43, 44 & 46 Practice Q & A- Neuro (MEDSURG

142 An older adult is brought to the clinic by a family member because of increasing confusion over the past week. What can the nurse ask clients to assess their orientation to place? 1 Explain a proverb. 2 State where they were born. 3 Identify the name of the town. 4 Recall what they had eaten for breakfast.

142 3 Orientation to place refers to an individual's awareness of the objective world in its relation to the self; orientation to time, place, and person is part of the assessment of cerebral functioning. 1 This requires abstract thinking, which involves a higher integrative function than orientation to place. 2 This assesses remote memory, not orientation. 4 This assesses recent memory, not orientation. Client Need: Psychosocial Integrity; Cognitive Level: Analysis; Nursing Process: Assessment/Analysis; Reference: Ch 18, Dementia, Nursing Care

473 When completing a neurological assessment, the nurse determines that a client has a positive Romberg test. Which finding supports the nurse's conclusion? 1 Inability to stand with feet together when eyes are closed 2 Fanning of toes when the sole of the foot is firmly stroked 3 Dilation of pupils when focusing on an object in the distance 4 Movement of eyes toward the opposite side when head is turned

473 1 The Romberg test evaluates proprioception. A client is asked to close the eyes when standing. If balance is lost after the client's eyes are closed, a positive Romberg test suggests that there is a sensory cause. 2 This is a positive Babinski reflex that is indicative of corticospinal pathology in an adult. 3 This is accommodation, a normal finding. 4 This is the oculocephalic or oculovestibular reflex, a normal finding. Client Need: Physiological Adaptation; Cognitive Level: Knowledge; Nursing Process: Assessment/Analysis; Reference: Ch 11, Brain Attack/Cerebrovascular Accident, Data Base

478 A client experiences a traumatic brain injury. Which finding identified by the nurse indicates damage to the upper motor neurons? 1 Absent reflexes 2 Flaccid muscles 3 Trousseau sign 4 Babinski response

478 4 A Babinski response (dorsiflexion of the first toe and fanning of the other toes) is a reaction to stroking the lateral sole of the foot with a blunt object; it is indicative of damage to the corticospinal tract when seen in adults. 1 Hyperreflexia is associated with upper motor neuron damage. 2 Increased muscle tone (spasticity) is associated with upper motor neuron damage. 3 This is indicative of hypocalcemia. Client Need: Physiological Adaptation; Cognitive Level: Analysis; Nursing Process: Assessment/Analysis; Reference: Ch 11, Traumatic Brain Injuries, Data Base

495 A client is admitted post traumatic brain injury and multiple fractures. The client's eyes remain closed, and there is no evidence of verbalization or movement when the nurse changes the client's position. What score on the Glasgow Coma Scale should the nurse document? Record your answer using a whole number. Answer: _______

495 Answer: 3. The score on the GCS ranges from 3 to 15. The client's lack of response earns the minimum of one point in each of the categories: eye opening response, best verbal response, and best motor response. Client Need: Reduction of Risk Potential; Cognitive Level: Analysis; Nursing Process: Assessment/Analysis; Reference: Ch 11, Related Procedures, Neurologic Assessment

515 A client develops hydrocephalus 2 weeks after cranial surgery for a ruptured cerebral aneurysm. The nurse concludes that the hydrocephalus probably is related to which physiologic response? 1 Vasospasm of adjacent cerebral arteries 2 Ischemic changes in the Broca speech center 3 Increased production of cerebrospinal fluid 4 Blocked absorption of fluid from the arachnoid space

515 4 Residual blood from the ruptured aneurysm may have blocked the arachnoid villi, interrupting the flow of CSF, resulting in hydrocephalus. 1 Vasospasm is a protective response during the active bleeding process; it does not cause hydrocephalus. 2 The Broca center is not directly affected; even if it were, there is no relationship to the development of hydrocephalus. 3 The production of cerebrospinal fluid is not increased in this situation; increased production may result when there is a tumor of the choroid plexus. Client Need: Physiological Adaptation; Cognitive Level: Comprehension; Nursing Process: Assessment/Analysis; Reference: Ch 11, Traumatic Brain Injuries, Data Bas

520 Which clinical indicator is the nurse most likely to identify when assessing a client with a ruptured cerebral aneurysm? 1 Tonic-clonic seizures 2 Decerebrate posturing 3 Sudden severe headache 4 Narrowed pulse pressure

520 3 Bleeding into the enclosed cavity of the skull creates pressure, causing pain. 1 Seizures are not directly related to the hemorrhage; they result from abnormal electrical charges that may eventually develop as a consequence of tissue ischemia. 2 Decerebrate posturing (extension posturing) indicates caudal deterioration with damage to the midbrain and pons. 4 As the systolic pressure increases, widening of the pulse pressure occurs because of compression of vasomotor centers. Client Need: Physiological Adaptation; Cognitive Level: Application; Nursing Process: Assessment/Analysis; Reference: Ch 11, Review of Anatomy & Physiology Review of Physical Principles

539 A client is diagnosed as having expressive aphasia. What type of impairment does the nurse expect the client to exhibit? 1 Speaking and/or writing 2 Following specific instructions 3 Understanding speech and/or writing 4 Recognizing words for familiar objects

539 1 Damage to the Broca area, located in the posterior frontal region of the dominant hemisphere, causes problems in the motor aspect of speech. 2, 3, 4 This is associated with receptive aphasia, not expressive aphasia; receptive aphasia is associated with disease of the Wernicke area of the brain. Client Need: Psychosocial Integrity; Cognitive Level: Comprehension; Integrated Process: Communication/Documentation; Nursing Process: Assessment/Analysis; Reference: Ch 11, Brain Attack/Cerebrovascular Accident, Data Base

64 A nurse is teaching clients about dietary restrictions when taking a monoamine oxidase inhibitor (MAOI). What response does the nurse tell them to anticipate if they do not follow these restrictions? 1 Occipital headaches 2 Generalized urticaria 3 Severe muscle spasms 4 Sudden drop in blood pressure

64 1 Occipital headaches are the beginning of a hypertensive crisis that results from excessive tyramine. 2 This is unrelated to the ingestion of tyramine. 3 These are unrelated to the ingestion of tyramine. 4 Excessive tyramine causes an increase, not a decrease, in blood pressure. Client Need: Pharmacological and Parenteral Therapies; Cognitive Level: Application; Integrated Process: Teaching/Learning; Nursing Process: Evaluation/Outcomes; Reference: Ch 16, Related Pharmacology: Psychotropic Medications, Antidepressants

89 A client has contrast medium injected into the brachial artery so that a cerebral angiogram can be performed. What nursing assessment is most essential immediately after the procedure? 1 Stability of gait 2 Presence of a gag reflex 3 Blood pressure in both arms 4 Symmetry of the radial pulses

89 4 Trauma to the artery can interfere with circulation to the accessed extremity. This is most easily assessed by checking the pulses bilaterally. 1 The client is prescribed bed rest after the procedure, so gait is not assessed. 2 The gag reflex is not affected by the test. 3 The blood pressure should not be taken in the affected arm; the increase in pressure may initiate bleeding. Client Need: Reduction of Risk Potential; Cognitive Level: Application; Nursing Process: Evaluation/Outcomes; Reference: Ch 6, Related Procedures, Angiography

Ch. 43, 44 & 46 Neuro Practice Q & A Exam 5 MedSurg

Ch. 43 Assess of Nervous Sys. Practice Q & A Exam 5 MedSurg