Neurologic/Sensorineural
A female patient has presented to the emergency department (ED) with complaints of a high fever and severe headache. The patient states that acetaminophen has had no appreciable effect on either symptom. The triage nurse recognizes the need to perform a rapid assessment for possible meningitis and should ask which of the following questions: -"Have you had a nosebleed since this problem started?" -"Have you noticed any tremors in your hands or arms?" -"Have you done any traveling in the last few weeks?" -"Are you having stiffness or pain in your neck?"
"Are you having stiffness or pain in your neck?" Feedback: Nuchal rigidity is an early sign of meningitis that is seen in 30% to 70% of patients. Nosebleed and tremors are not characteristic of meningitis, and the disease is not commonly preceded by travel.
The nurse is performing a detailed mental status assessment of an older adult patient who has a diagnosis of mild Alzheimer's disease. What assessment most accurately gauges the patient's abstract reasoning? -"What city and state are we in right now?" -"What would you do if you found a stamped envelope on the street?" -"If you divide 16 by four and then double it, what do you get?" -"How do you believe that Alzheimer's disease if affecting you?"
"What would you do if you found a stamped envelope on the street?" Feedback: Abstract reasoning is often assessed by presenting a scenario that requires the patient to weigh various options in an effort to craft a plausible response. Orientation to place and math ability do not necessarily indicate normal abstract reasoning ability. Asking about the patient's diagnosis may indicate the presence or absence of insight.
The nurse educator is reviewing the proper way to instill eye drops in a patient's eye. How long would the educator teach the nurses to wait between successive eye drops in the same eye, in order to achieve adequate eye drop drug retention and absorption? -30 seconds -1 minute -3 minutes -5 minutes
5 minutes Feedback: A 5-minute interval between successive eye drop administration allows for adequate drug retention and absorption. Any time frame less than 5 minutes will not allow adequate absorption.
A 37-year-old male is brought to the clinic by his wife because the patient is experiencing loss of motor function and sensation. After initial neurological assessment, the health care provider suspects the patient has a spinal cord tumor and hospitalizes him for diagnostic testing. In preparation for diagnostic studies, the nurse will inform the patient that the most commonly used study to diagnosis spinal cord compression from a tumor is what? -An Xray -An ultrasound -A computed tomography (CT) scan -A magnetic resonance imaging (MRI) scan
A magnetic resonance imaging (MRI) scan Feedback: The MRI scan is the most commonly used diagnostic procedure. It is the most sensitive diagnostic tool that is particularly helpful in detecting epidural spinal cord compression and vertebral bone metastases.
A patient with herpes simplex virus (HSV) encephalitis has been admitted to the ICU. What medication would the nurse expect the health care provider to order for the treatment of this disease process? -Cyclosporine (Neoral) -Acyclovir (Zovirax) -Cyclobenzaprine (Flexeril) -Amipicillin (Principen)
Acyclovir (Zovirax) Feedback: Acyclovir (Zovirax), an antiviral agent, is the medication of choice in HSV treatment. The mode of action is the inhibition of viral DNA replication. To prevent relapse, treatment would continue for up to 3 weeks. Cyclosporine is an immunosuppressant and antirheumatic. Cyclobenzaprine is a centrally acting skeletal muscle relaxant. Ampicillin is an antibiotic.
A patient with spinal cord injury has a nursing diagnosis of altered mobility. Which of the following would be included as an appropriate nursing intervention to prevent deep vein thrombosis (DVT) from occurring? -Placing the patient on a fluid restriction -Applying thigh-high elastic stockings -Administering an antifibrinolytic agent -Assisting the patient with passive range of motion exercises
Applying thigh-high elastic stockings Feedback: It is important to promote venous return to the heart and prevent venous stasis in a patient with altered mobility. Applying elastic stockings will aid in the prevention of a DVT. The patient should not be placed on fluid restriction because a dehydrated state will increase the risk of clotting throughout the body. Antifibrinolytic agents cause the blood to clot, which is absolutely contraindicated in this situation.
While reviewing the nursing documentation on a patient on the neurological unit, the nurse notes that the patient complained of a headache several times over the previous shift. How can the nurse differentiate between a headache that is caused by a brain tumor and a headache that is caused by meningitis or encephalitis? -Assess the patient's carotid pulses bilaterally -Assess the patient's orientation to person, place, and time. -Assess the active and passive range of motion of the patient's neck -Assess for the presence of a fever
Assess for the presence of a fever. Feedback: When the patient complains of a headache, the nurse assesses the patient's temperature. The nurse knows that fever with headache is associated with an infectious process such as meningitis or encephalitis, whereas headache without fever is associated with a tumor or intracerebral bleeding.
A patient who suffered a T6 lesion during a spinal cord injury (SCI) 10 days ago is progressing with treatment and rehabilitation following the immediate treatment of his injury. When preparing to help the physical therapist mobilize the patient for the first time since the injury, the nurse should prioritize which of the following assessments? -Assessing the patient's blood pressure -Monitoring the patient's cognition -Monitoring the patient's pain level -Assessing the patient's respiratory rate
Assessing the patient's blood pressure Feedback: For the first 2 weeks following SCI, blood pressure tends to be unstable and quite low. It gradually returns to preinjury levels, but periodic episodes of severe orthostatic hypotension frequently interfere with efforts to mobilize the patient. Close monitoring of vital signs before and during position changes is essential. The other listed assessments should be addressed but they are less closely related to the specific risks associated with this procedure at this point in the patient's recovery.
As part of a start-of-shift nursing assessment, the nurse is documenting a patient's neurological status according to the Glasgow Coma Scale (GCS). What responses will the nurse assess to determine the patient's GCS score? Select all that apply. -Best sensory response -Best judgement -Best eye opening -Best verbal response -Best motor response
Best eye opening Best verbal responses Best motor responses Feedback: The three domains of the GCS are best eye opening, best verbal response, and best motor response. The three domains of the GCS are best eye opening, best verbal response, and best motor response. The three domains of the GCS are best eye opening, best verbal response, and best motor response.
A nurse is caring for a patient who is exhibiting signs and symptoms of autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient? -Tachycardia and hypotension -Bradycardia and hypertension -Tachycardia and hypertension -Bradycardia and hypotension
Bradycardia and hypertension Feedback: Autonomic dysreflexia is characterized by a pounding headache, profuse sweating, nasal congestion, piloerection ("goose bumps"), bradycardia, and hypertension. It may occur in cord lesions above T6 after spinal shock has resolved.
A neurological nurse is conducting a scheduled assessment of a patient who is receiving care on the unit. The nurse is aware of the need to conduct a vigilant assessment of the patient's level of consciousness (LOC). How should the nurse best gauge a patient's LOC? -By assessing according to the Glasgow Coma Scale (GCS) -By eliciting the patient's response to a question requiring judgment -By engaging the patient in a conversation, if possible -By observing the patient's interactions with caregivers
By assessing according to the Glasgow Coma Scale (GCS) Feedback: The GCS provides a valid, reliable, and objective indication of LOC. As such, it is superior to other assessment techniques such as asking the patient to respond to a scenario, conducting a conversation, or passively observing his or her interactions.
A patient who just suffered a hemorrhagic stroke is brought to the emergency department by ambulance. What should be the nurse's primary assessment focus? -Cardiac and respiratory status -Seizure activity -Urinary output -Fluid and electrolyte balance
Cardiac and respiratory status Feedback: Acute care begins with managing the ABC's. Patients may have difficulty keeping an open and clear airway secondary to decreased level of consciousness. Neurological assessment with close monitoring for signs of increased neurological deficit and seizure activity occurs next. Fluid and electrolyte balance must be controlled carefully, with the goal of adequate hydration to promote perfusion and decrease further brain damage.
Magnetic resonance imaging has confirmed a diagnosis of glioblastoma multiforme (GBM) in a 56-year-old male patient. The nurse who is planning this patient's care should prioritize which of the following nursing actions? -Liaising the community agencies to organize long-term rehabilitation -Teaching the patient about the importance of healthy lifestyle in recovery from GBM -Choosing psychosocial interventions that are relevant to the patient's poor prognosis -Teaching the patient about the pharmacological interventions relevant to his treatment
Choosing psychosocial interventions that are relevant to the patient's poor prognosis. Feedback: GBM is the most common and aggressive malignant brain tumor, and the overall prognosis is poor. Consequently, interventions should be chosen in light of this difficult reality. Pharmacological interventions are not the central treatments of GBM.
A patient with generalized seizure disorder has just had a seizure. The nurse would assess for what characteristic associated with the postictal state? -Epileptic cry -Confusion -Urinary incontinence -Body rigidity
Confusion Feedback: In the postictal state (after the seizure), the patient is often confused, hard to arouse, and may sleep for hours. The epileptic cry occurs from the simultaneous contractions of the diaphragm and chest muscles that occur during the seizure. Urinary incontinence and intense rigidity of the entire body are followed by alternating muscle relaxation and contraction (generalized tonic-clonic contraction) during the seizure.
A female patient who is recovering from a stroke has begun eating a minced and pureed diet after passing the speech pathologist's swallowing assessment. This morning, the nurse set up the patient with her breakfast tray and later noticed that the woman was swallowing her food well but dribbling small amounts of food out of affected side of her mouth. How should the nurse follow up this observation? -Provide oral suctioning after each bite that the patient swallows. -Make the patient NPO and encourage the care provider to consider enteral nutrition. -Remove the patient's tray because of the risk of aspiration. -Cue the patient to the fact that she is dribbling food while commending her for eating.
Cue the patient to the fact that she is dribbling food while commending her for eating. Feedback: Dribbling of food should be noted and addressed but does not necessarily constitute an acute risk of aspiration. Close observation is warranted but enteral feeding and NPO status are not likely necessary. Suctioning after each bite of food is not necessary. Dribbling of food should be noted and addressed but does not necessarily constitute an acute risk of aspiration. Close observation is warranted but enteral feeding and NPO status are not likely necessary. Suctioning after each bite of food is not necessary.
A patient diagnosed with multiple sclerosis (MS) has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen (Lioresal). What would be the expected outcome of this medication? -Reduction in the appearance of new lesions on magnetic resonance imaging (MRI) -Decreased muscle spasms in the lower extremities -Increased muscle strength in the upper extremities -Promotion of urinary continence
Decreased muscle spasms in the lower extremities Feedback: Baclofen, a GABA agonist, is the medication of choice in treating spasms. It can be administered orally or by intrathecal injection. It is not used to promote continence or to increase strength. Avonex and Betaseron reduce the appearance of new lesions on the MRI.
An 80-year-old man has been brought to the emergency department (ED) by his daughter, who states that her father has become confused and agitated over the past several days. The daughter expresses fear that her father is "getting senile" and states that this concern is what prompted her to seek care. The ED nurse and the other members of the care team should prioritize which of the following aspects of assessment? -Assessing for cranial nerve defects -Assessing the man's nutritional status -Correlating the man's cognitive function with his motor function -Differentiating delirium from dementia
Differentiating delirium from dementia Feedback: This patient would require a thorough medical and nursing assessment. A primary focus of these assessments, however, would be ascertaining whether the patient's cognitive changes are attributable to modifiable factors (delirium) or organic brain changes (dementia). Assessment would include the other listed parameters, but assessing for delirium and dementia would be a priority.
An elderly female resident of a long-term care facility has a diagnosis of Alzheimer's disease (AD). The resident is visibly anxious and is insisting to the nurse that she needs to "take care of my babies." How should the nurse respond to the resident's statement? -Reorient the resident to the fact that she does not have young children. -Ask the resident questions about her children to help her realize that her children are now adults. -Ignore the resident's statement and return to the room later. -Engage the resident in a conversation about a different topic.
Engage the resident in a conversation about a different topic. Feedback: Attempts at reorientation can exacerbate the stress and frustration of an individual with AD. It is inappropriate and ineffective to ignore the resident. Redirection is likely of greater therapeutic benefit.
A patient scheduled for a magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the patient for the MRI should: -Withold stimulants 24-48 hours prior to exam -Ensure no metal-containing objects are present -Instruct the patient to void prior to exam -Administer oral contrast solutino
Ensure no metal-containing objects are present. Feedback: Patient preparation for an MRI consists of removing all metal-containing objects prior to the exam. Withholding stimulants would not affect an MRI; this relates to electroencephalography (EEG). The patient does not need to void prior to MRI. Oral contrast is only used for GI scans.
The victim of a motor vehicle accident has been admitted with massive trauma, including traumatic brain injury. Emergency treatment of increased intracranial pressure (ICP) has failed to resolve the problem, and monitoring reveals the ominous presence of Cushing's triad. What assessment findings would be consistent with this clinical phenomenon? -PaO2 70 mm Hg; RR 12 breaths per minute; HR 116 beats per minute -Temperature 104°F (40°C); RR 33 breaths per minute; HR 111 beats per minute -HR 38 beats per minute; BP 198/107 mm Hg; RR 7 breaths per minute -pH 7.2; PaO2 72 mm Hg; HCO3 20 mEq/L
HR 38 beats per minute; BP 198/107 mm Hg; RR 7 breaths per minute Feedback: At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. When this occurs, the patient exhibits significant changes in mental status and vital signs. The bradycardia, hypertension, and bradypnea associated with this deterioration are known as Cushing's triad
An emergency department (ED) nurse has administered an ordered bolus of tissue plasminogen activator (tPA) to a male patient who was diagnosed with stroke. During the administration of tPA, the nurse should prioritize assessments related to what problem? -Fluid overload -Peripheral edema -Hemorrhage -Acute pain
Hemorrhage Feedback: Bleeding is the most common side effect of tPA. The patient is closely monitored for bleeding (at IV insertion sites, gums, urine/stools, and intracranially by assessing changes in level of consciousness). Edema, fluid overload, and pain are not likely to result from tPA.
The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would indicate that the patient is experiencing increased brain compression causing brainstem damage? -Hyperthermia -Tachycardia -Hypertension -Bradypnea
Hyperthermia Feedback: Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic blood pressure, and widening pulse pressure. As brain compression increases, respirations become rapid, blood pressure may decrease, and the pulse slows further. A rapid rise in body temperature is regarded as unfavorable. Hyperthermia increases the metabolic demands of the brain and may indicate brainstem damage.
The staff educator is orientating a nurse new to the neurological ICU when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. What sign or symptom is consistent with this diagnosis? -Increased cardiac biomarkers -Hypotension -Tachycardia -Excessive sweating
Hypotension Feedback: Manifestations of neurogenic shock include decreased blood pressure and heart rate. Cardiac markers would be expected to rise in cardiogenic shock. Patients do not perspire on the paralyzed portions of their body due to blockage of sympathetic activity.
The nurse is caring for a patient on the neurological unit who is in status epilepticus. What medication does the nurse anticipate being given to halt the seizure? -IV phenobarbital -IV diazepam -IV lidocaine -Oral phenytoin
IV diazepam Feedback: Status epilepticus (acute prolonged seizure activity) is a series of generalized seizures that occur without full recovery of consciousness between attacks. Medical management of status epilepticus includes IV diazepam (Valium) and IV lorazepam (Ativan), given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state.
The nurse is planning the care of a 28-year-old female hospitalized with a diagnosis of myasthenia gravis. What schedule would be most appropriate for the organization of diagnostic procedures for this patient? -All at one time, to provide a longer rest period -Before meals, to stimulate her appetite -In the morning, with frequent rest periods -Before bedtime, to promote rest
In the morning, with frequent rest periods. Feedback: Myasthenia gravis, an autoimmune disorder affecting the myoneural junction, is characterized by varying degrees of weakness of the voluntary muscles. Procedures should be spaced to allow for rest in between. Procedures should be avoided before meals, or the patient may be too exhausted to eat. Procedures should be avoided at bedtime.
A male patient with a history of poorly controlled type 1 diabetes has experienced an accelerated deterioration in his vision and is now considered to be legally blind. When planning this patient's care, the nurse should recognize the possibility of what nursing diagnosis? -Unilateral neglect -Decisional conflict -Ineffective coping -Moral distress
Ineffective coping Feedback: Although every patient will respond differently to a decrease in visual acuity, ineffective coping has been identified as a common phenomenon. This is more likely than unilateral neglect, moral distress, or decisional conflict.
A 20-year-old male patient has been brought to the emergency department (ED) by ambulance with a gunshot wound that has resulted in urethral trauma. In light of this patient's injuries, the ED nurse should anticipate what intervention? -Insertion of a urinary catheter -Cystoscopy -Insertion of a suprapubic catheter -Lithotripsy
Insertion of a suprapubic catheter Feedback: In urethral trauma, unstable patients who need monitoring of urine output may need a suprapubic catheter inserted. Lithotripsy is not relevant to the treatment of genitourinary trauma. Cystoscopy and insertion of a urinary catheter could exacerbate the patient's injuries.
A public health nurse has formed a partnership with an advocacy group that acts on behalf of individuals who have experienced spinal cord injuries (SCIs). Health promotion efforts are being planned with a knowledge that the incidence of SCIs varies widely between demographic groups. What population has the highest incidence of spinal cord injuries? -Males between ages 16 and 30 -Children between ages 3 and 12 -Adults older than 70 years -Females in their 20's
Males between ages 16 and 30 Feedback: Males account for 80% of SCI in a reported national database (NSCISC, 2009). Young people between the ages of 16 and 30 years account for more than half of the new SCIs each year.
A patient is brought to the emergency room following a motor vehicle accident in which she sustained a head trauma. The patient is complaining of blindness in her left eye. The nurse would be correct in suspecting that this sensory deficit is related to damage in what cerebral lobe? -Temporal -Occipital -Parietal -Frontal
Occipital Feedback: The posterior lobe of the cerebral hemisphere is responsible for visual interpretation. The temporal lobe contains the auditory receptive areas. The parietal lobe contains the primary sensory cortex, and is essential to an individual's awareness of the body in space, as well as orientation in space and spatial relations. The frontal lobe functions in concentration, abstract thought, information storage or memory, and motor function.
A patient has had an ischemic stroke and has been admitted to the unit. The nurse knows the importance of the principles of body alignment and correct positioning to stroke victims. How should the nurse position the patient to prevent joint deformities? -Place the patient flat in the prone position for 30 minutes per day. -Assist the patient in acutely flexing the thigh to promote movement. -Place a pillow in the axilla when there is limited external rotation. -Place patient's hand in pronation.
Place a pillow in the axilla when there is limited external rotation Feedback: A pillow in the axilla prevents adduction of the affected shoulder and keeps the arm away from the chest. The prone position with a pillow under the pelvis, not flat, promotes hyperextension of the hip joints, essential for normal gait. To promote venous return and prevent edema, the upper thigh should not be flexed acutely. The hand is placed in slight supination, not pronation, which is its most functional position.
A nursing educator is talking with nurses about the effects of the aging process and neurologic changes. What would the educator identify as a normal neurological change that accompanies the aging process? -Hyperactive deep tendon reflexes -Reduction in cerebral blood flow (CBF) -Increased cerebral metabolism -Hypersensitivity to painful stimuli
Reduction in cerebral blood flow (CBF) Feedback: Reduction in CBF is a change that occurs in the normal aging process. Deep tendon reflexes can be decreased or in some cases absent. Cerebral metabolism decreases as the patient advances in age. Reaction to painful stimuli may be decreased with age. Because pain is an important warning signal, caution must be used when hot or cold packs are applied.
A patient has been admitted to the neurological unit from the PACU after successful neurosurgery to remove a brain tumor. The nurse's admitting assessment reveals that the patient's gag reflex has not yet fully returned. The nurse should recognize that this assessment finding has the potential to cause which of the following nursing diagnoses? -Risk for aspiration -Impaired spontaneous ventilation -Dysfunctional ventilator weaning response -Imbalanced nutrition: less than body requirements
Risk for aspiration Feedback: A patient with an impaired gag reflex should receive nothing by mouth due to the risk of aspiration. Nutrition can be addressed through alternative delivery methods. An impaired gag reflex does not necessarily impair oxygenation.
A patient with Parkinson's disease is undergoing a swallowing assessment because she is experiencing difficulties when swallowing. What consistency is most appropriate for this patient, to reduce the risk of aspiration? -Solid food with thin liquids -Pureed food with water -Semisolid food with thick liquids -Thin liquids only
Semisolid food with thick liquids Feedback: A semisolid diet with thick liquids is easier to swallow for a patient with swallowing difficulties than a solid diet. Thin liquids should be avoided. Pureed foods with water are not indicated for this patient.
A 71-year-old man has made an appointment with his primary care provider at the urging of his wife, who states that he has occasionally had episodes of weakness and slurring of words over the past several weeks. The care provider recognizes the possibility that the man has been experiencing transient ischemic attacks (TIAs). TIAs have which of the following characteristics? -TIAs result in motor symptoms rather than sensory symptoms. -TIAs are a result of minor cerebral hemorrhages that spontaneously resolve. -TIAs cause irreversible, but minor, neurological damage. -TIAs cause symptoms that last less than 1 hour.
TIAs cause symptoms that last less than 1 hour. Feedback: A TIA is defined as a brief episode of neurologic dysfunction caused by focal brain or retinal ischemia, with clinical symptoms typically lasting less than 1 hour, and without evidence of acute infarction. They may cause sensory symptoms and are not a result of hemorrhage.
The nurse is preparing discharge teaching for a patient who is being discharged after hospitalization for a hemorrhagic stroke. What should be included in the discharge teaching for this patient? -Intermittent seizures can be expected. -Take ibuprofen for complaints of a serious headache. -Take antihypertensive medication as ordered. -Drowsiness is normal for the first week after discharge.
Take antihypertensive medication as ordered Feedback: The patient and family are provided with information that will enable them to cooperate with the care and restrictions required during the acute phase of hemorrhagic stroke and to prepare them to return home. Patient and family teaching includes information about the causes of hemorrhagic stroke and its possible consequences. Symptoms of hydrocephalus include gradual onset of drowsiness and behavioral changes. Hypertension is the most serious risk factor, suggesting that appropriate antihypertensive treatment is essential for a patient being discharged. Seizure activity is not normal; complaints of a serious headache should be called to the health care provider before any medication is taken. Drowsiness is not normal.
A patient with a suspected brain tumor has been scheduled for a positron emission tomography (PET) scan. The nurse should explain to the patient that this test is being performed to assess: -The metabolic activity taking place in the patient's brain -The blood flow in the patient's brain -The distribution patterns of cerebrospinal fluid (CSF) in the patient's central nervous system -The tissue characteristics of the patient's brain
The metabolic activity taking place in the patient's brain. Feedback: PET, which measures the brain's activity rather than simply its structure, is useful in differentiating tumor from scar tissue or radiation necrosis. PET is not primarily used to assess blood flow, CSF flow, or structural characteristics.
A patient has severe shoulder pain from subluxation of the shoulder is being cared for on the unit. To prevent further injury and pain, the nurse caring for this patient is aware of what? -Use of a sling should be avoided due to adduction of the affected shoulder. -Elevation of the arm and hand can lead to further complications associated with edema. -Passively exercising the affected extremity is avoided to minimize pain. -The patient should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder.
The patient should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder Feedback: To prevent shoulder pain, the nurse should never lift a patient by the flaccid shoulder or pull on the affected arm or shoulder. The patient is taught how to move and exercise the affected arm/shoulder through proper movement and positioning. The use of a properly worn sling when the patient is out of bed prevents the paralyzed upper extremity from dangling without support. Range of motion exercises are still vitally important in preventing a frozen shoulder and ultimate atrophy of subcutaneous tissues, which can cause more pain. Elevation of the arm and hand is also important in preventing dependent edema of the hand.
The nurse is writing a care plan for a patient with brain metastases. Following a thorough assessment, the nurse decides that an appropriate nursing diagnosis is "Anxiety related to lack of control over the health care needs and situation." In establishing this plan of care for the patient, the nurse will identify what measure as appropriate for the care of this patient? -The patient will receive antianxiety medications every 4 hours. -The patient's family will be instructed on measures to implement when providing care for the patient. -The patient will be encouraged to verbalize concerns related to the disease and its treatment. -The patient will begin a busy schedule of therapy, so that he will forget about the anxiety.
The patient will be encouraged to verbalize concerns related to the disease and its treatment. Feedback: Patients need the opportunity to exercise some control over their situation. A sense of mastery can be gained as they learn to understand the disease and its treatment and how to deal with their feelings. Distraction, assuming care responsibilities, and administering medications will not allow the patient to gain some control over his situation or discuss his feelings.
The nurse is developing a plan of care for a patient who has stabilized after the emergency treatment of Guillain-Barré syndrome (GBS). What nursing intervention would receive priority for this patient? -Using the incentive spirometer as prescribed -Maintaining the patient on bed rest -Reorienting the patient to person, time, and place -Limiting free water to 1 L per day
Using the incentive spirometer as prescribed Feedback: Respiratory function can be maximized in GBS with incentive spirometry and chest physiotherapy. Nursing interventions toward enhancing physical mobility should be utilized. Nursing interventions are aimed at preventing a deep vein thrombosis. Guillain-Barré does not affect cognitive function or level of consciousness. Fluid restriction is not indicated.
The nurse is performing stroke risk screenings at a hospital open house. Identification of high-risk individuals is the goal of the screenings. The nurse has identified four patients who might be at risk for a stroke. Which patient is likely at highest risk for a stroke? -White woman, age 60 with history of excessive alcohol intake -White man, age 60 with history of uncontrolled hypertension -Black man, age 60, with history of diabetes -Black man, age 50 with history of smoking
White man, age 60 with history of uncontrolled hypertension Feedback: Uncontrolled hypertension is the primary cause of a hemorrhagic stroke. Control of hypertension, especially in individuals over 55 years of age, clearly reduces the risk for hemorrhagic stroke. Additional risk factors are increased age, male gender, and excessive alcohol intake. Another high-risk group is African Americans, where the incidence of first stroke is almost twice that in Caucasians. Modifiable risk factors for ischemic stroke include hypertension, atrial fibrillation, hyperlipidemia, obesity, smoking, and diabetes.
