MED SURG CH. 27 EAQ

A patient with Parkinson disease comes to the clinic for a follow-up appointment a few weeks after being newly diagnosed. The patient is currently taking carbidopa/levodopa. Which statement, made by the patient is a priority concern for the nurse to report to the health care provider? 1. "I began taking several herbal supplements." 2. "I participate in a sit-and-be-fit exercise regimen." 3. "I take my medication exactly as I was instructed." 4. "I have noticed that my fine tremors are getting worse."

1. "I began taking several herbal supplements." Patients with Parkinson syndrome should be cautioned about taking herbal supplements before consulting a health care provider. Herbs such as kava kava can worsen the symptoms of Parkinson syndrome, and Indian snakeroot interferes with the actions of levodopa and carbidopa. Stretching and exercise should be encouraged to maintain motility and balance; therefore a sit-and-be-fit program is appropriate. Taking medication as prescribed is recommended. Fine tremors may get worse with the disorder.

A nurse is caring for a patient with a suspected spinal accessory nerve injury. What instructions will the nurse anticipate the health care provider will give to the patient to test the functions of this nerve? Select all that apply. 1. "Shrug the shoulders." 2. "Stick out your tongue." 3. "Read the clock on the wall across from you." 4. "Move the tongue up and down and side to side." 5. "Turn the head to either side against resistance."

1. "Shrug the shoulders." 5. "Turn the head to either side against resistance." The spinal accessory nerve is tested by asking the patient to shrug the shoulders and turn the head to either side against resistance. The gag reflex is elicited to test the glossopharyngeal and vagus nerves. When testing the hypoglossal nerve, the patient is asked to protrude the tongue.

What is the normal intracranial pressure, measured in mm Hg? 1. 0 to 15 2. 15 to 30 3. 30 to 60 4. 60 to 90

1. 0 to 15 Normal intracranial pressure is 0 to 15 mm Hg. Anything higher than 15 is considered increased intracranial pressure.

A patient has increased intracranial pressure (ICP). The nurse evaluates the patient's level of consciousness and records a Glasgow Coma Scale (GCS) score that indicates the patient is in a comatose state. What would be an appropriate GCS score? Select all that apply. 1. 4 2. 5 3. 6 4. 9 5. 11

1. 4 2. 5 3. 6 A GCS score of 7 or less (4, 5, and 6) generally indicates coma. Scores of 9 or 11 are greater than 8 and do not indicate coma

A child with a seizure disorder is admitted to the pediatric unit. His mother reports that the child has brief periods of loss of consciousness during which he appears to be daydreaming. The nurse knows that the child is experiencing which type of seizure? 1. Absence 2. Tonic-clonic 3. Focal motor 4. Simple partial

1. Absence Absence seizures are brief periods of loss of consciousness during which the individual may appear to be daydreaming. A tonic-clonic seizure is generalized; the patient loses consciousness, and a stiffening of the muscles or extremities and rhythmic movement of the extremities occur. Focal motor seizures are a subtype of simple seizures during which the abnormal brain activity remains localized to a specific motor area. A simple partial seizure may include motor, somatosensory, autonomic, or psychic symptoms.

The nurse is preparing medications to include in an emergency department medication room. Which intravenous medication should be available for the initial medical treatment for status epilepticus? 1. Anticonvulsant drugs 2. sychotropic medications 3. General anesthetic agents 4. Neuromuscular blocking agents

1. Anticonvulsant drugs Status epilepticus is treated with intravenous anticonvulsant drugs. If the patient does not respond to anticonvulsants, general anesthetic agents and neuromuscular blocking agents may be used. Psychotropic medications are not used at this time.

A nurse is caring for a patient with suspected facial nerve injury. Which methods of assessment of facial nerve palsy does the nurse anticipate will be used by the health care provider? Select all that apply. 1. Ask the patient to puff out the cheeks. 2. Pin prick the tip of the nose. 3. Ask the patient to protrude the tongue. 4. Test the sense of taste on the posterior third of the tongue. 5. Ask the patient to shut his or her eyes.

1. Ask the patient to puff out the cheeks. 5. Ask the patient to shut his or her eyes. The facial nerve can be evaluated by asking the patient to puff out the cheeks and to shut his or her eyes. A pin prick on the nose will help to test sensation perception. Protrusion of the tongue tests the hypoglossal nerve. The facial nerve is responsible for taste in the anterior two-thirds of the tongue, but the sensory fibers for taste from the posterior third of the tongue are associated with the glossopharyngeal nerve.

When performing a physical examination on a healthy patient, how would the nurse anticipate the health care provider tests the glossopharyngeal and vagus nerves? Select all that apply. 1. Assess the gag reflex. 2. Turn the head against resistance. 3. Swallow a sip of water when asked. 4. Ask the patient to shrug the shoulders. 5. Ask the patient to protrude the tongue to see midline protrusion.

1. Assess the gag reflex. 3. Swallow a sip of water when asked. The vagus and glossopharyngeal nerves are tested by having the patient swallow upon command and by assessing the gag reflex. Asking the patient to turn the head against resistance and to shrug the shoulders evaluates cranial nerve XI, the spinal accessory nerve. The patient's ability to move the tongue evaluates cranial nerve XII, the hypoglossal nerve.

A patient sustained multiple injuries from a traumatic fall down several flights of stairs. Upon arrival to the emergency department, the patient is exhibiting an increase in intracranial pressure. Which consideration should be given priority? 1. Assessing level of consciousness 2. Drawing laboratory values as ordered 3. Controlling bleeding from minor wounds 4. Getting an x-ray and setting a neck fracture

1. Assessing level of consciousness Level of consciousness (LOC) is the most reliable indicator of mental status because of the extreme sensitivity to oxygen levels in the cerebral blood. As intracranial pressure increases and perfusion is decreased, oxygen delivery to cerebral tissue is also reduced. Drawing laboratory values is important and warranted, but failure to address LOC can lead to respiratory depression. Bleeding from minor wounds will need to be controlled at some point, but it does not take priority over assessment of LOC. Getting an x-ray should occur once intracranial pressure is addressed.

A patient has recently been diagnosed with multiple sclerosis (MS) and has been researching the disease on the Internet. Some of the information the patient has shared with the nurse is incorrect. Which information is factual? Select all that apply. 1. Bowel and bladder problems are common. 2. Multiple sclerosis attacks the myelin sheath. 3. Gabapentin is sometimes used for pain. 4. Usually the disease strikes during the fifth decade of life. 5. The disease is always characterized by remissions and exacerbations. 6. Avoidance of cold is important, so consider a warm climate.

1. Bowel and bladder problems are common. 2. Multiple sclerosis attacks the myelin sheath. 3. Gabapentin is sometimes used for pain. Bowel and bladder problems such as urgency and spasticity are common. Multiple sclerosis attacks the myelin sheath, disrupting the conduction of nerve impulses. Gabapentin is used to treat neuropathic pain. Multiple sclerosis patients can experience periods of remissions and exacerbations, or may have a chronic progressive form of the disease. Symptoms worsen with warm weather. The incidence of multiple sclerosis is highest between 20 and 40 years of age.

Which symptom is the earliest indication of increased intracranial pressure (ICP)? 1. Changes in level of consciousness 2. Change from normal to dilated pupil 3. Altered motor function on side opposite from mass 4. Increasing systolic blood pressure without change in diastolic reading

1. Changes in level of consciousness Changes in the patient's level of consciousness are the earliest indicator of ICP. This is due to oxygen sensitivity in cerebral blood, which decreases as ICP rises. A dilated pupil is a later sign of ICP. Altered motor function occurs as pressure on the frontal lobe increases. Changes in vital signs are later signs of the condition, and the widening pulse pressure described is a part of Cushing's triad.

The nurse is assisting with data collection during a neurologic assessment performed on a patient. The patient is asked to identify a common smell with the eyes closed. In addition, visual acuity and a hearing test were also done. Which cranial nerves were assessed? Select all that apply. 1. Cranial nerve I 2. Cranial nerve II 3. Cranial nerve VII 4. Cranial nerve VIII 5. Cranial nerve IX

1. Cranial nerve I 2. Cranial nerve II 4. Cranial nerve VIII Cranial nerve I is assessed by having a patient identify a familiar smell. A visual acuity test assesses cranial nerve II, and a hearing test assesses cranial nerve VIII. Cranial nerve VII can be tested via smiling, frowning, and puffing the cheeks. Cranial nerve IX is tested by swallowing on command and assessing the gag reflex.

In Parkinson disease, a deficiency of which neurotransmitter at the basal ganglia contributes to a loss of motor function? 1. Dopamine 2. Epinephrine 3. Acetylcholine 4. Norepinephrine

1. Dopamine Parkinson disease is related to a decreased level of dopamine in the basal ganglia, contributing to the loss of motor function. Epinephrine increases the heart rate in times of stress. Acetylcholine is a transmitter at the junction connecting motor nerves to muscles. Norepinephrine causes vasoconstriction in the skin, raising blood pressure.

A nurse is preparing to administer medication for a patient with a diagnosis of increased intracranial pressure. Which drugs should the nurse expect to administer for this disease process? Select all that apply. 1. Furosemide 2. Plavix 3. Mannitol 4. Warfarin 5. Dexamethasone

1. Furosemide 3. Mannitol 5. Dexamethasone Intravenous mannitol is administration is one of the mainstays in the treatment of increased ICP. Mannitol draws edema fluid from the tissue spaces into the bloodstream. The excess fluid is excreted via the kidneys. Diuretics such as furosemide may also be used to reduce cerebral edema. Corticosteroids, although controversial may be used to help decrease the edema and ICP. Dexamethasone is a major agent used to treat inflammation for patients with neurologic disorders. Plavix is used to prevent platelet clotting which is not an issue with increased intracranial pressure. Warfarin is an anticoagulant, and would not be used for increased intracranial pressure.

A patient with Parkinson disease arrives at the clinic with the currently prescribed medications. The nurse knows which category of medications has been prescribed for treatment of Parkinson disease? 1. L-dopa 2. Antiinfective drugs 3. Anticholinergic drugs 4. Antidepressant medications

1. L-dopa The cornerstone of therapy for Parkinson disease is the use of L-dopa. L-dopa can cross the blood-brain barrier and is converted to dopamine in the basal ganglia, thereby supplementing levels of the neurotransmitter and reducing symptoms of the disease. Anticholinergic drugs may be used in patients with less severe symptoms or who are unresponsive to L-dopa. Treatment for depression that may accompany the diagnosis of Parkinson disease include antidepressant drug therapy. Antiinfective drugs are not used to treat the symptoms of Parkinson disease.

When participating in a planning conference for a patient in the acute phase of Guillain-Barré syndrome, which aspects of care should the nurse incorporate? Select all that apply. 1. Monitor respiratory status. 2. Turn the patient every 2 hours. 3. Exercise routine three times daily. 4. Use alternative methods of communication. 5. Monitor flow rate of total parenteral nutrition (TPN).

1. Monitor respiratory status. 2. Turn the patient every 2 hours. 4. Use alternative methods of communication. Management during the acute phase of the illness is directed at preserving vital function, particularly respiration. Respiratory status is closely monitored, and mechanical ventilation may be initiated. Careful positioning is crucial. Communication and immobility are major issues to address in the patient with Guillain Barré syndrome. If mobility is severely impaired, then the patient may benefit from the use of rotational bed therapy. Active and passive exercise, along with a continuous passive motion machine, may be used to prevent contractures. Total parenteral nutrition (TPN) is not a usual aspect of care for a patient with Guillain-Barré syndrome.

In what alternative treatment for myasthenia gravis are the acetylcholine receptor antibodies washed from the plasma in an exchange? 1. Plasmapheresis 2. Computed tomography (CT) 3. Electroencephalogram (EEG) 4. Magnetic resonance imaging (MRI)

1. Plasmapheresis Plasmapheresis involves an exchange in which acetylcholine receptor antibodies are washed from the plasma. The procedure involves routing blood through a pheresis field, washing it, and then returning it to the patient. The procedure is repeated over several days. Improvement is usually seen 24 to 48 hours after treatment.

During a neurologic assessment, the health care provider will test the functionality of the facial nerve of a patient. What instructions should the nurse give to the patient? Select all that apply. 1. Puff out the cheeks 2. Protrude the tongue 3. Frown 4. Read a vision chart 5. Move the tongue side to side

1. Puff out the cheeks 3. Frown Asymmetry in facial movements indicates damage to the facial nerve. When assessing cranial nerve VII (the facial nerve), the patient is asked to puff out the cheeks, frown, and may also be asked to close the eyes tightly. A Snellen chart is used to test visual acuity (the optic nerve), and protrusion of the tongue or moving the tongue from side to side assesses the hypoglossal nerve.

A patient is prescribed mannitol to help decrease intracranial pressure. What should the nurse monitor in an attempt to validate the effectiveness of this drug? 1. Temperature 2. Urinary output 3. Glucose levels 4. Specific gravity

2. Urinary output Intravenous mannitol is one of the mainstay treatments for increased intracranial pressure. The hyperosmolar diuretic draws edema fluid from the tissue spaces into the bloodstream. Urinary output should be monitored because the mannitol and excess fluid is eliminated via the kidneys. Glucose levels are more of an indication of diabetes, temperature may indicate an infection, and specific gravity is related to urine concentration.

A patient has been diagnosed with amyotrophic lateral sclerosis, commonly known as Lou Gehrig disease. Which symptoms might the patient display? Select all that apply. 1. Slurred speech 2. Muscle weakness 3. Difficulty swallowing 4. Altered intellectual ability 5. Loss of vision and hearing 6. Difficulty clearing the airway

1. Slurred speech 2. Muscle weakness 3. Difficulty swallowing 6. Difficulty clearing the airway Initially the patient experiences weakness of the upper extremities, which progresses to incapacitation. Slurred speech occurs due to weakness of the oropharyngeal muscles. Weakness of these muscles affects swallowing. The patient eventually has difficulty clearing the airway as the disease progresses. Intellectual ability, vision, and hearing are not affected by the disease.

An immunosuppressive drug is being used to treat a patient with multiple sclerosis. Which assessment finding if elicited by the nurse would be of greatest concern? 1. Temperature of 100.9° F 2. Pulse rate of 66 beats/min 3. Blood pressure of 150/86 mm Hg 4. Respiratory rate of 24 breaths/min

1. Temperature of 100.9° F The patient with multiple sclerosis who is being treated with immunosuppressive drugs has a decreased resistance to infection. A temperature of 100.9° F indicates a possible infection and should be of great concern. A pulse rate of 66, respiratory rate of 24, and blood pressure of 150/86 are not associated with adverse effects of an immunosuppressive drug.

A patient returned to the unit 3 hours after having a lumbar puncture. Which findings would be of concern if noted on the postprocedure assessment? Select all that apply. 1. Tingling in the extremities 2. Bright red blood oozing from the puncture site 3. Requests pain medication for slight discomfort 4. Increased respirations, heart rate, and blood pressure 5. Headache with hypersensitivity to light; preferring a dark room

1. Tingling in the extremities 2. Bright red blood oozing from the puncture site 4. Increased respirations, heart rate, and blood pressure Assess the patient for numbness, tingling, or pain in the extremities; cerebral spinal fluid or bleeding from the puncture site; and changes in vital signs. The patient may experience some discomfort at the puncture site, and this is an expected outcome. Headache with light hypersensitivity is a symptom of a migraine headache and is not associated with lumbar puncture.

A high school baseball player was hit in the head with a pitch during afterschool practice. The nurse monitors most closely during which time frame, when the player is most at risk for acute subdural hematoma? 1. Within 24 hours of the injury 2. Immediately at the time of injury 3. Within weeks or months of the original injury 4. Between the first 24 hours but before 1 week after the initial injury

1. Within 24 hours of the injury Acute subdural hematomas develop within 24 hours of the injury. Chronic subdural hematomas occur within weeks or even months of the original injury and are associated with low-impact injuries that cause very slow, diffuse bleeding. Subacute subdural hematomas are seen between the first 24 hours but before 1 week after the initial injury.

The nurse is assessing a fully alert patient who moves all extremities well. What score should the nurse give the patient on the Glasgow Coma Scale (GCS)? Record your answer using a whole number.

15 The highest GCS score is 15 for a fully alert person.

Which area of the brain is responsible for coordinating movement? 1. Medulla 2. Cerebellum 3. Occipital Lobe 4. Temporal Lobe

2. Cerebellum The cerebellum coordinates movement, balance, posture, and spatial judgment. The medulla deals with cardiac and respiratory function. The occipital lobe is responsible for vision. The temporal lobe deals with hearing.

The nurse is assisting with data collection for a patient who is hospitalized with a concussion head injury. Which steps are part of this data collection? Select all that apply. 1. Orders computed tomography (CT) scans of the head. 2. Checks the patient's reflexes. 3. Orders appropriate laboratory tests. 4. Asks the patient to state name, where he or she is, and the date. 5. Shines a pen light into the patient's eyes to check pupillary response.

2. Checks the patient's reflexes. 4. Asks the patient to state name, where he or she is, and the date. 5. Shines a pen light into the patient's eyes to check pupillary response. The neurologic assessment provides baseline data to compare with ongoing assessment and serves as the basis for developing the nursing care plan. The four components of the neurologic exam that provide valuable information regarding the integrity of the central nervous system are neuromuscular response, including movement and reflexes; level of consciousness (orientation to person/place/time); pupillary evaluation (response to light); and vital signs. Ordering CT scans and laboratory tests may be appropriate, but these are not within the function of the nurse.

When educating the patient about ways to prevent head injuries, about which measures should the nurse counsel the patient? Select all that apply. 1. Use of carpooling 2. Use of car seat belts 3. Use of tinted glasses 4. Use of helmets on construction sites 5. Use of helmets by cyclists

2. Use of car seat belts 4. Use of helmets on construction sites 5. Use of helmets by cyclists Using car seat belts, using helmets on construction sites, and using helmets by cyclists can help to prevent head injuries. Use of carpooling and use of tinted glasses do not help to reduce the rate of head injuries.

A patient with myasthenia gravis is admitted to the emergency department. The patient is experiencing extreme weakness, including difficulty swallowing and breathing. The patient is administered a dose of intravenous edrophonium, and there is no marked improvement in the patient's overall condition. The nurse suspects the patient is experiencing what kind of crisis? 1. Adrenal 2. Cholinergic 3. Myasthenic 4. Hypertensive

2. Cholinergic The patient with myasthenia gravis may experience a myasthenic crisis (not enough medication) or a cholinergic crisis (too much medication). Both crises have very similar signs, and a differentiation must be made. Tensilon is given, and if the patient shows a remarkable improvement, which lasts a few seconds, then the crisis is myasthenic in nature. However, if there is no improvement after the drug is given, it indicates a cholinergic crisis. Based on the information in the question, there is not enough evidence for the nurse to conclude that the patient is experiencing either adrenal or hypertensive crises.

A patient complains of poor peripheral vision. The nurse anticipates which nerve will be evaluated by the health care provider? 1. Cranial nerve (CN) I 2. Cranial nerve (CN) II 3. Cranial nerve (CN) III 4. Cranial nerve (CN) VII

2. Cranial nerve (CN) II Cranial nerve II, the optic nerve, should be evaluated for visual acuity and visual fields. Cranial nerve I, the olfactory nerve, would be evaluated for difficult with the sense of smell. Cranial nerve III, the oculomotor nerve would be evaluated for movements of the eye. Cranial nerve VII, the facial nerve, would be evaluated for the ability to close the eye.

A patient with amyotrophic lateral sclerosis (Lou Gehrig's disease) has been recently admitted. Which patient problem listed in the nursing care plan would be a priority? 1. Inability to grieve 2. Inability to clear airway 3. Impaired physical mobility 4. Compromised skin integrity

2. Inability to clear airway The patient's respiratory rate and effort, breath sounds, and pulse rate are monitored to detect inadequate oxygenation. The patient with amyotrophic lateral sclerosis is prone to secretion production and potentially atelectasis and pneumonia. Therefore, this is the priority in the care of the patient. Progressive muscle wasting and paralysis occurs and results in immobility, which can lead to skin breakdown. Patients usually die in 3 years and will require time to grieve once the diagnosis is made.

Which advice does the nurse give to a patient who has undergone a brain scan to confirm a brain abscess? 1. Shampoo the hair 2. Increase oral intake of fluids 3. Lie in a supine position for 2 hours 4. Return to the hospital within 5 days for enzyme tests

2. Increase oral intake of fluids During a brain scan, an isotope is injected to diagnose neurologic disorders such as brain abscesses, tumors, and contusions. Increased oral intake of fluids promotes the elimination of the isotope. The nurse tells a patient to shampoo his or her hair after electroencephalography to remove the electrode paste but not after a brain scan. The nurse places the patient in a flat supine position to reduce or prevent headache after lumbar puncture. The nurse instructs the patient to return to the hospital within 5 days after an electromyography for enzyme tests. It is not required for a patient who has undergone a brain scan.

The health care provider requests cerebral angiography for a patient to detect a potential brain tumor. Which patient instruction is most appropriate to provide? 1. Explain that the procedure is noninvasive. 2. Instruct that a contrast medium will be injected. 3. Instruct that the bladder should be full for this test. 4. Explain that full activity will be allowed after the procedure.

2. Instruct that a contrast medium will be injected. Cerebral angiography is a contrast-based test. The nurse should explain that a contrast medium will be injected by a small needle into the artery, making this procedure invasive. A full bladder is not required with this test. The patient's activity will be restricted to bed rest for a specified amount of time after the procedure.

The LPN is caring for a patient who has undergone a lumbar puncture. The nurse should provide which nursing intervention related to postprocedure care and prevention of headache? 1. Limit the patient's intake of oral fluids. 2. Instruct the patient to lie flat after the procedure. 3. Frequently assess the patient for changes in vital signs. 4. Assess for numbness, tingling, or pain in the extremities.

2. Instruct the patient to lie flat after the procedure. The risk for headache may be reduced by lying flat for a specific period after the procedure. Fluids are not restricted after a lumbar puncture. Frequently assessing the patient for changes in vital signs, numbness, tingling, or pain in the extremities are also important interventions for the patient after a lumbar puncture, but are not interventions for the prevention of headache.

A nurse is evaluating the mental status of a patient. What criterion should the nurse use to judge the mental status of the patient? 1. Intact sense of smell 2. Level of consciousness 3. Pupils reactive to light 4. Midline protrusion of tongue

2. Level of consciousness The patient's alertness and orientation help the nurse evaluate the mental status of the patient. An intact sense of smell, reaction of pupils to light, and a midline protrusion of the tongue suggest normal functioning of associated cranial nerves.

In an effort to promote mobility in a patient with Parkinson disease, what should be included in the patient teaching? 1. Sleep sitting up in a chair. 2. March in place before beginning to walk. 3. Lie flat, and place pillows under the feet before going to bed. 4. Keep a wheelchair at the side of the bed, and use it pull up to a sitting position.

2. March in place before beginning to walk. Suggestions to improve mobility with Parkinson disease includes marching in place before walking. Sleeping in a chair may put the patient at risk as coordination and balance is an issue. Lying flat and placing pillows under the feet may make it more difficult for the patient to get out of bed. Using a wheelchair to pull up to a sitting position is a hazard and could cause the patient to fall.

A patient returned to the nursing unit after a lumbar puncture. In which position should the patient be placed after the procedure to avoid complications? 1. Prone 2. Supine 3. Mid-Fowler 4. High-Fowler

2. Supine The risk of post-lumbar puncture headache is reduced by lying flat, which is the supine position. The prone position is uncomfortable for many patients and would make it more difficult to assess vital signs. The mid-Fowler position has the head of the bed raised to 45 degrees and may contribute to a spinal headache. The high-Fowler position has the head of bed raised and can cause a severe headache.

The health care provider elicits the gag reflex on a patient. Which cranial nerve is being evaluated with this technique? Select all that apply. 1. Olfactory nerve 2. Vagus nerve 3. Facial nerve 4. Trochlear nerve 5. Glossopharyngeal nerve

2. Vagus nerve 5. Glossopharyngeal nerve The gag reflex tests the performance of the vagus nerve and the glossopharyngeal nerve. The olfactory nerve is assessed by asking the patient to close each nostril one at a time and identify easily recognized odors. The facial nerve is assessed by asking the patient to, close the eyes tightly, purse the lips, draw back the corners of the mouth in an exaggerated smile, and frown. The trochlear nerve is assessed along with oculomotor and abducens nerves, as all three nerves help move the eyes.

Neurons that transmit information from distal parts of the body or environment toward the central nervous system (CNS) are sensory neurons, which are also known by which term? 1. Axons 2. Dendrites 3. Afferent neurons 4. Efferent neurons

3. Afferent neurons Neurons that transmit information from distal parts of the body or environment toward the CNS are sensory neurons, which are also known as afferent neurons. Motor information is carried from the CNS to the periphery by motor neurons, which are also known as efferent neurons. Dendrites are branches of the main cell body that convey impulses toward the cell body. Axons are branches of the main cell body that conduct impulses away from the cell body.

A patient who is newly diagnosed with seizure disorder is crying in her room. She says that she is not sure what the word "aura" means. The nurse is correct if she explains what to the patient? 1. An aura is not real; it is imagined. 2. An aura occurs once consciousness is regained after a seizure. 3. An aura can be a sensation such as a noise, odor, and/or pain. 4. An aura happens only when the patient has an epileptic seizure.

3. An aura can be a sensation such as a noise, odor, and/or pain. An aura is something that a patient experiences before a seizure such as an odor, visual disturbance, perception, and/or offensive odor. It is not imagined. It occurs before a seizure, not afterward. An aura can occur before any seizure, and it is not limited to specific types of seizure.

The nurse is caring for a patient with Guillain Barré syndrome. The nurse knows which diagnostic test confirmed this diagnosis? 1. Nerve conduction velocity studies 2. Results of magnetic resonance imaging 3. Characteristic onset and pattern of ascending motor involvement 4. Elevated protein level in cerebrospinal fluid (CSF) obtained by lumbar puncture

3. Characteristic onset and pattern of ascending motor involvement The characteristic onset and pattern of ascending motor involvement provide the basis for the diagnosis of Guillain-Barré syndrome. An elevated protein level in the CSF obtained by lumbar puncture provides additional evidence for the diagnosis. Nerve conduction velocity studies reveal slowed conduction speed in the involved nerves. Magnetic resonance imaging is not diagnostic for Guillain-Barré syndrome.

A witness to a person having a seizure described a rhythmic movement of the extremities that followed the person becoming stiff, dropping to the floor, and becoming unconscious. Which term describes this rhythmic movement? 1. Aura 2. Tonic 3. Clonic 4. Myoclonic

3. Clonic The clonic phase follows the tonic phase and is the term for the rhythmic movement of the extremities. An aura is a sensation that precedes a seizure. Tonic phase is the stiffening of muscles or extremities with loss of consciousness. A myoclonic seizure has brief jerking or stiffening rather than a rhythmic movement.

A patient who had a tumor removed from the brain is crying. When questioned, the patient says that he wished that he had died in surgery because he looks like a monster. What is the best action for the nurse to take? 1. Return when the patient stops crying. 2. Have the patient call a spiritual advisor for comfort. 3. Encourage the patient to express fears and concerns. 4. Offer to stay with the patient until a family member arrives for support.

3. Encourage the patient to express fears and concerns. The losses associated with a head injury can render the patient unable to perform usual activities. The injury may also leave distinguishing scars or distorted features. Demonstrate acceptance of the patient, and encourage him or her to ask questions and express concerns. Returning when the patient stops crying is inappropriate. Having the patient call a spiritual advisor may help, but the nurse should address any patient concerns immediately. Although it is a good gesture, staying with the patient until a family member arrives is not feasible as the nurse must tend to other patients.

The health care provider determines that a patient's symptoms are related to meningitis. Lumbar puncture results confirm this diagnosis. The nurse explains to the patient's family members that meningitis involves which process? 1. Inflammation of brain tissue 2. An autoimmune response to a viral infection 3. Inflammation of the meningeal coverings of the brain and spinal cord 4. A degenerative disorder of the basal ganglia that results in eventual loss of coordination

3. Inflammation of the meningeal coverings of the brain and spinal cord Meningitis is an inflammation of the meningeal coverings of the brain and spinal cord. Encephalitis is inflammation of brain tissue. Guillain-Barré syndrome is an autoimmune response to a viral infection. Parkinson disease is a degenerative disorder of the basal ganglia that results in eventual loss of coordination.

Which is the most accurate and reliable indicator of neurologic status? 1. Vital signs 2. Pupillary evaluation 3. Level of consciousness 4. Neuromuscular response

3. Level of consciousness The most accurate and reliable indicator of neurologic status is the level of consciousness. Pupillary evaluation is the second major component of the neurologic assessment. Vital signs and neuromuscular response are not the most accurate indicators of neurologic status.

The LPN is caring for a patient who has myasthenia gravis. Which is the nurse's priority action for this patient? 1. Allow the patient to grieve. 2. Observe for excessive fatigue. 3. Monitor for difficulty breathing. 4. Involve the family in the patient's care.

3. Monitor for difficulty breathing. The most important intervention for the patient with myasthenia gravis is to monitor for difficulty breathing, since the patient may be experiencing a myasthenic or cholinergic crisis. Secondarily, the nurse should allow the patient to grieve, observe for excessive fatigue, and involve the family in the patient's care.

A patient sustained a head injury, and a diagnosis of subdural hematoma was made. The patient was taken to surgery, and the hematoma was removed. When the nurse assessed the patient postsurgery, the patient was drowsy, but responded to his name and was able to give today's date. An hour later, the patient was disorientated, restless, and lethargic. Which should be the nurse's priority action? 1. Reassess the patient within 1 hour. 2. Increase the rate of intravenous fluids. 3. Notify the health care provider immediately. 4. Position the patient flat, and place a pillow under the feet.

3. Notify the health care provider immediately. After surgery, the patient who has a subdural hematoma is at risk for ineffective tissue perfusion. A change in the level of consciousness or disorientation, restlessness, and lethargy are indications of an increase in intracranial pressure and impaired cerebral flow. The health care provider should be notified immediately. Reassessing the patient in 1 hour may be detrimental to the patient's recovery. Increasing the flow rate of IV fluids can lead to fluid volume excess. Positioning the patient flat with the feet elevated would further increase intracranial pressure.

An older adult patient was brought into the clinic by the patient's son. The patient's gait was unsteady and shuffled. The patient presented with a blank facial expression, slurred speech, and hand tremor. Based on these signs, the nurse would anticipate that the patient is diagnosed with which disorder? 1. Multiple sclerosis 2. Myasthenia gravis 3. Parkinson disease 4. Guillain Barré syndrome

3. Parkinson disease A blank facial expression, slurred speech, hand tremor, and shuffling gate are classic signs of Parkinson disease. Multiple sclerosis is a progressive disorder with remissions and exacerbations. Myasthenia gravis is characterized by weakness of voluntary muscles. Guillain Barré syndrome involves a pattern of ascending motor paralysis.

A patient has increased intracranial pressure (ICP). What will the nurse evaluate using the Glasgow Coma Scale (GCS)? Select all that apply. 1. Patient's ability to swallow 2. Patient's digestion capacity 3. Patient's ability to speak clearly 4. Patient's ability to obey commands 5. Patient's ability to open eyes in response to painful stimulus

3. Patient's ability to speak clearly 4. Patient's ability to obey commands 5. Patient's ability to open eyes in response to painful stimulus Patient's ability to obey commands, to speak, and to open his or her eyes to verbal or painful stimulus are evaluated with the GCS. This scale does not include the assessment of patient's ability to swallow or assessment of digestion capacity.

The licensed practical nurse (LPN) is caring for a patient who will be discharged on a treatment regimen that includes phenytoin. Which instruction should the nurse give the patient? 1. Follow a low-fiber diet. 2. Monitor blood pressure daily. 3. Provide daily meticulous mouth care. 4. Take the medication on an empty stomach.

3. Provide daily meticulous mouth care. Meticulous mouth care should be provided to prevent gingival overgrowth when Dilantin is being administered. Blood pressure should be monitored frequently with Dilantin if it is being administered intravenously. It is also important to tell the patient to eat high-fiber foods to prevent constipation and to take medicine with food to reduce gastrointestinal irritation.

The LPN is caring for a patient who is experiencing a seizure. Which is the nurse's priority action for this patient? 1. Note the time of the start of the seizure. 2. Cradle the patient's head in the nurse's lap. 3. Quickly move objects away from the patient. 4. Turn the patient onto his or her side if possible.

3. Quickly move objects away from the patient. Although all of the interventions are important and should be implemented, the nurse's priority action would be to quickly move objects away from the patient to prevent injury. The next step would be to turn the patient onto his or her side if possible. It may not be possible to cradle the patient's head in the nurse's lap. It is important to note the time of the start of the seizure, but safety measures are the most important nursing intervention.

When taking the history of a patient with a migraine headache, what features of a migraine headache is the patient likely to report? Select all that apply. 1. The headache is caused by prolonged muscle contraction. 2. The headache has no warning symptoms. 3. The headache is usually unilateral. 4. The headache can be triggered by particular foods, such as chocolate. 5. The patient may experience nausea before the headache.

3. The headache is usually unilateral. 4. The headache can be triggered by particular foods, such as chocolate. 5. The patient may experience nausea before the headache. Migraine headaches are usually unilateral and can be triggered by certain foods, including chocolate, cheese, tomatoes, onions, and oranges. The headache can by preceded by nausea and other symptoms. A tension headache is caused by prolonged muscle contraction. A cluster headache usually has no warning symptoms.

A patient presents with an inability to turn his eyes together in the same direction. Which nerves should be tested to detect paralysis of the eye muscle in this patient? Select all that apply. 1. Optic nerve 2. Olfactory nerve 3. Trochlear nerve 4. Abducens nerve 5. Oculomotor nerve 6. Hypoglossal nerve

3. Trochlear nerve 4. Abducens nerve 5. Oculomotor nerve The trochlear, oculomotor, and abducens nerves help in movements of the eyes. Therefore, these three nerves should be tested together by asking the patient to hold the head steady and follow the movement of the nurse's finger with the eyes only. A normal response is parallel tracking of an object with both eyes. The optic nerve plays a role in visual acuity. The hypoglossal nerve and olfactory nerve do not play a role in eye movements.

A patient presents to the emergency department for excruciating pain to the jaw. Factors such as chewing and eating hot or cold food cause further debilitation. Based on the data provided, there is a preliminary diagnosis of trigeminal neuralgia. This disease involves which cranial nerve? 1. II 2. IV 3. V 4. VIII

3. V Trigeminal neuralgia is a disorder associated with cranial nerve V, whose function is facial sensation to hot, cold, light touch, and chewing. It is characterized by intense pain along the three branches of the trigeminal nerve. Pain usually has an abrupt onset and is unilateral in nature. The pain is crippling and restricts the patient's daily routine.

Which statement made by the parent of a patient with a history of grand mal seizures indicates a need for additional teaching? 1. "I should place my child on one side if possible." 2. "If the seizure continues for more than 4 minutes, I should call 911." 3. "When a seizure starts, I must remove hazardous objects from the area." 4. "Always place a stick or spoon in the mouth to prevent tongue swallowing."

4. "Always place a stick or spoon in the mouth to prevent tongue swallowing." Nothing should be forced into a person's mouth when having a seizure. The practice may cause damage to the mouth. This statement indicates that additional teaching is necessary. Placing a person who is having a seizure in a side position will help to prevent aspiration of secretions and occlusion of the airway by the tongue. Seizures lasting more than 4 minutes, or in rapid succession, warrant calling a medical emergency. Removing hazards from the immediate area helps to prevent injuries.

During a patient care planning conference, the goal of patient care is identified as keeping the intracranial pressure (ICP) low enough to allow adequate cerebral perfusion pressure. The nurse identifies which value as the minimum cerebral perfusion pressure (CPP) that ensures adequate cerebral functioning? 1. 20 mm Hg 2. 30 mm Hg 3. 40 mm Hg 4. 70 mm Hg

4. 70 mm Hg A patient with an elevated ICP may have decreased cerebral perfusion pressure. A minimum perfusion pressure of 70 mm Hg is necessary to ensure adequate cerebral functioning.

Which test is an excellent tool in the diagnosis of seizure activity? 1. Lumbar puncture 2. Electromyography 3. Graphesthesia test 4. Electroencephalography (EEG)

4. Electroencephalography (EEG) Electroencephalography (EEG) provides a graphic representation of the electrical activity in brain cells. It is an excellent tool in the diagnosis of seizure activity. Electromyography studies the response of peripheral motor and sensory nerves to electrical stimuli. Graphesthesia tests the patient's ability to recognize a number or letter "written" on the palm with a dull object and is a test for tactile discrimination. A lumbar puncture is an invasive procedure that is used most often to detect infections and other disorders of the central nervous system, tumors, and hydrocephalus.

A young adult is admitted with a head injury, and it is determined that the injury has caused an increase in intracranial pressure. Upon admission, the patient's blood pressure was 110/70 mm Hg and the pulse was 80 beats/min. Four hours later, the patient's blood pressure was 170/100 mm Hg and the pulse was 64 beats/min. Based on the patient's injury, these changes in vital signs would indicate that the patient is experiencing which condition? 1. Experiencing an acute cerebrovascular accident 2. Developing an incident of orthostatic hypotension 3. Experiencing an increase in blood pressure caused by a change in position 4. Exhibiting a widening pulse pressure due to an increase in intracranial pressure

4. Exhibiting a widening pulse pressure due to an increase in intracranial pressure Although it is important to monitor vital signs in the neurological patient, remember that changes in pulse, respiratory patterns, and blood pressure are late signs of increasing intracranial pressure. The combination of hypertension, bradycardia, and a widening pulse pressure (an increasing difference between systolic and diastolic pulse pressure) is referred to as Cushing's triad. Hypotension is not present, as hypertension is a common sign associated with increased intracranial pressure. The patient may have a stroke as a result of the hypertension, but there is no sufficient information to support a stroke at this time. Changes in position often cause hypotension, not hypertension.

What would the LPN evaluate first as the most accurate reliable indicator of neurologic status? 1. Vital signs 2. Patient blood flow 3. Pupillary evaluation 4. Level of consciousness

4. Level of consciousness The most reliable indication of neurologic status is the level of consciousness. The caregiver should evaluate patient's orientation by asking him or her to state names, where he or she is, and what time it is. Patient blood flow is not descriptive enough to indicate neurological status. Changes in vital signs and pupils occur later with neurologic disorders.

A patient presents with complaints of severe headaches beginning in the temple area, accompanied by nausea and vomiting, as well as light and noise worsening symptoms. Upon questioning, the patient states that these headaches come frequently around her menstrual period or after drinking red wine. Which type of headache do these symptoms suggest? 1. Sinus headache 2. Cluster headache 3. Tension headache 4. Migraine headache

4. Migraine headache Migraine headaches can cause irritability, visual disturbances, nausea, hypersensitivity to light, and other symptoms. Pain often begins in the eye or temporal area and is usually unilateral. Sinus headaches are connected to issues with the sinus. Cluster headaches come in a series and have no warning symptoms, unlike migraines. Tension headaches are the result of prolonged muscle contractions connected with stress.

The LPN is caring for a patient who will be on a treatment regimen that includes lamotrigine. Which is the nurse's priority nursing action for this patient? 1. Monitor the patient's blood counts. 2. Administer the drug with food or milk. 3. Monitor the patient for the complaint of headache. 4. Notify the health care provider of the evidence of a rash.

4. Notify the health care provider of the evidence of a rash. The rash associated with an adverse effect from lamotrigine is potentially life threatening and must be reported to the health care provider. The patient's blood count must be monitored; however, a rash is potentially life threatening and is the priority. Headaches can be treated with medications. The patient should take the medication with food or milk, however a rash is potentially life threatening and is the priority.

An LVN/LPN is at the bedside of a patient with meningitis. Which intervention if found in the nursing care plan should the nurse view as the greatest concern? 1. Monitor the level of consciousness frequently. 2. Position the patient to maintain a patent airway. 3. Elevate the head of the bed at a 45-degree angle. 4. Restrain the patient with chest restraint if restless.

4. Restrain the patient with chest restraint if restless. A complication of meningitis is an increase in intracranial pressure. The patient with meningitis should not be restrained unless absolutely necessary, as this causes an increase in intracranial pressure. The level of consciousness must be monitored frequently. Also, the patient must be positioned to maintain a patent airway. The head of the bed should be elevated.

To promote ease of swallowing for a patient with Parkinson disease, which intervention should the nurse use? 1. Provide three large meals daily. 2. Request a liquid diet instead of solid foods. 3. Encourage the patient to finish meals as quickly as possible. 4. Sit the patient in an upright position with the head of the bed elevated during meals.

4. Sit the patient in an upright position with the head of the bed elevated during meals. The patient with Parkinson disease should be placed in a comfortable position for meals, with the head of the bed elevated. Small, frequent meals are better tolerated than larger ones. Patients must never be rushed through meals. If the patient chokes on liquids, the dietician should be consulted for semisolids, and thick liquids are better tolerated.

A patient has an order for valproic acid 1 g PO every day. On hand is valproic acid 250 mg per 5 mL. How much will the patient receive in teaspoons? Record your answer using a whole number. _____tsp

X=4 250 mg : 5 mL = 1000 mg (converted from gram to mg): X=250X=5000mL=20 ml 20mL=X tsp, so X=4