Honan Ch.43 & 46 - Neurologic Function
A client is diagnosed with meningococcal meningitis. The 22-year-old client shares an apartment with one other person. What would the nurse expect as appropriate care for the client's roommate? A) Treatment with antimicrobial prophylaxis as soon as possible B) Admission to the nearest hospital for observation C) No treatment unless the roommate begins to show symptoms D) Bedrest at home for 72 hours
A) Treatment with antimicrobial prophylaxis as soon as possible People in close contact with clients who have meningococcal meningitis should be treated with antimicrobial chemoprophylaxis, ideally within 24 hours after exposure.
A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient? A) Within 24 hours after exposure B) Within 48 hours after exposure C) Within 72 hours after exposure D) Therapy is not necessary prophylactically and should only be used if the person develops symptoms.
A) Within 24 hours after exposure People in close contact with patients with meningococcal meningitis should be treated with antimicrobial chemoprophylaxis using rifampin (Rifadin), ciprofloxacin hydrochloride (Cipro), or ceftriaxone sodium (Rocephin). Therapy should be started within 24 hours after exposure because a delay in the initiation of therapy limits the effectiveness of the prophylaxis.
A nurse is working on a surgical floor. The nurse must logroll a client following a: A) laminectomy. B) thoracotomy. C) hemorrhoidectomy. D) cystectomy.
A) laminectomy. The client who has had spinal surgery, such as laminectomy, must be logrolled to keep the spinal column straight when turning. The client who has had a thoracotomy or cystectomy may turn himself or may be assisted into a comfortable position. Under normal circumstances, hemorrhoidectomy is an outpatient procedure, and the client may resume normal activities immediately after surgery.
Which positions is used to help reduce intracranial pressure (ICP)? A) Avoiding flexion of the neck with use of a cervical collar B) Keeping the head flat, avoiding the use of a pillow C) Rotating the neck to the far right with neck support D) Extreme hip flexion, with the hip supported by pillows
A) Avoiding flexion of the neck with use of a cervical collar Use of a cervical collar promotes venous drainage and prevents jugular vein distortion, which can increase ICP. Slight elevation of the head is maintained to aid in venous drainage unless otherwise prescribed. Extreme rotation of the neck is avoided because compression or distortion of the jugular veins increases ICP. Extreme hip flexion is avoided because this position causes an increase in intra-abdominal pressure and intrathoracic pressure, which can produce a rise in ICP.
A patient comes to the emergency department with severe pain in the face that was stimulated by brushing the teeth. What cranial nerve does the nurse understand can cause this type of pain? A) III B) IV C) V D) VI
C) V (CN 5) The trigeminal nerve (cranial nerve V) innervates the forehead, cheeks, and jaw, so pain in the face elicited when brushing the teeth would most likely involve this nerve.
A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode? A) The type of anticonvulsant prescribed to manage the epileptic condition B) Recent stress level C) Recent weight gain and loss D) Compliance with the prescribed medication regimen
D) Compliance with the prescribed medication regimen
A nurse is caring for a client with lower back pain who is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should place the client in which position? A) Head of the bed elevated 45 degrees B) Prone C) Supine with feet raised D) Supine with the head lower than the trunk
A) Head of the bed elevated 45 degrees After a myelogram, positioning depends on the dye injected. When a water-soluble dye such as metrizamide is injected, the head of the bed is elevated to a 45-degree angle to slow the upward dispersion of the dye. The prone and supine positions are contraindicated when a water-soluble contrast dye is used. The client should be positioned supine with the head lower than the trunk after an air-contrast study.
Which of the following areas of the brain are responsible for temperature regulation? A) Hypothalamus B) Thalamus C) Pons D) Medulla
A) Hypothalamus The hypothalamus also controls and regulates the autonomic nervous system and maintains temperature by promoting vasoconstriction or vasodilation. The thalamus acts primarily as a relay station for all sensation except smell. The medulla and pons are essential for respiratory function.
A 55-year-old male patient has been admitted to the hospital with a gastrointestinal bleed, and the patient has just experienced a generalized seizure that may be attributable to alcohol withdrawal. When providing immediate care during the patient's seizure, what nursing diagnosis should be prioritized? A) Impaired gas exchange B) Acute pain C) Acute confusion D) Risk for impaired skin integrity
A) Impaired gas exchange Airway and breathing are priorities in any emergency situation, including seizures. These considerations would be prioritized over confusion, pain, and skin integrity.
Which lobe of the brain is responsible for spatial relationships? A) Parietal B) Temporal C) Occipital D) Frontal
A) Parietal The parietal lobe is essential to a person's awareness of body position in space, size and shape discrimination, and right-left orientation.
A patient with a neurological disorder is being assessed by the nurse. The nurse assesses the patient's biceps reflex as diminished. The nurse would be correct in documenting this response as what? A) 0 B) 1+ C) 2+ D) 3+
B) 1+ Deep tendon reflexes are graded on a scale of 0 to 4. A diminished response to a deep tendon reflex would be documented as 1+. A grade of 0 would refer to no response. A grade of 2+ would be assessed as normal. 3+ is an increased response, but may be interpreted as normal.
Which occurs when reflexes are hyperactive when the foot is abruptly dorsiflexed? A) Ataxia B) Clonus C) Rigidity D) Flaccidity
B) Clonus Clonus occurs when the foot is abruptly dorsiflexed. It continues to "beat" two or three times before it settles into a position of rest.
A client is waiting in a triage area to learn the medical status of family members following a motor vehicle accident. The client is pacing, taking deep breaths, and handwringing. Considering the effects in the body systems, what does the nurse anticipate the liver will do? A) Cease function and shunt blood to the heart and lungs. B) Convert glycogen to glucose for immediate use. C) Produce a toxic byproduct in relation to stress. D) Maintain a basal rate of functioning.
B) Convert glycogen to glucose for immediate use. When the body is under stress, the sympathetic nervous system is activated readying the body for action. The effect of the body is to mobilize stored glycogen to glucose to provide additional energy for body action.
The clinic nurse caring for a patient with Parkinson's disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. What common side effects of Sinemet would the nurse assess this patient for? A) Pruritus B) Dyskinesia C) Lactose intolerance D) Diarrhea
B) Dyskinesia Within 5 to 10 years of taking levodopa, most patients develop a response to the medication characterized by dyskinesia (abnormal involuntary movements).
A patient has difficulty interpreting his awareness of body position in space. Which lobe is most likely to be damaged? A) Frontal B) Parietal C) Temporal D) Occipital
B) Parietal The parietal lobe is the primary sensory cortex. It is essential to a person's awareness of his body in space, as well as orientation in space and spatial relations.
Lower motor neuron lesions cause A) increased muscle tone. B) flaccid muscles. C) no muscle atrophy. D) hyperactive and abnormal reflexes.
B) flaccid muscles Lower motor neuron lesions cause flaccidity, muscle atrophy, decreased muscle tone, and loss of voluntary control. Upper motor neuron lesions cause increased muscle tone. Upper motor neuron lesions cause no muscle atrophy. Upper motor neuron lesions cause hyperactive and abnormal reflexes.
A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure? A) Prone, with the head turned to the right B) Supine, with the knees raised toward the chest C) Lateral recumbent, with thighs flexed D) Lateral, with right leg flexed
C) Lateral recumbent, with thighs flexed The positions in the other answer choices would not allow as much space between L4 and L5.
A client has undergone a lumbar puncture as part of a neurological assessment. The client is put under the care of a nurse after the procedure. Which important postprocedure nursing intervention should be performed to ensure the client's maximum comfort? A) Administer antihistamines according to the physician's prescription B) Keep the room brightly lit and play soothing music in the background C) Help the client take a brisk walk around the testing area D) Encourage the client to drink liberal amounts of fluids
D) Encourage the client to drink liberal amounts of fluids The nurse should encourage the client to take liberal fluids and should inspect the injection site for swelling or hematoma. These measures help restore the volume of cerebrospinal fluid extracted. The client is administered antihistamines before a test only if he or she is allergic to contrast dye and contrast dye will be used. The room of the client who has undergone a lumbar puncture should be kept dark and quiet. The client should be encouraged to rest, because sensory stimulation tends to magnify discomfort.
