Radical's Neuro Review

A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the spouse. Which action will the nurse take first? a. Obtain oxygen saturation. b. Check pupil reaction to light. c. Palpate the head for hematoma. d. Assess Glasgow Coma Scale (GCS).

ANS: A Airway patency and breathing are the most vital functions and should be assessed first. The neurologic assessments should be accomplished next and the health and medication history last.

Which of these patients is most appropriate for the intensive care unit (ICU) charge nurse to assign to an RN who has floated from the medical unit? a. A 44-year-old receiving IV antibiotics for meningococcal meningitis b. A 23-year-old who had a skull fracture and craniotomy the previous day c. A 30-year-old who has an intracranial pressure (ICP) monitor in place after a head injury a week ago d. A 61-year-old who has increased ICP and is receiving hyperventilation therapy

ANS: A An RN who works on a medical unit will be familiar with administration of IV antibiotics and with meningitis. The postcraniotomy patient, patient with an ICP monitor, and the patient on a ventilator should be assigned to an RN familiar with the care of critically ill patients.

When developing a plan of care for a patient with dysfunction of the cerebellum, the nurse will include interventions to a. prevent falls. b. stabilize mood. c. enhance swallowing ability. d. improve short-term memory.

ANS: A Because functions of the cerebellum include coordination and balance, the patient with dysfunction is at risk for falls. The cerebellum does not affect memory, mood, or swallowing ability.

The health care provider recommends a carotid endarterectomy for a patient with carotid atherosclerosis and a history of transient ischemic attacks (TIAs). The patient asks the nurse to describe the procedure. Which response by the nurse is appropriate? a. "The carotid endarterectomy involves surgical removal of plaque from an artery in the neck." b. "The diseased portion of the artery in the brain is removed and replaced with a synthetic graft." c. "A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed." d. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque."

ANS: A In a carotid endarterectomy, the carotid artery is incised and the plaque is removed. The response beginning, "The diseased portion of the artery in the brain is removed" describes an arterial graft procedure. The answer beginning, "A catheter with a deflated balloon is positioned at the narrow area" describes an angioplasty. The final response beginning, "A wire is threaded through the artery" describes the MERCI procedure.

When a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter, which information obtained by the nurse is most important to communicate to the health care provider? a. Oral temperature 101.6° F b. Apical pulse 102 beats/min c. Intracranial pressure 15 mm Hg d. Mean arterial pressure 90 mm Hg

ANS: A Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters. The temperature indicates the need for antibiotics or removal of the monitor. The ICP, arterial pressure, and apical pulse are all borderline high but require only ongoing monitoring at this time.

A patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care? a. Encourage family members to remain at the bedside. b. Apply soft restraints to protect the patient from injury. c. Keep the room well-lighted to improve patient orientation. d. Minimize contact with the patient to decrease sensory input.

ANS: A Patients with meningitis and disorientation will be calmed by the presence of someone familiar at the bedside. Restraints should be avoided because they increase agitation and anxiety. The patient requires frequent assessment for complications; the use of touch and a soothing voice will decrease anxiety for most patients. The patient will have photophobia, so the light should be dim.

While admitting a patient with a basal skull fracture, the nurse notes clear drainage from the patient's nose. Which of these admission orders should the nurse question? a. Insert nasogastric tube. b. Turn patient every 2 hours. c. Keep the head of bed elevated. d. Apply cold packs for facial bruising.

ANS: A Rhinorrhea may indicate a dural tear with cerebrospinal fluid (CSF) leakage, and insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold pack are appropriate orders.

The charge nurse observes an inexperienced staff nurse who is caring for a patient who has had a craniotomy for a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene? a. The staff nurse suctions the patient every 2 hours. b. The staff nurse assesses neurologic status every hour. c. The staff nurse elevates the head of the bed to 30 degrees. d. The staff nurse administers a mild analgesic before turning the patient.

ANS: A Suctioning increases intracranial pressure and is done only when the patient's respiratory condition indicates it is needed. The other actions by the staff nurse are appropriate.

A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a. Blood pressure 156/60, pulse 55, respirations 12 b. Blood pressure 130/72, pulse 90, respirations 32 c. Blood pressure 148/78, pulse 112, respirations 28 d. Blood pressure 110/70, pulse 120, respirations 30

ANS: A Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad and indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.

When caring for a patient who has had a head injury, which assessment information requires the most rapid action by the nurse? a. The patient is more difficult to arouse. b. The patient's pulse is slightly irregular. c. The patient's blood pressure increases from 120/54 to 136/62 mm Hg. d. The patient complains of a headache at pain level 5 of a 10-point scale.

ANS: A The change in level of consciousness (LOC) is an indicator of increased intracranial pressure (ICP) and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache is not unusual in a patient after a head injury. A slightly irregular apical pulse is not unusual.

The nurse obtains these assessment findings for a patient who has a head injury. Which finding should be reported rapidly to the health care provider? a. Urine output of 800 mL in the last hour b. Intracranial pressure of 16 mm Hg when patient is turned c. Ventriculostomy drains 10 mL of cerebrospinal fluid per hour d. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg

ANS: A The high urine output indicates that diabetes insipidus may be developing and interventions to prevent dehydration need to be rapidly implemented. The other data do not indicate a need for any change in therapy.

A patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Check the respiratory rate. b. Monitor the blood pressure. c. Send the patient for a CT scan. d. Obtain the Glasgow Coma Scale score.

ANS: A The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, circulation) are completed.

A 32-year-old patient has a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan? a. Applying intermittent pneumatic compression stockings b. Assisting to dangle on edge of bed and assess for dizziness c. Encouraging patient to cough and deep breathe every 4 hours d. Inserting an oropharyngeal airway to prevent airway obstruction

ANS: A The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboemboism (VTE). Activities such as coughing and sitting up that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.

An unconscious patient has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care? a. Keep the head of the bed elevated to 30 degrees. b. Position the patient with the knees and hips flexed. c. Encourage coughing and deep breathing to improve oxygenation. d. Cluster nursing interventions to provide uninterrupted rest periods.

ANS: A The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP. Flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP.

To assess the functioning of the trigeminal and facial nerves (CN V and VII), the nurse should a. apply a cotton wisp strand to the cornea. b. have the patient read a magazine or book. c. shine a bright light into the patient's pupil. d. check for unilateral drooping of the eyelids.

ANS: A The trigeminal and facial nerves are responsible for the corneal reflex. The optic nerve is tested by having the patient read a Snellen chart or a newspaper. Assessment of pupil response to light and ptosis are used to check function of the oculomotor nerve.

When admitting a patient with a possible coup-contracoup injury after a car accident to the emergency department, the nurse obtains the following information. Which finding is most important to report to the health care provider? a. The patient takes warfarin (Coumadin) daily. b. The patient's blood pressure is 162/94 mm Hg. c. The patient is unable to remember the accident. d. The patient complains of a severe dull headache.

ANS: A The use of anticoagulants increases the risk for intracranial hemorrhage and should be immediately reported. The other information would not be unusual in a patient with a head injury who had just arrived to the ED.

A patient who has had a subarachnoid hemorrhage is being cared for in the intensive care unit. Which information about the patient is most important to communicate to the health care provider? a. The patient's blood pressure is 90/50 mm Hg. b. The patient complains about having a stiff neck. c. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs). d. The patient complains of an ongoing severe headache.

ANS: A To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider.

When admitting an acutely confused patient with a head injury, which action should the nurse take? a. Ask family members about the patient's health history. b. Ask leading questions to assist in obtaining health data. c. Wait until the patient is better oriented to ask questions. d. Obtain only the physiologic neurologic assessment data.

ANS: A When admitting a patient who is likely to be a poor historian, the nurse should obtain health history information from others who have knowledge about the patient's health. Waiting until the patient is oriented or obtaining only physiologic data will result in incomplete assessment data; this could adversely affect decision-making about treatment. Asking leading questions may result in inaccurate or incomplete information.

The charge nurse is observing a new staff nurse who is assessing a patient with a possible spinal cord lesion for sensation. Which action indicates a need for further teaching about neurologic assessment? a. The new nurse asks the patient, "Does this feel sharp?" b. The new nurse tests for light touch before testing for pain. c. The new nurse has the patient close the eyes during testing. d. The new nurse uses an irregular pattern to test for intact touch.

ANS: A When performing a sensory assessment, the nurse should not provide verbal clues. The other actions by the new nurse are appropriate.

After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a. A patient with right-sided weakness who has an infusion of tPA prescribed b. A patient who has atrial fibrillation and a new order for warfarin (Coumadin) c. A patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due d. A patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled

ANS: A tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury. The other medications also should be given as quickly as possible, but timing of the medications is not as critical.

A patient who has a head injury is diagnosed with a concussion. Which action will the nurse plan to take? a. Coordinate the transfer of the patient to the operating room. b. Provide discharge instructions about monitoring neurologic status. c. Transport the patient to radiology for magnetic resonance imaging (MRI) of the brain. d. Arrange to admit the patient to the neurologic unit for observation for 24 hours.

ANS: B A patient with a minor head trauma is usually discharged with instructions about neurologic monitoring and the need to return if neurologic status deteriorates. MRI, hospital admission, or surgery are not indicated in a patient with a concussion.

The nurse notes in the patient's medical history that the patient has a positive Romberg test. Which nursing diagnosis is appropriate? a. Acute pain related to hyperreflexia and spasm b. Risk for falls related to dizziness or weakness c. Disturbed tactile sensory perception related to spinal cord damage d. Ineffective thermoregulation related to decreased vasomotor response

ANS: B A positive Romberg test indicates that the patient has difficulty maintaining balance with the eyes closed. The Romberg does not test for tactile perception, thermoregulation, or hyperreflexia.

The following orders are received for an unconscious patient who has just arrived in the emergency department after a head injury caused by an automobile accident. Which one should the nurse question? a. Obtain x-rays of the skull and spine. b. Prepare the patient for lumbar puncture. c. Send for computed tomography (CT) scan. d. Perform neurologic checks every 15 minutes.

ANS: B After a head injury, the patient may be experiencing intracranial bleeding and increased intracranial pressure, which could lead to herniation of the brain with lumbar puncture. The other orders are appropriate.

Which information about a 71-year-old patient is most important for the admitting nurse to report to the patient's health care provider? a. Triceps reflex response graded at 1/5 b. Recent unintended weight loss of 20 pounds c. Patient complaint of chronic difficulty in falling asleep d. Orthostatic drop in systolic blood pressure of 10 mm Hg

ANS: B Although changes in appetite are normal with aging, a 20-pound weight loss requires further investigation. Orthostatic drops in blood pressure, changes in sleep patterns, and slowing of reflexes are normal changes in aging.

A patient has a lesion that affects lower motor neurons. During assessment of the patient's lower extremities, the nurse expects to find a. spasticity. b. flaccidity. c. loss of sensation. d. hyperactive reflexes.

ANS: B Because the cell bodies of lower motor neurons are located in the spinal cord, damage to the neuron will decrease motor activity of the affected muscles. Spasticity and hyperactive reflexes are caused by upper motor neuron damage. Sensation is not impacted by motor neuron lesions.

After noting that a patient with a head injury has clear nasal drainage, which action should the nurse take? a. Have the patient blow the nose. b. Check the nasal drainage for glucose. c. Assure the patient that rhinorrhea is normal after a head injury. d. Obtain a specimen of the fluid to send for culture and sensitivity.

ANS: B Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage.

The nurse identifies 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. have the patient practice facial and tongue exercises. b. ask simple questions that the patient can answer with "yes" or "no." c. develop a list of words that the patient can read and practice reciting. d. prevent embarrassing the patient by changing the subject if the patient does not respond.

ANS: B 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.

Which assessment information will the nurse collect to determine whether a patient is developing postconcussion syndrome? a. Muscle resistance b. Short-term memory c. Glasgow coma scale d. Pupil reaction to light

ANS: B Decreased short-term memory is one indication of postconcussion syndrome. The other data may be assessed but are not indications of postconcussion syndrome.

Several weeks after a stroke, a patient has urinary incontinence resulting from an impaired awareness of bladder fullness. For an effective bladder training program, which nursing intervention will be best to include in the plan of care? a. Limit fluid intake to 1200 mL daily to reduce urine volume. b. Assist the patient onto the bedside commode every 2 hours. c. Perform intermittent catheterization after each voiding to check for residual urine. d. Use an external "condom" catheter to protect the skin and prevent embarrassment.

ANS: B Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1200 mL fluid restriction may lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke but should not be considered solutions for long-term management because of the risks for urinary tract infection (UTI) and skin breakdown.

A patient is admitted to the hospital with dysphasia and right-sided weakness that resolves in a few hours. The nurse will anticipate teaching the patient about a. alteplase (tPA). b. aspirin (Ecotrin). c. warfarin (Coumadin). d. nimodipine (Nimotop).

ANS: B Following a TIA, patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Coumadin is usually used for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage.

Which statement by a patient who is being discharged from the emergency department (ED) after a head injury indicates a need for intervention by the nurse? a. "I will return if I feel dizzy or nauseated." b. "I am going to drive home and go to bed." c. "I do not even remember being in an accident." d. "I can take acetaminophen (Tylenol) for my headache."

ANS: B Following a head injury, the patient should avoid operating heavy machinery. Retrograde amnesia is common after a concussion. The patient can take acetaminophen for headache and should return if symptoms of increased intracranial pressure such as dizziness or nausea occur.

. A patient is scheduled for a lumbar puncture. The nurse will plan to a. transfer the patient to radiology just before the procedure. b. help the patient to a side lying position before the procedure. c. place the patient on NPO status for 4 hours before the procedure. d. administer a sedative medication 30 minutes before the procedure.

ANS: B For a lumbar puncture, the patient lies in the lateral recumbent position. The procedure does not usually require a sedative, is done in the patient room, and has no risk for aspiration.

A patient is scheduled for a myelogram to confirm the presence of a herniated intervertebral disk. Which information obtained when admitting the patient is most important for the nurse to communicate to the health care provider before the procedure? a. The patient is anxious about the test. b. The patient has an allergy to shellfish. c. The patient had 4 ounces of apple juice 4 hours earlier. d. The patient has back pain when lying flat for long periods.

ANS: B Iodine-containing contrast medium is injected into the subarachnoid space during a myelogram. The health care provider may need to modify the postmyelogram orders to prevent back pain, but this can be done after the procedure. Clear liquids are usually considered safe up to 4 hours before a diagnostic or surgical procedure. The patient's anxiety should be addressed, but this is not as important as the iodine allergy.

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.

ANS: B 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 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.

ANS: B 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.

When family members ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring for a patient, which response by the nurse is best? a. "This type of monitoring system is complex and highly skilled staff are needed." b. "The monitoring system helps show whether blood flow to the brain is adequate." c. "The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure." d. "This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage."

ANS: B Short and simple explanations should be given to patients and family members. The other explanations are either too complicated to be easily understood or may increase the family member's anxiety.

After suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 16 mm Hg. Which action should the nurse take first? a. Document the increase in intracranial pressure. b. Assure that the patient's neck is not in a flexed position. c. Notify the health care provider about the change in pressure. d. Increase the rate of the prescribed propofol (Diprovan) infusion.

ANS: B Since suctioning will cause a transient increase in intracranial pressure, the nurse should initially check for other factors that might be contributing to the increase and observe the patient for a few minutes. Documentation is needed, but this is not the first action. There is no need to notify the health care provider about this expected reaction to suctioning. Propofol is used to control patient anxiety or agitation; there is no indication that anxiety has contributed to the increase in intracranial pressure.

The nurse is caring for a patient with carotid artery narrowing who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a. The pulse rate is 104 beats/min. b. The patient has difficulty talking. c. The blood pressure is 142/88 mm Hg. d. There are fine crackles at the lung bases.

ANS: B Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual because of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure; the nurse should have the patient take some deep breaths.

Neurologic testing of the patient indicates impaired functioning of the left glossopharyngeal nerve (CN IX) and the vagus nerve (CN X). Which action will the nurse include in the plan of care? a. Insert an oral airway. b. Withhold oral fluid or foods. c. Provide highly seasoned foods. d. Apply artificial tears every hour.

ANS: B The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex; a patient with impaired function of these nerves is at risk for aspiration. An oral airway may be needed when a patient is unconscious and unable to maintain the airway, but it will not decrease aspiration risk. Taste and eye blink are controlled by the facial nerve.

Following a head injury, an unconscious 32-year-old patient is admitted to the emergency department (ED). The patient's spouse and children stay at the patient's side and constantly ask about the treatment being given. What action is best for the nurse to take? a. Ask the family to stay in the waiting room until the initial assessment is completed. b. Allow the family to stay with the patient and briefly explain all procedures to them. c. Call the family's pastor or spiritual advisor to support them while initial care is given. d. Refer the family members to the hospital counseling service to deal with their anxiety.

ANS: B The need for information about the diagnosis and care is very high in family members of acutely ill patients, and the nurse should allow the family to observe care and explain the procedures. A pastor or counseling service can offer some support, but research supports information as being more effective. Asking the family to stay in the waiting room will increase their anxiety.

A patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. The nurse records the patient's Glasgow Coma Scale score as a. 9. b. 11. c. 13. d. 15.

ANS: B The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.

A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115 mmol/L) and a decreasing level of consciousness (LOC) and complains of a headache. Which of these prescribed interventions should the nurse implement first? a. Draw blood for arterial blood gases (ABGs). b. Administer 5% hypertonic saline intravenously. c. Administer acetaminophen (Tylenol) 650 mg orally. d. Send patient for computed tomography (CT) of the head.

ANS: B The patient's low sodium indicates that hyponatremia may be causing the cerebral edema, and the nurse's first action should be to correct the low sodium level. Acetaminophen (Tylenol) will have minimal effect on the headache because it is caused by cerebral edema and increased intra-cranial pressure (ICP). Drawing ABGs and obtaining a CT scan may add some useful information, but the low sodium level may lead to seizures unless it is addressed quickly.

After reviewing a patient's cerebrospinal fluid analysis, which result will be most important for the nurse to communicate to the health care provider? a. Specific gravity 1.007 b. Protein 65 mg/dL (0.30 g/L) c. White blood cell (WBC) count 4/μL d. Glucose 45 mg/dL (1.7 mmol/L)

ANS: B The protein level is high. The pH, WBCs, and glucose values are normal.

Which equipment will the nurse obtain to assess vibration sense in a patient who has peripheral nerve dysfunction? a. Sharp pin b. Tuning fork c. Reflex hammer d. Calibrated compass

ANS: B Vibration sense is testing by touching the patient with a vibrating tuning fork. The other equipment is needed for testing of pain sensation, reflexes, and two-point discrimination.

Which assessments will the nurse make to test a patient's cerebellar function (select all that apply)? a. Assess for graphesthesia. b. Perform the finger-to-nose test. c. Observe arm movement with gait. d. Check ability to push against resistance. e. Determine ability to sense heat and cold.

ANS: B, C The cerebellum is responsible for coordination and is assessed by looking at the patient's gait and the finger-to-nose test. The other assessments will be used for other parts of the neurological assessment.

Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the health care provider before giving the aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient states, "My symptoms started with a terrible headache." d. The patient has a history of brief episodes of right-sided hemiplegia.

ANS: C A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer the aspirin.

Which of these nursing actions included in the care of a patient who has been experiencing stroke symptoms for 60 minutes can the nurse delegate to an LPN/LVN? a. Assess the patient's gag and cough reflexes. b. Determine when the stroke symptoms began. c. Administer the prescribed clopidogrel (Plavix). d. Infuse the prescribed IV metoprolol (Lopressor).

ANS: C Administration of oral medications is included in LPN education and scope of practice. The other actions require more education and scope of practice and should be done by the RN.

A patient admitted with bacterial meningitis and a temperature of 102° F (38.8° C) has orders for all of these collaborative interventions. Which action should the nurse take first? a. Administer ceftizoxime (Cefizox) 1 g IV. b. Use a cooling blanket to lower temperature. c. Swap the nasopharyngeal mucosa for cultures. d. Give acetaminophen (Tylenol) 650 mg PO.

ANS: C Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics are started. As soon as the cultures are done, the antibiotic should be started. Hypothermia therapy and acetaminophen administration are appropriate but can be started after the other actions are implemented.

A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering the medications, the patient says, "I don't need the aspirin today. I don't have any aches or pains." Which action should the nurse take? a. Document that the aspirin was refused by the patient. b. Tell the patient that the aspirin is used to prevent aches. c. Explain that the aspirin is ordered to decrease stroke risk. d. Call the health care provider to clarify the medication order.

ANS: C Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patient's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The aspirin is not ordered to prevent aches and pains.

The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a patient with right-sided hemiplegia. Which intervention should be included in the plan of care? a. Provide a wide variety of food choices. b. Provide oral care before and after meals. c. Assist the patient to eat with the left hand. d. Teach the patient the "chin-tuck" technique.

ANS: C Because the nursing diagnosis indicates that the patient's imbalanced nutrition is related to the right-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use the left hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition.

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.

ANS: C 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.

Propranolol (Inderal), a β-adrenergic blocker that inhibits sympathetic nervous system activity, is prescribed for a patient. The nurse monitors the patient for a. dry mouth. b. constipation. c. slowed pulse. d. urinary retention.

ANS: C Inhibition of the fight or flight response leads to decreased heart rate. Dry mouth, constipation, and urinary retention are associated with peripheral nervous system blockade.

When the nurse applies a painful stimulus to the nail beds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as a. flexion withdrawal. b. localization of pain. c. decorticate posturing. d. decerebrate posturing.

ANS: C Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal.

While caring for a patient who has just been admitted with meningococcal meningitis, the RN observes all of the following. Which one requires action by the RN? a. The bedrails at the head and foot of the bed are both elevated. b. The patient receives a regular diet from the dietary department. c. The nursing assistant goes into the patient's room without a mask. d. The lights in the patient's room are turned off and the blinds are shut.

ANS: C Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions. Because the patient may be confused and weak, bedrails should be elevated at both the food and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an important aspect of care in a patient with meningitis.

When caring for a patient who has had cerebral angiography, which nursing action will be included in the plan of care? a. Ask about headache and photophobia. b. Keep patient NPO until gag reflex returns. c. Check pulse and blood pressure frequently. d. Assess orientation to person, place, and time.

ANS: C Since a catheter is inserted into an artery (such as the femoral artery) during cerebral angiography, the nurse should assess for bleeding after this procedure. The other nursing assessments are not necessary after angiography.

The community health nurse is developing a program to decrease the incidence of meningitis in adolescents and young adults. Which nursing action is most important? a. Vaccinate 11- and 12-year-old children against Haemophilus influenzae. b. Emphasize the importance of hand washing to prevent spread of infection. c. Immunize adolescents and college freshman against Neisseria meningitides. d. Encourage adolescents and young adults to avoid crowded areas in the winter.

ANS: C The Neisseria meningitides vaccination is recommended for children ages 11 and 12, unvaccinated teens entering high school, and college freshmen. Hand washing may help decrease the spread of bacteria, but it is not as effective as immunization. Vaccination with Haemophilus influenzae is for infants and toddlers. Because adolescents and young adults are in school or the workplace, avoiding crowds is not realistic.

Which information about a patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse? a. Intracranial pressure of 15 mm Hg b. Cerebrospinal fluid (CSF) drainage of 15 mL/hour c. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg d. Cardiac monitor shows sinus tachycardia, with a heart rate of 126 beats/min

ANS: C The PbtO2 should be 20 to 40 mm Hg. Lower levels indicate brain ischemia. An intracranial pressure (ICP) of 15 mm Hg is at the upper limit of normal. CSF is produced at a rate of 20 to 30 mL/hour. The reason for the sinus tachycardia should be investigated, but the elevated heart rate is not as concerning as the decrease in PbtO2.

A patient who has right-sided weakness after a stroke is attempting to use the left hand for feeding and other activities. The patient's wife insists on feeding and dressing him, telling the nurse, "I just don't like to see him struggle." Which nursing diagnosis is most appropriate for the patient? a. Situational low self-esteem related to increasing dependence on others b. Interrupted family processes related to effects of illness of a family member c. Disabled family coping related to inadequate understanding by patient's spouse d. Impaired nutrition: less than body requirements related to hemiplegia and aphasia

ANS: C The information supports the diagnosis of disabled family coping because the wife does not understand the rehabilitation program. There are no data supporting low self-esteem, and the patient is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. There is no indication that the patient has impaired nutrition.

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.

ANS: C 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.

A patient has a systemic BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? a. Elevate the head of the patient's bed to 60 degrees. b. Document the BP and ICP in the patient's record. c. Report the BP and ICP to the health care provider. d. Continue to monitor the patient's vital signs and ICP.

ANS: C The patient's cerebral perfusion pressure is 56 mm Hg, below the normal of 60 to 100 mm Hg and approaching the level of ischemia and neuronal death. Immediate changes in the patient's therapy such as fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation also will be done, but they are not the first actions that the nurse should take.

The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include a. prophylactic clipping of cerebral aneurysms. b. heparin via continuous intravenous infusion. c. oral administration of low dose aspirin therapy. d. therapy with tissue plasminogen activator (tPA).

ANS: C The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.

The nurse receives a verbal report that a patient has an occlusion of the left posterior cerebral artery. The nurse will anticipate that the patient may have a. dysphasia. b. confusion. c. visual deficits. d. poor judgment.

ANS: C Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion.

When assessing a patient with a possible stroke, the nurse finds that the patient's aphasia started 3.5 hours previously and the blood pressure is 170/92 mm Hg. Which of these orders by the health care provider should the nurse question? a. Infuse normal saline at 75 mL/hr. b. Keep head of bed elevated at least 30 degrees. c. Administer tissue plasminogen activator (tPA) per protocol. d. Titrate labetolol (Normodyne) drip to keep BP less than 140/90 mm Hg.

ANS: D Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if mean arterial pressure (MAP) is >130 mm Hg or systolic pressure is >220 mm Hg. Fluid intake should be 1500 to 2000 mL daily to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees, unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use.

The care plan for a patient who has increased intracranial pressure and a ventriculostomy includes the following nursing actions. Which action can the nurse delegate to nursing assistive personnel (NAP) who regularly work in the intensive care unit? a. Monitor cerebrospinal fluid color hourly. b. Document intracranial pressure every hour. c. Turn and reposition the patient every 2 hours. d. Check capillary blood glucose level every 6 hours.

ANS: D Experienced NAP can obtain capillary blood glucose levels when they have been trained and evaluated in the skill. Monitoring and documentation of cerebrospinal fluid (CSF) color and intracranial pressure (ICP) require RN-level education and scope of practice. Although repositioning patients is frequently delegated to NAP, repositioning a patient with a ventriculostomy is complex and should be done by the RN.

During the neurologic assessment, the patient cooperates with the nurse's directions to grip with the hands and to move the feet but is unable to respond orally to the nurse's questions. The nurse will suspect a. a brainstem lesion. b. a temporal lobe lesion. c. injury to the cerebellum. d. damage to the frontal lobe.

ANS: D Expressive speech is controlled by Broca's area in the frontal lobe. The temporal lobe contains Wernicke's area, which is responsible for receptive speech. The cerebellum and brainstem do not affect higher cognitive functions such as speech.

The nurse obtains all of the following information about a 65-year-old patient in the clinic. When developing a plan to decrease stroke risk, which risk factor is most important for the nurse to address? a. The patient has a daily glass of wine to relax. b. The patient is 25 pounds above the ideal weight. c. The patient works at a desk and relaxes by watching television. d. The patient's blood pressure (BP) is usually about 180/90 mm Hg.

ANS: D Hypertension is the single most important modifiable risk factor and this patient's hypertension is at the stage 2 level. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not so much as hypertension.

Which parameter is best for the nurse to monitor to determine whether the prescribed IV mannitol (Osmitrol) has been effective for an unconscious patient? a. Hematocrit b. Blood pressure c. Oxygen saturation d. Intracranial pressure

ANS: D Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and increase blood pressure, but these are not the best parameters for evaluation of the effectiveness of the drug. Oxygen saturation will not directly improve as a result of mannitol administration.

Which assessment finding in a patient who was admitted the previous day with a basilar skull fracture is most important to report to the health care provider? a. Bruising under both eyes b. Complaint of severe headache c. Large ecchymosis behind one ear d. Temperature of 101.5° F (38.6° C)

ANS: D Patients who have basilar skull fractures are at risk for meningitis, so the elevated temperature should be reported to the health care provider. The other findings are typical of a patient with a basilar skull fracture.

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.

ANS: D 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.

A patient with a stroke has progressive development of neurologic deficits with increasing weakness and decreased level of consciousness (LOC). Which nursing diagnosis has the highest priority for the patient? a. Impaired physical mobility related to weakness b. Disturbed sensory perception related to brain injury c. Risk for impaired skin integrity related to immobility d. Risk for aspiration related to inability to protect airway

ANS: D Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses also are appropriate, but interventions to prevent aspiration are the priority at this time.

After having a craniectomy and left anterior fossae incision, a patient has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to a. position the bed flat and log roll the patient. b. cluster nursing activities to allow longer rest periods. c. turn and reposition the patient side to side every 2 hours. d. perform range-of-motion (ROM) exercises every 4 hours.

ANS: D ROM exercises will help to prevent the complications of immobility. Patients with anterior craniotomies are positioned with the head elevated. The patient with a craniectomy should not be turned to the operative side. When the patient is weak, clustering nursing activities may lead to more fatigue and weakness.

A patient with right-sided weakness that started 90 minutes earlier is admitted to the emergency department and all these diagnostic tests are ordered. Which test should be done first? a. Electrocardiogram (ECG) b. Complete blood count (CBC) c. Chest radiograph (Chest x-ray) d. Noncontrast computed tomography (CT) scan

ANS: D Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the smaller the area of brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.

A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When admitting the patient, which clinical manifestation will the nurse expect to find? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided reflexes d. Difficulty in understanding commands

ANS: D Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side stroke.

A patient is hospitalized with a possible seizure disorder. To determine the cause of the patient's symptoms, the nurse will anticipate the need to teach the patient about which of these tests? a. Cerebral angiography b. Evoked potential studies c. Electromyography (EMG) d. Electroencephalography (EEG)

ANS: D Seizure disorders are usually studied using EEG testing. Evoked potential is used for diagnosing problems with the visual or auditory systems. Cerebral angiography is used to diagnose vascular problems. EMG is used to evaluate electrical innervation to skeletal muscle.

When assessing a patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider? a. The patient has a positive Kernig's sign. b. The patient complains of having a stiff neck. c. The patient's temperature is 101° F (38.3° C). d. The patient's blood pressure is 86/42 mm Hg.

ANS: D Shock is a serious complication of meningitis, and the patient's low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig's sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the hypotension.

After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? a. A patient whose cranial x-ray shows a linear skull fracture b. A patient who has an initial Glasgow Coma Scale score of 13 c. A patient who lost consciousness for a few seconds after a fall d. A patient whose right pupil is 10 mm and unresponsive to light

ANS: D The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage and increased intracranial pressure. The other patients are not at immediate risk for complications such as herniation.

A patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. The nurse anticipates the need to prepare the patient for a. surgical endarterectomy. b. transluminal angioplasty. c. intravenous heparin administration. d. tissue plasminogen activator (tPA) infusion.

ANS: D The patient's history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke.

When performing a focused assessment on a patient with a lesion of the left posterior temporal lobe, the nurse will assess for a. sensation on the left side of the body. b. voluntary movement on the right side. c. reasoning and problem-solving abilities. d. understanding of written and oral language.

ANS: D The posterior temporal lobe integrates the visual and auditory input for language comprehension. Reasoning and problem solving are functions of the anterior frontal lobe. Sensation on the left side of the body is located in the right postcentral gyrus. Voluntary movement on the right side is controlled in the left precentral gyrus.

A patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse plan to take? a. Administer IV furosemide (Lasix). b. Initiate high-dose barbiturate therapy. c. Type and crossmatch for blood transfusion. d. Prepare the patient for immediate craniotomy.

ANS: D The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If intracranial pressure (ICP) is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but these will not be of benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries, and transfusion is usually not necessary.

A patient with sudden-onset right-sided weakness has a CT scan and is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patient's speech is difficult to understand. b. The patient's blood pressure is 144/90 mm Hg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin).

ANS: D The use of warfarin will have contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.

A patient with a brainstem infarction is admitted to the nursing unit. The priority nursing assessment for the patient is a. reflex reaction time. b. pupil reaction to light. c. level of consciousness. d. respiratory rate and rhythm.

ANS: D Vital centers that control respiration are located in the medulla, and these are the priority assessments because changes in respiratory function may be life threatening. The other information also will be collected by the nurse, but it is not as urgent.

When admitting a patient who has a tumor of the right frontal lobe, the nurse would expect to find a. judgment changes. b. expressive aphasia. c. right-sided weakness. d. difficulty swallowing.

ANS: A The frontal lobes control intellectual activities such as judgment. Speech is controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumor. Swallowing is controlled by the brainstem.

A patient is scheduled for a myelogram to confirm the presence of a herniated intervertebral disk. Which information obtained when admitting the patient is most important for the nurse to communicate to the health care provider before the procedure? a. The patient is anxious about the test. b. The patient has an allergy to shellfish. c. The patient had 4 ounces of apple juice 4 hours earlier. d. The patient has back pain when lying flat for long periods.

...

The nurse is caring for a client who is experiencing an exacerbation of gout. When providing instruction, which dietary modifications are stressed? SATA 1. Eat a low-purine diet 2. Limit fluid intake to no more than 1 L/day. 3. Eat a high-protein diet, with at least two servings of lean meat per day. 4. Eat a high-purine diet 5. Limit alcohol intake

1. Eat a low-purine diet. 5. Limit alcohol intake.

A nurse is caring for a client with a T5 complete spinal cord injury. upon assessment, the nurse notes flushed skin, diaphoresis above T5, and blood pressure of 162/96 mm Hg. The client reports a severe, pounding headache. Which nursing interventions would be appropriate for the client? SATA 1. Elevate the head of the bed to 90 degrees. 2. Loosen constrictive clothing. 3. Use a fan to reduce diaphoresis 4. Assess for bladder distention and bowel impaction. 5. Administer antihypertensive medication. 6. Place the client in a supine position with legs elevated.

1. Elevate the head of the bed to 90 degrees. 2. Loosen constrictive clothing. 4. Assess for bladder distention and bowel impaction. 5. Administer antihypertensive medication.

A nurse is caring for a client, diagnosed with Alzheimer's disease, who scored a 7 (High risk) on the Hendrich II Fall Risk Model. Which nursing interventions should the nurse implement? SATA 1. Implement a bed alarm. 2. Request a low-dose sedative. 3. Instruct the client to ask for help before ambulating. 4. Maintain the bed in the lowest position. 5. Offer toileting every 2 to 3 hours. 6. Advise family to notify staff when leaving.

1. Implement a bed alarm. 4. Maintain the bed in the lowest position. 5. Offer toileting every 2 to 3 hours. 6. Advise family to notify staff when leaving.

A nurse is providing discharge instructions on phenytoin (Dilantin) to a female client with tonic-clonic seizure disorder. Which instructions should the nurse include? SATA 1. Monitor the body for any skin rash 2. Maintain adequate amounts of fluid and fiber in the diet 3. Perform good oral hygiene, including daily brushing and flossing. 4. Receive necessary periodic blood work. 5. Report any problems with walking or coordination, slurred speech, or nausea. 6. Feel safe about taking this drug, even during pregnancy

1. Monitor the body for any skin rash 3. Perform good oral hygiene, including daily brushing and flossing. 4. Receive necessary periodic blood work. 5. Report any problems with walking or coordination, slurred speech, or nausea.

A nurse is comparing the neurological status of a client who suffered a head injury with the status on the previous shift. Using the Glosgow Coma Scale, the nurse determines that the client's score has changed from 11 to 15. Which of the following responses did the nurse assess in this client? SATA 1. Spontaneous eye opening. 2. Tachypnea, bradycardia, and hypotension. 3. Unequal pupil size. 4. Orientation to person, place, and time. 5. Pain localization. 6. Incomprehensible sounds.

1. Spontaneous eye opening. 4. Orientation to person, place, and time.

The nurse is caring for a client who is scheduled to undergo a computerized tomography (CT) scan to assess recent symptoms of muscle weakness and tingling in the extremities. Which information should the nurse include in a preprocedural teaching plan? SATA 1. The test requires standing alone without assistance. 2. A contrast dye may be given before the test. 3. Throat irritation and facial flushing may occur if contrast dye is used. 4. All medications must be withheld for 12 hours prior to the procedure. 5. The CT scan is considered an invasive procedure, but not dangerous. 6. It is necessary to report any known allergies to iodine or seafood prior to the procedure.

2. A contrast dye may be given before the test. 3. Throat irritation and facial flushing may occur if contrast dye is used. 6. It is necessary to report any known allergies to iodine or seafood prior to the procedure.

A nurse assesses a client with suspected bacterial meningitis. Which documented finding of meningeal irritation suggests this diagnosis? SATA 1. Generalized seizures 2. Nuchal rigidity 3. Postive Brudzinski's sign 4. Postive Kernig's sign 5. Babinski's reflex 6. Photophobia

2. Nuchal rigidity 3. Postive Brudzinski's sign 4. Postive Kernig's sign 6. Photophobia

A nurse is assessing a client's extraocular eye movements as part of evaluating neurological functioning. Which cranial nerve status is documented? SATA 1. Optic (II) 2. Oculomotor (III) 3. Trochlear (IV) 4. Trigeminal (V) 5. Abducens (VI) 6. Acustic (VIII)

2. Oculomotor (III) 3. Trochlear (IV) 5. Abducens (VI)

A nurse is preparing to teach students in a health class about hearing pathways. Place the following steps in chronological order to match how the nurse should describe the normal pathway of sound wave transmission and hearing to the class. Use all of the options 1. Interpretation of sound by the cerebral cortex. 2. Transmission of vibrations through the hammer, anvil, and stirrup. 3. Stimulation of nerve impulses in the inner ear. 4. Tranmission of vibrations to the auditory area of the cerebral cortex. 5. Collection of the sound waves in the pinna.

5. Collection of the sound waves in the pinna. 2. Transmission of vibrations through the hammer, anvil, and stirrup. 3. Stimulation of nerve impulses in the inner ear. 4. Tranmission of vibrations to the auditory area of the cerebral cortex. 1. Interpretation of sound by the cerebral cortex.

A client is scheduled to undergo cerebral angiography to allow for examination of the cerebral arteries. Place the following interventions in the order in which the nurse would perform them them. Use all of the options. 1. Administer antianxiety medication if ordered. 2. Ask the client about allerdies to iodine, seafood, or radiopaque dyes. 3. Make sure the client has signed an informed consent form. 4. Maintain the affected extremity in straight alignment for 6 hours as ordered. 5. Encourage the client to verbalize questions about the procedure.

5. Encourage the client to verbalize questions about the procedure. 3. Make sure the client has signed an informed consent form. 2. Ask the client about allerdies to iodine, seafood, or radiopaque dyes. 1. Administer antianxiety medication if ordered. 4. Maintain the affected extremity in straight alignment for 6 hours as ordered.

A community nurse is leading a support group discussion on the progressive nature of multiple sclerosis (MS). Arrange the following degenerative changes in the order in which they occur. Use all of the options. 1. Degeneration of axons. 2. Demyelination throughtout the central nervous system. 3. Periodic and unpredictable exacerbations and remissions. 4. Plaque formation that interrups nerve impluses. 5. The immune system attacks myelin.

5. The immune system attacks myelin. 2. Demyelination throughtout the central nervous system. 1. Degeneration of axons. 4. Plaque formation that interrups nerve impluses. 3. Periodic and unpredictable exacerbations and remissions.

A nurse is preparing to administer phenytoin (Dilantin) to a 99 lb client with a seizure disorder. The medication administration record documdents phenytoin 5 mg/kg/day to be administered in three divided doses. How many milligrams of phenytoin should be administered in the first dose?

75 mg

A 58-year-old patient who began experiencing right-sided arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Obtain CT scan without contrast. b. Infuse tissue plasminogen activator (tPA). c. Administer oxygen to keep O2 saturation >95%. d. Use National Institute of Health Stroke Scale to assess patient.

ANS: C, D, A, B The initial actions should be those that help with airway, breathing, and circulation. Baseline neurologic assessments should be done next. A CT scan will be needed to rule out hemorrhagic stroke before tPA can be administered.