NEURO 05032013

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The nurse determines that the son of a client with Alzheimer's disease needs further education about the disease when he makes which of the following statements? 1. "I didn't realize the deterioration would be so incapacitating." 2. "The Alzheimer's support group has so much good information." 3. "I get tired of the same old stories, but I know it's important for Dad." 4. "I woke up this morning expecting that my old Dad would be back."

4. The statement about expecting that the old Dad would be back conveys a lack of acceptance of the irreversible nature of the disease. The statement about not realizing that the deterioration would be so incapacitating is based in reality. The statement about the Alzheimer's group is based in reality and demonstrates the son's involvement with managing the disease. Stating that reminiscing is important reflects a realistic interpretation on the son's part.

16. The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to inability to feed self for a patient with right-sided hemiplegia. An appropriate nursing intervention is to a. assist the patient to eat with the left hand. b. provide oral care before and after meals. c. teach the patient the "chin-tuck" technique. d. provide a wide variety of food choices.

Correct Answer: A Rationale: Because the nursing diagnosis indicates that the patient's imbalanced nutrition is related to the right-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use the left hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition. Cognitive Level: Application Text Reference: p. 1522 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When obtaining admission assessment data about the patient's clinical manifestations, it is most important the nurse assess the patient's a. ability to follow commands. b. visual fields. c. right-sided reflexes. d. emotional state.

Correct Answer: A Rationale: Because the patient with a left-sided brain stroke may also have difficulty with comprehension and use of language, so it is important to obtain baseline data about the ability to follow commands. This will impact on patient safety and nursing care. The visual fields are not typically affected by a left-sided stroke. Information about reflexes and emotional state will be collected but is not as high a priority as information about language abilities. Cognitive Level: Application Text Reference: p. 1508 Nursing Process: Assessment NCLEX: Physiological Integrity

26. A patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Obtain the Glasgow Coma Scale score. b. Check the respiratory rate. c. Monitor the blood pressure. d. Send the patient for a CT scan.

Correct Answer: B Rationale: The initial nursing action should be to assess the airway and take any needed actions to assure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, circulation) are completed. Cognitive Level: Application Text Reference: p. 1511 Nursing Process: Implementation NCLEX: Physiological Integrity

9. On initial assessment of a patient hospitalized following a stroke, the nurse finds the patient's blood pressure to be 180/90 mm Hg. Which of the following orders by the health care provider should the nurse question? a. Infuse normal saline at 75 ml/hr. b. Keep head of bed elevated at least 30 degrees. c. Administer tissue plasminogen activator (tPA) per protocol. d. Titrate labetolol (Normodyne) drip to keep BP less than 140/90 mm Hg.

Correct Answer: D Rationale: Since elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if MAP is >130 mm Hg or systolic pressure is >220 mm Hg. Fluid intake should be 1500 to 2000 ml daily to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use. Cognitive Level: Application Text Reference: p. 1511 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency room with hemiparesis and dysarthria that started 2 hours previously. The nurse anticipates the need to prepare the patient for a. intravenous heparin administration. b. transluminal angioplasty. c. surgical endarterectomy. d. tissue plasminogen activator (tPA) infusion.

Correct Answer: D Rationale: The patient's history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 3 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy are not indicated for the patient who is having an acute ischemic stroke. Cognitive Level: Application Text Reference: p. 1512 Nursing Process: Planning NCLEX: Physiological Integrity

11. The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. An appropriate nursing intervention to help the patient communicate is to a. ask simple questions that the patient can answer with "yes" or "no." b. develop a list of words that the patient can read and practice reciting. c. have the patient practice facial and tongue exercises to improve motor control necessary for speech. d. prevent embarrassing the patient by changing the subject if the patient does not respond in a timely manner.

Correct Answer: A Rationale: Communication will be facilitated and less frustrating to the patient when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond. Cognitive Level: Application Text Reference: p. 1520 Nursing Process: Implementation 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

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

7. The health care provider prescribes clopidogrel (Plavix) for a patient with cerebral atherosclerosis. When teaching about the new medication, the nurse will tell the patient a. that Plavix will reduce cerebral artery plaque formation. b. to monitor and record the blood pressure daily. c. to call the health care provider if stools are tarry. d. that Plavix will dissolve clots in the cerebral arteries.

Correct Answer: C Rationale: Plavix inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots. Cognitive Level: Application Text Reference: p. 1510 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient has a new prescription for levodopa (L-dopa) to control symptoms of Parkinson's disease. Which assessment data obtained by the nurse may indicate a need for a decrease in the dose? a. The patient has a chronic dry cough. b. The patient has 4 loose stools in a day. c. The patient develops a deep vein thrombosis. d. The patient's blood pressure is 90/46 mm Hg.

Correct Answer: D Rationale: Hypotension is an adverse effect of L-dopa, and the nurse should check with the health care provider before giving the medication. Diarrhea, cough, and deep vein thrombosis are not associated with L-dopa use. Cognitive Level: Application Text Reference: p. 1552 Nursing Process: Evaluation NCLEX: Physiological Integrity

10. A patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency room with hemiparesis and dysarthria that started 2 hours previously. The nurse anticipates the need to prepare the patient for a. intravenous heparin administration. b. transluminal angioplasty. c. surgical endarterectomy. d. tissue plasminogen activator (tPA) infusion.

Nursing implementations for tx of AD include:

- Health promotion: early recognition and treatment are important - Acute intervention: in early stage, pts may cover up or mask faulty memory; assess for depression; assess coping of family, collaborate with caregiver to manage clinical manifestations as they change over time, teach caregiver to perform tasks

Early Warning signs of AD

- Memory loss that affects job skills - Difficulty performing familiar tasks - problems with language - disorientation to time and place - poor or decreased judgement - problems with abstract thinking - misplacing things - changes in mood or behavior - changes in personality - loss of initiative

What are the most common infections to occur in pts with AD?

- UTI d/t reduced fluid intake, prostate hyperplasia in men, poor hygeine, and urinary drainage devices (catheter) can predispose to bladder infx - pneumonia d/t risk for aspiration, immobility - these infx are ultimately the cause of death in many pts with AD

Characteristic findings of AD relate to changes in the brain's structure and function:

- amyloid plaques (more plaques in certain parts of the brain) - neurofibrillary tangles - loss of connections between cells and cell death

Methods for dealing with behavioral problems

- assess pt's physical status (changes in VS, urinary and bowel patterns, pain - assess environment (extremes in temp, excessive noise) - use reality orientation - rephrase pt's statement to validate - closely observe pt's emotional state - redirection (have pt perform activities like sweeping or dusting) - distraction (provide snacks, listen to music, look at pics, take a walk) - reassurance (communicate to pt they will be safe and protected) - use of repetitive activities, songs, poems, aromas, favorite object - don't threaten to restrain the pt or call the physician - document all interventions - as verbal skills decline, rely on body language to communicate

Care for caregivers includes

- assess stressors and identify coping strategies - determining what the caregiver views as the most disruptive or distressful (likely to change over time) can help establish priorities for care - risk to safety of pt and caregiver is high priority - support groups

What are some specific problems r/t the care of the pt with AD?

- behavioral problems - safety - pain management - eating and swallowing difficulties - oral care - skin care - elimination problems - caregiver support

What are manifestations of infx that should be promptly evaluated and treated?

- change in behavior, fever, cough (pneumonia), or pain on urination

Screening done with a thorough physical exam includes

- cobalamin (B12) deficiency - hypothyroidism - neurosyphilis (based on pt hx)

Diagnostic studies of AD include

- complete health hx, physical exam, neuro and mental status assessments, lab tests - CT or MRI may show brain atrophy and enlarged ventricles in the later stages - Single photon emission computed tomography (SPECT), magnetic resonance spectroscopy (MRS) and PET techniques allow for detection of early change in the disease as well as monitoring of treatment response

Family and Caregiver teaching in the mild stage includes

- confirm the diagnosis (many treatable and reversible conditions can mimic AD) - Get person to stop driving - Encourage activities such as visiting family and friends, listening to music, participating in hobbies, exercising - provide cues in the home, establish a routine and determine a specific location where essential items (eg glasses) need to be kept - don't correct misstatements or faulty memory - register with Medic Alert-Safe Return - make plans for future regarding advance directives, care options, financial concerns, and personal preference for care

In late stages of AD, what can lead to poor oral hygeine?

- decreased brushing and flossing - d/t swallowing difficulties, pt may pocket food in the mouth - dental caries and tooth abscess can add to pt discomfort or pain and subsequently may increase agitation

Factors affecting caregiver support

- family roles may be altered - couples sexual relations may be seriously affected

Early (mild) dementia

- forgetfulness beyond what is seen in a normal person - short-term memory impairment, esp. for new learning - difficulty recognizing what numbers mean - loss of initiative and interest - decreased judgement - geographic disorientation

Characteristics of Alzheimer's Disease Memory loss

- forgets what an item is used for or puts it in an inappropriate place - may not remember knowing a person - begins to lose language skills and may withdraw from social interaction - loses the sense of time; doesn't know what day it is - has seriously impaired recent memory and difficulty learning and remembering new info - becomes easily disoriented or lost in familiar places, sometimes for hours - may have little or no awareness of cognitive problems

What are cellular factors affecting r/f AD development?

- formation of free radicals (by-products of normal cell metabolism) damages neurons, resulting in loss of function - this oxidative damage leads to inflammation which may be a factor in AD development

Characteristics of MCI memory loss

- frequently misplaces items - frequently forgets people's names and is slow to recall them - has increasing difficulty finding desired words - begins to forget important events and appointments - may forget recent events or newly learned info - becomes temporarily lost more often; may have trouble understanding and following a map - worries about memory loss; family and friends notice lapses

Beta-amyloid affect on AD

- genetic factors may play a critical role in how the brain processes beta-amyloid - overproduction of beta-amyloid appears to be an important risk factor for AD - abnormally high levels of the protein produce cell damage (and ultimately neuron death) either directly or through and inflammatory response

Teach the caregiver to take these steps to promote safety:

- have stairwells well-lit - handrails should be graspable - tack down carpet edges - remove throw rugs and extension cords - use nonskid mats in tub or shower - install handrails in bath and commode

Middle (moderate) dementia

- impaired ability to recognize close family or friends - agitation - wandering, getting lost - loss of remote memory - confusion - impaired comprehension - forgets how to do simple tasks - apraxia - receptive aphasia - expressive aphasia - insomnia - delusions - illusions, hallucinations - behavioral problems

Collaborative management of AD is aimed at

- improving or controlling decline in cognition - controlling the undesirable behavior - providing support for the caregiver

Family and Caregiver teaching in the moderate stage includes

- install door locks for pt safety - provide protective wear for urinary and fecal incontinence - ensure home has good lighting, handrails for stairs and bathroom, remove or tack down area rugs - label drawers and faucets (hot and cold) - develop strategies such as distraction and diversion to cope with behavioral problems. Identify triggers - provide memory triggers such as pics of family and friends

Late (severe) dementia

- little memory, unable to process new information - can't understand words - difficulty eating, swallowing - repetitious words or sound - unable to perform self-care activities - immobility - incontinence

What are factors that contribute to undernutrition being a problem in the middle and late stages of AD

- loss of interest in food and decreased ability to self-feed (feeding apraxia) - co-morbid conditions - inadequate assistance with feeding

Goals for pt with AD

- maintain functional ability for as long as possible - be maintained in a safe environment with a minimum of injuries - have personal care needs met - have dignity maintained

What tools may be helpful in the early stages of AD?

- memory aids (eg calendars) - drug therapy with cholinesterase inhibiors appears to be most effective during the early stages of AD, must be taken on regular basis (adherance may be challenging d/t memory impairment) - inform family and pt that progression of dz is variable and may be slowed with effective mgmt - intitiate health care decisions, including advance directives, while pt has capacity

Characteristics of Parkinson's and Huntington's Diseases

- neurodegenerative - chronic, progressive and incurable - different etiologies and patho but both are associated with the development of dementia in the later stages of disease

Late-onset AD

- older than 60 - genetically more complex

Clinical features of depression

- onset coincides with life changes; often abrupt - course: diurnal effects, typically worse in the morning; situational fluctuations - progression is variable, rapid to slow but uneven - duration at least 2 wks, but can be several months to years - awareness is clear - alertness is normal - orientation: selective disorientation resulting from impaired concentration and attention span, which may manifest as memory deficit - thinking is intact but with apathy, fatigue; may not want to live; may be at r/f suicide - perception: may deny depression - psychomotor behavior: variable; psychomotor retardation or agitation - sleep-wake cycle is disturbed, often early morning awakening - mental status testing: frequent "don't know" answers, little effort, frequently gives up, indifferent

Clinical features of Delirium

- onset is rapid, often at night - course fluctuates, worse at night; lucid intervals - progression is abrupt - duration is hours to <1 mo - awareness is reduced - alertness fluctuates, lethargic or hypervigilant - orientation fluctuates in severity, generally impaired - thinking is disorganized, distorted, fragmented; slow or accelerated incoherent speech - perception is distorted; illusions, delusions and hallucinations - psychomotor behavior is variable, hyperkinetic, hypokinetic or mixed - sleep-wake cycle is disturbed, cycle reversed - mental status testing reveals distracted from task, poor performance; improves when pt recovers

Lewy Body disease

- presence of Lewy bodies (abnormal deposits of protein alpha-synuclein) in the brainstem and cortex - common cause of dementia often unrecognized by health care providers - sx of parkinsons, hallucinations, short-term memory loss, unpredictable cognitive shifts, sleep disturbances - dementia plus 2 of the following indicates a possible diagnosis: 1) EPS such as bradykinesia, rigidity and postural instability but not always a tremor, 2) fluctuating cognitive ability 3) hallucinations - this dz has features of both AD an parkinsons and it is imperative a correct diagnosis be reached - meds includ Sinemet and acetylcholinesterase inhibitors - nursing care focuses on mgmt of dementia, dysphagia and immobility - pt may have swallowing problems, impaired nutrition, r/f falls, pneumonia - dx is based on s/sx and histologic exam at autopsy

Family and Caregiver teaching in the late stage includes

- provide regular schedule for toileting - provide care to meet needs, including oral and skin care - monitor diet and fluid intake - continue communication through talking and touching - consider placement in LTC

What are the benefits of adult day care?

- provide respite for the family and a protective environment for the pt - during early and middle stages, pt can benefit from stimulating activities that encourage independence and decision-making in a protective environment - pt returns home tired, content, less frustrated and ready to be with the family - allows caregiver to have a respite and be more responsive to pt's needs

What is sundowning and what are the causes?

- pt becomes more confused and agitated in the late afternoon or evening - may be d/t a disruption in circadian rhythms - other possible causes include fatigue, unfamiliar environment , and noise (esp. in an acute setting), meds, reduced lighting, and sleep fragmentation

Creutzfeldt-Jakob disease

- rare and fatal brain disorder caused by a prion protein - a prion is a small infectious pathogen containing protein but lacking nucleic acid - variant form of CJD (vCJD) is from beef from cows with bovine spongiform encephalopathy (mad cow disease), extremely rare

Progression of AD in order of occurance:

- recent events and new info can't be recalled - personal hygiene and the ability to concentrate and maintain attention deteriorates - behavioral changes that are neither intentional nor controllable may include agitation, agression - some pts may develop psychotic manifestations (eg delusions, illusions, hallucinations - dysphasia (difficulty comprehending language and oral communication) - apraxia ( inability to manipulate objects or perform purposeful acts) - visual agnosia (inability to recognize objects by sight) - dysgraphia ( difficulty communicating via writing) - long-term memories can't be recalled - unable to recognize friends or family - possible aggression, tendancy to wander - lose the ability to communicate and perform ADLs - final stages: unresponsive, incontinent, requires total care

Goals for caregiver of pt with AD

- reduce caregiver stress - maintain personal, emotional and physical health - cope with the long-term effects of caregiving

Behavioral problems occur in about 90% of pts with AD and include:

- repetitiveness (asking same questions repeatedly) - delusions (false beliefs) - illusions - hallucinations - agitation - aggression - altered sleep patterns - wandering - resisting care

Normal pressure hydrocephalus

- uncommon - characterized by an obstruction in the flow of CSF which causes a buildup of CSF in the brain - dementia, urinary incontinence, difficulty in walking - meningitis, encephalitis or head injury may cause the condition - treatable by surgery, shunt

Many times behavior problems are unpredictable and may challenge caregivers, however they are

- unintentional and often difficult to control - may be pt's way of responding to a precipitating factor (eg pain, frustration, temp extremes, anxiety)

Nursing interventions for nutritional deficiencies

- use pureed foods, thickened liquids and nutritional supplements when chewing and swallowing become problematic - quiet, unhurried environment - low lighting, music, and simulated nature sounds may improve eating behaviors - easy-grip eating utensils and finger foods - offer liquids frequently - NG feeding may be used for short periods

Definition and characteristics of Alzheimer's Disease

--chronic, progressive, degenerative disease of the brain - most common form of dementia - 5% of people age 65-74, almost 50% of those over 85 have it - Fatal with death typically ocurring 4-6 yrs after diagnosis

Mini-Mental State Exam includes

-Orientation to Time: What is the date? -Registration: Listen carefully, I'm going to say 3 word. You say them back after I stop. Ready? Here they are... House (pause), car (pause) Lake (pause) Now repeat those words back to me. (Repeat up to 5x but only score first trial -Naming: What is this? (point to pen) -Reading

Frontotemporal dementia

-shrinking of the frontal and temporal anterior lobes - Pick's disease has abnormal microscopic deposits called Pick bodies, but these are not always present - often misdiagnosed as a psychiatric problem or as AD - tends to occur at a younger age (40-70) - marked symmetric lobar atrophy of the temporal and/or frontal lobes - characterized by disturbances in behavior, sleep, personality and eventually memory - relentless in progression - may ultimately include language impairment, erratic behavior, and dementia - strange behavior - psychiatrists often see these pts first - no specific tx, dx at autopsy

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

...

What percentage of people with MCI will develop dementia?

15%

Rate of progression from mild to late is highly variable and ranges from

3-20 years

When providing family education for those who have a relative with Alzheimer's disease about minimizing stress, which of the following suggestions is most relevant? 1. Allow the client to go to bed four to five times during the day. 2. Test the cognitive functioning of the client several times a day. 3. Provide reality orientation even if the memory loss is severe. 4. Maintain consistency in environment, routine, and caregivers.

4. Change increases stress. Therefore, the most important and relevant suggestion is to maintain consistency in the client's environment, routine, and caregivers. Although rest periods are important, going to bed interferes with the sleep-wake cycle. Rest in a recliner chair is more useful. Testing cognitive functioning and reality orientation are not likely to be successful and may increase stress if memory loss is severe.

What is familial Alzheimer's disease?

A clear pattern of inheritence within the family is established - associated with an earlier onset (<60) and more rapid disease course

Before antipsychotic drugs are used for disruptive behaviors, what should be done?

All other measures of treating behavioral issues should be exhausted d/t r/f death

Frequency of causes of Dementia

Alzheimer's - 60% Lewy Body Disease - 10% Vascular Dementia - 20% Other Types include Frontotemporal dementia, Normal pressure hydrocephalus, Creutzfeldt-Jakob disease

Pathological changes often precede clinicla manifestations of dementia by how much?

Anywhere from 5-20 years

What are neuroimaging techniques used to dx dementia?

CT scan, MRI, SPECT, PET (not routinely used)

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

16. A patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). In planning the patient teaching necessary with the use of the drug, the nurse recognizes that the patient will need to be taught a. how to draw up and administer injections of the medication. b. use of contraceptive methods other than oral contraceptives for birth control. c. to plan laboratory monitoring of CBC, chemistries, and liver function every 3 months. d. that the drug will control symptoms but has no effect on the progression of the disease.

Correct Answer: A Rationale: Copaxone is administered by self-injection. Oral contraceptives are an appropriate choice for birth control. No laboratory monitoring is needed. The purpose of the medication is to modify the MS disease process. Cognitive Level: Application Text Reference: p. 1544 Nursing Process: Planning NCLEX: Physiological Integrity

30. Which information obtained about a 75-year-old patient with new-onset seizures will be of concern to the nurse when the patient is being started on therapy with phenytoin (Dilantin)? a. The patient has a history of chronic hepatitis C. b. The patient experienced menopause at age 52. c. The patient lives alone in an assisted living facility. d. The patient has had a recent right hemisphere stroke.

Correct Answer: A Rationale: Phenytoin is metabolized by the liver, and the patient's age and history of hepatitis may increase the risk for toxic effects. The patient's age at menopause, living in an assisted living facility, and stroke history do not increase the risk for adverse effects of phenytoin. Cognitive Level: Application Text Reference: p. 1538 Nursing Process: Assessment NCLEX: Physiological Integrity

A patient with right-sided weakness that started 1 hour ago is admitted to the emergency department and all these diagnostic tests are ordered. Which order should the nurse act on first? a. Noncontrast computed tomography (CT) scan b. Chest radiograph c. Complete blood count (CBC) d. Electrocardiogram (ECG)

Correct Answer: A Rationale: Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 3 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the smaller the area of brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.

2. A patient with right-sided weakness that started 1 hour ago is admitted to the emergency department and all these diagnostic tests are ordered. Which order should the nurse act on first? a. Noncontrast computed tomography (CT) scan b. Chest radiograph c. Complete blood count (CBC) d. Electrocardiogram (ECG)

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. The health care provider is considering the use of sumatriptan (Imitrex) for a patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider? a. The patient has a history of a recent acute myocardial infarction. b. The patient has had migraine headaches for 30 years. c. The patient has been taking topiramate (Topamax) for 2 months. d. The patient has at least 1 to 2 cups of coffee daily.

Correct Answer: A Rationale: The triptans cause coronary artery vasoconstriction and should be avoided in patients with coronary artery disease. The other information will be reported to the health care provider, but none is an indication that sumatriptan would be an inappropriate treatment. Cognitive Level: Application Text Reference: p. 1530 Nursing Process: Assessment NCLEX: Physiological Integrity

The nurse on the medical unit receives a verbal report from the emergency department nurse that a patient has an occlusion of the left posterior cerebral artery. When admitting the patient to the medical floor, the nurse will anticipate that the patient may have a. visual deficits. b. dysphasia. c. confusion. d. poor judgment.

Correct Answer: A Rationale: Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion. Cognitive Level: Application Text Reference: p. 1507 Nursing Process: Assessment NCLEX: Physiological Integrity

MULTIPLE RESPONSE 1. 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. Suction tubing b. Oxygen mask c. Nasogastric tube d. Siderail pads e. Tongue blade f. Oral airway

Correct Answer: A, B, D Rationale: The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The bed's side rails should be padded to minimize the risk for patient injury during a seizure. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. Use of tongue blades or oral airways during a seizure is contraindicated. Cognitive Level: Application Text Reference: pp. 1539-1540 Nursing Process: Planning NCLEX: Physiological Integrity

2. A patient with Parkinson's disease is admitted to the hospital for treatment of an acute infection. Which nursing interventions will be included in the plan of care? (Select all that apply.) a. Cut patient's food into small pieces. b. Provide high protein foods at each meal. c. Observe for sudden exacerbation of symptoms. d. Remind the patient to keep eyes ahead when ambulating. e. Place an arm chair at the patient's bedside. f. Use an elevated toilet seat.

Correct Answer: A, E, F Rationale: Since the patient with Parkinson's has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High-protein foods will decrease the effectiveness of L-dopa. Parkinson's is a steadily progressive disease without acute exacerbations. Bradykinesia associated with ambulation is relieved by asking the patient to step over imaginary lines or rice kernels on the floor. Cognitive Level: Application Text Reference: pp. 1552-1553 Nursing Process: Planning NCLEX: Physiological Integrity

27. A patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care? a. Observing for agitation and paranoia b. Assisting the patient with active range of motion (ROM) c. Using simple words and phrases to explain procedures d. Administer muscle relaxants as needed for muscle spasms

Correct Answer: B Rationale: ALS causes progressive muscle weakness, but assisting the patient to perform active ROM will help to maintain strength as long as possible. Psychotic symptoms such as agitation and paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the patient's ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations. Cognitive Level: Application Text Reference: p. 1558 Nursing Process: Planning NCLEX: Physiological Integrity

29. A hospitalized 24-year-old patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first? a. Notify the patient's health care provider immediately. b. Start the ordered PRN oxygen at 9 L/min. c. Give the ordered prn acetaminophen (Tylenol). d. Put a moist hot pack on the patient's neck.

Correct Answer: B Rationale: Acute treatment for cluster headache is administration of 100% oxygen at 7 to 9 L/min. If the patient obtains relief with the oxygen, there is no immediate need to notify the health care provider. Cluster headaches last only 60 to 90 minutes, so oral pain medications have minimal effect. Hot packs are helpful for tension headaches but are not as likely to reduce pain associated with a cluster headache. Cognitive Level: Application Text Reference: pp. 1530-1531 Nursing Process: Implementation NCLEX: Physiological Integrity

20. A patient who has been taking bromocriptine (Parlodel) and benztropine (Cogentin) for Parkinson's disease is experiencing a worsening of symptoms. The nurse will anticipate that patient may benefit from a. complete drug withdrawal for a few weeks. b. use of levodopa (L-dopa)-carbidopa (Sinemet). c. withdrawal of anticholinergic therapy. d. increasing the dose of bromocriptine.

Correct Answer: B Rationale: After the dopamine receptor agonists begin to fail to relieve symptoms, the addition of L-dopa with carbidopa can be added to the regimen. Complete drug withdrawal will result in worsening of symptoms. Anticholinergic therapy should be continued to help maintain the balance between the actions of dopamine and acetylcholine. Increasing the dose of bromocriptine will increase the risk for toxic effects. Cognitive Level: Comprehension Text Reference: p. 1551 Nursing Process: Planning NCLEX: Physiological Integrity

24. A patient is admitted to the hospital with dysphasia and right-sided weakness that resolves in a few hours. The nurse will anticipate teaching the patient about a. alteplase (tPA). b. aspirin (Ecotrin). c. warfarin (Coumadin). d. nimodipine (Nimotop).

Correct Answer: B Rationale: Following a TIA, patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Coumadin is usually used for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage. Cognitive Level: Application Text Reference: pp. 1505, 1510 Nursing Process: Planning NCLEX: Physiological Integrity

The nurse obtains all of the following information about a 65-year-old patient in the clinic. When developing a plan to decrease stroke risk, which risk factor is most important for the nurse to address? a. The patient smokes a pack of cigarettes daily. b. The patient's blood pressure (BP) is chronically between 150/80 to 170/90 mm Hg. c. The patient works at a desk and relaxes by watching television. d. The patient is 25 pounds above the ideal weight.

Correct Answer: B Rationale: Hypertension is the most important modifiable risk factor. Smoking, physical inactivity, and obesity all contribute to stroke risk but not so much as hypertension. Cognitive Level: Application Text Reference: p. 1503 Nursing Process: Assessment NCLEX: Health Promotion and Maintenance

19. The nurse identifies the nursing diagnosis of impaired physical mobility related to bradykinesia for a patient with Parkinson's disease. To assist the patient to ambulate safely, the nurse should a. allow the patient to ambulate only with assistance. b. instruct the patient to rock from side to side to initiate leg movement. c. have the patient take small steps in a straight line directly in front of the feet. d. teach the patient to keep the feet in contact with the floor and slide them forward.

Correct Answer: B Rationale: Rocking the body from side to side stimulates balance and improves mobility. The patient should initially be ambulated with assistance but might not require continual assistance with ambulation. The patient should maintain a wide base of support to help with balance. The patient should lift the feet and avoid a shuffling gait. Cognitive Level: Application Text Reference: p. 1554 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

18. A patient with multiple sclerosis (MS) has a nursing diagnosis of urinary retention related to sensorimotor deficits. An appropriate nursing intervention for this problem is to a. decrease fluid intake in the evening. b. teach the patient how to use the Credé method. c. suggest the use of incontinence briefs for nighttime use only. d. assist the patient to the commode every 2 hours during the day.

Correct Answer: B Rationale: The Credé method can be used to improve bladder emptying. Decreasing fluid intake will not improve bladder emptying and may increase risk for urinary tract infection (UTI) and dehydration. The use of incontinence briefs and frequent toileting will not improve bladder emptying. Cognitive Level: Application Text Reference: p. 1548 Nursing Process: Planning NCLEX: Physiological Integrity

2. A patient seen at the health clinic with a severe migraine headache tells the nurse about having four similar headaches in the last 3 months. The patient says, "I am afraid to make social plans because I never know when I will have these headaches." The most appropriate nursing action at this time is to a. refer the patient for counseling to assist with stress reduction. b. ask the patient to keep a diary with details about headaches. c. encourage the patient to learn muscle-relaxation techniques to minimize headache frequency. d. teach the patient about the effectiveness of the triptan drugs in treating migraine headaches.

Correct Answer: B Rationale: The initial nursing action should be further assessment of the precipitating causes of the headaches, quality and location of pain, etc. Stress reduction, muscle relaxation, and the triptan drugs may be helpful, but more assessment is needed. Cognitive Level: Application Text Reference: p. 1532 Nursing Process: Implementation 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

1. A hospitalized patient complains of a moderate bilateral headache that radiates from the base of the skull. Which of the following medications ordered on a PRN basis for the patient should the nurse administer initially? a. Lorazepam (Ativan) b. Acetaminophen (Tylenol) c. Morphine sulfate (Roxanol) d. Butalbital and aspirin (Fiorinal)

Correct Answer: B Rationale: The patient's symptoms are consistent with a tension headache, and initial therapy usually involves a nonopioid analgesic such as acetaminophen, sometimes combined with a sedative or muscle relaxant. Lorazepam may be used in conjunction with acetaminophen but would not be appropriate as the initial monotherapy. Morphine sulfate and Fiorinal would be more appropriate for a headache that did not respond to a nonopioid analgesic. Cognitive Level: Application Text Reference: p. 1530 Nursing Process: Implementation NCLEX: Physiological Integrity

25. A hospitalized patient with myasthenia gravis (MG) has a nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired swallowing. To promote nutrition, the nurse suggests that before meals the patient should avoid a. watching television. b. talking on the phone. c. typing on the computer. d. ambulating in the halls.

Correct Answer: B Rationale: The same muscles are used for talking and swallowing, so the patient should avoid fatiguing the muscles of the mouth and throat before meals. The other activities will not affect the muscles used for chewing and swallowing. Cognitive Level: Application Text Reference: pp. 1555-1556 Nursing Process: Implementation 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

11. When a patient experiences a generalized tonic-clonic seizure in the emergency department after a head injury, all of the following orders are received. Which one will the nurse implement first? a. Send to radiology for computed tomography (CT) scan. b. Administer midazolam (Versed). c. Check capillary blood glucose. d. Monitor level of consciousness (LOC).

Correct Answer: B Rationale: To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary. Although the capillary blood glucose may offer information about the cause of the seizure, the initial nursing action is to decrease the risk for further seizures. Monitoring level of consciousness is important, but the highest priority is to decrease seizure risk. Cognitive Level: Application Text Reference: p. 1537 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

17. When planning care for a patient with MS who has a nursing diagnosis of risk for activity intolerance related to extremity weakness secondary to stress, the most appropriate patient goal is a. "The patient will express minimal stress level." b. "Strength in arms and legs will be maintained." c. "The patient will complete ADLs without fatigue." d. "Intake of high-nutrition foods will be adequate."

Correct Answer: C Rationale: Because the nurse has identified the patient's problem as activity intolerance, a patient goal that indicates improvement in activity tolerance, such as ability to accomplish ADLs without fatigue, is most appropriate. The other goals are appropriate for nursing diagnoses such as ineffective coping, impaired physical mobility, and inadequate nutritional intake. Cognitive Level: Application Text Reference: pp. 1546-1547 Nursing Process: Planning NCLEX: Physiological Integrity

23. A patient with myasthenia gravis (MG) is admitted to the hospital with severe weakness and acute respiratory insufficiency. The health care provider performs a Tensilon test to distinguish between myasthenic crisis and cholinergic crisis. During the test, it will be most important to monitor the patient's a. pupillary size. b. muscle strength. c. respiratory function. d. level of consciousness (LOC).

Correct Answer: C Rationale: Because the patient's respiratory insufficiency is life threatening, it will be most important to monitor respiratory function during the Tensilon test. Pupillary size and muscle strength may also be affected by the test but are not as important to monitor. LOC is not typically affected by MG, although the LOC may be affected by oxygenation in this patient. Cognitive Level: Application Text Reference: p. 1556 Nursing Process: Assessment NCLEX: Physiological Integrity

4. When a patient is being evaluated for new onset cluster-type headaches, the nurse will anticipate a. scheduling a magnetic resonance imaging (MRI) of the brain. b. teaching the patient about electromyelography (EMG). c. obtaining a detailed patient history. d. arranging for a cerebral angiogram.

Correct Answer: C Rationale: Diagnosis of cluster headache is made primarily on the basis of the patient's symptoms. Other diagnostic tests are only obtained if an underlying disorder is suspected as the cause of the headache. Cognitive Level: Application Text Reference: p. 1529 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

14. When obtaining a health history and physical assessment for a patient with possible multiple sclerosis (MS), the nurse should a. confirm patient information with family members. b. ask about a recent history of temperature spikes. c. question the patient about any leg weakness or spasm. d. determine whether hypersexuality has caused problems.

Correct Answer: C Rationale: Extremity weakness or spasms are common motor symptoms of MS. Memory deficit and confusion are not symptoms of MS, and the patient will be an accurate historian. Although viral infection appears to trigger the onset of MS in some patients, temperature spikes are not associated with viral illness. Decreased libido and diminished sexual response are common MS symptoms. Cognitive Level: Application Text Reference: p. 1543 Nursing Process: Assessment NCLEX: Physiological Integrity

3. After teaching a patient about management of migraine headaches, the nurse determines that the teaching has been effective when the patient says, a. "I will take the topiramate (Topamax) as soon as any headaches start." b. "The sumatriptan (Imitrex) will help to increase the blood flow to my brain." c. "I will try to lie down someplace dark and quiet when the headaches begin." d. "A glass of wine might help me relax and prevent headaches from developing."

Correct Answer: C Rationale: It is recommended that the patient with a migraine rest in a dark, quiet area. Topamax is used to prevent migraines and must be taken for several months to determine effectiveness. Blood flow to the brain is decreased by the triptan drugs. Alcohol may precipitate migraine headaches. Cognitive Level: Application Text Reference: p. 1532 Nursing Process: Evaluation 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

28. A patient with a left-sided brain stroke suddenly bursts into tears when family members visit. The nurse should a. explain to the family that depression is normal following a stroke. b. have the family members leave the patient alone for a few minutes. c. teach the family that emotional outbursts are common after strokes. d. use a calm voice to ask the patient to stop the crying behavior.

Correct Answer: C Rationale: Patients who have left-sided brain stroke are prone to emotional outbursts, which are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient's control and asking the patient to stop will lead to embarrassment. Cognitive Level: Application Text Reference: p. 1523 Nursing Process: Implementa

10. The health care provider prescribes phenytoin (Dilantin) for control of complex partial seizures. After the nurse has taught the patient about phenytoin, which patient statement indicates understanding of the medication? a. "I should use soft swabs rather than a toothbrush to clean my mouth." b. "After I have a seizure, I should call an ambulance to take me to the hospital." c. "I may need to have my blood taken frequently to check the level of the Dilantin." d. "I will take the medication at the beginning of the seizure when I experience an aura."

Correct Answer: C Rationale: Serum levels of phenytoin may be checked to ascertain that a therapeutic level of the medication is achieved. Gingival hyperplasia associated with phenytoin use can be decreased by frequent brushing and flossing. Most seizures do not require hospitalization. The phenytoin is taken regularly to prevent seizures, not acutely when seizures occur. Cognitive Level: Application Text Reference: p. 1536 Nursing Process: Evaluation NCLEX: Physiological Integrity

31. A patient is seen in the health clinic with symptoms of a stooped posture, shuffling gait, and pill rolling-type tremor. The nurse will anticipate teaching the patient about a. preparation for an MRI. b. purpose of EEG testing. c. antiparkinsonian drugs. d. oral corticosteroids.

Correct Answer: C Rationale: The diagnosis of Parkinson's is made when two of the three characteristic signs of tremor, rigidity, and bradykinesia are present. The confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered. This patient has symptoms of tremor and bradykinesia; the next anticipated step will be treatment with medications. MRI and EEG are not useful in diagnosing Parkinson's disease, and corticosteroid therapy is not used to treat it. Cognitive Level: Application Text Reference: p. 1550 Nursing Process: Planning NCLEX: Physiological Integrity

21. A patient with Parkinson's disease has decreased tongue mobility and an inability to move the facial muscles. The nurse recognizes that these impairments commonly contribute to the nursing diagnosis of a. disuse syndrome related to loss of muscle control. b. self-care deficit related to bradykinesia and rigidity. c. impaired verbal communication related to difficulty articulating. d. impaired oral mucous membranes related to inability to swallow.

Correct Answer: C Rationale: The inability to use the tongue and facial muscles decreases the patient's ability to socialize or communicate needs. Disuse syndrome is not an appropriate nursing diagnosis because the patient is continuing to use the muscles as much as possible. There is no indication in the stem that the patient has a self-care deficit, bradykinesia, or rigidity. The oral mucous membranes will continue to be moist and should not be impaired by the patient's difficulty swallowing. Cognitive Level: Application Text Reference: p. 1554 Nursing Process: Diagnosis NCLEX: Physiological Integrity

A patient with Parkinson's disease has decreased tongue mobility and an inability to move the facial muscles. The nurse recognizes that these impairments commonly contribute to the nursing diagnosis of a. disuse syndrome related to loss of muscle control. b. self-care deficit related to bradykinesia and rigidity. c. impaired verbal communication related to difficulty articulating. d. impaired oral mucous membranes related to inability to swallow.

12. A patient found in a tonic-clonic seizure reports afterward that the seizure was preceded by numbness and tingling of the arm. The nurse knows that this finding indicates a(n) _____ seizure. a. absence b. simple partial c. complex partial d. generalized myoclonic

Correct Answer: C Rationale: The initial symptoms of a complex partial seizure involve clinical manifestations that are localized to a particular part of the body or brain. In addition, an alteration in consciousness is always manifested. Symptoms of an absence seizure are staring and a brief loss of consciousness. During a simple partial seizure, the patient does not lose consciousness. A generalized myoclonic seizure is characterized by a sudden jerk of the body or extremities. Cognitive Level: Comprehension Text Reference: p. 1535 Nursing Process: Assessment 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

13. When teaching the patient with newly diagnosed multiple sclerosis (MS) about the disease, the nurse explains that a. MS is a congenitally acquired illness that causes progressive neurologic deterioration. b. impulses travel too fast over nerves that have lost their myelin coat and cause overstimulation of muscle fibers. c. autoimmune processes cause gradual destruction of the myelin sheath of nerves in the brain and spinal cord. d. antibodies are produced against acetylcholine receptors at the synapse and result in blocked muscle contraction.

Correct Answer: C Rationale: The primary pathology in MS is an autoimmune process that leads to loss of the myelin sheath and results in decreased nerve transmission. Although MS susceptibility does appear to be inherited, the disease is not congenital because the interaction of multiple factors precipitates MS development. Impulse transmission along nerve fibers is slowed. Antibodies to acetylcholine receptors do not cause MS. Cognitive Level: Comprehension Text Reference: p. 1542 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

5. A patient experiences cluster headaches that occur for 2 months every year. During assessment of the patient who is experiencing a headache episode, the nurse would expect to find a. nuchal rigidity. b. projectile vomiting. c. unilateral eyelid swelling. d. throbbing, bilateral facial pain.

Correct Answer: C Rationale: Unilateral eye edema, tearing, and ptosis are characteristic of cluster headaches. Nuchal rigidity suggests meningeal irritation, such as occurs with meningitis. Although nausea and vomiting may occur with migraine headaches, projectile vomiting is more consistent with increases in intracranial pressure (ICP). Unilateral sharp, stabbing pain, rather than throbbing pain, is characteristic of cluster headaches. Cognitive Level: Comprehension Text Reference: pp. 1528-1529 Nursing Process: Assessment 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

7. A patient has a tonic-clonic seizure while the nurse is in the patient's room. During the seizure, it is important for the nurse to 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.

Correct Answer: D Rationale: Because diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure. Cognitive Level: Application Text Reference: pp. 1536, 1539 Nursing Process: Implementation NCLEX: Physiological Integrity

15. A 28-year-old woman has had multiple sclerosis (MS) for 3 years and wants to have children before her disease worsens. When she asks about the risks associated with pregnancy, the nurse explains that a. MS is associated with a slightly increased risk for congenital defects. b. symptoms of MS are likely to become worse during her pregnancy. c. women with MS frequently have premature labor. d. MS symptoms may be worse after the pregnancy.

Correct Answer: D Rationale: During the postpartum period, women with MS are at greater risk for exacerbation of symptoms. There is no increased risk for congenital defects in infants born of mothers with MS. Symptoms of MS may improve during pregnancy. Pregnancy, labor, and delivery are not affected by MS. Cognitive Level: Application Text Reference: p. 1543 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance

28. A 42-year-old patient who was adopted at birth is diagnosed with early Huntington's disease (HD). When teaching the patient, spouse, and children about this disorder, the nurse will provide information about the a. use of levodopa-carbidopa (Sinemet) to help reduce HD symptoms. b. need to take prophylactic antibiotics to decrease the risk for pneumonia. c. lifestyle changes, such as increased exercise, that delay disease progression. d. availability of genetic testing to determine the HD risk for the patient's children.

Correct Answer: D Rationale: Genetic testing is available to determine whether an asymptomatic individual has the HD gene. The patient and family should be informed of the benefits and problems associated with genetic testing. Sinemet will increase symptoms of HD given that HD involves an increase in dopamine. The patient is at risk for pneumonia in the later stages of HD, but this patient has early HD. There are no effective treatments or lifestyle changes that delay the progression of symptoms in HD. Cognitive Level: Application Text Reference: p. 1559 Nursing Process: Implementation NCLEX: Physiological Integrity

22. A patient has a new prescription for levodopa (L-dopa) to control symptoms of Parkinson's disease. Which assessment data obtained by the nurse may indicate a need for a decrease in the dose? a. The patient has a chronic dry cough. b. The patient has 4 loose stools in a day. c. The patient develops a deep vein thrombosis. d. The patient's blood pressure is 90/46 mm Hg.

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

A 71-year-old patient is diagnosed with moderate dementia as a result of multiple strokes. During assessment of the patient, the nurse would expect to find a. excessive nighttime sleepiness. b. variable ability to perform simple tasks. c. difficulty eating and swallowing. d. loss of recent and long-term memory.

Correct Answer: D Rationale: Loss of both recent and long-term memory is characteristic of moderate dementia. Patients with dementia have frequent nighttime awakening. Dementia is progressive, and the patient's ability to perform tasks would not have periods of improvement. Difficulty eating and swallowing is characteristic of severe dementia. Cognitive Level: Application Text Reference: pp. 1562-1563 Nursing Process: Assessment 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

24. When teaching a patient with myasthenia gravis (MG) about management of the disease, the nurse advises the patient to a. anticipate the need for weekly plasmapheresis treatments. b. protect the extremities from injury due to poor sensory perception. c. do frequent weight-bearing exercise to prevent muscle atrophy. d. perform necessary physically demanding activities in the morning.

Correct Answer: D Rationale: Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then. Plasmapheresis is not routinely scheduled but is used for myasthenia crisis or for in situations where corticosteroid therapy should be discontinued. There is no decrease in sensation with MG, and muscle atrophy does not occur because muscles are used during part of the day. Cognitive Level: Application Text Reference: pp. 1555-1557 Nursing Process: Implementation NCLEX: Physiological 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

9. After experiencing a generalized tonic-clonic seizure in the classroom, an elementary school teacher is evaluated and diagnosed with idiopathic epilepsy. The patient cries and tells the nurse, "I can not teach anymore. It will be too difficult for the students if this happens again at work." The most appropriate nursing diagnosis for the patient is a. anxiety related to loss of control during seizures. b. hopelessness related to diagnosis of chronic illness. c. disturbed body image related to new diagnosis of a seizure disorder. d. ineffective role performance related to misinformation about epilepsy.

Correct Answer: D Rationale: The data indicate that the patient has ineffective role performance caused by inadequate information about the disease because most patients are able to control seizures with medication. Because the focus of the patient's statement is on career issues, this is a more appropriate diagnosis than anxiety, hopelessness, or disturbed body issues. Cognitive Level: Application Text Reference: p. 1541 Nursing Process: Diagnosis 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: D 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

8. 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. document the timing and description of the seizure. b. notify the patient's health care provider about the seizure. c. give the scheduled dose of divalproex (Depakote). d. assess the patient for a possible head injury.

Correct Answer: D Rationale: The patient who has had a myoclonic seizure and fall is at risk for head injury and should be evaluated and treated for this possible complication first. Documentation of the seizure, notification of the seizure, and administration of antiseizure medications are also appropriate actions, but the initial action should be assessment for injury. Cognitive Level: Application Text Reference: p. 1535 Nursing Process: Implementation 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

26. A patient with restless legs syndrome (RLS) tells the nurse, "My leg pain and twitching keep me awake so much of the night, I am tired most of the day. Is there anything I can do?" Based on this information, which nursing diagnosis is most appropriate? a. Ineffective role performance related to fatigue b. Chronic pain related to RLS c. Anxiety related to lack of knowledge about RLS treatment d. Sleep deprivation related to leg pain and involuntary movement

Correct Answer: D Rationale: The patient's statement indicates that daytime fatigue caused by lack of sleep is the major concern. The patient does not indicate concern with role performance. Although pain is a concern with RLS, the patient's concern is with the impact of pain on sleep. The patient is asking for information about treatment but does not appear anxious. Cognitive Level: Application Text Reference: p. 1557 Nursing Process: Diagnosis NCLEX: Physiological Integrity

What are modifiable risk factors for AD?

Diabetes mellitis, ApoE gene variation, current smoking, and depression are associated with an increased r/f AD and cognitive decline

Term for developing AD before age 60

Early-onset AD (autosomal dominant disorder) - rare form of AD (less than 5% of cases) - 50% r/f dz for kids with affected parents - may occur in people as young as 30

What is MCI

Mild cognitive impairment is a state of cognitive function in which individuals have problems with memory, language or another essential cognitive function that are severe enough to be noticeable to others and show up on tests but don't interfere with ADLs

What are the 2 most frequent causes of dementia?

Neurodegenerative conditions account for 60-80% (eg AD) and vascular disorders

Causes of Dementia

Neurodegenerative disorders Vascular diseases Toxic, metabolic or nutritional diseases Immunologic diseases or infections Systemic diseases Trauma Tumors Ventricular disorders Drugs

What are treatments for sundowners?

Nursing interventions that may be helpful include - creating a calm, quiet environment - maximizing exposure to daylight (open blinds and turn on lights during the day) - evaluating meds to determine if any could cause sleep disturbance - limiting naps and caffeine - consulting with the health care provider regarding drug therapy

Who often reports the pt's declining memory to the hcp?

Often a family member, esp. a spouse

Dementia

Syndrome characterized by dysfunction or loss of memory, orientation, attention, judgement, and reasoning -peronality disorders such as agitation, delusions and hallucinations may result - diagnosed usually when 2 or more brain functions such as memory loss or language skills are significantly impaired - not a normal part of aging - 100 causes of dementia - more than 60% of those with dementia have Alzheimer's

Mental stimulation, exercise and dietary supplements have what effect on AD?

These have not been shown to delay the onset and/or reduce the severity of decline

Drug therapy for AD slow rate of decline and worsening of sx, but are not

a cure and do not reverse the progression

Neurofibrillary tangles are

abnormal collections of twisted protein threads inside nerve cells - main component is protein called tau - tau provide support of microtubules - when tau are altered in AD, the microtubules twist together in a helical fashion

pt with AD is subject to

acute and other chronic illnesses

What are important risk factors for dementia?

advanced age and family history

What is the most important risk factor for AD?

age

Vascular dementia

also called multiinfarct dementia loss of cognitive function resulting from ischemic, ischemic-hypoxic, or hemorrhagic brain lesions caused by cardiovascular disease

An acute (days to weeks) or subacute (weeks to months) pattern of change in dementia may be indicative of what kind of cause?

an infectious or metabolic cause, including encephalitis, meningitis, hypothyroidism, or drug-related dementia

Care of pt with AD in acute care setting (hospitalized) includes

close observation d/t safety concerns, frequent orientation to place and time, give reassurance, use of consistent nurses may be helpful in reducing anxiety or disruptive behavior

Amyloid plaques consist of

clusters of insoluble deposits of a protein called beta-amyloid, remnants of neurons, non-nerve cells (microglia) and other cells such as astrocytes

Treating depression associated with AD may improve

cognitive function

Neuropsychologic testing can help document

degree of cognitive impairment - important also to determine a baseline

people with a mild cognitive impairment (MCI) need a cognitive evaluation and ongoing clinical monitoring d/t r/f developing

dementia

What is often mistaken for dementia in older adults?

depression (and vise versa)

Diagnosis of dementia is often focused on

determining the cause

A definitive diagnosis of AD requires

exam of brain tissue and presence of neurofibrillary tangles and neuritic plaques at autopsy

All pts with cognitive impairment are at high r/f

falls

Nursing interventions for incontinence

habit or behavioral retraining of bladder and bowel function (eg toileting schedule)

Risk factors for vascular dementia

hx of smoking, cardiac dysrhythmias, hypertension, hypercholesterolemia, diabetes mellitus and CAD predispose to dementia pts w metabolic syndrome are at increased r/f dementia and Alzheimer's

trazadone (Desyrel) antidepressant may help with problems of sleep but may cause

hypotension

The majority of family members are providing care to pts with AD or dementia where?

in the home

Factors that lead to skin alterations

incontinence along with immobility and undernutrition

Treatment for constipation d/t immobility, dietary intake (eg reduced fiber) and decreased fluid intake?

increase dietary fiber, fiber supplements, and stool softeners are the first lines of management

antipsychotic meds have been used for management of behavioral problems in AD pts (agitation, aggression) but have been shown to

increase the r/f death in elderly dementia pts

Apolipoprotein E is a gene on chromosome 19 which is associated with

increased r/f developing late-onset AD

Pain can result in alterations in the pt's behavior, such as

increased vocalization, agitation, withdrawal and changes in function

What are safety risks for pt w AD?

injury from falls, injury from ingesting dangerous substances, wandering, injury to others and self with sharp objects, fire or burns, and inability to respond to crisis situations

Nursing care for oral hygeine

inspect mouth regularly and perform oral care for pts unable to

In AD, plaques develop first in areas of the brain used for

memory and cognitive function, including the hippocampus (structure important for finding and storing memories) - eventually AD attacks the cerebral cortex, esp the areas responsible for language and reasoning

Cognitive testing is focused on evaluating

memory, ability to calculate, language, visual-spatial skills and degree of alertness

What is normal age-related memory decline characterized as?

mild changes that do not affect ADLs

Wandering is a major concern for caregivers. What can be implemented?

observe for factors or events that may precipitate wandering Medic Alert and Alzheimer's Association Safe Return program

What is the current primary treatment of MCI?

ongoing monitoring

10-20% of what age group has MCI?

people 65 and up

Traumatic brain injury may be a risk factor for developing AD, so nurses should promote safety in

physical activities and driving

Diagnosis of dementia r/t vascular causes is based on?

presence of cognitive loss, vascular brain lesions demonstrated by neuroimaging techniques, and the exclusion of other causes of dementia

PEG tubes are an option but can be problematic d/t

pts with AD are particularly vulnerable to aspiration of feeding formula and tube dislodgment

Incidence of AD

slightly higher in African Americans and Hispanic Americans - associated with lower socioeconomic status and education level and poor access to health care - women more likely to develop d/t living longer, twice as many die from AD than men - men have a higher incidence of vascular dementia than women

Clinical Features of Dementia

slow onset long course, sx progressive yet relatively stable over time progression is slow but even duration is months to years Memory loss initialy relates to recent events Awareness is clear, alertness is generally normal, orientation has progressive impairment Thinking: difficulty with abstraction, judgment impaired, words difficult to find Misperceptions often present; delusions, illusions, and hallucinations Phsychomotor behavior: apraxia Sleep-wake cycle: frequent awakenings Mental status testing: frequent "near miss" answers, struggles with test, great effort to find an appropriate reply; consistently poor performance

Cases in whom no familial connection can be made for AD are termed

sporadic

Loss of connections between cells in AD results from

structural damage and eventual death of the neurons. Affected parts of the brain begin to shrink causing brain atrophy

What is an initial sign of AD?

subtle deterioration in memory

What are preventative measures for development of vascular dementia?

treatment of risk factors such as HTN, diabetes, smoking, hyperfibrinogenemia, hyperhomocystinemia and cardiac dysrhythmias

Cholinesterase inhibitors block cholinesterase, the enzyme responsible for the breakdown of acetylcholine in the synaptic cleft. Examples:

tx of decreased memory and cognition - donepezil (Aricept) - rivastigmine (Exelon) - galantamine (Razadyne)

NMDA receptor antagonist

tx of decreased memory and cognition - memantine (Namenda)

SSRIs

tx of depression - fluoxetine (Prozac) - sertraline (Zoloft) - fluvoxamine (Luvox) - citalopram (Celexa)

Patients in LTC facilities have the highest incidence of

undernutrition

Nursing staff are trying to provide for the safety of an elderly female client with moderate dementia. She is wandering at night and has trouble keeping her balance. She has fallen twice but has had no resulting injuries. The nurse should: 1. Move the client to a room near the nurse's station and install a bed alarm. 2. Have the client sleep in a reclining chair across from the nurse's station. 3. Help the client to bed and raise all four bedrails. 4. Ask a family member to stay with the client at night.

1. Using a bed alarm enables the staff to respond immediately if the client tries to get out of bed. Sleeping in a chair at the nurse's station interferes with the client's restful sleep and privacy. Using all four bedrails is considered a restraint and unsafe practice. It is not appropriate to expect a family member to stay all night with the client.

A patient with a stroke has progressive development of neurologic deficits with increasing weakness and decreased level of consciousness (LOC). The priority nursing diagnosis for the patient is a. risk for impaired skin integrity related to immobility. b. disturbed sensory perception related to brain injury. c. risk for aspiration related to inability to protect airway. d. impaired physical mobility related to weakness.

Correct Answer: C Rationale: Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses are also appropriate, but interventions to prevent aspiration are the priority at this time. Cognitive Level: Application Text Reference: p. 1515 Nursing Process: Diagnosis 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

...

In planning for the discharge of a client with a cognitive disorder, it is important to assess the client's caregiver support system. Which aspects are the most crucial to assess? Select all that apply. 1. Availability of resources for caregiver support. 2. Ability to provide the level of care and supervision needed by the client. 3. Willingness to transport the client to medical and psychiatric services. 4. Interest in engaging the cognitively disordered family member in reminiscence and games. 5. Willingness to install door alarms and make other safety changes. 6. Understanding the client's abilities and limitations.

1, 2, 3, 5, 6. It is important for a caregiver to have support for herself as well as be able to provide adequate safety, supervision, and medical care to the client. The caregiver must also have realistic expectations of the client, given his abilities and limitations. Reminiscing and engaging the client in games is desirable but not crucial to care.

An 83-year-old woman is admitted to the unit after being examined in the emergency department (ED) and diagnosed with delirium. After the admission interviews with the client and her grandson, the nurse explains that there will be more laboratory tests and X-rays done that day. The grandson says, "She has already been stuck several times and had a brain scan or something. Just give her some medicine and let her rest." The nurse should tell the grandson which of the following? Select all that apply. 1. "I agree she needs to rest, but there is no one specific medicine for your grandmother's condition." 2. "The doctor will look at the results of those tests in the ED and decide what other tests are needed." 3. "Delirium commonly results from underlying medical causes that we need to identify and correct." 4. "Tell me about your grandmother's behaviors and maybe I could figure out what medicine she needs." 5. "I'll ask the doctor to postpone more tests until tomorrow."

1, 2, 3. The client does need rest and it is true that there is no specific medicine for delirium, but it is crucial to identify and treat the underlying causes of delirium. Other tests will be based on the results of already completed tests. Although some medications may be prescribed to help the client with her behaviors, this is not the primary basis for medication orders. Because the underlying medical causes of delirium could be fatal, treatment must be initiated as soon as possible. It is not the nurse's role to determine medications for this client. Postponing tests until the next day is inappropriate.

A client has been in the critical care unit for 3 days following a severe myocardial infarction. Although he is medically stable, he has begun to have fluctuating episodes of consciousness, illogical thinking, and anxiety. He is picking at the air to "catch these baby angels flying around my head." While waiting for medical and psychiatric consults, the nurse must intervene with the client's needs. Which of the following needs have the highest priority? Select all that apply. 1. Decreasing as much "foreign" stimuli as possible. 2. Avoiding challenging the client's perceptions about "baby angels." 3. Orienting the client about his medical condition. 4. Gently presenting reality as needed. 5. Calling the client's family to report his onset of dementia.

1, 3, 4. The abnormal stimuli of the critical care unit can aggravate the symptoms of delirium. Arguing with hallucinations is inappropriate. When a client has illogical thinking, gently presenting reality is appropriate. Dementia is not the likely cause of the client's symptoms. The client is experiencing delirium, not dementia.

The client with dementia states to the nurse, "I know you. You're Margaret, the girl who lives down the street from me." Which of the following responses by the nurse is most therapeutic? 1. "Mrs. Jones, I'm Rachel, a nurse here at the hospital." 2. "Now Mrs. Jones, you know who I am." 3. "Mrs. Jones, I told you already, I'm Rachel and I don't live down the street." 4. "I think you forgot that I'm Rachel, Mrs. Jones."

1. Because of the client's short-term memory impairment, the nurse gently corrects the client by stating her name and who she is. This approach decreases anxiety, embarrassment, and shame and maintains the client's self-esteem. Telling the client that she knows who the nurse is or that she forgot can elicit feelings of embarrassment and shame. Saying, "I told you already" sounds condescending, as if blaming the client for not remembering.

The nurse is attempting to draw blood from a woman with a diagnosis of delirium who was admitted last evening. The client yells out, "Stop; leave me alone. What are you trying to do to me? What's happening to me?" Which response by the nurse is most appropriate? 1. "The tests of your blood will help us figure out what is happening to you." 2. "Please hold still so I don't have to stick you a second time." 3. "After I get your blood, I'll get some medicine to help you calm down." 4. "I'll tell you everything after I get your blood tests to the laboratory."

1. Explaining why blood is being taken responds to the client's concerns or fears about what is happening to her. Threatening more pain or promising to explain later ignores or postpones meeting the client's need for information. The client's statements do not reflect loss of self control requiring medication intervention.

Which of the following should the nurse expect to include as a priority in the plan of care for a client with delirium based on the nurse's understanding about the disturbances in orientation associated with this disorder? 1. Identifying self and making sure that the nurse has the client's attention. 2. Eliminating the client's napping in the daytime as much as possible. 3. Engaging the client in reminiscing with relatives or visitors. 4. Avoiding arguing with a suspicious client about his perceptions of reality.

1. Identifying oneself and making sure that the nurse has the client's attention addresses the difficulties with focusing, orientation, and maintaining attention. Eliminating daytime napping is unrealistic until the cause of the delirium is determined and the client's ability to focus and maintain attention improves. Engaging the client in reminiscing and avoiding arguing are also unrealistic at this time.

The husband of a client with Alzheimer's disease that was diagnosed 6 years ago approaches the nurse and says, "I'm so excited that my wife is starting to use donepezil (Aricept) for her illness." The nurse should tell the husband: 1. The medication is effective mostly in the early stages of the illness. 2. The adverse effects of the drug are numerous. 3. The client will attain a functional level of that of 6 years ago. 4. Effectiveness in the terminal phase of the illness is scientifically proven.

1. When compared with other similar medications, donepezil (Aricept) has fewer adverse effects. Donepezil is effective primarily in the early stages of the disease. The drug helps to slow the progression of the disease if started in the early stages. After the client has been diagnosed for 6 years, improvement to the level seen 6 years ago is highly unlikely. Data are not available to support the drug's effectiveness for clients in the terminal phase of the disease.

During a home visit to an elderly client with mild dementia, the client's daughter reports that she has one major problem with her mother. She says, "She sleeps most of the day and is up most of the night. I can't get a decent night's sleep anymore." Which suggestions should the nurse make to the daughter? Select all that apply. 1. Ask the client's physician for a strong sleep medicine. 2. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime. 3. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day. 4. Promote relaxation before bedtime with a warm bath or relaxing music. 5. Have the daughter encourage the use of caffeinated beverages during the day to keep her mother awake.

2, 3, 4. A set routine and brief exercises help decrease daytime sleeping. Decreasing caffeine and fluids and promoting relaxation at bedtime promote nighttime sleeping. A strong sleep medicine for an elderly client is contraindicated due to changes in metabolism, increased adverse effects, and the risk of falls. Using caffeinated beverages may stimulate metabolism but can also have long-lasting adverse effects and may prevent sleep at bedtime.

Which of the following is a realistic short-term goal to be accomplished in 2 to 3 days for a client with delirium? 1. Explain the experience of having delirium. 2. Resume a normal sleep-wake cycle. 3. Regain orientation to time and place. 4. Establish normal bowel and bladder function.

3. In approximately 2 to 3 days, the client should be able to regain orientation and thus become oriented to time and place. Being able to explain the experience of having delirium is something that the client is expected to achieve later in the course of the illness, but ultimately before discharge. Resuming a normal sleep-wake cycle and establishing normal bowel and bladder function probably will take longer, depending on how long it takes to resolve the underlying condition.

The nurse discusses the possibility of a client's attending day treatment for clients with early Alzheimer's disease. Which of the following is the best rationale for encouraging day treatment? 1. The client would have more structure to his day. 2. Staff are excellent in the treatment they offer clients. 3. The client would benefit from increased social interaction. 4. The family would have more time to engage in their daily activities.

3. The best rationale for day treatment for the client with Alzheimer's disease is the enhancement of social interactions. More daily structure, excellent staff, and allowing caregivers more time for themselves are all positive aspects, but they are less focused on the client's needs.

The client with Alzheimer's disease may have delusions about being harmed by staff and others. When the client expresses fear of being killed by staff, which of the following responses is most appropriate? 1. "What makes you think we want to kill you?" 2. "We like you too much to want to kill you." 3. "You are in the hospital. We are nurses trying to help you." 4. "Oh, don't be so silly. No one wants to kill you here."

3. The nurse needs to present reality without arguing with the delusions. Therefore, stating that the client is in the hospital and the nurses are trying to help is most appropriate. The client doesn't recognize the delusion or why it exists. Telling the client that the staff likes him too much to want to kill him is inappropriate because the client believes the delusions and doesn't know that they are false beliefs. It also restates the word, kill, which may reinforce the client's delusions. Telling the client not to be silly is condescending and disparaging and therefore inappropriate.

An elderly woman's husband died. When her brother arrives for the funeral, he notices her short-term memory problems and occasional disorientation. A few weeks later, she calls him to say that her husband just died. She says, "I didn't know he was so sick. Why did he die now?" She also complains of not sleeping, urinary frequency and burning, and seeing rats in the kitchen. A home care nurse is sent to evaluate her situation and finds the woman reclusive and passive, but pleasant. The nurse calls the woman's primary care physician to discuss the client's situation and background, and give his assessment and recommendations. The nurse concludes that the woman: 1. Is experiencing the onset of Alzheimer's disease. 2. Is having trouble adjusting to living alone without her husband. 3. Is having delayed grieving related to her Alzheimer's disease. 4. Is experiencing delirium and a urinary tract infection.

4. Delirium is commonly due to a medical condition such as a UTI in the elderly. Delirium often involves memory problems, disorientation, and hallucinations. It develops rather quickly. There is not enough data to suggest Alzheimer's disease especially given the quick onset of symptoms. Delayed grieving and adjusting to being alone are unlikely to cause hallucinations.

The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. An appropriate nursing intervention to help the patient communicate is to a. ask simple questions that the patient can answer with "yes" or "no." b. develop a list of words that the patient can read and practice reciting. c. have the patient practice facial and tongue exercises to improve motor control necessary for speech. d. prevent embarrassing the patient by changing the subject if the patient does not respond in a timely manner.

The nurse has identified the nursing diagnosis of disturbed thought processes related to effects of dementia for a patient with late-stage Alzheimer's disease (AD). An appropriate intervention for this problem is to a. maintain a consistent daily routine for the patient's care. b. encourage the patient to discuss events from the past. c. reorient the patient to the date and time every few hours. d. provide the patient with current newspapers and magazines.

Correct Answer: A Rationale: Providing a consistent routine will decrease anxiety and confusion for the patient. In late-stage AD, the patient will not remember events from the past. Reorientation to time and place will not be helpful to the patient with late-stage AD. The patient with late-stage AD will not be able to read. Cognitive Level: Application Text Reference: p. 1571 Nursing Process: Planning NCLEX: Physiological Integrity

When developing a plan of care for a hospitalized patient with moderate dementia, which intervention will the nurse include? a. Reminding the patient frequently about being in the hospital b. Placing suction at the bedside to decrease the risk for aspiration c. Providing complete personal hygiene care for the patient d. Repositioning the patient frequently to avoid skin breakdown

Correct Answer: A Rationale: The patient with moderate dementia will have problems with short- and long-term memory and will need reminding about the hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty with swallowing, self-care, and immobility. Cognitive Level: Application Text Reference: p. 1563 Nursing Process: Planning NCLEX: Physiological 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

22. A 72-year-old is being discharged home following a stroke. The patient is able to walk with assistance but needs help with hygiene, dressing, and eating. Which statement by the patient's wife indicates that discharge planning goals have been met? a. "I can provide the care my husband needs if I use the support and resources available in the community." b. "Because my husband will have continuous improvement in his condition, I won't need outside assistance in his care for very long." c. "I can handle all of my husband's needs thanks to the instructions you've given me." d. "I have arranged for a home health aide to provide all the care my husband will need."

Correct Answer: A Rationale: The statement that community resources will be used indicates a realistic outcome. The patient is unlikely to continue to improve to the point of needing no assistance. The wife is likely to be overwhelmed by the patient's needs if she attempts to manage without assistance. There is no indication that the patient will need a home health aide to meet all of his care needs. Cognitive Level: Application Text Reference: p. 1524 Nursing Process: Evaluation NCLEX: Physiological Integrity

27. A patient with sudden-onset right-sided weakness has a CT scan and is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patient has atrial fibrillation and takes warfarin (Coumadin). b. The patient takes a diuretic because of a history of hypertension. c. The patient's blood pressure is 144/90 mm Hg. d. The patient's speech is difficult to understand.

Correct Answer: A Rationale: The use of warfarin will have contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated. Cognitive Level: Application Text Reference: p. 1512 Nursing Process: Assessment NCLEX: Physiological Integrity

A patient with Parkinson's disease is admitted to the hospital for treatment of an acute infection. Which nursing interventions will be included in the plan of care? (Select all that apply.) a. Cut patient's food into small pieces. b. Provide high protein foods at each meal. c. Observe for sudden exacerbation of symptoms. d. Remind the patient to keep eyes ahead when ambulating. e. Place an arm chair at the patient's bedside. f. Use an elevated toilet seat.

A patient who has been taking bromocriptine (Parlodel) and benztropine (Cogentin) for Parkinson's disease is experiencing a worsening of symptoms. The nurse will anticipate that patient may benefit from a. complete drug withdrawal for a few weeks. b. use of levodopa (L-dopa)-carbidopa (Sinemet). c. withdrawal of anticholinergic therapy. d. increasing the dose of bromocriptine.

21. Several weeks after a stroke, a patient has urinary incontinence resulting from an impaired awareness of bladder fullness. A bladder retraining program for the patient should include a. limiting fluid intake to 1000 ml daily to reduce urine volume. b. assisting the patient onto the bedside commode every 2 hours. c. performing intermittent catheterization after each voiding to check for residual urine. d. using an external "condom" catheter to protect the skin and prevent embarrassment.

Correct Answer: B Rationale: Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1000-ml fluid intake is too restricted and will lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke but should not be considered solutions for long-term management because of the risks for urinary tract infection (UTI) and skin breakdown. Cognitive Level: Application Text Reference: p. 1523 Nursing Process: Planning 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

1. The nurse obtains all of the following information about a 65-year-old patient in the clinic. When developing a plan to decrease stroke risk, which risk factor is most important for the nurse to address? a. The patient smokes a pack of cigarettes daily. b. The patient's blood pressure (BP) is chronically between 150/80 to 170/90 mm Hg. c. The patient works at a desk and relaxes by watching television. d. The patient is 25 pounds above the ideal weight.

8. The health care provider recommends a carotid endarterectomy for a patient with carotid atherosclerosis and a history of transient ischemic attacks (TIA). The patient asks the nurse to describe the procedure. Which response by the nurse is appropriate? a. "The diseased portion of the artery in the brain is removed and replaced with a synthetic graft." b. "The carotid endarterectomy involves surgical removal of plaque from an artery in the neck." c. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque." d. "A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed."

Correct Answer: B Rationale: In a carotid endarterectomy, the carotid artery is incised and the plaque is removed. The response beginning, "The diseased portion of the artery in the brain is removed" describes an arterial graft procedure. The answer beginning, "A catheter with a deflated balloon is positioned at the narrow area" describes an angioplasty. The final response (beginning, "A wire is threaded through the artery") describes the Merci procedure. Cognitive Level: Application Text Reference: p. 1510 Nursing Process: Implementation NCLEX: Physiological Integrity

The health care provider recommends a carotid endarterectomy for a patient with carotid atherosclerosis and a history of transient ischemic attacks (TIA). The patient asks the nurse to describe the procedure. Which response by the nurse is appropriate? a. "The diseased portion of the artery in the brain is removed and replaced with a synthetic graft." b. "The carotid endarterectomy involves surgical removal of plaque from an artery in the neck." c. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque." d. "A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed."

17. The nurse is assisting the patient who is recovering from an acute stroke and has right-side hemiplegia to transfer from the bed to the wheelchair. Which action by the nurse is appropriate? a. Positioning the wheelchair next to the bed on the patient's right side b. Placing the wheelchair parallel to the bed on the patient's left side c. Setting the wheelchair directly in front of the patient, who is sitting on the side of the bed d. Moving the wheelchair a few steps from the bed and having the patient walk to the chair

Correct Answer: B Rationale: Placing the wheelchair on the patient's left side will allow the patient to use the left hand to grasp the left arm of the chair to transfer. If the chair is placed on the patient's right side or in front of the patient, it will be awkward to use the strong arm, and the patient will be at increased risk for a fall. Because the patient has hemiplegia, it is not appropriate to place the chair where the patient will need to walk to it. Cognitive Level: Application Text Reference: p. 1522 Nursing Process: Implementation NCLEX: Physiological Integrity

The nurse identifies the nursing diagnosis of impaired physical mobility related to bradykinesia for a patient with Parkinson's disease. To assist the patient to ambulate safely, the nurse should a. allow the patient to ambulate only with assistance. b. instruct the patient to rock from side to side to initiate leg movement. c. have the patient take small steps in a straight line directly in front of the feet. d. teach the patient to keep the feet in contact with the floor and slide them forward.

A family member of a patient with possible Alzheimer's disease asks the nurse the purpose of the Mini-Mental State Examination (MMSE). Which response by the nurse is appropriate? a. The MMSE helps in establishing the diagnosis of Alzheimer's disease (AD). b. The MMSE is useful in determining the degree of mental impairment. c. The MMSE determines the choice of the most appropriate treatment. d. The MMSE aids in differentiating acute delirium from chronic dementia.

Correct Answer: B Rationale: The MMSE establishes the degree of mental impairment at the time it is given. It does not establish a diagnosis of AD but when given repeatedly over time may help to determine the progression of AD. The choice of treatment is made on the basis of multiple data, not just the MMSE. The MMSE may be abnormal with either delirium or dementia and is not useful in determining which condition the patient has. Cognitive Level: Application Text Reference: p. 1563 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

15. A patient who has had a subarachnoid hemorrhage is being cared for in the intensive care unit. Which information about the patient is most important to communicate to the health care provider? a. The patient complains of an ongoing severe headache. b. The patient's blood pressure is 90/50 mm Hg. c. The cerebrospinal fluid (CFS) report shows red blood cells (RBCs). d. The patient complains about having a stiff neck.

Correct Answer: B Rationale: To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a high level after a subarachnoid hemorrhage. A low or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider. Cognitive Level: Analysis Text Reference: p. 1515 Nursing Process: Assessment NCLEX: Physiological Integrity

4. Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the health care provider before giving the aspirin? a. The patient has atrial fibrillation. b. The patient has dysphasia. c. The patient states, "I suddenly developed a terrible headache." d. The patient has a history of brief episodes of right hemiplegia.

Correct Answer: C Rationale: A sudden-onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer the aspirin. Cognitive Level: Application Text Reference: p. 1507 Nursing Process: Assessment NCLEX: Physiological Integrity

Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the health care provider before giving the aspirin? a. The patient has atrial fibrillation. b. The patient has dysphasia. c. The patient states, "I suddenly developed a terrible headache." d. The patient has a history of brief episodes of right hemiplegia.

23. A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering the medications, the patient says, "I don't need the aspirin today. I don't have any aches or pains." Which action should the nurse take? a. Document that the aspirin was refused by the patient. b. Call the health care provider to clarify the medication order. c. Explain that the aspirin is ordered to decrease stroke risk. d. Tell the patient that the aspirin is used to prevent aches.

Correct Answer: C Rationale: Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patient's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The aspirin is not ordered to prevent aches and pains. Cognitive Level: Application Text Reference: pp. 1505, 1510 Nursing Process: Implementation NCLEX: Physiological Integrity

14. A patient with homonymous hemianopsia resulting from a stroke has a nursing diagnosis of disturbed sensory perception related to hemianopsia. To help the patient learn to compensate for the deficit during the rehabilitation period, the nurse should a. apply an eye patch to the affected eye. b. approach the patient on the unaffected side. c. place objects necessary for activities of daily living on the patient's affected side. d. have the patient use the eye muscles to move the eyes through the entire visual field.

Correct Answer: C Rationale: During the rehabilitation period, placing objects on the affected side will encourage the patient to use the scanning technique to visualize the affected side. Because homonymous hemianopsia affects half the visual field in each eye, use of an eye patch is not appropriate. Approaching the patient on the affected side is appropriate during the acute period but does not help the patient learn skills needed to compensate for the visual defect. The problem is with the visual field, not with the eye muscles, so practice moving the eyes through the visual field will not be effective. Cognitive Level: Application Text Reference: p. 1517 Nursing Process: Implementation NCLEX: Physiological Integrity

A patient with homonymous hemianopsia resulting from a stroke has a nursing diagnosis of disturbed sensory perception related to hemianopsia. To help the patient learn to compensate for the deficit during the rehabilitation period, the nurse should a. apply an eye patch to the affected eye. b. approach the patient on the unaffected side. c. place objects necessary for activities of daily living on the patient's affected side. d. have the patient use the eye muscles to move the eyes through the entire visual field.

Coexisting dementia and depression are identified in a patient with Parkinson's disease. The nurse anticipates that the greatest improvement in the patient's condition will occur with administration of a. antipsychotic drugs. b. anticholinergic agents. c. dopaminergic agents and antidepressant drugs. d. selective serotonin reuptake inhibitor (SSRI) agents.

Correct Answer: C Rationale: Parkinson's disease and depression are both potentially reversible conditions, and the patient's symptoms that are caused by these two conditions will improve with appropriate treatment. Anticholinergic agents are likely to worsen the patient's condition because they will block the effect of acetylcholine at the synaptic cleft. There is no indication that the patient needs an antipsychotic agent at this time. A selective serotonin reuptake inhibitor (SSRI) may be effective for the depression, but it does not address the patient's other conditions. Cognitive Level: Application Text Reference: p. 1563 Nursing Process: Planning NCLEX: Physiological Integrity

he health care provider prescribes clopidogrel (Plavix) for a patient with cerebral atherosclerosis. When teaching about the new medication, the nurse will tell the patient a. that Plavix will reduce cerebral artery plaque formation. b. to monitor and record the blood pressure daily. c. to call the health care provider if stools are tarry. d. that Plavix will dissolve clots in the cerebral arteries.

12. A patient with a stroke has progressive development of neurologic deficits with increasing weakness and decreased level of consciousness (LOC). The priority nursing diagnosis for the patient is a. risk for impaired skin integrity related to immobility. b. disturbed sensory perception related to brain injury. c. risk for aspiration related to inability to protect airway. d. impaired physical mobility related to weakness.

13. A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the effects of right brain damage, the nurse establishes a nursing diagnosis of a. impaired physical mobility related to right hemiplegia. b. impaired verbal communication related to speech-language deficits. c. risk for injury related to denial of deficits and impulsiveness. d. ineffective coping related to depression and distress about disability.

Correct Answer: C Rationale: Right-sided brain damage typically causes denial of any deficits and poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability. Cognitive Level: Application Text Reference: p. 1508 Nursing Process: Diagnosis NCLEX: Physiological Integrity

A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the effects of right brain damage, the nurse establishes a nursing diagnosis of a. impaired physical mobility related to right hemiplegia. b. impaired verbal communication related to speech-language deficits. c. risk for injury related to denial of deficits and impulsiveness. d. ineffective coping related to depression and distress about disability.

25. The nurse is caring for a patient with carotid artery narrowing who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a. The pulse rate is 104 beats/min. b. There are fine crackles at the lung bases. c. The patient has difficulty talking. d. The blood pressure is 142/88 mm Hg.

Correct Answer: C Rationale: Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual as a result of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure; the nurse should have the patient take some deep breaths. Cognitive Level: Application Text Reference: p. 1510 Nursing Process: Assessment NCLEX: Physiological Integrity

20. A patient has right-sided weakness and aphasia as a result of a stroke but is attempting to use the left hand for feeding and other activities. The patient's wife insists on feeding and dressing him, telling the nurse, "I just don't like to see him struggle." A nursing diagnosis that is most appropriate in this situation is a. situational low self-esteem related to increasing dependence on others. b. interrupted family processes related to effects of illness of a family member. c. disabled family coping related to inadequate understanding by patient's spouse. d. ineffective therapeutic regimen management related to hemiplegia and aphasia.

Correct Answer: C Rationale: The information supports the diagnosis of disabled family coping because the wife does not understand the rehabilitation program. There are no data supporting low self-esteem, and the patient is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. The patient's attempts to use the left hand indicate that he is managing the therapeutic regimen appropriately. Cognitive Level: Application Text Reference: p. 1523 Nursing Process: Diagnosis NCLEX: Psychosocial Integrity

A patient with Alzheimer's disease (AD) is hospitalized with a urinary tract infection. The spouse tells the nurse, "I am just exhausted from the constant care and worry. We don't have any children and we can't afford a nursing home. I don't know what to do." The most appropriate nursing diagnosis for the spouse is a. anxiety related to limited financial resources. b. ineffective health maintenance related to stress. c. caregiver role strain related to limited resources for caregiving. d. social isolation related to unrelieved caregiving responsibilities.

Correct Answer: C Rationale: The spouse's statements are most consistent with caregiver role strain. The other diagnoses each address one aspect of the spouse's problem, but caregiver-role strain related to limited resources for caregiving addresses all the information the nurse has about this situation. Cognitive Level: Application Text Reference: pp. 1574-1575 Nursing Process: Diagnosis NCLEX: Psychosocial Integrity

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

On initial assessment of a patient hospitalized following a stroke, the nurse finds the patient's blood pressure to be 180/90 mm Hg. Which of the following orders by the health care provider should the nurse question? a. Infuse normal saline at 75 ml/hr. b. Keep head of bed elevated at least 30 degrees. c. Administer tissue plasminogen activator (tPA) per protocol. d. Titrate labetolol (Normodyne) drip to keep BP less than 140/90 mm Hg.

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

19. A patient who has had a stroke has a new order to attempt oral feedings. The nurse should assess the gag reflex and then a. offer the patient a sip of juice. b. order a varied pureed diet. c. assess the patient's appetite. d. assist the patient into a chair.

Correct Answer: D Rationale: The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted regardless. Cognitive Level: Application Text Reference: pp. 1518-1519 Nursing Process: Implementation NCLEX: Physiological Integrity

18. A 32-year-old patient has a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan? a. Encouraging patient to cough and deep breath every 4 hours b. Inserting an oropharyngeal airway to prevent airway obstruction c. Assisting to dangle on edge of bed and assess for dizziness d. Applying intermittent pneumatic compression stockings

Correct Answer: D Rationale: The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for deep vein thrombosis (DVT). Activities (such as coughing and sitting up) that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate. Cognitive Level: Application Text Reference: p. 1518 Nursing Process: Planning NCLEX: Physiological Integrity

3. The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include a. heparin via continuous intravenous infusion. b. prophylactic clipping of cerebral aneurysms. c. therapy with tissue plasminogen activator (tPA). d. oral administration of ticlopidine (Ticlid).

Correct Answer: D Rationale: The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, but not for TIA. Cognitive Level: Application Text Reference: p. 1505 Nursing Process: Implementation NCLEX: Physiological Integrity

The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include a. heparin via continuous intravenous infusion. b. prophylactic clipping of cerebral aneurysms. c. therapy with tissue plasminogen activator (tPA). d. oral administration of ticlopidine (Ticlid).

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

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The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The client recently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the family about the use of lorazepam (Ativan). The nurse should instruct the family to report which of the following significant side effects to the health care provider? 1. Paradoxical excitement. 2. Headache. 3. Slowing of reflexes. 4. Fatigue.

1. Although all of the side effects listed are possible with Ativan, paradoxical excitement is cause for immediate discontinuation of the medication. (Paradoxical excitement is the opposite reaction to Ativan than is expected.) The other side effects tend to be minor and usually are transient.

When developing the plan of care for a client with Alzheimer's disease who is experiencing moderate impairment, which of the following types of care should the nurse expect to include? 1. Prompting and guiding activities of daily living. 2. Managing a medication schedule. 3. Constant supervision and total care. 4. Supervision of risky activities such as shaving.

1. Considerable assistance is associated with moderate impairment when the client cannot make decisions but can follow directions. Managing medications is needed even in mild impairment. Constant care is needed in the terminal phase, when the client cannot follow directions. Supervision of shaving is appropriate with mild impairment— that is, when the client still has motor function but lacks judgment about safety issues.

In addition to developing over a period of hours or days, the nurse should assess delirium as distinguishable by which of the following characteristics? 1. Disturbances in cognition and consciousness that fluctuate during the day. 2. The failure to identify objects despite intact sensory functions. 3. Significant impairment in social or occupational functioning over time. 4. Memory impairment to the degree of being called amnesia.

1. Fluctuating symptoms are characteristic of delirium. The failure to identify objects despite intact sensory functions, significant impairment in social or occupational functioning over time, and memory impairment to the degree

The client in the early stage of Alzheimer's disease and his adult son attend an appointment at the community mental health center. While conversing with the nurse, the son states, "I'm tired of hearing about how things were 30 years ago. Why does Dad always talk about the past?" The nurse should tell the son: 1. "Your dad lost his short-term memory, but he still has his long-term memory." 2. "You need to be more accepting of your dad's behavior." 3. "I want you to understand your dad's level of anxiety." 4. "Telling your dad that you are tired of hearing about the past will help him stop."

1. The son's statements regarding his father's recalling past events is typical for family members of clients in the early stage of Alzheimer's disease, when recent memory is impaired. Telling the son to be more accepting is critical and not an attempt to educate. Understanding the client's level of anxiety is unrelated to the memory loss of Alzheimer's disease. The client cannot stop reminiscing at will.

When helping the families of clients with Alzheimer's disease cope with vulgar or sexual behaviors, which of the following suggestions is most helpful? 1. Ignore the behaviors, but try to identify the underlying need for the behaviors. 2. Give feedback on the inappropriateness of the behaviors. 3. Employ anger management strategies. 4. Administer the prescribed risperidone (Risperdal).

1. The vulgar or sexual behaviors are commonly expressions of anger or more sensual needs that can be addressed directly. Therefore, the families should be encouraged to ignore the behaviors but attempt to identify their purpose. Then the purpose can be addressed, possibly leading to a decrease in the behaviors. Because of impaired cognitive function, the client is not likely to be able to process the inappropriateness of the behaviors if given feedback. Likewise, anger management strategies would be ineffective because the client would probably be unable to process the inappropriateness of the behaviors. Risperidone (Risperdal) may decrease agitation, but it does not improve social behaviors.

The family of a client, diagnosed with Alzheimer's disease, wants to keep the client at home. They say that they have the most difficulty in managing his wandering. The nurse should instruct the family to do which of the following? (Select all that apply). 1. Ask the physician for a sleeping medication. 2. Install motion and sound detectors. 3. Have a relative sit with the client all night. 4. Have the client wear a Medical Alert bracelet. 5. Install door alarms and high door locks.

2, 4, 5. Motion and sound detectors, a Medical Alert bracelet, and door alarms are all appropriate interventions for wandering. Sleep medications do not prevent wandering before and after the client is asleep and may have negative effects. Having a relative sit with the client is usually an unrealistic burden.

Which of the following is a priority to include in the plan of care for a client with Alzheimer's disease who is experiencing difficulty processing and completing complex tasks? 1. Repeating the directions until the client follows them. 2. Asking the client to do one step of the task at a time. 3. Demonstrating for the client how to do the task. 4. Maintaining routine and structure for the client.

2. Because the client is experiencing difficulty processing and completing complex tasks, the priority is to provide the client with only one step at a time, thereby breaking the task up into simple steps, ones that the client can process. Repeating the directions until the client follows them or demonstrating how to do the task is still too overwhelming to the client because of the multiple steps involved. Although maintaining structure and routine is important, it is unrelated to task completion.

A client with early dementia exhibits disturbances in her mental awareness and orientation to reality. The nurse should expect to assess a loss of ability in which of the following other areas? 1. Speech. 2. Judgment. 3. Endurance. 4. Balance.

2. Clients with chronic cognitive disorders experience defects in memory orientation and intellectual functions, such as judgment and discrimination. Loss of other abilities, such as speech, endurance, and balance, is less typical.

A client diagnosed with dementia wanders the halls of the locked nursing unit during the day. To ensure the client's safety while walking in the halls, the nurse should do which of the following? 1. Administer PRN haloperidol (Haldol) to decrease the need to walk. 2. Assess the client's gait for steadiness. 3. Restrain the client in a geriatric chair. 4. Administer PRN lorazepam (Ativan) to provide sedation.

2. Elderly clients have increased risk for falls due to balance problems, medication use, and decreased eyesight. Haldol may cause extrapyramidal side effects (EPSE) which increase the risk for falls. The client is not agitated, so restraints are not indicated. Ativan may increase fall risk and cause paradoxical excitement.

The term motor apraxia relates to a decline in motor patterns essential for complex motor tasks. However, the client with severe dementia may be able to perform which of the following actions? 1. Balance a checkbook accurately. 2. Brush the teeth when handed a toothbrush. 3. Use confabulation when telling a story. 4. Find misplaced car keys.

2. Highly conditioned motor skills, such as brushing the teeth, may be retained by the client who has dementia and motor apraxia. Balancing a checkbook involves calculations, a complex skill that is lost with severe dementia Confabulation is fabrication of details to fill a memory gap. This is more common when the client is aware of a memory problem, not when dementia is severe. Finding keys is a memory factor, not a motor function.

A 69-year-old client is admitted and diagnosed with delirium. Later in the day, he tries to get out of the locked unit. He yells, "Unlock this door. I've got to go see my doctor. I just can't miss my monthly Friday appointment." Which of the following responses by the nurse is most appropriate? 1. "Please come away from the door. I'll show you your room." 2. "It's Tuesday and you are in the hospital. I'm Anne, a nurse." 3. "The door is locked to keep you from getting lost." 4. "I want you to come eat your lunch before you go the doctor."

2. Loss of orientation, especially for time and place, is common in delirium. The nurse should orient the client by telling him the time, date, place, and who the client is with. Taking the client to his room and telling him why the door is locked does not address his disorientation. Telling the client to eat before going to the doctor reinforces his disorientation.

Which of the following is essential when caring for a client who is experiencing delirium? 1. Controlling behavioral symptoms with low-dose psychotropics. 2. Identifying the underlying causative condition or illness. 3. Manipulating the environment to increase orientation. 4. Decreasing or discontinuing all previously prescribed medications.

2. The most critical aspect when caring for the client with delirium is to institute measures to correct the underlying causative condition or illness. Controlling behavioral symptoms with low-dose psychotropics, manipulating the environment, and decreasing or discontinuing all medications may be dangerous to the client's health.

A nurse on the Geropsychiatric unit receives a call from the son of a recently discharged client. He reports that his father just got a prescription for memantine (Namenda) to take "on top of his donepezil (Aricept)." The son then asks, "Why does he have to take extra medicines?" The nurse should tell the son: 1. "Maybe the Aricept alone isn't improving his dementia fast enough or well enough." 2. "Namenda and Aricept are commonly used together to slow the progression of dementia." 3. "Namenda is more effective than Aricept. Your father will be tapered off the Aricept." 4. "Aricept has a short half-life and Namenda has a long half-life. They work well together."

2. The two medicines are commonly given together. Neither medicine will improve dementia, but may slow the progression. Neither medicine is more effective than the other; they act differently in the brain. Both medicines have a half-life of 60 or more hours.

While assessing a client diagnosed with dementia, the nurse notes that her husband is concerned about what he should do when she uses vulgar language with him. The nurse should: 1. Tell her that she is very rude. 2. Ignore the vulgarity and distract her. 3. Tell her to stop swearing immediately. 4. Say nothing and leave the room.

2. Vulgar language is common in clients with dementia when they are having trouble communicating about a topic. Ignoring the vulgarity and distracting her is appropriate. Telling the client she is rude or to stop swearing will have no lasting effect and may cause agitation. Just leaving the room is abandonment that the client will not understand.

A client is experiencing agnosia as a result of vascular dementia. She is staring at dinner and utensils without trying to eat. Which intervention should the nurse attempt first? 1. Pick up the fork and feed the client slowly. 2. Say, "It's time for you to start eating your dinner." 3. Hand the fork to the client and say, "Use this fork to eat your green beans." 4. Save the client's dinner until her family comes in to feed her.

3. Agnosia is the lack of recognition of objects and their purpose. The nurse should inform the client about the fork and what to do with it. Feeding the client does not address the agnosia or give the client specific directions. It should only be attempted if identifying the fork and explaining what to do with it is ineffective. Waiting for the family to care for the client is not appropriate unless identifying the fork and explaining or feeding the client are not successful.

The physician orders risperidone (Risperdal) for a client with Alzheimer's disease. The nurse anticipates administering this medication to help decrease which of the following behaviors? 1. Sleep disturbances. 2. Concomitant depression. 3. Agitation and assaultiveness. 4. Confusion and withdrawal.

3. Antipsychotics are most effective with agitation and assaultiveness. Antipsychotics have little effect on sleep disturbances, concomitant depression, or confusion and withdrawal.

When communicating with the client who is experiencing dementia and exhibiting decreased attention and increased confusion, which of the following interventions should the nurse employ as the first step? 1. Using gentle touch to convey empathy. 2. Rephrasing questions the client doesn't understand. 3. Eliminating distracting stimuli such as turning off the television. 4. Asking the client to go for a walk while talking.

3. Competing and excessive stimuli lead to sensory overload and confusion. Therefore, the nurse should first eliminate any distracting stimuli. After this is accomplished, then using touch and rephrasing questions are appropriate. Going for a walk while talking has little benefit on attention and confusion.

When caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate? 1. Cancer of any kind. 2. Impaired hearing. 3. Prescription drug intoxication. 4. Heart failure.

3. Polypharmacy is much more common in the elderly. Drug interactions increase the incidence of intoxication from prescribed medications, especially with combinations of analgesics, digoxin, diuretics, and anticholinergics. With drug intoxication, the onset of the delirium typically is quick. Although cancer, impaired hearing, and heart failure could lead to delirium in the elderly, the onset would be more gradual.

The nurse observes a client in a group who is reminiscing about his past. Which effect should the nurse expect reminiscing to have on the client's functioning in the hospital? 1. Increase the client's confusion and disorientation. 2. Cause the client to become sad. 3. Decrease the client's feelings of isolation and loneliness. 4. Keep the client from participating in therapeutic activities.

3. Reminiscing can help reduce depression in an elderly client and lessens feelings of isolation and loneliness. Reminiscing encourages a focus on positive memories and accomplishments as well as shared memories with other clients. An increase in confusion and disorientation is most likely the result of other cognitive and situational factors, such as loss of short-term memory, not reminiscing. The client will not likely become sad because reminiscing helps the client connect with positive memories. Keeping the client from participating in therapeutic activities is less likely with reminiscing.

A 90-year-old client diagnosed with major depression is suddenly experiencing sleep disturbances, inability to focus, poor recent memory, altered perceptions, and disorientation to time and place. Lab results indicate the client has a urinary tract infection and dehydration. After explaining the situation and giving the background and assessment data, the nurse should make which of the following recommendations to the client's physician? 1. An order to place the client in restraints. 2. A reevaluation of the client's mental status. 3. The transfer of the client to a medical unit. 4. A transfer of the client to a nursing home.

3. The client is showing symptoms of delirium, a common outcome of UTI in older adults. The nurse can request a transfer to a medical unit for acute medical intervention. The client's symptoms are not just due to a worsening of the depression. There are not indications that the client needs restraints or a transfer to a nursing home at this point.

A client with dementia who prefers to stay in his room has been brought to the dayroom. After 10 minutes, the client becomes agitated and retreats to his room again. The nurse decides to assess the conditions in the dayroom. Which is the most likely occurrence that is disturbing to this client? 1. There is only one other client in the dayroom; the rest are in a group session in another room. 2. There are three staff members and one physician in the nurse's station working on charting. 3. A relaxation tape is playing in one corner of the room, and a television airing a special on crime is playing in the opposite corner. 4. A housekeeping staff member is washing off the countertops in the kitchen, which is on the far side of the dayroom.

3. The tape and television are competing, even conflicting, stimuli. Crime events portrayed on television could be misperceived as a real threat to the client. A low number of clients and the presence of a few staff members quietly working are less intense stimuli for the client and not likely to be disturbing.

The son of an elderly client who has cognitive impairments approaches the nurse and says, "I'm so upset. The physician says I have 4 days to decide on where my dad is going to live." The nurse responds to the son's concerns, gives him a list of types of living arrangements, and discusses the needs, abilities, and limitations of the client. The nurse should intervene further if the son makes which comment? 1. "Boy, I have a lot to think about before I see the social worker tomorrow." 2. "I think I can handle most of Dad's needs with the help of some home health care." 3. "I'm so afraid of making the wrong decision, but I can move him later if I need to." 4. "I want the social worker to make this decision so Dad won't blame me."

4. Expecting the social worker to make the decision indicates that the son is avoiding participating in decisions about his father. The other responses convey that the son understands the importance of a careful decision, the availability of resources, and the ability to make new plans if needed.

While educating the daughter of a client with dementia about the illness, the daughter complains to the nurse that her mother distorts things. The nurse understands that the daughter needs further teaching about dementia when she makes which statement? 1. "I tell her reality, such as, 'That noise is the wind in the trees.'" 2. "I understand the misperceptions are part of the disease." 3. "I turn off the radio when we're in another room." 4. "I tell her she is wrong and then I tell her what's right."

4. Telling the client that she is wrong and then telling her what is right is argumentative and challenging. Arguing with or challenging distortions is least effective because it increases defensiveness. Telling the client about reality indicates awareness of the issues and is appropriate. Acknowledging that misperceptions are part of the disease indicates an understanding of the disease and an awareness of the issues. Turning off the radio helps to limit environmental stimuli and indicates an awareness of the issues.

6. The nurse on the medical unit receives a verbal report from the emergency department nurse that a patient has an occlusion of the left posterior cerebral artery. When admitting the patient to the medical floor, the nurse will anticipate that the patient may have a. visual deficits. b. dysphasia. c. confusion. d. poor judgment.

The nurse is caring for a patient with carotid artery narrowing who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a. The pulse rate is 104 beats/min. b. There are fine crackles at the lung bases. c. The patient has difficulty talking. d.

correct answer: D

5. A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When obtaining admission assessment data about the patient's clinical manifestations, it is most important the nurse assess the patient's a. ability to follow commands. b. visual fields. c. right-sided reflexes.

d. emotional state. Correct Answer: A Rationale: Because the patient with a left-sided brain stroke may also have difficulty with comprehension and use of language, so it is important to obtain baseline data about the ability to follow commands. This will impact on patient safety and nursing care. The visual fields are not typically affected by a left-sided stroke. Information about reflexes and emotional state will be collected but is not as high a priority as information about language abilities. Cognitive Level: Application Text Reference: p. 1508 Nursing Process: Assessment NCLEX: Physiological Integrity

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