs are properly supported. The client may be lifted as long as the nurse has assistance and uses proper body mechanics to avoid injury to himself or herself or the client. Having the client help lift herself off the bed with a trapeze is an acceptable means to move a client without causing friction burns or skin breakdown.

36. A client states that she is afraid she will not be able to drive again because of her seizures. Which response by the nurse would be best? ■ 1. A person with a history of seizures can drive only during daytime hours. ■ 2. A person with evidence that the seizures are under medical control can drive. ■ 3. A person with evidence that seizures occur no more often than every 12 months can drive. ■ 4. A person with a history of seizures can drive if he carries a medical identification card.

2. Specific motor vehicle regulations and restrictions for people who experience seizures vary locally. Most commonly, evidence that the seizures are under medical control is required before the person is given permission to drive. Time of day is not a consideration when determining driving restrictions related to seizures. The amount of time a person has been seizure-free is a consideration for lifting driving restrictions; however, the time frame is usually 2 years. It is recommended, not required, that a person who is subject to seizures carry a card or wear an identification bracelet describing the illness to facilitate questions

95. When administering intermittent enteral feeding to an unconscious client, the nurse should: ■ 1. Heat the formula in a microwave. ■ 2. Place the client in a semi-Fowler's position. ■ 3. Obtain a sterile gavage bag and tubing. ■ 4. Weigh the client before administering the feeding

2. The client should be placed in a semiFowler's position to reduce the risk of aspiration. The formula should be at room temperature, not heated. Administering enteral tube feedings is a clean procedure, not a sterile one; therefore, sterile supplies are not required. Clients receiving enteral feedings should be weighed regularly, but not necessarily before each feeding.

Vasopressin (Pitressin) is administered to the client with diabetes insipidus because it: ■ 1. Decreases blood pressure. ■ 2. Increases tubular reabsorption of water. ■ 3. Increases release of insulin from the pancreas. ■ 4. Decreases glucose production within the liver.

2. The major characteristic of diabetes insipidus is decreased tubular reabsorption of water due to insufficient amounts of antidiuretic hormone (ADH). Vasopressin (Pitressin) is administered to the client with diabetes insipidus because it has pressor and ADH activities. Vasopressin works to increase the concentration of the urine by increasing tubular reabsorption, thus preserving up to 90% water. Vasopressin is administered to the client with diabetes insipidus because it is a synthetic ADH. The administration of vasopressin results in increased tubular reabsorption of water, and it is effective for emergency treatment or daily maintenance of mild diabetes insipidus. Vasopressin does not decrease blood pressure or affect insulin production or glucose metabolism, nor is insulin production a factor in diabetes insipidus.

The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestation would the nurse document? 1. Hemiparesis of the client's left arm and apraxia. 2. Paralysis of the right side of the body and ataxia. 3. Homonymous hemianopsia and diplopia. 4. Impulsive behavior and hostility toward family.

2. The most common motor dysfunction of a CVA is paralysis of one side of the body, hemiplegia; in this case with a left-sided CVA, the paralysis would affect the right side. Ataxia is an impaired ability to coordinate movement.

89. An unconscious intubated client does not have increased intracranial pressure. Which nursing intervention would be essential? ■ 1. Monitoring the oral temperature, keep the room temperature at 70° F (21.1° C), and place the client on a cooling blanket if the client's temperature is higher than 101° F (38.3° C). ■ 2. Cleaning the mouth carefully, applying a thin coat of petroleum jelly, and moving the endotracheal tube to the opposite side daily. ■ 3. Positioning the client in the supine position with the head to the side and slightly elevated on two pillows. ■ 4. Turning the client with a drawsheet and placing a pillow behind the back and one between the legs

2. The nurse must clean the unconscious client's mouth carefully, apply a thin coat of petroleum jelly, and move the endotracheal tube to the opposite side daily to prevent dryness, crusting, inflammation, and parotiditis. The unconscious client's temperature should be monitored by a route other than the oral route (e.g., rectal, tympanic) because oral temperatures will be inaccurate. The client should be positioned in a lateral or semiprone position, not a supine position, to allow for drainage of secretions and for the jaw and tongue to fall forward. The client should not be dragged when turned, as may happen when a drawsheet is used. Care should be taken to lift the client's heels, buttocks, arms, and head off of the sheets when turning. Trochanter rolls, splints, foam boot aids, specialty beds, and so on—not just two pillows—should be used to keep the client in correct body position and to decrease pressure on bony prominences.

58. When communicating with a client who has aphasia, which of the following nursing interventions is not appropriate? ■ 1. Present one thought at a time. ■ 2. Encourage the client not to write messages. ■ 3. Speak with normal volume. ■ 4. Make use of gestures.

2. The nurse should encourage the client to write messages or use alternative forms of communication to avoid frustration. Presenting one thought at a time decreases stimuli that may distract the client, as does speaking in a normal volume and tone. The nurse should ask the client to "show me" and should encourage the use of gestures to assist in getting the message across with minimal frustration and exhaustion for the client.

38. Which statement by a client with a seizure disorder taking topiramate (Topamax) indicates the client has understood the nurse's instruction? ■ 1. "I will take the medicine before going to bed." ■ 2. "I will drink 6 to 8 glasses of water a day." ■ 3. "I will eat plenty of fresh fruits." ■ 4. "I will take the medicine with a meal or snack."

2. Toxic effects of topiramate (Topamax) include nephrolithiasis, and clients are encouraged to drink 6 to 8 glasses of water a day to dilute the urine and fl ush the renal tubules to avoid stone formation. Topiramate is taken in divided doses because it produces drowsiness. Although eating fresh fruits is desirable from a nutritional standpoint, this is not related to the topiramate. The drug does not have to be taken with meals

93. The nurse observes that the right eye of an unconscious client does not close completely. Which nursing intervention is most appropriate? ■ 1. Have the client wear eyeglasses at all times. ■ 2. Lightly tape the eyelid shut. ■ 3. Instill artificial tears once every shift. ■ 4. Clean the eyelid with a washcloth every shift.

2. When the blink reflex is absent or the eyes do not close completely, the cornea may become dry and irritated. Corneal abrasion can occur. Taping the eye closed will prevent injury. Having the client wear eyeglasses or cleaning the eyelid will not protect the cornea from dryness or irritation. Artificial tears instilled once per shift are not frequent enough for preventing dryness.

13. A client is being admitted with a spinal cord transection at C7. Which of the following assessments take priority upon the client's arrival? Select all that apply. ■ 1. Reflexes. ■ 2. Bladder function. ■ 3. Blood pressure. ■ 4. Temperature. ■ 5. Respirations

3, 4, 5. The nurse should assess the client for spinal shock, which is the immediate response to spinal cord transection. Hypotension occurs and the body loses core temperature to environmental temperature. The nurse must treat the client immediately to manage hypotension and hypothermia. The nurse should also ensure that there is an adequate airway and respirations; there may be respiratory compromise due to intercostal muscle involvement. Once the client is stable, the nurse should conduct a complete neurologic check. The nurse should take all precautions to keep the client's head, neck, and spine position in straight alignment. If the client is conscious, the nurse should briefl y assess major refl exes, such as the Achilles, patellar, biceps, and triceps tendons, and sensation of the perineum for bladder function.

A 78-year-old client is admitted to the emergency department (ED) with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? 1. Prepare to administer recombinant tissue plasminogen activator (rt-PA). 2. Discuss the precipitating factors that caused the symptoms. 3. Schedule for a STAT computed tomography (CT) scan of the head. 4. Notify the speech pathologist for an emergency consult

3. A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. If a CVA is diagnosed, the CT scan can determine if it is a hemorrhagic or an ischemic accident and guide treatment

56. A client is experiencing mood swings after a stroke and often has episodes of tearfulness that are distressing to the family. Which is the best technique for the nurse to instruct family members to try when the client experiences a crying episode? ■ 1. Sit quietly with the client until the episode is over. ■ 2. Ignore the behavior. ■ 3. Attempt to divert the client's attention. ■ 4. Tell the client that this behavior is unacceptable.

3. A client who has brain damage may be emotionally labile and may cry or laugh for no explainable reason. Crying is best dealt with by attempting to divert the client's attention. Ignoring the behavior will not affect the mood swing or the crying and may increase the client's sense of isolation. Telling the client to stop is inappropriate.

39. Which clinical manifestation is a typical reaction to long-term phenytoin sodium (Dilantin) therapy? ■ 1. Weight gain. ■ 2. Insomnia. ■ 3. Excessive growth of gum tissue. ■ 4. Deteriorating eyesight.

3. A common adverse effect of long-term phenytoin therapy is an overgrowth of gingival tissues. Problems may be minimized with good oral hygiene, but in some cases, overgrown tissues must be removed surgically. Phenytoin does not cause weight gain, insomnia, or deteriorating eyesight.

31. What is the priority nursing intervention in the postictal phase of a seizure? ■ 1. Reorient the client to time, person, and place. ■ 2. Determine the client's level of sleepiness. ■ 3. Assess the client's breathing pattern. ■ 4. Position the client comfortably.

3. A priority for the client in the postictal phase (after a seizure) is to assess the client's breathing pattern for effective rate, rhythm, and depth. The nurse should apply oxygen and ventilation to the client as appropriate. Other interventions, to be completed after the airway has been established, include reorientation of the client to time, person, and place. Determining the client's level of sleepiness is useful, but it is not a priority. Positioning the client comfortably promotes rest but is of less importance than ascertaining that the airway is patent.

85. A client is brought to the emergency department unconscious. An empty bottle of aspirin was found in his car, and a drug overdose is suspected. Which of the following medications should the nurse have available for further emergency treatment? ■ 1. Vitamin K. ■ 2. Dextrose 50%. ■ 3. Activated charcoal powder. ■ 4. Sodium thiosulfate

3. Activated charcoal powder is administered to absorb remaining particles of salicylate. Vitamin K is an antidote for warfarin sodium (Coumadin). Dextrose 50% is used to treat hypoglycemia. Sodium thiosulfate is an antidote for cyanide.

37. The nurse is teaching a client to recognize an aura. The nurse should instruct the client to note: ■ 1. A postictal state of amnesia. ■ 2. An hallucination that occurs during a seizure. ■ 3. A symptom that occurs just before a seizure. ■ 4. A feeling of relaxation as the seizure begins to subside.

3. An aura is a premonition of an impending seizure. Auras usually are of a sensory nature (e.g., an olfactory, visual, gustatory, or auditory sensation); some may be of a psychic nature. Evaluating an aura may help identify the area of the brain from which the seizure originates. Auras occur before a seizure, not during or after (postictal). They are not similar to hallucinations or amnesia or related to relaxation.

45. During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's: ■ 1. Pulse. ■ 2. Respirations. ■ 3. Blood pressure. ■ 4. Temperature.

3. Control of blood pressure is critical during the first 24 hours after treatment because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Vital signs are monitored, and blood pressure is maintained as identified by the physician and specific to the client's ischemic tissue needs and risk of bleeding from treatment. The other vital signs are important, but the priority is to monitor blood pressure.

18. Which activity should the nurse encourage the client to avoid when there is a risk for increased intracranial pressure (ICP)? ■ 1. Deep breathing. ■ 2. Turning. ■ 3. Coughing. ■ 4. Passive range-of-motion (ROM) exercises.

3. Coughing is contraindicated for a client at risk for increased ICP because coughing increases ICP. Deep breathing can be continued. Turning and passive ROM exercises can be continued with care not to extend or fl ex the neck

88. Which of the following is a priority during the first 24 hours of hospitalization for a comatose client with suspected drug overdose? ■ 1. Educate regarding drug abuse. ■ 2. Minimize pain. ■ 3. Maintain intact skin. ■ 4. Increase caloric intake.

3. Maintaining intact skin is a priority for the unconscious client. Unconscious clients need to be turned every hour to prevent complications of immobility, which include pressure ulcers and stasis pneumonia. The unconscious client cannot be educated at this time. Pain is not a concern. During the first 24 hours, the unconscious client will mostly likely be on nothing-by-mouth status.

9. Which of the following nursing interventions is appropriate for a client with an increased intracranial pressure (ICP) of 20 mm Hg? ■ 1. Give the client a warming blanket. ■ 2. Administer low-dose barbiturates. ■ 3. Encourage the client to hyperventilate. ■ 4. Restrict fluids.

3. Normal ICP is 15 mm Hg or less for 15 to 30 seconds or longer. Hyperventilation causes vasoconstriction, which reduces cerebrospinal fl uid and blood volume, two important factors for reducing a sustained ICP of 20 mm Hg. A cooling blanket is used to control the elevation of temperature because a fever increases the metabolic rate, which in turn increases ICP. High doses of barbiturates may be used to reduce the increased cellular metabolic demands. Fluid volume and inotropic drugs are used to maintain cerebral perfusion by supporting the cardiac output and keeping the cerebral perfusion pressure greater than 80 mm Hg.

111. A nursing assistant is providing care to a client with left-sided paralysis. Which of the following actions by the nursing assistant requires the nurse to provide further instruction? ■ 1. Providing passive range of motion exercises to the left extremities during the bed bath. ■ 2. Elevating the foot of the bed to reduce edema. ■ 3. Pulling up the client under the left shoulder when getting out of bed to a chair. ■ 4. Putting high top tennis shoes on the client after bathing

3. Pulling the client up under the arm can cause shoulder displacement. A belt around the waist should be used to move the client. Passive range of motion exercises prevents contractures and atrophy. Raising the foot of the bed assists in venous return to reduce edema. High top tennis shoes are used to prevent foot drop

20. A client who had a serious head injury with increased intracranial pressure is to be discharged to a rehabilitation facility. Which of the following rehabilitation outcomes would be appropriate for the client? The client will: ■ 1. Exhibit no further episodes of short-term memory loss. ■ 2. Be able to return to his construction job in 3 weeks. ■ 3. Actively participate in the rehabilitation process as appropriate. ■ 4. Be emotionally stable and display pre-injury personality traits.

3. Recovery from a serious head injury is a long-term process that may continue for months or years. Depending on the extent of the injury, clients who are transferred to rehabilitation facilities most likely will continue to exhibit cognitive and mobility impairments as well as behavior and personality changes. The client would be expected to participate in the rehabilitation efforts to the extent he is capable. Family members and signifi cant others will need long-term support to help them cope with the changes that have occurred in the client.

94. Which sign is an early indicator of hypoxia in the unconscious client? ■ 1. Cyanosis. ■ 2. Decreased respirations. ■ 3. Restlessness. ■ 4. Hypotension.

3. Restlessness is an early indicator of hypoxia. The nurse should suspect hypoxia in the unconscious client who becomes restless. The most accurate method for determining the presence of hypoxia is to evaluate the pulse oximeter value or arterial blood gas values. Cyanosis and decreased respirations are late indicators of hypoxia. Hypertension, not hypotension, is a sign of hypoxia.

44. A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. The nurse should first: ■ 1. Ask what medications the client is taking. ■ 2. Complete a history and health assessment. ■ 3. Identify the time of onset of the stroke. ■ 4. Determine if the client is scheduled for any surgical procedures.

3. Studies show that clients who receive recombinant t-PA treatment within 3 hours after the onset of a stroke have better outcomes. The time from the onset of a stroke to t-PA treatment is critical. A complete health assessment and history is not possible when a client is receiving emergency care. Upcoming surgical procedures may need to be delayed because of the administration of t-PA, which is a priority in the immediate treatment of the current stroke. While the nurse should identify which medications the client is taking, it is more important to know the time of the onset of the stroke to determine the course of action for administering t-PA.

25. Which of the following is contraindicated for a client with seizure precautions? ■ 1. Encouraging him to perform his own personal hygiene. ■ 2. Allowing him to wear his own clothing. ■ 3. Assessing oral temperature with a glass thermometer. ■ 4. Encouraging him to be out of bed.

3. Temperatures are not assessed orally with a glass thermometer because the thermometer could break and cause injury if a seizure occurred. The client can perform personal hygiene. There is no clinical reason to discourage the client from wearing his own clothes. As long as there are no other limitations, the client should be encouraged to be out of bed

7. What should the nurse do first when a client with a head injury begins to have clear drainage from his nose? ■ 1. Compress the nares. ■ 2. Tilt the head back. ■ 3. Give the client tissues to collect the fluid. ■ 4. Administer an antihistamine for postnasal drip.

3. The clear drainage must be analyzed to determine whether it is nasal drainage or cerebrospinal fluid (CSF). The nurse should not give the client tissues because it is important to know how much leakage of CSF is occurring. Compressing the nares will obstruct the drainage flow. It is inappropriate to tilt the head back, which would allow the fluid to drain down the throat and not be collected for a sample. It is inappropriate to administer an antihistamine because the drainage may not be from postnasal drip.

90. The client is to be placed in a right side-lying position. The nurse should intervene when observing a client in which of the following positions? ■ 1. The head is placed on a small pillow. ■ 2. The right leg is extended without pillow support. ■ 3. The left arm is rested on the mattress with the elbow flexed. ■ 4. The left leg is supported on a pillow with the knee flexed

3. The client is not in proper body alignment if, when in the right side-lying position, the client's left arm rests on the mattress with the elbow flexed. This positioning of the arm pulls the left shoulder out of good alignment, restricting respiratory movements. The arm should be supported on a pillow. The client's head also should be placed on a small pillow to keep it in alignment with the body. The right leg should be extended on the mattress without a pillow to avoid hyperrotation of the hip. A pillow should be placed between the left and right legs with the left knee flexed so that on no parts of the legs is skin touching skin.

87. The wife and sister of a client who had attempted suicide with an overdose are distraught about his comatose condition and the possibility that he took an intentional drug overdose. Which of the following would be an appropriate initial nursing intervention with this family? ■ 1. Explain that because the client was found on hospital property, he was probably asking for help and did not intentionally overdose. ■ 2. Give the wife and sister a big hug and assure them that the client is in good hands. ■ 3. Encourage the wife and sister to express their feelings and concerns, and listen carefully. ■ 4. Allow the wife and sister to help care for the client by rubbing his back when he is turned

3. The initial response to crisis is high anxiety. Anxiety must dissipate before a person can deal with the actual situation. Allowing family members to ventilate their feelings can help diffuse their anxiety. The reasons for the client's actions are unknown; assumptions must be validated before they become facts. Touch can be appropriate but not when it is used as false reassurance. Helping with the client's care is appropriate at a later time.

50. Which nursing intervention has been found to be the most effective means of preventing plantar flexion in a client who has had a stroke with residual paralysis? ■ 1. Place the client's feet against a firm footboard. ■ 2. Reposition the client every 2 hours. ■ 3. Have the client wear ankle-high tennis shoes at intervals throughout the day. ■ 4. Massage the client's feet and ankles regularly.

3. The use of ankle-high tennis shoes has been found to be most effective in preventing plantar flexion (footdrop) because they add support to the foot and keep it in the correct anatomic position. Footboards stimulate spasms and are not routinely recommended. Regular repositioning and range-of-motion exercises are important interventions, but the client's foot needs to be in the correct anatomic position to prevent overextension of the muscle and tendon. Massaging does not prevent plantar fl exion and, if rigorous, could release emboli.

59. What is the expected outcome of thrombolytic drug therapy for stroke? ■ 1. Increased vascular permeability. ■ 2. Vasoconstriction. ■ 3. Dissolved emboli. ■ 4. Prevention of hemorrhage.

3. Thrombolytic enzyme agents are used for clients with a thrombotic stroke to dissolve emboli, thus reestablishing cerebral perfusion. They do not increase vascular permeability, cause vasoconstriction, or prevent further hemorrhage.

57. The client who has had a stroke with residual physical handicaps becomes discouraged by his physical appearance. What approach to the client is best for the nurse to use to help the client overcome his negative self-concept? Select all that apply. ■ 1. Helpfulness. ■ 2. Charity. ■ 3. Firmness. ■ 4. Encouragement. ■ 5. Patience.

4, 5. When offering emotional support to a client who is discouraged and has a negative selfconcept because of physical handicaps, the nurse should approach the client with encouragement and patience. The client should be praised when he or she shows progress in efforts to overcome handicaps. An attitude of helpfulness and sympathy allows the client to assume a role of someone not ordinary, someone who is not like others. Regardless of the handicap, the client still feels the same on the inside and has the same innate needs for his or her growth and developmental age-group. An attitude of charity tends to make the client feel like a "charity case" or like someone who is given something free because of his "condition." The client feels unequal to his peers or unable to fulfi ll the role relationships that were obtained before the stroke. An approach using fi rmness is inappropriate because it implies that the client can do better if he just tries harder and leaves no room for softness in the approach to overcoming a negative self-concept.

10. The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider about which of the following changes in the client's condition? ■ 1. Widening pulse pressure. ■ 2. Decrease in the pulse rate. ■ 3. Dilated, fixed pupils. ■ 4. Decrease in level of consciousness (LOC).

4. A decrease in the client's LOC is an early indicator of deterioration of the client's neurologic status. Changes in level of consciousness, such as restlessness and irritability, may be subtle. Widening of the pulse pressure, decrease in the pulse rate, and dilated, fixed pupils occur later if the increased ICP is not treated.

26. Which of the following will the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure? ■ 1. Jerking in one extremity that spreads gradually to adjacent areas. ■ 2. Vacant staring and abruptly ceasing all activity. ■ 3. Facial grimaces, patting motions, and lip smacking. ■ 4. Loss of consciousness, body stiffening, and violent muscle contractions.

4. A generalized tonic-clonic seizure involves both a tonic phase and a clonic phase. The tonic phase consists of loss of consciousness, dilated pupils, and muscular stiffening or contraction, which lasts about 20 to 30 seconds. The clonic phase involves repetitive movements. The seizure ends with confusion, drowsiness, and resumption of respiration. A partial seizure starts in one region of the cortex and may stay focused or spread (e.g., jerking in the extremity spreading to other areas of the body). An absence seizure usually occurs in children and involves a vacant stare with a brief loss of consciousness that often goes unnoticed. A complex partial seizure involves facial grimacing with patting and smacking

21. Which of the following describes decerebrate posturing? ■ 1. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers. ■ 2. Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of feet. ■ 3. Supination of arms, dorsiflexion of the feet. ■ 4. Back arched, rigid extension of all four extremities.

4. Decerebrate posturing occurs in clients with damage to the upper brain stem, midbrain, or pons and is demonstrated clinically by arching of the back, rigid extension of the extremities, pronation of the arms, and plantar flexion of the feet. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers describes decorticate posturing, which indicates damage to corticospinal tracts and cerebral hemispheres

33. What nursing assessments should be documented at the beginning of the ictal phase of a seizure? ■ 1. Heart rate, respirations, pulse oximeter, and blood pressure. ■ 2. Last dose of anticonvulsant and circumstances at the time. ■ 3. Type of visual, auditory, and olfactory aura the client experienced. ■ 4. Movement of the head and eyes and muscle rigidity

4. During a seizure, the nurse should note movement of the client's head and eyes and muscle rigidity, especially when the seizure first begins, to obtain clues about the location of the trigger focus in the brain. Other important assessments would include noting the progression and duration of the seizure, respiratory status, loss of consciousness, pupil size, and incontinence of urine and stool. It is typically not possible to assess the client's pulse and blood pressure during a tonic-clonic seizure because the muscle contractions make assessment difficult to impossible. The last dose of anticonvulsant medication can be evaluated later. The nurse should focus on maintaining an open airway, preventing injury to the client, and assessing the onset and progression of the seizure to determine the type of brain activity involved. The type of aura should be assessed in the preictal phase of the seizure

96. The client is to receive 200 mL of tube feeding every 4 hours. The nurse checks for the client's gastric residual before administering the next scheduled feeding and obtains 40 mL of gastric residual. The nurse should: ■ 1. Withhold the tube feeding and notify the physician. ■ 2. Dispose of the residual and continue with the feeding. ■ 3. Delay feeding the client for 1 hour and then recheck the residual. ■ 4. Readminister the residual to the client and continue with the feeding

4. Gastric residuals are checked before administration of enteral feedings to determine whether gastric emptying is delayed. A residual of less than 50% of the previous feeding volume is usually considered acceptable. In this case, the amount is not excessive and the nurse shouldreinstill the aspirate through the tube and then administer the feeding. If the amount of gastric residual is excessive, the nurse should notify the physician and withhold the feeding. Disposing of the residual can cause electrolyte and fl uid losses

A 22-year-old client is brought to the emergency department with his fi ancée after being involved in a serious motor vehicle accident. His Glasgow Coma Scale score is 7 and he demonstrates evidence of decorticate posturing. Which of the following is appropriate for obtaining permission to place a catheter for intracranial pressure (ICP) monitoring? ■ 1. The nurse will obtain a signed consent from the client's fiancée because he is of legal age and they are engaged to be married. ■ 2. The physician will get a consultation from another physician and proceed with placement of the ICP catheter until the family arrives to sign the consent. ■ 3. Two nurses will receive a verbal consent by telephone from the client's next of kin before inserting the catheter. ■ 4. The physician will document the emergency nature of the client's condition and that an ICP catheter for monitoring was placed without a consent.

4. In a life-threatening emergency where time is of the essence in saving life or limb, consent is not required. This client has a Glasgow Coma Scale score of 7, which means he is comatose. The client has deteriorated to a level where he cannot be aroused, withdraws in a purposeless manner from painful stimuli, exhibits decorticate posturing, and may or may not have brain stem reflexes intact. The placement of the ICP monitor is crucial to determine cerebral blood flow and prevent herniation. The client's fiancée cannot sign his consent because, until she is his wife or has designated power of attorney, she is not considered his next of kin. The physician should insert the catheter in this emergency. He does not need to get a consultation from another physician. When consent is needed for a situation that is not a true emergency, two nurses can receive a verbal consent by telephone from the client's next of kin

16. A male client with a head injury regains consciousness after several days. Which of the following nursing statements is most appropriate as the client awakens? ■ 1. "I'll get your family." ■ 2. "Can you tell me your name and where you live?" ■ 3. "I'll bet you're a little confused right now." ■ 4. "You are in the hospital. You were in an accident and unconscious."

4. It is important to first explain where a client is to orient him to time, person, and place. Offering to get his family and asking him questions to determine whether he is oriented are important, but the fi rst comments should let the client know where he is and what happened to him. It is useful to be empathetic to the client, but making a comment such as "I'll bet you're a little confused" when he first awakens is not helpful and may cause him anxiety.

27. It is the night before a client is to have a computed tomography (CT) scan of the head without contrast. The nurse should tell the client? ■ 1. "You must shampoo your hair tonight to remove all oil and dirt." ■ 2. "You may drink fluids until midnight, but after that drink nothing until the scan is completed." ■ 3. "You will have some hair shaved to attach the small electrode to your scalp." ■ 4. "You will need to hold your head very still during the examination."

4. The client will be asked to hold the head very still during the examination, which lasts about 30 to 60 minutes. In some instances, food and fl uids may be withheld for 4 to 6 hours before the procedure if a contrast medium is used because the radiopaque substance sometimes causes nausea. There is no special preparation for a CT scan, so a shampoo the night before is not required. The client may drink fl uids until 4 hours before the scan is scheduled. Electrodes are not used for a CT scan, nor is the head shaved

14. The nurse is assessing a client for movement after halo traction placement for a C8 fracture. The nurse should document which of the following? ■ 1. The client's shoulders shrug against downward pressure of the examiner's hands. ■ 2. The client's arm pulls up from a resting position against resistance. ■ 3. The client's arm straightens out from a flexed position against resistance. ■ 4. The client's hand-grasp strength is equal.

4. The correct motor function test for C8 is a hand-grasp check. The motor function check for C4 to C5 is shoulders shrugging against downward pressure of the examiner's hands. The motor function check for C5 to C6 is an arm pulling up from a resting position against resistance. The motor function check for C7 is an arm straightening out from a flexed position against resistance.

91. The nursing team has been performing passive range-of-motion (ROM) exercises on an unconscious client? Which of the following indicate the exercises have been successful? ■ 1. Preservation of muscle mass. ■ 2. Prevention of bone demineralization. ■ 3. Increase in muscle tone. ■ 4. Maintenance of joint mobility.

4. The goal of performing passive ROM exercises is to maintain joint mobility. Active exercise is needed to preserve bone and muscle mass. Passive

20. You are supervising a senior nursing student who is caring for a client with a right hemisphere stroke. Which action by the student nurse requires that you intervene? 1. Instructing the client to sit up straight, and the client responding with a puzzled expression 2. Moving the client's food tray to the right side of his over-bed table 3. Assisting the client with passive range-of-motion (ROM) exercises 4. Combing the hair on the left side of the client's head when the client always combs his hair on the right side

Ans: 1 Clients with right cerebral hemisphere stroke often manifest neglect syndrome. They lean to the left and, when asked, respond that they believe they are sitting up straight. They often neglect the left side of their bodies and ignore food on the left side of their food trays. The nurse needs to remind the student of this phenomenon and discuss the appropriate interventions.

30. You are in charge of developing a standard plan of care in an Alzheimer disease care facility and are responsible for delegating and supervising resident care given by LPNs/LVNs and UAPs. Which activity is best to delegate to the LPN/LVN team leaders? 1. Checking for improvement in resident memory after medication therapy is initiated 2. Using the Mini-Mental State Examination to assess residents every 6 months 3. Assisting residents in using the toilet every 2 hours to decrease risk for urinary incontinence 4. Developing individualized activity plans after consulting with residents and family

Ans: 1 LPN/LVN education and team leader responsibilities include checking for the therapeutic and adverse effects of medications. Changes in the residents' memory would be communicated to the RN supervisor, who is responsible for overseeing the plan of care for each resident. Assessing for changes in score on the Mini-Mental State Examination and developing the plan of care are RN responsibilities. Assisting residents with personal care and hygiene would be delegated to UAPs working at the long-term care facility.

22. A client who had a stroke needs to be fed. What instruction should you give to the UAP who will feed the client? 1. Position the client sitting up in bed before you feed him. 2. Check the client's gag and swallowing reflexes. 3. Feed the client quickly, because there are three more you must feed. 4. Suction the client's secretions between bites of food.

Ans: 1 Positioning the client in a sitting position decreases the risk of aspiration. The UAP is not trained to assess gag or swallowing reflexes. The client should not be rushed during feeding. A client who needs suctioning performed between bites of food is not handling secretions and is at risk for aspiration. Such a client should be assessed further before feeding.

26. Which nursing action will be implemented first if a client has a generalized tonic-clonic seizure? 1. Turn the client to one side. 2. Give lorazepam (Ativan) 2 mg IV. 3. Administer oxygen via nonrebreather mask. 4. Assess the client's level of consciousness.

Ans: 1 The priority action during a generalized tonic-clonic seizure is to protect the airway by turning the client to one side. Administering lorazepam should be the next action, because it will act rapidly to control the seizure. Although oxygen may be useful during the postictal phase, the hypoxemia during tonic-clonic seizures is caused by apnea, which cannot be corrected by oxygen administration. Checking level of consciousness is not appropriate during the seizure, because generalized tonic-clonic seizures are associated with a loss of consciousness.

25. A 23-year-old with a recent history of encephalitis is admitted to the medical unit with new onset generalized tonic-clonic seizures. Which nursing activities included in the client's care will be best to delegate to an LPN/LVN whom you are supervising? (Select all that apply.) 1. Observing and documenting the onset and duration of any seizure activity 2. Administering phenytoin (Dilantin) 200 mg by mouth (PO) three times a day 3. Teaching the client about the need for frequent tooth brushing and flossing 4. Developing a discharge plan that includes referral to the Epilepsy Foundation 5. Assessing for adverse effects caused by new antiseizure medications

Ans: 1, 2 Any nursing staff member who is involved in caring for the client should observe for the onset and duration of any seizures (although a more detailed assessment of seizure activity should be done by the RN). Administration of medications is included in LPN/LVN education and scope of practice. Teaching, discharge planning, and assessment for adverse effects of new medications are complex activities that require RN-level education and scope of practice.

2. You are creating a teaching plan for a client with newly-diagnosed migraine headaches. Which key items will you include in the teaching plan? (Select all that apply.) 1. Foods that contain tyramine, such as alcohol and aged cheese, should be avoided. 2. Drugs such as nitroglycerin (Nitrostat) and nifedipine (Procardia) should be avoided. 3. Abortive therapy is aimed at eliminating the pain during the aura. 4. A potential side effect of medications is rebound headache. 5. Complementary therapies such as biofeedback and relaxation may be helpful. 6. Estrogen therapy should be continued as prescribed by your physician.

Ans: 1, 2, 3, 4, 5 Medications such as estrogen supplements may actually trigger a migraine headache attack. All of the other statements are accurate.

21. Which actions should you delegate to an experienced UAP when caring for a client with a thrombotic stroke who has residual left-sided weakness? (Select all that apply.) 1. Assisting the client to reposition every 2 hours 2. Reapplying pneumatic compression boots 3. Reminding the client to perform active ROM exercises 4. Assessing the extremities for redness and edema 5. Setting up meal trays and assisting with feeding

Ans: 1, 2, 3, 5 An experienced UAP would know how to reposition the client, reapply compression boots, and feed a client, and would remind the client to perform activities the client has been taught to perform. Assessing for redness and swelling (signs of deep venous thrombosis) requires additional education and skill, appropriate to the professional nurse.

27. A client who recently started taking phenytoin to control simple partial seizures is seen in the outpatient clinic. Which information obtained during her chart review and assessment will be of greatest concern? 1. The gums appear enlarged and inflamed. 2. The white blood cell count is 2300/mm3 . 3. The client sometimes forgets to take the phenytoin until the afternoon. 4. The client wants to renew her driver's license in the next month.

Ans: 2 Leukopenia is a serious adverse effect of phenytoin therapy and would require discontinuation of the medication. The other data indicate a need for further assessment and/or client teaching but will not require a change in medical treatment for the seizures.

4. You are preparing to admit a client with a seizure disorder. Which actions can you delegate to an LPN/LVN? 1. Completing the admission assessment 2. Setting up oxygen and suction equipment 3. Placing a padded tongue blade at the bedside 4. Padding the side rails before the client arrives

Ans: 2 The LPN/LVN can set up the equipment for oxygen and suctioning. The RN should perform the complete initial assessment. Controversy exists as to whether padded side rails actually provide safety, and their use may embarrass the client and family. Tongue blades should not be at the bedside and should never be inserted into the client's mouth after a seizure begins.

33. A 70-year-old alcoholic client who has become lethargic, confused, and incontinent during the last week is admitted to the ED. His wife tells you that he fell down the stairs about a month ago, but that "he didn't have a scratch afterward." Which collaborative interventions will you implement first? 1. Place the client on the hospital alcohol withdrawal protocol. 2. Transport the client to the radiology department for a computed tomographic (CT) scan. 3. Make a referral to the social services department. 4. Give the client phenytoin 100 mg PO.

Ans: 2 The client's history and assessment data indicate that he may have a chronic subdural hematoma. The priority goal is to obtain a rapid diagnosis and send the client to surgery to have the hematoma evacuated. The other interventions also should be implemented as soon as possible, but the initial nursing activities should be directed toward diagnosis and treatment of any intracranial lesion.

9. Which client should you, as charge nurse, assign to a new RN graduate who is on orientation to the neurologic unit? 1. 28-year-old newly-admitted client with an SCI 2. 67-year-old who had a stroke 3 days ago and has left-sided weakness 3. 85-year-old with dementia who is to be transferred to long-term care today 4. 54-year-old with Parkinson disease who needs assistance with bathing

Ans: 2 The new RN graduate who is on orientation to the unit should be assigned to care for clients with stable, noncomplex conditions, such as the client with stroke. The task of helping the client with Parkinson disease to bathe is best delegated to the UAP. The client being transferred to the nursing home and the newly-admitted client with SCI should be assigned to experienced nurses.

19. You are providing care for a client with an acute hemorrhagic stroke. The client's spouse tells you that he has been reading a lot about strokes and asks why his wife has not received alteplase (Activase). What is your best response? 1. "Your wife was not admitted within the time frame that alteplase is usually given." 2. "This drug is used primarily for clients who experience an acute heart attack." 3. "Alteplase dissolves clots and may cause more bleeding into your wife's brain." 4. "Your wife had gallbladder surgery just 6 months ago, and this prevents the use of alteplase."

Ans: 3 Alteplase is a clot buster. In a client who has experienced hemorrhagic stroke, there is already bleeding into the brain. A drug such as alteplase can worsen the bleeding. The other statements about the use of alteplase are accurate but are not pertinent to this client's diagnosis.

3. After a client has a seizure, which action can you delegate to the UAP? 1. Documenting the seizure 2. Performing neurologic checks 3. Taking the client's vital signs 4. Restraining the client for protection

Ans: 3 Measurement of vital signs is within the education and scope of practice of UAPs. The nurse should perform neurologic checks and document the seizure. Clients with seizures should not be restrained; however, the nurse may guide the client's movements if necessary.

The nurse enters the room as the client is beginning to have a tonic-clonic seizure. What action should the nurse implement first? 1. Note the first thing the client does in the seizure. 2. Assess the size of the client's pupils 3. Determine if the client is incontinent of urine or stool. 4. Provide the client with privacy during the seizure.

1. Noticing the first thing the client does during a seizure provides information and clues as to the location of the seizure in the brain. It is important to document whether the beginning of the seizure was observed

A nurse is caring for a patient who experiences debilitating cluster headaches. The patient should be taught to take appropriate medications at what point in the course of the onset of a new headache? A) As soon as the patients pain becomes unbearable B) As soon as the patient senses the onset of symptoms C) Twenty to 30 minutes after the onset of symptoms D) When the patient senses his or her symptoms peaking

B A migraine or a cluster headache in the early phase requires abortive medication therapy instituted assoon as possible. Delaying medication administration would lead to unnecessary pain

5. A nursing student is teaching a client and family about epilepsy before the client's discharge. For which statement should you intervene? 1. "You should avoid consumption of all forms of alcohol." 2. "Wear your medical alert bracelet at all times." 3. "Protect your loved one's airway during a seizure." 4. "It's OK to take over-the-counter medications."

Ans: 4 A client with a seizure disorder should not take over-the-counter medications without consulting with the health care provider first. The other three statements are appropriate teaching points for clients with seizure disorders and their families.

A patient is being admitted to the neurologic ICU following an acute head injury that has resulted incerebral edema. When planning this patients care, the nurse would expect to administer what prioritymedication? A) Hydrochlorothiazide (HydroDIURIL) B) Furosemide (Lasix) C) Mannitol (Osmitrol) D) Spirolactone (Aldactone)

C The osmotic diuretic mannitol is given to dehydrate the brain tissue and reduce cerebral edema. Thisdrug acts by reducing the volume of brain and extracellular fluid. Spirolactone, furosemide, andhydrochlorothiazide are diuretics that are not typically used in the treatment of increased ICP resultingfrom cerebral edema.

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? 1. Blowing the nose 2. Isometric exercises 3. Coughing vigorously 4. Exhaling during repositioning

4 Rationale: Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure. Some of these activities include isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising

5. An unconscious client with multiple injuries arrives in the emergency department. Which nursing intervention receives the highest priority? ■ 1. Establishing an airway. ■ 2. Replacing blood loss. ■ 3. Stopping bleeding from open wounds. ■ 4. Checking for a neck fracture.

1. The highest priority for a client with multiple injuries is to establish an open airway for effective ventilation and oxygenation. Unless the client has a patent airway, other care measures will be futile. Replacing blood loss, stopping bleeding from open wounds, and checking for a neck fracture are important nursing interventions to be completed after the airway and ventilation are established.

The client being admitted with transient ischemic attack is complaining of a headache. The client is allergic to morphine, iodine, and codeine. Which healthcare provider order should the nurse question? 1. Schedule for CT scan with contrast in a.m. 2. Administer acetaminophen 2 PO for headache. 3. Take client's vital signs per protocol. 4. Provide the client with a low-fat, low-cholesterol diet.

1. The client is allergic to iodine; therefore, the client cannot have the CT scan with contrast because it is iodine. The nurse should question this HCP order.

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? 1. A blood glucose level of 480 mg/dL. 2. A right-sided carotid bruit. 3. A blood pressure (BP) of 220/120 mm Hg. 4. The presence of bronchogenic carcinoma.

3. Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured blood vessel inside the cranium.

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

2 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 assessing the motor and sensory function of an unconscious client. The nurse should use which technique to test the client's peripheral response to pain? 1. Sternal rub 2. Nail bed pressure 3. Pressure on the orbital rim 4. Squeezing of the sternocleidomastoid muscle

2 Rationale: Nail bed pressure tests a basic motor and sensory peripheral response. Cerebral responses to pain are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle

The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply. 1. Maintain the head of the bed at 60 degrees of elevation. 2. Administer stool softeners daily. 3. Ensure the pulse oximeter reading is higher than 93%. 4. Perform deep nasal suction every two (2) hours. 5. Administer mild sedatives.

2.3.5 Stool softeners are initiated to prevent the Valsalva maneuver, which increases intracranial pressure. Oxygen saturation higher than 93% ensures oxygenation of the brain tissues; decreasing oxygen levels increase cerebral edema. Mild sedatives will reduce the client's agitation; strong narcotics would not be administered because they decrease the client's level of consciousness

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? 1. A negative Kernig's sign 2. Absence of nuchal rigidity 3. A positive Brudzinski's sign 4. A Glasgow Coma Scale score of 1

3 Rationale: Signs of meningeal irritation compatible with meningitis include nuchal rigidity, a positive Brudzinski's sign, and positive Kernig's sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is flexed. Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the leg is fully flexed at the knee and hip. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glasgow Coma Scale score of 15 is a perfect score and indicates that the client is awake and alert, with no neurological deficit

The male client is admitted to the emergency department following a motorcycle accident. The client was not wearing a helmet and struck his head on the pavement. The nurse identifies the concept as impaired intracranial regulation. Which interventions should the emergency department nurse implement in the first five (5) minutes? Select all that apply. 1. Stabilize the client's neck and spine. 2. Contact the organ procurement organization to speak with the family. 3. Elevate the head of the bed to 70 degrees. 4. Perform a Glasgow Coma Scale assessment. 5. Ensure the client has a patent peripheral venous catheter in place. 6. Check the client's driver's license to see if he will accept blood

4, 5 The Glasgow Coma Scale is a systematic tool used to assess a client's neurological status. It gives health-care workers a standard method to determine the progress of a client's condition. The client should have an access to be able to administer emergency medications.

The client has been diagnosed with a cerebrovascular accident (stroke). The client's wife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge? 1. Obtain a rubber mat to place under the dinner plate. 2. Purchase a long-handled bath sponge for showering. 3. Purchase clothes with Velcro closure devices. 4. Obtain a raised toilet seat for the client's bathroom.

4. Raising the toilet seat is modifying the home and addresses the client's weakness in being able to sit down and get up without straining muscles or requiring lifting assistance from the wife

55. A nurse is teaching a client who had a stroke about ways to adapt to a visual disability. Which does the nurse identify as the primary safety precaution to use? ■ 1. Wear a patch over one eye. ■ 2. Place personal items on the sighted side. ■ 3. Lie in bed with the unaffected side toward the door. ■ 4. Turn the head from side to side when walking.

4. To expand the visual fi eld, the partially sighted client should be taught to turn the head from side to side when walking. Neglecting to do so may result in accidents. This technique helps maximize the use of remaining sight. Covering an eye with a patch will limit the fi eld of vision. Personal items can be placed within sight and reach, but most accidents occur from tripping over items that cannot be seen. It may help the client to see the door, but walking presents the primary safety hazard

A patient is scheduled for a myelogram and the nurse explains to the patient that this is an invasiveprocedure, which assesses for any lesions in the spinal cord. The nurse should explain that the preparation is similar to which of the following neurologic tests? A) Lumbar puncture B) MRI C) Cerebral angiography D) EEG

A. A myelogram is an x-ray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture. Patient preparation for a myelogram would be similar to that for lumbar puncture. The other listed diagnostic tests do not involve lumbarpuncture.

While completing a health history on a patient who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state? A) Epileptic cry B) Confusion C) Urinary incontinence D) Body rigidity

B In the postictal state (after the seizure), the patient is often confused and hard to arouse and may sleepfor hours. The epileptic cry occurs from the simultaneous contractions of the diaphragm and chestmuscles that occur during the seizure. Urinary incontinence and intense rigidity of the entire body arefollowed by alternating muscle relaxation and contraction (generalized tonicclonic contraction) duringthe seizure.

The neurologic ICU nurse is admitting a patient following a craniotomy using the supratentorial approach. How should the nurse best position the patient? A) Position the patient supine. B) Maintain head of bed (HOB) elevated at 30 to 45 degrees. C) Position patient in prone position. D) Maintain bed in Trendelenberg position.

B The patient undergoing a craniotomy with a supratentorial (above the tentorium) approach should be placed with the HOB elevated 30 to 45 degrees, with the neck in neutral alignment. Each of the other listed positions would cause a dangerous elevation in ICP

A patient scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the patient for the MRI should prioritize which of the following actions? A) Withholding stimulants 24 to 48 hours prior to exam B) Removing all metal-containing objects C) Instructing the patient to void prior to the MRI D) Initiating an IV line for administration of contrast

B. Patient preparation for an MRI consists of removing all metal-containing objects prior to theexamination. Withholding stimulants would not affect an MRI; this relates to an electroencephalography(EEG). Instructing the patient to void is patient preparation for a lumbar puncture. Initiating an IV linefor administration of contrast would be done if the patient was having a CT scan with contrast

The client diagnosed with a right-sided cerebral vascular accident (CVA), or brain attack, is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply. 1. Position the client to prevent shoulder adduction. 2. Refer the client to occupational therapy daily. 3. Encourage the client to move the affected side. 4. Perform quadriceps exercises five times a day. 5. Instruct the client to hold the fingers in a fist

1, 2, 3, and 4 are correct. Placing a small pillow under the shoulder will prevent the shoulder from adducting toward the chest and developing a contracture. The client should be referred to occupational therapy for assistance with performing activities of daily living (ADLs). The client should not ignore the paralyzed side, and the nurse must encourage the client to move it as much as possible; a written schedule may assist the client in exercising. These exercises should be done at least five times a day for 10 minutes at a time to help strengthen the muscles used for walking.

The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? 1. An oral anticoagulant medication. 2. A beta blocker medication. 3. An anti-hyperuricemic medication. 4. A thrombolytic medication.

1. The nurse would anticipate an oral anticoagulant, warfarin (Coumadin), to be prescribed to help prevent thrombi formation in the atria secondary to atrial fibrillation. The thrombi can become embolic and may cause a TIA or CVA (stroke).

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.

1, 2, 4 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 instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. 1. Padding the side rails of the bed 2. Placing an airway at the bedside 3. Placing the bed in the high position 4. Putting a padded tongue blade at the head of the bed 5. Placing oxygen and suction equipment at the bedside 6. Flushing the intravenous catheter to ensure that the site is patent

1, 2, 5, 6 Rationale: Seizure precautions may vary from agency to agency, but they generally have some common features. Usually, an airway, oxygen, and suctioning equipment are kept available at the bedside.The side railsofthe bed are padded, and the bed iskept in the lowest position. The client has an intravenous access in place to have a readily accessible route if antiseizure medications must be administered, and as part of the routine assessment the nurse should be checking patency of the catheter. The use of padded tongue blades ishighlycontroversial, and theyshould not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure more likely will harm the client who bites down during seizure activity. Risks include blocking the airway from improper placement, chipping the client's teeth, and subsequent risk of aspirating tooth fragments. Ifthe client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begins

The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply. 1. Position the client to prevent shoulder adduction. 2. Turn and reposition the client every shift. 3. Encourage the client to move the affected side. 4. Perform quadriceps exercises three (3) times a day. 5. Instruct the client to hold the fingers in a fist

1, 3 Placing a small pillow under the shoulder will prevent the shoulder from adducting toward the chest and developing a contracture. The client should not ignore the paralyzed side, and the nurse must encourage the client to move it as much as possible; a written schedule may assist the client in exercising.

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply. 1. Loosening restrictive clothing 2. Restraining the client's limbs 3. Removing the pillow and raising padded side rails 4. Positioning the client to the side, if possible, with the head flexed forward 5. Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist

1, 3, 4 Rationale: Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising padded side rails in the bed, and placing the client on 1 side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible; protects the head from injury; and moves furniture that may injure the client.

The client has been newly diagnosed with epilepsy. Which discharge instructions should be taught to the client? Select all that apply. 1. Keep a record of seizure activity. 2. Take tub baths only; do not take showers. 3. Avoid over-the-counter medications. 4. Have anticonvulsant medication serum levels checked regularly. 5. Do not drive alone; have someone in the car.

1,3,4 Keeping a seizure and medication chart will be helpful when keeping follow-up appointments with the health-care provider and in identifying activities that may trigger a seizure. Over-the-counter medications may contain ingredients that will interact with antiseizure medications or, in some cases, as with use of stimulants, possibly cause a seizure. Most of the anticonvulsant medications have therapeutic serum levels that should be maintained, and regular checks of the serum levels help to ensure the correct level

The nurse asks the male client with epilepsy if he has auras with his seizures. The client says, "I don't know what you mean. What are auras?" Which statement by the nurse would be the best response? 1. "Some people have a warning that the seizure is about to start." 2. "Auras occur when you are physically and psychologically exhausted." 3. "You're concerned that you do not have auras before your seizures?" 4. "Auras usually cause you to be sleepy after you have a seizure."

1. An aura is a visual, an auditory, or an olfactory occurrence that takes place prior to a seizure and warns the client a seizure is about to occur. The aura often allows time for the client to lie down on the floor or find a safe place to have the seizure

The charge nurse is making client assignments for a neuro-medical floor. Which client should be assigned to the most experienced nurse? 1. The elderly client who is experiencing a stroke in evolution. 2. The client diagnosed with a transient ischemic attack 48 hours ago. 3. The client diagnosed with Guillain-Barré syndrome who complains of leg pain. 4. The client with Alzheimer's disease who is wandering in the halls

1. Because the client is having an evolving stroke, the client is experiencing a worsening of signs/symptoms over several minutes to hours; thus, the client is at risk for dying and should be cared for by the most experienced nurse.

The occupational health nurse is concerned about preventing occupation-related acquired seizures. Which intervention should the nurse implement? 1. Ensure that helmets are worn in appropriate areas. 2. Implement daily exercise programs for the staff. 3. Provide healthy foods in the cafeteria. 4. Encourage employees to wear safety glasses.

1. Head injury is one of the main reasons for epilepsy that can be prevented through occupational safety precautions and highway safety programs

The client diagnosed with a gunshot wound to the head assumes decorticate posturing when the nurse applies painful stimuli. Which assessment data obtained three (3) hours later would indicate the client is improving? 1. Purposeless movement in response to painful stimuli. 2. Flaccid paralysis in all four extremities. 3. Decerebrate posturing when painful stimuli are applied. 4. Pupils that are 6 mm in size and nonreactive on painful stimuli.

1. Purposeless movement indicates that the client's cerebral edema is decreasing. The best motor response is purposeful movement, but purposeless movement indicates an improvement over decorticate movement, which, in turn, is an improvement over decerebrate movement or flaccidity

A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement? 1. Administer a stool softener bid. 2. Encourage the client to cough hourly. 3. Monitor neurological status every shift. 4. Maintain the dopamine drip to keep BP at 160/90

1. The client is at risk for increased intracranial pressure whenever performing the Valsalva maneuver, which will occur when straining during defecation. Therefore, stool softeners would be appropriate.

The client is diagnosed with a closed head injury and is in a coma. The nurse writes the client problem as "high risk for immobility complications." Which intervention would be included in the plan of care? 1. Position the client with the head of the bed elevated at intervals. 2. Perform active range-of-motion (ROM) exercises every four (4) hours. 3. Turn the client every shift and massage bony prominences. 4. Explain all procedures to the client before performing them.

1. The head of the client's bed should be elevated to help the lungs expand and prevent stasis of secretions that could lead to pneumonia, a complication of immobility

The critical care charge nurse is making client assignments for the shift. Which client should the charge nurse assign to the graduate nurse who just completed the orientation? 1. The client with amyotrophic lateral sclerosis on a ventilator who is dying and whose family is at the bedside. 2. The client who has a closed head injury and has increasing intracranial pressure receiving intravenous osmitrol (Mannitol). 3. The client with a C-5 spinal cord injury who is experiencing spinal shock and is on the vasoconstrictor dopamine. 4. The client with a seizure disorder who has been experiencing status epilepticus for the past 24 hours.

1. The less experienced nurse could care for the client on a ventilator and console the family as needed. This client is not in a life-threatening situation and is stable for the condition.

48. In planning care for the client who has had a stroke, the nurse should obtain a history of the client's functional status before the stroke because? ■ 1. The rehabilitation plan will be guided by it. ■ 2. Functional status before the stroke will help predict outcomes. ■ 3. It will help the client recognize his physical limitations. ■ 4. The client can be expected to regain much of his functioning.

1. The primary reason for the nursing assessment of a client's functional status before and after a stroke is to guide the plan. The assessment does not help to predict how far the rehabilitation team can help the client to recover from the residual effects of the stroke, only what plans can help a client who has moved from one functional level to another. The nursing assessment of the client's functional status is not a motivating factor.

The client diagnosed with a cerebrovascular accident (CVA) has residual right-sided hemiparesis and difficulty swallowing, but is scheduled for discharge. Which referral is most appropriate for the case manager to make at this time? 1. Inpatient rehabilitation unit. 2. Home healthcare agency. 3. Long-term care facility. 4. Outpatient therapy center

1. This client should be referred to an inpatient rehabilitation facility for intensive therapy before deciding on long-term placement (home with home healthcare or a long-term care facility). The initial rehabilitation a client receives can set the tone for all further recuperation. This is the appropriate referral at this time.

The client is prescribed phenytoin (Dilantin), an anticonvulsant, for a seizure disorder. Which statement indicates the client understands the discharge teaching concerning this medication? 1. "I will brush my teeth after every meal." 2. "I will check my Dilantin level daily." 3. "My urine will turn orange while on Dilantin." 4. "I won't have any seizures while on this medication."

1. Thorough oral hygiene after each meal, gum massage, daily flossing, and regular dental care are essential to prevent or control gingival hyperplasia, which is a common occurrence in clients taking Dilantin.

The 29-year-old client who was employed as a forklift operator sustains a traumatic brain injury (TBI) secondary to a motor-vehicle accident. The client is being discharged from the rehabilitation unit after three (3) months and has cognitive deficits. Which goal would be most realistic for this client? 1. The client will return to work within six (6) months. 2. The client is able to focus and stay on task for 10 minutes. 3. The client will be able to dress self without assistance. 4. The client will regain bowel and bladder control

2. "Cognitive" pertains to mental processes of comprehension, judgment, memory, and reasoning. Therefore, an appropriate goal would be for the client to stay on task for 10 minutes

The client diagnosed with atrial fibrillation complains of numbness and tingling of her left arm and leg. The nurse assesses facial drooping on the left side and slight slurring of speech. Which nursing interventions should the nurse implement first? 1. Schedule a STAT Magnetic Resonance Imaging of the brain. 2. Call a Code STROKE. 3. Notify the health-care provider (HCP). 4. Have the client swallow a glass of water

2. A Code STROKE (for an RRT related to a stroke) has been instituted in most facilities to have personnel to respond so that there is no delay in initiating interventions, thus reducing the impact of a cerebrovascular accident (stroke) on a client

The client diagnosed with a closed head injury is admitted to the rehabilitation department. Which medication order would the nurse question? 1. A subcutaneous anticoagulant. 2. An intravenous osmotic diuretic. 3. An oral anticonvulsant. 4. An oral proton pump inhibitor.

2. An osmotic diuretic would be ordered in the acute phase to help decrease cerebral edema, but this medication would not be expected to be ordered in a rehabilitation unit

The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care? 1. Potential for injury. 2. Powerlessness. 3. Disturbed thought processes. 4. Sexual dysfunction

2. Expressive aphasia means that the client cannot communicate thoughts but understands what is being communicated; this leads to frustration, anger, depression, and the inability to verbalize needs, which, in turn, causes the client to have a lack of control and feel powerless

The critical care nurse is caring for a client with a head injury secondary to a motorcycle accident who, on morning rounds, is responsive to painful stimuli and assumes decorticate posturing. Two hours later, which data would warrant immediate intervention by the nurse? 1. The client has purposeful movement when the nurse rubs the sternum. 2. The client extends the upper and lower extremities in response to painful stimuli. 3. The client is aimlessly thrashing in the bed when a noxious stimulus is applied. 4. The client is able to squeeze the nurse's hand on a verbal request.

2. Extension of the upper and lower extremities is assuming a decerebrate posture, which indicates the client's intracranial pressure (ICP) is increasing. This would warrant immediate intervention by the nurse.

The nurse enters the room, and the client is beginning to have a tonic-clonic seizure. Which action should the nurse implement first? 1. Identify the first area that began seizing. 2. Note the time the client's seizure began. 3. Pad the siding of the client's bed rails. 4. Provide the client with privacy during the seizure.

2. The nurse should first look at his or her watch and time the seizure. Assessment is the first intervention because there is no action the nurse can impalement to stop or intervene with the seizure

The nurse and LPN are caring for a client diagnosed with a stroke. Which intervention should the nurse assign to the LPN? 1. Feed the client who is being allowed to eat for the first time. 2. Administer the client's anticoagulant subcutaneously. 3. Check the client's neurological signs and limb movement. 4. Teach the client to turn the head and tuck the chin to swallow

2. The LPN could administer routine parenteral medications. This is the best task to assign to the LPN.

A client sustained a severe head injury, and his wife is concerned about what to do if he has a seizure when they go home. Which statement indicates the wife understands the most important action to take if her husband has a seizure? 1. "I should check to see if my husband urinates on himself." 2. "I will move all the furniture out of his way." 3. "I will call 911 as soon as the seizure begins." 4. "I will make sure he rests after the seizure is over."

2. The most important action the wife can take if her husband has a seizure is to make sure he does not get injured during the seizure. Moving all the furniture out of the way will help ensure the client's safety.

The unlicensed assistive personnel (UAP) is attempting to put an oral airway in the mouth of a client having a tonic-clonic seizure. Which action should the primary nurse take? 1. Help the UAP to insert the oral airway in the mouth. 2. Tell the UAP to stop trying to insert anything in the mouth. 3. Take no action because the UAP is handling the situation. 4. Notify the charge nurse of the situation immediately

2. The nurse should tell the UAP to stop trying to insert anything in the mouth of the client experiencing a seizure. Broken teeth and injury to the lips and tongue may result from trying to place anything in the clenched jaws of a client having a tonic-clonic seizure.

The resident in a long-term care facility fell during the previous shift and has a laceration in the occipital area that has been closed with steristrips. Which signs/symptoms would warrant transferring the resident to the emergency department? 1. A 4-cm area of bright red drainage on the dressing. 2. A weak pulse, shallow respirations, and cool pale skin. 3. Pupils that are equal, react to light, and accommodate. 4. Complaints of a headache that resolves with medication.

2. These signs/symptoms—weak pulse, shallow respirations, cool pale skin—indicate increased intracranial pressure from cerebral edema secondary to the fall, and they require immediate attention.

The intensive care unit nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis secondary to a cerebrovascular accident. Which action by the UAP requires the nurse to intervene? 1. The UAP performs passive range-of-motion (ROM) exercises for the client. 2. The UAP places the client on the abdomen with the head to the side. 3. The UAP uses a lift sheet when moving the client up in bed. 4. The UAP praises the client for attempting to feed him- or herself

2. This is not an appropriate intervention because the client is at risk for increased intracranial pressure (ICP); therefore, the client should not be placed on the stomach. The prone position helps promote hyperextension of the hip joints, which is essential for normal gait and helps prevent knee and hip flexion contractures, and done in rehabilitation.

The nurse educator is presenting an in-service on seizures. Which disease process is the leading cause of seizures in the elderly? 1. Alzheimer's disease. 2. Parkinson's disease (PD). 3. Cerebral Vascular Accident (CVA, stroke). 4. Brain atrophy due to aging

3. A CVA (stroke) is the leading cause of seizures in the elderly; increased intracranial pressure associated with the stroke can lead to seizures

The client is admitted to the intensive care unit (ICU) experiencing status epilepticus. Which collaborative intervention should the nurse anticipate? 1. Assess the client's neurological status every hour. 2. Monitor the client's heart rhythm via telemetry. 3. Administer an anticonvulsant medication by intravenous push. 4. Prepare to administer a glucocorticosteroid orally

3. Administering an anticonvulsant medication by intravenous push requires the nurse to have an order or confer with another member of the health-care team

The client diagnosed with a cerebrovascular accident (CVA) is confined to a wheelchair for most of the waking hours. Which intervention is priority for the nurse to implement? 1. Encourage the client to move the buttocks every 2 hours. 2. Order a high-protein diet to prevent skin breakdown. 3. Get a pressure-relieving cushion to place in the wheelchair. 4. Refer the client to physical therapy for transfer teaching.

3. All clients remaining in a wheelchair for extended periods of time should have a wheelchair cushion that relieves pressure to prevent skin breakdown.

The client who just had a three (3)-minute seizure has no apparent injuries and is oriented to name, place, and time but is very lethargic and just wants to sleep. Which intervention should the nurse implement? 1. Perform a complete neurological assessment. 2. Awaken the client every 30 minutes. 3. Turn the client to the side and allow the client to sleep. 4. Interview the client to find out what caused the seizure

3. During the postictal (after-seizure) phase, the client is very tired and should be allowed to rest quietly; placing the client on the side will help prevent aspiration and maintain a patent airway

The nurse is caring for a client with increased intracranial pressure (ICP) who has secretions pooled in the throat. Which intervention should the nurse implement first? 1. Set the ventilator to hyperventilate the client in preparation for suctioning. 2. Assess the client's lung sounds and check for peripheral cyanosis. 3. Turn the client to the side to allow the secretions to drain from the mouth. 4. Suction the client using the in-line suction, wait 30 seconds, and repeat

3. Secretions can drain if the client is turned to the side unless the secretions are too heavy. The first action is to attempt to relieve the situation without increasing the ICP even further

Which statement by the female client indicates that the client understands factors that may precipitate seizure activity? 1. "It is all right for me to drink coffee for breakfast." 2. "My menstrual cycle will not affect my seizure disorder." 3. "I am going to take a class in stress management." 4. "I should wear dark glasses when I am out in the sun."

3. Tension states, such as anxiety and frustration, induce seizures in some clients, so stress management may be helpful in preventing seizures.

The nurse is caring for several clients. Which client would the nurse assess first after receiving the shift report? 1. The 22-year-old male client diagnosed with a concussion who is complaining someone is waking him up every two (2) hours. 2. The 36-year-old female client admitted with complaints of left-sided weakness who is scheduled for a magnetic resonance imaging (MRI) scan. 3. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale (GCS) score of 6. 4. The 62-year-old client diagnosed with a cerebrovascular accident (CVA) who has expressive aphasia

3. The Glasgow Coma Scale is used to determine a client's response to stimuli (eyeopening response, best verbal response, and best motor response) secondary to a neurological problem; scores range from 3 (deep coma) to 15 (intact neurological function). A client with a score of 6 should be assessed first by the nurse

The client is scheduled for an electroencephalogram (EEG) to help diagnose a seizure disorder. Which preprocedure teaching should the nurse implement? 1. Tell the client to take any routine antiseizure medication prior to the EEG. 2. Tell the client not to eat anything for eight (8) hours prior to the procedure. 3. Instruct the client to stay awake for 24 hours prior to the EEG. 4. Explain to the client that there will be some discomfort during the procedure.

3. The goal is for the client to have a seizure during the EEG. Sleep deprivation, hyperventilating, or flashing lights may induce a seizure.

The client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first? 1. Notify the health-care provider immediately. 2. Prepare to administer an antihistamine. 3. Test the drainage for presence of glucose. 4. Place a 2 × 2 gauze under the nose to collect drainage.

3. The presence of glucose in drainage from the nose or ears indicates cerebrospinal fluid, and the HCP should be notified immediately once this is determined

The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? 1. The assistant places a gait belt around the client's waist prior to ambulating. 2. The assistant places the client on the back with the client's head to the side. 3. The assistant places a hand under the client's right axilla to move up in bed. 4. The assistant praises the client for attempting to perform ADLs independently.

3. This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; the client should be pulled up by placing the arm underneath the back or using a lift sheet.

The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? 1. The UAP places the gait belt around the client's waist prior to ambulating. 2. The UAP places the client on the abdomen with the client's head to the side. 3. The UAP places her hand under the client's right axilla to help the client move up in bed. 4. The UAP praises the client for performing activities of daily living independently

3. This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; the client should be pulled up by placing the arm underneath the client's back or using a lift sheet.

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

4 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 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 eyeglasses." 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.

4 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 has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? 1. Fluid is clear and tests negative for glucose. 2. Fluid is grossly bloody in appearance and has a pH of 6. 3. Fluid clumps together on the dressing and has a pH of 7. 4. Fluid separates into concentric rings and tests positive for glucose.

4 Rationale: Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.

32. Which intervention is most effective in minimizing the risk of seizure activity in a client who is undergoing diagnostic studies after having experienced several episodes of seizures? ■ 1. Maintain the client on bed rest. ■ 2. Administer butobarbital sodium (phenobarbital) 30 mg P.O., three times per day. ■ 3. Close the door to the room to minimize stimulation. ■ 4. Administer carbamazepine (Tegretol) 200 mg P.O., twice per day.

4. Carbamazepine (Tegretol) is an anticonvulsant that helps prevent further seizures. Bed rest, sedation (phenobarbital), and providing privacy do not minimize the risk of seizures.

The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative intervention will be included in the plan of care? 1. Observe the client swallowing for possible aspiration. 2. Position the client in a semi-Fowler's position when sleeping. 3. Place a suction setup at the client's bedside during meals. 4. Refer the client to an occupational therapist for evaluation.

4. A collaborative intervention is an intervention in which another health-care discipline—in this case, occupational therapy—is used in the care of the client.

The male client is sitting in the chair and his entire body is rigid with his arms and legs contracting and relaxing. The client is not aware of what is going on and is making guttural sounds. Which action should the nurse implement first? 1. Push aside any furniture. 2. Place the client on his side. 3. Assess the client's vital signs. 4. Ease the client to the floor.

4. The client should not remain in the chair during a seizure. He should be brought safely to the floor so that he will have room to move the extremities.

The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first? 1. Administer a nonnarcotic analgesic. 2. Prepare for STAT magnetic resonance imaging (MRI). 3. Start an intravenous infusion with D5W at 100 mL/hr. 4. Complete a neurological assessment

4. The nurse must complete a neurological assessment to help determine the cause of the headache before taking any further action

The nurse is enjoying a day at the lake and witnesses a water skier hit the boat ramp. The water skier is in the water not responding to verbal stimuli. The nurse is the first health-care provider to respond to the accident. Which intervention should be implemented first? 1. Assess the client's level of consciousness. 2. Organize onlookers to remove the client from the lake. 3. Perform a head-to-toe assessment to determine injuries. 4. Stabilize the client's cervical spine.

4. The nurse should always assume that a client with traumatic head injury may have sustained spinal cord injury. Moving the client could further injure the spinal cord and cause paralysis; therefore, the nurse should stabilize the cervical spinal cord as best as possible prior to removing the client from the water.

The nurse has created a plan of care for a patient who is at risk for increased ICP. The patients care plan should specify monitoring for what early sign of increased ICP? A) Disorientation and restlessness B) Decreased pulse and respirations C) Projectile vomiting D) Loss of corneal reflex

A Early indicators of ICP include disorientation and restlessness. Later signs include decreased pulse andrespirations, projectile vomiting, and loss of brain stem reflexes, such as the corneal reflex

A patient is postoperative day 1 following intracranial surgery. The nurses assessment reveals that the patients LOC is slightly decreased compared with the day of surgery. What is the nurses best response to this assessment finding? A) Recognize that this may represent the peak of post-surgical cerebral edema. B) Alert the surgeon to the possibility of an intracranial hemorrhage. C) Understand that the surgery may have been unsuccessful. D) Recognize the need to refer the patient to the palliative care team.

A Some degree of cerebral edema occurs after brain surgery; it tends to peak 24 to 36 hours after surgery,producing decreased responsiveness on the second postoperative day. As such, there is not necessarilyany need to deem the surgery unsuccessful or to refer the patient to palliative care. A decrease in LOC isnot evidence of an intracranial hemorrhage

When caring for a patient with increased ICP the nurse knows the importance of monitoring for possiblesecondary complications, including syndrome of inappropriate antidiuretic hormone (SIADH). What nursing interventions would the nurse most likely initiate if the patient developed SIADH? A) Fluid restriction B) Transfusion of platelets C) Transfusion of fresh frozen plasma (FFP) D) Electrolyte restriction

A The nurse also assesses for complications of increased ICP, including diabetes insipidus, and SIADH.SIADH requires fluid restriction and monitoring of serum electrolyte levels. Transfusions areunnecessary

A hospital patient has experienced a seizure. In the immediate recovery period, what action best protects the patients safety? A) Place the patient in a side-lying position. B) Pad the patients bed rails. C) Administer antianxiety medications as ordered. D) Reassure the patient and family members.

A To prevent complications, the patient is placed in the side-lying position to facilitate drainage of oral secretions. Suctioning is performed, if needed, to maintain a patent airway and prevent aspiration. None of the other listed actions promotes safety during the immediate recovery period

A patient with lower back pain is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should prioritize what action? A) Positioning the patient with the head of the bed elevated 45 degrees B) Administering IV morphine sulfate to prevent headache C) Limiting fluids for the next 12 hours D) Helping the patient perform deep breathing and coughing exercises

A. After myelography, the patient lies in bed with the head of the bed elevated 30 to 45 degrees. The patient is advised to remain in bed in the recommended position for 3 hours or as prescribed. Drinking liberal amounts of fluid for rehydration and replacement of CSF may decrease the incidence of post lumbar puncture headache. Deep breathing and coughing exercises are not normally necessary since there is no consequent risk of atelectasis

The patient in the ED has just had a diagnostic lumbar puncture. To reduce the incidence of a post-lumbar puncture headache, what is the nurses most appropriate action? A) Position the patient prone. B) Position the patient supine with the head of bed flat. C) Position the patient left side-lying. D) Administer acetaminophen as ordered.

A. The lumbar puncture headache may be avoided if a small-gauge needle is used and if the patient remains prone after the procedure. Acetaminophen is not administered as a preventative measure for post-lumbarpuncture headaches

1. What is the priority nursing diagnosis for a client experiencing a migraine headache? 1. Acute Pain related to biologic and chemical factors 2. Anxiety related to change in or threat to health status 3. Hopelessness related to deteriorating physiologic condition 4. Risk for Injury related to side effects of medical therapy

Ans: 1 The priority for interdisciplinary care for the client experiencing a migraine headache is pain management. All of the other nursing diagnoses are accurate, but none of them is urgent like the issue of pain, which is often incapacitating.

28. After you receive the change-of-shift report at 7:00 am, which client will you assess first? 1. 23-year-old with a migraine headache who reports severe nausea associated with retching 2. 45-year-old who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching 3. 59-year-old with Parkinson disease who will need a swallowing assessment before breakfast 4. 63-year-old with MS who has an oral temperature of 101.8° F (38.8° C) and flank pain

Ans: 4 Urinary tract infections (UTIs) are a frequent complication in clients with MS because of the effect of the disease on bladder function, and UTIs may lead to sepsis in these clients. The elevated temperature and flank pain suggest that this client may have pyelonephritis. The physician should be notified immediately so that IV antibiotic therapy can be started quickly. The other clients should be assessed as soon as possible, but their needs are not as urgent as those of this client.

A patient has been admitted to the ICU after being recently diagnosed with an aneurysm and the patients admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate into the patients plan of care? A) Elevate the head of the bed to 45 degrees. B) Maintain the patient on complete bed rest. C) Administer enemas when the patient is constipated. D) Avoid use of thigh-high elastic compression stockings.

B Cerebral aneurysm precautions are implemented for the patient with a diagnosis of aneurysm to provide a nonstimulating environment, prevent increases in ICP, and prevent further bleeding. The patient is placed on immediate and absolute bed rest in a quiet, nonstressful environment because activity, pain, and anxiety elevate BP, which increases the risk for bleeding. Visitors, except for family, are restricted. The head of the bed is elevated 15 to 30 degrees to promote venous drainage and decrease ICP. Some neurologists, however, prefer that the patient remains flat to increase cerebral perfusion. No enemas are permitted, but stool softeners and mild laxatives are prescribed. Thigh-high elastic compression stockings or sequential compression boots may be ordered to decrease the patients risk for deep vein thrombosis (DVT

A trauma patient in the ICU has been declared brain dead. What diagnostic test is used in making thedetermination of brain death? A) Magnetic resonance imaging (MRI) B) Electroencephalography (EEG) C) Electromyelography (EMG) D) Computed tomography (CT)

B The EEG can be used in determining brain death. MRI, CT, and EMG are not normally used indetermining brain death

The nurse is performing stroke risk screenings at a hospital open house. The nurse has identified four patients who might be at risk for a stroke. Which patient is likely at the highest risk for a hemorrhagic stroke A) White female, age 60, with history of excessive alcohol intake B) White male, age 60, with history of uncontrolled hypertension C) Black male, age 60, with history of diabetes D) Black male, age 50, with history of smoking

B Uncontrolled hypertension is the primary cause of a hemorrhagic stroke. Control of hypertension,especially in individuals over 55 years of age, clearly reduces the risk for hemorrhagic stroke. Additionalrisk factors are increased age, male gender, and excessive alcohol intake. Another high-risk groupincludes African Americans, where the incidence of first stroke is almost twice that as in Caucasians.

As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential forbenefit and for harm. The nurse should be cognizant of what contraindications for thrombolytic therapy?Select all that apply. A) INR above 1.0 B) Recent intracranial pathology C) Sudden symptom onset D) Current anticoagulation therapy E) Symptom onset greater than 3 hours prior to admission

B, D, E Some of the absolute contraindications for thrombolytic therapy include symptom onset greater than 3hours before admission, a patient who is anticoagulated (with an INR above 1.7), or a patient who hasrecently had any type of intracranial pathology (e.g., previous stroke, head injury, trauma

A patient has had an ischemic stroke and has been admitted to the medical unit. What action should thenurse perform to best prevent joint deformities? A) Place the patient in the prone position for 30 minutes/day. B) Assist the patient in acutely flexing the thigh to promote movement. C) Place a pillow in the axilla when there is limited external rotation. D) Place patients hand in pronation.

C A pillow in the axilla prevents adduction of the affected shoulder and keeps the arm away from thec hest. The prone position with a pillow under the pelvis, not flat, promotes hyperextension of the hip joints, essential for normal gait. To promote venous return and prevent edema, the upper thigh shouldnot be flexed acutely. The hand is placed in slight supination, not pronation, which is its most functional position.

Following a traumatic brain injury, a patient has been in a coma for several days. Which of the following statements is true of this patients current LOC? A) The patient occasionally makes incomprehensible sounds. B) The patients current LOC will likely become a permanent state. C) The patient may occasionally make nonpurposeful movements. D) The patient is incapable of spontaneous respirations.

C Coma is a clinical state of unarousable unresponsiveness in which no purposeful responses to internal orexternal stimuli occur, although nonpurposeful responses to painful stimuli and brain stem reflexes maybe present. Verbal sounds, however, are atypical. Ventilator support may or may not be necessary.Comas are not permanent stat

A patient with increased ICP has a ventriculostomy for monitoring ICP. The nurses most recentassessment reveals that the patient is now exhibiting nuchal rigidity and photophobia. The nurse wouldbe correct in suspecting the presence of what complication? A) Encephalitis B) CSF leak C) Meningitis D) Catheter occlusion

C Complications of a ventriculostomy include ventricular infectious meningitis and problems with themonitoring system. Nuchal rigidity and photophobia are clinical manifestations of meningitis, but arenot suggestive of encephalitis, a CSF leak, or an occluded catheter

A patient has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize? A) Unclassified seizure B) Absence seizure C) Generalized seizure D) Focal seizure

C Generalized seizures often involve both hemispheres of the brain, causing both sides of the body toreact. Intense rigidity of the entire body may occur, followed by alternating muscle relaxation andcontraction (generalized tonicclonic contraction). This pattern of rigidity does not occur in patients whoexperience unclassified, absence, or focal seizures.

A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the patients plan of care? A) Monitoring of pulse oximetry B) Administration of a low-protein diet C) Administration of thorough oral hygiene D) Fluid restriction as ordered

C Gingival hyperplasia (swollen and tender gums) can be associated with long-term phenytoin (Dilantin)use. Thorough oral hygiene should be provided consistently and encouraged after discharge. Fluid and protein restriction are contraindicated and there is no particular need for constant oxygen saturation monitoring

The nurse is caring for a patient diagnosed with an ischemic stroke and knows that effective positioning of the patient is important. Which of the following should be integrated into the patients plan of care? A) The patients hip joint should be maintained in a flexed position. B) The patient should be in a supine position unless ambulating. C) The patient should be placed in a prone position for 15 to 30 minutes several times a day. D) The patient should be placed in a Trendelenberg position two to three times daily to promote cerebral perfusion.

C If possible, the patient is placed in a prone position for 15 to 30 minutes several times a day. A small pillow or a support is placed under the pelvis, extending from the level of the umbilicus to the upper third of the thigh. This helps to promote hyperextension of the hip joints, which is essential for normal gait, and helps prevent knee and hip flexion contractures. The hip joints should not be maintained inflexion and the Trendelenberg position is not indicated

A patient is scheduled for CT scanning of the head because of a recent onset of neurologic deficits. Whatshould the nurse tell the patient in preparation for this test? A) No metal objects can enter the procedure room. B) You need to fast for 8 hours prior to the test. C) You will need to lie still throughout the procedure. D) There will be a lot of noise during the test.

C Preparation for CT scanning includes teaching the patient about the need to lie quietly throughout theprocedure. If the patient were having an MRI, metal and noise would be appropriate teaching topics.There is no need to fast prior to a CT scan of the brain.

The nurse is caring for a patient in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the patients mean arterial pressure (MAP) is 60mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurses most appropriate action? A) Position the patient in the high Fowlers position as tolerated. B) Administer osmotic diuretics as ordered. C) Participate in interventions to increase cerebral perfusion pressure. D) Prepare the patient for craniotomy.

C The cerebral perfusion pressure (CPP) is 55 mm Hg, which is considered low. The normal CPP is 70 to100 mm Hg. Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage. Asa result, interventions are necessary. A craniotomy is not directly indicated. Diuretics and increasedheight of bed would exacerbate the patients condition

A patient diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose? A) To decrease cerebral edema B) To prevent seizure activity that is common following a TIA C) To remove atherosclerotic plaques blocking cerebral flow D) To determine the cause of the TIA

C The main surgical procedure for select patients with TIAs is carotid endarterectomy, the removal of anatherosclerotic plaque or thrombus from the carotid artery to prevent stroke inpatients with occlusive disease of the extracranial arteries. An endarterectomy does not decrease cerebraledema, prevent seizure activity, or determine the cause of a TIA

The nurse is preparing health education for a patient who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education? A) Mild, intermittent seizures can be expected. B) Take ibuprofen for complaints of a serious headache. C) Take antihypertensive medication as ordered. D) Drowsiness is normal for the first week after discharge.

C The patient and family are provided with information that will enable them to cooperate with the careand restrictions required during the acute phase of hemorrhagic stroke and to prepare the patient toreturn home. Patient and family teaching includes information about the causes of hemorrhagic strokeand its possible consequences. Symptoms of hydrocephalus include gradual onset of drowsiness andbehavioral changes. Hypertension is the most serious risk factor, suggesting that appropriateantihypertensive treatment is essential for a patient being discharged. Seizure activity is not normal;complaints of a serious headache should be reported to the physician before any medication is taken.Drowsiness is not normal or expected.

A nurse is admitting a patient with a severe migraine headache and a history of acute coronarysyndrome. What migraine medication would the nurse question for this patient? A) Rizatriptan (Maxalt) B) Naratriptan (Amerge) C) Sumatriptan succinate (Imitrex) D) Zolmitriptan (Zomig)

C Triptans can cause chest pain and are contraindicated in patients with ischemic heart disease. Maxalt,Amerge, and Zomig are triptans used in routine clinical use for the treatment of migraine headaches

A nurse is collaborating with the interdisciplinary team to help manage a patients recurrent headaches. What aspect of the patients health history should the nurse identify as a potential contributor to the patients headaches? A) The patient leads a sedentary lifestyle. B) The patient takes vitamin D and calcium supplements. C) The patient takes vasodilators for the treatment of angina. D) The patient has a pattern of weight loss followed by weight gain.

C Vasodilators are known to contribute to headaches. Weight fluctuations, sedentary lifestyle, and vitamin supplements are not known to have this effec

The nurse is caring for a patient who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to prevent seizures in this patient? A) Prednisone B) Dexamethasone C) Cafergot D) Phenytoin

D Antiseizure medication (phenytoin, diazepam) is often prescribed prophylactically for patients who haveundergone supratentorial craniotomy because of the high risk of seizures after this procedure. Prednisoneand dexamethasone are steroids and do not prevent seizures. Cafergot is used in the treatment ofmigraine

What should be included in the patients care plan when establishing an exercise program for a patient affected by a stroke? A) Schedule passive range of motion every other day. B) Keep activity limited, as the patient may be over stimulated. C) Have the patient perform active range-of-motion (ROM) exercises once a day. D) Exercise the affected extremities passively four or five times a day.

D The affected extremities are exercised passively and put through a full ROM four or five times a day tomaintain joint mobility, regain motor control, prevent development of a contracture in the paralyzedextremity, prevent further deterioration of the neuromuscular system, and enhance circulation. ActiveROM exercises should ideally be performed more than once per day.

A patient with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure(ICP). What nursing intervention would be most appropriate for this patient? A) Range-of-motion exercises to prevent contractures B) Encouraging independence with ADLs to promote recovery C) Early initiation of physical therapy D) Absolute bed rest in a quiet, nonstimulating environment

D The patient is placed on immediate and absolute bed rest in a quiet, nonstressful environment becauseactivity, pain, and anxiety elevate BP, which increases the risk for bleeding. Visitors are restricted. Thenurse administers all personal care. The patient is fed and bathed to prevent any exertion that might raiseBP

After a subarachnoid hemorrhage, the patients laboratory results indicate a serum sodium level of less than 126 mEq/L. What is the nurses most appropriate action? A) Administer a bolus of normal saline as ordered. B) Prepare the patient for thrombolytic therapy as ordered. C) Facilitate testing for hypothalamic dysfunction. D) Prepare to administer 3% NaCl by IV as ordered.

D The patient may be experiencing syndrome of inappropriate antidiuretic hormone (SIADH) or cerebralsalt-wasting syndrome. The treatment most often is the use of IV hypertonic 3% saline. A normal salinebolus would exacerbate the problem and there is no indication for tests of hypothalamic function orthrombolytic therapy.

A patient recovering from a stroke has severe shoulder pain from subluxation of the shoulder and is being cared for on the unit. To prevent further injury and pain, the nurse caring for this patient is aware of what principle of care? A) The patient should be fitted with a cast because use of a sling should be avoided due to adduction of the affected shoulder. B) Elevation of the arm and hand can lead to further complications associated with edema. C) Passively exercising the affected extremity is avoided in order to minimize pain. D) The patient should be taught to interlace fingers, place palms together, and slowly bring scapulaeforward to avoid excessive force to shoulder.

D To prevent shoulder pain, the nurse should never lift a patient by the flaccid shoulder or pull on the affected arm or shoulder. The patient is taught how to move and exercise the affected arm/shoulder through proper movement and positioning. The patient is instructed to interlace the fingers, place the palms together, and push the clasped hands slowly forward to bring the scapulae forward; he or she then raises both hands above the head. This is repeated throughout the day. The use of a properly worn sling when the patient is out of bed prevents the paralyzed upper extremity from dangling without support. Range-of-motion exercises are still vitally important in preventing a frozen shoulder and ultimately atrophy of subcutaneous tissues, which can cause more pain. Elevation of the arm and hand is also important in preventing dependent edema of the hand