Test 4

A client with a metastatic brain tumor of the frontal lobe experiences a generalized seizure for the first time. The nurse should prepare for what action? A STAT MRI STAT computed tomography (CT) health care provider Administration of anticonvulsants Intubation

Administration of anticonvulsants Explanation: Seizure activity necessitates anticonvulsants. In most cases, the development of seizure activity does not require immediate diagnostic imaging. Intubation is unnecessary except in cases of respiratory failure.

A nurse is reviewing the trend of a client's scores on the Glasgow Coma Scale (GCS). This allows the nurse to gauge what aspect of the client's status? Sensory involvement Level of consciousness Cognitive ability Reflex activity

Level of consciousness Explanation: The Glasgow Coma Scale (GCS) examines three responses related to LOC: eye opening, best verbal response, and best motor response.

A client with type 1 diabetes has told the nurse that his most recent urine test for ketones was positive. What is the nurse's most plausible conclusion based on this assessment finding? The client should withhold his next scheduled dose of insulin. The client would benefit from a dose of metformin. The client should promptly eat some protein and carbohydrates. The client's insulin levels are inadequate.

The client's insulin levels are inadequate. Explanation: Ketones in the urine signal that there is a deficiency of insulin and that control of type 1 diabetes is deteriorating. Withholding insulin or eating food would exacerbate the client's ketonuria. Metformin will not cause short-term resolution of hyperglycemia.

A medical nurse is caring for a client with type 1 diabetes. The client's medication administration record includes the administration of regular insulin three times daily. Knowing that the client's lunch tray will arrive at 11:45 AM, when should the nurse administer the client's insulin? 11:45 AM 11:15 AM 10:45 AM 11:50 AM

11:15 AM Explanation: Regular insulin is usually given 20 to 30 minutes before a meal. Earlier administration creates a risk for hypoglycemia; later administration creates a risk for hyperglycemia.

A client has been prescribed phenytoin for the treatment of seizures. How should the nurse most accurately determine whether the client has therapeutic levels of the medication? Assess the client's cognitive status. Review the client's laboratory blood work. Assess the client carefully for adverse effects. Monitor the client for seizure activity.

Review the client's laboratory blood work. Explanation: Measuring serum drug levels evaluates whether the therapeutic range of circulating drug can be found in the serum. It does not directly evaluate effectiveness of therapy, however, which can only be evaluated by determining whether the drug is having the desired effect of reducing number of seizures. Short-term absence of seizures does not necessarily indicate that drug is within therapeutic range.

The nurse is teaching a client that the body needs iodine for the thyroid to function. What food would be the best source of iodine for the body? Red meat Table salt Eggs Shellfish

Table salt Explanation: The major use of iodine in the body is by the thyroid. Iodized table salt is the best source of iodine.

A newly admitted client with type 1 diabetes asks the nurse what caused her diabetes. When the nurse is explaining to the client the etiology of type 1 diabetes, what process should the nurse describe? "The amount of glucose that your body makes overwhelms your pancreas and decreases your production of insulin." "The tissues in your body are resistant to the action of insulin, making the glucose levels in your blood increase" "Damage to your pancreas causes an increase in the amount of glucose that it releases, and there is not enough insulin to control it." "Destruction of special cells in the pancreas causes a decrease in insulin production. Glucose levels rise because insulin normally breaks it down."

"Destruction of special cells in the pancreas causes a decrease in insulin production. Glucose levels rise because insulin normally breaks it down." Explanation: Type 1 diabetes is characterized by the destruction of pancreatic beta cells, resulting in decreased insulin production, unchecked glucose production by the liver, and fasting hyperglycemia. Also, glucose derived from food cannot be stored in the liver and remains circulating in the blood, which leads to postprandial hyperglycemia. Type 2 diabetes involves insulin resistance and impaired insulin secretion. The body does not "make" glucose.

A nurse is caring for a client diagnosed with a hemorrhagic stroke. When creating this client's plan of care, what goal should be prioritized? Relieve anxiety and pain. Relieve sensory deprivation. Prevent complications of immobility. Maintain and improve cerebral tissue perfusion.

Maintain and improve cerebral tissue perfusion. Explanation: Each of the listed goals is appropriate in the care of a client recovering from a stroke. However, promoting cerebral perfusion is a priority physiologic need, on which the client's survival depends.

A client with a recent diagnosis of hypothyroidism is being treated for an unrelated injury. When administering medications to the client, the nurse should know that the client's diminished thyroid function may have what effect? Increased risk of drug interactions Prolonged duration of effect Anaphylaxis Nausea and vomiting

Prolonged duration of effect Explanation: In all clients with hypothyroidism, the effects of analgesic agents, sedatives, and anesthetic agents are prolonged. There is no direct increase in the risk of anaphylaxis, nausea, or drug interactions, although these may potentially result from the prolonged half-life of drugs.

A client has presented to the emergency department with a new onset of unilateral weakness and visual disturbances. The care team suspects that the client has had a cerebrovascular accident and the administration of alteplase is being considered. What is the care priority prior to administering alteplase? Determining whether the client takes beta-adrenergic blockers or aminoglycoside antibiotics Ruling out a hemorrhagic stroke Determining the client's blood type Assessing the client's allergy status

Ruling out a hemorrhagic stroke Explanation: Administration of alteplase would exacerbate a hemorrhagic stroke by increase bleeding. For this reason, a hemorrhagic stroke must be ruled out. With regard to alteplase administration, this is a priority over the client's allergy status or blood type. Beta-blockers and aminoglycosides do not contraindicate the use of alteplase.

A client who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this client? The client should be approached on the opposite side of where the visual perception is intact to promote recovery. The client should be approached on the side where visual perception is intact. Attention to the affected side should be minimized in order to decrease anxiety. The client should avoid turning in the direction of the defective visual field to minimize shoulder subluxation.

The client should be approached on the side where visual perception is intact. Explanation: Clients with decreased field of vision should first be approached on the side where visual perception is intact. All visual stimuli should be placed on this side. The client can and should be taught to turn the head in the direction of the defective visual field to compensate for this loss. The nurse should constantly remind the client of the other side of the body and should later stand at a position that encourages the client to move or turn to visualize who and what is in the room.

An older adult client is brought to the emergency department by family members. The family states the client has been uncharacteristically confused and appears to have abnormal perception of movement. The nurse reviews the client's current medication regimen and suspects the client overdosed on what medication? metoprolol lorazepam cephalexin acetaminophen

lorazepam Explanation: Common manifestations of benzodiazepine toxicity include increased anxiety, psychomotor agitation, insomnia, irritability, headache, tremor, and palpitations. Less common but more serious manifestations include confusion, abnormal perception of movement, depersonalization, psychosis, and seizures. These symptoms are not found in association with antibiotics, beta-blockers, or acetaminophen.

The public health nurse is planning a health promotion campaign that reflects current epidemiologic trends. The nurse should know that hemorrhagic stroke currently accounts for what percentage of total strokes? 23% 33% 43% 13%

13% Explanation: Strokes can be divided into two major categories: ischemic (87%), in which vascular occlusion and significant hypoperfusion occur, and hemorrhagic (13%), in which there is extravasation of blood into the brain or subarachnoid space.

A client diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse? Inform the nurse manager. Call the health care provider immediately. Administer an analgesic. Sit with the client for a few minutes.

Call the health care provider immediately. Explanation: A headache may be an indication that the aneurysm is leaking. The nurse should notify the health care provider immediately. The health care provider will decide whether administration of an analgesic is indicated. Informing the nurse manager is not necessary. Sitting with the client is appropriate, once the health care provider has been notified of the change in the client's condition.

A client who just experienced a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurse's primary assessment focus? Fluid and electrolyte balance Seizure activity Pain Cardiac and respiratory status

Cardiac and respiratory status Explanation: Acute care begins with managing ABCs. Clients may have difficulty keeping an open and clear airway secondary to decreased LOC. Neurologic assessment with close monitoring for signs of increased neurologic 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 activity.

While completing a health history on a client who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state? Body rigidity Urinary incontinence Epileptic cry Confusion

Confusion Explanation: In the postictal state (after the seizure), the client is often confused and 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 client is being given a medication that stimulates the parasympathetic system. Following administration of this medication, the nurse should anticipate what effect? Dilated bronchioles Relaxed muscular walls of the urinary bladder Decreased peristaltic movement Constricted pupils

Constricted pupils Explanation: Parasympathetic stimulation results in constricted pupils, constricted bronchioles, increased peristaltic movement, and contracted muscular walls of the urinary bladder.

A client has recently begun mobilizing during the recovery from an ischemic stroke. To protect the client's safety during mobilization, the nurse should perform what action? Have a colleague follow the client closely with a wheelchair. Support the client's full body weight with a waist belt during ambulation. Avoid mobilizing the client in the early morning or late evening. Ensure that the client's family members do not participate in mobilization.

Have a colleague follow the client closely with a wheelchair. Explanation: During mobilization, a chair or wheelchair should be readily available in case the client suddenly becomes fatigued or feels dizzy. The family should be encouraged to participate, as appropriate, and the nurse should not have to support the client's full body weight. Morning and evening activities are not necessarily problematic.

The nurse's assessment of a client with thyroidectomy suggests tetany and a review of the most recent blood work corroborates this finding. The nurse should prepare to administer what intervention? Oral calcium chloride and vitamin D Administration of parathyroid hormone (PTH) STAT levothyroxine IV calcium gluconate

IV calcium gluconate Explanation: When hypocalcemia and tetany occur after a thyroidectomy, the immediate treatment is administration of IV calcium gluconate. This has a much faster therapeutic effect than PO calcium or vitamin D supplements. PTH and levothyroxine are not used to treat this complication.

A diabetic educator is discussing "sick day rules" with a newly diagnosed type 1 diabetic. The educator is aware that the client will require further teaching when the client states what? "I will call the doctor if my blood sugar is over 300 mg/dL (16.6 mmol/L) or if I have ketones in my urine." "If I cannot eat a meal, I will eat a soft food such as soup, gelatin, or pudding six to eight times a day." "I will not take my insulin on the days when I am sick, but I will certainly check my blood sugar every 2 hours." "I will call the doctor if I am not able to keep liquids in my body due to vomiting or diarrhea."

"I will not take my insulin on the days when I am sick, but I will certainly check my blood sugar every 2 hours." Explanation: The nurse must explain the "sick day rules" again to the client who plans to stop taking insulin when sick. The nurse should emphasize that the client should take insulin agents as usual and test one's blood sugar and urine ketones every 3 to 4 hours. In fact, insulin-requiring clients may need supplemental doses of regular insulin every 3 to 4 hours. The client should report elevated glucose levels (greater than 300 mg/dL or 16.6 mmol/L, or as otherwise instructed) or urine ketones to the physician. If the client is not able to eat normally, the client should be instructed to substitute with soft foods such a gelatin, soup, and pudding. If vomiting, diarrhea, or fever persists, the client should have an intake of liquids every 30 to 60 minutes to prevent dehydration.

A diabetes nurse educator is presenting current recommendations for levels of caloric intake. What should the nurse describe? 10% to 20% of calories from carbohydrates, 20% to 30% from fat, and the remaining 50% to 60% from protein 10% of calories from carbohydrates, 50% from fat, and the remaining 40% from protein 50% to 60% of calories from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein 20% to 30% of calories from carbohydrates, 50% to 60% from fat, and the remaining 10% to 20% from protein

50% to 60% of calories from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein Explanation: Currently, the ADA and the Academy of Nutrition and Dietetics (formerly the American Dietetic Association) recommend that for all levels of caloric intake, 50% to 60% of calories come from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein. Low fat does not automatically mean low sugar. Dietary animal fat does not need to be eliminated from the diet.

A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this client? Supine positioning Early initiation of physical therapy Absolute bed rest in a quiet, nonstimulating environment Passive range-of-motion exercises to prevent contractures

Absolute bed rest in a quiet, nonstimulating environment Explanation: The client is placed on immediate and absolute bed rest in a quiet, nonstressful environment because activity, pain, and anxiety elevate BP, which increases the risk for bleeding. Visitors are restricted. The nurse administers all personal care. The client is fed and bathed to prevent any exertion that might raise BP. Clients with increased ICP are normally positioned with the HOB elevated.

A client with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased the risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring? Administering an antifibrinolytic agent Applying thigh-high elastic stockings Placing the client on a fluid restriction as ordered Assisting the client with passive range-of-motion (PROM) exercises

Applying thigh-high elastic stockings Explanation: It is important to promote venous return to the heart and prevent venous stasis in a client with altered mobility. Applying elastic stockings will aid in the prevention of a DVT. The client 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. PROM exercises are not an effective protection against the development of DVT.

The nurse is caring for an older adult in the long-term care facility who has begun to display signs of anxiety and insomnia. What is the priority nursing action? Suggest the family visit more often to reduce the resident's stress level. Increase the client's social time, encouraging interaction with others. Call the provider and request an antianxiety drug order. Assess the client for physical problems.

Assess the client for physical problems. Explanation: The client should be screened for physical problems, neurological deterioration, or depression, which could contribute to the insomnia or anxiety. Only after physical problems are ruled out would the nurse consider nondrug measures such as increased socialization with other residents or family members. If nothing else is effective, pharmacological intervention may be necessary.

The nurse is assessing a client diagnosed with Graves disease. What physical characteristics of Graves disease would the nurse expect to find? Fatigue Hair loss Moon face Bulging eyes

Bulging eyes Explanation: Clinical manifestations of the endocrine disorder Graves disease include exophthalmos (bulging eyes) and fine tremor in the hands. Graves disease is not associated with hair loss, a moon face, or fatigue.

A client exhibiting an uncoordinated gait has presented at the clinic. Which of the following is the most plausible cause of this client's health problem? Dysfunction of the medulla Cerebellar dysfunction A lesion in the pons A hemorrhage in the midbrain

Cerebellar dysfunction Explanation: The cerebellum controls fine movement, balance, position sense, and integration of sensory input. Portions of the pons control the heart, respiration, and blood pressure. Cranial nerves IX to XII connect to the brain in the medulla. Cranial nerves III and IV originate in the midbrain.

A client is experiencing intense nausea while being treated with chemotherapeutics. What actions should the nurse perform? Select all that apply. Ensure that the client has had a dietician consult. Administer antacids as prescribed, 30 minutes before meals. Provide the client with a low-residue diet. Administer antiemetics as prescribed. Provide the client with small, frequent meals.

Ensure that the client has had a dietician consult. Administer antiemetics as prescribed. Provide the client with small, frequent meals. Explanation: A dietician should consult in the treatment of a client with nausea secondary to chemotherapy. Small, frequent meals and vigilant use of antiemetics are useful as well. There is no need for a low-residue diet and antacids do not normally prevent nausea.

An older adult client with type 2 diabetes is brought to the emergency department by his daughter. The client is found to have a blood glucose level of 600 mg/dL (33.3 mmol/L). The client's daughter reports that the client recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority? Administration of antihypertensive medications Fluid and electrolyte replacement Administering sodium bicarbonate intravenously Reversing acidosis by administering insulin

Fluid and electrolyte replacement Explanation: The overall approach to HHS includes fluid replacement, correction of electrolyte imbalances, and insulin administration. Antihypertensive medications are not indicated, as hypotension generally accompanies HHS due to dehydration. Sodium bicarbonate is not given to clients with HHS, as their plasma bicarbonate level is usually normal. Insulin administration plays a less important role in the treatment of HHS because it is not needed for reversal of acidosis, as in diabetic ketoacidosis (DKA).

What would alert the nurse to suspect that a client is developing ketoacidosis? Fruity breath odor Fluid retention Hunger Blurred vision

Fruity breath odor Explanation: Fruity breath odor would be noted as ketones build up in the system and are excreted through the lungs. Dehydration would be noted as fluid and electrolytes are lost through the kidneys. Blurred vision and hunger would be associated with hypoglycemia.

The anatomy and physiology instructor is discussing hormones with the pre-nursing class. Which gland would the instructor tell the students controls secretions of the pituitary gland? Pineal Thyroid Adrenal cortex Hypothalamus

Hypothalamus Explanation: The hypothalamus uses a number of hormones or factors to either stimulate or inhibit the release of hormones from the anterior pituitary. These factors are not secreted by the pineal, the thyroid, and the adrenal cortex.

The nurse is providing client education regarding the administration of levothyroxine (Synthroid). Which information should the nurse include? Take the medication before going to bed at night. Take the medication on an empty stomach. Take with a full glass of water. Remain in the upright position for 30 minutes after taking the medication.

Take with a full glass of water. Explanation: The client should be instructed to take the medication with a full glass of water to help prevent difficulty swallowing. The medication should not be taken on an empty stomach and the client does not have to remain in the upright position after taking the medication. The medication should be taken as a single daily dose before breakfast each day to ensure consistent therapeutic levels.

The nurse is discussing macrovascular complications of diabetes with a client. The nurse would address what topic during this dialogue? The need to monitor urine for the presence of albumin The need for frequent eye examinations for clients with diabetes The relationship between kidney function and blood glucose levels The fact that clients with diabetes have an elevated risk of myocardial infarction

The fact that clients with diabetes have an elevated risk of myocardial infarction Explanation: Myocardial infarction and stroke are considered macrovascular complications of diabetes, while the effects on vision and kidney function are considered to be microvascular.

When is calcitonin released by the body? When serum calcium levels rise When PTH secretion mobilizes calcium When serum calcium levels fall When PTH secretion immobilizes calcium

When serum calcium levels rise Explanation: The release of calcitonin is not controlled by the hypothalamic-pituitary axis, but is regulated locally at the cellular level. Calcitonin is released when serum calcium levels rise.

The nurse is working with a client who is newly diagnosed with hypothyroidism. Diagnostic testing has indicated that the client's health problem is caused by anterior pituitary dysfunction. This client's hypothyroidism is rooted in a deficiency of: tetraiodothyronine. triiodothyronine. thyroid-stimulating hormone (TSH). thyrotropin-releasing hormone (TRH).

thyroid-stimulating hormone (TSH). Explanation: Thyroid hormone production and release are regulated by the anterior pituitary hormone called thyroid-stimulating hormone (TSH). The secretion of TSH is regulated by thyrotropin-releasing hormone (TRH), a hypothalamic regulating factor. A client who has adequate levels of TRH will still have deficient TSH if the anterior pituitary is dysfunctioning. Tetraiodothyronine and triiodothyronine are thyroid hormones produced by the thyroid gland because of TSH stimulation.

In which specific instances should the nurse assess the client's cranial nerves? Select all that apply. When a neurogenic bladder develops When level of consciousness is decreased In the presence of peripheral nervous system disease With brain stem pathology When a spinal reflex is interrupted

When level of consciousness is decreased With brain stem pathology In the presence of peripheral nervous system disease Explanation: Cranial nerves are assessed when level of consciousness is decreased, with brain stem pathology, or in the presence of peripheral nervous system disease. Abnormalities in muscle tone and involuntary movements are less likely to prompt the assessment of cranial nerves, since these nerves do not directly mediate most aspects of muscle tone and movement.

A client's muscle weakness has been found to result from a lack of neurotransmitter communication between nerves and muscles. What neurotransmitter is most likely deficient? acetylcholine serotonin gamma-aminobutyric acid (GABA) dopamine

acetylcholine Explanation: Acetylcholine communicates between nerves and muscles. Dopamine is involved in the coordination of impulses and responses, both motor and intellectual. GABA inhibits nerve activity. Serotonin is important in arousal and sleep.

The nurse is providing client teaching about a prescribed opioid analgesic. When monitoring the client for potential adverse effects, what assessment should the nurse prioritize? heart rhythm coordination visual acuity blood pressure

blood pressure Explanation: Orthostatic hypotension is commonly seen in association with some narcotics. For most clients, changes in blood pressure are most likely than arrhythmias, ataxia and changes is vision.

Information has been received by a client's neuron and transmitted into the cell body. What component of the neurologic system performed this function? dendrite nucleus axon soma

dendrite Explanation: Dendrites carry information to the nerve and axons; they also carry information from a nerve to be transmitted to effector cells, which are found in muscles, glands, or another nerve. Soma refers to the cell body. The nucleus is the central part of a cell, which is responsible for the cell's growth, reproduction, and metabolism.

An 11 year-old client has been diagnosed with epilepsy and prescribed phenytoin 100 mg PO b.i.d. What statement by the client's parent suggests an accurate understanding of the client's medication regimen? "I will make sure my child has routine visits to the dentist." "I will stop the drug immediately if any side effects occur." "I will make sure my child takes the medication on an empty stomach." "I will weigh my child daily and feed them a high-calorie diet."

"I will make sure my child has routine visits to the dentist." Explanation: Gingival hyperplasia is common in clients, especially children, who take phenytoin, which makes regular dentist visits important to oral health. Taking the medication on a full stomach or with meals reduces gastrointestinal (GI) adverse effects. The mother should call the healthcare provider if adverse effects are noted and needs to understand the risks associated with abrupt withdrawal of the medication. Daily weight taking and high-calorie diets are not necessary during phenytoin administration.

An occupational health nurse is screening a group of workers for diabetes. What statement should the nurse interpret as being suggestive of diabetes? "I've always been a fan of sweet foods, but lately I'm turned off by them." "No matter how much sleep I get, it seems to take me hours to wake up." "Lately, I drink and drink and can't seem to quench my thirst." "When I went to the washroom the last few days, my urine smelled odd."

"Lately, I drink and drink and can't seem to quench my thirst." Explanation: Classic clinical manifestations of diabetes include the "three Ps": polyuria, polydipsia, and polyphagia. Lack of interest in sweet foods, fatigue, and foul-smelling urine are not suggestive of diabetes.

A client has just been diagnosed with type 2 diabetes. The health care provider has prescribed an oral antidiabetic agent that will inhibit the production of glucose by the liver and thereby aid in the control of blood glucose. What type of oral antidiabetic agent did the health care provider prescribe for this client? A thiazolidinedione An alpha-glucosidase inhibitor A sulfonylurea A biguanide

A biguanide Explanation: Sulfonylureas exert their primary action by directly stimulating the pancreas to secrete insulin and therefore require a functioning pancreas to be effective. Biguanides inhibit the production of glucose by the liver and are in used in type 2 diabetes to control blood glucose levels. Thiazolidinediones enhance insulin action at the receptor site without increasing insulin secretion from the beta cells of the pancreas. Alpha-glucosidase inhibitors work by delaying the absorption of glucose in the intestinal system, resulting in a lower postprandial blood glucose level.

A neurologic nurse is reviewing seizures with a group of staff nurses. How should this nurse best describe the cause of a seizure? A dysrhythmia in the peripheral nervous system A dysrhythmia in the nerve cells in one section of the brain Sudden disruptions in the blood flow throughout the brain Sudden electrolyte changes throughout the brain

A dysrhythmia in the nerve cells in one section of the brain Explanation: The underlying cause of a seizure is an electrical disturbance (dysrhythmia) in the nerve cells in one section of the brain; these cells emit abnormal, recurring, uncontrolled electrical discharges. Seizures are not caused by changes in blood flow or electrolytes.

The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration? Tonic-clonic seizures Shortness of breath Generalized pain Alteration in level of consciousness (LOC)

Alteration in level of consciousness (LOC) Explanation: Alteration in LOC is the earliest sign of deterioration in a client after a hemorrhagic stroke, such as mild drowsiness, slight slurring of speech, and sluggish papillary reaction. Sudden headache may occur, but generalized pain is less common. Seizures and shortness of breath are not identified as early signs of hemorrhagic stroke.

The nurse is caring for a client with hyperparathyroidism. What level of activity would the nurse expect to promote? Bed rest with bathroom privileges Ambulation and activity as tolerated Complete bed rest Out of bed (OOB) to the chair twice a day

Ambulation and activity as tolerated Explanation: Mobility, with walking or use of a rocking chair for those with limited mobility, is encouraged as much as possible because bones subjected to normal stress give up less calcium. Bed rest should be discouraged because it increases calcium excretion and the risk of renal calculi. Limiting the client to getting out of bed only a few times a day also increases calcium excretion and the associated risks.

An elderly client with diabetes comes to the clinic with her daughter. The nurse reviews foot care with the client and her daughter. Why would the nurse feel that foot care is so important to this client? Avoiding foot ulcers may mean the difference between institutionalization and continued independent living. Oral antihyperglycemics have the possible adverse effect of decreased circulation to the lower extremities. Hypoglycemia is linked with a risk for falls; this risk is elevated in older adults with diabetes. An elderly client with foot ulcers experiences severe foot pain due to the diabetic polyneuropathy.

Avoiding foot ulcers may mean the difference between institutionalization and continued independent living. Explanation: The nurse recognizes that providing information on the long-term complications—especially foot and eye problems—associated with diabetes is important. Avoiding amputation through early detection of foot ulcers may mean the difference between institutionalization and continued independent living for the elderly person with diabetes. While the nurse recognizes that hypoglycemia is a dangerous situation and may lead to falls, hypoglycemia is not directly connected to the importance of foot care. Decrease in circulation is related to vascular changes and is not associated with drugs given for diabetes.

The thyroid gland produces and secretes which in direct response to serum calcium levels? Insulin Calcitonin Erythropoietin Aldosterone

Calcitonin Explanation: Calcitonin is produced and secreted by the thyroid gland. Aldosterone is an adrenocorticoid hormone that is released in response to ACTH. Erythropoietin is released by the juxtaglomerular cells in the kidney in response to decreased pressure or decreased oxygenation of the blood flowing into the glomerulus. Insulin is produced by the pancreas in response to varying blood glucose levels.

The nurse is discharging home a client who had a stroke. The client has a flaccid right arm and leg and is experiencing urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common client response to a change in body image? Uncertainty Depression Disassociation Confusion

Depression Explanation: Depression is a common and serious problem in the client who has had a stroke. It can result from a profound disruption in his or her life and changes in total function, leaving the client with a loss of independence. The nurse needs to encourage the client to verbalize feelings to assess the effect of the stroke on self-esteem. Confusion, uncertainty, and disassociation are not the most common client response to a change in body image, although each can occur in some clients.

The nurse is caring for a client with a brain tumor. What drug would the nurse expect to be prescribed to reduce the edema surrounding the tumor? Dexamethasone Furosemide Dextromethorphan Solumedrol

Dexamethasone Explanation: If a brain tumor is the cause of the increased ICP, corticosteroids (e.g., dexamethasone) help reduce the edema surrounding the tumor. Solumedrol, a steroid, and furosemide, a loop diuretic, are not the drugs of choice in this instance. Dextromethorphan is used in cough medicines.

The nurse has created a plan of care for a client who is at risk for increased ICP. The client's care plan should specify monitoring for what early sign of increased ICP? Loss of corneal reflex Disorientation and restlessness Decreased pulse and respirations Projectile vomiting

Disorientation and restlessness Explanation: Early indicators of ICP include disorientation and restlessness. Later signs include decreased pulse and respirations, projectile vomiting, and loss of brain stem reflexes, such as the corneal reflex.

A diabetes nurse educator is teaching a group of clients with type 1 diabetes about "sick day rules." What guideline applies to periods of illness in a diabetic client? Report elevated glucose levels greater than 150 mg/dL (8.3 mmol/L). Do not eliminate insulin when nauseated and vomiting. Eat three substantial meals a day, if possible. Reduce food intake and insulin doses in times of illness.

Do not eliminate insulin when nauseated and vomiting. Explanation: The most important issue to teach clients with diabetes who become ill is not to eliminate insulin doses when nausea and vomiting occur. Rather, they should take their usual insulin or oral hypoglycemic agent dose, and then attempt to consume frequent, small portions of carbohydrates. In general, blood sugar levels will rise but should be reported if they are greater than 300 mg/dL (16.6 mmol/L).

The nurse evaluates the client's latest serum phenytoin level which is revealed to be 16 mcg/mL. What is the nurse's best action? Contact the provider to discuss withholding the next scheduled dose. Document the fact that the client's phenytoin level is therapeutic. Contact the provider to discuss the need for a supplementary dose of phenytoin. Promptly establish seizure precautions.

Document the fact that the client's phenytoin level is therapeutic. Explanation: The therapeutic serum level range for phenytoin is between 10 and 20 mcg/mL. As such, there is no need to contact the provider. Seizure precautions are likely already in place, and if they are not, this laboratory result does not provide an indication for reinstituting them.

A nurse is providing health education to an adolescent newly diagnosed with type 1 diabetes mellitus and her family. The nurse teaches the client and family that what nonpharmacologic measures will decrease the body's need for insulin? Low stimulation Exercise Adequate sleep Low-fat diet

Exercise Explanation: Exercise lowers blood glucose, increases levels of HDLs, and decreases total cholesterol and triglyceride levels. Low-fat intake and low levels of stimulation do not reduce a client's need for insulin. Adequate sleep is beneficial in reducing stress, but does not have an effect that is pronounced as that of exercise.

The nurse is assessing a client with a suspected stroke. What assessment finding is most suggestive of a stroke? Projectile vomiting Dysrhythmias Facial droop Periorbital edema

Facial droop Explanation: Facial drooping or asymmetry is a classic abnormal finding on a physical assessment that may be associated with a stroke. Facial edema is not suggestive of a stroke and clients less commonly experience dysrhythmias or vomiting.

The nurse is developing a plan of care for a client newly diagnosed with Bell palsy. The nurse's plan of care should address what characteristic manifestation of this disease? Tinnitus Facial paralysis Pain at the base of the tongue Diplopia

Facial paralysis Explanation: Bell palsy is characterized by facial dysfunction, weakness, and paralysis. It does not result in diplopia, pain at the base of the tongue, or tinnitus.

The nurse is planning the care of a client who has been recently diagnosed with a cerebellar tumor. Due to the location of this client's tumor, the nurse should implement measures to prevent what complication? Labile BP Audio hallucinations Falls Respiratory depression

Falls Explanation: A cerebellar tumor causes dizziness, an ataxic or staggering gait with a tendency to fall toward the side of the lesion, and marked muscle incoordination. Because of this, the client faces a high risk of falls. Hallucinations and unstable vital signs are not closely associated with cerebellar tumors.

A client presents to the clinic reporting symptoms that suggest diabetes. What criteria would support checking blood levels for the diagnosis of diabetes? Random plasma glucose greater than 150 mg/dL (8.3 mmol/L) Fasting plasma glucose greater than or equal to 126 mg/dL (7.0 mmol/L) Random plasma glucose greater than 126 mg/dL (7.0 mmol/L) Fasting plasma glucose greater than 116 mg/dL (6.4 mmol/L) on two separate occasions

Fasting plasma glucose greater than or equal to 126 mg/dL (7.0 mmol/L) Explanation: Criteria for the diagnosis of diabetes include symptoms of diabetes plus random plasma glucose greater than or equal to 200 mg/dL (11.1 mmol/L), or a fasting plasma glucose greater than or equal to 126 mg/dL (7.0 mmol/L).

The nurse is caring for a client diagnosed with hypothyroidism secondary to Hashimoto thyroiditis. When assessing this client, what sign or symptom would the nurse expect? Flushed skin Palpitations Bulging eyes Fatigue

Fatigue Explanation: Symptoms of hypothyroidism include extreme fatigue, hair loss, brittle nails, dry skin, voice huskiness or hoarseness, menstrual disturbance, and numbness and tingling of the fingers. Bulging eyes, palpitations, and flushed skin would be signs and symptoms of hyperthyroidism.

A client has been admitted to the neurologic ICU with a diagnosis of a brain tumor. The client is scheduled to have a tumor resection/removal in the morning. Which of the following assessment parameters should the nurse include in the initial assessment? Deep tendon reflexes Abdominal girth Hearing acuity Gag reflex

Gag reflex Explanation: Preoperatively, the gag reflex and ability to swallow are evaluated. In clients with diminished gag response, care includes teaching the client to direct food and fluids toward the unaffected side, having the client sit upright to eat, offering a semisoft diet, and having suction readily available. Deep tendon reflexes, abdominal girth, and hearing acuity are less commonly affected by brain tumors and do not affect the risk for aspiration.

The nurse has admitted a new client to the unit. One of the client's admitting orders is for an adrenergic medication. The nurse knows that this medication will have what effect on the circulatory system? Constricted bronchioles Decreased BP Increased heart rate Thin, watery saliva

Increased heart rate Explanation: The term "adrenergic" refers to the sympathetic nervous system. Sympathetic effects include an increased rate and force of the heartbeat. Cholinergic effects, which correspond to the parasympathetic division of the autonomic nervous system, include thin, watery saliva, decreased rate and force of heartbeat, and decreased BP.

The nurse is caring for a client who is in status epilepticus. What medication should the nurse anticipated administering to halt the seizure immediately? Intravenous phenobarbital Oral phenytoin Oral lorazepam Intravenous diazepam

Intravenous diazepam Explanation: Medical management of status epilepticus includes IV diazepam and IV lorazepam given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state. Oral medications are not given during status epilepticus.

The nurse is conducting a focused neurologic assessment and is assessing the client's gag reflex. How should the nurse best perform this aspect of the assessment? Observe the client swallowing a small mouthful of water Lightly touch the client's pharynx with a cotton swab Depress the client's tongue with a sterile tongue depressor Ask the client to swallow a small quantity of any soft food

Lightly touch the client's pharynx with a cotton swab Explanation: The gag reflex is elicited by gently touching the back of the pharynx with a cotton-tipped applicator, first on one side of the uvula and then the other. The gag reflex is not assessed by having the client swallow or by depressing the tongue.

A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate? Restrain the client to prevent injury. Open the client's jaws to insert an oral airway. Loosen the client's restrictive clothing. Place client in high Fowler position.

Loosen the client's restrictive clothing. Explanation: An appropriate nursing intervention would include loosening any restrictive clothing on the client. No attempt should be made to restrain the client during the seizure because muscular contractions are strong and restraint can produce injury. Do not attempt to pry open jaws that are clenched in a spasm to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. If possible, place the client on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus.

A school nurse is teaching a group of high school students about risk factors for diabetes. What action has the greatest potential to reduce an individual's risk for developing diabetes? Lose weight, if obese Undergo eye examinations regularly Have blood glucose levels checked annually Stop using tobacco in any form

Lose weight, if obese Explanation: Obesity is a major modifiable risk factor for diabetes. Smoking is not a direct risk factor for the disease. Eye examinations are necessary for persons who have been diagnosed with diabetes, but they do not screen for the disease or prevent it. Similarly, blood glucose checks do not prevent diabetes.

The neurologic ICU nurse is admitting a client with increased intracranial pressure. How should the nurse best position the client? Position client in prone position. Maintain bed in Trendelenburg position. Maintain head of bed (HOB) elevated at 30 to 45 degrees. Position the client supine.

Maintain head of bed (HOB) elevated at 30 to 45 degrees. Explanation: The client with increased ICP should be placed with the HOB elevated 30 to 45 degrees, with the neck in neutral alignment. Each of the other listed positions would cause a dangerous elevation in ICP.

The critical care nurse is caring for 25-year-old man admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this client? Promoting mobility Monitoring neurologic status closely Providing health education Maintaining the client's functional independence

Monitoring neurologic status closely Explanation: Vigilant neurologic monitoring is a key aspect of caring for a client who has a brain abscess. This supersedes education, ADLs, and mobility, even though these are all valid and important aspects of nursing care.

A client with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a client with this diagnosis? Neck flexion produces flexion of knees and hips Inability to stand with eyes closed and arms extended without swaying Numbness and tingling in the lower extremities Pain upon ankle dorsiflexion of the foot

Neck flexion produces flexion of knees and hips Explanation: Clinical manifestations of bacterial meningitis include a positive Brudzinski sign. Neck flexion producing flexion of knees and hips correlates with a positive Brudzinski sign. Positive Homan sign (pain upon dorsiflexion of the foot) and negative Romberg sign (inability to stand with eyes closed and arms extended) are not expected assessment findings for the client with bacterial meningitis. Peripheral neuropathy manifests as numbness and tingling in the lower extremities. Again, this would not be an initial assessment to rule out bacterial meningitis.

When caring for a client with an altered level of consciousness, the nurse is preparing to test cranial nerve VII. What assessment technique would most likely elicit a response from cranial nerve VII? Administer the whisper or watch-tick test. Note any hoarseness in the client's voice. Palpate trapezius muscle while client shrugs shoulders against resistance. Observe for facial movement symmetry, such as a smile.

Observe for facial movement symmetry, such as a smile. Explanation: Cranial nerve VII is the facial nerve. An appropriate assessment technique for this cranial nerve would include observing for symmetry while the client performs facial movements: smiles, whistles, elevates eyebrows, and frowns. Cranial nerve XI (spinal accessory) does not affect the muscles of the face. Assessing cranial nerve VIII (acoustic) would involve evaluating hearing. Cranial nerve X (vagus) does not affect the face.

The nurse is caring for a client in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the client's mean arterial pressure (MAP) is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurse's most appropriate action? Administer osmotic diuretics as prescribed. Prepare the client for craniotomy. Position the client the high Fowler position as tolerated. Participate in interventions to increase cerebral perfusion pressure (CPP).

Participate in interventions to increase cerebral perfusion pressure (CPP). Explanation: The CPP is 55 mm Hg, which is considered low. The normal CPP is 70 to 100 mm Hg. Clients with a CPP of less than 50 mm Hg experience irreversible neurologic damage. As a result, interventions are necessary. A craniotomy is not directly indicated. Diuretics and increased height of bed would exacerbate the client's condition.

The nurse is caring for a client who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to prevent seizures in this client? Prednisone Phenytoin Cafergot Dexamethasone

Phenytoin Explanation: Anticonvulsant medication (phenytoin, diazepam) is often prescribed prophylactically for clients who have undergone supratentorial craniotomy because of the high risk of seizures after this procedure. Prednisone and dexamethasone are steroids and do not prevent seizures. Cafergot is used in the treatment of migraines.

A hospital client has experienced a seizure. In the immediate recovery period, what action best protects the client's safety? Pad the client's bed rails. Place the client in a side-lying position. Administer antianxiety medications as prescribed. Reassure the client and family members.

Place the client in a side-lying position. Explanation: To prevent complications, the client is placed in the side-lying position to facilitate drainage of oral secretions. Suctioning is performed, if needed, to maintain a patent airway and prevent aspiration. None of the other listed actions promotes safety during the immediate recovery period.

The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication? Help the client complete his or her sentences as needed. Have the client speak to loved ones on the phone daily. Provide a board of commonly used needs and phrases. Speak in a loud and deliberate voice to the client.

Provide a board of commonly used needs and phrases. Explanation: The inability to talk on the telephone or answer a question or exclusion from conversation causes anger, frustration, fear of the future, and hopelessness. A common pitfall is for the nurse or other health care team member to complete the thoughts or sentences of the client. This should be avoided because it may cause the client to feel more frustrated at not being allowed to speak and may deter efforts to practice putting thoughts together and completing a sentence. The client may also benefit from a communication board, which has pictures of commonly requested needs and phrases. The board may be translated into several languages.

A client scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the client for the MRI should prioritize what action? Removing all metal-containing objects Withholding stimulants 24 to 48 hours prior to exam Initiating an IV line for administration of contrast Instructing the patient to void prior to the MRI

Removing all metal-containing objects Explanation: Client preparation for an MRI consists of removing all metal-containing objects prior to the examination. Withholding stimulants would not affect an MRI; this relates to an electroencephalography (EEG). Instructing the client to void is client preparation for a lumbar puncture. Initiating an IV line for administration of contrast would be done if the client was having a CT scan with contrast.

The nurse is planning the care of a client with hyperthyroidism. What should the nurse specify in the client's meal plan? Three large, bland meals a day Small, frequent meals, high in protein and calories A reduced calorie diet, high in nutrients A diet high in fiber and plant-sourced fat

Small, frequent meals, high in protein and calories Explanation: A client with hyperthyroidism has an increased appetite. The client should be counseled to consume several small, well-balanced meals. High-calorie, high-protein foods are encouraged. A clear liquid diet would not satisfy the client's caloric or hunger needs. A diet rich in fiber and fat should be avoided because these foods may lead to GI upset or increase peristalsis.

A client with type 2 diabetes normally achieves adequate glycemic control through diet and exercise. Upon being admitted to the hospital for a cholecystectomy, however, the client has required insulin injections on two occasions. The nurse would identify what likely cause for this short-term change in treatment? Alterations in bile metabolism and release have likely caused hyperglycemia. The client's volatile fluid balance surrounding surgery has likely caused unstable blood sugars. Stress has likely caused an increase in the client's blood sugar levels. The client has likely overestimated her ability to control her diabetes using nonpharmacologic measures.

Stress has likely caused an increase in the client's blood sugar levels. Explanation: During periods of physiologic stress, such as surgery, blood glucose levels tend to increase, because levels of stress hormones (epinephrine, norepinephrine, glucagon, cortisol, and growth hormone) increase. The client's need for insulin is unrelated to the action of bile, the client's overestimation of previous blood sugar control, or fluid imbalance.

The nurse is preparing health education for a client who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education? Take ibuprofen for complaints of a serious headache. Mild, intermittent seizures can be expected. Take antihypertensive medication as prescribed. Drowsiness is normal for the first week after discharge.

Take antihypertensive medication as prescribed. Explanation: The client 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 the client to return home. Client 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 client being discharged. Seizure activity is not normal; complaints of a serious headache should be reported to the health care provider before any medication is taken. Drowsiness is not normal or expected.

A client with a history of partial seizures has been taking lamotrigine for the past several days. The client calls the clinic and reports the development of a facial and torso rash to the nurse. What is the nurse's best action? Recommend that the client take 50 mg diphenhydramine PO and check back tomorrow. Rule out any shortness of breath and inform the client that this adverse effect will resolve with time. Tell the client to take no further doses and come be assessed at the clinic immediately. Tell the client to take the medication with a high-fat food to minimize adverse effects.

Tell the client to take no further doses and come be assessed at the clinic immediately. Explanation: The nurse should inform the client to discontinue the drug and return to the clinic. Rashes associated with the use of lamotrigine can be life-threatening. The client needs to return to the clinic to be evaluated and will need a change of medication. Recommending another medication is insufficient, and is also beyond the nurse's scope. High-fat foods are of no benefit.

A client who has experienced an ischemic stroke has been admitted to the medical unit. The client's family is adamant that she remain on bed rest to hasten her recovery and to conserve energy. What principle of care should inform the nurse's response to the family? The client should mobilize as soon as she is physically able. To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks. The client should remain on bed rest until she expresses a desire to mobilize. Lack of mobility will greatly increase the client's risk of stroke recurrence.

The client should mobilize as soon as she is physically able. Explanation: As soon as possible, the client is assisted out of bed and an active rehabilitation program is started. Delaying mobility causes complications, but not necessarily stroke recurrence. Mobility should not be withheld until the client initiates.

The nurse is providing care for a client who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the client has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following? The client's activities immediately prior to the seizure. The ability of the client to follow instructions during the seizure. The success or failure of the care team to physically restrain the client. The client's ability to explain his seizure during the postictal period.

The client's activities immediately prior to the seizure. Explanation: Before and during a seizure, the nurse observes the circumstances before the seizure, including visual, auditory, or olfactory stimuli; tactile stimuli; emotional or psychological disturbances; sleep; and hyperventilation. Communication with the client is not possible during a seizure and physical restraint is not attempted. The client's ability to explain the seizure is not clinically relevant.

An elderly woman found with a head injury on the floor of her home is subsequently admitted to the neurologic ICU. What is the best rationale for the following health care provider prescriptions: elevate the HOB; keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion? To prevent aspiration of stomach contents To decrease cerebral arterial pressure To prevent flexion contractures To avoid impeding venous outflow

To avoid impeding venous outflow Explanation: Any activity or position that impedes venous outflow from the head may contribute to increased volume inside the skull and possibly increase ICP. Cerebral arterial pressure will be affected by the balance between oxygen and carbon dioxide. Flexion contractures are not a priority at this time. Stomach contents could still be aspirated in this position.

A 15-year-old child is brought to the emergency department with symptoms of hyperglycemia. Based on the fact that the child's pancreatic beta cells are being destroyed, the client would be diagnosed with what type of diabetes? Non-insulin-dependent diabetes Type 2 diabetes Prediabetes Type 1 diabetes

Type 1 diabetes Explanation: Beta cell destruction is the hallmark of type 1 diabetes. Non-insulin-dependent diabetes is synonymous with type 2 diabetes, which involves insulin resistance and impaired insulin secretion, but not beta cell destruction. Prediabetes is characterized by normal glucose metabolism, but a previous history of hyperglycemia, often during illness or pregnancy.

The nurse is preparing to assess a client with neurologic dysfunction. What does accurate and appropriate assessment require? Select all that apply. The ability to interpret the results of diagnostic tests Knowledge of nursing interventions related to assessment and diagnostic testing Understanding of the tests used to diagnose neurologic disorders Knowledge of the anatomy of the nervous system The ability to select basic medications for the neurologic dysfunction

Understanding of the tests used to diagnose neurologic disorders Knowledge of nursing interventions related to assessment and diagnostic testing Knowledge of the anatomy of the nervous system Explanation: Assessment requires knowledge of the anatomy and physiology of the nervous system and an understanding of the array of tests and procedures used to diagnose neurologic disorders. Knowledge about the nursing implications and interventions related to assessment and diagnostic testing is also essential. Selecting medications and interpreting diagnostic tests are beyond the normal scope of the nurse.

The nurse is planning discharge education for a client with trigeminal neuralgia. The nurse knows to include information about factors that precipitate an attack. What would the nurse be correct in teaching the client to avoid? Drinking large amounts of fluids Exposing his skin to sunlight Using artificial tears Washing his face

Washing his face Explanation: Washing the face should be avoided if possible because this activity can trigger an attack of pain in a client with trigeminal neuralgia. Using artificial tears would be an appropriate behavior. Exposing the skin to sunlight would not be harmful to this client. Temperature extremes in beverages should be avoided.

The nurse is caring for a client who received a new diagnosis of cancer. The client exhibits signs of a sympathetic stress reaction. What signs and symptoms will the nurse assess in this client consistent with an acute reaction to stress? Select all that apply. tachypnea confusion diaphoresis (profuse sweating) hypotension tachycardia

diaphoresis (profuse sweating) tachycardia tachypnea Explanation: Anxiety is often accompanied by signs and symptoms of the sympathetic stress reaction that may include sweating, fast heart rate, rapid breathing, and elevated blood pressure. Confusion is atypical.

What is the major inhibitory neurotransmitter in the CNS? gamma-aminobutyric acid (GABA) dopamine acetylcholine serotonin

gamma-aminobutyric acid (GABA) Explanation: GABA, which is found in the brain, inhibits nerve activity and is important in preventing overexcitability or stimulation such as seizure activity. Acetylcholine, which communicates between nerves and muscles, is also important as the preganglionic neurotransmitter throughout the autonomic nervous system and as the postganglionic neurotransmitter in the parasympathetic nervous system and in several pathways in the brain. Dopamine is involved in the coordination of impulses and responses, both motor and intellectual. Acetylcholine, dopamine, and serotonin are not the major inhibitory neurotransmitter in the CNS. Serotonin is important in arousal and sleep.

A school-aged child has been diagnosed with a seizure disorder and phenytoin has been prescribed. What nursing diagnosis would be most appropriate if the child demonstrated adverse effects to the drug related to cellular toxicity? impaired skin integrity related to dermatological effects insomnia related to CNS stimulation noncompliance to drug therapy related to avoidance of adverse effects deficient fluid volume related to diuresis

impaired skin integrity related to dermatological effects Explanation: Impaired skin integrity related to dermatological effects would be appropriate because phenytoin can cause potentially serious dermatological effects. This is related to cellular toxicity Usually this drug will cause the client to be sleepy all day and should enhance sleep at night. Deficient fluid volume is not a concern with this drug. Noncompliance will probably not be an issue at this age because the parents and school nurse will administer the medication.

A client sustained a closed-head injury 4 hours ago and now presents to the emergency department with difficulty breathing. The nurse should suspect damage to what part of the brain? medulla oblongata pituitary cerebrum thalamus

medulla oblongata Explanation: The hindbrain, which runs from the top of the spinal cord into the midbrain, is the most primitive area of the brain and contains the brainstem, where the pons and medulla oblongata are located. This area of the brain controls basic vital functions such as the respiratory centers, which control breathing; the cardiovascular centers, which regulate blood pressure; the chemoreceptor trigger zone and emetic zone, which control vomiting; the swallowing center, which coordinates the complex swallowing reflex; and the reticular activating system (RAS), which controls arousal and awareness of stimuli and contains the sleep center. The midbrain contains the thalamus and hypothalamus and the limbic system that transfer sensations into the cerebrum and control temperature. The pituitary gland is known as the master gland, controlling other glands with hormones secreted here.

The nurse is providing client education for a client newly prescribed a hydantoin antiseizure medication. The nurse has taught the client about the need to taper down the dose of the drug slowly when the provider decides it should be discontinued. What benefit of tapering should the nurse describe? shorter duration of absence seizures reduced risk of cardiac arrhythmias reduced risk of status epilepticus improved blood pressure stability

reduced risk of status epilepticus Explanation: Discontinuing hydantoins could result in status epilepticus so that drugs should be withdrawn, or added to the medication regimen, carefully to avoid danger. An abrupt withdrawal of antiseizure medications would not precipitate hypertensive crisis, arrhythmias. The actual duration of absence seizures would not be affected.

The nurse is describing the structure and function of the two hemispheres of the brain to a recent graduate. What regulatory function should the nurse describe? regulation of the efferent conduction system regulation of communication between sensory and motor neurons regulation of the afferent conduction system regulation of the electrical conduction system of the brain

regulation of communication between sensory and motor neurons Explanation: The cerebral cortex consists of two hemispheres, which regulate the communication between sensory and motor neurons and are the sites of thinking and learning. The regulatory functions of the hemispheres do not focus electrical, afferent, or efferent conduction.

What is the purpose of the myelin sheath? speeds electrical conduction produces Schwann cells secretes neurotransmitters protects the nerve from damage

speeds electrical conduction Explanation: Long nerves are myelinated: they have a myelin sheath that speeds electrical conduction and protects the nerves from the fatigue that results from frequent formation of action potentials, not from damage. Although myelin sheaths have Schwann cells, they do not produce these cells and the myelin sheath does not secrete neurotransmitters.

The nurse is preparing to provide health education to a client. The client's learning will take place in what brain region? the areas that coordinate speech and communication the area that coordinates sensation the area that coordinates movement the areas that communicate between motor and sensory neurons

the areas that coordinate speech and communication Explanation: The forebrain is made up of two cerebral hemispheres that contain areas that coordinate speech and communication and are thought to be the area where learning takes place. The forebrain does not coordinate sensation or movement or communicate between the sensory and motor systems.

A client with thyroid cancer has undergone surgery and a significant amount of parathyroid tissue has been removed. The nurse caring for the client should prioritize what question when addressing potential complications? "Do you feel flushed or sweaty?" "Are you experiencing any dizziness or lightheadedness?" "Do you feel any muscle twitches or spasms?" "Are you having any pain that seems to be radiating from your bones?"

"Do you feel any muscle twitches or spasms?" Explanation: As the blood calcium level falls, hyperirritability of the nerves occurs, with spasms of the hands and feet and muscle twitching. This is characteristic of hypoparathyroidism. Flushing, diaphoresis, dizziness, and pain are atypical signs of the resulting hypocalcemia.

A diabetes educator is teaching a client about type 2 diabetes. The educator recognizes that the client understands the primary treatment for type 2 diabetes when the client states what? "I read that a pancreas transplant will provide a cure for my diabetes." "I will make sure to follow the weight loss plan designed by the dietitian." "I will make sure I call the diabetes educator when I have questions about my insulin." "I will take my oral antidiabetic agents when my morning blood sugar is high."

"I will make sure to follow the weight loss plan designed by the dietitian." Explanation: Insulin resistance is associated with obesity; thus the primary treatment of type 2 diabetes is weight loss. Oral antidiabetic agents may be added if diet and exercise are not successful in controlling blood glucose levels. If maximum doses of a single category of oral agents fail to reduce glucose levels to satisfactory levels, additional oral agents may be used. Some clients may require insulin on an ongoing or on a temporary basis during times of acute psychological stress, but it is not the central component of type 2 treatment. Pancreas transplantation is associated with type 1 diabetes.

Which of the following clients with type 1 diabetes is most likely to experience adequate glucose control? A client who eliminates carbohydrates from his daily intake A client who adheres closely to a meal plan and meal schedule A client who never deviates from her prescribed dose of insulin A client who skips breakfast when his glucose reading is greater than 220 mg/dL (12.3 mmol/L)

A client who adheres closely to a meal plan and meal schedule Explanation: The therapeutic goal for diabetes management is to achieve normal blood glucose levels without hypoglycemia. Therefore, diabetes management involves constant assessment and modification of the treatment plan by health professionals and daily adjustments in therapy (possibly including insulin) by clients. For clients who require insulin to help control blood glucose levels, maintaining consistency in the amount of calories and carbohydrates ingested at meals is essential. In addition, consistency in the approximate time intervals between meals, and the snacks, helps maintain overall glucose control. Skipping meals is never advisable for person with type 1 diabetes.

A 69-year-old client is brought to the ED by ambulance because a family member found him lying on the floor disoriented and lethargic. The health care provider suspects bacterial meningitis and admits the client to the ICU. What interventions should the nurse perform? Select all that apply. Monitor pain levels and administer analgesics Administer antipyretics as prescribed Obtain a blood type and cross-match Perform frequent neurologic assessments Place the client in positive pressure isolation

Administer antipyretics as prescribed Perform frequent neurologic assessments Monitor pain levels and administer analgesics Explanation: Clients with meningitis require antipyretics and analgesia to treat fever and pain. As well, their neurologic status must be monitored closely. Transfusions are not anticipated. Infection control precautions are implemented, but positive pressure isolation is not necessary because the client is not immunocompromised.

Paramedics have brought an intubated client to the RD following a head injury due to acceleration-deceleration motor vehicle accident. Increased ICP is suspected. Appropriate nursing interventions would include which of the following? Keep the head of the bed (HOB) flat at all times. Perform endotracheal suctioning every hour. Administer benzodiazepines on a PRN basis. Teach the client to perform the Valsalva maneuver.

Administer benzodiazepines on a PRN basis. Explanation: If the client with a brain injury is very agitated, benzodiazepines are the most commonly used sedatives and do not affect cerebral blood flow or ICP. The HOB should be elevated 30 degrees. Suctioning should be done on a limited basis, due to increasing pressure in the cranium. The Valsalva maneuver is to be avoided. This also causes increased ICP.

A client is being admitted to the neurologic ICU with suspected herpes simplex virus encephalitis. What nursing action best addresses the client's complaints of headache? Initiating a patient-controlled analgesia (PCA) of morphine sulfate Administering hydromorphone IV as needed Distracting the client with activity Dimming the lights and reducing stimulation

Dimming the lights and reducing stimulation Explanation: Comfort measures to reduce headache include dimming the lights, limiting noise and visitors, grouping nursing interventions, and administering analgesic agents. Opioid analgesic medications may mask neurologic symptoms; therefore, they are used cautiously. Nonopioid analgesics may be preferred. Distraction is unlikely to be effective, and may exacerbate the patient's pain.

When caring for a client who has had a stroke, a priority is reduction of ICP. What client position is most consistent with this goal? Position changes every 15 minutes while awake Elevation of the head of the bed Head turned slightly to the right side Extension of the neck

Elevation of the head of the bed Explanation: Elevation of the head of the bed promotes venous drainage and lowers ICP; the nurse should avoid flexing or extending the neck or turning the head side to side. The head should be in a neutral midline position. Excessively frequent position changes are unnecessary.

A client is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what? Evidence of hemorrhagic stroke Previous thrombolytic therapy within the past 12 months Blood pressure of ≥ 180/110 mm Hg Evidence of stroke evolution

Evidence of hemorrhagic stroke Explanation: Thrombolytic therapy would exacerbate a hemorrhagic stroke with potentially fatal consequences. Stroke evolution, high BP, or previous thrombolytic therapy does not contraindicate its safe and effective use.

What neurologic assessment should the nurse perform to gauge the client's function of cranial nerve I? Have the client identify familiar odors with the eyes closed. Assess papillary reflex. Test for air and bone conduction (Rinne test). Utilize the Snellen chart.

Have the client identify familiar odors with the eyes closed. Explanation: Cranial nerve I is the olfactory nerve. The client's sense of smell could be assessed by asking him or her to identify common odors. Assessment of papillary reflex does not address the olfactory function of cranial nerve I. The Snellen chart would be used to assess cranial nerve II (optic).

A nurse is caring for a client diagnosed with Ménière disease. While completing a neurologic examination on the client, the nurse assesses cranial nerve VIII. The nurse would be correct in identifying the function of this nerve as what? Sense of smell Visual acuity Hearing and equilibrium Movement of the tongue

Hearing and equilibrium Explanation: Cranial nerve VIII (acoustic) is responsible for hearing and equilibrium. Cranial nerve XII (hypoglossal) is responsible for movement of the tongue. Cranial nerve II (optic) is responsible for visual acuity and visual fields. Cranial nerve I (olfactory) functions in sense of smell.

A nurse is about to administer a parenteral benzodiazepine to a client in the hospital before the performance of an invasive diagnostic procedure. What action should the nurse prioritize before administration of the drug? Auscultate the client's lungs and set up pulse oximetry monitoring. Help the client out of bed to the bathroom and encourage the client to void. Close the blinds and ensure appropriate room temperature for the client. Ask all visitors to leave the room and remain in the waiting area.

Help the client out of bed to the bathroom and encourage the client to void. Explanation: The priority action would be to help the client up to void. After the medication is administered, the client should not get out of bed because of possible injury due to drowsiness. Safety should always be the priority concern. Respiratory assessment is not a priority, since respiratory depression does not normally occur. Creating a calm environment and asking visitors to leave may be necessary for the diagnostic procedure, but these actions do not have to precede benzodiazepine administration.

An 82-year-old man is admitted for observation after a fall. Due to his age, the nurse knows that the client is at increased risk for what complication of his injury? Embolus Skull fracture Hematoma Stroke

Hematoma Explanation: Two major factors place older adults at increased risk for hematomas. First, the dura becomes more adherent to the skull with increasing age. Second, many older adults take aspirin and anticoagulants as part of routine management of chronic conditions. Because of these factors, the client's risk of a hematoma is likely greater than that of stroke, embolism, or skull fracture. Strokes are more common among older adults, but not typically as a complication of falls.

A client diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the client and family needs to begin as soon as the client is settled on the unit and will continue until the client is discharged. What will family education need to include? How to differentiate between hemorrhagic and ischemic stroke How to correctly modify the home environment Risk factors for ischemic stroke Techniques for adjusting the client's medication dosages at home

How to correctly modify the home environment Explanation: For a client with a hemorrhagic stroke, teaching addresses the use of assistive devices or modification of the home environment to help the client live with the disability. This is more important to the client's needs than knowing about risk factors for ischemic stroke. It is not necessary for the family to differentiate between different types of strokes. Medication regimens should never be altered without consultation.

A client has returned to the floor after having a thyroidectomy for thyroid cancer. What laboratory finding may be an early indication of parathyroid gland injury or removal? Hypophosphatemia Hypocalcemia Hypokalemia Hyponatremia

Hypocalcemia Explanation: Injury or removal of the parathyroid glands may produce a disturbance in calcium metabolism and result in a decline of calcium levels (hypocalcemia). As the blood calcium levels fall, hyperirritability of the nerves occurs, with spasms of the hands and feet and muscle twitching. This group of symptoms is known as tetany and must be reported to the physician immediately, because laryngospasm may occur and obstruct the airway. Hypophosphatemia, hyponatremia, and hypokalemia are not expected responses to parathyroid injury or removal. In fact, parathyroid removal or injury that results in hypocalcemia may lead to hyperphosphatemia.

A client in the OR goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows that the area of the brain that regulates body temperature is which of the following? Midbrain Cerebellum Thalamus Hypothalamus

Hypothalamus Explanation: The hypothalamus plays an important role in the endocrine system because it regulates the pituitary secretion of hormones that influence metabolism, reproduction, stress response, and urine production. It works with the pituitary to maintain fluid balance through hormonal release and maintains temperature regulation by promoting vasoconstriction or vasodilatation. The cerebellum, thalamus, and midbrain are not directly involved in temperature regulation.

A client has been admitted to the neurologic unit for the treatment of a newly diagnosed brain tumor. The client has just exhibited seizure activity for the first time. What is the nurse's priority response to this event? Teach the client's family about the relationship between brain tumors and seizure activity. Identify the triggers that precipitated the seizure. Ensure that the client is housed in a private room. Implement precautions to ensure the client's safety.

Implement precautions to ensure the client's safety. Explanation: Clients with seizures are carefully monitored and protected from injury. Client safety is a priority over health education, even though this is appropriate and necessary. Specific triggers may or may not be evident; identifying these are not the highest priority. A private room is preferable, but not absolutely necessary.

A nurse is assessing a client with an acoustic neuroma who has been recently admitted to an oncology unit. What symptoms is the nurse likely to find during the initial assessment? Loss of hearing, tinnitus, and vertigo Loss of vision, change in mental status, and hyperthermia Loss of vision, headache, and tachycardia Loss of hearing, increased sodium retention, and hypertension

Loss of hearing, tinnitus, and vertigo Explanation: An acoustic neuroma is a tumor of the eighth cranial nerve, the cranial nerve most responsible for hearing and balance. The client with an acoustic neuroma usually experiences loss of hearing, tinnitus, and episodes of vertigo and staggering gait. Acoustic neuromas do not cause loss of vision, increased sodium retention, or tachycardia.

The nurse is participating in the care of a client with increased ICP. What diagnostic test is contraindicated in this client's treatment? Computed tomography (CT) scan Lumbar puncture Magnetic resonance imaging (MRI) Venous Doppler studies

Lumbar puncture Explanation: A lumbar puncture in a client with increased ICP may cause the brain to herniate from the withdrawal of fluid and change in pressure during the lumbar puncture. Herniation of the brain is a dire and frequently fatal event. CT, MRI, and venous Doppler are considered noninvasive procedures and they would not affect the ICP itself.

A client with increased ICP has a ventriculostomy for monitoring ICP. The nurse's most recent assessment reveals that the client is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication? Catheter occlusion CSF leak Meningitis Encephalitis

Meningitis Explanation: Complications of a ventriculostomy include ventricular infectious meningitis and problems with the monitoring system. Nuchal rigidity and photophobia are clinical manifestations of meningitis, but are not suggestive of encephalitis, a CSF leak, or an occluded catheter.

A nurse is caring for a client with type 1 diabetes who is being discharged home tomorrow. What is the best way to assess the client's ability to prepare and self-administer insulin? Review the client's first hemoglobin A1C result after discharge. Observe the client drawing up and administering the insulin. Provide a health education session reviewing the main points of insulin delivery. Ask the client to describe the process in detail.

Observe the client drawing up and administering the insulin. Explanation: Nurses should assess the client's ability to perform diabetes-related self-care as soon as possible during the hospitalization or office visit to determine whether the client requires further diabetes teaching. While consulting a home care nurse is beneficial, an initial assessment should be performed during the hospitalization or office visit. Nurses should directly observe the client performing the skills such as insulin preparation and infection, blood glucose monitoring, and foot care. Simply questioning the client about these skills without actually observing performance of the skill is not sufficient. Further education does not guarantee learning.

A client is brought to the ER following a motor vehicle accident in which he sustained head trauma. Preliminary assessment reveals a vision deficit in the client's left eye. The nurse should associate this abnormal finding with trauma to what cerebral lobe? Temporal Parietal Occipital Frontal

Occipital Explanation: 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.

The nurse is doing an initial assessment on a client newly admitted to the unit with a diagnosis of cerebrovascular disease. The client has difficulty copying a figure that the nurse has drawn and is diagnosed with visual receptive aphasia. What brain region is primarily involved in this client's deficit? Parietal—occipital area Temporal lobe Inferior-posterior frontal areas Posterior frontal area

Parietal—occipital area Explanation: Difficulty copying a figure that the nurse has drawn would be considered visual receptive aphasia, which involves the parietal—occipital area. Expressive aphasia, the inability to express oneself, is often associated with damage to the frontal area. Receptive aphasia, the inability to understand what someone else is saying, is often associated with damage to the temporal lobe area.

What term is used to describe the fibrous connective tissue that hugs the brain closely and extends into every fold of the brain's surface? Pia mater Arachnoid Dura mater Fascia

Pia mater Explanation: The term "meninges" describes the fibrous connective tissue that covers the brain and spinal cord. The meninges have three layers, the dura mater, arachnoid, and pia mater. The pia mater is the innermost membrane that hugs the brain closely and extends into every fold of the brain's surface. The dura mater, the outermost layer, covers the brain and spinal cord. The arachnoid, the middle membrane, is responsible for the production of cerebrospinal fluid. This is not known as "fascia."

A male client presents to the clinic reporting a headache. The nurse notes that the client is guarding his neck and tells the nurse that he has stiffness in the neck area. The nurse suspects the client may have meningitis. What is another well-recognized sign of this infection? Sluggish pupil reaction Negative Brudzinski sign Positive Kernig sign Hyperpatellar reflex

Positive Kernig sign Explanation: Meningeal irritation results in a number of well-recognized signs commonly seen in meningitis, such as a positive Kernig sign, a positive Brudzinski sign, and photophobia. Hyperpatellar reflex and a sluggish pupil reaction are not commonly recognized signs of meningitis.

A client has a neurologic disorder that affects the structure and function of the myelin sheath and Schwann cells. What effect will this client likely experience? personality changes chronic pain lack of coordination slower than normal nerve conduction

slower than normal nerve conduction Explanation: Myelinated nerves have Schwann cells, which speed up nerve conduction. Their absence does not cause personality changes, pain, or lack of coordination.