Neuro

11. The nurse is preparing materials for the families of patients who have sustained a stroke. What information should the nurse include to reduce the risk for additional strokes? 1) Heart-healthy diet 2) Smoking cessation 3) Stress management 4) Weight-reduction strategies

1) A heart-healthy diet might be appropriate if the stroke is caused by atherosclerosis. 2) Smoking cessation is essential for the nurse to include. Exposure to nicotine due to cigarette smoking causes a decrease in oxygen levels in the blood, which may contribute to blood clot formation and vasoconstriction with each inhalation of smoke. Additionally, nicotine may cause more rapid deposition and accumulation of atherosclerotic plaque. Patients may be more willing to consider smoking cessation after an illness such as stroke. 3) Stress management has not been identified as essential teaching to reduce the risk of stroke. 4) Weight reduction has not been identified as essential teaching to reduce the risk of stroke.

A patient with Guillain-Barré syndrome (GBS) asks how the illness develops. What should the nurse respond about the pathophysiology of the disorder? 1) "An infection eats away at the nerve endings." 2) "An infection enters the spinal cord and erodes the nerves at the roots." 3) "The nerves are killed by infiltration of your body's white blood cells used to fight an infection." 4) "After an infection your immune system created antibodies that affect the covering of the nerves."

1) An infection does not eat away at the nerve endings in GBS. 2) An infection does not enter the spinal cord and erode the nerves at the roots in GBS. 3) The nerves are not killed by the body's white blood cells in GBS. 4) In GBS, the patient's own immune system begins to destroy the myelin that surrounds the peripheral nerves. Destruction occurs between the nodes of Ranvier that results in slowing of impulses or conduction block. There is infiltration of lymphocytes into the peripheral nervous system, which attracts macrophages; the macrophages penetrate the Schwann cell and invade the myelin resulting in demyelination.

27. A patient is being discharged after treatment for an ischemic stroke. Which medications should the nurse expect to be prescribed for this patient? Select all that apply. 1) Antibiotics 2) Anticoagulant 3) Antihypertensive 4) Antiplatelet therapy 5) Lipid-lowering agent

1) Antibiotics are not routinely prescribed in the treatment of an ischemic stroke. 2) According to primary stroke center accreditation guidelines, stroke patients should be discharged with anticoagulation if indicated for atrial fibrillation. 3) According to primary stroke center accreditation guidelines, stroke patients should be discharged with a blood pressure control strategy in patients with hypertension. 4) According to primary stroke center accreditation guidelines, stroke patients should be discharged with antiplatelet therapy. 5) According to primary stroke center accreditation guidelines, stroke patients should be discharged with lipid-lowering therapy if indicated.

27. The nurse is assessing a patient with multiple sclerosis. What should the nurse expect to assess in this patient? Select all that apply. 1) Anxiety 2) Dizziness 3) Double vision 4) Unsteady gait 5) Electric shocks with head movement

1) Anxiety is not an identified manifestation of multiple sclerosis. Depending on the location of the affected nerve fibers, a manifestation of multiple sclerosis includes dizziness, double vision, unsteady gait, and includes electric shocks with head movement.

A patient is experiencing bilateral symmetrical muscle weakness and sensory changes of both feet and legs. What should the nurse expect to assess that determines the presence of Guillain-Barré syndrome (GBS)? 1) Areflexia 2) Hyporeflexia 3) Hyperreflexia 4) Hyperanalgesia

1) Areflexia is recognized as a key finding in GBS. 2) The reflexes in a patient with GBS will be absent and not just diminished. 3) The reflexes in a patient with GBS will be absent and not exaggerated. 4) There is no evidence to suggest that the patient with GBS will have a heightened pain response.

The nurse notes that a patient with Guillain-Barré syndrome (GBS) sweats profusely. What should the nurse do about this finding? 1) Place on a cooling blanket 2) Notify the health-care provider 3) Monitor body temperature every two hours 4) Change linen and gown and keep comfortable

1) Autonomic dysfunction is causing the sweating. The patient does not have a temperature. 2) The health-care provider does not need to be notified. 3) The patient does not have a fever. Autonomic dysfunction is causing the sweating. 4) Patients with GBS may perspire because of autonomic manifestations, and the patient's clothing and linens require frequent changes.

The nurse is caring for a patient with myasthenia gravis. Which assessment should the nurse complete to determine respiratory functioning? 1) Vital capacity 2) Pulse oximetry 3) Auscultate lung sounds 4) Arterial blood gas analysis

1) Because of the potential for respiratory weakness, a bedside test known as the vital capacity is performed. 2) Pulse oximetry is not helpful in determining respiratory deterioration in a patient with myasthenia gravis because failure is due to weakness of the diaphragm and intercostal muscles. 3) Auscultating lung sounds will not help determine oxygenation at the cellular and capillary level. 4) An arterial blood gas is a prescribed and obtained by a health-care provider. It is beyond the nurse's scope of practice to draw this sample for analysis.

The nurse notes that a patient with myasthenia gravis is experiencing bulbar manifestations. On what should the nurse focus when assessing this patient? Select all that apply. 1) Swallowing 2) Eye opening 3) Blood pressure 4) Tongue movement 5) Head and neck movement

1) Bulbar manifestations affect CN IX, which controls swallowing. 2) Eye opening is an ocular manifestation of myasthenia gravis. 3) Bulbar manifestations affect CN IX, which has a role in blood pressure control. 4) Bulbar manifestations affect CN XII, which controls tongue movement. 5) Bulbar manifestations affect CN XI, which controls movement of the head and neck.

4. A patient reports a change in the taste of food. Which cranial nerve should the nurse suspect as being affected? 1) CN VII Facial 2) CN V Trigeminal 3) CN XI Accessory 4) CN XII Hypoglossal

1) CN VII Facial influences taste. 2) CN V Trigeminal controls touch, temperature, pain sensations from the upper and lower face, and chewing. 3) CN XI Accessory controls swallowing and head, neck, and shoulder movements. 4) CN XII Hypoglossal controls tongue movement with speech, food manipulation, and swallowing.

8. Which technique should the nurse use to assess a patient's CN IX Glossopharyngeal? 1) Apply a tongue depressor to the back of the throat 2) Ask the patient to read from a book or a newspaper 3) Ask the patient to smile, frown, puff cheeks, and raise eyebrows 4) Ask the patient to follow the examiner's finger as it is moved toward the patient's nose

1) CN XI Glossopharyngeal is assessed by applying a tongue depressor to the back of the throat to check for a gag reflex. 2) Reading assesses CN II Optic. 3) Smiling, frowning, puffing out the cheeks, and raising the eyebrows assesses CN VII Facial. 4) Having the patient follow a finger as it is moved toward the nose assesses CN IV Trochlear.

23. The nurse contacts the health-care provider with data collected from a patient recovering from a stroke. Which information indicated the patient was experiencing central herniation? Select all that apply. 1) Coma 2) Bradycardia 3) Positive Babinski's 4) Unilateral dilated pupil 5) Increased systolic blood pressure

1) Clinical manifestations of central herniation include coma. 2) Clinical manifestations of central herniation include bradycardia. 3) Clinical manifestations of central herniation include positive Babinski's. 4) Unilateral dilated pupil is a clinical manifestation of uncal herniation. 5) Clinical manifestations of central herniation include increased systolic blood pressure.

9. A patient with multiple sclerosis is admitted for treatment of clinical manifestations. What should the nurse expect to be prescribed for this patient? 1) Corticosteroids 2) Beta interferons 3) Muscle relaxants 4) Immunosuppressive agents

1) Corticosteroids are used to treat attacks. 2) Beta interferons are used to modify the disease course. 3) Medications used to treat clinical manifestations include muscle relaxants. 4) Immunosuppressive agents are used to modify the disease course.

10. A patient with multiple sclerosis is developing speech difficulties. What should the nurse realize as being the reason for this new manifestation? 1) Depression 2) Medications 3) Nerve regeneration 4) Mental status changes

1) Depression is an adverse effect of the disease. It does not cause speech deficits. 2) Speech defects due to muscle weakness may be due to medications. 3) Nerve regeneration would improve speech. 4) Mental status changes is an adverse effect of the disease. It does not cause speech deficits.

18. A patient with Parkinson's disease is prescribed carbidopa/levodopa (Sinemet). Which clinical manifestation should the nurse expect to be most affected with this medication? 1) Tremors 2) Mood instability 3) Impaired balance 4) Behavioral changes

1) Dopamine precursors such as carbidopa/levodopa (Sinemet) are later utilized and are most effective in the treatment of tremors. Dopamine precursors are not identified to target mood instability, impaired balance, or behavioral changes.

8. A patient receives a definitive diagnosis of multiple sclerosis. What finding occurred to validate this diagnosis? 1) Onset of double vision 2) Loss of bowel and bladder control 3) Numbness and tingling of one limb 4) MRI changes in two separate locations.

1) Double vision is a manifestation of multiple sclerosis; however, it does not provide a definitive diagnosis of the disease. 2) Loss of bowel and bladder control is a manifestation of a herniated disk. 3) Numbness and tingling of one limb is a manifestation of multiple sclerosis; however, it does not provide a definitive diagnosis of the disease. 4) For a definitive diagnosis multiple sclerosis, the patient must have MRI changes in at least two separate locations.

14. A client with amyotrophic lateral sclerosis is prescribed riluzole (Rilutek). What statement indicates additional teaching is required about the effects of this medication? 1) "This will cure my disease." 2) "This will help me stay awake." 3) "This will stop my bladder spasms." 4) "This will increase the progression of my disease."

1) Riluzole (Rilutek) does not repair damaged neurons but has been shown both to increase survival and to extend the period without the need for ventilator support. 2) Analeptics improve wakefulness. 3) Antispasmodics improve bladder spasms. 4) Riluzole (Rilutek) is the first drug approved to slow disease progression.

The nurse is reviewing orders written for a patient with myasthenia gravis. Which medication order should the nurse question before administering? Select all that apply. 1) Verapamil 2) Furosemide 3) Erythromycin 4) Nicotine patch 5) Warfarin sodium

1) The antiarrhythmic verapamil is known to aggravate myasthenia gravis. 2) Furosemide is not identified as aggravating myasthenia gravis. 3) Erythromycin is an antibiotic known to aggravate myasthenia gravis. 4) Nicotine patch is known to aggravate myasthenia gravis. 5) Warfarin sodium, an anticoagulant, is not identified as aggravating myasthenia gravis.

17. A patient returns to the community clinic after being diagnosed with Parkinson's disease. What should the nurse expect to see documented in the patient's medical record to support this diagnosis? 1) Rigidity with ambulation 2) Unremarkable electroencephalogram 3) Results of serum potassium and calcium levels 4) Integrity of cerebral vessels after a cerebral angiogram

1) The diagnosis of Parkinson's disease is made when two or more cardinal symptoms with asymmetrical presentation—such as rigidity—are observed in the absence of other causes. Progressive decline in motor function accompanied by rigidity is typically how the diagnosis is made. 2), 3), 4) There are no specific diagnostic studies to confirm Parkinson's disease. This would not be documented in this patient's medical record.

A client is diagnosed with myasthenia gravis. What should the nurse explain about this disease process? 1) "Your nerve endings are worn out." 2) "Your body does not recognize the neurotransmitter needed for movement." 3) "Your body does not make enough of the neurotransmitter needed for movement." 4) "Your nerves have lost their protective covering and impulses cannot reach body areas."

1) The nerve endings are not worn out in myasthenia gravis. 2) In myasthenia gravis the postsynaptic receptor sites are unavailable. 3) The amount of neurotransmitter is not altered in myasthenia gravis. 4) The nerves in myasthenia gravis have not lost their protective covering or myelin sheath.

The nurse is reviewing discharge instructions for a patient with myasthenia gravis. What should the nurse emphasize regarding medications? 1) Keep extra doses of medication in the car 2) Store extra doses of medication in the refrigerator 3) Take an extra dose of medication before leaving the house 4) Pack prescribed medications in a suitcase before flying on an airplane

1) The patient should be instructed to keep medication available at all times. Spare doses should be kept in the car. 2) Extra doses of the medication do not need to be stored in the refrigerator. 3) The medication should be taken as prescribed. Efforts should be taken to not miss doses but not to take extra doses. 4) When the patient travels, medication should remain with the patient in carry-on luggage.

A patient seeks treatment for progressively deteriorating motor and sensory function. What question is essential for the nurse to ask when completing this patient's health history? 1) "Have you been around any small children?" 2) "When was the last time you had anything to eat?" 3) "When was the last time you traveled out of the country?" 4) "Have you recently experienced any lung or stomach infections?"

1) There is no evidence to suggest that GBS is transmitted from small children. 2) Recent ingestion of food most likely did not cause the patient's symptoms. 3) Traveling out of the country is not directly linked to the development of GBS. 4) About two-thirds of patients who develop GBS demonstrate clinical manifestations of an infection three weeks prior to onset. Respiratory or gastrointestinal infections are the most common sources.

2. The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestation would the nurse document? 1. Hemiparesis of the client's left arm and apraxia. 2. Paralysis of the right side of the body and ataxia. 3. Homonymous hemianopsia and diplopia. 4. Impulsive behavior and hostility toward family.

1. A left-sided cerebrovascular accident (CVA) will result in right-sided motor deficits; hemi- paresis is weakness of one-half of the body, not just the upper extremity. Apraxia, the inability to perform a previously learned task, is a com- munication loss, not a motor loss. 2. The most common motor dysfunction ofa CVA is paralysis of one side of the body, hemiplegia; in this case with a left-sided CVA, the paralysis would affect the right side. Ataxia is an impaired ability to coordi- nate movement. 3. Homonymous hemianopsia (loss of half of the visual field of each eye) and diplopia (double vision) are visual field deficits that a client with a CVA may experience, but they are not motor losses. 4. Personality disorders occur in clients with a right-sided CVA and are cognitive deficits; hostility is an emotional deficit. TEST TAKING HINT: Be sure to always notice adjectives describing something. In this case, "left-sided" describes the type of CVA. Also be sure to identify exactly what the question is asking—in this case, about "motor loss," which will help rule out many of the possible answer options.

107. The client with end-stage ALS requires a gastrostomy tube feeding. Which finding would require the nurse to hold a bolus tube feeding? 1. A residual of 125 mL. 2. The abdomen is soft. 3. Three episodes of diarrhea. 4. The potassium level is 3.4 mEq/L.

1. A residual (aspirated gastric contents) of greater than 50 to 100 mL indicates that the tube feeding is not being digested and that the feeding should be held. 2. A soft abdomen is normal; a distended abdomen would be cause to hold the feeding. 3. Diarrhea is a common complication of tube feedings, but it is not a reason to hold the feeding. 4. The potassium level is low and needs intervention, but this would not indicate a need to hold the bolus tube feeding. TEST TAKING HINT: Knowing normal assessment data would lead the test taker to eliminate option "2" as a possible correct answer. Diarrhea and hypokalemia would not cause the client to not receive a feeding. Even if the test taker did not know what "residual" means, this would be the best option.

79. The nurse researcher is working with clients diagnosed with Parkinson's disease. Which is an example of an experimental therapy? 1. Stereotactic pallidotomy/thalamotomy. 2. Dopamine receptor agonist medication. 3. Physical therapy for muscle strengthening. 4. Fetal tissue transplantation.

1. A stereotactic pallidotomy and/or thalamotomy are surgeries that use CT or MRI scans to localize specific areas of the brain in which to produce lesions in groups of brain cells through electrical stimulation or thermocoagulation. These procedures are done when medication has failed to control tremors. 2. Dopamine receptor agonists are medications that activate the dopamine receptors in the striatum of the brain. 3. Physical therapy is a standard therapy used to improve the quality of life for clients diag- nosed with PD. 4. Fetal tissue transplantation has shown some success in PD, but it is an ex- perimental and highly controversial procedure. TEST TAKING HINT: The test taker should not overlook the adjective "experimental." This would eliminate at least option "3," physi- cal therapy, and option "2," which refers to standard dopamine treatment, even if the test taker was not familiar with all of the procedures.

75. The nurse caring for a client diagnosedwith Parkinson's disease writes a problemof "impaired nutrition." Which nursing intervention would be included in the plan of care? 1. Consult the occupational therapist for adaptive appliances for eating. 2. Request a low-fat, low-sodium diet from the dietary department. 3. Provide three (3) meals per day that include nuts and whole-grain breads. 4. Offer six (6) meals per day with a soft consistency.

1. Adaptive appliances will not help the client's shaking movements and are not used for clients with Parkinson's disease. 2. Clients with Parkinson's disease are placed on high-calorie, high-protein, soft or liquid diets. Supplemental feedings may also be ordered. If liquids are ordered because of difficulty chewing, then the liquids should be thickened to a honey or pudding consistency. 3. Nuts and whole-grain food would require ex- tensive chewing before swallowing and would not be good for the client. Three large meals would get cold before the client can consume the meal, and one-half or more of the food would be wasted. 4. The client's energy levels will not sustain eating for long periods. Offering frequent and easy-to-chew (soft) meals of small proportions is the preferred dietary plan. TEST TAKING HINT: The correct answer for a nursing problem question must address the actual problem.

3. The client comes to the clinic and reports a sudden drooping of the left side of the face and complains of pain in that area. The nurse notes that the client cannot wrinkle the forehead or close the left eye. Which condition should the nurse suspect? 1. Bell's palsy. 2. Right-sided stroke. 3. Tetany. 4. Mononeuropathy.

1. Bell's palsy, called facial paralysis, is a disorder of the 7th cranial nerve (facial nerve) characterized by unilateral paralysis of facial muscles. 2. These are symptoms of a left-sided stroke. 3. Tetany is due to low calcium levels. In this disorder, the face twitches when touched; this is known as a positive Chvostek's sign. 4. Mononeuropathy is limited to a single peripheral nerve and its branches and occurs because the trunk of the nerve is compressed, such as in carpal tunnel syndrome.

5. The client has glossopharyngeal nerve (cranial nerve IX) paralysis secondary to a stroke. Which referral would be most appropriate for this client? 1. Hospice nurse. 2. Speech therapist. 3. Physical therapist. 4. Occupational therapist.

1. Clients are referred to hospice when there is a life expectancy of less than six (6) months. This client has difficulty swallowing, which is not life threatening. 2. Speech therapists address the needs of clients who have difficulty with the innervations and musculature of the face and neck. This includes the swallow- ing reflex. 3. The physical therapist assists the client to ambulate and transfer (e.g., from bed to chair) and with muscle strength training. 4. The occupational therapist focuses on cognitive disability and activities of daily living.

105. The client is in the terminal stage of ALS. Which intervention should the nurse implement? 1. Perform passive ROM every two (2) hours. 2. Maintain a negative nitrogen balance. 3. Encourage a low-protein, soft-mechanical diet. 4. Turn the client and have him cough and deep breathe every shift.

1. Contractures can develop within a week because extensor muscles are weaker than flexor muscles. If the client cannot perform ROM exercises, then the nurse must do it for him—passive ROM. 2. The client should maintain a positive nitrogen balance to promote optimal body functioning. 3. Adequate protein is required to maintain osmotic pressure and prevent edema. 4. The client is usually on bedrest in the last stages and should be turned and told to cough and deep breathe more often than every shift. TEST TAKING HINT: "Terminal stage" is the key term in the stem that should cause the test taker to look for an option addressing immobility issues—option "1." An interven- tion implemented only once in every shift should be eliminated as a possible answer when addressing immobility issues.

81. The nurse is admitting a client with the diagnosis of Parkinson's disease. Which assessment data support this diagnosis? 1. Crackles in the upper lung fields and jugular vein distention. 2. Muscle weakness in the upper extremities and ptosis. 3. Exaggerated arm swinging and scanning speech. 4. Masklike facies and a shuffling gait.

1. Crackles and jugular vein distention indicate heart failure, not PD. 2. Upper extremity weakness and ptosis are clinical manifestations of myasthenia gravis. 3. The client has very little arm swing, and scanning speech is a clinical manifestation of multiple sclerosis. 4. Masklike facies and a shuffling gait are two clinical manifestations of PD. TEST TAKING HINT: Option "3" refers to arm swing and speech, both of which are affected by PD. The test taker needs to decide if the adjectives used to describe these activities—"exaggerated" and "scanning"— are appropriate. They are not, but masklike facies and shuffling gait are.

98. The client is diagnosed with ALS. Which client problem would be most appropriate for this client? 1. Disuse syndrome. 2. Altered body image. 3. Fluid and electrolyte imbalance. 4. Alteration in pain.

1. Disuse syndrome is associated with com- plications of bedrest. Clients with ALS cannot move and reposition themselves, and they frequently have altered nutritional and hydration status. 2. The client does not usually have a change in body image. 3. ALS is a disease affecting the muscles, not the kidneys or circulatory system. 4. ALS is not painful. TEST TAKING HINT: The test taker would have to be knowledgeable about ALS to answer this question. This disease is chronic and debilitating over time and leads to wasting of the muscles.

97. Which diagnostic test is used to confirm the diagnosis of Amyotropic Lateral Sclerosis (ALS)? 1. Electromyogram (EMG). 2. Muscle biopsy. 3. Serum creatine kinase (CK). 4. Pulmonary function test.

1. EMG is done to differentiate a neuropathy from a myopathy, but it does not confirm ALS. 2. Biopsy confirms changes consistent with atrophy and loss of muscle fiber, both characteristic of ALS. 3. CK may or may not be elevated in ALS so it cannot confirm the diagnosis of ALS. 4. This is done as ALS progresses to determine respiratory involvement, but it does not con- firm ALS. TEST TAKING HINT: The test taker must be clear as to what the question is asking. The word "confirm" is the key to answering this question correctly. The test taker would need to know that this disease affects the muscle tissue to correctly identify the answer.

101. The client with ALS is admitted to the medical unit with shortness of breath, dyspnea, and respiratory complications. Which intervention should the nurse implement first? 1. Elevate the head of the bed 30 degrees. 2. Administer oxygen via nasal cannula. 3. Assess the client's lung sounds. 4. Obtain a pulse oximeter reading.

1. Elevating the head of the bed will enhance lung expansion, but it is not the first intervention. 2. Oxygen should be given immediatelyto help alleviate the difficulty breathing. Remember that oxygenation is a priority. 3. Assessment is the first part of the nursing process and is a priority, but assessment will not help the client breathe easier. 4. This is an appropriate intervention, but obtaining the pulse oximeter reading will not alleviate the client's respiratory distress. TEST TAKING HINT: The test taker should not automatically select assessment. Make sure that there is not another intervention that will directly help the client, especially if the client is experiencing a life-threatening complication.

4. The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply. 1. Position the client to prevent shoulder adduction. 2. Turn and reposition the client every shift. 3. Encourage the client to move the affected side. 4. Perform quadriceps exercises three (3) times a day. 5. Instruct the client to hold the fingers in a fist.

1. Placing a small pillow under the shoulder will prevent the shoulder from adduct- ing toward the chest and developing a contracture. 2. The client should be repositioned at least every two (2) hours to prevent contractures, pneumonia, skin breakdown, and other com- plications of immobility. 3. The client should not ignore the para- lyzed side, and the nurse must encourage the client to move it as much as possible; a written schedule may assist the client in exercising. 4. These exercises are recommended, but they must be done at least five (5) times a day for10 minutes to help strengthen the muscles for walking. 5. The fingers are positioned so that they are barely flexed to help prevent contracture of the hand. TEST TAKING HINT: Be sure to look at the in- tervals of time for any intervention; note that "every shift" and "three (3) times a day" are not appropriate time intervals for this client. Because this is a "select all that apply" ques- tion, the test taker must read each answer option and decide if it is correct; one will not eliminate another.

9. The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care? 1. Potential for injury. 2. Powerlessness. 3. Disturbed thought processes. 4. Sexual dysfunction.

1. Potential for injury is a physiological, not a psychosocial, problem. 2. Expressive aphasia means that the client cannot communicate thoughts but under- stands what is being communicated; this leads to frustration, anger, depression, and the inability to verbalize needs, which, in turn, causes the client to have a lack of control and feel powerless. 3. A disturbance in thought processes is a cognitive problem; with expressive aphasia the cli- ent's thought processes are intact. 4. Sexual dysfunction can have a psychosocial or physical component, but it is not related to expressive aphasia. TEST TAKING HINT: The test taker should always make sure that the choice selected as the correct answer matches what the ques- tion is asking. The stem has the adjective "psychosocial," so the correct answer must address psychosocial needs.

103. The nurse is caring for several clients on a medical unit. Which client should the nurse assess first? 1. The client with ALS who is refusing to turn every two (2) hours. 2. The client with abdominal pain who is complaining of nausea. 3. The client with pneumonia who has a pulse oximeter reading of 90%. 4. The client who is complaining about not receiving any pain medication.

1. Refusing to turn needs to be addressed by the nurse, but it is not a priority over a life- threatening condition. 2. Nausea needs to be assessed by the nurse, but it is not a priority over an oxygenation problem. 3. A pulse oximeter reading of less than 93% indicates that the client is experiencing hypoxemia, which is a life-threatening emergency. This client should be assessed first. 4. The nurse must address the client's com- plaints, but it is not a priority over a physiological problem. TEST TAKING HINT: The test taker should apply Maslow's hierarchy of needs, in which oxygenation is a priority. The nurse must know normal parameters for diagnostic tools and laboratory data.

123. The nurse identifies the concept of intracranial regulation disturbance in a client diagnosed with Parkinson's Disease. Which priority intervention should the nurse implement? 1. Keep the bed low and call light in reach. 2. Provide a regular diet of three (3) meals per day. 3. Obtain an order for home health to see the client. 4. Perform the Braden scale skin assessment.

1. Safety is always a priority intervention when working with a client whose physical functioning is impaired or when the client's cognitive judgment is compromised. 2. The client should receive six (6) small meals each day. The client's swallowing ability may be impaired and the client will be unable to consume the meal before it gets cold. The consistency should be soft to not require extended chewing. 3. Home health may be needed but the prior- ity intervention is safety. 4. A skin assessment is not priority over keep- ing the patient safe. TEST TAKING HINT: The test taker should remember that basic nursing care is ap- propriate for client protection. Maslow's hierarchy of needs lists safety in the second highest priority tier. Physiological needs that involve life-threatening or life-altering complications are the only things that are more important than safety.

124. The client newly diagnosed with Parkinson's Disease (PD) asks the nurse, "Why can't I control these tremors?" Which is the nurse's best response? 1. "You can control the tremors when you learn to concentrate and focus on the cause." 2. "The tremors are caused by a lack of the chemical dopamine in the brain; medication may help." 3. "You have too much acetylcholine in your brain causing the tremors but they will get better with time." 4. "You are concerned about the tremors? If you want to talk I would like to hear how you feel."

1. Sometimes a client can temporarily over- come a freezing of motion or a tremor by making an intentional movement, but the issue is not enough of the neurotransmitter, dopamine, in the brain. Concentration or focusing will not increase the amount of dopamine available in the brain. 2. This is the cause of the tremors, cogwheel motion of movement, and bradykinesia, and so forth. It is alsoin layman's terms that the client can understand and provides some measure of hope that something can be done without giving false reassurance. 3. The issue is dopamine. The acetylcholine effects are caused by the dopamine not be- ing available to counteract the acetylcholine. 4. This is a therapeutic response and the client is asking for information. TEST TAKING HINT: The test taker should read the stem of the question carefully and determine what the client is requesting. The client is newly diagnosed and wants to know about the disease. The nurse should respond to the client's question.

128. Which diagnostic evaluation tool would the nurse use to assess the client's cognitive functioning? Select all that apply. 1. The Geriatric Depression Scale (GDS). 2. The St. Louis University Mental Status (SLUMS) scale. 3. The Mini-Mental Status Examination (MMSE) scale. 4. The Manic Depression vs Elderly Depression (MDED) scale. 5. The Functional Independence Measurement Scale (FIMS)

1. The GDS assesses the older client for depression, not cognitive functioning. 2. The SLUMS scale is a measurement tool for cognitive functioning. 3. The MMSE scale is another tool to assess cognitive functioning. 4. There is no MDED scale and, in addition, depression is not cognitive functioning. 5. The FIMS measures how well the client can perform activities of daily living, not cogni- tive functioning. TEST TAKING HINT: The test taker could eliminate options "1," "4," and "5" based on the word "cognitive" in the stem of the question. The test taker should highlight any word that gives a clue as to what the question is asking. Words matter.

133. The nurse is performing a Glascow Coma Scale (GCS) assessment on a client with a problem with intracranial regulation. The client's GCS one (1) hour ago was scored at 10. Which datum indicates the client is improving? 1. The current GSC rating is 3. 2. The current GSC rating is 9. 3. The current GSC rating is 10. 4. The current GSC rating is 12.

1. The lowest ranking possible on the GCS is 3. The client would be considered brain dead, not improving. 2. The lower the numbers are on the GCS, the worse the client's functioning; this client is not improving. 3. This GCS rating indicates the client is the same as one (1) hour ago. 4. The GCS rating is going up, which means the client is improving. TEST TAKING HINT: The test taker can eliminate options "1" and "2" because they both present a lower score; both cannot be correct in a multiple-choice question and, here, both indicate a worsening of the cli- ent's condition. Likewise, option "3" is the same score as 1 hour ago, so the test taker should be careful to note this. Therefore, because only one answer can show an im- proving condition, the test taker can deduce that it is option "4."

108. The client diagnosed with ALS is prescribed an antiglutamate, riluzole (Rilutek). Which instruction should the nurse discuss with the client? 1. Take the medication with food. 2. Do not eat green, leafy vegetables. 3. Use SPF 30 when going out in the sun. 4. Report any febrile illness.

1. The medication should be given without food at the same time each day. 2. This medication is not affected by green, leafy vegetables. (The anticoagulant warfarin [Coumadin] is a well-known medication that is affected by eating green, leafy vegetables.) 3. This medication is not affected by the sun. 4. The medication can cause blood dyscrasias. Therefore, the client is monitored for liver function, blood count, blood chemistries, and alkaline phosphatase. The client should report any febrile ill- ness. This is the first medication developed to treat ALS. TEST TAKING HINT: Blood dyscrasias occur with many medications, and this might prompt the test taker to select option "4" as the correct option. Otherwise, the test taker must be knowledgeable of medication administration.

7. The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? 1. An oral anticoagulant medication. 2. A beta blocker medication. 3. An anti-hyperuricemic medication. 4. A thrombolytic medication

1. The nurse would anticipate an oral antico- agulant, warfarin (Coumadin), to be pre- scribed to help prevent thrombi formation in the atria secondary to atrial fibrillation. The thrombi can become embolic and may cause a TIA or CVA (stroke). 2. Beta blockers slow the heart rate and decrease blood pressure but would not be an anticipated medication to help prevent a TIA secondary to atrial fibrillation. 3. An antihyperuricemic medication is administered for a client experiencing gout and de- creases the formation of tophi. 4. A thrombolytic medication is administered to dissolve a clot, and it may be ordered during the initial presentation for a client with a CVA but not on discharge. TEST TAKING HINT: In the stem of this question, there are two disease processes mentioned—atrial fibrillation and TIA. The reader must determine how one process affects the other before answering the ques- tion. In this question, the test taker must know atrial fibrillation predisposes the client to the formation of thrombi, and, therefore, the nurse should anticipate the health-care provider ordering a medication to prevent clot formation, an anticoagulant.

8. The client has been diagnosed with a cerebrovascular accident (stroke). Theclient's wife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge? 1. Obtain a rubber mat to place under the dinner plate. 2. Purchase a long-handled bath sponge for showering. 3. Purchase clothes with Velcro closure devices. 4. Obtain a raised toilet seat for the client's bathroom.

1. The rubber mat will stabilize the plate and prevent it from slipping away from the client learning to feed himself, but this does not ad- dress generalized weakness. 2. A long-handled bath sponge will assist the client when showering hard-to-reach areas, but it is not a home modification nor will it help with generalized weakness. 3. Clothes with Velcro closures will make dress- ing easier, but they do not constitute a home modification and do not address generalized weakness. 4. Raising the toilet seat is modifying the home and addresses the client's weakness in being able to sit down and get up with- out straining muscles or requiring lifting assistance from the wife. TEST TAKING HINT: The test taker must read the stem of the question carefully and note that the intervention must be one in which the home is modified in some way. This would eliminate three of the options, leaving the correct answer.

99. The client is being evaluated to rule out ALS. Which signs/symptoms would the nurse note to confirm the diagnosis? 1. Muscle atrophy and flaccidity. 2. Fatigue and malnutrition. 3. Slurred speech and dysphagia. 4. Weakness and paralysis.

1. These signs and symptoms occur during the course of ALS, but they are not early symptoms. 2. These signs and symptoms will occur as the disease progresses. 3. These are late signs/symptoms of ALS. 4. ALS results from the degeneration and demyelination of motor neurons in the spinal cord, which results in paralysis and weakness of the muscles. TEST TAKING HINT: This is an application question in which the test taker must know that ruling out of ALS would result in the answer being early signs/symptoms. The test taker could rule out option "1" because of atrophy, which is a long-term occurrence; rule out option "2" because these symptoms will occur as the disease progresses; and rule out option "3" because these are late signs/ symptoms.

100. The client diagnosed with ALS asks the nurse, "I know this disease is going to kill me. What will happen to me in the end?" Which statement by the nurse would be most appropriate? 1. "You are afraid of how you will die?" 2. "Most people with ALS die of respiratory failure." 3. "Don't talk like that. You have to stay positive." 4. "ALS is not a killer. You can live a long life."

1. This is a therapeutic response, but the client is asking for specific information. 2. About 50% of clients die within two (2) to five (5) years from respiratory failure, aspiration pneumonia, or another infectious process. 3. The nurse should allow the client to talk freely about the disease process and should provide educational and emotional support. 4. This is incorrect information; ALS is a dis- ease that results in death within 5 years in most cases. TEST TAKING HINT: When the client is ask- ing for factual information, the nurse should provide accurate and truthful information. This helps foster a trusting client-nurse relationship. A therapeutic response (option "1") should be used when the client needs to ventilate feelings and is not asking spe- cific questions about the disease process.

83. The nurse is conducting a support group for clients diagnosed with Parkinson's disease and their significant others. Which information regarding psychosocial needs should be included in the discussion? 1. The client should discuss feelings about being placed on a ventilator. 2. The client may have rapid mood swings and become easily upset. 3. Pill-rolling tremors will become worse when the medication is wearing off. 4. The client may automatically start to repeat what another person says.

1. This is information that should be discussed when filling out an advance directive form. A ventilator is used to treat a physiological problem. 2. These are psychosocial manifestations of PD. These should be discussed in the sup- port meeting. 3. The reduction in the unintentional pill- rolling movement of the hands is controlled at times by the medication; this is a physiological problem. 4. Echolalia is a speech deficit in which the client automatically repeats the words or sentences of another person; this is a physiological problem. TEST TAKING HINT: Psychosocial problems should address the client's feelings or inter- actions with another person.

122. The client diagnosed with atrial fibrillation complains of numbness and tingling of her left arm and leg. The nurse assesses facial drooping on the left side and slight slurring of speech. Which nursing interventions should the nurse implement first? 1. Schedule a STAT Magnetic Resonance Imaging of the brain. 2. Call a Code STROKE. 3. Notify the health-care provider (HCP). 4. Have the client swallow a glass of water.

1. This may be needed once the client is sta- ble, but the first action is to get the needed personnel to intervene to prevent lasting damage for the client. 2. A Code STROKE (for an RRT related to a stroke) has been instituted in most facilities to have personnel to respond so that there is no delay in initiating interventions, thus reducing the impact of a cerebrovascular accident (stroke) on a client. 3. The first nursing intervention is to call the Code STROKE, then the health-care provider would be notified next. 4. Having the client swallow could be an assessment step but not a glass of water and with standby suction available in case the client is unable to swallow. TEST TAKING HINT: The test taker should remember that certain physiological processes carry risks that have to be contended with. Atrial fibrillation can cause the blood to become stagnant and coat the atrial interior surfaces. If this coating of blood breaks loose, then the result can be an intracranial embolus.

29. The nurse is preparing the male client for an electroencephalogram (EEG). Which intervention should the nurse implement? 1. Explain that this procedure is not painful. 2. Premedicate the client with a benzodiazepine drug. 3. Instruct the client to shave all facial hair. 4. Tell the client it will cause him to see "floaters."

1. This procedure is not painful, although electrodes are attached to the scalp. The client will need to wash the hair after the procedure. 2. Antianxiety medication would make the client drowsy and could cause a false EEG reading. 3. There is no reason for facial hair to be shaved. 4. This procedure measures the electrical conductivity in the brain and does not cause the client to see "floaters" (spots before the eyes). Flashing bright lights may be used in an at- tempt to evoke a seizure.

104. The client is diagnosed with ALS. As the disease progresses, which intervention should the nurse implement? 1. Discuss the need to be placed in a long-term care facility. 2. Explain how to care for a sigmoid colostomy. 3. Assist the client to prepare an advance directive. 4. Teach the client how to use a motorized wheelchair.

1. With assistance, the client may be able to stay at home. Therefore, placement in a long-term care facility should not be dis- cussed until the family can no longer care for the client in the home. 2. There is no indication that a client with ALS will need a sigmoid colostomy. 3. A client with ALS usually dies within five (5) years. Therefore, the nurse should offer the client the opportunity to determine how he/she wants to die. 4. ALS affects both upper and lower extremities and leads to a debilitating state, so the client will not be able to transfer into and operate a wheelchair. TEST TAKING HINT: The nurse should always help the client prepare for death in disease processes that are terminal and should dis- cuss advance directives, which include both a durable power of attorney for health care and a living will.

16. The client is undergoing post-thrombolytic therapy for a stroke. The health-care provider has ordered heparin to be infused at 1,000 units per hour. The solution comes as 25,000 units of heparin in 500 mL of D5W. At what rate will the nurse set the pump? ___________

20 mL/hr. To arrive at the answer, the test taker must divide 25,000 units by 500 mL = 50 units in 1 mL. Divide 1,000 units by 50 units = 20 mL/hr.

A patient with myasthenia gravis is experiencing sweating and pallor. After administering edrophonium (Tensilon), which finding suggests the patient is experiencing a cholinergic crisis? 1) Clear vision 2) Fasciculations 3) Strong hand grasps 4) Equal shoulder shrugs

When Tensilon is administered, if the patient demonstrates muscle strength improvement, it is determined to be a myasthenic crisis. 2) If Tensilon is administered and the patient demonstrates fasciculations and muscle weakness, including respiratory muscles, it is a cholinergic crisis.

The nurse is reading the results of a single-fiber electromyography completed on a patient suspected of having myasthenia gravis. Which information would validate this patient's diagnosis? 1) Increased jitter 2) Nerve compression 3) Increased antibodies 4) Decreased muscle response

1) In myasthenia gravis, there is increased "jitter" in a single-fiber electromyography test. 2) Specific nerve function and status is not measured through a single-fiber electromyography. 3) Antibodies would be measured through the use of serology testing. 4) In myasthenia gravis, decreased muscle response would be seen in a repetitive nerve stimulation test.

2. A patient with multiple sclerosis experiences exacerbations of new symptoms that last a few days and then disappear. Which type of multiple sclerosis is this patient most likely experiencing? 1) Relapsing-remitting 2) Primary progressive 3) Progressive relapsing 4) Secondary progressive

1) In relapsing-remitting multiple sclerosis, relapses or exacerbations occur during which new symptoms appear and old ones worsen or reappear; these relapses can last days or months. 2) Primary progressive multiple sclerosis has gradual progression with no remissions. 3) Progressive relapsing multiple sclerosis has a gradual worsening of symptoms from onset, and the relapses may or may not have recovery. 4) Secondary progressive multiple sclerosis is when the patient initially had relapsing- remitting but it gradually becomes worse.

The nurse notes that a patient has been diagnosed with trigeminal neuralgia. What should the nurse expect the patient to be experiencing? 1) Pain 2) Nausea 3) Sensory deficit 4) Motor weakness

1) Trigeminal neuralgia is a pain disorder, and the patient seeks medical attention for relief. It is not unusual for the patient to present to a primary care practitioner with a chief complaint of facial pain. 2) Nausea is not typically associated with trigeminal neuralgia. 3) Sensory deficits are not typically associated with trigeminal neuralgia. 4) Motor weakness is not typically associated with trigeminal neuralgia.

31. The intensive care nurse is caring for the client who has had intracranial surgery. Which interventions should the nurse implement? Select all that apply. 1. Assess for deep vein thrombosis. 2. Administer intravenous anticoagulant. 3. Monitor intake and output strictly. 4. Apply warm compresses to the eyes. 5. Perform passive range-of-motion exercises.

1. Assessing for deep vein thrombosis, which is a complication of immobility, would be appropriate for this client. 2. Anticoagulants may cause bleeding; therefore, the client who has had surgery would not be prescribed this medication. 3. Monitoring of intake and output helps to detect possible complications of the pituitary gland, which include diabetes insipidus and syndrome of inappropriate antidiuretic hormone (SIADH). 4. The nurse should apply cool compresses to alleviate periocular edema. 4. The nurse does not want the client to be active and possibly increase intracranial pressure; therefore, the nurse should perform passive range-of-motion for the client.

82. Which is a common cognitive problem associated with Parkinson's disease? 1. Emotional lability. 2. Depression. 3. Memory deficits. 4. Paranoia.

1. Emotional lability is a psychosocial problem, not a cognitive one. 2. Depression is a psychosocial problem. 3. Memory deficits are cognitive impairments. The client may also develop a dementia. 4. Paranoia is a psychosocial problem. TEST TAKING HINT: The test taker must know the definitions of common medical terms. "Cognitive" refers to mental capacity to function.

1. The client is admitted with a diagnosis of trigeminal neuralgia. Which assessment data would the nurse expect to find in this client? 1. Joint pain of the neck and jaw. 2. Unconscious grinding of the teeth during sleep. 2. Sudden severe unilateral facial pain. 3. Progressive loss of calcium in the nasal septum.

1. Joint pain is usually associated with some type of arthritis. 2. Unconscious grinding of the teeth during sleep is usually associated with temporoman- dibular joint (TMJ) disorder. 3. Trigeminal neuralgia affects the 5th cranial nerve and is characterized by paroxysms of pain in the area innervated by the three branches of the nerve. The uni- lateral nature of the pain is an important diagnostic characteristic. The disorder is also known as tic douloureux. 4. The nasal structure is not made up of bone.

50. The nurse is assessing a client who is experiencing anosmia on a neurological floor. Which area should the nurse assess for cranial nerve I that is pertinent to anosmia? 1. A - Eyes 2. B - Tongue 3. C - Cheek 4. D - Nose

1. The eyes, indicated by A, would be assessed if checking cranial nerves II, III, IV, or VI. 2. The tongue located in the mouth, indicated by B, would be assessed if checking cranial nerves IX, X, or XII. 3. The cheek, indicated by C, would be assessed if checking for cranial nerve V, the trigeminal nerve. 4. Anosmia, the loss of the sense of smell, would require the nurse to assess for cranial nerve I, the olfactory nerve, indicated by D.

35. Which assessment data should the nurse expect to observe for the client diagnosed with Parkinson's disease? 1. Ascending paralysis and pain. 2. Masklike facies and pill rolling. 3. Diplopia and ptosis. 4. Dysphagia and dysarthria.

1. The spread of pain and paralysis are signs/ symptoms of Guillain-Barré syndrome. 2. Masklike facies and pill rolling are signs/ symptoms of Parkinson's disease, along with cogwheeling, postural instability, and stooped and shuffling gait. 3. Diplopia and ptosis are signs/symptoms of myasthenia gravis. 4. Dysphagia and dysarthria are signs/ symptoms of myasthenia gravis.

22. The student nurse asks the nurse, "Why do you ask the client to identify how many fingers you have up when the client hit the front of the head, not the back?" The nurse would base the response on which scientific rationale? 1. This is part of the routine neurological examination. 2. This is done to determine if the client has diplopia. 3. This assesses the amount of brain damage. 4. This is done to indicate if there is a rebound effect on the brain.

1. This is part of the neurological examination, but this is not the scientific rationale for why it is done. The nurse must understand what is being assessed to interpret the data. 2. Diplopia, double vision, is a sign of head injury, but it is not the scientific rationale. 3. The procedure does assess for brain damage, but this answer does not explain why. 4. When the client hits the front of the head, there is a rebound effect known as "coupcontrecoup" in which the brain hits the back of the skull. The occipital lobe is in the back of the head, and an injury to it may be manifested by seeing double.

12. A patient is experiencing increasing flaccid upper arms while the lower extremities periodically cramp and contract. On which health problem should the nurse focus when assessing this patient? 1) Brain tumor 2) Spinal cord tumor 3) Multiple sclerosis 4) Amyotrophic lateral sclerosis (ALS)

1) The manifestations of a brain tumor will depend upon the location of the mass in the cerebrum. 2) The manifestations of a spinal cord tumor will depend upon the location of the mass within the cord. 3) Both spasticity and flaccidity do not need to be present to diagnose multiple sclerosis. 4) To be diagnosed with ALS, patients must have clinical manifestations of both upper and lower motor neuron damage that cannot be attributed to other causes. Upper motor neuron damage is associated with spasticity, while lower motor neuron damage is characterized by flaccidity.

6. The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? 1. The assistant places a gait belt around the client's waist prior to ambulating. 2. The assistant places the client on the back with the client's head to the side. 3. The assistant places a hand under the client's right axilla to move up in bed. 4. The assistant praises the client for attempting to perform ADLs independently.

1. Placing a gait belt prior to ambulating is an appropriate action for safety and would not require the nurse to intervene. 2. Placing the client in a supine position with the head turned to the side is not a problem position, so the nurse does not need to intervene. 3. This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; the client should be pulled up by placing the arm underneath the back or using a lift sheet. 4. The client should be encouraged and praised for attempting to perform any activities independently, such as combing hair or brushing teeth. TEST TAKING HINT: This type of question has three answer options that do not require a nurse to intervene to correct a subordinate. Remember to read every possible answer option before deciding on a correct one.

8. Which should be the nurse's first intervention with the client diagnosed with Bell's palsy? 1. Explain that this disorder will resolve within a month. 2. Tell the client to apply heat to the involved side of the face. 3. Encourage the client to eat a soft diet. 4. Teach the client to protect the affected eye from injury.

1. This is correct information, but it is not a priority when discussing Bell's palsy. 2. Heat will help promote comfort and increase blood flow to the muscles, but safety of the client's eye is a priority. 3. The client may have difficulty chewing on the affected side, so a soft diet should be encouraged, but it is not a priority teaching. 4. Teaching the client to protect the eye isa priority because the eye does not close completely and the blink reflex is diminished, making the eye vulnerable to injury. The client should wear an eye patch at night and wraparound sunglasses or goggles during the day; he or she may also need artificial tears.

12. A patient recovering from an ischemic stroke is prescribed verapamil (Calan). In preparation for patient teaching, which medication category will the nurse review? 1) Diuretic 2) Beta blocker 3) Lipid-lowering agent 4) Calcium channel blocker

4) Verapamil (Calan) is a calcium channel blocker.

779. The 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? 1. Taking medications as scheduled 2. Eating large, well-balanced meals 3. Doing muscle-strengthening exercises 4. Doing all chores early in the day while less fatigued

1 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 expo- sure to heat, crowds, erratic sleep habits, and emotional stress. Test-Taking Strategy: Note the strategic words, most effective. Recalling that the common causes of myasthenic and cholinergic crises are under medication and overmedication, respectively, will assist you in eliminating each of the incorrect options. No other option would prevent both of those complications.

28. A patient with amyotrophic lateral sclerosis (ALS) is being prepared for discharge. What teaching would be essential for the family to receive prior to taking the patient home? Select all that apply. 1) Skin care 2) Aspiration precautions 3) Recognizing exacerbations 4) Lower extremity circulation 5) Reporting changes in continence

1) Amyotrophic lateral sclerosis is a progressive disease that leads to the inability to move. Complications include pressure ulcers. 2) Amyotrophic lateral sclerosis is a progressive disease that leads to the inability to move. Complications include aspiration of food or fluid, respiratory failure, and pneumonia. 3) Exacerbations occur with multiple sclerosis and not ALS. 4) Amyotrophic lateral sclerosis is a progressive disease that leads to the inability to move. Complications include deep vein thrombosis (DVT) and pulmonary embolism (PE). 5) Changes in continence would be a potential complication of a herniated disk.

13. A patient is admitted for diagnosis and treatment of ongoing spasticity and flaccidity of the extremities. Which diagnostic test should the nurse expect to be prescribed that will definitively determine this patient's health problem? 1) MRI of the neck 2) CT scan of the head 3) A variety of tests will be ordered to help rule out other causes 4) Analysis of cerebrospinal fluid from a lumbar puncture

1) An MRI of the neck may be completed to rule out nerve compression. 2) A CT scan of the head may be completed to rule out masses or other structural abnormalities causing the patient's symptoms. 3) No single test can be used to diagnose ALS; therefore, a complete history and physical examination must be performed by the health-care provider. 4) Analysis of the cerebrospinal fluid will be done; however, this will not definitively diagnose the patient with ALS.

A patient is admitted for diagnosis and treatment of Guillain-Barré syndrome (GBS). What should the nurse expect to assess during the acute stage of this syndrome? Select all that apply. 1) Edema 2) Paralysis 3) Difficulty breathing 4) Urinary incontinence 5) Numbness and tingling

1) Edema is seen in the acute stage of GBS. 2) Paralysis is seen in the acute stage of GBS. 3) Difficulty breathing is seen in the acute stage of GBS. 4) Urinary incontinence is not identified as a manifestation of GBS. 5) Numbness and tingling are seen in the acute stage of GBS.

26. A patient with an ischemic stroke is being considered for recombinant tissue plasminogen activator (rt-PA). What would cause this procedure to be contraindicated in this patient? Select all that apply. 1) Age 83 years 2) Symptoms present for 45 minutes 3) CT scan demonstrates area of ischemia 4) 10-year history of type 2 diabetes mellitus 5) Takes warfarin sodium for atrial fibrillation

1) Exclusion criteria for rt-PA include age greater than 80 years. 2) Include criteria for re-PA include symptoms present for at least 30 minutes. 3) Include criteria for re-PA include a CT scan consistent with an ischemic stroke. 4) Exclusion criteria for rt-PA include a prior history of diabetes. 5) Exclusion criteria for re-PA include receiving anticoagulants.

The nurse is planning care for a patient with Guillain-Barré syndrome (GBS). Which intervention will help with neuropathic pain? 1) Administer gabapentin 2) Turn and reposition every two hours 3) Apply sequential compression devices 4) Perform passive range of motion several times a day

1) Gabapentin may be used to relieve neuropathic pain. 2) Frequent repositioning promotes comfort and prevents complications of immobility including thromboembolism and impaired skin integrity. 3) Sequential compression devices prevent venous stasis. 4) Range-of-motion exercises promote joint mobility and function.

A patient with progressively deteriorating lower extremity motor and sensory function is having a lumbar puncture. What finding suggests that this patient has Guillain-Barré syndrome (GBS)? 1) Elevated protein level 2) Elevated glucose level 3) Reduction in white blood cell count 4) Increased number of red blood cells

1) In GBS, cerebrospinal fluid findings include an elevated protein level. 2) In GBS, there is no evidence to suggest that glucose is elevated in the cerebrospinal fluid. 3)/4) In GBS, the cell count in the cerebrospinal fluid is normal.

9. A patient recovering from a hemorrhagic stroke has a blood pressure of 90/50 mm Hg. What action should the nurse take? 1) Increase the head of the bed 2) Notify the health-care provider 3) Place the head in a neutral position 4) Reassess the pressure in 15 minutes

1) Increasing the head of the bed could further reduce blood flow to the brain. 2) A protective mechanism of the brain, cerebral autoregulation, is dysfunctional after stroke, rendering the brain vulnerable to hypotension because the cerebral blood vessels are not able to automatically dilate ensuring adequate oxygen delivery to brain tissue. The health-care provider should be notified with the blood pressure measurement. 3) Placing the head in a neutral position will not impact the patient's blood pressure. 4) The patient's condition could deteriorate in 15 minutes. The blood pressure should be reported immediately.

11. The nurse is caring for a patient with multiple sclerosis. What should the nurse do to increase venous return, prevent stiffness, and maintain muscle strength and endurance? 1) Administer interferon 2) Administer corticosteroids 3) Turn and reposition every two hours 4) Encourage range-of-motion exercises

1) Interferon decreases exacerbations and slows disease progression. 2) Corticosteroids decreases the inflammatory processes associated with the flare. 3) Turning and repositioning every two hours prevents skin breakdown. 4) Range-of-motion exercises increases venous return, prevents stiffness, and maintains muscle strength and endurance.

25. The nurse suspects a patient is experiencing an ischemic stroke of the basilar artery. What manifestations did the nurse most likely assess in this patient? Select all that apply. 1) Ataxia 2) Nausea 3) Dysphasia 4) Inability to swallow 5) Difficulty with speech

1) Manifestations of basilar artery syndrome include ataxia. 2) Manifestations of basilar artery syndrome include nausea. 3) Dysphagia is a manifestation of left middle cerebral artery syndrome. 4) Manifestations of basilar artery syndrome include difficulty swallowing. 5) Manifestations of basilar artery syndrome include difficulty in the articulation of speech.

A patient with trigeminal neuralgia asks if there are any nonpharmacological strategies to treat the pain. What should the nurse suggest to this patient? 1) Massage 2) Apply heat 3) Apply cold 4) Acupuncture

1) Massage could be a trigger for trigeminal neuralgia. 2) Heat could be a trigger for trigeminal neuralgia. 3) Cold could be a trigger for trigeminal neuralgia. 4) Acupuncture has been found to have efficacy similar to that of Tegretol.

10. A patient with a cerebral vasospasm is receiving triple H therapy. What parameter should the nurse use to determine adequacy of hemodilution? 1) Hemoglobin level = 30 g/dL 2) Blood pressure 154/80 mm Hg 3) Serum sodium level less than 160 mg/dL 4) Serum potassium level between 4.0 and 4.5 mEq/L

1) Minimum thresholds for hemoglobin hemodilution are typically maintained at approximately 30 g/dL. 2) A blood pressure of 154/80 mm Hg would indicate adequacy of hypertension within the triple H therapy. 3) Serum sodium is not an indicator of effectiveness of triple H therapy. 4) Serum potassium is not an indicator of effectiveness of triple H therapy.

A patient with Guillain-Barré syndrome (GBS) loses respiratory function three weeks into the acute phase. When should the nurse expect respiratory function to return in this patient? 1) During the plateau phase 2) Early in the recovery stage 3) At the end of the plateau stage 4) At the end of the recovery stage

1) No further damage or repair occurs during the plateau stage. 2) The pattern of recovery is the reverse of onset, and the nerves that were affected last are the first to improve. The respiratory nerves will repair first. 3) No further damage or repair occurs during the plateau stage. 4) The pattern of recovery is the reverse of onset, and the nerves that were affected last are the first to improve. The respiratory nerves will repair first.

6. The nurse is concerned that a patient is at high risk for having a stroke. What finding did the nurse use to make this clinical decision? 1) BMI 24.8 2) Heart rate 90 bpm 3) Blood pressure 182/90 mm Hg 4) Pulse oximetry 98% on room air

1) Overweight is not identified as a risk factor for stroke. 2) Heart rate of 90 bpm is within normal limits and is not a risk factor for stroke. 3) A significant risk factor for stroke is hypertension. 4) A pulse oximeter reading of 98% on room air indicates adequate oxygenation and is not a risk factor for stroke.

A patient is being prepared for a tensilon test. What should the nurse ensure is available prior to the beginning of this test? 1) Oxygen 2) Atropine sulfate 3) Intravenous fluids 4) Nasogastric suction

1) Oxygen is not required for a tensilon test. 2) Edrophonium (Tensilon) is a rapid-acting AChE inhibitor. This leads to increased levels of ACh at the neuromuscular junction, leading to improved muscle strength in patients with myasthenia. However, ACh accumulates in the parasympathetic autonomic nervous system and can cause side effects such as bronchospasm, bradycardia, and diarrhea. Atropine is a muscarinic blocker, and thus the side effects of edrophonium and other AChE inhibitors can be reversed with this medication. 3) Intravenous fluids are not required for a tensilon test. 4) Nasogastric suction is not required for a tensilon test.

8. A patient is diagnosed with a subarachnoid hemorrhage caused by a cerebral aneurysm that has a wide neck and tortuous vascular anatomy. For which procedure should the nurse prepare teaching material for this patient? 1) Aneurysm coiling 2) Aneurysm clipping 3) Reinforcing aneurysm wall 4) Evacuation of the hematoma

1) Patients with high-grade Hunt and Hess scores (grade 4 or 5), as well as patients with multiple comorbid conditions and with hemodynamic instability at baseline, may be better candidates for aneurysm coiling. 2) Aneurysms with a wide neck and tortuous vascular anatomy may be better candidates for aneurysm clipping. 3) In cases where neither clipping nor coiling the aneurysm is feasible, reinforcement of the aneurysmal wall by wrapping the outside of the aneurysm with synthetic material or muscle during the surgery may be accomplished. 4) Surgical management of intracranial hemorrhage above the tentorium cerebelli has not been shown to improve outcomes unless a hematoma is superficial in location.

16. The nurse suspects that a patient is experiencing Parkinson's disease. What did the nurse assess to make this clinical determination? 1) Photophobia 2) Nuchal rigidity 3) Slow movements 4) Elevated body temperature

1) Photophobia occurs with migraine headaches, meningitis, and encephalitis. 2) Nuchal rigidity occurs with meningitis and encephalitis. 3) One discernible symptom of Parkinson's disease is slowness of movement or bradykinesia. 4) Elevated body temperature can occur with meningitis and encephalitis

A patient with Guillain-Barré syndrome (GBS) is receiving plasmapheresis. What finding should the nurse identify as being a complication of this treatment? 1) Septicemia 2) Flu-like symptoms 3) Aseptic meningitis 4) Acute renal failure

1) Plasmapheresis increases the risk for infection. Septicemia is a complication of plasmapheresis. 2) Flu-like symptoms are associated with intravenous immunoglobulin therapy. 3) Aseptic meningitis is associated with intravenous immunoglobulin therapy. 4) Acute renal failure is associated with intravenous immunoglobulin therapy.

During an assessment the nurse suspects that patient should be evaluated for myasthenia gravis. What did the nurse assess to make this clinical determination? Select all that apply. 1) Ptosis 2) Diplopia 3) Abdominal pain 4) Left leg weakness 5) Epigastric burning

1) Ptosis is an ocular manifestation of myasthenia gravis. 2) Diplopia is an ocular manifestation of myasthenia gravis. 3) Abdominal pain is not a manifestation of myasthenia gravis. 4) Left leg weakness is not a specific manifestation of myasthenia gravis. 5) Epigastric burning is not a manifestation of myasthenia gravis.

The nurse notes that a patient's primary complaint is burning pain on the right side of the face. What should the nurse realize this patient is describing? 1) Referred pain 2) Atypical pain 3) Vascular compression 4) Peripheral neuropathy

1) Referred pain is pain felt somewhere on the body but occurs in another body organ or location. 2) In trigeminal neuralgia, atypical pain is a constant burning sensation that covers a more diffuse region of the face. 3) Vascular compression is identified as a cause for the classic pain seen in trigeminal neuralgia. 4) The pain of trigeminal neuralgia is not considered peripheral neuropathy.

19. The nurse interrupts unlicensed assistive personnel who is assisting a patient with Parkinson's disease with breakfast. Which observation caused the nurse to immediately intervene? 1) Patient sitting out of bed in a chair 2) Head of the bed raised to 30 degrees 3) Thickener added to liquid menu items 4) Oral suction catheter equipment turned on

1) Sitting out of bed for meals facilitates swallowing. 2) The patient's head of the bed should be elevated when eating and drinking. Impaired swallowing associated with Parkinson's disease increases the risk of aspiration. Elevating the head facilitates the swallow reflex. 3) Adding thickener to liquids improves swallowing and reduces the risk of aspiration. 4) Oral suction equipment is a safety precaution and would be appropriate.

7. The nurse suspects that a patient is experiencing a hemorrhagic stroke from a ruptured cerebral aneurysm. What assessment finding caused the nurse to make this conclusion? 1) Slurred speech 2) Visual field deficits 3) Sudden severe headache 4) Lower extremity weakness

1) Slurred speech is not identified as a manifestation of a ruptured cerebral aneurysm. 2) Visual field deficits are not identified as a manifestation of a ruptured cerebral aneurysm. 3) Subarachnoid hemorrhage is characterized by a sudden severe headache, often termed a "thunderclap" headache because of the intensity of the pain experienced at the onset. 4) Lower extremity weakness is not identified as a manifestation of a ruptured cerebral aneurysm.

A patient with myasthenia gravis has lost 6 kg of weight over the last two months. What should the nurse suggest to improve this patient's nutritional status? 1) Eat three large meals per day 2) Plan medication doses to occur before meals 3) Restrict drinking fluids prior to and during meals 4) Increase the amount of fat and carbohydrates in meals

1) Small, frequent meals will help maintain calorie intake. 2) Plan meals when medications are at peak levels. Often patients take pyridostigmine an hour before meals to minimize difficulty with chewing and swallowing. 3) The patient does not have difficulty with digestion. Fluids do not need to be restricted prior to or during meals. 4) It is not recommended to alter the amount of fat and carbohydrates in the diet of a patient with myasthenia gravis.

The nurse is conducting a physical examination on a female patient experiencing trigeminal neuralgia. What observation indicates that the pain is triggered by hygienic practices? 1) Limited talking 2) Hair not combed 3) Wearing tennis shoes 4) Not wearing makeup

1) Talking can be a trigger for pain; however, this is not a hygienic practice. 2) Hygiene activities such as combing the hair may be neglected because it triggers pain. 3) Wearing tennis shoes is a personal choice and is not a hygienic practice. 4) Not all females wear makeup. Wearing makeup is not necessarily a hygienic practice.

18. A patient recovering from a stroke has profound bradycardia. What should the nurse suspect as the cause of this manifestation? 1) Parasympathetic nervous system disruption 2) Irritation of the sympathetic nervous system 3) Shunting of fluid from the cerebral vasculature 4) Alteration in the vasomotor center in the brainstem

1)/2) Neurogenic shock is caused by a disruption in the sympathetic nervous system. 3) Neurogenic shock is not caused by the shunting of fluid from the cerebral vasculature. 4) When neurogenic shock is caused by stroke in the brainstem, symptoms of neurogenic shock arise from the vasomotor center in the brainstem.

776. The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. 1. The client is aphasic. 2. The client has weakness on the right side of the body. 3. The client has complete bilateral paralysis of the arms and legs. 4. The client has weakness on the right side of the face and tongue. 5. The client has lost the ability to move the right arm but is able to walk independently. 6. The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance.

1,2,4 Rationale: Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic: unable to discriminate words and letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bath- ing, and ambulating.Test-Taking Strategy: Focus on the subject, right-sided hemiparesis. Recalling that hemiparesis indicates weakness on one side of the body and focusing on the subject will direct you to the correct option. Also, noting the word complete in the ques- tion will assist you in answering correctly.

84. The nurse is caring for clients on a medical- surgical floor. Which clients should be assessed first? 1. The 65-year-old client diagnosed with seizures who is complaining of a headache that is a "2" on a 1-to-10 scale. 2. The 24-year-old client diagnosed with a T10 spinal cord injury who cannot move his toes. 3. The 58-year-old client diagnosed with Parkinson's disease who is crying and worried about her facial appearance. 4. The 62-year-old client diagnosed with a cerebrovascular accident who has a resolving left hemiparesis.

1. A headache of "2" on a 1-to-10 scale is a mild headache. 2. A spinal cord injury at T10 involves deficits at approximately the waist area. Inability to move the toes would be expected. 3. Body image is a concern for clients diagnosed with PD. This client is the one client who is not experiencing expected sequelae of the disease. 4. This client is getting better; "resolving" indicates an improvement in the client's clinical manifestations. TEST TAKING HINT: At times a psychological problem can have priority. All the physi-cal problems are expected and are not life threatening or life altering.

3. Which client would the nurse identify as being most at risk for experiencing a cerebrovascular accident (CVA)? 1. A 55-year-old African American male. 2. An 84-year-old Japanese female. 3. A 67-year-old Caucasian male. 4. A 39-year-old pregnant female.

1. African Americans have twice the rate of CVAs as Caucasians and men have a higher incidence than women; African Americans also suffer more extensive damage from a CVA than do people of other cultural groups. 2. Females are less likely to have a CVA than males, but advanced age does increase the risk for CVA. The Asian population has a lower risk, possibly as a result of their relatively high intake of omega-3 fatty acids, antioxidants found in fish. 3. Caucasians have a lower risk of CVA than do African Americans, Hispanics, and Native Pacific Islanders. 4. Pregnancy is a minimal risk for having a CVA. TEST TAKING HINT: Note the age of the cli-ent if this information is given, but take this information in context with the additional in- formation provided in the answer options. The 84-year-old may appear to be the best answer but not if the client is a female and Asian, which rules out this option for the client most at risk.

78. The nurse is planning the care for a client diagnosed with Parkinson's disease. Which would be a therapeutic goal of treatment for the disease process? 1. The client will experience periods of akinesia throughout the day. 2. The client will take the prescribed medications correctly. 3. The client will be able to enjoy a family outing with the spouse. 4. The client will be able to carry out activities of daily living.

1. Akinesia is lack of movement. The goal intreating PD is to maintain mobility. 2. This could be a goal for a problem of non- compliance with the treatment regimen but not a goal for treating the disease process. 3. This might be a goal for a psychosocial problem of social isolation. 4. The major goal of treating PD is to maintain the ability to function. Clients diagnosed with PD experience slow, jerky movements and have difficulty performing routine daily tasks. TEST TAKING HINT: The test taker should match the goal to the problem. A "thera- peutic goal" is the key to answering this question.

25. The client is being evaluated to rule out Parkinson's disease. Which diagnostic test confirms this diagnosis? 1. A positive magnetic resonance imaging (MRI) scan. 2. A biopsy of the substantia nigra. 3. A stereotactic pallidotomy. 4. There is no test that confirms this diagnosis.

1. An MRI is not able to confirm the diagnosis of Parkinson's disease. 2. This is the portion of the brain where Parkinson's disease originates, but this area lies deep in the brain and cannot be biopsied. 3. This is a surgery that relieves some of the symptoms of Parkinson's disease. To be eligible for this procedure, the client must have failed to achieve an adequate response with medical treatment. 4. Many diagnostic tests are completed to rule out other diagnoses, but Parkinson's disease is diagnosed based on the clinical presentation of the client and the presence of two of the three cardinal manifestations: tremor, muscle rigidity, and bradykinesia.

48. The nurse is caring for clients on a medical unit. Which client would be most at risk for experiencing a stroke? 1. A 92-year-old client who is an alcoholic. 2. A 54-year-old client diagnosed with hepatitis. 3. A 60-year-old client who has a Greenfield filter. 4. A 68-year-old client with chronic atrial fibrillation.

1. An alcoholic is not at risk for having a stroke anymore than someone in the general population. 2. A client with hepatitis is not at risk for having a stroke anymore than someone in the general population. 3. A Greenfield filter is positioned in the inferior vena cava to prevent an embolism result- ing from deep vein thrombosis; these filters prevent strokes and pulmonary emboli. 4. A client with atrial fibrillation is at high risk to have a stroke and is usually given oral anticoagulants to prevent a stroke.

26. The client diagnosed with a transient ischemic attack (TIA) is being discharged from the hospital. Which medication should the nurse expect the HCP to prescribe? 1. The oral anticoagulant warfarin (Coumadin). 2. The antiplatelet medication, a baby aspirin. 3. The beta blocker propranolol (Inderal). 4. The anticonvulsant valproic acid (Depakote).

1. An oral coagulant is ordered if the TIA was caused by atrial fibrillation, and that information is not presented in the stem. 2. Atherosclerosis is the most common cause of a TIA or stroke, and taking a baby aspirin every day helps prevent clot formation around plaques. 3. If the client had hypertension, a beta blocker may be prescribed, but this information is not in the stem. 4. Anticonvulsant medications are not prescribed to help prevent TIAs.

24. Which intervention has the highest priority for the client in the emergency department who has been in a motorcycle collision with an automobile and has a fractured left leg? 1. Assessing the neurological status. 2. Immobilizing the fractured leg. 3. Monitoring the client's output. 4. Starting an 18-gauge saline lock.

1. Assessment is the first step in the nursing process, and a client in a motorcycle accident must be assessed for a head injury. 2. Neurological assessment is a priority over a fractured leg. 3. The client's urinary output is not a priority over an assessment. 4. An 18-gauge IV access should be started in case the client has to go to surgery, but it is not a priority over an assessment.

36. The client diagnosed with Parkinson's diseaseis prescribed carbidopa/levodopa (Sinemet). Which intervention should the nurse implement prior to administering the medication? 1. Discuss how to prevent orthostatic hypotension. 2. Take the client's apical pulse for one (1) full minute. 3. Inform the client that this medication is for short-term use. 4. Tell the client to take the medication on an empty stomach.

1. Because carbidopa/levodopa has been linked to hypotension, teaching a client given the medication ways to help prevent a drop in blood pressure when standing— orthostatic hypotension—decreases the risks associated with hypotension and falling. 2. The medication will not cause the heart rate to change, so taking the client's apical pulse for one (1) minute is not a priority. 3. This medication is prescribed for the client the rest of his or her life unless the medication stops working or the client experiences adverse side effects. The medication should be administered with food to help prevent gastrointestinal distress.

74. The client diagnosed with PD is being discharged on carbidopa/levodopa (Sinemet), an antiparkinsonian drug. Which statement is the scientific rationale for combining these medications? 1. There will be fewer side effects with this combination than with carbidopa alone. 2. Dopamine D requires the presence of both of these medications to work. 3. Carbidopa makes more levodopa available to the brain. 4. Carbidopa crosses the blood-brain barrier to treat Parkinson's disease.

1. Carbidopa is never given alone. Carbidopa is given together with levodopa to help the levodopa cross the blood-brain barrier. 2. Levodopa is a form of dopamine given orally to clients diagnosed with PD. 3. Carbidopa enhances the effects of levodopa by inhibiting decarboxylase in the periphery, thereby making more levodopa available to the central nervous system. Sinemet is the most effective treatment for PD. 4. Carbidopa does not cross the blood-brain barrier. TEST TAKING HINT: The nurse must be knowledgeable of the rationale for administering a medication for a specific disease.

50. Which assessment information is the most critical indicator of a neurological deficit? 1. Changes in pupil size. 2. Level of consciousness. 3. A decrease in motor function. 4. Numbness of the extremities.

1. Changes in pupil size are a late sign of a neurological deficit. 2. A change in level of consciousness is the first and most critical indicator of any neurological deficit. 3. A decrease in motor function occurs with a neurological deficit, but it is not the most critical indicator. 4. Numbness of the extremities occurs with a neurological deficit, but it is not the most critical indicator.

77. The charge nurse is making assignments. Which client should be assigned to the new graduate nurse? 1. The client diagnosed with aseptic meningitis who is complaining of a headache and the light bothering his eyes. 2. The client diagnosed with Parkinson's disease who fell during the night and is complaining of difficulty walking. 3. The client diagnosed with a cerebrovascular accident whose vitals signs are P 60, R 14, and BP 198/68. 4. The client diagnosed with a brain tumor who has a new complaint of seeing spots before the eyes.

1. Headache and photophobia are expected clinical manifestations of meningitis. The new graduate could care for this client. 2. This client has had an unusual occurrence (fall) and now has a potential complication (a fracture). The experienced nurse should take care of this client. 3. These vital signs indicate increased intracranial pressure. The more experienced nurse should care for this client. 4. This could indicate a worsening of the tumor. This client is at risk for seizures and herniation of the brainstem. The more experienced nurse should care for this client. TEST TAKING HINT: The test taker should de- termine if the clinical manifestations are ex- pected as part of the disease process. If they are, a new graduate can care for the client; if they are not expected occurrences, a more experienced nurse should care for the client.

73. The client diagnosed with Parkinson's disease (PD) is being admitted with a fever and patchy infiltrates in the lung fields on the chest x-ray. Which clinical manifestations of PD would explain these assessment data? 1. Masklike facies and shuffling gait. 2. Difficulty swallowing and immobility. 3. Pill rolling of fingers and flat affect. 4. Lack of arm swing and bradykinesia.

1. Masklike facies is responsible for lack of expression and is part of the motor manifestations of Parkinson's disease but is not related to the symptoms listed. Shuffling is also a motor deficit and does pose a risk for falling, but fever and patchy infiltrates on a chest x-ray do not result from a gait problem. They are manifestations of a pulmonary complication. 2. Difficulty swallowing places the client at risk for aspiration. Immobility predisposes the client to pneumonia. Both clinical manifestations place the client at risk for pulmonary complications. 3. Pill rolling of fingers and flat affect do not have an impact on the development of pulmonary complications. 4. Arm swing and bradykinesia are motor deficits. TEST TAKING HINT: The nurse must recog- nize the clinical manifestations of a disease and the resulting bodily compromise. In this situation, fever and patchy infiltrates on a chest x-ray indicate a pulmonary complica- tion. Options "1," "3," and "4" focus on mo- tor problems and could be ruled out as too similar. Only option "2" includes dissimilar information.

53. Which comment by the client diagnosed with rule-out Guillain-Barré (GB) syndrome is most significant when completing the admission interview? 1. "I had a bad case of gastroenteritis a few weeks ago." 2. "I never use sunblock and I use a tanning bed often." 3. "I started smoking cigarettes about 20 years ago." 4. "I was out of the United States for the last 2 months."

1. The cause of GB syndrome is unknown, but a precipitating event usually occurs one (1) to three (3) weeks prior to the onset. The precipitating event may be a respiratory or gastrointestinal viral or bacterial infection. 2. These are not precipitating events or risk factors for developing GB syndrome. 3. Smoking is not a risk factor for developing GB syndrome. 4. GB syndrome is not more prominent in foreign countries than in the United States.

2. The client recently has been diagnosed with trigeminal neuralgia. Which intervention is most important for the nurse to implement with the client? 1. Assess the client's sense of smell and taste. 2. Teach the client how to care for the eyes. 3. Instruct the client to have carbamazepine (Tegretol) levels monitored regularly. 4. Assist the client to identify factors that trigger an attack.

1. The client's sense of smell and taste are not affected. 2. The cornea is at risk for abrasions because of the twitching, which causes irritation. Therefore, the nurse must teach the client how to care for the eye, but the most important in- tervention is to prevent the attacks. 3. Tegretol is the treatment of choice for trigeminal neuralgia, but it is not the most important intervention when the client is first diagnosed with this condition. 4. Stimulating specific areas of the face, called trigger zones, many initiate the on- set of pain. Therefore, the nurse should help the client identify situations that exacerbate the condition, such as chewing gum, eating, brushing the teeth, or being exposed to a draft of cold air.

1. A 78-year-old client is admitted to the emergency department (ED) with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? 1. Prepare to administer recombinant tissue plasminogen activator (rt-PA). 2. Discuss the precipitating factors that caused the symptoms. 3. Schedule for a STAT computed tomography (CT) scan of the head. 4. Notify the speech pathologist for an emergency consult.

1. The drug rt-PA may be administered, but a cerebrovascular accident (CVA) must be veri- fied by diagnostic tests prior to administering it. The drug rt-PA helps dissolve a blood clot, and it may be administered if an ischemic CVA is verified; rt-PA is not given if the client is ex- periencing a hemorrhagic stroke. 2. Teaching is important to help prevent another CVA, but it is not the priority interventionon admission to the emergency department. Slurred speech indicates problems that may interfere with teaching. 3. A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. If a CVA is diagnosed, the CT scan can determine if it is a hemorrhagic or an ischemic accident and guide treatment. 4. The client may be referred for speech deficits and/or swallowing difficulty, but referrals are not the priority in the emergency department. TEST TAKING HINT: When "priority" is usedin the stem, all answer options may be ap- propriate for the client situation, but only one option is the priority. The client must have a documented diagnosis before treatment is started.

80. The client diagnosed with Parkinson's disease is being discharged. Which statement made by the significant other indicates an understanding of the discharge instructions? 1. "All of my spouse's emotions will slow down now just like his body movements." 2. "My spouse may experience hallucinations until the medication starts working." 3. "I will schedule appointments late in the morning after his morning bath." 4. "It is fine if we don't follow a strict medication schedule on weekends."

1. The emotions of a person diagnosed with PD are labile. The client has rapid mood swings and is easily upset. 2. Hallucinations are a sign that the client is experiencing drug toxicity. 3. Scheduling appointments late in the morning gives the client a chance to complete ADLs without pressure and allows the medications time to give the best benefits. 4. The client should take the prescribed medications at the same time each day to provide a continuous drug level. TEST TAKING HINT: The test taker could eliminate option "2" because hallucinations are never an expected part of legal medication administration.

47. The nurse is preparing to administer acetaminophen (Tylenol) to a client diagnosed with a stroke who is complaining of a headache. Which intervention should the nurse implement first? 1. Administer the medication in pudding. 2. Check the client's armband. 3. Crush the tablet and dissolve in juice. 4. Have the client sip some water.

1. The medication can be administered in pudding, but it is not the first intervention. 2. The armband should be checked but not before determining if the client can swallow. 3. Tylenol comes in liquid form, and the nurse should request this before crushing a very bitter tablet. 4. Asking the client to sip some water assesses the client's ability to swallow, which is a priority when placing anything in the mouth of the client who has had a stroke.

11. The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first? 1. Administer a nonnarcotic analgesic. 2. Prepare for STAT magnetic resonance imaging (MRI). 3. Start an intravenous infusion with D5W at 100 mL/hr. 4. Complete a neurological assessment.

1. The nurse should not administer any medication to a client without first assessing the cause of the client's complaint or problem. 2. An MRI scan may be needed, but the nurse must determine the client's neurological status prior to diagnostic tests. 3. Starting an IV infusion is appropriate, but it is not the action the nurse should implement when assessing pain, and 100 mL/hr might be too high a rate for an 85-year-old client. 4. The nurse must complete a neurological assessment to help determine the cause of the headache before taking any further action. TEST TAKING HINT: The test taker should al- ways apply the nursing process when answer- ing questions. If the test taker narrows down the choices to two possible answer options, always select the assessment option as the first intervention.

76. The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical- surgical unit. Which task should not be assigned to the UAP? 1. Feed the 69-year-old client diagnosed with Parkinson's disease who is having difficulty swallowing. 2. Turn and position the 89-year-old client diagnosed with a pressure ulcer secondary to Parkinson's disease. 3. Assist the 54-year-old client diagnosed with Parkinson's disease with toilet-training activities. 4. Obtain vital signs on a 72-year-old client diagnosed with pneumonia secondary to Parkinson's disease.

1. The nurse should not delegate feedinga client who is at risk for complications during feeding. This requires judgment that the UAP is not expected to possess. 2. Unlicensed assistive personnel can turn and position clients with pressure ulcers. The nurse should assist in this at least once during the shift to assess the wound area. 3. The UAP can assist the client to the bath- room every two (2) hours and document the results of the attempt. 4. The UAP can obtain the vital signs on a stable client. TEST TAKING HINT: When reading the answer options in a question in which the nurse is delegating to an unlicensed-assistive person- nel, read the stem carefully. Is the question asking what to delegate or what not to del- egate? Anything requiring professional judg- ment should not be delegated.

129. Which priority goal would the nurse identify for a client diagnosed with Parkinson's Disease (PD)? 1. The client will be able to maintain mobility and swallow without aspiration. 2. The client will verbalize feelings about the diagnosis of Parkinson's Disease. 3. The client will understand the purpose of medications administered for PD. 4. The client will have a home health agency for monitoring at home.

1. The priority goal is for the client to maintain functional ability. This improves quality and quantity of life. 2. Verbalizing feelings is a good goal but feel- ing will not impact stabilizing the physiological deterioration of the client. 3. There is no way to measure the client's understanding. 4. Having a home health agency does not ensure that functional ability is maintained. TEST TAKING HINT: Using Maslow's hierar- chy of needs, physiological needs are higher than psychosocial needs, so the test taker can eliminate option "2." The nurse cannot determine or measure "understanding," so option "3" can be eliminated.

106. The son of a client diagnosed with ALS asks the nurse, "Is there any chance that I could get this disease?" Which statement by the nurse would be most appropriate? 1. "It must be scary to think you might get this disease." 2. "No, this disease is not genetic or contagious." 3. "ALS does have a genetic factor and runs in families." 4. "If you are exposed to the same virus, you may get the disease."

1. The son is not sure if he may get ALS, so this is not an appropriate response. 2. This is incorrect information. 3. There is a genetic factor with ALS that is linked to a chromosome 21 defect. 4. ALS is not caused by a virus. The exact etiology is unknown, but studies indicate that some environmental factors may lead to ALS. TEST TAKING HINT: This question requires knowledge of ALS. There are some ques- tions for which test-taking hints are not available.

49. The charge nurse is making client assignments for a neuro-medical floor. Which client should be assigned to the most experienced nurse? 1. The elderly client who is experiencing a stroke in evolution. 2. The client diagnosed with a transient ischemic attack 48 hours ago. 3. The client diagnosed with Guillain-Barré syndrome who complains of leg pain. 4. The client with Alzheimer's disease who is wandering in the halls.

1. This client is experiencing a progressing stroke, is at risk for dying, and should be cared for by the most experienced nurse. 2. A TIA by definition lasts less than 24 hours, so this client should be stable at this time. 3. Pain is expected in clients with Guillain-Barré syndrome, and symptoms are on the lower half of the body, which does not affect the airway. Therefore, a less experienced nurse could care for this client. 4. The charge nurse could delegate much of the care of this client to a UAP.

10. Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? 1. A blood glucose level of 480 mg/dL. 2. A right-sided carotid bruit. 3. A blood pressure (BP) of 220/120 mm Hg. 4. The presence of bronchogenic carcinoma.

1. This glucose level is elevated and could predispose the client to ischemic neurological changes due to blood viscosity, but it is not a risk factor for a hemorrhagic stroke. 2. A carotid bruit predisposes the client to an embolic or ischemic stroke but not to a hemorrhagic stroke. 3. Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured blood vessel inside the cranium. 4. Cancer is not a precursor to developing a hemorrhagic stroke. TEST TAKING HINT: Both options "1" and "2" are risk factors for an ischemic or embolic type of stroke. Knowing this, the test taker can rule out these options as incorrect.

32. Which client should the nurse assess first after receiving the shift report? 1. The client diagnosed with a stroke who has right-sided paralysis. 2. The client diagnosed with meningitis who complains of photosensitivity. 3. The client with a brain tumor who has projectile vomiting. 4. The client with epilepsy who complains of tender gums.

1.Paralysis is an expected occurrence with a client who has had a stroke. 2. Photosensitivity is an expected sign of meningitis. 3. Projectile vomiting indicates that in- creased intracranial pressure is exerting pressure on the vomiting center of the brain. 4. Tender gums could be secondary to medication given for epilepsy. The client may need to see a dentist, but this client does not need to be assessed first.

797. The nurse has given medication instructions to a client receiving phenytoin. Which statement indi- cates that the client has an adequate understanding of the instructions? 1. "Alcohol is not contraindicated while taking this medication." 2. "Good oral hygiene is needed, including brush- ing and flossing." 3. "The medication dose may be self-adjusted, depending on side effects." 4. "The morning dose of the medication should be taken before a serum medication level is drawn."

2 Rationale: Typical antiseizure medication instructions include taking the prescribed daily dosage to keep the blood level of the medication constant and having a sample drawn for serum medication level determination before taking the morning dose. The client is taught not to stop the medication abruptly, to avoid alcohol, to check with a health care provider before taking over-the-counter medications, to avoid activities in which alertness and coordination are required until medica- tion effects are known, to provide good oral hygiene, and to obtain regular dental care. The client should also wear a Med- icAlert bracelet.Test-Taking Strategy: Focus on the subject, an understanding of medication instructions for phenytoin. Using knowledge of general principles related to medication administration will assist you in eliminating options 1 and 3. From the remaining options, recall that medications generally are not taken just before determining therapeutic serum levels because the results would be artificially high. This leaves oral hygiene as the correct option because of the risk of gingival hyperplasia.

796. The nurse is caring for a client with chronic back pain. Codeine has been prescribed for the client. Specific to this medication, which intervention should the nurse include in the plan of care while the client is taking this medication? 1. Monitor radial pulse. 2. Monitor bowel activity. 3. Monitor apical heart rate. 4. Monitor peripheral pulses.

2 Rationale: While the client is taking codeine, the nurse would monitor vital signs and assess for hypotension. The nurse also should increase fluid intake, palpate the bladder for urinary retention, auscultate bowel sounds, and monitor the pattern of daily bowel activity and stool consistency because the med- ication causes constipation. The nurse should monitor respiratory status and initiate deep-breathing and coughing exercises. In addition, the nurse monitors the effectiveness of the pain medication.Test-Taking Strategy: Focus on the subject, a specific nursing consideration related to codeine. Eliminate options 1, 3, and 4 because they are comparable or alike. In addition, relate codeine with constipation.

792. Meperidine has been prescribed for a client to treat pain. Which side and adverse effects should the nurse monitor for? Select all that apply. 1. Diarrhea 2. Tremors 3. Drowsiness 4. Hypotension 5. Urinary frequency 6. Increased respiratory rate

2, 3, 4 Rationale: Meperidine is an opioid analgesic. Side and adverse effects include respiratory depression, drowsiness, hypoten- sion, constipation, urinary retention, nausea, vomiting, and tremors.Test-Taking Strategy: Note the subject, side and adverse effects of meperidine. Recalling that this medication is an opi- oid analgesic and recalling the effects of an opioid analgesic will assist you in identifying the correct options.

799. A client with trigeminal neuralgia tells the nurse that acetaminophen is taken daily for the relief of generalized discomfort. Which laboratory value would indicate toxicity associated with the medication? 1. Sodium level of 140 mEq/L (140 mmol/L) 2. Platelet count of 400,000 mm3 (400Â109/L) 3. Prothrombin time of 12 seconds (12 seconds) 4. Direct bilirubin level of 2 mg/dL (34 mcmol/L)

4 Rationale: In adults, overdose of acetaminophen causes liver damage. The correct option is an indicator of liver function and is the only option that indicates an abnormal laboratory value. The normal direct bilirubin level is 0.1 to 0.3 mg/dL(1.7 to 5.1 mcmol/L). The normal sodium level is 135 to 145 mEq/ L(135 to 145 mmol/L). The normal prothrombin time is 11 to 12.5 seconds (11 to 12.5 seconds). The normal platelet count is 150,000 to 400,000 mm3 (150-400 Â 109/L).Test-Taking Strategy: Focus on the subject, acetaminophen toxicity. Knowledge that acetaminophen causes liver damage and knowledge of normal laboratory results will assist you in answering this question. The correct option is the only abnormal value. Also, of all the options, the bilirubin level is the laboratory value most directly related to liver function. Review: The effects of toxicity from acetaminophen and normal laboratory values

798. A client with myasthenia gravis has become increasingly weaker. The health care provider pre- pares 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 adminis- tered. Which finding would indicate that the client is in cholinergic crisis? 1. No change in the condition 2. Complaints of muscle spasms 3. An improvement of the weakness 4. A temporary worsening of the condition

4 Rationale: An edrophonium injection makes the client in cho- linergic crisis temporarily worse. An improvement in the weak- ness indicates myasthenia crisis. Muscle spasms are not associated with this test.Test-Taking Strategy: Focus on the subject, results of an edro- phonium test. Recalling that a cholinergic crisis indicates an over- dose of medication, it seems reasonable that a worsening of the condition willoccurwhen additionalmedication isadministered.

789. Carbidopa-levodopa 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 experienc- ing an adverse effect? 1. Pruritus 2. Tachycardia 3. Hypertension 4. Impaired voluntary movements

4 Rationale: Dyskinesia and impaired voluntary movements may occur with high carbidopa-levodopa dosages. Nausea, anorexia, dizziness, orthostatic hypotension, bradycardia, and akinesia are frequent side effects of the medication. Test-Taking Strategy: Focus on the subject, an adverse effect. Options 2 and 3 are comparable or alike and are cardiac-related options, so these options can be eliminated first. Next, focus on the client's diagnosis and select the correct option over option 1 because it relates to the neurological system.

783. A client with Guillain-Barre syndrome has ascend- ing 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? 1. Giving client full control over care decisions and restricting visitors 2. Providing positive feedback and encouraging active range of motion 3. Providing information, giving positive feed- back, and encouraging relaxation 4. Providing intravenously administered sedatives, reducing distractions, and limiting visitors

4 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 vacci- nation or surgery.Test-Taking Strategy: Note the strategic word, most. Use knowledge regarding the causes related to this disorder.

782. 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? 1. Meningitis or encephalitis during the last 5 years 2. Seizures or trauma to the brain within the last year 3. Back injury or trauma to the spinal cord during the last 2 years 4. Respiratory or gastrointestinal infection during the previous month

4 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.Test-Taking Strategy: Note the strategic word, most. Use knowledge regarding the causes related to this disorder.

788. 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. Know- ing the complications of the disorder, the nurse should bring which most essential items into the client's room? 1. Nebulizer and pulse oximeter 2. Blood pressure cuff and flashlight 3. Flashlight and incentive spirometer 4. Electrocardiographic monitoring electrodes and intubation tray

4 Rationale: The client with Guillain-Barre syndrome is at risk for respiratory failure because of ascending paralysis. An intu- bation 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 thrombo- sis 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.Test-Taking Strategy: Note the strategic words, most essential. With an ascending paralysis, the client is at risk for involve- ment of respiratory muscles and subsequent respiratory failure. The correct option is the only one that includes an intubation tray, which would be needed if the client's status deteriorated to needing intubation and mechanical ventilation. This option most directly addresses the airway.

780. The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching? 1. "I can sit down to put on my pants and shoes." 2. "I try to exercise everyday and rest when I'm tired." 3. "My son removed all loose rugs from my bedroom." 4. "I don't need to use my walker to get to the bathroom."

4 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 every day in the morning when energy levels are highest. The client should have all loose rugs in the home removed to pre- vent falling.Test-Taking Strategy: Note the strategic words, need for further teaching. These words indicate a negative event query and the need to select the incorrect client statement as the answer. Recall that clients with Parkinson's disease are at risk for falls.

101. According to the nursing process, which interventions should the nurse implement when caring for a client diagnosed with a right-sided cerebrovascular accident (stroke) and who has difficulty swallowing? List the interventions in order of the nursing process. 1. Write the client problem of "altered tissue perfusion." 2. Assess the client's level of consciousness and speech. 3. Request dietary to send a full liquid tray with Thick-It. 4. Instruct the UAP to elevate the head of the bed 30 degrees. 5. Note the amount of food consumed on the dinner tray.

In order of the nursing process: 2, 1, 3, 4, 5. 2. This is the assessment step, the first step of the nursing process. 1. Diagnosis is the second step in the nursing process. In this case, it is "altered tissue perfusion." 3. Planning is the third step of the nursing process. 4. Implementation is the fourth step in the nursing process. 5. Evaluation is the last step of the nursing process.

794. The client arrives at the emergency department complaining of back spasms. The client states, "I have been taking 2 to 3 aspirin every 4 hours for the last week, and it hasn't helped my back." Since acetylsalicylic acid intoxication is suspected, the nurse should assess the client for which manifestation? 1. Tinnitus 2. Diarrhea 3. Constipation 4. Photosensitivity

1 Rationale: Mild intoxication with acetylsalicylic acid is called salicylism and is experienced commonly when the daily dosage is higher than 4 g. Tinnitus (ringing in the ears) is the most fre- quent effect noted with intoxication. Hyperventilation may occur because salicylate stimulates the respiratory center. Fever may result because salicylate interferes with the metabolic pathways coupling oxygen consumption and heat production. Options 2, 3, and 4 are not associated specifically with toxicity. Test-Taking Strategy: Focus on the subject, acetylsalicylic acid intoxication. Options 2 and 3 relate to gastrointestinal symp- toms, are comparable or alike, and are eliminated first. From the remaining options, you must know that tinnitus occurs.

795. A client with trigeminal neuralgia is being treated with carbamazepine, 400 mg orally daily. Which value indicates that the client is experiencing an adverse effect to the medication? 1. Sodium level, 140 mEq/L (140 mmol/L) 2. Uric acid level, 4.0 mg/dL (0.24 mmol/L) 3. White blood cell count, 3000mm3 (3.0Â109/L) 4. Blood urea nitrogen level, 10 mg/dL (3.6 mmol/L)

3 Rationale: Adverse effects of carbamazepine appear as blood dyscrasias, including aplastic anemia, agranulocytosis, throm- bocytopenia, and leukopenia; cardiovascular disturbances, including thrombophlebitis and dysrhythmias; and dermato- logical effects. The low white blood cell count reflects agranu- locytosis. The laboratory values in options 1, 2, and 4 are normal values.Test-Taking Strategy: Focus on the subject, an adverse effect of carbamazepine. If you are familiar with normal laboratory values, you will note that the only option that indicates an abnormal value is the correct option.

777. The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client over- come the deficit. Which statement suggests that the family understands the measures to use when caring for the client? 1. "We need to discourage him from wearing eyeglasses." 2. "We need to place objects in his impaired field of vision." 3. "We need to approach him from the impaired field of vision." 4. "We need to remind him to turn his head to scan the lost visual field."

4 Rationale: Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eye- glasses, if they are available.Test-Taking Strategy: Focus on the subject, homonymous hemianopsia. Eliminate options 2 and 3 first because they are comparable or alike. Recalling the definition of homonymous hemianopsia will direct you easily to the correct option.

791. The nurse is caring for a client in the emergency department who has been diagnosed with Bell's palsy. The client has been taking acetaminophen, and acetaminophen overdose is suspected. Which antidote should the nurse prepare for administra- tion if prescribed? 1. Pentostatin 2. Auranofin 3. Fludarabine 4. Acetylcysteine

4 Rationale: The antidote for acetaminophen is acetylcysteine. The normal therapeutic serum level of acetaminophen is 10 to 20 mcg/mL(40 to 79 mcmol/L). Atoxic level is higher than 50 mcg/mL(200 mcmol/L), and levels higher than 100 mcg/mL (400 mcmol/L) could indicate hepatotoxicity. Auranofin is a gold preparation that may be used to treat rheumatoid arthritis. Pentostatin and fludarabine are antineoplastic agents. Test-Taking Strategy: Eliminate options 1 and 3 first because they are comparable or alike (antineoplastic agents). Recalling that auranofin is used to treat rheumatoid arthritis will direct you to the correct option.