Medsurg 2 - Exam 2

The nurse is caring for a client who had a hemorrhagic stroke. Which assessment finding is the earliest sign of increasing intracranial pressure (ICP) for this client? a. Projectile vomiting b. Dilated and nonreactive pupils c. Severe hypertension d. Decreased level of consciousness

ANS: D The earliest sign of increasing ICP is decreased level of consciousness. The other signs occur later.

A male client was admitted with left sided stroke this morning. The UAP asks about meeting the clients nutritional needs. Which response by the nurse is appropriate? A. He is NPO until the the speech-language pathologist performs a swallow evaluation. B. You may give him a full liquid diet, but please avoid solid foods until he gets stronger. C. Just be sure to add some thickener in his liquids to prevent choking and aspiration. D. Be sure to sit him up when you feed him to make him feel more normal

ANS: A

The nurse is caring for a patient with increased intracranial pressure. Which action is considered unsafe? A. aligning the neck with the body B. clustering many nursing activities C. elevating HOB 30 degrees D. providing stool softeners or laxatives as ordered

ANS: B

The nurse is taking a history from a daughter about her fathers onset of stroke signs and symptoms. Which statement by the daughter indicates that the client likely had an embolic stroke? A. clients symptoms occurred slowly over several hours B. client became increasingly lethargic and drowsy C. client has a long history of afib D. client reported severe headache before other symptoms

ANS: C

Within which time frame does the nurse expect administration of IV fibrinolytic therapy with alteplase to occur related to a clients stroke symptom onset? A. 24-30 hours B. 6-8 hours C. 3-4.5 hours D. 30-60 minutes

ANS: C

The nurse is assessing a client who has symptoms of stroke. What are the leading causes of a stroke for which the nurse would assess for this client? (Select all that apply.) a. Heavy alcohol intake b. Diabetes mellitus c. Elevated cholesterol d. Obesity e. Smoking f. Hypertension

ANS: A, B, C, D, E, F The leading causes of stroke include all of these factors.

Which assessment finding would be the earliest and most sensitive indicator that there is an alteration in intracranial regulation? A. change in LOC B. inability to focus visually C. loss of primitive reflexes D. unequal pupil size

ANS: A

A male client was admitted with a left-sided stroke this morning. The assistive personnel asks about meeting the client's nutritional needs. Which response by the nurse is appropriate? a. "He is NPO until the speech-language pathologist performs a swallowing evaluation." b. "You may give him a full-liquid diet, but please avoid solid foods until he gets stronger." c. "Just be sure to add some thickener in his liquids to prevent choking and aspiration." d. "Be sure to sit him up when you are feeding him to make him feel more natural."

ANS: A Any client who has or is suspected of having a stroke should have nothing by mouth until he or she is evaluated for any swallowing problem by the speech-language pathologist (SLP). If dysphagia is present, the SLP makes specific recommendations for the client's plan of care which all staff members must follow to prevent choking and aspiration/aspiration pneumonia.

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

ANS: A Brain tumors can lead to seizures as a complication. The nurse would explain this to the spouse. Preventing febrile seizures is not related to a tumor. Seizures are possible but do not always occur in clients with brain tumors. This drug is not used for sedation.

The nurse is performing an assessment of cranial nerve III. Which testing isappropriate? a. Pupil constriction b. Deep tendon reflexes c. Upper muscle strength d. Speech and language

ANS: A CN III is the oculomotor nerve which controls eye movement, pupil constriction, and eyelid movement.

A client who has multiple sclerosis reports increased severe muscle spasticity and tremors. What nursing action is most appropriate to manage this client's concern? a. Request a prescription for an antispasmodic drug such as baclofen. b. Prepare the client for deep brain stimulation surgery. c. Refer the client to a massage therapist to relax the muscles. d. Consult with the occupational therapist for self-care assistance.

ANS: A Clients who have multiple sclerosis often have muscle spasticity which may be reduced by drug therapy, such as baclofen. While massage and assistance with self-care may be helpful, these interventions are not the most effective and therefore not the most appropriate in managing muscle spasticity. If drug therapy and other interventions do not help reduce muscle spasms, some client are candidates for deep brain stimulation as a last resort.

Which statement would the nurse include when teaching the assistive personnel (AP) about how to 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-Fowler position for all meals." c. "Make sure the client's food is visually appetizing." d. "Assist the client by placing the fork in the left hand."

ANS: A Cranial nerve II, the optic nerve, provides central and peripheral vision. A patient who has cranial nerve II impairment will have decreased visual acuity, so the AP would tell the client where different food items are on the meal tray. The other options are not appropriate for client with cranial nerve II impairment.

A nurse teaches assistive personnel (AP) about how to care for a client with Parkinson disease. Which statement would the nurse include as part of this teaching? 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 client's ability to eat and swallow before eachmeal." d. "Schedule appointments early in the morning to ensure rest in the afternoon."

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

A nurse is providing community screening for risk factors associated with stroke. Which person would the nurse identify as being at the 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

ANS: A Heavy drug use, particularly cocaine, is a risk factor for stroke. Heavy alcohol use is also a risk factor, but one beer a day is not considered heavy drinking. Antihistamines may contain phenylpropanolamine, which also increases the risk for stroke, but this person 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.

The nurse is caring for a 60-year-old female client who sustained a thoracic spinal cord injury 10 years ago. For which potential complication will the nurse assess during this client's care? a. Fracture b. Malabsorption c. Delirium d. Anemia

ANS: A Older adults who have impaired mobility due to a health problem or injury are at risk for complications of immobility, such as osteoporosis (bone loss) which leads to fracture. Being an older woman increases that risk due to loss of estrogen to protect bone loss. The other choices are not problems of immobility. Delirium is possible but is more common in clients over 70 years of age.

A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The patient's spouse is very frustrated, stating that the patient's personality has changed and the situation is very difficult. What response by the nurse is most appropriate? a. Explain that personality changes are common following brain injuries. b. Ask the client why he or she is acting out and behaving differently. c. Refer the client and spouse to a head injury support group. d. Tell the spouse that this is expected and he or she will have to learn to cope.

ANS: A Personality and behavior often change permanently after head injury. The nurse will explain this to the spouse. Asking the client about his or her behavior isn't useful because the patient probably cannot help it. A referral might be a good idea, but the nurse needs to do something in addition to just referring the couple. Telling the spouse to learn to cope belittles his or her concerns and feelings.

A client is admitted with a sudden decline in level of consciousness. What is the nursing action at this time? a. Assess the client for hypoglycemia and hypoxia. b. Place the client on his or her side. c. Prepare for administration of a fibrinolytic agent. d. Start a continuous IV heparin sodium infusion.

ANS: A The cause of a sudden decline in level of consciousness may or may not be related to a neurologic health problem. Therefore, the client must be evaluated for other common causes, especially hypoglycemia and hypoxia. Placing the client on his or her side may be helpful to prevent aspiration in case the client experiences vomiting, but the clinical situation does not indicate that the client has nausea or vomiting. Administering either an anticoagulant like heparin or a fibrinolytic agent assumes that the client has an acute ischemic stroke, which has not been confirmed through imaging tests.

After teaching a client with a high thoracic spinal cord injury, the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of how to prevent respiratory problems at home? a. "I'll use my incentive spirometer every 2 hours while I'm 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."

ANS: A The client with a cervical or high thoracic spinal cord injury typically has 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 helps prevent atelectasis and other respiratory problems. Clients should drink fluids that they can tolerate; usually thick fluids are easier to tolerate. The client would be encouraged to cough and clear secretions, and placed in high-Fowler position to prevent aspiration.

The nurse assesses a client who has a mild traumatic brain injury (TBI) for signs and symptoms consistent with this injury. What signs and symptoms does the nurse expect? (Select all that apply.) a. Sensitivity to light and sound b. Reports "feeling foggy" c. Unconscious for an hour after injury d. Elevated temperature e. Widened pulse pressure

ANS: A, B A mild TBI would possibly lead to sensitivity to light and sound and a feeling of mental fogginess. The patient would have been unconscious for less than 30 minutes. An elevated temperature is not related. A widened pulse pressure is indicative of increased intracranial pressure, not a mild TBI.

Which questions are essential for the nurse to ask when getting an accurate history of a clients TBI? select all that apply A. When, where, how did injury occur? B. Did client lose consciousness? How long? C. Was drug or alcohol consumption related? D. Does client have history of seizures? E. How did the older client fall? F. Has there been a change in LOC?

ANS: A, B, C, D, E, F

A nurse is caring for a group of stroke patients. Which clients would the nurse consider referring to a mental health provider? (Select all that apply.) a. Female client who exhibits extreme emotional lability b. Male client with an initial National Institutes of Health (NIH) Stroke Scale score of 38 c. Female client with mild forgetfulness and a history of depression d. Male client who has a past hospitalization for a suicide attempt e. Male client who is unable to walk or eat 3 weeks poststroke

ANS: A, B, C, D, E Patients most at risk for poststroke depression are those with a previous history of depression, severe stroke (NIH Stroke Scale score of 38 is severe), and poststroke physical or cognitive impairment.

Based on the known risk factors for stroke, which health promotion practices would the nurse teach a client to promote heart health and prevent strokes? (Select all that apply.) a. Blood pressure control b. Aspirin use c. Smoking cessation d. Low carbohydrate diet e. Cholesterol management f. Increased red wine consumption

ANS: A, B, C, E The evidence-based health promotion practices include blood pressure control, aspirin use, smoking cessation, and cholesterol management. There is no consensus on which diet is best to promote heart health and red wine does not protect the heart or prevent strokes.

The nurse is caring for a client with increasing intracranial pressure (ICP) following a stroke. Which evidence-based nursing actions are indicated for this client? (Select all that apply.) a. Hyperoxygenate the client before and after suctioning. b. Avoid sudden or extreme hip or neck flexion. c. Provide oxygen to maintain an SaO2 of 95% or greater. d. Maintain the client in a supine position at all times. e. Avoid clustering care nursing activities and procedures. f. Provide environmental stimulation to improve cognition.

ANS: A, B, C, E These precautions help prevent further increases in ICP. Clustering nursing activities and procedures and providing stimulation can increase ICP and should be avoided.

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

ANS: A, B, D, E 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 decreased respirations, 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 with a brain tumor. Which newly identified assessment findings would alert the nurse to urgently communicate with the primary health care provider? (Select all that apply.) a. Glasgow Coma Scale score of 8 b. Decerebrate posturing c. Reactive pupils d. Uninhibited speech e. Decreasing level of consciousness

ANS: A, B, E The nurse would urgently communicate changes in a patient's neurologic status, including a decrease in the Glasgow Coma Scale score; abnormal flexion or extension; changes in cognition or level of consciousness; and pinpointed, dilated, and nonreactive pupils.

The nurse assesses a client who has Parkinson disease. Which signs and symptoms would the nurse recognize as a key feature of this disease? (Select all that apply.) a. Flexed trunk b. Long, extended steps c. Slow movements d. Uncontrolled drooling e. Tachycardia

ANS: A, C, D Key features of Parkinson disease include a flexed trunk, slow and hesitant steps, bradykinesia, and uncontrolled drooling. Tachycardia is not a key feature of this disease.

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which assessment findings would 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

ANS: A, C, D Neurogenic shock with acute spinal cord 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 does 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

ANS: A, C, D Older adults 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.

Which signs and symptoms indicate to the nurse that a client's TBI will be diagnosed as mild? select all that apply A. client appears dazed or stunned B. LOC (if any) was between 30-60 minutes C. nausea and vomiting D. headache E. difficulty with gait or balance F. sensitivity to noise

ANS: A, C, D, E, F

A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which assessment data would the nurse obtain to assess the client's coping strategies? (Select all that apply.) a. Spiritual beliefs b. Level of pain c. Family support d. Level of independence e. Annual income f. Previous coping strategies

ANS: A, C, D, F Info about the client's preinjury psychosocial status, methods of coping with illness, difficult situations, and disappointments would be obtained. Determine the client's level of independence and his comfort level in discussing feelings and emotions with family members or close friends. Clients who are emotionally secure and have a positive self-image, a supportive family, and financial and job security often adapt to their injury. Info about the client's spiritual and religious beliefs or cultural background also assists the nurse in developing the plan of care. The other options do not supply as much information about coping.

When assessing a client who has a TBI, the nurse notes that the client is drowsy, but easily aroused. What LOC will the nurse document? A. alert B. lethargic C. stuporous D. comatose

ANS: B

A client who had a complete spinal cord injury at level L5-S1 is admitted with a sacral pressure injury. What other assessment finding will the nurse anticipate for this client? a. Quadriplegia b. Flaccid bowel c. Spastic bladder d. Tetraparesis

ANS: B A low-level complete spinal cord injury (SCI) is a lower motor neuron injury because the reflect arc is damaged. Therefore, the client would be expected to have paraplegia and a flaccid bowel and bladder. Quadriplegia and tetraparesis are seen in clients with cervical or high thoracic SCIs.

A client is receiving IV alteplase and reports a sudden severe headache. What is the nurse's first action? a. Perform a comprehensive pain assessment. b. Discontinue the infusion of the drug. c. Conduct a neurologic assessment. d. Administer an antihypertensive drug.

ANS: B A severe headache may indicate that the client's blood pressure has markedly increased and, therefore, the drug should be stopped immediately as the first action. The nurse would then perform the appropriate assessments and possibly administer an antihypertensive medication.

A nurse is teaching a client who experiences migraine headaches and is prescribed propranolol. Which statement would the nurse include in this client's teaching? a. "Take this drug only when you have symptoms indicating the onset of a migraine headache." b. "Take this drug as prescribed, 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 drug will have no effect on your heart rate or blood pressure because you are taking it for migraines."

ANS: B Propranolol is a beta-adrenergic blocker which is prescribed as prophylactic treatment to prevent the vascular changes that initiate migraine headaches. Heart rate and blood pressure will also be affected, and the client would monitor these side effects. The other responses do not discuss appropriate uses of this drug.

When assessing a client who had a traumatic brain injury, the nurse notes that the client is drowsy but easily aroused. What level of consciousness will the nurse document to describe this client's current level of consciousness? a. Alert b. Lethargic c. Stuporous d. Comatose

ANS: B The client is categorized as being lethargic because he or she can be easily aroused even though drowsy. The nurse would carefully monitor the client to determine any decrease in the level of consciousness (LOC).

The nurse is teaching assistive personnel (AP) about care for a male client diagnosed with acute ischemic stroke and left-sided weakness. Which statement by the AP indicates understanding of the nurse's teaching? a. "I will use "yes" and "no" questions when communicating with the client." b. "I will remind the client frequently to not get out of bed without help." c. "I will offer a urinal every hour to the client due to incontinence." d. "I will feed the client slowly using soft or pureed foods."

ANS: B The client who has left-sided weakness has likely had a right-sided stroke in the brain. Clients who have strokes on the right side of the brain tend to be very impulsive and exhibit poor judgment. Therefore, to keep the client safe, the staff will need to remind the client to stay in bed unless he has assistance to prevent falling. There is no evidence in the clinical situation that the client has aphasia (which is less common in those with right-sided strokes), difficulty swallowing, or urinary incontinence.

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

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

After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes, acute confusion, and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse would the nurse take first? a. Assess the client's urinary output. b. Assess the client's serum sodium level. c. Increase the rate of the IV infusion. d. Provide oral care every hour.

ANS: B This client has signs and symptoms of hypernatremia, which is a possible complication after craniotomy. The nurse would assess the client's serum sodium level first and then possibly 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 numbness in his left leg. Currently the client's neurologic examination is normal. About what drug would the nurse plan to teach the patient? a. Alteplase b. Clopidogrel c. Heparin sodium d. Mannitol

ANS: B This client's signs and symptoms are consistent with a transient ischemic attack, and the client would likely be prescribed aspirin or clopidogrel to prevent platelet aggregation on discharge. Alteplase is used for ischemic stroke. Heparin and mannitol are not used for this condition.

A client is admitted with a confirmed left middle cerebral artery occlusion. Which assessment findings will the nurse expect? (Select all that apply.) a. Ataxia b. Dysphagia c. Aphasia d. Apraxia e. Hemiparesis/hemiplegia f. Ptosis

ANS: B, C, D, E, F All of these assessment findings are common in clients who have a stroke caused by an occlusion of the left middle cerebral artery with the exception of ataxia (most often present in clients who have cerebellar strokes). This artery supplies the majority of the left side of the brain where motor, sensory, speech, and language centers are located.

A client is admitted with a traumatic brain injury. What is the nurse's priority assessment? a. Complete neurologic assessment b. Comprehensive pain assessment c. Airway and breathing assessment d. Functional assessment

ANS: C Although the client has a brain injury, the most important assessment is to assess the client's ABCs, which includes airway, breathing, and circulation. The other assessments are performed later after the client is stabilized.

An 84-year-old client who is usually alert and oriented experiences an acute cognitive decline. Which of the following factors would the nurse anticipate as contributing to this neurologic change? (Select all that apply.) a. Chronic hearing loss b. Infection c. Drug toxicity d. Dementia e. Hypoxia f. Aging

ANS: B, C, E Acute client conditions that occur in older adults often cause acute confusion and associated emotional behaviors. Infection, drug toxicity, and hypoxia are all acute health problems that can contribute to the client's cognitive decline. Aging does not cause changes in cognition. If the client had dementia, he or she would not be alert and oriented. Having a chronic hearing loss is not a change in the client's condition.

A nurse is discharging a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management? (Select all that apply.) a. Does not want to purchase a thermometer. b. Is allergic to acetaminophen. c. Laughing, says "Strenuous? What's that?" d. Lives alone and is new in town with no friends. e. Plans to have a beer and go to bed once home.

ANS: B, D, E Clients who have mild traumatic brain injuries should take acetaminophen for headache. An allergy to this drug may mean that the patient takes aspirin or ibuprofen, which should be avoided. The patient needs neurologic checks every 1 to 2 hours, and this client does not seem to have anyone available who can do that. Alcohol needs to be avoided for at least 24 hours. A thermometer is not needed. The patient laughing at strenuous activity probably does not engage in any kind of strenuous activity, but the nurse should confirm this.

A client with multiple sclerosis is being discharged from rehabilitation. Which statement would the nurse include in the client's discharge teaching? a. "Be sure that you use a wheelchair when you go out in public." b. "Wear an undergarment brief at all times in case of incontinence." c. "Avoid overexertion, stress, and extreme temperature if possible." d. "Avoid having sexual intercourse to conserve energy."

ANS: C Clients who have multiple sclerosis have chronic fatigue and are prone to disease exacerbation (flare-up) is they overexert, are stressed, or are exposed to extreme temperature and humidity. They should not wear briefs unless they have actual problems with continence and should not use a wheelchair if they are able to ambulate with a cane or walker. Maintaining independence and self-esteem is important, so participating in sexual activities is encouraged.

The nurse is teaching the daughter of a client who has middle-stage Alzheimer disease. The daughter asks, "Will the sertraline my mother is taking improve her dementia?" How would the nurse respond about the purpose of the drug? a. "It will allow your mother to live independently for several more years." b. "It is used to halt the advancement of Alzheimer disease but will not cure it." c. "It will not improve her dementia but can help control emotional responses." d. "It is used to improve short-term memory but will not improve problem solving."

ANS: C Drug therapy is not effective for treating dementia or halting the advancement of Alzheimer disease. However, certain psychoactive drugs may help suppress emotional disturbances and manage depression, psychoses, or anxiety. Drug therapy will not allow the client with middle-stage dementia to safely live independently.

A client who is experiencing a traumatic brain injury has increasing intracranial pressure (ICP). What drug will the nurse anticipate to be prescribed for this client? a. Phenytoin b. Lorazepam c. Mannitol d. Morphine

ANS: C Increased intracranial pressure is often the result of cerebral edema as a result of traumatic brain injury. Therefore, as osmotic diuretic such as mannitol or a loop diuretic like furosemide is administered. The other drugs are not appropriate to manage increasing ICP.

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

ANS: C Participation in rehabilitation programs has many purposes, including prevention of disability, maintenance of functional ability, and restoration of function. The other responses do not meet this client's needs.

A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. After raising the head of the bed, what action would the nurse take next? a. Initiate oxygen via a nasal cannula. b. Recheck the client's blood pressure. c. Palpate the bladder for distention. d. Administer a prescribed beta blocker.

ANS: C The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury such as s stroke. The other actions are not appropriate for this complication.

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

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

The nurse is preparing a client for discharge from the emergency department after experiencing a transient ischemic attack (TIA). Before discharge, which factor would the nurse identify as placing the client at high risk for a stroke? a. Age greater than or equal to 75 b. Blood pressure greater than or equal to 160/95 c. Unilateral weakness during a TIA d. TIA symptoms lasting less than a minute

ANS: C The client who has a TIA is at risk for a stroke is he or she has one-sided (unilateral) weakness during a TIA. Risk factors also include an age greater than or equal to 60, blood pressure greater than or equal to 140/90 (either or both systolic and diastolic), and/or a long duration of TIA symptoms. One minute is not a very long time for symptoms to occur.

A nurse cares for a client with a spinal cord injury. With which interprofessional health team member would the nurse collaborate to assist the client with activities of daily living? a. Social worker b. Physical therapist c. Occupational therapist d. Case manager

ANS: C The occupational therapist instructs the patient in the correct use of all adaptive equipment. In collaboration with the therapist, the nurse instructs family members or the caregiver about transfer skills, feeding, bathing, dressing, positioning, and skin care. The other team members are consulted to assist the client with other issues.

After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the his understanding. Which client statements indicate a correct understanding of the teaching related to sexual effects of his injury? (Select all that apply.) a. "I will explore other ways besides intercourse to please my partner." b. "I will not be able to have an erection because of my injury." c. "Ejaculation may not be as predictable as before." d. "I may urinate with ejaculation but this will not cause infection." e. "I should be able to have an erection with stimulation."

ANS: C, D, E Men with injuries above T6 often are able to have erections by stimulating reflex activity. For example, stroking the penis will cause an erection. Ejaculation is less predictable and may be mixed with urine. However, urine is sterile, so the client's partner will not get an infection.

A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client's hips and sacrum. What actions would the nurse take? (Select allthat apply.) a. Apply a barrier cream to protect the skin from excoriation. b. Perform range-of-motion (ROM) exercises for the hip joint. c. Reposition the client off of the reddened areas. d. Get the client out of bed and into a chair several times a day. e. Apply a pressure-reducing mattress.

ANS: C, E Appropriate interventions to relieve pressure on the reddened areas include frequent repositioning, using a pressure-reducing mattress, and having the client sit in a chair to remove pressure from the hips and sacrum. Correct sitting position would allow the pressure to be on both ischial tuberosities. ROM exercises are used to prevent contractures.

A client recovering from a stroke reports double vision that is preventing client from completing ADLs. How would the nurse help the client compensate? A. approach client on the effected side B. encourage turning the head from side to side C. place objects in the clients field of vision D. cover the affected eye, if possible

ANS: D

What is the nurse's best interpretation when assessing a client with a TBI and finding that the right pupil appears more ovoid in shape than the left? A. an ovoid pupil is not significant unless the client has severe hypotension , changes in LOC, and respiratory distress B. an ovoid pupil is assumed to signal brain herniation in progress with a poor prognosis C. an ovoid pupil is considered a normal variation for a small percentage of clients who sustain minor head injuries D. an ovoid pupil is regarded as the mid-stage between a normal pupil and a dilated pupil and must be reported immediately.

ANS: D

The nurse is collaborating with the occupational therapist to assist a client with a complete cervical spinal cord injury to transfer from the bed to the wheelchair. What ambulatory aid would be most appropriate for the client to meet this outcome? a. Rolling walker b. Quad cane c. Adjustable crutches d. Sliding board

ANS: D A client who has a complete cervical spinal cord injury is unable to use any extremity except for parts of the hands and possibly the lower arms. Therefore, the client would be unable to use any of these ambulatory aids except for a sliding board, also known as a slider, which provides a "bridge" between the bed and a chair. The client uses his or her arms in a locked position to support the body while moving slowly across the board.

A client is admitted to the emergency department with a probable traumatic brain injury. Which assessment finding would be the priority for the nurse to report to the primary health care provider? a. Mild temporal headache b. Pupils equal and react to light c. Alert and oriented 3 d. Decreasing level of consciousness

ANS: D A decreasing level of consciousness is the first sign of increasing intracranial pressure, a potentially severe and possibly fatal complication of a traumatic brain injury (TBI). A mild headache would be expected for a client having a TBI. Equal reactive pupils and being alert and oriented are normal assessment findings.

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

ANS: D A fever is a poor prognostic indicator in patients with brain injuries. The nurse should see this client first. A Glasgow Coma Scale score of 12, a PaCO2 of 36, and amnesia for the incident are all either expected or positive findings.

The nurse is preparing to administer IV alteplase for a client diagnosed with an acute ischemic stroke. Which statement is correct about the administration of this drug? a. The recommended time for drug administration is within 90 minutes after admission to the emergency department. b. The drug is given in a bolus over the first 3 minutes followed by a continuous infusion. c. The maximum dosage of the drug, including the bolus, is 120 mg intravenously. d. The drug is not given to clients who are already on anticoagulant or antiplatelet therapy.

ANS: D Alteplase is a thrombolytic which dissolves clots and can cause bleeding as an adverse effect. Clients who are already taking an anticoagulant or antiplatelet agent are at risk for bleeding and therefore they are not candidates for alteplase therapy.

A client diagnosed with Parkinson disease will be starting ropinirole for symptom control. Which statement by the client indicates a need for further teaching? a. "This drug should help decrease my tremors and help me move better." b. "I need to change positions slowly to prevent dizziness or falls." c. "I should take the drug at the same time each day for the best effect." d. "I know the drug will probably make help me prevent constipation."

ANS: D Although ropinirole is a dopamine agonist and mimics dopamine to promote movement, it does not work to prevent constipation. This class of drugs can cause orthostatic hypotension and should be taken at the same time every day.

After teaching the wife of a client who has Parkinson disease, the nurse assesses the wife's understanding. Which statement by the client's wife indicates that she correctly understands changes associated with this disease? a. "His mask like 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."

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

The nurse is assessing a client diagnosed with trigeminal neuralgia affecting cranial nerve V. What assessment findings will the nurse expect for this client? a. Expressive aphasia b. Ptosis (eyelid drooping) c. Slurred speech d. Severe facial pain

ANS: D Cranial nerve (CN) V is the Trigeminal Nerve which has both a motor and sensory function in the face. When affected by a health problem, the client experiences severely facial pain. Expressive aphasia results from damage to the Broca speech area in the frontal lobe of the brain. Ptosis can result from damage to CN III and slurred speech often occurs from either damage to several cranial nerves or from damage to the motor strip in the frontal lobe of the brain.

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

ANS: D 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.

The primary health care provider prescribes donepezil for a client diagnosed with early-stage Alzheimer disease. What teaching about this drug will the nurse provide for the client's family caregiver? a. "Monitor the client's temperature because the drug can cause a low grade fever." b. "Observe the client for nausea and vomiting to determine drug tolerance." c. "Donepezil will prevent the client's dementia from progressing as usual." d. "Report any client dizziness or falls because the drug can cause bradycardia."

ANS: D Donepezil is a cholinesterase inhibitor that may temporarily slow cognitive decline for some clients but does not alter the course of the disease. The family caregiver would want to monitor the client's heart rate and report any incidence of dizziness or falls because the drug can cause bradycardia. It does not typically cause fever or nausea/vomiting.

The nurse plans care for a client with Parkinson disease. Which intervention would the nurse include in this client's plan of care? a. Restrain the client to prevent falling. b. Ensure that the client uses incentive spirometry. c. Teach the client pursed-lip breathing techniques. d. Keep the head of bed at 30 degrees or greater.

ANS: D Elevation of 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. Pursed-lip breathing increases exhalation of carbon dioxide; incentive spirometry expands the lungs. The client should not be restrained to prevent falls. Other less restrictive interventions should be used to maintain client safety.

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

ANS: D Investigate specific concerns about situational or role changes before providing additional information. The nurse would not tell the client what is or is not a priority for him or her. Although community resources may be available, they may not be appropriate for the patient. Consulting a psychologist would not be appropriate without obtaining further information from the client related to current concerns.

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

ANS: D No post-procedure 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 client's urine would not be radioactive. The procedure does not impact the client's gag reflex

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

ANS: D 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 due to interference with diaphragmatic innervation. The other actions would be performed after airway and breathing are assessed.

The nurse is taking a history from a daughter about her father's onset of stroke signs and symptoms. Which statement by the daughter indicates that the client likely had an embolic stroke? a. Client's symptoms occurred slowly over several hours. b. Client because increasingly lethargic and drowsy. c. Client reported severe headache before other symptoms. d. Client has a long history of atrial fibrillation.

ANS: D The major cause of embolic strokes is a history of heart disease, especially atrial fibrillation. Most clients who have an embolic stroke have acute sudden neurologic symptoms but stay alert rather than lethargic. Decreasing level of consciousness and severe headache are more common in clients who have hemorrhagic strokes.