Adult - Neurological
1, 2, 6 (Rationale:Any nursing staff member who is involved in caring for the client should observe for the onset and duration of seizures (although a more detailed assessment of seizure activity should be done by the RN). Administration of medications is included in LPN/LVN education and scope of practice. Turning the client on his or her side to avoid aspiration is certainly within the scope of practice for an LPN/LVN. Teaching, discharge planning, and assessment for adverse effects of new medications are complex activities that require RN-level education and scope of practice.)
A 23-year-old client with a recent history of encephalitis is admitted to the medical unit with new-onset generalized tonic-clonic seizures. Which nursing activities included in the client's care will be best to assign to an LPN/LVN whom the nurse is supervising? Select all that apply. 1.Observing and documenting the onset and duration of any seizure activity 2.Administering phenytoin 200 mg PO three times a day 3.Teaching the client about the need for frequent tooth brushing and flossing 4.Developing a discharge plan that includes referral to the Epilepsy Foundation 5.Assessing for adverse effects caused by new antiseizure medications 6.Turning the client to his or her side to avoid aspiration
a (Patients with meningitis and disorientation will be calmed by the presence of someone familiar at the bedside. Restraints should be avoided because they increase agitation and anxiety. The patient requires frequent assessment for complications. The use of touch and a soothing voice will decrease anxiety for most patients. The patient will have photophobia, so the light should be dim.)
A 42-year-old patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care? a. Encourage family members to remain at the bedside. b. Apply soft restraints to protect the patient from injury. c. Keep the room well-lighted to improve patient orientation. d. Minimize contact with the patient to decrease sensory input.
D (Rationale: leakage of cerebrospinal fluid (CSF) in the ears or nose may accompany the basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into blood and yellow concentric rings on dressing material, called a "halo sign". The fluid also test positive for glucose.)
A client has clear fluid leaking from the nose following of a basilar skull fracture. Which finding would alert the nurse that the cerebrospinal fluid is present? a. fluid is clear and tests negative for glucose. b. fluid is grossly bloody in appearance and has a pH of 6. c. fluid clumps together on the dressing and has a pH of 7. d. fluid separates into concentric rings and tests positive for glucose.
D (Rationale: activities that increase intrathoracic and intraabdominal pressure cause an indirect elevation of the intracranial pressure. Some of these activities include isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as re-positioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising.)
A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? a. blowing the nose b. isometric exercise c. coughing vigorously d. exhaling during repositioning
2 (Rationale:Leukopenia is a serious adverse effect of phenytoin therapy and would require discontinuation of the medication. The other data indicate a need for further assessment or client teaching but will not require a change in medical treatment for the seizures.)
A client who recently started taking phenytoin to control simple partial seizures is seen in the outpatient clinic. Which information obtained during the nurse's chart review and assessment will be of greatest concern? 1.The gums appear enlarged and inflamed. 2.The white blood cell count is 2300/mm3 (2.3 x 109/L). 3.The client sometimes forgets to take the phenytoin until the afternoon. 4.The client wants to renew her driver's license in the next month.
A, B, D (Rationale: The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too infrequent), And urinary catheters should be checked frequently to prevent Kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Ensuring a bowel movement once a week is much too infrequent. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.)
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk for occurrence? Select all that apply. a. keeping the linens wrinkle-free under the client b. preventing unnecessary pressure on the lower limbs c. limiting bladder catheterization to once every 12 hours d. turning and repositioning the client at least every 2 hours e. ensuring that the client has a bowel movement at least once a week
1 (Rationale:At this time, based on the client's statement, the priority is inability to perform ADLs most likely related to being tired (fatigue) after physical therapy. The other three nursing concerns are appropriate to a client with MS but are not related to the client's statement.)
A client with multiple sclerosis tells the unlicensed assistive personnel (UAP) after physical therapy that she is too tired to take a bath. What is the priority nursing concern at this time? 1.Fatigue 2.Inability to perform activities of daily living (ADLs) 3.Decreased mobility 4.Muscular weakness
4 (Rationale:A client with a seizure disorder should not take over-the-counter medications without consulting with the health care provider first. The other three statements are appropriate teaching points for clients with seizure disorders and their families.)
A nursing student is teaching a client and family about epilepsy before the client's discharge. For which statement should the nurse intervene? 1."You should avoid consumption of all forms of alcohol." 2."Wear your medical alert bracelet at all times." 3."Protect your loved one's airway during a seizure." 4."It's OK to take over-the-counter medications."
d (Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics are started. As soon as the cultures are done, the antibiotic should be started. Hypothermia therapy and acetaminophen administration are appropriate but can be started after the other actions are implemented.)
A patient being admitted with bacterial meningitis has a temperature of 102.5 F (39.2 C) and a severe headache. Which order for collaborative intervention should the nurse implement first? a. Administer ceftizoxime (Cefizox) 1 g IV . b. Give acetaminophen (Tylenol) 650 mg PO. c. Use a cooling blanket to lower temperature. d. Swab the nasopharyngeal mucosa for cultures.
d (Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions. Because the patient may be confused and weak, bedrails should be elevated at both the foot and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an important aspect of care in a patient with meningitis.)
A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action? a. The bedrails at the head and foot of the bed are both elevated. b. The patient receives a regular diet from the dietary department. c. The lights in the patients room are turned off and the blinds are shut. d. Unlicensed assistive personnel enter the patients room without a mask.
b (The patient with meningitis has increased fluid needs, so oral fluids should be encouraged. The other actions are appropriate. Slight elevation of the head of the bed will decrease headache without causing leakage of cerebrospinal fluid from the lumbar puncture site. Antibiotics should be administered until bacterial meningitis is ruled out by the cerebrospinal fluid analysis.)
A patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider should the nurse question? a. Elevate the head of the bed 20 degrees. b. Restrict oral fluids to 1000 mL daily. c. Administer ceftriaxone (Rocephin) 1 g IV every 12 hours. d. Give ibuprofen (Motrin) 400 mg every 6 hours as needed for headache.
3 (Rationale:Measurement of vital signs is within the education and scope of practice of UAPs. The nurse should perform neurologic checks and document the seizure. Clients with seizures should not be restrained; however, the nurse may guide the client's movements if necessary to prevent injury.)
After a client has a seizure, which action can the nurse delegate to the unlicensed assistive personnel (UAP)? 1.Documenting the seizure 2.Performing neurologic checks 3.Checking the client's vital signs 4.Restraining the client for protection
4 (Rationale:Urinary tract infections (UTIs) are a frequent complication in clients with MS because of the effect of the disease on bladder function, and UTIs may lead to sepsis in these clients. The elevated temperature and flank pain suggest that this client may have pyelonephritis. The health care provider should be notified immediately so that IV antibiotic therapy can be started quickly. The other clients should be assessed as soon as possible, but their needs are not as urgent as those of this client.)
After the nurse receives the change-of-shift report at 7:00 am, which client must the nurse assess first? 1.A 23-year-old client with a migraine headache who reports severe nausea associated with retching 2.A 45-year-old client who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching 3.A 59-year-old client with Parkinson disease who will need a swallowing assessment before breakfast 4.A 63-year-old client with multiple sclerosis (MS) who has an oral temperature of 101.8°F (38.8°C) and flank pain
3 (Rationale:Sumatriptan is a triptan preparation developed to treat migraine headaches. Most are contraindicated in clients with actual or suspected ischemic heart disease, cerebrovascular ischemia, hypertension, and peripheral vascular disease and in those with Prinzmetal angina because of the potential for coronary vasospasm.)
For which client with severe migraine headaches would the nurse question an order for sumatriptan? 1.A 58-year-old client with gastrointestinal reflux disease 2.A 48-year-old client with hypertension 3.A 65-year-old client with mild emphysema 4.A 72-year-old client with hyperthyroidism
2 (Rationale:The changes that the RN notes are characteristic of myasthenic crisis, which often follows some type of infection. The client is at risk for inadequate respiratory function. In addition to notifying the health care provider or Rapid Response Team, the nurse should carefully monitor the client's respiratory status. The client may need intubation and mechanical ventilation.)
The RN notes that a client with myasthenia gravis has an elevated temperature (102.2°F [39°C]), an increased heart rate (120 beats/min), and a rise in blood pressure (158/94 mm Hg) and is incontinent of urine and stool. What is the nurse's best action at this time? 1.Administer an acetaminophen suppository. 2.Notify the health care provider immediately. 3.Recheck vital signs in 1 hour. 4.Reschedule the client's physical therapy.
2 (Rationale:Bacterial meningitis is a medical emergency, and antibiotics are administered even before the diagnosis is confirmed (after specimens have been collected for culture). The other interventions will also help to reduce central nervous system stimulation and irritation and should be implemented as soon as possible but are not as important as starting antibiotic therapy.)
The nurse has just admitted a client with bacterial meningitis who reports a severe headache with photophobia and has a temperature of 102.6°F (39.2°C) orally. Which prescribed intervention should be implemented first? 1.Administer codeine 15 mg orally for the client's headache. 2.Infuse ceftriaxone 2000 mg IV to treat the infection. 3.Give acetaminophen 650 mg orally to reduce the fever. 4.Give furosemide 40 mg IV to decrease intracranial pressure.
1, 3, 4 (Rationale:Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising padded side rails in the bed, and placing the client on one side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible; protects the head from injury; and moves furniture that may injure the client.)
The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply. a. loose restrictive clothing b. restraining the clients limbs c. removing the pillow and raising padded side rails d. positioning the client to the side, if possible, with the head flex forward e. keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist
B (Rationale: A change in vital signs may be a late sign of increased intracranial pressure. Trans include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur.)
The nurse is caring for the client with increased cranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? a. increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure b. increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure c. decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure d. decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure
1, 2, 3, 4, 5 (Rationale:Medications such as estrogen supplements may actually trigger a migraine headache attack. All of the other statements are accurate and should be included in the teaching plan.)
The nurse is creating a teaching plan for a client with newly diagnosed migraine headaches. Which key items will be included in the teaching plan? Select all that apply. 1.Foods that contain tyramine, such as alcohol and aged cheese, should be avoided. 2.Drugs such as nitroglycerin and nifedipine should be avoided. 3.Abortive therapy is aimed at eliminating the pain during the aura. 4.A potential side effect of medications is rebound headache. 5.Complementary therapies such as biofeedback and relaxation may be helpful. 6.Estrogen therapy should be continued as prescribed by the client's health care provider.
C (Rationale: signs of meningeal irritation compatible with meningitis include nuchal rigidity, a positive Brudzinski's sign, and positive Kernig's sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is flexed. Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the leg is fully flexed at the knee and hip. Brudzinski's sign as positive when the client flexes the hip and knees in response to the nurse gently flexing the head and neck onto the chest. A Glasgow coma scale score of 15 is a perfect score and indicates that the client is awake and alert, with no neurological deficits.)
The nurse is evaluating the status of a client who had a craniotomy three days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? a. A negative Kernig's sign b. absence of nuchal rigidity c. A positive Brudzinski's sign d. A Glasgow coma scale score of 15
A, B, E, F (Rationale: seizure precautions may vary from agency to agency, but they generally have some common features. Usually, and airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous Access in place to have a readily accessible route if anti-seizure medications must be administered, and as part of the routine assessment the nurse should be checking patency of the catheter. The use of padded tongue blades is highly controversial, and they should not be kept at the bedside. Forcing the tongue back into the mouth during a seizure more likely will harm the client who bites down during seizure activity. Risks include blocking The airway from improper placement, chipping the clients teeth, and subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begins.)
The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client safety? Select all that apply. a. Padding the side rails of the bed b. placing an airway at the bedside c. place in the bed in the high position d. putting a padded tongue blade at the end of the bed e. placing oxygen and suction equipment at the bedside f. flushing the intravenous catheter to ensure that the site is patent
1 (Rationale:Meningococcal meningitis is spread through contact with respiratory secretions, so use of a mask and gown is required to prevent transmission of the infection to staff members or other clients. The other actions may or may not be appropriate. The presence of a family member at the bedside may decrease client confusion and agitation. Clients with hyperthermia frequently report feeling chilled, but warming the client is not an appropriate intervention. Checking the pupils' response to light is appropriate but is not needed every 30 minutes and is uncomfortable for a client with photophobia.)
The nurse is mentoring a student nurse in the intensive care unit while caring for a client with meningococcal meningitis. Which action by the student requires that the nurse intervene most rapidly? 1.Entering the room without putting on a protective mask and gown 2.Instructing the family that visits are restricted to 10 minutes 3.Giving the client a warm blanket when he says he feels cold 4.Checking the client's pupil response to light every 30 minutes
4 (Rationale:The LPN/LVN scope of practice includes setting up the equipment for oxygen and suctioning. The RN should perform the complete initial assessment. Controversy exists as to whether padded side rails actually provide safety, and their use may embarrass the client and family. Tongue blades should not be at the bedside and should never be inserted into the client's mouth after a seizure begins.)
The nurse is preparing to admit a client with a seizure disorder. Which action can be assigned to an LPN/LVN? 1.Completing the admission assessment 2.Setting up oxygen and suction equipment 3.Placing a padded tongue blade at the bedside 4.Padding the side rails before the client arrives
1 (Rationale:Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is important. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional stress.)
The nurse is teaching a client with myasthenia gravis about the prevention of myastenic and cholinergic crisis. Which client activity suggest that teaching is most effective? a. taking medications as scheduled b. eating large, well balanced meals c. doing muscle strengthening exercises d. doing all chores early in the day while less fatigued
1, 3, 4, 6 (Rationale:After determining alertness in a client, the next step is to evaluate orientation. When the client's attention is engaged, ask him or her questions to determine orientation. Varying the sequence of questioning on repeated assessments prevents the client from memorizing the answers. Responses that indicate orientation include the ability to answer questions about person, place, and time by asking for information such as the client's ability to relate the onset of symptoms, the name of his or her health care provider or nurse, the year and month, his or her address, and the name of the referring physician or health care agency. Asking about mayors' names or parents' address may be inappropriate to assess orientation.)
The nurse on the neurologic acute care unit is assessing the orientation of a client with severe headaches. Which questions would the nurse use to determine orientation? Select all that apply. 1.When did you first experience the headache symptoms? 2.Who is the Mayor of Cleveland 3.What is your health care provider's name? 4.What year and month is this? 5.What is your parents' address? 6.What is the name of this health care facility?
c (The Neisseria meningitides vaccination is recommended for children ages 11 and 12, unvaccinated teens entering high school, and college freshmen. Hand washing may help decrease the spread of bacteria, but it is not as effective as immunization. Vaccination with Haemophilus influenzae is for infants and toddlers. Because adolescents and young adults are in school or the workplace, avoiding crowds is not realistic.)
The public health nurse is planning a program to decrease the incidence of meningitis in adolescents and young adults. Which action is most important? a. Encourage adolescents and young adults to avoid crowds in the winter. b. Vaccinate 11- and 12-year-old children against Haemophilus influenzae. c. Immunize adolescents and college freshman against Neisseria meningitides. d. Emphasize the importance of hand washing to prevent the spread of infection.
1 (Rationale:The priority for interdisciplinary care for the client experiencing a migraine headache is pain management. All of the other problems are accurate, but none of them is as urgent as the issue of pain, which is often incapacitating.)
What is the priority nursing concern for a client experiencing a migraine headache? 1.Pain 2.Anxiety 3.Hopelessness 4.Risk for brain injury
d (Shock is a serious complication of meningitis, and the patients low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernigs sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the hypotension.)
When assessing a 53-year-old patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider? a. The patient exhibits nuchal rigidity. b. The patient has a positive Kernigs sign. c. The patients temperature is 101 F (38.3 C). d. The patients blood pressure is 88/42 mm Hg.
3 (Rationale:Of the clients listed, the client with bacterial meningitis is in the most stable condition and likely the least complex. An RN from the medical unit would be familiar with administering IV antibiotics. The other clients require assessments and care from RNs more experienced in caring for clients with neurologic diagnoses.)
Which client in the neurologic intensive care unit should the charge nurse assign to an RN who has been floated from the medical unit? 1.A 26-year-old client with a basilar skull fracture who has clear drainage coming out of the nose 2.A 42-year-old client admitted several hours ago with a headache and a diagnosis of a ruptured berry aneurysm 3.A 46-year-old client who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due 4.A 65-year-old client with an astrocytoma who has just returned to the unit after undergoing craniotomy
2 (Rationale:The new graduate RN who is on orientation to the unit should be assigned to care for clients with stable, noncomplex conditions, such as the client with stroke. The task of helping the client with Parkinson disease to bathe is best delegated to the unlicensed assistive personnel (UAP). The client being transferred to the nursing home, and the newly admitted client with spinal cord injury should be assigned to experienced nurses.)
Which client should the charge nurse assign to a new graduate RN who is orientating to the neurologic unit? 1.A 28-year-old newly admitted client with a spinal cord injury 2.A 67-year-old client who had a stroke 3 days ago and has left-sided weakness 3.An 85-year-old client with dementia who is to be transferred to long-term care today 4.A 54-year-old client with Parkinson disease who needs assistance with bathing
1 (Rationale:The priority action during a generalized tonic-clonic seizure is to protect the airway by turning the client to one side to prevent aspiration. Administering lorazepam should be the next action because it will act rapidly to control the seizure. Although oxygen may be useful during the postictal phase, the hypoxemia during tonic-clonic seizures is caused by apnea, which cannot be corrected by oxygen administration. Checking level of consciousness is not appropriate during the seizure because generalized tonic-clonic seizures are associated with a loss of consciousness.)
Which nursing action will be implemented first if a client has a generalized tonic-clonic seizure? 1.Turn the client to one side. 2.Give lorazepam 2 mg IV. 3.Administer oxygen via nonrebreather mask. 4.Assess the client's level of consciousness.