NURS 376- Neuro
A patient with a left-sided brain stroke suddenly bursts into tears when family members visit. The nurse should a. use a calm voice to ask the patient to stop the crying behavior. b. explain to the family that depression is normal following a stroke. c. have the family members leave the patient alone for a few minutes. d. teach the family that emotional outbursts are common after strokes
Patients who have left-sided brain stroke are prone to emotional outbursts, which are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient's control and asking the patient to stop will lead to embarrassment.
Which statement by the wife of a patient with Alzheimer's disease (AD) demonstrates an accurate understanding of her husband's medication regimen? a) "I'm really hoping his medications will slow down his mental losses." b) "We're both holding out hope that this medication will cure his disease." c) "I know that this won't cure him, but we learned that it might prevent a bodily decline while he declines mentally." d) "I learned that if we are vigilant about his medication schedule, he may not experience the physical effects of his disease."
a) "I'm really hoping his medications will slow down his mental losses." There is presently no cure for Alzheimer's disease, and drug therapy aims at improving or controlling decline in cognition. Medications do not directly address the physical manifestations of AD.
A patient with a suspected traumatic brain injury has bloody nasal drainage. What observation should cause the nurse to suspect that this patient has a cerebrospinal fluid (CSF) leak? a) A halo sign on the nasal drip pad b) Decreased blood pressure and urinary output c) A positive reading for glucose on a Test-tape strip d) Clear nasal drainage along with the bloody discharge
a) A halo sign on the nasal drip pad When drainage containing both CSF and blood is allowed to drip onto a white pad, within a few minutes the blood will coalesce into the center, and a yellowish ring of CSF will encircle the blood, giving a halo effect. The presence of glucose would be unreliable for determining the presence of CSF because blood also contains glucose. Decreased blood pressure and urinary output would not be indicative of a CSF leak.
For which patient should the nurse prioritize an assessment for depression? a) A patient in the early stages of Alzheimer's disease b) A patient who is in the final stages of Alzheimer's disease c) A patient experiencing delirium secondary to dehydration d) A patient who has become delirious following an atypical drug response
a) A patient in the early stages of Alzheimer's disease Patients in the early stages of Alzheimer's disease are particularly susceptible to depression, since the patient is acutely aware of his or her cognitive changes and the expected disease trajectory. Delirium is typically a shorter-term health problem that does not typically pose a heightened risk of depression.
Which clinical manifestation would the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury? a) Bradycardia b) Hypertension c) Neurogenic spasticity d) Bounding pedal pulses
a) Bradycardia Neurogenic shock is due to the loss of vasomotor tone caused by injury and is characterized by bradycardia and hypotension. Loss of sympathetic innervations causes peripheral vasodilation, venous pooling, and a decreased cardiac output. Thus hypertension, neurogenic spasticity, and bounding pedal pulses are not seen in neurogenic shock.
The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which medications might the nurse expect to provide discharge instructions (select all that apply)? a) Clopidogrel (Plavix) b) Enoxaparin (Lovenox) c) Dipyridamole (Persantine) d) Enteric-coated aspirin (Ecotrin) e) Tissue plasminogen activator (tPA)
a) Clopidogrel (Plavix) c) Dipyridamole (Persantine) d) Enteric-coated aspirin (Ecotrin) Aspirin is the most frequently used antiplatelet agent. Other drugs to prevent clot formation include clopidogrel (Plavix), dipyridamole (Persantine), ticlopidine (Ticlid), combined dipyridamole and aspirin (Aggrenox), and anticoagulant drugs, such as oral warfarin (Coumadin). Tissue plasminogen activator is a fibrinolytic medication used to treat ischemic stroke not prevent TIAs or strokes.
Which manifestations in a patient with a T4 spinal cord injury should alert the nurse to the possibility of autonomic dysreflexia? a) Headache and rising blood pressure b) Irregular respirations and shortness of breath c) Decreased level of consciousness or hallucinations d) Abdominal distention and absence of bowel sounds
a) Headache and rising blood pressure Manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic), a throbbing headache, bradycardia, and diaphoresis. Respiratory manifestations, decreased level of consciousness, and gastrointestinal manifestations are not characteristic manifestations.
Which modifiable risk factors for stroke would be most important for the nurse to include when planning a community education program? a) Hypertension b) Hyperlipidemia c) Alcohol consumption d) Oral contraceptive use
a) Hypertension Hypertension is the single most important modifiable risk factor, but it is still often undetected and inadequately treated. The public is often more aware of hyperlipidemia and oral contraceptive use as risk factors for stroke. Alcohol is also a modifiable risk factor.
The patient with type 1 diabetes mellitus with hypoglycemia is having a seizure. Which medication should the nurse anticipate administering to stop the seizure? a) IV dextrose solution b) IV diazepam (Valium) c) IV phenytoin (Dilantin) d) Oral carbamazepine (Tegretol)
a) IV dextrose solution This patient's seizure is caused by low blood glucose, so IV dextrose solution should be given first to stop the seizure. IV diazepam, IV phenytoin, and oral carbamazepine would be used to treat seizures from other causes such as head trauma, drugs, and infections.
The nurse is caring for a patient admitted with a subdural hematoma following a motor vehicle accident. Which change in vital signs would the nurse interpret as a manifestation of increased intracranial pressure (ICP)? a) Tachypnea b) Bradycardia c) Hypotension d) Narrowing pulse pressure
b) Bradycardia Bradycardia could indicate increased ICP. Changes in vital signs (known as Cushing's triad) occur with increased ICP. They consist of increasing systolic pressure with a widening pulse pressure, bradycardia with a full and bounding pulse, and irregular respirations.
The nurse who has administered a dose of risperidone (Risperdal) to a patient with delirium should assess for what intended effect of the medication? a) Lying quietly in bed b) Alleviation of depression c) Reduction in blood pressure d) Disappearance of confusion
a) Lying quietly in bed Risperidone is an antipsychotic drug that reduces agitation and produces a restful state in patients with delirium. However, it should be used with caution. Antidepressant medications treat depression, and antihypertensive medications treat hypertension. However, there are no medications that will cause confusion to disappear in a patient with delirium.
Computed tomography (CT) of a 68-year-old male patient's head reveals that he has experienced a hemorrhagic stroke. What is the priority nursing intervention in the emergency department? a) Maintenance of the patient's airway b) Positioning to promote cerebral perfusion c) Control of fluid and electrolyte imbalances d) Administration of tissue plasminogen activator (tPA)
a) Maintenance of the patient's airway Maintenance of a patent airway is the priority in the acute care of a patient with a hemorrhagic stroke. It supersedes the importance of fluid and electrolyte imbalance and positioning. tPA is contraindicated in hemorrhagic stroke.
What nursing intervention should be implemented in the care of a patient who is experiencing increased ICP? a) Monitor fluid and electrolyte status carefully. b) Position the patient in a high Fowler's position. c) Administer vasoconstrictors to maintain cerebral perfusion. d) Maintain physical restraints to prevent episodes of agitation.
a) Monitor fluid and electrolyte status carefully. Fluid and electrolyte disturbances can have an adverse effect on ICP and must be monitored vigilantly. The head of the patient's bed should be kept at 30 degrees in most circumstances, and physical restraints are not applied unless absolutely necessary. Vasoconstrictors are not typically administered in the treatment of ICP.
A 48-year-old man was just diagnosed with Huntington's disease. His 20-year-old son is upset about his father's diagnosis. How can the nurse best help this young man? a) Provide emotional and psychologic support. b) Encourage him to get diagnostic genetic testing done. c) Tell him the cognitive deterioration will be treated with counseling. d) Tell him the chorea and psychiatric disorders can be treated with haloperidol (Haldol).
a) Provide emotional and psychologic support. The patient's son will first need emotional and psychologic support. He should be taught about diagnostic genetic testing for himself but should decide for himself with a genetic counselor if and when he wants this done. The treatment plan for his father will be determined depending on his father's needs.
The patient with diabetes mellitus has had a right-sided stroke. Which nursing intervention should the nurse plan to provide for this patient related to expected manifestations of this stroke? a) Safety measures b) Patience with communication c) Mobility assistance on the right side d) Place food in the left side of patient's mouth.
a) Safety measures A patient with a right-sided stroke has spatial-perceptual deficits, tends to minimize problems, has a short attention span, is impulsive, and may have impaired judgment. Safety is the biggest concern for this patient. Hemiplegia occurs on the left side of this patient's body. The patient with a left-sided stroke has hemiplegia on the right, is more likely to have communication problems, and needs mobility assistance on the right side with food placed on the left side if the patient needs to be fed after a swallow evaluation has taken place.
Magnetic resonance imaging (MRI) has revealed the presence of a brain tumor in a patient. The nurse should recognize that the patient will most likely need which treatment modality? a) Surgery b) Chemotherapy c) Radiation therapy d) Biologic drug therapy
a) Surgery Surgical removal is the preferred treatment for brain tumors. Chemotherapy and biologic drug therapy are limited by the blood-brain barrier, tumor cell heterogeneity, and tumor cell drug resistance. Radiation therapy may be used as a follow-up measure after surgery.
The patient is having some increased memory and language problems. What diagnostic tests will be done before this patient is diagnosed with Alzheimer's disease (select all that apply)? a) Urinalysis b) MRI of the head c) Liver function tests d) Neuropsychologic testing e) Blood urea nitrogen and serum creatinine
a) Urinalysis b) MRI of the head c) Liver function tests d) Neuropsychologic testing e) Blood urea nitrogen and serum creatinine Because there is no definitive diagnostic test for Alzheimer's disease, and many conditions can cause manifestations of dementia, testing must be done to eliminate any other causes of cognitive impairment. These include urinalysis to eliminate a urinary tract infection, an MRI to eliminate brain tumors, liver function tests to eliminate encephalopathy, BUN and serum creatinine to rule out renal dysfunction, and neuropsychologic testing to assess cognitive function.
Which intervention should the nurse perform in the acute care of a patient with autonomic dysreflexia? a) Urinary catheterization b) Administration of benzodiazepines c) Suctioning of the patient's upper airway d) Placement of the patient in the Trendelenburg position
a) Urinary catheterization Because the most common cause of autonomic dysreflexia is bladder irritation, immediate catheterization to relieve bladder distention may be necessary. Benzodiazepines are contraindicated, and suctioning is likely unnecessary. The patient should be positioned upright.
Which measure should the nurse prioritize when providing care for a patient with a diagnosis of multiple sclerosis (MS)? a) Vigilant infection control and adherence to standard precautions b) Careful monitoring of neurologic assessment and frequent reorientation c) Maintenance of a calorie count and hourly assessment of intake and output d) Assessment of blood pressure and monitoring for signs of orthostatic hypotension
a) Vigilant infection control and adherence to standard precautions Infection control is a priority in the care of patients with MS, since infection is the most common cause of an exacerbation of the disease. Decreases in cognitive function are less likely, and MS does not typically result in malnutrition, hypotension, or fluid volume excess or deficit.
When establishing a diagnosis of MS, the nurse should teach the patient about what diagnostic studies (select all that apply)? a) EEG b) CT scan c) Carotid duplex scan d) Evoked response testing e) Cerebrospinal fluid analysis
b) CT scan d) Evoked response testing e) Cerebrospinal fluid analysis There is no definitive diagnostic test for MS. CT scan, evoked response testing, cerebrospinal fluid analysis, and MRI along with history and physical examination are used to establish a diagnosis for MS. EEG and carotid duplex scan are not used for diagnosing MS.
The nurse is caring for a patient admitted for evaluation and surgical removal of a brain tumor. The nurse will plan interventions for this patient based on knowledge that brain tumors can lead to which complications (select all that apply)? a) Vision loss b) Cerebral edema c) Pituitary dysfunction d) Parathyroid dysfunction e) Focal neurologic deficits
a) Vision loss b) Cerebral edema c) Pituitary dysfunction e) Focal neurologic deficits Brain tumors can manifest themselves in a wide variety of symptoms depending on location, including vision loss and focal neurologic deficits. Tumors that put pressure on the pituitary can lead to dysfunction of the gland. As the tumor grows, clinical manifestations of increased intracranial pressure (ICP) and cerebral edema appear. The parathyroid gland is not regulated by the cerebral cortex or the pituitary gland.
You, as the nurse, identify the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. An appropriate nursing intervention to help the patient communicate is to a) ask simple questions that the patient can answer with "yes" or "no." b) develop a list of words that the patient can read and practice reciting. c) have the patient practice facial and tongue exercises to improve motor control necessary for speech d) prevent embarrassing the patient by changing the subject if the patient does not respond in a timely manner.
a) ask simple questions that the patient can answer with "yes" or "no." Communication will be facilitated and less frustrating to the patient when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.
A 28-year-old woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which response by the nurse is accurate? a. "MS symptoms may be worse after the pregnancy." b. "Women with MS frequently have premature labor." c. "Symptoms of MS are likely to become worse during pregnancy." d. "MS is associated with a slightly increased risk for congenital defects."
a. "MS symptoms may be worse after the pregnancy." During the postpartum period, women with MS are at greater risk for exacerbation of symptoms. There is no increased risk for congenital defects in infants born of mothers with MS. Symptoms of MS may improve during pregnancy. Onset of labor is not affected by MS.
A patient who sustained a spinal cord injury a week ago becomes angry, telling the nurse "I want to be transferred to a hospital where the nurses know what they are doing!" Which reaction by the nurse is best? a. Ask for the patient's input into the plan for care. b. Clarify that abusive behavior will not be tolerated. c. Reassure the patient about the competence of the nursing staff. d. Continue to perform care without responding to the patient's comments.
a. Ask for the patient's input into the plan for care. The patient is demonstrating behaviors consistent with the anger phase of the mourning process, and the nurse should allow expression of anger and seek the patient's input into care. Expression of anger is appropriate at this stage and should be tolerated by the nurse. Reassurance about the competency of the staff will not be helpful in responding to the patient's anger. Ignoring the patient's comments will increase the patient's anger and sense of helplessness.
A patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care? a. Assist with active range of motion. b. Observe for agitation and paranoia. c. Give muscle relaxants as needed to reduce spasms. d. Use simple words and phrases to explain procedures.
a. Assist with active range of motion. ALS causes progressive muscle weakness, but assisting the patient to perform active ROM will help to maintain strength as long as possible. Psychotic symptoms such as agitation and paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the patient's ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations.
To evaluate the effectiveness of IV methylprednisolone (Solu-Medrol) given to a patient with a T4 spinal cord injury, which information is most important for the nurse to obtain? a. Leg strength and sensation b. Skin temperature and color c. Blood pressure and apical heart rate d. Respiratory effort and O2 saturation
a. Leg strength and sensation The purpose of methylprednisolone administration is to help preserve motor function and sensation. Therefore the nurse will assess this patient for lower extremity function. The other data also will be collected by the nurse, but they do not reflect the effectiveness of the methylprednisolone.
A patient who is hospitalized with pneumonia is disoriented and confused 2 days after admission. Which information obtained by the nurse about the patient indicates that the patient is experiencing delirium rather than dementia? a. The patient was oriented and alert when admitted. b. The patient's speech is fragmented and incoherent. c. The patient is disoriented to place and time but oriented to person. d. The patient has a history of increasing confusion over several years.
a. The patient was oriented and alert when admitted. The onset of delirium occurs acutely. The degree of disorientation does not differentiate between delirium and dementia. Increasing confusion for several years is consistent with
A patient with a neck fracture at the C5 level is admitted to the intensive care unit. During initial assessment of the patient, the nurse recognizes the presence of neurogenic shock on finding a. hypotension, bradycardia, and warm extremities. b. involuntary, spastic movements of the arms and legs. c. hyperactive reflex activity below the level of the injury. d. lack of movement or sensation below the level of the injury.
a. hypotension, bradycardia, and warm extremities. Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement and sensation indicate spinal cord injury, but not neurogenic shock.
Which characteristic of a patient's recent seizure is consistent with a focal seizure? a) The patient lost consciousness during the seizure. b) The seizure involved lip smacking and repetitive movements. c) The patient fell to the ground and became stiff for 20 seconds. d) The etiology of the seizure involved both sides of the patient's brain.
b) The seizure involved lip smacking and repetitive movements. The most common complex focal seizure involves lip smacking and automatisms (repetitive movements that may not be appropriate). Loss of consciousness, bilateral brain involvement, and a tonic phase are associated with generalized seizure activity.
When teaching a patient with myasthenia gravis (MG) about management of the disease, the nurse advises the patient to a. perform physically demanding activities in the morning. b. anticipate the need for weekly plasmapheresis treatments. c. do frequent weight-bearing exercise to prevent muscle atrophy. d. protect the extremities from injury due to poor sensory perception.
a. perform physically demanding activities in the morning. Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then. Plasmapheresis is not routinely scheduled but is used for myasthenia crisis or for situations in which corticosteroid therapy should be discontinued. There is no decrease in sensation with MG, and muscle atrophy does not occur because muscles are used during part of the day.
A patient with Bell's palsy refuses to eat while others are present because of embarrassment about drooling. The best response by the nurse to the patient's behavior is to a. respect the patient's desire and arrange for privacy at mealtimes. b. teach the patient to chew food on the unaffected side of the mouth. c. offer the patient liquid nutritional supplements at frequent intervals. d. discuss the patient's concerns with visitors who arrive at mealtimes.
a. respect the patient's desire and arrange for privacy at mealtimes. The patient's desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements will reduce the patient's enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the patient's embarrassment with visitors unless the patient wishes to share this information. Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food but will not decrease the drooling.
When assessing a patient with newly diagnosed trigeminal neuralgia, the nurse will ask the patient about a. triggers that lead to facial pain. b. visual problems caused by ptosis. c. poor appetite caused by a loss of taste. d. weakness on the affected side of the face.
a. triggers that lead to facial pain. The major clinical manifestation of trigeminal neuralgia is severe facial pain that is triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and facial weakness are not characteristics of trigeminal neuralgia.
The nurse has given medication instructions to the client recieving phenytoin (Dilantin). The nurse determines that the client has an adequate understanding if the client states that: 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 the medication should be taken before a serum drug level is drawn."
b) "Good oral hygiene is needed, including brushing and flossing." Typical anticonvulsant medication instructions include taking the prescribed daily dosage to keep blood level of the drug constant and having a sample drawn for serum level before taking the morning dose (trough level). The client is taught not to stop the medication abruptly, to avoid alcohol, check with the physician before taking over-the-counter meidcations, avoid activities where alterness and coordination are required until medication effects are known, provide good oral hygiene, and obtain regular dental care. Oral hygiene is particularly important in patients taking Dilantin due to the potential development of gingival hyperplasia. The client should wear a Medic-Alert bracelet.
A 59-year-old female patient, who has frontotemporal lobar degeneration, has difficulty with verbal expression. One day she walks out of the house and goes to the gas station to get a soda but does not understand that she needs to pay for it. What is the best thing the nurse can suggest to this patient's husband to keep the patient safe during the day while the husband is at work? a) Assisted living b) Adult day care c) Advance directives d) Monitor for behavioral changes
b) Adult day care To keep this patient safe during the day while the husband is at work, an adult day care facility would be the best choice. This patient would not need assisted living. Advance directives are important but are not related to her safety. Monitoring for behavioral changes will not keep her safe during the day.
A female patient has left-sided hemiplegia following an ischemic stroke that she experienced 4 days earlier. How should the nurse best promote the health of the patient's integumentary system? a) Position the patient on her weak side the majority of the time. b) Alternate the patient's positioning between supine and side-lying. c) Avoid the use of pillows in order to promote independence in positioning. d) Establish a schedule for the massage of areas where skin breakdown emerges.
b) Alternate the patient's positioning between supine and side-lying. A position change schedule should be established for stroke patients. An example is side-back-side, with a maximum duration of 2 hours for any position. The patient should be positioned on the weak or paralyzed side for only 30 minutes. Pillows may be used to facilitate positioning. Areas of skin breakdown should never be massaged.
A 68-year-old patient with a spinal cord injury has a neurogenic bowel. Beyond the use of bisacodyl (Dulcolax) suppositories and digital stimulation, which measures should the nurse teach the patient and the caregiver to assist the patient with bowel evacuation (select all that apply)? a) Drink more milk. b) Eat 20-30 g of fiber per day. c) Use oral laxatives every day. d) Drink 1800 to 2800 mL of water or juice. e) Establish bowel evacuation time at bedtime.
b) Eat 20-30 g of fiber per day. d) Drink 1800 to 2800 mL of water or juice. The patient with a spinal cord injury and neurogenic bowel should eat 20-30 g of fiber and drink 1800 to 2800 mL of water or juice each day. Milk may cause constipation. Daily oral laxatives may cause diarrhea and are avoided unless necessary. Bowel evacuation time is usually established 30 minutes after the first meal of the day to take advantage of the gastrocolic reflex induced by eating.
The nurse is providing care for a patient who has been admitted to the hospital with a head injury and who requires regular neurologic and vital sign assessment. Which assessments will be components of the patient's score on the Glasgow Coma Scale (GCS) (select all that apply)? a) Judgment b) Eye opening Correct c) Abstract reasoning d) Best verbal response Correct e) Best motor response Correct f) Cranial nerve function
b) Eye opening Correct d) Best verbal response Correct e) Best motor response Correct The three dimensions of the GCS are eye opening, best verbal response, and best motor response. Judgment, abstract reasoning, and cranial nerve function are not components of the GCS.
The nurse would expect to find what clinical manifestation in a patient admitted with a left-sided stroke? a) Impulsivity b) Impaired speech c) Left-side neglect d) Short attention span
b) Impaired speech Clinical manifestations of left-sided brain damage include right hemiplegia, impaired speech/language, impaired right/left discrimination, and slow and cautious performance. Impulsivity, left-sided neglect, and short attention span are all manifestations of right-sided brain damage.
When providing community health care teaching regarding the early warning signs of Alzheimer's disease, which signs should the nurse advise family members to report (select all that apply)? a) Misplacing car keys b) Losing sense of time c) Difficulty performing familiar tasks d) Problems with performing basic calculations e) Becoming lost in a usually familiar environment
b) Losing sense of time c) Difficulty performing familiar tasks d) Problems with performing basic calculations e) Becoming lost in a usually familiar environment Difficulty performing familiar tasks, problems with performing basic calculations, losing sense of time, and becoming lost in a usually familiar environment are all part of the early warning signs of Alzheimer's disease. Misplacing car keys is a normal frustrating event for many people.
The nurse is positioning the client with increased intracranial pressure. Which of the following positions would the nurse avoid? a) Head midline. b) Neck flexed and head turned to the side. c) Neck in neutral position. d) Head of the bed elevated 30 degrees.
b) Neck flexed and head turned to the side. The head of the client with increased intracranial pressure should be positioned so the head is in a neutral midline position. The nurse should avoid flexing or extending the client's neck or turning the head from side to side which can inhibit venous outflow and increase intracranial pressure. The HOB should be raised to 30-45 degrees to promote venous drainage. Having the HOB greater than 45 degrees can decrease cerebral blood flow and less than 30 degrees can increase intracranial pressure. Use of proper positions promotes venous drainage to keep intracranial pressure down.
A 50-year-old male patient has been diagnosed with amyotrophic lateral sclerosis (ALS). What nursing intervention is most important to help prevent a common cause of death for patients with ALS? a) Reduce fat intake. b) Reduce the risk of aspiration. c) Decrease injury related to falls. d) Decrease pain secondary to muscle weakness.
b) Reduce the risk of aspiration. Reducing the risk of aspiration can help prevent respiratory infections that are a common cause of death from deteriorating muscle function. Reducing fat intake may reduce cardiovascular disease, but this is not a common cause of death for patients with ALS. Decreasing injury related to falls and decreasing pain secondary to muscle weakness are important nursing interventions for patients with ALS but are unrelated to causes of death for these patients.
The nurse is caring for a client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated? a) Loosening restrictive clothing b) Restraining the client's limbs c) Removing the pillow and raising padded side rails d) Positioning the client to the side, if possible, with the head flexed forward
b) Restraining the client's limbs Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow, raising the side rails (if padded), and placing the client on one side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never 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, if possible, protects the head from injury, and moves furniture that may injure the client. Other aspects of care are as described for the client who is in bed.
The client with Parkinson's disease has a nursing diagnosis of Falls, Risk for related to an abnormal gait documented in the nursing care plan. The nurse assesses the client, expecting to observe which type of gait? a) Unsteady and staggering b) Shuffling and propulsive c) Broadbased and waddling d) Accelerating with walking on the heels
b) Shuffling and propulsive The parkinsonian gait is characterized by short, accelerating, shuffling steps. The client leans forward with the head, hips, and knees flexed, and has difficulty starting and stopping. Also called a festination gait. A dystrophic gait is broad-based and waddling. An ataxic gait is staggering and unsteady.
The nurse is caring for a patient admitted with a spinal cord injury following a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following? a) Central cord syndrome b) Spinal shock syndrome c) Anterior cord syndrome d) Brown-Séquard syndrome
b) Spinal shock syndrome About 50% of people with acute spinal cord injury experience a temporary loss of reflexes, sensation, and motor activity that is known as spinal shock. Central cord syndrome is manifested by motor and sensory loss greater in the upper extremities than the lower extremities. Anterior cord syndrome results in motor and sensory loss but not reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory function.
While on a mission trip, the nurse is caring for a patient diagnosed with tetanus. The patient has been given tetanus immune globulin (TIG). What should be the focus of collaborative care (select all that apply)? a) Administration of penicillin b) Tracheostomy for mechanical ventilation c) Administration of polyvalent antitoxin d) Teach correct processing of canned foods. e) Control of spasms with diazepam (Valium)
b) Tracheostomy for mechanical ventilation e) Control of spasms with diazepam (Valium) Control of the spasms of tetanus is essential because the laryngeal and respiratory system spasms cause apnea and anoxia. A tracheostomy is performed early so mechanical ventilation may be done to maintain ventilation. Penicillin is administered for neurosyphilis. Use of polyvalent antitoxin and teaching the correct canning process is done for botulism.
The patient has been diagnosed with the mild cognitive impairment stage of Alzheimer's disease. What nursing interventions should the nurse expect to use with this patient? a) Treat disruptive behavior with antipsychotic drugs. b) Use a calendar and family pictures as memory aids. c) Use a writing board to communicate with the patient. d) Use a wander guard mechanism to keep the patient in the area.
b) Use a calendar and family pictures as memory aids. The patient with mild cognitive impairment will have problems with memory, language, or another essential cognitive function that is severe enough to be noticeable to others but does not interfere with activities of daily living. A calendar and family pictures for memory aids will help this patient. This patient should not yet have disruptive behavior or get lost easily. Using a writing board will not help this patient with communication.
The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain? a) sternal rub b) nail bed pressure c) pressure on the orbital rim d) squeezing of the sternocleidomastoid muscle
b) nail bed pressure Motor testing in the unconscious client can be done only be testing the response of the extremities to a noxious stimuli- in this case pain/pressure. Cerebral (or central) responses to pain are tested using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.
A patient has been receiving scheduled doses of phenytoin (Dilantin) and begins to experience diplopia. The nurse immediately assesses the patient for a) an aura or focal seizure. b) nystagmus or confusion. c) abdominal pain or cramping. d) irregular pulse or palpitations.
b) nystagmus or confusion. Diplopia is a sign of phenytoin toxicity. The nurse should assess for other signs of toxicity, which include neurologic changes, such as nystagmus, ataxia, confusion, dizziness, or slurred speech. An aura, focal seizure, abdominal pain or cramping, irregular pulse, or palpitations are not associated with phenytoin toxicity.
A patient seen at the health clinic with a severe migraine headache tells the nurse about having four similar headaches in the last 3 months. Which initial action should the nurse take? a. Refer the patient for stress counseling. b. Ask the patient to keep a headache diary. c. Suggest the use of muscle-relaxation techniques. d. Teach about the effectiveness of the triptan drugs.
b. Ask the patient to keep a headache diary. The initial nursing action should be further assessment of the precipitating causes of the headaches, quality, and location of pain, etc. Stress reduction, muscle relaxation, and the triptan drugs may be helpful, but more assessment is needed first.
When developing a plan of care for a hospitalized patient with moderate dementia, which intervention will the nurse include? a. Provide complete personal hygiene care for the patient. b. Remind the patient frequently about being in the hospital. c. Reposition the patient frequently to avoid skin breakdown. d. Place suction at the bedside to decrease the risk for aspiration.
b. Remind the patient frequently about being in the hospital. The patient with moderate dementia will have problems with short- and long-term memory and will need reminding about the hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty with swallowing, self-care, and immobility.
A patient with paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. Which action will the nurse include in the plan of care? a. Educate on the use of the Credé method. b. Teach the patient how to self-catheterize. c. Catheterize for residual urine after voiding. d. Assist the patient to the toilet every 2 hours.
b. Teach the patient how to self-catheterize. Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with a reflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence.
A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the effects of right brain damage, the nurse establishes a nursing diagnosis of: a. impaired physical mobility related to right hemiplegia. b. risk for injury related to denial of deficits and impulsiveness. c. impaired verbal communication related to speech-language deficits. d. ineffective coping related to depression and distress about disability.
b. risk for injury related to denial of deficits and impulsiveness. Right-sided brain damage typically causes denial of any deficits and poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability.
The health care provider prescribes clopidogrel (Plavix) for a patient with cerebral atherosclerosis. When teaching about the new medication, the nurse will tell the patient a. to monitor and record the blood pressure daily. b. to call the health care provider if stools are tarry. c. that Plavix will dissolve clots in the cerebral arteries. d. that Plavix will reduce cerebral artery plaque formation.
b. to call the health care provider if stools are tarry. Plavix inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots.
A female patient complains of a throbbing headache. When her history is obtained, the nurse discovers that the patient has had this type of headache before and experienced photophobia before the headache occurred. The nurse should know that what is probably the cause of this patient's headache? a) Polycythemia vera b) A cluster headache c) A migraine headache d) A hemorrhagic stroke
c) A migraine headache Although a headache may occur with any of these options, a migraine headache is the only one that has a throbbing headache with an aura (the photophobia). Headache from polycythemia vera is from erythrocytosis. The cluster headache pain is sharp and stabbing, and the headache with a hemorrhagic stroke has a sudden onset and is not recurrent.
Which nursing diagnosis is likely to be a priority in the care of a patient with myasthenia gravis (MG)? a) Acute confusion b) Bowel incontinence c) Activity intolerance d) Disturbed sleep pattern
c) Activity intolerance The primary feature of MG is fluctuating weakness of skeletal muscle. Bowel incontinence and confusion are unlikely signs of MG, and although sleep disturbance is likely, activity intolerance is usually of primary concern.
The patient with peripheral facial paresis on the left side of her face is diagnosed with Bell's palsy. What should the nurse include in teaching the patient about self-care (select all that apply)? a) Administration of antiseizure medications b) Preparing for a nerve block to relieve pain c) Administration of corticosteroid medications d) Dark glasses and artificial tears to protect the eyes e) Surgeries available if conservative therapy is not effective
c) Administration of corticosteroid medications d) Dark glasses and artificial tears to protect the eyes Self-care for Bell's palsy includes corticosteroid medications to decrease inflammation of the facial nerve (CNVII) and protecting the cornea from drying out because of the inability to close the eyelid. Antiseizure medications, a nerve block, or surgeries are used for trigeminal neuralgia.
Benzodiazepines are indicated in the treatment of cases of delirium that have which cause? a) Polypharmacy b) Cerebral hypoxia c) Alcohol withdrawal d) Electrolyte imbalances
c) Alcohol withdrawal Benzodiazepines can be used to treat delirium associated with sedative and alcohol withdrawal. However, these drugs may worsen delirium caused by other factors and must be used cautiously. Polypharmacy, cerebral hypoxia, and electrolyte imbalances are not treated with benzodiazepines.
A 25-year-old male patient who is a professional motocross racer has anterior spinal cord syndrome at T10. His history is significant for tobacco, alcohol, and marijuana use. What is the nurse's priority during rehabilitation? a) Prevent urinary tract infections. b) Monitor the patient every 15 minutes. c) Encourage him to verbalize his feelings. d) Teach him about using the gastrocolic reflex.
c) Encourage him to verbalize his feelings. To help him with his coping and prevent self-harm, the nurse should create a therapeutic patient environment that encourages his self-expression and verbalization of thoughts and feelings. This patient is at high risk for depression and self-injury because he is likely to lose function below the umbilicus involving lost motor and sensory function. In addition, he is a young adult male patient who is likely to need a wheelchair, have impaired sexual function, and is unlikely to resume his racing career. Because the patient uses tobacco, alcohol, and marijuana frequently, hospitalization is likely to result in a loss of these habits that can make coping especially difficult for him. Prevention of urinary tract infections and facilitating bowel evacuation with the gastrocolic reflex will be important but not as important as helping him cope. In rehabilitation, monitoring every 15 minutes is not needed unless he is on a suicide watch.
Which nursing intervention is most appropriate when caring for patients with dementia? a) Avoid direct eye contact. b) Lovingly call the patient "honey" or "sweetie." c) Give simple directions, focusing on one thing at a time. d) Treat the patient according to his or her age-related behavior.
c) Give simple directions, focusing on one thing at a time. When dealing with patients with dementia, tasks should be simplified, giving directions using gestures or pictures and focusing on one thing at a time. It is best to treat these patients as adults, with respect and dignity, even when their behavior is childlike. The nurse should use gentle touch and direct eye contact. Calling the patient "honey" or "sweetie" can be condescending and does not demonstrate respect.
A patient has a systemic blood pressure of 120/60 and an ICP of 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), how does the nurse interpret the results? a) High blood flow to the brain b) Normal intracranial pressure c) Impaired blood flow to the brain d) Adequate autoregulation of blood flow
c) Impaired blood flow to the brain Normal CPP is 60 to 100 mm Hg. The CPP is calculated with mean arterial pressure (MAP) minus ICP. MAP = SBP + 2 (DBP)/ 3: 120 mm Hg + 2 (60 mm Hg)/3 = 80 mm Hg. MAP - ICP: 80mm Hg - 24 mm Hg = 56 mm Hg CPP. The decreased CPP indicates that there is impaired cerebral blood flow and that autoregulation is impaired. Because the ICP is 24, it is elevated and requires treatment.
A male patient with a diagnosis of Parkinson's disease (PD) has been admitted recently to a long-term care facility. Which action should the health care team take in order to promote adequate nutrition for this patient? a) Provide multivitamins with each meal. b) Provide a diet that is low in complex carbohydrates and high in protein. c) Provide small, frequent meals throughout the day that are easy to chew and swallow.* d) Provide the patient with a minced or pureed diet that is high in potassium and low in sodium.
c) Provide small, frequent meals throughout the day that are easy to chew and swallow.* Nutritional support is a priority in the care of individuals with PD. Such patients may benefit from meals that are smaller and more frequent than normal and that are easy to chew and swallow. Multivitamins are not necessary at each meal, and vitamin intake, along with protein intake, must be monitored to prevent contraindications with medications. It is likely premature to introduce a minced or pureed diet, and a low carbohydrate diet is not indicated.
Which information about a patient with MS indicates that the nurse should consult with the health care provider before giving the prescribed dose of dalfampridine (Ampyra)? a. The patient has relapsing-remitting MS. b. The patient enjoys walking for relaxation. c. The patient has an increased creatinine level. d. The patient complains of pain with neck flexion.
c. The patient has an increased creatinine level. Dalfampridine should not be given to patients with impaired renal function. The other information will not impact on whether the dalfampridine should be administered.
The nurse is planning psychosocial support for the patient and family of the patient who suffered a stroke. What factor will most likely have the greatest impact on positive family coping with the situation? a) Specific patient neurologic deficits b) The patient's ability to communicate c) Rehabilitation potential of the patient d) Presence of complications of a stroke
c) Rehabilitation potential of the patient Although a patient's neurologic deficit might initially be severe after a stroke, the ability of the patient to recover is most likely to positively impact the family's coping with the situation. Providing explanations and emotional support beginning in the acute phase through the rehabilitation phase will facilitate coping. Emphasizing successes will offer the most realistic hope for the patient's rehabilitation and helps maintain hope for the patient's future abilities.
The nurse is providing care for a patient who has been diagnosed with Guillain-Barré syndrome. Which assessment should be the nurse's priority? a) Pain assessment b) Glasgow Coma Scale c) Respiratory assessment d) Musculoskeletal assessment
c) Respiratory assessment Although all of the assessments are necessary in the care of patients with Guillain-Barré syndrome, the acute risk of respiratory failure necessitates vigilant monitoring of the patient's respiratory status.
Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)? a) Overestimation of physical abilities b) Difficulty judging position and distance c) Slow and possibly fearful performance of tasks d) Impulsivity and impatience at performing tasks
c) Slow and possibly fearful performance of tasks Patients with a left-sided stroke (right hemiplegia) commonly are slower in organization and performance of tasks and may have a fearful, anxious response to a stroke. Overconfidence, spatial disorientation, and impulsivity are more commonly associated with a right-sided stroke.
In planning long-term care for a patient after a craniotomy, what must the nurse include when teaching the patient, family, and caregiver? a) Seizure disorders may occur in weeks or months. b) The family will be unable to cope with role reversals. c) There are often residual changes in personality and cognition. d) Referrals will be made to eliminate residual deficits from the damage.
c) There are often residual changes in personality and cognition. In long-term care planning, the nurse must include the family and caregiver when teaching about potential residual changes in personality, emotions, and cognition as these changes are most difficult for the patient and family to accept. Seizures may or may not develop. The family and patient may or may not be able to cope with role reversals. Although residual deficits will not be eliminated with referrals, they may be improved.
The patient with increased ICP from a brain tumor is being monitored with a ventriculostomy. What nursing intervention is the priority in caring for this patient? a) Administer IV mannitol (Osmitrol). b) Ventilator use to hyperoxygenate the patient c) Use strict aseptic technique with dressing changes. d) Be aware of changes in ICP related to leaking CSF.
c) Use strict aseptic technique with dressing changes. The priority nursing intervention is to use strict aseptic technique with dressing changes and any handling of the insertion site to prevent the serious complication of infection. IV mannitol (Osmitrol) or hypertonic saline will be administered as ordered. Ventilators may be used to maintain oxygenation. CSF leaks may cause inaccurate ICP readings, or CSF may be drained to decrease ICP, but strict aseptic technique to prevent infection is the nurse's priority of care.
A patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching? a. Recommendation to drink at least 3 to 4 L daily b. Need to avoid driving or operating heavy machinery c. How to draw up and administer injections of the medication d. Use of contraceptive methods other than oral contraceptives
c. How to draw up and administer injections of the medication Copaxone is administered by self-injection. Oral contraceptives are an appropriate choice for birth control. There is no need to avoid driving or drink large fluid volumes when taking glatiramer.
A 24-year-old patient is hospitalized with the onset of Guillain-Barré syndrome. During this phase of the patient's illness, the most essential assessment for the nurse to carry out is a. monitoring the cardiac rhythm. b. determining level of consciousness. c. Observing respiratory rate and effort. d. checking strength of the extremities.
c. Observing respiratory rate and effort. The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments also will be included in nursing care, but they are not as important as respiratory assessment.
When caring for a patient with left-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care during the acute period of the stroke? a. Apply an eye patch to the left eye. b. Approach the patient from the left side. c. Place objects needed for activities of daily living on the patient's right side. d. Reassure the patient that the visual deficit will resolve as the stroke progresses.
c. Place objects needed for activities of daily living on the patient's right side. During the acute period, the nurse should place objects on the patient's unaffected side. Since there is a visual defect in the left half of each eye, an eye patch is not appropriate. The patient should be approached from the right side. The visual deficit may not resolve, although the patient can learn to compensate for the defect.
A patient has an incomplete right spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which nursing action should be included in the plan of care? a. Assessment of the patient for left leg pain b. Assessment of the patient for left arm weakness c. Positioning the patient's right leg when turning the patient d. Teaching the patient to look at the left leg to verify its position
c. Positioning the patient's right leg when turning the patient The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the right leg. Pain sensation will be lost on the patient's left leg. Left arm weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the left leg.
When teaching the children of a patient who is being evaluated for Alzheimer's disease (AD) about the disorder, the nurse explains that a. the most important risk factor for AD is a family history of the disorder. b. new drugs have been shown to reverse AD dramatically in some patients. c. a diagnosis of AD can be made only when other causes of dementia have been ruled out. d. the presence of brain atrophy detected by MRI confirms the diagnosis of AD in patients with dementia.
c. a diagnosis of AD can be made only when other causes of dementia have been ruled out. The diagnosis of AD is one of exclusion. Age is the most important risk factor for development of AD. Drugs can slow the deterioration but do not dramatically reverse the effects of AD. Brain atrophy is a common finding in AD, but it can occur in other diseases as well and does not confirm an AD diagnosis.
A patient who has had a stroke has a new order to attempt oral feedings. The nurse should assess the gag reflex and then a. order a varied pureed diet. b. assess the patient's appetite. c. assist the patient into a chair. d. offer the patient a sip of juice.
c. assist the patient into a chair. The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted regardless.
After learning about rehabilitation for his spinal cord tumor, which statement shows the patient understands what rehabilitation is and can do for him? a) "I want to be rehabilitated for my daughter's wedding in 2 weeks." b) "Rehabilitation will be more work done by me alone to try to get better." c) "I will be able to do all my normal activities after I go through rehabilitation." d) "With rehabilitation, I will be able to function at my highest level of wellness."
d) "With rehabilitation, I will be able to function at my highest level of wellness." Rehabilitation is an interdisciplinary endeavor carried out with a team approach to teach and enable the patient to function at the patient's highest level of wellness and adjustment. It will be a lot of work for all involved and take longer than 2 weeks. With neurologic dysfunction, the patient will not be able to do all the normal activities in the same way as before the lesion, so this statement should be discussed.
A client is suspected as having myasthenia gravis. Edrophonium (Tensilon) 2 mg is administered intravenously to determine the diagnosis. Which of the following indicates that the client has myasthnia gravis? a) Joint pain following administration of the medication b) Feelings of faintness, dizziness, hypotension, and signs of flushing in the client c) A decrease in muscle strength within 30 to 60 seconds following administration of the medication d) An increase in muscle strength within 30 to 60 seconds following administration of the medication
d) An increase in muscle strength within 30 to 60 seconds following administration of the medication Edrophonium is a short-acting acetylcholinesterase inhibitor used as a diagnostic agent. When a client with suspected myasthenia gravis is given 2 mg of the medication IV, an increase in muscle strength should be seen in 30-60 seconds, due to an increase in acetylcholine in the neuromuscluar junction.. If no response occurs, another 4-10 mg is given over the next 2 minutes, and muscle strength is tested again. If no increase in muscle strength occurs with this higher dose, the muscle weakness is not caused by myasthenia gravis. Clients receiving injection of this medication commonly demonstrate a drop in blood pressure, feel faint and dizzy, and are flushed, but this doesn't indicate the diagnosis of myasthenia gravis.
Which patient may face the greatest risk of developing delirium? a) A patient with fibromyalgia whose chronic pain has recently worsened b) A patient with a fracture who has spent the night in the emergency department c) An older patient whose recent computed tomography (CT) shows brain atrophy d) An older patient who takes multiple medications to treat various health problems
d) An older patient who takes multiple medications to treat various health problems Polypharmacy is implicated in many cases of delirium, and this phenomenon is especially common among older adults. Brain atrophy, if associated with cognitive changes, is indicative of dementia. Alterations in sleep and environment, as well as pain, may cause delirium, but this is less of a risk than in an older adult who takes multiple medications.
The family of a client with a spinal cord injury rushes to the nursing station, saying that the client needs immediate help. On entering the room, the nurse notes that the client is diaphoretic with a flushed face and neck and complains of a severe headache. The client's heart rate is 40 beats/min and blood pressure is 230/100 mmHg. The nurse acts quickly, suspecting that the clinet is experiencing: a) Spinal shock b) Pulmonary Embolism c) Malignant Hyperthermia d) Autonomic Dysreflexia
d) Autonomic Dysreflexia The client with a spinal cord injury is at risk for autonomic dysreflexia with an injury above the level of T6. It is characterized by severe, throbbing headache (all spinal cord injured patients with a headache should have their vital signs taken), flushing of the face and neck, bradycardia, and sudden severe hypertension. Other signs include nasal stuffiness, blurred vision, nausea, and sweating. Autonomic dysreflexia is a life-threatening condition triggered by a noxious stumulus below the level of the injury causing a release of catecholamines and reflex innervation of the parasympathetic nervous system.
Carbidopa-levodopa (Sinemet) is prescribed for a patient with Parkinson's disease. The nurse monitors the client for adverse reactions to the medication. Which of the following would indicate that the client is experiencing an adverse reaction? a) Pruritus b) Tachycardia c) Hypertension d) Impaired voluntary movements
d) Impaired voluntary movements Impaired voluntary movement may occur with high levodopa dosages. Parkinson's disease is characterized by low levels of dopamine and impairment of the Acetylcholine/dopamine balance. Excess levels of dopamine also alter the balance and impair movement. Other symptoms of levodopa excess include nausea, anorexia, dizziness, orthostatic hypotension, bradycardia, and akinesia (the temporary muscle weakness that lasts 1 minute to 1 hour, also known as "on-off" phenomenon).
When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis has the highest priority? a) Risk for impairment of tissue integrity caused by paralysis b) Altered patterns of urinary elimination caused by tetraplegia c) Altered family and individual coping caused by the extent of trauma d) Ineffective airway clearance caused by high cervical spinal cord injury
d) Ineffective airway clearance caused by high cervical spinal cord injury Maintaining a patent airway is the most important goal for a patient with a high cervical fracture. Although all of these are appropriate nursing diagnoses for a patient with a spinal cord injury, respiratory needs are always the highest priority. Remember the ABCs.
A male patient suffered a diffuse axonal injury from a traumatic brain injury (TBI). He has been maintained on IV fluids for 2 days. The nurse seeks enteral feeding for this patient based on what rationale? a) Free water should be avoided. b) Sodium restrictions can be managed. c) Dehydration can be better avoided with feedings. d) Malnutrition promotes continued cerebral edema.
d) Malnutrition promotes continued cerebral edema. A patient with diffuse axonal injury is unconscious and, with increased ICP, is in a hypermetabolic, hypercatabolic state that increases the need for fuel for healing. Malnutrition promotes continued cerebral edema, and early feeding may improve outcomes when begun within 3 days after injury. Fluid and electrolytes will be monitored to maintain balance with the enteral feedings.
The nurse assesses a patient for signs of meningeal irritation and observes for nuchal rigidity. What indicates the presence of this sign of meningeal irritation? a) Tonic spasms of the legs b) Curling in a fetal position c) Arching of the neck and back d) Resistance to flexion of the neck
d) Resistance to flexion of the neck Nuchal rigidity is a clinical manifestation of meningitis. During assessment, the patient will resist passive flexion of the neck by the health care provider. Tonic spasms of the legs, curling in a fetal position, and arching of the neck and back are not related to meningeal irritation.
The nurse is planning to test the function of the trigeminal nerve (Cranial Nerve V). The nurse would gather which of the following items to perform the test? a) Tuning fork and audiometer. b) Snellen chart, ophthalmoscope. c) Flashlight, pupil size chart or millimeter ruler. d) Safety pin, hot and cold water in test tubes, cotton wisp.
d) Safety pin, hot and cold water in test tubes, cotton wisp. The trigeminal nerve has motor and sensory divisions The motor division innervates the muscles for chewing. The sensory division innervates the entire face, scalp, cornea, and nasal and oral cavities. The sensations of pain, temperature, and touch can be assessed using each of the respective items noted in option 4. The corneal reflex also can be tested using the cotton wisp. The supplies noted in options a, b, and c are used for testing cranial nerves II, III, and VIII.
The female patient has been brought to the ED with a sudden onset of a severe headache that is different from any other headache she has had previously. When considering the possibility of a stroke, which type of stroke should the nurse know is most likely occurring? a) TIA b) Embolic stroke c) Thrombotic stroke d) Subarachnoid hemorrhage
d) Subarachnoid hemorrhage Headache is common in a patient who has a subarachnoid hemorrhage or an intracerebral hemorrhage. A TIA is a transient loss of neurologic function usually without a headache. A headache may occur with an ischemic embolic stroke, but severe neurologic deficits are the initial symptoms. The ischemic thrombotic stroke manifestations progress in the first 72 hours as infarction and cerebral edema increase.
Which intervention is most appropriate when communicating with a patient suffering from aphasia following a stroke? a) Present several thoughts at once so that the patient can connect the ideas. b) Ask open-ended questions to provide the patient the opportunity to speak. c) Finish the patient's sentences to minimize frustration associated with slow speech. d) Use simple, short sentences accompanied by visual cues to enhance comprehension.
d) Use simple, short sentences accompanied by visual cues to enhance comprehension. When communicating with a patient with aphasia, the nurse should present one thought or idea at a time. Ask questions that can be answered with a "yes," "no," or simple word. Use visual cues and allow time for the individual to comprehend and respond to conversation.
A patient who has numbness and weakness of both feet is hospitalized with Guillain-Barré syndrome. The nurse will anticipate the need to teach the patient about a. intubation and mechanical ventilation. b. administration of IV corticosteroid drugs. c. insertion of a nasogastric (NG) feeding tube. d. IV infusion of immunoglobulin (Sandoglobulin).
d. IV infusion of immunoglobulin (Sandoglobulin). Because the Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and tube feedings may be used later in the progression of the syndrome but are not needed now. Corticosteroid use is not helpful in reducing the duration or symptoms of the syndrome.
Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia in order to prevent autonomic dysreflexia? a. Assist with selection of a high protein diet. b. Use quad coughing to assist cough effort. c. Discuss options for sexuality and fertility. d. Teach the purpose of a prescribed bowel program.
d. Teach the purpose of a prescribed bowel program. Fecal impaction is a common stimulus for autonomic dysreflexia. The other actions may be included in the plan of care but will not reduce the risk for autonomic dysreflexia.
Which information about a patient who is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease is most important for the nurse to report to the health care provider? a. Shuffling gait b. Tremor at rest c. Cogwheel rigidity of limbs d. Uncontrolled head movement
d. Uncontrolled head movement Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other findings are typical with Parkinson's disease.
To protect a patient from injury during an episode of delirium, the most appropriate action by the nurse is to a. secure the patient in bed using a soft chest restraint. b. ask the health care provider about ordering an antipsychotic drug. c. instruct family members to remain with the patient and prevent injury. d. assign a nursing assistant to stay with the patient and offer frequent reorientation.
d. assign a nursing assistant to stay with the patient and offer frequent reorientation. The priority goal is to protect the patient from harm, and a staff member will be most experienced in providing safe care. Visits by family members are helpful in reorienting the patient, but families should not be responsible for protecting patients from injury. Antipsychotic medications may be ordered, but only if other measures are not effective because these medications have multiple side effects. Restraints are sometimes used but tend to increase agitation and disorientation.
A 72-year-old patient is diagnosed with moderate dementia as a result of multiple strokes. During assessment of the patient, the nurse would expect to find a. excessive nighttime sleepiness. b. difficulty eating and swallowing. c. variable ability to perform simple tasks. d. loss of both recent and long-term memory.
d. loss of both recent and long-term memory. Loss of both recent and long-term memory is characteristic of moderate dementia. Patients with dementia have frequent nighttime awakening. Dementia is progressive, and the patient's ability to perform tasks would not have periods of improvement. Difficulty eating and swallowing is characteristic of severe dementia.
When the nurse is developing a rehabilitation plan for a patient with a C6 spinal cord injury, an appropriate patient goal is that the patient will be able to a. transfer independently to a wheelchair. b. drive a car with powered hand controls. c. turn and reposition independently when in bed. d. push a manual wheelchair on flat, smooth surfaces.
d. push a manual wheelchair on flat, smooth surfaces. The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed.