Dr. Strange part deux

86. A client admitted to the emergency department for head trauma is diagnosed with an epidural hematoma. Which of the following would most likely cause this condition? 1. Laceration of the middle meningeal artery 2. Rupture of the carotid artery 3. Trauma to the middle cerebral artery 4. Venous bleeding from the arachnoid space

1. Epidural hematoma or extradural hematoma is usually caused by laceration of the middle meningeal artery. Trauma to the middle cerebral artery would be associated with intracerebral hemorrhage or stroke. Venous bleeding from the arachnoid space is usually observed with subdural hematoma.

After falling 208 feet (6 m), a 36-year-old construction worker sustains a C6 fracture with spinal cord transection. Which other findings should the nurse expect? 1. Quadriplegia with gross arm movement and diaphragmatic breathing 2. Quadriplegia and loss of respiratory function 3. Paraplegia with intercostal muscle loss 4. Loss of bowel and bladder control

1. A client with a spinal cord injury at levels C5-C6 has quadriplegia with gross arm movement and diaphragmatic breathing. Injuries at levels C1- C4 lead to quadriplegia with total loss of respiratory function. Paraplegia with intercostal muscle loss occurs with injuries at T1-L2. Injuries below L2 cause paraplegia and loss of bowel and bladder control.

The nurse assesses clear fluid draining from the nose of a client who experienced head trauma 3 hours ago. The nurse suspects this finding may indicate: 1. basilar skull fracture. 2. cerebral concussion. 3. cerebral palsy. 4. sinus infection

1. Clear fluid draining from the ear or nose of a client may mean a cerebrospinal fluid leak, which is common in basilar skull fractures. Concussion is associated with a brief loss of consciousness, cerebral palsy is associated with nonprogressive paralysis present since birth, and sinus infection is associated with facial pain and pressure with or without nasal drainage. CN: Physiological

24. A nurse is planning care for a 33-year-old client who has just undergone a L4-L5 laminectomy. What is the most important intervention for the nurse to include? 1. Encourage the client to be out of bed the first postoperative day. 2. Maximize bracing while in bed. 3. Limit movement in bed and reposition only when necessary. 4. Use a soft mattress.

1. Encourage the client to be out of bed the first postoperative day.

The nurse is concerned that a client recovering from a brain injury may be developing foot drop and contractures. What is the best intervention for the nurse to implement? 1. High-topped sneakers or other type of foot-up ankle support 2. Low-dose heparin therapy 3. Physical therapy consultation 4. Sequential compression device

1. High-topped sneakers or other types of foot-up ankle support devices are used to prevent foot drop and contractures in neurological clients. Lowdose heparin therapy and sequential compression boots will prevent deep vein thrombosis. Although a physical therapy consultation is important to initiate other interventions to prevent foot drop, a nurse may use high-topped sneakers independently. CN: Physiological

An unconscious client is receiving mechanical ventilation. Which nursing diagnosis takes priority? 1. Ineffective airway clearance related to the inability to expectorate 2. Risk for impaired skin integrity related to immobility 3. Imbalanced nutrition: Less than body requirements related to inability to swallow 4. Dressing self-care deficit related to unconsciousness 403

1. Ineffective airway clearance related to the inability to expectorate takes priority in an unconscious client. The other nursing diagnoses are appropriate but are less important than airway, breathing, and circulation.

A client with a spinal cord injury has a neurogenic bladder. When planning for discharge, the nurse anticipates the client will need which procedure or program? 1. Intermittent catheterization program 2. Kock pouch 3. Transurethral prostatectomy 4. Ureterostomy

1. Intermittent catheterization, starting with 2-hour intervals and increasing to 4- to 6-hour intervals, is used to manage neurogenic bladder. A Kock pouch is a type of urinary diversion. Transurethral prostatectomy is indicated for obstruction to urinary outflow by benign prostatic hyperplasia or for the treatment of cancer. An ileostomy or ureterostomy isn't necessary.

A client with a subdural hematoma was given mannitol to decrease intracranial pressure (ICP). The nurse assesses the client and determines that the mannitol was effective when: 1. urine output increases. 2. pupils are 8 mm and nonreactive. 3. systolic blood pressure remains at 150 mm Hg. 4. blood urea nitrogen (BUN) and creatinine levels return to normal.

1. Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubules, thus increasing urine output. Fixed and dilated pupils are symptoms of increased ICP or cranial nerve damage. No information is given about abnormal BUN and creatinine levels or that mannitol is being given for renal dysfunction or blood pressure maintenance.

When teaching the family of a client with C4 quadriplegia how to suction his tracheostomy, the nurse includes which instruction? 1. Suction for 10 to 15 seconds at a time.

1. Suction should be applied for 10 to 15 seconds at a time. Suction is regulated to 80 to 120 cm. Suction should be applied only during withdrawal of the catheter. When suctioning the trachea, the catheter is inserted 40 to 60 (10 to 15 cm) or until resistance is felt.

The nurse is teaching a client who has a diagnosis of a stroke versus a transient ischemic attack (TIA). Which statement by the nurse describing to the client the difference between stroke and TIA would be the most accurate? 1. TIAs resolve in less than 24 hours. 2. TIAs may be hemorrhagic in origin. 3. TIAs may cause a permanent motor deficit. 4. TIAs may predispose the client to a myocardial infarction (MI).

1. Symptoms of a TIA result from a transient lack of oxygen to the brain and usually resolve within 24 hours, and the average time is less than 30 minutes. Unlike an ischemic stroke, TIAs are not permanent. However, people who have had a TIA are at high risk of having a stroke, and secondary stroke prevention is required. TIAs are due to an ischemic process, not a hemorrhage. The risk factors for stroke, TIA, and MI are similar, but the question asked about the difference between a stroke and TIA.

136. An 18-year-old client is admitted with a closed head injury sustained in a motor vehicle collision. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first? 1. Reposition the client to avoid neck flexion. 2. Administer 1 g of mannitol (Osmitrol) I.V. as ordered. 3. Increase the ventilator's respiratory rate to 20 breaths/minute. 4. Administer 100 mg of pentobarbital I.V. as ordered.

1. The nurse should first attempt a nursing intervention, such as repositioning the client to avoid neck flexion, which increases venous return and lowers ICP. If nursing measures prove ineffective, notify the physician. CN: Safe, effective care environment;

52. What is the most important nursing intervention for a client having a tonicclonic seizure? 1. Maintaining a patent airway 2. Timing the duration of the seizure 3. Noting the origin of seizure activity 4. Inserting a padded tongue blade to prevent the client from biting his tongue

1. The priority during and after a seizure is to maintain a patent airway. Timing the seizure activity and noting the origin of motor dysfunction are done but not first. Nothing should be placed in the client's mouth during a seizure because teeth may be dislodged or the tongue pushed back, further obstructing the airway.

The nurse is assessing a client with head trauma. The nurse notes a urine output of 300 ml/hour, dry skin, dry mucous membranes, and a high serum sodium. The most important intervention for the nurse to implement would be? 1. Evaluate urine specific gravity. 2. Anticipate treatment for renal failure. 3. Provide emollients to the skin to prevent breakdown. 4. Slow the I.V. fluids and notify the physician.

1. Urine output of 300 ml/hour in the presence of high serum sodium may indicate diabetes insipidus (DI), which is a failure of the pituitary to produce antidiuretic hormone. Sodium disturbances are common in clients with brain injury because of the major role that the central nervous system plays in the regulation of sodium and water homeostasis. Other related conditions include cerebral salt wasting and syndrome of inappropriate antidiuretic hormone. These conditions are respectively differentiated from DI by low serum sodium and low urine output. DI may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration. There's no evidence that the client is experiencing renal failure. Providing emollients to prevent skin breakdown is important but doesn't need to be performed immediately. Slowing the rate of I.V. fluid would contribute to dehydration when polyuria is present.

A client recalls smelling an unpleasant odor before his seizure. What would the nurse document this as? 1. Atonic seizure 2. Aura 3. Icterus 4. Postictal experience

2. An aura occurs in some clients as a warning before a seizure. The client may experience a certain smell, a vision such as flashing lights, or a sensation. Atonic seizure or drop attack refers to an abrupt loss of muscle tone. Icterus refers to jaundice. Postictal experience occurs after a seizure, during which the client may be confused, somnolent, and fatigued.

A client recovering from a spinal cord injury has a great deal of spasticity. Which medication may be used to control spasticity? 1. Hydralazine 2. Baclofen (Lioresal) 3. Lidocaine (Xylocaine) 4. Methylprednisolone (Medrol)

2. Baclofen is a skeletal muscle relaxant used to decrease spasms. It may be given orally or intrathecally. Hydralazine is an antihypertensive and afterload-reducing agent. Lidocaine is an antiarrhythmic and a local anesthetic agent. Methylprednisolone, an anti-inflammatory drug, is used to decrease spinal cord edema in the acute phase.

When assessing the ability of a client's pupil to constrict, which cranial 400 nerve (CN) is being tested? 1. II 2. III 3. IV 4. V

2. CN III, the oculomotor nerve, controls pupil constriction. CN II is the optic nerve, which controls vision. CN IV is the trochlear nerve, which coordinates eye movement. CN V is the trigeminal nerve, which innervates the muscles of chewing.

71. A client is admitted with intervertebral disk prolapse and now shows new symptoms of loss of bladder control and paralysis of both legs. Which of the following nursing interventions should be the priority? 1. Obtaining an order for a urinary drainage device 2. Notifying the physician immediately 3. Increasing the frequency of vital signs 4. Administering medication to decrease inflammation

2. Cauda equina syndrome occurs when there is compression on the nerve roots. It affects areas below the level of these nerve roots. It is an emergency that requires surgical intervention; if not treated, it may lead to permanent loss of bladder and bowel control and paralysis of the legs. Inserting a urinary drainage device, increasing the frequency of vital signs, and administering anti-inflammatory medication may be interventions that are needed; however, they are not the priority.

A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which nursing intervention should be done first? 1. Position the client flat in bed. 2. Notify the physician of potential cerebrospinal fluid leak 3. Suction the nose to maintain airway patency. 4. Insert nasal and ear packing with sterile gauze.

2. Clear or light pink-tinged liquid from the nose (rhinorrhea) or ear (otorrhea) in the presence of a head injury may be leakage of cerebral spinal fluid due to a basilar skull fracture. The physician should be notified and precautions to prevent infection taken. Placing the client flat in bed may increase intracranial pressure and promote pulmonary aspiration. The nose wouldn't be suctioned because of the risk of suctioning brain tissue through the sinuses. Nothing is inserted into the ears or nose of a client with a skull fracture because of the risk of infection.

A client is taking carbamazepine (Tegretol). For which of the following potential complications should the nurse be monitoring the client? 1. Acute respiratory distress syndrome (ARDS) 2. Diplopia 3. Elevated levels of phenytoin (Dilantin) 4. Leukocytosis

2. Complications of carbamazepine include diplopia, dizziness, ataxia, and rash. ARDS isn't a complication of carbamazepine. Carbamazepine decreases blood levels of phenytoin and hormonal contraceptives; it also causes agranulocytosis because of the reduction in leukocytes

The nurse is aware that a client who had a transsphenoidal hypophysectomy should be observed carefully for hemorrhage. The nurse is most concerned when the client displays: 1. bloody drainage from the ears. 2. frequent swallowing. 3. guaiac-positive stools. 4. hematuria.

2. Frequent swallowing after brain surgery may indicate fluid or blood leaking from the sinuses into the oropharynx. Blood or fluid draining from the ear may indicate a basilar skull fracture, guaiac-positive stools indicate GI bleeding, and hematuria may result from cystitis or other urological complications

Client teaching for a client with Gardner-Wells tongs should include which reason for their use? 1. To reduce intracranial pressure (ICP) 2. To reduce dislocations and pain 3. To prevent deep vein thrombosis (DVT) 4. To prevent the need for surgery

2. Gardner-Wells tongs are used to reduce dislocations, subluxations, pain, and spasm in cervical spinal cord injuries. They may be used to stabilize a neck fracture until a definitive surgical procedure can be performed. Gardner-Wells tongs aren't used to reduce ICP or prevent DVT.

29. When prioritizing care, which client should the nurse assess first? 1. A 17-year-old client 24 hours postappendectomy 2. A 33-year-old client with a recent diagnosis of Guillain-Barré syndrome 3. A 50-year-old client 3 days postmyocardial infarction 4. A 50-year-old client with diverticulitis

2. Guillain-Barré syndrome is characterized by ascending paralysis and potential respiratory failure. The order of client assessment should follow client priorities, with disorders of airway, breathing, and then circulation. There's no information to suggest the postmyocardial infarction client has an arrhythmia or other complication. There's no evidence to suggest hemorrhage or perforation for the remaining clients as a priority of care.

A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which symptom(s) should also be anticipated? 1. Decreased urine output or oliguria 2. Hypertension and bradycardia 3. Respiratory depression 4. Symptoms of shock

2. Hypertension, bradycardia, anxiety, blurred vision, and flushing above the lesion occur with autonomic dysreflexia due to uninhibited sympathetic nervous system discharge. The other options are incorrect. The most common cause of autonomic dysreflexia is bowel impaction or bladder distension.

Which intervention describes an appropriate bladder program for a client in rehabilitation for a recent spinal cord injury? 1. Insert an indwelling urinary catheter. 2. Schedule intermittent catheterization every 2 to 4 hours. 3. Perform a straight catheterization every 8 hours while the client is awake. 4. Perform Credé's maneuver to the lower abdomen before the client voids.

2. Intermittent catheterization should begin every 2 to 4 hours early in treatment. When residual volume is less than 400 ml, the schedule may advance to every 4 to 6 hours. Indwelling catheters may predispose the client to infection and are removed as soon as possible. Credé's maneuver is applied after voiding to enhance bladder emptying.

A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of phenytoin (Dilantin) I.V. Which consideration is most important when administering this dose? 1. Therapeutic drug levels should be maintained between 20 and 30 mg/ml. 2. Rapid phenytoin administration can cause cardiac arrhythmias. 3. Phenytoin should be mixed in dextrose in water before administration. 4. Phenytoin should be administered through an I.V. catheter in the client's hand.

2. Phenytoin I.V. should not exceed 50 mg/minute, as rapid administration can depress the myocardium, causing lethal dysrhythmias. Therapeutic drug levels range from 10 to 20 mg/ml. Phenytoin is only compatible with normal saline, not dextrose in water. It is very irritating to the blood vessels and may cause purple glove syndrome when administered I.V. in a hand.

Stool softeners would be given to a client prior to repair of a cerebral aneurysm for which reason? 1. To stimulate the bowel due to loss of nerve innervation 2. To prevent straining, which increases intracranial pressure (ICP) 3. To prevent reflex bradycardia from the Valsalva maneuver 4. To prevent constipation when osmotic diuretics are used

2. Straining when having a bowel movement, sneezing, coughing, and suctioning may lead to increased ICP and should be avoided when potential increased ICP exists. Stool softeners don't stimulate the bowel and aren't used in combination with osmotic diuretics. Although the Valsalva maneuver may lead to an increase in intracranial pressure, the given rationale doesn't apply to this client.

81. A client is scheduled for magnetic resonance imaging (MRI) of the head. Which area is essential to assess before the procedure? 1. Food or drink intake within the past 8 hours 2. Prostheses or a pacemaker 3. The presence of carotid artery disease 4. Voiding before the procedure

2. Strong magnetic waves may dislodge metal in the client's body, causing tissue injury. Although the client may be told to restrict food for 8 hours, particularly if contrast is used, metal is an absolute contraindication for this procedure. Voiding beforehand would make the client more comfortable and better able to remain still during the procedure but isn't essential for the test. Having carotid artery disease isn't a contraindication to having an MRI.

A client is admitted to the hospital with a subarachnoid hemorrhage and is now experiencing severe headache, nuchal rigidity, and projectile vomiting. The nurse is aware that a lumbar puncture (LP) would be contraindicated if: 1. vomiting continues. 2. intracranial pressure (ICP) is increased. 3. the client needs mechanical ventilation. 4. blood is anticipated in the cerebrospinal fluid (CSF).

2. Sudden removal of CSF results in pressures lower in the lumbar area than the brain and favors herniation of the brain; therefore, LP is contraindicated with increased ICP. An LP is performed if brain imaging is negative or inconclusive in the presence of subarachnoid hemorrhage-type symptoms. Vomiting may be caused by reasons other than increased ICP; therefore, LP isn't strictly contraindicated. An LP may be performed on clients requiring mechanical ventilation. Blood in the CSF is diagnostic for subarachnoid hemorrhage.

Which condition indicates that spinal shock is resolving in a client with C7 quadriplegia? 1. Absence of pain sensation in the chest 2. Return of reflexes below the injury 3. Spontaneous respirations 4. Urinary continence

2. The return of reflexes and spasticity are signs of resolving shock. Spinal or neurogenic shock is characterized by hypotension, bradycardia, dry skin, flaccid paralysis, or the absence of reflexes below the level of injury. The absence of pain sensation in the chest doesn't apply to spinal shock. Spinal shock descends from the injury, and respiratory difficulties occur at C4 and above. Slight muscle contraction at the bulbocavernosus reflex occurs but not enough for urinary continence.

One hour after receiving pyridostigmine bromide (Mestinon), a client reports difficulty swallowing and excessive respiratory secretions. The nurse notifies the physician and prepares to administer which medication? 1. Additional pyridostigmine bromide (Mestinon) 2. Atropine 3. Edrophonium (Tensilon) 4. Acyclovir (Zovirax)

2. These symptoms suggest cholinergic crisis or excessive acetylcholinesterase medication, typically appearing 45 to 60 minutes after the last dose of acetylcholinesterase inhibitor. Atropine, an anticholinergic drug, is used to antagonize acetylcholinesterase inhibitors. The other drugs are acetylcholinesterase inhibitors. Edrophonium is used for the diagnosis and pyridostigmine bromide is used for the treatment of myasthenia gravis and would worsen these symptoms. Acyclovir is an antiviral and would not be used to treat these symptoms.

23. A client's intracranial pressure (ICP) is fluctuating between 20 and 25 mm Hg. Which of the following nursing interventions is the most appropriate? 1. Ensure that the mean arterial pressure (MAP) is less than 90 mm Hg. 2. Lower the head of the bed to less than 15 degrees. 3. Encourage visitation. 4. Reassess the client's ABCs (airway, breathing, and circulation).

23. 4. The nurse should always reassess the client's ABCs when the ICP is elevated (normal is between 0 and 15 mm Hg). MAP should be maintained at or above 90 mm Hg. The head of the bed should be elevated between 15 and 30 degrees to facilitate venous drainage. External stimulation, such as visitors, should be limited as it may increase ICP. CN: Physiological integrity; CNS: Physiological adaptation;

When assessing a client with a spinal injury at C6, the nurse would expect the highest level of functioning to include which of the following? 1. Significant loss of function at the biceps and shoulders 2. Potential loss of function at the shoulders and biceps and complete loss of function at the wrists and hands 3. Limited wrist control and complete loss of hand function 4. Lack of dexterity in the hands and fingers but allows for limited use of arms

3. A lesion at C6 will result in limited wrist control and complete loss of hand function. Significant loss of function of the biceps and shoulder occurs with C4, with potential loss of function at the shoulder and biceps occurring at C5. An injury at C7 and T1 results in dexterity in the hands and finger but allows for limited use of arms

A child is admitted to the emergency department with a recent head injury. In educating the client and family, the nurse discusses concerns regarding the lucid period. This is best described as: 1. an interval when the client's speech is garbled. 2. an interval when the client is alert but can't recall recent events. 3. an interval when the client is oriented but then becomes somnolent. 4. an interval when the client has a "warning" symptom, such as an odor or visual disturbance.

3. A lucid interval is described as a brief period of unconsciousness followed by alertness; after several hours, the client again loses consciousness. This is most common with an epidural hematoma. Therefore, clients should be closely monitored and swift action taken (such as surgical evacuation of the hematoma) if the client deteriorates. Garbled speech is known as dysarthria. An interval in which the client is alert but can't recall recent events is known as amnesia. Warning symptoms or auras typically occur before seizures. CN: Physiological integrity;

64. A 30-year-old client is admitted to the progressive care unit with a C5 fracture from a motorcycle collision. Which assessment would take priority? 1. Bladder distention 2. Neurological deficit 3. Pulse oximetry readings 4. The client's feelings about the injury

3. After a spinal cord injury, ascending cord edema may cause a higher level of injury. The diaphragm is innervated at the level of C4, so assessment of adequate oxygenation and ventilation is necessary. Although the other options are important, observation for respiratory failure is the priority.

61. A client comes to the emergency department after hitting his head in a motor vehicle collision. He's alert and oriented. Which nursing intervention should be done first? 1. Assess full range of motion (ROM) to determine the extent of injuries. 2. Call for an immediate chest X-ray. 3. Immobilize the client's head and neck. 4. Open the airway with the head-tilt, chin-lift maneuver.

3. All clients with a head injury are treated as if a cervical spine injury is present until X-rays confirm their absence. ROM would be contraindicated at this time. There is no indication the client needs a chest X-ray. The airway doesn't need to be opened since the client appears alert and not in respiratory distress. The head-tilt, chin-lift maneuver wouldn't be used until cervical spine injury is ruled out.

A nurse is discussing the purpose of an EEG with the family of a client with massive cerebral hemorrhage and loss of consciousness. Which of the following responses by the nurse would be the most accurate in describing what the test measures? 1. Extent of intracranial bleeding 2. Sites of brain injury 3. Activity of the brain 4. Percentage of functional brain tissue

3. An EEG measures the electrical activity of the brain. Extent of intracranial bleeding and location of the injury site would be determined by computerized tomography or magnetic resonance imaging. Percentage of functional brain tissue would be determined by a series of tests.

A client arrives at the emergency department after slipping on a patch of ice and hitting his head. A computed tomography scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest? 1. Subdural hematoma 2. Subarachnoid hemorrhage 3. Epidural hematoma 4. Contusion

3. An epidural hematoma occurs when blood collects between the skull and dura mater. In a subdural hematoma, venous blood collects between the dura mater and arachnoid mater. In a subarachnoid hemorrhage, blood collects between the pia mater and arachnoid membrane. A contusion is a bruise on the brain's surface.

A client was admitted to the hospital because of a transient ischemic attack secondary to atrial fibrillation. The nurse anticipates the physician will prescribe which medication? 1. Digoxin (Lanoxin) 2. Diltiazem (Cardizem) 3. Warfarin (Coumadin) 4. Quinidine gluconate

3. Atrial fibrillation may lead to the formation of mural thrombi, which may embolize to the brain. Coumadin will prevent further clot formation and prevent clot enlargement. The other drugs are used in the treatment and control of atrial fibrillation but won't affect clot formation.

92. Which client on the rehabilitation unit is most likely to develop autonomic dysreflexia? 1. A client with brain injury 2. A client with herniated nucleus pulposus 3. A client with a high cervical spine injury 4. A client with a stroke

3. Autonomic dysreflexia refers to uninhibited sympathetic outflow in clients with spinal cord injuries most commonly above the level of T6. Autonomic dysreflexia is characterized by severe paroxysmal hypertension associated with throbbing headaches, profuse sweating, nasal stuffiness, flushing of the skin above the level of the lesion, bradycardia, apprehension, and anxiety, which is sometimes accompanied by cognitive impairment. The other clients aren't prone to dysreflexia.

An 18-year-old client was hit in the head with a baseball during practice. When discharging him to the care of his mother, the nurse gives which instruction? 1. "Watch him for keyhole pupil for the next 24 hours." 2. "Expect profuse vomiting for 24 hours after the injury." 3. "Wake him every hour and assess his orientation to person, time, and place." 4. "Notify the physician immediately if he has a headache." 397

3. Changes in level of consciousness (LOC) may indicate expanding lesions such as subdural hematoma; orientation and LOC are assessed frequently for 24 hours. A keyhole pupil is found after iridectomy. Profuse or projectile vomiting is a symptom of increased intracranial pressure and should be reported immediately. A slight headache may last for several days after concussion; severe or worsening headaches should be reported.

A client with a right stroke has a flaccid left side. Which intervention would best prevent shoulder subluxation? 1. Splint the wrist. 2. Use an air splint. 3. Put the affected arm in a sling. 4. Perform range-of-motion exercises on the affected side.

3. Due to the weight of the flaccid extremity, the shoulder may disarticulate. A sling will support the extremity. The other options won't support the shoulder. Air splints are used to support fractured or broken bones.

142. An 87-year-old client is admitted with a stroke. During the admission interview and assessment, his speech is slow, nonfluent, and labored. How should the nurse document this finding? 1. Receptive aphasia 2. Wernicke's aphasia 3. Expressive aphasia 4. Global aphasia

3. Expressive (Broca's) aphasia results from damage to Broca's area, located in the frontal lobe of the brain's dominant hemisphere. Typically, the client with expressive aphasia has difficulty expressing himself and his speech is slow, nonfluent, and labored; however, comprehension of written and verbal communication is intact. With receptive (Wernicke's) aphasia (which results from injury to Wernicke's area, located in the temporal lobe of the dominant hemisphere), the client can't comprehend written or verbal communication; his speech is normal, but he conveys information poorly. With global aphasia—a combination of receptive and expressive aphasia—most of the brain's communication system is damaged. Global aphasia results from extensive damage to Broca's and Wernicke's areas.

A 20-year-old client who fell approximately 31 feet (9 m) is unresponsive and breathless. A cervical spine injury is suspected. How should the first responder open the client's airway for rescue breathing? 1. By inserting a nasopharyngeal airway 2. By inserting an oropharyngeal airway 3. By performing the jaw-thrust maneuver 4. By performing the head-tilt, chin-lift maneuver

3. If the client has a suspected cervical spine injury, the jaw-thrust maneuver should be used to open the airway. If the tongue or relaxed throat muscles are obstructing the airway, a nasopharyngeal or oropharyngeal airway can be inserted; however, the client must have spontaneous respirations when the airway is open. The head-tilt, chin-lift maneuver requires neck hyperextension, which can worsen a cervical spine injury.

An 86-year-old client with a stroke in evolution and a history of coronary artery disease is brought to the medical-surgical floor. His medications include isosorbide (Isordil). Which condition is a concern? 1. Dehydration 2. Hypocarbia 3. Hypotension 4. Tube feeding

3. Isosorbide is a potent vasodilator and can cause hypotension, which reduces brain perfusion and should be avoided in acute stroke. Treatment for an acute stroke and stroke in evolution includes permissive hypertension. Dehydration would be inappropriate in this instance. Hypocarbia is intermittently used in the emergent reduction of intracranial pressure through cerebral vasoconstriction. Nutrition may be delivered by tube when dysphagia exists.

A client with a T1 spinal cord injury arrives at the emergency department with a blood pressure of 82/40 mm Hg, pulse of 34 beats/minute, dry skin, and flaccid paralysis of the lower extremities. Which condition should be suspected? 1. Autonomic dysreflexia 2. Hypervolemia 3. Neurogenic shock 4. Sepsis

3. Loss of sympathetic control and unopposed vagal stimulation below the level of the injury typically cause hypotension, bradycardia, pallor, flaccid paralysis, and warm, dry skin in the client in neurogenic shock. Hypervolemia is indicated by a rapid and bounding pulse and edema. Autonomic dysreflexia occurs after neurogenic shock abates. Signs of sepsis would include elevated temperature, increased heart rate, and increased respiratory

A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which reason? 1. To reduce intraocular pressure 2. To prevent acute tubular necrosis 3. To promote osmotic diuresis to decrease intracranial pressure (ICP) 4. To draw water into the vascular system to increase blood pressure

3. Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. Although mannitol is used for all the reasons described, the reduction of ICP in this client is of greatest concern.

A 19-year-old client with a mild concussion is discharged from the emergency department. Before discharge, he complains of a headache. When offered acetaminophen, his mother tells the nurse she would like her son to have something stronger. The most appropriate response by the nurse is: 1. "Your son had a mild concussion; acetaminophen is strong enough." 2. "Aspirin is avoided because of the danger of Reye's syndrome in children or young adults." 3. "Opioids are avoided after a head injury because they may hide a worsening condition." 4. "Stronger medications may lead to vomiting, which increases the intracranial pressure (ICP).

3. Opioids may mask changes in the level of consciousness (LOC) that indicate increased ICP and shouldn't be given as a first-line drug. Saying acetaminophen is strong enough ignores the mother's question and therefore isn't appropriate. Aspirin is contraindicated in conditions that may have 333 bleeding, such as trauma, and for children or young adults with viral illnesses due to the danger of Reye's syndrome. Stronger medications may not necessarily lead to vomiting but will sedate the client, thereby masking changes in his LOC.

123. When giving I.V. phenytoin (Dilantin), which method should be used? 1. Administering rapidly 2. Withholding other anticonvulsants 3. Mixing the drug with saline solution only 4. Flushing the I.V. catheter with dextrose solution

3. Phenytoin is compatible only with saline solutions; dextrose causes an insoluble precipitate to form. Phenytoin should be administered slowly (50 mg/minute). There's no need to withhold additional anticonvulsants.

A client has just begun exhibiting signs of myasthenia gravis. The nurse anticipates assessment of the client to include: 1. dysphagia. 2. fatigue improving at the end of the day. 3. ptosis. 4. respiratory distress.

3. Ptosis and diplopia are early signs of myasthenia gravis; dysphagia and respiratory distress occur later. Symptoms are typically milder in the morning and may be exacerbated by stress or lack of rest.

A client is admitted with a newly acquired spinal cord injury at the level of T12. He has limited movement of his upper extremities. The nurse anticipates the physician may prescribe which medication? 1. Acetazolamide (Diamox) 2. Furosemide (Lasix) 3. Methylprednisolone (Solu-Medrol) 4. Sodium bicarbonate

3. Spinal cord injuries below T12 do not affect the upper extremities, unless edema of the spinal cord is present. High doses of methylprednisolone are used within 8 hours of spinal cord injury to reduce cord swelling and limit neurological deficit. The other drugs aren't indicated in this circumstance. Acetazolamide and furosemide are both diuretics

25. A client who has undergone a lumbar laminectomy is experiencing frequent voiding of small amounts of urine. The nurse suspects the client may have developed which condition? 1. Diabetes insipidus 2. Diabetic ketoacidosis 3. Urine retention 4. Urinary tract infection (UTI)

3. Swelling or pressure on the peripheral nerves controlling micturition, anesthesia, or use of an indwelling urinary catheter may lead to urine retention with frequent overflow of small amounts of urine. Diabetes insipidus and diabetic ketoacidosis are shown by polyuria. UTI may be shown by dysuria and frequent voiding of small amounts of urine but would be less likely in this situation

While in the emergency department, a client with C8 quadriplegia develops a blood pressure of 80/44 mm Hg, pulse of 48 beats/minute, and respiratory rate of 18 breaths/minute. The nurse suspects which condition? 1. Autonomic dysreflexia 2. Hemorrhagic shock 3. Neurogenic shock 4. Pulmonary embolism

3. Symptoms of neurogenic shock include hypotension, bradycardia, and warm, dry skin due to loss of adrenergic stimulation below the level of the lesion. Hypertension, bradycardia, flushing, and sweating of the skin are seen with autonomic dysreflexia. Hemorrhagic shock presents with anxiety, tachycardia, and hypotension; this wouldn't be suspected without an injury. Pulmonary embolism presents with chest pain, hypotension, hypoxemia, tachycardia, and hemoptysis; this may be a later complication of spinal cord injury due to immobility.

A nurse is preparing a client with suspected lumbar herniated nucleus pulposus for magnetic resonance imaging (MRI). The most important action by the nurse would be? 1. Question the client about allergy to iodine. 2. Mark distal pulses on the foot in indelible ink. 3. Teach the client relaxation techniques. 4. Tell the client he may be asked to cough or pant to clear the dye.

3. The MRI scanner is a narrow tube that contains a magnet. The client lies on a platform and is placed in the tube. Some clients may become claustrophobic during the test; teaching relaxation techniques may help to alleviate this. Radiopaque dyes, used in myelography and cardiac catheterization, are usually iodine based and may cause a reaction in those clients who are allergic. No dyes are used in MRI. During cardiac catheterization, a client is asked to cough or pant to clear the dye, and before cardiac catheterization or arteriogram, the nurse marks pedal pulses in ink.

85. Which sign or symptom of increased intracranial pressure (ICP) after head trauma would appear first? 1. Bradycardia 2. Large amounts of very dilute urine 3. Restlessness and confusion 4. Widened pulse pressure

3. The earliest symptom of increased ICP is a change in mental status. Bradycardia, widened pulse pressure, and bradypnea occur later. The client may void large amounts of very dilute urine if there's damage to the posterior pituitary.

A client with paraplegia from a T10 injury is getting ready to transfer to a rehabilitation hospital. When the nurse offers to assist him, the client throws his suitcase on the floor and says, "You don't want to help me." What is the most appropriate response by the nurse? 1. "You know I want to help you. I offered." 2. "I'll pick these things up for you and come back later." 3. "You seem angry today. Going to rehab may be scary." 4. "When you get to rehab, they won't let you behave like this."

3. The nurse should always focus on the feelings underlying a particular action. Options 1 and 4 are confrontational. Offering to pick up the client's belongings doesn't deal with the situation and assumes he can't do it alone.

A client with a halo vest is being discharged from the hospital. What is the most important information for the nurse to give the client and family? 1. "Don't use the wheelchair while the halo vest is in place." 2. "Clean the pin sites with peroxide." 3. "Keep the wrench that opens the vest attached to the client at all times." 4. "Perform range-of-motion (ROM) exercises to the neck and shoulders four times daily."

3. The wrench must be attached at all times to remove the vest in case the client needs cardiopulmonary resuscitation. The vest is designed to improve mobility; the client may use a wheelchair. Peroxide, especially full strength, can disrupt the healing process and normal flora. The purpose of the vest is to immobilize the neck; ROM exercises to the neck are prohibited but should be performed to other areas.

A nurse performs a neurological assessment on a client complaining of headache and dizziness. Which assessment technique helps assess the motor function of cranial nerve VII (facial nerve)? 1. Asking the client to clench his jaw 2. Testing the gag reflex by placing an applicator against the pharynx 3. Asking the client to frown, smile,

3. To assess the motor function of cranial nerve VII, the nurse should ask the client to frown, smile, and raise his eyebrows. If these facial expressions are symmetrical, motor function is intact. Jaw clenching is a test for cranial nerve V function. Testing the gag reflex by placing an applicator against the pharynx, and assessing swallowing ability are ways to evaluate cranial nerve IX function. Testing the gag reflex also helps assess cranial nerve X function.

59. When assessing vital signs in a client with a seizure disorder, which measure is used? 1. Checking for a pulse deficit 2. Checking for pulsus paradoxus 3. Taking axillary instead of oral temperatures 4. Checking the blood pressure for an auscultator

3. To reduce the risk of injury, the nurse should take an axillary temperature or use a non glass thermometer when taking an oral temperature to prevent injury if a seizure occurs. Pulse deficit occurs in an arrhythmia. Pulsus paradoxus may occur with cardiac tamponade. An auscultatory gap occurs in hypertension.

Which condition is the leading risk factor for hemorrhagic stroke? 1. Coronary artery disease 2. Diabetes 3. Hypertension 4. Recent viral infection

3. Uncontrolled hypertension is the major cause of hemorrhagic stroke. Nurses need to address secondary prevention of stroke by educating clients and their families about blood pressure control. Both diabetes and heart disease increase the probability of stroke by hastening atherosclerosis but are lesser risk factors compared to hypertension. A recent viral infection is not directly linked to this problem.

A nurse would use which of the following instruments in recording intraocular pressure? 1. Goniometer 2. Ophthalmoscope 3. Slit lamp 4. Tonometer

4. A tonometer is a device used in glaucoma screening to record intraocular pressure. A goniometer measures joint movement and angles. An ophthalmoscope examines the interior of the eye, especially the retina. A slit lamp evaluates structures in the anterior chamber of the eye.

A nurse is developing a discharge teaching plan for a client who has been prescribed phenytoin (Dilantin). Which instruction should the plan include? 1. "Take the drug on an empty stomach." 2. "You can consume alcoholic beverages in moderation." 3. "You can take any phenytoin brand because all brands are the same." 4. "Don't stop taking the drug except with medical supervision."

4. Abrupt phenytoin withdrawal may trigger status epilepticus, so the client should be warned not to stop taking the drug unless the physician approves. Taking phenytoin with food minimizes GI distress. Alcoholic beverages can decrease the drug's effectiveness. Changing phenytoin brands may alter the therapeutic effect.

107. Which method should be used to assess pupil accommodation? 1. Assessing for peripheral vision 2. Touching the cornea lightly with a wisp of cotton 3. Having the client follow an object upward, downward, obliquely, and horizontally 4. Observing for pupil constriction and convergence while focusing on an object coming toward the client

4. Accommodation refers to convergence and constriction of the pupil while following a near object. Assessing for peripheral vision refers to visual fields. Touching the cornea lightly with a wisp of cotton describes assessment of the corneal reflex. Having the client follow an object upward, downward, obliquely, and horizontally refers to cardinal fields of gaze.

22. The nurse is preparing to administer vasopressin to a client who has undergone a hypophysectomy. What is the purpose of the medication? 1. To treat growth failure 2. To prevent syndrome of inappropriate antidiuretic hormone (SIADH) 3. To reduce cerebral edema and lower intracranial pressure 4. To replace antidiuretic hormone (ADH) normally secreted from the pituitary

4. After hypophysectomy, or removal of the pituitary gland, the body can't synthesize ADH. Somatropin or growth hormone, not vasopressin, is used to treat growth failure. SIADH results from excessive ADH secretion.

58. A client asks the nurse if he can drink alcohol while taking phenytoin. What is the best response by the nurse? 1. Alcohol increases phenytoin activity. 2. Alcohol raises the seizure threshold. 3. Alcohol impairs judgment and coordination. 4. Alcohol decreases the effectiveness of phenytoin.

4. Alcohol decreases phenytoin activity, diminishing its effectiveness. Although alcohol also reduces the seizure threshold and impairs judgment and coordination, these effects aren't the primary concern.

A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 mm Hg and heart rate of 50 beats/minute. Which nursing intervention should be done first? 1. Place the client flat in bed. 2. Assess patency of the indwelling urinary catheter. 3. Give one sublingual nitroglycerin tablet. 4. Raise the head of the bed immediately to 90 degrees.

4. Anxiety, flushing above the level of the lesion, piloerection, hypertension, and bradycardia are symptoms of autonomic dysreflexia, typically caused by such noxious stimuli as a full bladder, fecal impaction, or pressure ulcer. Putting the client flat will cause the blood pressure to increase more. The indwelling urinary catheter should be assessed immediately after the head of the bed is raised. Nitroglycerin is given to relieve chest pain and reduce preload; it isn't used for hypertension or dysreflexia.

When caring for a client with quadriplegia, which nursing intervention takes priority? 1. Forcing fluids to prevent renal calculi 2. Maintaining skin integrity 3. Obtaining adaptive devices for more independence 4. Preventing atelectasis

4. Clients with quadriplegia have paralysis or weakness of the diaphragm, abdominal, or intercostal muscles. Maintenance of airway and breathing take top priority. Although forcing fluids, maintaining skin integrity, and obtaining adaptive devices for more independence are all important interventions, preventing atelectasis has more priority.

In assessing a client with a spinal cord injury, the nurse reports that the client can't control his abdominal muscles and is a paraplegic. The spinal cord lesion is most likely at which level? 1. Cervical 2. Lumbar 3. Sacral 4. Thoracic

4. Complete injuries at or below the thoracic spinal levels (T1-T8) result in paraplegia and the inability to control the abdominal muscles. Accordingly, trunk stability is affected. Functions of the hands, arms, neck, and breathing are associated with cervical injuries. The effects of injuries to the lumbar or sacral regions of the spinal cord are decreased control of the legs and hips, urinary system, and anus

106. A 40-year-old paraplegic client must perform intermittent catheterization of the bladder. Which instruction should be given? 1. "Clean the meatus from back to front." 2. "Measure the quantity of urine." 3. "Gently rotate the catheter during removal." 4. "Clean the meatus with soap and water."

4. Intermittent catheterization may be performed chronically with clean technique, using soap and water to clean the urinary meatus. The meatus is always cleaned from front to back in a woman, or in expanding circles working outward from the meatus in a man. It isn't necessary to measure the urine. The catheter doesn't need to be rotated during removal. CN: Physiological integrity; CNS: Basic care and comfort; CL: Application

When discharging a client from the hospital after a laminectomy, the nurse recognizes that the client needs further teaching when he makes which statement? 1. "I'll sleep on a firm mattress." 2. "I won't drive for 2 to 4 weeks." 3. "When I pick things up, I'll bend my knees." 4. "I can't wait to pick up my 1-year-old granddaughter."

4. Lifting more than 10 lb (4.5 kg) for several weeks after surgery is contraindicated. The other responses are appropriate. CN: Physiological integrity; CNS: Reduction of risk potential; CL:

A client is newly diagnosed with myasthenia gravis. The nurse is teaching the client about the cause of this disease. The nurse determines that teaching has been effective when the client states: 1. a postviral illness characterized by ascending paralysis. 2. loss of the myelin sheath surrounding peripheral nerves. 3. inability of basal ganglia to produce sufficient dopamine. 4. destruction of acetylcholine receptors causing muscle weakness.

4. Myasthenia gravis, an autoimmune disorder, is caused by the destruction of acetylcholine receptors. Guillain-Barré syndrome is a postviral illness characterized by ascending paralysis, multiple sclerosis is caused by loss of the myelin sheath, and Parkinson's disease is caused by the inability of basal ganglia to produce sufficient dopamine. CN: Health promotion and maintenance; CNS: None;

96. A nurse assesses a client who has episodes of autonomic dysreflexia. Which condition can cause autonomic dysreflexia? 1. Headache 2. Lumbar spinal cord injury 3. Neurogenic shock 4. Noxious stimuli

4. Noxious stimuli, such as a full bladder, fecal impaction, or a decubitus ulcer, may cause autonomic dysreflexia. A headache is a symptom of autonomic dysreflexia, not a cause. Autonomic dysreflexia is most commonly seen with injuries at T6 or above. Neurogenic shock isn't a cause of dysreflexia.

A client is experiencing an episode of autonomic dysreflexia and becomes hypertensive. The most important intervention by the nurse would be? 1. Elevate the client's legs. 2. Put the client flat in bed. 3. Put the bed in Trendelenburg's position. 4. Put the client in high Fowler's position.

4. Putting the client in high Fowler's position can help reduce blood pressure below dangerous levels until other treatment can be started (e.g., removing or treating the stimulus and administration of antihypertensives). Elevating the client's legs, putting the client flat in bed, or putting the bed in Trendelenburg's position places the client in positions that can increase blood pressure.

62. A client is admitted with a C6 spinal injury. The nurse anticipates the client most likely has which condition? 1. Aphasia 2. Hemiparesis 3. Paraplegia 4. Quadriplegia

4. Quadriplegia occurs as a result of cervical spine injuries. Aphasia refers to difficulty expressing or understanding spoken words and is caused by injury to the Broca and or Wernicke areas of the brain. Hemiparesis describes weakness of one side of the body. Paraplegia occurs as a result of injury to the thoracic cord and below.

A client has a cervical spine injury at the level of C5. Which condition should the nurse anticipate during the acute phase? 1. Absent corneal reflex 2. Decerebrate posturing 3. Movement of only the right or left half of the body 4. The need for mechanical ventilation

4. The diaphragm is stimulated by nerves at the level of C4. Initially, this client may need mechanical ventilation due to cord edema. This may resolve in time. Absent corneal reflexes, decerebrate posturing, and hemiplegia occur with brain injuries, not spinal cord injuries.

When assessing a client with herniated nucleus pulposus of L4-L5, the nurse should expect to find which sign or symptom of spinal cord compression? 1. Lower back pain 2. Pain radiating across the buttocks 3. Positive Kernig's sign 4. Urinary incontinence

95. 4. Progressive neurological deficits at L4-L5, including worsening muscle weakness, paresthesia, and loss of bowel and bladder control, are symptoms of spinal cord compression. The other symptoms usually occur in clients with herniated nucleus pulposus without spinal cord compression. Kernig's sign is a symptom of meningitis and is characterized by severe stiffness of the hamstrings causing an inability to straighten the leg when the hip is flexed to 90 degrees.