Ch 55-60

A patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. The nurse records the patients Glasgow Coma Scale score as a. 9 b. 11 c. 13 d. 15

b. 11 The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.

Doctor's Order: Bumex 0.8 mg IV bolus bid; Reconstitution instructions: Constitute to 1000 micrograms/3.1 mL with 4.8mL of 5% Dextrose Water for Injection. How many mL will you administer? a. 2 b. 2.5 c. 3 d. 3.5

b. 2.5

An unconscious patient with a traumatic head injury has a blood pressure of 126/72 mm Hg, and an intracranial pressure of 18 mm Hg. The nurse will calculate the cerebral perfusion pressure as ____________________. a. 55 b. 60 c. 72 d. 90

c. 72 The formula for calculation of cerebral perfusion pressure is [(Systolic pressure + Diastolic blood pressure 2)/3] - intracranial pressure.

When developing a plan of care for a patient with dysfunction of the cerebellum, the nurse will include interventions to a. prevent falls. b. stabilize mood. c. enhance swallowing ability. d. improve short-term memory.

a. prevent falls. Because functions of the cerebellum include coordination and balance, the patient with dysfunction is at risk for falls. The cerebellum does not affect memory, mood, or swallowing ability.

Order: levetiracetam (Keppra), PO, 20 mg/kg/day, divided b.i.d. Available: Keppra 100 mg/mL Patient weight: 20 kg How many mL will the patient receive per dose? a. 2 b. 4 c. 5 d. 7

a. 2

Which of these patients is most appropriate for the intensive care unit (ICU) charge nurse to assign to an RN who has floated from the medical unit? a. A 44-year-old receiving IV antibiotics for meningococcal meningitis b. A 23-year-old who had a skull fracture and craniotomy the previous day c. A 30-year-old who has an intracranial pressure (ICP) monitor in place after a head injury a week ago d. A 61-year-old who has increased ICP and is receiving hyperventilation therapy

a. A 44-year-old receiving IV antibiotics for meningococcal meningitis An RN who works on a medical unit will be familiar with administration of IV antibiotics and with meningitis. The post-craniotomy patient, patient with an ICP monitor, and the patient on a ventilator should be assigned to an RN familiar with the care of critically ill patients.

After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a. A patient with right-sided weakness who has an infusion of tPA prescribed b. A patient who has atrial fibrillation and a new order for warfarin (Coumadin) c. A patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due d. A patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled

a. A patient with right-sided weakness who has an infusion of tPA prescribed tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury. The other medications also should be given as quickly as possible, but timing of the medications is not as critical.

A nurse delegates care for a client with Parkinson disease to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this clients care? a. Allow the client to be as independent as possible with activities. b. Assist the client with frequent and meticulous oral care. c. Assess the clients ability to eat and swallow before each meal. d. Schedule appointments early in the morning to ensure rest in the afternoon.

a. Allow the client to be as independent as possible with activities. Clients with Parkinson disease do not move as quickly and can have functional problems. The client should be encouraged to be as independent as possible and provided time to perform activities without rushing. Although oral care is important for all clients, instructing the UAP to provide frequent and meticulous oral is not a priority for this client. This statement would be a priority if the client was immune-compromised or NPO. The nurse should assess the clients ability to eat and swallow; this should not be delegated. Appointments and activities should not be scheduled early in the morning because this may cause the client to be rushed and discourage the client from wanting to participate in activities of daily living.

A patient who sustained a spinal cord injury a week ago becomes angry, telling the nurse I want to be transferred to a hospital where the nurses know what they are doing! Which reaction by the nurse is best? a. Ask for the patients input into the plan for care. b. Clarify that abusive behavior will not be tolerated. c. Reassure the patient about the competence of the nursing staff. d. Continue to perform care without responding to the patients comments.

a. Ask for the patients input into the plan for care. The patient is demonstrating behaviors consistent with the anger phase of the mourning process, and the nurse should allow expression of anger and seek the patients input into care. Expression of anger is appropriate at this stage and should be tolerated by the nurse. Reassurance about the competency of the staff will not be helpful in responding to the patients anger. Ignoring the patients comments will increase the patients anger and sense of helplessness.

A parent of a child who has been taking valproic acid (Depakote) for several years calls the clinic to report a recent recurrence of seizures and states that the child is having 3 or 4 seizures per week. The nurse will perform which action? a. Ask the parent about to describe the childs drug regimen. b. Request an order for a serum valproic acid level. c. Suggest that the parent take the child to the emergency department. d. Tell the parent that the provider will increase the childs dose of Depakote.

a. Ask the parent about to describe the childs drug regimen. Questions pertaining to medication adherence are a no-cost, non-invasive way of troubleshooting cause of decreased drug effect. The serum drug level will be assessed next. Children may need changes in doses as they grow. The child is not in status epilepticus so does not need to go to the emergency department. The dose will not be increased until the serum drug level is known.

An older client is hospitalized with Guillain-Barr syndrome. A family member tells the nurse the client is restless and seems confused. What action by the nurse is best? a. Assess the clients oxygen saturation. b. Check the medication list for interactions. c. Place the client on a bed alarm. d. Put the client on safety precautions.

a. Assess the clients oxygen saturation. In the older adult, an early sign of hypoxia is often confusion and restlessness. The nurse should first assess the clients oxygen saturation. The other actions are appropriate, but only after this assessment occurs.

A nurse plans care for a client with a halo fixator. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Assess the pin sites for signs of infection. b. Loosen the pins when sleeping. c. Decrease the clients oral fluid intake. d. Assess the chest and back for skin breakdown. clean pin sites

a. Assess the pin sites for signs of infection. c. Decrease the clients oral fluid intake. d. Assess the chest and back for skin breakdown. clean pin sites A special halo wrench should be taped to the clients vest in case of a cardiopulmonary emergency. The nurse should assess the pin sites for signs of infection or loose pins and for complications from the halo. The nurse should also increase fluids and fiber to decrease bowel straining and assess the clients chest and back for skin breakdown from the halo vest.

A nurse is caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first? a. Client with a Glasgow Coma Scale score that was 10 and is now is 8 b. Client with a Glasgow Coma Scale score that was 9 and is now is 12 c. Client with a moderate brain injury who is amnesic for the event d. Client who is requesting pain medication for a headache

a. Client with a Glasgow Coma Scale score that was 10 and is now is 8 A 2-point decrease in the Glasgow Coma Scale score is clinically significant and the nurse needs to see this client first. An improvement in the score is a good sign. Amnesia is an expected finding with brain injuries, so this client is lower priority. The client requesting pain medication should be seen after the one with the declining Glasgow Coma Scale score.

A nurse assesses a client with a brain tumor. Which newly identified assessment findings should alert the nurse to urgently communicate with the health care provider? (Select all that apply.) a. Glasgow Coma Scale score of 8 b. Decerebrate posturing c. Reactive pupils d. Uninhibited speech e. Diminished cognition

a. Glasgow Coma Scale score of 8 b. Decerebrate posturing e. Diminished cognition The nurse should urgently communicate changes in a clients neurologic status, including a decrease in the Glasgow Coma Scale score, abnormal flexion or extension, changes in cognition or speech, and pinpointed, dilated, and nonreactive pupils.

A nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Have suction equipment at the bedside. b. Place a padded tongue blade at the bedside. c. Permit only clear oral fluids. d. Keep bed rails up at all times. e. Maintain the client on strict bedrest. f. Ensure that the client has IV access.

a. Have suction equipment at the bedside. d. Keep bed rails up at all times. f. Ensure that the client has IV access. Oxygen and suctioning equipment with an airway must be readily available. The bed rails should be up at all times while the client is in the bed to prevent injury from a fall if the client has a seizure. If the client does not have an IV access, insert a saline lock, especially for those clients who are at significant risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV drug therapy must be given to stop the seizure. Padded tongue blades may pose a danger to the client during a seizure and should not be used. Dietary restrictions and strict bedrest are not interventions associated with epilepsy. The client should be encouraged to eat a well-balanced diet and ambulate while in the hospital.

A client has a brain abscess and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying the client does not have a seizure disorder. What response by the nurse is best? a. Increased pressure from the abscess can cause seizures. b. Preventing febrile seizures with an abscess is important. c. Seizures always occur in clients with brain abscesses. d. This drug is used to sedate the client with an abscess.

a. Increased pressure from the abscess can cause seizures. Brain abscesses can lead to seizures as a complication. The nurse should explain this to the spouse. Phenytoin is not used to prevent febrile seizures. Seizures are possible but do not always occur in clients with brain abscesses. This drug is not used for sedation.

A client, being tested for a stroke, is not a candidate for tPA. Which of the following would be contraindicated for the use of tPA? (Select all that apply.) a. Minor ischemic stroke within 30 days b. History of peptic ulcer disease c. Blood pressure 190/120 mmHg d. Platelet count 70,000/ml e. Stroke onset 5 hours ago f. INR 1.0

a. Minor ischemic stroke within 30 days c. Blood pressure 190/120 mmHg d. Platelet count 70,000/ml e. Stroke onset 5 hours ago only active peptic disease is a contraindication. contraindications of tPA to treat an embolic stroke include minor ischemic stroke within the last 30 days, blood pressure greater an 185 mmHg systolic or greater than 110 mmHg diastolic, lumbar puncture within the last 3 days, and onset of stroke greater than 3 hours. Glucose level of 120 mg/dL and INR of 1.0 would not be contraindications for tPA therapy.

A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the spouse. Which action will the nurse take first? a. Obtain oxygen saturation. b. Check pupil reaction to light. c. Palpate the head for hematoma. d. Assess Glasgow Coma Scale (GCS).

a. Obtain oxygen saturation. Airway patency and breathing are the most vital functions and should be assessed first. The neurologic assessments should be accomplished next and the health and medication history last.

When a patients intracranial pressure (ICP) is being monitored with an intraventricular catheter, which information obtained by the nurse is most important to communicate to the health care provider? a. Oral temperature 101.6 F b. Apical pulse 102 beats/min c. Intracranial pressure 15 mm Hg d. Mean arterial pressure 90 mm Hg

a. Oral temperature 101.6 F Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters. The temperature indicates the need for antibiotics or removal of the monitor. The ICP, arterial pressure, and apical pulse are all borderline high but require only ongoing monitoring at this time.

A nurse prepares a client for lumbar puncture (LP). Which assessment finding should alert the nurse to contact the health care provider? a. Shingles on the clients back b. Client is claustrophobic c. Absence of intravenous access d. Paroxysmal nocturnal dyspnea

a. Shingles on the clients back An LP should not be performed if the client has a skin infection at or near the puncture site because of the risk of infection. A nurse would want to notify the health care provider if shingles were identified on the clients back. If a client has shortness of breath when lying flat, the LP can be adapted to meet the clients needs. Claustrophobia, absence of IV access, and paroxysmal nocturnal dyspnea have no impact on whether an LP can be performed.

A nurse delegates care to the unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating care for a client with cranial nerve II impairment? a. Tell the client where food items are on the breakfast tray. b. Place the client in a high-Fowlers position for all meals. c. Make sure the clients food is visually appetizing. d. Assist the client by placing the fork in the left hand.

a. Tell the client where food items are on the breakfast tray. Cranial nerve II, the optic nerve, provides central and peripheral vision. A client who has cranial nerve II impairment will not be able to see, so the UAP should tell the client where different food items are on the meal tray. The other options are not appropriate for a client with cranial nerve II impairment.

When caring for a patient who has had a head injury, which assessment information requires the most rapid action by the nurse? a. The patient is more difficult to arouse. b. The patients pulse is slightly irregular. c. The patients blood pressure increases from 120/54 to 136/62 mm Hg. d. The patient complains of a headache at pain level 5 of a 10-point scale.

a. The patient is more difficult to arouse. The change in level of consciousness (LOC) is an indicator of increased intracranial pressure (ICP) and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache is not unusual in a patient after a head injury. A slightly irregular apical pulse is not unusual.

When admitting a patient with a possible coup-contracoup injury after a car accident to the emergency department, the nurse obtains the following information. Which finding is most important to report to the health care provider? a. The patient takes warfarin (Coumadin) daily. b. The patients blood pressure is 162/94 mm Hg. c. The patient is unable to remember the accident. d. The patient complains of a severe dull headache.

a. The patient takes warfarin (Coumadin) daily. The use of anticoagulants increases the risk for intracranial hemorrhage and should be immediately reported. The other information would not be unusual in a patient with a head injury who had just arrived to the ED.

The charge nurse observes an inexperienced staff nurse who is caring for a patient who has had a craniotomy for a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene? a. The staff nurse suctions the patient every 2 hours. b. The staff nurse assesses neurologic status every hour. c. The staff nurse elevates the head of the bed to 30 degrees. d. The staff nurse administers a mild analgesic before turning the patient.

a. The staff nurse suctions the patient every 2 hours. Suctioning increases intracranial pressure and is done only when the patients respiratory condition indicates it is needed. The other actions by the staff nurse are appropriate.

The crossed arms of the examiner when assessing muscle strength in a neurologic assessment is done in order to: a. align the examiners hands with the patients hands. b. create greater distance between the examiner and the patient. c. allow a comfortable stance for the examiner. d. equalize sensitivity of the examiners hands

a. align the examiners hands with the patients hands. By crossing the arms, the examiners hands and the patients hands are aligned. Whatever the examiner feels in her right hand would be happening in the patients right hand as well.

A patient with a neck fracture at the C5 level is admitted to the intensive care unit. During initial assessment of the patient, the nurse recognizes the presence of neurogenic shock on finding a. hypotension, bradycardia, and warm extremities. b. involuntary, spastic movements of the arms and legs. c. hyperactive reflex activity below the level of the injury. d. lack of movement or sensation below the level of the injury.

a. hypotension, bradycardia, and warm extremities. Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement and sensation indicate spinal cord injury, but not neurogenic shock.

Doctor's Order: Infuse 50 mg of Amphotericin B in 250 mL NS over 4 hr 15 min; Drop factor: 12 gtt/mL. What flow rate (mL/hr) will you set on the IV infusion pump? a. 11.8 b. 58.8 c. 14.1 d. 60.2

b. 58.8

Following a head injury, an unconscious 32-year-old patient is admitted to the emergency department (ED). The patients spouse and children stay at the patients side and constantly ask about the treatment being given. What action is best for the nurse to take? a. Ask the family to stay in the waiting room until the initial assessment is completed. b. Allow the family to stay with the patient and briefly explain all procedures to them. c. Call the family's pastor or spiritual advisor to support them while initial care is given. d. Refer the family members to the hospital counseling service to deal with their anxiety.

b. Allow the family to stay with the patient and briefly explain all procedures to them. The need for information about the diagnosis and care is very high in family members of acutely ill patients, and the nurse should allow the family to observe care and explain the procedures. A pastor or counseling service can offer some support, but research supports information as being more effective. Asking the family to stay in the waiting room will increase their anxiety.

After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse is best? a. Assess the clients magnesium level. b. Assess the clients sodium level. c. Increase the rate of the IV infusion. d. Provide oral care every hour.

b. Assess the clients sodium level. This client has manifestations of hypernatremia, which is a possible complication after craniotomy. The nurse should assess the clients serum sodium level. Magnesium level is not related. The nurse does not independently increase the rate of the IV infusion. Providing oral care is also a good option but does not take priority over assessing laboratory results.

A nurse is teaching a client with multiple sclerosis who is prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which statement should the nurse include in this clients discharge teaching? a. Take warm baths to promote muscle relaxation. b. Avoid crowds and people with colds. c. Relying on a walker will weaken your gait. d. Take prescribed medications when symptoms occur.

b. Avoid crowds and people with colds. The client should be taught to avoid people with any type of upper respiratory illness because these medications are immunosuppressive. Warm baths will exacerbate the clients symptoms. Assistive devices may be required for safe ambulation. Medication should be taken at all times and should not be stopped.

A nurse assesses a client who is recovering from a lumbar puncture (LP). Which complication of this procedure should alert the nurse to urgently contact the health care provider? a. Weak pedal pulses b. Nausea and projectile vomiting c. Increased thirst d. Hives on the chest

b. Nausea and projectile vomiting The nurse should immediately contact the provider if the client experiences a severe headache, nausea, vomiting, photophobia, or a change in level of consciousness after an LP, which are all signs of increased intracranial pressure. Weak pedal pulses, increased thirst, and hives are not complications of an LP.

When the home health RN is planning care for a patient with a seizure disorder, which nursing action can be delegated to an LPN/LVN? a. Make referrals to appropriate community agencies. b. Place medications in the home medication organizer. c. Teach the patient and family how to manage seizures. d. Assess for use of medications that may precipitate seizures.

b. Place medications in the home medication organizer. LPN/LVN education includes administration of medications. The other activities require RN education and scope of practice.

A clients mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm Hg. Based on the clients cerebral perfusion pressure, what should the nurse anticipate for this client? a. Impending brain herniation b. Poor prognosis and cognitive function c. Probable complete recovery d. Unable to tell from this information

b. Poor prognosis and cognitive function The cerebral perfusion pressure (CPP) is the intracranial pressure subtracted from the mean arterial pressure: in this case, 60 20 = 40. For optimal outcomes, CPP should be at least 70 mm Hg. This client has very low CPP, which will probably lead to a poorer prognosis with significant cognitive dysfunction should the client survive. This data does not indicate impending brain herniation or complete recovery.

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

b. The patient has difficulty talking. Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual because of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure; the nurse should have the patient take some deep breaths.

A 25 year-old female patient will begin taking phenytoin for epilepsy. The patient tells the nurse she is taking oral contraceptives (OCPs). Which response will the nurse give? a. Consult with provider to increase the dose of OCPs b. You should use a backup method of contraception along with OCPs. c. You should stop taking OCPs because of drug-drug interactions with phenytoin. d. You should take low-dose aspirin while taking these medications to reduce your risk of stroke.

b. You should use a backup method of contraception along with OCPs. Female patients who take oral contraceptives and anticonvulsants should be advised to use a backup method of contraception because of reduced effectiveness of OCPs. Patients should be cautioned to consult with a provider if considering pregnancy because of the teratogenic effects of anticonvulsants. Patients should not stop taking OCPs and do not need to take precautions against stroke.

A patient with a T1 spinal cord injury is admitted to the intensive care unit. The nurse will teach the patient and family that a. use of the shoulders will be preserved. b. full function of the patients arms will be retained. c. total loss of respiratory function may occur temporarily. d. elevations in heart rate are common with this type of injury.

b. full function of the patients arms will be retained. The patient with a T1 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Loss of respiratory function occurs with cervical spine injuries. Bradycardia is associated with injuries above the T6 level.

A nurse assesses a client with a brain tumor. The client opens his eyes when the nurse calls his name, mumbles in response to questions, and follows simple commands. How should the nurse document this clients assessment using the Glasgow Coma Scale shown below? a. 8 b. 10 c. 12 d. 14

c. 12 The client opens his eyes to speech (Eye opening: To sound = 3), mumbles in response to questions (Verbal response: Inappropriate words = 3) and follows simple commands (Motor response: Obeys commands = 6). Therefore, the clients Glasgow Coma Scale score is: 3 + 3 + 6 = 12.

A nurse is providing community screening for risk factors associated with stroke. Which client would the nurse identify as being at highest risk for a stroke? a. A 30-year-old who drinks 3 beers a day b. A 40-year-old who uses seasonal antihistamines c. A 27-year-old heavy cocaine user d. A 65-year-old who is active and on no medications

c. A 27-year-old heavy cocaine user Heavy drug use, particularly cocaine, is a risk factor for stroke. Heavy alcohol use is also a risk factor, but one beer a day is not considered heavy drinking. Antihistamines may contain phenylpropanolamine, which also increases the risk for stroke, but this client uses them seasonally and there is no information that they are abused or used heavily. The 65-year-old has only age as a risk factor.

Which of these nursing actions included in the care of a patient who has been experiencing stroke symptoms for 60 minutes can the nurse delegate to an LPN/LVN? a. Assess the patients gag and cough reflexes. b. Determine when the stroke symptoms began. c. Administer the prescribed clopidogrel (Plavix). d. Infuse the prescribed IV metoprolol (Lopressor).

c. Administer the prescribed clopidogrel (Plavix). Administration of oral medications is included in LPN education and scope of practice. The other actions require more education and scope of practice and should be done by the RN.

A nurse is teaching a client with cerebellar function impairment. Which statement should the nurse include in this clients discharge teaching? a. Connect a light to flash when your door bell rings. b. Label your faucet knobs with hot and cold signs. c. Ask a friend to drive you to your follow-up appointments. d. Use a natural gas detector with an audible alarm.

c. Ask a friend to drive you to your follow-up appointments. Cerebellar function enables the client to predict distance or gauge the speed with which one is approaching an object, control voluntary movement, maintain equilibrium, and shift from one skilled movement to another in an orderly sequence. A client who has cerebellar function impairment should not be driving. The client would not have difficulty hearing, distinguishing between hot and cold, or smelling.

A patient with a history of a T2 spinal cord injury tells the nurse, I feel awful today. My head is throbbing, and I feel sick to my stomach. Which action should the nurse take first? a. Assess for a fecal impaction. b. Give the prescribed antiemetic. c. Check the blood pressure (BP). d. Notify the health care provider.

c. Check the blood pressure (BP). The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is occurring. Notification of the patients health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. The nurse may assess for a fecal impaction, but this should be done after checking the BP and lidocaine jelly should be used to prevent further increases in the BP.

After noting that a patient with a head injury has clear nasal drainage, which action should the nurse take? a. Have the patient blow the nose. b. Assure the patient that rhinorrhea is normal after a head injury. c. Check the nasal drainage for glucose. d. Obtain a specimen of the fluid to send for culture and sensitivity.

c. Check the nasal drainage for glucose. Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage.

A nurse is caring for four clients in the neurologic/neurosurgical intensive care unit. Which client should the nurse assess first? a. Client who has been diagnosed with meningitis with a fever of 101 F (38.3 C) b. Client who had a transient ischemic attack and is waiting for teaching on clopidogrel (Plavix) c. Client receiving tissue plasminogen activator (t-PA) who has a change in respiratory pattern and rate d. Client who is waiting for subarachnoid bolt insertion with the consent form already signed

c. Client receiving tissue plasminogen activator (t-PA) who has a change in respiratory pattern and rate The client receiving t-PA has a change in neurologic status while receiving this fibrinolytic therapy. The nurse assesses this client first as he or she may have an intracerebral bleed. The client with meningitis has expected manifestations. The client waiting for discharge teaching is a lower priority. The client waiting for surgery can be assessed quickly after the nurse sees the client who is receiving t-PA, or the nurse could delegate checking on this client to another nurse.

A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that a priority goal for this problem has been met? a. Chooses preferred items from the menu b. Eats 75% to 100% of all meals and snacks c. Has clear lung sounds on auscultation d. Gains 2 pounds after 1 week

c. Has clear lung sounds on auscultation Impaired swallowing can lead to aspiration, so the priority goal for this problem is no aspiration. Clear lung sounds is the best indicator that aspiration has not occurred. Choosing menu items is not related to this problem. Eating meals does not indicate the client is not still aspirating. A weight gain indicates improved nutrition but still does not show a lack of aspiration.

The community health nurse is developing a program to decrease the incidence of meningitis in adolescents and young adults. Which nursing action is most important? a. Vaccinate 11- and 12-year-old children against Haemophilus influenzae. b. Emphasize the importance of hand washing to prevent spread of infection. c. Immunize adolescents and college freshman against Neisseria meningitides. d. Encourage adolescents and young adults to avoid crowded areas in the winter.

c. Immunize adolescents and college freshman against Neisseria meningitides. 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.

In assessing the patient with a significant right-sided closed head injury, the nurse would anticipate the patient to demonstrate which sign? a. Right-sided motor deficit with brisk right pupil response b. Bilateral motor deficit with bilaterally sluggish pupil response c. Left-sided motor deficit with sluggish right pupil response d. Left-sided motor deficit and bilateral PERRLA

c. Left-sided motor deficit with sluggish right pupil response A right-sided injury will cause contralateral (opposite side) motor deficit and ipsilateral (same side) pupillary response.

A nurse cares for several clients on a neurologic unit. Which prescription for a client should direct the nurse to ensure that an informed consent has been obtained before the test or procedure? a. Sensation measurement via the pinprick method b. Computed tomography of the cranial vault c. Lumbar puncture for cerebrospinal fluid sampling d. Venipuncture for autoantibody analysis

c. Lumbar puncture for cerebrospinal fluid sampling A lumbar puncture is an invasive procedure with many potentially serious complications. The other assessments or tests are considered noninvasive and do not require an informed consent.

A 26-year-old patient with a T3 spinal cord injury asks the nurse about whether he will be able to be sexually active. Which initial response by the nurse is best? a. Reflex erections frequently occur, but orgasm may not be possible. b. Sildenafil (Viagra) is used by many patients with spinal cord injury. c. Multiple options are available to maintain sexuality after spinal cord injury. d. Penile injection, prostheses, or vacuum suction devices are possible options.

c. Multiple options are available to maintain sexuality after spinal cord injury. Although sexuality will be changed by the patients spinal cord injury, there are options for expression of sexuality and for fertility. The other information also is correct, but the choices will depend on the degrees of injury and the patients individual feelings about sexuality.

A client had an embolectomy for an arteriovenous malformation (AVM). The client is now reporting a severe headache and has vomited. What action by the nurse takes priority? a. Administer pain medication. b. Assess the clients vital signs. c. Notify the Rapid Response Team. d. Raise the head of the bed.

c. Notify the Rapid Response Team. This client may be experiencing a rebleed from the AVM. The most important action is to call the Rapid Response Team as this is an emergency. The nurse can assess vital signs while someone else notifies the Team, but getting immediate medical attention is the priority. Administering pain medication may not be warranted if the client must return to surgery. The optimal position for the client with an AVM has not been determined, but calling the Rapid Response Team takes priority over positioning.

A nurse assesses a client with a spinal cord injury at level T5. The clients blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first? a. Initiate oxygen via a nasal cannula. b. Place the client in a supine position. c. Palpate the bladder for distention. d. Administer a prescribed beta blocker.

c. Palpate the bladder for distention. The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury. Precipitating conditions should be eliminated and the physician notified. The other actions would not be appropriate.

A nurse delegates care for a client with early-stage Alzheimers disease to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this clients care? a. If she is confused, play along and pretend that everything is okay. b. Remove the clock from her room so that she doesnt get confused. c. Reorient the client to the day, time, and environment with each contact. d. Use validation therapy to recognize and acknowledge the clients concerns.

c. Reorient the client to the day, time, and environment with each contact. Clients who have early-stage Alzheimers disease should be reoriented frequently to person, place, and time. The UAP should reorient the client and not encourage the clients delusions. The room should have a clock and white board with the current date written on it. Validation therapy is used with late-stage Alzheimers disease.

A client has a traumatic brain injury and a positive halo sign. The client is in the intensive care unit, sedated and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time? a. Inability to communicate b. Nutritional deficit c. Risk for acquiring an infection d. Risk for skin breakdown

c. Risk for acquiring an infection The positive halo sign indicates a leak of cerebrospinal fluid. This places the client at high risk of acquiring an infection. Communication and nutrition are not priorities compared with preventing a brain infection. The client has a definite risk for a skin breakdown, but it is not the immediate danger a brain infection would be.

The emergency room nurse assessing clear drainage from the nose of a newly admitted patient with a head injury should perform which intervention? a. Document the presence of rhinorrhea. b. Inform the physician of the assessment. c. Test fluid with a glucose Accu-Chek or Dextrostix. d. Tape a drip pad under the nose.

c. Test fluid with a glucose Accu-Chek or Dextrostix. The presence of glucose in the fluid from the nose confirms that the fluid is cerebrospinal fluid. Documentation and informing the physician should occur after confirmation of the character of the fluid.

While caring for a patient who has just been admitted with meningococcal meningitis, the RN observes all of the following. Which one requires action by the RN? 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 nursing assistant goes into the patients room without a mask. d. The lights in the patients room are turned off and the blinds are shut.

c. The nursing assistant goes into the patients room without a mask. 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.

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

c. The patient states, "My symptoms started with a terrible headache." A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer the aspirin.

A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program. The client states, I do not understand the need for rehabilitation; the paralysis will not go away and it will not get better. How should the nurse respond? a. If you dont want to participate in the rehabilitation program, Ill let the provider know. b. Rehabilitation programs have helped many clients with your injury. You should give it a chance. c. The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability. d. When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first.

c. The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability. participation in rehabilitation programs has many purposes, including prevention of disability, maintenance of functional ability, and restoration of function. The other responses do not meet this clients needs.

After a 25-year-old patient has returned home following rehabilitation for a spinal cord injury, the home care nurse notes that the spouse is performing many of the activities that the patient had been managing during rehabilitation. The most appropriate action by the nurse at this time is to a. tell the spouse that the patient can perform activities independently. b. remind the patient about the importance of independence in daily activities. c. develop a plan to increase the patients independence in consultation with the patient and the spouse. d. recognize that it is important for the spouse to be involved in the patients care and support the spouses participation.

c. develop a plan to increase the patients independence in consultation with the patient and the spouse. The best action by the nurse will be to involve all the parties in developing an optimal plan of care. Because family members who will be assisting with the patients ongoing care need to feel that their input is important, telling the spouse that the patient can perform activities independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviors of the spouse. Supporting the activities of the spouse will lead to ongoing dependency by the patient.

The nurse caring for a patient with an epidural hematoma suspects diabetes insipidus when the patient exhibits increased: a. lethargy b. pulse pressure. c. urinary output. d. blood glucose levels.

c. urinary output. A large increase in urinary output of pale urine with a low specific gravity is the clue to the development of diabetes insipidus related to edema of the posterior pituitary. Lethargy and increased pulse pressure are not typical signs of diabetes insipidus. Increased serum glucose levels is a sign of diabetes mellitus.

Doctor's Order: streptomycin 1.75 mg/ lb IM q 12 hr; Available: Streptomycin 0.35 g / 2.3 mL. How many mL will you administer a day to a 59 Kg patient? a. 1.5 b. 2 c. 2.5 d. 3

d. 3

After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? a. A patient whose cranial x-ray shows a linear skull fracture b. A patient who has an initial Glasgow Coma Scale score of 13 c. A patient who lost consciousness for a few seconds after a fall d. A patient whose right pupil is 10 mm and unresponsive to light

d. A patient whose right pupil is 10 mm and unresponsive to light The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage and increased intracranial pressure. The other patients are not at immediate risk for complications such as herniation.

Which of these prescribed interventions will the nurse implement first for a hospitalized patient who is experiencing continuous tonic-clonic seizures? a. Give phenytoin (Dilantin) 100 mg IV. b. Monitor level of consciousness (LOC). c. Obtain computed tomography (CT) scan. d. Administer lorazepam (Ativan) 4 mg IV.

d. Administer lorazepam (Ativan) 4 mg IV. To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary. Phenytoin also will be administered, but it is not rapidly acting. Patients who are experiencing tonic-clonic seizures are nonresponsive, although the nurse should assess LOC after the seizure.

A client is taking long-term corticosteroids for myasthenia gravis. What teaching is most important? a. Wear properly fitting socks and shoes. b. Use two forms of contraception. c. Check blood sugars four times a day. d. Avoid large crowds and people who are ill.

d. Avoid large crowds and people who are ill. Corticosteroids reduce immune function, so clients taking these medications must avoid being exposed to illness. Long-term use can lead to secondary diabetes, but the client would not need to start checking blood glucose unless diabetes had been detected. Corticosteroids do not affect the effectiveness of contraception. Wearing well-fitting shoes would be important to avoid injury, but not just because the client takes corticosteroids.

The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first? a. Client with cerebral perfusion pressure of 72 mm Hg b. Client who has a Glasgow Coma Scale score of 12 c. Client with a PaCO2 of 36 mm Hg who is on a ventilator d. Client who has a temperature of 102 F (38.9 C)

d. Client who has a temperature of 102 F (38.9 C) A fever is a poor prognostic indicator in clients with brain injuries. The nurse should see this client first. A Glasgow Coma Scale score of 12, a PaCO2 of 36, and cerebral perfusion pressure of 72 mm Hg are all desired outcomes.

An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first? a. Assess level of consciousness. b. Obtain vital signs. c. Administer oxygen therapy. d. Evaluate respiratory status.

d. Evaluate respiratory status. The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency. Clients with cervical spine injuries are particularly prone to respiratory compromise and may even require intubation. The other assessments should be performed after airway and breathing are assessed.

A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The clients spouse is very frustrated, stating that the clients personality has changed and the situation is intolerable. What action by the nurse is best? a. Refer the client and spouse to a head injury support group. b. No answer text provided. c. Ask the client why he or she is acting out and behaving differently. d. Explain that personality changes are common following brain injuries.

d. Explain that personality changes are common following brain injuries. Personality and behavior often change permanently after head injury. The nurse should explain this to the spouse. Asking the client about his or her behavior isnt useful because the client probably cannot help it. A referral might be a good idea, but the nurse needs to do something in addition to just referring the couple. Telling the spouse to learn to cope belittles the spouses concerns and feelings.

A nurse cares for a client who is experiencing deteriorating neurologic functions. The client states, I am worried I will not be able to care for my young children. How should the nurse respond? a. Caring for your children is a priority. You may not want to ask for help, but you have to. b. Our community has resources that may help you with some household tasks so you have energy to care for your children. c. You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status? d. Give me more information about what worries you, so we can see if we can do something to make adjustments.

d. Give me more information about what worries you, so we can see if we can do something to make adjustments. Investigate specific concerns about situational or role changes before providing additional information. The nurse should not tell the client what is or is not a priority for him or her. Although community resources may be available, they may not be appropriate for the client. Consulting a psychologist would not be appropriate without obtaining further information from the client related to current concerns.

After teaching the wife of a client who has Parkinson disease, the nurse assesses the wife's understanding. Which statement by the clients wife indicates she correctly understands changes associated with this disease? a. His masklike face makes it difficult to communicate, so I will use a white board. b. He should not socialize outside of the house due to uncontrollable drooling. c. This disease is associated with anxiety causing increased perspiration. d. He may have trouble chewing, so I will offer bite-sized portions.

d. He may have trouble chewing, so I will offer bite-sized portions. Because chewing and swallowing can be problematic, small frequent meals and a supplement are better for meeting the clients nutritional needs. A masklike face and drooling are common in clients with Parkinson disease. The client should be encouraged to continue to socialize and communicate as normally as possible. The wife should understand that the clients masklike face can be misinterpreted and additional time may be needed for the client to communicate with her or others. Excessive perspiration is also common in clients with Parkinson disease and is associated with the autonomic nervous systems response.

Which of these nursing actions for a patient with Guillain-Barr syndrome is most appropriate for the nurse to delegate to an experienced nursing assistant? a. Nasogastric tube feeding q4hr b. Artificial tear administration q2hr c. Assessment for bladder distention q2hr d. Passive range of motion to extremities q8hr

d. Passive range of motion to extremities q8hr Assisting a patient with movement is included in nursing assistant education and scope of practice. Administration of tube feedings, administration of ordered medications, and assessment are skills requiring more education and scope of practice, and the RN should perform these skills.

A nurse receives a report on a client who had a left-sided stroke and has homonymous hemianopsia. What action by the nurse is most appropriate for this client? a. Assess for bladder retention and/or incontinence. b. Listen to the clients lungs after eating or drinking. c. Prop the clients right side up when sitting in a chair. d. Rotate the clients meal tray when the client stops eating.

d. Rotate the clients meal tray when the client stops eating. This condition is blindness on the same side of both eyes. The client must turn his or her head to see the entire visual field. The client may not see all the food on the tray, so the nurse rotates it so uneaten food is now within the visual field. This condition is not related to bladder function, difficulty swallowing, or lack of trunk control.

The nurse obtains all of the following information about a 65-year-old patient in the clinic. When developing a plan to decrease stroke risk, which risk factor is most important for the nurse to address? a. The patient has a daily glass of wine to relax. b. The patient is 25 pounds above the ideal weight. c. The patient works at a desk and relaxes by watching television. d. The patient's blood pressure (BP) is usually about 180/90 mm Hg.

d. The patient's blood pressure (BP) is usually about 180/90 mm Hg. Hypertension is the single most important modifiable risk factor and this patients hypertension is at the stage 2 level. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not so much as hypertension.

When assessing a patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider? a. The patient has a positive Kernigs sign. b. The patient complains of having a stiff neck. c. The patients temperature is 101 F (38.3 C). d. The patients blood pressure is 86/42 mm Hg.

d. The patients blood pressure is 86/42 mm Hg. 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.

A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain? a. Loss of bladder control b. Other medical conditions c. Progression of symptoms d. Time of symptom onset

d. Time of symptom onset The time limit for initiating fibrinolytic therapy for a stroke is 3 to 4.5 hours, so the exact time of symptom onset is the most important information for this client. The other information is not as critical.

When assessing a patient with a possible stroke, the nurse finds that the patients aphasia started 3.5 hours previously and the blood pressure is 170/92 mm Hg. Which of these orders by the health care provider should the nurse question? a. Infuse normal saline at 75 mL/hr. b. Keep head of bed elevated at least 30 degrees. c. Administer tissue plasminogen activator (tPA) per protocol. d. Titrate labetolol (Normodyne) drip to keep BP less than 140/90 mm Hg.

d. Titrate labetolol (Normodyne) drip to keep BP less than 140/90 mm Hg. Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if mean arterial pressure (MAP) is >130 mm Hg or systolic pressure is >220 mm Hg. Fluid intake should be 1500 to 2000 mL daily to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use.

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

d. teach the family that emotional outbursts are common after strokes. Patients who have left-sided brain stroke are prone to emotional outbursts, which are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patients outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patients control and asking the patient to stop will lead to embarrassment.