NURS 221 Nclex and Book Questions

18. 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 1. The client in rehabilitation is at risk for the development of deep vein thrombosis; therefore, this is an appropriate medication. 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. 3. Clients with head injuries are at risk for post-traumatic seizures; thus an oral anticonvulsant would be administered for seizure prophylaxis. 4. The client is at risk for a stress ulcer; therefore, an oral proton pump inhibitor would be an appropriate medication. TEST-TAKING HINT: The client is in the rehabilitation unit and therefore must be stable. The use of any intravenous medication should be questioned under those circumstances, even if the test taker is not sure why the medication may be considered.

24. The 29-year-old client who was employed as a forklift operator sustains a traumatic brain injury 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 1. The client is at risk for seizures and does not process information appropriately. Allowing him to return to his occupation as a forklift operator is a safety risk for him and other employees. Vocational training may be required. 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. 3. The client's ability to dress self addresses self-care problems, not a cognitive problem. 4. The client's ability to regain bowel and bladder control does not address cognitive deficits. TEST-TAKING HINT: The test taker must note adjectives closely. The question is asking about "cognitive" deficits; therefore, the correct answer must address cognition.

16. The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is "brain dead." Which data support that the client is brain dead? 1. When the client's head is turned to the right, the eyes turn to the right. 2. The electroencephalogram (EEG) has identifiable waveforms. 3. There is no eye activity when the cold caloric test is performed. 4. The client assumes decorticate posturing when painful stimuli are applied.

#3 1. This is an oculocephalic test (doll's eye movement) that determines brain activity. If the eyes move with the head, it means the brainstem is intact and there is no brain death. 2. Waveforms on the EEG indicate that there is brain activity. 3. The cold caloric test, also called the oculovestibular test, is a test used to determine if the brain is intact or dead. No eye activity indicates brain death. If the client's eyes moved, that would indicate that the brainstem is intact. 4. Decorticate posturing after painful stimuli are applied indicates that the brainstem is intact; flaccid paralysis is the worse neuro- logical response when assessing a client with a head injury. TEST-TAKING HINT: The test taker needs to know what the results of the cold caloric test signify—in this case, no eye activity indicates brain death.

8. A client with a spinal cord injury (SCI) reports sudden severe throbbing headache that started a short time ago. Assessment of the client reveals increased blood pressure (168/94 mm Hg) and decreased heart rate (48 beats/min), diaphoresis, and flushing of the face and neck. What action should you take first? 1. Administer the ordered acetaminophen (Tylenol). 2. Check the Foley tubing for kinks or obstruction. 3. Adjust the temperature in the client's room. 4. Notify the physician about the change in status.

2

20. 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 that pulse oximeter reading is higher than 93%. 4. Perform deep nasal suction every two (2) hours. 5. Administer mild sedatives.

2,3,5 1. The head of the bed should be elevated no more than 30 degrees to help decrease cerebral edema by gravity. 2. Stool softeners are initiated to prevent the Valsalva maneuver, which increases intracranial pressure. 3. Oxygen saturation higher than 93% ensures oxygenation of the brain tissues; decreasing oxygen levels increase cerebral edema. 4. Noxious stimuli, such as suctioning, increase intracranial pressure and should be avoided. 5. Mild sedatives will reduce the client's agitation; strong narcotics would not be administered because they decrease the client's level of consciousness. TEST-TAKING HINT: In "select all that apply" questions, the test taker should look at each answer option as a separate entity. In option "1" the test taker should attempt to get a mental picture of the client's position in the bed. A 60-degree angle is almost upright in the bed. Would any client diagnosed with a head injury be placed this high? The client would be at risk for slumping over because of the inability to control the body position. Nasal suctioning, option "4," which increases intracranial pressure, should also be avoided.

15. The nurse is caring for the following 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 score of 6. 4. The 62-year-old client diagnosed with a cerebrovascular accident (CVA) who has expressive aphasia

3 1. A client with a head injury must be awakened every two (2) hours to determine alertness; decreasing level of consciousness is the first indicator of increased intracranial pressure. 2. A diagnostic test, MRI, would be an expected test for a client with left-sided weakness and would not require immediate attention. 3. The Glasgow Coma Scale is used to determine a client's response to stimuli (eye-opening 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. 4. The nurse would expect a client diagnosed with a CVA (stroke) to have some sequelae of the problem, including the inability to speak. TEST-TAKING HINT: This is a prioritizing question that asks the test taker to determine which client has priority when assessing all four clients. The nurse should assess the client who has abnormal data for the disease process.

21. 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 2 × 2 gauze under the nose to collect drainage.

3 1. Prior to notifying the HCP, the nurse should always make sure that all the needed assessment information is available to discuss with the HCP. 2. With head injuries, any clear drainage may indicate a cerebrospinal fluid leak; the nurse should not assume the drainage is secondary to allergies and administer an antihistamine. 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. 4. This would be appropriate, but it is not the first intervention. The nurse must determine where the fluid is coming from. TEST-TAKING HINT: The question is asking which intervention should be implemented first, and the nurse should always assess the situation before calling the HCP or taking an action.

17. The client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority? 1. Assess neurological status. 2. Monitor pulse, respiration, and blood pressure. 3. Initiate an intravenous access. 4. Maintain an adequate airway.

4 1. Assessing the neurological status is important, but ensuring an airway is priority over assessment. 2. Monitoring vital signs is important, but maintaining an adequate airway is higher priority. 3. Initiating an IV access is an intervention the nurse can implement, but it is not the priority intervention. 4. The most important nursing goal in the management of a client with a head injury is to establish and maintain an adequate airway. TEST-TAKING HINT: If the question asks for a priority intervention, it means that all of the options would be appropriate for the client but only one intervention is priority. Always apply Maslow's hierarchy of needs—an adequate airway is first.

22. 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 1. Assessment is important, but with clients with head injury the nurse must assume spinal cord injury until it is ruled out with x-ray; therefore, stabilizing the spinal cord is priority. 2. Removing the client from the water is an appropriate intervention, but the nurse must assume spinal cord injury until it is ruled out with x-ray; therefore, stabilizing the spinal cord is priority. 3. Assessing the client for further injury is appropriate, but the first intervention is to stabilize the spine because the impact was strong enough to render the client unconsciousness. 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; there- fore, the nurse should stabilize the cervical spinal cord as best as possible prior to removing the client from the water. TEST-TAKING HINT: When two possible answer options contain the same directive word—in this case, "assess"—the test taker can either rule out these two as incorrect or prioritize between the two assessment responses.

1. The nurse is monitoring the neurologic status of a client admitted with concussion. The client's response to which statement would be most helpful in identify-ing a change in mental status? A. "Tell me your name." B. "Do you have a headache?" C. "Are you having trouble breathing?" D. "Squeeze my hand."

A

ICP can be increased by anything that does what? A. Increases intracranial volume B. Results in high compliance C. Results in low elastance D. Decreases carbon dioxide levels

A

What term describes the process whereby cerebral vessels have the capacity to dilate or constrict in response to changes in perfusion pressures? A. Autoregulation B. Shunting C. Herniation D. Dispensability

A

Which problems can cause secondary injury? (Select all that apply.) A. Hypoxia B. Cerebral swelling C. Inflammation of cerebral tissue D. Skull fracture E. Ischemia

A B C E

The nurse is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by: a. Eating large, well-balanced meals b. Doing muscle-strengthening exercises c. Doing all chores early in the day while less fatigued d. Taking medications on time to maintain therapeutic blood levels

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

1. A brief loss of consciousness followed by a period of being alert and oriented and then a loss of consciousness again is a typical presentation for which condition? A. Subdural hematoma B. Epidural hematoma C. Intracranial hematoma D. Subarachnoid hemorrhage

B

2. On admission to the ED, a client who has altered LOC after being struck on the head with a baseball bat has a variety of diagnostic tests ordered. Which test should be done first? A. Urine for WBCs B. CT scan C. Chest x-ray D. Serum electrolyte

B

Management of intraparenchymal hematoma may include which intervention? A. Anticoagulation B. Maintaining mean arterial pressure of 70 mmHg or less C. Emergent surgical evacuation D. Maximizing cerebral perfusion pressure (CPP

B

1. Select all the TRUE statements about the pathophysiology of multiple sclerosis: A. "The dendrites on the neuron are overstimulated leading to the destruction of the axon." B. "The myelin sheath, which is made up of Schwann cells, is damaged along the axon." C. "This disease affects the insulating structure found on the neuron in the central nervous system." D. "The dopaminergic neurons in the part of the brain called substantia nigra have started to die."

B,C The answers are B and C. In multiple sclerosis the myelin sheath (which is the insulating and protective structure made up of Schwann cells that protects the axon) is damaged. MS affects the CNS (central nervous system) and when the myelin sheath becomes damaged it leads to a decrease in nerve transmission.

3. A client is admitted to the hospital with a cerebral contusion. During the night, he develops a headache, vomits, and seems more lethargic. What are the appropriate actions for the nurse to take? A. Give the client pain medication to treat the head-ache and reassess in 1 hour. B. Give the client antinausea medication and reassess in 1 hour. C. Perform a neurological and pupillary assessment immediately. D. Assess the client's lung fields.

C

Accumulation of CSF results in what condition? A. Herniation B. Cerebral dilation C. Hydrocephalus D. Seizures

C

10. A patient with multiple sclerosis has issues with completely emptying the bladder. The physician orders the patient to take ___________, which will help with bladder emptying. A. Bethanechol B. Oxybutynin C. Avonex D. Amantadine

The answer is A. This medication is a cholinergic medication that will help with bladder emptying.

9. During your discharge teaching to a patient with multiple sclerosis, you educate the patient on how to avoid increasing symptoms and relapses. You tell the patient to avoid: A. Cold temperatures B. Infection C. Overexertion D. Salt F. Stress

The answer is B, C, and F. The patient should also avoid extreme heat, which can increase symptoms.

7. Your patient is scheduled for a lumbar puncture to help diagnose multiple sclerosis. The patient wants clarification about what will be found in the cerebrospinal fluid during the lumbar puncture to confirm the diagnosis of MS. You explain that ____________ will be present in the fluid if MS is present. A. high amounts of IgM B. oligoclonal bands C. low amounts of WBC D. oblong red blood cells and glucose

The answer is B. These specific proteins, oligoclonal bands, which are immunoglobulins will be found in the CSF. This demonstrates there is inflammation in the CNS and is a common finding in multiple sclerosis.

3. The administration of narcotics to a client with a traumatic brain injury may have which effect? A. It will make the pain worse. B. It may mask neurological changes in the client. C. It allows the injury to heal quicker. D. It may increase intracranial pressure.

B

4. Presence of dizziness, headache, and confusion for long periods of time after concussion is _______. A. always expected B. known as post concussive syndrome C. caused by taking too much pain medication D. the result of something other than the concussion

B

23. 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 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 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. 2. Active range-of-motion exercises require that the client participate in the activity. This is not possible because the client is in a coma. 3. The client is at risk for pressure ulcers and should be turned more frequently than every shift, and research now shows that massaging bony prominences can increase the risk for tissue breakdown. 4. The nurse should always talk to the client, even if he or she is in a coma, but this will not address the problem of immobility. TEST-TAKING HINT: Whenever a client problem is written, interventions must address the specific problem, not the disease. Positioning the client addresses the possibility of immobility complications, whereas talking to a comatose client addresses communication deficit and psychosocial needs, not immobility issues.

A female client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond? A"You may have difficulty believing this, but the paralysis caused by this disease is temporary." B"You'll have to accept the fact that you're permanently paralyzed. However, you won't have any sensory loss." C"It must be hard to accept the permanency of your paralysis." D"You'll first regain use of your legs and then your arms."

Answer A. The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs.

19. 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 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. 2. Flaccidity would indicate a worsening of the client's condition. 3. Decerebrate posturing would indicate a worsening of the client's condition. 4. The eyes respond to light, not painful stimuli, but a 6-mm nonreactive pupil indicates severe neurological deficit. TEST-TAKING HINT: The test taker must have strong assessment skills and know what specific signs/symptoms signify for each of the body systems—in this case, the significance of different stages of posturing/movement in assessing neurological status.

The client diagnosed with a mild concussion is being discharged from the emergency department. Which discharge instruction should the nurse teach the client's significant other? 1. Awaken the client every two (2) hours. 2. Monitor for increased intracranial pressure. 3. Observe frequently for hypervigilance. 4. Offer the client food every three (3) to four (4) hours.

#1 1. Awakening the client every two (2) hours allows the identification of headache, dizziness, lethargy, irritability, and anxiety—all signs of post concussion syndrome—that would warrant the significant other's taking the client back to the emergency department. 2. The nurse should monitor for signs of increased intracranial pressure (ICP), but a layman, the significant other, would not know what these signs and medical terms mean. 3. Hypervigilance, increased alertness and super-awareness of the surroundings, is a sign of amphetamine or cocaine abuse, but it would not be expected in a client with a head injury. 4. The client can eat food as tolerated, but feeding the client every three (3) to four (4) hours does not affect the development TEST-TAKING HINT: Remember to pay close attention to answer options that have times (e.g., "every two [2] hours," "every three [3] to four [4] hours"). Also consider the likelihood of the options listed. Would a nurse teach the significant other terms such as increased intracranial pressure or hypervigilance? Probably not, so options "2" and "3" should be eliminated.

12. 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 b.i.d. 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 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. 2. Coughing increases intracranial pressure and is discouraged for any client who has had a craniotomy. The client is encouraged to turn and breathe deeply, but not to cough. 3. Monitoring the neurological status is appropriate for this client, but it should be done much more frequently than every shift. 4. Dopamine is used to increase blood pressure or to maintain renal perfusion, and a BP of 160/90 is too high for this client. TEST-TAKING HINT: The test taker should always notice if an answer option has a time frame—every shift, every four (4) hours, or daily. Whether or not the time frame is correct may lead the test taker to the correct answer.

14. 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 Steri-Strips. 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 1. The scalp is a very vascular area and a moderate amount of bleeding would be expected. 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. 3. This is a normal pupillary response and would not warrant intervention. 4. A headache that resolves with medication is not an emergency situation, and the nurse would expect the client to have a headache after the fall; a headache not relieved with Tylenol would warrant further investigation. TEST-TAKING HINT: The test taker is looking for an answer option that is not normal for the client's situation. Of the options listed, three would be expected and would not warrant a trip to the emergency department.

10. A client with an SCI at level C3-C4 is being cared for in the emergency department (ED). What is the priority assessment? 1. Determine the level at which the client has intact sensation. 2. Assess the level at which the client has retained mobility . 3. Check blood pressure and pulse for signs of spinal shock. 4. Monitor respiratory effort and oxygen saturation level.

Ans: 4 The first priority for the client with an SCI is assessing respiratory patterns and ensuring an adequate airway . A client with a high cervical injury is at risk for respiratory compromise, because spinal nerves C3 through C5 innervate the phrenic nerve, which controls the diaphragm. The other assessments are also necessary but are not as high a priority

A female client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test? A . Immobilize the neck before the client is moved onto a stretcher. B . Determine whether the client is allergic to iodine, contrast dyes, or shellfish. C . Place a cap over the client's head. D . Administer a sedative as ordered.

Answer B. Because CT commonly involves use of a contrast agent, the nurse should determine whether the client is allergic to iodine, contrast dyes, or shellfish. Neck immobilization is necessary only if the client has a suspected spinal cord injury. Placing a cap over the client's head may lead to misinterpretation of test results; instead, the hair should be combed smoothly. The physician orders a sedative only if the client can't be expected to remain still during the CT scan.

The nurse is teaching a female client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to: A take a hot bath. B rest in an air-conditioned room. C increase the dose of muscle relaxants. D avoid naps during the day.

Answer B. Fatigue is a common symptom in clients with multiple sclerosis. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness and fatigue. Planning for frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with multiple sclerosis include treating depression, using occupational therapy to learn energy conservation techniques, and reducing spasticity.

The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use which plan to use which of the following to test the client's peripheral response to pain? A . Sternal rub B . Nail bed pressure C . Pressure on the orbital rim D . Squeezing of the sternocleidomastoid muscle

Answer B. Motor testing in the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. Cerebral responses to pain are tested using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid? A . Head mildline B . Head turned to the side C . Neck in neutral position D . Head of bed elevated 30 to 45 degrees

Answer B. The head of the client with increased intracranial pressure should be positioned so the head is in a neutral midline position. The nurse should avoid flexing or extending the client's neck or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure down.

A female client has experienced an episode of myasthenic crisis. The nurse would assess whether the client has precipitating factors such as: a. Getting too little exercise b. Taking excess medication c. Omitting doses of medication d. Increasing intake of fatty foods

Answer C. Myasthenic crisis often is caused by undermedication and responds to the administration of cholinergic medications, such as neostigmine (Prostigmin) and pyridostigmine (Mestinon). Cholinergic crisis (the opposite problem) is caused by excess medication and responds to withholding of medications. Too little exercise and fatty food intake are incorrect. Overexertion and overeating possibly could trigger myasthenic crisis.

A female client with Guillian-Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which of the following strategies would the nurse incorporate in the plan of care to help the client cope with this illness? a. Giving client full control over care decisions and restricting visitors b. Providing positive feedback and encouraging active range of motion c. Providing information, giving positive feedback, and encouraging relaxation d. Providing intravaneously administered sedatives, reducing distractions and limiting visitors

Answer C. The client with Guillain-Barré syndrome experiences fear and anxiety from the ascending paralysis and sudden onset of the disorder. The nurse can alleviate these fears by providing accurate information about the client's condition, giving expert care and positive feedback to the client, and encouraging relaxation and distraction. The family can become involved with selected care activities and provide diversion for the client as well.

For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to: A . prevent respiratory alkalosis. B . lower arterial pH. C . promote carbon dioxide elimination. D . maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg

Answer C. The goal of treatment is to prevent acidemia by eliminating carbon dioxide. That is because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP. Preventing respiratory alkalosis and lowering arterial pH may bring about acidosis, an undesirable condition in this case. It isn't necessary to maintain a PaO2 as high as 80 mm Hg; 60 mm Hg will adequately oxygenate most clients.

A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority in this client's plan of care? A . Disturbed sensory perception (visual) B . Self-care deficient: Dressing/grooming C . Impaired verbal communication D . Risk for injury

Answer D. Because the client is disoriented and restless, the most important nursing diagnosis is risk for injury. Although the other options may be appropriate, they're secondary because they don't immediately affect the client's health or safety.

Female client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. The nurse inquires during the nursing admission interview if the client has history of: a. Seizures or trauma to the brain b. Meningitis during the last 5 years c. Back injury or trauma to the spinal cord d. Respiratory or gastrointestinal infection during the previous month.

Answer D. Guillain-Barré syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits. Occasionally, the syndrome can be triggered by vaccination or surgery.

A male client is having a lumbar puncture performed. The nurse would plan to place the client in which position? A . Side-lying, with a pillow under the hip B . Prone, with a pillow under the abdomen C . Prone, in slight-Trendelenburg's position D . Side-lying, with the legs pulled up and head bent down onto chest.

Answer D. The client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen and the head bent down onto the chest. This position helps open the spaces between the vertebrae.

A male client with a spinal cord injury is prone to experiencing automatic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? A . Strict adherence to a bowel retraining program B. Keeping the linen wrinkle-free under the client C . Preventing unnecessary pressure on the lower limbs D . Limiting bladder catheterization to once every 12 hours

B

What is CBV?

Cerebral Blood Volume Cerebral blood volume (CBV) is a dynamic value. CBV may increase under three circumstances: hypoxemia and/ or hypercapnia (causes vasodilation) , cerebral venous outflow obstruction (any mechanism that impedes jugular venous drainage from the head, such as head or neck rotation or flexion, hip flexion, and circumferential medical devices that may be applied too tightly), or loss of cerebral autoregulation (cerebral vessels have the capacity to dilate or constrict in response to changes in perfusion pressures.)

2. What is the term used to describe an accumulation of blood between the dura and the arachnoid layers of the meninges? A. Intracerebral hematoma B. Subarachnoid hemorrhage C. Epidural hematoma D. Subdural hematoma

D

4. The nurse reports that a trauma client's pupils are "blown." What has the nurse assessed? A. Pupils are slow to react to light. B. Pupils are not equal. C. Pupils have been injured and are not assessable. D. Pupils are dilated and nonreactive to light

D

A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid: A . Is clear and tests negative for glucose B . Is grossly bloody in appearance and has a pH of 6 C . Clumps together on the dressing and has a pH of 7 D . Separates into concentric rings and test positive of glucose

D

3. True or False: Patients with multiple sclerosis have different signs and symptoms because this disease can affect various areas of the peripheral nervous system. True False

False: Yes, patients with MS have different signs and symptoms because lesions can present at different locations in the CENTRAL NERVOUS SYSTEM....hence the brain and spinal cord (not the peripheral nervous system).

5. You're performing a head-to-toe assessment on a patient with multiple sclerosis. When you ask the patient to move the head and neck downward the patient reports an "electric shock" sensation that travels down the body. You would report your finding to the doctor that the patient is experiencing: A. Romberg's Sign B. Lhermitte's Sign C. Uhthoff's Sign D. Homan's Sign

The answer is B. This finding is known as Lhermitte's Sign.

11. A patient is receiving Interferon Beta for treatment of multiple sclerosis. As the nurse you will stress the importance of? A. Physical exercise to improve fatigue B. Low fat diet C. Hand hygiene and avoiding infection D. Reporting ideation of suicide

The answer is C. Interferon Beta decreases the number of relapses of symptoms in MS patients by decreasing the immune system response, but it lowers the white blood cells count. Hence, there is a risk of infection. It is very important the nurse stresses the importance of hand hygiene and avoiding infection.

4. A patient is suspected of having multiple sclerosis. The neurologist orders various test. The patient's MRI results are back and show lesions on the cerebellum and optic nerve. What signs and symptoms below would correlate with this MRI finding in a patient with multiple sclerosis? A. Blurry vision B. Pain when moving eyes C. Dysarthria (issue articulating words) D. Balance and coordination issues E. "Pill rolling" of fingers and hands G. Heat intolerance H. Dark spots in vision I. Ptosis (drooping of the upper eyelid)

The answers are A, B C, D, and H. If lesions are present on the optic nerves, optic neuritis can occurs which can lead to blurry vision, pain when moving the eyes, and dark spots in the vision. If cerebellar lesions are found, this can affect movement, speech, and some cognitive abilities. This would present as dysarthria (issues articulating words), and balance/coordination issues. "Pill rolling" of the fingers and hands is found in Parkinson's disease. Ptosis is common in myasthenia gravis, and heat intolerance in thyroid issues.

8. You're developing a plan of care for a patient with multiple sclerosis who presents with Uhthoff's Sign. What interventions will you include in the patient's plan of care? Select all that apply: A. Avoid movements of the head and neck downward B. Keep room temperature cool C. Encourage patient to use warm packs and heating pads for symptoms D. Educate the patient on three ways to avoid overheating during exercise

The answers are B and D. Uhthoff's Sign is where when the patient experiences too much heat their symptoms increase and get worst. Therefore, it is important the patient stays cool and doesn't overheat (overheating can come from outside temperatures, exercise, emotional events etc.). The room should be cool and the patient should be encouraged to exercise but to avoid overheating.

12. Which medications below can help treat muscle spasms in a patient with multiple sclerosis? Select all that apply: A. Propranolol B. Isoniazid C. Baclofen D. Diazepam E. Modafinil

The answers are C and D. These medications treat muscle spasms in patients with MS.