neuro management ?s
An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client? a) Trigeminal neuralgia b) Epilepsy c) Hypostatic pneumonia d) Brain tumor
Brain tumor Explanation: The incidence of brain tumor decreases with age. Headache and papilledema are less common symptoms of a brain tumor in the older adult. Symptoms of epilepsy include fits and spasms, while symptoms of trigeminal neuralgia would be pain in the jaws or facial muscles. Hypostatic pneumonia develops due to immobility or prolonged bed rest in older clients.
At which of the following spinal cord injury levels does the patient have full head and neck control? a) C2 b) C5 c) C4 d) C3
Correct response: C5 Explanation: At the level of C5, the patient should have full head and neck control, shoulder strength, and elbow flexion. At C4 injury, the patient will have good head and neck sensation and motor control, some shoulder elevation, and diaphragm movement. At C2 to C3, the patient will have head and neck sensation, some neck control, and can be independent of mechanical ventilation for short periods of time
When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication? a) Shock b) Status epilepticus c) Encephalitis d) Increased intracranial pressure (ICP)
Increased intracranial pressure (ICP) Correct Explanation: When ICP increases, Cushing's triad may develop, which involves decreased heart and respiratory rates and increased systolic blood pressure. Shock typically causes tachycardia, tachypnea, and hypotension. In encephalitis, the temperature rises and the heart and respiratory rates may increase from the effects of fever on the metabolic rate. (If the client doesn't maintain adequate hydration, hypotension may occur.) Status epilepticus causes unceasing seizures, not changes in vital signs
Following a motorcycle accident, a client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure? a) Blood pressure 100/60 mm Hg b) Nausea c) Periorbital edema d) Lethargy
Lethargy Correct Explanation: Decreasing level of consciousness is one of the earliest signs of increased ICP. Without a baseline for the BP, it is difficult to determine whether this is a significant change for this client. Vomiting (usually without forewarning of nausea) when associated with a head injury suggests increasing ICP. Perioribital edema is more suggestive of fluid overload than ICP
A patient 3 days postoperative from a craniotomy informs the nurse, "I feel something trickling down the back of my throat and I taste something salty." What priority intervention does the nurse initiate? a) Request an antihistamine for the postnasal drip. b) Ask the patient to cough to observe the sputum color and consistency. c) Notify the physician of a possible cerebrospinal fluid leak. d) Give the patient some mouthwash to gargle with.
Notify the physician of a possible cerebrospinal fluid leak. Correct Explanation: Any sudden discharge of fluid from a cranial incision is reported at once, because a large leak requires surgical repair. Attention should be paid to the patient who complains of a salty taste or "postnasal drip," because this can be caused by cerebrospinal fluid trickling down the throat.
A patient is diagnosed with an aggressive, primary malignant brain tumor. The nurse is aware that the glioma: a) Metastasized from a cancer in another part of the body. b) Originated within the brain tissue. c) Originated from the coverings of the brain. d) Developed on the cranial nerves.
Originated within the brain tissue. Correct Explanation: The most aggressive type of malignant brain tumor is a glioma, which originates within the brain tissue.
A patient is admitted to the hospital for management of an extrapyramidal disorder. Included in the physician's admitting orders are the medications levodopa, Cogentin, and Eldepryl. The nurse knows that most likely, the client has a diagnosis of ________. a) Parkinson's disease b) Seizure disorder c) Multiple sclerosis d) Huntington's disease
Parkinson's disease Explanation: These drugs are commonly used in the medical management of Parkinson's disease. Although antiparkinson drugs are used in some clients with Huntington's disease, these drugs are commonly used in the medical management of Parkinson's disease. The listed medications are not used to treat a seizure disorder. The listed medications are not used to treat MS.
Which of the following drugs may be used after a seizure to maintain a seizure-free state? a) Valium b) Phenobarbital c) Ativan d) Cerebyx
Phenobarbital Correct Explanation: IV diazepam (Valium), lorazepam (Ativan), or fosphenytoin (Cerebyx) are administered slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are administered later to maintain a seizure-free state. In general, a single drug is used to control the seizures
A client diagnosed with Huntington's disease has developed severe depression. What would be most important for the nurse to assess for? a) Choreiform movements b) Emotional apathy c) Suicidal ideations d) Loss of bowel and bladder contro
Suicidal ideations Correct Explanation: Severe depression is common and can lead to suicide, so it is most important for the nurse to assess for suicidal ideations. Symptoms of Huntington's disease develop slowly and include mental apathy and emotional disturbances, choreiform movements (uncontrollable writhing and twisting of the body), grimacing, difficulty chewing and swallowing, speech difficulty, intellectual decline, and loss of bowel and bladder control. Assessing for these symptoms is appropriate, but not as important as assessing for suicidal ideations
Which of the following positions should be utilized after supratentorial intracranial surgery? a) Sitting position b) Body and head aligned c) Supine position with head slightly elevated d) Bed rest with a firm mattress and bed board
Supine position with head slightly elevated Correct Explanation: After surgery, the nurse should place the patient in either a supine position with the head slightly elevated or a side-lying position on the unaffected side. Bed rest with a firm mattress and bed board is used for patients with a lumbar herniated disk. Sitting position and body and head aligned are the correct positions to place the patient after the surgery. (less)
Which of the following is a disease in which there is a loss of motor neurons in the anterior horns of the spinal cord and motor nuclei of the lower brain stem? a) Parkinson's disease (PD) b) Amyotrophic lateral sclerosis (ALS) c) Huntington disease d) Alzheimer's disease
Amyotrophic lateral sclerosis (ALS) Correct Explanation: ALS is a disease of unknown cause in which there is a loss of motor neurons in the anterior horns of the spinal cord and the motor nuclei of the lower brain stem. Parkinson's disease is a slowly progressing neurologic movement disorder that eventually leads to disability. Alzheimer's disease is a chronic, progressive, and degenerative brain disorder that is accompanied by profound effects on memory, cognition and ability for self-care. Huntington disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary choreiform movement and dementia
A nurse is caring for a patient with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis? a) Chewing b) Smelling c) Tasting d) Swallowing
Chewing Correct Explanation: Trigeminal neuralgia is a painful condition that involves the fifth (V) cranial nerve (the trigeminal nerve) and is important to chewing. Trigeminal neuralgia involves the fifth (V) cranial nerve (the trigeminal nerve) and is important to chewing. Trigeminal neuralgia involves the fifth (V) cranial nerve (the trigeminal nerve) and is important to chewing. Trigeminal neuralgia involves the fifth (V) cranial nerve (the trigeminal nerve) and is important to chewing. (less)
Which of the following types of posturing is exhibited by abnormal flexion of the upper extremities and extension of the lower extremities? a) Flaccid b) Normal c) Decerebrate d) Decorticate
Decorticate Correct Explanation: Decorticate posturing is an abnormal posture associated with severe brain injury, characterized by abnormal flexion of the upper extremities and extension of the lower extremities. Decerebration is an abnormal body posture associated with a severe brain injury, characterized by extreme extension of the upper and lower extremities. Flaccidity occurs when the patient has no motor function, is limp, and lacks motor tone.
The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began? a) Muscle spasms b) Shortness of breath c) Sensitivity to bright light d) Drooping eyelids
Drooping eyelids Explanation: Ptosis is the most common manifestation of myasthenia gravis. Muscle weakness varies depending on the muscles affected. Shortness of breath and respiratory distress occurs later as the disease progresses. Muscle spasms are more likely in multiple sclerosis. Photophobia is not significant in myasthenia gravis
The nurse is caring for a patient immediately following supratentorial intracranial surgery. What action by the nurse is appropriate? a) Place patient in prone position with head turned to unaffected side. b) Place patient in the Trendelenburg position. c) Place patient in the dorsal recumbent position. d) Place patient in supine position with head slightly elevated.
Place patient in supine position with head slightly elevated. Correct Explanation: After surgery, the nurse should place the patient in either a supine position with the head slightly elevated or a side-lying position on the unaffected side. The dorsal recumbent position, the Trendelenburg position, and the prone position can increase intracranial pressure
A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following? a) Intracranial pressure is increased by a space-occupying bleed. b) A ruptured intracranial aneurysm must quickly be repaired. c) A ruptured arteriovenous malformation will cause deficits until it is stopped. d) Thrombolytic therapy has a time window of only 3 hours.
d
Choice Multiple question - Select all answer choices that apply. Which of the following nursing interventions might need to be considered in a care plan for a client with advanced multiple sclerosis? Select all that apply. a) Ensure access to language board when communicating with client. b) Obtain daily weights to monitor weight gain. c) Establish a voiding time schedule. d) Encourage client to walk with feet wide apart.
• Ensure access to language board when communicating with client. • Establish a voiding time schedule. • Encourage client to walk with feet wide apart. Explanation: Language assistive devices may be needed if communication is severely affected. Occasional bladder incontinence may lead to total incontinence. A voiding time schedule will allow the client greater independence. If motor dysfunction causes problems of incoordination and clumsiness, the patient is at risk for falling. As the disease progresses, nutritional deficiencies may develop. Weight should be assessed to ensure that there is no significant weight loss
