FINAL: Neuro

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79. The nurse researcher is working with clients diagnosed with Parkinson's disease. Which is an example of an experimental therapy? 1. Sterotactic pallidotomy/thalamotomy. 2. Dopamine receptor agonist medication. 3. Physical therapy for muscle strengthening. 4. Fetal tissue transplantation.

4. Fetal tissue transplantation has shown some success in PD, but it is an experimental and highly controversial procedure.

78. The nurse is planning the care for a client diagnosed with Parkinson's disease. Which would be a therapeutic goal of treatment for the disease process? 1. The client will experience periods of akinesia throughout the day. 2. The client will take the prescribed medications correctly. 3. The client will be able to enjoy a family outing with the spouse. 4. The client will be able to carry out activities of daily living.

4. The major goal of treating PD is to maintain the ability to function. Clients diagnosed with PD experience slow, jerky movements and have difficulty performing routine daily tasks.

A client asks the nurse what might trigger a seizure. Which situation should the nurse include in the response? A.Exposure to toxins B.Decreased intracranial pressure C.Low body temperature D.Low blood pressure

A patient has been started on lamotrigine (Lamictal). How does the nurse instruct this patient to take the medication to decrease the incidence of gastric irritation? A. With milk or food B. Between meals with a glass of orange juice C. At bedtime D. One hour before meals or 2 hours after meals

Medication has been ineffective in controlling a client's seizures. Which treatment option should the nurse suspect will be discussed with the client? A.Surgical resection B.Herbal remedies C.More sleep D.Head massage

The nurse is caring for a client with a seizure disorder currently controlled with antiseizure medication. The client states, "A friend recommended an herbal supplement for my depression. Can I take it?" Which response by the nurse is correct? A."St. John's wort has been known to decrease the effectiveness of your antiseizure medication." B."You can take valerian along with your antiseizure medication to help you sleep." C."You should avoid garlic, because it can decrease the effectiveness of your antiseizure medication." D."Essential oils would be a better option with your antiseizure medication."

The nurse should question the use of barbiturates for the treatment of seizure activity if prescribed for which of the following clients? A. 30-year-old pregnant female B. 24-year-old male with new diagnosis of seizures C. 55-year-old female with history of diabetes mellitus D. 45-year-old male with history of hypertension

The nurse witnesses a patient with a seizure disorder as the patient suddenly jerks the arms and legs, falls to the floor, and regains consciousness immediately. It will be most important for the nurse to a. assess the patient for a possible head injury. b. give the scheduled dose of divalproex (Depakote). c. document the timing and description of the seizure. d. notify the patient's health care provider about the seizure.

The patient with type 1 diabetes mellitus with hypoglycemia is having a seizure. Which medication should the nurse anticipate administering to stop the seizure? A. IV dextrose solution B. IV diazepam (Valium) C. IV phenytoin (Dilantin) D. Oral carbamazepine (Tegretol)

Which action will the nurse take when evaluating a patient who is taking phenytoin (Dilantin) for adverse effects of the medication? a. Inspect the oral mucosa. b. Listen to the lung sounds. c. Auscultate the bowel tones. d. Check pupil reaction to light.

Which antiepileptic drug is effective for almost all forms of seizures? A. Valproic acid (Depakene) B. Carbamazepine (Tegretol) C. Phenobarbital (Luminal) D. Phenytoin (Dilantin)

You recognize that status epilepticus is a medical emergency because A. seizures continue without a return of consciousness. B. fractures of a limb may occur. C. urinary fecal incontinence may occur. D. heart rate becomes bradycardic.

a nurse is caring for a client who just experienced a generalized seizure. which of the following actions should the nurse perform first? A.keep the client in a side lying position B.document the duration of the seizure C.reorient the client to the environment D.provide client hygiene

Toy with a tentative diagnosis of myasthenia gravis is admitted for diagnostic make up. Myasthenia gravis can confirmed by: A.Brudzinski's sign B. A positive edrophonium (Tensilon) test C. A positive sweat chloride test D. Kernigs sign

A positive edrophonium (Tensilon) test

The terminally ill client diagnosed with ALS has a DNR order in place and is currently complaining of "pain all over." The nurse notes the client has shallow breathing and a P 67, R 8, B/P 104/62. Which intervention should the nurse implement? A. Administer the narcotic pain medication IVP. B. Turn and reposition the client for comfort. C. Refuse to administer pain medication. D . Notify the HCP of the client's vital signs.

A. A) The nurse should administer the IVP narcotic pain medication even if the client has shallow breathing, with respirations of 8. A nurse should never administer a medication with the intent of hastening the client's death, but medicating a dying client to achieve a peaceful death is an appropriate intervention B) Repositioning the client would not be effective for "pain all over." C) This is cruel to do to a client who is dying and has made himself or herself a DNR D) The HCP has all the orders needed in place. There is no reason to notify the HCP.

A client has meningitis following brain surgery. What comfort measures may the nurse delegate to the unlicensed assistive personnel (UAP)? (select all that apply) A. Applying a cool washcloth to the head B. Assisting the client to a position of comfort C. Keeping voices soft and soothing D. Maintaining low lighting in the room E. providing antipyretics for fever

A. Applying a cool washcloth to the head B. Assisting the client to a position of comfort C. Keeping voices soft and soothing D. Maintaining low lighting in the room Rationale: The client with meningitis often has high fever, pain, and some degree of confusion. Cool washcloths to the forehead are comforting and help with pain. Allowing the client to assume a position of comfort also helps manage pain. Keeping voices low and lights dimmed also helps convey caring in a nonthreatening manner. The nurse provides antipyretics for fever.

A nurse is caring for a client who has myasthenia gravis and has developed drooping eyelids. Which of the following actions should the nurse take? Select all that apply. A. Apply lubricating eyedrops B. Encourage use of sunglasses C. Support the head with pillows D. Tape eyes closed at night E. Provide for periods of rest during the day

A. D. A) Lubrication decreases corneal dryness and irritation, caused by weakness of eyelids B) Sunglass does not prevent corneal dryness and irritation C) Providing head support does not correct drooping eyelids caused by muscle weakness D) Taping eye lids at night prevents corneal dryness and irritation E) Promoting rest does not reduce eyelid drooping in the patient who has MG

The diagnostic work-up of a client hospitalized with complaints of progressive weakness and fatigue confirms a diagnosis of myasthenia gravis. The medication used to treat myasthenia gravis is: A. Prostigmine (neostigmine) B. Atropine (atropine sulfate) C. Didronel (etidronate) D. Tensilon (edrophonium)

A. Prostigmine (neostigmine) Protigmine is used to treat clients with myasthenia gravis. Atropine (atropine sulfate) is incorrect because it is used to reverse the effects of neostigmine. Didronel (etidronate)is incorrect because the drug is unrelated to the treatment of myasthenia gravis. Tensilon (edrophonium) is incorrect because it is the test for myasthenia gravis.

The nurse should observe a client with bacterial meningitis for A. Sensory deficits B. High blood pressure C. Hypothermia D. Muscle spasms

A. Sensory Deficits Rationale: Other general manifestations related to infection are also present, such as fever, tachycardia, headache, prostration, chills, fever, nausea, and vomiting. The client may be irritable at first, but as the infection progresses, the sensorium often becomes clouded, and coma may develop.

In making a diagnosis of myasthenia gravis Edrophonium HCI (Tensilon) is used. The nurse knows that this drug will cause a temporary increase in: A.Muscle strength B.Symptoms C.Blood pressure D.Consciousness

A.Muscle strength Tensilon, an anticholinesterase drug, causes temporary relief of symptoms of myasthenia gravis in client who have the disease and is therefore an effective diagnostic aid.

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

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

a nurse is reviewing trigger factos that can cause seizures with a client who has na new diagnosis of generalized seizures. which of the following information should the nurse include in this review? (select all that apply) A. avoid overwhelming fatigue B. remove caffeinated products from the diet C. limit looking at flashing lights D. perform aerobic exercise E. limit episodes of hypoventilation F. use of aerosol hairspray is recommended

ABC

a nurse is assessing a client who has seizure disorder. the client reports he thinks he is out to have a seizure. which of the following actions should the nurse implement (select all that apply) A. provide privacy B. ease the client to the floor if standing C. move furniture away from the client D. loosen the clients clothing E. protect the clients head with padding F. restrain the client

ABCDE

A 50-year-old client with a newly diagnosed seizure disorder is depressed because they are not allowed to drive and have lost their independence. Which question should the nurse ask to support the client? (Select all that apply.) A."What does being able to drive mean to you?" B."How is not being able to drive affecting you?" C."Who is supporting you during this transition?" D."Do you have someone who can drive you to appointments?" E."What kind of alternate transportation are you using?"

ABCE

The nurse is teaching a client about possible seizure triggers. Which information should the nurse include? (Select all that apply.) A.Specific odors B.Flashing lights C.Menstruation D.Lactose consumption E.Fever

ABCE

The nurse is planning discharge teaching for a 30-year-old female client who was newly diagnosed with tonic-clonic seizures. Which information should the nurse include in this teaching plan? (Select all that apply.) A.Wearing a bracelet that provides health information B.Avoiding driving while taking antiseizure medication C.Keeping a padded tongue blade at home in case of a seizure D.Taking showers rather than tub baths E.Monitoring the menstrual cycle

ABDE

the nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. which measures should the nurse include in planning care for the client's safety? Select all that apply A. padding the side rails of the bed B. placing an airway at the bedside C. placing the bed in the high position D. putting a padded tongue blade at the head of the bed E. placing oxygen and suction equipment at the bed side F. having intravenous equipment ready for insertion of an intravenous catheter

ABEF

The nurse is admitting a client with a history of frequent tonic-clonic seizures. Which information would be most valuable for the nurse to obtain when performing the health history assessment? (Select all that apply.) A.Presence of auras B.Incontinence during seizure C.Triggers for seizures D.Age of seizure onset E.Duration of seizures

ACD

When preparing to admit a patient who has been treated for status epilepticus in the emergency department, which equipment should the nurse have available in the room (select all that apply)? a. Siderail pads b. Tongue blade c. Oxygen mask d. Suction tubing e. Nasogastric tube

ACD

The nurse is administering an oral antiseizure medication to an adult client. Which intervention should the nurse implement when administering this medication? (Select all that apply.) A.Monitoring the client for seizure activity B.Monitoring oxygen levels C.Assessing the client for slurred speech D.Administering antiseizure medication 2 hours after antacids are administered E.Asking the client for a list of home medications

ACE

Which action will the public health nurse take to reduce the incidence of epidemic encephalitis in a community? a. Encourage the use of effective insect repellents during mosquito season. b. Remind patients that most cases of viral encephalitis can be cared for at home. c. Teach about the importance of prophylactic antibiotics after exposure to encephalitis. d. Arrange for screening of school-age children for West Nile virus during the school year.

ANS: A Epidemic encephalitis is usually spread by mosquitoes and ticks. Use of insect repellent is effective in reducing risk. Encephalitis frequently requires that the patient be hospitalized in an intensive care unit during the initial stages. Antibiotic prophylaxis is not used to prevent encephalitis because most encephalitis is viral. West Nile virus is most common in adults over age 50 during the summer and early fall

A 42-year-old patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care? a. Encourage family members to remain at the bedside. b. Apply soft restraints to protect the patient from injury. c. Keep the room well-lighted to improve patient orientation. d. Minimize contact with the patient to decrease sensory input.

ANS: A Patients with meningitis and disorientation will be calmed by the presence of someone familiar at the bedside. Restraints should be avoided because they increase agitation and anxiety. The patient requires frequent assessment for complications. The use of touch and a soothing voice will decrease anxiety for most patients. The patient will have photophobia, so the light should be dim

A patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care? a. Encourage family members to remain at the bedside. b. Apply soft restraints to protect the patient from injury. c. Keep the room well-lighted to improve patient orientation. d. Minimize contact with the patient to decrease sensory input.

ANS: A Patients with meningitis and disorientation will be calmed by the presence of someone familiar at the bedside. Restraints should be avoided because they increase agitation and anxiety. The patient requires frequent assessment for complications; the use of touch and a soothing voice will decrease anxiety for most patients. The patient will have photophobia, so the light should be dim. DIF: Cognitive Level: Application REF: 1453-1455

A patient admitted with bacterial meningitis and a temperature of 102° F (38.8° C) has orders for all of these collaborative interventions. Which action should the nurse take first? a. Administer ceftizoxime (Cefizox) 1 g IV. b. Use a cooling blanket to lower temperature. c. Swap the nasopharyngeal mucosa for cultures. d. Give acetaminophen (Tylenol) 650 mg PO.

ANS: C Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics are started. As soon as the cultures are done, the antibiotic should be started. Hypothermia therapy and acetaminophen administration are appropriate but can be started after the other actions are implemented. DIF: Cognitive Level: Application REF: 1440-1441

While caring for a patient who has just been admitted with meningococcal meningitis, the RN observes all of the following. Which one requires action by the RN? a. The bedrails at the head and foot of the bed are both elevated. b. The patient receives a regular diet from the dietary department. c. The nursing assistant goes into the patient's room without a mask. d. The lights in the patient's room are turned off and the blinds are shut.

ANS: C Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions. Because the patient may be confused and weak, bedrails should be elevated at both the food and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an important aspect of care in a patient with meningitis. DIF: Cognitive Level: Application REF: 1453-1455

The community health nurse is developing a program to decrease the incidence of meningitis in adolescents and young adults. Which nursing action is most important? a. Vaccinate 11- and 12-year-old children against Haemophilus influenzae. b. Emphasize the importance of hand washing to prevent spread of infection. c. Immunize adolescents and college freshman against Neisseria meningitides. d. Encourage adolescents and young adults to avoid crowded areas in the winter.

ANS: C The Neisseria meningitides vaccination is recommended for children ages 11 and 12, unvaccinated teens entering high school, and college freshmen. Hand washing may help decrease the spread of bacteria, but it is not as effective as immunization. Vaccination with Haemophilus influenzae is for infants and toddlers. Because adolescents and young adults are in school or the workplace, avoiding crowds is not realistic. DIF: Cognitive Level: Application REF: 1453-1455

A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action? a. The bedrails at the head and foot of the bed are both elevated. b. The patient receives a regular diet from the dietary department. c. The lights in the patient's room are turned off and the blinds are shut. d. Unlicensed assistive personnel enter the patient's room without a mask.

ANS: D Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions. Because the patient may be confused and weak, bedrails should be elevated at both the foot and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an important aspect of care in a patient with meningitis

When assessing a 53-year-old patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider? a. The patient exhibits nuchal rigidity. b. The patient has a positive Kernig's sign. c. The patient's temperature is 101° F (38.3° C). d. The patient's blood pressure is 88/42 mm Hg.

ANS: D Shock is a serious complication of meningitis, and the patient's low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig's sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the hypotension

When assessing a patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider? a. The patient has a positive Kernig's sign. b. The patient complains of having a stiff neck. c. The patient's temperature is 101° F (38.3° C). d. The patient's blood pressure is 86/42 mm Hg.

The client is experiencing a myasthenic crisis. Which of the following is a priority action of the following ordered actions? A) Insert NG tube B) Administer Ativan C) Monitor I&O D) Immediately stop anticholinesterase medications

Answer: A. Inserting the NG tube is the priority because it will help reduce risk for aspiration. The patient experiencing a myasthenic crisis is at a large risk for respiratory failure due to dysphagia and extreme muscle weakness. All priority actions should be focused on respiratory assessment and support. Ativan and any other sedating medication should NEVER be administered. Stopping anticholinesterase medications is associated with a cholinergic crisis. Monitoring I&O is important, but not as important as NG tube

You are teaching your patient diagnosed with myasthenia gravis about treatments. Which of the following statements, if made by the patient indicates the need for further teaching? A) Plasmapheresis is way to reduce symptoms but will need to be done every day B) A thymectomy is a removal of my thymus gland and will show some immediate relieving of my symptoms C) Corticosteroids can be used for short periods of time to help improve my symptoms, but it isn't good for long periods of time D) I need to take my Mestinon four times a day at the same time each day

Answer: B. A thymectomy may help reduce symptoms, but the effects may not be seen for many months after surgery. Plasmapheresis is the removal of antibodies from blood plasma. It must be done daily for a period of time. Corticosteroids are mostly used for short periods of time unless the patient is experiencing ocular complications. Pyridostigmine bromide (Mestinon) is divided into several doses and should be taken at the same time daily.

The patient with myasthenia gravis arrives to the clinic and states that he is experiencing nausea and diarrhea. His blood pressure is 125/85 HR 70 Temp 100.0 R 19 O2 97%. What is the nursing priority? A) Prepare the patient for intubation. He is about to go into a myasthenic crisis. B) Perform teaching on medication side effects C) Assess for signs of infection D) Further assess for other thymectomy complications

Answer: C. Although the GI symptoms is a common side effect of medicaitons, it is important to follow up on the high temperature and assess for sings of infection. An infection can often exacerbate a Myasthenic crisis and should be carefully monitored for. There is no evidence that this person is about to have a myasthenic crisis and intubation should only be done if the patient is experiencing respiratory failure. There is no evidence that this patient has had a thymectomy.

Which of the following would be most likely given as a top nursing diagnosis for a patient experiencing a cholinergic crisis? A) Impaired Gas Exchange B) Acute Fatigue C) Ineffective airway clearance D) Altered mental status

Answer: C. During a cholinergic crisis, secretions are increased and the gag reflex is decreased, putting the patient at risk for a blocked airway. Impaired gas exchange, while has to do with respiratory, is not as appropriate as ineffective airway clearance based on the problems of the crisis. Acute fatigue and altered mental status are not priorities

The nurse is teaching a client about myasthenia gravis. Which statement, if made by the patient indicates the need for further teaching? A) The doctor will take me off of my beta blocker because it could exacerbate my symptoms B) I should report any signs of infection to my PCP C) I can take a ibuprofen to help with pain that may occur with spasms D) I should avoid taking long walks

Answer: C. OTC medication should be avoided as they may worsen MG symptoms. The doctor may stop a beta blocker as they can exacerbate symptoms (unless benefit outweighs the risk). Any signs of infection should be reported as they can exacerbate a myasthenic crisis. Long walks should be avoided due to muscle weakness and fatigue

Your patient has just been diagnosed with myasthenia gravis. Which of the following orders should be questioned? A) Prednisone PO daily B) Eyepatch to be worn every night C) Pyrodostigmine bromide (Mestinon) 4 times daily PO D) Procaine (Novocain) SQ stat to reduce pain in lower limb

Answer: D. Novocain is contraindicated in patients with MG because of its long lasting effects.

The patient with myasthenia gravis is complaining about dealing with muscle weakness. Which of the following could the nurse do for this patient? A) Administer antispasmodic medication B) Teach the patient to do physical exercise for several hours each day to help strengthen muscles C) Teach the patient it is important to avoid all forms of physical activity whenever possible D) Help the patient form a plan to take medications on time

Answer: D. Taking medications at the same time each day will help reduce the exacerbation of muscle weakness. Antispasmodic medications are not indicated for this patient. Exercising for that much time each day will worsen muscle weakness and fatigue and is not feasible. The patient does not need to avoid all forms of physical activity. They need to time out physical activity with peaks of the medication in order to conserve energy.

A client is having a seizure. Which nursing intervention is of immediate importance? A.Administering medication B.Maintaining the airway C.Placing a padded tongue blade in the client's mouth D.Intubating the client

A client reports that they usually have a seizure on the first day of their period. Which response by the nurse is correct? A."Having your period has no relationship to your seizures." B."Menstruation is a common trigger for seizures." C."What makes you think having your period is related?" D."Females who have a lot of menstrual cramps often have seizure activity."

During the postictal period of a seizure, you would expect the patient to A. demonstrate minor jerking and eye fluttering. B. sleep for several hours. C. be incontinent of urine and feces. D. require ventilator assistance.

The client, age 8, is prescribed valproic acid (Depokene) for treatment of a seizure disorder. The nurse should monitor the client closely for: A.Vitamin B deficiency. B. Restlessness and agitation. C. Hyperthermia. D. Respiratory distress

The nurse provides information to the caregiver of a 68-year-old man with epilepsy who has tonic-clonic seizures. Which statement, if made by the caregiver, requires further teaching? A. "It is normal for a person to be sleepy after a seizure." B. "I should call 911 if breathing stops during the seizure." C. "The jerking movements may last for 30 to 40 seconds." D. "Objects should not be placed in the mouth during a seizure."

The patient has been receiving scheduled doses of phenytoin (Dilantin) and begins to experience diplopia. You immediately assess the patient for A. an aura. B. nystagmus or confusion. C. abdominal pain or cramping. D. irregular pulse or palpitations

The patient is seen in the clinic due to an increase in the frequency of seizure activity. In addition to a thorough health history you should draw blood for A. anemia. B. serum drug levels. C. arterial blood gases. D. electrolytes.

When the home health RN is planning care for a patient with a seizure disorder, which nursing action can be delegated to an LPN/LVN? a. Make referrals to appropriate community agencies. b. Place medications in the home medication organizer. c. Teach the patient and family how to manage seizures. d. Assess for use of medications that may precipitate seizures.

the nurse is caring for a client who begins to experience seizure activity while in bed. which action by the nurse is contraindicated? A. loosening restrictive clothing B. restraining the clients limbs C. removing the pillow and raising padded side rails D. positioning the client to the side, if possible, with the head flexed forward

When caring for a patient who has Guillain-Barré syndrome, which assessment data obtained by the nurse will require the most immediate action? a. The patient complains of severe tingling pain in the feet. b. The patient has continuous drooling of saliva. c. The patient's blood pressure (BP) is 106/50 mm Hg. d. The patient's quadriceps and triceps reflexes are absent.

B. A) The foot pain should be treated with appropriate analgesics B) Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation C) The BP requires ongoing monitoring, but this actions are not as urgently needed as maintenance of respiratory function. D) Absence of the reflexes should be documented, but this is a common finding in Guillain-Barré syndrome.

A patient with Guillain-Barré syndrome asks the nurse what has caused the disease. In responding to the patient, the nurse explains that Guillain-Barré syndrome? A. Results from an acute infection and inflammation of the peripheral nerves. B. Is due to an immune reaction that attacks the covering of the peripheral nerves. C. Is caused by destruction of the peripheral nerves after exposure to a viral infection. D. Results from degeneration of the peripheral nerve caused by viral attacks.

B. Guillain-Barre syndrome is believed to result from an immunologic reaction that damages the myelin sheath of the peripheral nerves. Acute infection or inflammation of the nerves is not a cause. The peripheral nerves are not destroyed and do not degenerate

The nurse is taking the health history of a client suspected of having bacterial meningitis. Which question is most important for the nurse to ask? A. "When was your last tetanus vaccination?" B. "Do you live in a crowded residence?" C. "Have you traveled out of the country in the last month?" D. "Have you had any viral infections recently?"

B. "Do you live in a crowded residence?" Rationale: Meningococcal meningitis tends to occur in outbreaks. It is most likely to occur in areas of high-density population, such as college dormitories, prisons, and military barracks. The other questions do not identify risk factors for bacterial meningitis.

The nurse is assessing the results of diagnostic tests on a client's cerebrospinal fluid (CSF). Which values and observations does the nurse correlate as most indicative of bacterial meningitis? (select all that apply.) A. Clear B. Cloudy C. Normal protein level D. Increased protein level E. Normal glucose level F. Decreased glucose level

B. Cloudy D. Increased protein level F. Decreased glucose level Rationale: Viral meningitis does not cause cloudiness or increased turbidity of CSF. Protein levels are slightly increased, and glucose levels are normal. In bacterial meningitis, the presence of bacteria and white blood cells causes the fluid to be cloudy.

Classic symptoms of bacterial meningitis include a. papilledema and psychomotor seizures b. high fever, nuchal rigidity, and severe headache c. behavioral changes with memory loss and lethargy d. positive Kernig's and Brudzinski's signs and hemiparesis

B. High fever, severe headache, nuchal rigidity, and positive Brudzinski's and Kernig's signs are such classic symptoms of meningitis that they are usually considered diagnostic for meningitis. Other symptoms, such as papilledema, generalized seizures, hemiparesis, and decreased LOC, may occur as complications of increased ICP and cranial nerve dysfunction.

Karina a client with myasthenia gravis is to receive immunosuppressive therapy. The nurse understands that this therapy is effective because it: A.Inhibits the breakdown of acetylcholine at the neuromuscular junction. B.Decreases the production of autoantibodies that attack the acetylcholine receptors. C.Promotes the removal of antibodies that impair the transmission of impulses D.Stimulates the production of acetylcholine at the neuromuscular junction.

B.Decreases the production of autoantibodies that attack the acetylcholine receptors Steroids decrease the body's immune response thus decreasing the production of antibodies that attack the acetylcholine receptors at the neuromuscular junction

Client is having tonic-clonic seizure. Nurse should take which of the following actions? SELECT ALL THAT APPLY A.Restrain client B.Maintain airway. C.Turn client to side. D.Place tongue blade in mouth E.Protect client from injury.

BCE

A client receiving phenytoin (Dilantin) has been experiencing fluctuating serum blood levels of the medication. Development of which symptoms in the client should prompt the nurse to notify the primary health care provider immediately? (Select all that apply.) A. GI cramping and diarrhea B. Migraine headaches and nausea C. Dry skin and constipation D. Double vision and lethargy

A client with myasthenia gravis has been receiving Neostigmine (Prostigmin). This drug acts by: A.Blocking the action of cholinesterase B.Accelerating transmission along neural swaths C.Replacing deficient neurotransmitters D.Stimulating the cerebral cortex

Blocking the action of cholinesterase

A nurse is providing discharge instructions to a female client who has a prescription for phenytoin. which of the following information should the nurse include? A.consider taking oral contraceptives when on this medication B.watch for receding gums when taking this medication C.take the medication at the same time everyday D.provide a urine sample to determine therapeutic levels f the medication

A patient taking phenytoin (Dilantin) and isoniazid reports feeling lethargic. Nystagmus is noted on physical examination. What problem does this information suggest to the nurse? A. Tubercular reactivation B. Abrupt discontinuation of isoniazid C. Phenytoin toxicity D. Liver damage

A patient with diabetes is started on phenytoin (Dilantin) for partial seizures. What does the nurse closely monitor in this individual? A. Blood pressure B. Hypoglycemia C. Hyperglycemia D. Weight loss

A client's husband asks, "What should I do if my wife has a seizure to keep her safe?" Which response by the nurse is correct? A."Monitor your wife's blood pressure." B."Restrain your wife." C."Place your wife in the side-lying position." D."Insert a padded tongue blade in your wife's mouth."

In which patient is carbamazepine (Tegretol) contraindicated? A. Patient with new onset of seizures B. Patient with an ulcer C. Patient with chronic hepatitis B D. Patient with diabetes mellitus

The nurse completes a history and physical on a client admitted with exacerbation of a seizure disorder. What datum collected by the nurse requires intervention? A.History of asthma B. History of diabetes mellitus C. Use of herb Ginkgo biloba D. Use of aspirin daily

The nurse is conducting a home visit for a 6-year-old client who has myoclonic and absence seizures. The parents are following a ketogenic diet for the child. Which observation requires follow-up by the nurse? A.Parents administer medium-chain-triglyceride (MCT) oil as needed. B.Parents include low carbohydrate foods. C.Parents include low-fat foods for each meal. D.Parents monitor urine ketone levels regularly.

Which complementary health approach may be specifically tailored to assist in the identification of the warning signs of seizures? A.Behavior modification B.Massage C.Biofeedback D.Meditation

Which drug used in the treatment of seizures requires careful monitoring of renal function? A. Lamotrigine (Lamictal) B. Primidone (Mysoline) C. Carbamazepine (Tegretol) D. Valproic acid (Depakene)

a nurse is completing discharge teaching to a client who has seizures and received a vagal nerves stimulator to decrease seizure activity. which of the following statements should the nurse include in the teaching? A. it is safe to use microwave that are 1200 watts or less B. you should avoid the use of CT scans with contrast C. you should place a magnet over the implantable device when you feel an aura occurring D. it is recommended that you use ultrasound diathermy for pain management

A 68-year-old man with suspected bacterial meningitis has just had a lumbar puncture in which cerebrospinal fluid was obtained for culture. Which medication should the nurse administer first? A. Codeine B. Phenytoin (Dilantin) C. Ceftriaxone (Rocephin) D. Acetaminophen (Tylenol)

C Bacterial meningitis is a medical emergency. When meningitis is suspected, antibiotic therapy (e.g., ceftriaxone) is instituted immediately after the collection of specimens for cultures, and even before the diagnosis is confirmed. Dexamethasone may also be prescribed before or with the first dose of antibiotics. The nurse should collaborate with the health care provider to manage the headache (with codeine), fever (with acetaminophen), and seizures (with phenytoin).

A nurse is teaching a client who has ALS about a new medication for riluzole. Which of the following instructions should the nurse give to the patient ? A. Take this medication immediately prior to eating B. Drink a glass of milk with this medication C. Avoid consuming alcoholic beverages D. Monitor your blood pressure daily

C. A) Riluzole should be taken on an empty stomach every 12 hrs, either 1 hr before or 2 hrs after meals B) Riluzole should be taken on an empty stomach C) Riluzole is hepatotoxic alcohol may result in liver damage D) Riluzole does not effect blood pressure

The home health (HH) nurse is admitting a female client diagnosed with myasthenia gravis. The client tells the nurse, "Even with my medication I get exhausted when I do anything." Which intervention should the nurse implement? A. Talk to the client's husband about helping around the house more. B. Contact the HH occupational therapist to discuss the client's concern. C. Allow the client to verbalize her feelings of being exhausted. D. . Recommend the client make an appointment with her HCP.

C. A) The client has a chronic illness. The nurse should empower the client to deal with her disease process, not put more responsibility on her husband B)The occupational therapist could assist the client in identifying ways to save energy when performing activities of daily living. Myasthenia gravis is a neurological condition that causes skeletal muscle weakness C) The HH nurse should realize that exhaustion is a symptom of her disease process and should utilize any member of the home healthcare team who could help the client. Allowing the client to verbalize her feelings about exhaustion is an appropriate therapeutic intervention, but this client needs specific advice on how to handle her exhaustion. D) If the client is taking her medication, she does not need to be referred to her HCP. Myasthenia gravis is a chronic illness, and muscle weakness is the primary symptom

A nurse instructs a client who has MG about home care and the risk factors that can exacerbate the disease. Which of the following client statement indicates a need for further teaching. A. I should take my medication 45 min before meals. B. I have suction equipment at home in case i start to choke. C. I will soak in a warm bath every day D. I ordered a medical identification bracelet

C. A) The patient who has MG is instructed to take cholinesterase inhibitors 45 min before meals B) Dysphagia occurs in patients who have MG, suction equipment should be available in case of choking C) Hot temps can cause patients who have MG to have exacerbations D) Medical alert bracelets identify patients who have MG and should be worn

A nurse is caring for a client admitted to the hospital with respiratory difficulty after being diagnosed with amyotrophic lateral sclerosis (ALS) approximately 1 year ago. Which of the following client finding should the nurse anticipate? Select all that apply. A. Loss of sensation B. Fluctuations in blood pressure C. Incontinence D. Ineffective cough E. Loss of cognitive function

C. D. A) Sensory changes are not associated with ALS B) Fluctuations in blood pressure are not a finding in ALS C) Incontince due to muscle weakness is a finding in ALS D) Ineffective cough due to progressive muscle weakness E) no rationale

The initial nursing goal for a client with myasthenia gravis during the diagnostic phase of her hospitalization would be to: A. Develop a teaching plan B. Facilitate psychologic adjustment C. Maintain the present muscle strength D. Prepare for the appearance of myasthenic crisis

C. Maintain the present muscle strength Until diagnosis is confirmed, primary goal should be to maintain adequate activity and prevent muscle atrophy

Three days following intracranial surgery a client develops fever, nuchal rigidity, and headache. The nurse would suspect A. Cerebral emboli B. Extradural hematoma C. Meningitis D. Diabetic neuropathy

C. Meningitis Rational The classic manifestations of meningitis are nuchal rigidity (rigidity of the neck), Brudzinski's sign and Kernig's sign, and photophobia. Intracranial surgery places the client at high risk of developing meningitis.

The nurse on the clinical unit is assigned to four patients. Which patient should she assess first? a. patient with a skull fracture whose nose is bleeding b. elderly patient with a stroke who is confused and whose daughter is present c. patient with meningitis who is suddenly agitated and reporting a HA of 10 on a 0 to 10 scale d. patient who had a craniotomy for a brain tumor who is now 3 days postoperative and has had continued emesis

C. patient with meningitis who is suddenly agitated and reporting a HA of 10 on a 0 to 10 scale

Which of the following is not an autoimmune disease? A. Insulin-dependent diabetes mellitus B.Myasthenia gravis C.Alzheimer's disease D.Graves disease

C.Alzheimer's disease

Treatment of status epilepticus requires initiation of a rapid-acting antiseizure drug that can be given intravenously. You would anticipate which drugs to be administered (select all that apply)? A. phenytoin (Dilantin) B. phenobarbital C. lorazepam (Ativan) D. diazepam (Valium) E. carbemazepine (Tegretol)

Helen, a client with myasthenia gravis, begins to experience increased difficulty in swallowing. To prevent aspiration of food, the nursing action that would be most effective would be to: A. Change her diet order from soft foods to clear liquids B. Place an emergency tracheostomy set in her room C. Assess her respiratory status before and after meals D. Coordinate her meal schedule with the peak effect of her medication, Mestinon

Coordinate her meal schedule with the peak effect of her medication, Mestinon Dysphagia should be minimized during peak effect of Mestinon, thereby decreasing the probability of aspiration. Mestinon can increase her muscle strength including her ability to swallow

18. A patient with a paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. When the nurse develops a plan of care for this problem, which nursing action will be most appropriate? a. Teaching the patient how to self-catheterize b. Assisting the patient to the toilet q2-3hr c. Use of the Credé method to empty the bladder d. Catheterization for residual urine after voiding

Correct Answer: A Rationale: Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with a reflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence. Cognitive Level: Application Text Reference: p. 1605 Nursing Process: Planning NCLEX: Physiological Integrity

2. During assessment of the patient with a recurrence of symptoms of trigeminal neuralgia, the nurse should a. examine the mouth and teeth thoroughly. b. have the patient clench and relax the jaw and eyes. c. identify trigger zones by lightly touching the affected side. d. gently palpate the face to compare skin temperature bilaterally.

Correct Answer: A Rationale: Oral hygiene is frequently neglected because of fear of triggering facial pain. Having the patient clench the facial muscles will not be useful because the sensory branches of the nerve are affected by trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided. Cognitive Level: Application Text Reference: p. 1583 Nursing Process: Assessment NCLEX: Physiological Integrity

5. When teaching patients who are at risk for Bell's palsy because of previous herpes simplex infection, which information should the nurse include? a. "You should call the doctor if pain or herpes lesions occur near the ear." b. "Treatment of herpes with antiviral agents will prevent development of Bell's palsy." c. "Medications to treat Bell's palsy work only if started before paralysis onset." d. "You may be able to prevent Bell's palsy by doing facial exercises regularly."

Correct Answer: A Rationale: Pain or herpes lesions near the ear may indicate the onset of Bell's palsy and rapid corticosteroid treatment may reduce the duration of Bell's palsy symptoms. Antiviral therapy for herpes simplex does not reduce the risk for Bell's palsy. Corticosteroid therapy will be most effective in reducing symptoms if started before paralysis is complete but will still be somewhat effective when started later. Facial exercises do not prevent Bell's palsy. Cognitive Level: Application Text Reference: p. 1585 Nursing Process: Implementation NCLEX: Physiological Integrity

24. The nurse is caring for a patient who is being evaluated for a possible metastatic spinal cord tumor. Which of these data obtained when assessing the patient requires most immediate action by the nurse? a. The patient has new onset weakness of both legs. b. The patient complains of chronic level 6 pain on a 10-point scale. c. The patient starts to cry and says, "I feel hopeless." d. The patient expresses anxiety about having surgery.

Correct Answer: A Rationale: The new onset of symptoms indicates cord compression, an emergency that requires rapid treatment to avoid permanent loss of function. The other patient assessments also indicate a need for nursing action but do not require intervention as rapidly as the new onset weakness. Cognitive Level: Application Text Reference: p. 1610 Nursing Process: Assessment NCLEX: Physiological Integrity

21. A patient who sustained a T1 spinal cord injury a week ago refuses to discuss the injury and becomes verbally abusive to the nurses and other staff. The patient demands to be transferred to another hospital, where "they know what they are doing." The best response by the nurse to the patient's behavior is to a. ask for the patient's input into the plan for care. b. clarify that abusive behavior will not be tolerated. c. reassure the patient that the anger will pass and rehabilitation will then progress. d. ignore the patient's anger and continue to perform needed assessments and care.

Correct Answer: A Rationale: The patient is demonstrating behaviors consistent with the anger phase of the mourning process, and the nurse should allow expression of anger and seek the patient's input into care. Expression of anger is appropriate at this stage and should be tolerated by the nurse. Refusal to acknowledge the patient's anger by telling the patient that the anger is just a phase is inappropriate. Continuing to perform needed assessments and care is appropriate, but the nurse should seek the patient's input into what care is needed. Cognitive Level: Application Text Reference: p. 1608 Nursing Process: Implementation NCLEX: Psychosocial Integrity

6. A patient with Bell's palsy refuses to eat while others are present because of embarrassment about drooling. The best response by the nurse to the patient's behavior is to a. respect the patient's desire and arrange for privacy at mealtimes. b. offer the patient liquid nutritional supplements at frequent intervals. c. discuss the patient's concerns with visitors who arrive at mealtimes. d. teach the patient to chew food on the unaffected side of the mouth.

Correct Answer: A Rationale: The patient's desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements will reduce the patient's enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the patient's embarrassment with visitors unless the patient wishes to share this information. Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food but will not decrease the drooling. Cognitive Level: Application Text Reference: p. 1585 Nursing Process: Implementation NCLEX: Psychosocial Integrity

1. When assessing a patient with newly diagnosed trigeminal neuralgia, the nurse will ask the patient about a. triggers that lead to facial pain. b. visual problems caused by ptosis. c. poor appetite caused by a loss of taste. d. decreased sensation on the affected side.

Correct Answer: A. Rationale: The major clinical manifestation of trigeminal neuralgia is severe facial pain that is triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and numbness are not characteristics of trigeminal neuralgia, although ptosis and numbness may occur after therapy, and poor appetite may be associated with pain stimulated by eating. Cognitive Level: Application Text Reference: p. 1581 Nursing Process: Assessment NCLEX: Physiological Integrity

9. When caring for a patient who has Guillain-Barré syndrome, which assessment data obtained by the nurse will require the most immediate action? a. The patient complains of severe tingling pain in the feet. b. The patient has continuous drooling of saliva. c. The patient's blood pressure (BP) is 106/50 mm Hg. d. The patient's quadriceps and triceps reflexes are absent.

Correct Answer: B Rationale: Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, and the BP requires ongoing monitoring, but these actions are not as urgently needed as maintenance of respiratory function. Absence of the reflexes should be documented, but this is a common finding in Guillain-Barré syndrome. Cognitive Level: Application Text Reference: pp. 1586-1587 Nursing Process: Assessment NCLEX: Physiological Integrity

7. A patient with Guillain-Barré syndrome asks the nurse what has caused the disease. In responding to the patient, the nurse explains that Guillain-Barré syndrome a. results from an acute infection and inflammation of the peripheral nerves. b. is due to an immune reaction that attacks the covering of the peripheral nerves. c. is caused by destruction of the peripheral nerves after exposure to a viral infection. d. results from degeneration of the peripheral nerve caused by viral attacks.

Correct Answer: B Rationale: Guillain-Barré syndrome is believed to result from an immunologic reaction that damages the myelin sheath of the peripheral nerves. Acute infection or inflammation of the nerves is not a cause. The peripheral nerves are not destroyed and do not degenerate. Cognitive Level: Comprehension Text Reference: pp. 1585-1586 Nursing Process: Implementation NCLEX: Physiological Integrity

19. A patient with a history of a T2 spinal cord tells the nurse, "I feel awful today. My head is throbbing, and I feel sick to my stomach." Which action should the nurse take first? a. Notify the patient's health care provider. b. Check the blood pressure (BP). c. Give the ordered antiemetic. d. Assess for a fecal impaction.

Correct Answer: B Rationale: The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is causing the symptoms, including hypertension. Notification of the patient's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. The nurse may assess for a fecal impaction, but this should be done after checking the BP and lidocaine jelly should be used to prevent further increases in the BP. Cognitive Level: Application Text Reference: p. 1603 Nursing Process: Assessment NCLEX: Physiological Integrity

14. When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort, bibasilar crackles, and decreased breath sounds, the initial intervention by the nurse should be to a. administer oxygen at 7 to 9 L/min with a face mask. b. place the hands on the epigastric area and push upward when the patient coughs. c. encourage the patient to use an incentive spirometer every 2 hours during the day. d. suction the patient's oral and pharyngeal airway.

Correct Answer: B Rationale: The nurse has identified that the cough effort is poor, so the initial action should be to use assisted coughing techniques to improve the ability to mobilize secretions. Administration of oxygen will improve oxygenation, but the data do not indicate hypoxemia, and oxygen will not help expel respiratory secretions. The use of the spirometer may improve respiratory status, but the patient's ability to take deep breaths is limited by the loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by coughing but should not be the nurse's first action. Cognitive Level: Application Text Reference: p. 1602 Nursing Process: Implementation NCLEX: Physiological Integrity

16. A patient with a T1 spinal cord injury is admitted to the intensive care unit (ICU). The nurse will teach the patient and family that a. use of the shoulders will be preserved. b. full function of the patient's arms will be retained. c. total loss of respiratory function may occur temporarily. d. elevations in heart rate are common with this type of injury.

Correct Answer: B Rationale: The patient with a T1 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Total loss of respiratory function occurs with injuries above the C4 level and is permanent. Bradycardia is associated with injuries above the T6 level. Cognitive Level: Application Text Reference: p. 1594 Nursing Process: Implementation NCLEX: Physiological Integrity

4. When the nurse is planning care for a hospitalized patient who is experiencing an acute episode of trigeminal neuralgia, an appropriate action to include is a. teach facial and jaw relaxation techniques. b. assess intake and output and dietary intake. c. apply ice packs for no more than 20 minutes. d. spend time at the bedside talking with the patient.

Correct Answer: B Rationale: The patient with an acute episode of trigeminal neuralgia may be unwilling to eat or drink, so assessment of nutritional and hydration status is important. Because stimulation by touch is the precipitating factor for pain, relaxation of the facial muscles will not improve symptoms. Application of ice is likely to precipitate pain. The patient will not want to engage in conversation, which may precipitate attacks. Cognitive Level: Application Text Reference: p. 1583 Nursing Process: Planning NCLEX: Physiological Integrity

11. A patient admitted to the emergency department is diagnosed with botulism, and an order for botulinum antitoxin is received. Before administering the antitoxin, it is most important for the nurse to a. obtain baseline vital signs. b. administer an intradermal test dose. c. ask the patient about a history of allergies. d. document the presence of neurologic symptoms.

Correct Answer: B Rationale: To prevent allergic reactions, an intradermal test dose of the antitoxin should be administered. Although baseline vital signs, allergy history, and symptom assessment and documentation are appropriate, these assessments will not impact on the decision to administer the antitoxin. Cognitive Level: Application Text Reference: pp. 1587-1588 Nursing Process: Implementation NCLEX: Physiological Integrity

MULTIPLE RESPONSE 1. When caring for a patient who experienced a T1 spinal cord transsection 2 days ago, which collaborative and nursing actions will the nurse include in the plan of care? (Select all that apply.) a. Endotracheal suctioning b. Continuous cardiac monitoring c. Avoidance of cool room temperature d. Nasogastric tube feeding e. Retention catheter care f. Administration of H2 receptor blockers

Correct Answer: B, C, E, F Rationale: The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature. Gastrointestinal (GI) motility is decreased initially and NG suctioning is indicated. To avoid bladder distension, a retention catheter is used during this acute phase. Stress ulcers are a common complication but can be avoided through the use of the H2 receptor blockers such as famotidine. Cognitive Level: Application Text Reference: pp. 1594-1595, 1597, 1603 Nursing Process: Planning NCLEX: Physiological Integrity

27. When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority? a. Continuous cardiac monitoring for bradycardia b. Administration of methylprednisolone (Solu-Medrol) infusion c. Assessment of respiratory rate and depth d. Application of pneumatic compression devices to both legs

Correct Answer: C Rationale: Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. The other actions are also appropriate but are not as important as assessment of respiratory effort. Cognitive Level: Application Text Reference: p. 1602 Nursing Process: Assessment NCLEX: Physiological Integrity

26. A patient with possible botulism poisoning is admitted for observation and administration of botulinum antitoxin. Which of the following health care provider orders should the nurse question? a. Maintain NPO status. b. Obtain lumbar puncture tray. c. Give magnesium citrate 8 oz now. d. Administer 1500-ml tapwater enema.

Correct Answer: C Rationale: Magnesium is contraindicated because it may worsen the neuromuscular blockade. The other orders are appropriate for the patient. Cognitive Level: Application Text Reference: p. 1588 Nursing Process: Implementation NCLEX: Physiological Integrity

15. As a result of a gunshot wound, a patient has an incomplete right spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which nursing action should be included in the plan of care? a. Assessment of the patient for left leg pain b. Assessment of the patient for left arm weakness c. Positioning the patient's right leg when turning the patient d. Teaching the patient to look at the left leg to verify its position

Correct Answer: C Rationale: The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the right leg. Pain sensation will be lost on the patient's left leg. Left arm weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the left leg. Cognitive Level: Application Text Reference: pp. 1591-1592 Nursing Process: Implementation NCLEX: Physiological Integrity

17. The health care provider orders administration of IV methylprednisolone (Solu-Medrol) for the first 24 hours to a patient who experienced a spinal cord injury at the T10 level 3 hours ago. When evaluating the effectiveness of the medication the nurse will assess a. blood pressure and heart rate. b. respiratory effort and O2 saturation. c. motor and sensory function of the legs. d. bowel sounds and abdominal distension.

Correct Answer: C Rationale: The purpose of methylprednisolone administration is to help preserve neurologic function; therefore, the nurse will assess this patient for lower-extremity function. Sympathetic nervous system dysfunction occurs with injuries at or above T6, so monitoring of BP and heart rate will not be useful in determining the effectiveness of the medication. Respiratory and GI function will not be impaired by a T10 injury, so assessments of these systems will not provide information about whether the medication is effective. Cognitive Level: Application Text Reference: p. 1596 Nursing Process: Evaluation NCLEX: Physiological Integrity

OTHER 1. In which order will the nurse perform the following actions when caring for a patient with possible cervical spinal cord trauma who is admitted to the emergency department? a. Administer O2 using a non-rebreathing mask. b. Monitor cardiac rhythm and blood pressure. c. Immobilize the patient's head, neck, and spine. d. Transfer the patient to radiology for spinal CT.

Correct Answer: C, A, B, D Rationale: The first action should be to prevent further injury by stabilizing the patient's spinal cord. Maintenance of oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible complication, continuous monitoring of heart rhythm and BP is indicated. CT scan to determine the extent and level of injury is needed once initial assessment and stabilization is accomplished. Cognitive Level: Application Text Reference: p. 1596 Nursing Process: Implementation NCLEX: Physiological Integrity

25. Which of these nursing actions for a patient with Guillain-Barré syndrome is most appropriate for the nurse to delegate to an experienced nursing assistant? a. Nasogastric tube feeding q4hr b. Artificial tear administration q2hr c. Assessment for bladder distension q2hr d. Passive range of motion to extremities q8hr

Correct Answer: D Rationale: Assisting a patient with movement is included in nursing assistant education and scope of practice. Administration of tube feedings, administration of ordered medications, and assessment are skills requiring more education and scope of practice, and the RN should perform these skills. Cognitive Level: Application Text Reference: pp. 1586-1587 Nursing Process: Implementation NCLEX: Safe and Effective Care Environment

10. A patient who has numbness and weakness of both feet is hospitalized with Guillain-Barré syndrome. The nurse will anticipate that collaborative interventions at this time will include a. intubation and mechanical ventilation. b. insertion of a nasogastric (NG) feeding tube. c. administration of methylprednisolone (Solu-Medrol). d. IV infusion of immunoglobulin (Sandoglobulin).

Correct Answer: D Rationale: Because the Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and tube feedings may be used later in the progression of the syndrome but are not needed now. Corticosteroid use is not helpful in reducing the duration or symptoms of the syndrome. Cognitive Level: Application Text Reference: p. 1586 Nursing Process: Implementation NCLEX: Physiological Integrity

3. A patient with trigeminal neuralgia has a glycerol rhizotomy. During a follow-up visit after the rhizotomy, the nurse will evaluate that the patient has had a successful outcome for the surgery if the patient a. uses an eye shield at night to protect the cornea from injury. b. develops and implements a daily routine of facial exercises. c. is careful to chew foods on the unaffected side of the mouth. d. talks about enjoying social activities with family and friends.

Correct Answer: D Rationale: Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, enjoyment of social activities indicates successful reduction of symptoms. Glycerol rhizotomy does not damage the corneal reflex or motor functions of the trigeminal nerve, so there is no need to use an eye shield, do facial exercises, or take precautions with chewing. Cognitive Level: Application Text Reference: pp. 1583-1584 Nursing Process: Evaluation NCLEX: Physiological Integrity

12. A patient arrives at an urgent care center with a deep puncture wound after stepping on a nail that was embedded in some old lumber in a field. The patient reports having had a tetanus booster 7 years ago. The nurse will anticipate a. IV infusion of tetanus immune globulin (TIG). b. initiation of the tetanus-diphtheria immunization series. c. intradermal injection of an immune globulin test dose. d. administration of the tetanus-diphtheria (Td) toxoid booster.

Correct Answer: D Rationale: If the patient has not been immunized within 5 years, administration of the Td booster is indicated because the wound is deep. Immune globulin administration is given by the IM route if the patient has no previous immunization. Administration of a series of immunization is not indicated. A test dose is not needed for immune globulin, and TIG is not indicated for the patient. Cognitive Level: Application Text Reference: p. 1589 Nursing Process: Implementation NCLEX: Physiological Integrity

22. A 26-year-old patient with a C8 spinal cord injury tells the nurse, "My wife and I have always had a very active sex life, and I am worried that she may leave me if I cannot function sexually." The most appropriate response by the nurse to the patient's comment is to a. advise the patient to talk to his wife to determine how she feels about his sexual function. b. tell the patient that sildenafil (Viagra) helps to decrease erectile dysfunction in patients with spinal cord injury. c. inform the patient that most patients with upper motor neuron injuries have reflex erections. d. suggest that the patient and his wife work with a nurse specially trained in sexual counseling.

Correct Answer: D Rationale: Maintenance of sexuality is an important aspect of rehabilitation after spinal cord injury and should be handled by someone with expertise in sexual counseling. Although the patient should discuss these issues with his wife, open communication about this issue may be difficult without the assistance of a counselor. Sildenafil does assist with erectile dysfunction after spinal cord injury, but the patient's sexuality is not determined solely by the ability to have an erection. Reflex erections are common after upper motor neuron injury, but these erections are uncontrolled and cannot be maintained during coitus. Cognitive Level: Application Text Reference: p. 1608 Nursing Process: Implementation NCLEX: Psychosocial Integrity

23. A 25-year-old patient has returned home following extensive rehabilitation for a C8 spinal cord injury. The home care nurse visits and notices that the patient's spouse and parents are performing many of the activities of daily living (ADLs) that the patient had been managing during rehabilitation. The most appropriate action by the nurse at this time is to a. tell the family members that the patient can perform ADLs independently. b. remind the patient about the importance of independence in daily activities. c. recognize that it is important for the patient's family to be involved in the patient's care and support their activities. d. develop a plan to increase the patient's independence in consultation with the with the patient, spouse, and parents.

Correct Answer: D Rationale: The best action by the nurse will be to involve all the parties in developing an optimal plan of care. Because family members who will be assisting with the patient's ongoing care need to feel that their input is important, telling the family that the patient can perform ADLs independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviors of the family members. Supporting the activities of the spouse and parents will lead to ongoing dependency by the patient. Cognitive Level: Application Text Reference: p. 1609 Nursing Process: Implementation NCLEX: Psychosocial Integrity

8. A 24-year-old patient is hospitalized with the onset of Guillain-Barré syndrome. During this phase of the patient's illness, the most essential assessment for the nurse to carry out is a. monitoring the cardiac rhythm continuously. b. determining the level of consciousness q2hr. c. evaluating sensation and strength of the extremities. d. performing constant evaluation of respiratory function.

Correct Answer: D Rationale: The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments will also be included in nursing care, but they are not as important as respiratory assessment. Cognitive Level: Comprehension Text Reference: p. 1586 Nursing Process: Assessment NCLEX: Physiological Integrity

20. The nurse discusses long-range goals with a patient with a C6 spinal cord injury. An appropriate patient outcome is a. transfers independently to a wheelchair. b. drives a car with powered hand controls. c. turns and repositions self independently when in bed. d. pushes a manual wheelchair on flat, smooth surfaces.

Correct Answer: D Rationale: The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed. Cognitive Level: Application Text Reference: p. 1594 Nursing Process: Planning NCLEX: Physiological Integrity

The client is diagnosed with MG. Which intervention should the nurse implement when administering the anticholinesterase pyridostigmine (Mestinon)? 1. Assess for excess salivation and abdominal cramps. 2. Administer the medication before the client has eaten. 3. Break the capsule and sprinkle the medication on the food. 4. Assess the client's potassium level prior to administering medication.

Correct answer 1: Anticholinesterase medications can cause the client to have excessive salivation and abdominal cramping. When this occurs, the client receives the antidote atropine simultaneously in small doses. Mestinon is administered with milk and/or crackers to prevent stomach upset. Mestinon does not affect potassium levels.

The male client with MG is undergoing plasmapheresis at the bedside. Which assessment data would warrant immediate intervention by the nurse? 1. The client complains of being lightheaded and dizzy. 2. The client can smile and clamp his teeth together. 3. The client states that his leg cramps have gone away. 4. The client has a small hematoma at the vascular access site.

Correct answer 1: Hypovolemia is a complication of plasmapheresis, especially during the procedure when up to 15% of the blood volume is in the cell separator. The nurse should immediately assess for shock. All other options are expected.

Which statement by the 20-year-old female client diagnosed with MG indicates the client understands the discharge teaching? 1. "I can have children, but I will have to see my neurologist during my pregnancy." 2. "I have a new job at a children's day care center to help with expenses." 3. "I should not take a bath because I could pass out and drown while in the tub." 4. "I will drink at least 1000 mL of water or other liquid every day."

Correct answer 1: MG will not prevent conception or delivery but can cause the client to experience an exacerbation of the disease. The client should be seen regularly by the neurologist and the obstetrician. Young children are ill frequently, and infections can result in an exacerbation for the client. Option 3 applies to clients who have seizures. The client is not restricted to 1000 mL of fluid per day.

The client diagnosed with MG is being discharged home. Which intervention should the nurse teach the significant other? 1. Discuss how to perform the Heimlich maneuver. 2. Explain how to perform oral hygiene on a conscious client. 3. Teach how to perform isometric exercises. l 4. Demonstrate correct hand placement for chest compressions.

Correct answer 1: The client is at risk for choking, and knowing specific measures to help the client helps decrease the client's as well as significant other's anxiety and promotes confidence in managing potential complications. The client should perform oral care. The client should perform isotonic exercises, not isometric exercises, and the client is not at an increased risk for cardiac complications, so teaching about chest compression is not necessary

Which statement by the client supports the diagnosis of myasthenia gravis (MG)? 1. "I have weakness and fatigue in my feet and legs." 2. "My eyelids droop, and I see double everything." 3. "I get chest pain and faint after I walk in the hall." 4. "I gained 3 pounds this week, and I am spitting up pink frothy sputum."

Correct answer 2: These are ocular signs/symptoms of MG. Ptosis is drooping of the eyelid, and diplopia is unilateral or bilateral double vision. Weakness and fatigue of upper body muscle occur with MG. .

The client diagnosed with MG is admitted to the emergency department with a sudden exacerbation of motor weakness. Which assessment data indicate the client is experiencing a myasthenic crisis? 1. The serum assay of circulating acetylcholine receptor antibodies is increased. 2. The client's symptoms improve when administering on a cholinesterase inhibitor. 3. The client's blood pressure, pulse, and respirations improve after intravenous (IV) fluid. 4. The Tensilon test does not show improvement in the client's muscle strength

Correct answer 2: This assessment datum indicates a myasthenic crisis that is due to undermedication, missed doses of medication, or developing an infection. Serum assays are useful in diagnosing the disease, not in identifying a crisis. Vital signs do not differentiate the type of crisis. No improvement after Tensilon indicates a cholinergic crisis, not a myasthenic crisis.

The male client diagnosed with MG is prescribed the cholinesterase inhibitor neostigmine (Prostigmin). Which data indicate the medication is not effective? 1. The client is able to perform activities of daily living (ADLs) independently. 2. The client states that his vision is clear. 3. The client cannot speak or look upward at the ceiling. 4. The client is smiling and laughing with the nurse.

Correct answer 3: Dysphonia and inability to utilize the muscles of the eye and eyelid indicate the medication is not effective. Performing ADLs, having clear vision, and smiling and laughing using the facial muscles indicate the medication is effective

The nurse is discharging a client diagnosed with MG. Which statement by the client indicates an understanding of the discharge instructions? 1. "I can control the MG with medication, but an adenectomy will cure it." 2. "I should take a holiday from my medications every 4 or 5 weeks." 3. "I must take my medications on time every day, or I could have problems." 4. "I should take my steroid medications with food so it won't upset my stomach."

Correct answer 3: The anti cholinesterase medications used to treat MG must be taken on time in order to prevent muscle weakness and respiratory complications. These medications are one of the very few that the nurse should administer at the exact scheduled time. Steroids are not prescribed for MG.

Which response to the Tensilon (edrophonium chloride) injection indicates the client has myasthenia gravis? 1. The client has no apparent change in the assessment data. 2. There is reduced amplitude of electrical stimulation in the muscle. 3. The anti-acetylcholine receptor antibodies are present. 4. The client shows a marked improvement of muscle strength.

Correct answer 4: Clients with myasthenia gravis show a significant improvement of muscle strength that lasts approximately 5 minutes when Tensilon (edrophonium chloride) is injected.

Which referral is appropriate for the client in the late stages of myasthenia gravis? 1. The infection control nurse. 2. The occupational health nurse. 3. A vocational guidance counselor. 4. The speech therapist.

Correct answer 4: Speech therapists address swallowing problems, and clients with myasthenia gravis are dysphagic and at risk for aspiration. The infection control and occupational health nurses do not consult with the client. A vocational counselor helps with the client finding a position suited for the disability, but clients with late-stage myasthenia gravis are usually not able to work.

Nurse on clinical unit is assigned to four patients. Which patient should she assess first? a. Patient with a skull fracture whose nose is bleeding b. Older patient with a stroke who is confused and whose daughter is present c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0-10 scale d. Patient who had a craniotomy for a brain tumor who now 3 days postoperative had had continued vomiting

Correct answer: c Rationale: The patient with meningitis should be seen first; patients with meningitis must be observed closely for manifestations of elevated ICP, which is thought to result from swelling around the dura and increased cerebrospinal fluid (CSF) volume. Sudden change in the level of consciousness or change in behavior along with a sudden severe headache may indicate an acute elevation of ICP. The patient who has undergone cranial surgery should be seen second; although nausea and vomiting are common after cranial surgery, it can result in elevations of ICP. Nausea and vomiting should be treated with antiemetics. The patient with a skull fracture needs to be evaluated for CSF leakage occurring with the nose bleed and should be seen third. Confusion after a stroke may be expected; the patient should have a family member present.

A male client is having a tonic-clonic seizures. What should the nurse do first? a. Elevate the head of the bed. b. Restrain the client's arms and legs. c. Place a tongue blade in the client's mouth. d. Take measures to prevent injury

A patient has a tonic-clonic seizure while the nurse is in the patient's room. Which action should the nurse take? a. Insert an oral airway during the seizure to maintain a patent airway. b. Restrain the patient's arms and legs to prevent injury during the seizure. c. Avoid touching the patient to prevent further nervous system stimulation. d. Time and observe and record the details of the seizure and postictal state.

A patient taking phenytoin (Dilantin) has started attending college and reports frequently drinking alcohol with friends. What does the nurse monitor for in this patient? A. Clinical manifestations of phenytoin toxicity B. Hyperglycemia C. Hypertension D. Increased seizure activity

An elementary teacher who has just been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, "I cannot teach anymore, it will be too upsetting if I have a seizure at work." Which response by the nurse is best? a. "You may want to contact the Epilepsy Foundation for assistance." b. "You might benefit from some psychologic counseling at this time." c. "The Department of Vocational Rehabilitation can help with work retraining." d. "Most patients with epilepsy are well controlled with antiseizure medications."

A client's mother asks the nurse if there is anything non-pharmacologic that her daughter can do to help with intractable seizures. Which response by the nurse is correct? A."Taking megadoses of vitamins might be worth a try." B."Eating a vegetarian diet has been proven to be successful." C."Taking in extra sugar on a regular basis could be helpful." D."Eating a ketogenic diet can be helpful."

The nurse giving discharge teaching for a client receiving carbamazepine (Tegretol) should include: A. Monitor blood glucose, and report decreased levels. B. Expect a discoloration of the contact lenses. C. Expect an orange discoloration of urine. D. Report unusual bleeding or bruises to the health care provider immediately.

Which assessment data should the nurse obtain when completing a health history on a client with a seizure disorder? A.Vital signs B.Level of consciousness C.Neurologic exam D.Presence of auras

Which of these prescribed interventions will the nurse implement first for a hospitalized patient who is experiencing continuous tonic-clonic seizures? a. Give phenytoin (Dilantin) 100 mg IV. b. Monitor level of consciousness (LOC). c. Obtain computed tomography (CT) scan. d. Administer lorazepam (Ativan) 4 mg IV.

The nurse assesses a patient for signs of meningeal irritation and observes for nuchal rigidity. What indicates the presence of this sign of meningeal irritation? A. Tonic spasms of the legs B. Curling in a fetal position C. Arching of the neck and back D. Resistance to flexion of the neck

D Nuchal rigidity is a clinical manifestation of meningitis. During assessment, the patient will resist passive flexion of the neck by the health care provider. Tonic spasms of the legs, curling in a fetal position, and arching of the neck and back are not related to meningeal irritation.

The rehabilitation nurse tells the unlicensed assistive personnel (UAP) to assist the client recovering from Guillain-Barré syndrome with a.m. care. Which action by the UAP warrants immediate intervention? A. The UAP closes the door and cubicle curtain. B. The UAP massages the client's back with lotion. C. The UAP checks the temperature of the bathing water. D. The UAP puts the side rails up when bathing the client

D. A) Closing the door and cubicle curtain protects the client's privacy and would not warrant immediate intervention from the nurse B) Providing a back massage is a wonderful action to take and would not warrant intervention by the nurse C) Checking the temperature of the bathwater prevents scalding the client with water that is too hot or making the client uncomfortable with water that is too cold. This action would not warrant immediate intervention D) The client is recovering from a potentially debilitating disease, and in the rehabilitation unit the client should be out of the bed as much as possible. Bathing the client in bed would warrant intervention by the nurse

A patient with Guillain-Barré syndrome who has numbness and weakness of both feet is hospitalized . The nurse will anticipate that collaborative interventions at this time will include? a. intubation and mechanical ventilation. b. insertion of a nasogastric (NG) feeding tube. c. administration of methylprednisolone (Solu-Medrol). d. IV infusion of immunoglobulin (Sandoglobulin).

D. Because the Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms

Helen is diagnosed with myasthenia gravis and pyridostigmine bromide (Mestinon) therapy is started. The Mestinon dosage is frequently changed during the first week. While the dosage is being adjusted, the nurse's priority intervention is to: A. Administer the medication exactly on time B. Administer the medication with food or mild C. Evaluate the client s muscle strength hourly after medication D. Evaluate the client s emotional side effects between doses

D. Evaluate the clients muscle strength hourly after medication Peak response occurs 1 hour after administration and lasts up to 8 hours; the response will influence dosage levels.

While reviewing a client's chart, the nurse notices that the female client has myasthenia gravis. Which of the following statements about neuromuscular blocking agents is true for a client with this condition? A. The client may be less sensitive to the effects of a neuromuscular blocking agent. B. Succinylcholine shouldn't be used; pancuronium may be used in a lower dosage. C. Pancuronium shouldn't be used; succinylcholine may be used in a lower dosage. D. Pancuronium and succinylcholine both require cautious administration

D. Pancuronium and succinylcholine both require cautious administration The nurse must cautiously administer pancuronium, succinylcholine, and any other neuromuscular blocking agent to a client with myasthenia gravis. Such a client isn't less sensitive to the effects of a neuromuscular blocking agent. Either succinylcholine or pancuronium can be administered in the usual adult dosage to a client with myasthenia gravis

The nurse is caring for a client admitted with suspected myasthenia gravis. Which finding is usually associated with a diagnosis of myasthenia gravis? A. Visual disturbances, including diplopia B. Ascending paralysis and loss of motor function C. Cogwheel rigidity and loss of coordination D. Progressive weakness that is worse at the day s end

D. Progressive weakness that is worse at the days end The client with myasthenia develops progressive weakness that worsens during the day. Visual disturbances, including diplopia is incorrect because it refers to symptoms of multiple sclerosis. Ascending paralysis and loss of motor function is incorrect because it refers to symptoms of Guillain Barre syndrome. Cogwheel rigidity and loss of coordination is incorrect because it refers to Parkinsons disease.

The most significant initial nursing observations that need to be made about a client with myasthenia include: A. Ability to chew and speak distinctly B. Degree of anxiety about her diagnosis C. Ability to smile an to close her eyelids D. Respiratory exchange and ability to swallow

D. Respiratory exchange and ability to swallow Muscle weakness can lead to respiratory failure that will require emergency intervention and inability to swallow may lead to aspiration.

A 6-year-old child is seen in the urgent care unit for a history of seizures at home. He begins to have seizures in the urgent care unit that last more than 5 minutes. IV access has not been successful. The nurse caring for this child is knowledgeable that either of these medications may be given to stop the child's seizures: a. IM phenytoin b. Rectal diazepam c. Buccal midazolam d. a and c e. b and c

A physician diagnoses a client with myasthenia gravis, prescribing pyridostigmine (Mestinon), 60 mg P.O. every 3 hours. Before administering this anticholinesterase agent, the nurse reviews the client's history. Which preexisting condition would contraindicate the use of pyridostigmine? A. Ulcerative colitis B. Blood dyscrasia C. Intestinal obstruction D. Spinal cord injury

Intestinal obstruction Anticholinesterase agents such as pyridostigmine are contraindicated in a client with a mechanical obstruction of the intestines or urinary tract, peritonitis, or hypersensitivity to anticholinesterase agents. Ulcerative colitis, blood dyscrasia, and spinal cord injury dont contraindicate use of the drug.

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

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

Your patient diagnosed with Myasthenia Gravis begins taking Mestinon. During the first week, the dosage is changed frequently. While the dosage is being adjusted, the nurse's priority intervention is to: A) Administer the medication with food or an 8 oz. glass of water B) Evaluate the client's muscle strength hourly after medication C) Take a full set of vital signs every 15 minutes D) Administer the medication exactly on time

Peak response occurs 1 hour after administration and lasts up to 8 hours. By giving the medication exactly on time, this will help determine dosage levels. Mestinon can be given with or without food/water. There is nothing in this question that indicates vitals should be taken every 15 minutes. The client's muscle strength is important to assess, but the priority intervention is to give the medication on time.

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

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

Correct The nursing assistant reports to you, the RN, that the patient with myasthenia gravis (MG) has an elevated temperature (102.20 F), heart rate of 120/minute, rise in blood pressure (158/94), and was incontinent off urine and stool. What is your best first action at this time? A.Reschedule patient's physical therapy. B.Recheck vital signs in 1 hour. C.Notify the physician immediately. D.Administer an acetaminophen suppository.

The changes that the nursing assistant is reporting are characteristics of myasthenia crisis, which often follows some type of infection. The patient is at risk for inadequate respiratory function. In addition to notifying the physician, the nurse should carefully monitor the patient's respiratory status. The patient may need incubation and mechanical ventilation. The nurse would notify the physician before giving the suppository because there may be orders for cultures before giving acetaminophen. This patient's vital signs need to be re-checked sooner than 1 hour. Rescheduling the physical therapy can be delegated to the unit clerk and is not urgent. Focus: Prioritization

13. A patient with a neck fracture at the C5 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding a. hypotension, bradycardia, and warm extremities. b. involuntary, spastic movements of the arms and legs. c. the presence of hyperactive reflex activity below the level of the injury. d. flaccid paralysis and lack of sensation below the level of the injury. Correct Answer: D Rationale: Clinical manifestations of spinal shock include decreased reflexes, loss of sensation, and flaccid paralysis below the area of injury. Hypotension, bradycardia, and warm extremities are evidence of neurogenic shock. Involuntary spastic movements and hyperactive reflexes are not seen in the patient at this stage of spinal cord injury. Cognitive Level: Comprehension Text Reference: p. 1590 Nursing Process: Assessment NCLEX: Physiological Integrity

...

The nurse is providing instructions to a client with a seizure disorder who will be taking phenytoin (Dilantin). Which statement, if made by the client, would indicate an understanding of the information about this medication? 1."I need to perform good oral hygiene, including flossing and brushing my teeth." 2."I should try to avoid alcohol, but if I'm not able to, I can drink alcohol in moderation." 3."I should take my medication before coming to the laboratory to have a blood level drawn." 4."I should monitor for side effects and adjust my medication dose depending on how severe the side effects are."

77. The charge nurse is making assignments. Which client should be assigned to the new graduate nurse? 1. The client diagnosed with aseptic meningitis who is complaining of a headache and the light bothering his eyes. 2. The client diagnosed with Parkinson's disease who fell during the night and is complaining of difficulty walking. 3. The client diagnosed with a cerebrovascular accident whose vitals signs are P 60, R 14, and BP 198/68. 4. The client diagnosed with a brain tumor who has a new complaint of seeing spots before the eyes.

1. Headache and photophobia are expected clinical manifestations of meningitis. The new graduate could care for this client.

76. The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical-surgical unit. Which task should not be assigned to the UAP? 1. Feed the 69-year-old client diagnosed with Parkinson's disease who is having difficulty swallowing. 2. Turn and position the 89-year-old client diagnosed with a pressure ulcer secondary to Parkinson's disease. 3. Assist the 54-year-old client diagnosed with Parkinson's disease with toilet-training activities. 4. Obtain vital signs on a 72-year-old client diagnosed with pneumonia secondary to Parkinson's disease.

1. The nurse should not delegate feeding a client who is at risk for complications during feeding. This requires judgment that the UAP is not expected to possess.

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. 1. Padding the side rails of the bed 2. Placing an airway at the bedside 3. Placing the bed in the high position 4. Putting a padded tongue blade at the head of the bed 5. Placing oxygen and suction equipment at the bedside 6. Flushing the intravenous catheter to ensure that the site is patent

1256

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take?Select all that apply. 1. Loosening restrictive clothing 2. Restraining the client's limbs 3. Removing the pillow and raising padded side rails 4. Positioning the client to the side, if possible, with the head flexed forward 5. Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist

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73. The client diagnosed with Parkinson's disease (PD) is being admitted with a fever and patchy infiltrates in the lung fields on the chest x-ray. Which clinical manifestations of PD would explain these assessment data? 1. Masklike facies and shuffling gait. 2. Difficulty swallowing and immobility. 3. Pill rolling of fingers and flat affect. 4. Lack of arm swing and bradykinesia.

2. Difficulty swallowing places the client at risk for aspiration. Immobility predisposes the client to pneumonia. Both clinical manifestations place the client at risk for pulmonary complications.

83. The nurse is conducting a support group for clients diagnosed with Parkinson's disease and their significant others. Which information regarding psychosocial needs should be included in the discussion? 1. The client should discuss feelings about being placed on a ventilator. 2. The client may have rapid mood swings and become easily upset. 3. Pill-rolling tremors will become worse when the medication is wearing off. 4. The client may automatically start to repeat what another person says.

2. These are psychosocial manifestations of PD. These should be discussed in the support meeting.

82. Which is a common cognitive problem associated with Parkinson's disease? 1. Emotional lability. 2. Depression. 3. Memory deficits. 4. Paranoia.

3. Memory deficits are cognitive impairments. The client may also develop a dementia.

80. The client diagnosed with Parkinson's disease is being discharged. Which statement made by the significant other indicates an understanding of the discharge instructions? 1. "All of my spouse's emotions will slow down now just like his body movements." 2. "My spouse may experience hallucinations until the medication starts working." 3. "I will schedule appointments late in the morning after his morning bath." 4. "It is fine if we don't follow a strict medication schedule on weekends."

3. Scheduling appointments late in the morning gives the client a chance to complete ADLs without pressure and allows the medications time to give the best benefits.

The nurse creates a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) need to be placed at the child's bedside? 1. Emergency cart 2. Tracheotomy set 3. Padded tongue blade 4. Suctioning equipment and oxygen

Which measurement is the best indicator of how well an antiseizure medication is working? A. Serum drug levels B. Frequency and duration of seizures C. Liver enzymes D. Urinary output

The nurse is creating a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply. 1. Time the seizure. 2. Restrain the child. 3. Stay with the child. 4. Place the child in a prone position. 5. Move furniture away from the child. 6. Insert a padded tongue blade in the child's mouth.

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The nurse is caring for a child who had a seizure 15 minutes after sustaining a head injury. After assuring a patent airway, which of the following is the priority intervention? 1 Assess fluid and electrolyte status 2 Administer prescribed benzodiazepine 3 Monitor for postconcussive syndrome 4 Observe for signs of increased intracranial pressure

81. The nurse is admitting a client with the diagnosis of Parkinson's disease. Which assessment data support this diagnosis? 1. Crackles in the upper lung fields and jugular vein distention. 2. Muscle weakness in the upper extremities and ptosis. 3. Exaggerated arm swinging and scanning speech. 4. Masklike facies and a shuffling gait.

4. Masklike facies and a shuffling gait are two clinical manifestations of PD.

84. The nurse is caring for clients on a medical-surgical floor. Which client should be assessed first? 1. The 65-year-old client diagnosed with seizures who is complaining of a headache that is a "2" on a 1-to-10 scale. 2. The 24-year-old client diagnosed with a T10 spinal cord injury who cannot move his toes. 3. The 58-year-old client diagnosed with Parkinson's disease who is crying and worried about her facial appearance. 4. The 62-year-old client diagnosed with a cerebrovascular accident who has a resolving left hemiparesis.

3. Body image is a concern for clients diagnosed with PD. This client is the one client who is not experiencing expected sequelae of the disease.

74. The client diagnosed with PD is being discharged on carbidopa/levodopa (Sinemet), an antiparkinsonian drug. Which statement is the scientific rationale for combining these medications? 1. There will be fewer side effects with this combination than with carbidopa alone. 2. Dopamine D requires the presence of both of these medications to work. 3. Carbidopa makes more levodopa available to the brain. 4. Carbidopa crosses the blood-brain barrier to treat Parkinson's disease.

3. Carbidopa enhances the effects of levodopa by inhibiting decarboxylase in the periphery, thereby making more levodopa available to the central nervous system. Sinemet is the most effective treatment for PD.

75. The nurse caring for a client diagnosed with Parkinson's disease writes a problem of "impaired nutrition." Which nursing intervention would be included in the plan of care? 1. Consult the occupational therapist for adaptive appliances for eating. 2. Request a low-fat, low-sodium diet from the dietary department. 3. Provide three (3) meals per day that include nuts and whole-grain breads. 4. Offer six (6) meals per day with a soft consistency.

4. The client's energy levels will not sustain eating for long periods. Offering frequent and easy-to-chew (soft) meals of small proportions is the preferred dietary plan.

Jane, a 20- year old college student is admiited to the hospital with a tentative diagnosis of myasthenia gravis. She is scheduled to have a series of diagnostic studies for myasthenia gravis, including a Tensilon test. In preparing her for this procedure, the nurse explains that her response to the medication will confirm the diagnosis if Tensilon produces: A. Brief exaggeration of symptoms B. Prolonged symptomatic improvement C. Rapid but brief symptomatic improvement D. Symptomatic improvement of just the ptosis

:Tensilon acts systemically to increase muscle strength; with a peak effect in 30 seconds, It lasts several minutes

A patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider should the nurse question? a. Elevate the head of the bed 20 degrees. b. Restrict oral fluids to 1000 mL daily. c. Administer ceftriaxone (Rocephin) 1 g IV every 12 hours. d. Give ibuprofen (Motrin) 400 mg every 6 hours as needed for headache.

ANS: B The patient with meningitis has increased fluid needs, so oral fluids should be encouraged. The other actions are appropriate. Slight elevation of the head of the bed will decrease headache without causing leakage of cerebrospinal fluid from the lumbar puncture site. Antibiotics should be administered until bacterial meningitis is ruled out by the cerebrospinal fluid analysis

Which characteristic of a patient's recent seizure indicates a partial seizure? A. The patient lost consciousness during the seizure. B. The seizure involved lipsmacking and repetitive movements. C. The patient fell to the ground and became stiff for 20 seconds. D. The etiology of the seizure involved both sides of the patient's brain.

FINAL: Neuro

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