NURS-244 Neuro Content

For a client with suspected increased intracranial pressure (ICP), an appropriate respiratory goal is to a.) Promote carbon dioxide elimination. b.) Lower arterial pH. c.) Prevent respiratory alkalosis. d.) Maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg.

A The goal of treatment for ICP is to prevent acidemia by eliminating carbon dioxide because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP.

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

A Cerebral angiography is performed by threading a catheter through the femoral or brachial artery. The extremity is kept immobilized after the procedure. The nurse checks the extremity for adequate circulation by noting skin color and temperature, presence and quality of pulses distal to the injection site, and capillary refill.

The nurse is assessing the motor and sensory function of an unconscious client who sustained a head injury. The nurse should use which technique to test the client's peripheral response to pain? a.) Sternal rub b.) Nailbed pressure c.) Pressure on the orbital rim d.) Squeezing of the sternocleidomastoid muscle

B Nailbed pressure tests a motor and sensory peripheral response. Cerebral responses are tested by sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

What are common causes of brain abcesses? Select all that apply. a.) UTI b.) Untreated dental abcess c.) Untreated sinus infection d.) MRSA e.) Respiratory infection f.) IV drug use g.) Trauma

B, C, D, F, G

A nurse assesses an older client. Which assessment findings would the nurse identify as normal changes in the nervous system related to aging? Select all that apply. a.) Long-term memory loss b.) Slower processing time c.) Increased sensory perception d.) Decreased risk for infection e.) Change in sleep patterns

B, E Normal changes in the nervous system related to aging include recent memory loss, slower processing time, decreased sensory perception, an increased risk for infection, changes in sleep patterns, changes in perception of pain, and altered balance and/or decreased coordination.

What are the non-surgical treatments for a tumor within the skull?

Chemotherapy, analgesics, steroids, prophylactic antiepileptic

What are the surgical treatments for a tumor within the skull?

Craniotomy, craniectomy, radiosurgery

What is the FIRST sign of increasing ICP? a.) Loss of PERRLA b.) Unilateral Droop/Weakness c.) Aphasia d.) Loss of consciousness

D

What are the signs/symptoms of a tumor located on the brain stem?

Hearing loss, dysphagia, nystagmus, hoarseness, apnea, bradycardia, hypotension

What are the 2 non-surgical options to treat ischemic stroke?

IV fibrinolytic therapy & endovascular interventions (embolectomy & angioplasty)

What are 3 medications used to prevent seizures?

Keppra, Vimpat, and phenytoin

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

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

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 inspect for which manifestation? a.) Tinnitus b.) Diarrhea c.) Constipation d.) Photosensitivity

A Mild intoxication of actylsalicylic acid is called salicylism and is experienced commonly when the daily dosage is higher tham 4 g. Tinnitus (ringing in the ears) is the most frequent effect noted with intoxication. Hyperventilation may result due to being a respiratory stimulus, and fever may result due to metabolic interference. Options 2, 3, and 4 are not associated with salicylism specifically.

The nurse observes a client with late-stage Alzheimer disease eat breakfast. Afterward the client states, "I am hungry and want breakfast." What is the nurse's best response? a. "I see you are still hungry. I will get you some toast." b. "You ate your breakfast 30 minutes ago." c. "It appears you are confused this morning." d. "Your family will be here soon. Let's get you dressed."

A Use of validation therapy with clients who have late-stage Alzheimer disease involves acknowledgment of the client's feelings and concerns. This technique has proved more effective in later stages of the disease because reality orientation only increases agitation. The other statements do not validate the client's concerns.

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

A An LP would not be performed if the client has a skin infection at or near the puncture site because of the risk of cerebrospinal fluid infection. A nurse would want to notify the primary health care provider if shingles were identified on the client's back.

A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question would the nurse ask? a. "Do you live in a crowded residence?" b. "When was your last tetanus vaccination?" c. "Have you had any viral infections recently?" d. "Have you traveled out of the country in the last month?"

A Bacterial meningitis tends to occur in multiple outbreaks. It is most likely to occur in areas of high-density population, such as college dormitories, prisons, and military barracks.

A nurse teaches assistive personnel (AP) about how to care for a client with Parkinson disease. Which statement would the nurse include as part of this teaching? a. "Allow the client to be as independent as possible with activities." b. "Assist the client with frequent and meticulous oral care." c. "Assess the client's ability to eat and swallow before each meal." d. "Schedule appointments early in the morning to ensure rest in the afternoon."

A Clients with Parkinson disease do not move as quickly and can have functional problems. The client would be encouraged to be as independent as possible and provided time to perform activities without rushing. Although oral care is important for all clients, instructing the UAP to provide frequent and meticulous oral is not a priority for this client.

Which statement would the nurse include when teaching the assistive personnel (AP) about how to care for a client with cranial nerve II impairment? a.) "Tell the client where food items are on the breakfast tray." b.) "Place the client in a high-Fowler position for all meals." c.) "Make sure the client's food is visually appetizing." d.) "Assist the client by placing the fork in the left hand."

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

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

A If testing is begun on the right hand and the client correctly identifies the pain stimulus, the nurse would continue the assessment on the left hand. This is a normal finding and does not need to be reported to the provider, but instead documented in the client's medical record.

A nurse assesses a client and notes the client's position being with the arms bent and harns, wrists, and finger flexed. How would the nurse document this finding? a.) Decorticate posturing b.) Decerebrate posturing c.) Atypical hyperreflexia d.) Spinal cord degeneration

A The client is demonstrating decorticate posturing, which is seen with interruption in the corticospinal pathway. This finding is abnormal and is a sign that the client's condition has deteriorated. The primary health care provider, the charge nurse/team leader, and other health care team members would be notified immediately of this change in status.

The nurse assesses clients on a medical-surgical unit. Which clients would the nurse identify as at risk for secondary seizures? Select all that apply. a. A 26-year-old woman with a left temporal brain tumor b. A 38-year-old male client in an alcohol withdrawal program c. A 42-year-old football player with a traumatic brain injury d. A 66-year-old female client with multiple sclerosis e. A 72-year-old man with chronic obstructive pulmonary disease

A, B, C Clients at risk for secondary seizures include those with a brain lesion from a tumor or trauma, and those who are experiencing a metabolic disorder, acute alcohol withdrawal, electrolyte disturbances, and high fever. Clients with a history of stroke, heart disease, and substance abuse are also at risk. Clients with multiple sclerosis or chronic obstructive pulmonary disease are not at risk for secondary seizures.

The nurse assesses a client who has meningitis. Which sign(s) and symptom(s) would the nurse anticipate? Select all that apply. a. Photophobia b. Decreased level of consciousness c. Severe headache d. Fever and chills e. Bradycardia

A, B, C, D All of the choices except for bradycardia are key features of meningitis. Tachycardia is more likely than bradycardia due to the infectious process and fever.

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. a.) The client is aphasic b.) The client has weakness on the right side of the body c.) The client has complete bilateral paralysis of the arms and legs d.) The client has weakness on the right side of the face and tongue e.) The client has lost the ability to move the right arm but is able to walk independently f.) The client has lost the ability to ambulate independently but is able to feed and bather herself or himself without assistance.

A, B, D Hemiparesis is 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 anxious when attempting a new task. Clients with hemiparesis will need assistance with feeding, bathing and ambulating. Complete bilateral paralysis does not occur in hemiparesis.

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

A, B, D, The most common cause of autonomic dysreflexia is a distended bladder. Straight caths should be done every 4 to 6 hours, and urinary catheters should be checked frequently for kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important . A bowel movement once a week is to infrequent. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli.

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

A, B, D, E Cranial nerves IX (glossopharyngeal), X (vagus), XI (accessory), and XII (hypoglossal) emerge from the medulla, as do portions of cranial nerves VII (facial) and VIII (acoustic). Damage to these nerves causes decreased respirations, impaired swallowing, inability to shrug shoulders, and loss of the gag reflex.

A patient received TPA for treatment of ischemic stroke. What are some interventions/precautions the nurse should expect? Select all that apply. a.) Assess for bleeding b.) Frequent vital checks c.) Collect labs from patient d.) Assess for dehydration e.) Frequent neuro checks

A, B, E TPA dissolves blood clots, so frequent assessment for bleeding would be important. After giving TPA, vitals need to be collected q15min for the first hour, q30min for the next 2 hours, and then every hour. Frequent neuro checks to see if the TPA has helped any. Collecting labs would increase the chance of bleeding. Assessment for dehydration is important, but not necessary at this time.

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

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

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. a.) Padding the side rails of the bed b.) Placing an airway at the bedside c.) Placing the bed in the highest position d.) Putting a padded tongue blade at the head of the bed e.) Placing oxygen and suction equipment at the bedside f.) Flushing the intravenous catheter to ensure the site is patent

A, B, E, F Seizure precautions may vary from angency to agency, but they generally have some common features. Usually, an airway, oxygen, and suction equipment are kept available at the bedside. The siderails of the bed are padded, and the bed is in the lowest position. The client has an intravenous access in place to have readily access for antiseizure medication. Placing a tongue blade is more of a hazard to the patient than it is helpful.

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply. a.) Loosening restrictive clothing b.) Restraining the clients limbs c.) Removing the pillow and raising the padded side rails d.) Positioning the client to the side, if possible, with the head flexed forward e.) Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist

A, C, D Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising the padded side rails, and placing the client on 1 side with the head flexed forward, if possible, to allow the tongue to falll forward and facilitate drainage. The limbs are never to be restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, protects the head from injury, and move furniture that may injure the client.

How do we go about diagnosing a brain abcess? Select all that apply. a.) Lumbar puncture b.) PTT and INR c.) EEG d.) ESR e.) WBC f.) CT scan g.) Needle biopsy

A, C, D, E, F, G

How is hemorrhagic stroke managed? Select all that apply. a.) Placement of EDV b.) Fluid restriction c.) Tight control of serum glucose d.) Stat head CT e.) Administration of TPA f.) Baseline neuro assessment g.) Surgical evacuation of clot

A, C, D, F, G EDV relieves IICP. Hypo/hyperglycemia can reduce outcomes in hemorrhagic stroke. Head CT would reveal free blood. Neuro assessment would reveal symptoms/severity. Surgical evacuation for clots that are large.

A nurse teaches the spouse of a client who has Alzheimer disease. Which statements should the nurse include in this teaching related to caregiver stress reduction? Select all that apply. a. "Establish advanced directives early." b. "Trust that family and friends will help." c. "Set aside time each day to be away from the client." d. "Use discipline to correct inappropriate behaviors." e. "Seek respite care periodically for longer periods of time."

A, C, E To reduce caregiver stress, the spouse should be encouraged to establish advanced directives early, set aside time each day for rest or recreation away from the client, seek respite care periodically for longer periods of time, use humor with the client, and explore alternative care settings and resources. Family and friends may not be available to help. A structured environment will assist the client with AD, but discipline will not correct inappropriate behaviors and not reduce caregiver stress.

What nursing interventions would you expect with increased ICP? Select all that apply. a.) Hyperoxygenated before suctioning b.) Cluster care activities to lengthen rest periods c.) Suction secretions up to 20 seconds, but no more than 25 d.) Monitor temperature e.) HOB no more than 30 degrees

A, D, E Hyperoxygenating helps prevent IICP; monitor temperature because elevation can cause IICP; HOB <30 degrees enhances respirations; not supposed to suction longer than 15 seconds; clustered activities can increase ICP due to the large amount - it's better to spread out activities.

The nurse is caring for a client in late-stage Alzheimer disease. Which assessment finding(s) will the nurse anticipate? Select all that apply. a. Immobile b. Has difficulty driving c. Wandering d. ADL dependent e. Incontinent f. Possible seizures

A, D, E, F The client in late-stage Alzheimer disease is totally bedridden and immobile, and therefore, cannot ambulate to wander or drive. The client is incontinent and ADL dependent.

The nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions would the nurse include in this client's plan of care? Select all that apply. a. Have suction equipment with an airway at the bedside. b. Place a padded tongue blade at the bedside. c. Permit only clear oral fluids. d. Have oxygen administration set at the bedside. e. Maintain the client on strict bedrest. f. Ensure that the client has IV access.

A, D, F Oxygen and suctioning equipment with an airway must be readily available. If the client does not have an IV access, insert a saline lock, especially for those clients who are at significant risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV drug therapy must be given to stop the seizure. Padded tongue blades may pose a danger to the client or nurse during a seizure and would not be used. Dietary restrictions and strict bedrest are not interventions associated with epilepsy.

The nurse has completed discharge instructions for a client with application of a halo device who sustained a cervical spinal cord injury. Which statement indicates that the client needs further clarification of the instructions? a.) "I will use a straw for drinking" b.) "I will drive only during the daytime" c.) "I will be careful because the device alters balance" d.) "I will wash the skin daily under the lamb's wool liner of the vest"

B The halo device alters balance and can cause fatigue because of its weight. The client should cleanse the skin daily under the vest to protect the skin from ulceration and should avoid the use of powders or lotions. The liner should be changed if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin care is done as instructed. The inability to turn the head without turning the torse would contraindicate driving, so the client wouldn't be able to drive at all.

A client has a neurological deficit regarding the limbic system. On assessment, which finding is specific to this type of deficit? a.) Disoriented to person, place, and time b.) Affect is flat, with periods of emotional liability c.) Cannot recall what was eaten for breakfast today d.) Demonstrates inability to add and subtract, and cannot recall the president of the U.S.

B The limbic system is responsible fo feelings (affect) and emotions. Calculation ability and knowledge of current events relate to functions of the frontal lobe. The cerebral hemispheres, with specific regional functions, control orientation. Recall of recent events is controlled by the hippocampus.

A nurse is caring for a client who suffered a stroke. The family reports that the nurse on the previous shift failed to administer medications properly or maintain client privacy. What is the best action by the nurse? a.) Explain to the client's family the previous nurse's actions were accidental. b.) Inform the charge nurse of the family's concerns. c.) Complete grievance paperwork for the family and hand it to them to submit. d.) Notify the health care provider and social services.

B The nurse should follow the facility's policy and chain of command for handling complaints, which commonly begins with the charge nurse.

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

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

The nurse has given medication instructions to a client receiving phenytoin. Which statement indicates that the client has an adequate understanding of the instructions? a.) "Alcohol is not contraindicated while taking this medication" b.) Good oral hygiene is needed, including brushing and flossing" c.) The medication dose may be self-adjusted, depending on side effects" d.) The morning dose of medication should be taken before serum medication level is drawn"

B 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 level evaluation before taking the morning dose. The client should be taught to not stop the drug suddenly, to check with the HCP before taking OTC medications, to avoid activities that affect alertness and coordination until effects of phenytoin on the client are known, good oral hygiene,, and regular dental care.

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? a.) Monitor radial pulse b.) Monitor bowel activity c.) Monitor apical heart rate d.) Monitor peripheral pulses

B While the client is taking codeine, the nurse would monitor vital signs and assess for hypotension. THe nurse would also increase the clients fluid intake palpate the bladder for urinary retention, auscultate bowel sounds, and monitor the pattern of daily bowel activity and stool consistency, because some medication causes constipation.

The nurse is caring for the client with increased intracranial pressure as a result of a head injury. The nurse would note which trend in vital signs if the intracranial pressure is rising? a.) increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure b.) Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure c.) Decreasing temperature, decreasing pulse, increaseing respirations, decreasing blood pressure d.) Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

B A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure, while pulse and respirations decrease. Respiratory irregularities may also occur.

A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication would the nurse anticipate to prepare for administration? a. Atenolol b. Lorazepam c. Phenytoin d. Lisinopril

B Initially, intravenous lorazepam or diazepam is administered to stop motor movements. This is followed by the administration of phenytoin

The nurse cares for a client with middle-stage (moderate) Alzheimer disease. The client's caregiver states, "She is always wandering off. What can I do to manage this restless behavior?" What is the nurse's best response? a. "This is a sign of fatigue. The client would benefit from a daily nap." b. "Engage the client in scheduled activities throughout the day." c. "It sounds like this is difficult for you. I will consult the social worker." d. "The provider can prescribe a mild sedative for restlessness."

B Several strategies may be used to cope with restlessness and wandering. One strategy is to engage the client in structured activities. Another is to take the client for frequent walks. Daily naps and a mild sedative will not be as effective in the management of restless behavior. Consulting the social worker does not address the caregiver's concern.

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

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

A patient has symptoms of IICP. What would you educate the patient to not do? Select all that apply. a.) Deep breathing b.) Coughing c.) Gagging d.) Lying supine e.) Bearing down/Straining f.) Vomitting

B, C, E, F

The nurse is caring for a client who had a cerebrovascular accident (CVA) and needs to be fed. What instruction would the RN give the unlicensed assistive personnel (UAP), who will feed the client? a.) "Check the client's gag and swallow reflexes." b.) "Feed the client quickly, there are four more client's to feed." c.) "Position the client in a sitting position before feeding." d.) "Suction the client's secretions between bites of food."

C Instructions to the UAP should include positioning the client in a sitting position, which will decrease the risk of aspiration for the client with CVA. The nursing assistant does not have the additional education to assess gag/swallow reflexes.

A client who is in rehabilitation following a cerebrovascular accident (or brain attack) is experiencing total hemiplegia of the dominant right side. The nurse finds that the client needs assistance with eating to ensure optimum nutrition. Which action is most important for the nurse to take to facilitate rehabilitation with eating? a.) Have a family member assist with feeding at mealtimes. b.) Request a diet of thickened liquids that can be taken through a straw. c.) Assist the client in learning to eat with the left hand. d.) Continue feeding the client until the hemiplegia resolves.

C It is important to involve the client in care. The client will need to learn to eat with the non-dominant hand. Promoting independence and supporting attainment of this skill will help the client positively meet the goal of rehabilitation.

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

C Phenytoin enhances the rate of estrogen metabolism, which can decrease the effectiveness of some birth control pills. Options 1, 2, and 4 are inappropriate instructions. Phenytoin can cause some risk potential to a fetus, so an HCP must be consulted if trying to conceive. Telling a client there is an increased risk of thrombophlebitis is incorrect and inappropriate as it could cause the client anxiety and stress. A client should not be instructed to stop antiseizure medication.

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? a.) A negative Kernig's sign b.) Absence of nuchal rigidity c.) A positive Brudzinski's sign d.) A GCS of 15

C Signs of meningeal irritation compatible with meningitis include nuchal rigidity and a positive Bridzinski's & Kernig's sign. Nuchal rigidity is characterized by a stif neck and soreness, which is especially noticable when the neck is flexed. A GCS is a perfect score and indicates that the client is awake and alert with no neurological deficits.

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

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

The nurse is teaching a group of college students about the importance of preventing meningitis. Which health promotion activity is the most appropriate for preventing this disease? a. Eating a well-balanced diet that is high in protein b. Having an annual physical examination c. Obtaining the recommended meningitis vaccination and boosters d. Identifying signs and symptoms for early treatment

C CDC-recommended vaccinations and boosters are available for prevention of a number of diseases including meningococcal meningitis. While the other activities are appropriate for general health promotion, they are not specific to meningitis prevention.

A nurse plans care for a 77-year-old client who is experiencing age-related peripheral sensory perception changes. Which intervention would the nurse include in this client's plan of care? a.) Provide a call button that requires only minimal pressure to activate. b.) Write the date on the client's white board to promote orientation. c.) Ensure that the path to the bathroom is free from clutter. d.) Encourage the client to season food to stimulate nutritional intake.

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

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

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

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

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

The nurse teaches an 80-year-old client with diminished peripheral sensation. Which statement would the nurse include in this client's teaching? a.) "Place soft rugs in your bathroom to decrease pain in your feet." b.) "Bathe in warm water to increase your circulation." c.) "Look at the placement of your feet when walking." d.) "Walk barefoot to decrease pressure injuries from your shoes."

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

The nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. What action would the nurse take first? a. Start fluids via a large-bore catheter. b. Administer IV push diazepam. c. Turn the client's head to the side. d. Prepare to intubate the client.

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

The nurse is monitoring a client with increased intracranial pressure (ICP). What indicators are the most critical for the nurse to monitor? Select all that apply! a.) Level of Pain b.) Urine Output c.) Systolic Blood Pressure d.) Cerebral Perfusion Pressure e.) Breath sounds

C, D The nurse must monitor the systolic and diastolic blood pressure to obtain the mean arterial pressure (MAP), which represents the pressure needed for each cardiac cycle to perfuse the brain. The nurse must also monitor the cerebral perfusion pressure (CPP), which is obtained from the ICP and the MAP.

A nurse is assessing a client with meningitis. The nurse places the client in a supine position and flexes the client's leg at the hip and knee. The nurse notes resistance when straightening the knee and the client reports pain. The nurse should document what neurologic sign as positive? a.) Brudzinski's Sign b.) Bobinski's Sign c.) Raynaud's Sign d.) Kernig's Sign

D A positive Kernig's sign is a manifestation of meningeal irritation. The nurse can elicit this sign by placing the client in a supine position and flexing the leg at the hip and knee. Pain or resistance when the knee is straightened suggests meningeal irritation.

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in ICP if the nurse observes the client doing which activity? a.) Blowing the nose b.) Isometric exercises c.) Coughing d.) Exhaling during repositioning

D Activities that can increase intrathoracic and intraabdominal pressure can indirectly increase ICP. Some of these activities include isometric exercises, valsalva maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising.

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

D An endophonium injection makes the client in cholinergic crisis temporarily worse. An improvement in the weakness indicates myasthenia crisis. Muscle spasms are not associated with this test.

The nurse is assessing the adaption of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully? a.) Gets angry with family if they interrupt a task b.) Experiences bouts of depression and irritability c.) Has difficulty with using modified feeding utensils d.) Consistently uses adaptive equipment in dressing self

D Clients are evaluated as coping successfully with lifestyle changes after a stroke if they make appropriate life-styl alterations, use the assistance of others, and have appropriate social interactions. Options 1 and 2 are not adaptive behaviors; option 3 indicates a not yet successful attempt to adapt.

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

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

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

D Guillian-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.

The nurse has instructed the family of a client with stroke (brain attack) who has homonymous heminopsia about measures to help the client overcome the deficit. Which statement suggests the the family understands the measures to use when caring for the client? a.) "We need to discourage him from wearing eyeglasses" b.) "We need to place objects in his impaired field of vision" c.) "We need to approach him from the impaired field of vision" d.) "We need to remind him to turn his head to scan the lost visual field"

D 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 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.

A client with trigeminal neuralgia tells the nurse that acetominophen is taken daily for the relief of generalized discomfort. Which laboratory value would indicate toxicity associated with the medication? a.) Sodium level of 140 mEq/L b.) Platelet count of 400,000 mm3 c.) PT time of 12 seconds d.) Direct bilirubin level of 2 mg/dL

D In adults, overdose of acetominophen 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 0.1-0.3 mg/dL.

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? a.) Fluid is clear and tests negative for glucose b.) Fluid is grossly bloody in appearance and has a pH of 6 c.) Fluid clumps together on the dressing and has a pH of 7 d.) Fluid separates in concentric rings and tests positive for glucose

D Leakage of cerebrospinal fluid from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric dressing material, termed halo sign. The fluid will also test positive for glucose.

The nurse is caring for a client in the emergency department who has been diagnosed with Bell's Palsy. The client has been taking acetominophen, and acetominophen overdose is suspected. Thich antidote should the nurse prepare for administration if prescribed? a.) Pentostatin b.) Auranofin c.) Fludarabine d.) Acetylcysteine

D The antitode for acetominophen id scetylcysteine. The normal therapeutic serum level of acetominophen is 10 to 20 mcg/mL. A toxic level is higher than 50 mcg/mL, and levels higher than 200 mcg/mL 4 hours after ingestion indicates there is risk for liver damage.

The nurse is admitting a client with Guillain-Barre syndrome to the nursing unit. The client has complaints of inability to move both legs and reports a tingling sensation above the waistline. Knowing the complications of the disorder, the nurse should bring which most essential items into the clients room? a.) Nebulizer and pulse oximeter b.) Blood pressure cuff and flashlight c.) Nasal cannula and incentive spirometer d.) Electrocardiographic monitoring electrodes and intubation tray

D The client with Guillain-Barre syndrome is at risk for respiratory failure because of ascending paralysis. An intubation tray should be available for use. Another complication of this syndrome is cardiac dyshythmias, which necessitates the use of electrocardiographic monitoring.

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

D 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, regardless, 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 prevent falling.

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

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

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

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

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

D Asking clients about recent events that can be verified, such as what the client ate for breakfast, assesses recent memory. Asking clients about certain facts from the past that can be verified assesses remote or long-term memory. Asking the client to repeat words assesses immediate memory.

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

D Because chewing and swallowing can be problematic, small frequent meals and a supplement are better for meeting the client's nutritional needs. A masklike face and drooling are common in clients with Parkinson disease. The client would be encouraged to continue to socialize and communicate as normally as possible.

Carbidopa-Levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side and adverse effects of the medication. Thich finding indicates that the client is experiencing an adverse effect? a.) Pruritis b.) Tachycardia c.) Hypertension d.) Impaired voluntary movement

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

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

D Elevation of the head of the bed will help prevent aspiration. The other options will not prevent aspiration, which is the greatest respiratory complication of Parkinson disease, nor do these interventions address any of the complications of Parkinson disease.

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

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

What is the formula for obtaining CPP?

MAP-ICP=CPP MAP is the pressure within the whole body while ICP is the pressure in the head. Subtracting both of these gives the Cranial Perfusion Pressure, or CPP.

A client has had a cerebrovascular accident (CVA) which has affected the left side of the client's brain. The nurse should assess the client for: a.) Expressive Aphasia b.) Dyslexia c.) Direct Pupillary Response d.) Dysarthria

A Broca's area, which controls expressive speech, is located on the left side of the brain. Therefore, a client with a cerebrovascular accident in this area is likely to exhibit expressive or motor aphasia.

When caring for a client with a head injury, the nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP? a.) Rising blood pressure and bradycardia b.) Hypotension and bradycardia c.) Hypotension and tachycardia d.) Hypertension and narrowing pulse pressure

A Rising blood pressure (HTN), bradycardia, and a widening pulse pressure (also known as Cushing's Triad) will all be present in cases of late increasing intracranial pressure.

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

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

Where is a supratentorial tumor located?

Above the cerebellum within the cerebrum

What class of drug is used to treat vasospasm from the 3rd day to the 21st day after a stroke? a.) Beta Blockers b.) Calcium Channel Blockers c.) Angiotensin Receptor Blockers d.) Non-Steroidal Anti-Inflammatory Drugs

B

A client with early-stage Alzheimer disease is admitted to the hospital with chest pain. Which nursing action is most appropriate to manage this client's dementia? a. Provide animal-assisted therapy as needed. b. Ensure a structured and consistent environment. c. Assist the client with activities of daily living (ADLs). d. Use validation therapy when communicating with the client.

B The client who has early Alzheimer disease (AD) does not require assistance with ADLs or validation therapy. While animal-assisted therapy may be helpful, some health care agencies do not allow this intervention. Therefore, the most appropriate action is to provide a structured and consistent environment while the client is hospitalized to prevent worsening of the client's symptoms.

Meperidine has been prescribed for a client to treat pain. Which side and adverse effects should the nurse monitor for? Select all that apply. a.) Diarrhea b.) Drowsiness c.) Tremors d.) Hypotension e.) Urinary frequency f.) Increased respiratory rate

B, C, D Meperidine is an opioid analgesic. Side and adverse effects include respiratory depression, drowsiness, hypotension, constipation, urinary retention, nausea, vomiting, and tremors.

A client who had a massive stroke exhibits decerebrate posture. What are the characteristics of this posture? Select all that apply! a.) Flexion of the arms and wrists with internal rotation b.) Plantar flexion of the feet c.) Wrist pronation d.) Opisthotonos e.) Stiff extension of the arms and legs

B, C, D, E Decerebrate posture, which results from damage to the upper brain stem, is characterized by adduction and stiff extension of the arms. These findings are accompanied by wrist pronation, finger flexion, opisthotonos, and stiff extension of the legs with plantar flexion of the feet.

How high can the Glascow Coma Scale go? a.) 21 b.) 18 c.) 15 d.) 14

C

What medication is given 24-48 hours after TPA administration? a.) Calcium Channel Blocker b.) NSAID c.) Aspirin d.) Beta Blocker

C

A client with trigeminal neuralgia is being treated with carbamazepine, 400 mg orally daily. Wich value indicates that the client is experiencing an adverse reaction to the medication? a.) Sodium level of 140 mEq/L b.) Uric acid level of 4.0 mg/dL c.) WBC of 3000 mm3 d.) BUN of 10 mg/dL

C Carbamazepine, classified as an antiseizure medication, is used to treat nerve pain. Adverse effects of this drug appear as blood dyscrasias, including aplastic anemia, agranulocytosis, thrombocytopenia, and leukopenia; cardiovascular disturbances including thrombophlebitis and dysrhythmias; and dermatological effects. The values in options 1, 2, and 4 are all normal.

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

C Resolution of spinal shock is occuring when there is return of the reflexes (especially noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, and reflex emptying of the bladder.

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

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

A patient recently had these vitals collected: HR 73, RR 19, O2 97, BP 126/82 with a GCS of 7. New vitals are as follows: HR 78, RR 13, O2 96, BP 110/71 with a GCS of 5. What finding is clinically significant? a.) Change in HR b.) Change in BP c.) Change in RR D.) Change in GCS

D A 2 point change in the GCS is indicative of a negative or deteriorating status.

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

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

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

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

A nurse prepares to provide perineal care to a client with meningococcal meningitis. Which personal protective equipment would the nurse wear? Select all that apply. a. Particulate respirator b. Isolation gown c. Shoe covers d. Surgical mask e. Gloves

D, E Meningococcal meningitis is spread via saliva and droplets, and Droplet Precautions are necessary. Caregivers would wear a surgical mask when within 6 feet (1.8 m) of the client and would continue to use Standard Precautions, including gloves.

Define a glioblastoma.

Fast-growing and aggressive brain tumor

What are signs/symptoms of a tumor located on the cerebrum?

Headache, seizures, visual changes, hypokinesia, aphasia, personality changes, hemiparesis, hemiplegia, parasthesia

Where is an acoustic neuroma located?

On the acoustic cranial nerve

Where is a infratentorial tumor located?

On the cerebellum or brainstem

What are the defining characteristics of Cushing's Triad?

Respiratory depression, widening pulse pressure, and bradycardia.