Chapter 39 The Brain

Which issue does the nurse consider a priority when caring for a client diagnosed with atonic (akinetic) seizures? A. Possibility of injury related to falls B. Limited mobility related to lack of tonicity of muscles C. Confusion related to postictal period D. Organ ischemia related to decreased perfusion Rationale: With an atonic (akinetic) seizure, the client has a sudden loss of muscle tone, lasting for sec-onds, followed by postictal (after the seizure) confusion. In most cases, these seizures cause the client to fall, which may result in injury.

A

Which task does the nurse delegate to the assis-tive personnel (AP) for clients with Alzheimer disease in a long-term care setting? A. Assist the client who has incontinence with toileting every 2 hours. B. Provide hygienic care for a client who is currently exhibiting agitation. C. Encourage the client to consume small amounts of fluid to avoid incontinence. D. Give the client a complete bed bath to conserve his or her energy. Rationale: A client with AD may remain continent of bowel and bladder for a long period of time if taken to the bathroom or given a bedpan or urinal every 2 hours. Toileting may be needed more often during the day and less frequently at night. Assistive personnel (AP) or home care-givers are taught to encourage the client to drink adequate fluids to promote optimal voiding. A client may refuse to drink enough fluids because of a fear of incontinence. The care providers would assure the client that he or she will be toileted on a regular schedule to prevent incontinent episodes.

A

Which does the nurse recognize as cardinal symptoms for a client with Parkinson disease (PD)? Select all that apply. A. Tremors B. Muscle rigidity C. Postural instability D. Bradykinesia or akinesia E. Choreiform movements F. Seizure activity Rationale: Parkinson disease (PD) is a progressive neuro-degenerative disease that is one of the most common neurologic disorders of older adults. It is a debilitating disease affecting mobility and is characterized by four cardinal symptoms: tremor, muscle rigidity, bradykinesia or akinesia (slow movement/no movement), and postural instability. Huntington disease, a rare hereditary disorder that is characterized by progressive dementia and choreiform movements (uncon-trollable rapid, jerky movements) in the limbs, trunk, and facial muscles.

A, B, C, D

For which deficits in cognition does the nurse assess in a client with Alzheimer disease? Select all that apply. A. Attention and concentration B. Judgment and perception C. Learning and memory D. Aggressiveness and rapid mood swings E. Communication and language F. Speed of information processing Rationale: Deficits in all of these areas of cognition should be assessed. Option D does not assess changes in cognition, but assesses changes in behavior and personality.

A, B, C, E, F

Which clients will the nurse advise to receive the meningococcal vaccine? Select all that apply. A. Healthy 18-year-old who has enlisted in the military B. 25-year-old who had a splenectomy after an auto accident C. Healthy 24-year-old who is interning with a lawyer for the summer D. Healthy 20-year-old who plans to live in a university dormitory E. Healthy 22-year-old who is unsure about vaccination and plans to visit Asia F. 21-year-old who has a summer job with a moving company Rationale: People aged 16 through 21 years have the high-est rates of infection from life-threatening N. meningitidis meningococcal infection. The Centers for Disease Control and Prevention (CDC) recommends an initial meningococcal vaccine between ages 11 and 12 years with a booster at age 16 years. Adults are advised to get an initial or a booster vaccine if living in a shared residence (e.g., residence hall, military barracks, group home), or traveling or residing in countries in which the disease is common, or if they are immunocompromised as a result of a damaged or surgically removed spleen or a serum complement deficiency. If the client's baseline vaccination status is unclear and the immediate risk for exposure to N. meningitidis infection is high, the CDC recommends vacci-nation. It is safe to receive a booster as early as 8 weeks after the initial vaccine.

A, B, D, E

Which are signs and symptoms that the nurse will assess in a client with migraine headaches? Select all that apply. A. Nausea B. Throbbing unilateral pain C. Transient loss of consciousness D. Sensitivity to light E. Recurrent episodic headaches F. Sensitivity to sound Rationale: All of these signs and symptoms occur with migraine headaches except option C, transient loss of consciousness. Photophobia is sensitiv-ity to light and phonophobia is sensitivity to sound. See the box in your text labeled Key Features of Migraine Headaches for additional manifestations of migraine

A, B, D, E, F

Which tasks will the nurse delegate to the assis-tive personnel (AP) when caring for a client with stage 3 moderate Parkinson disease? Select all that apply. A. Assist client to the bathroom. B. Record accurate intake and output. C. Teach the client about safety precautions. D. Assist client with activities of daily living as needed. E. Assess client's gait and posture. F. Check and record client's vital signs every 4 hours. Rationale: To correctly respond to this question, the nurse must be familiar with the AP's scope of practice which includes assisting clients with ambula-tion, activities of daily living, recording intake and output, and checking as well as recording vital signs. Assessment and teaching for clients requires the additional training and skills of a professional RN

A, B, D, F

What equipment will the nurse ensure is in the room of a client being admitted on seizure precautions to prevent harm? Select all that apply. A. Oxygen equipment B. Padding for siderails C. Suctioning equipment D. Saline lock insertion equipment E. Padded tongue blade F. Neurological assessment flow sheet Rationale: Seizure precautions include ensuring that oxy-gen and suctioning equipment with an airway are readily available. If the client does not have an IV access, a saline lock should be inserted, especially if the client is at significant risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV drug therapy must be given to stop the seizure. Padded side-rails may be embarrassing to the client and family. Padded tongue blades do not belong at the bedside and should never be inserted into the client's mouth because the jaw may clench down as soon as the seizure begins. Forcing a tongue blade or airway into the mouth is more likely to chip the teeth and increase the risk for aspirating tooth fragments than prevent the client from biting the tongue. Improper place-ment of a padded tongue blade can also obstruct the airway. The seizure must be docu-mented but a neurological assessment flow sheet is not necessary

A, C, D

Which actions will the nurse expect when a cli-ent with Parkinson disease (PD) develops drug toxicity or tolerance? Select all that apply. A. A reduction in drug dosage B. Complete cessation of all drugs used to treat PD symptoms C. A change of drug or in the frequency of administration D. A drug holiday (particularly with levodopa therapy) E. Prescription of additional drugs to help relieve symptoms associated with the disease F. Implementation of exercise therapy to maintain functional abilities Rationale: When drug tolerance is reached, the drug's ef-fects do not last as long. The treatment of PD drug toxicity or tolerance includes: a reduction in drug dosage; a change of drug or in the fre-quency of administration; and a drug holiday (particularly with levodopa therapy). During a drug holiday, which can last up to 10 days, the client receives no drug therapy for PD and the nurse would carefully monitor the client for symptoms of PD and document assessment findings. Many clients are on additional drugs to help relieve symptoms associated with the disease (e.g., muscle spasms may be relieved by baclofen, drooling can be minimized by sublin-gual atropine sulfate, and insomnia may re-quire a sleeping aid such as zolpidem tartrate).

A, C, D, E

Which drugs will the nurse expect the health care provider to prescribe for a client with mild migraine headaches? Select all that apply. A. Acetaminophen B. Eletriptan C. Naproxen D. Cafergot E. Metoclopramide F. Isometheptene combination Rationale: Drugs commonly prescribed for mild mi-graines include acetaminophen, NSAIDs (e.g., naproxen, ibuprofen), NSAIDs combined with caffeine (e.g., OTC acetaminophen with aspirin and caffeine), and antiemetics for nausea. Metoclopramide may be administered with NSAIDs to promote gastric emptying and de-crease vomiting. For more severe migraines, drugs such as triptan preparations, ergotamine derivatives, and isometheptene combinations are needed.

A, C, E

Which signs and symptoms are commonly as-sessed by the nurse when a client is diagnosed with meningitis? Select all that apply. A. Disorientation to person, place, and time B. Nuchal rigidity (stiff neck) C. Severe, unrelenting headaches D. Positive Kernig's sign E. Decreased level of consciousness F. Generalized muscle aches and pain (myalgia) Rationale: See the box labeled Key Features of Meningitis in your text for additional common signs and symptoms. The classic nuchal rigidity (stiff neck) and positive Kernig's and Brudzinski's signs have been traditionally used to diagnose meningitis, however, these findings occur in only a small percentage of clients with a definitive diagnosis.

A, C, E, F

How does the nurse interpret a serum sodium finding of 126 mEq/L (126 mmol/L) for a client with bacterial meningitis? A. An early warning sign that the electrolyte imbalance will potentiate an acute myocardial infarction B. Evidence of syndrome of inappropriate antidiuretic hormone which is a complication of bacterial meningitis C. Within normal limits considering the diagnosis of bacterial meningitis but test should be repeated looking for downward trend D. A protective measure that causes increased urination and therefore reduces the risk of increased intracranial pressure Rationale: B Seizure activity may occur when meningeal inflammation and infection spreads to the cere-bral cortex. Inflammation can also result in abnormal stimulation of the hypothalamic area where excessive amounts of antidiuretic hor-mone (ADH) (vasopressin) are produced. Ex-cess vasopressin results in water retention and dilution of serum sodium caused by increased sodium loss by the kidneys. This syndrome of inappropriate antidiuretic hormone (SIADH) may lead to further increases in ICP.

B

To prevent harm, which prescribed drug would the nurse question for an older client with Parkinson disease (PD)? A. Bromocriptine mesylate B. Benztropine C. Amantadine D. Levodopa-carbidopa For severe motor symptoms such as tremors and rigidity, one of the older anticholinergic drugs may be prescribed, but they are rarely used as primary drugs of choice for PD. Examples are benztropine, trihexyphenidyl HCl, and procyclidine. These drugs should be avoided in older adults because they can cause acute confusion, urinary retention, constipation, dry mouth, and blurred vision. The nurse would be sure to clarify a prescrip-tion for this drug written for an older adult with PD.

B

What does the Mini-Mental State Examination (MMSE) measure when the nurse assesses an older adult client with Alzheimer disease? A. Level of intelligence B. Severity of cognitive impairment C. Alterations in communication D. Functional ability Rationale: he Mini-Mental State Examination (MMSE) is an example of a tool used to determine the onset and severity of cognitive impairment. The MMSE, also known as the "mini-mental exam", assesses five major areas—orientation, registration, attention and calculation, recall, and speech-language (including reading).

B

Which action will the nurse consider the high-est priority when caring for a client who is cur-rently experiencing a migraine headache? A. Avoiding environmental triggers of migraine headaches B. Providing pain management for client C. Assessing the client for visual symptoms D. Detecting a pre-migraine aura Rationale: The priority for care of the client having mi-graines is pain management. This outcome may be achieved by abortive and preventive therapy. Drug therapy, trigger management, and complementary and integrative therapies are the major approaches to managing pain.

B

The nurse will collaborate with which members of the interprofessional team to determine the needs of a client with Alzheimer disease for adaptive devices? Select all that apply. A. Social services B. Occupational therapist C. Surgeon D. Physical therapist E. Registered dietitian nutritionist F. Speech language therapist Rationale: he nurse would collaborate with the occupa-tional and physical therapists to provide a com-plete evaluation and assistance in helping the client remain as independent as possible. Adap-tive devices, such as grab bars in the bathtub or shower area, an elevated commode, and adap-tive eating utensils, may enable him or her to maintain independence in grooming, toileting, and feeding. The physical therapist prescribes an exercise program to improve physical health and functionality.

B, D

Which actions will the nurse avoid when a client with Alzheimer disease is agitated? Select all that apply. A. Talking softly and calmly to the client B. Confronting the client C. Attempting to redirect the client D. Reasoning with the client E. Taking offense at what the client says F. Explaining the situation to the client Rationale: When a client with AD is agitated, actions to avoid include raising the voice, confronting, arguing, reasoning, taking offense, or explain-ing. Talking calmly and softly and attempting to redirect the client to a more positive behav-ior or activity are effective strategies when he or she is agitated

B, D, E, F

Which are microscopic changes that occur in the brain of a client with Alzheimer disease (AD)? Select all that apply. A. Widening of the cerebral sulci B. Neurofibrillary tangles C. Decreasing size of the brain D. Neuritic plaques E. Narrowing of the gyri F. Vascular degeneration Rationale: While all of these options are changes that occur in the brain with AD, only neurofibril-lary tangles, amyloid-rich senile or neuritic plaques, and vascular degeneration are micro-scopic changes.

B, D, F

What is the priority nursing concern for a client with Parkinson disease (PD) with right-sided trembling and weakness, as well as dizziness when moving from sitting to standing? A. Decreased ability to perform activities of daily living B. Feelings of isolation and loneliness C. Safety related to possible injury due to falls D. Poor nutritional and fluid intake Rationale: The nurse's priority concern for this client with PD is related to safety. The client has right-sided trembling and weakness, as well as expe-riencing dizziness when first moving from a sitting to a standing position, all of which in-creases the risk for injuries due to falls.

C

Which action by a client with Alzheimer dis-ease and documented by the nurse demon-strates the finding of apraxia? A. Client is unable to understand or follow a simple command. B. Client sustains a burn from a heating pad without realizing it. C. Client pushes food on his or her plate with eye glasses. D. Client is unable to find words when asked the name of his or her pet dog. Rationale: Apraxia is the inability to use words or objects correctly. In this case the client is attempting to use eye glasses for eating food. Inability to understand or follow simple commands is aphasia. Agnosia is the loss of sensory compre-hension so a client may be burned without real-izing that it occurs. Anomia is the inability to find words, as when the client is unable to find the word to name his or her pet.

C

Which action is best for the nurse to take while caring for a client with late-stage advanced Alzheimer disease in a long-term care setting? A. Repeating the date, time, and place frequently B. Using memory aids such as pill reminders C. Reflecting a client's feelings and concerns D. Providing puzzles, games, and hands-on activities Rationale: For the client in the later stages of AD or another form of dementia, reality orientation does not work and often increases agitation. The interprofessional health care team uses validation therapy for the client with moderate or severe AD. In validation therapy, the staff member recognizes and acknowledges the cli-ent's feelings and concerns

C

Which functional assessment is a priority when the nurse assesses a client with Parkinson disease and notes masklike face? A. Ability to sense pain in the facial area B. Ability to hear normal voice tones C. Ability to chew and swallow D. Ability to see in a dim lighted environment Rationale: Changes in facial expression or a masklike face with wide-open, fixed, staring eyes is caused by rigidity of the facial muscles. In late-stage PD, this rigidity can lead to difficulties in chewing and swallowing, particularly if the pharyngeal muscles are involved. As a result, the client may have inadequate nutrition and uncontrolled drooling may occur

C

Which intervention will the nurse implement for a client who has a migraine headache with phonophobia?. A. Ensure that the staff knows that the client will need help with ambulation. B. Dim the lights in the client's room and close the curtains. C. Place the client in a quiet room and instruct the staff to minimize noise. D. Increase the amount of ambient light to make it easier for the client to see. Rationale: Phonophobia is sensitivity to sound. The nurse would intervene by placing the client in a quiet room and keeping the noise level to a minimum.

C

Which statement does the nurse recognize as accurate with regard to drugs used to treat a client with Alzheimer disease? A. If started early enough, cholinesterase inhibitors may cure AD. B. All clients with AD are treated with antidepressants. C. No drugs can cure AD but some may improve symptoms. D. A family member should know how to check pulse because of tachycardia. Rationale: There are no drugs that can cure or slow the progression of Alzheimer disease, but a few drugs may improve symptoms associated with the disease for some clients. Cholinesterase inhibitors work to improve cholinergic neuro-transmission in the brain by delaying the destruction of acetylcholine (ACh) by the en-zyme cholinesterase. This action may slow the onset of cognitive decline in some clients, but none of these drugs alters the course of the disease. Memantine blocks excess amounts of glutamate that can damage in some clients.

C

What is the nurse's best action when a client is having a generalized tonic-clonic seizure and becomes cyanotic? A. Raise the head of the bed and apply oxygen by nasal cannula. B. Suction the client and alert the Rapid Response Team. C. Call the health care provider and obtain intubation equipment. D. Stay with the client because the cyanosis is usually self-limiting. Rationale: It is not unusual for a client to become cyanotic during a generalized tonic-clonic seizure. The cyanosis is generally self-limiting, and no treat-ment is needed so the nurse would remain with the client. Some primary health care providers prefer to give a high-risk client (e.g., older adult, critically ill, or debilitated client) oxygen by nasal cannula or facemask during the post-ictal (after seizure) phase

D

What is the priority for interprofessional care of clients with Alzheimer disease (AD)? A. Preserving memory B. Promoting functional abilities C. Teaching clients and families D. Keeping clients safe Rationale: For clients with AD, the priority for interpro-fessional care is safety. Chronic confusion and physical deficits place the client with AD at a high risk for injury, accidents, and elder abuse.

D

What priority information does the nurse in-clude when teaching a client with Parkinson disease (PD) about the prescribed drug selegi-line, a selective monoamine oxidase type B (MAO-B) inhibitor? A. Take the drug with meals. B. Avoid driving or operating heavy machinery. C. Take the medication daily at bedtime. D. Avoid eating aged cheese or cured meats. Rationale: The nurse would teach clients taking MAOIs about the need to avoid foods, beverages, and drugs that contain tyramine, such as cheese and aged, smoked, or cured foods and sausage. Remind them to also avoid red wine and beer to prevent severe headache and life-threatening hypertension. Clients are taught to continue these restrictions for 14 days after the drug is discontinued

D

What priority teaching will the nurse provide for a client on migraine preventive therapy who is taking a beta blocker and a calcium channel blocker drug? A. Move slowly when getting out of bed. B. Use handrails whenever possible. C. Avoid calcium-based foods. D. Learn to check your pulse Rationale: The nurse will teach clients who take beta-adrenergic blockers or calcium channel blockers how to take their pulse because both drugs lower blood pressure and heart rate. Clients are taught to report bradycardia or ad-verse reactions such as fatigue and shortness of breath to their primary health care provider as soon as possible. Rising slowly from bed and using handrails are also useful but not the high-est priority. The client would not be advised to avoid foods with calcium

D

Which diagnostic test does the emergency de-partment nurse anticipate for a client admitted with headache, fever, nausea, and light sensitiv-ity, and who has been living with two people recently diagnosed with meningitis? A. Skull x-rays B. Myelography C. Cerebral angiogram D. Lumbar puncture Rationale: The nurse would anticipate assisting the health care provider with a lumbar puncture. The most significant laboratory test used in the diagnosis of meningitis is the analysis of the cerebrospinal fluid (CSF). Clients older than 60 years, those who are immunocompro-mised, or those who have signs of increased ICP usually have a CT scan before the lumbar puncture. If there will be a delay in obtaining the CSF, blood is drawn for culture and sensi-tivity. A broad-spectrum antibiotic should be given before the lumbar puncture. The CSF is analyzed for cell count, differential count, and protein. Glucose concentrations are deter-mined, and culture, sensitivity, and Gram stain studies are performed.

D

Which medication prescription will the nurse clarify before administering it to a client? A. Gabapentin for a client who has partial seizures B. Diazepam rectal gel for a client with status epilepticus C. Carbamazepine for a client with tonic-clonic seizures D. Warfarin for a client who takes phenytoin for seizures Rationale: Using warfarin together with phenytoin may cause a client to bleed more easily. It may also increase phenytoin levels. Phenytoin levels and prothrombin time or international normalized ratio (INR) should be monitored whenever the dosage is changed or discontinued

D