Med Surg III Exam 3

A nurse is planning care for a client who has a closed traumatic brain injury from a fall and is receiving mechanical ventilation. Which of the following interventions is the nurse's priority? a. Maintain a PaCO2 of approximately 35 mmHg b. Provide small doses of fentanyl via IV bolus for pain management c. Measure body temperature every 1 to 2 hr d. Reposition the client every 2 hr

A Rationale: The greatest risk to the client is injury from increased intracranial pressure. Therefore, the nurse's priority intervention is to maintain the PaCO2 at 35 to 38 mmHg to prevent hypercarbia and subsequent vasodilation that can lead to an increase in intracranial pressure.

A client has a small-bore feeding tube (Dobhoff tube) inserted for continuous enteral feedings while recovering from a traumatic brain injury. What actions should the nurse include in the clients care? (Select all that apply.) a. Assess tube placement per agency policy. b. Keep the head of the bed elevated at least 30 degrees. c. Listen to lung sounds at least every 4 hours. d. Run continuous feedings on a feeding pump. e. Use blue dye to determine proper placement.

A, B, C, D Rationale: All of these options are important for client safety when continuous enteral feedings are in use. Blue dye is not used because it can cause lung injury if aspirated.

The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess? (Select all that apply.) a. Alcohol intake b. Diabetes c. High-fat diet d. Obesity e. Smoking

A, C, D, E Rationale: Alcohol intake, a high-fat diet, obesity, and smoking are all modifiable risk factors for stroke. Diabetes is not modifiable but it is a risk factor that can be controlled with medical intervention.

A client has been diagnosed with Bells palsy. About what drugs should the nurse anticipate possibly teaching the client? (Select all that apply.) a. Acyclovir (Zovirax) b. Carbamazepine (Tegretol) c. Famciclovir (Famvir) d. Prednisone (Deltasone) e. Valacyclovir (Valtrex)

A, C, D, E Rationale: Possible pharmacologic treatment for Bells palsy includes acyclovir, famciclovir, prednisone, and valacyclovir. Carbamazepine is an anticonvulsant and mood-stabilizing drug and is not used for Bells palsy.

A nurse assesses a client who has a history of migraines. Which clinical manifestation should the nurse identify as an early sign of a migraine with aura? a. Vertigo b. Lethargy c. Visual disturbances d. Numbness of the tongue

C Rationale: Early warning of impending migraine with aura usually consists of visual changes, flashing lights, or diplopia. The other manifestations are not associated with an impending migraine with aura.

A nurse assesses a client after administering prescribed levetiracetam (Keppra). Which laboratory tests should the nurse monitor for potential adverse effects of this medication? a. Serum electrolyte levels b. Kidney function tests c. Complete blood cell count d. Antinuclear antibodies

B Rationale: Adverse effects of levetiracetam include coordination problems and renal toxicity. The other laboratory tests are not affected by levetiracetam.

A nurse obtains a focused health history for a client who is scheduled for magnetic resonance angiography. Which priority question should the nurse ask before the test? a. Have you had a recent blood transfusion? b. Do you have allergies to iodine or shellfish? c. Are you taking any cardiac medications? d. Do you currently use oral contraceptives?

B Rationale: Allergies to iodine and/or shellfish need to be explored because the client may have a similar reaction to the dye used in the procedure. In some cases, the client may need to be medicated with antihistamines or steroids before the test is given. A recent blood transfusion or current use of cardiac medications or oral contraceptives would not affect the angiography.

A nurse is caring for a client in the ICU who has suffered a head injury and requires a monitor to check intracranial pressure. Which of the following are late signs of increased intracranial pressure? (Select all that apply.) a. Contracted extremities b. Loss of reflexes c. Tachycardia d. Hyper-response to painful stimuli e. Arm drift

B, E Rationale: Intracranial pressure refers to the pressure of CSF within the skull. With certain injuries, intracranial pressure may be increased, which can cause significant harm to the patient due to compression of the brain and spinal cord. The skull does not have the flexibility to shift with an increase in intracranial pressure, so the brain and/or spinal cord are compressed with an increased pressure instead. Late signs of increased intracranial pressure in a patient may include loss of reflexes, arm drift, changes in LOC, paralysis, and seizures.

A client with myasthenia gravis is undergoing assessment. Which of the following symptoms does the nurse expect? (Select all that apply). a. Hyperkalemia b. Double vision c. Moon faces d. Anuria e. Dysphagia

B, E Rationale: MG is an autoimmune neuromuscular disorder. Auto-antibodies destroy and block the neuromuscular junction receptor sites, giving rise to the symptoms associated with this condition, including diplopia or double vision, ptosis, facial weakness, dysphagia, dysarthria, weakness, fatigue, decreased function of the lower extremities, weakened intercostal muscles, grimacing, poor gas exchange, dyspnea, and decrease in diaphragmatic movement.

A client with Guillain-Barr syndrome is admitted to the hospital. The nurse plans caregiving priority to interventions that address which priority client problem? a. Anxiety b. Low fluid volume c. Inadequate airway d. Potential for skin breakdown

C Rationale: Airway takes priority. Anxiety is probably present, but a physical diagnosis takes priority over a psychosocial one. The client has no reason to have low fluid volume unless he or she has been unable to drink for some time. If present, airway problems take priority over a circulation problem. An actual problem takes precedence over a risk for a problem.

The nurse learns that the pathophysiology of Guillain-Barr syndrome includes segmental demyelination. The nurse should understand that this causes what? a. Delayed afferent nerve impulses b. Paralysis of affected muscles c. Paresthesia in upper extremities d. Slowed nerve impulse transmission

D Rationale: Demyelination leads to slow nerve impulse transmission. The other options are not correct.

After teaching a client newly diagnosed with epilepsy, the nurse assesses the clients understanding. Which statement by the client indicates a need for additional teaching? a. I will wear my medical alert bracelet at all times. b. While taking my epilepsy medications, I will not drink any alcoholic beverages. c. I will tell my doctor about my prescription and over-the-counter medications. d. If I am nauseated, I will not take my epilepsy medication.

D Rationale: The nurse must emphasize that antiepileptic drugs must be taken even if the client is nauseous. Discontinuing the medication can predispose the client to seizure activity and status epilepticus. The client should not drink alcohol while taking seizure medications. The client should wear a medical alert bracelet and should make the doctor aware of all medications to prevent complications of polypharmacy.

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

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

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

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

A client had an embolic stroke and is having an echocardiogram. When the client asks why the provider ordered a test on my heart, how should the nurse respond? a. Most of these types of blood clots come from the heart. b. Some of the blood clots may have gone to your heart too. c. We need to see if your heart is strong enough for therapy. d. Your heart may have been damaged in the stroke too.

A Rationale: An embolic stroke is caused when blood clots travel from one area of the body to the brain. The most common source of the clots is the heart. The other statements are inaccurate.

A client with myasthenia gravis is prescribed pyridostigmine (Mestinon). What teaching should the nurse plan regarding this medication? (Select all that apply.) a. Do not eat a full meal for 45 minutes after taking the drug. b. Seek immediate care if you develop trouble swallowing. c. Take this drug on an empty stomach for best absorption. d. The dose may change frequently depending on symptoms. e. Your urine may turn a reddish-orange color while on this drug.

A, B, D Rationale: Pyridostigmine should be given with a small amount of food to prevent GI upset, but the client should wait to eat a full meal due to the potential for aspiration. If difficulty swallowing occurs, the client should seek immediate attention. The dose can change on a day-to-day basis depending on the clients manifestations. Taking the drug on an empty stomach is not related although the client needs to eat within 45 to 60 minutes afterwards. The clients urine will not turn reddish-orange while on this drug.

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. a. Keeping the linens wrinkle-free under the client b. Preventing unnecessary pressure on the lower limbs c. Limiting bladder catheterization to once every 12 hours d. Turning and repositioning the client at least every 2 hours e. Ensuring that the client has a bowel movement at least once a week

A, B, D Rationale: The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too infrequent), and urinary catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Ensuring a bowel movement once a week is too infrequent. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

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

A, B, E Rationale: A special halo wrench should be taped to the clients vest in case of a cardiopulmonary emergency. The nurse should assess the pin sites for signs of infection or loose pins and for complications from the halo. The nurse should also increase fluids and fiber to decrease bowel straining and assess the clients chest and back for skin breakdown from the halo vest.

A nurse assesses a client who is experiencing a cluster headache. Which clinical manifestations should the nurse expect to find? (Select all that apply.) a. Ipsilateral tearing of the eye b. Miosis c. Abrupt loss of consciousness d. Neck and shoulder tenderness e. Nasal congestion f. Exophthalmos

A, B, E Rationale: Cluster headache is usually accompanied by ipsilateral tearing, eye miosis (constricted pupil), rhinorrhea or nasal congestion, ptosis (drooping eye), eyelid edema, and facial sweating. Abrupt loss of consciousness, neck and shoulder tenderness, and exophthalmos are not associated with cluster headaches.

The nurse caring for a client with Guillain-Barr syndrome has identified the priority client problem of decreased mobility for the client. What actions by the nurse are best? (Select all that apply.) a. Ask occupational therapy to help the client with activities of daily living. b. Consult with the provider about a physical therapy consult. c. Provide the client with information on support groups. d. Refer the client to a medical social worker or chaplain. e. Work with speech therapy to design a high-protein diet.

A, B, E Rationale: Improving mobility and strength involves the collaborative assistance of occupational therapy, physical therapy, and speech therapy. While support groups, social work, or chaplain referrals may be needed, they do not help with mobility.

A nursing student studying traumatic brain injuries (TBIs) should recognize which facts about these disorders? (Select all that apply.) a. A client with a moderate trauma may need hospitalization. b. A Glasgow Coma Scale score of 10 indicates a mild brain injury. c. Only open head injuries can cause a severe TBI. d. A client with a Glasgow Coma Scale score of 3 has severe TBI. e. The terms mild TBI and concussion have similar meanings

A, D, E Rationale: Mild TBI is a term used synonymously with the term concussion. A moderate TBI has a Glasgow Coma Scale (GCS) score of 9 to 12, and these clients may need to be hospitalized. Both open and closed head injuries can cause a severe TBI, which is characterized by a GCS score of 3 to 8.

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

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

A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt like his legs were very heavy. Currently the clients neurologic examination is normal. About what drug should the nurse plan to teach the client? a. Alteplase (Activase) b. Clopidogrel (Plavix) c. Heparin sodium d. Mannitol (Osmitrol)

B Rationale: This clients manifestations are consistent with a transient ischemic attack, and the client would be prescribed aspirin or clopidogrel on discharge. Alteplase is used for ischemic stroke. Heparin and mannitol are not used for this condition.

A nurse assesses a client with an injury to the medulla. Which clinical manifestations should the nurse expect to find? (Select all that apply.) a. Loss of smell b. Impaired swallowing c. Visual changes d. Inability to shrug shoulders e. Loss of gag reflex

B, D, E Rationale: Cranial nerves IX (glossopharyngeal), X (vagus), XI (accessory), and XII (hypoglossal) emerge from the medulla, as do portions of cranial nerves VII (facial) and VIII (acoustic). Damage to these nerves causes impaired swallowing, inability to shrug shoulders, and loss of the gag reflex. The other manifestations are not associated with damage to the medulla.

A nurse assesses a client who has encephalitis. Which manifestations should the nurse recognize as signs of increased intracranial pressure (ICP), a complication of encephalitis? (Select all that apply.) a. Photophobia b. Dilated pupils c. Headache d. Widened pulse pressure e. Bradycardia

B, D, E Rationale: Increased ICP is a complication of encephalitis. The nurse should monitor for signs of increased ICP, including dilated pupils, widened pulse pressure, bradycardia, irregular respirations, and less responsive pupils. Photophobia and headache are not related to increased ICP.

A nurse is teaching a client who has chronic headaches. Which statements about headache triggers should the nurse include in this clients plan of care? (Select all that apply.) a. Increase your intake of caffeinated beverages. b. Incorporate physical exercise into your daily routine. c. Avoid all alcoholic beverages. d. Participate in a smoking cessation program. e. Increase your intake of fruits and vegetables.

B, D, E Rationale: Triggers for headaches include caffeine, smoking and ingestion of pickled foods, so these factors should avoided. Clients are taught to eat a balanced diet and get adequate exercise and rest. Alcohol does not trigger chronic headaches but can enhance headaches during the headache period.

A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the clients hips and sacrum. Which actions should the nurse take? (Select all that apply.) a. Apply a barrier cream to protect the skin from excoriation. b. Perform range-of-motion (ROM) exercises for the hip joint. c. Re-position the client off of the reddened areas. d. Get the client out of bed and into a chair once a day. e. Obtain a low-air-loss mattress to minimize pressure.

C, E Rationale: Appropriate interventions to relieve pressure on these areas include frequent re-positioning and low-air-loss mattress. Reddened areas should not be rubbed because this action could cause more extensive damage to the already fragile capillary system. Barrier cream will not protect the skin from pressure wounds. ROM exercises are used to prevent contractures. Sitting in the chair once a day will decrease the clients risk of respiratory complications but will not decrease pressure on the clients hips and sacrum.

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

D Rationale: A fever is a poor prognostic indicator in clients with brain injuries. The nurse should see this client first. A Glascow Coma Scale score of 12, a PaCO2 of 36, and cerebral perfusion pressure of 72mmHg are all desired outcomes.

After a stroke, a client has ataxia. What intervention is most appropriate to include on the clients plan of care? a. Ambulate only with a gait belt. b. Encourage double swallowing. c. Monitor lung sounds after eating. d. Perform post-void residuals

A Rationale: Ataxia is a gait disturbance. For the clients safety, he or she should have assistance and use the gait belt when ambulating. Ataxia is not related to swallowing, aspiration, or voiding.

A nurse is assessing a client who has a head injury following a motor vehicle crash. The nurse should identify that which of the following findings indicates increasing intracranial pressure? a. Restlessness b. Dizziness c. Hypotension d. Fever

A Rationale: Behavioral changes, such as restlessness and irritability, are early manifestations of increased intracranial pressure.

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

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

A nurse teaches a client who is scheduled for a positron emission tomography scan of the brain. Which statement should the nurse include in this clients teaching? a. Avoid caffeine-containing substances for 12 hours before the test. b. Drink at least 3 liters of fluid during the first 24 hours after the test. c. Do not take your cardiac medication the morning of the test. d. Remove your dentures and any metal before the test begins.

A Rationale: Caffeine-containing liquids and foods are central nervous system stimulants ad may alter the test results. No contrast is used; therefore, the client does not need to increase fluid intake. The client should take cardiac medications as prescribed. Metal does not have to be removed; this is done for MRIs.

A nurse assesses a client recovering from a cerebral angiography via the clients right femoral artery. Which assessment should the nurse complete? a. Palpate bilateral lower extremity pulses. b. Obtain orthostatic blood pressure readings. c. Perform a funduscopic examination. d. Assess the gag reflex prior to eating.

A Rationale: Cerebral angiography is performed by threading a catheter through the femoral or brachial artery. The extremity is kept immobilized after the procedure. The nurse checks the extremity for adequate circulation by noting skin color and temperature, presence and quality of pulses distal to the injection site, and capillary refill. Clients usually are on bedrest; therefore, orthostatic blood pressure readings cannot be performed. The funduscopic examination would not be affected by cerebral angiography. The client is given analgesics but not conscious sedation; therefore, the clients gag reflex would not be compromised.

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

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

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

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

A nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective? a. Taking medications as scheduled b. Eating large, well balanced meals c. Doing muscle-strengthening exercises d. Doing all chores early in the day while less fatigued

A Rationale: Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is important. Muscle strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, emotional stress.

A client has trigeminal neuralgia and has begun skipping meals and not brushing his teeth, and his family believes he has become depressed. What action by the nurse is best? a. Ask the client to explain his feelings related to this disorder. b. Explain how dental hygiene is related to overall health. c. Refer the client to a medical social worker for assessment. d. Tell the client that he will become malnourished in time.

A Rationale: Clients with trigeminal neuralgia are often afraid of causing pain, so they may limit eating, talking, dental hygiene, and socializing. The nurse first assesses the client for feelings related to having the disorder to determine if a psychosocial link is involved. The other options may be needed depending on the outcome of the initial assessment.

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

A Rationale: Corticosteroids reduce immune function, so clients taking these medications must avoid being exposed to illness. Long-term use can lead to secondary diabetes, but the client would not need to to start checking blood glucose unless diabetes has been detected. Corticosteroids do not affect the effectiveness of contraception. Wearing well-fitting shoes would be important to avoid injury, but not just because the client takes corticosteroids.

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

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

A client with a stroke has damage to Brocas area. What intervention to promote communication is best for this client? a. Assess whether or not the client can write. b. Communicate using yes-or-no questions. c. Reinforce speech therapy exercises. d. Remind the client not to use neologisms.

A Rationale: Damage to Brocas area often leads to expressive aphasia, wherein the client can understand what is said but cannot express thoughts verbally. In some instances the client can write. The nurse should assess to see if that ability is intact. Yes-or-no questions are not good for this type of client because he or she will often answer automatically but incorrectly. Reinforcing speech therapy exercises is good for all clients with communication difficulties. Neologisms are made-up words often used by clients with sensory aphasia.

A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which instruction should the nurse include in this education? a. Participate in an exercise program to strengthen muscles. b. Purchase a mattress that allows you to adjust the firmness. c. Wear flat instead of high-heeled shoes to work each day. d. Keep your weight within 20% of your ideal body weight.

A Rationale: Exercise can strengthen back muscles, reducing the incidence of low back pain. The other options will not prevent low bak pain.

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

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

A nurse performs an assessment of pain discrimination on an older adult client. The client correctly identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin. Which action should the nurse take next? a. Touch the pin on the same area of the left hand. b. Contact the provider with the assessment results. c. Ask the client about current medications. d. Continue the assessment on the clients feet.

A Rationale: If testing is begun on the right hand and the client correctly identifies the pain stimulus, the nurse should continue the assessment on the left hand. This is a normal finding and does not need to be reported to the provider, but instead documented on the clients chart. Medications do not need to be assessed in response to this finding. The nurse should assess the left hand prior to assessing the feet.

A client with myasthenia gravis (MG) asks the nurse to explain the disease. What response by the nurse is best? a. MG is an autoimmune problem in which nerves do not cause muscles to contract. b. MG is an inherited destruction of peripheral nerve endings and junctions. c. MG consists of trauma-induced paralysis of specific cranial nerves. d. MG is a viral infection of the dorsal root of sensory nerve fibers.

A Rationale: MG is an autoimmune disorder in which nerve fibers are damaged and their impulses do not lead to muscle contraction. MG is not an inherited or viral disorder and does not paralyze specific cranial nerves.

After teaching a client with a spinal cord injury, the nurse assesses the clients understanding. Which client statement indicates a correct understanding of how to prevent respiratory problems at home? a. I'll use my incentive spirometer every 2 hours while Im awake. b. I'll drink thinned fluids to prevent choking. c. I'll take cough medicine to prevent excessive coughing. d. I'll position myself on my right side so I don't aspirate.

A Rationale: Often, the person with a spinal cord injury will have weak intercostal muscles and is at higher risk for developing atelectasis and stasis pneumonia. Using an incentive spirometer every 2 hours helps the client expand the lungs more fully and prevents atelectasis. Clients should drink fluids that they can tolerate; usually thick fluids are easier to tolerate. The client should be encouraged to cough and clear secretions. Clients should be placed in high-Fowlers position to prevent aspiration.

A client in the emergency department is having a stroke and needs a carotid artery angioplasty with stenting. The clients mental status is deteriorating. What action by the nurse is most appropriate? a. Attempt to find the family to sign a consent. b. Inform the provider that the procedure cannot occur. c. Nothing; no consent is needed in an emergency. d. Sign the consent form for the client.

A Rationale: The nurse should attempt to find the family to give consent. If no family is present or can be found, under the principle of emergency consent, a life-saving procedure can be performed without formal consent. The nurse should not just sign the consent form.

A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg, and respiratory irregularities. What action by the nurse takes priority? a. Call the provider or Rapid Response Team. b. Increase the rate of the IV fluid administration. c. Notify respiratory therapy for a breathing treatment. d. Prepare to give IV pain medication.

A Rationale: These manifestations indicate Cushings syndrome, a potentially life-threatening increase in intracranial pressure (ICP), which is an emergency. Immediate medical attention is necessary, so the nurse notifies the provider or the Rapid Response Team. Increasing fluids would increase the ICP. The client does not need a breathing treatment or pain medication.

A nurse at an emergency department is caring for a client who suddenly lost consciousness and fell while at home/ The provider determines that the client had an embolic stroke. Which of the following medications should the nurse expect to administer? a. Tissue plasminogen activator b. Recombinant factor VIII c. Nitroglycerin d. Lidocaine

A Rationale: Tissue plasminogen activator is a thrombolytic agent that should dissolve the blood clot that caused the stroke.

A nursing student studying the neurologic system learns which information? (Select all that apply.) a. An aneurysm is a ballooning in a weakened part of an arterial wall. b. An arteriovenous malformation is the usual cause of strokes. c. Intracerebral hemorrhage is bleeding directly into the brain. d. Reduced perfusion from vasospasm often makes stroke worse. e. Subarachnoid hemorrhage is caused by high blood pressure.

A, C, D Rationale: An aneurysm is a ballooning of the weakened part of the arterial wall. Intracerebral hemorrhage is bleeding directly into the brain. Vasospasm often makes the damage from the initial stroke worse because it causes decreased perfusion. An arteriovenous malformation (AVM) is unusual. Subarachnoid hemorrhage is usually caused by a ruptured aneurysm of AVM.

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.) a. Heart rate of 34 beats/min b. Blood pressure of 185/65 mm Hg c. Urine output less than 30 mL/hr d. Decreased level of consciousness e. Increased oxygen saturation

A, C, D Rationale: Neurogenic shock with acute spinal injury manifests with decreased oxygen saturation, symptomatic bradycardia, decreased level of consciousness, decreased urine output, and hypotension.

A nurse cares for older clients who have traumatic brain injury. What should the nurse understand about this population? (Select all that apply.) a. Admission can overwhelm the coping mechanisms for older clients. b. Alcohol is typically involved in most traumatic brain injuries for this age group. c. These clients are more susceptible to systemic and wound infections. d. Other medical conditions can complicate treatment for these clients. e. Very few traumatic brain injuries occur in this age group.

A, C, D Rationale: Older clients often tolerate stress poorly, which includes being admitted to a hospital that is unfamiliar and noisy. Because of decreased protective mechanisms, they are more susceptible to both local and systemic infections. Other medical conditions can complicate their treatment and recovery. Alcohol is typically not related to traumatic brain injury in this population; such injury is most often from falls and motor vehicle crashes. The 65 to 76 year old age group has the second highest rate of brain injuries compared to other age groups.

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

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

A nurse is teaching a client who experiences migraine headaches and is prescribed a beta blocker. Which statement should the nurse include in this clients teaching? a. Take this drug only when you have prodromal symptoms indicating the onset of a migraine headache. b. Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches. c. This drug will relieve the pain during the aura phase soon after a headache has started. d. This medication will have no effect on your heart rate or blood pressure because you are taking it for migraines.

B Rationale: Beta blockers are prescribed as a prophylactic treatment to prevent the vascular changes that initiate migraine headaches. Heart rate and blood pressure will also be affected, and the client should monitor these side effects. The other responses do not discuss appropriate uses of the medication.

A nurse is teaching a client who has multiple sclerosis and has a new prescription for glatiramer acetate. Which of the following statements indicates that the client understands the teaching? a. "I will ask my partner to give the injection in the same spot each time." b. "I will avoid going to the store when it is crowded." c. "I will see relief of my symptoms in about 1 week." d. "I will exercise rigorously while taking this medication."

B Rationale: Clients who are prescribed this medication are instructed to avoid crowds and individuals who have infection.

A nurse plans care for a client who has a hypoactive response to a test of deep tendon reflexes. Which intervention should the nurse include in this clients plan of care? a. Check bath water temperature with a thermometer. b. Provide the client with assistance when ambulating. c. Place elastic support hose on the clients legs. d. Assess the clients feet for wounds each shift.

B Rationale: Hypoactive deep tendon reflexes and loss of vibration sense can impair balance and coordination, predisposing the client to falls. The nurse should plan to provide the client with ambulation assistance to prevent injury. The other interventions do not address the clients problem.

A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication should the nurse prepare to administer? a. Atenolol (Tenormin) b. Lorazepam (Ativan) c. Phenytoin (Dilantin) d. Lisinopril (Prinivil)

B Rationale: Initially, IV lorazepam is administered to stop motor movements. This is followed by the administration of phenytoin. Atenolol, a beta blocker, and lisinopril, an angiotensin-converting enzyme inhibitor, are not administered for seizure activity. These medications are typically administered for hypertension and heart failure.

A nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How should the nurse document this activity? a. Atonic seizure b. Tonic-clonic seizure c. Myoclonic seizure d. Absence seizure

B Rationale: Seizure activity that begins with stiffening of the arms and legs, followed by loss of consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure. An atonic seizure presents as a sudden loss of muscle tone followed by postictal confusion. A myoclonic seizure presents with brief jerking or stiffening of extremities that may occur singly or in groups. Absence seizures present with automatisms, and the client is unaware of his or her environment.

A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the docusate sodium (Colace) because the client had a large stool earlier. What action by the supervising nurse is best? a. Have the student ask the client if it is desired or not. b. Inform the student that the docusate should be given. c. Tell the student to document the rationale. d. Tell the student to give it unless the client refuses.

B Rationale: Stool softeners should be given to clients with neurologic disorders in order to prevent an elevation in intracranial pressure that accompanies the Valsalva maneuver when constipated. The supervising nurse should instruct the student to administer the docusate. The other options are not appropriate. The medication could be held for diarrhea.

A nurse obtains a health history on a client prior to administering prescribed sumatriptan succinate (Imitrex) for migraine headaches. Which condition should alert the nurse to hold the medication and contact the health care provider? a. Bronchial asthma b. Prinzmetal's angina c. Diabetes mellitus d. Chronic kidney disease

B Rationale: Sumatriptan succinate effectively reduces pain and other associated symptoms of migraine headache by binding to serotonin receptors and triggering cranial vasoconstriction. Vasoconstrictive effects are not confined to the cranium and can cause coronary vasospasm in clients with Prinzmetal's angina. The other conditions would not affect the clients treatment.

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

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

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

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

A nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. Which action should the nurse take? a. Start fluids via a large-bore catheter. b. Turn the clients head to the side. c. Administer IV push diazepam. d. Prepare to intubate the client.

B Rationale: The nurse should turn the clients head to the side to prevent aspiration and allow drainage of secretions. Anticonvulsants are administered on a routine basis if a seizure is sustained. If the seizure is sustained (status epilepticus), the client must be intubated and should be administered oxygen, 0.9% sodium chloride, and IV push lorazepam or diazepam.

An older adult client is hospitalized with Guillain-Barr syndrome. The client is given amitriptyline (Elavil). After receiving the hand-off report, what actions by the nurse are most important? (Select all that apply.) a. Administering the medication as ordered b. Advising the client to have help getting up c. Consulting the provider about the drug d. Cutting the dose of the drug in half e. Placing the client on safety precautions

B, C, E Rationale: Amitriptyline is a tricyclic antidepressant and is considered inappropriate for use in older clients due to concerns of anticholinergic effects, confusion, and safety risks. The nurse should tell the client to have help getting up, place the client on safety precautions, and consult the provider. Since this drug is not appropriate for older clients, cutting the dose in half is not warranted.

A client with myasthenia gravis is malnourished. What actions to improve nutrition may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assessing the clients gag reflex b. Cutting foods up into small bites c. Monitoring prealbumin levels d. Thickening liquids prior to drinking e. Weighing the client daily

B, D Rationale: Cutting up foods into smaller bites makes it easier for the client to chew and swallow. Thickened liquids help prevent aspiration. The UAP can weight the client, but this does not help improve nutrition. The nurse assesses the gag reflex and monitors laboratory values.

After administering a medication that stimulates the sympathetic division of the autonomic nervous system, the nurse assesses the client. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Decreased respiratory rate b. Increased heart rate c. Decreased level of consciousness d. Increased force of contraction e. Decreased blood pressure

B, D Rationale: Stimulation of the sympathetic nervous system initiates the fight-or-flight response, increasing both the heart rate and the force of contraction. A medication that stimulates the sympathetic nervous system would also increase the clients respiratory rate, blood pressure, and level of consciousness.

A nurse is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assess neurologic status with the Glasgow Coma Scale. b. Check and document oxygen saturation every 1 to 2 hours. c. Cluster client care to allow periods of uninterrupted rest. d. Elevate the head of the bed to 45 degrees to prevent aspiration. e. Position the client supine with the head in a neutral midline position.

B, E Rationale: The UAP can take and document vital signs, including oxygen saturation, keep the clients head in a neutral, midline position with correct direction from the nurse. The nurse assesses the Glasgow Coma Scale score. The nursing staff should not cluster care because this can cause an increase in the intracranial pressure. The head of the bed should be minimally elevated, up to 30 degrees.

The nurse is assessing a client with trigeminal neuralgia. Which of the following are true with this condition? (Select all that apply). a. Hypotension occurs b. Ophthalmic sensory division is affected c. Frequent falls occur d. Slurred speech occurs e. Pain occurs

B, E Rationale: The outstanding symptom of trigeminal neuralgia is pain that occurs when trigger zones are stimulated, usually described as "lancinating". Factors such as touch, eating, swallowing, talking, sneezing, shaving, chewing gum, brushing teeth, washing the face, exposure to wind, and changes in temperature can trigger the painful sensation. Medications such as anticonvulsants and skeletal muscle relaxants are commonly prescribed to control the painful sensations. These drugs act to decrease afferent impulse transmission. Hypotension, frequent falls, and slurred speech do not occur with this condition.

A nurse assesses a client who is experiencing an absence seizure. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Intermittent rigidity b. Lip smacking c. Sudden loss of muscle tone d. Brief jerking of the extremities e. Picking at clothing f. Patting of the hand on the leg

B, E, F Rationale: Automatisms are characteristic of absence seizures. These behaviors consist of lip smacking, picking at clothing, and patting. Rigidity of muscles is associated with the tonic phase of a seizure, and jerking of the extremities is associated with the clonic phase of a seizure. Loss of muscle tone occurs with atonic seizures.

A nurse is teaching a client with chronic migraine headaches. Which statement related to complementary therapy should the nurse include in this clients teaching? a. Place a warm compress on your forehead at the onset of the headache. b. Wear dark sunglasses when you are in brightly lit spaces. c. Lie down in a darkened room when you experience a headache. d. Set your alarm to ensure you do not sleep longer than 6 hours at one time

C Rationale: At the onset of a migraine attack, the client may be able to alleviate pain by lying down and darkening the room. He or she may want both eyes covered and cool cloth on the forehead. If the client falls asleep, he or she should remain undisturbed until awakening. The other options are not recognized therapies for migraines.

The nurse is preparing a client for a Tensilon (edrophonium chloride) test. What action by the nurse is most important? a. Administering anxiolytics b. Having a ventilator nearby c. Obtaining atropine sulfate d. Sedating the client

C Rationale: Atropine sulfate is the antidote for edrophonium chloride and should be readily available when a client is having a Tensilon test. The nurse would not want to give medications that might cause increased weakness or sedation. A ventilator is not necessary to have nearby, although emergency equipment should be available.

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

C Rationale: Cerebellar function enables the client to predict distance or gauge the speed with which one is approaching an object, control voluntary movement, maintain equilibrium, and shift form one skilled movement to another in an orderly sequence. A client who has cerebellar function impairment should not be driving. The client would not have difficulty hearing, distinguishing between hot and cold, or smelling.

A nurse is caring for a client with multiple sclerosis. Which of the following findings should the nurse expect? a. Hypoactive deep-tendon reflexes b. Ascending paralysis c. Intention tremors d. Increased lacrimation

C Rationale: Clients who have multiple sclerosis are at risk for motor dysfunction, with intention tremors, poor coordination, and loss of balance.

A client is admitted with Guillain-Barr syndrome (GBS). What assessment takes priority? a. Bladder control b. Cognitive perception c. Respiratory system d. Sensory functions

C Rationale: Clients with GBS have muscle weakness, possibly to the point of paralysis. If respiratory muscles are paralyzed, the may need mechanical ventilation, so the respiratory system is the priority. The nurse will complete urinary, cognitive, and sensory assessments as part of a thorough evaluation.

A nurse plans care for an 83-year-old client who is experiencing age-related sensory perception changes. Which intervention should the nurse include in this clients plan of care? a. Provide a call button that requires only minimal pressure to activate. b. Write the date on the clients white board to promote orientation. c. Ensure that the path to the bathroom is free from equipment. d. Encourage the client to season food to stimulate nutritional intake.

C Rationale: Dementia and confusion are not common phenomena in older adults. However, physical impairment related to illness can be expected. Providing opportunities for hazard-free ambulation will maintain strength and mobility (and ensure safety). Providing a call, providing the date, and seasoning food do not address the clients impaired sensory perception.

A nurse is teaching a client who has Parkinson's disease and is prescribed carbidopa-levidopa. Which of the following client statements indicates an understanding of the teaching? a. "I should expect an increase in my blood pressure while taking this medication." b. "I should take this medication 2 hours after meals to increase absorption." c. "I should expect that this medication can cause me to be drowsy." d. "I should expect this medication to be effective within 48 hours."

C Rationale: Drowsiness is a known adverse effect of carbidopa-levidopa; therefore, clients are taught to avoid heavy machinery and driving if they experience drowsiness.

A nurse assesses a client with early-onset multiple sclerosis (MS). Which clinical manifestation should the nurse expect to find? a. Hyper-responsive reflexes b. Excessive somnolence c. Nystagmus d. Heat intolerance

C Rationale: Early signs and symptoms of MS include changes in motor skills, vision, and sensation. Hyper-responsive reflexes, excessive somnolence, and heat intolerance are later manifestations of MS.

A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod (Gilenya). For which adverse effect should the nurse monitor? a. Peripheral edema b. Black tarry stools c. Bradycardia d. Nausea and vomiting

C Rationale: Fingolimod (Gilenya) is an antineoplastic agent that can cause bradycardia, especially within the first 6 hours after administration. Peripheral edema, black and tarry stools, and nausea and vomiting are not adverse effects of fingolimod.

A nurse asks a client to take deep breaths during an electroencephalography. The client asks, Why are you asking me to do this? How should the nurse respond? a. Hyperventilation causes vascular dilation of cerebral arteries, which decreases electoral activity in the brain. b. Deep breathing helps you to relax and allows the electroencephalograph to obtain a better waveform. c. Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity. d. Deep breathing will help you to blow off carbon dioxide and decreases intracranial pressures.

C Rationale: Hyperventilation produces cerebral vasoconstriction and alkalosis, which increases the likelihood of seizure activity. The client is asked to breathe deeply 20 to 30 times for 3 minutes. The other responses are not accurate.

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

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

An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago. Which prescribed medication should the nurse prepare to administer? a. Intrathecal baclofen (Lioresal) b. Methylprednisolone (Medrol) c. Atropine sulfate d. Epinephrine (Adrenalin)

C Rationale: Methylprednisolone (Medrol) should be given within 8 hours of the injury. Clients who receive this therapy usually show improvement in motor and sensory function. The other medications are inappropriate for this client.

After teaching a client who is scheduled for magnetic resonance imaging (MRI), the nurse assesses the clients understanding. Which client statement indicates a correct understanding of the teaching? a. I must increase my fluids because of the dye used for the MRI. b. My urine will be radioactive so I should not share a bathroom. c. I can return to my usual activities immediately after the MRI. d. My gag reflex will be tested before I can eat or drink anything.

C Rationale: No postprocedural restrictions are imposed after MRI. The client can return to normal activities after the test is complete. There are no dyes or radioactive materials used for the MRI; therefore, increased fluids are not needed and the clients urine would not be radioactive. The procedure does not impact the clients gag reflex.

A nurse teaches an 80-year-old client with diminished touch sensation. Which statement should the nurse include in this clients teaching? a. Place soft rugs in your bathroom to decrease pain in your feet. b. Bathe in warm water to increase your circulation. c. Look at the placement of your feet when walking. d. Walk barefoot to decrease pressure ulcers from your shoes.

C Rationale: Older clients with decreased sensation are at risk of injury from the inability to sense changes in terrain when walking. To compensate for this loss, the client is instructed to look at the placement of her or his feet when walking. Throw rugs can slip and increase fall risk. Bath water that is too warm places the client at risk for thermal injury. The client should wear sturdy shoes for ambulation.

A nurse assesses clients at a community center. Which client is at greatest risk for lower back pain? a. A 24-year-old female who is 25 weeks pregnant b. A 36-year-old male who uses ergonomic techniques c. A 45-year-old male with osteoarthritis d. A 53-year-old female who uses a walker

C Rationale: Osteoarthritis causes changes to support structures, increasing the clients risk for low back pain. The other clients are not at risk.

The home health nurse visits a client who is taking phenytoin for control of seizures. During the assessment, the nurse notes that the client is taking birth control pills. Which information should the nurse include in the teaching plan? a. Pregnancy must be avoided while taking phenytoin. b. The client may stop the medication if it is causing severe GI effects c. There is the potential of decreased effectiveness of birth control pills while taking phenytoin. d. There is the increased risk of thrombophlebitis while taking phenytoin and birth control pills together.

C Rationale: Phenytoin enhances the rate of estrogen metabolism, which can decrease the effectiveness of some birth control pills. Options a, b, and d are inappropriate instructions. Pregnancy does not need to be "avoided" while taking phenytoin; however, because phenytoin may cause some risk to the fetus (Pregnancy Category D medication), consultation with the health care provider is considered. Telling a client that there is an increased risk of thrombophlebitis is incorrect and inappropriate and could cause anxiety in the client. A client should not be instructed to stop antiseizure medication.

A client is receiving plasmapheresis. What action by the nurse best prevents infection in this client? a. Giving antibiotics prior to treatments b. Monitoring the clients vital signs c. Performing appropriate hand hygiene d. Placing the client in protective isolation

C Rationale: Plasmapheresis is an invasive procedure, and the nurse uses good hand hygiene before and after client contact to prevent infection. Antibiotics are not necessary. Monitoring vital signs does not prevent infection but could alert the nurse to its possibility. The client does not need isolation.

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? a. Hyperreflexia b. Positive reflexes c. Flaccid paralysis d. Reflex emptying of the bladder

C Rationale: Resolution of spinal shock is occurring when there is return of reflexes, a state of hyperreflexia rather than flaccidity, and reflex emptying of the bladder.

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

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

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

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

A client with Guillain-Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness? a. Giving client full control over care decisions and restricting visitors. b. Providing positive feedback and encouraging active range of motion. c. Providing information, giving positive feedback, and encouraging relaxation. d. Providing IV administered sedatives, reducing distractions, and limiting visitors.

C Rationale: The client with Guillain-Barre syndrome experiences fear and anxiety from the ascending paralysis and sudden onset of the disorder. The nurse can alleviate these fears by providing accurate information about the client's condition, giving expert care and positive feedback to the client, and encouraging relaxation and distraction. The family can become involved with selected care activities and provide diversion for the client as well.

A nurse is caring for a client who has advancing ALS. Which of the following is the nurse's priority? a. Provide frequent rest periods throughout the day b. Administer pain medication on a regular schedule c. Monitor pulse oximetry findings d. Administer baclofen for spasticity

C Rationale: The greatest risk to the client is respiratory compromise due to progressive paralysis of respiratory muscles. Therefore, the priority intervention is to monitor the client's oxygen saturation to identify respiratory compromise as soon as possible.

A nurse is assessing a client who had a right hemispheric stroke. Which of the following neurologic deficits should the nurse expect? a. Aphasia b. Right-sided neglect c. Impulsive behavior d. Inability to read

C Rationale: The nurse should expect clients who had a right hemispheric stroke to demonstrate impulsive behavior, poor judgment, and lack of awareness of neurologic deficits.

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

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

A nurse prepares to teach a client who has experienced damage to the left temporal lobe of the brain. Which action should the nurse take when providing education about newly prescribed medications to this client? a. Help the client identify each medication by its color. b. Provide written materials with large print size. c. Sit on the clients right side and speak into the right ear. d. Allow the client to use a white board to ask questions.

C Rationale: The temporal lobe contains the auditory center for sound interpretation. The clients hearing will be impaired in the left ear. The nurse should sit on the clients right side and speak into the right ear. The other interventions do not address the clients left temporal lobe damage.

A client is taking the prescribed dose of phenytoin to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/mL. Which finding would be expected as a result of this laboratory result? a. Hypotension b. Tachycardia c. Slurred speech d. No abnormal finding

C Rationale: The therapeutic phenytoin level is 10 to 20 mcg/mL. At a level of higher than 20 mcg/Ml, involuntary movements of the eyeballs (nystagmus) occur. At a level higher than 30 mcg/mL, ataxia and slurred speech occur.

A nurse is assessing a client with Parkinson's disease who experiences unsteadiness when turning. According to this finding, which stage of the disease is the client experiencing? a. Second b. First c. Third d. Fourth

C Rationale: There are 5 stages in the progression of Parkinson's disease. Stage 1 is characterized by unilateral involvement with minimal or no functional impairment in the movement. In stage 2, there is bilateral and midline involvement but without impairment of balance. Stage 3 is characterized by impairment of reflexes, which results in symptoms that include unsteadiness with turning. Tremors become more profound in this stage, often restricting activities. Stage 4 is characterized by fulminant manifestation of symptoms that include tremor, bradykinesia, rigidity, postural instability, and festination. Stage 5 of Parkinson's disease is characterized by confinement to bed or wheelchair as the client's condition worsens.

A client with myasthenia gravies has become increasingly weaker. The health care provider prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium is administered. Which finding would indicate that the client is in cholinergic crisis? a. No change in the condition b. Complaints of muscle spasms c. An improvement of the weakness d. A temporary worsening of the condition

D Rationale: An edrophonium injection makes the client in cholinergic crisis temporarily worse. An improvement in the weakness indicates myasthenic crisis. Muscle spasms are not associated with this test.

A nurse assesses a clients recent memory. Which client statement confirms that the clients remote memory is intact? a. A young girl wrapped in a shroud fell asleep on a bed of clouds. b. I was born on April 3, 1967, in Johnstown Community Hospital. c. Apple, chair, and pencil are the words you just stated. d. I ate oatmeal with wheat toast and orange juice for breakfast.

D Rationale: Asking clients about recent events that can be verified, such as what the client ate for breakfast, assesses the clients recent memory. The clients ability to make up a rhyme tests not memory, but rather a higher level of cognition. Asking clients about certain facts from the past that can be verified assesses remote or long-term memory. Asking the client to repeat words assesses the clients immediate memory.

A nurse cares for a client who presents with an acute exacerbation of multiple sclerosis (MS). Which prescribed medication should the nurse prepare to administer? a. Baclofen (Lioresal) b. Interferon beta-1b (Betaseron) c. Dantrolene sodium (Dantrium) d. Methylprednisolone (Medrol)

D Rationale: Methylprednisolone (Medrol) is the drug of choice for acute exacerbation of the disease. The other drugs are not used to treat acute exacerbations of MS. Interferon beta-1b is used to treat and control MS, decrease specific symptoms, and slow the progression of the disease. Baclofen and dantrolene sodium are prescribed to lessen muscle spasticity associated with MS.

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

D Rationale: Because chewing and swallowing can be problematic, small frequent meals and a supplement are better for meeting the clients nutritional needs. A masklike face and drooling are common in clients with Parkinson's disease. The client should be encouraged to continue to socialize and communicate as normally as possible. The wife should understand that the clients masklike face can be misinterpreted and additional time may be needed for he client to communicate with her or others. Excessive perspiration is also common in clients with Parkinson's disease and is associated with the autonomic nervous system response.

A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder. Which of the following assessment findings should the nurse report to the provider? a. Glasgow Coma Scale score of 15 b. Intracranial pressure reading of 15 mmHg c. Ecchymosis at base of skull d. Clear drainage from the nose

D Rationale: Clear drainage from the nose indicates that CSF is leaking from the skull fracture. This places the client at risk for meningeal infection because micro-organisms have access to the cranium through the nose and the tear in the dura. The nurse should report this finding to the provider.

A nurse is caring for a client who is recovering from a stroke and has right-sided homonymous hemianopsia. To help the client adapt to the hemianopsia, the nurse should take which of the following actions? a. Check the client's cheek on the affected side after meals to be sure no food remains there. b. Encourage the client the sit upright with their head tilted slightly forward during meals. c. Provide the client with eating utensils that have large handles. d. Remind the client to look consciously at both sides of their meal tray

D Rationale: Clients who have right-sided homonymous hemianopsia have lost the right visual field of both eyes and might only eat the food they are able to see on the left half of the meal tray. Therefore, the nurse should remind the client to look at both sides of his meal tray to help compensate for the visual loss.

After teaching a client who is diagnosed with new-onset status epilepticus and prescribed phenytoin (Dilantin), the nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching? a. To prevent complications, I will drink at least 2 liters of water daily. b. This medication will stop me from getting an aura before a seizure. c. I will not drive a motor vehicle while taking this medication. d. Even when my seizures stop, I will continue to take this drug.

D Rationale: Discontinuing antiepileptic drugs can lead to the recurrence of seizures or status epilepticus. The client does not need to drink more water and can drive while taking this medication. The medication will not stop an aura before a seizure.

Carbidopa-levidopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side and adverse effects of the medication. Which finding indicates that the client is experiencing an adverse affect? a. Pruritus b. Tachycardia c. Hypertension d. Impaired voluntary movements

D Rationale: Dyskinesia and impaired voluntary movements may occur with high carbidopa-levidopa dosages. Nausea, anorexia, dizziness, orthostatic hypotension, bradycardia, and akinesia are frequent side effects of the medication.

A nurse plans care for a client with Parkinson disease. Which intervention should the nurse include in this clients plan of care? a. Ambulate the client in the hallway twice a day. b. Ensure a fluid intake of at least 3 liters per day. c. Teach the client pursed-lip breathing techniques. d. Keep the head of the bed at 30 degrees or greater.

D Rationale: Elevation of the head of the bed will help prevent aspiration. The other options will not prevent aspiration, which is the greatest respiratory complication of Parkinson disease, nor do these interventions address any of the complications of Parkinson disease. Ambulation in the hallway is usually implemented to prevent venous thrombosis. Increased fluid intake flushes out toxins from the clients blood. Pursed-lip breathing increases exhalation of carbon dioxide.

The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement? a. "I will wash my face with cotton pads." b. "I'll have to start chewing on my unaffected side." c. "I should rinse my mouth if toothbrushing is painful." d. "i'll try to eat my food either very warm or very cold."

D Rationale: Facial pain can be minimized by using cotton pads to wash the face and using room temperature water. The client should chew on the unaffected side of the mouth, eat a soft diet, and take in foods and beverages at room temperature. If brushing the teeth triggers pain, an oral rinse after meals may be helpful instead.

The client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. Which past medical history finding makes the client most at risk for this disease? a. Meningitis or encephalitis during the last 5 years b. Seizures or trauma to the brain within the last year c. Back injury or trauma to the spinal cord during the last 2 years d. Respiratory or gastrointestinal infection during the previous month

D Rationale: Guillain-Barre syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits. On occasion, the syndrome can be triggered by vaccination or surgery.

A nurse assesses a client with a neurologic disorder. Which assessment finding should the nurse identify as a late manifestation of amyotrophic lateral sclerosis (ALS)? a. Dysarthria b. Dysphagia c. Muscle weakness d. Impairment of respiratory muscles

D Rationale: In ALS, progressive muscle atrophy occurs until a flaccid quadriplegia develops. Eventually, the respiratory muscles are involved, which leads to respiratory compromise. Dysarthria, dysphagia, and muscle weakness are early clinical manifestations of ALS.

The nurse is admitting a client with Guillain-Barre syndrome to the nursing unit. The client has ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which most essential items into the client's room? a. Nebulizer and pulse oximeter b. Blood pressure cuff and flashlight c. Flashlight and incentive spirometer d. Electrocardiographic monitoring electrodes and intubation tray

D Rationale: The client with Guillain-Barre syndrome is at risk for respiratory failure because of ascending paralysis. An intubation tray should be available for use. Another complication of this syndrome is cardiac dysrhythmias, which necessitates the use of electrocardiographic monitoring. Because the client is immobilized, the nurse should assess for deep vein thrombosis and pulmonary embolism routinely. Although items in the incorrect options may be used in care, they are not the most essential items from the options provided.

The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need of further teaching? a. "I can sit down to put on my pants and shoes." b. "I try to exercise every day and rest when I'm tired." c. "My son removed all loos rugs from my bedroom." d. "I don't need to use my walker to get to the bathroom."

D Rationale: The client with Parkinson's disease should be instructed regarding safety measures in the home. The client should use his or her walker as support to get to the bathroom because of bradykinesia. The client should sit down to put on pants and shoes to prevent falling. The client should exercise everyday in the morning when energy levels are the highest. The client should have all loose rugs in the home removed to prevent falling.

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

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

A nurse is caring for a client who has a history of status epilepticus and requires seizure precautions. Which of the following actions should the nurse take? a. Assess hourly for a spike in blood pressure b. Keep the client on bed rest c. Keep a padded tongue blade at the bedside d. Establish IV access

D Rationale: The nurse should plan to establish IV access with a large-bore catheter and administer 0.9& sodium chloride if seizures are imminent. If the client is stable, the nurse should initiate a saline lock.

A nurse is planning to teach a client who has epilepsy and a new prescription for phenytoin. Which of the following instructions should the nurse plan to include? a. Rinse with antiseptic mouthwash instead of using dental floss. b. Use an over-the-counter antihistamine if a rash develops. c. Slowly taper the medication after 6 consecutive months without seizure activity. d. Take medications at a consistent time each day to maintain therapeutic blood levels.

D Rationale: The nurse should teach the client to take antiepileptic medications on a regular schedule to maintain therapeutic blood levels and achieve the maximum effect.

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

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

A nurse is assessing a client who is quadriplegic following a cervical fracture at vertebral level C5. The client reports a throbbing headache and nausea. The nurse notes facial flushing and a blood pressure of 220/110 mmHg. Which of the following actions should the nurse take first? a. Administer hydralazine via IV bolus b. Loosen the client's clothing c. Empty the client's bladder d. Elevate the head of the client's bed

D Rationale: These assessment findings indicate that the client is experiencing autonomic dysreflexia and is at greatest risk for possible rupture of a cerebral vessel or increased intracranial pressure. The first action the nurse should take is to move the client from a supine to an upright position, which will result in rapid postural hypotension.

A client in the intensive care unit is scheduled for a lumbar puncture (LP) today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. What action by the nurse is best? a. Ensure that informed consent is on the chart. b. Document these findings in the clients record. c. Give the prescribed preprocedure sedation. d. Notify the provider of the findings immediately.

D Rationale: This client is exhibiting signs of increased intracranial pressure. The nurse should notify the provider immediately because performing the LP now could lead to herniation. Informed consent is needed for an LP, but this is not the priority. Documentation should be thorough, but again this is not the priority. The preprocedure sedation (or other preprocedure medications) should not be given as the LP will most likely be cancelled.

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

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

A client with myasthenia gravis has the priority client problem of inadequate nutrition. What assessment finding indicates that the priority goal for this client problem has been met? a. Ability to chew and swallow without aspiration b. Eating 75% of meals and between-meal snacks c. Intake greater than output 3 days in a row d. Weight gain of 3 pounds in 1 month

D Rationale: Weight gain is the best indicator that the client is receiving enough nutrition. Being able to chew and swallow is important for eating, but adequate nutrition can be accomplished though enteral means if needed. Swallowing without difficulty indicates and intact airway. Since the question does not indicate what the clients meals and snacks consist of, eating 75% may or may not be adequate. Intake and output refers to liquid balance.