Chapter 48-Nursing Care of Patients with CNS Disorders
34. A patient with a spinal cord injury is unable to move the extremities. In which area should the nurse suspect that this clients injury occurred? a. L1L4 b. C4C8 c. T8T11 d. Above C4
B. C4C8 Cervical cord injuries can affect all four extremities, causing paralysis and paresthesias, impaired respiration, and loss of bowel and bladder control
48. The nurse is caring for an individual who has a tension headache. Which interventions should be included in the patients plan of care? (Select all that apply.) a. Massage b. Moist heat c. Ergotamine d. Dark glasses e. Aerobic exercise f. Cold compresses
A, B A. Massage B. Moist heat
50. The nurse is caring for a patient with an acute brain injury. Which interventions should the nurse use to prevent increased intracranial pressure in this patient? (Select all that apply.) a. Avoid hip flexion. b. Administer stool softeners. c. Keep head of bed elevated 30 degrees. d. Encourage deep breathing and coughing. e. Administer opioid analgesics for headache.
A, B, C A. Avoid hip flexion B. Administer stool softeners C. Keep HOB elevated 30 degrees Elevation of the head of the bed may help reduce intracranial pressure (ICP). Stool softeners prevent straining, which can increase ICP. Hip flexion may also increase ICP. D. E. Coughing can increase ICP, and opioid analgesics make neurological assessment difficult.
56. The nurse is caring for a patient diagnosed with bacterial meningitis. Which medications should the nurse expect to be prescribed for this patient? (Select all that apply.) a. Analgesics b. Antibiotics c. Antipyretics d. Anticoagulants e. Anti-inflammatory agents
A, B, C, E A. Analgesics B. Antibiotics C. Antipyretics E. Anti-inflammatory agents Analgesics are given to lessen head and neck pain. Antibiotics are administered for bacterial meningitis. Antipyretics such as acetaminophen are used to control the fever. Anti-inflammatory agents are given to decrease swelling.
58. A patient with a brain injury is not able to respond appropriately to sensory stimulation. What should the nurse do to ensure that this patient does not develop skin breakdown? (Select all that apply.) a. Protect bony prominences b. Assess the skin every 2 hours c. Moisturize the skin as needed d. Apply paper tape over wounds e. Turn and reposition every 2 hours
A, B, C, E A. Protect bony prominences B. Assess the skin every 2 hours C. Moisturize the skin as needed E. Turn and reposition every 2 hours
52. The nurse suspects that a patient is experiencing increasing intracranial pressure. What observations did the nurse make to come to this conclusion? (Select all that apply.) a. Headache b. Rising temperature c. Decreasing systolic pressure d. Dilated pupil on affected side e. Decreasing level of consciousness (LOC)
A, B, D, E A. Headache B. Rising temperature D. Dilated pupil on affected side E. Decreasing LOC
57. A patient with bacterial meningitis has an elevated temperature. Which actions should the nurse take to reduce this patients temperature? (Select all that apply.) a. Use tepid sponge baths as needed b. Monitor temperature every 4 hours c. Apply ice to the groin every 2 hours d. Administer antipyretics as prescribed e. Place on a cooling blanket if available
A, B, D, E A. Use tepid sponge baths as needed B. Monitor temperature every 4 hours D. Administer antipyretics as prescribed E. Place on a cooling blanket if available
51. A patient is experiencing a new onset of a seizure. What should the nurse include in this patients plan of care? (Select all that apply.) a. Suction if necessary. b. Monitor vital signs when possible. c. Place the patient in a supine position. d. Restrain the patient to prevent injury. e. Observe and document progression of symptoms. f. Protect the patient from injury by removing nearby objects.
A, B, E, F A. Suction if necessary B. Monitor vital signs when possible E. Observe and document progression of symptoms F. Protect the patient from injury by removing nearby objects
49. The nurse is planning care for a patient with a migraine headache. Which actions should the nurse include in this plan of care? (Select all that apply.) a. Rest b. White noise c. A dark, quiet room d. Sumatriptan (Imitrex) e. Acetaminophen (Tylenol) f. Pseudoephedrine (Sudafed)
A, C, D A. Rest C. A dark, quiet room D. Sumatriptan (Imitrex)
59. After collecting data the nurse determines that a patient is experiencing cluster headaches. What information did the nurse use to come to this conclusion? (Select all that apply.) a. Throbbing and excruciating pain b. Bright sunlight causes severe eye pain c. Sudden onset at the same time during the night d. Pain that affects one side of the nose, eye and forehead e. The eye on the side of the headache is bloodshot and tearing
A, C, D, E A. Throbbing and excruciating pain C. Sudden onset at the same time during the night D. Pain that affects one side of the nose, eye and forehead E. The eye on the side of the headache is bloodshot and tearing
33. An adolescent sustains an injury while swimming in a river. Friends bring the adolescent to the riverbank and note that the adolescent is conscious and breathing but not moving any extremities. What should the friends do next? a. Immobilize the boy, and call for help. b. Push on his stomach to rid his lungs of water. c. Use a four-man carry to take the boy to safety. d. Turn him onto his stomach to allow water to drain from his lungs.
A. Immobilize the boy, and call for help
55. A patient with a spinal cord injury at T3T4 experiences a sudden increase in blood pressure (BP) and has cool, pale, gooseflesh skin on the lower extremities. What should the nurse do while awaiting physician orders? (Select all that apply.) a. Monitor BP every 5 minutes. b. Place the patient in supine position. c. Place elastic stockings on the patients legs. d. Check to see if the indwelling catheter is patent. e. Perform a rectal examination to determine if impaction is present.
A, D, E A. Monitor BP every 5 minutes D. Check to see if the indwelling catheter is patent E. Perform rectal examination to determine if impaction is present
31. A patient with suspected spinal cord and head injuries has a Glasgow Coma Scale score of 15; blood pressure 130/82 mm Hg, pulse 102 beats/min, respirations 20 breaths/min, and temperature 98F (36.6C). What is the most important nursing intervention during the initial care of the patient? a. Avoid moving the patient. b. Check the extremities for range of motion. c. Turn the patient to the side to avoid aspiration. d. Keep the head of the bed elevated 30 degrees.
A. Avoid moving the patient The first priority is prevention of further spinal cord injury, so the patient must be kept flat without movement of the trunk. B. C. D. Checking range of motion, turning, or elevating the head could cause further injury.
43. A patient is prescribed phenytoin (Dilantin) for seizure activity. What should the nurse include when teaching the patient about this medication? a. Be sure to brush and floss your teeth daily. b. Be sure to arrange for regular checkups for potassium levels. c. You may notice some vision changes while taking this drug. d. You may experience shortness of breath as a side effect of the drug.
A. Be sure to brush and floss your teeth daily Regular dental care is important because of risk for gingival hyperplasia.
2. The vital signs for a client with a possible head injury were on admission: blood pressure 128/72 mm Hg, pulse 90 beats/min, and respirations 66 breaths/min. Which vital sign assessment conducted four hours later most likely indicates the presence of increased intracranial pressure (ICP)? a. Blood pressure 172/68 mm Hg, pulse 42 beats/min, respirations 10 breaths/min b. Blood pressure 160/90 mm Hg, pulse 112 beats/min, respirations 16 breaths/min c. Blood pressure 130/72 mm Hg, pulse 50 beats/min, respirations 24 breaths/min d. Blood pressure 100/70 mm Hg, pulse 120 beats/min, respirations 30 breaths/min
A. Blood pressure 172/68 mm Hg, pulse 42 beats/min, respirations 10 breaths/min Vital sign changes are a late indication of increasing ICP. Cushings response is a classic late sign of increased ICP. Cushings response (or Cushings triad) is characterized by bradycardia, bradypnea, and arterial hypertension (increasing systolic blood pressure while diastolic blood pressure remains the same), resulting in widening pulse pressure.
30. A patient with quadriplegia from a C5 injury is wearing a Halo vest and begins to experience a throbbing headache and nausea. What should the nurse do first? a. Check the patients blood pressure. b. Do a digital rectal examination for the presence of an impaction. c. Notify the charge nurse or physician immediately of the patients headache. d. Advise the patient that sitting in the wheelchair will help relieve the headache.
A. Check the patients blood pressure The patient has symptoms of autonomic dysreflexia, which can occur in patients with injuries above the T6 level. B. Once blood pressure is checked and under control, then further assessment can be done to find the source of the problem. D. Sitting will not fix the problem. C. The physician or charge nurse can be notified as needed once further assessment and intervention are completed.
29. The nurse suspects a patient with a spinal cord injury is experiencing spinal shock. What did the nurse assess to come to this conclusion? a. Flaccid paralysis and lack of sensation below the level of the injury b. Loss of voluntary motor control, but presence of reflex activity below the level of the injury c. Falling blood pressure and rising pulse accompanied by reduced level of consciousness d. Loss of motor control below the level of the injury with sensations of touch and position intact
A. Flaccid paralysis and lack of sensation below the level of the injury Immediately following a spinal cord injury, the cord below the injury stops functioning completely. This leads to a loss of motor and sensory functions as well as reflexes. B. C. D. Falling blood pressure and rising pulse indicate shock from blood loss or cardiovascular cause.
7. The nurse is determining care for a patient with acute migraine headaches. What should the nurse teach the patient to do first in order to determine a plan of care for the headaches? a. Keep a headache diary. b. Avoid sugar and caffeine. c. Avoid bright light and noise. d. Avoid taking analgesics until the cause has been determined.
A. Keep a headache diary The patient can identify aggravating factors by keeping a headache diary for a time, recording the time of day the headache occurs, foods eaten or other aggravating factors, description of the pain, identification of associated symptoms such as nausea or visual disturbances, and other factors related to headache symptoms.
47. A patient recovering from a brain injury is having difficulty completing activities of daily living. What should the nurse suggest to help this patient recover independence with self-care? a. Occupational therapy consultation b. Transfer to a rehabilitation facility c. Hire long-term private care assistance d. Cognitive stimulation to keep on track
A. Occupational therapy consultation
40. The nurse is planning care for a patient with advancing Alzheimers disease. Which nursing diagnosis should be the priority for this patient? a. Risk for Injury b. Noncompliance c. Bathing Self-Care Deficit d. Ineffective Role Performance
A. Risk for injury According to Maslows hierarchy, safety needs come before higher-level needs. In addition, injury is the most life- and health-threatening problem. B. C. D. These nursing diagnoses can be addressed after the Risk for Injury has been addressed.
15. A patient who has had a seizure is crying, saying life is over, and that working and driving will no longer be possible. Which response by the nurse is most appropriate? a. With good seizure control, you should be able to work and drive again. b. Maybe the social worker can help you identify some alternative activities. c. You may be able to work again in time; you can use public transportation. d. You should be able to discontinue your medication within a month and return to work.
A. With good seizure control, you should be able to work and drive again Patients with poorly controlled seizures should not operate motor vehicles. If seizures can be well controlled with medication, then driving is possible.
53. A patient is diagnosed with a benign familial tremor. Which characteristics of this tremor should the nurse expect to observe? (Select all that apply.) a. Resting tremor b. Intention tremor c. Pill-rolling tremor d. Head/voice tremor e. Relieved by beta blocker drugs
B, D, E B. Intention tremor D. Head/voice tremor E. Relieved by beta blocker drugs Patients with familial tremor experience an intention tremor and head and voice tremors; symptoms may be improved with beta blockers. A. C. A resting, pill-rolling tremor is common with Parkinsons disease.
39. The nurse is caring for residents on an Alzheimers unit. Which assessment finding indicates that a patient is in early stages of the disease? a. Agitation b. Forgetfulness c. Combativeness d. Increased intracranial pressure (ICP)
B. Forgetfulness The signs and symptoms of Alzheimers disease are typically broken down into three stages. The early stage, stage one, lasts 2 to 4 years and is characterized by increasing forgetfulness. A. C. D. Behavior changes occur later, and increased ICP is not associated with Alzheimers.
26. The nurse is preparing to assess a patient with a head injury. Which data should the nurse include in this routine neurological nursing assessment? a. Vital signs, lung sounds, and pedal pulses b. Glasgow Coma Scale, pupil response, and vital signs c. Range of motion, deep tendon reflexes, and capillary refill d. Romberg test, Babinski reflex, and cranial nerve assessment
B. Glasgow Coma Scale, pupil response, and vital signs
18. A patient arriving in the emergency department with a bullet wound to the left frontal lobe is comatose. What should the nurse make a priority for this patient? a. Evaluate fluid balance. b. Maintain an open airway. c. Maintain body temperature. d. Evaluate neurological status.
B. Maintain an open airway ABC's. Airway is fist priority
10. While walking to the bathroom a patient begins having a generalized tonic-clonic seizure. What should the nurse do first? a. Reduce external stimuli. b. Maintain the patients airway. c. Maintain the patients privacy. d. Perform a brief neurological assessment.
B. Maintain the patients airway
4. A patient with a severe headache due to viral meningitis requests an opioid analgesic. What explanation about opioids should the nurse provide? a. Opioid analgesics increase intracranial pressure. b. Opioid analgesics are used as a last resort for headaches. c. Opioid analgesics are contraindicated in patients with meningitis. d. Acetaminophen (Tylenol) is more effective in treating meningitis-related headaches.
B. Opioid analgesics are used as a last resort for headaches Opioids are habit forming and are used only as a last resort for headaches.
9. A student under a great deal of stress develops a severe tension headache and goes to the school clinic. What strategy should the nurse teach the student for dealing with the onset of headaches in the future? a. Aerobic exercise b. Relaxation exercises c. Use of vitamin C and zinc d. Use of distraction techniques
B. Relaxation exercises
17. A 17-year-old patient with a new onset of seizures is diagnosed with epilepsy. What should the nurse include in the patient teaching? a. Aspirin can inhibit the action of anticonvulsants. b. Sudden withdrawal of anticonvulsants can lead to status epilepticus. c. Anticonvulsants must be taken frequently during the day to prevent seizures. d. When the seizures have been controlled, the medications can be discontinued.
B. Sudden withdrawal of anticonvulsants can lead to status epilepticus Sudden discontinuance of a medication can result in status epilepticus
41. A nursing home resident with Alzheimers disease appears extremely distressed after breakfast. On which understanding should the nurse base interventions for this patient? a. The patient needs an increase in antipsychotic medications. b. The patient could quickly become more anxious and dysfunctional. c. The patient would benefit from external stimuli and diversionary activities. d. This is part of the sundowning syndrome associated with Alzheimers disease.
B. The patient could quickly become more anxious and dysfunctional Stress may increase dysfunctional behaviors.
12. A patient is incontinent during a seizure and sleeps for several hours afterward. What type of seizure did the patient most likely experience? a. Absence b. Tonic-clonic c. Simple partial d. Status epilepticus
B. Tonic-clonic Generalized tonic-clonic seizures follow a typical progression. Aura and loss of consciousness may or may not occur. The patient is often incontinent. Patients who experience a generalized seizure may sleep deeply for 30 minutes to several hours
54. A patient has been prescribed the dopamine agonist pramipexole (Mirapex) for Parkinsons disease. Which are important for the nurse to include when teaching about this medication? (Select all that apply.) a. Take it at noon each day. b. Increase fluids and fiber in your diet. c. Taking the medication with food may reduce nausea. d. You may experience sudden bouts of excessive sleepiness. e. Do not drive until the effects of this drug on you are fully known. f. Because this drug may interact with some painkillers, be sure to tell health care providers that you are taking Mirapex.
C, D, E C. Taking the medication with food may reduce nausea D. You may experience sudden bouts of excessive sleepiness E. Do not drive until the effects of this drug on you are fully known
19. The nurse is caring for a patient admitted to the emergency department with massive trauma to the right frontal lobe of the brain. Which data should the nurse collect related to the location of the injury? a. Presence of intact smell b. Presence of intact pupillary reflex c. Ability to remember the name of the current president d. Ability to use extraocular muscles (EOMs) of the eyes
C. Ability to remember the name of the current president The cerebral cortex, and therefore the frontal lobe, is involved in thinking, learning, and memory. A. B. D. Olfactory sense, pupils, and EOMs are controlled by cranial nerves.
21. The nurse is caring for a patient with a traumatic brain injury. Which assessment finding alerts the nurse to possible diabetes insipidus? a. Headache b. Confusion c. Frequent urination d. Elevated blood glucose
C. Frequent urination Edema or direct injury affects the posterior portion of the pituitary gland or hypothalamus. Inadequate release of antidiuretic hormone results in polyuria and, if the patient is awake, polydipsia. Fluid replacement and intravenous vasopressin are used to maintain fluid and electrolyte balance.
14. A patient with a newly diagnosed seizure disorder is being prepared for discharge. What medication should the nurse anticipate will be prescribed for the patient to prevent recurrent seizures? a. Selegiline (Eldepryl) b. Haloperidol (Haldol) c. Gabapentin (Neurontin) d. Dexamethasone (Decadron)
C. Gabapentin (Neurontin) Gabapentin is an anticonvulsant agent.
38. A patient with Parkinsons disease has difficulty tying shoes. What nursing intervention would be the most helpful? a. Tie the shoes for the patient. b. Reteach the patient to tie shoes. c. Have a family member purchase shoes with Velcro fasteners. d. Explain to the patient that as the disease progresses, there will be many things that will require assistance.
C. Have a family member purchase shoes with Velcro fasteners Providing Velcro fasteners allows the patient to remain independent as long as possible
3. A patient who was in an industrial accident has had a sudden increase in intracranial pressure and is being prepared for placement of an emergency subarachnoid bolt. Which action should the nurse make a priority at this time? a. Find out how the accident happened. b. Ensure the patient is bathed before surgery. c. Have the patients next of kin sign a consent form. d. Send the patients belongings home with a family member.
C. Have the patients next of kin sign a consent form The patient is unlikely to be able to sign a consent form, and it must be signed for surgery to begin
22. The physician prescribes intravenous mannitol for a patient who has a head injury and increased intracranial pressure (ICP). Which assessment finding indicates to the nurse that the patient is having a therapeutic response to the mannitol? a. Return of the gag reflex b. Increased blood glucose c. Increased urinary output d. Decreased Glasgow Coma Scale (GCS) score
C. Increased urinary output If ICP remains elevated despite drainage of cerebrospinal fluid, the next step is use of an osmotic diuretic. The most commonly used drug is intravenous mannitol (Osmitrol). Mannitol utilizes osmosis to pull fluid into the intravascular space and eliminate it via the renal system.
44. The nurse is notes that a patient recovering from a craniotomy has a pink spot with a yellow ring around it on the pillow. What should the nurse do? a. Change the patients pillowcase. b. Do a basic neurological assessment. c. Notify the charge nurse immediately. d. Change the patients cranial dressing.
C. Notify the charge nurse immediately Drainage that is blood-tinged in the center with a yellowish ring around it may be cerebrospinal fluid (CSF) leakage. A suspected CSF leak should be reported to the charge nurse or physician immediately. A. B. These actions can be completed after the charge nurse has been notified. D. The dressing is changed only with a physicians order.
35. A patient is unable to move the extremities after experiencing a spinal cord injury. What term should the nurse use to document paralysis of all four extremities? a. Paraplegia b. Hemiparesis c. Quadriplegia d. Quadriparesis
C. Quadriplegia Paralysis of all four extremities is called quadriplegia. D. Weakness of all extremities is called quadriparesis. A. Paraplegia is paralysis of the lower extremities. B. Hemiparesis is weakness of one side.
27. The nurse notes that a patient with a head injury has a widening pulse pressure. Which action should the nurse take at this time? a. Give an extra dose of diuretic. b. Lay the bed flat and check pupil response. c. Raise the head of the bed and notify the registered nurse (RN). d. None; this is an expected finding after a head injury.
C. Raise the HOB and notify the RN Widening pulse pressure or falling blood pressure are signs of increased intracranial pressure (ICP) and should be reported promptly. B. Raising the head of the bed 30 degrees may help reduce ICP. D. Increased ICP is not unexpected, but it is not normal and must be reported. A. A diuretic would only be given with a physicians order.
6. The nurse is assisting with teaching a patient about tension headaches. Which explanation of tension headaches should the nurse provide? a. Tension headaches result from release of pain mediators in the periphery. b. Tension headaches are caused by stress, which causes cerebral vessel constriction. c. Tension headaches are a result of stress and sustained muscle contraction of the head and neck. d. Tension headaches are caused by blood sugar fluctuations that result from excessive stress.
C. Tension headaches are a result of stress and sustained muscle contraction of the head and neck Persistent contraction of the scalp, facial, cervical, and upper thoracic muscles can cause tension headaches. A cycle of muscle tension, muscle tenderness, and further muscle tension is established.
28. A patient with a newly diagnosed brain tumor receives dexamethasone (Decadron) IV, which completely relieves the patients symptoms. What should the nurse explain to the family about the patients response to the medication? a. The brain is such a unique organ; we never really know what will happen. b. By dilating the arteries in the brain, blood flow is improved and symptoms improve. c. The Decadron works to reduce swelling in the brain caused by the tumor; we often see remarkable improvement. d. Decadron regenerates neurons in the central nervous system, so the patient should continue to get even better over the next week or so.
C. The Decadron works to reduce swelling in the brain caused by the tumor; we often see remarkable improvement Dexamethasone is a steroid that may reduce brain swelling. A. B. D. Dexamethasone is not a vasodilator, and it does not regenerate nerve tissue.
16. The nurse is assessing a patient recovering from a tonic-clonic seizure. Which finding indicates a need for immediate nursing intervention? a. The patient is difficult to arouse. b. The patient has been incontinent of urine. c. The patient has frothy sputum in the pharynx and gurgling respirations. d. The patient becomes belligerent when the nurse does neurological assessments.
C. The patient has frothy sputum in the pharynx and gurgling respirations Gurgling respirations and frothy sputum indicate aspiration, and a clear airway is a priority.
23. A teen is experiencing a headache and dizziness after falling of a bicycle and hitting the head. The physician diagnoses a concussion. What explanation should the nurse provide to the patients mother? a. The patient may lose consciousness before beginning to recover. b. The patient has had some intracranial bleeding but should recover in time. c. The patient has had a minor head trauma and should recover spontaneously. d. The patient may need to have surgery to relieve increased intracranial pressure.
C. The patient has had a minor head trauma and should recover spontaneously Cerebral concussion is considered a mild brain injury. If there is a loss of consciousness, it is for 5 minutes or less. Concussion is characterized by headache, dizziness, or nausea and vomiting. The patient may complain of amnesia of events before or after the trauma. On clinical examination, there is no skull or dura injury and no abnormality detected by computed tomography (CT) or magnetic resonance imaging (MRI). A. B. D. These statements explain more serious head injuries.
13. A patient in the post-ictal period after a seizure remembers smelling something like dead fish prior to the seizure. Which response by the nurse is best? a. Today is Friday; the hospital always cooks fish on Fridays. b. You were probably hallucinating; I will ask for an order for an anti-hallucinatory agent. c. The smell of dead fish might be your aura; you should call for help immediately if you smell it again. d. Most people see a flash of light before a seizure; if this occurs, you should get to safety immediately.
C. The smell of dead fish might be your aura; you should call for help immediately if you smell it again. Some patients experience an aura or sensation that warns the patient that a seizure is about to occur. An aura may be a visual distortion, a noxious odor, or an unusual sound. Patients who experience an aura may have enough time to sit or lie down before the seizure starts, thereby minimizing the chance of injury.
5. The nurse concludes that a patients meningitis is improving. What activity did the patient perform for the nurse to come to this conclusion? a. Dorsiflex both feet. b. Sit up and drink water. c. Touch the chin to the chest. d. Maintain a side-lying position in bed.
C. Touch the chin to the chest Ability to touch the chin to the chest indicates improvement in nuchal rigidity
42. The nurse caring for patients with dementia. Which intervention would be least helpful when coordinating care for patients who are experiencing confusion? a. Providing finger foods b. Monitoring cognitive functioning c. Using soft restraints when the patient is left alone d. Providing structured rest periods to prevent fatigue
C. Using soft restraints when the patient is left alone
45. A patient is diagnosed with increased intracranial pressure. What pressure measurement should the nurse expect to be associated with this diagnosis? a. 3 b. 5 c. 8 d. 17
D. 17 Normal ICP is 0 to 15 mm Hg. This pressure fluctuates with normal physiological changes, such as arterial pulsations, changes in position, and increases in intrathoracic pressure. A. B. C. These are considered normal intracranial pressure measurements.
46. The nurse is observing a patient to determine if seizure activity is status epilepticus. For what length of time should seizure activity occur for this diagnosis to be appropriate for the patient? a. 1 minute b. 5 minutes c. 20 minutes d. 30 minutes
D. 30 minutes Status epilepticus is characterized by at least 30 minutes of repetitive seizure activity without a return to consciousness. This is a medical emergency and requires prompt intervention to prevent irreversible neurological damage. A. B. C. Seizure activity must occur for longer than 1, 5 or 20 minutes before being identified as status epilepticus.
32. The spouse of a patient with a C7 spinal cord injury provides all care for the patient in addition to caring for three children. Which outcome criteria should the nurse identify as relevant for a nursing diagnosis of Caregiver Role Strain for this patients plan of care? a. Caregiver maintains patients health. b. Caregiver accepts constructive criticism. c. Caregiver accepts responsibility for own actions. d. Caregiver identifies resources available to assist with care.
D. Caregiver identifies resources available to assist with care The spouse needs help, and the nurse can help identify resources to assist her.
1. The nurse is caring for a patient brought to the emergency department after an automobile accident. The patient is fully conscious. For what early signs of increased intracranial pressure (ICP) should the nurse be alert? a. Bradycardia b. Hypothermia c. Pinpoint pupils d. Decreased level of consciousness
D. Decreased level of consciousness Initial symptoms of increased ICP include restlessness, irritability, and decreased level of consciousness, because cerebral cortex function is impaired. If not intubated, the patient may hyperventilate, causing vasoconstriction as the body attempts to compensate. As the pressure increases, the oculomotor nerve may be compressed on the side of the impairment.
8. The nurse administers an analgesic to a patient with a headache. How should the nurse assess the patients response to the medication? a. Observe the patients behavior. b. Ask the patient to describe the pain. c. Monitor the patients blood pressure and pulse. d. Have the patient rate the pain on a scale of 0 to 10.
D. Have the patient rate the pain on a scale of 0 to 10
25. The nurse is assisting with teaching family members about a patients epidural bleed. Which information about an epidural bleed should guide the nurses teaching? a. It is usually venous and absorbs in time. b. It is within the brain tissue, so residual effects are likely. c. It usually causes quadriplegia, and rehabilitation will be necessary. d. It is usually arterial and may lead to death without rapid intervention.
D. It is usually arterial and may lead to death without rapid intervention An epidural bleed is usually arterial in nature. Arterial bleeding can cause the hematoma to become large very quickly. The patient will die without rapid intervention. A. Subdural bleeds are more likely venous. B. A contusion is bruising of brain tissue. C. Paralysis depends on the area of central nervous system (CNS) injured.
11. A patient recovering from surgery to remove a brain tumor is found jerking rhythmically in the bed and unresponsive to verbal stimuli. What should the nurse do first? a. Call the physician. b. Find another nurse to assist. c. Hold the patient firmly to keep the patient from injuring someone. d. Protect the patient from injury and observe the sequence of events.
D. Protect the patient from injury and observe the sequence of events The prime objective in caring for a patient experiencing a seizure is to prevent injury to the patient
36. The nurse is caring for a patient who has had Parkinsons disease for 15 years. What symptoms should the nurse anticipate when assisting with a routine assessment? a. Cough, fever, and impaired airway clearance b. Intention tremor, flaccid muscles, and tachykinesia c. Hemiparesis, tremor of the head, and blurred vision d. Slow shuffling gait, difficulty swallowing, and pill-rolling tremor
D. Slow shuffling gait, difficulty swallowing, and pill-rolling tremor Slow shuffling gait, difficulty swallowing, and pill-rolling tremor are typical of Parkinsons disease. B. Intention tremor is more common with a familial tremor. C. Hemiparesis is most common with stroke or brain injury. A. Cough and fever are signs of respiratory illness.
24. A patient is recovering from an epidural bleed. In which part of the brain should the nurse explain to the family that this bleed occurred? a. Circle of Willis b. Spinal meninges c. Space below the dura d. Space between the dura and the skull
D. Space between the dura and the skull An epidural hematoma is a collection of blood between the dura mater and skull, is usually arterial in nature, and is often associated with skull fracture. A subdural hematoma is typically venous in nature and accumulates between the dura and arachnoid membranes. A. B. C. An epidural bleed does not occur within the Circle of Willis, spinal meninges or the space below the dura.
20. A patient with a cerebral injury is experiencing increased intracranial pressure (ICP). Which intervention should the nurse use to help prevent further increasing intracranial pressure? a. Avoid touching the patient as much as possible. b. Provide stimulation such as radio and television for 12 hours each day. c. Provide as much nursing care at one time as possible to allow the patient to rest. d. Space nursing care at intervals so that necessary care is distributed evenly throughout a shift.
D. Space nursing care at intervals so that necessary care is distributed evenly throughout a shift The nurse should space care activities to provide rest between each disturbance
37. A patient newly diagnosed with Parkinsons disease is prescribed carbidopa/levodopa (Sinemet). Which patient statement indicates teaching about the medication has been effective? a. The medication causes urinary retention and a dry mouth. b. Sinemet reduces inflammation in the central nervous system. c. I should take this medication when my hand tremors bother me. d. This medication converts to dopamine in the brain so my symptoms should improve.
D. This medication converts to dopamine in the brain so my symptoms should improve Levodopa/carbidopa (Sinemet) converts to dopamine in the brain. Carbidopa prevents peripheral breakdown of levodopa, so more is available in the central nervous system (CNS).
