121Mid

Otoscope

instrument for examining the ear

healthy tympanic membrane

translucent, pearly gray

Air conduction is the more efficient pathway. true or false?

true

The nurse is caring for a patient with Huntington's disease in the long-term care facility. What does the nurse recognize as the most prominent symptom of the disease that the patient exhibits? a) Slow, shuffling gait b) Dysphagia and dysphonia c) Dementia d) Rapid, jerky, involuntary movements

D, The most prominent clinical features of the disease are chorea rapid, jerky, involuntary, purposeless movements), impaired voluntary movement, intellectual decline, and often personality changes (Aubeeluck & Wilson, 2008)

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

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

What are the chances of a child having Huntington's disease if a parent has the disease

50%

Contracture

Shrinkage of burn scar through collagen maturation.

vertigo

Vertigo is defined as: - the misperception or illusion of motion of the person or their surroundings. - Most people with vertigo describe a spinning sensation or say they feel as though objects are moving around them.

From which direction should a nurse approach a client who is blind in the right eye?

From the left side of the client

What are manifestations of ALS?

Patients with amyotrophic lateral sclerosis present with progressive muscle weakness, atrophy, fatigue hyperactive deep tendon reflexes and spasticity

laceration

to cut

You are caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke do you know this client has? a) Ischemic b) Hemorrhagic c) Right-sided d) Left-sided

A, Ischemic strokes occur when a thrombus or embolus obstructs an artery carrying blood to the brain; about 80% of strokes are the ischemic variety. Options B, C, and D are incorrect.

Which of the following is a late symptom of spinal cord compression? a) Paralysis b) Urinary incontinence c) Urinary retention d) Fecal incontinence

A, Later symptoms include evidence of motor weakness and sensory deficits progressing to paralysis. Early symptoms associated with spinal cord compression include bladder and bowel dysfunction (urinary incontinence or retention; fecal incontinence or constipation)

Which of the following are clinical manifestations associated with increased intracranial pressure (ICP)? Select all that apply. a) Seizures b) Angina c) Headache d) Papilledema e) Nausea with or without vomiting

A,C,D,E Symptoms of increased intracranial pressure include headache, nausea with or without vomiting, and papilledema. Angina is not associated with increased ICP.

The nurse is caring for a patient recovering from an ischemic stroke. What intervention best addresses a potential complication after an ischemic stroke? A) Providing frequent small meals rather than three larger meals B) Teaching the patient to perform deep breathing and coughing exercises C) Keeping a urinary catheter in situ for the full duration of recovery D) Limiting intake of insoluble fiber

B) Teaching the patient to perform deep breathing and coughing exercises

Three most common systemic signs of ICP are: (Select all that apply) Select one or more: a. Headache b. Nausea and vomiting c. Irregular breathing d. Papilledema e. Posturing

a. Headache b. Nausea and vomiting d. Papilledema

Which of the following is a contraindication for the administration of tissue plasminogen activator (t-PA)? a) Systolic blood pressure less than or equal to 185 mm Hg b) Ischemic stroke c) Intracranial hemorrhage d) Age 18 years of age or older

Intracranial hemorrhage Intracranial hemorrhage, neoplasm, or aneurysm is a contraindication to t-PA. Clinical diagnosis of ischemic stroke, age 18 years of age or older, and a systolic BP less than or equal to 185 mm Hg are eligibility criteria. (less)

Warren has a full thickness burn to one arm when he was scalded with boiling water. How is it determined that the burned area is a full thickness burn? Select one: a. Classification by the appearance of blisters b. Identification by the destruction of the dermis and epidermis c. Not associated with edema formation d. Usually very painful because of exposed nerve endings

b. Identification by the destruction of the dermis and epidermis

A client has been admitted with a diagnosis of stroke (brain attack). The nurse suspects that the client has had a right hemisphere stroke because the client exhibits which symptoms? a. Aphasia and cautiousness b. Impulsiveness and smiling c. Inability to discriminate words d. Quick to anger and frustration

b. Impulsiveness and smiling

The nurse is planning discharge education for a patient with trigeminal neuralgia. The nurse knows to include information about factors that precipitate an attack. What would the nurse be correct in teaching the patient to avoid? A) Washing his face B) Exposing his skin to sunlight C) Using artificial tears D) Drinking large amounts of fluids

A) Washing his face

Acoustic neuroma

benign tumor on the auditory nerve (8th cranial nerve) that causes vertigo, tinnitus, and hearing loss

What is the drug classification of Lorazepam and what is the trade name?

benzodiazepine, Ativan

contusion

bruise

The critical care nurse is caring for 25-year-old man admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this patient? A) Maintaining the patient's functional independence B) Providing health education C) Monitoring neurologic status closely D) Promoting mobility

C) Monitoring neurologic status closely

The nurse is caring for a patient treated with alteplase following a stroke. What assessment finding is the highest priority for the nurse?

Client is having epistaxis.

The Snellen chart is used to test visual acuity for both near (14 inches) and far (20 feet) away. Select one: True False

False

Xenograft

Graft obtained from an animal of a species different than that of the recipient - also called a heterograft.

Which is a contraindication for the administration of tissue plasminogen activator (t-PA)?

Intracranial hemorrhage

When a nurse asks a patient to describe the quality of the pain, what type of descriptive term does the nurse expect the patient to use? a. Burning b. Chronic c. Intermittent d. Severe

a When asking the patient to describe how the pain feels, the nurse should suggest to the patient descriptors such as "sharp," "shooting," or "burning," which may help identify the presence of neuropathic pain.

What would happen if the tympanic membrane was injured?

could impair hearing

How long does the typical neurological deficit last with a TIA?

less than 24 hrs, lasting 1-2 hrs

Signs of neurogenic shock include:

- bradycardia, decreased blood pressure and cardiac output, peripheral vasodilation and venous pooling

blindness

20/400 to no light perception

The nurse is discussing the results of a patient's diagnostic testing with the nurse practitioner. What Weber test result would indicate the presence of a sensorineural loss? A) The sound is heard better in the ear in which hearing is better. B) The sound is heard equally in both ears. C) The sound is heard better in the ear in which hearing is poorer. D) The sound is heard longer in the ear in which hearing is better.

A (A patient whose Sensorineural hearing loss is conductive hears the sound better in the affected ear.)

The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of a stroke? A) Facial droop B) Dysrhythmias C) Periorbital edema D) Projectile vomiting

A) Facial droop

A nurse assesses a client with a brain tumor. Which newly identified assessment findings would alert the nurse to urgently communicate with the primary health care provider? (Select all that apply.) a. Glasgow Coma Scale score of 8 b. Decerebrate posturing c. Reactive pupils d. Uninhibited speech e. Decreasing level of consciousness

ANS: A, B, E The nurse would urgently communicate changes in a patient's neurologic status, including a decrease in the Glasgow Coma Scale score; abnormal flexion or extension; changes in cognition or level of consciousness; and pinpointed, dilated, and nonreactive pupils.

major neurotransmitter of the parasympathetic nervous system

Acetylcholine

33. The nurse caring for a patient diagnosed with Parkinson's disease has prepared a plan of care that would include what goal? A) Promoting effective communication B) Controlling diarrhea C) Preventing cognitive decline D) Managing choreiform movements

Ans: A Feedback: The goals for the patient may include improving functional mobility, maintaining independence in ADLs, achieving adequate bowel elimination, attaining and maintaining acceptable nutritional status, achieving effective communication, and developing positive coping mechanisms. Constipation is more likely than diarrhea and cognition largely remains intact. Choreiform movements are related to Huntington disease.

What is the drug classification of Clopidogrel and dipyridamole?

Antiplatelet- platelet inhibiting meds

A patient has undergone diagnostic testing and has been diagnosed with otosclerosis? What ear structure is primarily affected by this diagnosis? A) Malleus B) Stapes C) Incus D) Tympanic membrane

B Otosclerosis = Stapes fixation

The nurse is admitting a patient to the unit who is scheduled to have an ossiculoplasty. What postoperative assessment will best determine whether the procedure has been successful? A) Otoscopy B) Audiometry C) Balance testing D) Culture and sensitivity testing of ear discharge

B (Ossiculoplasty is the surgical reconstruction of the middle ear bones to restore hearing) *Otoscopy: visualize the ear *Audiometry: testing hearing

A client is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for: a) fever. b) hypoxia. c) visual disturbance. d) gait alteration.

B - hypoxia Lower brain stem dysfunction alters bulbar functions, such as breathing, talking, swallowing, and coughing. Therefore, the nurse should monitor the client closely for hypoxia. Temperature control, vision, and gait aren't lower brain stem functions.

Which of the following psychotropic drug classifications is often prescribed for neuropathic pain? a) Antipsychotics b) Tricyclic antidepressants c) Anxiolytics d) Mood stabilizers

B,Tricyclic antidepressants are often prescribed for neuropathic pain

7. The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for? a. Hypophysectomy b. Application of halo traction c. Burr holes d. Insertion of Crutchfield tongs

C

A patient is being discharged home after mastoid surgery. What topic should the nurse address in the patient's discharge education? A) Expected changes in facial nerve function B) The need for audiometry testing every 6 months following recovery C) Safe use of analgesics and antivertiginous agents D) Appropriate use of OTC ear drops

C ( Patients require instruction about medication therapy, such as analgesics and antivertiginous agents (e.g., antihistamines) prescribed for balance disturbance. OTC ear drops are not recommended and changes in facial nerve function are signs of a complication that needs to be addressed promptly. There is no need for serial audiometry testing. )

Nursing students are reviewing the various types of brain tumors. The students demonstrate understanding of the material when they identify which of the following as the most common type? a) Meningiomas b) Pituitary adenomas c) Gliomas d) Acoustic neuromas

C , Gliomas are the most common type of intracerebral brain tumor. Menigiomas account for approximately 15% of all primary brain tumors. Pituitary adenomas represent approximately 10% to 15% of all brain tumors. Acoustic neuromas are less common.

TRUE

Careful maintenance of cerebral hemodynamics to maintain cerebral perfusion is extremely important after a stroke.

Herpes Zoster

Cranial nerve Vll (Facial)

Your patient who had a stroke has issues with understanding speech. What type of aphasia is this patient experiencing and what area of the brain is affected? A. Expressive; Wernicke's area B. Receptive, Broca's area C. Expressive; hippocampus D. Receptive; Wernicke's area

D. Receptive; Wernicke's area

The nurse is monitoring a client after supratentorial surgery. Which sign/symptom does the nurse report immediately to the provider?

Decorticate positioning

What will alteration in level of consciousness (LOC) look like for this patient? Name two symptoms.

Drowsiness, slight slurring of speech, sluggish pupillary reaction

What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke?

Left visual field deficit Explanation: A left visual field deficit is a common clinical manifestation of a right hemispheric stroke. Aphasia, slow, cautious behavior, and altered intellectual ability are all clinical manifestations of a left hemispheric stroke.

Which of the following is accurate regarding a hemorrhagic stroke?

Main presenting symptom is an "exploding headache."

What is the drug classification for Naproxen?

NSAID

Otalgia

Otalgia is a sensation of fullness or pain in the ear.

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:

Severe headache and early change in level of consciousness

Which is indicative of a right hemisphere stroke? Spatial-perceptual deficits Slow, cautious behavior Aphasia Altered intellectual ability

Spatial-perceptual deficits

Which interventions would be recommended for a client with dysphagia? Select all that apply.

Test the gag reflex before offering food or fluids. Assist the client with meals. Allow ample time to eat.

An eye treatment for a splash injury would be used of irrigation with normal saline solution. Select one: True False

True

A home health nursing practice has 7 out of 10 clients who are over the age of 65. Understanding the prevalence of noncancerous chronic pain among those over 65, how many of the clients would the nurse expect to experience chronic pain? a. 5 b. 3 c. 2 d. 0

a At least 70% of all persons over 65 years of age experience noncancerous chronic pain, primarily due to osteoarthritis and neuralgia (Davis et al., 2002).

senile dementia

a decrease in mental ability that sometimes occurs after the age of 65

Serous otitis media

a fluid buildup in the middle ear that can follow acute otitis media or can be caused by obstruction of the Eustachian tube

The client reports chest pain. The nurse uses which of the following questions to assess the pain further. Select all answers that apply. a. "How long have you experienced this pain?" b. "Please point to where you are experiencing pain." c. "You've never had this pain before, have you?" d. "Rate the pain on a scale of 0 to 10, with 10 being the worst possible pain." e. "What aggravates your chest pain?"

a, b, d, e The nurse needs to assess pain as to intensity, timing, location, and aggravating factors. Assessing frequency is important, but the statement "You've never had this pain before, have you" is leading and nontherapeutic.

The nurse is teaching a client and family about home care after a stroke. Which statement made by the client's spouse indicates a need for further teaching? a. "I should spend all my time with my husband in case I'm needed." b. "My husband may get depressed." c. "My husband must take his medicine every day to prevent another stroke." d. "The physical therapist will show us how to use the equipment so my husband can climb the stairs and get into and out of bed."

a. "I should spend all my time with my husband in case I'm needed."

Claire had a large ischemic stroke and is hospitalized in the hospital neuro ICU. What nursing interventions would be provided ti decrease intracranial pressure? (Select all that apply) Select one or more: a. Administer mannitol b. Maintain paCO2 within a range of 30-35 mm Hg c. Administer heparin to induce anticoagulation d. Administer supplemental O2 if oxygen saturation is below 88% e. Elevate the head of bed 30 degrees

a. Administer mannitol b. Maintain paCO2 within a range of 30-35 mm Hg d. Administer supplemental O2 if oxygen saturation is below 88% e. Elevate the head of bed 30 degrees

Generalized pruritis can be a symptom of which diseases? (Select all that apply) Select one or more: a. End stage kidney disease b. Hypothyroidism c. Pneumonia d. Myasthenia Gravis e. COPD

a. End stage kidney disease

Ronnie had a stroke and is now experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe? Select one: a. Frontal b. Occipital c. Parietal d. Temporal

a. Frontal

Marty sustained a head injury during a fall, changing personality and affect. Which part of the brain has been affected in this injury? Select one: a. Frontal lobe b. Occipital lobe c. Patietal lobe d. Brain stem

a. Frontal lobe

ankylosis

abnormal condition of stiffness

The nurse is caring for a patient in the neuro ICU who sustained head trauma during a physical altercation. What is the optimal range for ICP for this patient? Select one: a. 8 - 15 mm Hg b. 0-10 mm Hg c. 20 - 30 mm Hg d. 25 - 40 mm Hg

b. 0-10 mm Hg

Which of the following is a physiologic response to pain? a. bradycardia b. dry skin c. pallor d. hypotension

c Physiologic responses to pain include pallor, tachycardia, diaphoresis, and hypertension.

A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include: a) elevated temperature. b) decreasing blood pressure. c) diminished responsiveness. d) pupillary changes.

c) diminished responsiveness. Usually, diminished responsiveness is the first sign of increasing ICP. Pupillary changes occur later. Increased ICP causes systolic blood pressure to rise. Temperature changes vary and may not occur even with a severe decrease in responsiveness.

Suspect a basilar fracture if

cerebral spinal fluid leaks from the nose or ears

The three signs of brain death

coma, absence of brain stem reflexes and apnea

You are assessing urinary output as an indicator of diabetes insipidus. What volume range may be a positive indicator of diabetes insipidus? Select one: a. 50-100 ml/hour b. 100-150 ml/hour c. 150-200 ml/hour d. over 200 ml/hour

d. over 200 ml/hour

corticosteroid drugs

decrease severe inflammation

What is brachytherapy?

internal radiation used to get the radiation close to the cancer or target tissue can be unsealed or sealed

emmetropia

normal vision

Barotrauma

pressure-related ear condition

bradykinesia

slow movement

keratoplasty

surgical repair of the cornea (corneal transplant)

What is methyldopa (Aldomet) used for?

to reduce blood pressure

Reports of crackling and popping sounds in the ear and a temporary loss of hearing following middle ear surgery are normal

true

The client with a cerebral aneurysm asks the nurse, "What's the big fuss over a headache?" Which is the best response from the nurse regarding to a cerebral aneurysm?

"Your physician wants to evaluate the location and condition of the aneurysm.

A physician orders morphine sulfate 1 mg IV stat for chest pain. The drug is available in 2 mg per 1 mL syringe. How many mL does the nurse administer? Enter the correct number ONLY.

0.5 The dose ordered is 1 mg. The dose available is 2 mg. The quantity is 1 mL. 1 mg/2 mg x 1 mL = 0.5 mL.

Normal intraocular pressure (IOP)

10-21

How to apply eye drops

1st. remove contact lens 2nd. hold lower lid down 3rd. instill eye drops before ointments 4th. apply gentle pressure to the inner canthus to occlude the punctum for 1-2 minutes and wait 5 minutes before instilling another medication (10 minutes for ointments)

How do organisms in the oropharynx (back of throat) infect the middle ear?

Organisms can travel through the Eustachian tube.

bulging eardrum is caused by

A bulging eardrum would suggest otitis media.

The nurse is providing care for a patient who has benefited from a cochlear implant. The nurse should understand that this patient's health history likely includes which of the following? Select all that apply. A) The patient was diagnosed with sensorineural hearing loss. B) The patient's hearing did not improve appreciably with the use of hearing aids. C) The patient has deficits in peripheral nervous function. D) The patient's hearing deficit is likely accompanied by a cognitive deficit. E) The patient is unable to lip-read.

A,B *Hearing aid not work -> Cochlear implant

When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes? a) 30-degree head elevation b) Flat c) Side-lying d) Trendelenburg's

A,For clients with increased intracranial pressure (ICP), the head of the bed should be elevated to 30 degrees to promote venous outflow. Trendelenburg's position is contraindicated because it can raise ICP. Flat or neutral positioning is indicated when elevating the head of the bed would increase the risk of neck injury or airway obstruction. A side-lying position isn't specifically a therapeutic treatment for increased ICP.

What is the trade name of Clopidogrel?

PLAVIX

Which of the following are possible indicators of pulmonary damage from an inhalation injury? Select all that apply. a) Bradypnea b) Hoarseness c) Facial burns d) Singed nasal hair e) Yellow sputum

BCD

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 (Feedback: The main surgical procedure for select patients with TIAs is carotid endarterectomy, the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in patients with occlusive disease of the extracranial arteries. An endarterectomy does not decrease cerebral edema, prevent seizure activity, or determine the cause of a TIA.)

The nurses assess LOC using the Glascow Coma Scale. What score indicates the most severe impairment of neurologic function? Select one: a. 3 b. 6 c. 9 d. 12

a. 3

Audiometry confirms a client's chronic progressive hearing loss. Further investigation reveals ankylosis of the stapes in the oval window, a condition that prevents sound transmission. This type of hearing loss is called:

Conductive hearing loss results from interference with the conduction of sound waves (sound transmission) from the tympanic membrane to the inner ear. * The stapes must move freely for sound to be transmitted. Bone tissue overgrowth causes the stapes to become fixed or immobile (ankylosed) in the oval window, preventing sound transmission.

Meniere's Syndrome

Cranial nerve Vlll (Acoustic)

GBS (guillain-barré syndrome)

Cranial nerve X (Vagus)

Cyst

Encapsulated fluid-filled or semisolid mass in subcutaneous tissue or dermis

What is the drug classification of Aspirin?

salicylate___

TRUE

Brain function depends on delivery of oxygen to the tissues

raccoon eyes

Bruising around the eyes, indicative of a basilar skull fracture

What is the cause of increased intracranial pressure (ICP)?

CEREBRAL EDEMA

The public health nurse is planning a health promotion campaign that reflects current epidemiologic trends. The nurse should know that hemorrhagic stroke currently accounts for what percentage of total strokes in the United States? A) 43% B) 33% C) 23% D) 13%

D (Feedback: Strokes can be divided into two major categories: ischemic (87%), in which vascular occlusion and significant hypoperfusion occur, and hemorrhagic (13%), in which there is extravasation of blood into the brain or subarachnoid space.)

papilledema

swelling of the optic disc

An emergency department nurse is interviewing a client who is presenting with signs of an ischemic stroke that began 2 hours ago. The client reports a history of a cholecystectomy 6 weeks ago and is taking digoxin, warfarin, and labetalol. What factor poses a threat to the client for thrombolytic therapy?

International normalized ratio greater than 2

A client returns from the postanesthesia care unit (PACU) after a surgical removal of a brainstem tumor. What position will the nurse place the client in at this time?

Keep the client flat in bed or up 10 degrees and reposition from side to side.

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention?

Keeping the client in one position to decrease bleeding Explanation: The student nurse shouldn't keep the client in one position. She should carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of rebleeding.

Fissure

Linear crack in the skin that may extend to dermis

What assessment(s) can you perform to assess extraocular movement?

the 6 cardinal positions

Debridement

Removal of foreign material and devitalized tissue until surrounding healthy tissue is exposed.

following a ear surgery the nurse tells the family

The caregiver and patient are cautioned that the patient may experience some vertigo and will therefore require help with ambulation to avoid falling

Disorders (amyotrophic lateral sclerosis, myasthenia gravis) that affect bulbar muscle function result in dysphagia, difficulty speaking and an increased risk for aspiration

true

Parkinson's disease is a slowly progressing neurologic movement disorder that eventually leads to disability.

true

What separates the external from the middle ear?

tympanic membrane

19. A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem? a. Diphenhydramine (Benadryl) b. Lioresal (Baclofen) c. Heparin d. Pregabalin (Lyrica)

b. Lioresal (Baclofen)

The nurse's major area of assessment for a patient receiving patient-controlled analgesia is assessment of what system? a. Cardiovascular b. Integumentary c. Neurologic d. Respiratory

d Essential to the safe use of a basal rate with PCA is close monitoring by nurses of sedation and respiratory status and prompt decreases in opioid dose (e.g., discontinue basal rate) if increased sedation is detected (Pasero, Quinn et al., 2011).

Which finding should lead the nurse to decide that spinal shock was resolving in the adolescent with a spinal cord injury? a) atonic urinary bladder b) widened pulse pressure c) flaccid paralysis d) hyperactive reflexes

d) hyperactive reflexes Spinal shock causes a loss of reflex activity below the level of the injury, resulting in bladder atony and flaccid paralysis. When the reflex arc returns, it tends to be overactive, resulting in spasticity. The reflexes and bladder become hypertonic during this phase of spinal shock resolution; sensation does not return. A widened pulse pressure is not associated with resolution of spinal shock.

The nurse judges that the mother understands the term cerebral palsy when she describes it as a term applied to impaired movement resulting from which factor? a) injury to the cerebrum caused by viral infection b) malformed blood vessels in the ventricles caused by inheritance c) inflammatory brain disease caused by metabolic imbalances d) nonprogressive brain damage caused by injury

d) nonprogressive brain damage caused by injury The term cerebral palsy (CP) refers to a group of nonprogressive disorders of upper motor neuron impairment that result in motor dysfunction due to injury. In addition, a child may have speech or ocular difficulties, seizures, hyperactivity, or cognitive impairment. The condition of congenital malformed blood vessels in the ventricles is known as arteriovenous malformations. Viral infection and metabolic imbalances do not cause CP.

radiculopathy

disease of the nerve roots

The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has?

Ischemic

Pat is being treated for chronic venous stasis ulcers in his lower leg. What medication does the nurse understand will increased peripheral blood flow by decreasing viscosity of blood and assist with the healing of the ulcers? Select one: a. Heparin b. Warfarin c. Aspirin d. Pentoxifylline

d. Pentoxifylline

Trigeminal neuralgia

Cranial nerve V (Trigeminal)

Which cranial nerves are involved with extraocular movement?

Oculomotor (III) Trochlear (IV) Abducens (VI) nerves.

The nurse is caring for a patient with expressive (Broca's) aphasia. Which nursing intervention is appropriate for communicating with the client?

Provide pictures to help the client communicate.

Why is client with Parkinson's at risk for constipation?

Reduced activity and side effects of meds.

During his annual physical examination, a retired airplane mechanic reports noticeable hearing loss. The nurse practitioner prescribes a series of hearing tests to confirm or rule out noise-induced hearing loss, which is classified as a:

Sensorineural loss. - noise-induced hearing loss refers to hearing loss that follows a long period of exposure to loud noise. It is inherent in jobs that involve heavy machinery, noisy engines, and artillery.

Epley maneuver

Series of head movements to relieve symptoms of benign positional vertigo

A 4+ deep tendon reflex with sustained clonus always indicates central nervous system impairment

TRUE

Ataxia

lack of muscle coordination

9. The nurse is planning the care of a patient with a TBI in the neurosurgical ICU. In developing the plan of care, what interventions should be a priority? (Select all that apply.) a. Making nursing assessments b. Setting priorities for nursing interventions c. Anticipating needs and complications d. Initiating rehabilitation e. Ensuring that the patient regains full brain function

A, B, C, D

When assessing gait, what features does the nurse inspect? (Select all that apply.) a. Balance b. Ease of stride c. Goniometer readings d. Length of stride e. Steadiness

ANS: A, B, D, E To assess gait, look at balance, ease and length of stride, and steadiness. Goniometer readings assess flexion and extension or joint range of motion. DIF: Remembering/Knowledge REF: 1021 KEY: Musculoskeletal system| musculoskeletal assessment| musculoskeletal disorders| nursing assessment MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A new nurse asks the precepting nurse "What is the best way to assess a client's pain?" Which response by the nurse is best? a. Numeric pain scale b. Behavioral assessment c. Client's self-report d. Objective observation

ANS: C Many ways to measure pain are in use, including numeric pain scales, behavioral assessments, and other objective observations. However, the most accurate way to assess pain is to get a self-report from the client.

TRUE

Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. Therefore, the nurse should question this order (HEPARIN ) to prevent additional hemorrhage in the brain.

Dermatosis

Any abnormal skin condition

5. While stopped at a stop sign, a patient's car was struck from behind by another vehicle. The patient sustained a cerebral contusion and was admitted to the hospital. During what time period after the injury will the effects of injury peak? a. 6 to 8 hours b. 18 to 36 hours c. 12 to 24 hours d. 48 to 72 hours

B

A patient with herpes simplex virus encephalitis (HSV) has been admitted to the ICU. What medication would the nurse expect the physician to order for the treatment of this disease process? A) Cyclosporine (Neoral) B) Acyclovir (Zovirax) C) Cyclobenzaprine (Flexeril) D) Ampicillin (Prinicpen)

B) Acyclovir (Zovirax)

Which of the following would be a pulse pressure indicative of shock? a) 120/90 b) 90/70 c) 100/60 d) 130/90

B, A narrowing or decreased pulse pressure is an early indicator of shock, thus 90/70 indicates a narrowing pulse pressur

bulbar muscle

Muscles of the mouth and throat choke risk with MG

In which patients does post-polio syndrome occur?

People who have had polio and survived the epidemic in the 1950s. Years after recovery from the disease

A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke?

Severe headache Explanation: The patient with a hemorrhagic stroke can present with a wide variety of neurologic deficits, similar to the patient with ischemic stroke. The conscious patient most commonly reports a severe headache.

Conductive hearing loss, such as from otosclerosis or otitis media, When performing the Weber test the sound lateralizes toward the affected ear

TRUE

What cranial nerve complication should the nurse assess for following surgery?

VII - facial nerve damage VII- hearing loss

The nurse understands that which statement is true about tolerance and addiction? a. Although clients may need increasing levels of opioids, they are not addicted. b. Tolerance to opioids is uncommon. c. Addiction to opioids commonly develops. d. The nurse must be primarily concerned about development of addiction by a client in pain.

a Physical tolerance usually occurs in the absence of addiction. Tolerance to opioids is common. Addiction to opioids is rare and should never be the primary concern for a client in pain.

The nurse is assessing someone with a primary skin lesion called a macule. What is a clinical example of this type of lesion? Select one: a. Hives b. Impetigo c. Port-wine stain d. Psoriasis

c. Port-wine stain

A client has been prescribed a fentanyl patch for pain control. The nurse understands that this patch should be replaced every a. 12-24 hours b. 24-36 hours c. 36-60 hours d. 48-72 hours

d Fentanyl patches should be replaced every 48-72 hours, depending on patient response. The other time frames are incorrect.

nystagmus

involuntary, jerking movements

A patient who just suffered a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurse's primary assessment focus? A) Cardiac and respiratory status B) Seizure activity C) Pain D) Fluid and electrolyte balance

A) Cardiac and respiratory status

You're educating a group of nursing students about left side brain damage. Select all the signs and symptoms noted with this type of stroke: A. Aphasia B. Denial about limitations C. Impaired math skills D. Issues with seeing on the right side E. Disoriented F. Depression and anger G. Impulsive H. Agraphia

A, C, D, F, and H. Patients who have left side brain damage will have aphasia, be AWARE of their limitations, impaired math skills, issues with seeing on the right side, no deficit in memory, depression/anger, cautious, and agraphia. All the other options are found in right side brain injury.

A nurse knows that the major clinical use of dobutamine (Dobutrex) is to: a) increase cardiac output. b) treat hypotension. c) treat hypertension. d) prevent sinus bradycardia.

A, Dobutamine increases cardiac output for clients with acute heart failure and those undergoing cardiopulmonary bypass surgery. Physicians may use epinephrine hydrochloride, another catecholamine agent, to treat sinus bradycardia. Physicians use many of the catecholamine agents, including epinephrine, isoproterenol, and norepinephrine, to treat acute hypotension. They don't use catecholamine agents to treat hypertension because catecholamine agents may raise blood pressure

The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? a) Semi-Fowler's b) High-Fowler's c) Prone d) Supine

A, The head of the bed is elevated 15 to 30 degrees (semi-Fowler's position) to promote venous drainage and decrease intracranial pressure.

20. Nursing activities for a client with ALS and family include helping them a.decide on an acceptable level of care early in the course of the disease. b.determine if they want to share the diagnosis to allow genetic testing. c.incorporate nonpharmacologic pain control techniques in the plan of care. d.plan for extensive rehabilitation after exacerbations.

ANS: A Disease management in ALS includes topics such as tube feedings and mechanical ventilation. Planning for an acceptable level of care should begin early in the disease, before a crisis occurs. Of course, decisions should be re-evaluated occasionally as the client's wishes may changes with their experiences with the disease. ALS is not a genetically-acquired disorder. Pain control is usually not an issue in the disease, and as the disease is relentlessly progressive (rather than characterized by remissions and exacerbations), extensive rehabilitation is not utilized. DIF: Application/Applying REF: p. 1919 OBJ: Intervention MSC: Psychosocial Integrity Coping and Adaptation-End of Life Care

A client who had therapeutic hypothermia after a traumatic brain injury is slowly rewarmed to a normal core temperature. For which assessment finding would the nurse monitor during the rewarming process? a. Cardiac dysrhythmias b. Loss of consciousness c. Nausea and vomiting d. Fever

ANS: A Due to fluid and electrolyte changes that typically occur during the rewarming process, the nurse monitors for cardiac dysrhythmias. The other findings are not common during this process.

16. When a client is admitted to the hospital with Guillain-Barré syndrome (GBS), the most important assessment the nurse should make is for a.decreasing alertness. b.respiratory difficulty. c.seizure activity. d.urinary retention.

ANS: B The two most dangerous features of GBS are respiratory muscle weakness and autonomic neuropathy involving both the sympathetic and the parasympathetic systems. DIF: Application/Applying REF: p. 1915 OBJ: Assessment MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures/Health Alteration

An older adult has diabetic neuropathy and often reports unbearable foot pain. About which medication would the nurse plan to educate the client? a. Desipramine b. Duloxetine c. Morphine sulfate d. Nortriptyline

ANS: B Antidepressants and anticonvulsants often are used for neuropathic pain relief. Morphine would not be used for this client. However, SNRIs are better tolerated than tricyclics, which eliminate desipramine and nortriptyline. Duloxetine would be the best choice for this older client.

A nurse is discharging a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management? (Select all that apply.) a. Does not want to purchase a thermometer. b. Is allergic to acetaminophen. c. Laughing, says "Strenuous? What's that?" d. Lives alone and is new in town with no friends. e. Plans to have a beer and go to bed once home.

ANS: B, D, E Clients who have mild traumatic brain injuries should take acetaminophen for headache. An allergy to this drug may mean that the patient takes aspirin or ibuprofen, which should be avoided. The patient needs neurologic checks every 1 to 2 hours, and this client does not seem to have anyone available who can do that. Alcohol needs to be avoided for at least 24 hours. A thermometer is not needed. The patient laughing at strenuous activity probably does not engage in any kind of strenuous activity, but the nurse should confirm this.

A new perioperative nurse is receiving orientation to the surgical area and learns about the Surgical Care Improvement Project (SCIP) goals. What major areas do these measures focus on? (Select all that apply.) a. Hemorrhage prevention b. Infection prevention c. Malignant hyperthermia testing d. Stroke recognition e. Thromboembolism prevention f. Correct hair removal

ANS: B, E, F The Surgical Care Improvement Project (SCIP), a set of core compliance measures, was initiated in 2006 to reduce surgical complications. Examples of focus included administration of prophylactic antibiotics to prevent infection, correct hair removal processes, the timing of discontinuation of urinary catheterization after surgery, and venous thromboembolism prophylaxis. These practices are now standard in surgical care.

The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for? a) Hypophysectomy b) Burr holes c) Insertion of Crutchfield tongs d) Application of Halo traction

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

Which of the following is the most common side effect of tissue plasminogen activator (tPA)? a) Increased intracranial pressure (ICP) b) Hypertension c) Headache d) Bleeding

Bleeding Bleeding is the most common side effect of tPA. The patient is closely monitored for bleeding (at IV insertion sites, gums, urine/stools, and intracranially by assessing changes in level of consciousness). Headache, increased ICP, and hypertension are not side effects of tPA.

Within the practice of nursing at the burn unit, there are specific potential complications common to specific types of burns. Which burns can impair ventilation? a) All options are correct b) Hands, major joints c) Face, neck, chest d) Perineal

C

A community health nurse is giving an educational presentation about stroke and heart disease at the local senior citizens center. What nonmodifiable risk factor for stroke should the nurse cite? A) Female gender B) Asian American race C) Advanced age D) Smoking

C (Feedback: Advanced age, male gender, and race are well-known nonmodifiable risk factors for stroke. High-risk groups include people older than 55 years of age; the incidence of stroke more than doubles in each successive decade. Men have a higher rate of stroke than that of women. Another high-risk group is African Americans; the incidence of first stroke in African Americans is almost twice that as in Caucasian Americans; Asian American race is not a risk factor. Smoking is a modifiable risk.)

A patient has been diagnosed with serous otitis media for the third time in the past year. How should the nurse best interpret this patient's health status? A) For some patients, these recurrent infections constitute an age-related physiologic change. B) The patient would benefit from a temporary mobility restriction to facilitate healing. C) The patient needs to be assessed for nasopharyngeal cancer. D) Blood cultures should be drawn to rule out a systemic infection.

C (A carcinoma (e.g., nasopharyngeal cancer) obstructing the eustachian tube should be ruled out in adults with persistent unilateral serous otitis media. )

A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke? a) Dizziness and tinnitus b) Numbness of an arm or leg c) Severe headache d) Double vision

C, The patient with a hemorrhagic stroke can present with a wide variety of neurologic deficits, similar to the patient with ischemic stroke. The conscious patient most commonly reports a severe headache.

A community health nurse is conducting a workshop for unlicensed care providers who work in a chain of long-term care facilities. The nurse is teaching the participants about the signs and symptoms of stroke. What signs and symptoms should the nurse identify? Select all that apply.

Confusion Sudden numbness Visual disturbances Explanation: The most common symptoms of stroke include numbness or weakness of the face, arm, or leg, especially on one side of the body; confusion or change in mental status; trouble speaking or understanding speech; visual disturbances; difficulty walking, dizziness, or loss of balance or coordination; and sudden, severe headache.

After mastoid surgery, an 81-year-old patient has been identified as needing assistance in her home. What would be a primary focus of this patient's home care? A) Preparation of nutritious meals and avoidance of contraindicated foods B) Ensuring the patient receives adequate rest each day C) Helping the patient adapt to temporary hearing loss D) Assisting the patient with ambulation as needed to avoid falling

D (The Epley maneuver is performed by placing the patient in a sitting position, turning the head to a 45-degree angle on the affected side, and then quickly moving the patient to the supine position. Saline is not instilled into the ears and there is no need to assess hearing before the test.)

You're assessing your patient's pupil size and vision after a stroke. The patient says they can only see half of the objects in the room. You document this finding as:

Hemianopia

A client has been admitted with a diagnosis of stroke (brain attack). The nurse suspects that the client has had a right hemisphere stroke because the client exhibits which symptoms?

Impulsiveness and smiling

Fasciotomy

Incision made through the fascia to release constriction of underlying muscle.

The nurse is monitoring a postoperative craniotomy client with increased intracranial pressure (ICP). Which pharmacologic agent does the nurse expect to be requested to maintain the ICP within a specified range?

Mannitol (Osmitrol)

What do platelets need to be above for Tissue Plasminogen Activator (tPA)?

Platelet count ≥100,000/mm

The nurse practitioner is able to correlate a patient's neurologic deficits with the location in the brain affected by ischemia or hemorrhage. For a patient with a left hemispheric stroke, the nurse would expect to see:

Right-sided paralysis. Explanation: A left hemispheric stroke will cause right-sided weakness or paralysis. Because upper motor neurons decussate, a disturbance on one side of the body can cause damage on the opposite side of the brain. Refer to Box 47-2 in the text.

migrane headache

a headache characterized by sudden onset and severe throbbing pain on one side of the head

What should the nurse inform the patient are indicators of infection and should be reported immediately to the physician? Select one: a. Constant, throbbing pain accompanied by fever b. Constant pain with no fever c. Intermittent pain that responds to a full dose of pain medication but not to half the dose d. Pain that seems excessive along with lethargy or sleepiness

a. Constant, throbbing pain accompanied by fever

When performing a neuro assessment, you ask the patient to smell coffee, tea, and a mint. The patient is unable to smell anything. The patient most likely has a dysfunction at which cranial nerve? Select one: a. Cranial nerve l b. Cranial nerve ll c. Cranial nerve lll d. Cranial nerve lV

a. Cranial nerve l

Tim had a carotid endarterectomy yesterday. When the nurse arrives in the room for a planned assessment, he suddenly states "I am having trouble moving my right arm and it just started happening!" What concern should the nurse have regarding this complaint? Select one: a. Thrombus formation at the site of endarterectomy b. Normal occurrence after endarterectomy, no immediate concern c. Bleeding from endarterectomy site d. Surgical would infection

a. Thrombus formation at the site of endarterectomy

The nurse administers lactulose to a client with cirrhosis. What is the expected outcome from the administration of the lactulose? a) Prevention of hemorrhage. b) Reduced serum ammonia levels. c) Stimulation of peristalsis of the bowel. d) Reduced peripheral edema and ascites.

b) Reduced serum ammonia levels. Lactulose is used to treat hepatic encephalopathy by reducing serum ammonia levels. It is not used to stimulate bowel peristalsis, even though diarrhea can be a side effect of the drug. Lactulose does not have any effect on edema, ascites, or hemorrhage.

A client is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for: a) fever. b) hypoxia. c) visual disturbance. d) gait alteration.

b) hypoxia. Lower brain stem dysfunction alters bulbar functions, such as breathing, talking, swallowing, and coughing. Therefore, the nurse should monitor the client closely for hypoxia. Temperature control, vision, and gait aren't lower brain stem functions.

4. When caring for a patient who has had a stroke, a priority is reduction of ICP. What patient position is most consistent with this goal? a. Head turned slightly to the right side b. Elevation of the head of the bed c. Position changes every 15 minutes while awake d. Extension of the neck

b. Elevation of the head of the bed

The nurse is monitoring a postoperative craniotomy client with increased intracranial pressure (ICP). Which pharmacologic agent does the nurse expect to be requested to maintain the ICP within a specified range? a. Dexamethasone (Decadron) b. Hydrochlorothiazide (HydroDIURIL) c. Mannitol (Osmitrol) d. Phenytoin (Dilantin)

c. Mannitol (Osmitrol)

You are assisting with a lumbar puncture and observe clear, colorless CSF obtained from the puncture site. What does this observation indicate? Select one: a. Subarachnoid hemorrhage b. Overwhelming infection c. Normal finding d. Local trauma from needle insertion

c. Normal finding

When educating a patient about the use of anti-seizure medication, what should the nurse inform the patient is a result of long-term use of the medication in women? Select one: a. Anemia b. Osteoarthritis c. Osteoporosis d. Obesity

c. Osteoporosis

Marcella informed the nurse of visual symptoms she has been having. Which symptoms commonly contribute to cataract development? Select one: a. Painful blurring of vision and photophobia b. Painless blurring of vision and vertigo c. Painless blurring of vision and sensitivity to glare d. Photophobia and decreasing visual acuity

c. Painless blurring of vision and sensitivity to glare

A client presents to the Emergency Department from an assisted living facility after a ground level fall with a head strike. The client has a Glasgow Coma Score (GCS) of 12, which is decreased for this client, and has projectile vomiting. What is the priority intervention for this client? a. Calling the Stroke Team b. Establishing an IV c. Positioning the client to prevent aspiration d. Preparing for thrombolytic administration

c. Positioning the client to prevent aspiration

A client in the emergency department (ED) has slurred speech, confusion, and visual problems and has been having intermittent episodes of worsening symptoms. The symptoms have a gradual onset. The client also has a history of hypertension and atherosclerosis. What does the nurse suspect that the client is probably experiencing? a. Embolic stroke b. Hemorrhagic stroke c. Thrombotic stroke d. Transient ischemic attack

c. Thrombotic stroke

What is the most effective agent and mainstay of treatment for parkinson's disease?

levodopa (converted to dopamine in the basal ganglia, producing symptom relief)

concussion

violent shaking up or jarring of the brain

What are some of the causes of conductive hearing loss?

•perforated TM •hardening of the ossicles •cerumen blocking ear canal

A patient is in the acute phase of an ischemic stroke. How long does the nurse know that this phase may last? a) Up to 1 week b) Up to 24 hours c) 1 to 3 days d) Up to 2 weeks

1 to 3 days The acute phase of an ischemic stroke may last 1 to 3 days, but ongoing monitoring of all body systems is essential as long as the patient requires care.

What is the most common cause of brain trauma?

1st. falls 2nd. motor vehicle accident

A patient with otosclerosis has significant hearing loss. What should the nurse do to best facilitate communication with the patient? A) Sit or stand in front of the patient when speaking. B) Use exaggerated lip and mouth movements when talking. C) Stand in front of a light or window when speaking. D) Say the patient's name loudly before starting to talk

A

To assess a client's cranial nerve function, a nurse should assess: a) gag reflex. b) arm drifting. c) hand grip. d) orientation to person, time, and place.

A - gag reflex The gag reflex is governed by the glossopharyngeal nerve, one of the cranial nerves. Hand grip and arm drifting are part of motor function assessment. Orientation is an assessment parameter related to a mental status examination.

The nurse is caring for a patient who is hospitalized with an exacerbation of MS. To ensure the patient's safety, what nursing action should be performed? A) Ensure that suction apparatus is set up at the bedside. B) Pad the patient's bed rails. C) Maintain bed rest whenever possible. D) Provide several small meals each day.

A) Ensure that suction apparatus is set up at the bedside.

Which positioning strategy should be utilized for the patient diagnosed with hypovolemic shock? a) Modified Trendelenburg b) Semi-Fowler's c) Supine d) Prone

A, A modified Trendelenburg position is recommended in hypovolemic shock. Elevation of the legs promotes the return of venous blood.

A nurse is concerned that a preoperative client has a great deal of anxiety about the upcoming procedure. What action by the nurse is best? a. Ask the client to describe current feelings. b. Determine if the client wants a chaplain. c. Reassure the client this surgery is common. d. Tell the client there is no need to be anxious.

ANS: A The nurse needs to conduct further assessment of the client's anxiety. Asking open-ended questions about current feelings is an appropriate way to begin. The client may want a chaplain, but the nurse needs to do more for the client. Reassurance can be good, but false hope is not, and simply reassuring the client may not be helpful. Telling the client not to be anxious belittles the client's feelings. DIF: Applying/Application REF: 222 KEY: Preoperative nursing| anxiety| support MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Psychosocial Integrity

A postoperative client has just been admitted to the postanesthesia care unit (PACU). What assessment by the PACU nurse takes priority? a. Airway b. Bleeding c. Breathing d. Cardiac rhythm

ANS: A Assessing the airway always takes priority, followed by breathing and circulation. Bleeding is part of the circulation assessment, as is cardiac rhythm.

Which statement would the nurse include when teaching the assistive personnel (AP) about how to care for a client with cranial nerve II impairment? a. "Tell the client where food items are on the breakfast tray." b. "Place the client in a high-Fowler position for all meals." c. "Make sure the client's food is visually appetizing." d. "Assist the client by placing the fork in the left hand."

ANS: A Cranial nerve II, the optic nerve, provides central and peripheral vision. A patient who has cranial nerve II impairment will have decreased visual acuity, so the AP would tell the client where different food items are on the meal tray. The other options are not appropriate for client with cranial nerve II impairment.

The nurse is assessing a client who has symptoms of stroke. What are the leading causes of a stroke for which the nurse would assess for this client? (Select all that apply.) a. Heavy alcohol intake b. Diabetes mellitus c. Elevated cholesterol d. Obesity e. Smoking f. Hypertension

ANS: A, B, C, D, E, F The leading causes of stroke include all of these factors.

A nurse learns older adults are at higher risk for complications after surgery. What reasons for this does the nurse understand? (Select all that apply.) a. Decreased cardiac output b. Decreased oxygenation c. Frequent nocturia d. Mobility alterations e. Inability to adapt to changes f. Slower reaction times

ANS: A, B, C, D, F Older adults have many age-related physiologic changes that put them at higher risk of falling and other complications after surgery. Some of these include decreased cardiac output, decreased oxygenation of tissues, nocturia, mobility alterations, and slower reaction times. They also have a decreased ability to adapt to new surroundings, but that is not the same as being unable to adapt.

18. Health promotion activities the nurse could suggest to a community group for Huntington's disease include a.Eating foods high in omega-3 fatty acids. b.genetic screening for high-risk individuals. c.limiting exposure to heavy metals. d.taking 400 International Units of vitamin E daily.

ANS: B Huntington's disease is inherited in an autosomal-dominant pattern. Genetic testing is available to families in which a member has Huntington's disease. The availability of the testing has created some ethical conflicts. DIF: Application/Applying REF: p. 1908 OBJ: Intervention MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Health Screening

A nurse assesses a client who has multiple areas of ecchymosis on both arms. Which question will the nurse ask first? a. "Are you using lotion on your skin?" b. "Do you have a family history of this?" c. "Do your arms itch?" d. "What medications are you taking?"

ANS: D Certain drugs such as aspirin, warfarin, and corticosteroids can lead to easy or excessive bruising, which can result in ecchymosis. The other options would not provide information about bruising.

Ménière's Disease

Abnormal inner ear fluid balance cause by malabsorption of the endolymphatic sac or blockage of the endolymphatic duct

A client with Cushing syndrome may have a brain tumor that produces which hormone

Adrenocorticotropic hormone (ACTH)

Which term refers to the failure to recognize familiar objects perceived by the senses?

Agnosia Explanation: Auditory agnosia is failure to recognize significance of sounds. Agraphia refers to disturbances in writing intelligible words. Apraxia refers to an inability to perform previously learned purposeful motor acts on a voluntary basis. Perseveration is the continued and automatic repetition of an activity, word, or phrase that is no longer appropriate.

Which of the following terms refer to the failure to recognize familiar objects perceived by the senses? a) Agnosia b) Perseveration c) Apraxia d) Agraphia

Agnosia Auditory agnosia is failure to recognize significance of sounds. Agraphia refers to disturbances in writing intelligible words. Apraxia refers to inability to perform previously learned purposeful motor acts on a voluntary basis. Perseveration is the continued and automatic repetition of an activity, word, or phrase that is no longer appropriate.

A nurse who provides care at a community clinic is in contact with a diverse group of patients. Which of the following individuals most clearly displays risk factors for stroke?

An obese woman with a history of atrial fibrillation and type 2 diabetes Explanation: Obesity, atrial fibrillation, and type 2 diabetes are all highly significant risk factors for stroke. None of the other listed individuals displays multiple risk factors for stroke.

26. The nurse is planning the care of a patient who has been recently diagnosed with a cerebellar tumor. Due to the location of this patient's tumor, the nurse should implement measures to prevent what complication? A)Falls B)Audio hallucinations C)Respiratory depression D)Labile BP

Ans: A Feedback: A cerebellar tumor causes dizziness, an ataxic or staggering gait with a tendency to fall toward the side of the lesion, and marked muscle incoordination. Because of this, the patient faces a high risk of falls. Hallucinations and unstable vital signs are not closely associated with cerebellar tumors.

The nurse is conducting a focused neurologic assessment. When assessing the patient's cranial nerve function, the nurse would include which of the following assessments? A) Assessment of hand grip B) Assessment of orientation to person, time, and place C) Assessment of arm drift D) Assessment of gag reflex

Ans: D Feedback: The gag reflex is governed by the glossopharyngeal nerve, one of the cranial nerves. Hand grip and arm drifting are part of motor function assessment. Orientation is an assessment parameter related to a mental status examination.

A patient got a sliver of glass in his eye when a glass container at work fell and shattered. The glass had to be surgically removed and the patient is about to be discharged home. The patient asks the nurse for a topical anesthetic for the pain in his eye. What should the nurse respond? A) Overuse of these drops could soften your cornea and damage your eye. B) You could lose the peripheral vision in your eye if you used these drops too much. C) I'm sorry, this medication is considered a controlled substance and patients cannot take it home. D) I know these drops will make your eye feel better, but I can't let you take them home.

Ans: A Feedback: Most patients are not allowed to take topical anesthetics home because of the risk of overuse. Patients with corneal abrasions and erosions experience severe pain and are often tempted to overuse topical anesthetic eye drops. Overuse of these drops results in softening of the cornea. Prolonged use of anesthetic drops can delay wound healing and can lead to permanent corneal opacification and scarring, resulting in visual loss. The nurse must explain the rationale for limiting the home use of these medications.

The nurse caring for a patient in a persistent vegetative state is regularly assessing for potential complications. Complications of neurologic dysfunction for which the nurse should assess include which of the following? Select all that apply. A) Contractures B) Hemorrhage C) Pressure ulcers D) Venous thromboembolism E) Pneumonia

Ans: A, C, D, E Feedback: Based on the assessment data, potential complications may include respiratory distress or failure, pneumonia, aspiration, pressure ulcer, deep vein thrombosis (DVT), and contractures. The pathophysiology of decreased LOC does not normally create a heightened risk for hemorrhage.

A patient is scheduled for enucleation and the nurse is providing anticipatory guidance about postoperative care. What aspects of care should the nurse describe to the patient? Select all that apply. A) Application of topical antibiotic ointment B) Maintenance of a supine position for the first 48 hours postoperative C) Fluid restriction to prevent orbital edema D) Administration of loop diuretics to prevent orbital edema E) Use of an ocular pressure dressing

Ans: A, E Feedback: Patients who undergo eye removal need to know that they will usually have a large ocular pressure dressing, which is typically removed after a week, and that an ophthalmic topical antibiotic ointment is applied in the socket three times daily. Fluid restriction, supine positioning, and diuretics are not indicated.

The nurse is participating in the care of a patient with increased ICP. What diagnostic test is contraindicated in this patient's treatment? A) Computed tomography (CT) scan B) Lumbar puncture C) Magnetic resonance imaging (MRI) D) Venous Doppler studies

Ans: B Feedback: A lumbar puncture in a patient with increased ICP may cause the brain to herniate from the withdrawal of fluid and change in pressure during the lumbar puncture. Herniation of the brain is a dire and frequently fatal event. CT, MRI, and venous Doppler are considered noninvasive procedures and they would not affect the ICP itself.

A nurse is reviewing the trend of a patient's scores on the Glasgow Coma Scale (GCS). This allows the nurse to gauge what aspect of the patient's status? A) Reflex activity B) Level of consciousness C) Cognitive ability D) Sensory involvement

Ans: B Feedback: The Glasgow Coma Scale (GCS) examines three responses related to LOC: eye opening, best verbal response, and best motor response.

The nurse is caring for a 51-year-old female patient whose medical history includes chronic fatigue and poorly controlled back pain. These medical diagnoses should alert the nurse to the possibility of what consequent health problem? A) Anxiety B) Skin breakdown C) Depression D) Hallucinations

Ans: Depression Feedback: Depression is associated with chronic pain and can be exacerbated by the effects of chronic fatigue. Anxiety is also plausible, but depression is a paramount risk. Skin breakdown and hallucinations are much less likely.

A client hospitalized for hypertension presses the call light and reports "feeling funny." When the nurse gets to the room, the client is slurring words and has right-sided weakness. What does the nurse do first?

Assesses airway, breathing, and circulation

Which level of the triage system is implemented when the patient requires two or more resources? a) Minor b) Urgent c) Emergent d) Nonurgent

B

A family member brings the patient to the clinic for a follow-up visit after a stroke. The family member asks the nurse what he can do to decrease his chance of having another stroke. What would be the nurse's best answer? A) "Have your heart checked regularly." B) "Stop smoking as soon as possible." C) "Get medication to bring down your sodium levels." D) "Eat a nutritious diet."

B) "Stop smoking as soon as possible."

Which of the following colloids is expensive but rapidly expands plasma volume? a) Dextran b) Albumin c) Hypertonic saline d) Lactated Ringer's

B, Albumin is a colloid that requires human donors, is limited in supply, and can cause congestive heart failure. Dextran interferes with platelet aggregation and is not recommended for hemorrhagic shock. Lactated Ringer's and hypertonic saline are crystalloids, not colloids

As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for benefit 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 (Feedback: Some of the absolute contraindications for thrombolytic therapy include symptom onset greater than 3 hours before admission, a patient who is anticoagulated (with an INR above 1.7), or a patient who has recently had any type of intracranial pathology (e.g., previous stroke, head injury, trauma).)

Which of the following is a common cancer that metastasizes to the spinal cord? Select all that apply. a) Brain b) Breast c) Colon d) Lung e) Prostate

B,D,E Cancer can spread to the spinal cord. The three most common cancers that metastasize to the spinal cord are breast, prostate, and lung. Cancer can invade the cord, causing vertebral metastases. Colon and brain cancers do not commonly metastasize to the spinal cord.

The nurse is assessing a patient with multiple sclerosis who is demonstrating involuntary, rhythmic eye movements. What term will the nurse use when documenting these eye movements? A) Vertigo B) Tinnitus C) Nystagmus D) Astigmatism

C

The nurse is discharging home a patient who suffered a stroke. He has a flaccid right arm and leg and is experiencing problems with urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common patient response to a change in body image? A) Denial B) Fear C) Depression D) Disassociation

C) Depression

Which of the following is the initial diagnostic in suspected stroke? a) CT with contrast b) Cerebral angiography c) Noncontrast computed tomography (CT) d) Magnetic resonance imaging (MRI)

C, An initial head CT scan will determine whether or not the patient is experiencing a hemorrhagic stroke. An ischemic infarction will not be readily visible on initial CT scan if it is performed within the first few hours after symptoms onset; however, evidence of bleeding will almost always be visible.

A patient arrives in the emergency department with complaints of chest pain radiating to the jaw. What medication does the nurse anticipate administering to reduce pain and anxiety as well as reducing oxygen consumption? a) Demerol b) Codeine c) Morphine d) Dilaudid

C, If a patient experiences chest pain, IV morphine is administered for pain relief. In addition to relieving pain, morphine dilates the blood vessels. This reduces the workload of the heart by both decreasing the cardiac filling pressure (preload) and reducing the pressure against which the heart muscle has to eject blood (afterload). Morphine also decreases the patient's anxiety and reduces the respiratory rate, and thus oxygen consumption.

The nurse observes for fluid and electrolyte changes during the acute phase based on the knowledge that fluid remobilization usually begins: a) After 10 days, when scar tissue begins to cover the wound and prevent evaporative fluid loss. b) After 5 days, when capillary permeability has returned to normal. c) After 48 to 72 hours later, when fluid is moving from the interstitial to the intravascular compartment. d) Within the first 24 hours, when massive amounts of fluid are being administered intravenously.

C, When fluid shifts back to the intravascular compartment, a number of electrolyte changes can occur. Refer to Table 53-4 in the text

The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following?

Cardiogenic emboli Explanation: Aneurysms, hemorrhages, and malformations are all examples of a hemorrhagic stroke. An embolism can block blood flow, leading to ischemia.

The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following? a) Cerebral aneurysm b) Cardiogenic emboli c) Intracerebral hemorrhage d) Arteriovenous malformation

Cardiogenic emboli Aneurysms, hemorrhages, and malformations are all examples of a hemorrhagic stroke. An embolism can block blood flow, leading to ischemia.

Which of the following nurse's actions carries the greatest potential to prevent hearing loss due to ototoxicity? A) Ensure that patients understand the differences between sensory hearing loss and conductive hearing loss. B) Educate patients about expected age-related changes in hearing perception. C) Educate patients about the risks associated with prolonged exposure to environmental noise. D) Be aware of patients' medication regimens and collaborate with other professionals accordingly.

D *aspirin and quinine, cause irreversible hearing loss.

A nursing student is writing a care plan for a newly admitted patient who has been diagnosed with a stroke. What major nursing diagnosis should most likely be included in the patient's plan of care? A) Adult failure to thrive B) Post-trauma syndrome C) Hyperthermia D) Disturbed sensory perception

D) Disturbed sensory perception

Inhalation of anthrax mimics which disease process? a) Burns b) Bronchospasm c) Respiratory distress d) Flu

D, Anthrax symptoms mimic those of the flu, and usually treatment is sought only when the second stage of severe respiratory distress occurs. Burns occur with sulfur mustard. Bronchospasm can occur with phosgene or chlorine. Respiratory distress may occur with cyanide.

What is the pathophysiology of Parkinson's disease?

Decreased levels of dopamine caused by destruction of cells in the substantia nigra in the basal ganglia; this affects the neurotransmission of impulses.

After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client?

Elevating the head of the bed to 30 degrees

Types of Aphasia

Global (Speech is absent or severely reduced) Broca's (Person can understand language, but cannot use language themselves) receptive, Wernicke's: (Can speak, but cannot understand)

Which is the most common motor dysfunction seen in clients diagnosed with stroke? a. Diplopia b. Ataxia c. Hemiparesis d. Hemiplegia

Hemiplegia which is caused by a lesion of the opposite side of the brain.

Chronic progressive hereditary disease that results in choreiform movement and dementia.

Huntington's disease

A client is receiving an I.V. infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant? a) Elevated blood pressure b) Decreased level of consciousness (LOC) c) Increased urine output d) Decreased heart rate

Increased urine output The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.

What is a complication of postpolio syndrome?

Low bone mass and osteoporosis.

The nurse is caring for a client after lumbar puncture. The client reports a severe headache. Which actions should the nurse complete? Select all that apply. a) Administer analgesic medication. b) Administer fluids to the client. c) Position the client in the supine position. d) Maintain the client on bed rest. e) Prepare for an epidural blood patch.

Maintain the patient on bed rest. Administer fluids to the patient. Administer analgesic medication. When the patient assumes an upright position, tension and stretching of the venous sinuses and pain-sensitive structures occur. A postpuncture headache is usually managed by bed rest, analgesic agents, and hydration. Postlumbar puncture headache may be avoided if a small-gauge needle is used and if the patient remains prone after the procedure. When more than 20 mL of the CSF is removed, the patient is positioned supine for 6 hours.

Which is the initial diagnostic test for a stroke?

Noncontrast computed tomography Explanation: The initial diagnostic test for a stroke is nonconstrast computed tomography performed emergently to determine whether the event is ischemic or hemorrhagic. Further diagnostics include a carotid Doppler, electrocardiogram, and transcranial Doppler.

How should the nurse irrigate the ear?

Remove cerumen using warm water (cold stimulates vomiting) and a gentle irrigation in order to avoid perforating the tympanic membrane

8. A nurse in the ICU is providing care for a patient who has been admitted with a hemorrhagic stroke. The nurse is performing frequent neurologic assessments and observes that the patient is becoming progressively more drowsy over the course of the day. What is the nurse's best response to this assessment finding? a. Report this finding to the physician as an indication of decreased metabolism. b. Provide more stimulation to the patient and monitor the patient closely. c. Recognize this as the expected clinical course of a hemorrhagic stroke. d. Report this to the physician as a possible sign of clinical deterioration.

Report this to the physician as a possible sign of clinical deterioration.

otolaryngologists.

Specialize in the ear, nose, and throat.

High doses of chemotherapy or radiation therapy is associated with bone marrow toxicity. What does this mean?

The patients red, white and platelet blood cells drop. Autologous bone marrow transplants help to rescue the patient form the bone marrow toxicity.

After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know whether the client has a cervical spinal injury. Until such an injury is ruled out, the nurse should restrict this client to which position? a. A head elevation of 90 degrees to prevent cerebral swelling b. Supine, with the head of the bed elevated 30 degrees c. Flat, except for logrolling as needed d. Flat

When caring for the client with a possible cervical spinal injury who's wearing a cervical collar, the nurse must keep the client FLAT to decrease mobilization and prevent further injury to the spinal column. The client can be logrolled, if necessary, with the cervical collar on.

Opioid analgesics are effective pain management tools for many clients. A significant portion of a nurse's practice is older adults who suffer from chronic pain. What impact does a client's age have on initial dosing? a. Older clients should receive a reduced dose. b. Older clients should receive an increased dose. c. Opioid analgesics should not be used to treat older adults. d. Age has no impact on dosing.

a A reduced dose of analgesics, especially opioid analgesics, may be prescribed for the older adult initially because older adults experience a higher peak effect and longer duration of pain relief from an opioid. An increased dose is not generally recommended for older adults. Opioid analgesics can be used to treat older adults, but there are special dosing considerations.

The nurse is caring for a client whose medical history includes chronic fatigue and poorly controlled back pain. These medical diagnoses should alert the nurse to the possibility of what consequent health problem? a. Anxiety b. Skin breakdown c. Depression d. Hallucinations

c Depression is associated with chronic pain and can be exacerbated by the effects of chronic fatigue. Anxiety is also plausible, but depression is a paramount risk. Skin breakdown and hallucinations are much less likely.

During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates: a) cranial nerves IX and X. b) cranial nerves III and V. c) cranial nerves VI and VIII. d) cranial nerves I and II.

cranial nerves IX and X. Swallowing is a motor function of cranial nerves IX and X. Cranial nerves I, II, and VIII don't possess motor functions. The motor functions of cranial nerve III include extraocular eye movement, eyelid elevation, and pupil constriction. The motor function of cranial nerve V is chewing. Cranial nerve VI controls lateral eye movement.

What laboratory value is unexpected during the fluid remobilization phase of a major burn? Select one: a. Hematocrit level 45% b. pH 7.2, paO2 38 mm Hg, and bicarbonate level of 15 meq/L c. Serum K+ 3.2 meq/L d. Serum Na+ 140 meq/L

d. Serum Na+ 140 meq/L

Lhermitte's phenomenon

electrical sensation passing down the back and limbs upon flexion of the neck.

An aneurysm is a balloon-like bulge of an artery wall. As an aneurysm grows it puts pressure on nearby structures and may eventually rupture. A ruptured aneurysm releases blood into the subarachnoid space around the brain. A subarachnoid hemorrhage (SAH) is a life-threatening type of stroke. Treatment:

focuses on stopping the bleeding and repairing the aneurysm with clipping, coiling, or bypass.

receptive aphasia

inability to understand spoken or written words

Labyrinthitis

inflammation of the labyrinth

Autonomic Dysreflexia

involves uncontrolled activation of autonomic neurons

Name a common medication that patients will be prescribed if they have atrial fibrillation?

warfarin (Coumadin)

Following mastoid surgery the patient asks about showering. How should the nurse respond?

•No water should be allowed to enter the ear for 2 wks. •OK to shampoo or shower 2 - 3 days after surgery as long as the affected ear is protected from water. •Saturate cotton ball with petrolatum jelly and place loosely into the ear.

Which clinical manifestations are associated with hearing loss?

•Tinnitus •Increased inability to hear in a group •Turning up the volume on the TV •Fatigue:

When communicating with a client who has sensory (receptive) aphasia, the nurse should: 1. allow time for the client to respond. 2. speak loudly and articulate clearly. 3. give the client a writing pad. 4. use short, simple sentences.

4. use short, simple sentences. Although receptive aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension. *Allowing time for the client to respond might be helpful, but it's less important than simplifying the communication.

A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time?

4:00 p.m. Explanation: Tissue plasminogen activator (tPA) must be given within 3 hours after symptom onset. Therefore, since symptom onset was 1:00 pm, the window of opportunity ends at 4:00 pm.

A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time? a) 5:30 p.m. b) 3:00 p.m. c) 4:00 p.m. d) 2:30 p.m.

4:00 p.m. Tissue plasminogen activator (tPA) must be given within 3 hours after symptom onset. Therefore, since symptom onset was 1:00 pm, the window of opportunity ends at 4:00 pm.

The nurse is providing discharge education for a patient with a new diagnosis of Ménière's disease. What food should the patient be instructed to limit or avoid? A) Sweet pickles B) Frozen yogurt C) Shellfish D) Red meat

A *The patient with MÈniËre's disease should avoid foods high in salt and/or sugar; sweet pickles are high in both.

After the patient has received tPA, the nurse knows to check vital signs every 30 minutes for 6 hours. Which of the following readings would require calling the provider? a) Diastolic pressure of 110 mm Hg b) Heart rate of 100 c) Systolic pressure of 180 mm Hg d) Respiration of 22

A, A diastolic pressure reading of over 105 mm Hg warrants notifying the health care provider. The other choices are within normal range. Refer to Table 47-5 in the text.

The client's chart indicates genu varum. What does the nurse understand this to mean? a. Bow-legged b. Fluid accumulation c. Knock-kneed d. Spinal curvature

ANS: A Genu varum is a bow-legged deformity. A fluid accumulation is an effusion. Genu valgum is knock-kneed. A spinal curvature could be kyphosis or lordosis. DIF: Remembering/Knowledge REF: 1023 KEY: Musculoskeletal system| musculoskeletal assessment| musculoskeletal disorders MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best? a. Assess the client for anxiety. b. Break the information into smaller bits. c. Give the client written information. d. Review the information again.

ANS: A Anxiety can interfere with learning, coping, and cooperation. The nurse should assess the client for anxiety. The other actions are appropriate too, and can be included in the teaching plan, but effective teaching cannot occur if the client is highly anxious.

The nurse reads on a chart that a client has lichenification. What assessment finding confirms this description? a. Increased skin thickness b. Excessive facial hair c. Purple skin patches d. Tightly stretched skin

ANS: A Lichenification is increased skin thickness as the result of scarring. Excessive facial hair (or body hair) is hirsutism. Purple patches on the skin are purpura. Tightly stretched skin is from edema.

A nurse assesses a client who has inflamed soft-tissue folds around the nail plates. Which question will the nurse ask to elicit useful information about the possible condition? a. "What do you do for a living?" b. "Are your nails professionally manicured?" c. "Do you have diabetes mellitus?" d. "Have you had a recent fungal infection?

ANS: A The condition chronic paronychia is common in people with frequent intermittent exposure to water, such as homemakers, bartenders, and laundry workers. The other questions would not provide information specifically related to this assessment finding.

A nurse is caring for several clients prior to surgery. Which medications taken by the clients require the nurse to consult with the physician about their administration? (Select all that apply.) a. Metformin (Glucophage) b. Omega-3 fatty acids (Sea Omega 30) c. Phenytoin (Dilantin) d. Pilocarpine hydrochloride (Isopto Carpine) e. Warfarin (Coumadin)

ANS: A, C, D, E Although the client will be on NPO status before surgery, the nurse should check with the provider about allowing the client to take medications prescribed for diabetes, hypertension, cardiac disease, seizure disorders, depression, glaucoma, anticoagulation, or depression. Metformin is used to treat diabetes; phenytoin is for seizures; pilocarpine is for glaucoma, and warfarin is an anticoagulant. The omega-3 fatty acids can be held the day of surgery. DIF: Analyzing/Analysis REF: 228 KEY: Preoperative nursing| medications| NPO MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

A client has been given hydroxyzine (Atarax) in the preoperative holding area. What action by the nurse is most important for this client? a. Document giving the drug. b. Raise the siderails on the bed. c. Record the client's vital signs. d. Teach relaxation techniques.

ANS: B All actions are appropriate for a preoperative client. However, for client safety, the nurse should raise the siderails on the bed because hydroxyzine can make the client sleepy. DIF: Applying/Application REF: 234 KEY: Preoperative nursing| safety| hydroxyzine MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom?

Cerebral aneurysm Explanation: A cerebral aneurysm is a type of hemorrhagic stroke that is characterized by an exploding headache.

A client is admitted to the emergency department with a probable traumatic brain injury. Which assessment finding would be the priority for the nurse to report to the primary health care provider? a. Mild temporal headache b. Pupils equal and react to light c. Alert and oriented 3 d. Decreasing level of consciousness

ANS: D A decreasing level of consciousness is the first sign of increasing intracranial pressure, a potentially severe and possibly fatal complication of a traumatic brain injury (TBI). A mild headache would be expected for a client having a TBI. Equal reactive pupils and being alert and oriented are normal assessment findings.

After teaching a patient who is scheduled for magnetic resonance imaging (MRI), the nurse assesses the client's understanding. Which statement indicates client understanding of the teaching? a. "I must increase my fluids because of the dye used for the MRI." b. "My urine will be radioactive so I should not share a bathroom." c. "My gag reflex will be tested before I can eat or drink anything." d. "I can return to my usual activities immediately after the MRI."

ANS: D No postprocedure restrictions are imposed after MRI. The client can return to normal activities after the test is complete. There are no dyes or radioactive materials used for the MRI; therefore, increased fluids are not needed and the client's urine would not be radioactive. The procedure does not impact the client's gag reflex.

The nurse is caring for a client who had a hemorrhagic stroke. Which assessment finding is the earliest sign of increasing intracranial pressure (ICP) for this client? a. Projectile vomiting b. Dilated and nonreactive pupils c. Severe hypertension d. Decreased level of consciousness

ANS: D The earliest sign of increasing ICP is decreased level of consciousness. The other signs occur later.

A patient with low vision has called the clinic and asked the nurse for help with acquiring some low-vision aids. What else can the nurse offer to help this patient manage his low vision? A) The patient uses OTC NSAIDs. B) The patient has a history of stroke. C) The patient has diabetes. D) The patient has Asian ancestry.

Ans: C Feedback: Diabetes is a risk factor for glaucoma, but Asian ancestry, NSAIDs, and stroke are not risk factors for the disease.

A patient with a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the patient's risk for orthostatic hypotension? A) Administer an IV bolus of normal saline prior to repositioning. B) Maintain bed rest until normal BP regulation returns. C) Monitor the patient's BP before and during position changes. D) Allow the patient to initiate repositioning.

Ans: C Feedback: To prevent hypotensive episodes, close monitoring of vital signs before and during position changes is essential. Prolonged bed rest carries numerous risks and it is not possible to provide a bolus before each position change. Following the patient's lead may or may not help regulate BP.

The nurse is administering eye drops to a patient with glaucoma. After instilling the patient's first medication, how long should the nurse wait before instilling the patient's second medication into the same eye? A) 30 seconds B) 1 minute C) 3 minutes D) 5 minutes

Ans: D Feedback: A 5-minute interval between successive eye drop administrations allows for adequate drug retention and absorption. Any time frame less than 5 minutes will not allow adequate absorption.

A patient with a diagnosis of retinal detachment has undergone a vitreoretinal procedure on an outpatient basis. What subject should the nurse prioritize during discharge education? A) Risk factors for postoperative cytomegalovirus (CMV) B) Compensating for vision loss for the next several weeks C) Non-pharmacologic pain management strategies D) Signs and symptoms of increased intraocular pressure

Ans: D Feedback: Patients must be educated about the signs and symptoms of complications, particularly of increasing IOP and postoperative infection. CMV is not a typical complication and the patient should not expect vision loss. Vitreoretinal procedures are not associated with high levels of pain.

Daniel is exhibiting classic signs of hemorrhagic stroke. What complaint is an indicator of this type of stroke? Select one: a. Arm or leg numbness b. Double vision c. Severe headache d. Dizziness and tinnitis

c. Severe headache

A patient diagnosed with myasthenia gravis has been hospitalized to receive plasmapheresis for a myasthenic exacerbation. The nurse knows that the course of treatment for plasmapheresis in a patient with myasthenia gravis is what? A) Every day for 1 week B) Determined by the patient's response C) Alternate days for 10 days D) Determined by the patient's weight

B) Determined by the patient's response

A client with a traumatic brain injury from a motor vehicle crash is monitored for signs/symptoms of increased intracranial pressure (ICP). Which sign/symptoms does the nurse monitor for?

Changes in breathing pattern

Brain stem ischemia

Cranial nerve Vl (Abducens)

8. A patient sustained a head injury and has been admitted to the neurosurgical intensive care unit (ICU). The patient began having seizures and was given a sedative-hypnotic medication that is ultrashort acting and can be titrated to patient response. What medication will the nurse be monitoring during this time? a. Lorazepam b. Midazolam c. Phenobarbital d. Propofol

D

A middle-aged woman has sought care from her primary care provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the woman to seek care? A) Cognitive declines B) Personality changes C) Contractures D) Difficulty in coordination

D) Difficulty in coordination

Which disturbance results in loss of half of the visual field?

Homonymous hemianopsia

Which terms refers to blindness in the right or left half of the visual field in both eyes?

Homonymous hemianopsia

What is the trade name for Atorvastatin?

LIPITOR

A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment?

Lack of deep tendon reflexes

A client who complains of recurring headaches, accompanied by increased irritability, photophobia, and fatigue is asked to track the headache symptoms and occurrence on a calendar log. Which is the best nursing rationale for this action?

Migraines often coincide with menstrual cycle. Explanation: Changes in reproductive hormones as found during menstrual cycle can be a trigger for migraine headaches and may assist in the management of the symptoms. Cluster headaches can cause severe pain but is not the reason for tracking. Tension headaches can be managed but is not associated with a monthly calendar. Headaches are common but not the reason for tracking.

Why is nutrition carefully assessed in patients with brain tumors?

Nausea, vomiting, diarrhea, breathlessness and pain can lead to nutritional deficits.

A client diagnosed with a stroke is ordered to receive warfarin. Later, the nurse learns that the warfarin is contraindicated and the order is canceled. The nurse knows that the best alternative medication to give is

aspirin.

A client is prescribed morphine for a possible ankle fracture. When the nurse brings in a second dose of the medication, the client states, "This medicine made me sick." The nurse replies a. "I will notify your physician." b. "What do you mean by the word sick?" c. "A lot of people have a similar problem with this medication." d. "A nausea medication has been prescribed that I will give you."

b Nausea may occur with opiod use; however, before taking any other action, the nurse needs to clarify that this is what the client means by the word "sick."

A sensorineural hearing loss results from impairment of which cranial nerve? Select one: a. 6th b. 8th c. 3rd d. 9th

b. 8th

Dopamine is typically inhibitory and affects _____ and ______ ______

behavior and fine movement

Excess production of tears is known as Select one: a. Photophobia b. Aphakia c. Epiphora d. Strabismus

c. Epiphora

Alpha-adrenergic agonists (brimonidine) and carbonic anyhdrase inhibitors (acetazolamide) both __________ aqueous humor production*

decrease

The nurse is instructing a community class when a student asks, "How does someone get super strength in an emergency?" The nurse should respond by describing the action of the: a) endocrine system. b) sympathetic nervous system. c) parasympathetic nervous system. d) musculoskeletal system.

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

During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer?

"Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation.

A client preparing to undergo a lumbar puncture states he doesn't think he will be able to get comfortable with his knees drawn up to his abdomen and his chin touching his chest. He asks if he can lie on his left side. Which statement is the best response by the nurse? a) "Lying on your left side will be fine during the procedure." b) "There's no other option but to assume the knee-chest position." c) "Although the required position may not be comfortable, it will make the procedure safer and easier to perform." d) "I'll report your concerns to the physician."

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

A client is considering treatments for a malignant brain tumor. Which statement by the client indicates a need for further instruction by the nurse?

"I can go home the day of my craniotomy."

The daughter of a client who has had a stroke asks the nurse for additional resources. What is the nurse's best response?

"The National Stroke Association has resources available."

Labyrinthitis treatment

- IV antibiotic therapy - fluid replacement - administration of an antihistamine ( meclizine and antiemetic medications )

Intraocular pressure (___ to ___ mm Hg) is determined by the amount of aqueous humor that is produced and drained

10-21

Fill in the blank (with a number) question - Enter the answer in the space provided. Your answer should contain only numbers and, if necesary, a decimal point. A nurse is assessing a client with increasing intracranial pressure. What is a client's mean arterial pressure (MAP) in mm Hg when blood pressure (BP) is 120/60 mm Hg? Record your answer using a whole number. __________ mm Hg

80mmHg

Flumazenil has been ordered for a client who has overdosed on oxazepam. Before administering the medication, the nurse should be prepared for which common adverse effect? a) Seizures b) Shivering c) Chest pain d) Anxiety

A - seizures Seizures are the most common serious adverse effect of using flumazenil to reverse benzodiazepine overdose. The effect is magnified if the client has a combined tricyclic antidepressant and benzodiazepine overdose. Less common adverse effects include shivering, anxiety, and chest pain.

A patient diagnosed with Bell's palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions? A) Applying a protective eye shield at night B) Chewing on the affected side to prevent unilateral neglect C) Avoiding the use of analgesics whenever possible D) Avoiding brushing the teeth

A) Applying a protective eye shield at night

A postoperative client has just been admitted to the postanesthesia care unit (PACU). What assessment by the PACU nurse takes priority? a. Airway b. Bleeding c. Breathing d. Cardiac rhythm

ANS: A Assessing the airway always takes priority, followed by breathing and circulation. Bleeding is part of the circulation assessment, as is cardiac rhythm. DIF: Applying/Application REF: 266 KEY: Postoperative nursing| nursing assessment| respiratory assessment| respiratory system| postanesthesia care unit (PACU)| airway MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

5. A client is being treated in the clinic for an exacerbation of multiple sclerosis. The nurse would anticipate administering which drug? a.Diazepam (Valium) b.Interferon b1b (Betaseron) c.Lioresal (Baclofen) d.Methylprednisolone (Solu-Cortef)

ANS: B Drugs used to treat exacerbations in ambulatory clients include Interferon b1b, Interferon b1a (Avonex), and glatiramer acetate (Copaxone). Diazepam and lioresal could be used to treat spasticity, while steroids are used for acute relapses. DIF: Application/Applying REF: p. 1911 OBJ: Intervention MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Pharmacological Agents/Actions

4. The nurse reminds a group of students about the major component of pathophysiology in multiple sclerosis (MS), which is a.damage occurs primarily to the dendrites and oligodendrites. b.once damaged, myelin cannot regenerate at all. c.plaques occur anywhere in the white matter of the central nervous system (CNS). d.Schwann cells are destroyed slowly but relentlessly.

ANS: C Although plaques may occur anywhere in the white matter of the CNS, the areas most commonly involved are the optic nerves, cerebrum, and cervical spinal cord. DIF: Comprehension/Understanding REF: p. 1909 OBJ: Intervention MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain? a. Loss of bladder control b. Other medical conditions c. Progression of symptoms d. Time of symptom onset

ANS: D The time limit for initiating fibrinolytic therapy for a stroke is 3 to 4.5 hours, so the exact time of symptom onset is the most important information for this client. The other information is not as critical.

A nurse is caring for a patient diagnosed with Ménière's disease. While completing a neurologic examination on the patient, the nurse assesses cranial nerve VIII. The nurse would be correct in identifying the function of this nerve as what? A) Movement of the tongue B) Visual acuity C) Sense of smell D) Hearing and equilibrium

Ans: D Feedback: Cranial nerve VIII (acoustic) is responsible for hearing and equilibrium. Cranial nerve XII (hypoglossal) is responsible for movement of the tongue. Cranial nerve II (optic) is responsible for visual acuity and visual fields. Cranial nerve I (olfactory) functions in sense of smell.

The nurse has admitted a new patient to the unit. One of the patient's admitting orders is for an adrenergic medication. The nurse knows that this medication will have what effect on the circulatory system? A) Thin, watery saliva B) Increased heart rate C) Decreased BP D) Constricted bronchioles

Ans: B The term "adrenergic" refers to the sympathetic nervous system. Sympathetic effects include an increased rate and force of the heartbeat. Cholinergic effects, which correspond to the parasympathetic division of the autonomic nervous system, include thin, watery saliva, decreased rate and force of heartbeat, and decreased BP.

An older adult patient has been diagnosed with macular degeneration and the nurse is assessing him for changes in visual acuity since his last clinic visit. When assessing the patient for recent changes in visual acuity, the patient states that he sees the lines on an Amsler grid as being distorted. What is the nurse's most appropriate response? A) Ask if the patient has been using OTC vasoconstrictors. B) Instruct the patient to repeat the test at different times of the day when at home. C) Arrange for the patient to visit his ophthalmologist. D) Encourage the patient to adhere to his prescribed drug regimen.

Ans: C Feedback: With a change in the patient's perception of the grid, the patient should notify the ophthalmologist immediately and should arrange to be seen promptly. This is a priority over encouraging drug adherence, even though this is also important. Vasoconstrictors are not a likely cause of this change and repeating the test at different times is not relevant.

The nurse is taking care of a client with a headache. In addition to administering medications, the nurse takes which measure to assist the client in reducing the pain associated with the headache?

Apply warm or cool cloths to the forehead or back of the neck. Explanation: Warmth promotes vasodilation; cool stimuli reduce blood flow.

A nurse is planning preoperative teaching for a patient with hearing loss due to otosclerosis. The patient is scheduled for a stapedectomy with insertion of a prosthesis. What information is most crucial to include in the patient's preoperative teaching? A) The procedure is an effective, time-tested treatment for sensory hearing loss. B) The patient is likely to experience resolution of conductive hearing loss after the procedure. C) Several months of post-procedure rehabilitation will be needed to maximize benefits. D) The procedure is experimental, but early indications suggest great therapeutic benefits.

B *Stapedectomy is a very successful time-tested procedure, resulting in the restoration of conductive hearing loss

As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for benefit 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) Recent intracranial pathology D) Current anticoagulation therapy E) Symptom onset greater than 3 hours prior to admission

A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as? a) An epidural hematoma b) An intracerebral hematoma c) An extradural hematoma d) A subdural hematoma

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

You're assisting a patient who has right side hemiparesis and dysphagia with eating. It is very important to: A. Keep the head of bed less than 30′. B. Check for pouching of food in the right cheek. C. Prevent aspiration by thinning the liquids. D. Have the patient extend the neck upward away from the chest while eating.

B. Because the patient has weakness on the right side and dysphagia the nurse should regularly check for pouching of food in the right cheek. Pouching of food in the cheek can lead to aspiration or choking. The HOB should be >30′, liquids thickened per MD order, and the patient should tuck in the chin to the chest while swallowing

Which of the following is the most common side effect of tissue plasminogen activator (tPA)?

Bleeding Explanation: Bleeding is the most common side effect of tPA. The patient is closely monitored for bleeding (at IV insertion sites, gums, urine/stools, and intracranially by assessing changes in level of consciousness). Headache, increased ICP, and hypertension are not side effects of tPA.

A 6-month-old infant is brought to the ED by his parents for inconsolable crying and pulling at his right ear. When assessing this infant, the advanced practice nurse is aware that the tympanic membrane should be what color in a healthy ear? A) Yellowish-white B) Pink C) Gray D) Bluish-white

C

A client is suspected of having had a stroke. Which is the initial diagnostic test for a stroke?

CT

The provider diagnoses the patient as having an ischemic stroke. The etiology of an ischemic stroke would include which of the following? a) Cerebral aneurysm b) Cardiogenic emboli c) Intracerebral hemorrhage d) Arteriovenous malformation

Cardiogenic emboli. * An embolism can block blood flow, leading to ischemia. * Aneurysms, hemorrhages, and malformations are all examples of a hemorrhagic stroke.

Merkel cells

Epidermal cells that play a role in transmission of sensory messages

A client is being discharged home after treatment for a brain attack. What is the mnemonic that the nurse can teach the family and client to help recognize and act on another stroke?

F-A-S-T

Which is a contraindication for the administration of tissue plasminogen activator (t-PA)?

Intracranial hemorrhage Explanation: Intracranial hemorrhage, neoplasm, and aneurysm are contraindications for t-PA. Clinical diagnosis of ischemic stroke, age 18 years or older, and a systolic blood pressure less than or equal to 185 mm Hg are eligibility criteria.

Which of the following antiseizure medication has been found to be effective for post-stroke pain? a) Carbamazepine (Tegretol) b) Lamotrigine (Lamictal) c) Topiramate (Topamax) d) Phenytoin (Dilantin)

Lamotrigine (Lamictal) The antiseizure medication lamotrigine (Lamictal) has been found to be effective for post-stroke pain.

A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings? a) Left-sided cerebrovascular accident (CVA) b) Completed Stroke c) Transient ischemic attack (TIA) d) Right-sided cerebrovascular accident (CVA)

Left-sided cerebrovascular accident (CVA) When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete.

________ (nearsighted) results in blurred distant vision and _______ (farsighted) results in blurred near vision

Myopia (A condition in which close objects appear clearly, but far ones don't.) hyperopia

When providing teaching to a client who reports tension headaches, which of the following instructions would be most beneficial to prevent onset of symptoms?

Perform stretching exercises and frequent position change. Explanation: Tension headaches are often associated with prolonged tensed muscles. Application of cool or warm cloths and avoidance of bright lights may help to reduce the headache after occurrence. Avoiding certain foods may prevent migraine headaches, but it is not likely to prevent tension headaches.

The _____________ test assesses both air and bone conduction of sound.

Rinne test

Abrasion

Scrape of the skin due to something abrasive

The nurse is participating in a health fair for stroke prevention. Which will the nurse say is a modifiable risk factor for ischemic stroke?

Smoking Explanation: Modifiable risk factors for transient ischemic attack (TIA) and ischemic stroke include hypertension, type 1 diabetes, cardiac disease, smoking, and chronic alcoholism. Advanced age, gender, and race are nonmodifiable risk factors for stroke.

A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following?

Thrombolytic therapy has a time window of only 3 hours. Explanation: Currently approved thrombolytic therapy for ischemic strokes has a treatment window of only 3 hours after the onset of symptoms. Urgency is needed on the part of the public for rapid entry into the medical system. The other three choices are related to hemorrhagic strokes.

_________ measures intraocular pressure and screens for glaucoma to assess IOP

Tonometry

A client reports light-headedness, speech disturbance, and left-sided weakness lasting for several hours. The neurologist diagnosed a transient ischemic attack, which caused the client great concern. What would the nurse include during client education?

When symptoms cease, the client will return to presymptomatic state.

Aleks has a known brain tumor and complains of early morning headaches. The nurse knows that the probable reason for early morning headaches is: Select one: a. Increased ICP b. Dehydration c. Migraines d. Tumor is shrinking Feedback

a. Increased ICP

Mary Anne has troubling and debilitating spasticity from her MS. What interventions can the nurse suggest to ameliorate this symptom? Select one or more: a. Take hot baths b. Demonstrate daily muscle stretching exercises c. Apply warm compresses to affected areas d. Encourage following suggested physical therapy exercises. e. Participate in a rigorous exercise program to prevent contractures.

b. Demonstrate daily muscle stretching exercises c. Apply warm compresses to affected areas d. Encourage following suggested physical therapy exercises. e. Participate in a rigorous exercise program to prevent contractures.

The nurse is assisting the anesthesiologist with the insertion of an epidural catheter and the administration of an epidural opioid for pain control. What adverse effect of epidural opioids should the nurse monitor for? a. Asystole b. Hypertension c. Bradypnea d. Tachycardia

c Most patients experience sedation at the beginning of opioid therapy and whenever the opioid dose is increased significantly. If left untreated, excessive sedation can progress to clinically significant respiratory depression (bradypnea, or reduced breathing rate).

13. A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke13% a. Numbness of an arm or leg b. Double vision c. Severe headache d. Dizziness and tinnitus

c. Severe headache

The physician has ordered a mu opioid analgesic for a patient with pain. What drug does the nurse anticipate administering? a. Nubain b. Stadol c. Buprenex d. Fentanyl

d Opioid analgesic agents are divided into two major groups: (1) mu agonist opioids (also called morphine-like drugs) and (2) agonist-antagonist opioids. The mu agonist opioids comprise the larger of the two groups and include morphine, hydromorphone, hydrocodone, fentanyl, oxycodone, and methadone, among others. The agonist-antagonist opioids include buprenorphine (Buprenex, Butrans), nalbuphine (Nubain), and butorphanol (Stadol).

A client is eating a soft diet while recovering from a stroke. The client reports food accumulating in the cheek of the affected side. What is the nurse's best response? a. "Next time you eat, try lifting your chin when you swallow." b. "Let's advance your diet to solid food." c. "Let's see if the dietitian can help." d. "Let's see if the speech-language pathologist can help."

d. "Let's see if the speech-language pathologist can help."

2. A client who has experienced an initial transient ischemic attack (TIA) states: "I'm glad it wasn't anything serious." Which is the best nursing response to this statement? a. "I sense that you are happy it was not a stroke". b. "People who experience a TIA will develop a stroke". c. "TIA symptoms are short-lived and resolve within 24 hours". d. "TIA is a warning sign. Let's talk about lowering your risks."

d. "TIA is a warning sign. Let's talk about lowering your risks."

Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a ______________ stroke.

hemorrhagic

The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has?

ischemic Ischemic strokes occur when a thrombus or embolus obstructs an artery carrying blood to the brain; about 80% of strokes are the ischemic variety. The other options are incorrect.

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

"A concussion results from a blow to the head that jars the brain. It usually is a consequence of falling, striking the head against a hard surface such as a windshield, colliding with another person (e.g., between athletes), battering during boxing, or being a victim of violence.

During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer? a) "Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation." b) "Clinical manifestations of a stroke generally include aphasia, one-sided flaccidity, and trouble swallowing." c) "Clinical manifestations of a stroke depend on how quickly the clot can be dissolved." d) "Clinical manifestations of a stroke are highly variable, depending on the cardiovascular health of the client."

"Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation." Clinical manifestations following a stroke are highly variable and depend on the area of the cerebral cortex and the affected hemisphere, the degree of blockage (total, partial), and the presence or absence of adequate collateral circulation. (Collateral circulation is circulation formed by smaller blood vessels branching off from or near larger occluded vessels.) Clinical manifestations of a stroke do not depend on the cardiovascular health of the client or how quickly the clot can be dissolved. Clinical manifestations of a stroke are not "general" but individual.

A family member asks the nurse about whether there would be any long-term psychological effects from a client's mild traumatic brain injury. What is the nurse's best response?

"Each person's reaction to brain injury is different."

A nurse is instructing the spouse of a client who suffered a stroke about the use of eating devices the client will be using. During the teaching, the spouse starts to cry and states, "One minute he is laughing, and the next he's crying; I just don't understand what's wrong with him." Which statement is the best response by the nurse?

"Emotional lability is common after a stroke, and it usually improves with time." Explanation: This is the most therapeutic and informative response. Often, most relatives of clients with stroke handle the physical changes better than the emotional aspects of care. The family should be prepared to expect occasional episodes of emotional lability. The client may laugh or cry easily and may be irritable and demanding or depressed and confused. The nurse can explain to the family that the client's laughter does not necessarily connote happiness, nor does crying reflect sadness, and that emotional lability usually improves with time. The remaining responses are nontherapeutic and do not address the spouse's concerns.

To help assess a client's cerebral function, a nurse should ask: a) "Have you noticed a change in your muscle strength?" b) "Have you had any problems with your eyes?" c) "Have you had any problems with coordination?" d) "Have you noticed a change in your memory?"

"Have you noticed a change in your memory?" To assess cerebral function, the nurse should ask about the client's level of consciousness, orientation, memory, and other aspects of mental status. Questions about muscle strength help evaluate the client's motor system. Questions about coordination help her assess cerebellar function. Questions about eyesight help the nurse evaluate the cranial nerves associated with vision.

A patient arrives to have an MRI done in the outpatient department. What information provided by the patient warrants further assessment to prevent complications related to the MRI? a) "I have been trying to get an appointment for so long." b) "I am trying to quit smoking and have a patch on." c) "My legs go numb sometimes when I sit too long." d) "I have not had anything to eat or drink since 3 hours ago."

"I am trying to quit smoking and have a patch on." Before the patient enters the room where the MRI is to be performed, all metal objects and credit cards (the magnetic field can erase them) must be removed. This includes medication patches that have a metal backing and metallic lead wires; these can cause burns if not removed (Bremner, 2005).

Which statements about stroke prevention indicate a client's understanding of health teaching by the nurse? (Select all that apply.)

"I have decided to stop smoking." "I will try to walk at least 30 minutes most days of the week." "I need to cut down a lot on my drinking." "I'm going to decrease salt in my diet."

The nurse is teaching a client and family about home care after a stroke. Which statement made by the client's spouse indicates a need for further teaching?

"I should spend all my time with my husband in case I'm needed."

A client is being prepared for a cochlear implant. Which client statement would alert the nurse to the need for additional teaching? a) "I'll be able to hear medium and loud sounds for once." b) "I'll wear an external transmitter and microphone." c) "I'll have a small incision behind my ear." d) "I'm going to be able to hear normally again."

"I'm going to be able to hear normally again." Explanation: A cochlear implant does not restore normal hearing. Rather, it helps the person detect medium to loud environmental sounds and conversation. A small receiver is implanted in the temporal bone through a postauricular incision with electrodes placed into the inner ear. The microphone and transmitter are worn on an external unit.

A client is being discharged home after surgery involving the middle ear. Which of the following client statements demonstrates understanding of the instructions? a) "I need to report any crackling sounds in my affected ear to the physician right away." b) "If I sneeze or cough during the first few weeks, I should keep my mouth open." c) "After the first 48 hours, I can bend over to pick things up if I need to." d) "I need to wait at least 1 week before washing my hair so that water doesn't enter my ear."

"If I sneeze or cough during the first few weeks, I should keep my mouth open." * After middle ear surgery, the client needs to sneeze or cough with an open mouth for a few weeks after surgery, wait 2 to 3 days to shampoo the hair (making sure that the ear is protected), and avoid bending at the waist, straining or lifting heavy objects for a few weeks. Poppling or crackling sounds or sensations in the operative ear are normal for the first 3 to 5 weeks after surgery.

A client is eating a soft diet while recovering from a stroke. The client reports food accumulating in the cheek of the affected side. What is the nurse's best response?

"Let's see if the speech-language pathologist can help."

The nurse is teaching the spouse and client who has had a brain attack about rehabilitation. Which statement by the spouse demonstrates understanding of the nurse's instruction?

"The rehabilitation therapist will help identify changes needed at home."

A client is being discharged home after surgery for brain cancer. Which statement by the client's spouse indicates a correct understanding of the nurse's discharge teaching?

"We can find a support group through the local American Cancer Society."

NURSING INTERVENTIONS for patient with increased intracranial pressure (ICP)?

*Controlling fever -is an important intervention for a client with increased ICP because fevers can cause an increase in cerebral metabolism and can lead to cerebral edema. - Antipyretics are appropriate to control a fever. *aseptic technique - It is imperative that the nurse use aseptic technique when caring for the intraventricular catheter because of its risk for infection. * Oral care should be provided frequently because the client is likely to be placed on a fluid restriction and will have dry mucous membranes. A nondrying oral rinse may be used.

Self-Care After Middle Ear or Mastoid Surgery

- Avoid nose blowing for 2-3 weeks after surgery. - Sneeze and cough with the mouth open for a few weeks after surgery. - Avoid heavy lifting (>10 pounds), straining, and bending over for a few weeks after surgery. - Be aware that popping and crackling sensations in the operative ear are normal for approximately 3-5 weeks after surgery. - Note that temporary hearing loss is normal in the operative ear due to fluid, blood, or packing in the ear. - Avoid getting water in the operative ear for 2 weeks after surgery. - You may shampoo the hair 2-3 days postoperatively if the ear is protected from water by saturating a cotton ball with petrolatum jelly (or some other water-insoluble substance) and loosely placing it in the ear.

- Signs and symptoms of glaucoma may be absent, "silent thief of sight", or include:

- blurred vision - difficulty focusing - decrease in peripheral vision

Meniere's disease management

- diet and medication - low-sodium diet (1,000 to 1,500 mg/day or less) * Sodium and fluid retention disrupts the delicate balance between endolymph and perilymph in the inner ear

Meniere's disease manifestation

- fluctuating, progressive hearing loss - tinnitus - feeling of pressure or fullness - episodic, incapacitating vertigo that may be accompanied by nausea and vomiting

Reduce complications following middle ear surgery by

- not blowing the nose or getting water in the operative ear for 2-3 weeks - keeping the mouth open when sneezing or coughing, not lifting (>10 lbs), bending or straining - promptly reporting excessive purulent ear drainage

Glaucoma symptoms

- significant vision loss - peripheral vision loss, - blurring, - halos, - difficulty focusing, - difficulty adjusting eyes to low lighting

What is the difference between spinal and neurogenic shock?

-During spinal shock reflex activity stops (bladder and bowel function stop) below the level of the injury and the muscles innervated by the nerve become flaccid and paralyzed -Neurogenic shock results in hypotension, bradycardia and a decrease in cardiac output which could lead to death

Later indications of increasing ICP include:

-decreasing level of consciousness until client is comatose -decreased or erratic pulse and respiratory rate - increased blood presure and temperature -widened pulse pressure - Chenyne-Stokes breathing - projectile vomiting - heimplegia or decorticate or decerebrate posturing - loss of brain stem reflexes (pupillary, corneal, gag, and swallowing).

What is the function of the eustachian tube?

1) ventilation of the middle ear so that ambient pressure and middle ear pressure are similar 2) protection of the middle ear from reflux of nasopharyngeal secretions and bacterial flora 3) drainage of secretions from the middle ear into the nasopharynx

The nurse is caring for a patient who was involved in a motor vehicle accident and sustained a head injury. When assessing deep tendon reflexes (DTR), the nurse observes diminished or hypoactive reflexes. How will the nurse document this finding? 3+ 1+ 2+ 0

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

A nurse knows that, for a patient with an ischemic stroke, tPA is contraindicated if the blood pressure reading is:

190 mm Hg/120 mm Hg Explanation: Elevated blood pressure (systolic >185; diastolic >110 mm Hg) is a contraindication to tPA.

A nurse knows that, for a patient with an ischemic stroke, tPA is contraindicated if the blood pressure reading is: a) 170 mm Hg/105 mm Hg b) 185 mm Hg/110 mm Hg c) 190 mm Hg/120 mm Hg d) 175 mm Hg/100 mm Hg

190 mm Hg/120 mm Hg Elevated blood pressure (systolic >185; diastolic >110 mm Hg) is a contraindication to tPA.

Name two more "tips' in communicating with a patient with Aphasia:

2. Face the patient and establish eye contact. 3. Speak in a clear, unhurried manner, and normal tone of voice. 4. Use short phrases, and pause between phrases to allow the patient time to understand what is being said. 5. Limit conversation to practical and concrete matters. 6. Use gestures, pictures, objects, and writing. 7. As the patient uses and handles an object, say what the object is. It helps to match the words with the object or action. 8. Be consistent in using the same words and gestures each time you give instructions or ask a question. 9. Keep extraneous noises and sounds to a minimum. Too much background noise can distract the patient or make it difficult to sort out the message being spoken.

If a person can read the row marked "40" with the right eye at 20 feet distance (and not the row above this) on a Snellen chart, this person would have a visual acuity of _______with that eye?

20/40

When communicating with a client who has sensory (receptive) aphasia, the nurse should: 1. allow time for the client to respond. 2. speak loudly and articulate clearly. 3. give the client a writing pad. 4. use short, simple sentences

4. - Although receptive aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension. - Allowing time for the client to respond might be helpful, but it's less important than simplifying the communication.

The nurse is preparing to administer tissue plasminogen activator (t-PA) to a patient who weighs 132 lb. The order reads 0.9 mg/kg t-PA. The nurse understands that 10% of the calculated dose is administered as an IV bolus over 1 minute, and the remaining dose (90%) is administered IV over 1 hour via an infusion pump. How many milligrams IV bolus over 1 minute will the nurse initially administer?

5.4 - First, the nurse must convert the patient's weight to kilograms (132/2.2 = 60 kg) - then multiply 0.9 mg × 60 kg = 54 mg. - Next, the nurse figure out that 10% of 54 mg is 5.4 (54 ×.10). - The nurse will initially administer 5.4 mgs IV bolus over 1 minute.

The nurse is caring for a client with acute pain. The nurse is aware that the client's pain has lasted for less than? (Fill in the blank with the correct number.)

6 Acute pain is discomfort that has a short duration (from a few seconds to less than 6 months).

A 154-pound woman has been prescribed tPA (0.9 mg/kg) for an ischemic stroke. The nurse knows to give how many mg initially? a. 7.5 mg b. 6.3 mg c. 8.3 mg d. 10 mg

6.3 mg A person who weighs 154 lbs weighs 70 kg. To calculate total dosage, multiply 70 × 0.9 mg/kg = 63 mg. Ten percent of the calculated dose is given as an IV bolus over 1 minute. The remaining dose (90%) is given IV over 1 hour via an infusion pump. So initially the nurse gives 10% (6.3 mg) over 1 minute.

13. A patient with a C7 spinal cord fracture informs the nurse, "My head is killing me!" The nurse assesses a blood pressure of 210/140 mm Hg, heart rate of 48, and observes diaphoresis on the face. What is the first action by the nurse? a. Place the patient in a sitting position b. Call the healthcare provider c. Assess the patient for a full bladder d. Assess the patient for a fecal impaction

A

2. A patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the healthcare provider sutures the wound? a. Irrigates the wound to remove debris b. Gives an oral analgesic for pain c. Gives acetaminophen for headache d. Shaves the hair around the wound

A

6. A patient brought to the hospital after a skiing accident was unconscious for a brief period of time at the scene, then woke up disoriented and refused to go to the hospital for treatment. The patient became very agitated and restless, then quickly lost consciousness again. What type of TBI is suspected in this situation? a. Epidural hematoma b. Acute subdural hematoma c. Chronic subdural hematoma d. Grade 1 concussion

A

An advanced practice nurse has performed a Rinne test on a new patient. During the test, the patient reports that air-conducted sound is louder than bone-conducted sound. How should the nurse best interpret this assessment finding? A) The patient's hearing is likely normal. B) The patient is at risk for tinnitus. C) The patient likely has otosclerosis. D) The patient likely has sensorineural hearing loss.

A

The nurse is caring for a client who has had a cerebrovascular accident. The client has a nursing diagnosis of altered nutritional status related to difficulty swallowing. What intervention would it be important for the nurse to institute? a) Encourage the client to eat semisolid foods and cold foods. b) Encourage the client to drink hot liquids. c) Encourage the client to eat tepid foods. d) Encourage the client to eat solid foods.

A

The nurse is triaging people that have been involved in a bus accident. A triaged patient with psychological disturbances would be tagged with which color? a) Green b) Red c) Black d) Yellow

A

While conversing with a patient who had a stroke six months ago, you note their speech is hard to understand and slurred. This is known as: A. Dysarthria B. Apraxia C. Alexia D. Dysphagia

A

A patient who just suffered a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurse's primary assessment focus? A) Cardiac and respiratory status B) Seizure activity C) Pain D) Fluid and electrolyte balance

A (Feedback: Acute care begins with managing ABCs. Patients may have difficulty keeping an open and clear airway secondary to decreased LOC. Neurologic assessment with close monitoring for signs of increased neurologic deficit and seizure activity occurs next. Fluid and electrolyte balance must be controlled carefully with the goal of adequate hydration to promote perfusion and decrease further brain activity.)

A patient who has experienced an ischemic stroke has been admitted to the medical unit. The patient's family in adamant that she remains on bed rest to hasten her recovery and to conserve energy. What principle of care should inform the nurse's response to the family? A) The patient should mobilize as soon as she is physically able. B) To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks. C) The patient should remain on bed rest until she expresses a desire to mobilize. D) Lack of mobility will greatly increase the patient's risk of stroke recurrence.

A (Feedback: As soon as possible, the patient is assisted out of bed and an active rehabilitation program is started. Delaying mobility causes complications, but not necessarily stroke recurrence. Mobility should not be withheld until the patient initiates.)

When preparing to discharge a patient home, the nurse has met with the family and warned them that the patient may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause? A) Frustration around changes in function and communication B) Unmet physiologic needs C) Changes in brain activity during sleep and wakefulness D) Temporary changes in metabolism

A (Feedback: Emotional problems associated with stroke are often related to the new challenges around ADLs and communication. These challenges are more likely than metabolic changes, unmet physiologic needs, or changes in brain activity, each of which should be ruled out.)

The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of a stroke? A) Facial droop B) Dysrhythmias C) Periorbital edema D) Projectile vomiting

A (Feedback: Facial drooping or asymmetry is a classic abnormal finding on a physical assessment that may be associated with a stroke. Facial edema is not suggestive of a stroke and patients less commonly experience dysrhythmias or vomiting.)

After a major ischemic stroke, a possible complication is cerebral edema. Nursing care during the immediate recovery period from an ischemic stroke should include which of the following? A) Positioning to avoid hypoxia B) Maximizing PaCO2 C) Administering hypertonic IV solution D) Initiating early mobilization

A (Feedback: Interventions during this period include measures to reduce ICP, such as administering an osmotic diuretic (e.g., mannitol), maintaining the partial pressure of carbon dioxide (PaCO2) within the range of 30 to 35 mm Hg, and positioning to avoid hypoxia. Hypertonic IV solutions are not used unless sodium depletion is evident. Mobilization would take place after the immediate threat of increased ICP has past.)

A patient who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this patient? A) The patient should be approached on the side where visual perception is intact. B) Attention to the affected side should be minimized in order to decrease anxiety. C) The patient should avoid turning in the direction of the defective visual field to minimize shoulder subluxation. D) The patient should be approached on the opposite side of where the visual perception is intact to promote recovery.

A (Feedback: Patients with decreased field of vision should first be approached on the side where visual perception is intact. All visual stimuli should be placed on this side. The patient can and should be taught to turn the head in the direction of the defective visual field to compensate for this loss. The nurse should constantly remind the patient of the other side of the body and should later stand at a position that encourages the patient to move or turn to visualize who and what is in the room.)

The patient has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the patient's atmosphere more conducive to communication? A) Provide a board of commonly used needs and phrases. B) Have the patient speak to loved ones on the phone daily. C) Help the patient complete his or her sentences. D) Speak in a loud and deliberate voice to the patient.

A (Feedback: The inability to talk on the telephone or answer a question or exclusion from conversation causes anger, frustration, fear of the future, and hopelessness. A common pitfall is for the nurse or other health care team member to complete the thoughts or sentences of the patient. This should be avoided because it may cause the patient to feel more frustrated at not being allowed to speak and may deter efforts to practice putting thoughts together and completing a sentence. The patient may also benefit from a communication board, which has pictures of commonly requested needs and phrases. The board may be translated into several languages.)

Following diagnostic testing, a patient has been admitted to the ICU and placed on cerebral aneurysm precautions. What nursing action should be included in patient's plan of care? A) Supervise the patient's activities of daily living closely. B) Initiate early ambulation to prevent complications of immobility. C) Provide a high-calorie, low-protein diet. D) Perform all of the patient's hygiene and feeding.

A (Feedback: 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. As such, independent ADLs and ambulation are contraindicated. There is no need for a high-calorie or low-protein diet.)

A patient is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this patient is aware that an absolute contraindication for thrombolytic therapy is what? A) Evidence of hemorrhagic stroke B) Blood pressure of ³ 180/110 mm Hg C) Evidence of stroke evolution D) Previous thrombolytic therapy within the past 12 months

A (Feedback: Thrombolytic therapy would exacerbate a hemorrhagic stroke with potentially fatal consequences. Stroke evolution, high BP, or previous thrombolytic therapy does not contraindicate its safe and effective use.)

A patient is postoperative day 6 following tympanoplasty and mastoidectomy. The patient has phoned the surgical unit and states that she is experiencing occasional sharp, shooting pains in her affected ear. How should the nurse best interpret this patient's complaint? A) These pains are an expected finding during the first few weeks of recovery. B) The patient's complaints are suggestive of a postoperative infection. C) The patient may have experienced a spontaneous rupture of the tympanic membrane. D) The patient's surgery may have been unsuccessful.

A *For 2 to 3 weeks after surgery, the patient may experience sharp, shooting pains intermittently BECAUSE the eustachian tube opens and allows air to enter the middle ear. *Infection = Constant, throbbing pain accompanied by fever, and should be reported to the primary care provider. * The patient's pain does not suggest tympanic perforation

A patient diagnosed with arthritis has been taking aspirin and now reports experiencing tinnitus and hearing loss. What should the nurse teach this patient? A) The hearing loss will likely resolve with time after the drug is discontinued. B) The patient's hearing loss and tinnitus are irreversible at this point. C) The patient's tinnitus is likely multifactorial, and not directly related to aspirin use. D) The patient's tinnitus will abate as tolerance to aspirin develops.

A *Tinnitus and hearing loss are signs of ototoxicity, which is associated with aspirin use. In most cases, this will resolve upon discontinuing the aspirin

The nurse in the ED is caring for a 4 year-old brought in by his parents who state that the child will not stop crying and pulling at his ear. Based on information collected by the nurse, which of the following statements applies to a diagnosis of external otitis? A) External otitis is characterized by aural tenderness. B) External otitis is usually accompanied by a high fever. C) External otitis is usually related to an upper respiratory infection. D) External otitis can be prevented by using cotton-tipped applicators to clean the ear.

A Patients with otitis externa usually exhibit pain, discharge from the external auditory canal, and aural tenderness. *Otitis Media: Fever and accompanying upper respiratory infection *Cotton-tipped applicators can actually cause external otitis so their use should be avoided

After the patient has received tPA, the nurse knows to check vital signs every 30 minutes for 6 hours. Which of the following readings would require calling the provider? a) Diastolic pressure of 110 mm Hg b) Heart rate of 100 c) Systolic pressure of 180 mm Hg d) Respiration of 22

A A diastolic pressure reading of over 105 mm Hg warrants notifying the health care provider. The other choices are within normal range

A patient with mastoiditis is admitted to the post-surgical unit after undergoing a radical mastoidectomy. The nurse should identify what priority of postoperative care? A) Assessing for mouth droop and decreased lateral eye gaze B) Assessing for increased middle ear pressure and perforated ear drum C) Assessing for gradual onset of conductive hearing loss and nystagmus D) Assessing for scar tissue and cerumen obstructing the auditory canal

A (The facial nerve runs through the middle ear and the mastoid; therefore, there is risk of injuring this nerve during a mastoidectomy. When injury occurs, the patient may display mouth droop and decreased lateral gaze on the operative side)

A hearing-impaired patient is scheduled to have an MRI. What would be important for the nurse to remember when caring for this patient? A) Patient is likely unable to hear the nurse during test. B) A person adept in sign language must be present during test. C) Lip reading will be the method of communication that is necessary. D) The nurse should interact with the patient like any other patient.

A (The healthy tympanic membrane appears pearly gray and is positioned obliquely at the base of the ear canal)

The advanced practice nurse is attempting to examine the patient's ear with an otoscope. Because of impacted cerumen, the tympanic membrane cannot be visualized. The nurse irrigates the patient's ear with a solution of hydrogen peroxide and water to remove the impacted cerumen. What nursing intervention is most important to minimize nausea and vertigo during the procedure? A) Maintain the irrigation fluid at a warm temperature. B) Instill short, sharp bursts of fluid into the ear canal. C) Follow the procedure with insertion of a cerumen curette to extract missed ear wax. D) Have the patient stand during the procedure.

A (Warm water = prevent nausea) *Instill gentle = prevent damage eardrum *Cerumen curette is removed by HCP

A patient in the emergency room has bruising over the mastoid bone and rhinorrhea. These are indicative of which type of skull fracture? a) Basilar b) Linear c) Simple d) Comminuted

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

The emergency department nurse has admitted an infant with bulging fontanels, setting sun eyes, and lethargy. Which diagnostic procedure would be contraindicated in this infant? a) lumbar puncture b) arterial blood draw c) computerized tomography scan d) magnetic resonance imaging

A - lumbar puncture The child is exhibiting signs and symptoms of increased intracranial pressure (ICP). A lumbar puncture is contraindicated in children with increased ICP due to the risk of herniation. Magnetic resonance imaging and a computerized tomography scan are indicated in children with suspected increased ICP. Radiology studies will allow visualization of the cause of the increased ICP, such as inflammation, a tumor, or hemorrhage. An arterial blood draw is not indicated in this client. However, there is no contraindication for performing an arterial blood draw on a child with increased ICP.

When caring for an adolescent who is at risk for injury related to intracranial pathology following a motor vehicle collision, which of the following nursing actions is the priority? a) Maintaining stable intracranial pressure b) Maintaining good body alignment c) Monitoring vital signs d) Monitoring cardiac rhythm

A - maintaining stable intracranial pressure Increased intracranial pressure contributes to increasingly severe pathology, including potential for brain stem herniation, so maintaining stable intracranial pressure is priority. Monitoring vital signs and monitoring cardiac rhythm are important but only represents a portion of the necessary nursing care. Maintaining good body alignment will prevent musculoskeletal problems but is not a priority.

A 24-year-old female rock climber is brought to the Emergency Department after a fall from the face of a rock. The young lady is admitted for observation after being diagnosed with a contusion to the brain. The client asks the nurse what having a contusion means. How should the nurse respond? a) Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue. b) Contusions are deep brain injuries. c) Contusions are microscopic brain injuries. d) Contusions occur when the brain is jarred and bounces off the skull on the opposite side from the blow.

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

A mother brings her daughter to the clinic for an evaluation because the child is complaining of ear pain. Which of the following would lead the nurse to suspect that the child is experiencing otitis externa and not otitis media? a. Fever b. bulging eardrum c. Ear drainage d. Aural tenderness

A client with otitis externa typically experiences aural tenderness. This finding is usually absent in clients with otitis media. * Fever and ear drainage may be present with either otitis externa or otitis media. * A bulging eardrum would suggest otitis media.

A client is admitted to the intensive care unit (ICU) with a diagnosis of cerebrovascular accident (CVA). Which assessment by the nurse provides the most significant finding in differentiating between ischemic and hemorrhagic strokes? a) Oropharyngeal suctioning as needed. b) Kepprais ordered for treatment of focal seizures. c) A unit of fresh frozen plasma is infusing. d) Neurological checks are ordered every 2 hours.

A unit of fresh frozen plasma is infusing. FFP is usedin the treatment of clotting deficiencies as seen with over dose of anticoagulants and would indicate a hemorrhagic stroke. Neuro checks ordered every 2 hours does not differentiate between types of strokes. Focal seizures can occur with any stroke and would not differentiate. Suctioning is a nursing action taken to maintain airway and does not indicate a specific type of stroke.

The nurse is teaching a patient with Guillain-Barré syndrome about the disease. The patient asks how he can ever recover if demyelination of his nerves is occurring. What would be the nurse's best response? A) "Guillain-Barré spares the Schwann cell, which allows for remyelination in the recovery phase of the disease." B) "In Guillain-Barré, Schwann cells replicate themselves before the disease destroys them, so remyelination is possible." C) "I know you understand that nerve cells do not remyelinate, so the physician is the best one to answer your question." D) "For some reason, in Guillain-Barré, Schwann cells become activated and take over the remyelination process."

A) "Guillain-Barré spares the Schwann cell, which allows for remyelination in the recovery phase of the disease."

A patient with MS has been admitted to the hospital following an acute exacerbation. When planning the patient's care, the nurse addresses the need to enhance the patient's bladder control. What aspect of nursing care is most likely to meet this goal? A) Establish a timed voiding schedule. B) Avoid foods that change the pH of urine. C) Perform intermittent catheterization q6h. D) Administer anticholinergic drugs as ordered.

A) Establish a timed voiding schedule.

A patient is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this patient is aware that an absolute contraindication for thrombolytic therapy is what? A) Evidence of hemorrhagic stroke B) Blood pressure of 180/110 mm Hg C) Evidence of stroke evolution D) Previous thrombolytic therapy within the past 12 months

A) Evidence of hemorrhagic stroke

When preparing to discharge a patient home, the nurse has met with the family and warned them that the patient may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause? A) Frustration around changes in function and communication B) Unmet physiologic needs C) Changes in brain activity during sleep and wakefulness D) Temporary changes in metabolism

A) Frustration around changes in function and communication

You are the clinic nurse caring for a patient with a recent diagnosis of myasthenia gravis. The patient has begun treatment with pyridostigmine bromide (Mestinon). What change in status would most clearly suggest a therapeutic benefit of this medication? A) Increased muscle strength B) Decreased pain C) Improved GI function D) Improved cognition

A) Increased muscle strength

A 35-year-old woman is diagnosed with a peripheral neuropathy. When making her plan of care, the nurse knows to include what in patient teaching? Select all that apply. A) Inspect the lower extremities for skin breakdown. B) Footwear needs to be accurately sized. C) Immediate family members should be screened for the disease. D) Assistive devices may be needed to reduce the risk of falls. E) Dietary modifications are likely necessary.

A) Inspect the lower extremities for skin breakdown. B) Footwear needs to be accurately sized. D) Assistive devices may be needed to reduce the risk of falls.

The nurse is working with a patient who is newly diagnosed with MS. What basic information should the nurse provide to the patient? A) MS is a progressive demyelinating disease of the nervous system. B) MS usually occurs more frequently in men. C) MS typically has an acute onset. D) MS is sometimes caused by a bacterial infection.

A) MS is a progressive demyelinating disease of the nervous system.

During a patient's recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help patients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply. A) National Institutes of Health Stroke Scale (NIHSS) score B) Race C) LOC at time of admission D) Gender E) Age

A) National Institutes of Health Stroke Scale (NIHSS) score C) LOC at time of admission E) Age

After a major ischemic stroke, a possible complication is cerebral edema. Nursing care during the immediate recovery period from an ischemic stroke should include which of the following? A) Positioning to avoid hypoxia B) Maximizing PaCO2 C) Administering hypertonic IV solution D) Initiating early mobilization

A) Positioning to avoid hypoxia

The nurse is caring for a 77-year-old woman with MS. She states that she is very concerned about the progress of her disease and what the future holds. The nurse should know that elderly patients with MS are known to be particularly concerned about what variables? Select all that apply. A) Possible nursing home placement B) Pain associated with physical therapy C) Increasing disability D) Becoming a burden on the family E) Loss of appetite

A) Possible nursing home placement C) Increasing disability D) Becoming a burden on the family

A patient with diabetes presents to the clinic and is diagnosed with a mononeuropathy. This patient's nursing care should involve which of the following? A) Protection of the affected limb from injury B) Passive and active ROM exercises for the affected limb C) Education about improvements to glycemic control D) Interventions to prevent contractures

A) Protection of the affected limb from injury

The patient has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the patient's atmosphere more conducive to communication? A) Provide a board of commonly used needs and phrases. B) Have the patient speak to loved ones on the phone daily. C) Help the patient complete his or her sentences. D) Speak in a loud and deliberate voice to the patient.

A) Provide a board of commonly used needs and phrases.

Following diagnostic testing, a patient has been admitted to the ICU and placed on cerebral aneurysm precautions. What nursing action should be included in patient's plan of care? A) Supervise the patient's activities of daily living closely. B) Initiate early ambulation to prevent complications of immobility. C) Provide a high-calorie, low-protein diet. D) Perform all of the patient's hygiene and feeding.

A) Supervise the patient's activities of daily living closely.

A patient who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this patient? A) The patient should be approached on the side where visual perception is intact. B) Attention to the affected side should be minimized in order to decrease anxiety. C) The patient should avoid turning in the direction of the defective visual field to minimize shoulder subluxation. D) The patient should be approached on the opposite side of where the visual perception is intact to promote recovery.

A) The patient should be approached on the side where visual perception is intact.

A patient who has experienced an ischemic stroke has been admitted to the medical unit. The patient's family in adamant that she remain on bed rest to hasten her recovery and to conserve energy. What principle of care should inform the nurse's response to the family? A) The patient should mobilize as soon as she is physically able. B) To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks. C) The patient should remain on bed rest until she expresses a desire to mobilize. D) Lack of mobility will greatly increase the patient's risk of stroke recurrence.

A) The patient should mobilize as soon as she is physically able.

The nurse is developing a plan of care for a patient with Guillain-Barré syndrome. Which of the following interventions should the nurse prioritize for this patient? A) Using the incentive spirometer as prescribed B) Maintaining the patient on bed rest C) Providing aids to compensate for loss of vision D) Assessing frequently for loss of cognitive function

A) Using the incentive spirometer as prescribed

Which of the following conditions occurs when there is bleeding between the dura mater and arachnoid membrane? a) Subdural hematoma b) Extradural hematoma c) Intracerebral hemorrhage d) Epidural hematoma

A, A subdural hematoma is bleeding between the dura mater and arachnoid membrane. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with displacement of surrounding structures. An epidural hematoma is bleeding between the inner skull and the dura, compressing the brain underneath. An extradural hematoma is another name for an epidural hematoma.

The nurse in the emergency department is caring for a patient brought in by the rescue squad after falling from a second-story window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of? a) Basilar skull fracture b) Temporal skull fracture c) Frontal skull fracture d) Occipital skull fracture

A, A fracture of the base of the skull is referred to as a basilar skull fracture. Fractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone or the middle ear located in the temporal bone (see Fig. 68-2). Therefore, they frequently produce hemorrhage from the nose, pharynx, or ears, and blood may appear under the conjunctiva. An area of ecchymosis (bruising) may be seen over the mastoid (Battle's sign). Basilar skull fractures are suspected when CSF escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea)

A 154-pound woman has been prescribed tPA (0.9 mg/kg) for an ischemic stroke. The nurse knows to give how many mg initially? a) 6.3 mg b) 7.5 mg c) 8.3 mg d) 10 mg

A, A person who weighs 154 lbs weighs 70 kg. To calculate dosage, multiply 70 × 0.9 mg/kg = 63 mg. The nurse gives 10% (6.3 mg) over 1 minute.

A nurse assesses a patient who has been diagnosed with having a pituitary adenoma that is pressing on the third ventricle. The nurse looks for the associated sign/symptom. What is that sign/symptom? a) Increased intracranial pressure b) Unusual sensitivity to heat and cold c) Visual disturbances d) Disruption in sleep patterns

A, All the choices are signs and symptoms that can occur with an adenoma, depending on whether the pressure is exerted on the hypothalamus, the third ventricle, or the optic nerves, chiasm, or tracts. Increased intracranial pressure occurs when the third ventricle is affected.

When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke? a) The day the patient has the stroke b) After the patient has passed the acute phase of the stroke c) The day before the patient is discharged d) After the nurse has received the discharge orders

A, Although rehabilitation begins on the day the patient has the stroke, the process is intensified during convalescence and requires a coordinated team effor

To prepare the community for the possible threat of anthrax, a nurse must teach that: a) anthrax can infect the integumentary, GI, and respiratory systems. b) physicians use isoniazid (INH), rifampin (Rifadin), and pyrazinamide to treat anthrax. c) immunizations can prevent anthrax. d) blood and body secretions can transmit anthrax.

A, Anthrax can infect the integumentary, GI, and respiratory systems. Immunizations are appropriate only for those at risk of anthrax exposure. Isoniazid, rifampin, and pyrazinamide are used to treat tuberculosis, not anthrax. Penicillin is the most common drug used to threat anthrax

A nurse on the neurological unit is caring for a client with a basilar skull fracture. Which high-risk nursing diagnosis is appropriate for this client? a) Risk for meningeal infection b) Risk for impaired skin integrity c) Risk for disturbed sleep pattern d) Risk for falls

A, Basilar skull fractures are suspected when cerebrospinal fluid escapes from the ears or nose. Drainage of cerebrospinal fluid is a serious problem, because meningeal infection can occur if organisms gain access to the cranial contents via the nose, ear, or sinus through a tear in the dura

10. The nurse is planning to provide education about prevention in the community YMCA due to the increase in numbers of SCIs. What predominant risk factors does the nurse determine should be addressed? (Select all that apply.) a. Young age b. Male gender c. Older adult d. Substance abuse e. Low-income community

A, C, D

During a patient's recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help patients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply. A) National Institutes of Health Stroke Scale (NIHSS) score B) Race C) LOC at time of admission D) Gender E) Age

A, C, E (Feedback: It is helpful for clinicians to be knowledgeable about the relative importance of predictors of stroke outcome (age, NIHSS score, and LOC at time of admission) to provide stroke survivors and their families with realistic goals. Race and gender are not predictors of stroke outcome.)

During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer? a) "Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation." b) "Clinical manifestations of a stroke are highly variable, depending on the cardiovascular health of the client." c) "Clinical manifestations of a stroke depend on how quickly the clot can be dissolved." d) "Clinical manifestations of a stroke generally include aphasia, one-sided flaccidity, and trouble swallowing."

A, Clinical manifestations following a stroke are highly variable and depend on the area of the cerebral cortex and the affected hemisphere, the degree of blockage (total, partial), and the presence or absence of adequate collateral circulation. (Collateral circulation is circulation formed by smaller blood vessels branching off from or near larger occluded vessels.) Clinical manifestations of a stroke do not depend on the cardiovascular health of the client or how quickly the clot can be dissolved. Clinical manifestations of a stroke are not "general" but individual.

The nurse is using continuous central venous oximetry (ScvO2) to monitor the blood oxygen saturation of a patient in shock. What value would the nurse document as normal for the patient? a) 70% b) 50% c) 40% d) 60%

A, Continuous central venous oximetry (ScvO2) monitoring may be used to evaluate mixed venous blood oxygen saturation and severity of tissue hypoperfusion states. A central catheter is introduced into the superior vena cava (SVC), and a sensor on the catheter measures the oxygen saturation of the blood in the SVC as blood returns to the heart and pulmonary system for re-oxygenation. A normal ScvO2 value is 70% (Ramos & Azevedo, 2010).

Which type of shock occurs from an antigen-antibody response? a) Anaphylactic b) Neurogenic c) Septic d) Cardiogenic

A, During anaphylactic shock, an antigen-antibody reaction provokes mast cells to release potent vasoactive substances, such as histamine or bradykinin, causing widespread vasodilation and capillary permeability. Septic shock is a circulatory state resulting from overwhelming infection causing relative hypovolemia. Neurogenic shock results from loss of sympathetic tone causing relative hypovolemia. Cardiogenic shock results from impairment or failure of the myocardium.

The nurse is performing an assessment for a patient in the clinic with Parkinson's disease. The nurse determines that the patient's voice has changed since the last visit and is now more difficult to understand. How should the nurse document this finding? a) Dysphonia b) Dysphagia c) Micrographia d) Hypokinesia

A, Dysphonia (voice impairment or altered voice production) may occur as a result of weakness and incoordination of the muscles responsible for speec

The nurse is aware that fluid replacement is a hallmark treatment for shock. Which of the following is the crystalloid fluid that helps treat acidosis? a) Lactated Ringer's b) Dextran c) Albumin d) 0.9% sodium chloride

A, Lactated Ringer's is an electrolyte solution that contains the lactate ion, which is converted by the liver to bicarbonate, thus assisting with acidosis.

A client with spinal cord compression from a tumor must undergo diagnostic testing. Which of the following is the most likely procedure for this client? a) Magnetic resonance imaging b) Ultrasonography c) Computed tomography d) Core needle biopsy

A, Magnetic resonance imaging is the most commonly used diagnostic procedure. It is the most sensitive diagnostic tool that is particularly helpful in detecting epidural spinal cord compression and vertebral bone metastases.

The nurse knows when the cardiovascular system becomes ineffective in maintaining an adequate mean arterial pressure (MAP). Select the reading below that indicates tissue hypoperfusion. a) 60 mm Hg b) 90 mm Hg c) 80 mm Hg d) 70 mm Hg

A, Mean arterial pressure is cardiac output × peripheral resistance. The body must exceed 65 mm Hg MAP for cells to receive oxygen and nutrients. The formula for calculating MAP is (2 × diastolic + systolic × 3)

A patient is being treated for septic shock. On assessment, the nurse notes an abnormal finding that is reported to the health care provider. Which of the following is most likely that finding? a) SVO2 of 55% b) MAR reading of 65 mm Hg c) CVP reading of 10 d) Urinary output of 60 mL/hr

A, Normal SVO2 values range from 60% to 80%. Lower values indicate inadequate tissue perfusion and the need for medical intervention.

Which of the following measures can be used to cool a burn? a) Application of cool water b) Application of ice directly to burn c) Using cold soaks or dressings for at least 1 hour d) Wrapping the person in ice

A, Once a burn has been sustained, the application of cool water is the best first-aid measure. Never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns.

During a mass casualty incident (hurricane), a triage nurse participated in separating patients according to the severity of their injuries. She tagged a patient with a sucking chest wound with the color: a) red b) green c) black d) yellow

A, Red refers to a life-threatening but survivable injury. Refer to Table 56-3 in the text for an explanation of the other colors.

Which of the following are the immediate complications of spinal cord injury? a) Spinal shock b) Respiratory arrest c) Paraplegia d) Tetraplegia

A, Respiratory arrest and spinal shock are the immediate complications of spinal cord injury. Tetraplegia is paralysis of all extremities when there is a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Autonomic dysreflexia is a long-term complication of spinal cord injury

A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem? a) Lioresal (Baclofen) b) Pregabalin (Lyrica) c) Heparin d) Diphenhydramine (Benadryl)

A, Spasticity, particularly in the hand, can be a disabling complication after stroke. Botulinum toxin type A injected intramuscularly into wrist and finger muscles has been shown to be effective in reducing this spasticity (although the effect is temporary, typically lasting 2 to 4 months) (Teasell, Foley, Pereira, et al., 2012). Other treatments for spasticity may include stretching, splinting, and oral medications such as baclofen (Lioresal)

Which of the following provides the best outcome for most tumor types? a) Surgery b) Radiation c) Chemotherapy d) Palliation

A, Surgical intervention provides the best outcome for most tumor types. The objective of surgical management is the removal of part of or the entire tumor without increasing the neurologic deficit. Radiation, chemotherapy, and palliation may be used for the patient with a brain tumor, but it does not provide the best outcome for most tumor types

A client recently experienced a stroke with accompanying left-sided paralysis. His family voices concerns about how to best interact with him. They report the client doesn't seem aware of their presence when they approach him on his left side. What advice should the nurse give the family? a) "The client is unaware of his left side. You should approach him on the right side." b) "The client is unaware of his left side. You need to encourage him to interact from this side." c) "The client is feeling an emotional loss. He'll eventually start acknowledging you on his left side." d) "This condition is temporary."

A, The client is experiencing unilateral neglect and is unaware of his left side. The nurse should advise the family to approach him on his nonaffected (right) side. Approaching the client on the affected side would be counterproductive. It's too premature to make the determination whether this condition will be permanent.

A client who experienced shock is now nonresponsive and having cardiac dysrhythmias. The client is being mechanically ventilated, receiving medications to maintain renal perfusion, and is not responding to treatment. In this stage, it is most important for the nurse to a) Encourage the family to touch and talk to the client. b) Inform the family that everything is being done to assist with the client's survival. c) Open up discussion among the family members about nursing home placement. d) Contact a spiritual advisor to provide comfort to the family.

A, The client is in the irreversible stage of shock and unlikely to survive. The family should be encouraged to touch and talk to the client. A spiritual advisor may be of comfort to the family. However, this is not definite. The second option provides false hope of the client's survival to the family as does the third option.

What priority intervention can the nurse provide to decrease the incidence of septic shock for patients who are at risk? a) Use strict hand hygiene techniques. b) Insert indwelling catheters for incontinent patients. c) Administer prophylactic antibiotics for all patients at risk. d) Have patients wear masks in the health care facility.

A, The incidence of septic shock can be reduced by using strict infection control practices, beginning with thorough hand-hygiene techniques (Fried et al., 2011). Inserting an indwelling catheter would increase the risk of infection and thus of septic shock, not decrease it. Hand hygiene is more of a priority than administering prophylactic antibiotics. Masks would not prevent many types of infections

A patient is diagnosed with an aggressive, primary malignant brain tumor. The nurse is aware that the glioma: a) Originated within the brain tissue. b) Originated from the coverings of the brain. c) Metastasized from a cancer in another part of the body. d) Developed on the cranial nerves.

A, The most aggressive type of malignant brain tumor is a glioma, which originates within the brain tissue.

A patient with a concussion is discharged after the assessment. Which of the following instructions should the nurse give the patient's family? a) Look for signs of increased intracranial pressure b) Look for a halo sign c) Emphasize complete bed rest d) Have the patient avoid physical exertion

A, The nurse informs the family to monitor the patient closely for signs of IICP if findings are normal and the patient does not require hospitalization. The nurse looks for a halo sign to detect any CSF drainage.

A client receiving emergency treatment for severe burns has just been assessed to establish the burn depth. Why is a nurse asked to reassess the burn depth after 72 hours? a) The early appearance of the burn injury may change. b) The wound is susceptible to infections. c) The client's condition is likely to deteriorate after 72 hours. d) It helps determine the percentage of the total body surface area (TBSA) that is burned.

A, The nurse is required to reassess and revise the estimate of burn depth because the early appearance of the burn injury may change. Assessing the burn depth helps determine the potential of the damaged tissue to survive. It does not establish the percentage of the TBSA that is burned or minimize the risk of infections. It also does not help determine whether the client's condition is likely to deteriorate after 72 hours.

In a client who has been burned, which medication should the nurse expect to use to prevent infection? a) Meperidine (Pethidine) b) Mafenide (Sulfamylon) c) Permethrin (LyClear) d) Diazepam (Valium)

A, The topical antibiotic mafenide is ordered to prevent infection in clients with partial-thickness and full-thickness burns. Permethrin is used to treat scabies infestation. Diazepam is an antianxiety agent that may be administered to clients with burns, but not to prevent infection. The opioid analgesic meperidine is used to help control pain in clients with burns.

A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time? a) 4:00 p.m. b) 5:30 p.m. c) 2:30 p.m. d) 3:00 p.m.

A, Tissue plasminogen activator (tPA) must be given within 3 hours after symptom onset. Therefore, since symptom onset was 1:00 pm, the window of opportunity ends at 4:00 pm.

Elevating the patient's legs slightly to improve cerebral circulation is contraindicated in which of the following disease processes? a) Head injury b) Diabetes c) Multiple sclerosis d) Myocardial infarction

A,An alternative to the "Trendelenburg" position is to elevate the patient's legs slightly to improve cerebral circulation and promote venous return to the heart, but this position is contraindicated for patients with head injuries

At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing's triad? Select all that apply. a) Hypertension b) Bradypnea c) Tachycardia d) Hypotension e) Bradycardia

A,B,E The bradycardia, hypertension, and bradypnea associated with this deterioration are known as Cushing's triad, a grave sign. At this point, herniation of the brainstem and occlusion of the cerebral blood flow occur if therapeutic intervention is not initiated immediately.

A nurse working as part of a disaster response team is triaging clients. Which of the following clients would the nurse color code as green? Select all that apply. a) Client with a fractured arm b) Client with multiple injuries in profound shock c) Client with a first-degree burn to the forearm d) Client with a sucking chest wound e) Unresponsive client with a penetrating head wound

A,C In triage, green indicates minor injuries for which treatment can be delayed hours to days. A client with a fractured arm or with a first-degree burn would be triaged green. A client with a sucking chest wound would require immediate care and be triaged red. An unresponsive client with a penetrating head wound or with multiple injuries and in profound shock would be triaged black because the injuries are extensive and chances of survival are unlikely, even with definitive care.

Which medication is administered for uveitis, or after surgery? A. Atropine B. Cyclopentolate C. Phenylephrine D. Tropicamide

A.

A patient has experienced right side brain damage. You note the patient is experiencing neglect syndrome. What nursing intervention will you include in the patient's plan of care? A. Remind the patient to use and touch both sides of the body daily. B. Offer the patient a soft mechanical diet with honey thick liquids. C. Ask direct questions that require one word responses. D. Offer the bedpan and bedside commode every 2 hours.

A. It is important to watch for neglect syndrome. This tends to happen in right side brain damage. The patient ignores the left side of the body in this condition. The nurse needs to remind the patient to use and touch both sides of the body daily and that the patient must make a conscious effort to do so.

1. The nurse instructs a group of nursing students that the pathologic changes that occur in the brain of a person with dementia of Alzheimer's disease include a.abnormal accumulation of proteins. b.damage to the myelin sheath of neurons. c.destruction of neurons. d.increase in production of cerebrospinal fluid (CSF).

ANS: A The neuritic plaque is a cluster of degenerating nerve terminals, both dendritic and axonal, that contains amyloid protein. DIF: Comprehension/Understanding REF: p. 1894 OBJ: Intervention MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

11. A nurse is performing an assessment on a client who is suspected of having MG. The complaint made by the client that reflects a manifestation commonly seen in clients with this disease is a."By the end of the day, my eyelids usually are drooping." b."I have a great deal of difficulty getting up after I rest for a while." c."I perspire more then I ever have in the past." d."When I have a cold, I usually have a strong cough with it."

ANS: A The primary feature of MG is increasing weakness with sustained muscle contraction. After a period of rest the muscles regain their strength. Muscle weakness is greatest after exertion or at the end of the day. Ocular manifestations are most common, with ptosis or diplopia occurring in a majority of clients. DIF: Analysis/Analyzing REF: p. 1916 OBJ: Assessment MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best? a. Assess the client for anxiety. b. Break the information into smaller bits. c. Give the client written information. d. Review the information again.

ANS: A Anxiety can interfere with learning and cooperation. The nurse should assess the client for anxiety. The other actions are appropriate too, and can be included in the teaching plan, but effective teaching cannot occur if the client is highly anxious. DIF: Applying/Application REF: 233 KEY: Preoperative nursing| anxiety| client education MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Psychosocial Integrity

A client is distressed at body changes related to kyphosis. What response by the nurse is best? a. Ask the client to explain more about these feelings. b. Explain that these changes are irreversible. c. Offer to help select clothes to hide the deformity. d. Tell the client safety is more important than looks.

ANS: A Assessment is the first step of the nursing process, and the nurse should begin by getting as much information about the client's feelings as possible. Explaining that the changes are irreversible discounts the client's feelings. Depending on the extent of the deformity, clothing will not hide it. While safety is more objectively important than looks, the client is worried about looks and the nurse needs to address this issue. DIF: Applying/Application REF: 1021 KEY: Musculoskeletal system| musculoskeletal assessment| musculoskeletal disorders| psychosocial response| coping| therapeutic communication MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Psychosocial Integrity

A client in the operating room has developed malignant hyperthermia. The client's potassium is 6.5 mEq/L. What action by the nurse takes priority? a. Administer 10 units of regular insulin. b. Administer nifedipine (Procardia). c. Assess urine for myoglobin or blood. d. Monitor the client for dysrhythmias

ANS: A For hyperkalemia in a client with malignant hyperthermia, the nurse administers 10 units of regular insulin in 50 mL of 50% dextrose. This will force potassium back into the cells rapidly. Nifedipine is a calcium channel blocker used to treat hypertension and dysrhythmias, and should not be used in a client with malignant hyperthermia. Assessing the urine for blood or myoglobin is important, but does not take priority. Monitoring the client for dysrhythmias is also important due to the potassium imbalance, but again does not take priority over treating the potassium imbalance. DIF: Applying/Application REF: 247 KEY: Intraoperative nursing| malignant hyperthermia| hyperkalemia MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A postoperative nurse is caring for a client whose oxygen saturation dropped from 98% to 95%. What action by the nurse is most appropriate? a. Assess other indicators of oxygenation. b. Call the Rapid Response Team. c. Notify the anesthesia provider. d. Prepare to intubate the client.

ANS: A If a postoperative client's oxygen saturation (SaO2) drops below 95% (or the client's baseline), the nurse should notify the anesthesia provider. If the SaO2 drops by 10% or more, the nurse should call the Rapid Response Team. Since this is approximately a 3% drop, the nurse should further assess the client. Intubation (if the client is not intubated already) is not warranted. DIF: Applying/Application REF: 259 KEY: Postoperative nursing| nursing assessment| respiratory assessment| oxygen saturation MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A client is having surgery. The circulating nurse notes the client's oxygen saturation is 90% and the heart rate is 110 beats/min. What action by the nurse is best? a. Assess the client's end-tidal carbon dioxide level. b. Document the findings in the client's chart. c. Inform the anesthesia provider of these values. d. Prepare to administer dantrolene sodium (Dantrium).

ANS: A Malignant hyperthermia is a rare but serious reaction to anesthesia. The triad of early signs include decreased oxygen saturation, tachycardia, and elevated end-tidal carbon dioxide (CO2) level. The nurse should quickly check the end-tidal CO2 and then report findings to the anesthesia provider and surgeon. Documentation is vital, but not the most important action at this stage. Dantrolene sodium is the drug of choice if the client does have malignant hyperthermia. DIF: Applying/Application REF: 246 KEY: Intraoperative nursing| malignant hyperthermia| dantrolene sodium MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

A circulating nurse has transferred an older client to the operating room. What action by the nurse is most important for this client? a. Allow the client to keep hearing aids in until anesthesia begins. b. Pad the table as appropriate for the surgical procedure. c. Position the client for maximum visualization of the site. d. Stay with the client, providing emotional comfort and support.

ANS: A Many older clients have sensory loss. To help prevent disorientation, facilities often allow older clients to keep their eyeglasses on and hearing aids in until the start of anesthesia. The other actions are appropriate for all operative clients. DIF: Remembering/Knowledge REF: 251 KEY: Intraoperative nursing| older adult MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Health Promotion and Maintenance

An older client is hospitalized after an operation. When assessing the client for postoperative infection, the nurse places priority on which assessment? a. Change in behavior b. Daily white blood cell count c. Presence of fever and chills d. Tolerance of increasing activity

ANS: A Older people have an age-related decrease in immune system functioning and may not show classic signs of infection such as increased white blood cell count, fever and chills, or obvious localized signs of infection. A change in behavior often signals an infection or onset of other illness in the older client. DIF: Applying/Application REF: 221 KEY: Preoperative nursing| infection| older adult MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Health Promotion and Maintenance

A student is caring for clients in the preoperative area. The nurse contacts the surgeon about a client whose heart rate is 120 beats/min. After consulting with the surgeon, the nurse administers a beta blocker to the client. The student asks why this was needed. What response by the nurse is best? a. "A rapid heart rate requires more effort by the heart." b. "Anesthesia has bad effects if the client is tachycardic." c. "The client may have an undiagnosed heart condition." d. "When the heart rate goes up, the blood pressure does too."

ANS: A Tachycardia increases the workload of the heart and requires more oxygen delivery to the myocardial tissues. This added strain is not needed on top of the physical and emotional stress of surgery. The other statements are not accurate. DIF: Applying/Application REF: 219 KEY: Preoperative nursing| tachycardia| beta blocker MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

A client is scheduled for a below-the-knee amputation. The circulating nurse ensures the proper side is marked prior to the start of surgery. What action by the nurse is most appropriate? a. Facilitate marking the site with the client and surgeon. b. Have the client mark the operative site. c. Mark the operative site with a waterproof marker. d. Tell the surgeon it is time to mark the surgical site.

ANS: A The Joint Commission now recommends that both the client and the surgeon mark the operative site together in order to prevent wrong-site surgery. The nurse should facilitate this process. DIF: Applying/Application REF: 250 KEY: Intraoperative nursing| wrong-site surgery| The Joint Commission National Patient Safety Goals MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

The perioperative nurse manager and the postoperative unit manager are concerned about the increasing number of surgical infections in their hospital. What action by the managers is best? a. Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met. b. Encourage staff on both units to provide peer pressure to adhere to hand hygiene policy. c. Hold educational meetings with the nursing and surgical staff on infection prevention. d. Monitor staff on both units for consistent adherence to established hand hygiene practices

ANS: A The SCIP project contains core measures that are mandatory for all surgical clients and focuses on preventing infection, serious cardiac events, and venous thromboembolism. The managers should start by reviewing charts to see if the guidelines of this project were implemented. The other actions may be necessary too, but first the managers need to assess the situation. DIF: Applying/Application REF: 216 KEY: Preoperative nursing| Surgical Care Improvement Project (SCIP)| infection MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A client had an arthroscopy 1 hour ago on the left knee. The nurse finds the left lower leg to be pale and cool, with 1+/4+ pedal pulses. What action by the nurse is best? a. Assess the neurovascular status of the right leg. b. Document the findings in the client's chart. c. Elevate the left leg on at least two pillows. d. Notify the provider of the findings immediately.

ANS: A The nurse should compare findings of the two legs as these findings may be normal for the client. If a difference is observed, the nurse notifies the provider. Documentation should occur after the nurse has all the data. Elevating the left leg will not improve perfusion if there is a problem. DIF: Applying/Application REF: 1027 KEY: Musculoskeletal system| musculoskeletal assessment| musculoskeletal disorders| nursing assessment MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A client is on the phone when the nurse brings a preoperative antibiotic before scheduled surgery. The circulating nurse has requested the antibiotic be started. The client wants the nurse to wait before starting it. What response by the nurse is most appropriate? a. Explain the rationale for giving the medicine now. b. Leave the room and come back in 15 minutes. c. Provide holistic client care and come back later. d. Tell the client you must start the medication now.

ANS: A The preoperative antibiotic must be given within 60 minutes of the surgical start time to ensure the proper amount is in the tissues when the incision is made. The nurse should explain the rationale to the client for this timing. The other options do not take this timing into consideration and do not give the client the information needed to be cooperative. DIF: Applying/Application REF: 234 KEY: Preoperative nursing| antibiotic| Surgical Care Improvement Project (SCIP) MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

nurse assesses a client in the preoperative holding area and finds brittle nails and hair, dry skin turgor, and muscle wasting. What action by the nurse is best? a. Consult the surgeon about a postoperative dietitian referral. b. Document the findings thoroughly in the client's chart. c. Encourage the client to eat more after recovering from surgery. d. Refer the client to Meals on Wheels after discharge.

ANS: A This client has signs of malnutrition, which can impact recovery from surgery. The nurse should consult the surgeon about prescribing a consultation with a dietitian in the postoperative period. The nurse should document the findings but needs to do more. Encouraging the client to eat more may be helpful, but the client needs a professional nutritional assessment so that the appropriate diet and supplements can be ordered. The client may or may not need Meals on Wheels after discharge. DIF: Applying/Application REF: 222 KEY: Preoperative nursing| malnutrition| nutrition MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A hospitalized client's strength of the upper extremities is rated at 3. What does the nurse understand about this client's ability to perform activities of daily living (ADLs)? a. The client is able to perform ADLs but not lift some items. b. No difficulties are expected with ADLs. c. The client is unable to perform ADLs alone. d. The client would need near-total assistance with ADLs

ANS: A This rating indicates fair muscle strength with full range of motion against gravity but not resistance. The client could complete ADLs independently unless they required lifting objects. DIF: Understanding/Comprehension REF: 1024 KEY: Musculoskeletal system| musculoskeletal assessment| musculoskeletal disorders| nursing assessment MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

A school nurse is conducting scoliosis screening. In screening the client, what technique is most appropriate? a. Bending forward from the hips b. Sitting upright with arms outstretched c. Walking across the room and back d. Walking with both eyes closed

ANS: A To assess for scoliosis, a spinal deformity, the student should bend forward at the hips. Standing behind the student, the nurse looks for a lateral curve in the spine. The other actions are not correct. DIF: Applying/Application REF: 1023 KEY: Musculoskeletal system| musculoskeletal assessment| musculoskeletal disorders| nursing assessment| secondary prevention MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Health Promotion and Maintenance

A nurse is providing community education about preventing traumatic musculoskeletal injuries related to car crashes. Which group does the nurse target as the priority for this education? a. High school football team b. High school homeroom class c. Middle-aged men d. Older adult women

ANS: A Young men are at highest risk for musculoskeletal injury due to trauma, especially due to motor vehicle crashes. The high school football team, with its roster of young males, is the priority group. DIF: Applying/Application REF: 1020 KEY: Musculoskeletal system| musculoskeletal assessment| musculoskeletal disorders MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

The nurse receives a hand-off report. One client is described as a drug seeker who is obsessed with even tiny changes in physical condition and is "on the light constantly" asking for more pain medication. When assessing this client's pain, which statement or question by the nurse is most appropriate? a. "Help me understand how pain is affecting you right now." b. "I wish I could do more; is there anything I can get for you?" c. "You cannot have more pain medication for 3 hours." d. "Why do you think the medication is not helping your pain?"

ANS: A A client who is preoccupied with physical symptoms and is "demanding" may have some psychosocial impact from the pain that is not being addressed. The nurse is providing the client the chance to explain the emotional effects of pain in addition to the physical ones. Saying the nurse wishes he or she could do more is very empathetic, but this response does not attempt to learn more about the pain. Simply telling the client when the next medication is due also does not help the nurse understand the client's situation. "Why" questions are probing and often make clients defensive, plus the client may not have an answer for this question.

A new nurse reports to the nurse preceptor that a client requested pain medication, and when the nurse brought it, the client was sound asleep. The nurse states the client cannot possibly sleep with the severe pain the client described. Which response by the experienced nurse is best? a. "Being able to sleep doesn't mean pain doesn't exist." b. "Have you ever experienced any type of pain?" c. "The client should be assessed for drug addiction." d. "You're right; I would put the medication back."

ANS: A A client's description is the most accurate assessment of pain. The nurse would believe the client and provide pain relief. Physiologic changes due to pain vary from client to client, and assessments of them would not supersede the client's descriptions, especially if the pain is chronic in nature. Asking if the new nurse has had pain is judgmental and flippant and does not provide useful information. This amount of information does not warrant an assessment for drug addiction. Putting the medication back and ignoring the client's report of pain serves no useful purpose and is unethical.

A nurse prepares a client for lumbar puncture (LP). Which assessment finding would alert the nurse to contact the primary health care provider? a. Shingles infection on the client's back b. Client is claustrophobic c. Absence of intravenous access d. Paroxysmal nocturnal dyspnea

ANS: A An LP would not be performed if the client has a skin infection at or near the puncture site because of the risk of cerebrospinal fluid infection. A nurse would want to notify the primary health care provider if shingles were identified on the client's back. If a client has shortness of breath when lying flat, the LP can be adapted to meet the client's needs. Claustrophobia, absence of IV access, and paroxysmal nocturnal dyspnea have no impact on whether an LP can be performed.

A male client was admitted with a left-sided stroke this morning. The assistive personnel asks about meeting the client's nutritional needs. Which response by the nurse is appropriate? a. "He is NPO until the speech-language pathologist performs a swallowing evaluation." b. "You may give him a full-liquid diet, but please avoid solid foods until he gets stronger." c. "Just be sure to add some thickener in his liquids to prevent choking and aspiration." d. "Be sure to sit him up when you are feeding him to make him feel more natural."

ANS: A Any client who has or is suspected of having a stroke should have nothing by mouth until he or she is evaluated for any swallowing problem by the speech-language pathologist (SLP). If dysphagia is present, the SLP makes specific recommendations for the client's plan of care which all staff members must follow to prevent choking and aspiration/aspiration pneumonia.

A nurse uses the Checklist of Nonverbal Pain Indicators to assess pain in a nonverbal client with advanced dementia but no other medical history except well-controlled hypertension and high cholesterol. The client scores a zero. Which action by the nurse is best? a. Assess physiologic indicators and vital signs. b. Do not give pain medication as no pain is indicated. c. Document the findings and continue to monitor. d. Try a small dose of analgesic medication for pain.

ANS: A Assessing pain in a nonverbal client is difficult despite the use of a scale specifically designed for this population. The hierarchy for assessing pain consists of (1) obtaining a verbal report, which is not possible in this client, (2) consider conditions that might reasonably be painful, (3) observe behaviors, (4) evaluate physiologic indicators, and (5) attempt an analgesic trial. The client is not known to have any conditions that reasonably would cause pain. The nurse would next look at physiologic indicators of pain and vital signs for clues to the presence of pain. Even a low score on this index does not mean that the client does not have pain; he or she may be holding very still to prevent more pain. Documenting pain is important but not the most important action in this case until the nurse has conducted a full assessment. The nurse can try a small dose of analgesia, but without having indices to monitor, it will be difficult to assess for effectiveness.

nurse assesses an older client who has two skin lesions on the chest. Each lesion is the size of a nickel, flat, and darker in color than the rest of the client's skin. What does the nurse tell the client regarding these lesions? a. "Monitor these spots for any changes." b. "You don't need to worry about these." c. "I will ask for a dermatology referral for you." d. "We need to schedule you for a skin biopsy."

ANS: A Because of melanocyte hyperplasia, the older adult frequently has "age spots," or darker spots on the skin. The nurse would teach the client to monitor the spots and report any changes indicative of cancer. Stating the client does not need to worry is inaccurate and dismissive. The client does not necessarily need a dermatology referral and does not need a skin biopsy at this point.

The postanesthesia care unit (PACU) nurse is caring for an older client following a lengthy surgery. The client's pulse is 48 beats/min which is 20 beats/min lower than the preoperative baseline. What assessment does the nurse make next? a. Temperature b. Level of consciousness c. Blood pressure d. Rate of IV infusion

ANS: A Bradycardia in the immediate postoperative client can indicate anesthesia effect or hypothermia. Older adults are at higher risk for hypothermia because of age-related changes in temperature regulation, decreased body fat, or prolonged exposure to cool environments, such as an OR suite. The nurse would first assess the client's temperature and take measures to correct any existing hypothermia. Level of consciousness, blood pressure, and IV infusion rate are not related, although all are important assessments in the postoperative period.

A client has a brain tumor and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying that the client does not have a seizure disorder. What response by the nurse is correct? a. "Increased pressure from the tumor can cause seizures." b. "Preventing febrile seizures with a tumor is important." c. "Seizures always occur in clients with brain tumors." d. "This drug is used to sedate with a brain tumor."

ANS: A Brain tumors can lead to seizures as a complication. The nurse would explain this to the spouse. Preventing febrile seizures is not related to a tumor. Seizures are possible but do not always occur in clients with brain tumors. This drug is not used for sedation.

The nurse is performing an assessment of cranial nerve III. Which testing is appropriate? a. Pupil constriction b. Deep tendon reflexes c. Upper muscle strength d. Speech and language

ANS: A CN III is the oculomotor nerve which controls eye movement, pupil constriction, and eyelid movement.

A nurse assesses a client recovering from a cerebral angiography via the right femoral artery. Which assessment would the nurse complete? a. Palpate bilateral lower extremity pulses. b. Obtain orthostatic blood pressure readings. c. Perform a funduscopic examination. d. Assess the gag reflex prior to eating.

ANS: A Cerebral angiography is performed by threading a catheter through the femoral or brachial artery. The extremity is kept immobilized after the procedure. The nurse checks the extremity for adequate circulation by noting skin color and temperature, presence and quality of pulses distal to the injection site, and capillary refill. Clients usually are on bedrest; therefore, orthostatic blood pressure readings cannot be performed. The funduscopic (eye) examination would not be affected by cerebral angiography. The client is not given general anesthesia; therefore, the client's gag reflex would not be compromised.

A nurse is providing community screening for risk factors associated with stroke. Which person would the nurse identify as being at the highest risk for a stroke? a. A 27-year-old heavy-cocaine user. b. A 30-year-old who drinks a beer a day. c. A 40-year-old who uses seasonal antihistamines. d. A 65-year-old who is active and on no medications.

ANS: A Heavy drug use, particularly cocaine, is a risk factor for stroke. Heavy alcohol use is also a risk factor, but one beer a day is not considered heavy drinking. Antihistamines may contain phenylpropanolamine, which also increases the risk for stroke, but this person uses them seasonally and there is no information that they are abused or used heavily. The 65 year old has only age as a risk factor.

A nurse performs an assessment of pain discrimination on an older adult. The client correctly identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin. Which action would the nurse take next? a. Touch the pin on the same area of the left hand. b. Contact the primary health care provider with the assessment results. c. Ask the client about current and past medications. d. Continue the assessment on the client's feet and legs.

ANS: A If testing is begun on the right hand and the client correctly identifies the pain stimulus, the nurse would continue the assessment on the left hand. This is a normal finding and does not need to be reported to the provider, but instead documented in the client's medical record. Medications do not need to be assessed in response to this finding. The nurse would assess the left hand prior to assessing the feet.

A nurse assesses a client who has open skin lesions. Which action by the nurse is most important? a. Put on gloves. b. Ask the client about his or her occupation. c. Assess the client's pain. d. Obtain vital signs.

ANS: A Nurses wear gloves as part of Standard Precautions when examining skin that is not intact. The other options are part of the full assessment but adhering to Standard Precautions is important for safety and infection control.

A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The patient's spouse is very frustrated, stating that the patient's personality has changed and the situation is very difficult. What response by the nurse is most appropriate? a. Explain that personality changes are common following brain injuries. b. Ask the client why he or she is acting out and behaving differently. c. Refer the client and spouse to a head injury support group. d. Tell the spouse that this is expected and he or she will have to learn to cope.

ANS: A Personality and behavior often change permanently after head injury. The nurse will explain this to the spouse. Asking the client about his or her behavior isn't useful because the patient probably cannot help it. A referral might be a good idea, but the nurse needs to do something in addition to just referring the couple. Telling the spouse to learn to cope belittles his or her concerns and feelings.

A nurse assesses an older adult client with the skin disorder shown below: How will the nurse document this finding? a. Petechiae b. Ecchymoses c. Actinic lentigo d. Senile angiomas

ANS: A Petechiae, or small, reddish purple nonraised lesions that do not fade or blanch with pressure, are pictured here. Ecchymoses are larger areas of hemorrhaging, commonly known as bruising. Actinic lentigo presents as paper-thin, transparent skin. Senile angiomas, also known as cherry angiomas, are red raised lesions.

The perioperative nurse manager and the postoperative unit manager are concerned about the increasing number of surgical infections in their hospital. What action by the managers is best? a. Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met. b. Encourage staff on both units to provide peer pressure to adhere to hand hygiene policy. c. Hold educational meetings with the nursing and surgical staff on infection prevention. d. Monitor staff on both units for consistent adherence to established hand hygiene practices.

ANS: A The SCIP project contains core measures to reduce surgical complications. Examples of focus included administration of prophylactic antibiotics, correct hair removal processes, the timing of discontinuation of urinary catheterization after surgery, and venous thromboembolism prophylaxis. These practices are now standard in surgical care. Prevention of infection is a heavy emphasis, so the managers would start by reviewing charts to see if the guidelines of this project were implemented. The other actions may be necessary too, but first the managers need to assess the situation.

A client is admitted with a sudden decline in level of consciousness. What is the nursing action at this time? a. Assess the client for hypoglycemia and hypoxia. b. Place the client on his or her side. c. Prepare for administration of a fibrinolytic agent. d. Start a continuous IV heparin sodium infusion.

ANS: A The cause of a sudden decline in level of consciousness may or may not be related to a neurologic health problem. Therefore, the client must be evaluated for other common causes, especially hypoglycemia and hypoxia. Placing the client on his or her side may be helpful to prevent aspiration in case the client experiences vomiting, but the clinical situation does not indicate that the client has nausea or vomiting. Administering either an anticoagulant like heparin or a fibrinolytic agent assumes that the client has an acute ischemic stroke, which has not been confirmed through imaging tests.

A client is admitted with a diagnosis of cerebellar stroke. What intervention is most appropriate to include on the client's plan of care? a. Ambulate only with a gait belt. b. Encourage double swallowing. c. Monitor lung sounds after eating. d. Perform postvoid residuals.

ANS: A The client who has a cerebellar stroke would be expected to have ataxia, an abnormal gait. For the client's safety, he or she should have assistance and use a gait belt when ambulating. Ataxia is not related to swallowing, aspiration, or voiding.

A nurse assesses a client in the preoperative holding area and finds brittle nails and hair, dry skin turgor, and muscle wasting. What action by the nurse is best? a. Consult the primary health care provider about a dietitian referral. b. Document the findings thoroughly in the client's chart. c. Encourage the client to eat more after recovering from surgery. d. Refer the client to Meals on Wheels after discharge.

ANS: A This client has signs of malnutrition, which can impact recovery from surgery. The nurse should consult the primary health care provider about prescribing a consultation with a dietitian in the postoperative period. The nurse should document the findings but needs to do more. Encouraging the client to eat more may be helpful, but the client needs a professional nutritional assessment so that the appropriate diet and supplements can be ordered. The client may or may not need Meals on Wheels after discharge.

The nurse assesses a client who has a mild traumatic brain injury (TBI) for signs and symptoms consistent with this injury. What signs and symptoms does the nurse expect? (Select all that apply.) a. Sensitivity to light and sound b. Reports "feeling foggy" c. Unconscious for an hour after injury d. Elevated temperature e. Widened pulse pressure

ANS: A, B A mild TBI would possibly lead to sensitivity to light and sound and a feeling of mental fogginess. The patient would have been unconscious for less than 30 minutes. An elevated temperature is not related. A widened pulse pressure is indicative of increased intracranial pressure, not a mild TBI.

The nurse would recognize which signs and symptoms as consistent with brainstem tumors? (Select all that apply.) a. Hearing loss b. Facial pain c. Nystagmus d. Vomiting e. Hemiparesis

ANS: A, B, C Hearing loss (CN VIII), facial pain (CN V), and nystagmus (CN III, IV, and VI) all are indicative of a brainstem tumor because these cranial nerves originate in the brainstem. Vomiting and hemiparesis are more indicative of cerebral tumors.

A student nurse asks why older adults are at higher risk for complications after surgery. What reasons does the registered nurse give? (Select all that apply.) a. Decreased cardiac output b. Decreased oxygenation c. Frequent nocturia d. Mobility alterations e. Inability to adapt to changes

ANS: A, B, C, D Older adults have many age-related physiologic changes that put them at higher risk of falling and other complications after surgery. Some of these include decreased cardiac output, decreased oxygenation of tissues, nocturia, and mobility alterations. They also have a decreased ability to adapt to new surroundings, but that is not the same as being unable to adapt. DIF: Understanding/Comprehension REF: 220 KEY: Preoperative nursing| older adult MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

What actions by the circulating nurse are important to promote client comfort? (Select all that apply.) a. Correct positioning b. Introducing one's self c. Providing warmth d. Remaining present e. Removing hearing aids

ANS: A, B, C, D The circulating nurse can do many things to promote client comfort, including positioning the client correctly and comfortably, introducing herself or himself to the client, keeping the client warm, and remaining present with the client. Removing hearing aids does not promote comfort and, if the client is still awake when they are removed, may contribute to disorientation and anxiety. DIF: Remembering/Knowledge REF: 239 KEY: Intraoperative nursing| comfort MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

A client is experiencing pain after leg surgery but cannot yet have more pain medication. What comfort interventions can the nurse provide? (Select all that apply.) a. Apply stimulation to the contralateral leg. b. Assess the client's willingness to try meditation. c. Elevate the client's operative leg and apply ice. d. Reduce the noise level in the client's environment. e. Turn the TV on loudly to distract the client.

ANS: A, B, C, D There are many nonpharmacologic comfort measures for pain, including applying stimulation to the opposite leg, providing opportunities for meditation, elevation of the leg, applying ice, and reducing noxious stimuli in the environment. Participating in diversional activities is another approach, but simply turning the TV on loudly does not provide a good diversion. DIF: Remembering/Knowledge REF: 271 KEY: Postoperative nursing| pain| nonpharmacologic pain management| nursing intervention| physical modalities| ice MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

A nurse is caring for a group of stroke patients. Which clients would the nurse consider referring to a mental health provider? (Select all that apply.) a. Female client who exhibits extreme emotional lability b. Male client with an initial National Institutes of Health (NIH) Stroke Scale score of 38 c. Female client with mild forgetfulness and a history of depression d. Male client who has a past hospitalization for a suicide attempt e. Male client who is unable to walk or eat 3 weeks poststroke

ANS: A, B, C, D, E Patients most at risk for poststroke depression are those with a previous history of depression, severe stroke (NIH Stroke Scale score of 38 is severe), and poststroke physical or cognitive impairment.

A nurse is admitting an older client for surgery to the inpatient surgical unit. The client relates a prior history of acute confusion after a previous operation. What interventions does the nurse include on the client's plan of care to minimize the potential for this occurring? (Select all that apply.) a. Allow family and friends to visit as the client desires. b. Ask the client about coping techniques frequently used. c. Instruct the nursing assistant to ensure the client is bathed. d. Place the client in a room secluded at the end of the hall. e. Provide the client with uninterrupted periods of sleep.

ANS: A, B, C, E Older clients may have difficulty adjusting to the stress of the hospital environment and illness or surgery. Techniques that are helpful include allowing liberal visitation, assisting the client to use successful coping techniques, and keeping the client bathed and groomed. Sleep deprivation can contribute to confusion, so the nurse ensures the client receives adequate sleep. Secluding the client at the end of the hall may lead to sensory deprivation and loneliness. DIF: Remembering/Knowledge REF: 267 KEY: Postoperative nursing| coping| psychosocial response| older adult MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Health Promotion and Maintenance

The circulating nurse reviews the day's schedule and notes clients who are at higher risk of anesthetic overdose and other anesthesia-related complications. Which clients does this include? (Select all that apply.) a. A 75-year-old client scheduled for an elective procedure b. Client who drinks a 6-pack of beer each day c. Client with a serum creatinine of 3.8 mg/dL d. Client who is taking birth control pills e. Young male client with a RYR1 gene mutation

ANS: A, B, C, E People at higher risk for anesthetic overdose or other anesthesia-related complications include people with a slowed metabolism (older adults generally have slower metabolism than younger adults), those with kidney or liver impairments, and those with mutations of the RYR1 gene. Drinking a 6-pack of beer per day possibly indicates some liver disease; a creatinine of 3.8 is high, indicating renal disease; and the genetic mutation increases the chance of malignant hyperthermia. Taking birth control pills is not a risk factor. DIF: Analyzing/Analysis REF: 247 KEY: Intraoperative nursing| anesthesia MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A postoperative client is being discharged with a prescription for oxycodone hydrochloride with acetaminophen (Percocet). What instructions does the nurse give the client? (Select all that apply.) a. "Check all over-the-counter medications for acetaminophen." b. "Do not take more pills each day than you are prescribed." c. "Eat a diet that is high in fiber and drink lots of water." d. "If this gives you diarrhea, loperamide (Imodium) can help." e. "You shouldn't drive while you are taking this medication."

ANS: A, B, C, E Percocet is a common opioid analgesic that contains acetaminophen. The client should be taught to check all over-the-counter medications for acetaminophen and to not take more than the prescribed amount of Percocet, as the maximum daily dose of acetaminophen is 3000 mg. Percocet, like all opioid analgesics, can cause constipation, and the client can minimize this by eating a high-fiber diet and drinking plenty of water. Since Percocet can cause drowsiness, the client taking it should not drive or operate machinery. The medication is more likely to cause constipation than diarrhea. DIF: Applying/Application REF: 269 KEY: Postoperative nursing| discharge planning/teaching| opioid analgesics| acetaminophen| constipation MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

Based on the known risk factors for stroke, which health promotion practices would the nurse teach a client to promote heart health and prevent strokes? (Select all that apply.) a. Blood pressure control b. Aspirin use c. Smoking cessation d. Low carbohydrate diet e. Cholesterol management f. Increased red wine consumption

ANS: A, B, C, E The evidence-based health promotion practices include blood pressure control, aspirin use, smoking cessation, and cholesterol management. There is no consensus on which diet is best to promote heart health and red wine does not protect the heart or prevent strokes.

The nurse is caring for a client with increasing intracranial pressure (ICP) following a stroke. Which evidence-based nursing actions are indicated for this client? (Select all that apply.) a. Hyperoxygenate the client before and after suctioning. b. Avoid sudden or extreme hip or neck flexion. c. Provide oxygen to maintain an SaO2 of 95% or greater. d. Maintain the client in a supine position at all times. e. Avoid clustering care nursing activities and procedures. f. Provide environmental stimulation to improve cognition.

ANS: A, B, C, E These precautions help prevent further increases in ICP. Clustering nursing activities and procedures and providing stimulation can increase ICP and should be avoided.

The nurse is preparing for discharge of a client who had a carotid artery angioplasty with stenting to prevent a stroke. For which signs and symptoms with the nurse teach the family to report to the primary health care provider immediately? (Select all that apply.) a. Muscle weakness b. Hoarseness c. Acute confusion d. Mild neck discomfort e. Severe headache f. Dysphagia

ANS: A, B, C, E, F Muscle weakness, acute confusion, severe headache, and dysphagia are all signs and symptoms that could indicate that a stroke occurred. Hoarseness and severe neck pain and swelling may occur as a result of the interventional radiologic procedure.

3. Important self-care measures a nurse can teach a client with Parkinson's disease in order to prevent contractures and improve mobility include which of the following? (Select all that apply.) a. Bend over with your head over your toes to get out of chairs. b. Exercise first thing in the morning. c. Keep a narrow-based gait. d. Look up when you walk, not down at the floor. e. Use a firm surface, like the floor, for exercising.

ANS: A, B, D Clients with PD need to maintain mobility and prevent contractures. Options a, b, and d are important self-help measures. The client should use a wide-based gait. If it is too hard to get on the floor to exercise, the client should do exercises in bed. DIF: Application/Applying REF: p. 1906 OBJ: Intervention MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Self Care

A client is clearly uncomfortable and anxious in the preoperative holding room waiting for emergent abdominal surgery. What actions can the nurse perform to increase comfort? (Select all that apply.) a. Allow the client to assume a position of comfort. b. Allow the client's family to remain at the bedside. c. Give the client a warm, non-caffeinated drink. d. Provide warm blankets or cool washcloths as desired. e. Pull the curtains around the bed to provide privacy

ANS: A, B, D, E There are many nonpharmacologic comfort measures the nurse can employ, such as allowing the client to remain in the position that is most comfortable, letting the family stay with the client, providing warmth or cooling measures as requested by the client, and providing privacy. The client in the preoperative holding area is NPO, so drinks should not be provided. DIF: Applying/Application REF: 233 KEY: Preoperative nursing| comfort MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

A nurse assesses a client with an injury to the medulla. Which clinical manifestations would the nurse expect to find? (Select all that apply.) a. Decreased respiratory rate b. Impaired swallowing c. Visual changes d. Inability to shrug shoulders e. Loss of gag reflex

ANS: A, B, D, E Cranial nerves IX (glossopharyngeal), X (vagus), XI (accessory), and XII (hypoglossal) emerge from the medulla, as do portions of cranial nerves VII (facial) and VIII (acoustic). Damage to these nerves causes decreased respirations, impaired swallowing, inability to shrug shoulders, and loss of the gag reflex. The other manifestations are not associated with damage to the medulla.

A nurse learns that there are physical consequences to unrelieved pain. Which factors are included in this problem? (Select all that apply.) a. Decreased immune response b. Development of chronic pain c. Increased gastrointestinal (GI) motility d. Possible immobility e. Slower healing f. Negative quality of life

ANS: A, B, D, E, F There are many physiologic impacts of unrelieved pain, including decreased immune response; development of chronic pain; decreased GI motility; immobility; slower healing; prolonged stress response; and increased heart rate, blood pressure, and oxygen demand. Decreased quality of life includes depression, anxiety, fear, anger, hopelessness, and insomnia; impaired family, work, and social relationships; and difficulty with ADLs.

A client has multiple lesions all over the body and a family history of skin cancer. The nurse teaches the client to perform a total skin self-examinations on a monthly basis. Which statements will the nurse include in this patient's teaching? (Select all that apply.) a. "Look for asymmetry of shape and irregular borders." b. "Assess for color variation within each lesion." c. "Examine the distribution of lesions over a section of the body." d. "Monitor for edema or swelling of tissues." e. "Focus your assessment on skin areas that itch." f. "Report any lesions that change over time in any way."

ANS: A, B, F Patients will be taught to examine each lesion following the ABCDE features associated with skin cancer: asymmetry of shape, border irregularity, color variation within one lesion, diameter greater than 6 mm, and evolving or changing in any feature.

A client is having shoulder surgery with regional anesthesia. What actions by the nurse are most important to enhance client safety related to this anesthesia? (Select all that apply.) a. Assessing distal circulation to the operative arm after positioning b. Keeping the client warm during the operative procedure c. Padding the client's shoulder and arm on the operating table d. Preparing to suction the client's airway if the client vomits e. Speaking in a low, quiet voice as anesthesia is administered

ANS: A, C After regional anesthesia is administered, the client loses all sensation distally. The nurse ensures client safety by assessing distal circulation and padding the shoulder and arm appropriately. Although awake, the client will not be able to report potential injury. Keeping the client warm is not related to this anesthesia, nor is suctioning or speaking quietly. DIF: Applying/Application REF: 248 KEY: Intraoperative nursing| regional anesthesia MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

A nursing student studying the musculoskeletal system learns about important related hormones. What information does the student learn? (Select all that apply.) a. A lack of vitamin D can lead to rickets. b. Calcitonin increases serum calcium levels. c. Estrogens stimulate osteoblastic activity. d. Parathyroid hormone stimulates osteoclastic activity. e. Thyroxine stimulates estrogen release.

ANS: A, C, D Vitamin D is needed to absorb calcium and phosphorus. A deficiency of vitamin D can lead to rickets. Estrogen stimulates osteoblastic activity. Parathyroid hormone stimulates osteoclastic activity. Calcitonin decreases serum calcium levels when they get too high. Thyroxine increases the rate of protein synthesis in all tissue types. DIF: Remembering/Knowledge REF: 1019 KEY: Musculoskeletal system MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

A nurse cares for older clients who have traumatic brain injury. What does the nurse understand about this population? (Select all that apply.) a. Admission can overwhelm the coping mechanisms for older clients. b. Alcohol is typically involved in most traumatic brain injuries for this age-group. c. These clients are more susceptible to systemic and wound infections. d. Other medical conditions can complicate treatment for these clients. e. Very few traumatic brain injuries occur in this age-group.

ANS: A, C, D Older adults often tolerate stress poorly, which includes being admitted to a hospital that is unfamiliar and noisy. Because of decreased protective mechanisms, they are more susceptible to both local and systemic infections. Other medical conditions can complicate their treatment and recovery. Alcohol is typically not related to traumatic brain injury in this population; such injury is most often from falls and motor vehicle crashes.

A student nurse is caring for clients on the postoperative unit. The student asks the registered nurse why malnutrition can lead to poor surgical outcomes. What responses by the nurse are best? (Select all that apply.) a. "A malnourished client will have fragile skin." b. "Malnourished clients always have other problems." c. "Many drugs are bound to protein in the body." d. "Protein stores are needed for wound healing." e. "Weakness and fatigue are common in malnutrition."

ANS: A, C, D, E Malnutrition can lead to poorer surgical outcomes for several reasons, including fragile skin that might break down, altered pharmacokinetics, poorer wound healing, and weakness or fatigue that can interfere with recovery. Malnutrition can exist without other comorbidities. DIF: Understanding/Comprehension REF: 222 KEY: Preoperative nursing| nutrition| malnutrition MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

A nurse is studying pain sources. Which statements accurately describe different types of pain? (Select all that apply.) a. Neuropathic pain sometimes accompanies amputation. b. Nociceptive pain originates from abnormal pain processing. c. Deep somatic pain is pain arising from bone and connective tissues. d. Somatic pain originates from skin and subcutaneous tissues. e. Visceral pain is often diffuse and poorly localized.

ANS: A, C, D, E Neuropathic pain results from abnormal pain processing and is seen in amputations and neuropathies. Somatic pain can arise from superficial sources such as skin, or deep sources such as bone and connective tissues. Visceral pain originates from organs or their linings and is often diffuse and poorly localized. Nociceptive pain is normal pain processing and consists of somatic and visceral pain.

A nurse plans care for a client who has a wound that is not healing. Which focused assessments will the nurse complete to develop the patient's plan of care? (Select all that apply.) a. Height b. Allergies c. Alcohol use d. Prealbumin laboratory results e. Liver enzyme laboratory results f. Weight

ANS: A, C, D, E Nutritional status can have a significant impact on skin health and wound healing. The care plan for a client with poor nutritional status will include a high-protein, high-calorie diet. To determine the patient's nutritional status, the nurse will assess height and weight, alcohol use, and prealbumin laboratory results. These data will provide information related to vitamin and protein deficiencies, and body mass. Allergies and liver enzyme laboratory results will not provide information about nutrition status or wound healing.

A nurse on the postoperative unit administers many opioid analgesics. Which actions by the nurse are best to prevent unwanted sedation as a complication of these medications? (Select all that apply.) a. Avoid using other medications that cause sedation. b. Delay giving medication if the client is sleeping. c. Give the lowest dose that produces good control. d. Identify clients at high risk for unwanted sedation. e. Use an oximeter to monitor clients receiving analgesia.

ANS: A, C, D, E Sedation is a side effect of opioid analgesics. Some sedation can be expected, but protecting the client against unwanted and dangerous sedation is a critical nursing responsibility. The nurse would identify clients at high risk for unwanted sedation and give the lowest possible dose that produces satisfactory pain control. Avoid using other sedating medications such as antihistamines to treat itching. An oximeter can alert the nurse to a decrease in the client's oxygen saturation, which often follows sedation. A postoperative client frequently needs to be awakened for pain medication in order to avoid waking to out-of-control pain later.

A nurse is caring for several clients in the morning prior to surgery. Which medications taken by the clients require the nurse to consult with the primary health care provider about their administration? (Select all that apply.) a. Insulin b. Omega-3 fatty acids c. Phenytoin d. Metoprolol e. Warfarin f. Prednisone

ANS: A, C, D, E, F Although the client will be on NPO status before surgery, the nurse should check with the primary health care provider about allowing the client to take medications prescribed for diabetes, hypertension, cardiac disease, seizure disorders, depression, glaucoma, anticoagulation, or depression and steroids. Metformin is used to treat diabetes; phenytoin is for seizures; metoprolol is for cardiac disease and/or hypertension; and warfarin is an anticoagulant. The omega-3 fatty acids can be held the day of surgery.

A student nurse learns about changes that occur to the musculoskeletal system due to aging. Which changes does this include? (Select all that apply.) a. Bone changes lead to potential safety risks. b. Increased bone density leads to stiffness. c. Osteoarthritis occurs due to cartilage degeneration. d. Osteoporosis is a universal occurrence. e. Some muscle tissue atrophy occurs with aging.

ANS: A, C, E Many age-related changes occur in the musculoskeletal system, including decreased bone density, degeneration of cartilage, and some degree of muscle tissue atrophy. Osteoporosis, while common, is not universal. Bone density decreases with age, not increases. DIF: Remembering/Knowledge REF: 1020 KEY: Musculoskeletal system| musculoskeletal disorders| older adult MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

2. The nurse cautions clients with ALS and their families to be aware that (Select all that apply) a.activities should be spaced throughout the day. b.clients experience incontinence, an early cause of falling. c.cognition will usually decline late in the disease. d.muscle weakness may cause a risk for injury.

ANS: A, D Safety is a prime concern with ALS (and with any degenerative neurologic disorder). Muscle weakness is progressive, leading to increased risk of falls. Some interventions to prevent this include spacing activities throughout the day, conserving energy, avoiding extremes of hot and cold, and using assistive devices such as canes or wheelchairs. Clients with ALS usually do not experience incontinence and cognition remains intact for the duration of the disorder. DIF: Application/Applying REF: pp. 1918-1919 OBJ: Intervention MSC: Safe, Effective Care Environment Safety and Infection Control-Injury Prevention

A client reports a great deal of pain following a fairly minor operation. The surgeon leaves a prescription for the nurse to administer a placebo instead of pain medication. Which actions by the nurse are most appropriate? (Select all that apply.) a. Consult with the surgeon and voice objections. b. Delegate administration of the placebo to another nurse. c. Give the placebo and reassess the client's pain. d. Notify the nurse manager of the placebo prescription. e. Tell the client what medications were prescribed.

ANS: A, D Nurses would never give placebos to treat a client's pain (unless the client is in a research study). This practice is unethical and, in many states, illegal. The nurse would voice concerns with the prescriber and, if needed, contact the nurse manager. The nurse would not delegate giving the placebo to someone else, nor would the nurse give it. Telling the client about the placebo prescription before voicing objections would not be beneficial.

A student nurse observing in the operating room notes that the functions of the Certified Registered Nurse First Assistant (CRNFA) include which activities? (Select all that apply.) a. Dressing the surgical wound b. Grafting new or synthetic skin c. Reattaching severed nerves d. Suctioning the surgical site e. Suturing the surgical wound

ANS: A, D, E The CRNFA can perform tasks under the direction of the surgeon such as suturing and dressing surgical wounds, cutting away tissue, suctioning the wound to improve visibility, and holding retractors. Reattaching severed nerves and performing grafts would be the responsibility of the surgeon. DIF: Remembering/Knowledge REF: 239 KEY: Surgery| Certified Registered Nurse First Assistant (CRNFA) MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

A client has received several doses of midazolam. The nurse assesses the client to be difficult to arouse with respirations of 6 breaths/min. What actions by the nurse are most important? (Select all that apply.) a. Administer oxygen per protocol. b. Obtain one dose of flumazenil. c. Obtain naloxone, 0.04 mg for IV push. d. Ensure suction is working e. Transfer the client to intensive care. f. Monitor client every 10 to 15 minutes for the next 2 hours.

ANS: A, D, E Midazolam is a benzodiazepine and its reversal agent is flumazenil. Naloxone is for opioid reversal. The nurse would apply oxygen as prescribed or by policy and obtain several doses at once because the drug can be given every 2 to 3 minutes if needed. Flumazenil can cause vomiting, so the nurse ensures suction equipment is present and working. Since flumazenil is metabolized more quickly than the midazolam, the client must be monitored every 10 to 15 minutes for the next 2 hours. The client may or may not need to be transferred.

A nurse learns the concepts of addiction, tolerance, and dependence. Which information is accurate? (Select all that apply.) a. Addiction is a chronic physiologic disease process. b. Physical dependence and addiction are the same thing. c. Pseudoaddiction can result in withdrawal symptoms. d. Tolerance is a normal response to regular opioid use. e. Tolerance is said to occur when opioid effects decrease. f. Physical dependence occurs after repeated doses of an opioid.

ANS: A, D, E, F Addiction, tolerance, and dependence are important concepts. Addiction is a chronic, treatable disease with a neurologic and biologic basis. Tolerance occurs with regular administration of opioid analgesics and is seen when the effect of the analgesic decreases (either therapeutic effect or side effects). Dependence and addiction are not the same; dependence occurs with regular administration of analgesics and can result in withdrawal symptoms when they are discontinued abruptly. Pseudoaddiction is the mistaken diagnosis of addictive disease.

The nursing student observing in the perioperative area notes the unique functions of the circulating nurse, which include which roles? (Select all that apply.) a. Ensuring the client's safety b. Accounting for all sharps c. Documenting all care given d. Maintaining the sterile field e. Monitoring traffic in the room

ANS: A, E The circulating nurse has several functions, including maintaining client safety and privacy, monitoring traffic in and out of the operating room, assessing fluid losses, reporting findings to the surgeon and anesthesia provider, anticipating needs of the team, and communicating to the family. The circulating nurse and scrub person work together to ensure accurate counts of sharps, sponges, and instruments. The circulating nurse also documents care, but in the perioperative area, the preoperative or holding room nurse would also document care received there. Maintaining the sterile field is a joint responsibility among all members of the surgical team. DIF: Remembering/Knowledge REF: 239 KEY: Perioperative| circulating nurse MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

A nurse assesses a client who presents with early koilonychias. Which assessments will the nurse complete next? (Select all that apply.) a. Review the client's health history for a diagnosis of iron deficiency anemia. b. Palpate the client's nail base for potential edemata and sponginess. c. Ask the client about prolonged contact with chemical irritants. d. Assess the client for signs of chronic obstructive pulmonary disease. e. Request a prescription to assess the client's hemoglobin A1C.

ANS: A, E Early koilonychias manifests as flattening of the nail plate with an increased smoothness of the nail. This is caused by iron deficiency with or without anemia, poorly controlled diabetes, and local injury. Nails with visible edema and sponginess when palpated are associated with clubbing. Chronic obstructive pulmonary disease may cause clubbing of the nails and chemical irritants are associated with late koilonychias.

15. To prevent complications caused by a common problem of Huntington's disease, the nurse should a.institute seizure precautions. b.pad wheelchairs and beds. c.start an exercise regimen. d.teach different communication signals.

ANS: B Excessive movements and falling can cause injury in the client with Huntington's disease. Interventions include padding wheelchairs and beds, providing shin guards, and using gait belts for ambulation. Communication does become difficult and alternative forms of communication are appropriate before the client becomes completely demented, but this does not take priority over safety precautions. The client does not need an exercise regimen as the client is already hyperactive, and seizures do not occur. DIF: Analysis/Analyzing REF: p. 1908 OBJ: Intervention MSC: Safe, Effective Care Environment Safety and Infection Control-Injury Prevention

13. A client with advanced ALS is admitted to the hospital. Because of manifestations that are common in clients with ALS, the nurse should a. attempt to institute bowel-training activities. b.provide the client with small, frequent feedings. c.obtain an order for intermittent catheterization. d.orient the client to his or her surroundings frequently.

ANS: B The course of the disease is relentlessly progressive. Cognition, as well as bowel and bladder sphincters, remains intact. The client may be malnourished because of dysphagia. Encourage small, frequent, high-nutrient feedings. The nurse should assess for aspiration and choking. A feeding tube may be considered during the course of the illness. DIF: Application/Applying REF: p. 1919 OBJ: Intervention MSC: Physiological Integrity Basic Care and Comfort-Nutrition and Oral Hydration

14. The nurse explains that the pathology of Huntington's disease involves a.a decrease in the neurotransmitter norepinephrine. b.an excess of the neurotransmitter dopamine. c.destruction of white matter in the brain. d.formation of neurofibrillary tangles and plaques.

ANS: B The degeneration of the caudate nucleus leads to a reduction in several neurotransmitters, including gamma-aminobutyric acid, acetylcholine, substance P, and metenkephalin, and their synthetic enzymes. This change leaves relatively higher concentrations of the other neurotransmitters, dopamine and norepinephrine. DIF: Comprehension/Understanding REF: p. 1908 OBJ: Intervention MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

12. A client with MG began to experience a sudden worsening of her condition with difficulty in breathing. The nurse explains that this complication of MG is usually initially treated with a.admission and administration of IV corticosteroids. b.an increased dose of anticholinesterase drugs. c.bolus doses of atropine titrated to effect. d.rest and increased sleep.

ANS: B With myasthenic crisis, if an increase in the dosage of the anticholinesterase drug does not improve the weakness, endotracheal intubation and mechanical ventilation may be required. None of the other options is used to treat a myasthenic crisis. DIF: Comprehension/Understanding REF: p. 1917 OBJ: Intervention MSC: Physiological Integrity Physiological Adaptation-Illness Management

A client waiting for surgery is very anxious. What intervention can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Assess the client's anxiety. b. Give the client a back rub. c. Remind the client to turn. d. Teach about postoperative care.

ANS: B A back rub reduces anxiety and can be delegated to the UAP. Once teaching has been done, the UAP can remind the client to turn, but this is not related to relieving anxiety. Assessing anxiety and teaching are not within the scope of practice for the UAP. DIF: Applying/Application REF: 233 KEY: Preoperative nursing| anxiety| unlicensed assistive personnel (UAP) MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

The circulating nurse and preoperative nurse are reviewing the chart of a client scheduled for minimally invasive surgery (MIS). What information on the chart needs to be reported to the surgeon as a priority? a. Allergies noted and allergy band on b. Consent for MIS procedure only c. No prior anesthesia exposure d. NPO status for the last 8 hours

ANS: B All MIS procedures have the potential for becoming open procedures depending on findings and complications. The client's consent should include this possibility. The nurse should report this finding to the surgeon prior to surgery taking place. Having allergies noted and an allergy band applied is standard procedure. Not having any prior surgical or anesthesia exposure is not the priority. Maintaining NPO status as prescribed is standard procedure. DIF: Applying/Application REF: 250 KEY: Intraoperative care| informed consent| circulating nurse MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A client is undergoing computed tomography (CT) of a joint. What action by the nurse is most important before the test? a. Administer sedation as prescribed. b. Assess for seafood or iodine allergy. c. Ensure that the client has no metal on the body. d. Provide preprocedure pain medication.

ANS: B Because CT uses iodine-based contrast material, the nurse assesses the client for allergies to iodine or seafood (which often contains iodine). The other actions are not needed. DIF: Applying/Application REF: 1028 KEY: Musculoskeletal system| musculoskeletal assessment| musculoskeletal disorders| diagnostic testing MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

A client is having robotic surgery. The circulating nurse observes the instruments being inserted, then the surgeon appears to "break scrub" when going to the console and sitting down. What action by the nurse is best? a. Call a "time-out" to discuss sterile procedure and scrub technique. b. Document the time the robotic portion of the procedure begins. c. Inform the surgeon that the scrub preparation has been compromised. d. Report the surgeon's actions to the charge nurse and unit manager.

ANS: B During a robotic operative procedure, the surgeon inserts the articulating arms into the client, then "breaks scrub" to sit at the viewing console to perform the operation. The nurse should document the time the robotic portion of the procedure began. There is no need for the other interventions. DIF: Applying/Application REF: 242 KEY: Intraoperative care| circulating nurse| robotic technology| sterile procedure MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A client is in stage 2 of general anesthesia. What action by the nurse is most important? a. Keeping the room quiet and calm b. Being prepared to suction the airway c. Positioning the client correctly d. Warming the client with blankets

ANS: B During stage 2 of general anesthesia (excitement, delirium), the client can vomit and aspirate. The nurse must be ready to react to this potential occurrence by being prepared to suction the client's airway. Keeping the room quiet and calm does help the client enter the anesthetic state, but is not the priority. Positioning the client usually occurs during stage 3 (operative anesthesia). Keeping the client warm is important throughout to prevent hypothermia. DIF: Applying/Application REF: 246 KEY: Intraoperative nursing| stages of anesthesia| airway MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best? a. Answer the questions and document that teaching was done. b. Do not have the client sign the consent and call the surgeon. c. Have the client sign the consent, then call the surgeon. d. Remind the client of what teaching the surgeon has done

ANS: B In order to give informed consent, the client needs sufficient information. Questions about potential complications should be answered by the surgeon. The nurse should notify the surgeon to come back and answer the client's questions before the client signs the consent form. The other actions are not appropriate. DIF: Applying/Application REF: 226 KEY: Preoperative nursing| informed consent MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A client has received intravenous anesthesia during an operation. What action by the postanesthesia care nurse is most important? a. Assist with administering muscle relaxants to the client. b. Place the client on a cardiac monitor and pulse oximeter. c. Prepare to administer intravenous antiemetics to the client. d. Prevent the client from experiencing postoperative shivering.

ANS: B Intravenous anesthetic agents have the potential to cause respiratory and circulatory depression. The nurse should ensure the client is on a cardiac monitor and pulse oximeter. Muscle relaxants are not indicated for this client at this time. Intravenous anesthetics have a lower rate of postoperative nausea and vomiting than other types. Shivering can occur in any client, but is more common after inhalation agents. DIF: Applying/Application REF: 246 KEY: Intraoperative nursing| anesthetic agents| inhalation agents MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

A nurse answers a call light on the postoperative nursing unit. The client states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action should the nurse take first? a. Assess the client's blood pressure. b. Perform hand hygiene and apply gloves. c. Reinforce the dressing with a clean one. d. Remove the dressing to assess the wound.

ANS: B Prior to assessing or treating the drainage from the wound, the nurse performs hand hygiene and dons gloves to protect both the client and nurse from infection. DIF: Applying/Application REF: 268 KEY: Postoperative nursing| Standard Precautions| infection control MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

A nurse is caring for a postoperative client who reports discomfort, but denies serious pain and does not want medication. What action by the nurse is best to promote comfort? a. Assess the client's pain on a 0-to-10 scale. b. Assist the client into a position of comfort. c. Have the client sit up in a recliner. d. Tell the client when pain medication is due.

ANS: B Several nonpharmacologic comfort measures can help postoperative clients with their pain, including distraction, music, massage, guided imagery, and positioning. The nurse should help this client into a position of comfort considering the surgical procedure and position of any tubes or drains. Assessing the client's pain is important but does not improve comfort. The client may be more uncomfortable in a recliner. Letting the client know when pain medication can be given next is important but does not improve comfort. DIF: Applying/Application REF: 269 KEY: Postoperative nursing| pain| nonpharmacologic pain management MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

A client has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best? a. Call the provider to request more analgesia. b. Demonstrate how to splint the incision. c. Have the client take shallower breaths. d. Tell the client a little pain is expected.

ANS: B Splinting an incision provides extra support during coughing and activity and helps decrease pain. If the client is otherwise comfortable, no more analgesia is required. Shallow breathing can lead to atelectasis and pneumonia. The client should know some pain is normal and expected after surgery, but that answer alone does not provide any interventions to help the client. DIF: Applying/Application REF: 230 KEY: Preoperative nursing| nonpharmacologic pain management| splinting MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

A nurse is giving a client instructions for showering with special antimicrobial soap the night before surgery. What instruction is most appropriate? a. "After you wash the surgical site, shave that area with your own razor." b. "Be sure to wash the area where you will have surgery very thoroughly." c. "Use a washcloth to wash the surgical site; do not take a full shower or bath." d. "Wash the surgical site first, then shampoo and wash the rest of your body."

ANS: B The entire proposed surgical site needs to be washed thoroughly and completely with the antimicrobial soap. Shaving, if absolutely necessary, should be done in the operative suite immediately before the operation begins, using sterile equipment. The client needs a full shower or bath (shower preferred). The client should wash the surgical site last; dirty water from shampooing will run over the cleansed site if the site is washed first. DIF: Applying/Application REF: 228 KEY: Preoperative nursing| client education| skin preparation MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A postoperative client has an abdominal drain. What assessment by the nurse indicates that goals for the priority client problems related to the drain are being met? a. Drainage from the surgical site is 30 mL less than yesterday. b. There is no redness, warmth, or drainage at the insertion site. c. The client reports adequate pain control with medications. d. Urine is clear yellow and urine output is greater than 40 mL/hr.

ANS: B The priority client problem related to a surgical drain is the potential for infection. An insertion site that is free of redness, warmth, and drainage indicates that goals for this client problem are being met. The other assessments are normal, but not related to the drain. DIF: Evaluating/Synthesis REF: 230 KEY: Preoperative nursing| drains MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A client is having a myelography. What action by the nurse is most important? a. Assess serum aspartate aminotransferase (AST) levels. b. Ensure that informed consent is on the chart. c. Position the client flat after the procedure. d. Reinforce the dressing if it becomes saturated.

ANS: B This diagnostic procedure is invasive and requires informed consent. The AST does not need to be assessed prior to the procedure. The client is positioned with the head of the bed elevated after the test to keep the contrast material out of the brain. The dressing should not become saturated; if it does, the nurse calls the provider. DIF: Applying/Application REF: 1025 KEY: Musculoskeletal system| musculoskeletal assessment| musculoskeletal disorders MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A nurse is giving a preoperative client a dose of ranitidine (Zantac). The client asks why the nurse is giving this drug when the client has no history of ulcers. What response by the nurse is best? a. "All preoperative clients get this medication." b. "It helps prevent ulcers from the stress of the surgery." c. "Since you don't have ulcers, I will have to ask." d. "The physician prescribed this medication for you."

ANS: B Ulcer prophylaxis is common for clients undergoing long procedures or for whom high stress is likely. The nurse is not being truthful by saying all clients get this medication. If the nurse does not know the information, it is appropriate to find out, but this is a common medication for which the nurse should know the rationale prior to administering it. Simply stating that the physician prescribed the medication does not give the client any useful information. DIF: Understanding/Comprehension REF: 234 KEY: Preoperative nursing| histamine blocker| ulcers MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most important? a. Allow the client to rest. b. Auscultate lung sounds. c. Document the episode. d. Encourage the client to eat dry toast.

ANS: B Vomiting after surgery has several complications, including aspiration. The nurse should listen to the client's lung sounds. The client should be allowed to rest after an assessment. Documenting is important, but the nurse needs to be able to document fully, including an assessment. The client should not eat until nausea has subsided. DIF: Applying/Application REF: 262 KEY: Postoperative nursing| nausea and vomiting| respiratory assessment| nursing assessment MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A client is receiving IV alteplase and reports a sudden severe headache. What is the nurse's first action? a. Perform a comprehensive pain assessment. b. Discontinue the infusion of the drug. c. Conduct a neurologic assessment. d. Administer an antihypertensive drug.

ANS: B A severe headache may indicate that the client's blood pressure has markedly increased and, therefore, the drug should be stopped immediately as the first action. The nurse would then perform the appropriate assessments and possibly administer an antihypertensive medication.

A nurse on the medical-surgical unit has received a hand-off report. Which client would the nurse see first? a. Client being discharged later on a complicated analgesia regimen. b. Client with new-onset abdominal pain, rated as an 8 on a 0-10 scale. c. Postoperative client who received oral opioid analgesia 45 minutes ago. d. Client who has returned from physical therapy and is resting in the recliner.

ANS: B Acute pain often serves as a physiologic warning signal that something is wrong. The client with new-onset abdominal pain needs to be seen first. The postoperative client needs at least 30 minutes for the oral medication to become effective and would be seen shortly to assess for effectiveness. The client going home requires teaching, which would be done after the first two clients have been seen and cared for, as this teaching will take some time. The client resting comfortably can be checked on quickly before spending time teaching the client who is going home.

A nurse is caring for a client who received intraspinal analgesia. Which action by the nurse is most important to ensure client safety? a. Assess and record vital signs every 4 hours. b. Instruct the client to report any unrelieved pain. c. Monitor for numbness and tingling in the legs. d. Perform frequent neurologic assessments.

ANS: B Complications from intraspinal anesthesia are rare, but can be life threatening. The nurse would perform frequent neurologic assessments and notify the primary health care provider for abnormal findings. Vital signs are taken every 1 to 2 hours for at least 12 hours. Unreported pain is managed, but this is not a safety concern. Numbness and tingling outside of the surgical site is not normal, but can usually be abated by decreasing the opioid dose. The nurse can also keep the client on bedrest, decreasing safety concerns, while reporting to the primary health care provider.

While assessing a client, a nurse detects a bluish tinge to the client's palms, soles, and mucous membranes. Which action will the nurse take next? a. Ask the client about current medications he or she is taking. b. Use pulse oximetry to assess the patient's oxygen saturation. c. Auscultate the patient's lung fields for adventitious sounds. d. Palpate the patient's bilateral radial and pedal pulses.

ANS: B Cyanosis can be present when impaired gas exchange occurs. In a client with dark skin, cyanosis can be seen because the palms, soles, and mucous membranes have a bluish tinge. The nurse will assess for systemic oxygenation before continuing with other assessments.

A hospitalized client has a history of depression for which sertraline is prescribed. The client also has a morphine allergy and a history of alcoholism. After surgery, several opioid analgesics are prescribed. Which one would the nurse choose? a. Hydrocodone and acetaminophen b. Hydromorphone c. Meperidine d. Tramadol

ANS: B Hydromorphone is a good alternative to morphine for moderate to severe pain. The nurse would not choose the combination with acetaminophen because it contains acetaminophen and the client has a history of alcoholism. Tramadol would not be used due to the potential for interactions with the client's sertraline. Meperidine is rarely used and is often restricted.

An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best? a. Answer the questions and document that teaching was done. b. Do not have the client sign the consent and call the primary health care provider. c. Have the client sign the consent, and then call the primary health care provider. d. Remind the client of what teaching the primary health care provider has done.

ANS: B In order to give informed consent, the client needs sufficient information. Questions about potential complications should be answered by the primary health care provider. The nurse can repeat some facts taught by the primary health care provider, but this topic is too broad for the nurse to address alone. The nurse should notify the primary health care provider to come back and answer the client's questions before the client signs the consent form. The other actions are not appropriate.

A nurse is giving a client instructions for showering the night before surgery. What instruction is most appropriate? a. "After you wash the surgical site, shave that area with your own razor." b. "Use the prescribed solution and wash the area where you will have surgery very thoroughly." c. "Use a washcloth to wash the surgical site; do not take a full shower or bath." d. "Use warm water and scrub the surgical area vigorously."

ANS: B One or two days before the scheduled surgery, the surgeon may ask the patient to shower using an antiseptic solution, often chlorhexidine gluconate. This cleaning reduces contamination of the surgical field and the number of organisms at the site. Hair removal if needed is done in the operating suite using evidence-based practices such as clipping or a depilatory agent. While the client should wash the area thoroughly, vigorous scrubbing might scrape the skin, increasing the risk of infection

A nurse assesses a client and identifies that the client has pale conjunctivae. Which focused assessment will the nurse complete next? a. Partial thromboplastin time b. Hemoglobin and hematocrit c. Liver enzymes d. Basic metabolic panel

ANS: B Pale conjunctivae signify anemia. The nurse will assess the client's hemoglobin and hematocrit to confirm anemia. The other laboratory results do not relate to this client's potential anemia.

A client has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best? a. Call the primary health care provider to request more analgesia. b. Demonstrate how to splint the incision. c. Have the client take shallower breaths. d. Tell the client that a little pain is expected.

ANS: B Splinting an incision provides extra support during coughing and activity and helps decrease pain. If the client is otherwise comfortable, no more analgesia is required. Shallow breathing can lead to atelectasis and pneumonia. The client should know that some pain is normal and expected after surgery, but that answer alone does not provide any interventions to help the client.

A client has received an opioid analgesic for pain. The nurse assesses that the client has a Pasero Scale score of 3 and a respiratory rate of 7 shallow breaths/min. The client's oxygen saturation is 87%. Which action would the nurse perform first? a. Apply oxygen at 4 L/min. b. Attempt to arouse the client. c. Give naloxone (Narcan). d. Notify the Rapid Response Team.

ANS: B The Pasero Opioid-Induced Sedation Scale is used to assess for unwanted opioid-associated sedation. A Pasero Scale score of 3 is unacceptable but is managed by trying to arouse the client in order to take deep breaths and staying with the client until he or she is more alert. Administering oxygen will not help if the client's respiratory rate is 7 breaths/min. Giving naloxone and calling for a Rapid Response Team would be appropriate for a higher Pasero Scale score.

The nurse in the outpatient surgery clinic is discussing an upcoming surgical procedure with a client. Which information provided by the nurse is most appropriate for the client's long-term outcome? a. "At least you know that the pain after surgery will diminish quickly." b. "Discuss acceptable pain control after your operation with the surgeon." c. "Opioids often cause nausea but you won't have to take them for long." d. "The nursing staff will give you pain medication when you ask them for it."

ANS: B The best outcome after a surgical procedure is timely and satisfactory pain control, which diminishes the likelihood of chronic pain afterward. The nurse suggests that the client advocate for himself or herself and discuss acceptable pain control with the surgeon. Stating that pain after surgery is usually short lived does not provide the client with options to have personalized pain control. To prevent or reduce nausea and other side effects from opioids, a multimodal pain approach is desired. For acute pain after surgery, giving pain medications around the clock instead of waiting until the client requests it is a better approach.

When assessing a client who had a traumatic brain injury, the nurse notes that the client is drowsy but easily aroused. What level of consciousness will the nurse document to describe this client's current level of consciousness? a. Alert b. Lethargic c. Stuporous d. Comatose

ANS: B The client is categorized as being lethargic because he or she can be easily aroused even though drowsy. The nurse would carefully monitor the client to determine any decrease in the level of consciousness (LOC).

A nurse on the postsurgical inpatient unit is observing a client perform leg exercises. What action by the client indicates a need for further instruction? a. Client states "This will help prevent blood clots in my legs." b. Bends both knees, pushes against the bed until calf and thigh muscles contract. c. Dorsiflexes and plantar flexes each foot several times an hour. d. Makes several clockwise then counterclockwise ankle circles with each foot.

ANS: B The client should perform this leg exercise one leg at a time. The other actions are correct.

The nurse is teaching assistive personnel (AP) about care for a male client diagnosed with acute ischemic stroke and left-sided weakness. Which statement by the AP indicates understanding of the nurse's teaching? a. "I will use "yes" and "no" questions when communicating with the client." b. "I will remind the client frequently to not get out of bed without help." c. "I will offer a urinal every hour to the client due to incontinence." d. "I will feed the client slowly using soft or pureed foods."

ANS: B The client who has left-sided weakness has likely had a right-sided stroke in the brain. Clients who have strokes on the right side of the brain tend to be very impulsive and exhibit poor judgment. Therefore, to keep the client safe, the staff will need to remind the client to stay in bed unless he has assistance to prevent falling. There is no evidence in the clinical situation that the client has aphasia (which is less common in those with right-sided strokes), difficulty swallowing, or urinary incontinence.

A client is put on twice-daily acetaminophen for osteoarthritis. Which finding in the client's health history would lead the nurse to consult with the primary health care provider over the choice of medication? a. 25-pack-year smoking history b. Drinking 3 to 5 beers a day c. Previous peptic ulcer d. Taking warfarin

ANS: B The major serious side effect of acetaminophen is hepatotoxicity and liver damage. Drinking 3 to 5 beers each day may indicate underlying liver disease, which would be investigated prior to prescribing chronic acetaminophen. The nurse would relay this information to the primary health care provider. Smoking is not related to acetaminophen side effects. Acetaminophen does not cause bleeding, so a previous peptic ulcer or taking warfarin would not be a problem.

A nurse assesses a patient who is recovering from a lumbar puncture (LP). Which complication of this procedure would alert the nurse to urgently contact the primary health care provider? a. Weak pedal pulses b. Nausea and vomiting c. Increased thirst d. Hives on the chest

ANS: B The nurse would immediately contact the provider if the client experiences a severe headache, nausea, vomiting, photophobia, or a change in level of consciousness after an LP, which are all signs of increased intracranial pressure. Weak pedal pulses, increased thirst, and hives are not complications of an LP.

A postoperative client has an abdominal drain. What assessment by the nurse indicates that goals for the priority client problems related to the drain are being met? a. Drainage from the surgical site is 30 mL less than yesterday. b. There is no redness, warmth, or drainage at the insertion site. c. The client reports adequate pain control with medications. d. Urine is clear yellow and urine output is greater than 40 mL/hr.

ANS: B The skin is the body's first line of defense against infection and a drain of any type increases this risk. The priority client problem related to a surgical drain is the potential for infection. An insertion site that is free of redness, warmth, and drainage indicates that goals for this client problem are being met. The other assessments are normal, but not related to the drain.

After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes, acute confusion, and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse would the nurse take first? a. Assess the client's urinary output. b. Assess the client's serum sodium level. c. Increase the rate of the IV infusion. d. Provide oral care every hour.

ANS: B This client has signs and symptoms of hypernatremia, which is a possible complication after craniotomy. The nurse would assess the client's serum sodium level first and then possibly increase the rate of the IV infusion. Providing oral care is also a good option but does not take priority over assessing laboratory results.

A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt numbness in his left leg. Currently the client's neurologic examination is normal. About what drug would the nurse plan to teach the patient? a. Alteplase b. Clopidogrel c. Heparin sodium d. Mannitol

ANS: B This client's signs and symptoms are consistent with a transient ischemic attack, and the client would likely be prescribed aspirin or clopidogrel to prevent platelet aggregation on discharge. Alteplase is used for ischemic stroke. Heparin and mannitol are not used for this condition.

A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most important? a. Allow the client to rest. b. Auscultate lung sounds. c. Document the episode. d. Encourage the client to eat dry toast.

ANS: B Vomiting after surgery has several complications, including aspiration. The nurse would listen to the client's lung sounds. The client should be allowed to rest after an assessment. Documenting is important, but the nurse needs to be able to document fully, including an assessment. The client should not eat until nausea has subsided.

An older client's serum calcium level is 8.7 mg/dL. What possible etiologies does the nurse consider for this result? (Select all that apply.) a. Good dietary intake of calcium and vitamin D b. Normal age-related decrease in serum calcium c. Possible occurrence of osteoporosis or osteomalacia d. Potential for metastatic cancer or Paget's disease e. Recent bone fracture in a healing stage

ANS: B, C This slightly low calcium level could be an age-related decrease in serum calcium or could indicate a metabolic bone disease such as osteoporosis or osteomalacia. A good dietary intake would be expected to produce normal values. Metastatic cancer, Paget's disease, or healing bone fractures will elevate calcium. DIF: Remembering/Knowledge REF: 1024 KEY: Musculoskeletal system| musculoskeletal assessment| musculoskeletal disorders| laboratory values MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

4. Nursing interventions to support the family caring for a client with Alzheimer's disease include (Select all that apply) a. encouraging emotion-focused coping mechanisms. b. helping the family identify safety concerns and modifying the home. c. showing the family how to deal with behavioral problems. d. teaching the family alternative communication techniques.

ANS: B, C, D Research has shown that interventions that focus on communication techniques, behavioral strategies, and environmental modifications improved the quality of life of the caregivers. Emotion-based coping styles are associated with grieving, worrying, and self-accusation and are not as effective as problem-based coping styles. DIF: Application/Applying REF: p. 1901 OBJ: Intervention MSC: Psychosocial Integrity Coping and Adaptation-Quality of Life

A postanesthesia care unit (PACU) nurse is assessing a postoperative client with a nasogastric (NG) tube. What laboratory values would warrant intervention by the nurse? (Select all that apply.) a. Blood glucose: 120 mg/dL b. Hemoglobin: 7.8 mg/dL c. pH: 7.68 d. Potassium: 2.9 mEq/L e. Sodium: 142 mEq/L

ANS: B, C, D Fluid and electrolyte balance are assessed carefully in the postoperative client because many imbalances can occur. The low hemoglobin may be from blood loss in surgery. The higher pH level indicates alkalosis, possibly from losses through the NG tube. The potassium is very low. The blood glucose is within normal limits for a postsurgical client who has been fasting. The sodium level is normal. DIF: Applying/Application REF: 262 KEY: Postoperative nursing| nasogastric tube| fluid and electrolyte balance| nursing assessment| laboratory values MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A nurse is learning about different surgical procedures and their classifications. Which examples below does this include? (Select all that apply.) a. Rhinoplasty: curative b. Liver biopsy: diagnostic c. Arthroscopy: preventative. Ileostomy: palliative. Total shoulder replacement: reconstructive d. Body contouring: cosmetic

ANS: B, C, D A cosmetic procedure is designed to improve the client's appearance or self-confidence; a body contouring procedure is an example. A diagnostic procedure is performed to determine the origin and cause of a disorder by taking a tissue sample with the intention of diagnosing (and staging, if applicable) a condition, such as a liver biopsy. A preventative procedure is performed with the intention that a specific condition will not occur. An example of this is a prophylactic bilateral mastectomy in a woman who carries the BRCA 1 or BRCA 2 gene to prevent the development of breast cancer. A palliative procedure is designed to improve quality of life; an example is an ileostomy. A reconstructive operation improves functional ability is an abnormal or damaged structure. A total shoulder replacement would be an example. A curative operation is performed to resolve a health problem by repairing or removing the cause; a gallbladder removal is an example.

A postanesthesia care unit (PACU) nurse is assessing a postoperative client with a nasogastric (NG) tube. What laboratory values would warrant intervention by the nurse? (Select all that apply.) a. Blood glucose: 120 mg/dL (6.7 mmol/L) b. Hemoglobin: 7.8 mg/dL (78 mmol/L) c. pH: 7.68 d. Potassium: 2.9 mEq/L (2.9 mmol/L) e. Sodium: 142 mEq/L (142 mmol/L)

ANS: B, C, D Fluid and electrolyte balance are assessed carefully in the postoperative client because many imbalances can occur. The low hemoglobin may be from blood loss in surgery. The higher pH level indicates alkalosis, possibly from losses through the NG tube. The potassium is very low. The blood glucose is within normal limits for a postsurgical client who has been fasting. The sodium level is normal.

1. The nurse would suggest to the family of a client who is in the moderate stages of AD and is being cared for in the home to (Select all that apply) a. assess orientation hourly by hiring a sitter if necessary. b.disable the stove but find ways for the client to participate in meal preparation. c.have the client wear an identification badge. d.move knickknacks to the middle of tables. e.secure the environment with a fence so the client cannot leave the home.

ANS: B, C, D, E To provide for the AD client's safety at home, the nurse could suggest several solutions: moving knickknacks to the middle of tables so the edges can be used for balance, blocking off unsafe areas, disabling stoves, removing rugs and runners, installing grab bars in the bathroom, obtaining bedside commodes and hand-held showers, and securing the environment so the client can wander safely. See the Bridge to Home Health Care feature Safety Solutions for People with Alzheimer's Disease for more ideas. DIF: Analysis/Analyzing REF: p. 1900 OBJ: Intervention MSC: Safe, Effective Care Environment Safety and Infection Control-Home Safety

A nurse recently hired to the preoperative area learns that certain clients are at higher risk for venous thromboembolism (VTE). Which clients are considered at high risk? (Select all that apply.) a. Client with a humerus fracture b. Morbidly obese client c. Client who underwent a prolonged surgical procedure d. Client with severe heart failure e. Wheelchair-bound client

ANS: B, C, D, E All surgical clients should be assessed for VTE risk. Those considered at higher risk include those who are obese; are over 40; have cancer; have decreased mobility, immobility, or a spinal cord injury; have a history of any thrombotic event, varicose veins, or edema; take oral contraceptives or smoke; have decreased cardiac output; have a hip fracture; or are having total hip or knee surgery. Prolonged surgical time increases risk due to mobility and positioning needs. DIF: Remembering/Knowledge REF: 231 KEY: Preoperative nursing| venous thromboembolism prevention MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A nurse working in the preoperative holding area performs which functions to ensure client safety? (Select all that apply.) a. Allow small sips of plain water. b. Check that consent is on the chart. c. Ensure the client has an armband on. d. Have the client help mark the surgical site. e. Allow the client to use the toilet before giving sedation

ANS: B, C, D, E Providing for client safety is a priority function of the preoperative nurse. Checking for appropriately completed consent, verifying the client's identity, having the client assist in marking the surgical site if applicable, and allowing the client to use the toilet prior to sedating him or her are just some examples of important safety measures. The preoperative client should be NPO, so water should not be provided. DIF: Applying/Application REF: 216 KEY: Preoperative nursing| safety MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

A nurse recently hired to the preoperative area learns that certain clients are at higher risk for venous thromboembolism (VTE). Which clients are considered to be at high risk? (Select all that apply.) a. Client with a humerus fracture b. Morbidly obese client c. Client who smokes d. Client with severe heart failure e. Wheelchair-bound client f. 50 years of age or older

ANS: B, C, D, E All surgical clients should be assessed for VTE risk. Those considered to be at higher risk include those who are obese; are over 40; have cancer; have decreased mobility, immobility, or a spinal cord injury; have a history of any thrombotic event, varicose veins, or edema; take oral contraceptives or smoke; have decreased cardiac output; have a hip fracture; or are having total hip or knee surgery.

Nurses at a conference learn the process by which pain is perceived by the client. Which processes are included in the discussion? (Select all that apply.) a. Induction b. Modulation c. Sensory perception d. Transduction e. Transmission f. Transition

ANS: B, C, D, E The four processes involved in making pain a conscious experience are modulation, sensory perception, transduction, and transmission.

A client is admitted with a confirmed left middle cerebral artery occlusion. Which assessment findings will the nurse expect? (Select all that apply.) a. Ataxia b. Dysphagia c. Aphasia d. Apraxia e. Hemiparesis/hemiplegia f. Ptosis

ANS: B, C, D, E, F All of these assessment findings are common in clients who have a stroke caused by an occlusion of the left middle cerebral artery with the exception of ataxia (most often present in clients who have cerebellar strokes). This artery supplies the majority of the left side of the brain where motor, sensory, speech, and language centers are located.

A nurse working in the preoperative holding area performs which functions to ensure client safety? (Select all that apply.) a. Allow small sips of plain water. b. Check that consent is on the chart. c. Ensure that the client has an armband on. d. Have the client help mark the surgical site. e. Allow the client to use the toilet before giving sedation. f. Assess the client for fall risks.

ANS: B, C, D, E, F Providing for client safety is a priority function of the preoperative nurse. Checking for appropriately completed consent, verifying the client's identity, having the client assist in marking the surgical site if applicable, assessing for fall risk, and allowing the client to use the toilet prior to sedating him or her are just some examples of important safety measures. The preoperative client should be NPO, so water should not be provided unless an oral medication is ordered to be given in pre-op

A new perioperative nurse is receiving orientation to the surgical area and learns about the Surgical Care Improvement Project (SCIP) goals. What major areas do these measures focus on preventing? (Select all that apply.) a. Hemorrhage b. Infection c. Serious cardiac events d. Stroke e. Thromboembolism

ANS: B, C, E The SCIP project includes core measures to prevent infection, serious cardiac events, and thromboembolic events such as deep vein thrombosis. DIF: Remembering/Knowledge REF: 216 KEY: Preoperative nursing| Surgical Care Improvement Project (SCIP)| core measures MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

An 84-year-old client who is usually alert and oriented experiences an acute cognitive decline. Which of the following factors would the nurse anticipate as contributing to this neurologic change? (Select all that apply.) a. Chronic hearing loss b. Infection c. Drug toxicity d. Dementia e. Hypoxia f. Aging

ANS: B, C, E Acute client conditions that occur in older adults often cause acute confusion and associated emotional behaviors. Infection, drug toxicity, and hypoxia are all acute health problems that can contribute to the client's cognitive decline. Aging does not cause changes in cognition. If the client had dementia, he or she would not be alert and oriented. Having a chronic hearing loss is not a change in the client's condition.

A nurse on the postoperative nursing unit provides care to reduce the incidence of surgical wound infection. What actions are best to achieve this goal? (Select all that apply.) a. Administering antibiotics for 72 hours b. Disposing of dressings properly c. Leaving draining wounds open to air d. Performing proper hand hygiene e. Removing and replacing wet dressings

ANS: B, D, E Interventions necessary to prevent surgical wound infection include proper disposal of soiled dressings, performing proper hand hygiene, and removing wet dressings as they can be a source of infection. Prophylactic antibiotics are given to clients at risk for infection, but are discontinued after 24 hours if no infection is apparent. Draining wounds should always be covered. DIF: Applying/Application REF: 267 KEY: Postoperative nursing care| infection control| hand hygiene| Surgical Care Improvement Project (SCIP)| wound infection MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

A nurse orienting to the postoperative area learns which principles about the postoperative period? (Select all that apply.) a. All phases require the client to be in the hospital. b. Phase I care may last for several days in some clients. c. Phase I requires intensive care unit monitoring. d. Phase II ends when the client is stable and awake. e. Vital signs may be taken only once a day in phase III

ANS: B, D, E There are three phases of postoperative care. Phase I is the most intense, with clients coming right from surgery until they are completely awake and hemodynamically stable. This may take hours or days and can occur in the intensive care unit or the postoperative care unit. Phase II ends when the client is at a presurgical level of consciousness and baseline oxygen saturation, and vital signs are stable. Phase III involves the extended care environment and may continue at home or in an extended care facility if needed. DIF: Remembering/Knowledge REF: 256 KEY: Postoperative nursing| nursing assessment| surgical procedures MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

A nurse on the postoperative nursing unit provides care to reduce the incidence of surgical wound infection. What actions are best to achieve this goal? (Select all that apply.) a. Administering antibiotics for 72 hours b. Disposing of dressings properly c. Leaving draining wounds open to air d. Performing proper hand hygiene e. Removing and replacing wet dressings

ANS: B, D, E Interventions necessary to prevent surgical wound infection include proper disposal of soiled dressings, performing proper hand hygiene, and removing wet dressings as they can be a source of infection. Prophylactic antibiotics may be given to clients at risk for infection, but not all clients need them for 72 hours. Draining wounds would always be covered.

A client with a broken arm had ice placed on it for 20 minutes. A short time after the ice was removed, the client reports that the effect has worn off and requests pain medication, which cannot be given yet. Which actions by the nurse are most appropriate? (Select all that apply.) a. Ask for a physical therapy consult. b. Educate the client on cold therapy. c. Offer to provide a heating pad. d. Repeat the ice application. e. Teach the client relaxation techniques. f. Offer the client headphones with music.

ANS: B, D, E Nonpharmacologic pain management can be very effective. These modalities include ice, heat, pressure, massage, vibration, and transcutaneous electrical stimulation. Since the client is unable to have more pain medication at this time, the nurse would focus on nonpharmacologic modalities. First the client must be educated; the effects of ice wear off quickly once it is removed, and the client may have had unrealistic expectations. The nurse can repeat the ice application and teach relaxation techniques if the client is open to them. Other nonpharmacologic methods to reduce pain include distraction, imagery, and mindfulness. A physical therapy consult will not help relieve acute pain of a fracture. Heat would not be a good choice for this type of injury.

A nursing instructor is teaching students about different surgical procedures and their classifications. Which examples does the instructor include? (Select all that apply.) a. Hemicolectomy: diagnostic b. Liver biopsy: diagnostic c. Mastectomy: restorative d. Spinal cord decompression: palliative e. Total shoulder replacement: restorative

ANS: B, E A diagnostic procedure is used to determine cell type of cancer and to determine the cause of a problem. An example is a liver biopsy. A restorative procedure aims to improve functional ability. An example would be a total shoulder replacement or a spinal cord decompression (not palliative). A curative procedure either removes or repairs the causative problem. An example would be a mastectomy (not restorative) or a hemicolectomy (not diagnostic). A palliative procedure relieves symptoms but will not cure the disease. An example is an ileostomy. A cosmetic procedure is done to improve appearance. An example is rhinoplasty (a "nose job"). DIF: Remembering/Knowledge REF: 218 KEY: Preoperative nursing| surgical procedures MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

A nurse assesses an older client. Which assessment findings would the nurse identify as normal changes in the nervous system related to aging? (Select all that apply.) a. Long-term memory loss b. Slower processing time c. Increased sensory perception d. Decreased risk for infection e. Change in sleep patterns

ANS: B, E Normal changes in the nervous system related to aging include recent memory loss, slower processing time, decreased sensory perception, an increased risk for infection, changes in sleep patterns, changes in perception of pain, and altered balance and/or decreased coordination.

2. A client is assessed as being in the mild stage of Alzheimer's disease (AD). The nurse recognizes the complaint made by the client's family that is most closely related to the diagnosis is that the client a."has difficulty using simple things, such as her toothbrush or comb." b."seems to have lost control over her bowels." c."seems indifferent about things she used to care about." d."uses words in the wrong context."

ANS: C A common clinical manifestation of mild AD would include indifference or apathy. Other changes in mild AD are memory disturbances, impaired judgment and problem- solving skills, confusion, taking longer to do routine tasks, inability to adapt to new situations, and becoming irritable or suspicious. The inability to use familiar objects appears in the moderate stage. Incontinence is occasional in the moderate stage and frequent in the severe stage. Using words in the wrong context is moderate AD. DIF: Application/Applying REF: p. 1895 OBJ: Assessment MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

6. A client with MS is being taught self-care measures to prevent constipation. The nurse would realize goals for teaching had been met when the client states he/she will avoid a.a high-fiber diet. b.citrus fruits. c.laxatives. d.stool softeners.

ANS: C A high-fiber diet, bulk formers, and stool softeners are useful for maintaining stool consistency. Explain that laxatives and enemas should be avoided because they lead to dependence. DIF: Application/Applying REF: pp. 1911, 1912-1913 OBJ: Evaluation MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Self Care

7. The nurse formulates the following nursing diagnosis for a client with MS: Impaired Physical Mobility related to muscle weakness. Useful interventions the nurse could plan include a.encouraging long naps or rest periods. b. encouraging strengthening exercises for affected muscles every 4 hours. c.having the client perform ROM exercises at least two times daily. d.performing all the activities of daily living (ADLs) for the client.

ANS: C Range-of-motion exercises should be performed at least twice daily. DIF: Application/Applying REF: pp. 1912-1913 OBJ: Intervention MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures/Health Alteration

17. A client is receiving donepezil (Aricept) for moderate Alzheimer's disease. The nurse would assess that teaching goals for this medication have been met when the client's spouse says a."Aricept works by blocking oxygen free radicals in the brain." b." Depression has been the worst part so I'm glad this pill will control it." c."I'm anxious to see how much improvement the medications allows." d."This medicine will prevent further deterioration in condition."

ANS: C Several medications are used to retain Ach in the neurojunctions of the brain. They can have small but noticeable effects and may temporarily lead to improvements. However, no drug stops the progression of AD. Aricept does not work to block oxygen free radical action, however; some studies show that alpha-tocopherol (vitamin E) and selegiline have this action. Aricept does not work on depression; often clients with AD also need antidepressants. DIF: Application/Applying REF: p. 1897 OBJ: Intervention MSC: Physiological Integrity Physiological Adaptation-Pharmacological and Parenteral Therapies-Pharmacological Agents/Actions

A client had a surgical procedure with spinal anesthesia. The nurse raises the head of the client's bed. The client's blood pressure changes from 122/78 mm Hg to 102/50 mm Hg. What action by the nurse is best? a. Call the Rapid Response Team. b. Increase the IV fluid rate. c. Lower the head of the bed. d. Nothing; this is expected.

ANS: C A client who had epidural or spinal anesthesia may become hypotensive when the head of the bed is raised. If this occurs, the nurse should lower the head of the bed to its original position. The Rapid Response Team is not needed, nor is an increase in IV rate. DIF: Applying/Application REF: 261 KEY: Postoperative nursing| neurologic system MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which result warrants immediate communication with the surgical team? a. Creatinine: 1.2 mg/dL b. Hemoglobin: 14.8 mg/dL c. Potassium: 2.9 mEq/L d. Sodium: 134 mEq/L

ANS: C A potassium of 2.9 mEq/L is critically low and can affect cardiac and respiratory status. The nurse should communicate this laboratory value immediately. The creatinine is at the high end of normal, the hemoglobin is normal, and the sodium is only slightly low (normal low being 136 mEq/L), so these values do not need to be reported immediately. DIF: Applying/Application REF: 223 KEY: Preoperative nursing| laboratory values MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A client in the preoperative holding room has received sedation and now needs to urinate. What action by the nurse is best? a. Allow the client to walk to the bathroom. b. Delegate assisting the client to the nurse's aide. c. Give the client a bedpan or urinal to use. d. Insert a urinary catheter now instead of waiting.

ANS: C Although possibly uncomfortable or embarrassing for the client, the client should not be allowed out of bed after receiving sedation. The nurse should get the client a bedpan or urinal. The client may or may not need a urinary catheter. DIF: Applying/Application REF: 234 KEY: Preoperative nursing| sedation| safety MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

A nurse is monitoring a client after moderate sedation. The nurse documents the client's Ramsay Sedation Scale (RSS) score at 3. What action by the nurse is best? a. Assess the client's gag reflex. b. Begin providing discharge instructions. c. Document findings and continue to monitor. d. Increase oxygen and notify the provider.

ANS: C An RSS score of 3 means the client is able to respond quickly, but only to commands. The client has not had enough time to fully arouse. The nurse should document the findings and continue to monitor per agency policy. If the client had an oral endoscopy or was intubated, checking the gag reflex would be appropriate prior to permitting eating or drinking. The client is not yet awake enough for teaching. There is no need to increase oxygen and notify the provider. DIF: Applying/Application REF: 250 KEY: Intraoperative nursing| Ramsay Sedation Scale| moderate sedation MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

The nurse knows that hematopoiesis occurs in what part of the musculoskeletal system? a. Cancellous tissue b. Collagen matrix c. Red marrow d. Yellow marrow

ANS: C Hematopoiesis occurs in the red marrow, which is part of the cancellous tissues containing both types of bone marrow. DIF: Remembering/Knowledge REF: 1018 KEY: Musculoskeletal system| musculoskeletal assessment| musculoskeletal disorders MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

The circulating nurse is plugging in a piece of equipment and notes that the cord is frayed. What action by the nurse is best? a. Call maintenance for repair. b. Check the machine before using. c. Get another piece of equipment. d. Notify the charge nurse.

ANS: C The circulating nurse is responsible for client safety. If an electrical cord is frayed, the risk of fire or sparking increases. The nurse should obtain a replacement. The nurse should also tag the original equipment for repair as per agency policy. Checking the equipment is not important as the nurse should not even attempt to use it. Calling maintenance or requesting maintenance per facility protocol is important, but first ensure client safety by having a properly working piece of equipment for the procedure about to take place. The charge nurse probably does need to know of the need for equipment repair, but ensuring client safety is the priority. DIF: Applying/Application REF: 239 KEY: Intraoperative nursing| circulating nurse| safety MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

A nurse works on the postoperative floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for post-discharge care? a. Married young adult who is the primary caregiver for children b. Middle-aged client who is post knee replacement, needs physical therapy c. Older adult who lives at home despite some memory loss d. Young client who lives alone, has family and friends nearby

ANS: C The older adult has the most potentially complex discharge needs. With memory loss, the client may not be able to follow the prescribed home regimen. The client's physical abilities may be limited by chronic illness. This client has several safety needs that should be assessed. The other clients all have evidence of a support system and no known potential for serious safety issues. DIF: Applying/Application REF: 221 KEY: Preoperative nursing| discharge planning| older adult MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client should the nurse assess first? a. Client with a blood pressure of 100/50 mm Hg b. Client with a pulse of 118 beats/min c. Client with a respiratory rate of 6 breaths/min d. Client with a temperature of 96° F (35.6° C)

ANS: C The respiratory rate is the most critical vital sign for any client who has undergone general anesthesia or moderate sedation, or has received opioid analgesia. This respiratory rate is too low and indicates respiratory depression. The nurse should assess this client first. A blood pressure of 100/50 mm Hg is slightly low and may be within that client's baseline. A pulse of 118 beats/min is slightly fast, which could be due to several causes, including pain and anxiety. A temperature of 96° F is slightly low and the client needs to be warmed. But none of these other vital signs take priority over the respiratory rate. DIF: Applying/Application REF: 258 KEY: Postoperative nursing| nursing assessment| sedation| respiratory system MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A registered nurse (RN) is watching a nursing student change a dressing and perform care around a Penrose drain. What action by the student warrants intervention by the RN? a. Cleaning around the drain per agency protocol b. Placing a new sterile gauze under the drain c. Securing the drain's safety pin to the sheets d. Using sterile technique to empty the drain

ANS: C The safety pin that prevents the drain from slipping back into the client's body should be pinned to the client's gown, not the bedding. Pinning it to the sheets will cause it to pull out when the client turns. The other actions are appropriate. DIF: Applying/Application REF: 268 KEY: Postoperative nursing| drains| infection control MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

The circulating nurse is in the operating room and sees the surgeon don gown and gloves using appropriate sterile procedure. The surgeon then folds the hands together and places them down below the hips. What action by the nurse is most appropriate? a. Ask the surgeon to change the sterile gown. b. Do nothing; this is acceptable sterile procedure. c. Inform the surgeon that the sterile field has been broken. d. Obtain a new pair of sterile gloves for the surgeon to put on

ANS: C The surgical gown is considered sterile from the chest to the level of the surgical field. By placing the hands down by the hips, the surgeon has broken sterile field. The circulating nurse informs the surgeon of this breach. Changing only the gloves or only the gown does not "restore" the sterile sections of the gown. Doing nothing is unacceptable. DIF: Applying/Application REF: 244 KEY: Intraoperative nursing| sterile field| surgical scrub| surgical gowning MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

During skin inspection, the nurse observes lesions with wavy borders that are widespread across the client's chest. Which descriptors will the nurse use to document these observations? a. Clustered and annular b. Linear and circinate c. Diffuse and serpiginous d. Coalesced and circumscribed

ANS: C "Diffuse" is used to describe lesions that are widespread. "Serpiginous" describes lesions with wavy borders. "Clustered" describes lesions grouped together. "Linear" describes lesions occurring in a straight line. Annular lesions are ring like with raised borders, circinate lesions are circular, and circumscribed lesions have well-defined sharp borders. "Coalesced" describes lesions that merge with one another and appear confluent.

A client had a surgical procedure with spinal anesthesia. The client's blood pressure was 122/78 mm Hg 30 minutes ago and is now 138/60 and the client reports nausea. What action by the nurse is best? a. Call the Rapid Response Team. b. Increase the IV fluid rate. c. Notify the primary health care provider. d. Nothing; this is expected.

ANS: C A widening pulse pressure (44 to 78 mm Hg) and nausea may indicate autonomic blockade, a complication of spinal anesthesia causing widespread vasodilation. The nurse would notify the primary health care provider. The Rapid Response Team is not yet warranted; the nurse would not increase the IV rate without a prescription.

A nurse is assessing pain on a confused older client who has difficulty with verbal expression. Which pain assessment tool would the nurse choose for this assessment? a. Numeric rating scale b. Verbal Descriptor Scale c. FACES Pain Scale-Revised d. Wong-Baker FACES Pain Scale

ANS: C All are valid pain rating scales; however, some research has shown that the FACES Pain Scale-Revised is preferred by both cognitively intact and cognitively impaired adults. A confused client with difficulty speaking would not be a good candidate for the numeric rating scale or the verbal descriptor scale. The cartoon images on the Wong-Baker FACES Pain Scale may not be appropriate for an adult client.

A client is admitted with a traumatic brain injury. What is the nurse's priority assessment? a. Complete neurologic assessment b. Comprehensive pain assessment c. Airway and breathing assessment d. Functional assessment

ANS: C Although the client has a brain injury, the most important assessment is to assess the client's ABCs, which includes airway, breathing, and circulation. The other assessments are performed later after the client is stabilized.

A nurse is teaching a client with cerebellar function impairment. Which statement would the nurse include in this client's discharge teaching? a. "Connect a light to flash when your door bell rings." b. "Label your faucet knobs with hot and cold signs." c. "Ask a friend to drive you to your follow-up appointments." d. "Use a natural gas detector with an audible alarm."

ANS: C Cerebellar function enables the client to predict distance or gauge the speed with which one is approaching an object, control voluntary movement, maintain equilibrium, and shift from one skilled movement to another in an orderly sequence. A client who has cerebellar function impairment should not be driving. The client would not have difficulty hearing, distinguishing between hot and cold, or smelling.

10. To assist the client with Parkinson's disease to reduce tremor, the nurse suggests that the client a. clasp arms about self and squeeze. b. sleep on the non-tremorous side. c. tightly hold change in the pocket. d. visualize stilling the tremor.

ANS: C Clasping change tightly in the pocket, using both hands to complete tasks, and sleeping on the tremorous side will help lessen the tremor. DIF: Application/Applying REF: pp. 1905, 1906 OBJ: Intervention MSC: Physiological Integrity Physiological Adaptation-Illness Management

A nurse cares for an older adult client who has a chronic skin disorder. The client states, "I have not been to church in several weeks because of the discoloration of my skin." How will the nurse respond? a. "I will consult the chaplain to provide you with spiritual support." b. "You do not need to go to church; God is everywhere." c. "Tell me more about your concerns related to your skin." d. "Religious people are nonjudgmental and will accept you."

ANS: C Clients with chronic skin disorders often become socially isolated related to the fear of rejection by others. Nurses will assess how the client's skin changes are affecting his or her body image and encourage the client to express feelings about a change in appearance. The other statements are dismissive of the client's concerns.

A nurse plans care for a 77-year-old client who is experiencing age-related peripheral sensory perception changes. Which intervention would the nurse include in this client's plan of care? a. Provide a call button that requires only minimal pressure to activate. b. Write the date on the client's white board to promote orientation. c. Ensure that the path to the bathroom is free from clutter. d. Encourage the client to season food to stimulate nutritional intake.

ANS: C Dementia and confusion are not common phenomena in older adults. However, physical impairment related to illness can be expected. Providing opportunities for hazard-free ambulation will maintain strength and mobility (and ensure safety). Providing a call button, providing the date, and seasoning food do not address the client's impaired sensory perception.

A nurse asks a client to take deep breaths during an electroencephalography. The client asks, "Why are you asking me to do this?" How would the nurse respond? a. "Hyperventilation causes vascular dilation of cerebral arteries, which decreases electoral activity in the brain." b. "Deep breathing helps you to relax and allows the electroencephalograph to obtain a better waveform." c. "Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity." d. "Deep breathing will help you to blow off carbon dioxide and decreases intracranial pressures."

ANS: C Hyperventilation produces cerebral vasoconstriction and alkalosis, which increase the likelihood of seizure activity. The client is asked to breathe deeply 20 times for 3 minutes. The other responses are not accurate.

A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that the expected outcome for this problem has been met? a. Chooses preferred items from the menu. b. Eats 75 to 100% of all meals and snacks. c. Has clear lung sounds on auscultation. d. Gains 2 lb (1 kg) after 1 week.

ANS: C Impaired swallowing can lead to aspiration and then aspiration pneumonia, so the expected outcome for this problem is to experience no aspiration. Clear lung sounds is the best indicator that aspiration has not occurred. Choosing menu items is not related to this problem. Eating meals does not indicate that the client is not still aspirating. A weight gain indicates improved nutrition but still does not show a lack of aspiration.

A client who is experiencing a traumatic brain injury has increasing intracranial pressure (ICP). What drug will the nurse anticipate to be prescribed for this client? a. Phenytoin b. Lorazepam c. Mannitol d. Morphine

ANS: C Increased intracranial pressure is often the result of cerebral edema as a result of traumatic brain injury. Therefore, as osmotic diuretic such as mannitol or a loop diuretic like furosemide is administered. The other drugs are not appropriate to manage increasing ICP.

9. The most helpful intervention by the nurse for a client experiencing a parkinsonian crisis would be to a. administer oxygen by nasal catheter. b. give the client IV fluids that contain potassium. c. place the client in a nonstimulating environment. d. provide the client with foods high in calcium.

ANS: C Occasionally, clients with PD experience a parkinsonian crisis as a result of emotional trauma or sudden or inadvertent withdrawal of anti-parkinsonian medication. Severe exacerbation of tremor, rigidity, and bradykinesia, accompanied by acute anxiety, sweating, tachycardia, and hyperpnea occur. The client should be placed in a quiet room with subdued lighting. Medical treatment may include barbiturates in addition to anti-parkinsonian drugs. DIF: Application/Applying REF: p. 1905 OBJ: Intervention MSC: Physiological Integrity Basic Care and Comfort-Rest and Sleep

The nurse teaches an 80-year-old client with diminished peripheral sensation. Which statement would the nurse include in this client's teaching? a. "Place soft rugs in your bathroom to decrease pain in your feet." b. "Bathe in warm water to increase your circulation." c. "Look at the placement of your feet when walking." d. "Walk barefoot to decrease pressure injuries from your shoes."

ANS: C Older clients with decreased sensation are at risk of injury from the inability to sense changes in terrain when walking. To compensate for this loss, the client is instructed to look at the placement of his or her feet when walking. Throw rugs can slip and increase fall risk. Bath water that is too warm places the client at risk for thermal injury.

After teaching a client who expressed concern about a rash located beneath her breast, a nurse assesses the client's understanding. Which statement indicates the client has a good understanding of this condition? a. "This rash is probably due to fluid overload." b. "I need to wash this daily with antibacterial soap." c. "I can use powder to keep this area dry." d. "I will schedule a mammogram as soon as I can."

ANS: C Rashes limited to skinfold areas (e.g., on the axillae, beneath the breasts, in the groin) may reflect problems related to excessive moisture. The client needs to keep the area dry; one option is to use powder. Good hygiene is important, but the rash does not need an antibacterial soap. Fluid overload and breast cancer are not related to rashes in skinfolds.

A nurse is caring for four clients receiving pain medication. After the hand-off report, which client would the nurse see first? a. Client who is crying and agitated b. Client with a heart rate of 104 beats/min c. Client with a Pasero Scale score of 4 d. Client with a verbal pain report of 9

ANS: C The Pasero Opioid-Induced Sedation Scale has scores ranging from S to 1 to 4. A score of 4 indicates unacceptable somnolence and is an emergency. The nurse would see this client first. The nurse can delegate visiting with the crying client to a nursing assistant; the client may be upset and might benefit from talking or a comforting presence. The client whose pain score is 9 needs to be seen next, or the nurse can delegate this assessment to another nurse while working with the priority client. A heart rate of 104 beats/min is slightly above normal, and that client can be seen after the other two clients are cared for.

A registered nurse is caring for a client who is receiving pain medication via patient-controlled analgesia (PCA). Which action by the nurse indicates the need for further education on pain control with PCA? a. Assesses the client's pain level per agency policy. b. Monitors the client's respiratory rate and sedation. c. Presses the button when the client cannot reach it. d. Reinforces client teaching about using the PCA pump.

ANS: C The client is the only person who should press the PCA button. If the client cannot reach it, the nurse would either reposition the client or the button, and would not press the button for the client. Pressing the button for the client ("PCA by proxy") indicates the need to review the information about this treatment modality. The other actions are appropriate.

The nurse is preparing a client for discharge from the emergency department after experiencing a transient ischemic attack (TIA). Before discharge, which factor would the nurse identify as placing the client at high risk for a stroke? a. Age greater than or equal to 75 b. Blood pressure greater than or equal to 160/95 c. Unilateral weakness during a TIA d. TIA symptoms lasting less than a minute

ANS: C The client who has a TIA is at risk for a stroke is he or she has one-sided (unilateral) weakness during a TIA. Risk factors also include an age greater than or equal to 60, blood pressure greater than or equal to 140/90 (either or both systolic and diastolic), and/or a long duration of TIA symptoms. One minute is not a very long time for symptoms to occur.

A postoperative client has respiratory depression after receiving morphine for pain. Which medication and dose does the nurse prepare to administer? a. Flumazenil 0.2 to 1 mg b. Flumazenil 2 to 10 mg c. Naloxone 0.4 to 2 mg d. Naloxone 4 to 20 mg

ANS: C The nurse would prepare to administer naloxone, an opioid antagonist, at a dose of between 0.04 and 0.05 mg up to 2 mg, depending on the client's symptoms. Flumazenil is a benzodiazepine antagonist.

A nurse works on the postoperative floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for postdischarge care? a. Married young adult who is the primary caregiver for children. b. Middle-age client who is post-knee replacement, and needs physical therapy. c. Older adult who lives alone at home despite some memory loss. d. Young client who lives alone, and has family and friends nearby.

ANS: C The older adult has the most potentially complex discharge needs. With memory loss, the client may not be able to follow the prescribed home regimen. The client's physical abilities may be limited by chronic illness. This client has several safety needs that should be assessed. The other clients all have evidence of a support system and no known potential for serious safety issues.

A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which result warrants immediate communication with the surgical team? a. Creatinine: 1.2 mg/dL (106.1 umol/L) b. Hemoglobin: 14.8 mg/dL (148 mmol/L) c. Potassium: 2.9 mEq/L (2.9 mmol/L) d. Sodium: 134 mEq/L (134 mmol/L)

ANS: C The potassium level is critically low and can affect cardiac and respiratory status. The nurse would communicate this laboratory value immediately. The creatinine is at the high end of normal, the hemoglobin is normal, and the sodium is only slightly low so these values do not need to be reported immediately.

The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client would the nurse assess first? a. Client with a blood pressure of 100/50 mm Hg b. Client with a pulse of 118 beats/min c. Client with a respiratory rate of 6 breaths/min d. Client with a temperature of 96° F (35.6° C)

ANS: C The respiratory rate is the most important vital sign for any client who has undergone general anesthesia or moderate sedation, or has received opioid analgesia. This respiratory rate is too low and indicates respiratory depression. The nurse would assess this client first. A blood pressure of 100/50 mm Hg is slightly low and may be within that client's baseline. A pulse of 118 beats/min is slightly fast, which could be due to several causes, including pain and anxiety. A temperature of 96° F (35.6° C) is slightly low and the client needs to be warmed. But none of these other vital signs take priority over the respiratory rate.

A registered nurse (RN) is watching a new nurse change a dressing and perform care around a Penrose drain. What action by the new nurse warrants intervention? a. Cleaning around the drain per agency protocol b. Placing a new sterile gauze under the drain c. Securing the drain's safety pin to the sheets d. Using sterile technique to empty the drain

ANS: C The safety pin that prevents the drain from slipping back into the client's body would not be pinned to the client's bedding. Pinning it to the sheets will cause it to pull out when the client turns. The other actions are appropriate.

A postoperative nurse is caring for a client who received a neuromuscular blocking agent during surgery. On assessment the nurse notes the client has weak hand grasps. What assessment does the nurse conduct next? a. Ability to raise head off the bed b. Blood pressure and pulse c. Signs of oxygenation d. Level of orientation

ANS: C When neuromuscular blocking agents are retained, muscle weakness could affect the diaphragm and impair gas exchange. Symptoms include the inability to maintain a head lift, weak hand grasps, and an abdominal breathing pattern. Since the client has weak hand grasps, the nurse would assess for signs of systemic oxygenation next. The nurse would assess head lift ability, but this does not take priority over oxygenation. Blood pressure, pulse, and level of orientation are all important in the postoperative period, but oxygenation would come first.

A postoperative client has an epidural infusion of morphine and bupivacaine. Which actions does the nurse delegate to the assistive personnel (AP)? (Select all that apply.) a. Ask the client to point out any areas of numbness or tingling. b. Determine how many people are needed to ambulate the client. c. Perform a bladder scan if the client is unable to void after 4 hours. d. Remind the client to use the incentive spirometer every hour. e. Take and record the client's vital signs per agency protocol.

ANS: C, D, E The AP can assess and record vital signs, perform a bladder scan and report the results to the nurse, and remind the client to use the spirometer. The nurse is legally responsible for assessments and would ask the client about areas of numbness or tingling, and assess if the client is able to bear weight and walk.

A nurse orienting to the postoperative area learns which principles about the postoperative period? (Select all that apply.) a. All phases require the client to be in the hospital. b. Phase I care may last for several days in some clients. c. Phase I requires intensive care unit monitoring. d. Phase II ends when the client is stable and awake. e. Vital signs may be taken only once a day in phase III. f. Some clients may be discharged directly after phase I.

ANS: C, D, E There are three phases of postoperative care. Phase I is the most intense, with clients coming right from surgery until they are completely awake and hemodynamically stable. This may take hours or days and can occur in the intensive care unit or the postoperative care unit. Some patients achieve this level of recovery in phase I and can be discharged directly to home. Phase II ends when the client is at a pre-surgical level of consciousness and baseline oxygen saturation, and vital signs are stable. Phase III involves the extended-care environment and may continue at home or in an extended-care facility if needed.

19. A nurse is caring for a client diagnosed with Creutzfeldt-Jakob Disease (CJD). Appropriate nursing care includes a.administering broad-spectrum antibiotics until culture results are known. b.giving the client anti-viral medications as ordered. c.placing the client in contact and airborne isolation. d.using standard precautions when handling body fluids.

ANS: D Clients with CJD do not need isolation although it can be transmitted person-to-person. Standard precautions are used for every client and are sufficient for clients with CJD. There is no effective treatment for this unique disease that can arise from genetic mutations or from infection with an agent that is neither bacterial nor viral. DIF: Application/Applying REF: p. 1907 OBJ: Intervention MSC: Safe, Effective Care Environment Safety and Infection Control-Standard/Transmission Based/Other Precautions

8. A client tells the nurse that he is experiencing some leg stiffness when walking and slowness when performing ADLs. Occasionally he has noted slight tremors in his hands at rest. This information leads the nurse to suspect a.amyotrophic lateral sclerosis (ALS). b.Huntington's disease. c.myasthenia gravis (MG). d.Parkinson's disease (PD).

ANS: D Early in PD the client may notice a slight slowing in the ability to perform ADLs. A general feeling of stiffness may be noticed, along with mild, diffuse muscular pain. Tremor is a common early manifestation that usually occurs in one of the upper limbs. DIF: Analysis/Analyzing REF: p. 1904 OBJ: Assessment MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

3. A client with AD begins to tell the nurse about his early-married life. The nurse should a.assess orientation to time and place. b.distract the client from this activity. c.encourage the client to talk about recent memories. d.listen to his stories

ANS: D Memory impairment occurs in all stages of AD and the nurse must use interventions that are designed to enhance memory. Because clients' long-term memory is retained longer than their short-term memory, allow them to reminisce about past experiences. Reminiscing is a normal activity; there is no need to assess orientation. Distracting the client not only will negatively impact memory but also may agitate the client. Recent memory is impaired, so encouraging the client to discuss recent events that he/she may not remember may also be agitating. DIF: Application/Applying REF: p. 1899 OBJ: Intervention MSC: Psychosocial Integrity Coping and Adaptation-Therapeutic Interactions

The nurse is assessing four clients with musculoskeletal disorders. The nurse should assess the client with which laboratory result first? a. Serum alkaline phosphatase (ALP): 108 units/L b. Serum aspartate aminotransferase (AST): 26 units/L c. Serum calcium: 10.2 mg/dL d. Serum phosphorus: 2 mg/dL

ANS: D A normal serum phosphorus level is 3 to 4.5 mg/dL; a level of 2 mg/dL is low, and this client should be assessed first. The values for serum ALP, AST, and calcium are all within normal ranges. DIF: Understanding/Comprehension REF: 1024 KEY: Musculoskeletal system| musculoskeletal assessment| laboratory values MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

Ten hours after surgery, a postoperative client reports that the antiembolism stockings and sequential compression devices itch and are too hot. The client asks the nurse to remove them. What response by the nurse is best? a. "Let me call the surgeon to see if you really need them." b. "No, you have to use those for 24 hours after surgery." c. "OK, we can remove them since you are stable now." d. "To prevent blood clots you need them a few more hours."

ANS: D According to the Surgical Care Improvement Project (SCIP), any prophylactic measures to prevent thromboembolic events during surgery are continued for 24 hours afterward. The nurse should explain this to the client. Calling the surgeon is not warranted. Simply telling the client he or she has to wear the hose and compression devices does not educate the client. The nurse should not remove the devices. DIF: Understanding/Comprehension REF: 260 KEY: Postoperative nursing| Surgical Care Improvement Project (SCIP)| venous thromboembolism prevention| thromboembolic events| core measures| quality improvement MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A client on the postoperative nursing unit has a blood pressure of 156/98 mm Hg, pulse 140 beats/min, and respirations of 24 breaths/min. The client denies pain, has normal hemoglobin, hematocrit, and oxygen saturation, and shows no signs of infection. What should the nurse assess next? a. Cognitive status b. Family stress c. Nutrition status d. Psychosocial status

ANS: D After ensuring the client's physiologic status is stable, these manifestations should lead the nurse to assess the client's psychosocial status. Anxiety especially can be demonstrated with elevations in vital signs. Cognitive and nutrition status are not related. Family stress is a component of psychosocial status. DIF: Remembering/Knowledge REF: 265 KEY: Postoperative nursing| support| psychosocial response| anxiety MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Psychosocial Integrity

A nurse is preparing a client for discharge after surgery. The client needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important? a. "Be sure you keep all your postoperative appointments." b. "Call your surgeon if you have any questions at home." c. "Eat a diet high in protein, iron, zinc, and vitamin C." d. "Wash your hands before touching the drain or dressing.

ANS: D All options are appropriate for the client being discharged after surgery. However, for this client who is changing a dressing and managing a drain, infection control is the priority. The nurse should instruct the client to wash hands often, including before and after touching the dressing or drain. DIF: Applying/Application REF: 272 KEY: Postoperative nursing| discharge planning/teaching| client education| infection control| hand hygiene MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

An older adult has been transferred to the postoperative inpatient unit after surgery. The family is concerned that the client is not waking up quickly and states "She needs to get back to her old self!" What response by the nurse is best? a. "Everyone comes out of surgery differently." b. "Let's just give her some more time, okay?" c. "She may have had a stroke during surgery." d. "Sometimes older people take longer to wake up."

ANS: D Due to age-related changes, it may take longer for an older adult to metabolize anesthetic agents and pain medications, making it appear that they are taking too long to wake up and return to their normal baseline cognitive status. The nurse should educate the family on this possibility. While everyone does react differently, this does not give the family any objective information. Saying "Let's just give her more time, okay?" sounds patronizing and again does not provide information. While an intraoperative stroke is a possibility, the nurse should concentrate on the more common occurrence of older clients taking longer to fully arouse and awake. DIF: Understanding/Comprehension REF: 261 KEY: Postoperative nursing| older adult| sedation| neurologic system MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Health Promotion and Maintenance

A client has arrived in the postoperative unit. What action by the circulating nurse takes priority? a. Assessing fluid and blood output b. Checking the surgical dressings c. Ensuring the client is warm d. Participating in hand-off report

ANS: D Hand-offs are a critical time in client care, and poor communication during this time can lead to serious errors. The postoperative nurse and circulating nurse participate in hand-off report as the priority. Assessing fluid losses and dressings can be done together as part of the report. Ensuring the client is warm is a lower priority. DIF: Applying/Application REF: 257 KEY: Postoperative nursing| communication| hand-off communication| SBAR MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team? a. Allergy to bee and wasp stings b. History of lactose intolerance c. No previous experience with surgery d. Use of multiple herbs and supplements

ANS: D Some herbs and supplements can interact with medications, so this information needs to be reported as the priority. An allergy to bee and wasp stings should not affect the client during surgery. Lactose intolerance should also not affect the client during surgery but will need to be noted before a postoperative diet is ordered. Lack of experience with surgery may increase anxiety and may require higher teaching needs, but is not the priority over client safety. DIF: Applying/Application REF: 228 KEY: Preoperative nursing| herbs and supplements| medication interactions MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

A circulating nurse wishes to provide emotional support to a client who was just transferred to the operating room. What action by the nurse would be best? a. Administer anxiolytics. b. Give the client warm blankets. c. Introduce the surgical staff. d. Remain with the client.

ANS: D The nurse can provide emotional support by remaining with the client until anesthesia has been provided. An extremely anxious client may need anxiolytics, but not all clients require this for emotional support. Physical comfort and introductions can also help decrease anxiety. DIF: Applying/Application REF: 251 KEY: Intraoperative nursing| anxiety| comfort MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Psychosocial Integrity

The nurse is assessing a client's pain and has elicited information on the location, quality, intensity, effect on functioning, aggravating and relieving factors, and onset and duration. Which question by the nurse would be best to ask the client for completing a comprehensive pain assessment? a. "Are you worried about addiction to pain pills?" b. "Do you attach any spiritual meaning to pain?" c. "How high would you say your pain tolerance is?" d. "What pain rating would be acceptable to you?"

ANS: D A comprehensive pain assessment includes the items listed in the question plus the client's opinion on a comfort-function outcome, such as what pain rating would be acceptable to him or her. Asking about addiction is not warranted in an initial pain assessment. Asking about spiritual meanings for pain may give the nurse important information, but getting the basics first is more important. Asking about pain tolerance may give the client the idea that pain tolerance is being judged.

The nurse is caring for four clients with traumatic brain injuries. Which client would the nurse assess first? a. Client with amnesia for the incident b. Client who has a Glasgow Coma Scale score of 12 c. Client with a PaCO2 of 36 mm Hg and on a ventilator d. Client who has a temperature of 102° F (38.9° C)

ANS: D A fever is a poor prognostic indicator in patients with brain injuries. The nurse should see this client first. A Glasgow Coma Scale score of 12, a PaCO2 of 36, and amnesia for the incident are all either expected or positive findings.

The nurse is preparing to administer IV alteplase for a client diagnosed with an acute ischemic stroke. Which statement is correct about the administration of this drug? a. The recommended time for drug administration is within 90 minutes after admission to the emergency department. b. The drug is given in a bolus over the first 3 minutes followed by a continuous infusion. c. The maximum dosage of the drug, including the bolus, is 120 mg intravenously. d. The drug is not given to clients who are already on anticoagulant or antiplatelet therapy.

ANS: D Alteplase is a thrombolytic which dissolves clots and can cause bleeding as an adverse effect. Clients who are already taking an anticoagulant or antiplatelet agent are at risk for bleeding and therefore they are not candidates for alteplase therapy.

The nurse assesses a client's recent memory. Which statement by the client confirms that recent memory is intact? a. "A young girl wrapped in a shroud fell asleep on a bed of clouds." b. "I was born on April 3, 1967, in Johnstown Community Hospital." c. "Apple, chair, and pencil are the words you just stated." d. "I ate oatmeal with wheat toast and orange juice for breakfast."

ANS: D Asking clients about recent events that can be verified, such as what the client ate for breakfast, assesses recent memory. Asking clients about certain facts from the past that can be verified assesses remote or long-term memory. Asking the client to repeat words assesses immediate memory.

A nurse on the postoperative inpatient unit receives hand-off report on four clients using patient-controlled analgesia (PCA) pumps. Which client would the nurse see first? a. Client who appears to be sleeping soundly. b. Client with no bolus request in 6 hours. c. Client who is pressing the button every 10 minutes. d. Client with a respiratory rate of 8 breaths/min.

ANS: D Continuous delivery of opioid analgesia can lead to respiratory depression and extreme sedation. A respiratory rate of 8 breaths/min is below normal, so the nurse would first check this client. The client "sleeping soundly" could be comfortable (no indicators of respiratory distress) and would be checked next. Pressing the button every 10 minutes indicates that the client has a high level of pain, but the device has a lockout determining how often a bolus can be delivered. Therefore, the client cannot overdose. The nurse would next assess that client's pain. The client who has not needed a bolus of pain medicine in several hours has well-controlled pain.

The nurse is assessing a client diagnosed with trigeminal neuralgia affecting cranial nerve V. What assessment findings will the nurse expect for this client? a. Expressive aphasia b. Ptosis (eyelid drooping) c. Slurred speech d. Severe facial pain

ANS: D Cranial nerve (CN) V is the Trigeminal Nerve which has both a motor and sensory function in the face. When affected by a health problem, the client experiences severely facial pain. Expressive aphasia results from damage to the Broca speech area in the frontal lobe of the brain. Ptosis can result from damage to CN III and slurred speech often occurs from either damage to several cranial nerves or from damage to the motor strip in the frontal lobe of the brain.

A nurse is preparing to give a client ketorolac intravenously for pain. Which assessment findings would lead the nurse to consult with the primary health care provider? a. Bilateral lung crackles b. Hypoactive bowel sounds c. Self-reported pain of 3/10 d. Urine output of 20 mL/2 hr

ANS: D Drugs in this category can affect renal function. Clients need to be adequately hydrated and demonstrate good renal function prior to administering ketorolac. A urine output of 20 mL/2 hr is well below normal, and the nurse would consult with the primary health care provider (PHCP) about the choice of drug. Crackles and hypoactive bowel sounds are not related. A pain report of 3 does not warrant a call to the PHCP.

A client has arrived in the inpatient postoperative unit. What action by the inpatient nurse takes priority? a. Assessing fluid and blood output b. Checking the surgical dressings c. Ensuring the client is warm d. Participating in hand-off report

ANS: D Hand-offs are a critical time in client care, and poor communication during this time can lead to serious errors. The inpatient nurse and postanesthesia care nurse participate in hand-off report as the priority. Assessing fluid losses and dressings can be done together as part of the report. Ensuring the client is warm is a lower priority.

A nurse receives a hand-off report on a female client who had a left-sided stroke with homonymous hemianopsia. What action by the nurse is most appropriate for this client? a. Assess for bladder and bowel retention and/or incontinence. b. Listen to the client's lungs after eating or drinking for diminished breath sounds. c. Support the client's left side when sitting in a chair or in bed. d. Remind the client to move her head from side to side to increase her visual field.

ANS: D Homonymous hemianopsia is blindness on the same side of both eyes. The client must turn his or her head to see the entire visual field. This condition is not related to bladder function, difficulty swallowing, or lack of trunk control.

A nurse cares for a client who is experiencing deteriorating neurologic functions. The client states, "I am worried I will not be able to care for my young children." How would the nurse respond? a. "Caring for your children is a priority. You may not want to ask for help, but you really have to." b. "Our community has resources that may help you with some household tasks so you have energy to care for your children." c. "You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?" d. "Can you tell me more about what worries you, so we can see if we can do something to make adjustments?"

ANS: D Investigate specific concerns about situational or role changes before providing additional information. The nurse would not tell the client what is or is not a priority for him or her. Although community resources may be available, they may not be appropriate for the patient. Consulting a psychologist would not be appropriate without obtaining further information from the client related to current concerns.

A nurse asks why several clients are getting more than one type of pain medication instead of very high doses of one medication. Which response by the charge nurse is best? a. "A multimodal approach is the preferred method of control." b. "Clients are consumers and they demand lots of pain medicine." c. "We are all much more liberal with pain medications now." d. "Pain is so complex it takes different approaches to control it."

ANS: D Pain is a complex phenomenon and often responds best to a regimen that uses different types of analgesia. This is called a multimodal approach. Using this terminology, however, may not be clear to the newer nurse if the terminology is not understood. Primary health care providers and nurses may be more liberal with different types of pain medications, but that is not the best reason for this approach, especially in light of the opioid epidemic. Saying that clients are consumers who demand medications sounds as if the charge nurse is discounting their pain experiences.

A client who had surgery has extreme postoperative pain that is worsened when trying to participate in physical therapy. Which intervention for pain management does the nurse include in the client's care plan? a. As-needed pain medication after therapy b. Pain medications prior to therapy only c. Patient-controlled analgesia with a basal rate d. Round-the-clock analgesia with PRN analgesics

ANS: D Severe pain related to surgery or tissue trauma is best managed with round-the-clock dosing. Breakthrough pain associated with specific procedures is managed with additional medication. An as-needed regimen will not control postoperative pain. A patient-controlled analgesia pump might be a good idea but needs bolus (intermittent) settings to accomplish adequate pain control, with or without a basal rate. Pain control needs to be continuous, not just administered prior to therapy.

A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team? a. Allergy to bee and wasp stings b. History of lactose intolerance c. No previous experience with surgery d. Use of multiple herbs and supplements

ANS: D Some herbs and supplements can interact with medications, so this information needs to be reported as the priority. An allergy to bee and wasp stings should not affect the client during surgery. Lactose intolerance should also not affect the client during surgery but will need to be noted before a postoperative diet is ordered. Lack of experience with surgery may increase anxiety and may require higher teaching needs, but client safety is more important.

A nurse is assessing pain in an older adult. Which action by the nurse is best? a. Ask only "yes-or-no" questions so the client doesn't get too tired. b. Give the client a picture of the pain scale and come back later. c. Question the client about new pain only, not normal pain from aging. d. Sit down, ask one question at a time, and allow the client to answer.

ANS: D Some older clients do not report pain because they think it is a normal part of aging or because they do not want to be a bother. Sitting down conveys time, interest, and availability. Ask only one question at a time and allow the client enough time to answer it. Yes-or-no questions are an example of poor communication technique. Giving the client a pain scale, and then leaving, might give the impression that the nurse does not have time for the client. Also, the client may not know how to use it. There is no normal pain from aging.

A client with a severe traumatic brain injury has an organ donor card in his wallet. Which nursing action is appropriate? a. Request a directive form the client's primary health care provider. b. Ask the family if they agree to organ donation for the client. c. Wait until brain death is determined before acting on organ donation. d. Contact the local organ procurement organization as soon as possible.

ANS: D The appropriate nursing action is to respect the client's desire to be an organ donor and contact the local organ procurement organization even if family members do not agree. In most agencies, the primary health care provider does not have to write an order or directive to approve the organ donation. Family consent is not required.

The postoperative nurse is caring for a client who reports feeling "something popped" after vomiting. What action by the nurse is best? a. Administer an antiemetic medication. b. Call the primary health care provider. c. Instruct client to avoid coughing. d. Gather sterile nonadherent dressings.

ANS: D The client may have a wound dehiscence. The nurse would gather needed supplies and assess the wound under the dressing. If the incision has dehisced, the nurse would cover it with a sterile nonadherent dressing or saline-moistened gauze dressing then call the primary health care provider. The client may need an antiemetic, but this is not the most important action at this time.

The nurse is taking a history from a daughter about her father's onset of stroke signs and symptoms. Which statement by the daughter indicates that the client likely had an embolic stroke? a. Client's symptoms occurred slowly over several hours. b. Client because increasingly lethargic and drowsy. c. Client reported severe headache before other symptoms. d. Client has a long history of atrial fibrillation.

ANS: D The major cause of embolic strokes is a history of heart disease, especially atrial fibrillation. Most clients who have an embolic stroke have acute sudden neurologic symptoms but stay alert rather than lethargic. Decreasing level of consciousness and severe headache are more common in clients who have hemorrhagic strokes.

A nurse assesses an older adult's skin. Which findings require immediate referral? (Select all that apply.) a. Excessive moisture under axilla b. Increased hair thinning c. Presence of toenail fungus d. Lesion with various colors e. Spider veins on legs f. Asymmetric 6-mm dark lesion on forehead

ANS: D, F The lesion with various colors, as well as the asymmetric 6-mm dark lesion, fits two of the Skin Cancer Foundation's hallmark signs for cancer according to the ABCDE method. Other signs and symptoms, while not normal, are not cause for concern.

Which of the following neurotransmitters are deficient in myasthenia gravis? GABA Dopamine Serotonin Acetylcholine

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

The nurse is evaluating the collaborative care of a client with traumatic brain injury (TBI). What is the most important goal for this client?

Achieving the highest level of functioning

Which brain tumor can cause loss of hearing, tinnitus, and vertigo

Acoustic neuroma.

You need to obtain informed consent from a patient for a procedure. The patient experienced a stroke three months ago. The patient is unable to sign the consent form because he can't write. This is known as what: A. Agraphia B. Alexia C. Hemianopia D. Apraxia

Agraphia

Which interventions would be recommended for a client with dysphagia? Select all that apply.

Allow ample time to eat. Test the gag reflex before offering food or fluids. Assist the client with meals.

19. A patient with Huntington disease has just been admitted to a long-term care facility. The charge nurse is creating a care plan for this patient. Nutritional management for a patient with Huntington disease should be informed by what principle? A)The patient is likely to have an increased appetite. B)The patient is likely to required enzyme supplements. C)The patient will likely require a clear liquid diet. D)The patient will benefit from a low-protein diet.

Ans: A Feedback: Due to the continuous involuntary movements, patients will have a ravenous appetite. Despite this ravenous appetite, patients usually become emaciated and exhausted. As the disease progresses, patients experience difficulty in swallowing and thin liquids should be avoided. Protein will not be limited with this disease. Enzyme supplements are not normally required.

23. A gerontologic nurse is advocating for diagnostic testing of an 81-year-old patient who is experiencing personality changes. The nurse is aware of what factor that is known to affect the diagnosis and treatment of brain tumors in older adults? A)The effects of brain tumors are often attributed to the cognitive effects of aging. B)Brain tumors in older adults do not normally produce focal effects. C)Older adults typically have numerous benign brain tumors by the eighth decade of life. D)Brain tumors cannot normally be treated in patient over age 75.

Ans: A Feedback: In older adult patients, early signs and symptoms of intracranial tumors can be easily overlooked or incorrectly attributed to cognitive and neurologic changes associated with normal aging. Brain tumors are not normally benign and they produce focal effects in all patients. Treatment options are not dependent primarily on age.

25. A male patient presents at the free clinic with complaints of impotency. Upon physical examination, the nurse practitioner notes the presence of hypogonadism. What diagnosis should the nurse suspect? A)Prolactinoma B)Angioma C)Glioma D)Adrenocorticotropic hormone (ACTH)-producing adenoma

Ans: A Feedback: Male patients with prolactinomas may present with impotence and hypogonadism. An ACTH-producing adenoma would cause acromegaly. The scenario contains insufficient information to know if the tumor is an angioma, glioma, or neuroma.

37. A patient with a new diagnosis of amyotrophic lateral sclerosis (ALS) is overwhelmed by his diagnosis and the known complications of the disease. How can the patient best make known his wishes for care as his disease progresses? A)Prepare an advance directive. B)Designate a most responsible physician (MRP) early in the course of the disease. C)Collaborate with representatives from the Amyotrophic Lateral Sclerosis Association. D)Ensure that witnesses are present when he provides instruction.

Ans: A Feedback: Patients with ALS are encouraged to complete an advance directive or "living will" to preserve their autonomy in decision making. None of the other listed actions constitutes a legally binding statement of end-of-life care.

27. A patient has been admitted to the neurologic ICU with a diagnosis of a brain tumor. The patient is scheduled to have a tumor resection/removal in the morning. Which of the following assessment parameters should the nurse include in the initial assessment? A)Gag reflex B)Deep tendon reflexes C)Abdominal girth D)Hearing acuity

Ans: A Feedback: Preoperatively, the gag reflex and ability to swallow are evaluated. In patients with diminished gag response, care includes teaching the patient to direct food and fluids toward the unaffected side, having the patient sit upright to eat, offering a semisoft diet, and having suction readily available. Deep tendon reflexes, abdominal girth, and hearing acuity are less commonly affected by brain tumors and do not affect the risk for aspiration.

40. A nurse is planning discharge education for a patient who underwent a cervical diskectomy. What strategies would the nurse assess that would aid in planning discharge teaching? A)Care of the cervical collar B)Technique for performing neck ROM exercises C)Home assessment of ABGs D)Techniques for restoring nerve function

Ans: A Feedback: Prior to discharge, the nurse should assess the patient's use and care of the cervical collar. Neck ROM exercises would be contraindicated and ABGs cannot be assessed in the home. Nerve function is not compromised by a diskectomy.

36. A family member of a patient diagnosed with Huntington disease calls you at the clinic. She is requesting help from the Huntington's Disease Society of America. What kind of help can this patient and family receive from this organization? Select all that apply. A)Information about this disease B)Referrals C)Public education D)Individual assessments E)Appraisals of research studies

Ans: A, B, C Feedback: The Huntington's Disease Society of America helps patients and families by providing information, referrals, family and public education, and support for research. It does not provide individual assessments or appraisals of individual research studies.

29. A patient with an inoperable brain tumor has been told that he has a short life expectancy. On what aspects of assessment and care should the home health nurse focus? Select all that apply. A)Pain control B)Management of treatment complications C)Interpretation of diagnostic tests D)Assistance with self-care E)Administration of treatments

Ans: A, B, D, E Feedback: Home care needs and interventions focus on four major areas: palliation of symptoms and pain control, assistance in self-care, control of treatment complications, and administration of specific forms of treatment, such as parenteral nutrition. Interpretation of diagnostic tests is normally beyond the purview of the nurse.

18. A patient has just returned to the unit from the PACU after surgery for a tumor within the spine. The patient complains of pain. When positioning the patient for comfort and to reduce injury to the surgical site, the nurse will position to patient in what position? A)In the high Fowler's position B)In a flat side-lying position C)In the Trendelenberg position D)In the reverse Trendelenberg position

Ans: B Feedback: After spinal surgery, the bed is usually kept flat initially. The side-lying position is usually the most comfortable because this position imposes the least pressure on the surgical site. The Fowler's position, Trendelenberg position, and reverse Trendelenberg position are inappropriate for this patient because they would result in increased pain and complications.

38. The nurse is caring for a patient who is scheduled for a cervical discectomy the following day. During health education, the patient should be made aware of what potential complications? A)Vertebral fracture B)Hematoma at the surgical site C)Scoliosis D)Renal trauma

Ans: B Feedback: Based on all the assessment data, the potential complications of diskectomy may include hematoma at the surgical site, resulting in cord compression and neurologic deficit and recurrent or persistent pain after surgery. Renal trauma and fractures are unlikely; scoliosis is a congenital malformation of the spine.

14. A patient diagnosed with a pituitary adenoma has arrived on the neurologic unit. When planning the patient's care, the nurse should be aware that the effects of the tumor will primarily depend on what variable? A)Whether the tumor utilizes aerobic or anaerobic respiration B)The specific hormones secreted by the tumor C)The patient's pre-existing health status D)Whether the tumor is primary or the result of metastasis

Ans: B Feedback: Functioning pituitary tumors can produce one or more hormones normally produced by the anterior pituitary and the effects of the tumor depend largely on the identity of these hormones. This variable is more significant than the patient's health status or whether the tumor is primary versus secondary. Anaerobic and aerobic respiration is not relevant.

13. A patient has been admitted to the neurologic unit for the treatment of a newly diagnosed brain tumor. The patient has just exhibited seizure activity for the first time. What is the nurse's priority response to this event? A)Identify the triggers that precipitated the seizure. B)Implement precautions to ensure the patient's safety. C)Teach the patient's family about the relationship between brain tumors and seizure activity. D)Ensure that the patient is housed in a private room.

Ans: B Feedback: Patients with seizures are carefully monitored and protected from injury. Patient safety is a priority over health education, even though this is appropriate and necessary. Specific triggers may or may not be evident; identifying these is not the highest priority. A private room is preferable, but not absolutely necessary.

28. A patient with a brain tumor has begun to exhibit signs of cachexia. What subsequent assessment should the nurse prioritize? A)Assessment of peripheral nervous function B)Assessment of cranial nerve function C)Assessment of nutritional status D)Assessment of respiratory status

Ans: C Feedback: Cachexia is a wasting syndrome of weight loss, muscle atrophy, fatigue, weakness, and significant loss of appetite. Consequently, nutritional assessment is paramount.

31. A patient, brought to the clinic by his wife and son, is diagnosed with Huntington disease. When providing anticipatory guidance, the nurse should address the future possibility of what effect of Huntington disease? A)Metastasis B)Risk for stroke C)Emotional and personality changes D)Pathologic bone fractures

Ans: C Feedback: Huntington disease causes profound changes to personality and behavior. It is a nonmalignant disease and stroke is not a central risk. The disease is not associated with pathologic bone fractures.

39. The nurse responds to the call light of a patient who has had a cervical diskectomy earlier in the day. The patient states that she is having severe pain that had a sudden onset. What is the nurse's most appropriate action? A)Palpate the surgical site. B)Remove the dressing to assess the surgical site. C)Call the surgeon to report the patient's pain. D)Administer a dose of an NSAID.

Ans: C Feedback: If the patient experiences a sudden increase in pain, extrusion of the graft may have occurred, requiring reoperation. A sudden increase in pain should be promptly reported to the surgeon. Administration of an NSAID would be an insufficient response and the dressing should not be removed without an order. Palpation could cause further damage.

20. A patient with amyotrophic lateral sclerosis (ALS) is being visited by the home health nurse who is creating a care plan. What nursing diagnosis is most likely for a patient with this condition? A)Chronic confusion B)Impaired urinary elimination C)Impaired verbal communication D)Bowel incontinence

Ans: C Feedback: Impaired communication is an appropriate nursing diagnosis; the voice in patients with ALS assumes a nasal sound and articulation becomes so disrupted that speech is unintelligible. Intellectual function is marginally impaired in patients with late ALS. Usually, the anal and bladder sphincters are intact because the spinal nerves that control muscles of the rectum and urinary bladder are not affected.

22. The nurse is caring for a patient newly diagnosed with a primary brain tumor. The patient asks the nurse where his tumor came from. What would be the nurse's best response? A)"Your tumor originated from somewhere outside the CNS." B)"Your tumor likely started out in one of your glands." C)"Your tumor originated from cells within your brain itself." D)"Your tumor is from nerve tissue somewhere in your body."

Ans: C Feedback: Primary brain tumors originate from cells and structures within the brain. Secondary brain tumors are metastatic tumors that originate somewhere else in the body. The scenario does not indicate that the patient's tumor is a pituitary tumor or a neuroma.

24. A patient who has been experiencing numerous episodes of unexplained headaches and vomiting has subsequently been referred for testing to rule out a brain tumor. What characteristic of the patient's vomiting is most consistent with a brain tumor? A)The patient's vomiting is accompanied by epistaxis. B)The patient's vomiting does not relieve his nausea. C)The patient's vomiting is unrelated to food intake. D)The patient's emesis is blood-tinged.

Ans: C Feedback: Vomiting is often unrelated to food intake if caused by a brain tumor. The presence or absence of blood is not related to the possible etiology and vomiting may or may not relieve the patient's nausea.

21. The nurse educator is discussing neoplasms with a group of recent graduates. The educator explains that the effects of neoplasms are caused by the compression and infiltration of normal tissue. The physiologic changes that result can cause what pathophysiologic events? Select all that apply. A)Intracranial hemorrhage B)Infection of cerebrospinal fluid C)Increased ICP D)Focal neurologic signs E)Altered pituitary function

Ans: C, D, E Feedback: The effects of neoplasms are caused by the compression and infiltration of tissue. A variety of physiologic changes result, causing any or all of the following pathophysiologic events: increased ICP and cerebral edema, seizure activity and focal neurologic signs, hydrocephalus, and altered pituitary function.

9. While assessing the patient at the beginning of the shift, the nurse inspects a surgical dressing covering the operative site after the patients' cervical diskectomy. The nurse notes that the drainage is 75% saturated with serosanguineous discharge. What is the nurse's most appropriate action? A)Page the physician and report this sign of infection. B)Reinforce the dressing and reassess in 1 to 2 hours. C)Reposition the patient to prevent further hemorrhage. D)Inform the surgeon of the possibility of a dural leak.

Ans: D Feedback: After a cervical diskectomy, the nurse will monitor the operative site and dressing covering this site. Serosanguineous drainage may indicate a dural leak. This constitutes a risk for meningitis, but is not a direct sign of infection. This should be reported to the surgeon, not just reinforced and observed.

10. A patient, diagnosed with cancer of the lung, has just been told he has metastases to the brain. What change in health status would the nurse attribute to the patient's metastatic brain disease? A)Chronic pain B)Respiratory distress C)Fixed pupils D)Personality changes

Ans: D Feedback: Neurologic signs and symptoms include headache, gait disturbances, visual impairment, personality changes, altered mentation (memory loss and confusion), focal weakness, paralysis, aphasia, and seizures. Pain, respiratory distress, and fixed pupils are not among the more common neurologic signs and symptoms of metastatic brain disease.

12. The nurse is caring for a patient with Huntington disease who has been admitted to the hospital for treatment of malnutrition. What independent nursing action should be implemented in the patient's plan of care? A)Firmly redirect the patient's head when feeding. B)Administer phenothiazines after each meal as ordered. C)Encourage the patient to keep his or her feeding area clean. D)Apply deep, gentle pressure around the patient's mouth to aid swallowing.

Ans: D Feedback: Nursing interventions for a patient who has inadequate nutritional intake should include the following: Apply deep gentle pressure around the patient's mouth to assist with swallowing, and administer phenothiazines prior to the patient's meal as ordered. The nurse should disregard the mess of the feeding area and treat the person with dignity. Stiffness and turning away by the patient during feeding are uncontrollable choreiform movements and should not be interrupted.

7. A 37-year-old man is brought to the clinic by his wife because he is experiencing loss of motor function and sensation. The physician suspects the patient has a spinal cord tumor and hospitalizes him for diagnostic testing. In light of the need to diagnose spinal cord compression from a tumor, the nurse will most likely prepare the patient for what test? A)Anterior-posterior x-ray B)Ultrasound C)Lumbar puncture D)MRI

Ans: D Feedback: The MRI scan is the most commonly used diagnostic procedure. It is the most sensitive diagnostic tool that is particularly helpful in detecting epidural spinal cord compression and vertebral bone metastases.

A patient is scheduled for a myelogram and the nurse explains to the patient that this is an invasive procedure, 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

Ans: A Feedback: 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 lumbar puncture.

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

Ans: A Feedback: 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.

A patient is being given a medication that stimulates her parasympathetic system. Following administration of this medication, the nurse should anticipate what effect? A) Constricted pupils B) Dilated bronchioles C) Decreased peristaltic movement D) Relaxed muscular walls of the urinary bladder

Ans: A Feedback: Parasympathetic stimulation results in constricted pupils, constricted bronchioles, increased peristaltic movement, and contracted muscular walls of the urinary bladder.

A gerontologic nurse educator is providing practice guidelines to unlicensed care providers. Because reaction to painful stimuli is sometimes blunted in older adults, what must be used with caution? A) Hot or cold packs B) Analgesics C) Anti-inflammatory medications D) Whirlpool baths

Ans: A Feedback: Reaction to painful stimuli may be decreased with age. Because pain is an important warning signal, caution must be used when hot or cold packs are used. The older patient may be burned or suffer frostbite before being aware of any discomfort. Any medication is used with caution in the elderly, but not because of the decreased sense of heat or cold. Whirlpool baths are generally not a routine treatment ordered for the elderly.

A patient exhibiting an uncoordinated gait has presented at the clinic. Which of the following is the most plausible cause of this patient's health problem? A) Cerebellar dysfunction B) A lesion in the pons C) Dysfunction of the medulla D) A hemorrhage in the midbrain

Ans: A Feedback: The cerebellum controls fine movement, balance, position sense, and integration of sensory input. Portions of the pons control the heart, respiration, and blood pressure. Cranial nerves IX through XII connect to the brain in the medulla. Cranial nerves III and IV originate in the midbrain.

A patient is admitted to the medical unit with an exacerbation of multiple sclerosis. When assessing this patient, the nurse has the patient stick out her tongue and move it back and forth. What is the nurse assessing? A) Function of the hypoglossal nerve B) Function of the vagus nerve C) Function of the spinal nerve D) Function of the trochlear nerve

Ans: A Feedback: The hypoglossal nerve is the 12th cranial nerve. It is responsible for movement of the tongue. None of the other listed nerves affects motor function in the tongue.

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 nurse's 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.

Ans: 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-lumbar puncture headaches.

1. A nurse is assessing a patient with an acoustic neuroma who has been recently admitted to an oncology unit. What symptoms is the nurse likely to find during the initial assessment? A) Loss of hearing, tinnitus, and vertigo B) Loss of vision, change in mental status, and hyperthermia C) Loss of hearing, increased sodium retention, and hypertension D) Loss of vision, headache, and tachycardia

Ans: A Feedback: An acoustic neuroma is a tumor of the eighth cranial nerve, the cranial nerve most responsible for hearing and balance. The patient with an acoustic neuroma usually experiences loss of hearing, tinnitus, and episodes of vertigo and staggering gait. Acoustic neuromas do not cause loss of vision, increased sodium retention, or tachycardia.

30. An older adult has encouraged her husband to visit their primary care provider, stating that she is concerned that he may have Parkinson's disease. Which of the wife's descriptions of her husband's health and function is most suggestive of Parkinson's disease? A) "Lately he seems to move far more slowly than he ever has in the past." B) "He often complains that his joints are terribly stiff when he wakes up in the morning." C) "He's forgotten the names of some people that we've known for years." D) "He's losing weight even though he has a ravenous appetite."

Ans: A Feedback: Parkinson's disease is characterized by bradykinesia. It does not manifest as memory loss, increased appetite, or joint stiffness.

4. A patient with suspected Parkinson's disease is initially being assessed by the nurse. When is the best time to assess for the presence of a tremor? A) When the patient is resting B) When the patient is ambulating C) When the patient is preparing his or her meal tray to eat D) When the patient is participating in occupational therapy

Ans: A Feedback: The tremor is present while the patient is at rest; it increases when the patient is walking, concentrating, or feeling anxious. Resting tremor characteristically disappears with purposeful movement, but is evident when the extremities are motionless. Consequently, the nurse should assess for the presence of a tremor when the patient is not performing deliberate actions.

The nurse is caring for a patient who exhibits abnormal results of the Weber test and Rinne test. The nurse should suspect dysfunction involving what cranial nerve? A) Trigeminal B) Acoustic C) Hypoglossal D) Trochlear

Ans: B Feedback: Abnormal hearing can correlate with damage to cranial nerve VIII (acoustic). The acoustic nerve functions in hearing and equilibrium. The trigeminal nerve functions in facial sensation, corneal reflex, and chewing. The hypoglossal nerve moves the tongue. The trochlear nerve controls muscles that move the eye.

The nurse is performing a neurologic assessment of a patient whose injuries have rendered her unable to follow verbal commands. How should the nurse proceed with assessing the patient's level of consciousness (LOC)? A) Assess the patient's vital signs and correlate these with the patient's baselines. B) Assess the patient's eye opening and response to stimuli. C) Document that the patient currently lacks a level of consciousness. D) Facilitate diagnostic testing in an effort to obtain objective data.

Ans: B Feedback: If the patient is not alert or able to follow commands, the examiner observes for eye opening; verbal response and motor response to stimuli, if any; and the type of stimuli needed to obtain a response. Vital signs and diagnostic testing are appropriate, but neither will allow the nurse to gauge the patient's LOC. Inability to follow commands does not necessarily denote an absolute lack of consciousness.

In the course of a focused neurologic assessment, the nurse is palpating the patient's major muscle groups at rest and during passive movement. Data gleaned from this assessment will allow the nurse to describe which of the following aspects of neurologic function? A) Muscle dexterity B) Muscle tone C) Motor symmetry D) Deep tendon reflexes

Ans: B Feedback: Muscle tone (the tension present in a muscle at rest) is evaluated by palpating various muscle groups at rest and during passive movement. Data from this assessment do not allow the nurse to ascertain the patient's dexterity, reflexes, or motor symmetry

The nurse is planning the care of a patient with Parkinson's disease. The nurse should be aware that treatment will focus on what pathophysiological phenomenon? A) Premature degradation of acetylcholine B) Decreased availability of dopamine C) Insufficient synthesis of epinephrine D) Delayed reuptake of serotonin

Ans: B Feedback: Parkinson's disease develops from decreased availability of dopamine, not acetylcholine, epinephrine, or serotonin.

The physician has ordered a somatosensory evoked responses (SERs) test for a patient for whom the nurse is caring. The nurse is justified in suspecting that this patient may have a history of what type of neurologic disorder? A) Hypothalamic disorder B) Demyelinating disease C) Brainstem deficit D) Diabetic neuropathy

Ans: B Feedback: SERs are used to detect deficits in the spinal cord or peripheral nerve conduction and to monitor spinal cord function during surgical procedures. The test is also useful in the diagnosis of demyelinating diseases, such as multiple sclerosis and polyneuropathies, where nerve conduction is slowed. The test is not done to diagnose hypothalamic disorders, brainstem deficits, or diabetic neuropathies.

34. The nurse is caring for a patient diagnosed with Parkinson's disease. The patient is having increasing problems with rising from the sitting to the standing position. What should the nurse suggest to the patient to use that will aid in getting from the sitting to the standing position as well as aid in improving bowel elimination? A) Use of a bedpan B) Use of a raised toilet seat C) Sitting quietly on the toilet every 2 hours D) Following the outlined bowel program

Ans: B Feedback: A raised toilet seat is useful, because the patient has difficulty in moving from a standing to a sitting position. A handicapped toilet is not high enough and will not aid in improving bowel elimination. Sitting quietly on the toilet every 2 hours will not aid in getting from the sitting to standing position; neither will following the outlined bowel program.

16. The nurse in an extended care facility is planning the daily activities of a patient with postpolio syndrome. The nurse recognizes the patient will best benefit from physical therapy when it is scheduled at what time? A) Immediately after meals B) In the morning C) Before bedtime D) In the early evening

Ans: B Feedback: Important activities for patients with postpolio syndrome should be planned for the morning, as fatigue often increases in the afternoon and evening.

2. A 25-year-old female patient with brain metastases is considering her life expectancy after her most recent meeting with her oncologist. Based on the fact that the patient is not receiving treatment for her brain metastases, what is the nurse's most appropriate action? A) Promoting the patient's functional status and ADLs B) Ensuring that the patient receives adequate palliative care C) Ensuring that the family does not tell the patient that her condition is terminal D) Promoting adherence to the prescribed medication regimen

Ans: B Feedback: Patients with intracerebral metastases who are not treated have a steady downhill course with a limited survival time, whereas those who are treated may survive for slightly longer periods, but for most cure is not possible. Palliative care is thus necessary. This is a priority over promotion of function and the family should not normally withhold information from the patient. Adherence to medications such as analgesics is important, but palliative care is a high priority.

6. The nurse is caring for a boy who has muscular dystrophy. When planning assistance with the patient's ADLs, what goal should the nurse prioritize? A) Promoting the patient's recovery from the disease B) Maximizing the patient's level of function C) Ensuring the patient's adherence to treatment D) Fostering the family's participation in care

Ans: B Feedback: Priority for the care of the child with muscular dystrophy is the need to maximize the patient's level of function. Family participation is also important, but should be guided by this goal. Adherence is not a central goal, even though it is highly beneficial, and the disease is not curable.

17. A patient newly diagnosed with a cervical disk herniation is receiving health education from the clinic nurse. What conservative management measures should the nurse teach the patient to implement? A) Perform active ROM exercises three times daily. B) Sleep on a firm mattress. C) Apply cool compresses to the back of the neck daily. D) Wear the cervical collar for at least 2 hours at a time.

Ans: B Feedback: Proper positioning on a firm mattress and bed rest for 1 to 2 days may bring dramatic relief from pain. The patient may need to wear a cervical collar 24 hours a day during the acute phase of pain from a cervical disk herniation. Hot, moist compresses applied to the back of the neck will increase blood flow to the muscles and help relax the spastic muscles.

5. The clinic nurse caring for a patient with Parkinson's disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. For what common side effect of Sinemet would the nurse assesses this patient? A) Pruritus B) Dyskinesia C) Lactose intolerance D) Diarrhea

Ans: B Feedback: Within 5 to 10 years of taking levodopa, most patients develop a response to the medication characterized by dyskinesia (abnormal involuntary movements). Another potential complication of long-term dopaminergic medication use is neuroleptic malignant syndrome characterized by severe rigidity, stupor, and hyperthermia. Side effects of long-term Sinemet therapy are not pruritus, lactose intolerance, or diarrhea.

Assessment is crucial to the care of patients with neurologic dysfunction. What does accurate and appropriate assessment require? Select all that apply. A) The ability to select mediations for the neurologic dysfunction B) Understanding of the tests used to diagnose neurologic disorders C) Knowledge of nursing interventions related to assessment and diagnostic testing D) Knowledge of the anatomy of the nervous system E) The ability to interpret the results of diagnostic tests

Ans: B, C, D Feedback: Assessment requires knowledge of the anatomy and physiology of the nervous system and an understanding of the array of tests and procedures used to diagnose neurologic disorders. Knowledge about the nursing implications and interventions related to assessment and diagnostic testing is also essential. Selecting medications and interpreting diagnostic tests are beyond the normal scope of the nurse.

The nurse educator is reviewing the assessment of cranial nerves. What should the educator identify as the specific instances when cranial nerves should be assessed? Select all that apply. A) When a neurogenic bladder develops B) When level of consciousness is decreased C) With brain stem pathology D) In the presence of peripheral nervous system disease E) When a spinal reflex is interrupted

Ans: B, C, D Feedback: Cranial nerves are assessed when level of consciousness is decreased, with brain stem pathology, or in the presence of peripheral nervous system disease. Abnormalities in muscle tone and involuntary movements are less likely to prompt the assessment of cranial nerves, since these nerves do not directly mediate most aspects of muscle tone and movement.

A patient had a lumbar puncture performed at the outpatient clinic and the nurse has phoned the patient and family that evening. What does this phone call enable the nurse to determine? A) What are the patient's and family's expectations of the test B) Whether the patient's family had any questions about why the test was necessary C) Whether the patient has had any complications of the test D) Whether the patient understood accurately why the test was done

Ans: C Feedback: Contacting the patient and family after diagnostic testing enables the nurse to determine whether they have any questions about the procedure or whether the patient had any untoward results. The other listed information should have been elicited from the patient and family prior to the test.

When caring for a patient with an altered level of consciousness, the nurse is preparing to test cranial nerve VII. What assessment technique would the nurse use to elicit a response from cranial nerve VII? A) Palpate trapezius muscle while patient shrugs should against resistance. B) Administer the whisper or watch-tick test. C) Observe for facial movement symmetry, such as a smile. D) Note any hoarseness in the patient's voice.

Ans: C Feedback: Cranial nerve VII is the facial nerve. An appropriate assessment technique for this cranial nerve would include observing for symmetry while the patient performs facial movements: smiles, whistles, elevates eyebrows, and frowns. Palpating and noting strength of the trapezius muscle while the patient shrugs shoulders against resistance would be completed to assess cranial nerve XI (spinal accessory). Assessing cranial nerve VIII (acoustic) would involve using the whisper or watch-tick test to evaluate hearing. Noting any hoarseness in the patient's voice would involve assessment of cranial nerve X (vagus)

A patient is scheduled for CT scanning of the head because of a recent onset of neurologic deficits. What should 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."

Ans: C Feedback: Preparation for CT scanning includes teaching the patient about the need to lie quietly throughout the procedure. 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.

During the performance of the Romberg test, the nurse observes that the patient sways slightly. What is the nurse's most appropriate action? A) Facilitate a referral to a neurologist. B) Reposition the patient supine to ensure safety. C) Document successful completion of the assessment. D) Follow up by having the patient perform the Rinne test.

Ans: C Feedback: Slight swaying during the Romberg test is normal, but a loss of balance is abnormal and is considered a positive Romberg test. Slight swaying is not a significant threat to the patient's safety. The Rinne test assesses hearing, not balance.

A patient is having a "fight or flight response" after receiving bad news about his prognosis. What affect will this have on the patient's sympathetic nervous system? A) Constriction of blood vessels in the heart muscle B) Constriction of bronchioles C) Increase in the secretion of sweat D) Constriction of pupils

Ans: C Feedback: Sympathetic nervous system stimulation results in dilated blood vessels in the heart and skeletal muscle, dilated bronchioles, increased secretion of sweat, and dilated pupils.

A trauma patient was admitted to the ICU with a brain injury. The patient had a change in level of consciousness, increased vital signs, and became diaphoretic and agitated. The nurse should recognize which of the following syndromes as the most plausible cause of these symptoms? A) Adrenal crisis B) Hypothalamic collapse C) Sympathetic storm D) Cranial nerve deficit

Ans: C Feedback: Sympathetic storm is a syndrome associated with changes in level of consciousness, altered vital signs, diaphoresis, and agitation that may result from hypothalamic stimulation of the sympathetic nervous system following traumatic brain injury. Alterations in cranial nerve or adrenal function would not have this result.

The nurse caring for an 80 year-old patient knows that she has a pre-existing history of dulled tactile sensation. The nurse should first consider what possible cause for this patient's diminished tactile sensation? A) Damage to cranial nerve VIII B) Adverse medication effects C) Age-related neurologic changes D) An undiagnosed cerebrovascular accident in early adulthood

Ans: C Feedback: Tactile sensation is dulled in the elderly person due to a decrease in the number of sensory receptors. While thorough assessment is necessary, it is possible that this change is unrelated to pathophysiological processes.

A patient in the OR goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows that the area of the brain that regulates body temperature is which of the following? A) Cerebellum B) Thalamus C) Hypothalamus D) Midbrain

Ans: C Feedback: The hypothalamus plays an important role in the endocrine system because it regulates the pituitary secretion of hormones that influence metabolism, reproduction, stress response, and urine production. It works with the pituitary to maintain fluid balance through hormonal release and maintains temperature regulation by promoting vasoconstriction or vasodilatation. The cerebellum, thalamus, and midbrain and not directly involved in temperature regulation.

The nurse is caring for a patient with an upper motor neuron lesion. What clinical manifestations should the nurse anticipate when planning the patient's neurologic assessment? A) Decreased muscle tone B) Flaccid paralysis C) Loss of voluntary control of movement D) Slow reflexes

Ans: C Upper motor neuron lesions do not cause muscle atrophy, flaccid paralysis, or slow reflexes. However, upper motor neuron lesions normally cause loss of voluntary control.

8. A patient with Parkinson's disease is undergoing a swallowing assessment because she has recently developed adventitious lung sounds. The patient's nutritional needs should be met by what method? A) Total parenteral nutrition (TPN) B) Provision of a low-residue diet C) Semisolid food with thick liquids D) Minced foods and a fluid restriction

Ans: C Feedback: A semisolid diet with thick liquids is easier for a patient with swallowing difficulties to consume than is a solid diet. Low-residue foods and fluid restriction are unnecessary and counterproductive to the patient's nutritional status. The patient's status does not warrant TPN.

35. A patient with Parkinson's disease is experiencing episodes of constipation that are becoming increasingly frequent and severe. The patient states that he has been achieving relief for the past few weeks by using OTC laxatives. How should the nurse respond? A) "It's important to drink plenty of fluids while you're taking laxatives." B) "Make sure that you supplement your laxatives with a nutritious diet." C) "Let's explore other options, because laxatives can have side effects and create dependency." D) "You should ideally be using herbal remedies rather than medications to promote bowel function."

Ans: C Feedback: Laxatives should be avoided in patients with Parkinson's disease due to the risk of adverse effects and dependence. Herbal bowel remedies are not necessarily less risky.

3. The nurse is writing a care plan for a patient with brain metastases. The nurse decides that an appropriate nursing diagnosis is "anxiety related to lack of control over the health circumstances." In establishing this plan of care for the patient, the nurse should include what intervention? A) The patient will receive antianxiety medications every 4 hours. B) The patient's family will be instructed on planning the patient's care. C) The patient will be encouraged to verbalize concerns related to the disease and its treatment. D) The patient will begin intensive therapy with the goal of distraction.

Ans: C Feedback: Patients need the opportunity to exercise some control over their situation. A sense of mastery can be gained as they learn to understand the disease and its treatment and how to deal with their feelings. Distraction and administering medications will not allow the patient to gain control over anxiety. Delegating planning to the family will not help the patient gain a sense of control and autonomy.

A 72-year-old man has been brought to his primary care provider by his daughter, who claims that he has been experiencing uncharacteristic lapses in memory. What principle should underlie the nurse's assessment and management of this patient? A) Loss of short-term memory is normal in older adults, but loss of long-term memory is pathologic. B) Lapses in memory in older adults are considered benign unless they have negative consequences. C) Gradual increases in confusion accompany the aging process. D) Thorough assessment is necessary because changes in cognition are always considered to be pathologic

Ans: D Feedback: Although mental processing time decreases with age, memory, language, and judgment capacities remain intact. Change in mental status should never be assumed to be a normal part of aging.

The neurologic nurse is testing the function of a patient's cerebellum and basal ganglia. What action will most accurately test these structures? A) Have the patient identify the location of a cotton swab on his or her skin with the eyes closed. B) Elicit the patient's response to a hypothetical problem. C) Ask the patient to close his or her eyes and discern between hot and cold stimuli. D) Guide the patient through the performance of rapid, alternating movements.

Ans: D Feedback: Cerebellar and basal ganglia influence on the motor system is reflected in balance control and coordination. Coordination in the hands and upper extremities is tested by having the patient perform rapid, alternating movements and point-to-point testing. The cerebellum and basal ganglia do not mediate cutaneous sensation or judgment.

The nursing students are learning how to assess function of cranial nerve VIII. To assess the function of cranial nerve VIII the students would be correct in completing which of the following assessment techniques? A) Have the patient identify familiar odors with the eyes closed. B) Assess papillary reflex. C) Utilize the Snellen chart. D) Test for air and bone conduction (Rinne test).

Ans: D Feedback: Cranial nerve VIII is the acoustic nerve. It functions in hearing and equilibrium. When assessing this nerve, the nurse would test for air and bone conduction (Rinne) with a tuning fork. Assessment of papillary reflex would be completed for cranial nerves III (oculomotor), IV (trochlear), and VI (abducens). The Snellen chart would be used to assess cranial nerve II (optic).

A patient for whom the nurse is caring has positron emission tomography (PET) scheduled. In preparation, what should the nurse explain to the patient? A) The test will temporarily limit blood flow through the brain. B) An allergy to iodine precludes getting the radio-opaque dye. C) The patient will need to endure loud noises during the test. D) The test may result in dizziness or lightheadedness.

Ans: D Feedback: Key nursing interventions for PET scan include explaining the test and teaching the patient about inhalation techniques and the sensations (e.g., dizziness, light-headedness, and headache) that may occur. A PET scan does not impede blood flow through the brain. An allergy to iodine precludes the dye for an MRI, and loud noise is heard in an MRI.

A patient is currently being stimulated by the parasympathetic nervous system. What effect will this nervous stimulation have on the patient's bladder? A) The parasympathetic nervous system causes urinary retention. B) The parasympathetic nervous system causes bladder spasms. C) The parasympathetic nervous system causes urge incontinence. D) The parasympathetic nervous system makes the bladder contract.

Ans: D Feedback: The parasympathetic division of the nervous system causes contraction (stimulation) of the urinary bladder muscles and a decrease (inhibition) in heart rate, whereas the sympathetic division produces relaxation (inhibition) of the urinary bladder and an increase (stimulation) in the rate and force of the heartbeat.

The nurse is admitting a patient to the unit who is diagnosed with a lower motor neuron lesion. What entry in the patient's electronic record is most consistent with this diagnosis? A) "Patient exhibits increased muscle tone." B) "Patient demonstrates normal muscle structure with no evidence of atrophy." C) "Patient demonstrates hyperactive deep tendon reflexes." D) "Patient demonstrates an absence of deep tendon reflexes."

Ans: D Lower motor neuron lesions cause flaccid muscle paralysis, muscle atrophy, decreased muscle tone, and loss of voluntary control.

An elderly patient is being discharged home. The patient lives alone and has atrophy of his olfactory organs. The nurse tells the patient's family that it is essential that the patient have what installed in the home? A) Grab bars B) Nonslip mats C) Baseboard heaters D) A smoke detector

Ans: D The sense of smell deteriorates with age. The olfactory organs are responsible for smell. This may present a safety hazard for the patient because he or she may not smell smoke or gas leaks. Smoke detectors are universally necessary, but especially for this patient.

What term is used to describe the fibrous connective tissue that hugs the brain closely and extends into every fold of the brain's surface? A) Dura mater B) Arachnoid C) Fascia D) Pia mater

Ans: D The term "meninges" describes the fibrous connective tissue that covers the brain and spinal cord. The meninges have three layers, the dura mater, arachnoid, and pia mater. The pia mater is the innermost membrane that hugs the brain closely and extends into every fold of the brain's surface. The dura mater, the outermost layer, covers the brain and spinal cord. The arachnoid, the middle membrane, is responsible for the production of cerebrospinal fluid.

11. A patient has just been diagnosed with Parkinson's disease and the nurse is planning the patient's subsequent care for the home setting. What nursing diagnosis should the nurse address when educating the patient's family? A)Risk for infection B)Impaired spontaneous ventilation C)Unilateral neglect D)Risk for injury

Ans: D Feedback: Individuals with Parkinson's disease face a significant risk for injury related to the effects of dyskinesia. Unilateral neglect is not characteristic of the disease, which affects both sides of the body. Parkinson's disease does not directly constitute a risk for infection or impaired respiration.

32. A patient who was diagnosed with Parkinson's disease several months ago recently began treatment with levodopa-carbidopa. The patient and his family are excited that he has experienced significant symptom relief. The nurse should be aware of what implication of the patient's medication regimen? A) The patient is in a "honeymoon period" when adverse effects of levodopa-carbidopa are not yet evident. B) Benefits of levodopa-carbidopa do not peak until 6 to 9 months after the initiation of treatment. C) The patient's temporary improvement in status is likely unrelated to levodopa-carbidopa. D) Benefits of levodopa-carbidopa often diminish after 1 or 2 years of treatment.

Ans: D Feedback: The beneficial effects of levodopa therapy are most pronounced in the first year or two of treatment. Benefits begin to wane and adverse effects become more severe over time. However, a "honeymoon period" of treatment is not known.

15. A male patient with a metastatic brain tumor is having a generalized seizure and begins vomiting. What should the nurse do first? A) Perform oral suctioning. B) Page the physician. C) Insert a tongue depressor into the patient's mouth. D) Turn the patient on his side.

Ans: D Feedback: The nurse's first response should be to place the patient on his side to prevent him from aspirating emesis. Inserting something into the seizing patient's mouth is no longer part of a seizure protocol. Obtaining supplies to suction the patient would be a delegated task. Paging or calling the physician would only be necessary if this is the patient's first seizure.

The wife of a patient you are caring for asks to speak with you. She tells you that she is concerned because her husband is requiring increasingly high doses of analgesia. She states, "He was in pain long before he got cancer because he broke his back about 20 years ago. For that problem, though, his pain medicine wasn't just raised and raised." What would be the nurses' best response? A) "I didn't know that. I will speak to the doctor about your husband's pain control." B) "Much cancer pain is caused by tumor involvement and needs to be treated in a way that brings the patient relief." C) "Cancer is a chronic kind of pain so the more it hurts the patient, the more medicine we give the patient until it no longer hurts." D) "Does the increasing medication dosage concern you?"

Ans: "Much cancer pain is caused by tumor involvement and needs to be treated in a way that brings the patient relief." Feedback: Much pain associated with cancer is a direct result of tumor involvement. Conveying patient/family concerns to the physician is something a nurse does, but is not the best response by the nurse. Cancer pain can be either acute or chronic, and you do not tell a family member that you are going to keep increasing the dosage of the medication until "it doesn't hurt anymore." The family member is obviously concerned.

The nurse is caring for a patient with metastatic bone cancer. The patient asks the nurse why he has had to keep getting larger doses of his pain medication, although they do not seem to affect him. What is the nurse's best response? A) "Over time you become more tolerant of the drug." B) "You may have become immune to the effects of the drug." C) "You may be developing a mild addiction to the drug." D) "Your body absorbs less of the drug due to the cancer."

Ans: "Over time you become more tolerant of the drug." Feedback: Over time, the patient is likely to become more tolerant of the dosage. Little evidence indicates that patients with cancer become addicted to the opioid medications. Patients do not become immune to the effects of the drug, and the body does not absorb less of the drug because of the cancer.

An unlicensed nursing assistant (NA) reports to the nurse that a postsurgical patient is complaining of pain that she rates as 8 on a 0-to-10 point scale. The NA tells the nurse that he thinks the patient is exaggerating and does not need pain medication. What is the nurse's best response? A) "Pain often comes and goes with postsurgical patients. Please ask her about pain again in about 30 minutes." B) "We need to provide pain medications because it is the law, and we must always follow the law." C) "Unless there is strong evidence to the contrary, we should take the patient's report at face value.'" D) "It's not unusual for patients to misreport pain to get our attention when we are busy."

Ans: "Unless there is strong evidence to the contrary, we should take the patient's report at face value.'" Feedback: A broad definition of pain is "whatever the person says it is, existing whenever the experiencing person says it does." Action should be taken unless there are demonstrable extenuating circumstances. The other answers are incorrect.

A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the patient complains of a severe throbbing headache. What should the nurse do first? A) Check the patient's indwelling urinary catheter for kinks to ensure patency. B) Lower the HOB to improve perfusion. C) Administer analgesia. D) Reassure the patient that headaches are expected after spinal cord injuries.

Ans: A Feedback: A severe throbbing headache is a common symptom of autonomic dysreflexia, which occurs after injuries to the spinal cord above T6. The syndrome is usually brought on by sympathetic stimulation, such as bowel and bladder distention. Lowering the HOB can increase ICP. Before administering analgesia, the nurse should check the patient's catheter, record vital signs, and perform an abdominal assessment. A severe throbbing headache is a dangerous symptom in this patient and is not expected.

A patient comes to the ophthalmology clinic for an eye examination. The patient tells the nurse that he often sees floaters in his vision. How should the nurse best interpret this subjective assessment finding? A) This is a normal aging process of the eye. B) Glasses will minimize this phenomenon. C) The patient may be exhibiting signs of glaucoma. D) This may be a result of weakened ciliary muscles.

Ans: A Feedback: As the body ages, the perfect gel-like characteristics of the vitreous humor are gradually lost, and various cells and fibers cast shadows that the patient perceives as floaters. This is a normal aging process.

The nurse is caring for a patient whose recent health history includes an altered LOC. What should be the nurse's first action when assessing this patient? A) Assessing the patient's verbal response B) Assessing the patient's ability to follow complex commands C) Assessing the patient's judgment D) Assessing the patient's response to pain

Ans: A Feedback: Assessment of the patient with an altered LOC often starts with assessing the verbal response through determining the patient's orientation to time, person, and place. In most cases, this assessment will precede each of the other listed assessments, even though each may be indicated.

The school nurse has been called to the football field where player is immobile on the field after landing awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse perform? A) Ensure that the player is not moved. B) Obtain the player's vital signs, if possible. C) Perform a rapid assessment of the player's range of motion. D) Assess the player's reflexes.

Ans: A Feedback: At the scene of the injury, the patient must be immobilized on a spinal (back) board, with the head and neck maintained in a neutral position, to prevent an incomplete injury from becoming complete. This is a priority over determining the patient's vital signs. It would be inappropriate to test ROM or reflexes.

The nurse is caring for a patient whose spinal cord injury has caused recent muscle spasticity. What medication should the nurse expect to be ordered to control this? A) Baclofen (Lioresal) B) Dexamethasone (Decadron) C) Mannitol (Osmitrol) D) Phenobarbital (Luminal)

Ans: A Feedback: Baclofen is classified as an antispasmodic agent in the treatment of muscles spasms related to spinal cord injury. Decadron is an anti-inflammatory medication used to decrease inflammation in both SCI and head injury. Mannitol is used to decrease cerebral edema in patients with head injury. Phenobarbital is an anticonvulsant that is used in the treatment of seizure activity.

A patient who is being treated in the hospital for a spinal cord injury is advocating for the removal of his urinary catheter, stating that he wants to try to resume normal elimination. What principle should guide the care team's decision regarding this intervention? A) Urinary retention can have serious consequences in patients with SCIs. B) Urinary function is permanently lost following an SCI. C) Urinary catheters should not remain in place for more than 7 days. D) Overuse of urinary catheters can exacerbate nerve damage.

Ans: A Feedback: Bladder distention, a major cause of autonomic dysreflexia, can also cause trauma. For this reason, removal of a urinary catheter must be considered with caution. Extended use of urinary catheterization is often necessary following SCI. The effect of a spinal cord lesion on urinary function depends on the level of the injury. Catheter use does not cause nerve damage, although it is a major risk factor for UTIs.

A patient is admitted to the neurologic ICU with a suspected diffuse axonal injury. What would be the primary neuroimaging diagnostic tool used on this patient to evaluate the brain structure? A) MRI B) PET scan C) X-ray D) Ultrasound

Ans: A Feedback: CT and MRI scans, the primary neuroimaging diagnostic tools, are useful in evaluating the brain structure. Ultrasound would not show the brain nor would an x-ray. A PET scan shows brain function, not brain structure.

A patient has developed diabetes insipidus after having increased ICP following head trauma. What nursing assessment best addresses this complication? A) Vigilant monitoring of fluid balance B) Continuous BP monitoring C) Serial arterial blood gases (ABGs) D) Monitoring of the patient's airway for patency

Ans: A Feedback: Diabetes insipidus requires fluid and electrolyte replacement, along with the administration of vasopressin, to replace and slow the urine output. Because of these alterations in fluid balance, careful monitoring is necessary. None of the other listed assessments directly addresses the major manifestations of diabetes insipidus.

A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding? A) Absence of reflexes along with flaccid extremities B) Positive Babinski's reflex along with spastic extremities C) Hyperreflexia along with spastic extremities D) Spasticity of all four extremities

Ans: A Feedback: During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the patient demonstrates a positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities

The nurse has created a plan of care for a patient who is at risk for increased ICP. The patient's 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

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

A nurse is teaching a patient with glaucoma how to administer eye drops to achieve maximum absorption. The nurse should teach the patient to perform what action? A) Instill the medication in the conjunctival sac. B) Maintain a supine position for 10 minutes after administration. C) Keep the eyes closed for 1 to 2 minutes after administration. D) Apply the medication evenly to the sclera

Ans: A Feedback: Eye drops should be instilled into the conjunctival sac, where absorption can best take place, rather than distributed over the sclera. It is unnecessary to keep the eyes closed or to maintain a supine position after administration.

The nurse is admitting a 55-year-old male patient diagnosed with a retinal detachment in his left eye. While assessing this patient, what characteristic symptom would the nurse expect to find? A) Flashing lights in the visual field B) Sudden eye pain C) Loss of color vision D) Colored halos around lights

Ans: A Feedback: Flashing lights in the visual field is a common symptom of retinal detachment. Patients may also report spots or floaters or the sensation of a curtain being pulled across the eye. Retinal detachment is not associated with eye pain, loss of color vision, or colored halos around lights.

The nurse is planning the care of a patient with a T1 spinal cord injury. The nurse has identified the diagnosis of "risk for impaired skin integrity." How can the nurse best address this risk? A) Change the patient's position frequently. B) Provide a high-protein diet. C) Provide light massage at least daily. D) Teach the patient deep breathing and coughing exercises.

Ans: A Feedback: Frequent position changes are among the best preventative measures against pressure ulcers. A high-protein diet can benefit wound healing, but does not necessarily prevent skin breakdown. Light massage and deep breathing do not protect or restore skin integrity.

The nurse is caring for a patient who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the patient's respiratory effort has increased. What is the nurse's most appropriate response? A) Inform the care team and assess for further signs of possible increased ICP. B) Administer bronchodilators as ordered and monitor the patient's LOC. C) Increase the patient's bed height and reassess in 30 minutes. D) Administer a bolus of normal saline as ordered.

Ans: A Feedback: Increased respiratory effort can be suggestive of increasing ICP, and the care team should be promptly informed. A bolus of IV fluid will not address the problem. Repositioning the patient and administering bronchodilators are insufficient responses, even though these actions may later be ordered.

A patient with glaucoma has presented for a scheduled clinic visit and tells the nurse that she has begun taking an herbal remedy for her condition that was recommended by a work colleague. What instruction should the nurse provide to the patient? A) The patient should discuss this new remedy with her ophthalmologist promptly. B) The patient should monitor her IOP closely for the next several weeks. C) The patient should do further research on the herbal remedy. D) The patient should report any adverse effects to her pharmacist.

Ans: A Feedback: Patients should discuss any new treatments with an ophthalmologist; this should precede the patient's own further research or reporting adverse effects to the pharmacist. Self-monitoring of IOP is not possible.

The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the patient may be experiencing increased brain compression causing brain stem damage? A) Hyperthermia B) Tachycardia C) Hypertension D) Bradypnea

Ans: A Feedback: Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic BP, and widening pulse pressure. As brain compression increases, respirations become rapid, BP may decrease, and the pulse slows further. A rapid rise in body temperature is regarded as unfavorable. Hyperthermia increases the metabolic demands of the brain and may indicate brain stem damage.

A patient is postoperative day 1 following intracranial surgery. The nurse's assessment reveals that the patient's LOC is slightly decreased compared with the day of surgery. What is the nurse's 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.

Ans: A Feedback: 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 necessarily any need to deem the surgery unsuccessful or to refer the patient to palliative care. A decrease in LOC is not evidence of an intracranial hemorrhage.

A patient has had a sudden loss of vision after head trauma. How should the nurse best describe the placement of items on the dinner tray? A) Explain the location of items using clock cues. B) Explain that each of the items on the tray is clearly separated. C) Describe the location of items from the bottom of the plate to the top. D) Ask the patient to describe the location of items before confirming their location.

Ans: A Feedback: The food tray's composition is likened to the face of a clock. It is unreasonable to expect the patient to describe the location of items or to state that items are separated.

The nurse should recognize the greatest risk for the development of blindness in which of the following patients? A) A 58-year-old Caucasian woman with macular degeneration B) A 28-year-old Caucasian man with astigmatism C) A 58-year-old African American woman with hyperopia D) A 28-year-old African American man with myopia

Ans: A Feedback: The most common causes of blindness and visual impairment among adults 40 years of age or older are diabetic retinopathy, macular degeneration, glaucoma, and cataracts. The 58-year-old Caucasian woman with macular degeneration has the greatest risk for the development of blindness related to her age and the presence of macular degeneration. Individuals with hyperopia, astigmatism, and myopia are not in a risk category for blindness.

When caring for a patient with increased ICP the nurse knows the importance of monitoring for possible secondary 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

Ans: A Feedback: 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 are unnecessary.

17. A 6-year-old child is brought to the pediatric clinic for the assessment of redness and discharge from the eye and is diagnosed with viral conjunctivitis. What is the most important information to discuss with the parents and child? A) Handwashing can prevent the spread of the disease to others. B) The importance of compliance with antibiotic therapy C) Signs and symptoms of complications, such as meningitis and septicemia D) The likely need for surgery to prevent scarring of the conjunctiva

Ans: A Feedback: The nurse must inform the parents and child that viral conjunctivitis is highly contagious and instructions should emphasize the importance of handwashing and avoiding sharing towels, face cloths, and eye drops. Viral conjunctivitis is not responsive to any treatment, including antibiotic therapy. Patients with gonococcal conjunctivitis are at risk for meningitis and generalized septicemia; these conditions do not apply to viral conjunctivitis. Surgery to prevent scarring of the conjunctiva is not associated with viral conjunctivitis.

The nurse has taken shift report on her patients and has been told that one patient has an ocular condition that has primarily affected the rods in his eyes. Considering this information, what should the nurse do while caring for the patient? A) Ensure adequate lighting in the patient's room. B) Provide a dimly lit room to aid vision by limiting contrast. C) Carefully point out color differences for the patient. D) Carefully point out fine details for the patient.

Ans: A Feedback: The nurse should provide adequate lighting in the patient's room, as the rods are mainly responsible for night vision or vision in low light. If the patient's rods are impaired, the patient will have difficulty seeing in dim light. The cones in the eyes provide best vision for bright light, color vision, and fine detail.

The nurse is caring for a patient with permanent neurologic impairments resulting from a traumatic head injury. When working with this patient and family, what mutual goal should be prioritized? A) Achieve as high a level of function as possible. B) Enhance the quantity of the patient's life. C) Teach the family proper care of the patient. D) Provide community assistance.

Ans: A Feedback: The overarching goals of care are to achieve as high a level of function as possible and to enhance the quality of life for the patient with neurologic impairment and his or her family. This goal encompasses family and community participation.

A patient is recovering from intracranial surgery performed approximately 24 hours ago and is complaining of a headache that the patient rates at 8 on a 10-point pain scale. What nursing action is most appropriate? A) Administer morphine sulfate as ordered. B) Reposition the patient in a prone position. C) Apply a hot pack to the patient's scalp. D) Implement distraction techniques.

Ans: A Feedback: The patient usually has a headache after a craniotomy as a result of stretching and irritation of nerves in the scalp during surgery. Morphine sulfate may also be used in the management of postoperative pain in patients who have undergone a craniotomy. Prone positioning is contraindicated due to the consequent increase in ICP. Distraction would likely be inadequate to reduce pain and a hot pack may cause vasodilation and increased pain.

The nurse is providing health education to a patient who has a C6 spinal cord injury. The patient asks why autonomic dysreflexia is considered an emergency. What would be the nurse's best answer? A) "The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel." B) "The suddenness of the onset of the syndrome tells us the body is struggling to maintain its normal state." C) "Autonomic dysreflexia causes permanent damage to delicate nerve fibers that are healing." D) "The sudden, severe headache increases muscle tone and can cause further nerve damage."

Ans: A Feedback: The sudden increase in BP may cause a rupture of one or more cerebral blood vessels or lead to increased ICP. Autonomic dysreflexia does not directly cause nerve damage.

A patient's ocular tumor has necessitated enucleation and the patient will be fitted with a prosthesis. The nurse should address what nursing diagnosis when planning the patient's discharge education? A) Disturbed body image B) Chronic pain C) Ineffective protection D) Unilateral neglect

Ans: A Feedback: The use of an ocular prosthesis is likely to have a significant impact on a patient's body image. Prostheses are not associated with chronic pain or ineffective protection. The patient experiences a change in vision, but is usually able to accommodate such changes and prevent unilateral neglect

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

Ans: A Feedback: 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.

An 82-year-old man is admitted for observation after a fall. Due to his age, the nurse knows that the patient is at increased risk for what complication of his injury? A) Hematoma B) Skull fracture C) Embolus D) Stroke

Ans: A Feedback: Two major factors place older adults at increased risk for hematomas. First, the dura becomes more adherent to the skull with increasing age. Second, many older adults take aspirin and anticoagulants as part of routine management of chronic conditions. Because of these factors, the patient's risk of a hematoma is likely greater than that of stroke, embolism, or skull fracture.

A nurse on an oncology unit has arranged for an individual to lead meditation exercises for patients who are interested in this nonpharmacological method of pain control. The nurse should recognize the use of what category of nonpharmacological intervention? A) A body-based modality B) A mind-body method C) A biologically based therapy D) An energy therapy

Ans: A mind-body method Feedback: Meditation is one of the recognized mind-body methods of nonpharmacological pain control. The other answers are incorrect.

A patient with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this patient? Select all that apply. A) Orthostatic hypotension B) Autonomic dysreflexia C) DVT D) Salt-wasting syndrome E) Increased ICP

Ans: A, B, C Feedback: For a spinal cord-injured patient, based on the assessment data, potential complications that may develop include DVT, orthostatic hypotension, and autonomic dysreflexia. Salt-wasting syndrome or increased ICP are not typical complications following the immediate recovery period.

The nurse is admitting a patient to the unit who is scheduled for removal of an intracranial mass. What diagnostic procedures might be included in this patient's admission orders? Select all that apply. A) Transcranial Doppler flow study B) Cerebral angiography C) MRI D) Cranial radiography E) Electromyelography (EMG)

Ans: A, B, C Feedback: Preoperative diagnostic procedures may include a CT scan to demonstrate the lesion and show the degree of surrounding brain edema, the ventricular size, and the displacement. An MRI scan provides information similar to that of a CT scan with improved tissue contrast, resolution, and anatomic definition. Cerebral angiography may be used to study a tumor's blood supply or to obtain information about vascular lesions. Transcranial Doppler flow studies are used to evaluate the blood flow within intracranial blood vessels. Regular x-rays of the skull would not be diagnostic for an intracranial mass. An EMG would not be ordered prior to intracranial surgery to remove a mass.

An adult patient has sought care for the treatment of headaches that have become increasingly severe and frequent over the past several months. Which of the following questions addresses potential etiological factors? Select all that apply? A) "Are you exposed to any toxins or chemicals at work?" B) "How would you describe your ability to cope with stress?" C) "What medications are you currently taking?" D) "When was the last time you were hospitalized?" E) "Does anyone else in your family struggle with headaches?"

Ans: A, B, C, E Feedback: Headaches are multifactorial, and may involve medications, exposure to toxins, family history, and stress. Hospitalization is an unlikely contributor to headaches.

A public health nurse is teaching a health promotion workshop that focuses on vision and eye health. What should this nurse cite as the most common causes of blindness and visual impairment among adults over the age of 40? Select all that apply. A) Diabetic retinopathy B) Trauma C) Macular degeneration D) Cytomegalovirus E) Glaucoma

Ans: A, C, E Feedback: The most common causes of blindness and visual impairment among adults 40 years of age or older are diabetic retinopathy, macular degeneration, glaucoma, and cataracts. Therefore, trauma and cytomegalovirus are incorrect.

The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should the nurse identify as prominent risk factors for SCI? Select all that apply. A) Young age B) Frequent travel C) African American race D) Male gender E) Alcohol or drug use

Ans: A, D, E Feedback: The predominant risk factors for SCI include young age, male gender, and alcohol and drug use. Ethnicity and travel are not risk factors.

You are the emergency department (ED) nurse caring for an adult patient who was in a motor vehicle accident. Radiography reveals an ulnar fracture. What type of pain are you addressing when you provide care for this patient? A) Chronic B) Acute C) Intermittent D) Osteopenic

Ans: Acute Feedback: Acute pain is usually of recent onset and commonly associated with a specific injury. Acute pain indicates that damage or injury has occurred. Chronic pain is constant or intermittent pain that persists beyond the expected healing time and that can seldom be attributed to a specific cause or injury. Phantom pain occurs when the body experiences a loss, such as an amputation, and still feels pain in the missing part. "Osteopenic" pain is not a recognized category of pain.

Your patient is receiving postoperative morphine through a patient-controlled analgesic (PCA) pump and the patient's orders specify an initial bolus dose. What is your priority assessment? A) Assessment for decreased level of consciousness (LOC) B) Assessment for respiratory depression C) Assessment for fluid overload D) Assessment for paradoxical increase in pain

Ans: Assessment for respiratory depression Feedback: A patient who receives opioids by any route must be assessed frequently for changes in respiratory status. Sedation is an expected effect of a narcotic analgesic, though severely decreased LOC is problematic. Fluid overload and paradoxical increase in pain are unlikely, though opioid-induced hyperalgesia (OIH) occurs in rare instances.

The nurse is doing an initial assessment on a patient newly admitted to the unit with a diagnosis of cerebrovascular accident (CVA). The patient has difficulty copying a figure that the nurse has drawn and is diagnosed with visual-receptive aphasia. What brain region is primarily involved in this deficit? A) Temporal lobe B) Parietal-occipital area C) Inferior posterior frontal areas D) Posterior frontal area

Ans: B Difficulty copying a figure that the nurse has drawn would be considered visual-receptive aphasia, which involves the parietal-occipital area. Expressive aphasia, the inability to express oneself, is often associated with damage to the frontal area. Receptive aphasia, the inability to understand what someone else is saying, is often associated with damage to the temporal lobe area.

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 patient's 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

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

A clinic nurse is caring for a patient diagnosed with migraine headaches. During the patient teaching session, the patient questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the patient about the effects of alcohol? A) Alcohol causes hormone fluctuations. B) Alcohol causes vasodilation of the blood vessels. C) Alcohol has an excitatory effect on the CNS. D) Alcohol diminishes endorphins in the brain.

Ans: B Feedback: Alcohol causes vasodilation of the blood vessels and may exacerbate migraine headaches. Alcohol has a depressant effect on the CNS. Alcohol does not cause hormone fluctuations, nor does it decrease endorphins (morphine-like substances produced by the body) in the brain.

A hospitalized patient with impaired vision must get a picture in his or her mind of the hospital room and its contents in order to mobilize independently and safely. What must the nurse monitor in the patient's room? A) That a commode is always available at the bedside B) That all furniture remains in the same position C) That visitors do not leave items on the bedside table D) That the patient's slippers stay under the bed

Ans: B Feedback: All articles and furniture must remain in the same positions throughout the patient's hospitalization. This will reduce the patient's risks for falls. Visual impairment does not necessarily indicate a need for a commode. Keeping slippers under the bed and keeping the bedside table clear are also appropriate, but preventing falls by maintaining the room arrangement is a priority.

An elderly woman found with a head injury on the floor of her home is subsequently admitted to the neurologic ICU. What is the best rationale for the following physician orders: elevate the HOB; keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion? A) To decrease cerebral arterial pressure B) To avoid impeding venous outflow C) To prevent flexion contractures D) To prevent aspiration of stomach contents

Ans: B Feedback: Any activity or position that impedes venous outflow from the head may contribute to increased volume inside the skull and possibly increase ICP. Cerebral arterial pressure will be affected by the balance between oxygen and carbon dioxide. Flexion contractures are not a priority at this time. Stomach contents could still be aspirated in this position.

A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient? A) Respiratory distress and projectile vomiting B) Bradycardia and hypertension C) Tachycardia and agitation D) Third-spacing and hyperthermia

Ans: B Feedback: Autonomic dysreflexia is characterized by a pounding headache, profuse sweating, nasal congestion, piloerection ("goose bumps"), bradycardia, and hypertension. It occurs in cord lesions above T6 after spinal shock has resolved; it does not result in vomiting, tachycardia

A patient presents at the ED after receiving a chemical burn to the eye. What would be the nurse's initial intervention for this patient? A) Generously flush the affected eye with a dilute antibiotic solution. B) Generously flush the affected eye with normal saline or water. C) Apply a patch to the affected eye. D) Apply direct pressure to the affected eye.

Ans: B Feedback: Chemical burns of the eye should be immediately irrigated with water or normal saline to flush the chemical from the eye. Antibiotic solutions, lubricant drops, and other prescription drops may be prescribed at a later time. Application of direct pressure may extend the damage to the eye tissue and should be avoided. Patching will be incorporated into the treatment plan at a later time to assist with the process of re-epithelialization, but at this point in the care of the patient, patching will prevent irrigation of the eye.

The nurse on the medicalsurgical unit is reviewing discharge instructions with a patient who has a history of glaucoma. The nurse should anticipate the use of what medications? A) Potassium-sparing diuretics B) Cholinergics C) Antibiotics D) Loop diuretics

Ans: B Feedback: Cholinergics are used in the treatment of glaucoma. The action of this medication is to increase aqueous fluid outflow by contracting the ciliary muscle and causing miosis and opening the trabecular meshwork. Diuretics and antibiotics are not used in the management of glaucoma.

A patient has just returned to the surgical floor after undergoing a retinal detachment repair. The postoperative orders specify that the patient should be kept in a prone position until otherwise ordered. What should the nurse do? A) Call the physician and ask for the order to be confirmed. B) Follow the order because this position will help keep the retinal repair intact. C) Instruct the patient to maintain this position to prevent bleeding. D) Reposition the patient after the first dressing change.

Ans: B Feedback: For pneumatic retinopexy, postoperative positioning of the patient is critical because the injected bubble must float into a position overlying the area of detachment, providing consistent pressure to reattach the sensory retina. The patient must maintain a prone position that would allow the gas bubble to act as a tamponade for the retinal break. Patients and family members should be made aware of these special needs beforehand so that the patient can be made as comfortable as possible. It would be inappropriate to deviate from this order and there is no obvious need to confirm the order.

The nurse is providing health education to a patient newly diagnosed with glaucoma. The nurse teaches the patient that this disease has a familial tendency. The nurse should encourage the patient's immediate family members to undergo clinical examinations how often? A) At least monthly B) At least once every 2 years C) At least once every 5 years D) At least once every 10 years

Ans: B Feedback: Glaucoma has a family tendency and family members should be encouraged to undergo examinations at least once every 2 years to detect glaucoma early. Testing on a monthly basis is not necessary and excessive.

A patient has been diagnosed with glaucoma and the nurse is preparing health education regarding the patient's medication regimen. The patient states that she is eager to beat this disease and looks forward to the time that she will no longer require medication. How should the nurse best respond? A) You have a great attitude. This will likely shorten the amount of time that you need medications. B) In fact, glaucoma usually requires lifelong treatment with medications. C) Most people are treated until their intraocular pressure goes below 50 mm Hg. D) You can likely expect a minimum of 6 months of treatment.

Ans: B Feedback: Glaucoma requires lifelong pharmacologic treatment. Normal intraocular pressure is between 10 and 21 mm Hg.

A patient is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 1½ hours ago. Endotracheal intubation has been deemed necessary and the nurse is preparing to assist. What nursing diagnosis should the nurse associate with this procedure? A) Risk for impaired skin integrity B) Risk for injury C) Risk for autonomic dysreflexia D) Risk for suffocation

Ans: B Feedback: If endotracheal intubation is necessary, extreme care is taken to avoid flexing or extending the patient's neck, which can result in extension of a cervical injury. Intubation does not directly cause autonomic dysreflexia and the threat to skin integrity is a not a primary concern. Intubation does not carry the potential to cause suffocation.

Following a spinal cord injury a patient is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action? A) Complete the pin site care to decrease risk of infection. B) Notify the neurosurgeon of the occurrence. C) Stabilize the head in a lateral position. D) Reattach the pin to prevent further head trauma.

Ans: B Feedback: If one of the pins became detached, the head is stabilized in neutral position by one person while another notifies the neurosurgeon. Reattaching the pin as a nursing intervention would not be done due to risk of increased injury. Pin site care would not be a priority in this instance. Prevention of neurologic injury is the priority.

The nurse's assessment of a patient with significant visual losses reveals that the patient cannot count fingers. How should the nurse proceed with assessment of the patient's visual acuity? A) Assess the patient's vision using a Snellen chart. B) Determine whether the patient is able to see the nurse's hand motion. C) Perform a detailed examination of the patient's external eye structures. D) Palpate the patient's periocular regions.

Ans: B Feedback: If the patient cannot count fingers, the examiner raises one hand up and down or moves it side to side and asks in which direction the hand is moving. An inability to count fingers precludes the use of a Snellen chart. Palpation and examination cannot ascertain visual acuity.

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

Ans: B Feedback: In the postictal state (after the seizure), the patient is often confused and hard to arouse and may sleep for hours. The epileptic cry occurs from the simultaneous contractions of the diaphragm and chest muscles that occur during the seizure. Urinary incontinence and intense rigidity of the entire body are followed by alternating muscle relaxation and contraction (generalized tonic-clonic contraction) during the seizure.

A patient with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased the risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring? A) Placing the patient on a fluid restriction as ordered B) Applying thigh-high elastic stockings C) Administering an antifibrinolyic agent D) Assisting the patient with passive range of motion (PROM) exercises

Ans: B Feedback: It is important to promote venous return to the heart and prevent venous stasis in a patient with altered mobility. Applying elastic stockings will aid in the prevention of a DVT. The patient should not be placed on fluid restriction because a dehydrated state will increase the risk of clotting throughout the body. Antifibrinolytic agents cause the blood to clot, which is absolutely contraindicated in this situation. PROM exercises are not an effective protection against the development of DVT.

A patient exhibiting an altered level of consciousness (LOC) due to blunt-force trauma to the head is admitted to the ED. The physician determines the patient's injury is causing increased intracranial pressure (ICP). The nurse should gauge the patient's LOC on the results of what diagnostic tool? A) Monro-Kellie hypothesis B) Glasgow Coma Scale C) Cranial nerve function D) Mental status examination

Ans: B Feedback: LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response. The Monro-Kellie hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the components (blood, brain tissue, cerebrospinal fluid) causes a change in the volume of the others. Cranial nerve function and the mental status examination would be part of the neurologic examination for this patient, but would not be the priority in evaluating LOC.

The nurse is providing care for a patient who is unconscious. What nursing intervention takes highest priority? A) Maintaining accurate records of intake and output B) Maintaining a patent airway C) Inserting a nasogastric (NG) tube as ordered D) Providing appropriate pain control

Ans: B Feedback: Maintaining a patent airway always takes top priority, even though each of the other listed actions is necessary and appropriate.

During discharge teaching the nurse realizes that the patient is not able to read medication bottles accurately and has not been taking her medications consistently at home. How should the nurse intervene most appropriately in this situation? A) Ask the social worker to investigate alternative housing arrangements. B) Ask the social worker to investigate community support agencies. C) Encourage the patient to explore surgical corrections for the vision problem. D) Arrange for referral to a rehabilitation facility for vision training.

Ans: B Feedback: Managing low vision involves magnification and image enhancement through the use of low-vision aids and strategies and referrals to social services and community agencies serving those with visual impairment. Community agencies offer services to patients with low vision, which include training in independent living skills and a variety of assistive devices for vision enhancement, orientation, and mobility, preventing patients from needing to enter a nursing facility. A rehabilitation facility is generally not needed by the patients to learn to use the assistive devices or to gain a greater degree of independence. Surgical options may or may not be available to the patient.

The staff educator is precepting a nurse new to the critical care unit when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the patient closely, what would be the nurse's most appropriate action? A) Prepare to transfuse packed red blood cells. B) Prepare for interventions to increase the patient's BP. C) Place the patient in the Trendelenberg position. D) Prepare an ice bath to lower core body temperature.

Ans: B Feedback: Manifestations of neurogenic shock include decreased BP and heart rate. Cardiac markers would be expected to rise in cardiogenic shock. Transfusion, repositioning, and ice baths are not indicated interventions.

The nurse is caring for a patient who is in status epilepticus. What medication does the nurse know may be given to halt the seizure immediately? A) Intravenous phenobarbital (Luminal) B) Intravenous diazepam (Valium) C) Oral lorazepam (Ativan) D) Oral phenytoin (Dilantin)

Ans: B Feedback: Medical management of status epilepticus includes IV diazepam (Valium) and IV lorazepam (Ativan) given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state. Oral medications are not given during status epilepticus.

A neurologic flow chart is often used to document the care of a patient with a traumatic brain injury. At what point in the patient's care should the nurse begin to use a neurologic flow chart? A) When the patient's condition begins to deteriorate B) As soon as the initial assessment is made C) At the beginning of each shift D) When there is a clinically significant change in the patient's condition

Ans: B Feedback: Neurologic parameters are assessed initially and as frequently as the patient's condition requires. As soon as the initial assessment is made, the use of a neurologic flowchart is started and maintained. A new chart is not begun at the start of every shift.

A patient who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing care should include which of the following? A) Preparation for emergency craniotomy B) Watchful waiting and close monitoring C) Administration of inotropic drugs D) Fluid resuscitation

Ans: B Feedback: Nondepressed skull fractures generally do not require surgical treatment; however, close observation of the patient is essential. A craniotomy would not likely be needed if the fracture is nondepressed. Even if treatment is warranted, it is unlikely to include inotropes or fluid resuscitation.

A school nurse is called to the playground where a 6-year-old girl has been found unresponsive and "staring into space," according to the playground supervisor. How would the nurse document the girl's activity in her chart at school? A) Generalized seizure B) Absence seizure C) Focal seizure D) Unclassified seizure

Ans: B Feedback: Staring episodes characterize an absence seizure, whereas focal seizures, generalized seizures, and unclassified seizures involve uncontrolled motor activity.

A patient who presents for an eye examination is diagnosed as having a visual acuity of 20/40. The patient asks the nurse what these numbers specifically mean. What is a correct response by the nurse? A) A person whose vision is 20/40 can see an object from 40 feet away that a person with 20/20 vision can see from 20 feet away. B) A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision can see from 40 feet away. C) A person whose vision is 20/40 can see an object from 40 inches away that a person with 20/20 vision can see from 20 inches away. D) A person whose vision is 20/40 can see an object from 20 inches away that a person with 20/20 vision can see from 40 inches away.

Ans: B Feedback: The Snellen chart is a tool used to measure visual acuity. It is composed of a series of progressively smaller rows of letters and is used to test distance vision. The fraction 20/20 is considered the standard of normal vision. Most people can see the letters on the line designated as 20/20 from a distance of 20 feet. A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision can see from 40 feet away.

A patient has lost most of her vision as a result of macular degeneration. When attempting to meet this patient's psychosocial needs, what nursing action is most appropriate? A) Encourage the patient to focus on her use of her other senses. B) Assess and promote the patient's coping skills during interactions with the patient. C) Emphasize that her lifestyle will be unchanged once she adapts to her vision loss. D) Promote the patient's hope for recovery.

Ans: B Feedback: The nurse should empathically promote the patient's coping with her loss. Focusing on the remaining senses could easily be interpreted as downplaying the patient's loss, and recovery is not normally a realistic possibility. Even with successful adaptation, the patient's lifestyle will be profoundly affected.

The nurse is providing discharge education to an adult patient who will begin a regimen of ocular medications for the treatment of glaucoma. How can the nurse best determine if the patient is able to self-administer these medications safely and effectively? A) Assess the patient for any previous inability to self-manage medications. B) Ask the patient to demonstrate the instillation of her medications. C) Determine whether the patient can accurately describe the appropriate method of administering her medications. D) Assess the patient's functional status.

Ans: B Feedback: The patient or the caregiver at home should be asked to demonstrate actual eye drop administration. This method of assessment is more accurate than asking the patient to describe the process or determining earlier inabilities to self-administer medications. The patient's functional status will not necessarily determine the ability to administer medication safely.

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.

Ans: B Feedback: 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.

The nurse is caring for a patient who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of "deficient fluid volume related to fluid restriction and osmotic diuretic use." What would be an appropriate intervention for this diagnosis? A) Change the patient's position as indicated. B) Monitor serum electrolytes. C) Maintain NPO status. D) Monitor arterial blood gas (ABG) values.

Ans: B Feedback: The postoperative fluid regimen depends on the type of neurosurgical procedure and is determined on an individual basis. The volume and composition of fluids are adjusted based on daily serum electrolyte values, along with fluid intake and output. Fluids may have to be restricted in patients with cerebral edema. Changing the patient's position, maintaining an NPO status, and monitoring ABG values do not relate to the nursing diagnosis of deficient fluid volume.

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

Ans: B Patient preparation for an MRI consists of removing all metal-containing objects prior to the examination. 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 line for administration of contrast would be done if the patient was having a CT scan with contrast.

A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, age-related changes. Of what phenomenon should the nurse be aware? A) Hyperactive deep tendon reflexes B) Reduction in cerebral blood flow C) Increased cerebral metabolism D) Hypersensitivity to painful stimuli

Ans: B Reduction in cerebral blood flow (CBF) is a change that occurs in the normal aging process. Deep tendon reflexes can be decreased or, in some cases, absent. Cerebral metabolism decreases as the patient advances in age. Reaction to painful stimuli may be decreased with age. Because pain is an important warning signal, caution must be used when hot or cold packs are used.

A patient is brought to the ER following a motor vehicle accident in which he sustained head trauma. Preliminary assessment reveals a vision deficit in the patient's left eye. The nurse should associate this abnormal finding with trauma to which of the following cerebral lobes? A)Temporal B)Occipital C)Parietal D)Frontal

Ans: B The posterior lobe of the cerebral hemisphere is responsible for visual interpretation. The temporal lobe contains the auditory receptive areas. The parietal lobe contains the primary sensory cortex, and is essential to an individual's awareness of the body in space, as well as orientation in space and spatial relations. The frontal lobe functions in concentration, abstract thought, information storage or memory, and motor function.

The nurse is caring for a patient who is rapidly progressing toward brain death. The nurse should be aware of what cardinal signs of brain death? Select all that apply. A) Absence of pain response B) Apnea C) Coma D) Absence of brain stem reflexes E) Absence of deep tendon reflexes

Ans: B, C, D Feedback: The three cardinal signs of brain death upon clinical examination are coma, the absence of brain stem reflexes, and apnea. Absences of pain response and deep tendon reflexes are not necessarily indicative of brain death.

You are assessing an 86-year-old postoperative patient who has an unexpressive, stoic demeanor. When you enter the room, the patient is curled into the fetal position and your assessment reveals that his vital signs are elevated and he is diaphoretic. You ask the patient what his pain level is on a 0-to-10 scale that you explained to the patient prior to surgery. The patient indicates a pain level of "three or so." You review your pain-management orders and find that all medications are ordered PRN. How would you treat this patient's pain? A) Treat the patient on the basis of objective signs of pain and reassess him frequently. B) Call the physician for new orders because it is apparent that the pain medicine is not working. C) Believe what the patient says, reinforce education, and reassess often. D) Ask the family what they think and treat the patient accordingly.

Ans: Believe what the patient says, reinforce education, and reassess often. Feedback: As always, the best guide to pain management and administration of analgesic agents in all patients, regardless of age, is what the individual patient says. However, further education and assessment are appropriate. You cannot usually treat pain the patient denies having if the orders are PRN only. The scenario does not indicate the present pain-management orders are not working for this patient. The family's insights do not override the patient's self-report.

A patient has informed the home health nurse that she has recently noticed distortions when she looks at the Amsler grid that she has mounted on her refrigerator. What is the nurse's most appropriate action? A) Reassure the patient that this is an age-related change in vision. B) Arrange for the patient to have her visual acuity assessed. C) Arrange for the patient to be assessed for macular degeneration. D) Facilitate tonometry testing.

Ans: C Feedback: 18, The Amsler grid is a test often used for patients with macular problems, such as macular degeneration. Distortions would not be attributed to age-related changes and there is no direct need for testing of intraocular pressure or visual acuity.

A patient is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this patient, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this patient? A) Risk for impaired skin integrity related to immobility and sensory loss B) Impaired physical mobility related to loss of motor function C) Ineffective breathing patterns related to weakness of the intercostal muscles D) Urinary retention related to inability to void spontaneously

Ans: C Feedback: A nursing diagnosis related to breathing pattern would be the priority for this patient. A C4 spinal cord injury will require ventilatory support, due to the diaphragm and intercostals being affected. The other nursing diagnoses would be used in the care plan, but not designated as a higher priority than ineffective breathing patterns.

When administering a patient's eye drops, the nurse recognizes the need to prevent absorption by the nasolacrimal duct. How can the nurse best achieve this goal? A) Ensure that the patient is well hydrated at all times. B) Encourage self-administration of eye drops. C) Occlude the puncta after applying the medication. D) Position the patient supine before administering eye drops.

Ans: C Feedback: Absorption of eye drops by the nasolacrimal duct is undesirable because of the potential systemic side effects of ocular medications. To diminish systemic absorption and minimize the side effects, it is important to occlude the puncta. Self-administration, supine positioning, and adequate hydration do not prevent this adverse effect.

The ED nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture? A) Epistaxis B) Periorbital edema C) Bruising over the mastoid D) Unilateral facial numbness

Ans: C Feedback: An area of ecchymosis (bruising) may be seen over the mastoid (Battle's sign) in a basilar skull fracture. Numbness, edema, and epistaxis are not directly associated with a basilar skull fracture.

A patient is brought to the ED by her family after falling off the roof. A family member tells the nurse that when the patient fell she was "knocked out," but came to and "seemed okay." Now she is complaining of a severe headache and not feeling well. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention? A) Insertion of an intracranial monitoring device B) Treatment with antihypertensives C) Emergency craniotomy D) Administration of anticoagulant therapy

Ans: C Feedback: An epidural hematoma is considered an extreme emergency. Marked neurologic deficit or respiratory arrest can occur within minutes. Treatment consists of making an opening through the skull to decrease ICP emergently, remove the clot, and control the bleeding. Antihypertensive medications would not be a priority. Anticoagulant therapy should not be ordered for a patient who has a cranial bleed. This could further increase bleeding activity. Insertion of an intracranial monitoring device may be done during the surgery, but is not priority for this patient.

A 56-year-old patient has come to the clinic for his routine eye examination and is told he needs bifocals. The patient asks the nurse what change in his eyes has caused his need for bifocals. How should the nurse respond? A) You know, you are getting older now and we change as we get older. B) The parts of our eyes age, just like the rest of us, and this is nothing to cause you to worry. C) There is a gradual thickening of the lens of the eye and it can limit the eye's ability for accommodation. D) The eye gets shorter, back to front, as we age and it changes how we see things.

Ans: C Feedback: As a result of a loss of accommodative power in the lens with age, many adults require bifocals or other forms of visual correction. This is not attributable to a change in the shape of the ocular globe. The nurse should not dismiss or downplay the patient's concerns.

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

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

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

Ans: C Feedback: Complications of a ventriculostomy include ventricular infectious meningitis and problems with the monitoring system. Nuchal rigidity and photophobia are clinical manifestations of meningitis, but are not 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

Ans: C Feedback: Generalized seizures often involve both hemispheres of the brain, causing both sides of the body to react. Intense rigidity of the entire body may occur, followed by alternating muscle relaxation and contraction (generalized tonic-clonic contraction). This pattern of rigidity does not occur in patients who experience 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 patient's 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

Ans: C Feedback: 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 with a brain tumor. What drug would the nurse expect to be ordered to reduce the edema surrounding the tumor? A) Solumedrol B) Dextromethorphan C) Dexamethasone D) Furosemide

Ans: C Feedback: If a brain tumor is the cause of the increased ICP, corticosteroids (e.g., dexamethasone) help reduce the edema surrounding the tumor. Solumedrol, a steroid, and furosemide, a loop diuretic, are not the drugs of choice in this instance. Dextromethorphan is used in cough medicines.

Paramedics have brought an intubated patient to the RD following a head injury due to acceleration-deceleration motor vehicle accident. Increased ICP is suspected. Appropriate nursing interventions would include which of the following? A) Keep the head of the bed (HOB) flat at all times. B) Teach the patient to perform the Valsalva maneuver. C) Administer benzodiazepines on a PRN basis. D) Perform endotracheal suctioning every hour.

Ans: C Feedback: If the patient with a brain injury is very agitated, benzodiazepines are the most commonly used sedatives and do not affect cerebral blood flow or ICP. The HOB should be elevated 30 degrees. Suctioning should be done a limited basis, due to increasing the pressure in the cranium. The Valsalva maneuver is to be avoided. This also causes increased ICP.

A patient is admitted to the neurologic ICU with a spinal cord injury. When assessing the patient the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect? A) Epidural hemorrhage B) Hypertensive emergency C) Spinal shock D) Hypovolemia

Ans: C Feedback: In spinal shock, the reflexes are absent, BP and heart rate fall, and respiratory failure can occur. Hypovolemia, hemorrhage, and hypertension do not cause this sudden change in neurologic function.

The nurse recognizes that a patient with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI? A) Position the patient in a high Fowler's position when in bed. B) Support the knees with a pillow when the patient is in bed. C) Perform passive ROM exercises as ordered. D) Administer NSAIDs as ordered.

Ans: C Feedback: Passive ROM exercises can prevent muscle spasticity following SCI. NSAIDs are not used for this purpose. Pillows and sitting upright do not directly address the patient's risk of muscle spasticity.

A patient is admitted to the neurologic ICU with a spinal cord injury. In writing the patient's care plan, the nurse specifies that contractures can best be prevented by what action? A) Repositioning the patient every 2 hours B) Initiating range-of-motion exercises (ROM) as soon as the patient initiates C) Initiating (ROM) exercises as soon as possible after the injury D) Performing ROM exercises once a day

Ans: C Feedback: Passive ROM exercises should be implemented as soon as possible after injury. It would be inappropriate to wait for the patient to first initiate exercises. Toes, metatarsals, ankles, knees, and hips should be put through a full ROM at least four, and ideally five, times daily. Repositioning alone will not prevent contractures.

The nurse is teaching a patient to care for her new ocular prosthesis. What should the nurse emphasize during the patient's health education? A) The need to limit exposure to bright light B) The need to maintain a low Fowler's position when removing the prosthesis C) The need to perform thorough hand hygiene before handling the prosthesis D) The need to apply antiviral ointment to the prosthesis daily

Ans: C Feedback: Proper hand hygiene must be observed before inserting and removing an ocular prosthesis. There is no need for a low Fowler's position or for limiting light exposure. Antiviral ointments are not routinely used.

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 patient's mean arterial pressure (MAP) is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurse's most appropriate action? A) Position the patient in the high Fowler's position as tolerated. B) Administer osmotic diuretics as ordered. C) Participate in interventions to increase cerebral perfusion pressure. D) Prepare the patient for craniotomy.

Ans: C Feedback: The cerebral perfusion pressure (CPP) is 55 mm Hg, which is considered low. The normal CPP is 70 to 100 mm Hg. Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage. As a result, interventions are necessary. A craniotomy is not directly indicated. Diuretics and increased height of bed would exacerbate the patient's condition.

Splints have been ordered for a patient who is at risk of developing footdrop following a spinal cord injury. The nurse caring for this patient knows that the splints are removed and reapplied when? A) At the patient's request B) Each morning and evening C) Every 2 hours D) One hour prior to mobility exercises

Ans: C Feedback: The feet are prone to footdrop; therefore, various types of splints are used to prevent footdrop. When used, the splints are removed and reapplied every 2 hours.

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

Ans: C Feedback: The osmotic diuretic mannitol is given to dehydrate the brain tissue and reduce cerebral edema. This drug acts by reducing the volume of brain and extracellular fluid. Spirolactone, furosemide, and hydrochlorothiazide are diuretics that are not typically used in the treatment of increased ICP resulting from cerebral edema.

Cytomegalovirus (CMV) is the most common cause of retinal inflammation in patients with AIDS. What drug, surgically implanted, is used for the acute stage of CMV retinitis? A) Pilocarpine B) Penicillin C) Ganciclovir D) Gentamicin

Ans: C Feedback: The surgically implanted sustained-release insert of ganciclovir enables higher concentrations of ganciclovir to reach the CMV retinitis. Pilocarpine is a muscarinic agent used in open-angle glaucoma. Gentamicin and penicillin are antibiotics that are not used to treat CMV retinitis.

A patient is recovering from intracranial surgery that was performed using the transsphenoidal approach. The nurse should be aware that the patient may have required surgery on what neurologic structure? A) Cerebellum B) Hypothalamus C) Pituitary gland D) Pineal gland

Ans: C Feedback: The transsphenoidal approach (through the mouth and nasal sinuses) is often used to gain access to the pituitary gland. This surgical approach would not allow for access to the pineal gland, cerebellum, or hypothalamus.

A neurologic nurse is reviewing seizures with a group of staff nurses. How should this nurse best describe the cause of a seizure? A) Sudden electrolyte changes throughout the brain B) A dysrhythmia in the peripheral nervous system C) A dysrhythmia in the nerve cells in one section of the brain D) Sudden disruptions in the blood flow throughout the brain

Ans: C Feedback: The underlying cause of a seizure is an electrical disturbance (dysrhythmia) in the nerve cells in one section of the brain; these cells emit abnormal, recurring, uncontrolled electrical discharges. Seizures are not caused by changes in blood flow or electrolytes.

The nurse planning the care of a patient with head injuries is addressing the patient's nursing diagnosis of "sleep deprivation." What action should the nurse implement? A) Administer a benzodiazepine at bedtime each night. B) Do not disturb the patient between 2200 and 0600. C) Cluster overnight nursing activities to minimize disturbances. D) Ensure that the patient does not sleep during the day.

Ans: C Feedback: To allow the patient longer times of uninterrupted sleep and rest, the nurse can group nursing care activities so that the patient is disturbed less frequently. However, it is impractical and unsafe to provide no care for an 8-hour period. The use of benzodiazepines should be avoided.

The nurse caring for a patient with a spinal cord injury notes that the patient is exhibiting early signs and symptoms of disuse syndrome. Which of the following is the most appropriate nursing action? A) Limit the amount of assistance provided with ADLs. B) Collaborate with the physical therapist and immobilize the patient's extremities temporarily. C) Increase the frequency of ROM exercises. D) Educate the patient about the importance of frequent position changes.

Ans: C Feedback: To prevent disuse syndrome, ROM exercises must be provided at least four times a day, and care is taken to stretch the Achilles tendon with exercises. The patient is repositioned frequently and is maintained in proper body alignment whether in bed or in a wheelchair. The patient must be repositioned by caregivers, not just taught about repositioning. It is inappropriate to limit assistance for the sole purpose of preventing disuse syndrome.

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

Ans: C Feedback: 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 patient's recurrent headaches. What aspect of the patient's health history should the nurse identify as a potential contributor to the patient's 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.

Ans: C Feedback: Vasodilators are known to contribute to headaches. Weight fluctuations, sedentary lifestyle, and vitamin supplements are not known to have this effect.

A patient has just arrived to the floor after an enucleation procedure following a workplace accident in which his left eye was irreparably damaged. Which of the following should the nurse prioritize during the patient's immediate postoperative recovery? A) Teaching the patient about options for eye prostheses B) Teaching the patient to estimate depth and distance with the use of one eye C) Assessing and addressing the patient's emotional needs D) Teaching the patient about his post-discharge medication regimen

Ans: C Feedback: When surgical eye removal is unexpected, such as in severe ocular trauma, leaving no time for the patient and family to prepare for the loss, the nurse's role in providing emotional support is crucial. In the short term, this is a priority over teaching regarding prostheses, medications, or vision adaptation.

A nurse is assessing reflexes in a patient with hyperactive reflexes. When the patient's foot is abruptly dorsiflexed, it continues to "beat" two to three times before settling into a resting position. How would the nurse document this finding? A) Rigidity B) Flaccidity C) Clonus D) Ataxia

Ans: C When reflexes are very hyperactive, a phenomenon called clonus may be elicited. If the foot is abruptly dorsiflexed, it may continue to "beat" two to three times before it settles into a position of rest. Rigidity is an increase in muscle tone at rest characterized by increased resistance to passive stretch. Flaccidity is lack of muscle tone. Ataxia is the inability to coordinate muscle movements, resulting in difficulty walking, talking, and performing self-care activities.

A 52-year-old female patient is receiving care on the oncology unit for breast cancer that has metastasized to her lungs and liver. When addressing the patient's pain in her plan of nursing care, the nurse should consider what characteristic of cancer pain? A) Cancer pain is often related to the stress of the patient knowing she has cancer and requires relatively low doses of pain medications along with a high dose of anti-anxiety medications. B) Cancer pain is always chronic and challenging to treat, so distraction is often the best intervention. C) Cancer pain can be acute or chronic and it typically requires comparatively high doses of pain medications. D) Cancer pain is often misreported by patients because of confusion related to their disease process.

Ans: Cancer pain can be acute or chronic and it typically requires comparatively high doses of pain medications. Feedback: Pain associated with cancer may be acute or chronic. Pain resulting from cancer is so ubiquitous that when cancer patients are asked about possible outcomes, pain is reported to be the most feared outcome. Higher doses of pain medication are usually needed with cancer patients, especially with metastasis. Cancer pain is not treated with anti-anxiety medications. Cancer pain can be chronic and difficult to treat so distraction may help, but higher doses of pain medications are usually the best intervention. No research indicates cancer patients misreport pain because of confusion related to their disease process.

You have just received report on a 27-year-old woman who is coming to your unit from the emergency department with a torn meniscus. You review her PRN medications and see that she has an NSAID (ibuprofen) ordered every 6 hours. If you wanted to implement preventive pain measures when the patient arrives to your unit, what would you do? A) Use a pain scale to assess the patient's pain, and let the patient know ibuprofen is available every 6 hours if she needs it. B) Do a complete assessment, and give pain medication based on the patient's report of pain. C) Check for allergies, use a pain scale to assess the patient's pain, and offer the ibuprofen every 6 hours until the patient is discharged. D) Provide medication as per patient request and offer relaxation techniques to promote comfort.

Ans: Check for allergies, use a pain scale to assess the patient's pain, and offer the ibuprofen every 6 hours until the patient is discharged. Feedback: One way preventive pain measures can be implemented is by using PRN medications on a more regular or scheduled basis to allow for more uniform pain control. Smaller drug doses of medication are needed with the preventive pain method when PRN medications are given around the clock. Offering the medication is more beneficial than letting the patient know ibuprofen is available.

You are the nurse coming on shift in a rehabilitation unit. You receive information in report about a new patient who has fibromyalgia and has difficulty with her ADLs. The off-going nurse also reports that the patient is withdrawn, refusing visitors, and has been vacillating between tears and anger all afternoon. What do you know about chronic pain syndromes that could account for your new patient's behavior? A) Fibromyalgia is not a chronic pain syndrome, so further assessment is necessary. B) The patient is likely frustrated because she has to be in the hospital. C) The patient likely has an underlying psychiatric disorder. D) Chronic pain can cause intense emotional responses.

Ans: Chronic pain can cause intense emotional responses. Feedback: Regardless of how patients cope with chronic pain, pain that lasts for an extended period can result in depression, anger, or emotional withdrawal. Nowhere in the scenario does it indicate the patient is upset about the hospitalization or that she has a psychiatric disorder. Fibromyalgia is closely associated with chronic pain.

A patient who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the patient's current health status is most likely to have precipitated this event? A) The patient received a blood transfusion. B) The patient's analgesia regimen was recent changed. C) The patient was not repositioned during the night shift. D) The patient's urinary catheter became occluded.

Ans: D Feedback: A distended bladder is the most common cause of autonomic dysreflexia. Infrequent positioning is a less likely cause, although pressure ulcers or tactile stimulation can cause it. Changes in mediations or blood transfusions are unlikely causes.

The ED is notified that a 6-year-old is in transit with a suspected brain injury after being struck by a car. The child is unresponsive at this time, but vital signs are within acceptable limits. What will be the primary goal of initial therapy? A) Promoting adequate circulation B) Treating the child's increased ICP C) Assessing secondary brain injury D) Preserving brain homeostasis

Ans: D Feedback: All therapy is directed toward preserving brain homeostasis and preventing secondary brain injury, which is injury to the brain that occurs after the original traumatic event. The scenario does not indicate the child has increased ICP or a secondary brain injury at this point. Promoting circulation is likely secondary to the broader goal of preserving brain homeostasis.

A patient with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate? A) Restrain the patient to prevent injury. B) Open the patient's jaws to insert an oral airway. C) Place patient in high Fowler's position. D) Loosen the patient's restrictive clothing.

Ans: D Feedback: An appropriate nursing intervention would include loosening any restrictive clothing on the patient. No attempt should be made to restrain the patient during the seizure because muscular contractions are strong and restraint can produce injury. Do not attempt to pry open jaws that are clenched in a spasm to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus.

The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing diagnosis of "ineffective cerebral tissue perfusion." What would be an expected outcome that the nurse would document for this diagnosis? A) Copes with sensory deprivation. B) Registers normal body temperature. C) Pays attention to grooming. D) Obeys commands with appropriate motor responses.

Ans: D Feedback: An expected outcome of the diagnosis of ineffective cerebral tissue perfusion in a patient with increased intracranial pressure (ICP) would include obeying commands with appropriate motor responses. Vitals signs and neurologic status are assessed every 15 minutes to every hour. Coping with sensory deprivation would relate to the nursing diagnosis of "disturbed sensory perception." The outcome of "registers normal body temperature" relates to the diagnosis of "potential for ineffective thermoregulation." Body image disturbance would have a potential outcome of "pays attention to grooming."

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

Ans: D Feedback: Antiseizure medication (phenytoin, diazepam) is often prescribed prophylactically for patients who have undergone supratentorial craniotomy because of the high risk of seizures after this procedure. Prednisone and dexamethasone are steroids and do not prevent seizures. Cafergot is used in the treatment of migraines.

The nurse is providing care for a patient who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the patient has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following? A) The ability of the patient to follow instructions during the seizure. B) The success or failure of the care team to physically restrain the patient. C) The patient's ability to explain his seizure during the postictal period. D) The patient's activities immediately prior to the seizure.

Ans: D Feedback: Before and during a seizure, the nurse observes the circumstances before the seizure, including visual, auditory, or olfactory stimuli; tactile stimuli; emotional or psychological disturbances; sleep; and hyperventilation. Communication with the patient is not possible during a seizure and physical restraint is not attempted. The patient's ability to explain the seizure is not clinically relevant.

A patient is being discharged home from the ambulatory surgical center after cataract surgery. In reviewing the discharge instructions with the patient, the nurse instructs the patient to immediately call the office if the patient experiences what? A) Slight morning discharge from the eye B) Any appearance of redness of the eye C) A scratchy feeling in the eye D) A new floater in vision

Ans: D Feedback: Cataract surgery increases the risk of retinal detachment and the patient must be instructed to notify the surgeon of new floaters in vision, flashing lights, decrease in vision, pain, or increase in redness. Slight morning discharge, some redness, and a scratchy feeling may be expected for a few days after surgery.

What should the nurse suspect when hourly assessment of urine output on a patient postcraniotomy exhibits a urine output from a catheter of 1,500 mL for two consecutive hours? A) Cushing syndrome B) Syndrome of inappropriate antidiuretic hormone (SIADH) C) Adrenal crisis D) Diabetes insipidus

Ans: D Feedback: Diabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in patients after brain surgery. Cushing syndrome is excessive glucocorticoid secretion resulting in sodium and water retention. SIADH is the result of increased secretion of ADH; the patient becomes volume-overloaded, urine output diminishes, and serum sodium concentration becomes dilute. Adrenal crisis is undersecretion of glucocorticoids resulting in profound hypoglycemia, hypovolemia, and hypotension.

The nurse has implemented interventions aimed at facilitating family coping in the care of a patient with a traumatic brain injury. How can the nurse best facilitate family coping? A) Help the family understand that the patient could have died. B) Emphasize the importance of accepting the patient's new limitations. C) Have the members of the family plan the patient's inpatient care. D) Assist the family in setting appropriate short-term goals.

Ans: D Feedback: Helpful interventions to facilitate coping include providing family members with accurate and honest information and encouraging them to continue to set well-defined, short-term goals. Stating that a patient's condition could be worse downplays their concerns. Emphasizing the importance of acceptance may not necessarily help the family accept the patient's condition. Family members cannot normally plan a patient's hospital care, although they may contribute to the care in some ways.

The public health nurse is addressing eye health and vision protection during an educational event. What statement by a participant best demonstrates an understanding of threats to vision? A) I'm planning to avoid exposure to direct sunlight on my next vacation. B) I've never exercised regularly, but I'm going to start working out at the gym daily. C) I'm planning to talk with my pharmacist to review my current medications. D) I'm certainly going to keep a close eye on my blood pressure from now on.

Ans: D Feedback: Hypertension is a major cause of vision loss, exceeding the significance of inactivity, sunlight, and adverse effects of medications.

A 13-year-old was brought to the ED, unconscious, after being hit in the head by a baseball. When the child regains consciousness, 5 hours after being admitted, he cannot remember the traumatic event. MRI shows no structural sign of injury. What injury would the nurse suspect the patient has? A) Diffuse axonal injury B) Grade 1 concussion with frontal lobe involvement C) Contusion D) Grade 3 concussion with temporal lobe involvement

Ans: D Feedback: In a grade 3 concussion there is a loss of consciousness lasting from seconds to minutes. Temporal lobe involvement results in amnesia. Frontal lobe involvement can cause uncharacteristic behavior and a grade 1 concussion does not involve loss of consciousness. Diagnostic studies may show no apparent structural sign of injury, but the duration of unconsciousness is an indicator of the severity of the concussion. Diffuse axonal injury (DAI) results from widespread shearing and rotational forces that produce damage throughout the brain—to axons in the cerebral hemispheres, corpus callosum, and brain stem. In cerebral contusion, a moderate to severe head injury, the brain is bruised and damaged in a specific area because of severe acceleration-deceleration force or blunt trauma.

A patient has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the patient's ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following? A) Hemiplegia B) Dry mucous membranes C) Signs of internal bleeding D) Loss of brain stem reflexes

Ans: D Feedback: Loss of brain stem reflexes, including pupillary, corneal, gag, and swallowing reflexes, is an ominous sign of approaching death. Dry mucous membranes, hemiplegia, and bleeding must be promptly addressed, but none of these is a common sign of impending death.

A nurse on the neurologic unit is providing care for a patient who has spinal cord injury at the level of C4. When planning the patient's care, what aspect of the patient's neurologic and functional status should the nurse consider? A) The patient will be unable to use a wheelchair. B) The patient will be unable to swallow food. C) The patient will be continent of urine, but incontinent of bowel. D) The patient will require full assistance for all aspects of elimination

Ans: D Feedback: Patients with a lesion at C4 are fully dependent for elimination. The patient is dependent for feeding, but is able to swallow. The patient will be capable of using an electric wheelchair.

A patient with chronic open-angle glaucoma is being taught to self-administer pilocarpine. After the patient administers the pilocarpine, the patient states that her vision is blurred. Which nursing action is most appropriate? A) Holding the next dose and notifying the physician B) Treating the patient for an allergic reaction C) Suggesting that the patient put on her glasses D) Explaining that this is an expected adverse effect

Ans: D Feedback: Pilocarpine, a miotic drug used to treat glaucoma, achieves its effect by constricting the pupil. Blurred vision lasting 1 to 2 hours after instilling the eye drops is an expected adverse effect. The patient may also note difficulty adapting to the dark. Because blurred vision is an expected adverse effect, the drug does not need to be withheld, nor does the physician need to be notified. Likewise, the patient does not need to be treated for an allergic reaction. Wearing glasses will not alter this temporary adverse effect.

A patient is ready to be discharged home after a cataract extraction with intraocular lens implant and the nurse is reviewing signs and symptoms that need to be reported to the ophthalmologist immediately. Which of the patient's statements best demonstrates an adequate understanding? A) I need to call the doctor if I get nauseated. B) I need to call the doctor if I have a light morning discharge. C) I need to call the doctor if I get a scratchy feeling. D) I need to call the doctor if I see flashing lights.

Ans: D Feedback: Postoperatively, the patient who has undergone cataract extraction with intraocular lens implant should report new floaters in vision, flashing lights, decrease in vision, pain, or increase in redness to the ophthalmologist. Slight morning discharge and a scratchy feeling can be expected for a few days. Blurring of vision may be experienced for several days to weeks.

During the examination of an unconscious patient, the nurse observes that the patient's pupils are fixed and dilated. What is the most plausible clinical significance of the nurse's finding? A) It suggests onset of metabolic problems. B) It indicates paralysis on the right side of the body. C) It indicates paralysis of cranial nerve X. D) It indicates an injury at the midbrain level.

Ans: D Feedback: Pupils that are fixed and dilated indicate injury at the midbrain level. This finding is not suggestive of unilateral paralysis, metabolic deficits, or damage to CN X.

A patient is exploring treatment options after being diagnosed with age-related cataracts that affect her vision. What treatment is most likely to be used in this patient's care? A) Antioxidant supplements, vitamin C and E, beta-carotene, and selenium B) Eyeglasses or magnifying lenses C) Corticosteroid eye drops D) Surgical intervention

Ans: D Feedback: Surgery is the treatment option of choice when the patient's functional and visual status is compromised. No nonsurgical (medications, eye drops, eyeglasses) treatment cures cataracts or prevents age-related cataracts. Studies recently have found no benefit from antioxidant supplements, vitamins C and E, beta-carotene, or selenium. Corticosteroid eye drops are prescribed for use after cataract surgery; however, they increase the risk for cataracts if used long-term or in high doses. Eyeglasses and magnification may improve vision in the patient with early stages of cataracts, but have limitations for the patient with impaired functioning.

An ED nurse has just received a call from EMS that they are transporting a 17-year-old man who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what? A) Sports-related injuries B) Acts of violence C) Injuries due to a fall D) Motor vehicle accidents

Ans: D Feedback: The most common causes of SCIs are motor vehicle crashes (46%), falls (22%), violence (16%), and sports (12%).

The registered nurse taking shift report learns that an assigned patient is blind. How should the nurse best communicate with this patient? A) Provide instructions in simple, clear terms. B) Introduce herself in a firm, loud voice at the doorway of the room. C) Lightly touch the patient's arm and then introduce herself. D) State her name and role immediately after entering the patient's room.

Ans: D Feedback: There are several guidelines to consider when interacting with a person who is blind or has low vision. Identify yourself by stating your name and role, before touching or making physical contact with the patient. When talking to the person, speak directly at him or her using a normal tone of voice. There is no need to raise your voice unless the person asks you to do so and there is no particular need to simplify verbal instructions.

Several residents of a long-term care facility have developed signs and symptoms of viral conjunctivitis. What is the most appropriate action of the nurse who oversees care in the facility? A) Arrange for the administration of prophylactic antibiotics to unaffected residents. B) Instill normal saline into the eyes of affected residents two to three times daily. C) Swab the conjunctiva of unaffected residents for culture and sensitivity testing. D) Isolate affected residents from residents who have not developed conjunctivitis.

Ans: D Feedback: To prevent spread during outbreaks of conjunctivitis caused by adenovirus, health care facilities must set aside specified areas for treating patients diagnosed with or suspected of having conjunctivitis caused by adenovirus. Antibiotics and saline flushes are ineffective and normally no need to perform testing of individuals lacking symptoms.

A patient with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. What is the nurse's best intervention for preventing injury? A) Restrain the patient as ordered. B) Administer opioids PRN as ordered. C) Arrange for friends and family members to sit with the patient. D) Pad the side rails of the patient's bed.

Ans: D Feedback: To protect the patient from self-injury, the nurse uses padded side rails. The nurse should avoid restraints, because straining against them can increase ICP or cause other injury. Narcotics used to control restless patients should be avoided because these medications can depress respiration, constrict the pupils, and alter the patient's responsiveness. Visitors should be limited if the patient is agitated.

You are the case manager for a 35-year-old man being seen at a primary care clinic for chronic low back pain. When you meet with the patient, he says that he is having problems at work; in the past year he has been absent from work about once every 2 weeks, is short-tempered with other workers, feels tired all the time, and is worried about losing his job. You are developing this patient's plan of care. On what should the goals for the plan of care focus? A) Increase the patient's pain tolerance in order to achieve psychosocial benefits. B) Decrease the patient's need to work and increase his sleep to 8 hours per night. C) Evaluate other work options to decrease the risk of depression and ineffective coping. D) Decrease the time lost from work to increase the quality of interpersonal relationships and decrease anxiety.

Ans: Decrease the time lost from work to increase the quality of interpersonal relationships and decrease anxiety. Feedback: Chronic pain may affect the patient's quality of life by interfering with work, interpersonal relationships, or sleep. Thus, the best set of goals would be to "decrease time lost from work to increase the quality of interpersonal relationships, and decrease anxiety." Increasing pain tolerance is an unrealistic and inappropriate goal; exercise could help, but would not be the focus of the plan of care. Decreasing the need to work does not address his pain. Evaluating other work options to decrease the risk of depression is a misdirected diagnosis.

The nurse caring for a 91-year-old patient with osteoarthritis is reviewing the patient's chart. This patient is on a variety of medications prescribed by different care providers in the community. In light of the QSEN competency of safety, what is the nurse most concerned about with this patient? A) Depression B) Chronic illness C) Inadequate pain control D) Drug interactions

Ans: Drug interactions Feedback: Drug interactions are more likely to occur in older adults because of the higher incidence of chronic illness and the increased use of prescription and OTC medications. The other options are all good answers for this patient because of the patient's age and disease process. However, they are not what the nurse would be most concerned about in terms of ensuring safety.

Two patients on your unit have recently returned to the postsurgical unit after knee arthroplasty. One patient is reporting pain of 8 to 9 on a 0-to-10 pain scale, whereas the other patient is reporting a pain level of 3 to 4 on the same pain scale. What is the nurse's most plausible rationale for understanding the patients' different perceptions of pain? A) Endorphin levels may vary between patients, affecting the perception of pain. B) One of the patients is exaggerating his or her sense of pain. C) The patients are likely experiencing a variance in vasoconstriction. D) One of the patients may be experiencing opioid tolerance.

Ans: Endorphin levels may vary between patients, affecting the perception of pain. Feedback: Different people feel different degrees of pain from similar stimuli. Opioid tolerance is associated with chronic pain treatment and would not likely apply to these patients. The nurse should not assume the patient is exaggerating the pain because the patient is the best authority of his or her existence of pain, and definitions for pain state that pain is "whatever the person says it is, existing whenever the experiencing person says it does."

You are caring for a patient admitted to the medical-surgical unit after falling from a horse. The patient states "I hurt so bad. I suffer from chronic pain anyway, and now it is so much worse." When planning the patient's care, what variables should you consider? Select all that apply. A) How the presence of pain affects patients and families B) Resources that can assist the patient with pain management C) The influence of the patient's cognition on her pain D) The advantages and disadvantages of available pain-relief strategies E) The difference between acute and intermittent pain

Ans: How the presence of pain affects patients and families, Resources that can assist the patient with pain management, The advantages and disadvantages of available pain-relief strategies Feedback: Nurses should understand the effects of chronic pain on patients and families and should be knowledgeable about pain-relief strategies and appropriate resources to assist effectively with pain management. There is no evidence of cognitive deficits in this patient and the difference between acute and intermittent pain has no immediate bearing on this patient's care.

A 74-year-old woman was diagnosed with rheumatoid arthritis 1 year ago, but has achieved adequate symptom control through the regular use of celecoxib (Celebrex), a COX-2 selective NSAID. The nurse should recognize that this drug, like other NSAIDs, influences what aspect of the pathophysiology of nociceptive pain? A) Distorting the action potential that is transmitted along the A-delta (δ) and C fibers B) Diverting noxious information from passing through the dorsal root ganglia and synapses in the dorsal horn of the spinal cord C) Blocking modulation by limiting the reuptake of serotonin and norepinephrine D) Inhibiting transduction by blocking the formation of prostaglandins in the periphery

Ans: Inhibiting transduction by blocking the formation of prostaglandins in the periphery Feedback: NSAIDs produce pain relief primarily by blocking the formation of prostaglandins in the periphery; this is a central component of the pathophysiology of transduction. NSAIDs do not act directly on the aspects of transmission, perception, or modulation of pain that are listed.

You are part of the health care team caring for an 87-year-old woman who has been admitted to your rehabilitation facility after falling and fracturing her left hip. The patient appears to be failing to regain functional ability and may have to be readmitted to an acute-care facility. When planning this patient's care, what do you know about the negative effects of the stress associated with pain? A) Stress is less pronounced in older adults because they generally have more sophisticated coping skills than younger adults B) It is particularly harmful in the elderly who have been injured or who are ill. C) It affects only those patients who are already debilitated prior to experiencing pain. D) It has no inherent negative effects; it just alerts the person/health care team of an underlying disease process.

Ans: It is particularly harmful in the elderly who have been injured or who are ill. Feedback: The widespread endocrine, immunologic, and inflammatory changes that occur with the stress of pain can have significant negative effects. This is particularly harmful in patients whose health is already compromised by age, illness, or injury. Older adults are not immune to the negative effects of stress. Prior debilitation does not have to be present in order for stress to cause potential harm.

You are admitting a patient to your rehabilitation unit who has a diagnosis of persistent, severe pain. According to the patient's history, the patient's pain has not responded to conventional approaches to pain management. What treatment would you expect might be tried with this patient? A) Intravenous analgesia B) Long-term intrathecal or epidural catheter C) Oral analgesia D) Intramuscular analgesia

Ans: Long-term intrathecal or epidural catheter Feedback: For patients who have persistent, severe pain that fails to respond to other treatments or who obtain pain relief only with the risk of serious side effects, medication administered by a long-term intrathecal or epidural catheter may be effective. The other listed means of pain control would already have been tried in a patient with persistent severe pain that has not responded to previous treatment.

The nurse who is a member of the palliative care team is assessing a patient. The patient indicates that he has been saving his PRN analgesics until the pain is intense because his pain control has been inadequate. What teaching should the nurse do with this patient? A) Medication should be taken when pain levels are low so the pain is easier to reduce. B) Pain medication can be increased when the pain becomes intense. C) It is difficult to control chronic pain, so this is an inevitable part of the disease process. D) The patient will likely benefit more from distraction than pharmacologic interventions.

Ans: Medication should be taken when pain levels are low so the pain is easier to reduce. Feedback: Better pain control can be achieved with a preventive approach, reducing the amount of time patients are in pain. Low levels of pain are easier to reduce or control than intense levels of pain. Pain medication is used to prevent pain so pain medication is not increased when pain becomes intense. Chronic pain is treatable. Giving the patient alternative methods to control pain is good, but it will not work if the patient is in so much pain that he cannot institute reliable alternative methods.

You are frequently assessing an 84-year-old woman's pain after she suffered a humeral fracture in a fall. When applying the nursing process in pain management for a patient of this age, what principle should you best apply? A) Monitor for signs of drug toxicity due to a decrease in metabolism. B) Monitor for an increase in absorption of the drug due to age-related changes. C) Monitor for a paradoxical increase in pain with opioid administration. D) Administer analgesics every 4 to 6 hours as ordered to control pain.

Ans: Monitor for signs of drug toxicity due to a decrease in metabolism. Feedback: Older people may respond differently to pain than younger people. Because elderly people have a slower metabolism and a greater ratio of body fat to muscle mass compared with younger people, small doses of analgesic agents may be sufficient to relieve pain, and these doses may be effective longer. This fact also corresponds to an increased risk of adverse effects. Paradoxical effects are not a common phenomenon. Frequency of administration will vary widely according to numerous variables.

A patient's intractable neuropathic pain is being treated on an inpatient basis using a multimodal approach to analgesia. After administering a recently increased dose of IV morphine to the patient, the nurse has returned to assess the patient and finds the patient unresponsive to verbal and physical stimulation with a respiratory rate of five breaths per minute. The nurse has called a code blue and should anticipate the administration of what drug? A) Acetylcysteine B) Naloxone C) Celecoxib D) Acetylsalicylic acid

Ans: Naloxone Feedback: Severe opioid-induced sedation necessitates the administration of naloxone, an opioid antagonist. Celecoxib, acetylcysteine, and acetylsalicylic acid are ineffective.

The nurse is accepting care of an adult patient who has been experiencing severe and intractable pain. When reviewing the patient's medication administration record, the nurse notes the presence of gabapentin (Neurontin). The nurse is justified in suspecting what phenomenon in the etiology of the patient's pain? A) Neuroplasticity B) Misperception C) Psychosomatic processes D) Neuropathy

Ans: Neuropathy Feedback: The anticonvulsants gabapentin (Neurontin) and pregabalin (Lyrica) are first-line analgesic agents for neuropathic pain. Neuroplasticity is the ability of the peripheral and central nervous systems to change both structure and function as a result of noxious stimuli; this does not likely contribute to the patient's pain. Similarly, psychosomatic factors and misperception of pain are highly unlikely.

A medical nurse is appraising the effectiveness of a patient's current pain control regimen. The nurse is aware that if an intervention is deemed ineffective, goals need to be reassessed and other measures need to be considered. What is the role of the nurse in obtaining additional pain relief for the patient? A) Primary caregiver B) Patient advocate C) Team leader D) Case manager

Ans: Patient advocate Feedback: If the intervention was ineffective, the nurse should consider other measures. If these are ineffective, pain-relief goals need to be reassessed in collaboration with the physician. The nurse serves as the patient's advocate in obtaining additional pain relief.

You are caring for a 20-year-old patient with a diagnosis of cerebral palsy who has been admitted for the relief of painful contractures in his lower extremities. When creating a nursing care plan for this patient, what variables should the nurse consider? Select all that apply. A) Patient's gender B) Patient's comorbid conditions C) Type of procedure be performed D) Changes in neurologic function due to the procedure E) Prior effectiveness in relieving the pain

Ans: Patient's comorbid conditions, Type of procedure be performed, Changes in neurologic function due to the procedure, Prior effectiveness in relieving the pain Feedback: The nursing care of patients who undergo procedures for the relief of chronic pain depends on the type of procedure performed, its effectiveness in relieving the pain, and the changes in neurologic function that accompany the procedure. The patient's comorbid conditions will also affect care, but his gender is not a key consideration.

A nurse has cited a research study that highlights the clinical effectiveness of using placebos in the management of postsurgical patients' pain. What principle should guide the nurse's use of placebos in pain management? A) Placebos require a higher level of informed consent than conventional care. B) Placebos are an acceptable, but unconventional, form of nonpharmacological pain management. C) Placebos are never recommended in the treatment of pain. D) Placebos require the active participation of the patient's family.

Ans: Placebos are never recommended in the treatment of pain. Feedback: Broad agreement is that there are no individuals for whom and no condition for which placebos are the recommended treatment. This principle supersedes the other listed statements.

You are the home health nurse caring for a homebound client who is terminally ill. You are delivering a patient-controlled analgesia (PCA) pump to the patient at your visit today. The family members will be taking care of the patient. What would your priority nursing interventions be for this visit? A) Teach the family the theory of pain management and the use of alternative therapies. B) Provide psychosocial family support during this emotional experience. C) Provide patient and family teaching regarding the operation of the pump, monitoring the IV site, and knowing the side effects of the medication. D) Provide family teaching regarding use of morphine, recognizing morphine overdose, and offering spiritual guidance.

Ans: Provide patient and family teaching regarding the operation of the pump, monitoring the IV site, and knowing the side effects of the medication. Feedback: If PCA is to be used in the patient's home, the patient and family are taught about the operation of the pump as well as the side effects of the medication and strategies to manage them. The family would also need to monitor the IV site and notify the nurse of any changes, such as infiltration, that could endanger the patient. Teaching the family the theory of pain management or the use of alternative therapies and the nurse providing emotional support are important, but the family must be able to operate the pump as well as know the side effects of the medication and strategies to manage them. Offering spiritual guidance would not be a priority at this point and morphine is not the only medication administered by PCA.

The nurse is caring for a male patient whose diagnosis of bone cancer is causing severe and increasing pain. Before introducing nonpharmacological pain control interventions into the patient's plan of care, the nurse should teach the patient which of the following? A) Nonpharmacological interventions must be provided by individuals other than members of the healthcare team. B) These interventions will not directly reduce pain, but will refocus him on positive stimuli. C) These interventions carry similar risks of adverse effects as analgesics. D) Reducing his use of analgesics is not the purpose of these interventions.

Ans: Reducing his use of analgesics is not the purpose of these interventions. Feedback: Patients who have been taking analgesic agents may mistakenly assume that clinicians suggest a nonpharmacolgical method to reduce the use or dose of analgesic agents. Nonpharmacological interventions indeed reduce pain and their use is not limited to practitioners outside the healthcare team. In general, adverse effects are minimal.

The nurse is assessing a patient's pain while the patient awaits a cholecystectomy. The patient is tearful, hesitant to move, and grimacing. When asked, the patient rates his pain as a 2 at this time using a 0-to-10 pain scale. How should the nurse best respond to this assessment finding? A) Remind the patient that he is indeed experiencing pain. B) Reinforce teaching about the pain scale number system. C) Reassess the patient's pain in 30 minutes. D) Administer an analgesic and then reassess.

Ans: Reinforce teaching about the pain scale number system Feedback: The patient is physically exhibiting signs and symptoms of pain. Further teaching may need to be done so the patient can correctly rate the pain. The nurse may also verify that the same scale is being used by the patient and caregiver to promote continuity. Although all answers are correct, the most accurate conclusion would be to reinforce teaching about the pain scale.

The home health nurse is developing a plan of care for a patient who will be managing his chronic pain at home. Using the nursing process, on which concepts should the nurse focus the patient teaching? A) Self-care and safety B) Autonomy and need C) Health promotion and exercise D) Dependence and health

Ans: Self-care and safety Feedback: The patient will be at home monitoring his own pain management, administering his own medication, and monitoring and reporting side effects. This requires the ability to perform self-care activities in a safe manner. Creating autonomy is important, but need is a poorly defined concept. Health promotion is an important global concept for maintaining health, and exercise is an appropriate activity; however, self-care and safety are the priorities. Dependence is not a concept used to develop a nursing plan of care, and health is too broad a concept to use as a basis for a nursing plan of care.

A 60-year-old patient who has diabetes had a below-knee amputation 1 week ago. The patient asks "why does it still feel like my leg is attached, and why does it still hurt?" The nurse explains neuropathic pain in terms that are accessible to the patient. The nurse should describe what pathophysiologic process? A) The proliferation of nociceptors during times of stress B) Age-related deterioration of the central nervous system C) Psychosocial dependence on pain medications D) The abnormal reorganization of the nervous system

Ans: The abnormal reorganization of the nervous system Feedback: At any point from the periphery to the CNS, the potential exists for the development of neuropathic pain. Hyperexcitable nerve endings in the periphery can become damaged, leading to abnormal reorganization of the nervous system called neuroplasticity, an underlying mechanism of some neuropathic pain states. Neuropathic pain is not a result of age-related changes, nociceptor proliferation, or dependence on medications.

The nurse caring for a 79-year-old man who has just returned to the medical-surgical unit following surgery for a total knee replacement received report from the PACU. Part of the report had been passed on from the preoperative assessment where it was noted that he has been agitated in the past following opioid administration. What principle should guide the nurse's management of the patient's pain? A) The elderly may require lower doses of medication and are easily confused with new medications. B) The elderly may have altered absorption and metabolism, which prohibits the use of opioids. C) The elderly may be confused following surgery, which is an age-related phenomenon unrelated to the medication. D) The elderly may require a higher initial dose of pain medication followed by a tapered dose.

Ans: The elderly may require lower doses of medication and are easily confused with new medications. Feedback: The elderly often require lower doses of medication and are easily confused with new medications. The elderly have slowed metabolism and excretion, and, therefore, the elderly should receive a lower dose of pain medication given over a longer period time, which may help to limit the potential for confusion. Unfortunately, the elderly are often given the same dose as younger adults, and the resulting confusion is attributed to other factors like environment. Opioids are not absolutely contraindicated and confusion following surgery is never normal. Medication should begin at a low dose and slowly increase until the pain is managed.

You are the nurse in a pain clinic caring for an 88-year-old man who is suffering from long-term, intractable pain. At this point, the pain team feels that first-line pharmacological and nonpharmacological methods of pain relief have been ineffective. What recommendation should guide this patient's subsequent care? A) The patient may want to investigate new alternative pain management options that are outside the United States. B) The patient may benefit from referral to a neurologist or neurosurgeon to discuss pain-management options. C) The patient may want to increase his exercise and activities significantly to create distractions. D) The patient may want to relocate to long-term care in order to have his ADL needs met.

Ans: The patient may benefit from referral to a neurologist or neurosurgeon to discuss pain-management options. Feedback: In some situations, especially with long-term severe intractable pain, usual pharmacologic and nonpharmacologic methods of pain relief are ineffective. In those situations, neurologic and neurosurgical approaches to pain management may be considered. Investigating new alternative pain-management options that are outside the United States is unrealistic and may even be dangerous advice. Increasing his exercise and activities to create distractions is unrealistic when a patient is in intractable pain and this recommendation conveys the attitude that the pain is not real. Moving into a nursing home so others may care for him is an intervention that does not address the issue of pain.

Your patient has just returned from the postanesthetic care unit (PACU) following left tibia open reduction internal fixation (ORIF). The patient is complaining of pain, and you are preparing to administer the patient's first scheduled dose of hydromorphone (Dilaudid). Prior to administering the drug, you would prioritize which of the following assessments? A) The patient's electrolyte levels B) The patient's blood pressure C) The patient's allergy status D) The patient's hydration status

Ans: The patient's allergy status Feedback: Before administering medications such as narcotics for the first time, the nurse should assess for any previous allergic reactions. Electrolyte values, blood pressure, and hydration status are not what you need to assess prior to giving a first dose of narcotics.

You are the nurse caring for the 25-year-old victim of a motor vehicle accident with a fractured pelvis and a ruptured bladder. The nurse's aide (NA) tells you that she is concerned because the patient's resting heart rate is 110 beats per minute, her respirations are 24 breaths per minute, temperature is 99.1°F axillary, and the blood pressure is 125/85 mm Hg. What other information is most important as you assess this patient's physiologic status? ) The patient's understanding of pain physiology B) The patient's serum glucose level C) The patient's white blood cell count D) The patient's rating of her pain

Ans: The patient's rating of her pain Feedback: The nurse's assessment of the patient's pain is a priority. There is no suggestion of diabetes and leukocytosis would not occur at this early stage of recovery. The patient does not need to fully understand pain physiology in order to communicate the presence, absence, or severity of pain.

The mother of a cancer patient comes to the nurse concerned with her daughter's safety. She states that her daughter's morphine dose that she needs to control her pain is getting "higher and higher." As a result, the mother is afraid that her daughter will overdose. The nurse educates the mother about what aspect of her pain management? A) The dose range is higher with cancer patients, and the medical team will be very careful to prevent addiction. B) Frequently, female patients and younger patients need higher doses of opioids to be comfortable. C) The increased risk of overdose is an inevitable risk of maintaining adequate pain control during cancer treatment. D) There is no absolute maximum opioid dose and her daughter is becoming more tolerant to the drug.

Ans: There is no absolute maximum opioid dose and her daughter is becoming more tolerant to the drug. Feedback: Patients requiring opioids for chronic pain, especially cancer patients, need increasing doses to relieve pain. The requirement for higher drug doses results in a greater drug tolerance, which is a physical dependency as opposed to addiction, which is a psychological dependency. The dose range is usually higher with cancer patients. Although tolerance to the drug will increase, addiction is not dose related, but is a separate psychological dependency issue. No research indicates that women and/or younger people need higher doses of morphine to be comfortable. Overdose is not an "inevitable" risk.

You are creating a nursing care plan for a patient with a primary diagnosis of cellulitis and a secondary diagnosis of chronic pain. What common trait of patients who live with chronic pain should inform your care planning? A) They are typically more comfortable with underlying pain than patients without chronic pain. B) They often have a lower pain threshold than patients without chronic pain. C) They often have an increased tolerance of pain. D) They can experience acute pain in addition to chronic pain.

Ans: They can experience acute pain in addition to chronic pain. Feedback: It is tempting to expect that people who have had multiple or prolonged experiences with pain will be less anxious and more tolerant of pain than those who have had little experience with pain. However, this is not true for many people. The more experience a person has had with pain, the more frightened he or she may be about subsequent painful events. Chronic pain and acute pain are not mutually exclusive.

Your patient is 12-hours post ORIF right ankle. The patient is asking for a breakthrough dose of analgesia. The pain-medication orders are written as a combination of an opioid analgesic and a nonsteroidal anti-inflammatory drug (NSAID) given together. What is the primary rationale for administering pain medication in this manner? A) To prevent respiratory depression from the opioid B) To eliminate the need for additional medication during the night C) To achieve better pain control than with one medication alone D) To eliminate the potentially adverse effects of the opioid

Ans: To achieve better pain control than with one medication alone Feedback: A multimodal regimen combines drugs with different underlying mechanisms, which allows lower doses of each of the drugs in the treatment plan, reducing the potential for each to produce adverse effects. This method also reduces, but does not eliminate, adverse effects of the opioid. This regimen is not motivated by the need to prevent respiratory depression or to eliminate nighttime dosing.

A patient is experiencing severe pain after suffering an electrical burn in a workplace accident. The nurse is applying knowledge of the pathophysiology of pain when planning this patient's nursing care. What is the physiologic process by which noxious stimuli, such as burns, activate nociceptors? A) Transduction B) Transmission C) Perception D) Modulation

Ans: Transduction Feedback: Transduction refers to the processes by which noxious stimuli, such as a surgical incision or burn, activate primary afferent neurons called nociceptors. Transmission, perception, and modulation are subsequent to this process.

You are the nurse caring for a postsurgical patient who is Asian-American who speaks very little English. How should you most accurately assess this patient's pain? A) Use a chart with English on one side of the page and the patient's native language on the other so he can rate his pain. B) Ask the patient to write down a number according to the 0-to-10 point pain scale. C) Use the Visual Analog Scale (VAS). D) Use the services of a translator each time you assess the patient so you can document the patient's pain rating.

Ans: Use a chart with English on one side of the page and the patient's native language on the other so he can rate his pain. Feedback: Of the listed options, a language comparison chart is most plausible. The VAS requires English language skills, even though it is visual. Asking the patient to write similarly requires the use of English. It is impractical to obtain translator services for every pain assessment, since this is among the most frequently performed nursing assessments.

You are caring for a patient with sickle cell disease in her home. Over the years, there has been joint damage, and the patient is in chronic pain. The patient has developed a tolerance to her usual pain medication. When does the tolerance to pain medication become the most significant problem? A) When it results in inadequate relief from pain B) When dealing with withdrawal symptoms resulting from the tolerance C) When having to report the patient's addiction to her physician D) When the family becomes concerned about increasing dosage

Ans: When it results in inadequate relief from pain Feedback: Tolerance to opioids is common and becomes a problem primarily in terms of maintaining adequate pain control. Symptoms of physical dependence may occur when opiates are discontinued, but there is no indication that the patient's medication will be discontinued. This patient does not have an addiction and the family's concerns are secondary to those of the patient.

A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the priority medical treatment to include which of the following?

Anticoagulant therapy

A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the priority medical treatment to include which of the following?

Anticoagulant therapy Explanation: Anticoagulant or antiplatelet therapy can prevent clot formation associated with cardiac dysrhythmias such as atrial fibrillation. Cholesterol-lowering drugs can be ordered if indicated to manage atherosclerosis. Prothrombin and international normalized ratio (INR) levels may be ordered to monitor therapeutic effects of anticoagulant therapy. Carotid endarterectomy would be anticipated only when the carotids have narrowing from plaque.

The nurse is taking care of a client with a headache. In addition to administering medications, the nurse takes which measure to assist the client in reducing the pain associated with the headache?

Apply warm or cool cloths to the forehead or back of the neck.

Patients with a decreased field of vision should be approached on the side where the visual perception is intact or the opposite side of the defect?

Approach the patient from side of intact field of vision.

Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis?

Apraxia Explanation: Verbal apraxia refers to difficulty forming and organizing intelligible words although the musculature is intact. Agnosia is a failure to recognize familiar objects perceived by the senses. Agraphia refers to disturbances in writing intelligible words. Perseveration is the continued and automatic repetition of an activity or word or phrase that is no longer appropriate.

Which of the following terms refer to the inability to perform previously learned purposeful motor acts on a voluntary basis? a) Agraphia b) Perseveration c) Agnosia d) Apraxia

Apraxia Verbal apraxia refers to difficulty in forming and organizing intelligible words although the musculature is intact. Agnosia is failure to recognize familiar objects perceived by the senses. Agraphia refers to disturbances in writing intelligible words. Perseveration is the continued and automatic repetition of an activity or word or phrase that is no longer appropriate. (less)

A nurse is caring for a client who has returned to his room after a carotid endarterectomy. Which action should the nurse take first? a) Take the client's blood pressure. b) Ask the client if he has a headache. c) Ask the client if he has trouble breathing. d) Place antiembolism stockings on the client.

Ask the client if he has trouble breathing. The nurse should first assess the client's breathing. A complication of a carotid endarterectomy is an incisional hematoma, which could compress the trachea causing breathing difficulty for the client. Although the other measures are important actions, they aren't the nurse's top priority.

If warfarin is contraindicated as a treatment for stroke, which medication is the best option?

Aspirin Explanation: If warfarin is contraindicated, aspirin is the best option, although other medications may be used if both are contraindicated.

A patient diagnosed with a stroke is ordered to receive warfarin (Coumadin). Later, the nurse learns that the warfarin is contraindicated and the order is canceled. The nurse knows that the best alternative medication to give is which of the following? a) Ticlodipine (Ticlid) b) Dipyridamole (Persantine) c) Clopidogrel (Plavix) d) Aspirin

Aspirin If warfarin is contraindicated, aspirin is the best option, although other medications may be used if both are contraindicated.

A client is ordered to undergo CT of the brain with IV contrast. Before the test, the nurse should complete which action first? a) Obtain two large-bore IV lines. b) Obtain a blood sample to evaluate BUN and creatinine concentrations. c) Maintain the client NPO for 6 hours before the test. d) Assess the client for medication allergies.

Assess the client for medication allergies. If a contrast agent is used, the client must be assessed before the CT scan for an iodine/shellfish allergy, because the contrast agent used may be iodine based. If the client has no allergies to shellfish, then kidney function must also be evaluated, as the contrast material is cleared through the kidneys. A suitable IV line for contrast injection and a period of fasting (usually 4 hours) are required before the study. Clients who receive an IV contrast agent are monitored during and after the procedure for allergic reactions and changes in kidney function.

The nurse is assessing a client with a traumatic brain injury after a skateboarding accident. Which sign/symptom is the nurse most concerned about?

Asymmetric pupils

Which term refers to the inability to coordinate muscle movements, resulting difficulty walking? a) Agnosia b) Spasticity c) Rigidity d) Ataxia

Ataxia Ataxia is the inability to coordinate voluntary muscle action; tremors (rhythmic, involuntary movements) noted at rest or during movement suggest a problem in the anatomic areas responsible for balance and coordination. Agnosia is the loss of ability to recognize objects through a particular sensory system. Spasticity is the sustained increase in tension of a muscle when it is passively lengthened or stretched.

Which of the following, if left untreated, can lead to an ischemic stroke?

Atrial fibrillation Explanation: Atrial fibrillation is the most frequently diagnosed arrhythmia in the United States. If left untreated, it can lead to an ischemic stroke. Cerebral hemorrhage, arteriovenous malformation, and cerebral hemorrhage can lead to a hemorrhagic stroke. Cerebral aneurysm, arteriovenous malformations, and ruptured cerebral arteries can lead to hemorrhagic stroke.

___________ testing is done in a sound proof room and is the single most important diagnostic test for detecting hearing loss

Audiometry

Lesions in the temporal lobe may result in which type of agnosia? Auditory Relationship Tactile Visual

Auditory Lesions in the temporal lobe (lateral and superior portions) may result in auditory agnosia. Lesions in the occipital lobe may result in visual agnosia. Lesions in the parietal lobe may result in tactile agnosia. Lesions in the parietal lobe (posteroinferior regions) may result in relationship and body part agnosia.

A client has experienced an ischemic stroke that has damaged the temporal (lateral and superior portions) lobe. Which of the following deficits would the nurse expect during assessment of this client?

Auditory agnosia

A client has experienced an ischemic stroke that has damaged the temporal (lateral and superior portions) lobe. Which of the following deficits would the nurse expect during assessment of this client?

Auditory agnosia Explanation: Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia. If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and lack of motivation. Damage to motor neurons may cause hemiparesis, hemaplegia, and a change in reflexes.

A client is scheduled for an EEG. The client inquires about any diet-related prerequisites before the EEG. Which diet-related advice should the nurse provide to the client? a) Avoid eating food for at least 8 hours before the test b) Include an increased amount of minerals in the diet c) Decrease the amount of minerals in the diet d) Avoid taking sedative drugs or drinks that contain caffeine for at least 8 hours before the test

Avoid taking sedative drugs or drinks that contain caffeine for at least 8 hours before the test The client is advised to refrain from taking sedative drugs or consuming food or drinks that contain caffeine for at least 8 hours before the test, because these may interfere with the EEG result. The client is not advised to increase or decrease the intake of minerals in the diet.

11. For a patient with a SCI, why is it beneficial to give oxygen to maintain a high partial pressure of oxygen (PaO2)? a. So that the patient will not have a respiratory arrest b. Because hypoxemia can create or worsen a neurologic deficit of the spinal cord c. To increase cerebral perfusion pressure d. To prevent secondary brain injury

B

12. A patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit from the application of the halo device? a. It is the only device that can be applied for stabilization of a spinal fracture b. It allows for stabilization of the cervical spine along with early ambulation c. It is less bulky and traumatizing for the patient to use d. The patient can remove it as needed

B

15. A patient has an S5 spinal fracture from a fall. What type of assistive device will this patient require? a. Voice or sip-and-puff controlled electric wheelchair b. Electric or modified manual wheelchair, needs transfer assistance c. Cane d. The patient will be able to ambulate independently

B

The nurse and a colleague are performing the Epley maneuver with a patient who has a diagnosis of benign paroxysmal positional vertigo. The nurses should begin this maneuver by performing what action? A) Placing the patient in a prone position B) Assisting the patient into a sitting position C) Instilling 15 mL of warm normal saline into one of the patient's ears D) Assessing the patient's baseline hearing by performing the whisper test

B

When caring for a patient who had a hemorrhagic stroke, close monitoring of vital signs and neurologic changes is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke of which the nurse should be aware? A) Generalized pain B) Alteration in level of consciousness (LOC) C) Tonic-clonic seizures D) Shortness of breath

B (Feedback: Alteration in LOC is the earliest sign of deterioration in a patient after a hemorrhagic stroke, such as mild drowsiness, slight slurring of speech, and sluggish papillary reaction. Sudden headache may occur, but generalized pain is less common. Seizures and shortness of breath are not identified as early signs of hemorrhagic stroke.)

The nurse is caring for a patient recovering from an ischemic stroke. What intervention best addresses a potential complication after an ischemic stroke? A) Providing frequent small meals rather than three larger meals B) Teaching the patient to perform deep breathing and coughing exercises C) Keeping a urinary catheter in situ for the full duration of recovery D) Limiting intake of insoluble fiber

B (Feedback: Because pneumonia is a potential complication of stroke, deep breathing and coughing exercises should be encouraged unless contraindicated. No particular need exists to provide frequent meals and normally fiber intake should not be restricted. Urinary catheters should be discontinued as soon as possible.)

A preceptor is discussing stroke with a new nurse on the unit. The preceptor would tell the new nurse which cardiac dysrhythmia is associated with cardiogenic embolic strokes? A) Ventricular tachycardia B) Atrial fibrillation C) Supraventricular tachycardia D) Bundle branch block

B (Feedback: Cardiogenic embolic strokes are associated with cardiac dysrhythmias, usually atrial fibrillation. The other listed dysrhythmias are less commonly associated with this type of stroke.)

A patient has been admitted to the ICU after being recently diagnosed with an aneurysm and the patient's admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate into the patient's 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 (Feedback: 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 patient's risk for deep vein thrombosis (DVT).)

A patient has recently begun mobilizing during the recovery from an ischemic stroke. To protect the patient's safety during mobilization, the nurse should perform what action? A) Support the patient's full body weight with a waist belt during ambulation. B) Have a colleague follow the patient closely with a wheelchair. C) Avoid mobilizing the patient in the early morning or late evening. D) Ensure that the patient's family members do not participate in mobilization.

B (Feedback: During mobilization, a chair or wheelchair should be readily available in case the patient suddenly becomes fatigued or feels dizzy. The family should be encouraged to participate, as appropriate, and the nurse should not have to support the patient's full body weight. Morning and evening activity are not necessarily problematic.)

A nurse is caring for a patient diagnosed with a hemorrhagic stroke. When creating this patient's plan of care, what goal should be prioritized? A) Prevent complications of immobility. B) Maintain and improve cerebral tissue perfusion. C) Relieve anxiety and pain. D) Relieve sensory deprivation.

B (Feedback: Each of the listed goals is appropriate in the care of a patient recovering from a stroke. However, promoting cerebral perfusion is a priority physiologic need, on which the patient's survival depends.)

When caring for a patient who has had a stroke, a priority is reduction of ICP. What patient position is most consistent with this goal? A) Head turned slightly to the right side B) Elevation of the head of the bed C) Position changes every 15 minutes while awake D) Extension of the neck

B (Feedback: Elevation of the head of the bed promotes venous drainage and lowers ICP; the nurse should avoid flexing or extending the neck or turning the head side to side. The head should be in a neutral midline position. Excessively frequent position changes are unnecessary.)

A rehabilitation nurse caring for a patient who has had a stroke is approached by the patient's family and asked why the patient has to do so much for herself when she is obviously struggling. What would be the nurse's best answer? A) We are trying to help her be as useful as she possibly can. B) The focus on care in a rehabilitation facility is to help the patient to resume as much self-care as possible. C) We aren't here to care for her the way the hospital staff did; we are here to help her get better so she can go home. D) Rehabilitation means helping patients do exactly what they did before their stroke.

B (Feedback: In both acute care and rehabilitation facilities, the focus is on teaching the patient to resume as much self-care as possible. The goal of rehabilitation is not to be useful, nor is it to return patients to their prestroke level of functioning, which may be unrealistic.)

A family member brings the patient to the clinic for a follow-up visit after a stroke. The family member asks the nurse what he can do to decrease his chance of having another stroke. What would be the nurse's best answer? A) Have your heart checked regularly. B) Stop smoking as soon as possible. C) Get medication to bring down your sodium levels. D) Eat a nutritious diet.

B (Feedback: Smoking is a modifiable and highly significant risk factor for stroke. The significance of smoking, and the potential benefits of quitting, exceed the roles of sodium, diet, and regular medical assessments.)

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 (Feedback: 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. Additional risk factors are increased age, male gender, and excessive alcohol intake. Another high-risk group includes African Americans, where the incidence of first stroke is almost twice that as in Caucasians.)

A patient is scheduled to have an electronystagmography as part of a diagnostic workup for Ménière's disease. What question is it most important for the nurse to ask the patient in preparation for this test? A) Have you ever experienced claustrophobia or feelings of anxiety while in enclosed spaces? B) Do you currently take any tranquilizers or stimulants on a regular basis? C) Do you have a history of falls or problems with loss of balance? D) Do you have a history of either high or low blood pressure?

B *Electronystagmography measures changes in electrical potentials created by eye movements during induced nystagmus. Medications such as tranquilizers, stimulants, or antivertigo agents are withheld for 5 days before the tes *Balance is impaired by MÈniËre's disease; therefore, a patient history of balance problems is important, but is not relevant to test preparation. *Hypertension or hypotension, while important health problems, should not be affected by this test.

A group of high school students is attending a concert, which will be at a volume of 80 to 90 dB. What is a health consequence of this sound level? A) Hearing will not be affected by a decibel level in this range. B) Hearing loss may occur with a decibel level in this range. C) Sounds in this decibel level are not perceived to be harsh to the ear. D) Ear plugs will have no effect on these decibel levels.

B *Sounds louder than 80 dB will damage inner ear

The nurse is caring for a patient who has undergone a mastoidectomy. In an effort to prevent postoperative infection, what intervention should the nurse implement? A) Teach the patient about the risks of ototoxic medications. B) Instruct the patient to protect the ear from water for several weeks. C) Teach the patient to remove cerumen safely at least once per week. D) Instruct the patient to protect the ear from temperature extremes until healing is complete.

B (To prevent infection, the patient is instructed to prevent water from entering the external auditory canal for 6 weeks. Ototoxic medications and temperature extremes do not present a risk for infection. Removal of cerumen during the healing process should be avoided due to the possibility of trauma.)

The nurse is planning the care of a patient who is adapting to the use of a hearing aid for the first time. What is the most significant challenge experienced by a patient with hearing loss who is adapting to using a hearing aid for the first time? A) Regulating the tone and volume B) Learning to cope with amplification of background noise C) Constant irritation of the external auditory canal D) Challenges in keeping the hearing aid clean while minimizing exposure to moisture

B (amplification of background noise is a difficult problem to manage and is the major reason why patients stop using their hearing aid. )

While reviewing the health history of an older adult experiencing hearing loss the nurse notes the patient has had no trauma or loss of balance. What aspect of this patient's health history is most likely to be linked to the patient's hearing deficit? A) Recent completion of radiation therapy for treatment of thyroid cancer B) Routine use of quinine for management of leg cramps C) Allergy to hair coloring and hair spray D) Previous perforation of the eardrum

B (quinne: herbs) *Radiation therapy for cancer should not affect hearing * Allergy to hair products may be associated with otitis externa; *Recurrent otitis media with perforation can affect hearing as a result of chronic inflammation of the ossicles in the middle ear.

The initial blood pressure of a client with a head injury is 124/80 mm Hg. One hour later the pulse pressure increases. Which of the following blood pressure readings indicates a pulse pressure greater than the initial pulse pressure? a) 140/100 mm Hg. b) 160/100 mm Hg. c) 102/60 mm Hg. d) 110/90 mm Hg.

B - 160/100 The pulse pressure is determined by subtracting the diastolic pressure from the systolic pressure. The pulse pressure in this scenario is 60 mm Hg. The client's initial pulse pressure was 44 mm Hg. Widening pulse pressure is a sign of increased intracranial pressure.

Which patients are NOT a candidate for tissue plasminogen activator (tPA) for the treatment of stroke? A. A patient with a CT scan that is negative. B. A patient whose blood pressure is 200/110. C. A patient who is showing signs and symptoms of ischemic stroke. D. A patient who received Heparin 24 hours ago.

B and D. Patients who are experiencing signs and symptoms of a hemorrhagic stroke, who have a BP for >185/110, and has received heparin or any other anticoagulants etc. are NOT a candidate for tPA. *tPA is only for an ischemic stroke.

A rehabilitation nurse caring for a patient who has had a stroke is approached by the patient's family and asked why the patient has to do so much for herself when she is obviously struggling. What would be the nurse's best answer? A) "We are trying to help her be as useful as she possibly can." B) "The focus on care in a rehabilitation facility is to help the patient to resume as much self-care as possible." C) "We aren't here to care for her the way the hospital staff did; we are here to help her get better so she can go home." D) "Rehabilitation means helping patients do exactly what they did before their stroke."

B) "The focus on care in a rehabilitation facility is to help the patient to resume as much self-care as possible."

When caring for a patient who had a hemorrhagic stroke, close monitoring of vital signs and neurologic changes is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke of which the nurse should be aware? A) Generalized pain B) Alteration in level of consciousness (LOC) C) Tonic-clonic seizures D) Shortness of breath

B) Alteration in level of consciousness (LOC)

A preceptor is discussing stroke with a new nurse on the unit. The preceptor would tell the new nurse which cardiac dysrhythmia is associated with cardiogenic embolic strokes? A) Ventricular tachycardia B) Atrial fibrillation C) Supraventricular tachycardia D) Bundle branch block

B) Atrial fibrillation

To alleviate pain associated with trigeminal neuralgia, a patient is taking Tegretol (carbamazepine). What health education should the nurse provide to the patient before initiating this treatment? A) Concurrent use of calcium supplements is contraindicated. B) Blood levels of the drug must be monitored. C) The drug is likely to cause hyperactivity and agitation. D) Tegretol can cause tinnitus during the first few days of treatment.

B) Blood levels of the drug must be monitored.

A patient diagnosed with MS has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen (Lioresal). What should the nurse identify as an expected outcome of this treatment? A) Reduction in the appearance of new lesions on the MRI B) Decreased muscle spasms in the lower extremities C) Increased muscle strength in the upper extremities D) Decreased severity and duration of exacerbations

B) Decreased muscle spasms in the lower extremities

When caring for a patient who has had a stroke, a priority is reduction of ICP. What patient position is most consistent with this goal? A) Head turned slightly to the right side B) Elevation of the head of the bed C) Position changes every 15 minutes while awake D) Extension of the neck

B) Elevation of the head of the bed

The nurse is developing a plan of care for a patient newly diagnosed with Bell's palsy. The nurse's plan of care should address what characteristic manifestation of this disease? A) Tinnitus B) Facial paralysis C) Pain at the base of the tongue D) Diplopia

B) Facial paralysis

A patient has recently begun mobilizing during the recovery from an ischemic stroke. To protect the patient's safety during mobilization, the nurse should perform what action? A) Support the patient's full body weight with a waist belt during ambulation. B) Have a colleague follow the patient closely with a wheelchair. C) Avoid mobilizing the patient in the early morning or late evening. D) Ensure that the patient's family members do not participate in mobilization.

B) Have a colleague follow the patient closely with a wheelchair.

A 69-year-old patient is brought to the ED by ambulance because a family member found him lying on the floor disoriented and lethargic. The physician suspects bacterial meningitis and admits the patient to the ICU. The nurse knows that risk factors for an unfavorable outcome include what? Select all that apply. A) Blood pressure greater than 140/90 mm Hg B) Heart rate greater than 120 bpm C) Older age D) Low Glasgow Coma Scale E) Lack of previous immunizations

B) Heart rate greater than 120 bpm C) Older age D) Low Glasgow Coma Scale

A nurse is caring for a patient diagnosed with a hemorrhagic stroke. When creating this patient's plan of care, what goal should be prioritized? A) Prevent complications of immobility. B) Maintain and improve cerebral tissue perfusion. C) Relieve anxiety and pain. D) Relieve sensory deprivation.

B) Maintain and improve cerebral tissue perfusion.

A patient has been admitted to the ICU after being recently diagnosed with an aneurysm and the patient's admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate into the patient's 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) Maintain the patient on complete bed rest.

A patient with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a patient with this diagnosis? A) Pain upon ankle dorsiflexion of the foot B) Neck flexion produces flexion of knees and hips C) Inability to stand with eyes closed and arms extended without swaying D) Numbness and tingling in the lower extremities

B) Neck flexion produces flexion of knees and hips

A patient with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform? A) Arrange for the patient to receive a low residue diet. B) Position the patient upright during feeding. C) Suction the patient following each meal. D) Withhold liquids until the patient has finished eating.

B) Position the patient upright during feeding.

A male patient presents to the clinic complaining of a headache. The nurse notes that the patient is guarding his neck and tells the nurse that he has stiffness in the neck area. The nurse suspects the patient may have meningitis. What is another well-recognized sign of this infection? A) Negative Brudzinski's sign B) Positive Kernig's sign C) Hyperpatellar reflex D) Sluggish pupil reaction

B) Positive Kernig's sign

The nurse is caring for a patient with multiple sclerosis (MS). The patient tells the nurse the hardest thing to deal with is the fatigue. When teaching the patient how to reduce fatigue, what action should the nurse suggest? A) Taking a hot bath at least once daily B) Resting in an air-conditioned room whenever possible C) Increasing the dose of muscle relaxants D) Avoiding naps during the day

B) Resting in an air-conditioned room whenever possible

A patient with metastatic cancer has developed trigeminal neuralgia and is taking carbamazepine (Tegretol) for pain relief. What principle applies to the administration of this medication? A) Tegretol is not known to have serious adverse effects. B) The patient should be monitored for bone marrow depression. C) Side effects of the medication include renal dysfunction. D) The medication should be first taken in the maximum dosage form to be effective.

B) The patient should be monitored for bone marrow depression.

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) White male, age 60, with history of uncontrolled hypertension

Following a disaster, a client's condition is serious, but she is stable enough to survive if treatment is delayed 6 to 8 hours. What category of triage would the nurse place this client? a) Green b) Yellow c) Red d) Black

B, A client in the yellow category is considered "delayed" triage, meaning the condition is serious, but stable enough for the client to survive if treatment is delayed 6 to 8 hours.

A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following? a) Deep partial-thickness b) Superficial c) Full-thickness d) Superficial partial-thickness

B, A superficial burn only damages the epidermis. A full-thickness burn involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone. In a superficial partial-thickness burn, the epidermis is destroyed and a small portion of the underlying dermis is injured. A deep partial-thickness burn extends into the reticular layer of the dermis and is hard to distinguish from a full-thickness burn. It is red or white, mottled, and can be moist or fairly dry

A client is hospitalized when they present to the Emergency Department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to their presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what? a) Right-sided stroke b) Transient ischemic attack c) Left-sided stroke d) Cerebral aneurysm

B, A transient ischemic attack (TIA) is a sudden, brief attack of neurologic impairment caused by a temporary interruption in cerebral blood flow. Symptoms may disappear within 1 hour; some continue for as long as 1 day. When the symptoms terminate, the client resumes his or her presymptomatic state. The symptoms do not describe a left- or right-sided stroke or a cerebral aneurysm

A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to: a) Measure hourly urinary output. b) Replace lost fluids and electrolytes. c) Prevent renal shutdown. d) Monitor cardiac status.

B, After managing respiratory difficulties, the next most urgent need is to prevent irreversible shock by replacing lost fluids and electrolytes. The total volume and rate of IV fluid replacement are gauged by the patient's response and guided by the resuscitation formula

In a client with burns on the legs, which nursing intervention helps prevent contractures? a) Performing shoulder range-of-motion exercises b) Applying knee splints c) Elevating the foot of the bed d) Hyperextending the client's palms

B, Applying knee splints prevents leg contractures by holding the joints in a position of function. Elevating the foot of the bed can't prevent contractures because this action doesn't hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs.

Which of the following is an accurate statement regarding malignant brain tumors? Select all that apply. a) They are slow-growing. b) They are life-threatening. c) They are rapidly growing. d) They can spread into surrounding tissue. e) They rarely cause death.

B, C,D,Malignant tumors are rapidly growing in nature, can spread into surrounding tissue, and are considered life-threatening.

Which of the following diagnostic studies provides visualization of cerebral blood vessels? a) Positron emission tomography (PET) b) Cerebral angiography c) Computer-assisted stereotactic biopsy d) Cytologic studies of cerebrospinal fluid (CSF)

B, Cerebral angiography provides visualization of cerebral blood vessels and can localize most cerebral trauma. A PET scan measures the brain's activity and is useful in differentiating tumor from scar tissue or radiation necrosis. Cytologic studies of the cerebral spinal fluid (CSF) may be performed to detect malignant cells because central nervous system tumors can shed cells into the CSF. Computer-assisted stereotactic biopsy is being used to diagnose deep-seated brain tumors.

A client has a spinal cord injury. The home health nurse is making an initial visit to the client at home and plans on reinforcing teaching on autonomic dysreflexia. What symptom would the nurse stress to the client and their family? a) Rapid heart rate b) Sweating c) Runny nose d) Slight headache

B, Characteristics of this acute emergency are as follows: severe hypertension; slow heart rate; pounding headache; nausea; blurred vision; flushed skin; sweating; goosebumps (erection of pilomotor muscles in the skin); nasal stuffiness; and anxiety.

A patient has right side brain damage from a stroke. Select all the signs and symptoms that occurs with this type of stroke: A. Right side hemiplegia B. Confusion on date, time, and place C. Aphasia D. Unilateral neglect E. Aware of limitations F. Impulsive G. Short attention span H. Agraphia

B, D, F, and G. Patients who have right side brain damage will have - LEFT side hemiplegia (opposite side) - confused on date, time, and place - unilateral neglect (left side neglect) - DENIAL about limitations - impulsive - short attention span * Agraphia, right side hemiplegia, aware of limitations, and aphasia occur in a LEFT SIDE brain injury.

When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following? a) Decorticate b) Decerebrate c) Flaccid d) Normal

B, Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The described posturing results from cerebral trauma and is not normal. The patient has no motor function, is limp, and lacks motor tone with flaccid posturing. In decorticate posturing, the patient has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.

A patient is in the progressive stage of shock with lung decompensation. What treatment does the nurse anticipate assisting with? a) Thoracotomy with chest tube insertion b) Intubation and mechanical ventilation c) Pericardiocentesis d) Administration of oxygen via venture mask

B, Decompensation of the lungs increases the likelihood that mechanical ventilation will be needed. Administration of oxygen via a mask would be appropriate in the compensatory stage but insufficient in the event of lung decompensation. Periocardiocentesis or thoracotomy with chest tube insertion would not be necessary or appropriate.

A nurse knows to assess a patient with a burn injury for gastrointestinal complications. Which of the following is a sign that indicates the presence of a paralytic ileus? a) Hyperactive bowel sounds b) Decreased peristalsis c) Hematemesis d) Fecal occult blood

B, Decreased peristalsis and hypoactive bowel sounds are manifestations of a paralytic ileus.

A patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit from the application of the halo device? a) It is the only device that can be applied for stabilization of a spinal fracture. b) It allows for stabilization of the cervical spine along with early ambulation. c) It is less bulky and traumatizing for the patient to use. d) The patient can remove it as needed.

B, Halo devices provide immobilization of the cervical spine while allowing early ambulation.

The daughter of a patient with Huntington's disease asks the nurse what the risk is of her inheriting the disease. What is the best response by the nurse? a) "The disease is inherited and all offspring of a parent will develop the disease." b) "If one parent has the disorder, there is a 50% chance that you will inherit the disease." c) "If one parent has the disorder, there is an 75% chance that you will inherit the disease." d) "The disease is not hereditary and therefore there is no risk to you."

B, Huntington disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary choreiform movement and dementia. The disease affects approximately 1 in 10,000 men or women of all races at midlife. It is transmitted as an autosomal dominant genetic disorder; therefore, each child of a parent with Huntington disease has a 50% risk of inheriting the disorder (Ha & Fung, 2012)

In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client? a) Body temperature readings all within normal limits b) A urine output consistently above 40 ml/hour c) A weight gain of 4 lb (2 kg) in 24 hours d) An electrocardiogram (ECG) showing no arrhythmias

B, In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 ml/kg/hour. Thus, the expected urine output of a 155-lb client is 35 ml/hour, and a urine output consistently above 40 ml/hour is adequate. Weight gain from fluid resuscitation isn't a goal. In fact, a 4-lb weight gain in 24 hours suggests third spacing. Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren't primary indicator

Cushing's triad is a late sign of increased intracranial pressure (ICP). Which of the following clinical manifestations correlate with Cushing's triad? a) Tachycardia b) Widening pulse pressure c) Hypotension d) Tachypnea

B, Late signs associated with rising ICP related to the vital signs (Cushing's triad) include hypertension with a widening pulse pressure, bradycardia, and respiratory depression.

Which of the following terms is used to describe edema of the optic nerve? a) Angioneurotic edema b) Papilledema c) Scotoma d) Lymphedema

B, Papilledema is edema of the optic nerve. Scotoma is a defect in vision in a specific area in one or both eyes. Lymphedema is the chronic swelling of an extremity due to interrupted lymphatic circulation, typically from an axillary dissection. Angioneurotic edema is a condition characterized by urticaria and diffuse swelling of the deeper layers of the skin.

Evaluating the level of consciousness using the Glasgow Coma Scale is an essential nursing assessment for a patient who has had an intracerebral hemorrhage. Which of the following scores would indicate the need for immediate intubation? a) 12 b) 8 c) 10 d) 15

B, Scores on the Glasgow Coma Scale range from 3 to 15. A score of 8 or less is cause for immediate intubatio

When preparing for an emergency bioterrorism drill, the nurse instructs the drill volunteers that each biological agent requires specific patient management and medications to combat the virus, bacteria, or toxin. Which of the following statements reflect the patient management of variola virus (smallpox)? a) Acyclovir is effective against smallpox. b) Smallpox spreads rapidly and requires immediate isolation. c) Smallpox is spread by inhalation of spores. d) A vaccination is effective only if administered within 12 to 24 hours of exposure.

B, Smallpox is spread by droplet or direct contact. No antiviral agents are effective against smallpox; however, vaccination within 2 to 3 days of exposure is protective. It spreads rapidly and requires immediate isolation. Even in death, the disease can be transmitted. Vaccination within 2 to 3 days of exposure of the smallpox virus is protective. In 4 to 5 days, vaccination may prevent death and should be administered with vaccinia immune globulin.

A patient is brought to the emergency department with a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for? a) Carotid ultrasound study b) Noncontrast computed tomogram c) Transcranial Doppler flow study d) 12-lead electrocardiogram

B, The initial diagnostic test for a stroke is usually a noncontrast computed tomography (CT) scan. This should be performed within 25 minutes or less from the time the patient presents to the emergency department (ED) to determine if the event is ischemic or hemorrhagic (the category of stroke determines treatment).

Which of the following triage categories refers to life-threatening or potentially life-threatening injury or illness requiring immediate treatment? a) Immediate b) Emergent c) Urgent d) Nonacute

B, The patient triaged as emergent must be seen immediately. The triage category of urgent refers to minor illness or injury needing first-aid-level treatment. The triage category of immediate refers to nonacute, non-life-threatening injury or illness.

You are caring for a client who is in neurogenic shock. You know that this is a subcategory of what kind of shock? a) Carcinogenic b) Circulatory (distributive) c) Hypovolemic d) Obstructive

B, Three types of circulatory (distributive) shock are neurogenic, septic, and anaphylactic shock. There is no such thing as carcinogenic shock. Obstructive and hypovolemic shock do not have subcatagories

In your role as a public health nurse, you offer public education in high school classes on personal responsibility in preventing head injuries as a way of life. While avoiding alcohol and drugs not only complies with existing law for minors, it also is an available intervention to prevent head injuries. Which of the following are measures available to prevent head injuries? a) None of the options are correct b) Using seatbelts c) Holding infants tightly while riding in an automobile d) Lowering neck restraints on seatbacks

B, To reduce the potential for both minor and life-threatening head injuries, the nurse stresses the importance of using seatbelts for all passengers in automobiles.

Several patients that have been involved in a bombing are unlikely to survive. What priority are these patients given during triage? a) Priority 1 b) Priority 4 c) Priority 3 d) Priority 2

B, Triage category "Expectant" is priority 4 (black) and applies to patients with injuries that are extensive and whose chances of survival are unlikely even with definitive care, such as unresponsive patients with penetrating head wounds, high spinal cord injuries, and wounds involving multiple anatomic sites and organs

Which of the following neuroendocrine changes occur within the first 24 hours of a serious burn? a) Sodium loss b) Hyperglycemia c) Polyuria d) Hypoglycemia

B, When the adrenal cortex is stimulated, it releases glucocorticoids , which cause hyperglycemia. Sodium retention leads to peripheral edema. There is a decreased urine output, initially.

Which of the following is an action of the osmotic diuretic mannitol? Select all that apply. a) Decreases seizure activity b) Reduces blood viscosity c) Enhances cerebral blood flow d) Dehydrates brain tissue e) Reduces cerebral edema

B,C,D,E Osmotic diuretics may be administered to dehydrate the brain tissue and reduce cerebral edema. Osmotic diuretics work by creating a gradient that draws water across intact membranes, thereby reducing the volume of the swollen brain. Secondarily, they reduce blood viscosity and hematocrit and enhance cerebral blood flow.

Stress ulcers occur frequently in acutely ill patient. Which of the following medications would be used to prevent ulcer formation? Select all that apply. a) Furosemide (Lasix) b) Lansoprazole (Prevacid) c) Ranitidine (Zantac) d) Desmopressin (DDAVP) e) Famotidine (Pepcid)

B,C,E Antacids, H2 blockers (Pepcid, Zantac), and/or proton pump inhibitors (Prevacid) are prescribed to prevent ulcer formation by inhibiting gastric acid secretion or increasing gastric pH. DDVAP is used in the treatment of diabetes insipidus. Lasix is a loop diuretic and does not prevent ulcer formation.

Which of the following is accurate regarding topical antibacterial therapy? a) They sterilize the wound. b) They are effective against gram-negative organisms. c) They lose their effectiveness over time. d) They are systemically toxic

B,Topical antibacterial therapy is effective against gram-negative organisms and even fungi. They do not sterilize the wound; they simply reduce the number of bacteria. They penetrate the eschar but are not systemically toxic. They do not lose their effectiveness, which would allow another infection to develop.

A patient is admitted with uncontrolled atrial fibrillation. The patient's medication history includes vitamin D supplements and calcium. What type of stroke is this patient at MOST risk for? A. Ischemic thrombosis B. Ischemic embolism C. Hemorrhagic D. Ischemic stenosis

B. If a patient is in uncontrolled a-fib they are at risk for clot formation within the heart chambers. This clot can leave the heart and travel to the brain. Hence, an ischemic embolism type stroke can occur. *An ischemic thrombosis type stroke is where a clot forms within the artery wall of the neck or brain

You receive a patient who is suspected of experiencing a stroke from EMS. You conduct a stroke assessment with the NIH Stroke Scale. The patient scores a 40. According to the scale, the result is: A. No stroke symptoms B. Severe stroke symptoms C. Mild stroke symptoms D. Moderate stroke symptoms

B. Scores on the NIH stroke scale range from 0 to 42, with 0 (no stroke symptoms) and 21-42 (severe stroke symptoms).

What is an anticholinergic medication used to treat Parkinson's disease? A.Benztropine mesylate (Cogentin) B.Diphenhydramine hydrochloride (Benadryl) C.Orphenadrine citrate (Banflex) D.Phenindamine hydrochloride (Neo-Synephrine)

Benztropine mesylate (Cogentin) is an anticholinergic medication used to control of tremor and rigidity and counteracts the action of acetylcholine with Parkinson's disease.

A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment?

Brain CT scan or MRI Explanation: CT scan or MRI differentiates CVA from other disorders and can differentiate between ischemic or hemorrhagic strokes. PT level would be done if the client is receiving anticoagulant therapy. Chest x-ray may be performed if respiratory concerns are indicated. Lumbar puncture would be done if subarachnoid bleeding is suspected.

A 73-year-old client is visiting the neurologist. The client reports light-headedness, speech disturbance, and left-sided weakness that have lasted for several hours. In the examination, an abnormal sound is auscultated in an artery leading to the brain. What is the term for the auscultated discovery? a) Atherosclerotic plaque b) TIA c) Diplopia d) Bruit

Bruit A neurologic examination during an attack reveals neurologic deficits. Auscultation of the artery may reveal a bruit (abnormal sound caused by blood flowing over a rough surface within one or both carotid arteries). The term for the auscultated discovery is bruit.

1. A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as? a. An epidural hematoma b. An extradural hematoma c. An intracerebral hematoma d. A subdural hematoma

C

14. A patient has developed autonomic dysreflexia and all measures to identify a trigger have been unsuccessful. What medication can the nurse provide as prescribed by the healthcare provider to decrease the blood pressure? a. Nifedipine sublingual b. Furosemide IV given rapidly c. Hydralazine hydrochloride IV given slowly d. Bumex rapid bolus IV

C

4. While riding a bicycle in a race, a patient fell into a ditch and sustained a head injury. Another cyclist found the patient lying unconscious in the ditch and called 911. What type of concussion does the patient most likely have? a. Grade 1 concussion b. Grade 2 concussion c. Grade 3 concussion d. Grade 4 concussion

C

A patient diagnosed with an ischemic stroke should be treated within the first 3 hours of symptom onset with which of the following? a) Atorvastatin b) Extended release dipyridamole c) Tissue plasminogen activator (tPA) d) Clopidogrel

C

The nurse is planning the care of a patient with a diagnosis of vertigo. What nursing diagnosis risk should the nurse prioritize in this patient's care? A) Risk for disturbed sensory perception B) Risk for unilateral neglect C) Risk for falls D) Risk for ineffective health maintenance

C

A patient has had an ischemic stroke and has been admitted to the medical unit. What action should the nurse 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 patient's hand in pronation.

C (Feedback: A pillow in the axilla prevents adduction of the affected shoulder and keeps the arm away from the chest. 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 should not be flexed acutely. The hand is placed in slight supination, not pronation, which is its most functional position.)

A patient with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the patient's cardiac and neurologic status, the nurse monitors the patient for signs of what complication? A) Acute pain B) Septicemia C) Bleeding D) Seizures

C (Feedback: Bleeding is the most common side effect of t-PA administration, and the patient is closely monitored for any bleeding. Septicemia, pain, and seizures are much less likely to result from thrombolytic therapy.)

The nurse is discharging home a patient who suffered a stroke. He has a flaccid right arm and leg and is experiencing problems with urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common patient response to a change in body image? A) Denial B) Fear C) Depression D) Disassociation

C (Feedback: Depression is a common and serious problem in the patient who has had a stroke. It can result from a profound disruption in his or her life and changes in total function, leaving the patient with a loss of independence. The nurse needs to encourage the patient to verbalize feelings to assess the effect of the stroke on self-esteem. Denial, fear, and disassociation are not the most common patient response to a change in body image, although each can occur in some patients.)

A patient diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the patient and family needs to begin as soon as the patient is settled on the unit and will continue until the patient is discharged. What will family education need to include? A) How to differentiate between hemorrhagic and ischemic stroke B) Risk factors for ischemic stroke C) How to correctly modify the home environment D) Techniques for adjusting the patient's medication dosages at home

C (Feedback: For a patient with a hemorrhagic stroke, teaching addresses the use of assistive devices or modification of the home environment to help the patient live with the disability. This is more important to the patient's needs than knowing about risk factors for ischemic stroke. It is not necessary for the family to differentiate between different types of strokes. Medication regimens should never be altered without consultation.)

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 patient's plan of care? A) The patient's 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 (Feedback: 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 in flexion and the Trendelenberg position is not indicated.)

The nurse is reviewing the medication administration record of a female patient who possesses numerous risk factors for stroke. Which of the woman's medications carries the greatest potential for reducing her risk of stroke? A) Naproxen 250 PO b.i.d. B) Calcium carbonate 1,000 mg PO b.i.d. C) Aspirin 81 mg PO o.d. D) Lorazepam 1 mg SL b.i.d. PRN

C (Feedback: Research findings suggest that low-dose aspirin may lower the risk of stroke in women who are at risk. Naproxen, lorazepam, and calcium supplements do not have this effect.)

The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps: 1. Change in pH 2. Blood flow decreases 3. A switch to anaerobic respiration 4. Membrane pumps fail 5. Cells cease to function 6. Lactic acid is generated Put these steps in order in which they occur. A) 635241 B) 352416 C) 236145 D) 162534

C (Feedback: The ischemic cascade begins when cerebral blood flow decreases to less than 25 mL per 100 g of blood per minute. At this point, neurons are no longer able to maintain aerobic respiration. The mitochondria must then switch to anaerobic respiration, which generates large amounts of lactic acid, causing a change in the pH. This switch to the less efficient anaerobic respiration also renders the neuron incapable of producing sufficient quantities of adenosine triphosphate (ATP) to fuel the depolarization processes. The membrane pumps that maintain electrolyte balances begin to fail, and the cells cease to function.)

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 (Feedback: The patient and family are provided with information that will enable them to cooperate with the care and restrictions required during the acute phase of hemorrhagic stroke and to prepare the patient to return home. Patient and family teaching includes information about the causes of hemorrhagic stroke and its possible consequences. Symptoms of hydrocephalus include gradual onset of drowsiness and behavioral changes. Hypertension is the most serious risk factor, suggesting that appropriate antihypertensive 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.)

Which of the following nursing interventions would most likely facilitate effective communication with a hearing-impaired patient? A) Ask the patient to repeat what was said in order to evaluate understanding. B) Stand directly in front of the patient to facilitate lip reading. C) Reduce environmental noise and distractions before communicating. D) Raise the voice to project sound at a higher frequency.

C *Asking the patient to repeat what was said is likely to provoke frustration in the patient. A more effective strategy would be to repeat the question or statement, choosing different words. *The nurse cannot assume that the patient reads lips. If the patient does read lips, on average he or she will understand only 50% of words accurately.

A patient has been diagnosed with hearing loss related to damage of the end organ for hearing or cranial nerve VIII. What term is used to describe this condition? A) Exostoses B) Otalgia C) Sensorineural hearing loss D) Presbycusis

C *Exostoses refer to small, hard, bony protrusions in the lower posterior bony portion of the ear canal. *Otalgia = ear pain *Presbycusis is the term used to refer to the progressive hearing loss associated with aging. Atrophy of Cochlear

The clinic nurse is assessing a child who has been brought to the clinic with signs and symptoms that are suggestive of otitis externa. What assessment finding is characteristic of otitis externa? A) Tophi on the pinna and ear lobe B) Dark yellow cerumen in the external auditory canal C) Pain on manipulation of the auricle D) Air bubbles visible in the middle ear

C Otitis Externa: infection of outer ear --- PAIN is most sx *Tophi are deposits of generally painless uric acid crystals; they are a common physical assessment finding in patients diagnosed with gout (chai chan^) *Air bubbles in the middle ear may be visualized with the otoscope; however, these do not indicate a problem involving the ear canal.

A child goes to the school nurse and complains of not being able to hear the teacher. What test could the school nurse perform that would preliminarily indicate hearing loss? A) Audiometry B) Rinne test C) Whisper test D) Weber test

C (A general estimate of hearing can be made by assessing the patient's ability to hear a whispered phrase or a ticking watch, testing one ear at a time) * Audiometry: HCP do it *Rinnie test, Whisper test: conductive sensorineural

Which finding would the nurse most expect to find in a neonate born at 28 weeks' gestation who is diagnosed with intraventricular hemorrhage (IVH)? a) hyperbilirubinemia b) hyperactivity c) bulging fontanels d) increased muscle tone

C - bulging fontanels A common finding of IVH is a bulging fontanel. The most common site of hemorrhage is the periventricular subependymal germinal matrix, where there is a rich blood supply and where the capillary walls are thin and fragile. Rapid volume expansion, hypercarbia, and hypoglycemia contribute to the development of IVH. Other common manifestations include neurologic signs such as hypotonia, lethargy, temperature instability, nystagmus, apnea, bradycardia, decreased hematocrit, and increasing hypoxia. Seizures also may occur. Hyperbilirubinemia refers to an increase in bilirubin in the blood and may be seen if bleeding was severe.

A nurse is aware that antipsychotic medications may cause: a) increased coagulation time. b) increased insulin production. c) lower seizure threshold. d) increased risk of heart failure.

C - lower seizure threshold Antipsychotic medications affect brain neurotransmitters in a way that lowers the seizure threshold and can, therefore, increase the risk of seizure activity. Antipsychotics don't affect insulin production or coagulation time. Heart failure isn't an adverse effect of antipsychotic agents.

The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps: 1. Change in pH 2. Blood flow decreases 3. A switch to anaerobic respiration 4. Membrane pumps fail 5. Cells cease to function 6. Lactic acid is generated Put these steps in order in which they occur. A) 635241 B) 352416 C) 236145 D) 162534

C) 236145

A community health nurse is giving an educational presentation about stroke and heart disease at the local senior citizens center. What nonmodifiable risk factor for stroke should the nurse cite? A) Female gender B) Asian American race C) Advanced age D) Smoking

C) Advanced age

The nurse is reviewing the medication administration record of a female patient who possesses numerous risk factors for stroke. Which of the woman's medications carries the greatest potential for reducing her risk of stroke? A) Naproxen 250 PO b.i.d. B) Calcium carbonate 1,000 mg PO b.i.d. C) Aspirin 81 mg PO o.d. D) Lorazepam 1 mg SL b.i.d. PRN

C) Aspirin 81 mg PO o.d.

The nurse is discharging a patient home after surgery for trigeminal neuralgia. What advice should the nurse provide to this patient in order to reduce the risk of injury? A) Avoid watching television or using a computer for more than 1 hour at a time. B) Use OTC antibiotic eye drops for at least 14 days. C) Avoid rubbing the eye on the affected side of the face. D) Rinse the eye on the affected side with normal saline daily for 1 week.

C) Avoid rubbing the eye on the affected side of the face.

A patient with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the patient's cardiac and neurologic status, the nurse monitors the patient for signs of what complication? A) Acute pain B) Septicemia C) Bleeding D) Seizures

C) Bleeding

A 33-year-old patient presents at the clinic with complaints of weakness, incoordination, dizziness, and loss of balance. The patient is hospitalized and diagnosed with MS. What sign or symptom, revealed during the initial assessment, is typical of MS? A) Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes B) Flexor spasm, clonus, and negative Babinski's reflex C) Blurred vision, intention tremor, and urinary hesitancy D) Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs

C) Blurred vision, intention tremor, and urinary hesitancy

A patient is admitted through the ED with suspected St. Louis encephalitis. The unique clinical feature of St. Louis encephalitis will make what nursing action a priority? A) Serial assessments of hemoglobin levels B) Blood glucose monitoring C) Close monitoring of fluid balance D) Assessment of pain along dermatomes

C) Close monitoring of fluid balance

A patient is being admitted to the neurologic ICU with suspected herpes simplex virus encephalitis. What nursing action best addresses the patient's complaints of headache? A) Initiating a patient-controlled analgesia (PCA) of morphine sulfate B) Administering hydromorphone (Dilaudid) IV as needed C) Dimming the lights and reducing stimulation D) Distracting the patient with activity

C) Dimming the lights and reducing stimulation

A patient diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the patient and family needs to begin as soon as the patient is settled on the unit and will continue until the patient is discharged. What will family education need to include? A) How to differentiate between hemorrhagic and ischemic stroke B) Risk factors for ischemic stroke C) How to correctly modify the home environment D) Techniques for adjusting the patient's medication dosages at home

C) How to correctly modify the home environment

A nurse is planning the care of a 28-year-old woman hospitalized with a diagnosis of myasthenia gravis. What approach would be most appropriate for the care and scheduling of diagnostic procedures for this patient? A) All at one time, to provide a longer rest period B) Before meals, to stimulate her appetite C) In the morning, with frequent rest periods D) Before bedtime, to promote rest

C) In the morning, with frequent rest periods

1. A patient has had an ischemic stroke and has been admitted to the medical unit. What action should the nurse 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 patient's hand in pronation.

C) Place a pillow in the axilla when there is limited external rotation.

A patient with Guillain-Barré syndrome has experienced a sharp decline in vital capacity. What is the nurse's most appropriate action? A) Administer bronchodilators as ordered. B) Remind the patient of the importance of deep breathing and coughing exercises. C) Prepare to assist with intubation. D) Administer supplementary oxygen by nasal cannula.

C) Prepare to assist with intubation.

The critical care nurse is admitting a patient in myasthenic crisis to the ICU. The nurse should prioritize what nursing action in the immediate care of this patient? A) Suctioning secretions B) Facilitating ABG analysis C) Providing ventilatory assistance D) Administering tube feedings

C) Providing ventilatory assistance

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) Take antihypertensive medication as ordered.

A 48-year-old patient has been diagnosed with trigeminal neuralgia following recent episodes of unilateral face pain. The nurse should recognize what implication of this diagnosis? A) The patient will likely require lifelong treatment with anticholinergic medications. B) The patient has a disproportionate risk of developing myasthenia gravis later in life. C) The patient needs to be assessed for MS. D) The disease is self-limiting and the patient will achieve pain relief over time.

C) The patient needs to be assessed for MS.

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 patient's plan of care? A) The patient's 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) The patient should be placed in a prone position for 15 to 30 minutes several times a day.

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) To remove atherosclerotic plaques blocking cerebral flow

Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura? a) Intracerebral b) Cerebral c) Subdural d) Epidural

C, A subdural hematoma results from venous bleeding, with blood gradually accumulating in the space below the dura. An epidural hematoma stems from arterial bleeding, usually from the middle meningeal artery, and blood accumulation above the dura. An intracerebral hematoma is bleeding within the brain that results from an open or closed head injury or from a cerebrovascular condition such as a ruptured cerebral aneurysm. A cerebral hematoma is bleeding within the skull.

A vasoactive medication is prescribed for a patient in shock to help maintain MAP and hemodynamic stability. A medication that acts on the alpha-adrenergic receptors of the SNS is ordered. Its purpose is to: a) Decrease heart rate. b) Vasodilate the skeletal muscles. c) Constrict blood vessels in the cardiorespiratory system. d) Relax the bronchioles.

C, Alpha- and beta-adrenergic receptors work synergistically to improve hemodynamic stability. Alpha receptors constrict blood vessels in the cardiorespiratory and gastrointestinal systems, as well as in the skin and kidneys.

Which Glasgow Coma Scale score is indicative of a severe head injury? a) 13 b) 9 c) 7 d) 11

C, 7 A score of 8 or less is generally accepted as indicating a severe head injury

A health care provider needs help in identifying the precise location of a brain tumor. To measure brain activity, as well as to determine structure, the nurse expects the health care provider to order which of the following tests? a) MRI b) Computed tomography (CT) c) Positron-emission tomography (PET) d) Computer-assisted stereotactic biopsy

C, A PET scan is most diagnostic for brain activity, as well as for assessment of tumor size. It can also be useful in differentiating a tumor from scar tissue or radiation necrosi

A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase should the nurse add to complete the nursing diagnosis statement? a) Related to difficulty swallowing b) Related to psychomotor seizures c) Related to impaired balance d) Related to visual field deficits

C, A client with a cerebellar brain tumor may suffer injury from impaired balance as well as disturbed gait and incoordination. Visual field deficits, difficulty swallowing, and psychomotor seizures may result from dysfunction of the pituitary gland, pons, occipital lobe, parietal lobe, or temporal lobe — not from a cerebellar brain tumor. Difficulty swallowing suggests medullary dysfunction. Psychomotor seizures suggest temporal lobe dysfunction

Which type of burn injury requires skin grafting? a) Superficial b) Deep partial-thickness c) Full-thickness d) Superficial partial-thickness

C, A full-thickness burn injury heals by contraction or epithelial migration and requires grafting. The other types of burn injury do not require skin grafting.

A halo sign is indicative of which of the following complication of brain injury? a) Seizure b) Ischemia c) Cerebrospinal fluid (CSF) leak d) Cerebral edema

C, A halo sign (a blood stain surrounded by a yellowish stain) may be seen on bed linens or on the head dressing and is highly suggestive of a CSF leak. A positive halo sign is not indicative of seizure, cerebral ischemia, or cerebral edema.

What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke? a) Altered intellectual ability b) Aphasia c) Left visual field deficit d) Slow, cautious behavior

C, A left visual field deficit is a common clinical manifestation of a right hemispheric stroke. Aphasia, slow, cautious behavior, and altered intellectual ability are all clinical manifestations of a left hemispheric stroke.

A client has sustained a traumatic brain injury with involvement of the hypothalamus. The nurse is concerned about the development of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus? a) Reposition the client frequently. b) Assess for pupillary response frequently. c) Take daily weights. d) Assess vital signs frequently.

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

You are caring for a client in shock who is deteriorating. You are infusing IV fluids and giving medications as ordered. What type of medications are you most likely giving to this client? a) Hormone antagonist drugs b) Antimetabolite drugs c) Adrenergic drugs d) Anticholinergic drugs

C, Adrenergic drugs are the main medications used to treat shock

The nurse reviews the patient's drug regimen for treatment of a brain tumor. She explains to the patient why one of the following drugs would not be prescribed, even though it might have therapeutic benefits. Which drug would not be prescribed for this patient? a) Paclitaxel b) Decadron c) Coumadin d) Dilantin

C, Although deep vein thrombosis and pulmonary embolism occur in about 15% of patients and cause significant morbidity, anticoagulants are not prescribed due to the risk for CNS hemorrhage.

You are a neuro trauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides? a) Tetraplegia b) Paraplegia c) Autonomic dysreflexia d) Areflexia

C, Autonomic dysreflexia is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury, usually after the spinal shock subsides. Tetraplegia results in the paralysis of all extremities when there is a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Areflexia is a loss of sympathetic reflex activity below the level of injury within 30 to 60 minutes of a spinal injury

A patient is admitted to the emergency room with a fractured skull sustained in a motorcycle accident. The nurse notes fluid leaking from the patient's ears. The nurse knows this is a probable sign of which type of skull fracture? a) Comminuted b) Simple c) Basilar d) Depressed

C, Basilar skull fractures are suspected when cerebrospinal fluid (CSF) escapes from the ears (CSF otorrhea) and/or the nose (CSF rhinorrhea).

A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority? a) Feeding self-care deficit related to neurologic trauma b) Disturbed sensory perception (visual) related to neurologic trauma c) Risk for injury related to neurologic deficit d) Impaired verbal communication related to confusion

C, Because a cerebral contusion causes altered cognition, the nurse should identify Risk for injury related to neurologic deficit as the primary nursing diagnosis and focus on interventions that promote client safety and prevent further injury. Disturbed sensory perception (visual) related to neurologic trauma, Feeding self-care deficit related to neurologic trauma, and Impaired verbal communication related to confusion are pertinent but don't take precedence over client safety

A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following? a) Intracranial pressure is increased by a space-occupying bleed. b) A ruptured arteriovenous malformation will cause deficits until it is stopped. c) Thrombolytic therapy has a time window of only 3 hours. d) A ruptured intracranial aneurysm must quickly be repaired.

C, Currently approved thrombolytic therapy for ischemic strokes has a treatment window of only 3 hours after the onset of symptoms. Urgency is needed on the part of the public for rapid entry into the medical system. The other three choices are related to hemorrhagic strokes

A client is hemorrhaging following chest trauma. Blood pressure is 74/52, pulse rate is 124 beats per minute, and respirations are 32 breaths per minute. A colloid solution is to be administered. The nurse assesses the fluid that is contraindicated in this situation is a) Salt-poor albumin b) Packed red blood cells c) Dextran d) Hetastarch

C, Dextran may interfere with platelet aggregation in clients who are in hypovolemic shock as a result of a hemorrhage. The other options are appropriate solutions to administer in this situation.

A client with a malignant glioma is scheduled for surgery. The client demonstrates a need for additional teaching about the surgery when he states which of the following? a) "My headache and nausea should be lessened somwhat." b) "There will be less cancer left that might be resistant to chemotherapy." c) "The surgeon will be able to remove all of the tumor." d) "Any tissue that was dead will be removed."

C, For clients with malignant gliomas, complete removal of the tumor and cure are not possible but the rationale for resection includes relief of increased intracranial pressure, removal of any necrotic tissue, and reduction in the bulk of the tumor, which theorectically leaves behind fewer cells to become resistant to radiation or chemotherapy.

Which of the following is the only known risk factor for brain tumors? a) Cellular telephones b) Use of hair dyes c) Ionizing radiation d) Head trauma

C, Ionizing radiation is the only known risk factor for brain tumors. Head trauma, use of hair dyes, and use of cellular phones are possible causes that have been investigated.

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)? a) To prevent secondary brain injury b) To increase cerebral perfusion pressure c) Because hypoxemia can create or worsen a neurologic deficit of the spinal cord d) So that the patient will not have a respiratory arrest

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

A 65-year-old client was hit in the head with a ball and knocked unconscious. Upon her arrival at the emergency department and subsequent diagnostic tests, it was determined that she suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would you expect her subdural hematoma to be classified? a) Chronic b) Subacute c) Acute d) Intracerebral

C, Subdural hematomas are classified as acute, subacute, and chronic according to the rate of neurologic changes. Symptoms progressively worsen in a client with an acute subdural hematoma within the first 24 hours of the head injury

When a patient is in the compensatory stage of shock which of the following symptoms occurs? a) Respiratory acidosis b) Urine output of 45 cc/hour c) Tachycardia d) Bradycardia

C, The compensatory stage of shock encompasses a normal blood pressure, tachycardia, decreased urinary output, confusion, and respiratory alkalosis.

A patient has been diagnosed with a lipoma. The nurse explains to the patient that this tumor is located in the part of the brain known as the: a) Optic chiasm. b) Cerebrum. c) Corpus callosum. d) Brainstem.

C, The corpus callosum is a thick collection of nerve fibers that connect both hemispheres of the brain and is responsible for transmitting information from one side of the brain to another. A lipoma only occurs in this area.

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: a) Weakness on one side of the body and difficulty with speech b) Footdrop and external hip rotation c) Severe headache and early change in level of consciousness d) Confusion or change in mental status

C, The main presenting symptoms for ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body, confusion or change in mental status, and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Footdrop and external hip rotation can occur if a stroke victim is not turned or positioned correctly.

A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the physician? a) Crust around the pin insertion site b) A slight reddening of the skin surrounding the insertion site c) A small amount of yellow drainage at the left pin insertion site d) Pain at the insertion site

C, The nurse should report the presence of yellow drainage, which indicates the presence of infection, at the left pin insertion site. Crust formation around the pin site is a natural response to the trauma caused by the pin insertion. Redness at the insertion site may be an early sign of infection; the nurse should continue to monitor the area, but this finding doesn't need to be reported to the physician. The client may experience pain at the pin insertion sites; therefore, the nurse should administer pain medications as ordered. It's necessary to notify the physician only if the pain medication is ineffective.

A patient has been diagnosed with a concussion. He is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the patient to contact the physician or return to the ED if the patient a) complains of headache. b) complains of generalized weakness. c) vomits. d) sleeps for short periods of time.

C, Vomiting is a sign of increasing intracranial pressure and should be reported immediately. In general, the finding of headache in the patient with a concussion is an expected abnormal observation. However, a severe headache should be reported or treated immediately. Weakness of one side of the body should be reported or treated immediately. Difficulty in waking the patient should be reported or treated immediately

A client tells the nurse that they have transient ischemic attacks. The client reports having undergone a carotid artery surgery. In such a case, what important assessments should be performed by the nurse? a) Sexual history b) Blood pressure and weight c) Frequent neurologic checks d) Motor and sensory responses

C, f the client undergoes carotid artery surgery, the nurse performs frequent neurologic checks to detect paralysis, confusion, facial asymmetry, or aphasia. Body weight is measured because obesity, hyperlipidemia, and atherosclerosis are related to cerebrovascular disease, and not in the case of carotid artery surgery. Sexual history and motor and sensory responses are not important assessments to be performed for such clients.

An older adult with a recent history of mixed hearing loss has been diagnosed with a cholesteatoma. What should this patient be taught about this diagnosis? Select all that apply A) Cholesteatomas are benign and self-limiting, and hearing loss will resolve spontaneously. B) Cholesteatomas are usually the result of metastasis from a distant tumor site. C) Cholesteatomas are often the result of chronic otitis media. D) Cholesteatomas, if left untreated, result in intractable neuropathic pain. E) Cholesteatomas usually must be removed surgically

C,E *Cholesteatoma is a tumor of the external layer of the eardrum into the middle ear, often resulting from chronic otitis media. They usually do not cause pain; however, if treatment or surgery is delayed, they may burst or destroy the mastoid bone. They are not normally the result of metastasis and are not self-limiting.

A client comes to the clinic for evaluation because of complaints of dizzinesss and difficulty walking. Further assessment reveals a staggering gait, marked muscle incoordination, and nystagmus. A brain tumor is suspected. Based on the client's assessment findings, the nurse would suspect that the tumor is located in which area of the brain? a) Occipital lobe b) Frontal lobe c) Cerebellum d) Motor cortex

C,Findings such as ataxic or staggering gait, dizziness, marked muscle incoordination, and nystagmus suggest a cerebellar tumor. A frontal lobe tumor frequently produces personality, emotional, and behavioral changes. A tumor in the motor cortex produces seizurelike movements localized on one side of the body. Occipital lobe tumors produce visual manifestations.

A 57-year-old client has been brought to your ED via squad. He is unresponsive and his wife is presenting his recent history. She reports his symptoms of elevated temperature and flushed skin. Physical assessment reveals a rapid, bounding pulse. The high school where the client is employed has had a significant increase in cases of staphylococcal and streptococcal infections among student athletes. His labs show an elevated WBC; cultures are forthcoming. Why is time of the essence in treating this client's condition? a) Cardiogenic shock is the deadliest form of shock b) Anaphylactic shock is the deadliest form of shock c) Septic shock is the deadliest form of shock d) Neurogenic shock is the deadliest form of shock

C,Hypovolemic shock is quite common, but septic shock, a form of distributive shock, is the 10th most common cause of death overall.

In order for tissue plasminogen activator (tPA) to be most effective in the treatment of stroke, it must be administered? A. 6 hours after the onset of stroke symptoms B. 3 hours before the onset of stroke symptoms C. 3 hours after the onset of stroke symptoms D. 12 hours before the onset of stroke symptoms

C. - tPa dissolves the clot causing the blockage in stroke by activating the protein that causes fibrinolysis. - It should be given within 3 hours after the onset of stroke symptoms. It can be given 3 to 4.5 hours after onset IF the patient meets strict criteria. * It is used for acute ischemia stroke, NOT hemorrhagic!!

You are teaching the daughter how to instill ear drops of her father to remove impacted cerumen. What is a priority action to teach this woman? a) Insert the irrigating syringe deeply. b) Refrigerate before instillation. c) Place the container in warm water before instillation. d) Direct the flow of the ear drops toward the eardrum.

C. If irrigation or instillation of liquids is ordered, the nurse should warm the liquid to body temperature by placing the container in warm water. Cold or hot liquids cause dizziness, and the potential for injury exists if the liquid is hot. * The nurse should avoid inserting the irrigating syringe too deeply so as not to close off the auditory canal. * The nurse should direct the flow toward the roof of the canal, rather than the eardrum.

A 76-year-old client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain?

Carotid endarterectomy Explanation: If narrowing of the carotid artery by atherosclerotic plaques is the cause of the TIAs, a carotid endarterectomy (surgical removal of atherosclerotic plaque) is a treatment option. A balloon angioplasty, a procedure similar to a percutaneous transluminal coronary artery angioplasty, is performed to dilate the carotid artery and increase blood flow to the brain. Options A, B, and C are not surgical options to increase blood flow through the carotid artery to the brain.

A client is prescribed warfarin. Client teaching has included instructions to maintain a diet rich in foods that contain vitamin K. What sources of food should the nurse instruct the client to eat?

Cereals, soybeans, and spinach Explanation: Clients who take warfarin (Coumadin) must be informed that they should eat foods rich in vitamin K. Examples of food sources of vitamin K include cabbage, cauliflower, spinach, and other green leafy vegetables, cereals, and soybeans. Other food groups are not known to contain vitamin K. Milk and dairy products are good sources of calcium, while citrus fruits are sources of vitamin C. Fish, meats, and oils are sources of proteins and fats.

A patient recently noted difficulty maintaining his balance and controlling fine movements. The nurse explains that the provider will order diagnostic studies for the part of his brain known as the: a) Midbrain. b) Pons. c) Medulla oblongata. d) Cerebellum.

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

A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom?

Cerebral aneurysm

A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom? a) Cerebral aneurysm b) Cardiogenic emboli c) Large artery thrombosis d) Small artery thrombosis

Cerebral aneurysm A cerebral aneurysm is a type of hemorrhagic stroke that is characterized by an exploding headache.

The physician's office nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm? a)Myelogram b) Cerebral angiography c) Echoencephalography d) Electroencephalogram

Cerebral angiography The nurse would anticipate a cerebral angiography, which detects distortion of the cerebral arteries and veins . A milligram detects abnormalities of the spinal canal. An electroencephalogram records electrical impulses of the brain. An echoencephalography is an ultrasound of the structures of the brain

The nurse is assisting the physician in completing a lumbar puncture. Which would the nurse note as a concern? a) Client reports a piercing feeling. b) Physician maintains aseptic procedure. c) Client reports pressure relief in the head. d) Cerebrospinal fluid is cloudy in nature.

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

Vesicle

Circumscribed, elevated, palpable mass containing serous fluid

During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer?

Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation."

Which occurs when reflexes are hyperactive when the foot is abruptly dorsiflexed? a) Clonus b) Rigidity c) Flaccidity d) Ataxia

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

Which of the following insults or abnormalities can cause an ischemic stroke? a) Arteriovenous malformation b) Intracerebral aneurysm rupture c) Cocaine use d) Trauma

Cocaine use Cocaine is a potent vasoconstrictor and may result in a life-threatening reaction, even with the individual's first use of the drug. Arteriovenous malformations are associated with hemorrhagic strokes. Trauma is associated with hemorrhagic strokes. Intracerebral aneurysm rupture is associated with hemorrhagic strokes.

The critical care nurse is giving end-of-shift report on a client she is caring for. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate? Normal Somnolence Stupor Comatose

Comatose The GSC is used to measure the LOC. The scale consists of three parts: eye opening response, best verbal response, and best motor response. A normal response is 15. A score of 7 or less is considered comatose. Therefore, a score of 6 indicates the client is in a state of coma and not in any other state such as stupor or somnolence. The evaluations are recorded on a graphic sheet where connecting lines show an increase or decrease in the LOC.

Osteoclerosis

Common cause of conductive hearing loss in young adults between the ages of 20-40 years. Gradual hardening that causes the footplate of the stapes to become fixed in the oval window

What is the therapeutic effect of anticholinergics in Parkinson's?

Control of tremor and rigidity, conteracts the action of acetylcholine

The nurse plays a critical role in the initial work-up of a patient with acute stroke symptoms. An immediate decision is to determine if the stroke is ischemic or hemorrhagic. Although there is overlap in some motor, sensory, and cognitive changes, hemorrhagic strokes can be identified by some specific signs. Which of the following signs are consistent with a hemorrhagic stroke? Select all that apply. Numbness or weakness of an extremity Loss of balance Altered level of consciousness Seizures Vomiting Sudden, severe headache

Correct response: Vomiting Sudden, severe headache Seizures * These three signs are usually diagnostic of a hemorrhagic stroke. The other signs can occur with both hemorrhagic and ischemic stroke.

A client recovering from a stroke reports double vision that is preventing the client from effectively completing activities of daily living. How does the nurse help the client compensate?

Covers the affected eye

Sinus tract tumor

Cranial nerve V (Trigeminal)

Bell's Palsy

Cranial nerve Vll (Facial)

Vagal body tumors

Cranial nerve X (Vagus)

Optic neuritis

Cranial nerve ll (Optic)

Pituitary tumor

Cranial nerve ll (Optic)

The ____________ is the phrase used to refer to the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure.

Cushing response

3. The nurse in the emergency department is caring for a patient brought in by the rescue squad after falling from a second-storey window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of? a. Occipital skull fracture b. Temporal skull fracture c. Frontal skull fracture d. Basilar skull fracture

D

A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom? a) Cardiogenic emboli b) Small artery thrombosis c) Large artery thrombosis d) Cerebral aneurysm

D

The nurse understands the urgency of timely intervention for an ischemic stroke. Based on her knowledge of cerebral blood flow (normal CBF = 50 to 55 mL/100 g/min) and obstruction, she is aware that neurons will no longer maintain aerobic respiration at which level of CBF? a) 35 to 45 mL/100 g/min b) 35 to 45 mL/100 g/min c) 45 to 50 mL/100 g/min d) 15 to 20 mL/100 g/min

D

When developing a care plan for a client who has recently suffered a stroke, a nurse includes the nursing diagnosis Risk for imbalanced body temperature. What is the rationale for this diagnosis? a) A decreased body temperature will signal the need to cover the client. b) An elevated body temperature indicates infection. c) An elevated temperature indicates cerebellum malfunction. d) The stroke may have impacted the body's thermoregulation centers.

D

A patient diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse? A) Sit with the patient for a few minutes. B) Administer an analgesic. C) Inform the nurse-manager. D) Call the physician immediately.

D (Feedback: A headache may be an indication that the aneurysm is leaking. The nurse should notify the physician immediately. The physician will decide whether administration of an analgesic is indicated. Informing the nurse-manager is not necessary. Sitting with the patient is appropriate, once the physician has been notified of the change in the patient's condition.)

A nurse in the ICU is providing care for a patient who has been admitted with a hemorrhagic stroke. The nurse is performing frequent neurologic assessments and observes that the patient is becoming progressively more drowsy over the course of the day. What is the nurse's best response to this assessment finding? A) Report this finding to the physician as an indication of decreased metabolism. B) Provide more stimulation to the patient and monitor the patient closely. C) Recognize this as the expected clinical course of a hemorrhagic stroke. D) Report this to the physician as a possible sign of clinical deterioration.

D (Feedback: Alteration in LOC often is the earliest sign of deterioration in a patient with a hemorrhagic stroke. Drowsiness and slight slurring of speech may be early signs that the LOC is deteriorating. This finding is unlikely to be the result of metabolic changes and it is not expected. Stimulating a patient with an acute stroke is usually contraindicated.)

What should be included in the patient's 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 (Feedback: The affected extremities are exercised passively and put through a full ROM four or five times a day to maintain joint mobility, regain motor control, prevent development of a contracture in the paralyzed extremity, prevent further deterioration of the neuromuscular system, and enhance circulation. Active ROM 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 (Feedback: 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 are restricted. The nurse administers all personal care. The patient is fed and bathed to prevent any exertion that might raise BP.)

After a subarachnoid hemorrhage, the patient's laboratory results indicate a serum sodium level of less than 126 mEq/L. What is the nurse's 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 (Feedback: The patient may be experiencing syndrome of inappropriate antidiuretic hormone (SIADH) or cerebral salt-wasting syndrome. The treatment most often is the use of IV hypertonic 3% saline. A normal saline bolus would exacerbate the problem and there is no indication for tests of hypothalamic function or thrombolytic therapy.)

A nursing student is writing a care plan for a newly admitted patient who has been diagnosed with a stroke. What major nursing diagnosis should most likely be included in the patient's plan of care? A) Adult failure to thrive B) Post-trauma syndrome C) Hyperthermia D) Disturbed sensory perception

D (Feedback: The patient who has experienced a stroke is at a high risk for disturbed sensory perception. Stroke is associated with multiple other nursing diagnoses, but hyperthermia, adult failure to thrive, and post-trauma syndrome are not among these.)

A female patient is diagnosed with a right-sided stroke. The patient is now experiencing hemianopsia. How might the nurse help the patient manage her potential sensory and perceptional difficulties? A) Keep the lighting in the patient's room low. B) Place the patient's clock on the affected side. C) Approach the patient on the side where vision is impaired. D) Place the patient's extremities where she can see them.

D (Feedback: The patient with homonymous hemianopsia (loss of half of the visual field) turns away from the affected side of the body and tends to neglect that side and the space on that side; this is called amorphosynthesis. In such instances, the patient cannot see food on half of the tray, and only half of the room is visible. It is important for the nurse to remind the patient constantly of the other side of the body, to maintain alignment of the extremities, and if possible, to place the extremities where the patient can see them. Patients with a decreased field of vision should be approached on the side where visual perception is intact. All visual stimuli (clock, calendar, and television) should be placed on this side. The patient can be taught to turn the head in the direction of the defective visual field to compensate for this loss. Increasing the natural or artificial lighting in the room and providing eyeglasses are important in increasing vision. There is no reason to keep the lights dim.)

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 scapulae forward to avoid excessive force to shoulder.

D (Feedback: 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.)

A patient presents to the ED complaining of a sudden onset of incapacitating vertigo, with nausea and vomiting and tinnitus. The patient mentions to the nurse that she suddenly cannot hear very well. What would the nurse suspect the patient's diagnosis will be? A) Ossiculitis B) Ménière's disease C) Ototoxicity D) Labyrinthitis

D *Labyrinthitis is characterized by a SUNDDEN onset of incapacitating vertigo, usually with nausea and vomiting, various degrees of hearing loss, and possibly tinnitus.

On otoscopy, a red blemish behind the tympanic membrane is suggestive of what diagnosis? A) Acoustic tumor B) Cholesteatoma C) Facial nerve neuroma D) Glomus tympanicum

D *In the case of glomus tympanicum, a red blemish on or behind the tympanic membrane is seen on otoscopy.

The nurse is reviewing the health history of a newly admitted patient and reads that the patient has been previously diagnosed with exostoses. How should the nurse accommodate this fact into the patient's plan of care? A) The nurse should perform the Rinne and Weber tests. B) The nurse should arrange for audiometry testing as soon as possible. C) The nurse should collaborate with the pharmacist to assess for potential ototoxic medications. D) No specific assessments or interventions are necessary to addressing exostoses.

D *Exostoses are small, hard, bony protrusions found in the lower posterior bony portion of the ear canal; they usually occur bilaterally. They do not normally impact hearing and no treatments or nursing actions are usually necessary.

A patient with a sudden onset of hearing loss tells the nurse that he would like to begin using hearing aids. The nurse understands that the health professional dispensing hearing aids would have what responsibility? A) Test the patient's hearing promptly. B) Perform an otoscopy. C) Measure the width of the patient's ear canal. D) Refer the patient to his primary care physician.

D (Health care professionals who dispense hearing aids are required to refer prospective users to a physician if the patient has sudden or rapidly progressive hearing loss. This would be a health priority over other forms of assessment, due to the possible presence of a pathologic process.)

A nurse is teaching preventative measures for otitis externa to a group of older adults. What action should the nurse encourage? A) Rinsing the ears with normal saline after swimming B) Avoiding loud environmental noises C) Instilling antibiotic ointments on a regular basis D) Avoiding the use of cotton swabs

D (Nurses should instruct patients not to clean the external auditory canal with cotton-tipped applicators and to avoid events that traumatize the external canal such as scratching the canal with the fingernail or other objects. Environmental noise should be avoided, but this does not address the risk for ear infection. Routine use of antibiotics is not encouraged and rinsing the ears after swimming is not recommended.)

Following a motorcycle accident, a 17-year-old man is brought to the ED. What physical assessment findings related to the ear should be reported by the nurse immediately? A) The malleus can be visualized during otoscopic examination. B) The tympanic membrane is pearly gray. C) Tenderness is reported by the patient when the mastoid area is palpated. D) Clear, watery fluid is draining from the patient's ear.

D (cerebrospinal fluid associated with skull fracture). *The ability to visualize the malleus (ossicle bone) is a normal physical assessment finding. *The tympanic membrane is normally pearly gray in color. *Tenderness of the mastoid area usually indicates inflammation but NOT emergency

The nurse is assessing a client with a head injury. On admission, the pupils were equal; now the right pupil is fully dilated and nonreactive, and the left pupil is 4 mm and reacts to light. What would this change in neurologic status of the client suggest to the nurse? a) The test was not performed accurately; there was too much light in the examination room. b) This is a normal response after a head injury, and the pupils will be expected to return to normal. c) Decreased intracranial pressure d) Increased intracranial pressure

D - increased intracranial pressure Movement of the eyes should be a balanced and coordinated function. Both pupils should be equal, reactive, and responsive to light and accommodation. Increased intracranial pressure is indicative of compression of the third, fourth, and sixth cranial nerves. The other choices are not reflective of neurologic status.

The client arrives in the emergency department following a bicycle accident in which the client's forehead hit the pavement. The client is diagnosed as having a hyphema. The nurse should place the client in which position? a) supine b) side-lying on the affected side c) side-lying on the unaffected side d) semi-Folwer's

D - semi-fowlers A hyphema is the presence of blood in the anterior chamber of the brain. Hyphema is produced when a force is sufficient to break the integrity of the blood vessels in the eye and can be caused by direct injury, such as penetrating injury from a small bullet or pellet, or indirectly, such as from striking the forehead on the pavement during an accident. The client is treated by bed rest in a semi-Fowler's position to assist gravity in keeping the hyphema away from the optical center of the cornea.

A child has been experiencing recurrent episodes of acute otitis media (AOM). The nurse should anticipate that what intervention is likely to be ordered? A) Ossiculoplasty B) Insertion of a cochlear implant C) Stapedectomy D) Insertion of a ventilation tube

D Eustachian tube = air pressure (If AOM recurs and there is no contraindication, a ventilating, or pressure-equalizing, tube may be inserted. The ventilating tube, which temporarily takes the place of the eustachian tube in equalizing pressure, is retained for 6 to 18 months. ) *cochlear implant => sensorineural hearing loss

The nurse is discharging a patient home after mastoid surgery. What should the nurse include in discharge teaching? A) "Try to induce a sneeze every 4 hours to equalize pressure." B) "Be sure to exercise to reduce fatigue." C) "Avoid sleeping in a side-lying position." D) "Don't blow your nose for 2 to 3 weeks."

D The patient is instructed to avoid heavy lifting, straining, exertion, and nose blowing for 2 to 3 weeks after surgery to prevent dislodging the tympanic membrane graft or ossicular prosthesis. Side-lying is not contraindicated; sneezing could cause trauma

The public health nurse is planning a health promotion campaign that reflects current epidemiologic trends. The nurse should know that hemorrhagic stroke currently accounts for what percentage of total strokes in the United States? A) 43% B) 33% C) 23% D) 13%

D) 13%

The nurse is preparing to provide care for a patient diagnosed with myasthenia gravis. The nurse should know that the signs and symptoms of the disease are the result of what? A) Genetic dysfunction B) Upper and lower motor neuron lesions C) Decreased conduction of impulses in an upper motor neuron lesion D) A lower motor neuron lesion

D) A lower motor neuron lesion

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) Absolute bed rest in a quiet, nonstimulating environment

The nurse caring for a patient in ICU diagnosed with Guillain-Barré syndrome should prioritize monitoring for what potential complication? A) Impaired skin integrity B) Cognitive deficits C) Hemorrhage D) Autonomic dysfunction

D) Autonomic dysfunction

A patient diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse? A) Sit with the patient for a few minutes. B) Administer an analgesic. C) Inform the nurse-manager. D) Call the physician immediately.

D) Call the physician immediately.

A patient with suspected Creutzfeldt-Jakob disease (CJD) is being admitted to the unit. The nurse would expect what diagnostic test to be ordered for this patient? A) Cerebral angiography B) ABG analysis C) CT D) EEG

D) EEG

What should be included in the patient's 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) Exercise the affected extremities passively four or five times a day.

The nurse is creating a plan of care for a patient who has a recent diagnosis of MS. Which of the following should the nurse include in the patient's care plan? A) Encourage patient to void every hour. B) Order a low-residue diet. C) Provide total assistance with all ADLs. D) Instruct the patient on daily muscle stretching.

D) Instruct the patient on daily muscle stretching.

A 73-year-old man comes to the clinic complaining of weakness and loss of sensation in his feet and legs. Assessment of the patient shows decreased reflexes bilaterally. Why would it be a challenge to diagnose a peripheral neuropathy in this patient? A) Older adults are often vague historians. B) The elderly have fewer peripheral nerves than younger adults. C) Many older adults are hesitant to admit that their body is changing. D) Many symptoms can be the result of normal aging process.

D) Many symptoms can be the result of normal aging process.

A patient presents at the clinic complaining of pain and weakness in her hands. On assessment, the nurse notes diminished reflexes in the upper extremities bilaterally and bilateral loss of sensation. The nurse knows that these findings are indicative of what? A) Guillain-Barré syndrome B) Myasthenia gravis C) Trigeminal neuralgia D) Peripheral nerve disorder

D) Peripheral nerve disorder

A female patient is diagnosed with a right-sided stroke. The patient is now experiencing hemianopsia. How might the nurse help the patient manage her potential sensory and perceptional difficulties? A) Keep the lighting in the patient's room low. B) Place the patient's clock on the affected side. C) Approach the patient on the side where vision is impaired. D) Place the patient's extremities where she can see them.

D) Place the patient's extremities where she can see them.

After a subarachnoid hemorrhage, the patient's laboratory results indicate a serum sodium level of less than 126 mEq/L. What is the nurse's 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) Prepare to administer 3% NaCl by IV as ordered.

A nurse in the ICU is providing care for a patient who has been admitted with a hemorrhagic stroke. The nurse is performing frequent neurologic assessments and observes that the patient is becoming progressively more drowsy over the course of the day. What is the nurse's best response to this assessment finding? A) Report this finding to the physician as an indication of decreased metabolism. B) Provide more stimulation to the patient and monitor the patient closely. C) Recognize this as the expected clinical course of a hemorrhagic stroke. D) Report this to the physician as a possible sign of clinical deterioration.

D) Report this to the physician as a possible sign of clinical deterioration.

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 scapulae forward to avoid excessive force to shoulder.

D) The patient should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder.

The nurse caring for a patient diagnosed with Guillain-Barré syndrome is planning care with regard to the clinical manifestations associated this syndrome. The nurse's communication with the patient should reflect the possibility of what sign or symptom of the disease? A) Intermittent hearing loss B) Tinnitus C) Tongue enlargement D) Vocal paralysis

D) Vocal paralysis

A patient diagnosed with Bell's palsy is having decreased sensitivity to touch of the involved nerve. What should the nurse recommend to prevent atrophy of the muscles? A) Blowing up balloons B) Deliberately frowning C) Smiling repeatedly D) Whistling

D) Whistling

Which of the following is not a manifestation of Cushing's Triad? a) Bradycardia b) Bradypnea c) Hypertension d) Tachycardia

D, Cushing's triad is manifested by bradycardia, hypertension, and bradypnea. Tachycardia is not a component of the triad.

During a mass casualty event, a person whose injuries are extensive and whose chances of survival are unlikely even with definitive care would receive which color tag? a) Red b) Yellow c) Green d) Black

D, A black tag means expectant death, and that the injuries are extensive and chances of survival are unlikely even with definitive care. A green tag is used when injuries are minor and treatment can be delayed hours to days. A red tag means that the person's injuries are life-threatening but survivable with minimal intervention. A yellow tag indicates a person whose injuries are significant and require medical care, but can wait hours without threat to life or limb

Which of the following types of skull fractures may be evident by Battle's sign? a) Comminuted b) Depressed c) Simple d) Basilar

D, A clinical manifestation of a basilar skull fracture is the Battle's sign (an area of ecchymosis may be seen over the mastoid). A simple (linear) fracture is a break in continuity of the bone. A comminuted skull fracture refers to a splintered fracture line. When bone fragments are embedded into the brain tissue, the fracture is depressed.

A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the: a) Entire dermis and subcutaneous tissue. b) Dermis and connective tissue. c) Epidermal layer only. d) Epidermis and a portion of deeper dermis.

D, A deep partial-thickness burn includes the epidermis, upper dermis, and a portion of the deeper dermis. A burn limited to the epidermal layer is classified as a superficial partial-thickness burn. The last two choices refer to a full-thickness burn

During a disaster, the nurse sees a victim with a green triage tag. The nurse knows that the person has which type of injuries? a) Significant and require medical care, but can wait hours without threat to life or limb b) Life-threatening but survivable with minimal intervention c) Extensive and chances of survival are unlikely even with definitive care d) Minor and treatment can be delayed hours to days

D, A green triage tag (priority 3 or minimal) indicates injuries that are minor and treatment can be delayed hours to days. A red triage tag (priority 1 or immediate) indicates injuries that are life threatening but survivable with minimal intervention. A yellow triage tag (priority 2 or delayed) indicates injuries that are significant and require medical care, but can wait hours without threat to life or limb. A black triage tag (priority 4 or expectant) indicates injuries that are extensive and chances of survival are unlikely even with definitive care.

A 37-year-old mother of three has just been diagnosed with a grade I meningioma. As part of patient education, the nurse tells the patient that: a) The tumor will cause pressure on the eighth cranial nerve. b) The tumor is malignant and aggressive. c) Surgery, which can result in complete removal of the possible tumor, should be done as soon as possible. d) Growth is slow and symptoms are caused by compression rather than tissue invasion.

D, A meningioma is benign, encapsulated, and slow-growing. Sometimes the patient has no symptoms because of the slow-growing nature of the tumo

You are the nurse caring for a client in septic shock. You know to closely monitor your client. What finding would you observe when the client's condition is in its initial stages? a) A weak and thready pulse b) A slow and imperceptible pulse c) A slow but steady pulse d) A rapid, bounding pulse

D, A rapid, bounding pulse is observed in a client in the initial stages of septic shock. In case of hypovolemic shock, the pulse volume becomes weak and thready and circulating volume diminishes in the initial stage. In the later stages when the circulating volume has severely diminished, the pulse becomes slow and imperceptible and pulse rhythm changes from regular to irregular

Hyperglycemia for a patient with a TBI may worsen the outcome of recovery. Select a serum glucose level that is considered critical. a) 120 mg/dL b) 80 mg/dL c) 140 mg/dL d) 180 mg/dL

D, A serum glucose level of over 150 mg/dL is considered a critical value.

A person suffers leg burns from spilled charcoal lighter fluid. A family member extinguishes the flames. While waiting for an ambulance, what should the burned person do? a) Sit in a chair, elevate his legs, and have someone cut his pants off around the burned area. b) Lie down, have someone cover him with a blanket, and cover his legs with petroleum jelly. c) Remove his burned pants so that the air can help cool the wound. d) Have someone assist him into a bath of cool water, where he can wait for emergency personnel.

D, After the flames are extinguished, the burned area and adherent clothing are soaked with cool water, briefly, to cool the wound and halt the burning process

Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels? a) L4 b) T10 c) S2 d) T6

D, Any patient with a lesion above T6 segment is informed that autonomic dysreflexia can occur and that it may occur even years after the initial injury.

A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase? a) Related to femoral artery occlusion b) Related to fat emboli c) Related to infection d) Related to circumferential eschar

D, As edema develops on circumferential burns, eschar forms a tight, constricting band, compromising circulation to the extremity distal to the circumferential site and impairing physical mobility. This client isn't likely to develop fat emboli unless long bone or pelvic fractures are present. Infection doesn't alter physical mobility. A client with burns on the lower portions of both legs isn't likely to have femoral artery occlusion

An alarm has reached your ED regarding a serious MVA between a full tour bus and a school bus — the number of casualties expected is quite high. While part of your staff is sent to the accident site, the remaining staff readies your unit for mass traumas. At the accident site, your practice begins. As a nurse, what would you expect as your top priority? a) Organize volunteers b) Set-up communication system c) Get forms ready for completion d) Assess as many victims as possible at the site

D, Assess as many victims as possible at the scene of the disaster to manage time efficiently and to avoid overwhelming valuable resources

A client with quadriplegia is in spinal shock. What finding should the nurse expect? a) Positive Babinski's reflex along with spastic extremities b) Spasticity of all four extremities c) Hyperreflexia along with spastic extremities d) Absence of reflexes along with flaccid extremities

D, During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the client will demonstrate positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities

A patient had a carotid endarterectomy yesterday and when the nurse arrived in the room to perform an assessment, the patient states, "All of a sudden, I am having trouble moving my right side." What concern should the nurse have about this complaint? a) Surgical wound infection b) This is a normal occurrence after an endarterectomy and would not be a concern. c) Bleeding from the endarterectomy site d) A thrombus formation at the site of the endarterectomy

D, Formation of a thrombus at the site of the endarterectomy is suspected if there is a sudden new onset of neurologic deficits, such as weakness on one side of the body.

A patient with a brain tumor is complaining of headaches that are worse in the morning. What does the nurse know could be the reason for the morning headaches? a) The tumor is shrinking. b) Migraines c) Dehydration d) Increased intracranial pressure

D, Headache, although not always present, is most common in the early morning and is made worse by coughing, straining, or sudden movement. It is thought to be caused by the tumor invading, compressing, or distorting the pain-sensitive structures or by edema that accompanies the tumor, leading to increased intracranial pressure.

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? a) Urine output of 70 ml the first hour b) Moderate to severe pain c) Complaints of intense thirst d) Hoarseness of the voice

D, Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss, leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The client's urine output is adequate.

Which of the following terms refers to blindness in the right or left halves of the visual fields of both eyes? a) Scotoma b) Nystagmus c) Diplopia d) Homonymous hemianopsia

D, Homonymous hemianopsia occurs with occipital lobe tumors. Scotoma refers to a defect in vision in a specific area in one or both eyes. Diplopia refers to double vision or the awareness of two images of the same object occurring in one or both eyes. Nystagmus refers to rhythmic, involuntary movements or oscillations of the eyes

The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regime, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is: a) Smoking b) Dyslipidemia c) Obesity d) Hypertension

D, Hypertension is the most modifiable risk factor for either ischemic or hemorrhagic stroke. Unfortunately, it remains under-recognized and undertreated in most communities.

Loss of 15% to 30% of blood volume would be classified as which type of shock? a) Class I b) Class III c) Class IV d) Class II

D, Loss of 15% to 30% of blood volume is classified as Class II hemorrhage. A Class I hemorrhage is loss of up to 15% of blood volume. Class III is loss of 30% to 40% of blood volume. Class IV is loss of >40% of blood volume.

Which category of the traditional triage system is reserved for patients who do not have life-threatening illnesses? a) Fast-track b) Urgent c) Emergent d) Nonurgent

D, Nonurgent patients are those who do not have life-threatening illnesses. Emergent patients are the highest priority or may have life-threatening injuries. Urgent patients are those with serious health problems that are not considered immediately life-threatening. Fast-track patients are those who require simple first aid.

A client is experiencing septic shock and infrequent bowel sounds. To ensure adequate nutrition, the nurse administers a) A full liquid diet b) An infusion of crystalloids at an increased rate of flow c) Isotonic enteral nutrition every 6 hours d) A continuous infusion of total parenteral nutrition

D, Nutritional supplementation is initiated within 24 hours of the start of septic shock. If the client has reduced peristalsis, then parenteral feedings will be required. Full liquid diet and enteral nutrition require the oral route and would be contraindicated if the client is experiencing decreased peristalsis. Increasing the rate of crystalloids does not provide adequate nutrition.

A patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the physician sutures the wound? a) Shaves the hair around the wound b) Administers acetaminophen (Tylenol) for headache c) Administers an oral analgesic for pain d) Irrigates the wound to remove debris

D, Scalp wounds are potential portals of entry for organisms that cause intracranial infections. Therefore, the area is irrigated before the laceration is sutured to remove foreign material and to reduce the risk for infection

Which of the following is a clinical manifestation of cardiac tamponade? a) Bradycardia b) Hypertension c) Widening pulse pressure d) Narrowing pulse pressure

D, Signs and symptoms of cardiac tamponade include narrowing pulse pressure, chest pain, distant or muffled heart sounds, jugular vein distention, hypotension, and tachycardia.

When describing the use of smallpox as a biologic agent, which of the following would the nurse include as the primary means of infection? a) Inhalation b) Percutaneous absorption c) Ingestion d) Direct contact

D, Smallpox is extremely contagious and infection occurs by direct contact, contact with clothing or linens, or droplets from person to person only after the fever has decreased and the rash phase has begun. Anthrax occurs via inhalation, skin contact, or gastrointestinal ingestion. Nerve agents can be precutaneously absorbed

A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned? a) 18% b) 27% c) 30% d) 36%

D, The Rule of Nines divides body surface area into percentages that, when totaled, equal 100%. According to the Rule of Nines, the arms account for 9% each, the anterior legs account for 9% each, and the anterior trunk accounts for 18%. Therefore, this client's burns cover 36% of the body surface area

A confused client exhibits a blood pressure of 112/84, pulse rate of 116 beats per minute, and respirations of 30 breaths per minute. The client's skin is cold and clammy. The nurse next a) Calls the Rapid Response Team b) Re-assesses the vital signs c) Contacts the admitting physician d) Administers oxygen by nasal cannula at 2 liters per minute

D, The client is exhibiting the compensatory stage of shock. The nurse performs all the listed options. The nurse needs to address physiological needs first by administering oxygen.

In a biologic attack with anthrax, which ingestion route develops into the most severe form of anthrax? a) Acquired by ingestion b) Acquired by contact with body fluids or contaminated objects c) Acquired by skin infection d) Acquired by inhalation

D, The most severe form of anthrax develops by inhalation. At the onset, it may be mistaken for a cold or flu, but if it is diagnosed wrongly and untreated, the infection can progress to severe respiratory distress and almost certain death.

From which direction should a nurse approach a client who is blind in the right eye? a) From directly behind the client b) From the right side of the client c) From directly in front of the client d) From the left side of the client

D, The nurse should approach the client from the left side so that the client can be aware of the nurse's approach. Likewise, personal items should be placed on the client's left side so that he can see them easily.

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene? a) Insert a 20-gauge I.V. catheter and infuse normal saline solution at 150 ml/hour. b) Do nothing until the chemical agent is identified. c) Wash the wounds with soap and water and apply a barrier cream. d) Irrigate the wounds with water.

D, The nurse should begin treatment by irrigating the wounds with water. Delaying treatment until the agent is identified allows the agent to cause further tissue damage. Washing the wounds with soap and water might cause a chemical reaction that may further damage tissue. The client may require I.V. fluid; however, the wounds should be irrigated first.

A patient has been diagnosed with a brain tumor, a glioblastoma multiforme. The nurse met with the family after the diagnosis to help them understand that: a) The tumor rarely spreads to other parts of the body. b) Chemotherapy, following surgery, has recently been shown to be a highly effective treatment. c) Radiation is not an option because of the tumor's location near the brainstem. d) Surgery can improve survival time but the results are not guaranteed.

D, The overall prognosis for this type of aggressive brain tumor is poor but surgery can improve survival time.

A nursing instructor is describing the role of a nurse during a disaster. Which of the following would best reflect the nurse's role? a) Provision of comprehensive client-specific care b) Client care within the area of expertise c) Directly specified by the physician in charge d) Variable depending on the needs of the situation

D, The role of the nurse during a disaster varies and depends on the needs or situation. Nurses may be asked to perform duties outside their areas of expertise and may take on responsibilities normally held by physicians or advanced practice nurses. During a disaster, nursing care focuses on essential care from a perspective of what is best for all clients.

A client has undergone surgery for a spinal cord tumor that was located in cervical area. The nurse would be especially alert for which of the following? a) Bowel incontinence b) Skin breakdown c) Hemorrhage d) Respiratory dysfunction

D, When a spinal tumor is located in the cervical area, respiratory compromise may occur from postoperative edema. Hemorrhage would be a concern with any surgery. Bowel incontinence and skin breakdown are possible but not specific to cervical spinal tumors.

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing: a) nuchal rigidity and Kernig's sign. b) motor loss in the legs that exceeds that in the arms. c) pupillary changes. d) raccoon's eyes and Battle sign.

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

A nurse practitioner visits a patient in a cardiac care unit. She assesses the patient for shock, knowing that the primary cause of cardiogenic shock is: a) Cardiomyopathies. b) Arrhythmias. c) Valvular damage. d) A myocardial infarction.

D,Cardiogenic shock is seen most frequently as a result of a myocardial infarction.

A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment: a) NS at 60 mL/hr via an intravenous line b) Dopamine (Intropin) intravenous solution c) Morphine 2 mg intravenously d) Oxygen at 2 L/min by nasal cannula

D,In the early stages of cardiogenic shock, the nurse first administers supplemental oxygen to achieve an oxygen saturation exceeding 90%. The nurse may then administer morphine to relieve chest pain and/or to reduce the workload of the heart and decrease client anxiety. Intravenous fluids are given carefully to prevent fluid overload. Vasoactive medications, such as dopamine, are then administered to restore and maintain cardiac output.

A client has a 12-year history of migraine headaches and is frustrated over how these headaches impact lifestyle. The nurse discusses the potential triggers of the client's migraines. Which is not a potential trigger to migraines? a. medications b. reproductive hormone fluctuations c. specific food chemicals d. seasonal changes

D. Researchers believe the contributing cofactors for the cause of migraines are from changes in serotonin receptors that promote dilation of cerebral blood vessels and pain intensification from neurochemicals released from the trigeminal nerve. It has been suggested that fluctuations in reproductive hormones, chemicals in certain foods, and medications can trigger migraines.

The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke? a. Severe headache and early change in level of consciousness b. Vomiting and seizures c. Footdrop and external hip rotation d .Weakness on one side of the body and difficulty with speech

D. The main presenting symptoms for an ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body; confusion or change in mental status; and trouble speaking or understanding speech.

A patient has recently been diagnosed with an acoustic neuroma. The nurse helps the patient understand that: a) Almost 80% of these tumors become malignant over time. b) Surgery is never needed; radiation has proven very effective. c) Compression of the seventh cranial nerve is a side effect. d) Hearing loss usually occurs.

D. An acoustic neuroma is a benign tumor of the eighth cranial nerve. About 50% can be treated with surgery. Hearing loss always occurs. Compression on the fifth cranial nerve can also cause facial paresthesia.

A client who is at high-risk for a cerebrovascular accident has medication ordered to lower their cholesterol and to prophylactically anticoagulate them. What specific agent might be diagnosed for this client?

Daily aspirin Explanation: To manage atherosclerosis and the consequences of cardiac dysrhythmias, especially atrial fibrillation, cholesterol-lowering drugs and prophylactic anticoagulant or antiplatelet therapy are prescribed. Specific agents include daily aspirin as well as antiplatelet or anticoagulant therapy such as clopidogrel (Plavix), ticlopidine (Ticlid), warfarin (Coumadin), and dipyridamole (Persantine). Heparin is not the drug of choice for prophylactic anticoagulation therapy. Victorin is a distractor for this question. Celebrex is not a drug to lower cholesterol or anticoagulate.

Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities?

Decorticate posturing is an abnormal posture associated with severe brain injury, characterized by abnormal flexion of the upper extremities and extension of the lower extremities. *Decerebration is an abnormal body posture associated with a severe brain injury, characterized by extreme extension of the upper and lower extremities. Flaccidity occurs when the client has no motor function, is limp, and lacks motor tone.

Which of the following is a sympathetic nervous system effect? a) Decreased peristalsis b) Constricted pupils C) Decreased blood pressure d)Constricted bronchioles

Decreased peristalsis Sympathetic effects of the nervous system include decreased peristalsis, increased blood pressure, dilated pupils, and dilated bronchioles.

A patient has a deficiency of the neurotransmitter serotonin. The nurse is aware that this deficiency can lead to: a) Parkinson's disease. b) Seizures. c) Depression. d) Myasthenia gravis.

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

Eschar

Devitalized tissue resulting from a burn or wound.

A patient admitted with a stroke is coming to the unit from the emergency department. The nurse assigned to care for the new patient knows that what assessment finding is indicative of a stroke?

Difficulty speaking Explanation: Difficulty speaking is a classic abnormal finding on a physical assessment that may be associated with a stroke. Tachycardia, edema, and electrolyte imbalances are not common initial presentations of stroke.

The nurse is caring for a patient with a history of transient ischemic attacks (TIAs) and moderate carotid stenosis who has undergone a carotid endarterectomy. Which of the following postoperative findings would cause the nurse the most concern? a) Blood pressure (BP): 128/86 mm Hg b) Neck pain: 3/10 (0 to 10 pain scale) c) Mild neck edema d) Difficulty swallowing

Difficulty swallowing The patient's inability to swallow without difficulty would cause the nurse the most concern. Difficulty in swallowing, hoarseness or other signs of cranial nerve dysfunction must be assessed. The nurse focuses on assessment of the following cranial nerves: facial (VII), vagus (X), spinal accessory (XI), and hypoglossal (XII). Some edema in the neck after surgery is expected; however, extensive edema and hematoma formation can obstruct the airway. Emergency airway supplies, including those needed for a tracheostomy, must be available. The patient's neck pain and mild BP elevation need addressing but would not cause the nurse the most concern. Hypotension is avoided to prevent cerebral ischemia and thrombosis. Uncontrolled hypertension may precipitate cerebral hemorrhage, edema, hemorrhage at the surgical incision, or disruption of the arterial reconstruction.

Ophthalmic Medications

Drugs given into the eye in the form of either eye drops or ointments.

What is the most common and most severe type of muscular dystrophy?

Duchenne's muscular dystrophy

A patient is being tested for a gag reflex. When the nurse places the tongue blade to the back of the throat, there is no response elicited. What dysfunction does the nurse determine the patient has? a) Dysfunction of the spinal accessory nerve b) Dysfunction of the vagus nerve c) Dysfunction of the facial nerve d) Dysfunction of the acoustic nerve

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

Battle's sign

Ecchymosis behind the ear

Which term refers to a method of recording, in graphic form, the electrical activity of a muscle? a) Electrocardiography b) Electrogastrography c) Electroencephalography d) Electromyography

Electromyography An electromyogram is obtained by inserting needle electrodes into the skeletal muscles to measure changes in the electrical potential of the muscles. Electroencephalography is a method of recording, in graphic form, the electrical activity of the brain. Electrocardiography is performed to assess the electrical activity of the heart. Electrogastrography is an electrophysiologic study performed to assess gastric motility disturbances.

Papule

Elevated, palpable solid mass with a circumscribed solid border

After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client?

Elevating the head of the bed to 30 degrees Explanation: Because the client's gag reflex is absent, elevating the head of the bed to 30 degrees helps minimize the client's risk of aspiration. Checking the stools, performing ROM exercises, and keeping the skin clean and dry are important, but preventing aspiration through positioning is the priority.

A client has undergone a lumbar puncture as part of a neurological assessment. The client is put under the care of a nurse after the procedure. Which important postprocedure nursing intervention should be performed to ensure the client's maximum comfort? a) Administer antihistamines according to the physician's prescription b) Keep the room brightly lit and play soothing music in the background c) Help the client take a brisk walk around the testing area d) Encourage the client to drink liberal amounts of fluids

Encourage the client to drink liberal amounts of fluids The nurse should encourage the client to take liberal fluids and should inspect the injection site for swelling or hematoma. These measures help restore the volume of cerebrospinal fluid extracted. The client is administered antihistamines before a test only if he or she is allergic to contrast dye and contrast dye will be used. The room of the client who has undergone a lumbar puncture should be kept dark and quiet. The client should be encouraged to rest, because sensory stimulation tends to magnify discomfort.

The nurse is caring for a client who has had a cerebrovascular accident. The client has a nursing diagnosis of altered nutritional status related to difficulty swallowing. What intervention would it be important for the nurse to institute?

Encourage the client to eat semisolid foods and cold foods. Explanation: When the client can resume oral intake after a CVA, individualize the diet according to his or her ability to chew and swallow. Semisolid and medium-consistency foods such as pudding, scrambled eggs, cooked cereals, and thickened liquids are easiest to swallow. Cold foods stimulate swallowing. The client should avoid tepid foods, because they are more difficult to locate in the mouth, and extremely hot foods, which can cause overreaction. Therefore options B, C, and D are incorrect.

Which of the following statements reflect nursing management of the patient with expressive aphasia? a) Frequently reorient the patient to time, place, and situation b) Speak clearly to the patient in simple sentences, use gestures or pictures when able c) Speak slowly and clearly to assist the patient in forming the sounds d) Encourage the patient to repeat sounds of the alphabet

Encourage the patient to repeat sounds of the alphabet Nursing management of the patient with expressive aphasia includes encouraging the patient to repeat sounds of the alphabet. Nursing management of the patient with global aphasia includes speaking clearly to the patient in simple sentences and using gestures or pictures when able. Nursing management of the patient with receptive aphasia includes speaking slowing and clearly to assist the patient in forming the sounds. Nursing management of the patient with cognitive deficits, such as memory loss, includes frequently reorienting the patient to time, place, and situation. (less)

The nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client?

Establishing eye contact Explanation: The following strategies should be used by the nurse to encourage communication with a client with aphasia: face the client and establish eye contact, speak in your usual manner and tone, use short phrases, and pause between phrases to allow the client time to understand what is being said; limit conversation to practical and concrete matters; use gestures, pictures, objects, and writing; and as the client uses and handles an object, say what the object is. It helps to match the words with the object or action. Be consistent in using the same words and gestures each time you give instructions or ask a question, and keep extraneous noises and sounds to a minimum. Too much background noise can distract the client or make it difficult to sort out the message being spoken.

The nurse is caring for a patient with aphasia. Which of the following strategies will the nurse use to facilitate communication with the patient? a) Avoiding the use of hand gestures b) Establishing eye contact c) Speaking in complete sentences d) Speaking loudly

Establishing eye contact The following strategies should be used by the nurse to encourage communication with a patient with aphasia: face the patient and establish eye contact, speak in your usual manner and tone, use short phrases, and pause between phrases to allow the patient time to understand what is being said; limit conversation to practical and concrete matters; use gestures, pictures, objects, and writing; and as the patient uses and handles an object, say what the object is. It helps to match the words with the object or action, be consistent in using the same words and gestures each time you give instructions or ask a question, and keep extraneous noises and sounds to a minimum. Too much background noise can distract the patient or make it difficult to sort out the message being spoken. (less)

The nurse is caring for a patient with aphasia. Which of the following strategies will the nurse use to facilitate communication with the patient? a) Speaking in complete sentences b) Speaking loudly c) Avoiding the use of hand gestures d) Establishing eye contact

Establishing eye contact The following strategies should be used by the nurse to encourage communication with a patient with aphasia: face the patient and establish eye contact, speak in your usual manner and tone, use short phrases, and pause between phrases to allow the patient time to understand what is being said; limit conversation to practical and concrete matters; use gestures, pictures, objects, and writing; and as the patient uses and handles an object, say what the object is. It helps to match the words with the object or action, be consistent in using the same words and gestures each time you give instructions or ask a question, and keep extraneous noises and sounds to a minimum. Too much background noise can distract the patient or make it difficult to sort out the message being spoken. (less)

How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)?

Every 15 minutes Explanation: Neurological assessment and vital signs (except temperature) should be taken every 15 minutes initially while the patient is receiving tPA infusion.

In caring for a client with recent cervical discectomy, a sudden increase in pain may mean?

Extrusion of the graft - Call surgeon immediately!

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

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

A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to perform which action?

Form words that are understandable or comprehend spoken words Explanation: Global aphasia is a combination of expressive and receptive aphasia and presents a tremendous challenge to the nurse to effectively communicate with the client. In receptive and expressive aphasia, the client is unable to form words that are understandable. The client who is unable to speak at all is referred to as mute.

A patient has been diagnosed as having global aphasia. The nurse recognizes that the patient will be unable to do which of the following actions? a) Form words that are understandable b) Speak at all c) Form words that are understandable or comprehend the spoken word d) Comprehend the spoken word

Form words that are understandable or comprehend the spoken word Global aphasia is a combination of expressive and receptive aphasia and presents tremendous challenge to the nurse to effectively communicate with the patient. In receptive aphasia, the patient is unable to form words that are understandable. In expressive aphasia, the patient is unable to form words that are understandable. The patient who is unable to speak at all is referred to as mute.

A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?

Frontal Explanation: If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation.

A patient sustained a head injury during a fall and has changes in personality and affect. What part of the brain does the nurse recognize has been affected in this injury? a) Frontal lobe b) Parietal lobe c) Temporal lobe d) Occipital lobe

Frontal lobe The frontal lobe, the largest lobe, located in the front of the brain. The major functions of this lobe are concentration, abstract thought, information storage or memory, and motor function. It contains Broca's area, which is located in the left hemisphere and is critical for motor control of speech. The frontal lobe is also responsible in large part for a person's affect, judgment, personality, and inhibitions (Hickey, 2009).

Homograft

Graft transferred from one human (living or cadaver to another human - also called allograft.

A nurse is caring for a client with lower back pain who is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should place the client in which position? a) Head of the bed elevated 45 degrees b) Supine with feet raised c) Prone d) Supine with the head lower than the trunk

Head of the bed elevated 45 degrees After a myelogram, positioning depends on the dye injected. When a water-soluble dye such as metrizamide is injected, the head of the bed is elevated to a 45-degree angle to slow the upward dispersion of the dye. The prone and supine positions are contraindicated when a water-soluble contrast dye is used. The client should be positioned supine with the head lower than the trunk after an air-contrast study.

A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term? Dystrophic Steppage Ataxic Helicopod

Helicopod A helicopod gait is an abnormal gait in which the client's feet make a half circle with each step. An ataxic gait is staggering and unsteady. In a dystrophic gait, the client waddles with the legs far apart. In a steppage gait, the feet and toes rise high off the floor and the heel comes down heavily with each step.

A client undergoes cerebral angiography for evaluation of a subarachnoid hemorrhage. Which findings indicate spasm or occlusion of a cerebral vessel by a clot?

Hemiplegia, seizures, and decreased level of consciousness

A physician orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? a) Phenytoin (Dilantin) b) Methyldopa (Aldomet) c) Heparin sodium d) Dexamethasone (Decadron)

Heparin sodium Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. Therefore, the nurse should question this order to prevent additional hemorrhage in the brain. In a client with hemorrhagic stroke, the physician may use dexamethasone to decrease cerebral edema and pressure; methyldopa, to reduce blood pressure; and phenytoin, to prevent seizures.

Which are risk factors for stroke?

High blood pressure Previous stroke or transient ischemic attack (TIA) Smoking Use of oral contraceptives

Which terms refers to blindness in the right or left half of the visual field in both eyes?

Homonymous hemianopsia Explanation: Homonymous hemianopsia occurs with occipital lobe tumors. Scotoma refers to a defect in vision in a specific area in one or both eyes. Diplopia refers to double vision or the awareness of two images of the same object occurring in one or both eyes. Nystagmus refers to rhythmic, involuntary movements or oscillations of the eyes.

Which disturbance results in loss of half of the visual field? a) Anisocoria b) Homonymous hemianopsia c) Nystagmus d) Diplopia

Homonymous hemianopsia Homonymous hemianopsia (loss of half of the visual field) may occur from stroke and may be temporary or permanent. Double vision is documented as diplopia. Nystagmus is ocular bobbing and may be seen in multiple sclerosis. Anisocoria is unequal pupils.

Those who have excellent distance vision but blurry near vision are farsighted and said to have the diagnosis of ____________.

Hyperopia (A vision condition in which nearby objects are blurry)

The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regime, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is: a) Dyslipidemia b) Obesity c) Hypertension d) Smoking

Hypertension Hypertension is the most modifiable risk factor for either ischemic or hemorrhagic stroke. Unfortunately, it remains under-recognized and undertreated in most communities.

What could an elevated temperature suggest in the setting of a head injury?

Hyperthermia increases metabolic demands and could suggest damage to the brain stem in the setting of a head injury

Keloid

Hypertrophied scar tissue

A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include honey thickened liquids. Which of the following is the priority nursing diagnosis for this client?

Impaired Swallowing Explanation: Impaired Swallowing was evident on the video fluoroscopy. Risk for Aspiration, Altered Nutrition, and Fluid Volume Deficit can occur but are not the primary diagnosis at this point in time.

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the physician in the emergency department. After completing ordered diagnostic tests, the physician indicates to the client what caused the symptoms that brought him to the hospital. What is the origin of the client's symptoms? a) Hypertension b) Cardiac disease c) Diabetes insipidus d) Impaired cerebral circulation

Impaired cerebral circulation TIAs result from impaired blood circulation in the brain, which can be caused by atherosclerosis and arteriosclerosis, cardiac disease, or diabetes. The symptoms of a TIA are the result of impaired blood circulation in the brain, which may have been caused by cardiac disease. The symptoms of a TIA are the result of impaired blood circulation in the brain, which may have been caused by diabetes. The symptoms of a TIA are the result of impaired blood circulation in the brain, which may have been caused by hypertension.

A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant?

Increased urine output Explanation: The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.

A nurse is planning discharge for a client who experienced right-sided weakness caused by a stroke. During his hospitalization, the client has been receiving physical therapy, occupational therapy, and speech therapy daily. The family voices concern about rehabilitation after discharge. How should the nurse intervene?

Inform the case manager of the family's concern and provide information about the client's current clinical status so appropriate resources can be provided after discharge. Explanation: As the coordinator of care, the nurse must assess the client's needs and initiate referrals for the appropriate health team members to coordinate services needed after discharge. The nurse isn't responsible for contacting agencies to provide care after discharge. Simply providing information about the family's concerns doesn't ensure that services will be arranged for the client after discharge. Alerting the physician is helpful; however, that step doesn't ensure that the necessary services will be provided after discharge. Doing nothing is irresponsible.

A nurse is caring for an older client who has had a hemorrhagic stroke. The client has exhibited impulsive behavior and, despite reminders from the nurse, doesn't recognize his limitations. Which priority measure should the nurse implement to prevent injury?

Install a bed alarm to remind the client to ask for assistance and to alert staff that the client is getting out of bed. Explanation: The bed alarm will alert staff that the client is attempting to transfer, so they can come to assist. The nurse shouldn't encourage the family to reprimand the client. Instead, the nurse should ask the family to encourage the client to request assistance. The nurse should encourage the client to use the call light in all situations, not just emergencies. A vest and wrist restraints aren't appropriate unless less-restrictive measures have failed and the client is a danger to himself or others.

The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has?

Ischemic Explanation: Ischemic strokes occur when a thrombus or embolus obstructs an artery carrying blood to the brain; about 80% of strokes are the ischemic variety. The other options are incorrect.

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention? a) Maintaining the client in a quiet environment b) Keeping the client in one position to decrease bleeding c) Positioning the client to prevent airway obstruction d) Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess

Keeping the client in one position to decrease bleeding The student nurse shouldn't keep the client in one position. She should carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of rebleeding.

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention? a) Maintaining the client in a quiet environment b) Positioning the client to prevent airway obstruction c) Keeping the client in one position to decrease bleeding d) Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess

Keeping the client in one position to decrease bleeding The student nurse shouldn't keep the client in one position. She should carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of rebleeding.

A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment?

Lack of deep tendon reflexes Explanation: Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia. If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and lack of motivation. Damage to the lower motor neurons may cause decreased muscle tone, flaccid muscle paralysis, and a decrease in or loss of reflexes.

A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment? a) Limited attention span and forgetfulness b) Visual agnosia c) Auditory agnosia d) Lack of deep tendon reflexes

Lack of deep tendon reflexes Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia. If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and lack of motivation. Damage to the lower motor neurons may cause decreased muscle tone, flaccid muscle paralysis, and a decrease in or loss of reflexes.

A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure? a) Lateral recumbent, with chin resting on flexed knees b) Supine, with the knees raised toward the chest c) Prone, with the head turned to the right d) Lateral, with right leg flexed

Lateral recumbent, with chin resting on flexed knees To maximize the space between the vertebrae, the client is placed in a lateral recumbent position with knees flexed toward the chin. The needle is inserted between L4 and L5. The other positions wouldn't allow as much space between L4 and L5.

A 53-year-old man presents to the emergency department with a chief complaint of inability to form words, and numbness and weakness of the right arm and leg. Where would you locate the site of injury? a) Left frontoparietal region b) Right frontoparietal region c) Left temporal region d) Left basal ganglia

Left frontoparietal region The patient is exhibiting signs of expressive aphasia with numbness/tingling and weakness of the right arm and leg. This indicates injury to the expressive speech center (Broca's area), which is located in the inferior portion of the frontal lobe. The motor strip is located in the posterior portion of the frontal lobe. The sensory strip is located in the anterior parietal lobe.

What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke?

Left visual field deficit

A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings?

Left-sided cerebrovascular accident (CVA) Explanation: When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete.

A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings? a) Left-sided cerebrovascular accident (CVA) b) Right-sided cerebrovascular accident (CVA) c) Transient ischemic attack (TIA) d) Completed Stroke

Left-sided cerebrovascular accident (CVA) When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete.

A client has experienced an ischemic stroke that has damaged the frontal lobe of his brain. Which of the following deficits does the nurse expect to observe during assessment?

Limited attention span and forgetfulness Explanation: Damage to the frontal lobe may impair learning capacity, memory, or other higher cortical intellectual functions. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation. Damage to the motor neurons may cause hemiparesis, hemiplegia, and a change in reflexes. Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia.

A client has experienced an ischemic stroke that has damaged the frontal lobe of his brain. Which of the following deficits does the nurse expect to observe during assessment?

Limited attention span and forgetfulness rationale: Damage to the frontal lobe may impair learning capacity, memory, or other higher cortical intellectual functions. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation. Damage to the motor neurons may cause hemiparesis, hemiplegia, and a change in reflexes. Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia.

Escharotomy

Linear incision made through eschar to release constriction of underlying tissueEscharotomy

A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem?

Lioresal (Baclofen) Explanation: Spasticity, particularly in the hand, can be a disabling complication after stroke. Botulinum toxin type A injected intramuscularly into wrist and finger muscles has been shown to be effective in reducing this spasticity (although the effect is temporary, typically lasting 2 to 4 months) (Teasell, Foley, Pereira, et al., 2012). Other treatments for spasticity may include stretching, splinting, and oral medications such as baclofen (Lioresal).

A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem? a) Pregabalin (Lyrica) b) Diphenhydramine (Benadryl) c) Heparin d) Lioresal (Baclofen)

Lioresal (Baclofen) Spasticity, particularly in the hand, can be a disabling complication after stroke. Botulinum toxin type A injected intramuscularly into wrist and finger muscles has been shown to be effective in reducing this spasticity (although the effect is temporary, typically lasting 2 to 4 months) (Teasell, Foley, Pereira, et al., 2012). Other treatments for spasticity may include stretching, splinting, and oral medications such as baclofen (Lioresal). (less)

What is the pathophysiology of ALS?

Loss of motor neurons in the anterior horn of the spinal cord and loss of motor nuclei in the brainstem

Which of the following is accurate regarding a hemorrhagic stroke?

Main presenting symptom is an "exploding headache." Explanation: One of hemorrhagic stroke's main presenting symptom is an "exploding headache." In ischemic stroke, functional recovery usually plateaus at 6 months; it may be caused by a large artery thrombosis and may have a presenting symptoms of numbness or weakness of the face.

Which of the following is accurate regarding a hemorrhagic stroke? a) It is caused by a large-artery thrombosis. b) One of the main presenting symptoms is numbness or weakness of the face. c) Main presenting symptom is an "exploding headache." d) Functional recovery usually plateaus at 6 months.

Main presenting symptom is an "exploding headache." One of hemorrhagic stroke's main presenting symptom is an "exploding headache." In ischemic stroke, functional recovery usually plateaus at 6 months; it may be caused by a large artery thrombosis and may have a presenting symptoms of numbness or weakness of the face

The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important?

Maintaining a patent airway Explanation: Maintaining the airway is the most important nursing intervention. Immediate complications of a hemorrhagic stroke include cerebral hypoxia, decreased cerebral blood flow, and extension of the area of injury. Providing adequate oxygenation of blood to the brain minimizes cerebral hypoxia. Brain function depends on delivery of oxygen to the tissues. Administering supplemental oxygen and maintaining hemoglobin and hematocrit at acceptable levels will assist in maintaining tissue oxygenation. All other interventions are appropriate, but the airway takes priority. The head of the bed should be elevated to 30 degrees, monitoring the client because of the risk for seizures, and stool softeners are recommended to prevent constipation and straining, but these are not the most important interventions.

A client has had a traumatic brain injury and is mechanically ventilated. Which technique does the nurse use to prevent increasing intracranial pressure (ICP)?

Maintaining neutral head position

What medication helps to decrease fluid in the brain?

Mannitol is an osmotic diuretic and helps to decrease fluid in the brain

The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly? a) Gently pressing the bones on the neck b) Moving the head toward both sides c) Moving the head and chin toward the chest d) Lightly tapping the lower portion of the neck to detect sensation

Moving the head and chin toward the chest The neck is examined for stiffness or abnormal position. The presence of rigidity is assessed by moving the head and chin toward the chest. The nurse should not maneuver the neck if a head or neck injury is suspected or known. The neck should also not be maneuvered if trauma to any part of the body is evident. Moving the head toward the sides or pressing the bones on the neck will not help assess for neck rigidity correctly. While assessing for neck rigidity, sensation at the neck area is not to be assessed

What are common characteristics of the muscular dystrophies?

Muscle wasting, weakness, and abnormal elevation in serum levels of muscle enzymes.

A client is admitted with a stroke (brain attack). Which tool does the nurse use to facilitate a focused neurologic assessment of the client?

National Institutes of Health Stroke Scale (NIHSS)

Which of the following is the initial diagnostic test for a stroke? a) Noncontrast CT scan b) Transcranial Doppler studies c) ECG d) Carotid Doppler

Noncontrast CT scan The initial diagnostic test for a stroke is a nonconstrast CT scan performed emergently to determine if the event is ischemic or hemorrhagic. Further diagnostics include a carotid Doppler, ECG, and a transcranial Doppler. (less)

Which is the initial diagnostic test for a stroke?

Noncontrast computed tomography

A client is suspected of having had a stroke. Which is the initial diagnostic test for a stroke?

Noncontrast computed tomography Explanation: The initial diagnostic test for a stroke is usually a noncontrast computed tomography (CT) scan. This should be performed within 25 minutes or less from the time the client presents to the ED to determine whether the event is ischemic or hemorrhagic (the category of stroke determines treatment). Further diagnostics include a carotid Doppler, electrocardiogram, and transcranial

The pre-nursing class is learning about the nervous system in their anatomy class. What part of the nervous system would the students learn is responsible for digesting food and eliminating body waste? a) Sympathetic b) Peripheral c) Parasympathetic d) Central

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

Which lobe of the brain is responsible for spatial relationships? Parietal Occipital Temporal Frontal

Parietal The parietal lobe is essential to a person's awareness of body position in space, size and shape discrimination, and right-left orientation. The frontal lobe controls information storage or memory and motor function. The temporal lobe contains the auditory receptive area. The occipital lobe is responsible for visual interpretation.

How should the nurse respond to a patient who complains of a disturbance in the way food tastes after middle ear surgery?

Patients experience a taste disturbance and dry mouth on the side of surgery for several months until the nerve regenerates

A client with a cerebrovascular accident (CVA) is having difficulty with eating food on the plate. Which is the best nursing action to be taken? a) Reposition the tray and plate. b) Perform a vision field assessment. c) Know this is a normal finding for CVA. d) Assist the client with feeding.

Perform a vision field assessment. The nurse should perform a vision field assessment to evaluate the client forhemianopia. This finding could indicate damage to the visual area of the brain as a result of evolving CVA. Repositioning the tray and assisting with feeding would not be the best nursing action until new finding has been evaluated. Hemianopia can be associated with a CVA but, when presenting as a new finding, should be evaluated and reported immediately. (less)

Petechiae

Pinpoint red spots appearing on the skin as a result of blood leakage into skin

The nurse is caring for a patient with dysphagia. Which of the following interventions would be contraindicated while caring for this patient? a) Allowing ample time to eat b) Assisting the patient with meals c) Testing the gag reflex prior to offering food or fluids d) Placing food on the affected side of mouth

Placing food on the affected side of mouth Interventions for dysphagia include placing food on the unaffected side of the mouth, allowing ample time to eat, assisting the patient with meals, and testing the patient's gag reflex prior to offering food or fluids.

The nurse is caring for a client with dysphagia. Which intervention would be contraindicated while caring for this client?

Placing food on the affected side of the mouth Explanation: Interventions for dysphagia include placing food on the unaffected side of the mouth, allowing ample time to eat, assisting the client with meals, and testing the client's gag reflex before offering food or fluids.

A client presents to the Emergency Department from an assisted living facility after a ground level fall with a head strike. The client has a Glasgow Coma Score (GCS) of 12, which is decreased for this client, and has projectile vomiting. What is the priority intervention for this client?

Positioning the client to prevent aspiration

Drag and Drop question - Click and drag the following steps to place them in the correct order. Question: A 10-year-old child has been admitted to the hospital with Reye's syndrome. Place the following findings in chronological order to show the clinical stages of Reye's syndrome. Use all of the options. 1 2 3 4 5 6 Deepened coma. Flaccid paralysis. Presence of a viral infection. Coma. Vomiting. Disorientation.

Presence of a viral infection. Vomiting. Disorientation. Coma. Deepened coma. Flaccid paralysis. Reye's syndrome is an acute multisystem disorder that causes encephalopathy and predominately affects school-age children. Symptoms develop within a few days to weeks after a viral infection, beginning with vomiting, sleepiness, and liver dysfunction. About 24 to 48 hours after onset of symptoms, the child's condition rapidly deteriorates, causing disorientation, hallucinations, and sometimes a coma with decorticate posturing. The coma may progress to a deepened coma with decerebrate posturing and, eventually, flaccid paralysis. The majority of children who survive the acute stage of illness completely recover.

The nurse is caring for a client diagnosed with a subarachnoid hemorrhage resulting from a leaking aneurysm. The client is awaiting surgery. Which nursing interventions would be appropriate for the nurse to implement? Select all that apply.

Provide a dimly lit environment. Elevate the head of bed 30 degrees. Administer docusate per order. Explanation: Cerebral aneurysm precautions are implemented for the patient with a diagnosis of aneurysm to provide a nonstimulating environment, prevent increases in intracranial pressure (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 blood pressure, which increases the risk for bleeding. Visitors, except for family, are restricted. Dim lighting is helpful because photophobia (visual intolerance of light) is common. The head of the bed is elevated 15 to 30 degrees to promote venous drainage and decrease ICP. No enemas are permitted, but stool softeners (Colace) and mild laxatives are prescribed. Both prevent constipation, which would cause an increase in ICP, as would enemas.

A nurse is planning care for a client who experienced a stroke in the right hemisphere of his brain. What should the nurse do?

Provide close supervision because of the client's impulsiveness and poor judgment. Explanation: The primary symptoms of a client who experiences a right-sided stroke are left-sided weakness, impulsiveness, and poor judgment. Aphasia is more commonly present when the dominant or left hemisphere is damaged. When a client has one-sided weakness, the nurse should place the wheelchair on the client's unaffected side. Because a right-sided stroke causes left-sided paralysis, the right side of the body should remain unaffected.

The nurse is providing diet-related advice to a male patient following a cerebrovascular accident (CVA). The patient wants to minimize the volume of food and yet meet all nutritional elements. Which of the following suggestions should the nurse give to the patient about controlling the volume of food intake?

Provide thickened commercial beverages and fortified cooked cereals. Explanation: Patients with CVA or other cerebrovascular disorders should lose weight and therefore should minimize their volume of food consumption. To ensure this, the nurse may provide thickened commercial beverages, fortified cooked cereals, or scrambled eggs. Patients should avoid eating high-fat foods, and serving foods hot or tepid will not minimize the volume consumed by the patient. Foods such as peanut butter, bread, tart foods, dry or crisp foods, and chewy meats should also be avoided because they cause choking.

The nurse is providing diet-related advice to a male patient following a cerebrovascular accident (CVA). The patient wants to minimize the volume of food and yet meet all nutritional elements. Which of the following suggestions should the nurse give to the patient about controlling the volume of food intake? a) Provide a high-fat diet. b) Include dry or crisp foods and chewy meats. c) Always serve hot or tepid foods. d) Provide thickened commercial beverages and fortified cooked cereals.

Provide thickened commercial beverages and fortified cooked cereals. Patients with CVA or other cerebrovascular disorders should lose weight and therefore should minimize their volume of food consumption. To ensure this, the nurse may provide thickened commercial beverages, fortified cooked cereals, or scrambled eggs. Patients should avoid eating high-fat foods, and serving foods hot or tepid will not minimize the volume consumed by the patient. Foods such as peanut butter, bread, tart foods, dry or crisp foods, and chewy meats should also be avoided because they cause choking.

The nurse is caring for a client following an aneurysm coiling procedure. The nurse documents that the client is experiencing Korsakoff syndrome. Which set of symptoms characterizes Korsakoff syndrome?

Psychosis, disorientation, delirium, insomnia, and hallucinations Explanation: Advances in technology have led to the introduction of interventional neuroradiology for the treatment of aneurysms. Endovascular techniques may be used in selected clients to occlude the blood flow from the artery that feeds the aneurysm with coils or other techniques to occlude the aneurysm itself. Postoperative complications are rare but can occur. Potential complications include psychological symptoms such as disorientation, amnesia, and Korsakoff syndrome (disorder characterized by psychosis, disorientation, delirium, insomnia, hallucinations, and personality changes). Creutzfeldt-Jakob disease results in severe dementia and myoclonus. The three cardinal signs of Parkinson disease are tremor, rigidity, and bradykinesia. Huntington disease results in progressive involuntary choreiform (dancelike) movements and dementia.

The geriatric advanced practice nurse (APN) is doing client teaching with a client who has had a cerebrovascular accident (CVA) and the client's family. One concern the APN addresses is a potential for falls related to the CVA and resulting muscle weakness. What would be most important for the APN to include in teaching related to this concern?

Remove throw rugs and electrical cords from home environment.

The geriatric advanced practice nurse (APN) is doing client teaching with a client who has had a cerebrovascular accident (CVA) and the client's family. One concern the APN addresses is a potential for falls related to the CVA and resulting muscle weakness. What would be most important for the APN to include in teaching related to this concern?

Remove throw rugs and electrical cords from home environment. Explanation: Client and family teaching is essential and focuses on the following points: Remove throw rugs, clutter, and electrical cords from the client's home environment to reduce the potential for falls. Although the other interventions may be appropriate, they are not as directly related to reducing fall risk.

A client on your unit is scheduled to have intracranial surgery in the morning. Which nursing intervention helps to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting? a. Administer prescribed medications. b. Administer an osmotic diuretic. c. Administer preoperative sedation. d. Restrict fluids before surgery.

Restrict fluids before surgery.

A client on your unit is scheduled to have intracranial surgery in the morning. Which nursing intervention helps to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting?

Restrict fluids before surgery. Explanation: Before surgery, the nurse should restrict fluids to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting. The nurse administers prescribed medications such as an anticonvulsant phenytoin, like Dilantin, to reduce the risk of seizures before and after surgery, an osmotic diuretic, and corticosteroids. Preoperative sedation is omitted.

A patient is receiving long term vancomycin for a bone infection. What toxic effect is the patient at risk for in regarding to hearing?

Risk for ototoxicity

The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient?

Semi-Fowler's

The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient?

Semi-Fowler's Explanation: The head of the bed is elevated 15 to 30 degrees (semi-Fowler's position) to promote venous drainage and decrease intracranial pressure.

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:

Severe headache and early change in level of consciousness Explanation: The main presenting symptoms for ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body, confusion or change in mental status, and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Footdrop and external hip rotation can occur if a stroke victim is not turned or positioned correctly.

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: a) Footdrop and external hip rotation b) Severe headache and early change in level of consciousness c) Confusion or change in mental status d) Weakness on one side of the body and difficulty with speech

Severe headache and early change in level of consciousness The main presenting symptoms for ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body, confusion or change in mental status, and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Footdrop and external hip rotation can occur if a stroke victim is not turned or positioned correctly. (less)

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: a) Footdrop and external hip rotation b) Severe headache and early change in level of consciousness c) Weakness on one side of the body and difficulty with speech d) Confusion or change in mental status

Severe headache and early change in level of consciousness The main presenting symptoms for ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body, confusion or change in mental status, and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Footdrop and external hip rotation can occur if a stroke victim is not turned or positioned correctly. (less)

What type of pain is associated with tumors that occur within the spinal canal?

Sharp pain, ranging from localized to shooting pains.

An emergency department nurse is interviewing a client with signs of an ischemic stroke that began 2 hours ago. The client reports that she had a cholecystectomy 6 weeks ago and is taking digoxin, coumadin, and labetelol. This client is not eligible for thrombolytic therapy for which of the following reasons? a) She is not within the treatment time window. b) She had surgery 6 weeks ago. c) She is taking digoxin. d) She is taking coumadin.

She is taking coumadin. To be eligible for thrombolytic therapy, the client cannot be taking coumadin. Initiation of thrombolytic therapy must be within 3 hours in clients with ischemic stroke. The client is not eligible for thrombolytic therapy if she has had surgery within 14 days. Digoxin and labetelol do not prohibit thrombolytic therapy.

The nurse is participating in a health fair for stroke prevention. Which will the nurse say is a modifiable risk factor for ischemic stroke?

Smoking

Which is a modifiable risk factor for transient ischemic attacks and ischemic strokes?

Smoking

Which is a modifiable risk factor for transient ischemic attacks and ischemic strokes?

Smoking Explanation: Modifiable risk factors for TIAs and ischemic stroke include hypertension, type 1 diabetes, cardiac disease, smoking, and chronic alcoholism. Advanced age, gender, and race are nonmodifiable risk factors for stroke.

A client with diabetes is hospitalized with a TIA. When planning this client's discharge teaching the nurse knows to include which of the following?

Techniques to control blood sugar within normal ranges Explanation: Clients with diabetes are educated in techniques to control blood sugar within normal ranges with diet, exercise, and medications. The scenario does not indicate the need to teach this client about hypoglycemia, hyperglycemia, or how to inject insulin.

A nurse and nursing student are caring for a client recovering from a lumbar puncture yesterday. The client reports a headache despite being on bedrest overnight. The physician plans an epidural blood patch this morning. The student asks how this will help the headache. The correct reply from the nurse is which of the following? a) "The blood will replace the cerebral spinal fluid that has leaked out." b) "The blood can repair damage to the spinal cord that occurred with the procedure." c) "The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid." d) "The blood provides moisture at the site, which encourages healing."

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

Canalith Repositioning Maneuver

The canalith repositioning procedure can treat benign paroxysmal positional vertigo (BPPV), which causes dizziness when you move your head. The procedure consists of head maneuvers that move particles in your inner ear (otoconia) — which cause dizziness — to a part of your ear where they won't.

When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke?

The day the patient has the stroke Explanation: Although rehabilitation begins on the day the patient has the stroke, the process is intensified during convalescence and requires a coordinated team effort.

The nurse is performing a neurological assessment of a client who has sustained damage to the frontal cortex. Which of the following deficits will the nurse look for during assessment? a) The inability to maintain steady balance for the Romberg test b) Intentional tremors c) Absence of movement below the waist d) The inability to tell how a mouse and a cat are alike

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

When assessing a client who has experienced a spinal injury, the nurse notes diaphragmatic breathing and loss of upper limb use and sensation. At what level does the nurse anticipate the injury has occurred?

The nurse should anticipate that the injury has occurred at level C5. Injuries above C3 result in the loss of spontaneous respiratory function. Clients with injuries at T6 and L1 retain some degree of upper limb use and sensation.

A patient with ALS is experiencing bulbar muscle dysfunction. What is a priority assessment for this patient?

The nurse should assess risk for aspiration

The nurse is completing the physical assessment of a patient suspected of a neurologic disorder. The patient reports to the nurse that he has recently suffered a head trauma. In such a case, which of the following precautions should the nurse take for the patient? Select all that apply. a) The nurse should make the patient sit in a chair and then assess his or her head for bleeding or swelling. b) The nurse should only move the patient's head with the help of an assistant. c) The nurse should explain the procedure of head assessment to the patient before doing the assessment. d) The nurse should not move or manipulate the patient's head while assessing for bleeding or swelling.

The nurse should not move or manipulate the patient's head while assessing for bleeding or swelling. The nurse evaluates the patient's body posture and any abnormal position of the head, neck, trunk, or extremities. The nurse carefully examines the head for bleeding, swelling, or wounds. The nurse does not move or manipulate the patient's head during physical assessment, especially if there is a recent history of trauma. The nurse should not make the patient sit on a chair or seek the help of an assistant while doing the head assessment. The nurse need not explain in detail about the procedure of head assessment to the patient.

An emergency department nurse is awaiting the arrival of a client with signs of an ischemic stroke that began 1 hour ago, as reported by emergency medical personnel. The treatment window for thrombolytic therapy is which of the following?

Three hours Explanation: Rapid diagnosis of stroke and initiation of thrombolytic therapy (within 3 hours) in clients with ischemic stroke leads to a decrease in the size of the stroke and an overall improvement in functional outcome after 3 months.

A client in the emergency department (ED) has slurred speech, confusion, and visual problems and has been having intermittent episodes of worsening symptoms. The symptoms have a gradual onset. The client also has a history of hypertension and atherosclerosis. What does the nurse suspect that the client is probably experiencing?

Thrombotic stroke

A patient diagnosed with an ischemic stroke should be treated within the first 3 hours of symptom onset with which of the following?

Tissue plasminogen activator (tPA)

A client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what?

Transient ischemic attack Explanation: A transient ischemic attack (TIA) is a sudden, brief attack of neurologic impairment caused by a temporary interruption in cerebral blood flow. Symptoms may disappear within 1 hour; some continue for as long as 1 day. When the symptoms terminate, the client resumes his or her presymptomatic state. The symptoms do not describe a left- or right-sided stroke or a cerebral aneurysm.

A client is hospitalized when they present to the Emergency Department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to their presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what? a) Cerebral aneurysm b) Transient ischemic attack c) Left-sided stroke d) Right-sided stroke

Transient ischemic attack A transient ischemic attack (TIA) is a sudden, brief attack of neurologic impairment caused by a temporary interruption in cerebral blood flow. Symptoms may disappear within 1 hour; some continue for as long as 1 day. When the symptoms terminate, the client resumes his or her presymptomatic state. The symptoms do not describe a left- or right-sided stroke or a cerebral aneurysm.

The spinal cord is composed of 31 pairs of spinal nerves. How many pairs of thoracic nerves are contained within the spinal column? a) One b) Twelve c) Eight d) Five

Twelve There are twelve pairs of thoracic nerves, five lumbar and sacral nerves, eight cervical, and one coccygeal.

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

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

The nurse who is employed in a neurologist's office is performing a history and assessment on a client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of cranial nerve: VI XI VIII II

VIII There are 12 pairs of cranial nerves. Cranial nerve VIII is the vestibulocochlear or auditory nerve responsible for hearing and balance. Cranial nerve II is the optic nerve. Cranial nerve VI is the abducens nerve responsible for eye movement. Cranial nerve XI is the accessory nerve and is involved with head and shoulder movement.

A nurse is caring for a client with a history of severe migraines. The client has a medical history that includes asthma, gastroesophageal reflux disease, and three pregnancies. Which medication does the nurse anticipate the physician will order for the client's migraines? a) Amiodarone (Cordarone) b) Verapamil (Calan) c) Metoprolol (Lopressor) d) Captopril (Coreg)

Verapamil (Calan) Calcium channel blockers, such as verapamil, and beta-adrenergic blockers, such as metoprolol, are commonly used to treat migraines because they help control cerebral blood vessel dilation. Calcium channels blockers, however, are ordered for clients who may not be able to tolerate beta-adrenergic blockers, such as those with asthma. Amiodarone and captopril aren't used to treat migraines.

The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke?

Weakness on one side of the body and difficulty with speech Explanation: The main presenting symptoms for an ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body; confusion or change in mental status; and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Footdrop and external hip rotation are things that can occur if a stroke victim is not turned or positioned correctly.

The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke? a) Footdrop and external hip rotation b) Vomiting and seizures c) Severe headache and early change in level of consciousness d) Weakness on one side of the body and difficulty with speech

Weakness on one side of the body and difficulty with speech The main presenting symptoms for an ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body; confusion or change in mental status; and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Footdrop and external hip rotation are things that can occur if a stroke victim is not turned or positioned correctly.

A client reports light-headedness, speech disturbance, and left-sided weakness lasting for several hours. The neurologist diagnosed a transient ischemic attack, which caused the client great concern. What would the nurse include during client education?

When symptoms cease, the client will return to presymptomatic state. Explanation: Impaired blood circulation can be caused by arteriosclerosis, cardiac disease, or diabetes. A TIA is a sudden, brief episode of neurologic impairment. Symptoms may disappear within 1 hour; some continue for as long as 1 day. One third of people who experience a TIA subsequently develop a stroke.

When completing a neurologic examination on a client, which question is most essential to evaluate the accuracy of the data? a) Have you experienced any unusual sensations? b) When, if any, was your last narcotic use? c) Do you have any history of forgetfulness? d) Have you been diagnosed with any mental health issues?

When, if any, was your last narcotic use? When completing a neurologic exam, it is essential to assess the use of morphine, heroin, narcotic, or central nervous system depressant because these affect the results of a neurologic examination. These types of drugs decrease the level of consciousness. The nurse can observe forgetfulness and mental status. Experiencing unusual sensations is good subjective data to have but is not essential to evaluate the accuracy of objective data.

A client is scheduled for standard EEG testing to evaluate a possible seizure disorder. Which nursing intervention should the nurse perform before the procedure? a) Maintain NPO status for 6 hours before the procedure b) Withhold anticonvulsant medications for 24 to 48 hours before the exam c) Sedate the client before the procedure, per orders d) Instruct the client that a standard EEG takes 2 hours

Withholding antiseizure medications for 24 to 48 hours prior to the exam Antiseizure agents, tranquilizers, stimulants, and depressants should be withheld 24 to 48 hours before an EEG because these medications can alter EEG wave patterns or mask the abnormal wave patterns of seizure disorders. To increase the chances of recording seizure activity, it is sometimes recommended that the patient be deprived of sleep on the night before the EEG. Coffee, tea, chocolate, and cola drinks are omitted in the meal before the test because of their stimulating effect. However, the meal is not omitted, because an altered blood glucose level can cause changes in brain wave patterns. The patient is informed that the standard EEG takes 45 to 60 minutes; a sleep EEG requires 12 hours.

The nurse is assessing a patient complaining of severe pain. What physiologic indicator does the nurse recognize as significant of acute pain? a. Diaphoresis b. Bradycardia c. Hypotension d. Decreased respiratory rate

a

A 10-year-old client twisted an ankle playing soccer. The ankle can't support weight and has already begun to swell despite application of an ice pack. As part of the pain assessment, the nurse must determine the intensity of the client's pain. Which question will the nurse ask to obtain this information? a. "Which one of the faces on this card shows how much your ankle hurts?" b. "How long ago did you hurt your ankle?" c. "Do you feel the pain only in your ankle or does it hurt anywhere else?" d. "Tell me if it hurts when I touch your ankle here."

a Adult patients are asked to report the intensity of their pain using a word scale, linear scale, or a numeric scale of 1 to 10. The Wong-Baker FACES Pain Rating Scale is an assessment tool used with children, the mentally challenged, and patients who would have difficulty understanding other assessment tools. Patients are asked to describe their pain by choosing a face that depicts how much they hurt. Intensity is not related to the timing of the injury, the general location of the pain, or the specific location of pain in the ankle.

When completing a teaching plan for a client receiving patient-controlled analgesia (PCA), which component would be important for the nurse to stress? a. The pump will deliver a preset amount of medication. b. The client should wait until the pain is severe to push the button to prevent overdose. c. Teach the client to avoid pushing the button multiple times because additional doses will be given. d. Chance of sedation is rare when using a PCA pump.

a A client experiencing pain can administer small amounts of medication directly into the IV, subcutaneous, or epidural catheter by pressing a button. The pump then delivers a preset amount of medication. The client should not wait until the pain is severe to push the button. Even if the client pushes the button multiple times in rapid succession, no additional doses are released because of the preset lock-out time. Sedation can occur with the use of the PCA pump. Assessment of respiratory status remains a major nursing role.

Which condition, approved by the U.S. Food and Drug Administration, is the only use for the lidocaine 5% patch? a. Postherpetic neuralgia b. Epidural anesthesia c. General anesthesia d. Diabetic neuropathy

a A lidocaine 5% patch has been approved for use in postherpetic neuralgia, though research suggests that is is effective and safe for a wide variety of acute and chronic pain conditions. A lidocaine 5% patch has not been approved for epidural anesthesia, general anesthesia, or diabetic neuropathy.

The nurse who is a member of the palliative care team is assessing a client. The client indicates that he has been saving his PRN analgesics until the pain is intense because his pain control has been inadequate. What teaching should the nurse do with this client? a. Medication should be taken when pain levels are low so the pain is easier to reduce. b. Pain medication can be increased when the pain becomes intense. c. It is difficult to control chronic pain, so this is an inevitable part of the disease process. d. The client will likely benefit more from distraction than pharmacologic interventions.

a Better pain control can be achieved with a preventive approach, reducing the amount of time clients are in pain. Low levels of pain are easier to reduce or control than intense levels of pain. Pain medication is used to prevent pain so pain medication is not increased when pain becomes intense. Chronic pain is treatable. Giving the client alternative methods to control pain is good, but it will not work if the client is in so much pain that he cannot institute reliable alternative methods.

Which substance reduces the transmission of pain? a. Endorphins b. Acetylcholine c. Serotonin d. Substance P

a Chemicals that reduce or inhibit the transmission of perception of pain include endorphins and enkephalin, which are morphinelike endogenous neurotransmitters . Acetylcholine, serotonin, and substance P are chemicals that increase the transmission of pain.

Which substance reduces the transmission of pain? a. endorphins b. acetylcholine c. serotonin d. substance P

a Chemicals that reduce or inhibit the transmission of perception of pain include endorphins and enkephalin, which are morphinelike endogenous neurotransmitters . Acetylcholine, serotonin, and substance P are chemicals that increase the transmission of pain.

A client reports abdominal pain as "8" on a pain intensity scale of 0-10 thirty minutes after receiving an opioid intravenously. Her past medical history includes partial-thickness burns to approximately 60% of her body several years ago. The nurse assesses a. That the client's past experiences with pain may influence her perception of current pain b. That based on her past experiences the client's perception of pain should be less c. That the client has become dependent on drugs from her previous experience of burns d. That the client is experiencing pain relating to the burn injuries from several years ago

a Clients who have had previous experiences with pain are usually more frightened about subsequent painful events, as in the client who experienced partial-thickness burns to more than 60% of her body. The clients in these situations are less able to tolerate pain. Insufficient data in the stem support that the client is dependent on drugs or that this current pain is related to the client's previous burn injuries.

A patient with a spirally fractured femur had surgical repair of the bone. After surgery, the client reports a pain rating of 7 (on a 0 to 10 scale). How would the nurse expect the client to describe the characteristics of the pain? a. local, sharp, intense b. generalized, dull, aching c. burning, sharp discomfort d. dull intermittent ache

a Deeper somatic pain such as that caused by trauma (e.g., a fracture) produces localized sensations that are sharp, throbbing, and intense. A generalized, dull, or aching pain is associated with visceral pain, which is not what this client is experiencing. A sharp, burning discomfort is associated with superficial somatic pain (cutaneous pain), such as that from an insect bite, not with a more significant injury such as a fracture requiring surgery. An intermittent dull ache is not intense and would not be rated as a 7 on a 0 to 10 pain scale.

Two clients have recently returned to the postsurgical unit after knee arthroplasty. One client is reporting pain of 8 to 9 on a 0-to-10 pain scale, whereas the other client is reporting a pain level of 3 to 4 on the same pain scale. What is the nurse's most plausible rationale for understanding the clients' different perceptions of pain? a. Endorphin levels may vary between clients, affecting the perception of pain. b. One of the clients is exaggerating the sense of pain. c. The clients are likely experiencing a variance in vasoconstriction. d. One of the clients may be experiencing opioid tolerance.

a Different people feel different degrees of pain from similar stimuli. Opioid tolerance is associated with chronic pain treatment and would not likely apply to these clients. The nurse should not assume the client is exaggerating the pain because the client is the best authority of their existence of pain, and definitions for pain state that pain is "whatever the person says it is, existing whenever the experiencing person says it does."

A 64-year-old client is experiencing joint pain on a regular basis and asks the nurse what the options are beyond heat and the yoga exercises the client has been doing. What does the nurse describe as the cornerstone treatment modality for pain? a. drug therapy b. physical therapy c. acupuncture d. psychological counseling

a Drug therapy is the primary method used for pain management. Physical therapy is often used as a co therapy, along with prescription or nonprescription drugs. It can help to strengthen muscles weakened by disuse. Acupuncture is a pain management technique that involves the insertion of very thin needles at strategic points on the body. It is not a primary therapy in conventional Western medicine. Psychological counseling may be recommended in some cases to help clients deal with depression and anxiety associated with pain. It is not a primary therapy.

The nurse applies a transdermal patch of fentanyl for a client with pain due to cancer of the pancreas. The client puts the call light on 1 hour later and tells the nurse that it has not helped. What is the best response by the nurse? a. "It will take approximately 12 to 18 hours for the medication to begin to work, so I will give you something else now to relieve the pain." b. "It should have begun working 30 minutes ago. I will call the doctor and let the doctor know you need something stronger." c. "You have probably developed a tolerance to the medication." d. "It will take about 24 hours for the medication to work. I can't give you anything else or you will overdose."

a Its lipophilicity makes fentanyl ideal for drug delivery by transdermal patch (Duragesic) for long-term opioid administration and by the oral transmucosal (Actiq) and buccal (Fentora) routes for BTP treatment in patients who are opioid tolerant. Following application of the transdermal patch, a subcutaneous depot of fentanyl is established in the skin near the patch. After absorption from the depot into the systemic circulation, the drug distributes to fat and muscle. When the first patch is applied, 12 to 18 hours are required for clinically significant analgesia to be obtained; attention must be paid to providing adequate supplemental analgesia during that time.

According to The Joint Commission's pain assessment and management standards, which of the following are essential components of a comprehensive pain assessment? a. location, onset, alleviating factors, and aggravating factors b. quality, location, intensity, and family history c. nutritional deficiencies, onset, duration, and effects of pain d. intensity, variations, range of motion, and the client's goal for pain control

a Location, onset, alleviating factors, and aggravating factors are all essential components of a comprehensive pain assessment according to The Joint Commission's standards. Family history is not an essential component of a comprehensive pain assessment according to The Joint Commission's standards. Nutritional deficiencies are not an essential component of a comprehensive pain assessment according to The Joint Commission's standards. Range of motion is not an essential component of a comprehensive pain assessment according to The Joint Commission's standards.

A client is on a second round of radiation therapy for an inoperable tumor, and asks the nurse for medication to help with pain. The nurse suspects that the client's pain is the result of nerve damage from the radiation. Which type of pain is the client likely experiencing? a. neuropathic pain b. somatic pain c. visceral pain d. referred pain

a Neuropathic pain can affect cancer patients due to nerve damage from chemotherapy or radiation therapy. Somatic pain is caused by damage or disorders that affect bones, joints, muscles, skin, or other structures. Visceral pain arises from internal organs such as the heart, kidneys, and intestine that are diseased or injured. Referred pain is pain felt in the body in a location that is different from the actual source of the pain.

The nurse has been frequently assessing an older adult's pain after she suffered a humeral fracture in a fall. When applying the nursing process in pain management for a client of this age, what principle should the nurse best apply? a. Monitor for signs of drug toxicity due to a decrease in metabolism. b. Monitor for an increase in absorption of the drug due to age-related changes. c. Monitor for a paradoxical increase in pain with opioid administration. d. Administer analgesics every 4 to 6 hours as prescribed to control pain.

a Older adults may respond differently to pain than younger adults. Because elderly people have a slower metabolism and a greater ratio of body fat to muscle mass compared with younger people, small doses of analgesic agents may be sufficient to relieve pain, and these doses may be effective longer. This fact also corresponds to an increased risk of adverse effects. Paradoxical effects are not a common phenomenon. Frequency of administration will vary widely according to numerous variables.

The nurse is caring for a client with metastatic bone cancer. The client asks the nurse why he has had to keep getting larger doses of his pain medication, although they do not seem to affect him. What is the nurse's best response? a. "Over time you become more tolerant of the drug." b. "You may have become immune to the effects of the drug." c. "You may be developing a mild addiction to the drug." d. "Your body absorbs less of the drug due to the cancer."

a Over time, the client is likely to become more tolerant of the dosage. Little evidence indicates that clients with cancer become addicted to the opioid medications. Clients do not become immune to the effects of the drug, and the body does not absorb less of the drug because of the cancer.

A client suffers from osteoarthritis and is prescribed a scheduled dose of analgesics to manage chronic pain. Because of limited income, the client sometimes skips doses or takes half doses to "make the medicine last longer." To ensure uniform pain management, the nurse should advise the client to: a. take medication doses when ordered. b. reduce all doses to the amount of the lowest dose. c. take pain medication on an "as needed" basis. d. None of the responses is correct.

a Pain management cannot be effective if medication is not consistently used. Especially for chronic pain, medication doses should never be skipped or reduced without physician input. Because chronic pain is pain that continues for an extended period of time (6 months or more), pain management cannot be effective if medication is not consistently used.

A client who is recovering from knee replacement surgery asks for the lowest possible dose of pain medication, and reports having been able to handle pain ever since childhood. Which of the following aspects of pain is the client describing to the nurse? a. tolerance b. threshold c. perception d. transmission

a Pain tolerance is the amount of pain a person can endure once the pain threshold has been reached. The pain threshold is the point at which pain-transmitting chemicals reach the brain, resulting in conscious awareness of the pain. Pain perception is the phase of impulse transmission during which the brain experiences pain at a conscious level. Pain transmission is the phase of impulse transmission during which peripheral nerve fibers form synapses with neurons in the spinal cord. The pain impulses move from the spinal cord to sequentially higher levels in the brain.

A client has been given a patient-controlled analgesia (PCA) device to control postoperative pain. The client expresses concern about administering too much of the analgesic and accidentally overdosing. What topic should the nurse teach the client about? a. the limits on dose and frequency that are programmed into the PCA b. the fact that naloxone will be kept readily available at all times c. the use of non-pharmacologic pain interventions to minimize use of the PCA d. the importance of limiting the use of the PCA to no more than twice per hour

a Patient-controlled analgesia (PCA) devices allow clients to self-administer their own narcotic analgesic using an intravenous pump system and pressing a handheld button. The dose and time intervals between doses are programmed into the device to prevent accidental overdose. Dosing may or may not be more than twice per hour. Naloxone treats overdoses, but this will not likely alleviate the client's concerns about overdosing in the first place. The client may benefit from non-pharmacologic pain measures, but should not be encouraged to minimize the use of the PCA or to endure pain.

A client has been given a patient-controlled analgesia (PCA) device to control postoperative pain. The client expresses concern about administering too much of the analgesic and accidentally overdosing. What topic should the nurse teach the client about? a. the limits on dose and frequency that are programmed into the PCA b. the fact that naloxone will be kept readily available at all times c. the use of non-pharmacologic pain interventions to minimize use of the PCA d. the importance of limiting the use of the PCA to no more than twice per hour

a Patient-controlled analgesia (PCA) devices allow clients to self-administer their own narcotic analgesic using an intravenous pump system and pressing a handheld button. The dose and time intervals between doses are programmed into the device to prevent accidental overdose. Dosing may or may not be more than twice per hour. Naloxone treats overdoses, but this will not likely alleviate the client's concerns about overdosing in the first place. The client may benefit from non-pharmacologic pain measures, but should not be encouraged to minimize the use of the PCA or to endure pain.

A patient is being seen in the health clinic for chronic headaches. He has been using pain medications on a regular basis. Which of the following would be part of the teaching plan for a patient? a. Inform the primary health care provider about the use of salicylates before any procedure. b. Avoid harsh sunlight for 2 hours after administering analgesic agents or salicylates. c. Minimize the intake of fiber during the therapy. d. Consume the medications just before or along with meals.

a Patients should be advised to inform the primary health care provider or dentist before any procedure when they use pain medications, especially salicylates or nonsteroidal anti-inflammatory agents, on a regular basis. Over-the-counter analgesic agents, such as aspirin, ibuprofen, or acetaminophen, should not be avoided consistently to treat chronic pain without consulting a physician. Pain medications administered 30 to 45 minutes before meals may enable the patient to consume an adequate intake, while a high-fiber diet may help ease constipation related to narcotic analgesics. Patients need not avoid harsh sunlight after administering analgesic agents; these drugs do not cause photosensitivity.

Regarding tolerance and addiction, the nurse understands that a. although clients may need increasing levels of opioids, they are not addicted. b. tolerance to opioids is uncommon. c. addiction to opioids often develops. d. the nurse must be primarily concerned about the development of addiction by a client in pain.

a Physical tolerance usually occurs in the absence of addiction. Tolerance to opioids is common. Addiction to opioids is rare and should never be the primary concern for a client in pain.

Prostaglandins are chemical substances with what property? a. Increase the sensitivity of pain receptors b. Reduce the perception of pain c. Inhibit the transmission of pain d. Inhibit the transmission of noxious stimuli

a Prostaglandins are believed to increase sensitivity to pain receptors by enhancing the pain-provoking effect of bradykinin. Endorphins and enkephalins reduce or inhibit transmission or perception of pain. Morphine and other opioid medications inhibit the transmission of noxious stimuli by mimicking enkephalin and endorphin.

In which situation is it most likely that pain management may not be readily forthcoming to an adult client in pain? a. The client's expressions of pain do not match the nurse's expectations. b. Analgesics are contraindicated for the client's condition. c. A numeric scale is used to assess pain intensity. d. The pain is chronic.

a Responses to pain and coping techniques are learned, and clients may express them in a variety of ways. If a client's expressions of pain are inconsistent with the nurse's expectations, pain management may not be readily forthcoming, and the client's pain may be undertreated. Analgesics may be contraindicated in certain situations, but efforts should still be made to alleviate a client's pain. The use of a numeric scale for pain assessment is not related to the lack of pain management. The risk for improper management of pain does not increase specifically in the case of chronic pain.

The home health nurse is developing a plan of care for a client who will be managing his chronic pain at home. Using the nursing process, on which concepts should the nurse focus the client teaching? a. Self-care and safety b. Autonomy and need c. Health promotion and exercise d. Dependence and health

a The client will be at home monitoring his own pain management, administering his own medication, and monitoring and reporting side effects. This requires the ability to perform self-care activities in a safe manner. Creating autonomy is important, but need is a poorly defined concept. Health promotion is an important global concept for maintaining health, and exercise is an appropriate activity; however, self-care and safety are the priorities. Dependence is not a concept used to develop a nursing plan of care, and health is too broad a concept to use as a basis for a nursing plan of care.

The nurse is receiving an older adult client from the PACU. Part of the report had been passed on from the preoperative assessment where it was noted that the client has been agitated in the past following opioid administration. What principle should guide the nurse's management of the client's pain? a. The elderly may require lower doses of medication and are easily confused with new medications. b. The elderly may have altered absorption and metabolism, which prohibits the use of opioids. c. The elderly may be confused following surgery, which is an age-related phenomenon unrelated to the medication. d. The elderly may require a higher initial dose of pain medication followed by a tapered dose.

a The elderly often require lower doses of medication and are easily confused with new medications. The elderly have slowed metabolism and excretion, and, therefore, the elderly should receive a lower dose of pain medication given over a longer period of time, which may help to limit the potential for confusion. Unfortunately, the elderly are often given the same dose as younger adults, and the resulting confusion is attributed to other factors like environment. Opioids are not absolutely contraindicated and confusion following surgery is never normal. Medication should begin at a low dose and slowly increase until the pain is managed.

When the nurse is performing an assessment and finds no physical cause for a patient's pain, what should the nurse do when the patient continues to complain of pain? a. Believe a patient when he or she states that pain is present. b. Doubt that pain exists when no physical origin can be identified. c. Realize that patients frequently imagine and state that they have pain without actually feeling painful sensations. d. Assume that the patient may be a drug seeker and should be given other methods for pain control.

a The highly subjective nature of pain causes challenges in assessment and management; however, the patient's selfreport is the undisputed standard for assessing the existence and intensity of pain (APS, 2008; McCaffery et al., 2011). Accepting and acting on the patient's report of pain are sometimes difficult. Because pain cannot be proved, the health care team is vulnerable to inaccurate or untruthful reports of pain. Clinicians are entitled to their personal doubts and opinions, but those doubts and opinions cannot be allowed to interfere with appropriate patient care.

A patient who is postoperative day 1 following a discectomy has lit his call light and requested a dose of hydromorphone, which he receives on a p.r.n. basis for breakthrough pain. What should the nurse first do in response to the patient's request? a. Assess the characteristics of the patient's pain. b. Draw up the prescribed dose of hydromorphone. c. Propose the use of nonpharmacologic interventions. d. Discuss the use of NSAIDs as an alternative to opioids.

a The most appropriate immediate response to a patient's complaint of pain is an assessment of characteristics such as intensity, quality, onset, location, timing, associated or aggravating factors, and radiation. This assessment should normally precede the nurse's chosen interventions.

A client is admitted to the trauma unit after being injured in an industrial accident. The nurse needs to carefully monitor traumatic injuries. How often should the nurse assess and document the client's pain? a. every time the client's vital signs are assessed b. upon the client's admission and discharge c. an hour after analgesics are administered d. an hour after every meal the client consumes

a The nurse should check and document the client's pain every time the client's temperature, pulse, respirations, and blood pressure are assessed. The American Pain Society (APS) has proposed that pain assessment should be considered the fifth vital sign. Pain assessment should be done on a different schedule that is not related to drug administration or food consumption. An hour after administration may be too long to wait for assessment of the effects of the intervention.

The nurse, as a member of the patient's health care team, obtains pain assessment information to identify goals for pain management. Select the most important factor that the nurse would use for goal setting: a. Severity of the pain as judged by the patient b. Anticipated harmful effects of the pain experience c. Anticipated duration of the pain d. Medical interventions for pain management

a The patient's perception of pain severity should always be the primary consideration. It forms the baseline for all management.

The nurse, as a member of the patient's health care team, obtains pain assessment information to identify goals for pain management. Select the most important factor that the nurse would use for goal setting: a. Severity of the pain as judged by the patient b. Anticipated harmful effects of the pain experience c. Anticipated duration of the pain d. Medical interventions for pain management

a The patient's perception of pain severity should always be the primary consideration. It forms the baseline for all management.

A client has been taking opioid analgesics for more than 2 weeks to control post-surgical pain. Although pleased with the client's progress, the surgeon decides to change the analgesic to a non-opioid drug. The surgeon prescribes a gradually lower opioid dose and increasingly larger non-opioid doses. The surgeon is changing medications in this manner to avoid: a. withdrawal symptoms. b. addiction. c. tolerance. d. respiratory depression.

a To avoid withdrawal symptoms, drugs that are known to cause physical dependence are discontinued gradually. The dosage or the frequency of their administration is lowered over 1 week or longer. The process described is not used in cases of drug addiction. Tolerance is a condition in which a client needs larger doses of a drug to achieve the same effect as when first administered. The process described is not used to address drug tolerance. Although respiratory depression is a risk associated with opioid therapy, this client has not shown any sign of respiratory problems.

The nurse is caring for a client with sickle cell disease who lives in the community. Over the years, there has been joint damage, and the client is in chronic pain. The client has developed a tolerance to her usual pain medication. When does the tolerance to pain medication become the most significant problem? a. When it results in inadequate relief from pain b. When dealing with withdrawal symptoms resulting from the tolerance c. When having to report the client's addiction to her physician d. When the family becomes concerned about increasing dosage

a Tolerance to opioids is common and becomes a problem primarily in terms of maintaining adequate pain control. Symptoms of physical dependence may occur when opiates are discontinued, but there is no indication that the client's medication will be discontinued. This client does not have an addiction and the family's concerns are secondary to those of the client.

A client is reporting her pain as "8" on a 0-to-10 pain intensity scale. Then, the client states the pain is "3." Before the nurse leaves the room, the client states her pain is "6." The best action of the nurse is to a. Obtain a pain scale with faces for the client to measure her pain. b. Average the numbers and report that number as the client's level of pain. c. Medicate the client for pain based on the highest number of "8." d. Record each of the numbers the client stated for her pain.

a Various scales are helpful to clients trying to describe pain intensity. If the client cannot use one scale, such as the numeric pain intensity scale, the nurse uses another pain intensity scale that the client finds easy to understand and use. The nurse does not average the numbers, medicate based on the highest number, nor record each of the numbers the client stated.

A client is admitted with generalized abdominal pain, nausea, vomiting, and hypotension. The client has not passed stool in over 1 week and has been in pain for the past 4 days. Which type of pain would you expect the client to be experiencing? a. visceral b. neuropathic c. deeper somatic d. chronic

a Visceral pain arises from internal organs such as the heart, kidneys, and intestine that are diseased or injured. Visceral pain usually is diffuse, poorly localized, and accompanied by autonomic nervous system symptoms such as nausea, vomiting, pallor, hypotension, and sweating. Neuropathic pain is pain that is processed abnormally by the nervous system. Deeper somatic pain such as that caused by trauma produces localized sensations that are sharp, throbbing, and intense. Chronic pain has a duration longer than 6 months.

What is the function and the structure of the membranous labyrinth?

a system of ducts and dilatations located within the bony labyrinth of the internal ear and it contains the receptors for hearing and balance.

A new mother asks, "When will the soft spot near the front of my baby's head close?" The nurse should tell the mother the soft spot will close in about: a) 12 to 18 months. b) 6 to 8 months. c) 2 to 3 months. d) 9 to 10 months.

a) 12 to 18 months. Normally, the anterior fontanel closes between ages 12 and 18 months. Premature closure (craniostenosis or premature synostosis) prevents proper growth and expansion of the brain, resulting in an intellectual disability. The posterior fontanel typically closes by ages 2 to 3 months.

Forty-eight hours after undergoing a ventriculoperitoneal shunt placement, an infant is irritable and vomits a large amount. Assessment reveals a bulging fontanel. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the primary health care provider with a recommendation for: a) A computerized tomography scan. b) A dose of morphine. c) A fluid bolus of normal saline. d) A dose of furosemide.

a) A computerized tomography scan. The infant is exhibiting signs and symptoms of increased intracranial pressure (ICP) caused by a shunt malfunction. A CT scan, shunt series X-ray, and tapping the shunt are performed to diagnose a shunt malfunction. Irritability results from the increased ICP, not postoperative pain. The infant has increased ICP; a fluid bolus will further increase it. The increased ICP is caused by a shunt malfunction and will not be relieved by furosemide. Surgical intervention is necessary to correct a shunt malfunction.

When assessing a preschooler who has sustained a head trauma, the nurse notes that the child appears to be obtunded. Which finding supports this level of consciousness? a) Can be roused with stimulation b) Limited spontaneous movement; sluggish speech c) Remains in a deep sleep; responsive only to vigorous and repeated stimulation d) No motor or verbal response to noxious (painful) stimuli

a) Can be roused with stimulation The child is obtunded if he can be aroused with stimulation. If the child shows no motor or verbal response to noxious stimuli, he's comatose. If the child remains in a deep sleep and is responsive only to vigorous and repeated stimulation, he's stuporous. If the child has limited spontaneous movement and sluggish speech, he's lethargic.

A client was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first? a) Declining level of consciousness (LOC) b) Irregular breathing pattern c) Pupillary asymmetry d) Involuntary posturing

a) Declining level of consciousness (LOC) With a brain injury such as an epidural hematoma (a likely diagnosis, based on this client's symptoms), the initial sign of increasing ICP is a change in LOC. As neurologic deterioration progresses, manifestations involving pupillary symmetry, breathing patterns, and posturing will occur.

A child who was intubated after a craniotomy now shows signs of decreased level of consciousness. The health care provider (HCP) prescribes manual hyperventilation to keep the PaCO2 between 25 and 29 mm Hg and the PaO2 between 80 and 100 mm Hg. The nurse interprets this prescription based on the understanding that this action will accomplish which goal? a) Decrease intracranial pressure. b) Lower the arousal level. c) Produce hypoxia. d) Ensure a patent airway.

a) Decrease intracranial pressure. Hypercapnia, hypoxia, and acidosis are potent cerebral vasodilating mechanisms that can cause increased intracranial pressure. Lowering the carbon dioxide level and increasing the oxygen level through hyperventilation is the most effective short-term method of reducing intracranial pressure. Although ensuring a patent airway is important, this is not accomplished by manual hyperventilation. Manual hyperventilation does not lower the arousal level; in fact, the arousal level may increase. Manual hyperventilation is used to reduce hypoxia, not produce it.

While caring for a term neonate who has been receiving phototherapy for 8 hours, the nurse should notify the health care provider (HCP) if which finding is noted? a) absent Moro reflex b) bronze-colored skin c) urine specific gravity of 1.018 d) maculopapular chest rash

a) absent Moro reflex An absent Moro reflex, lethargy, opisthotonos, and seizures are symptoms of bilirubin encephalopathy, which, although rare, can be life-threatening. Bronze discoloration of the skin and maculopapular chest rash are normal and are caused by the phototherapy. They will disappear once the phototherapy is discontinued. A urine specific gravity of 1.001 to 1.020 is normal in term neonates. The Moro reflex is an infantile reflex normally present in all infants/newborns up to 4 or 5 months of age as a response to a sudden loss of support, when the infant feels as if it is falling. It involves three distinct components: spreading out the arms (abduction) unspreading the arms (adduction) crying (usually) The primary significance of the Moro reflex is in evaluating integration of the central nervous system.

Choice Multiple question - Select all answer choices that apply. The nurse is monitoring an infant with meningitis for signs of increased intracranial pressure (ICP). The nurse should assess the infant for which signs and symptoms? Select all that apply. a) bulging fontanel b) mood swings c) headache d) emesis e) irritability

a) bulging fontanel d) emesis e) irritability Irritability, bulging fontanel, and emesis are all signs of increased ICP in an infant. A headache may be present in an infant with increased ICP; however, the infant has no way of communicating this to the parent. A headache is an indication of increased ICP in a verbal child. An infant cannot exhibit mood swings; this is indicative of increased ICP in a child or adolescent.

A client has atrial fibrillation. The nurse should monitor the client for: a) crebrovascular accident. b) cardiac arrest. c) hHeart block. d) ventricular fibrillation.

a) crebrovascular accident. Because of the poor emptying of blood from the atrial chambers, there is an increased risk for clot formation around the valves. The clots become dislodged and travel through the circulatory system. As a result, cerebrovascular accident is a common complication of atrial fibrillation.

A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates: a) dysfunction in the brain stem. b) dysfunction in the cerebrum. c) dysfunction in the spinal column. d) risk for increased intracranial pressure.

a) dysfunction in the brain stem. Decerebrate posturing indicates damage of the upper brain stem. Decorticate posturing indicates cerebral dysfunction. Increased intracranial pressure is a cause of decortication and decerebration. Alterations in sensation or paralysis indicate dysfunction in the spinal column.

The nurse understands the definition of pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." Which of the following comments by a client confirm the client's understanding of the fundamental concepts of pain? Select all that apply. a. "I am tired of living with this nagging pain; I'm not sure how much longer I can go on." b. "I would love to go to church, but my back pain is too uncomfortable to make it through the service." c. "I used to walk every day for exercise; pain in my knee made me stop walking." d. "I feel good in knowing that my doctor will determine when and how I get pain medication." e. "I will depend on you and your experience to treat my pain, as you feel appropriate."

a, b, c A fundamental concept of pain is that pain is a complex phenomenon that can affect a person's psychosocial, emotional, and physical functioning. Helplessness is an emotional response to pain. Inability to continue normal activities, such as going to church, is a psychosocial consequence of pain. Inability to perform normal exercise because of pain is a physical restriction related to pain. Pain is highly personal and subjective. The client's report is the most reliable indicator of pain. The client works with the nurse and doctor to establish a pain management regimen.

Which are risk factors for stroke? Select all that apply. a. High blood pressure b. Previous stroke or transient ischemic attack (TIA) c. Smoking d. Use of oral contraceptives e. Female gender

a, b, c, and e

After having a stroke, a patient has cognitive deficits. What are the cognitive deficits the nurse recognizes the patient has as a result of the stroke? (Select all that apply.) a) Poor abstract reasoning b) Decreased attention span c) Expressive aphasia d) Short- and long-term memory loss e) Paresthesias

a,b,d Cognitive deficits associated with stroke include short- and long-term memory loss, decreased attention span, and poor abstract reasoning. Expressive aphasia is a verbal deficit, not a cognitive deficit. Paresthesias are sensory deficits, not cognitive deficits.

Patient arrives to have MRI done in outpatient.what information warrants further assessment to prevent complications related to the MRI procedure? a. "I am trying to quit smoking and have a patch on." b. I have been trying to get an appointment for a long time." c. "I have not had anything to eat or drink for 3 hours." d. "My legs feel numb sometimes when I sit too long.

a. "I am trying to quit smoking and have a patch on."

The nurse knows that symptoms associated with a TIA usually subside in what period of time? Select one: a. 1 hour b. 3-6 hours c. 12 hours d. 24 -36 hours e. 48-72 hours

a. 1 hour

14. A 154-pound woman has been prescribed tPA (0.9 mg/kg) for an ischemic stroke. The nurse knows to give how many mg initially? a. 6.3 mg b. 7.5 mg c. 8.3 mg d. 10 mg

a. 6.3 mg - bolus 56.7mg- infusion dose

6. A nurse is assisting with a community screening for people at high risk for stroke. To which of the following clients would the nurse pay most attention? a. A 60-year-old African-American man b. A 40-year-old Caucasian woman c. A 62-year-old Caucasian woman d. A 28-year-old pregnant African-American woman

a. A 60-year-old African-American man

The nurse is evaluating the collaborative care of a client with traumatic brain injury (TBI). What is the most important goal for this client? a. Achieving the highest level of functioning b. Increasing cerebral perfusion c. Preventing further injury d. Preventing skin breakdown

a. Achieving the highest level of functioning

The term to describe hair loss is Select one: a. Alopecia b. Hair loss c. Hirsutism d. Vitiligo

a. Alopecia

A client hospitalized for hypertension presses the call light and reports "feeling funny." When the nurse gets to the room, the client is slurring words and has right-sided weakness. What does the nurse do first? a. Assesses airway, breathing, and circulation b. Calls the provider c. Performs a neurologic check d. Assists the client to a sitting position

a. Assesses airway, breathing, and circulation

Brian has just received a diagnosis of glaucoma and is instructed to avoid the following behaviors: (Select all that apply) Select one or more: a. Avoid squeezing eyelids b. Avoid bending over c. Avoid eating ice cream d. Avoid holding the breath e. Avoid twisting laterally

a. Avoid squeezing eyelids b. Avoid bending over d. Avoid holding the breath

You are monitoring Bob for Cushing's Triad. What do you recognize as symptoms associated with Cushing's Triad? (Select all that apply) Select one or more: a. Bradycardia b. Bradypnea c. Hypertension d. Tachycardia e. Pupillary constriction

a. Bradycardia b. Bradypnea c. Hypertension

A client with a traumatic brain injury from a motor vehicle crash is monitored for signs/symptoms of increased intracranial pressure (ICP). Which sign/symptoms does the nurse monitor for? a. Changes in breathing pattern b. Dizziness c. Increasing level of consciousness d. Reactive pupils

a. Changes in breathing pattern

Rite was unconscious at the scene, then wok up disoriented and refused to go the the hospital for treatment. Rite became agitated and restless, then quickly lost consciousness again. What thpe of TBI do you suspect? Select one: a. Epidural hematoma b. Acute subdural hematoma c. Chronic subdural hematoma d. Grade 1 concussion

a. Epidural hematoma

16. A physician orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? a. Heparin sodium b. Dexamethasone (Decadron) c. Methyldopa (Aldomet) d. Phenytoin (Dilantin)

a. Heparin sodium

11. Which of the following is a contraindication for the administration of tissue plasminogen activator (t-PA)? a. Intracranial hemorrhage b. Ischemic stroke c. Age 18 years of age or older d. Systolic blood pressure less than or equal to 185 mm Hg

a. Intracranial hemorrhage

Bettie has a serum bilirubin concentration of 3 mg/100 ml. What does the nurse observe when performing a skin assessment? Select one: a. Jaundice b. Pallor c. Bronzed appearance d. Cherry red face Feedback

a. Jaundice

What are the potential complications of SJS (Stevens-Johnson Syndrome) and TEN (Toxic epidermal necrolysis)? Select one or more: a. Keratoconjunctivitis b. Sepsis c. Heart murmur d. Tinnitis e. Multiple organ dysfunction

a. Keratoconjunctivitis b. Sepsis e. Multiple organ dysfunction

The nurse is caring for a person with a brain abscess that developed from untreated otitis media. What assessment data is a priority to alter the nurse to changes in intracranial pressure? Select one: a. LOC b. Peripheral pulses c. Sensory perception d. Crackles bilaterally

a. LOC

15. What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke? a. Left visual field deficit b. Aphasia c. Slow, cautious behavior d. Altered intellectual ability

a. Left visual field deficit

Typical nursing considerations to prioritize when caring for someone with a neurologic injury include: (choose two best answers) Select one or more: a. Prevent further injury b. Assess motor function c. Maintain skin integrity d. Plan long term rehabilitation e. Establish consistent nutritional support

a. Prevent further injury c. Maintain skin integrity

9. An emergency department nurse is interviewing a client with signs of an ischemic stroke that began 2 hours ago. The client reports that she had a cholecystectomy 6 weeks ago and is taking digoxin, coumadin, and labetelol. This client is not eligible for thrombolytic therapy for which of the following reasons? a. She is taking coumadin. b. She is not within the treatment time window. c. She is taking digoxin. d. She had surgery 6 weeks ago

a. She is taking coumadin.

Commonly used topical antibacterials are: (Select all that apply) Select one or more: a. Silver sulfadiazine b. Silver nitrite c. Furosemide d. Diphenyloxide e. Mafenide acetate

a. Silver sulfadiazine b. Silver nitrite e. Mafenide acetate

MJ is a dark skinned person who is having some acute GI bleeding. How can the nurse determine from skin color change if shock is present? Select one: a. Skin is ashen gray and dull b. Skin is dusky blue c. Skin is reddish pink d. Skin is whitish pink

a. Skin is ashen gray and dull

Bullous impetigo, a deep-seated infection characterizeed by large, fluid-filled blisters, is cause by what microorganism? Select one: a. Staphylococcus aureus b. Psuedomonas c. Streptococci d. HIV

a. Staphylococcus aureus

Otosclerosis is best described as Select one: a. The condition of having small bony protrusions in the lower posterior bony portion of the ear canal. b. The condition of having demyelination of the eighth craanial nerve c. The condition of having altered sensation of orientation in space due to sclerotic bone d. The condition of having a sensation of fullness in the ear due to sclerosed cerumen

a. The condition of having small bony protrusions in the lower posterior bony portion of the ear canal.

Mechanical vibrations are transformed into neural activity so that sounds can be differentiated by Select one: a. The organ of Corti b. The tympanic membrane c. Both stapes and incus d. By semilunar canals and eustachian tube

a. The organ of Corti

After administering a Tensilon test, a positive diagnosis is made. What can the nurse expect to happen next? Select one: a. Thirty seconds after administration of Tensilon, facial weakness and ptosis will abate for approximately 5 minutes. b. After administration of Tensilon, there will be no change in the status of ptosis or facial weakness. c. After administration of Tensilon, facial weakness and ptosis will abate for approximately 24 hours.

a. Thirty seconds after administration of Tensilon, facial weakness and ptosis will abate for approximately 5 minutes.

What are the cardinal signs of Parkinson's Disease? (Select all that apply) Select one or more: a. Tremor b. Rigidity c. Bradykinesia d. Postural instability e. Poor coordination

a. Tremor b. Rigidity c. Bradykinesia d. Postural instability

A patient with vertigo is scheduled for an electronystagmography in 2 weeks. What will the nurse isntruct the patient to do prior to the test? Select one: a. Withhold caffeine and alcohol 48 hours before the test b. Withhold BP medication 24 hours before the test c. Withhold vestibular suppressants 48 hours before the test d. Do not eat or drink anything 12 hours before the test

a. Withhold caffeine and alcohol 48 hours before the test

Connie has a suspected detached retina. What does the nurse recognize as significant for retinal detachment? (Select all that apply) Select one or more: a. visual field of floating particles b. A definite area of blank vision c. Momentary flashes of light d. Pain with bright light e. Halos around the eyes f. Ptosis g. Elevated temperature h. Nystagmus

a. visual field of floating particles b. A definite area of blank vision c. Momentary flashes of light

presbycusis

age related hearing loss

Which term refers to the failure to recognize familiar objects perceived by the senses?

agnosia

Aneurysm rebleeding occurs most frequently during which time frame after the initial hemorrhage? a. First 48 hours b. First 12 hours c. First 72 hours d. First 24 hours

aneurysm rebleeding occurs most frequently during the first 2-12 hours after the initial hemorrhage and is considered a major complication.

A client diagnosed with a stroke is ordered to receive warfarin. Later, the nurse learns that the warfarin is contraindicated and the order is canceled. The nurse knows that the best alternative medication to give is

aspirin. Explanation: If warfarin is contraindicated, aspirin is the best option, although other medications may be used if both are contraindicated.

A client is receiving postoperative morphine through a patient-controlled analgesia (PCA) pump and the client's prescriptions specify an initial bolus dose. What is the nurse's priority assessment? a. Assessment for decreased level of consciousness (LOC) b. Assessment for respiratory depression c. Assessment for fluid overload d. Assessment for paradoxical increase in pain

b

A client is prescribed methadone 10 mg three times a day for neuralgia following chemotherapy treatment. The client reports that he is experiencing constipation and asks the nurse for information about preventing constipation. The nurse recommends a. ingesting up to 6 glasses of fluids per day b. increasing the amount of bran and fresh fruits and vegetables c. using milk of magnesia 30 mL every day d. inserting a bisacodyl (Dulcolax) rectal suppository every morning

b Constipation is a common problem with the use of opioid medications, such as methadone. Activities to prevent constipation include increasing bran and fresh fruits and vegetables in the diet. The client should ingest 8 to 10 glasses of fluids per day. Milk of magnesia may be used if no bowel movement is produced in 3 days. Milk of magnesia is not to be used daily. A glycerin suppository, not bisacodyl, may be used to make the bowel movement less painful.

A nurse documents the presence of chronic pain on an electronic health record. Choose a description that could be used. The pain can be: a. Attributed to a specific cause. b. Prolonged in duration. c. Rapidly occurring and subsiding with treatment. d. Separate from any central or peripheral pathology.

b A major distinguishing characteristic between acute and chronic pain is its duration. Chronic is always prolonged.

The nurse is caring for a patient who has been hospitalized on several occasions for lower abdominal pain related to Crohn's disease. How may this chronic pain be described? a. Attributable to a specific cause b. Prolonged in duration c. Rapidly occurring and subsiding with treatment d. Separate from any central or peripheral pathology

b Acute pain differs from chronic pain primarily in its duration. For example, tissue damage as a result of surgery, trauma, or burns produces acute pain, which is expected to have a relatively short duration and resolve with normal healing. Chronic pain is subcategorized as being of cancer or noncancer origin and can be time limited (e.g., may resolve within months) or persist throughout the course of a person's life.

The emergency department (ED) nurse is caring for an adult client who was in a motor vehicle accident. Radiography reveals an ulnar fracture. What type of pain is the nurse addressing with this client? a. Chronic b. Acute c. Intermittent d. Osteopenic

b Acute pain is usually of recent onset and commonly associated with a specific injury. Acute pain indicates that damage or injury has occurred. Chronic pain is constant or intermittent pain that persists beyond the expected healing time and that can seldom be attributed to a specific cause or injury. Phantom pain occurs when the body experiences a loss, such as an amputation, and still feels pain in the missing part. "Osteopenic" pain is not a recognized category of pain.

When drafting a nursing care plan for a patient in pain, it is important for the nurse to determine if the pain is acute or chronic. Choose an example of chronic pain. a. A migraine headache b. Intervertebral disk herniation c. Angina d. Appendicitis

b Chronic pain is found with degeneration or traumatic conditions and can sometimes be the cause of the patient's primary disorder. The other three choices refer to acute pain.

About which issue should the nurse inform clients who use pain medications on a regular basis? a. Avoid harsh sunlight for 2 hours after administering analgesic agents or salicylates. b. Inform the primary health care provider about the use of salicylates before any procedure, and avoid over-the-counter analgesics consistently without consulting a physician. c. Minimize fiber intake during the therapy. d. Consume the medications just before or along with meals.

b Clients should be advised to inform the primary health care provider or dentist before any procedure when they use pain medications, especially salicylates or nonsteroidal anti-inflammatory agents, on a regular basis. Over-the-counter analgesic agents, such as aspirin, ibuprofen, or acetaminophen, should not be avoided consistently to treat chronic pain without consulting a physician. Pain medications administered 30 to 45 minutes before meals may enable the client to consume an adequate intake, while a high-fiber diet may help ease constipation related to narcotic analgesics. Clients need not avoid harsh sunlight after administering analgesic agents because these drugs do not cause photosensitivity.

A client who fell at home is hospitalized for a hip fracture. The client is in Buck's traction, anticipating surgery, and reports pain as "2" on a pain intensity scale of 0 to 10. The client also exhibits moderate anxiety and moves restlessly in the bed. The best nursing intervention to address the client's anxiety is to a. Administer the prescribed alprazolam (Xanax). b. Assess the reason for the client's anxiety. c. Administer the prescribed dose of morphine. d. Assist the client out of bed and into a chair.

b Following the steps of the nursing process, the nurse needs to assess the reason for the client's anxiety. The client could be anxious about impending surgery, an unattended pet, a sick family member, etc. Then, the nurse intervenes appropriately by obtaining the assistance the client may need or administering anti-anxiety medication. The question is asking about treatment for anxiety. Pain medication should not be administered for anxiety. The nurse will not assist the client to a chair, because the client is on bedrest and in Buck's traction.

A medical nurse is appraising the effectiveness of a client's current pain control regimen. The nurse is aware that if an intervention is deemed ineffective, goals need to be reassessed and other measures need to be considered. What is the role of the nurse in obtaining additional pain relief for the client? a. Primary caregiver b. Client advocate c. Team leader d. Case manager

b If the intervention was ineffective, the nurse should consider other measures. If these are ineffective, pain-relief goals need to be reassessed in collaboration with the physician. The nurse serves as the client's advocate in obtaining additional pain relief.

The nurse in a pain clinic is caring for a client who is suffering from long-term, intractable pain. The pain team feels that first-line pharmacologic and nonpharmacologic methods of pain relief have been ineffective. What recommendation should guide this client's subsequent care? a. The client may want to investigate new alternative pain management options that are available in other countries. b. The client may benefit from referral to a neurologist or neurosurgeon to discuss pain-management options. c. The client may want to increase his exercise and activities significantly to create distractions. d. The client may want to relocate to long-term care in order to have his ADL needs met.

b In some situations, especially with long-term severe intractable pain, usual pharmacologic and nonpharmacologic methods of pain relief are ineffective. In those situations, neurologic and neurosurgical approaches to pain management may be considered. Investigating new alternative pain-management options that are available abroad is unrealistic and may even be dangerous advice. Increasing his exercise and activities to create distractions is unrealistic when a client is in intractable pain and this recommendation conveys the attitude that the pain is not real. Moving into a nursing home so others may care for him is an intervention that does not address the issue of pain.

The decision to order an opioid dosage for an elderly patient that is slightly smaller than the dose of medication prescribed for younger patients is based on the following physiologic reason: a. Increased metabolism results in higher blood levels. b. Decreased renal excretion of drugs increases toxic levels. c. Some opioids have increased binding by plasma proteins. d. Susceptibility to respiratory system depression is lowered.

b In the elderly, metabolism tends to decrease, respiratory system depression is increased, and metabolism is decreased. The kidneys tend to decrease renal excretion.

Which is a true statement regarding placebos? a. A placebo effect is an indication that the client does not have pain. b. Placebos should never be used to test a client's truthfulness about pain. c. A placebo should be used as the first line of treatment for a client. d. A positive response to a placebo indicates that the client's pain is not real.

b Many pain guidelines, position papers, nurse practice acts, and hospital policies nationwide agree that placebos should not be used to assess or manage pain in any client, regardless of age or diagnosis. Perception of pain is highly individualized. A placebo effect is a true physiologic response. A placebo should never be used as a first line of treatment. Reduction in pain as a response to placebo should never be interpreted as an indication that the person's pain is not real.

A nurse on an oncology unit has arranged for an individual to lead meditation exercises for clients who are interested in this nonpharmacologic method of pain control. The nurse should recognize the use of what category of nonpharmacologic intervention? a. A body-based modality b. A mind-body method c. A biologically based therapy d. An energy therapy

b Meditation is one of the recognized mind-body methods of nonpharmacologic pain control. The other answers are incorrect.

A preventative approach to pain relief with non-steroidal anti-inflammatory drugs (NSAIDs) means that the medication is given: a. Before pain becomes severe. b. Before pain is experienced. c. When pain is at its peak. d. When the level of pain tolerance has been exceeded.

b NSAIDs are most effective for preventive pain management when administered on a fixed-schedule (ie, every 3-4 hours) to prevent the pain experience. When combined with an opioid, the medication regimen is highly effective in managing moderate to severe pain.

How can the nurse determine that a client's pain is characteristic of acute pain? a. It does not respond well to treatment. b. It is associated with a specific injury. c. It serves no useful purpose. d. It responds well to placebos.

b Pain often is described as being acute or chronic (persistent) (Pasero & Portenoy, 2011). Acute pain differs from chronic pain primarily in its duration. For example, tissue damage as a result of surgery, trauma, or burns produces acute pain, which is expected to have a relatively short duration and resolve with normal healing. Chronic pain is subcategorized as being of cancer or noncancer origin and can be time limited (e.g., may resolve within months) or persist throughout the course of a person's life.

Which condition is a heightened response that occurs after exposure to a noxious stimulus? a. Pain tolerance b. Sensitization c. Pain threshold d. Dependence

b Sensitization is a heightened response that occurs after exposure to a noxious stimulus. Pain tolerance is the maximum intensity or duration of pain that a person is willing to endure. Pain threshold is the point at which a stimulus is perceived as painful. Dependence occurs when a client who has been taking opioids experiences a withdrawal syndrome when the opioids are discontinued.

A client's intractable neuropathic pain is being treated using a multimodal approach to analgesia. After administering a recently increased dose of IV morphine to the client, the nurse has returned to assess the client and finds the client unresponsive to verbal and physical stimulation with a respiratory rate of five breaths per minute. The nurse has called a code blue and should anticipate the administration of what drug? a. Acetylcysteine b. Naloxone c. Celecoxib d. Acetylsalicylic acid

b Severe opioid-induced sedation necessitates the administration of naloxone, an opioid antagonist. Celecoxib, acetylcysteine, and acetylsalicylic acid are ineffective.

The nurse is assessing a client's pain while the client awaits a cholecystectomy. The client is tearful, hesitant to move, and grimacing, but rates his pain as a 2 at this time on a 0-to-10 pain scale. How should the nurse best respond to this assessment finding? a. Remind the client that he is indeed experiencing pain. b. Reinforce teaching about the pain scale number system. c. Reassess the client's pain in 30 minutes. d. Administer an analgesic and then reassess.

b The client is physically exhibiting signs and symptoms of pain. Further teaching may need to be done so the client can correctly rate the pain. The nurse may also verify that the same scale is being used by the client and caregiver to promote continuity. Although all answers are correct, the best initial approach would be to reinforce teaching about the pain scale.

An older adult client has been admitted to the rehabilitation facility after falling and fracturing her left hip. The client has not regained functional ability and may have to be readmitted to an acute-care facility. When planning this client's care, what should the nurse know about the negative effects of the stress associated with pain? a. Stress is less pronounced in older adults because they generally have more sophisticated coping skills than younger adults b. Stress is particularly harmful in the elderly who have been injured or who are ill. c. It affects only those clients who are already debilitated prior to experiencing pain. d. It has no inherent negative effects; it just alerts the person/health care team of an underlying disease process.

b The widespread endocrine, immunologic, and inflammatory changes that occur with the stress of pain can have significant negative effects. This is particularly harmful in clients whose health is already compromised by age, illness, or injury. Older adults are not immune to the negative effects of stress. Prior debilitation does not have to be present in order for stress to cause potential harm.

A client who has been using a combination of drugs and alcohol is admitted to the emergency unit. Behavior has been combative and disoriented. The client has now become uncoordinated and incoherent. What is the priority action by the nurse? a) Check vital signs and level of consciousness; then place the client in a quiet area with a family member. b) Complete a thorough assessment, including a Glasgow Coma Scale, and place the client in a location for frequent monitoring. c) Notify the emergency physician and request a telephone order for sedation. Administer the medication and place the client in a quiet place for monitoring. d) Monitor the level of agitation, and when the client calms down, refer to the community addiction team.

b) Complete a thorough assessment, including a Glasgow Coma Scale, and place the client in a location for frequent monitoring. This client has been ingesting an unknown amount of drugs and alcohol and is now exhibiting a change in neurologic status. It is a priority to carefully assess and closely monitor for any deterioration. The other choices are incorrect because a family member is not qualified to monitor the client. The client would eventually be referred to an addiction team but is not medically stable. Sedation is not appropriate at this time.

A nurse caring for a child notes that the child begins to experience decreased urinary output, drop in blood pressure, and rapid thready pulse. Which of the following is the appropriate nursing intervention? a) Reassessing vital signs in 15 minutes b) Contacting the physician c) Inserting a Foley catheter to monitor urine output d) Increasing the rate of IV fluids

b) Contacting the physician The nurse should immediately contact the physician as these are concerning findings and may be indicative of serious critical events such as hypovolemic shock and hemorrhaging. Waiting to reassess the vital signs in 15 minutes can delay critical treatment, as would inserting a Foley catheter to monitor urine output.

After striking his head on a tree while falling from a ladder, a client is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention should the nurse question? a) Elevating the head of his bed b) Performing a lumbar puncture c) Placing him on mechanical ventilation d) Giving him a barbiturate

b) Performing a lumbar puncture The client's history and assessment suggest that he may have increased intracranial pressure (ICP). If this is the case, lumbar puncture shouldn't be done because it can quickly decompress the central nervous system, causing additional damage. After a head injury, barbiturates may be given to prevent seizures; mechanical ventilation may be required if breathing deteriorates; and elevating the head of the bed may be used to reduce ICP.

Choice Multiple question - Select all answer choices that apply. A client with a history of epilepsy is admitted to the medical-surgical unit. While assisting the client from the bathroom, the nurse observes the start of a tonic-clonic seizure. Which nursing interventions are appropriate for this client? Select all that apply. a) Give the prescribed dose of oral phenytoin. b) Place a pillow under the client's head. c) Assist the client to the floor. d) Turn the client to the side. e) Insert an oral suction device to remove secretions in the mouth.

b) Place a pillow under the client's head. c) Assist the client to the floor. d) Turn the client to the side. During a seizure, the nurse should assist the client to the floor to reduce the risk of falling and turn the client on the side to help clear the mouth of oral secretions. If available, it is appropriate to place a pillow under the client's head to protect against injury. It is inappropriate to introduce anything into the mouth during a seizure because of the risk of choking or compromising the airway; therefore, oral medications and suction devices should not be used.

Which effects do most antipsychotic medications exert on the central nervous system (CNS)? a) They sedate the CNS by stimulating serotonin at the synaptic cleft. b) They depress the CNS by blocking the postsynaptic transmission of dopamine, serotonin, and norepinephrine. c) They depress the CNS by stimulating the release of acetylcholine. d) They stimulate the CNS by blocking postsynaptic dopamine, norepinephrine, and serotonin receptors.

b) They depress the CNS by blocking the postsynaptic transmission of dopamine, serotonin, and norepinephrine. The exact mechanism of antipsychotic medication action is unknown, but these drugs appear to depress the CNS by blocking the transmission of three neurotransmitters: dopamine, serotonin, and norepinephrine. Antipsychotics don't sedate the CNS by stimulating serotonin, and they don't stimulate neurotransmitter action or acetylcholine release.

A nurse is assessing an 8-month-old child for signs of neurologic deficit and increased intracranial pressure (ICP). These signs include: a) tachycardia. b) an altered level of consciousness. c) a depressed fontanel. d) slurred speech.

b) an altered level of consciousness. One sign of neurologic deficit in an 8-month-old child includes a decreased or altered level of consciousness. The fontanel would bulge — not depress — if he had increased ICP. Slurred speech isn't a sign of increased ICP in an infant because the child isn't able to speak at this age. However, a change in cry may be noted. Bradycardia — not tachycardia — is a sign of increased ICP.

A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include: a) decreasing blood pressure. b) diminished responsiveness. c) pupillary changes. d) elevated temperature.

b) diminished responsiveness. Usually, diminished responsiveness is the first sign of increasing ICP. Pupillary changes occur later. Increased ICP causes systolic blood pressure to rise. Temperature changes vary and may not occur even with a severe decrease in responsiveness.

The nurse administered an analgesic to a client who was reporting pain. The medication is ordered as needed every 3 hours. Forty minutes later the client states he has had little relief. The nurse does all of the following: a. states, "I can administer the medication to you in about 2 hours" b. evaluates the pain level using the established pain scale c. assesses respirations, pulse, and blood pressure d. consults with the healthcare provider about the client's report e. plans to place the client in a position of comfort when pain is relieved

b, c, d The dose of the pain medication is ineffective in relieving the client's pain. The nurse evaluates client response using the same pain scale and vital signs. The nurse may need to consult with the healthcare provider and inform of the ineffectiveness of the medication. The nurse places the client in a position of comfort to enhance effectiveness of the medication now, not later. The nurse's statement delays appropriate treatment for the client.

Which statements about stroke prevention indicate a client's understanding of health teaching by the nurse? (Select all that apply.) a. "I will take aspirin every day." b. "I have decided to stop smoking." c. "I will try to walk at least 30 minutes most days of the week." d. "I need to cut down a lot on my drinking." e. "I'm going to decrease salt in my diet."

b, c, d, and e

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which I.V. fluid does the nurse plan to administer first? a) Dextrose 5% in water (D5W) b) Lactated Ringer's solution c) Normal saline solution with 20 mEq of potassium per 1,000 ml d) Albumin

b,Lactated Ringer's solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a burn. Albumin is used as adjunct therapy, not as primary fluid replacement. D5W isn't given to burn clients during the first 24 hours because it can cause pseudodiabetes. The client is hyperkalemic as a result of the potassium shift from the intracellular space to the plasma, so giving potassium would be detrimental

Prince was involved in a MVA and now has diminished or hypoactive deep tendon reflexes (DTRs). How will you document these? Select one: a. 0 b. 1+ c. 2+ d. 3+

b. 1+

While stopped, Hal's car was hit by another vehicle. Hal sustained a cerebral contusion and was admitted to the hospital. During what time period after the injury will effects of this injury peak? Select one: a. 6-8 hours b. 18-36 hours c. 12-24 hours d. 48-72 hours

b. 18-36 hours

Burns that exceed ______% of total body surface area (TBSA) are considered major burn injuries and produce both a local and systemic inflammatory response. Select one: a. 33% b. 25% c. 40% d. 20% e. 50%

b. 25%

An Ed nurse understands that a 110 pound lady with stroke will receive at least the minimum dose of t-PA. What minimum dose is anticipated? Select one: a. 50 mg b. 60 mg c. 85 mg d. 100 mg

b. 60 mg

Danielle complains of ringing in the left ear and hearing loss in the same ear, but no associated dizziness or vertigo. What should she be assessed for next because of these presenting symptoms? Select one: a. Otitis media b. Acoustic neuroma c. Labyrinthitis d. Tinnitis e. Chronic allergies

b. Acoustic neuroma

3. When caring for a patient who had a hemorrhagic stroke, close monitoring of vital signs and neurologic changes is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke of which the nurse should be aware? a. Generalized pain b. Alteration in level of consciousness (LOC) c. Tonic-clonic seizures d. Shortness of breath

b. Alteration in level of consciousness (LOC)

12. A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the medical treatment to include which of the following? a. Cholesterol-lowering drugs b. Anticoagulant therapy c. Monthly prothrombin levels d. Carotid endarterectomy

b. Anticoagulant therapy

What is the most common source of fungal infections affecting the external ear? Select one: a. Staphylococcus aureus b. Aspergillus c. Pseudomonas d. Streptococus

b. Aspergillus

The nurse is assessing a client with a traumatic brain injury after a skateboarding accident. Which sign/symptom is the nurse most concerned about? a. Amnesia b. Asymmetric pupils c. Headache d. Head laceration

b. Asymmetric pupils

Nan has a boil on her face and the nurse observes her squeezing it. What does the nurse understand is a potentially severe complication of this manipulation? Select one: a. Scarring b. Brain abscess c. Erythema d. Cellulitis e. Acne

b. Brain abscess

The nurse is caring for a patient treated with alteplase following a stroke. What assessment finding is the highest priority for the nurse? a. Client's blood pressure is 144/90. b. Client is having epistaxis. c. Client ate only half of the last meal. d. Client continues to be drowsy.

b. Client is having epistaxis.

A client recovering from a stroke reports double vision that is preventing the client from effectively completing activities of daily living. How does the nurse help the client compensate? a. Approaches the client on the affected side b. Covers the affected eye c. Encourages turning the head from side to side d. Places objects in the client's field of vision

b. Covers the affected eye

You obtain a Snellen eye chart as part of the neuro exam. Which cranial nerve are you testing? Select one: a. Cranial nerve l b. Cranial nerve ll c. Cranial nerve lll d. Cranial nerve lV

b. Cranial nerve ll

Fever in the patient with TBI can be the result of damage to: (Select all that apply) Select one or more: a. Damage to the pituitary b. Damage to the hypothalamus c. Infection d. Cerebral irritation from hemorrhage e. Damage tot he reticular activating system

b. Damage to the hypothalamus c. Infection d. Cerebral irritation from hemorrhage

Max exhibits symptoms related to Parkinson's Disease. The nurse understands that these symptoms are directly related to what decreased neurotransmitter level? Select one: a. Acetylcholine b. Dopamine c. Serotonin d. Phenylalanine e. Insulin

b. Dopamine

Tom had a lumbar puncture 3 days ago. He now calls with c/o headache. What can the nurse educate Tom to do for relief of discomfort? Select one or more: a. Limit the amount of fluid to decrease cerebral edema. b. Force fluids. c. Get plenty of bed rest. d. Take some over-the-counter analgesics. e. Walk around.

b. Force fluids. c. Get plenty of bed rest. d. Take some over-the-counter analgesics.

A client returns from the postanesthesia care unit (PACU) after a surgical removal of a brainstem tumor. What position will the nurse place the client in at this time? a. Turn the patient from side to side to prevent aspiration. b. Keep the client flat in bed or up 10 degrees and reposition from side to side. c. Elevate the head of the bed to at least 30 degrees at all times. d. Keep the client in a sitting position in bed at all times.

b. Keep the client flat in bed or up 10 degrees and reposition from side to side.

A client has had a traumatic brain injury and is mechanically ventilated. Which technique does the nurse use to prevent increasing intracranial pressure (ICP)? a. Assessing for Grey Turner's sign b. Maintaining neutral head position c. Placing the client in the Trendelenburg position d. Suctioning the client frequently

b. Maintaining neutral head position

Chief symptoms of ALS include: (Select all that apply) Select one or more: a. Shuffling gait b. Poor coordination c. Fasiculations d. Fatigue e. Progressive muscle weakness

b. Poor coordination c. Fasiculations d. Fatigue e. Progressive muscle weakness

A patient having an acute stroke with no other significant medical history has a blood gluose level of 420 mg/dL. What significance does this hyperglycemia have for the patient? Select one: a. New onset diabetes b. Significant for poor neurological outcome c. Development of diabetes insipidus due to location of stroke d. Significant for liver failure

b. Significant for poor neurological outcome

18. 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. White male, age 60, with history of uncontrolled hypertension

Carbon monoxide, a byproduct of the combustion of organic materials, combines with _____ to form carboxyhemglobin which then competes with ___________ for available hemoglobin binding sites. Select one: a. oxygen; hemoglobin b. hemoglobin; oxygen c. oxygen; potassium d. carbon dioxide; hemoglobin

b. hemoglobin; oxygen

David has classic Meniere's Disease. What are the classic symptoms that are diagnostic for this condition? Select one: a. vertigo and hearing loss b. tinnitis and fluctuating, progressive sensorineural hearing loss c. constant throbbing pain accompanied by fever d. feeling of pressure or fullness in the ear and occasional seizures

b. tinnitis and fluctuating, progressive sensorineural hearing loss

Hemianopia

blindness in one-half of the visual field

A client reports light-headedness, speech disturbance, and left-sided weakness that have lasted for several hours. In the examination, an abnormal sound is auscultated in an artery leading to the brain. What is the term for the auscultated discovery?

bruit Explanation: A neurologic examination during an attack reveals neurologic deficits. Auscultation of the artery may reveal a bruit (abnormal sound caused by blood flowing over a rough surface within one or both carotid arteries). The term for the auscultated discovery is "bruit."

What is radiculopathy? A.A progressive organic mental disorder characterized by personality changes, confusion, disorientation, and deterioration of intellect associated with impaired memory and judgment B.A disease, process, or condition that leads to deterioration of normal cells or function of the nervous system C.A disease of a spinal nerve root, often resulting in pain and extreme sensitivity to touch D.Ankylosis or stiffening of the cervical or lumber vertebrae

c

An unlicensed nursing assistant (NA) reports to the nurse that a postsurgical client rates her pain as 8 on a 0-to-10 point scale. The NA tells the nurse that he thinks the client is exaggerating and does not need pain medication. What is the nurse's best response? a. "Pain often comes and goes with postsurgical clients. Please ask her about pain again in about 30 minutes." b. "We need to provide pain medications because it is the law, and we must always follow the law." c. "Unless there is strong evidence to the contrary, we should take the client's report at face value.'" d. "It's not unusual for clients to misreport pain to get our attention when we are busy."

c A broad definition of pain is "whatever the person says it is, existing whenever the experiencing person says it does." Action should be taken unless there are demonstrable extenuating circumstances. Rechecking without offering an intervention would be insufficient and the law is not the sole reason for providing care.

An unlicensed nursing assistant (NA) reports to the nurse that a postsurgical client rates her pain as 8 on a 0-to-10 point scale. The NA tells the nurse that he thinks the client is exaggerating and does not need pain medication. What is the nurse's best response? a. "Pain often comes and goes with postsurgical clients. Please ask her about pain again in about 30 minutes." b. "We need to provide pain medications because it is the law, and we must always follow the law." c. "Unless there is strong evidence to the contrary, we should take the client's report at face value.'" d. "It's not unusual for clients to misreport pain to get our attention when we are busy."

c A broad definition of pain is "whatever the person says it is, existing whenever the experiencing person says it does." Action should be taken unless there are demonstrable extenuating circumstances. Rechecking without offering an intervention would be insufficient and the law is not the sole reason for providing care.

A client is asking for a breakthrough dose of analgesia. The pain-medication prescriptions are written as a combination of an opioid analgesic and a nonsteroidal anti-inflammatory drug (NSAID) given together. What is the primary rationale for administering pain medication in this manner? a. To prevent respiratory depression from the opioid b. To eliminate the need for additional medication during the night c. To achieve better pain control than with one medication alone d. To eliminate the potentially adverse effects of the opioid

c A multimodal regimen combines drugs with different underlying mechanisms, which allows lower doses of each of the drugs in the treatment plan, reducing the potential for each to produce adverse effects. This method also reduces, but does not eliminate, adverse effects of the opioid. This regimen is not motivated by the need to prevent respiratory depression or to eliminate nighttime dosing.

A client is asking for a breakthrough dose of analgesia. The pain-medication prescriptions are written as a combination of an opioid analgesic and a nonsteroidal anti-inflammatory drug (NSAID) given together. What is the primary rationale for administering pain medication in this manner? a. To prevent respiratory depression from the opioid b. To eliminate the need for additional medication during the night c. To achieve better pain control than with one medication alone d. To eliminate the potentially adverse effects of the opioid

c A multimodal regimen combines drugs with different underlying mechanisms, which allows lower doses of each of the drugs in the treatment plan, reducing the potential for each to produce adverse effects. This method also reduces, but does not eliminate, adverse effects of the opioid. This regimen is not motivated by the need to prevent respiratory depression or to eliminate nighttime dosing.

A patient comes into the clinic frequently with complaints of pain. What would the nurse recognize as chronic benign pain in a patient? a. A migraine headache b. An exacerbation of rheumatoid arthritis c. Low back pain d. Sickle cell crisis

c Acute pain differs from chronic pain primarily in its duration. For example, tissue damage as a result of surgery, trauma, or burns produces acute pain, which is expected to have a relatively short duration and resolve with normal healing. Chronic pain is subcategorized as being of cancer or noncancer origin and can be time limited (e.g., may resolve within months) or persist throughout the course of a person's life. Examples of noncancer pain include peripheral neuropathy from diabetes, back or neck pain after injury, and osteoarthritis pain from joint degeneration.

The nurse is assessing an 86-year-old postoperative client who has an unexpressive, stoic demeanor. The client is curled into the fetal position, vital signs are elevated and he is diaphoretic. On a 10-point scale, the client indicates a pain level of "3 or so." How should the nurse treat this client's pain? a. Treat the client on the basis of objective signs of pain and reassess him frequently. b. Call the physician for new prescriptions because it is apparent that the pain medicine is not working. c. Believe what the client says, reinforce education, and reassess often. d. Ask the family what they think and treat the client accordingly.

c As always, the best guide to pain management and administration of analgesic agents in all clients, regardless of age, is what the individual client says. However, further education and assessment are appropriate. The scenario does not indicate the present pain-management prescriptions are not working for this client. The family's insights do not override the client's self-report.

A nurse has cited a research study that highlights the clinical effectiveness of using placebos in the management of postsurgical clients' pain. What principle should guide the nurse's use of placebos in pain management? a. Placebos require a higher level of informed consent than conventional care. b. Placebos are an acceptable, but unconventional, form of nonpharmacologic pain management. c. Placebos are never recommended in the treatment of pain. d. Placebos require the active participation of the client's family.

c Broad agreement is that there are no individuals for whom and no condition for which placebos are the recommended treatment. This principle supersedes the other listed statements.

The nurse needs to carefully monitor a client with traumatic injuries. Which action by the nurse demonstrates understanding of the most essential component of the client's pain assessment? a. The nurse administers ketorolac upon admission to the unit. b. The nurse validates the client's report of pain by assessing the client's blood pressure. c. The nurse administers pain medication based on the client's reported pain level. d. The nurse assesses the response to medication after every meal consumed by the client.

c Clients quickly adapt physiologically despite pain and may have normal or below normal vital signs in the presence of severe pain. The overriding principle is that the absence of an elevated blood pressure or heart rate does not mean the absence of pain. The ability of an individual to give a report of pain, especially its intensity, is the most essential component of pain assessment. Pain does not need to be assessed an hour after analgesics are administered or after every meal consumed by the client. Pain medication should not routinely be administered to a client upon admission to the unit.

The home health nurse is caring for a homebound client who is terminally ill and is delivering a patient-controlled analgesia (PCA) pump at today's visit. The family members will be taking care of the client. What would the nurse's priority interventions be for this visit? a. Teach the family the theory of pain management and the use of alternative therapies. b. Provide psychosocial family support during this emotional experience. c. Provide client and family teaching regarding the operation of the pump, monitoring the IV site, and knowing the side effects of the medication. d. Provide family teaching regarding use of morphine, recognizing morphine overdose, and offering spiritual guida

c If PCA is to be used in the client's home, the client and family are taught about the operation of the pump as well as the side effects of the medication and strategies to manage them. The family would also need to monitor the IV site and notify the nurse of any changes, such as infiltration, that could endanger the client. Teaching the family the theory of pain management or the use of alternative therapies and the nurse providing emotional support are important, but the family must be able to operate the pump as well as know the side effects of the medication and strategies to manage them. Offering spiritual guidance would not be a priority at this point and morphine is not the only medication given by PCA.

The nurse is administering an analgesic to an older adult patient. Why is it important for the nurse to assess the patient carefully? a. Older people metabolize drugs more rapidly. b. Older people have increased hepatic, renal, and gastrointestinal function. c. Older people are more sensitive to drugs. d. Older people have lower ratios of body fat and muscle mass.

c Older adults are often sensitive to the effects of the adjuvant analgesic agents that produce sedation and other CNS effects, such as antidepressants and anticonvulsants. Therapy should be initiated with low doses, and titration should proceed slowly with systematic assessment of patient response.

The nurse has just received report on a client who is coming to the unit from the emergency department with a torn meniscus. The nurse reviews the PRN medications and sees that an NSAID (ibuprofen) is prescribed every 6 hours. How should the nurse best implement preventive pain measures? a. Use a pain scale to assess the client's pain, and let the client know ibuprofen is available every 6 hours if she needs it. b. Do a complete assessment, and give pain medication based on the client's report of pain. c. Check for allergies, use a pain scale to assess the client's pain, and offer the ibuprofen every 6 hours until the client is discharged. d. Provide medication as per client request and offer relaxation techniques to promote comfort.

c One way preventive pain measures can be implemented is by using PRN medications on a more regular or scheduled basis to allow for more uniform pain control. Smaller drug doses of medication are needed with the preventive pain method when PRN medications are given around the clock. Offering the medication is more beneficial than letting the client know ibuprofen is available.

A client is receiving care on the oncology unit for breast cancer that has metastasized to her lungs and liver. When addressing the client's pain in the plan of nursing care, the nurse should consider what characteristic of cancer pain? a. Cancer pain is often related to the stress of the client knowing she has cancer and requires relatively low doses of pain medications along with a high dose of anti-anxiety medications. b. Cancer pain is always chronic and challenging to treat, so distraction is often the best intervention. c. Cancer pain can be acute or chronic and it typically requires comparatively high doses of pain medications. d. Cancer pain is often misreported by clients because of confusion related to their disease process.

c Pain associated with cancer may be acute or chronic. Pain resulting from cancer is so ubiquitous that when cancer clients are asked about possible outcomes, pain is reported to be the most feared outcome. Higher doses of pain medication are usually needed with cancer clients, especially with metastasis. Cancer pain is not treated with anti-anxiety medications. Cancer pain can be chronic and difficult to treat so distraction may help, but higher doses of pain medications are usually the best intervention. No research indicates cancer clients misreport pain because of confusion related to their disease process.

The advance nurse practitioner, who is treating a client diagnosed with neuropathic pain, decides to start adjuvant analgesic agent therapy. Which medication is appropriate for the nurse practitioner to prescribe? a. Tramadol b. Ketamine c. Gabapentin d. Hydromorphone

c The anticonvulsant gabapentin is a first-line analgesic agent for neuropathic pain. Tramadol is designated as a second-line analgesic agent for the treatment of neuropathic pain. Ketamine is used as a third-line analgesic agent for refractory acute pain. Hydromorphone is a first-line opioid not used as an analgesic agent for neuropathic pain.

A teenage client is undergoing a dressing change to burns on the thigh. The client refuses pain medication and states, "I do not hurt, and I don't need it." He is withdrawn, grimaces, and turns away during the dressing change. He was last medicated 8 hours ago. What is the best statement by the nurse? a. "You are so brave to not take your pain medication when the dressing change will hurt." b. "If you need pain relief, I can give you some medication when I have completed the dressing change." c. "I saw you grimacing during the dressing change. Please explain the reason you refused the pain medication." d. b "You are so right to not take your pain medication. You can become dependent on the medication."

c The nurse needs to explore the reason a client denies pain when pain is expected during a treatment, as with a dressing change to burns, and when the client grimaces during the dressing change. The nurse needs to educate clients about effects of pain on recovery. The nurse also cannot ignore that pain relief will hasten recovery. The nurse should not allow the client to associate pain with his dressing changes.

The nurse needs to carefully monitor a client with traumatic injuries. How often should the nurse check and document the client's pain? a. Upon admission and discharge b. An hour after analgesics are administered c. Every time the client's vital signs are assessed d. After every meal consumed by the client

c The nurse should check and document the client's pain every time the client's temperature, pulse, respirations, and blood pressure are assessed. The American Pain Society (APS) has proposed that pain assessment should be considered the fifth vital sign. Pain does not need to be assessed an hour after analgesics are administered or after every meal consumed by the client. Pain should not be assessed only on admission and discharge of the client.

Which nursing intervention should a nurse perform when caring for a client who is prescribed opiate therapy for pain? a. Avoid caffeine or other stimulants, such as decongestants b. Monitor weight, vital signs, and serum glucose concentration c. Do not administer if respirations are d. Monitor blood counts and liver function tests

c The nurse should not administer the prescribed opiate therapy if respirations are <12 breaths per minute. The nurse should instruct a client who is prescribed psychostimulants to avoid caffeine or other stimulants, such as decongestants. The nurse should monitor weight, vital signs, and serum glucose concentration when administering corticosteroids. When administering anticonvulsants, the nurse should also monitor blood counts and liver function tests.

Prior to starting a peripheral intravenous line on a patient, what intervention can the nurse provide to decrease the pain from the needle puncture? a. Give an oral opioid analgesic 30 minutes before the procedure. b. Apply diclofenac gel over the site 1 hour before the procedure. c. Apply eutectic mixture of local anesthetic cream 30 minutes prior to the procedure. d. Inject lidocaine 2% with epinephrine locally around the potential procedure site.

c The topical route of administration is used for both acute and chronic pain. For example, the nonopioid diclofenac is available in patch and gel formulations for application directly over painful areas. Local anesthetic creams, such as EMLA (eutectic mixture or emulsion of local anesthetics) and L.M.X.4 (lidocaine cream 4%), can be applied directly over the injection site prior to painful needle stick procedures, and the lidocaine patch 5% is often used for well-localized types of neuropathic pain, such as postherpetic neuralgia.

A 20-year-old man has presented to the emergency department with a 24-hour history of abdominal pain. The nurse who is admitting the patient notes that he is diaphoretic, wincing, and guarding the lower right quadrant of his abdomen. The nurse asks the patient to rate his pain on a scale of 1 to 10, to which the patient responds, "One or two." How should the nurse best respond to this patient's statement? a. Administer ibuprofen or acetaminophen rather than an opioid. b. Reassess the patient's pain in 30 to 45 minutes. c. Explain the 0-to-10 pain scale in greater detail. d. Document the fact that the patient has slight pain.

c While it is important to accept a patient's self-report of pain, this does not mean that further education about pain scales is not sometimes necessary. This is especially the case when there is a clear inconsistency between patient's subjective pain report and the nurse's assessment findings. Thus, further teaching should take place prior to choosing an intervention or documenting the patient's pain as "slight."

A nurse is preparing a client for lumbar puncture. The client has heard about post-lumbar puncture headaches and asks how to avoid having one. The nurse tells the client that these headches can be avoided by doing which of the following after the procedure? a) "Remain NPO for 6 hours." b) "Ambulate as soon as possible." c) "Remain prone for 2 to 3 hours." d) "Remain on bedrest for 3 days."

c) "Remain prone for 2 to 3 hours." he headache is caused by cerebral spinal fluid (CSF) leakage at the puncture site. The supply of CSF in the cranium is depleted so that there is not enough to cushion and stabilize the brain. When the client assumes an upright position, tension and stretching of the venous sinuses and pain-sensitive structures occur. The headache may be avoided if the client remains prone for 2 to 3 hours after the procedure. Drinking plenty of fluids will help in replacing the CSF. Hydration is important for replacement of the CSF lost so remaining NPO is not an option unless it is for other reasons, then IV fluid replacement will be important. Ambulating right away will make the possibility of a headache more likely. It is not necessary to remain on bedrest for more than a few hours, unless a headache has occurred; then bedest for overnight is usually sufficient

If a client has a lower motor neuron lesion, the nurse would expect the client to exhibit hyperactive reflexes. decreased muscle tone. muscle spasticity. no muscle atrophy.

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

When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication? a) Status epilepticus b) Shock c) Increased intracranial pressure (ICP) d) Encephalitis

c) Increased intracranial pressure (ICP) When ICP increases, Cushing's triad may develop, which involves decreased heart and respiratory rates and increased systolic blood pressure. Shock typically causes tachycardia, tachypnea, and hypotension. In encephalitis, the temperature rises and the heart and respiratory rates may increase from the effects of fever on the metabolic rate. (If the client doesn't maintain adequate hydration, hypotension may occur.) Status epilepticus causes unceasing seizures, not changes in vital signs.

A nurse is caring for a client who requires intracranial pressure (ICP) monitoring. The nurse should be alert for what complication of ICP monitoring? a) Coma b) High blood pressure c) Infection d) Apnea

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

A nurse is working with a client who is on the rehabilitation unit after a cerebrovascular accident (or brain attack). To support the client in developing independence with activities of daily living, which of the following is the most important action for the nurse to take? a) Provide feedback by identifying the client's weaknesses. b) Establish daily goals for the client to achieve. c) Reinforce participation and success in tasks accomplished. d) Demonstrate ways to regain independence in activities.

c) Reinforce participation and success in tasks accomplished. It is important to involve the client in the care and to encourage participation. As the client accomplishes relearning different tasks, it is important to commend the client for success. Small steps in progress serve to reinforce motivation. The other options either do not involve the client in regaining independence or establishing goals, or the focus is on the client's weaknesses, rather than the successes.

While assessing a 4-day-old neonate born at 28 weeks' gestation, the nurse cannot elicit the neonate's Moro reflex, which was present 1 hour after birth. The nurse notifies the health care provider (HCP) because this may indicate which complication? a) postnatal asphyxia b) facial nerve paralysis c) intracranial hemorrhage d) skull fracture

c) intracranial hemorrhage When the nurse cannot elicit the Moro reflex of a 4-day-old preterm infant and the Moro reflex was present at birth, intracranial hemorrhage or cerebral edema should be suspected. Other symptoms include lethargy, bulging fontanels, and seizure activity. Confirmation can be made by ultrasound. Postnatal asphyxia is suggested by respiratory distress, grunting, nasal flaring, and cyanosis. A skull fracture can be confirmed by radiography. However, it is unlikely to occur in a preterm neonate. Rather, it is more common in the large-for-gestational-age neonate. Facial nerve paralysis is indicated when there is no movement on one side of the face. This condition is more common in the large-for-gestational-age neonate.

Which of the following is the analgesic of choice for burn pain? a) Demerol b) Fentanyl c) Morphine sulfate d) Tylenol with codeine

c, Morphine sulfate remains the analgesic of choice. It is titrated to obtain pain relief on the patient's self-report of pain. Fentanyl is particularly useful for procedural pain, because it has a rapid onset, high potency, and short duration, all of which make it effective for use with procedures. Demerol and Tylenol with codeine are not analgesics of choice for burn pain.

A client has a spinal cord injury. The home health nurse is making an initial visit to the client at home and plans on reinforcing teaching on autonomic dysreflexia. What symptom would the nurse stress to the client and his family? a. Slight headache b. Rapid heart rate c. Sweating d. Runny nose

c. Characteristics of this acute emergency are as follows: severe hypertension; slow heart rate; pounding headache; nausea; blurred vision; flushed skin; sweating; goosebumps (erection of pilomotor muscles in the skin); nasal stuffiness; and anxiety.

Which precaution should the nurse take when a client is at risk of injury secondary to vertigo and probable imbalance? a. Encourage the client to move the head slowly b. Restrict the client from focusing on one spot c. Have the client wait for help before moving d. Recommend that the client keep his or her eyes closed

c. * The nurse should have the client wait to move until help arrives. * Safety measures such as assisted ambulation are implemented to prevent falls and injury. * The client should restrict movement. * The client should keep his or her eyes open and focus on one spot to reduce vertigo.

A family member asks the nurse about whether there would be any long-term psychological effects from a client's mild traumatic brain injury. What is the nurse's best response? a. "You need to talk with the client's primary health care provider." b. "Usually any effects last for only a few weeks or months." c. "Each person's reaction to brain injury is different." d. "You should expect a change in the client's personality."

c. "Each person's reaction to brain injury is different."

A client is considering treatments for a malignant brain tumor. Which statement by the client indicates a need for further instruction by the nurse? a. "A combination of treatments might be necessary." b. "In a craniotomy, holes are cut in the skull to access the tumor." c. "I can go home the day of my craniotomy." d. "The goal is to decrease tumor size and improve survival time."

c. "I can go home the day of my craniotomy."

The daughter of a client who has had a stroke asks the nurse for additional resources. What is the nurse's best response? a. "Call hospice." b. "Check the Internet." c. "The National Stroke Association has resources available." d. "The charge nurse at the desk has all of the information."

c. "The National Stroke Association has resources available."

The acute phase of an ischemic stroke usually lasts... Select one: a. up to 2 weeks b. up to 1 week c. 1-3 days d. up to 24 hours

c. 1-3 days

Two significant changes in the optic nerve that occur in persons with glaucoma are: Select one: a. 1. Cupping of the optic nerve and 2. compression of the cornea b. 1. Lack of blood supply and 2. thinning of the retina c. 1. Lack of blood supply and 2. cupping of the optic nerve disk d. 1. Compression of the optic nerve and 2. irreversible damage to rods and cones

c. 1. Lack of blood supply and 2. cupping of the optic nerve disk

Cheri is admitted into Neuro ICU with ICP reading for 20 mm Hg and a mean arterial pressure of 90 mm Hg. What would the nurse calculate the CPP to be? Select one: a. 50 mm Hg b. 60 mm Hg c. 70 mm Hg d. 80 mm Hg

c. 70 mm Hg

Hearing is conducted using two pathways which are _________ and ____________. Select one: a. Bone and fluid b. Air and fluid c. Air and bone d. Bone and tiny cilia

c. Air and bone

7. The nurse is reviewing the medication administration record of a female patient who possesses numerous risk factors for stroke. Which of the woman's medications carries the greatest potential for reducing her risk of stroke? a. Naproxen 250 PO b.i.d. b. Calcium carbonate 1,000 mg PO b.i.d. c. Aspirin 81 mg PO o.d. d. Lorazepam 1 mg SL b.i.d. PRN

c. Aspirin 81 mg PO o.d.

Lyndon has a C7 spinal cord injury and tells the nurse "my head is suddenly killing me it hurts so bad". His BP is now 210/140 mm Hg, his heart rate is 48 and his face is profusely diaphoretic. What action does the nurse do FIRST? Select one: a. Place Lyndon in the sitting position b. Call the physician c. Assess for a full bladder d. Assess for fecal impaction

c. Assess for a full bladder

The tensilon test is administered to someone with ptosis. What does a positive test indicate? Select one: a. Diagnosis of Multiple Sclerosis b. Diagnosis of Guillian Barre Syndrome c. Diagnosis of Myasthenia Gravis d. Diagnosis of Viral meningitis

c. Diagnosis of Myasthenia Gravis

Patient has a severe neurologic impairment from head trauma.What does the nurse recognize is the type of posturing that occurs with the most severe neurologic impairment? Select one: a. Decerebrate b. Decorticate c. Flaccid d. Rigid

c. Flaccid

10. From which direction should a nurse approach a client who is blind in the right eye? a. From directly in front of the client b. From the right side of the client c. From the left side of the client d. From directly behind the client

c. From the left side of the client

While riding a bicycle in a race, the patient fell and sustained a head injury. Another cyclist found the patient lying unconscious in a ditch and called 911. What grade of concussion does this patient most likely have? Select one: a. Grade 1 b. Grade 2 c. Grade 3 d. Grade 4

c. Grade 3

Terri sustained a head injury during a diving injury. She has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as? Select one: a. Epidural b. Extradural c. Intracerebral d. Subdural

c. Intracerebral

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention? a. Positioning the client to prevent airway obstruction b. Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess c. Keeping the client in one position to decrease bleeding d. Maintaining the client in a quiet environment

c. Keeping the client in one position to decrease bleeding. * The student nurse shouldn't keep the client in one position. She should carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained.

The nurse is caring for Tony and his ICP is rising. As the pressure continues to rise, what osmotic diuretic does the nurse prepare to administer? Select one: a. Glycerin b. Isosorbide c. Mannitol d. Urea

c. Mannitol

When assessing visual fields for someone with glaucoma, what do you expect to find? Select one: a. Clear cornea b. Constricted pupil c. Marked blurring of vision d. Watery ocular discharge

c. Marked blurring of vision

Exhibiting seizure-like movements localized to one side of the body most likely reflect what type of tumor? Select one: a. Cerebellar tumor b. Frontal lobe tumor c. Motor complex tumor d. Occipital lobe tumor e. Brain stem tumor

c. Motor complex tumor

Ms. D is brought to the ED with possible stroke. What initial test for stroke, usually performed in ED, would the nurse anticipate? Select one: a. 12 lead ECG b. Carotid ulotrasound c. Non-contrast CT d. Transcranial Doppler study

c. Non-contrast CT

A term for the right eye is Select one: a. Oculus strabismus b. Oculus lymphadum c. Oculus dexter d. Oculus sinister

c. Oculus dexter

When assessing auricles, the person complains of pain upon manipulation of the left auricle. What does this imply? Select one: a. Person may have seborrheic dermatitis b. Person may have inner ear infection c. Person may have acute external otitis d. Person may have acute otitis media

c. Person may have acute external otitis

The nurse is caring for a patient with expressive (Broca's) aphasia. Which nursing intervention is appropriate for communicating with the client? a. Refer the patient to the speech-language pathologist. b. Speak loudly to help the client interpret what is being said. c. Provide pictures to help the client communicate. d. Ask the client to read messages on a white board.

c. Provide pictures to help the client communicate.

5. A patient diagnosed with an ischemic stroke should be treated within the first 3 hours of symptom onset with which of the following? a. Clopidogrel b. Extended release dipyridamole c. Tissue plasminogen activator (tPA) d. Atorvastatin

c. Tissue plasminogen activator (tPA)

There are three zones of burn injury, categorized by degree of thermal damage to cells. The central area of the burn wound is termed ________ because of the characteristic coagulation necrosis of cells. Select one: a. Zone of stasis b. Zone of hyperemia c. Zone of coagulation d. Zone of centrality e. Zone of no return

c. Zone of coagulation

The patient is scheduled for an EEG in the morning. What food should be removed from the tray prior to the test? Select one: a. orange juice b. toast c. coffee d. eggs

c. coffee

A nurse is reading a journal article about stroke and the underlying causes associated with this condition. The nurse demonstrates understanding of the information when identifying which subtype of stroke as being due to atrial fibrillation?

cardio embolic Explanation: Ischemic strokes are further divided into five subtypes, according to a mechanism-based classification system: large-artery thrombotic strokes (representing 20% of ischemic strokes); small, penetrating artery thrombotic strokes (25%); cardio embolic strokes (20%); cryptogenic strokes (strokes that cannot be attributed to any specific cause) (30%); and "other" (5%). Large-artery thrombotic strokes are caused by atherosclerotic plaques in the large blood vessels of the brain. Thrombus formation and occlusion can occur at the site of the atherosclerosis and result in ischemia and infarction (tissue death). Small, penetrating artery thrombotic strokes that affect one or more vessels and cause reduced blood flow are the most common type of ischemic stroke, typically caused by longstanding hypertension, hyperlipidemia, or diabetes. Cardio embolic strokes are associated with cardiac dysrhythmias, such as atrial fibrillation, but can also be associated with valvular heart disease or left ventricular thrombus. The last two classifications of ischemic strokes are cryptogenic strokes, which have no identified cause, and strokes from other causes, such as illicit drug use (cocaine), coagulopathies, migraine, or spontaneous dissection of the carotid or vertebral arteries.

A nurse is working in a neurologist's office. The physician orders a Romberg test. The nurse should have the client: a) close his or her eyes and stand erect. b) close his or her eyes and jump on one foot. c) touch his or her nose with one finger. d) close his or her eyes and discriminate between dull and sharp.

close his or her eyes and stand erect. In the Romberg test, the client stands erect with the feet close together and eyes closed. If the client sways as if to fall, it is considered a positive Romberg test. All of the other options include components of neurologic tests, indicating neurologic deficits and balance.

When assessing unilateral hearing loss with the Weber test, sound is heard better in the affected ear with ______ deafness and in the unaffected ear with __________deafness

conductive sensorineural

A client has been prescribed a fentanyl patch for pain control. The nurse understands that this patch should be replaced how often? a. Every 12-24 hours b. Every 24-36 hours c. Every 36-60 hours d. Every 48-72 hours

d Fentanyl patches should be replaced every 48-72 hours, depending on client response. The other time frames are incorrect.

A client is being treated in a substance abuse unit of a local hospital. The nurse understands that when this client has compulsive behavior to use a drug for its psychic effect, the client needs to be monitored for which effect? a. Placebo b. Dependence c. Tolerance d. Addiction

d Addiction is a behavioral pattern of substance use characterized by a compulsion to take the substance primarily to experience its psychic effects. Placebo effect is analgesia that results from the expectation that a substance will work, not from the actual substance itself. Dependence occurs when a client who has been taking opioids experiences a withdrawal syndrome when the opioids are discontinued. Tolerance occurs when a client who has been taking opioids becomes less sensitive to their analgesic properties.

A 60-year-old client who has diabetes had a below-knee amputation 1 week ago. The client asks, "Why does it still feel like my leg is attached, and why does it still hurt?" The nurse explains neuropathic pain in terms that are accessible to the client. The nurse should describe what pathophysiologic process? a. The proliferation of nociceptors during times of stress b. Age-related deterioration of the central nervous system c. Psychosocial dependence on pain medications d. The abnormal reorganization of the nervous system

d At any point from the periphery to the CNS, the potential exists for the development of neuropathic pain. Hyperexcitable nerve endings in the periphery can become damaged, leading to abnormal reorganization of the nervous system called neuroplasticity, an underlying mechanism of some neuropathic pain states. Neuropathic pain is not a result of age-related changes, nociceptor proliferation, or dependence on medications.

The mother of a client with cancer comes to the nurse concerned with her daughter's safety. She states that the dose of morphine that her daughter requires to control her pain is getting "higher and higher." As a result, the mother is afraid that her daughter will overdose. The nurse should educate the mother about what aspect of her daughter's pain management? a. The dose range is higher with cancer clients, and the medical team will be very careful to prevent addiction. b. Frequently, female clients and younger clients need higher doses of opioids to be comfortable. c. The increased risk of overdose is an inevitable risk of maintaining adequate pain control during cancer treatment. d. There is no absolute maximum opioid dose and her daughter is becoming more tolerant to the drug.

d Clients requiring opioids for chronic pain, especially cancer clients, need increasing doses to relieve pain. The requirement for higher drug doses results in a greater drug tolerance, which is a physical dependency as opposed to addiction, which is a psychological dependency. The dose range is usually higher with cancer clients. Although tolerance to the drug will increase, addiction is not dose related, but is a separate psychological dependency issue. No research indicates that women and/or younger people need higher doses of morphine to be comfortable. Overdose is not an "inevitable" risk.

The nurse caring for an older adult client with osteoarthritis is reviewing the client's chart. This client is on a variety of medications prescribed by different care providers in the community. In light of the QSEN competency of safety, what is the nurse most concerned about with this client? a. Depression b. Chronic illness c. Inadequate pain control d. Drug interactions

d Drug interactions are more likely to occur in older adults because of the higher incidence of chronic illness and the increased use of prescription and OTC medications. The other options are all good answers for this client because of the client's age and disease process. However, they are not what the nurse would be most concerned about in terms of ensuring safety.

A 19-year-old woman had a mandibular osteotomy (jaw surgery) performed early this morning and is being assessed by the nurse after being transferred from the PACU. The nurse has asked the patient about her pain, to which the patient has responded, "I'm not really having any pain, but I've got a dull ache all around my jaw that's really bad." How should the nurse best interpret this patient's statement? a. The patient is not experiencing pain but likely requires interventions for her discomfort. b. The patient is misinterpreting her body's pain response. c. The patient is currently free of pain but is likely to experience pain in the near future. d. The patient is experiencing pain but is describing it in different terms.

d It is reasonable to conclude that this patient is experiencing pain but is using different terms to describe the sensation. It would be erroneous for the nurse to conclude that this patient is pain free and to reject interventions. This patient is not "misinterpreting" her sensation but is rather characterizing it in a different way from the nurse.

A client was diagnosed with rheumatoid arthritis 1 year ago, but has achieved adequate symptom control with celecoxib, a COX-2 selective NSAID. The nurse should recognize that this drug, like other NSAIDs, influences what aspect of the pathophysiology of nociceptive pain? a. Distorting the action potential that is transmitted along the A-delta (δ) and C fibers b. Diverting noxious information from passing through the dorsal root ganglia and synapses in the dorsal horn of the spinal cord c. Blocking modulation by limiting the reuptake of serotonin and norepinephrine d. Inhibiting transduction by blocking the formation of prostaglandins in the periphery

d NSAIDs produce pain relief primarily by blocking the formation of prostaglandins in the periphery; this is a central component of the pathophysiology of transduction. NSAIDs do not act directly on the aspects of transmission, perception, or modulation of pain that are listed.

A client is scheduled for abdominal surgery and states that he is afraid of postoperative pain. The best nursing action is to inform the client a. About activities that would distract him from pain b. That the nurse will notify the surgeon of his fear c. How anxiety could increase his pain perception d. That medication will be prescribed for pain relief

d Pain is expected postoperatively, and the client should be reassured that medication will be prescribed to relieve pain. The client may have less pain knowing that measures will be taken to reduce it. Diversional activities may be used in addition to analgesics. Anxiety about pain could increase the client's perception of pain. Another nursing activity is being an advocate for the client and notifying his surgeon of the client's fear.

A high school football player hurts his foot while playing a game. The client complains of intense pain with muscle spasms and swelling of the toe. Which pain assessment tool will the nurse most likely use to assess the client's pain level? a. Wong-Baker FACES Pain Rating Scale b. Verbal Descriptor Scales (VDS) c. Visual Analog Scale (VAS) d. Numeric Rating Scale (NRS)

d The NRS is most appropriate for this client. The VDS requires the patient to use words or phrases; in this situation, intense pain may affect the client's ability to use this scale appropriately. The FACES scale is most often used in adults and children as young as 3 years of age. The VAS is impractical for use in daily clinical practice.

The nurse is caring for a victim of a motor vehicle accident with a fractured pelvis and a ruptured bladder. The nurse's aide (NA) tells the nurse that she is concerned because the client's resting heart rate is 110 beats per minute, her respirations are 24 breaths per minute, temperature is 37.3°C (99.1°F) axillary, and the blood pressure is 125/85 mm Hg. What other information is most important as the nurse assesses this client's physiologic status? a. The client's understanding of pain physiology b. The client's serum glucose level c. The client's white blood cell count d. The client's rating of her pain

d The nurse's assessment of the client's pain is a priority. There is no suggestion of diabetes and leukocytosis would not occur at this early stage of recovery. The client does not need to fully understand pain physiology in order to communicate the presence, absence, or severity of pain.

A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following? a) Superficial b) Deep partial-thickness c) Superficial partial-thickness d) Full-thickness

d A full-thickness burn involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone. A superficial burn only damages the epidermis. In a superficial partial-thickness burn, the epidermis is destroyed and a small portion of the underlying dermis is injured. A deep partial-thickness burn extends into the reticular layer of the dermis and is hard to distinguish froma full-thickness burn. It is red or white, mottled, and can be moist or fairly dry.

A 9-year-old client with a mild concussion is discharged following a magnetic resonance imaging (MRI) of the brain. Before discharge, the client complains of a headache. The mother questions pain medication for home. Which response by the nurse is most appropriate? a) "Maybe the physician will prescribe aspirin for the head pain." b) "Opioid medications may lead to vomiting, which increases the intracranial pressure (ICP)." c) "Pain medication is avoided after a head injury to avoid hiding a worsening condition." d) "Your child has a mild concussion; acetaminophen (Tylenol) can be given."

d) "Your child has a mild concussion; acetaminophen (Tylenol) can be given." Following MRI of the brain, it is confirmed that there is no bleeding on the brain; thus, pain medication may be administered. The mother asks for medication for a headache. The most appropriate response is that acetaminophen (Tylenol) may be given. Opioids may mask changes in the level of consciousness (LOC) that indicate increased intracranial pressure (ICP); therefore, it should not be given. Aspirin is contraindicated in conditions that may involve bleeding, such as traumatic injuries, and for children or young adults with viral illnesses due to the danger of Reye's syndrome.

A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood pressure is 90/60 mm Hg and the ICP is 18 mm Hg; therefore his cerebral perfusion pressure (CPP) is: a) 88 mm Hg. b) 48 mm Hg. c) 68 mm Hg. d) 52 mm Hg.

d) 52 mm Hg.

The nurse is caring for a client with possible Cushing's syndrome undergoing diagnostic testing. The physician orders lab work and a dexamethasone suppression test. Which parameter is measured with the dexamethasone suppression test? a) The amount of dexamethasone in the system. b) Cortisol levels after the system is challenged. c) Changes in certain body chemicals, which are altered in depression. d) Cortisol levels before and after the system is challenged with a synthetic steroid.

d) Cortisol levels before and after the system is challenged with a synthetic steroid. The dexamethasone suppression test measures cortisol levels before and after the system is challenged with a synthetic steroid. The dexamethasone suppression test does not measure dexamethasone or body chemicals altered in depression. Dexamethasone is used to challenge the cortisol level.

While in the emergency department, an adolescent who has been in a motorcycle accident less than 1 hour earlier remains conscious but is agitated and anxious. The nurse observes that his pulse and respirations are increasing and his blood pressure is decreasing. The nurse should initiate interventions to manage which of the following? a) Autonomic dysreflexia. b) Increased intracranial pressure. c) Metabolic alkalosis. d) Spinal shock.

d) Spinal shock. Spinal shock occurs 30 to 60 minutes after a spinal cord injury owing to the sudden disruption of central and autonomic pathways. This disruption causes flaccid paralysis, loss of reflexes, vasodilation, hypotension, and increased pulse and respiratory rates. Autonomic dysreflexia occurs only after the return of spinal reflexes and is characterized by hypertension. Increased intracranial pressure is associated with widened pulse pressure and decreased pulse and respiratory rates. Metabolic alkalosis, manifested by vomiting, elevated plasma and urine pH, and elevated plasma bicarbonate levels, does not occur with spinal shock. Rather, hydrogen ion loss leading to metabolic alkalosis would occur with pyloric stenosis, diuretic therapy, and potassium depletion.

Which finding would be most indicative of hydrocephalus in an infant? a) A positive glabellar reflex. b) Increased blood pressure. c) A pulsating fontanel. d) Sunsetting eyes.

d) Sunsetting eyes. Sunsetting eyes, or downward deviations of the irises, are a sign of hydrocephalus. A positive glabellar reflex, or blinking in response to taps on the forehead, and a pulsating fontanel are normal findings. Hydrocephalus in the newborn manifests as hypotension.

A nurse is performing a neurologic assessment on a client. The nurse observes the client's tongue for symmetry, tremors, and strength, and assesses the client's speech. Which cranial nerve is the nurse assessing? a) VI b) IV c) IX d) XII

d) XII Cranial nerve XII, the hypoglossal nerve, controls tongue movements involved in swallowing and speech. The tongue should be midline, symmetrical, and free from tremors and fasciculations. The nurse tests tongue strength by asking the client to push his tongue against his cheek as the nurse applies resistance. To test the client's speech, the nurse may ask him to repeat the sentence, "Round the rugged rock that ragged rascal ran." The trochlear nerve (IV) is responsible for extraocular movement (inferior medial). The glossopharyngeal nerve (IX) is responsible for swallowing movements and throat sensations. It's also responsible for taste in the posterior third of the tongue. The abducent nerves (VI) are responsible for lateral extraocular movements.

An 8-month-old infant is admitted to the pediatric unit following a fall from his high chair. The child is awake, alert, and crying. The nurse should know that a brain injury is more severe in children because of: a) increased myelination b) intracranial hypotension c) a slightly thicker cranium d) cerebral hyperemia

d) cerebral hyperemia Cerebral hyperemia (excess blood in the brain) causes an initial increase in intracranial pressure in the head of an injured child. The brain is less myelinated in a child and more easily injured than an adult brain. Intracranial hypertension — not hypotension — places the child at greater risk for secondary brain injury. A child's cranium is thinner and more pliable than an adult's, causing the child to receive a more severe injury.

The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider (HCP) about which early change in the client's condition? a) dilated, fixed pupils b) decrease in the pulse rate c) widening pulse pressure d) decrease in level of consciousness (LOC)

d) decrease in level of consciousness (LOC) A decrease in the client's LOC is an early indicator of deterioration of the client's neurologic status. Changes in LOC, 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.

Which respiratory pattern indicates increasing intracranial pressure in the brain stem? a) nasal flaring b) rapid, shallow respirations c) asymmetric chest excursion d) slow, irregular respirations

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

The nurse is aware that, when assessing a patient for symptoms of a brain tumor, the symptom most frequently found is: a) Vertigo and fainting. b) Unilateral loss of motor coordination. c) Sharp, unrelenting headaches. d) Simple to generalized seizures.

d, Seizures are usually the first symptom of a brain tumor.

A client is being discharged home after surgery for brain cancer. Which statement by the client's spouse indicates a correct understanding of the nurse's discharge teaching? a. "I will have to quit my job to care for my spouse." b. "Life will be back to normal soon." c. "The case manager will provide home care." d. "We can find a support group through the local American Cancer Society."

d. "We can find a support group through the local American Cancer Society."

When changing the dressing of a chronic wound with no sign of infection and no heavy drainage, how long does the nurse leave the wound covered? Select one: a. 6-12 hours b. 12-24 hours c. 24-36 hours d. 48-72 hours e. Until the dressing falls off

d. 48-72 hours

The patient has suffered a stroke and is unable to maintain respiration, thus is intubated and placed on mechanical ventilatory support. What portion of the brain is most likely responsible for the inability to breathe? a. Frontal lobe b. Occipital lobe c. Parietal lobe d. Brain stem

d. Brain stem

The nurse is monitoring a client after supratentorial surgery. Which sign/symptom does the nurse report immediately to the provider? a. Periorbital edema b. Bilateral ecchymoses of both eyes c. Moderate amount of serosanguineous drainage on the head dressing d. Decorticate positioning

d. Decorticate positioning

A characteristic sign of viral conjunctivitis is Select one: a. Presence of petechiae b. Constriction of conjunctival blood vessels c. Clouded retina d. Dilation of conjunctival blood vessels

d. Dilation of conjunctival blood vessels

A patient is being tested for gag reflex. When the nurse places the tongue blade to the back of the throat, there is no response. What dysfunction does the nurse determine that this patient has? Select one: a. Dysfunction of the spinal accessory nerve. b. Dysfunction of the acoustic nerve. c. Dysfunction of the facial nerve. d. Dysfunction of the vagus nerve.

d. Dysfunction of the vagus nerve.

1. A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take? a. Use one long sentence to say everything that needs to be said. b. Keep the television on while she speaks. c. Talk in a louder than normal voice. d. Face the client and establish eye contact.

d. Face the client and establish eye contact.

What is recognized as the earliest sign of serious impairment of brain circulation related to increasing ICP? Select one: a. Bounding pulse b. Bradycardia c. Hypertension d. Lethargy and stupor

d. Lethargy and stupor

17. The nurse is caring for a patient diagnosed with a hemorrhagic stroke. The nurse recognizes that which of the following interventions is most important? a. Elevating the head of the bed at 30 degrees b. Monitoring for seizure activity c. Administering a stool softener d. Maintaining a patent airway

d. Maintaining a patent airway

The nurse is caring for a person with altered LOC. What is the first priority treatment for this patient? Select one: a. Assessment of pupillary light reflexes b. Determination of the cause c. Positioning to prevent complications d. Maintenance of patent airway

d. Maintenance of patent airway

A client is admitted with a stroke (brain attack). Which tool does the nurse use to facilitate a focused neurologic assessment of the client? a. Glasgow Coma Score (GCS) b. Intracranial pressure monitor c. Mini-Mental State Examination (MMSE; mini-mental status examination) d. National Institutes of Health Stroke Scale (NIHSS)

d. National Institutes of Health Stroke Scale (NIHSS)

Ted had a hemorrhagic stroke and the the optimal position for him in bed would be? Select one: a. High-Fowler's b. Prone c. Supone d. Semi-Fowler's

d. Semi-Fowler's

The vitreous humor is Select one: a. The white part of the eye b. Area where most blood vessels for the eye are located c. The pigmented, vascular coating of the eye d. The substance that maintains the eyeball form or shape

d. The substance that maintains the eyeball form or shape

The nurse is teaching the spouse and client who has had a brain attack about rehabilitation. Which statement by the spouse demonstrates understanding of the nurse's instruction? a. "Frequent stimulation will help with the rehabilitation process." b. "My spouse will no longer need to take blood pressure medication." c. "Rehabilitation and physical therapy are the same thing." d."The rehabilitation therapist will help identify changes needed at home."

d."The rehabilitation therapist will help identify changes needed at home."

Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities? Flaccid Normal Decorticate Decerebrate

decorticate

Astigmatism

defective curvature of the cornea or lens of the eye

Korsakoff syndrome after surgery

disorder characterized by psychosis, disorientation, delirium, insomnia, hallucinations, personality changes

Which set of symptoms characterize Korsakoff syndrome? a. Choreiform movement and dementia b. Psychosis, disorientation, delirium, insomnia, and hallucinations c. Severe dementia and myoclonus D. Tremor, rigidity, and bradykinesia

disorder characterized by psychosis, disorientation, delirium, insomnia, hallucinations, personality changes

Early indications of increasing ICP include:

disorientation, restlessness, increased respiratory effort, mental confusion, pupillary changes, weakness on onside of the body or in one extremity, and constant, worsening headache

Nursing management of the client with expressive aphasia includes

encouraging the client to repeat sounds of the alphabet.

Which activity should be avoided in clients with increased intracranial pressure (ICP)? Suctioning Enemas Minimal environmental stimuli Position changes

enema *Enemas should be avoided in clients with increased ICP. The Valsalva maneuver causes increased ICP. *Suctioning should not last longer than 15 seconds.

cluster headache

excruciating stabbing or burning sensations located in the eye or cheek

Lower motor neuron lesions cause a) hyperactive and abnormal reflexes. b) no muscle atrophy. c) flaccid muscles. d) increased muscle tone.

flaccid muscles Lower motor neuron lesions cause flaccid muscle paralysis, muscle atrophy, decreased muscle tone, and loss of voluntary control.

Nursing management of the client with cognitive deficits, such as memory loss, includes

frequently reorienting the client to time, place, and situation.

During assessment of cognitive impairment, post-stroke, the nurse documents that the patient was experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?

frontal lobe

A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?

heparin sodium

A client is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for: a) fever. b) visual disturbance. c) gait alteration. d) hypoxia.

hypoxia. Lower brain stem dysfunction alters bulbar functions, such as breathing, talking, swallowing, and coughing. Therefore, the nurse should monitor the client closely for hypoxia. Temperature control, vision, and gait aren't lower brain stem functions.

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the physician in the emergency department. What is the origin of the client's symptoms?

impaired cerebral circulation Explanation: TIAs result from impaired blood circulation in the brain, which can be caused by atherosclerosis and arteriosclerosis, cardiac disease, hypertension, or diabetes.

A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include honey thickened liquids. Which of the following is the priority nursing diagnosis for this client?

impaired swallowing

A nurse is providing care to a client who has had a stroke. Which symptoms are consistent with right-sided stroke?

impulsive behavior, poor judgment, deficits in left visual fields

Apraxia

inability to perform particular purposive actions, as a result of brain damage.

You're reading the physician's history and physical assessment report. You note the physician wrote that the patient has apraxia. What assessment finding in your morning assessment correlates with this condition? A. The patient is unable to read. B. The patient has limited vision in half of the visual field. C. The patient is unable to wink or move his arm to scratch his skin. D. The patient doesn't recognize a pencil or television.

inability to perform particular purposive actions, as a result of brain damage. (motor activities) C. The patient is unable to wink or move his arm to scratch his skin.

Miotics (pilocarpine) _______ the outflow of aqueous humor by constricting the pupil but this could also make it difficult to see in the dark (pupil dilation is needed when lighting is low)*

increase

Which is a contraindication for the administration of tissue plasminogen activator (t-PA)?

intracranial hemmorhage

- Tonometry measures _____________

intraocular pressure

three classic features of Parkinson's disease?

is bradykinesia, resting tremors, rigidity and postural instability

The nurse is caring for a client in the emergency department with a diagnosis of head trauma secondary to a motorcycle accident. The nurse aide is assigned to clean the client's face and torso. The nurse would provide further instruction after seeing that the nurse aide: a) cleaned the eye area from the inner to outer eye area. b) cleaned the neck and upper chest area. c) moved the client's head to clean behind the ears. d) used mild soapy water to clean the face.

moved the client's head to clean behind the ears. Further instruction would be provided to the nurse aide when the nurse aide attempted to move the client's head to clean behind the ears. There should be no movement of the client's head when there is a history of head trauma. Cleaning the client's face with soapy water, cleaning the eye area, and cleaning the neck and upper chest are all appropriate actions completed by the nurse aide.

A client is admitted to an acute care facility for treatment of a brain tumor. When reviewing the chart, the nurse notes that the client's extremity muscle strength is rated 1/5. Which assessment finding should the nurse anticipate? a) Muscle contraction or movement is undetectable. b) Muscles move actively against gravity alone. c) Normal, full muscle strength is present. d) Muscle contraction is palpable and visible.

muscle contraction is palpable and visible Muscle strength is assessed and rated on a five-point scale in all four extremities, comparing one side to the other. A rating of 1/5 indicates palpable, visible muscle contraction on the affected side and normal, full muscle strength on the unaffected side. Normal, full muscle strength on both sides is rated 5/5. Active muscle movement against gravity alone on the affected side with normal, full muscle strength on the unaffected side is rated 3/5. Undetectable muscle contraction or movement on the affected side with normal, full muscle strength on the unaffected side is rated 0/5.

The Eustachian tube connects the _________ to the middle ear and opens with yawning, swallowing or the Valsalva maneuver

nasopharynx

The Eustachian tube connects the ____________ to the middle ear and opens with yawning, swallowing or the Valsalva maneuver

nasopharynx

organ of Corti ear

organ located in the cochlea; contains receptors (hair cells) that receive vibrations and generate nerve impulses for hearing

Tympanogram

record of middle ear function (presented in graph form)

A nurse is caring for a client with an injury to the central nervous system. When caring for a client with a spinal cord insult slowing transmission of the motor neurons, the nurse would anticipate a delayed reaction in: a) processing information transferred from the environment. b) identification of information due to slowed passages of information to brain. c) cognitive ability to understand relayed information. d) response due to interrupted impulses from the central nervous system

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

A client is receiving long-term intravenous therapy with gentamicin for a chronic wound infection. Which of the following would be most important for the nurse to ensure? a. Monitor complete blood counts every other day. b. Assess intravenous access site daily. c. d. Obtain specimens for wound cultures daily. Arrange for audiograms twice a week.

rrange for audiograms twice a week.

Damage to the upper motor neurons could result in ___________while lower motor neuron lesions could result in flaccid limbs

spasticity

Nursing management of the client with global aphasia includes

speaking clearly to the client in simple sentences and using gestures or pictures when able.

Nursing management of the client with receptive aphasia

speaking slowing and clearly to assist the client in forming the sounds

A nurse is evaluating a client's cranial nerves during a routine examination. To assess the function of cranial nerve XII (hypoglossal), the nurse should assess the client's ability to: a) elevate the shoulders, both with and without resistance. b) read an eye chart from a distance of 20?. c) stick out the tongue and move it rapidly from side to side and in and out. d) smell and identify a nonirritating, aromatic odor.

stick out the tongue and move it rapidly from side to side and in and out. To test cranial nerve XII, which controls tongue movement, the nurse should instruct the client to stick out the tongue and move it rapidly from side to side and in and out. The nurse would ask the client to smell and identify a nonirritating, aromatic odor when testing the function of cranial nerve I, the olfactory cranial nerve. Asking the client to read an eye chart is part of assessing cranial nerve II, the optic cranial nerve. Having the client elevate the shoulders with and without resistance is part of assessing cranial nerve XI, the spinal accessory cranial nerve that innervates the sternocleidomastoid muscle and the upper portion of the trapezius muscle.

Signs of a retinal detachment include:

sudden flashing lights, floaters (spots or strings), decrease in vision, and/or a curtain covering a portion of one's vision*

Lichenification

thickening and roughening of the skin or accentuated skin markings that may be secondary to repeated scratching

Unilateral pupil dilation and a poor response to light suggests increased pressure to the ____________________ whereby bilateral pupil dilation suggests ______________

third cranial nerve brain stem injury

What is Dexamethasone (decadron) used for?

to decrease cerebral edema and pressure;

What is phenytoin (Dilantin) used for?

to prevent seizures.

A client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what?

transient ischemic attack

- Acute angle closure glaucoma is accompanied by periocular pain, conjunctival hyperemia, and a fixed semidilated pupil.

true

A cochlear implant is an auditory prosthesis used for people with profound sensorineural hearing loss bilaterally who do not benefit from conventional hearing aids

true

Acute angle closure (pupillary block) glaucoma is associated with a quick rise in intraocular pressure and is an ocular emergency.

true

Vision is blurred following the administration of ocular ointments and stinging and burning may occur

true

vInfection (endophthalmitis) can occur following cataract surgery and is marked by pain, decreasing vision, eyelid redness or edema, and/or a yellowish/green discharge from the eye.

true

When communicating with a client who has sensory (receptive) aphasia, the nurse should:

use short, simple sentences. Explanation: Although sensory aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension. Allowing time for the client to respond might be helpful but is less important than simplifying the communication. Because the client's hearing isn't affected, speaking loudly isn't necessary. A writing pad is helpful for clients with expressive, not receptive, aphasia.

When communicating with a client who has sensory (receptive) aphasia, the nurse should: a) speak loudly and articulate clearly. b) allow time for the client to respond. c) give the client a writing pad. d) use short, simple sentences.

use short, simple sentences. Although sensory aphasia allows the client to hear words, it impairs the ability to comprehend their meaning. The nurse should use short, simple sentences to promote comprehension. Allowing time for the client to respond might be helpful but is less important than simplifying the communication. Because the client's hearing isn't affected, speaking loudly isn't necessary. A writing pad is helpful for clients with expressive, not receptive, aphasia.

Rinne test

useful for distinguishing between conductive hearing loss or sensorineural hearing loss. •AC is greater than BC in normal hearing

A client suffered a closed head injury in a motor vehicle collision, and an ICP monitor was inserted. In the occurrence of increased ICP, what physiologic function contributes to the increase in intracranial pressure? hypertension increased PaO vasodilation vasoconstriction

vasodilation *Hypotension and hypoxia lead to vasodilation, which contributes to increased ICP, compressing blood vessels and leading to cerebral ischemia. *As ICP continues to rise, autoregulatory mechanisms can become compromised; hypotension and hypoxia lead to vasodilation, which contributes to increased ICP.

Ophthalmoscopy

visual examination of the interior of the eye

Name three modifiable risk factors for an Ischemic Stroke.

• Asymptomatic carotid stenosis • Atrial fibrillation • Diabetes (associated with accelerated atherogenesis) • Dyslipidemia • Excessive alcohol consumption • Hypercoagulable states • Hypertension (controlling hypertension, the major risk factor, is the key to preventing stroke) • Migraine • Obesity • Sedentary lifestyle • Sleep apnea • Smoking

Choice Multiple question - Select all answer choices that apply. The nurse is caring for a client who is scheduled to undergo a computerized tomography (CT) scan to assess recent symptoms of muscle weakness and tingling in the extremities. Which information should the nurse include in a preprocedural teaching plan? Select all that apply. a) The CT scan is considered an invasive procedure, but not dangerous. b) The test requires standing alone without assistance. c) Throat irritation and facial flushing may occur if contrast dye is used. d) All medications must be withheld for 12 hours prior to the procedure. e) It is necessary to report any known allergies to iodine or seafood prior to the procedure. f) A contrast dye may be given before the test.

• Throat irritation and facial flushing may occur if contrast dye is used. • It is necessary to report any known allergies to iodine or seafood prior to the procedure. • A contrast dye may be given before the test. The nurse should inform the client who is scheduled to undergo a CT scan that a contrast medium may be administered before the procedure and that the dye can cause throat irritation and facial flushing. Because the dye is iodine based, it is essential for the client to report any known allergies to iodine or seafood before testing begins. The CT scan is not invasive or dangerous. The client will need to lie still (not stand) during the procedure and will not be able to take routine medications for 24 hours beforehand.

What are the primary, secondary, and tertiary roles of nursing in regards to hearing?

•Primary promote and educate the public on activities that preserve hearing and balance •Secondary - screen individuals for hearing loss, balance disorders - assist with accurate diagnosis •Tertiary - assist individuals with managing hearing or balance disorders oimprove outcomes. o •Aural rehab ohelps to maximize communication skills in individuals with hearing impairment

A client is scheduled for surgery to remove an acoustic neuroma. The nurse observes the client crying and stating "I don't want to die". How should the nurse respond?

•Respond to the client in a way that shows empathy (understanding). •Ask the patient what they were informed and know about the surgery. •Allow the patient to discuss how they feel. •The nurse should know that death from acoustic neuroma surgery is rare.

momost troublesome complaint related to Ménière's disease

•Vertigo

What surgical procedures are used to correct disorders of the middle ear?

•tympanoplasty •ossiculoplasty •mastoidectomy

Weber test hearing

•uses BONE conduction to test lateralization of sound •useful for detecting unilateral hearing loss •The sound should be heard equally in both ears * conductive hearing loss hear the sound better in the affected ear * sensorineural hearing loss hear the sound better in the unaffected hear