ICP/Spinal Cord Injury/Seizures

A client is experiencing mood swings after a stroke and often has episodes of tearfulness that are distressing to the family. Which is the best technique for the nurse to instruct family members to try when the client experiences a crying episode? A. Sit quietly with the client until the episode is over B. Ignore the behavior C. Attempt to divert the client's attention D. Tell the client that this behavior is unacceptable

RATIONALE: A client who has brain damage may be emotionally labile and may cry or laugh for no explainable reason. Crying is best dealt with by attempting to divert the client's attention. Ignoring the behavior will not affect the mood swing or the crying and may increase the client's sense of isolation. Telling the client to stop is inappropriate. CLIENT NEED: Psychosocial adaptation; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: C

The client's physician decides to change the analgesia medication from meperidine hydrochloride (Demerol) 75 mg I.M. every 4 hours as needed to meperidine hydrochloride by the oral route. What dosage of oral meperidine is required to provide an equivalent analgesic dose? A. 25 to 50 mg B. 75 to 100 mg C. 125 to 150 mg D. 250 to 300 mg

RATIONALE: Although meperidine hydrochloride can be given orally, it is more effective when given intramuscularly. The equianalgesic dose of oral meperidine is up to four times the I.M. dose (75 × 4 = 300). CLIENT NEED: Pharmacological and parenteral therapies; COGNITIVE LEVEL: Apply CORRECT ANSWER: D

The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which of the following strategies is not appropriate? A. Maintaining an upright position B. Restricting the diet to liquids until swallowing improves C. Introducing foods on the unaffected side of the mouth D. Keeping distractions to a minimum

RATIONALE: A client with dysphagia (difficulty swallowing) commonly has the most difficulty ingesting thin liquids, which are easily aspirated. Liquids should be thickened to avoid aspiration. Maintaining an upright position while eating is appropriate because it minimizes the risk of aspiration. Introducing foods on the unaffected side allows the client to have better control over the food bolus. The client should concentrate on chewing and swallowing; therefore, distractions should be avoided. CLIENT NEED: Safety and infection control; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: B

Which clinical manifestation is a typical reaction to long-term phenytoin sodium (Dilantin) therapy? A. Weight gain B. Insomnia C. Excessive growth of gum tissue D. Deteriorating eyesight

RATIONALE: A common adverse effect of long-term phenytoin therapy is an overgrowth of gingival tissues. Problems may be minimized with good oral hygiene, but in some cases, overgrown tissues must be removed surgically. Phenytoin does not cause weight gain, insomnia, or deteriorating eyesight. CLIENT NEED: Pharmacological and parenteral therapies; COGNITIVE LEVEL: Evaluate CORRECT ANSWER: C

The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider about which of the following changes in the client's condition? A. Widening pulse pressure B. Decrease in the pulse rate C. Dilated, fixed pupils D. Decrease in level of consciousness (LOC)

RATIONALE: A decrease in the client's LOC is an early indicator of deterioration of the client's neurologic status. Changes in level of consciousness, such as restlessness and irritability, may be subtle. Widening of the pulse pressure, decrease in the pulse rate, and dilated, fixed pupils occur later if the increased ICP is not treated. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Analyze CORRECT ANSWER: D Continue press ENTER

Which of the following will the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure? A. Jerking in one extremity that spreads gradually to adjacent areas B. Vacant staring and abruptly ceasing all activity C. Facial grimaces, patting motions, and lip smacking D. Loss of consciousness, body stiffening, and violent muscle contractions

RATIONALE: A generalized tonic-clonic seizure involves both a tonic phase and a clonic phase. The tonic phase consists of loss of consciousness, dilated pupils, and muscular stiffening or contraction, which lasts about 20 to 30 seconds. The clonic phase involves repetitive movements. The seizure ends with confusion, drowsiness, and resumption of respiration. A partial seizure starts in one region of the cortex and may stay focused or spread (e.g., jerking in the extremity spreading to other areas of the body). An absence seizure usually occurs in children and involves a vacant stare with a brief loss of consciousness that often goes unnoticed. A complex partial seizure involves facial grimacing with patting and smacking. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Analyze CORRECT ANSWER: D

Regular oral hygiene is essential for the client who has had a stroke. Which of the following nursing measures is not appropriate when providing oral hygiene? A. Placing the client on the back with a small pillow under the head B. Keeping portable suctioning equipment at the bedside C. Opening the client's mouth with a padded tongue blade D. Cleaning the client's mouth and teeth with a toothbrush

RATIONALE: A helpless client should be positioned on the side, not on the back, with the head on a small pillow. A lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration. It may be necessary to suction the client if he aspirates. Suction equipment should be nearby. It is safe to use a padded tongue blade, and the client should receive oral care, including brushing with a toothbrush. CLIENT NEED: Reduction of risk potential; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: A

What is the priority nursing intervention in the postictal phase of a seizure? A. Reorient the client to time, person, and place B. Determine the client's level of sleepiness C. Assess the client's breathing pattern D. Position the client comfortably

RATIONALE: A priority for the client in the postictal phase (after a seizure) is to assess the client's breathing pattern for effective rate, rhythm, and depth. The nurse should apply oxygen and ventilation to the client as appropriate. Other interventions, to be completed after the airway has been established, include reorientation of the client to time, person, and place. Determining the client's level of sleepiness is useful, but it is not a priority. Positioning the client comfortably promotes rest but is of less importance than ascertaining that the airway is patent. CLIENT NEED: Reduction of risk potential; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: C

The nurse administers mannitol (Osmitrol) to the client with increased intracranial pressure. Which parameter requires close monitoring? A. Muscle relaxation B. Intake and output C. Widening of the pulse pressure D. Pupil dilation

RATIONALE: After administering mannitol, the nurse closely monitors intake and output because mannitol promotes diuresis and is given primarily to pull water from the extracellular fluid of the edematous brain. Mannitol can cause hypokalemia and may lead to muscle contractions, not muscle relaxation. Signs and symptoms, such as widening pulse pressure and pupil dilation, should not occur because mannitol serves to decrease ICP. CLIENT NEED: Pharmacological and parenteral therapies; COGNITIVE LEVEL: Analyze CORRECT ANSWER: B

The nurse is teaching a client to recognize an aura. The nurse should instruct the client to note: A. A postictal state of amnesia B. An hallucination that occurs during a seizure C. A symptom that occurs just before a seizure D. A feeling of relaxation as the seizure begins to subside

RATIONALE: An aura is a premonition of an impending seizure. Auras usually are of a sensory nature (e.g., an olfactory, visual, gustatory, or auditory sensation); some may be of a psychic nature. Evaluating an aura may help identify the area of the brain from which the seizure originates. Auras occur before a seizure, not during or after (postictal). They are not similar to hallucinations or amnesia or related to relaxation. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: C

When preparing to teach a client about phenytoin sodium (Dilantin) therapy, the nurse should urge the client not to stop the drug suddenly because: A. Physical dependency on the drug develops over time B. Status epilepticus may develop C. A hypoglycemic reaction develops D. Heart block is likely to develop

RATIONALE: Anti-convulsant drug therapy should never be stopped suddenly; doing so can lead to life-threatening status epilepticus. Phenytoin sodium does not carry a risk of physical dependency or lead to hypoglycemia. Phenytoin has antiarrhythmic properties, and discontinuation does not cause heart block. CLIENT NEED: Pharmacological and parenteral therapies; COGNITIVE LEVEL: Apply CORRECT ANSWER: B

For breakfast on the morning a client is to have an electroencephalogram (EEG), the client is served a soft-boiled egg, toast with butter and marmalade, orange juice, and coffee. Which of the following should the nurse do? A. Remove all the food B. Remove the coffee C. Remove the toast, butter, and marmalade only D. Substitute vegetable juice for the orange juice

RATIONALE: Beverages containing caffeine, such as coffee, tea, and cola drinks, are withheld before an EEG because of the stimulating effects of the caffeine on the brain waves. A meal should not be omitted before an EEG because low blood sugar could alter brain wave patterns; the client can have the entire meal except for the coffee. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: B

Which intervention is most effective in minimizing the risk of seizure activity in a client who is undergoing diagnostic studies after having experienced several episodes of seizures? A. Maintain the client on bed rest B. Administer butabarbital sodium (phenobarbital) 30 mg P.O., three times per day C. Close the door to the room to minimize stimulation D. Administer carbamazepine (Tegretol) 200 mg P.O., twice per day

RATIONALE: Carbamazepine (Tegretol) is an anticonvulsant that helps prevent further seizures. Bed rest, sedation (phenobarbital), and providing privacy do not minimize the risk of seizures. CLIENT NEED: Pharmacological and parenteral therapies; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: D

A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. The nurse should: A. Count the rate to be sure that ventilations are deep enough to be sufficient B. Notify the physician of the client's breathing pattern C. Increase the rate of ventilations D. Increase the tidal volume on the ventilator

RATIONALE: Cluster breathing consists of clusters of irregular breaths followed by periods of apnea on an irregular basis. A lesion in the upper medulla or lower pons is usually the cause of cluster breathing. Because the client had a bleed in the occipital lobe, which is just superior and posterior to the pons and medulla, clinical manifestations that indicate a new lesion are monitored very closely in case another bleed ensues. The nurse should notify the physician immediately so that treatment can begin before respirations cease. The client is not obtaining sufficient oxygen and the depth of breathing is assisted by the ventilator. The health care provider will determine changes in the ventilator settings. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: B

During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's: A. Pulse B. Respirations C. Blood pressure D. Temperature

RATIONALE: Control of blood pressure is critical during the first 24 hours after treatment because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Vital signs are monitored, and blood pressure is maintained as identified by the physician and specific to the client's ischemic tissue needs and risk of bleeding from treatment. The other vital signs are important, but the priority is to monitor blood pressure. CLIENT NEED: Reduction of risk potential; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: C

Which activity should the nurse encourage the client to avoid when there is a risk for increased intracranial pressure (ICP)? A. Deep breathing B. Turning C. Coughing D. Passive range-of-motion (ROM) exercises

RATIONALE: Coughing is contraindicated for a client at risk for increased ICP because coughing increases ICP. Deep breathing can be continued. Turning and passive ROM exercises can be continued with care not to extend or flex the neck. CLIENT NEED: Reduction of risk potential; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: C

Which of the following describes decerebrate posturing? A. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers B. Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of feet C. Supination of arms, dorsiflexion of the feet D. Back arched, rigid extension of all four extremities

RATIONALE: Decerebrate posturing occurs in clients with damage to the upper brain stem, midbrain, or pons and is demonstrated clinically by arching of the back, rigid extension of the extremities, pronation of the arms, and plantar flexion of the feet. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers describes decorticate posturing, which indicates damage to corticospinal tracts and cerebral hemispheres. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Apply CORRECT ANSWER: D

At what time of day should the nurse encourage a client with Parkinson's disease to schedule the most demanding physical activities to minimize the effects of hypokinesia? A. Early in the morning, when the client's energy level is high B. To coincide with the peak action of drug therapy C. Immediately after a rest period D. When family members will be available

RATIONALE: Demanding physical activity should be performed during the peak action of drug therapy. Clients should be encouraged to maintain independence in self-care activities to the greatest extent possible. Although some clients may have more energy in the morning or after rest, tremors are managed with drug therapy. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: B

Which of the following is most effective in assessing the client suspected of developing diabetes insipidus? A. Taking vital signs every 2 hours B. Measuring urine output hourly C. Assessing arterial blood gas values every other day D. Checking blood glucose levels

RATIONALE: Diabetes insipidus results from deficiency of antidiuretic hormone (ADH). The condition may occur in conjunction with head injuries as well as with other disorders. In ADH deficiency, the client is extremely thirsty and excretes large amounts of highly diluted urine. Measuring the urine output to detect excess amount and checking the specific gravity of urine samples to determine urine concentration are appropriate measures to determine the onset of diabetes insipidus. The client may be tachycardic and hypotensive from fluid deficit; however, altered vital signs in a client with a head injury may occur for other reasons as well. Blood gas analysis and blood glucose levels will not reveal diabetes insipidus. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Analyze CORRECT ANSWER: B

What nursing assessments should be documented at the beginning of the ictal phase of a seizure? A. Heart rate, respirations, pulse oximeter, and blood pressure B. Last dose of anticonvulsant and circumstances at the time C. Type of visual, auditory, and olfactory aura the client experienced D. Movement of the head and eyes and muscle rigidity

RATIONALE: During a seizure, the nurse should note movement of the client's head and eyes and muscle rigidity, especially when the seizure first begins, to obtain clues about the location of the trigger focus in the brain. Other important assessments would include noting the progression and duration of the seizure, respiratory status, loss of consciousness, pupil size, and incontinence of urine and stool. It is typically not possible to assess the client's pulse and blood pressure during a tonic-clonic seizure because the muscle contractions make assessment difficult to impossible. The last dose of anticonvulsant medication can be evaluated later. The nurse should focus on maintaining an open airway, preventing injury to the client, and assessing the onset and progression of the seizure to determine the type of brain activity involved. The type of aura should be assessed in the preictal phase of the seizure. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Analyze CORRECT ANSWER: D

In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when positioning the client? A. Keeping the client flat on one side or the other B. Elevating the head of the bed to 30 degrees C. Logrolling or turning as a unit when turning D. Keeping the neck in a neutral position

RATIONALE: Elevating the head of the bed to 30 degrees is contraindicated for infratentorial craniotomies because it could cause herniation of the brain down onto the brain stem and spinal cord, resulting in sudden death. Elevation of the head of the bed to 30 degrees with the head turned to the side opposite the incision, if not contraindicated by the increased intracranial pressure, is used for supratentorial craniotomies. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: B

The nurse finds it difficult to relieve a client's pain satisfactorily. Which of the following measures should the nurse take next when continuing efforts to promote comfort? A. Improve the nurse-client relationship B. Enlist the help of the client's family C. Allow the client additional time to work through his or her own responses to pain D. Arrange to have the client share a room with a client who has little pain

RATIONALE: Experience has demonstrated that clients who feel confidence in the persons who are caring for them do not require as much therapy for pain relief as those who have less confidence. Without the client's confidence, developed in an effective nurse-client relationship, other interventions may be less effective. The client's family can be an important source of support, but it is the nurse who plans strategies for pain relief. The client may require time to adjust to the pain, but the nurse and client can collaborate to try to evaluate a variety of pain relief strategies. Arranging for the client to share a room with another client who has little pain may have negative effects on the client who has pain that is difficult to relieve. CLIENT NEED: Basic care and comfort; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: A

For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication? A. Speaking loudly B. Using a picture board C. Writing directions so client can read them D. Speaking in short sentences

RATIONALE: Expressive aphasia is a condition in which the client understands what is heard or written but cannot say what he or she wants to say. A communication or picture board helps the client communicate with others in that the client can point to objects or activities that he or she desires. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: B

Which of the following should the nurse include in the teaching plan for a client with seizures who is going home with a prescription for gabapentin (Neurontin)? A. Take all the medication until it is gone B. Notify the physician if vision changes occur C. Store gabapentin in the refrigerator D. Take gabapentin with an antacid to protect against ulcers

RATIONALE: Gabapentin (Neurontin) may impair vision. Changes in vision, concentration, or coordination should be reported to the physician. Gabapentin should not be stopped abruptly because of the potential for status epilepticus; this is a medication that must be tapered off. Gabapentin is to be stored at room temperature and out of direct light. It should not be taken with antacids. CLIENT NEED: Pharmacological and parenteral therapies; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: B

Which food-related behaviors are expected in a client who has had a stroke that has left him with homonymous hemianopia? A. Increased preference for foods high in salt B. Eating food on only half of the plate C. Forgetting the names of foods D. Inability to swallow liquids

RATIONALE: Homonymous hemianopia is blindness in half of the visual field; therefore, the client would see only half of his plate. Eating only the food on half of the plate results from an inability to coordinate visual images and spatial relationships. There may be an increased preference for foods high in salt after a stroke, but this would not be related to homonymous hemianopia. Forgetting the names of foods would be aphasia, which involves a cerebral cortex lesion. Being unable to swallow liquids is dysphagia, which involves motor pathways of cranial nerves IX and X, including the lower brain stem. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Analyze CORRECT ANSWER: B

A client is at risk for increased intracranial pressure (ICP). Which of the following would be the priority for the nurse to monitor? A. Unequal pupil size B. Decreasing systolic blood pressure C. Tachycardia D. Decreasing body temperature

RATIONALE: Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage. CLIENT NEED: Reduction of risk potential; COGNITIVE LEVEL: Analyze CORRECT ANSWER: A Continue

A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the I.V. line. Which nursing intervention protects the client without increasing her increased intracranial pressure (ICP)? A. Place her in a jacket restraint B. Wrap her hands in soft "mitten" restraints C. Tuck her arms and hands under the drawsheet D. Apply a wrist restraint to each arm

RATIONALE: It is best for the client to wear mitts, which help prevent the client from pulling on the I.V. without causing additional agitation. Using a jacket or wrist restraint or tucking the client's arms and hands under the draw sheet restrict movement and add to feelings of being confined, all of which would increase her agitation and increase ICP. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: B

What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? A. Cholesterol level B. Pupil size and pupillary response C. Bowel sounds D. Echocardiogram

RATIONALE: It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. The cholesterol level is not a priority assessment, although it may be an assessment to be addressed for long-term healthy lifestyle rehabilitation. Bowel sounds need to be assessed because an ileus or constipation can develop, but this is not a priority in the first 24 hours, when the primary concerns are cerebral hemorrhage and increased intracranial pressure. An echocardiogram is not needed for the client with a thrombotic stroke without heart problems. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Analyze CORRECT ANSWER: B

A male client with a head injury regains consciousness after several days. Which of the following nursing statements is most appropriate as the client awakens? A. "I'll get your family." B. "Can you tell me your name and where you live?" C. "I'll bet you're a little confused right now." D. "You are in the hospital. You were in an accident and unconscious."

RATIONALE: It is important to first explain where a client is to orient him to time, person, and place. Offering to get his family and asking him questions to determine whether he is oriented are important, but the first comments should let the client know where he is and what happened to him. It is useful to be empathetic to the client, but making a comment such as "I'll bet you're a little confused" when he first awakens is not helpful and may cause him anxiety. CLIENT NEED: Psychosocial adaptation; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: D

Which of the following respiratory patterns indicates increasing intracranial pressure in the brain stem? A. Slow, irregular respirations B. Rapid, shallow respirations C. Asymmetric chest excursion D. Nasal flaring

RATIONALE: Neural control of respiration takes place in the brain stem. Deterioration and pressure produce irregular respiratory patterns. Rapid, shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic of respiratory distress or hypoxia. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Apply CORRECT ANSWER: A

Which of the following nursing interventions is appropriate for a client with an increased intracranial pressure (ICP) of 20 mm Hg? A. Give the client a warming blanket B. Administer low-dose barbiturates C. Encourage the client to hyperventilate D. Restrict fluids

RATIONALE: Normal ICP is 15 mm Hg or less for 15 to 30 seconds or longer. Hyperventilation causes vasoconstriction, which reduces cerebrospinal fluid and blood volume, two important factors for reducing a sustained ICP of 20 mm Hg. A cooling blanket is used to control the elevation of temperature because a fever increases the metabolic rate, which in turn increases ICP. High doses of barbiturates may be used to reduce the increased cellular metabolic demands. Fluid volume and inotropic drugs are used to maintain cerebral perfusion by supporting the cardiac output and keeping the cerebral perfusion pressure greater than 80 mm Hg. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: C

After administering meperidine hydrochloride (Demerol), the nurse determines its effectiveness as an analgesic was related to its ability to: A. Reduce the perception of pain B. Decrease the sensitivity of pain receptors C. Interfere with pain impulses traveling along sensory nerve fibers D. Block the conduction of pain impulses along the central nervous system

RATIONALE: Opioid analgesics relieve pain by reducing or altering the perception of pain. Meperidine hydrochloride does not decrease the sensitivity of pain receptors, interfere with pain impulses traveling along sensory nerve fibers, or block the conduction of pain impulses in the central nervous system. CLIENT NEED: Pharmacological and parenteral therapies; COGNITIVE LEVEL: Evaluate CORRECT ANSWER: A

The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm and hand. Which of the following positions are appropriate? A. Placing a pillow in the axilla so the arm is away from the body B. Inserting a pillow under the slightly flexed arm so the hand is higher than the elbow C. Immobilizing the extremity in a sling D. Positioning a hand cone in the hand so the fi ngers are barely flexed E. Keeping the arm at the side using a pillow

RATIONALE: Placing a pillow in the axilla so the arm is away from the body keeps the arm abducted and prevents skin from touching skin to avoid skin breakdown. Placing a pillow under the slightly flexed arm so the hand is higher than the elbow prevents dependent edema. Positioning a hand cone (not a rolled washcloth) in the hand prevents hand contractures. Immobilization of the extremity may cause a painful shoulder-hand syndrome. Flexion contractures of the hand, wrist, and elbow can result from immobility of the weak or paralyzed extremity. It is better to extend the arms to prevent contractures. CLIENT NEED: Reduction of risk potential; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: A,B,E

A client who had a serious head injury with increased intracranial pressure is to be discharged to a rehabilitation facility. Which of the following rehabilitation outcomes would be appropriate for the client? The client will: A. Exhibit no further episodes of short-term memory loss B. Be able to return to his construction job in 3 weeks C. Actively participate in the rehabilitation process as appropriate D. Be emotionally stable and display pre-injury personality traits

RATIONALE: Recovery from a serious head injury is a long-term process that may continue for months or years. Depending on the extent of the injury, clients who are transferred to rehabilitation facilities most likely will continue to exhibit cognitive and mobility impairments as well as behavior and personality changes. The client would be expected to participate in the rehabilitation efforts to the extent he is capable. Family members and significant others will need long-term support to help them cope with the changes that have occurred in the client. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Evaluate CORRECT ANSWER: C

Which of the following techniques does the nurse avoid when changing a client's position in bed if the client has hemiparalysis? A. Rolling the client onto the side B. Sliding the client to move up in bed C. Lifting the client when moving the client up in bed D. Having the client help lift off the bed using a trapeze

RATIONALE: Sliding a client on a sheet causes friction and is to be avoided. Friction injures skin and predisposes to pressure ulcer formation. Rolling the client is an acceptable method to use when changing positions as long as the client is maintained in anatomically neutral positions and her limbs are properly supported. The client may be lifted as long as the nurse has assistance and uses proper body mechanics to avoid injury to himself or herself or the client. Having the client help lift herself off the bed with a trapeze is an acceptable means to move a client without causing friction burns or skin breakdown. CLIENT NEED: Reduction of risk potential; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: B

A client states that she is afraid she will not be able to drive again because of her seizures. Which response by the nurse would be best? A. A person with a history of seizures can drive only during daytime hours B. A person with evidence that the seizures are under medical control can drive C. A person with evidence that seizures occur no more often than every 12 months can drive D. A person with a history of seizures can drive if he carries a medical identification card

RATIONALE: Specific motor vehicle regulations and restrictions for people who experience seizures vary locally. Most commonly, evidence that the seizures are under medical control is required before the person is given permission to drive. Time of day is not a consideration when determining driving restrictions related to seizures. The amount of time a person has been seizure-free is a consideration for lifting driving restrictions; however, the time frame is usually 2 years. It is recommended, not required, that a person who is subject to seizures carry a card or wear an identification bracelet describing the illness to facilitate quick identification in the event of an emergency. CLIENT NEED: Reduction of risk potential; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: B

A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. The nurse should first: A. Ask what medications the client is taking B. Complete a history and health assessment C. Identify the time of onset of the stroke D. Determine if the client is scheduled for any surgical procedures

RATIONALE: Studies show that clients who receive recombinant t-PA treatment within 3 hours after the onset of a stroke have better outcomes. The time from the onset of a stroke to t-PA treatment is critical. A complete health assessment and history is not possible when a client is receiving emergency care. Upcoming surgical procedures may need to be delayed because of the administration of t-PA, which is a priority in the immediate treatment of the current stroke. While the nurse should identify which medications the client is taking, it is more important to know the time of the onset of the stroke to determine the course of action for administering t-PA. CLIENT NEED: Pharmacological and parenteral therapies; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: C

Which of the following is contraindicated for a client with seizure precautions? A. Encouraging him to perform his own personal hygiene B. Allowing him to wear his own clothing C. Assessing oral temperature with a glass thermometer D. Encouraging him to be out of bed

RATIONALE: Temperatures are not assessed orally with a glass thermometer because the thermometer could break and cause injury if a seizure occurred. The client can perform personal hygiene. There is no clinical reason to discourage the client from wearing his own clothes. As long as there are no other limitations, the client should be encouraged to be out of bed. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: C

What should the nurse do first when a client with a head injury begins to have clear drainage from his nose? A. Compress the nares B. Tilt the head back C. Give the client tissues to collect the fluid D. Administer an antihistamine for postnasal drip

RATIONALE: The clear drainage must be analyzed to determine whether it is nasal drainage or cerebrospinal fluid (CSF). The nurse should not give the client tissues because it is important to know how much leakage of CSF is occurring. Compressing the nares will obstruct the drainage fl ow. It is inappropriate to tilt the head back, which would allow the fluid to drain down the throat and not be collected for a sample. It is inappropriate to administer an antihistamine because the drainage may not be from postnasal drip. CLIENT NEED: Reduction of risk potential; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: C

It is the night before a client is to have a computed tomography (CT) scan of the head without contrast. The nurse should tell the client? A. "You must shampoo your hair tonight to remove all oil and dirt." B. "You may drink fluids until midnight, but after that drink nothing until the scan is completed." C. "You will have some hair shaved to attach the small electrode to your scalp." D. "You will need to hold your head very still during the examination."

RATIONALE: The client will be asked to hold the head very still during the examination, which lasts about 30 to 60 minutes. In some instances, food and fluids may be withheld for 4 to 6 hours before the procedure if a contrast medium is used because the radio-paque substance sometimes causes nausea. There is no special preparation for a CT scan, so a shampoo the night before is not required. The client may drink fluids until 4 hours before the scan is scheduled. Electrodes are not used for a CT scan, nor is the head shaved. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: D

Four days after surgery for internal fixation of a C3 to C4 fracture, a nurse is moving a client from the bed to the wheelchair. The nurse is checking the wheelchair for correct features for this client. Which of the following features of the wheelchair are appropriate for the needs of this client? Select all that apply. Select All That Apply A. Back at the level of the client's scapula B. Back and head that are high C. Seat that is lower than normal D. Seat with firm cushions E. Chair controlled by the client's breath

RATIONALE: The client with a C3 to C4 fracture has neck control but may tire easily using sore muscles around the incision area to hold up his head. Therefore, the head and neck of his wheelchair should be high. The seat of the wheelchair should be lower than normal to facilitate transfer from the bed to the wheelchair. When a client can use his hands and arms to move the wheelchair, the placement of the back to the client's scapula is necessary. This client cannot use his arms and will need an electric chair with breath, chin, or voice control to manipulate movement of the chair. A firm or hard cushion adds pressure to bony prominences; the cushion should instead be padded to reduce the risk of pressure ulcers. CLIENT NEED: Basic care and comfort; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: B,C,E

The client has a sustained increased intracranial pressure (ICP) of 20 mm Hg. Which client position would be most appropriate? A. The head of the bed elevated 30 to 45 degrees B. Trendelenburg's position C. Left Sims position D. The head elevated on two pillows

RATIONALE: The client's ICP is elevated, and the client should be positioned to avoid extreme neck flexion or extension. The head of the bed is usually elevated 30 to 45 degrees to drain the venous sinuses and thus decrease the ICP. Trendelenburg's position places the client's head lower than the body, which would increase ICP. The Sims position (side lying) and elevating the head on two pillows may extend or flex the neck, which increases ICP. CLIENT NEED: Reduction of risk potential; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: A Continue press ENTER

A client is arousing from a coma and keeps saying, "Just stop the pain." The nurse responds based on the knowledge that the human body typically and automatically responds to pain first with attempts to: A. Tolerate the pain B. Decrease the perception of pain C. Escape the source of pain D. Divert attention from the source of pain

RATIONALE: The client's innate responses to pain are directed initially toward escaping from the source of pain. Variations in tolerance and perception of pain are apparent only in conscious clients, and only conscious clients can employ distraction to help relieve pain. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Apply CORRECT ANSWER: C

The nurse is assessing a client for movement after halo traction placement for a C8 fracture. The nurse should document which of the following? A. The client's shoulders shrug against downward pressure of the examiner's hands B. The client's arm pulls up from a resting position against resistance C. The client's arm straightens out from a flexed position against resistance D. The client's hand-grasp strength is equal

RATIONALE: The correct motor function test for C8 is a hand-grasp check. The motor function check for C4 to C5 is shoulders shrugging against downward pressure of the examiner's hands. The motor function check for C5 to C6 is an arm pulling up from a resting position against resistance. The motor function check for C7 is an arm straightening out from a flexed position against resistance. CLIENT NEED: Management of care; COGNITIVE LEVEL: Analyze CORRECT ANSWER: D

Which of the following is an initial sign of Parkinson's disease? A. Rigidity B. Tremor C. Bradykinesia D. Akinesia

RATIONALE: The first sign of Parkinson's disease is usually tremors. The client commonly is the first to notice this sign because the tremors may be minimal at first. Rigidity is the second sign, and bradykinesia is the third sign. Akinesia is a later stage of bradykinesia. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Analyze CORRECT ANSWER: B

An unconscious client with multiple injuries arrives in the emergency department. Which nursing intervention receives the highest priority? A. Establishing an airway B. Replacing blood loss C. Stopping bleeding from open wounds D. Checking for a neck fracture

RATIONALE: The highest priority for a client with multiple injuries is to establish an open airway for effective ventilation and oxygenation. Unless the client has a patent airway, other care measures will be futile. Replacing blood loss, stopping bleeding from open wounds, and checking for a neck fracture are important nursing interventions to be completed after the airway and ventilation are established. CLIENT NEED: Safety and infection control; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: A

The nurse is teaching a client about taking prophylactic warfarin sodium (Coumadin). Which statement indicates that the client understands how to take the drug? Select all that apply. Select All That Apply A. "The drug's action peaks in 2 hours." B. "Maximum dosage is not achieved until 3 to 4 days after starting the medication." C. "Effects of the drug continue for 4 to 5 days after discontinuing the medication." D. "Protamine sulfate is the antidote for warfarin." E. "I should have my blood levels tested periodically."

RATIONALE: The maximum dosage of warfarin sodium (Coumadin) is not achieved until 3 to 4 days after starting the medication, and the effects of the drug continue for 4 to 5 days after discontinuing the medication. The client should have his blood levels tested periodically to make sure that the desired level is maintained. Warfarin has a peak action of 9 hours. Vitamin K is the antidote for warfarin; protamine sulfate is the antidote for heparin. CLIENT NEED: Pharmacological and parenteral therapies; COGNITIVE LEVEL: Evaluate CORRECT ANSWER: B,C,E

The nurse is monitoring a client with increased intracranial pressure (ICP). What indicators are the most critical for the nurse to monitor? Select all that apply. Select All That Apply A. Systolic blood pressure B. Urine output C. Breath sounds D. Cerebral perfusion pressure E. Level of pain

RATIONALE: The nurse must monitor the systolic and diastolic blood pressure to obtain the mean arterial pressure (MAP), which represents the pressure needed for each cardiac cycle to perfuse the brain. The nurse must also monitor the cerebral perfusion pressure (CPP), which is obtained from the ICP and the MAP. The nurse should also monitor urine output, respirations, and pain; however, crucial measurements needed to maintain CPP are ICP and MAP. When ICP equals MAP, there is no CPP. CLIENT NEED: Management of care; COGNITIVE LEVEL: Analyze CORRECT ANSWER: A,D

A client is being admitted with a spinal cord transection at C7. Which of the following assessments take priority upon the client's arrival? Select all that apply. Select All That Apply A. Reflexes B. Bladder function C. Blood pressure D. Temperature ERespirations

RATIONALE: The nurse should assess the client for spinal shock, which is the immediate response to spinal cord transection. Hypotension occurs and the body loses core temperature to environmental temperature. The nurse must treat the client immediately to manage hypotension and hypothermia. The nurse should also ensure that there is an adequate airway and respirations; there may be respiratory compromise due to intercostal muscle involvement. Once the client is stable, the nurse should conduct a complete neurologic check. The nurse should take all precautions to keep the client's head, neck, and spine position in straight alignment. If the client is conscious, the nurse should briefly assess major reflexes, such as the Achilles, patellar, biceps, and triceps tendons, and sensation of the perineum for bladder function. CLIENT NEED: Management of care; COGNITIVE LEVEL: Analyze CORRECT ANSWER: C,D,E

A 21-year-old female client takes clonazepam (Klonopin). What should the nurse ask this client about? Select all that apply. Select All That Apply A. Seizure activity B. Pregnancy status C. Alcohol use D. Cigarette smoking E. Intake of caffeine and sugary drinks

RATIONALE: The nurse should assess the number and type of seizures the client has experienced since starting clonazepam monotherapy for seizure control. The nurse should also determine if the client might be pregnant because clonazepam crosses the placental barrier. The nurse should also ask about the client's use of alcohol because alcohol potentiates the action of clonazepam. Although the nurse may want to check on the client's diet or use of cigarettes for health maintenance and promotion, such information is not specifically related to clonazepam therapy. CLIENT NEED: Pharmacological and parenteral therapies; COGNITIVE LEVEL: Evaluate CORRECT ANSWER: A,B,C

A health care provider has ordered carbidopa- levodopa (Sinemet) four times per day for a client with Parkinson's disease. The client states that he wants "to end it all now that the Parkinson's disease has progressed." What should the nurse do? Select all that apply. Select All That Apply A. Explain that the new prescription for Sinemet will treat his depression B. Encourage the client to discuss his feelings as the Sinemet is being administered C. Contact the health care provider before administering the Sinemet D. Determine if the client is on antidepressants or monoamine oxidase (MAO) inhibitors E. Determine if the client is at risk for suicide

RATIONALE: The nurse should contact the health care provider before administering Sinemet because this medication can cause further symptoms of depression. Suicide threats in clients with chronic illness should be taken seriously. The nurse should also determine if the client is on an MAO inhibitor because concurrent use with Sinemet can cause a hypertensive crisis. Sinemet is not a treatment for depression. Having the client discuss his feelings is appropriate when the prescription is finalized. CLIENT NEED: Pharmacological and parenteral therapies; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: C,D,E

A client with a contusion has been admitted for observation following a motor vehicle accident when he was driving his wife to the hospital to deliver their child. The next morning, instead of asking about his wife and baby, he asked to see the football game on television that he thinks is starting in 5 minutes. He is agitated that the nurse will not turn on the television. What should the nurse do next? Select all that apply. Select All That Apply A. Find a television so the client can view the football game B. Determine if the client's pupils are equal and react to light C. Ask the client if he has a headache D. Arrange for the client to be with his wife and baby E. Administer a sedative

RATIONALE: The nurse should determine if the client's pupils are equal and react to light, and ask the client if he has a headache. Confusion, agitation, and restlessness are subtle clinical manifestations of increased intracranial pressure (ICP). At this time, it is not appropriate for the nurse to find a television or arrange for the client to see his wife and baby. Administering a sedative at this time will obscure assessment of increased ICP. CLIENT NEED: Management of care; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: B,C

When communicating with a client who has aphasia, which of the following nursing interventions is not appropriate? A. Present one thought at a time B. Encourage the client not to write messages C. Speak with normal volume D. Make use of gestures

RATIONALE: The nurse should encourage the client to write messages or use alternative forms of communication to avoid frustration. Presenting one thought at a time decreases stimuli that may distract the client, as does speaking in a normal volume and tone. The nurse should ask the client to "show me" and should encourage the use of gestures to assist in getting the message across with minimal frustration and exhaustion for the client. CLIENT NEED: Psychosocial adaptation; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: B

The nurse is assessing a client in the postictal phase of generalized tonic-clonic seizure. The nurse should determine if the client has? A. Drowsiness B. Inability to move C. Paresthesia D. Hypotension

RATIONALE: The nurse should expect a client in the postictal phase to experience drowsiness to somnolence because exhaustion results from the abnormal spontaneous neuron firing and tonic-clonic motor response. An inability to move a muscle part is not expected after a tonic-clonic seizure because a lack of motor function would be related to a complication, such as a lesion, tumor, or stroke, in the correlating brain tissue. A change in sensation would not be expected because this would indicate a complication such as an injury to the peripheral nerve pathway to the corresponding part from the central nervous system. Hypotension is not typically a problem after a seizure. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Analyze CORRECT ANSWER: A

Following a craniotomy, a client has been admitted to the neurologic intensive care unit. The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range. What should the nurse do? Select all that apply. Select All That Apply A. Encourage the client to cough and take deep breaths B. Elevate the head of the bed 15 to 30 degrees C. Contact the health care provider if ICP is greater than 20 mm Hg D. Monitor neurologic status using the Glasgow Coma Scale E. Stimulate the client with active range-of-motion exercises

RATIONALE: The nurse should maintain ICP by elevating the head of the bed and monitoring neurologic status. An ICP greater than 20 mm Hg indicates increased ICP, and the nurse should notify the health care provider. Coughing and range-of-motion exercises will increase ICP and should be avoided in the early postoperative stage. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: B,C,D

The nurse develops a teaching plan for a client newly diagnosed with Parkinson's disease. Which of the following topics that the nurse plans to discuss is the most important? A. Maintaining a balanced nutritional diet B. Enhancing the immune system C. Maintaining a safe environment D. Engaging in diversional activity

RATIONALE: The primary focus is on maintaining a safe environment because the client with Parkinson's disease usually has a propulsive gait, characterized by a tendency to take increasingly quicker steps while walking. This type of gait commonly causes the client to fall or to have trouble stopping. The client should maintain a balanced diet, enhance the immune system, and enjoy diversional activities; however, safety is the primary concern. CLIENT NEED: Reduction of risk potential; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: C

In planning care for the client who has had a stroke, the nurse should obtain a history of the client's functional status before the stroke because? A. The rehabilitation plan will be guided by it B. Functional status before the stroke will help predict outcomes C. It will help the client recognize his physical limitations D. The client can be expected to regain much of his functioning

RATIONALE: The primary reason for the nursing assessment of a client's functional status before and after a stroke is to guide the plan. The assessment does not help to predict how far the rehabilitation team can help the client to recover from the residual effects of the stroke, only what plans can help a client who has moved from one functional level to another. The nursing assessment of the client's functional status is not a motivating factor. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Apply CORRECT ANSWER: A

Which nursing intervention has been found to be the most effective means of preventing plantar flexion in a client who has had a stroke with residual paralysis? A. Place the client's feet against a firm footboard B. Reposition the client every 2 hours C. Have the client wear ankle-high tennis shoes at intervals throughout the day D. Massage the client's feet and ankles regularly

RATIONALE: The use of ankle-high tennis shoes has been found to be most effective in preventing plantar flexion (foot drop) because they add support to the foot and keep it in the correct anatomic position. Foot boards stimulate spasms and are not routinely recommended. Regular repositioning and range-of-motion exercises are important interventions, but the client's foot needs to be in the correct anatomic position to prevent over-extension of the muscle and tendon. Massaging does not prevent plantar flexion and, if rigorous, could release emboli. CLIENT NEED: Reduction of risk potential; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: C

What is the expected outcome of thrombolytic drug therapy for stroke? A. Increased vascular permeability B. Vasoconstriction C. Dissolved emboli D. Prevention of hemorrhage

RATIONALE: Thrombolytic enzyme agents are used for clients with a thrombotic stroke to dissolve emboli, thus reestablishing cerebral perfusion. They do not increase vascular permeability, cause vasoconstriction, or prevent further hemorrhage. CLIENT NEED: Pharmacological and parenteral therapies; COGNITIVE LEVEL: Evaluate CORRECT ANSWER: C

A nurse is teaching a client who had a stroke about ways to adapt to a visual disability. Which does the nurse identify as the primary safety precaution to use? A. Wear a patch over one eye B. Place personal items on the sighted side C. Place personal items on the sighted side D. Turn the head from side to side when walking

RATIONALE: To expand the visual field, the partially sighted client should be taught to turn the head from side to side when walking. Neglecting to do so may result in accidents. This technique helps maximize the use of remaining sight. Covering an eye with a patch will limit the field of vision. Personal items can be placed within sight and reach, but most accidents occur from tripping over items that cannot be seen. It may help the client to see the door, but walking presents the primary safety hazard. CLIENT NEED: Reduction of risk potential; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: D

Which statement by a client with a seizure disorder taking topiramate (Topamax) indicates the client has understood the nurse's instruction? A. "I will take the medicine before going to bed." B. "I will drink 6 to 8 glasses of water a day." C. "I will eat plenty of fresh fruits." D. "I will take the medicine with a meal or snack."

RATIONALE: Toxic effects of topiramate (Topamax) include nephrolithiasis, and clients are encouraged to drink 6 to 8 glasses of water a day to dilute the urine and flush the renal tubules to avoid stone formation. Topiramate is taken in divided doses because it produces drowsiness. Although eating fresh fruits is desirable from a nutritional standpoint, this is not related to the topiramate. The drug does not have to be taken with meals. CLIENT NEED: Pharmacological and parenteral therapies; COGNITIVE LEVEL: Evaluate CORRECT ANSWER: B

A 20-year-old who hit his head while playing football has a tonic-clonic seizure. Upon awakening from the seizure, the client asks the nurse, "What caused me to have a seizure? I've never had one before." Which cause should the nurse include in the response as a primary cause of tonic-clonic seizures in adults older than age 20? A. Head trauma B. Electrolyte imbalance C. Congenital defect D. Epilepsy

RATIONALE: Trauma is one of the primary causes of brain damage and seizure activity in adults. Other common causes of seizure activity in adults include neoplasms, withdrawal from drugs and alcohol, and vascular disease. Given the history of head injury, electrolyte imbalance is not the cause of the seizure. There is no information to indicate that the seizure is related to a congenital defect. Epilepsy is usually diagnosed in younger clients. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Apply CORRECT ANSWER: A

The nurse observes that a client's upper arm tremors disappear as he unbuttons his shirt. Which statement best guides the nurse's analysis of this observation about the client's tremors? A. The tremors are probably psychological and can be controlled at will B. The tremors sometimes disappear with purposeful and voluntary movements C. The tremors disappear when the client's attention is diverted by some activity D. There is no explanation for the observation; it is probably a chance occurrence

RATIONALE: Voluntary and purposeful movements often temporarily decrease or stop the tremors associated with Parkinson's disease. In some clients, however, tremors may increase with voluntary effort. Tremors associated with Parkinson's disease are not psychogenic but are related to an imbalance between dopamine and acetylcholine. Tremors cannot be reduced by distracting the client. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Analyze CORRECT ANSWER: B

The client who has had a stroke with residual physical handicaps becomes discouraged by his physical appearance. What approach to the client is best for the nurse to use to help the client overcome his negative self-concept? Select all that apply. Select All That Apply A. Helpfulness B. Charity C. Firmness D. Encouragement E. Patience

RATIONALE: When offering emotional support to a client who is discouraged and has a negative self-concept because of physical handicaps, the nurse should approach the client with encouragement and patience. The client should be praised when he or she shows progress in efforts to overcome handicaps. An attitude of helpfulness and sympathy allows the client to assume a role of someone not ordinary, someone who is not like others. Regardless of the handicap, the client still feels the same on the inside and has the same innate needs for his or her growth and developmental age-group. An attitude of charity tends to make the client feel like a "charity case" or like someone who is given something free because of his "condition." The client feels unequal to his peers or unable to fulfill the role relationships that were obtained before the stroke. An approach using firmness is inappropriate because it implies that the client can do better if he just tries harder and leaves no room for softness in the approach to overcoming a negative self-concept. CLIENT NEED: Psychosocial adaptation; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: D,E