UWorld Neuro GOOD/Starred

GOOD The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. 1. Padding the side rails of the bed. 2. Placing an airway at the bedside. 3. Placing the bed in the high position 4. Putting a padded tongue blade at the head of the bed 5. Placing oxygen and suction equipment at the bedside 6. Flushing the intravenous catheter to ensure that the site is patent.

1, 2, 5, 6 1. Padding the side rails of the bed. 2. Placing an airway at the bedside 5. Placing oxygen and suction equipment at the bedside 6. Flushing the intravenous catheter to ensure that the site is patent. Seizure precautions may vary from agency to agency, but they generally have some common features. Usually, an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if antiseizure medications must be administered, and as part of the routine assessment the nurse should be checking the patency of the catheter. The use of padded tongue blades is highly controversial, and they should not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure more likely will harm the client who bites down during seizure activity. Risks include blocking the airway from improper placement, chipping the client's teeth, and subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begins.

A client with Parkinson disease is prescribed carbidopa-levodopa. Which of the following instructions should the nurse include with the client's discharge teaching? Select all that apply. 1. "Change positions slowly, and sit on the side of the bed before standing." 2. "This medication takes several weeks to reach maximum benefit." 3. "You may experience some facial and eye twitching, but this is not harmful." 4. "Your tremors should disappear completely while on this medication." 5. "Your urine and saliva may turn reddish-brown, but this is not harmful.

1. "Change positions slowly, and sit on the side of the bed before standing." 2. "This medication takes several weeks to reach maximum benefit." 5. "Your urine and saliva may turn reddish-brown, but this is not harmful. Educational objective: Carbidopa-levodopa is a medication used to reduce symptoms of tremor and rigidity in clients with Parkinson disease. Teach clients that the medication takes several weeks to become effective; urine, perspiration, or saliva discoloration is a common side effect; and fall precautions should be implemented for client safety.

The home health nurse reviews the serum laboratory test results for a client with seizures. The phenytoin level is 27 mcg/mL. The client makes which statement that may indicate the presence of dose-related drug toxicity and prompt the nurse to notify the health care provider? 1. "I am feeling unsteady when I walk." 2. "I am getting up to urinate about 4 times during the night." 3. "I have a metallic taste in my mouth when I eat." 4. "My gums are getting so puffy and red."

1. "I am feeling unsteady when I walk." Educational objective: Phenytoin, an anticonvulsant drug, is used to treat generalized tonic-clonic seizures. Common symptoms of phenytoin drug-induced toxicity involve the central nervous system and include ataxia, nystagmus, slurred speech, and decreased alertness.

A client having an ischemic stroke arrives at the emergency department. The health care provider prescribes tissue plasminogen activator (tPA). Which client statement would be most important to clarify before administering tPA? 1. "I can't believe this is happening right after my stomach surgery." 2. "I had a concussion after a car accident a year ago." 3. "I started noticing my right arm becoming weak approximately an hour ago." 4. "I stopped taking my warfarin 4 weeks ago."

1. "I can't believe this is happening right after my stomach surgery." Tissue plasminogen activator (tPA) dissolves clots and restores perfusion in clients with ischemic stroke. It must be administered within a 3- to 4½-hour window from onset of symptoms for full effectiveness. The nurse assesses for contraindications to tPA due to the risk of hemorrhage. The client should not have a history of intracranial hemorrhage or be actively bleeding. Surgery within the last 2 weeks is a contraindication as tPA dissolves all clots in the body and may disrupt the surgical site. This client indicates a recent stomach surgery, which would need further clarification to determine eligibility to receive tPA (Option 1).

The clinic nurse educator is developing a teaching plan for the following 6 clients. The nurse should instruct which client to avoid the Valsalva maneuver when defecating? Select all that apply. 1. 22-year-old man with a head injury sustained during a college football game 2. 30-year-old woman recently hospitalized for reconstructive augmentation mammoplasty 3. 56-year-old man 2 weeks post myocardial infarction 4. 68-year-old woman recently diagnosed with pancreatic cancer 5. 74-year-old man with portal hypertension related to alcohol-induced cirrhosis 6. 82-year-old woman 1 week post cataract surgery

1. 22-year-old man with a head injury sustained during a college football game 3. 56-year-old man 2 weeks post myocardial infarction 5. 74-year-old man with portal hypertension related to alcohol-induced cirrhosis 6. 82-year-old woman 1 week post cataract surgery 1, 3, 5, 6 The Valsalva maneuver (straining during defecation) involves holding the breath while bearing down on the perineum to pass a stool. Straining to have a bowel movement is to be avoided in clients recently diagnosed with increased intracranial pressure, stroke, or head injury as straining increases intra-abdominal and intrathoracic pressure, which raises the intracranial pressure (Option 1). The vagus nerve is stimulated when bearing down; this temporarily slows the heart and decreases cardiac output, leading to potential cardiac complications in clients with heart disease (Option 3). Straining increases intra-abdominal and intrathoracic pressure and should be avoided in clients diagnosed with portal hypertension related to cirrhosis due to the risk of variceal bleeding (Option 5). The maneuver increases intraocular pressure and is contraindicated in clients with glaucoma and recent eye surgery (Option 6). (Option 2) The otherwise healthy client recovering from reconstructive augmentation mammoplasty is not at risk for complications related to the Valsalva maneuver. (Option 4) The client recently diagnosed with pancreatic cancer is not at risk for complications related to the Valsalva maneuver. Educational objective: The Valsalva maneuver is contraindicated in the client diagnosed with increased intracranial pressure, stroke, head injury, heart disease, glaucoma, eye surgery, abdominal surgery, and liver cirrhosis.

The nurse is reviewing new prescriptions for assigned clients. Which prescription would require further clarification from the health care provider? 1. Alteplase (TPA) for an ischemic stroke in a client with a blood pressure of 192/112 mm Hg 2. Amoxicillin for a respiratory infection in a client who is 20 weeks pregnant 3. Fentanyl for moderate to severe pain in a client post appendectomy with an allergy to codeine 4. Sodium chloride 3% infusion for a client with syndrome of inappropriate antidiuretic hormone

1. Alteplase for an ischemic stroke in a client with a blood pressure of 192/112 mm Hg Educational objective: Thrombolytic agents (eg, alteplase, tenecteplase, reteplase) place clients at risk for bleeding. Therefore, they are contraindicated in clients with active bleeding, recent trauma, aneurysm, arteriovenous malformation, history of hemorrhagic stroke, and uncontrolled hypertension.

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

1. The client is aphasic. 2. The client has weakness on the right side of the body. 4. The client has weakness on the right side of the face and tongue. Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic: unable to discriminate words and letters. They are generally very cautions and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.

The nurse is reinforcing education to a client newly prescribed levetiracetam (keppra) for seizures. Which statement made by the client indicates a need for further instruction? 1. "Drowsiness is a common side effect of this medication and will improve over time." 2. "I can begin driving again after I have been on this medication for a few weeks." 3. "I need to immediately report any new or increased anxiety when on this medication." 4. "I need to immediately report any new rash when on this medication."

2. "I can begin driving again after I have been on this medication for a few weeks." Educational objective: Levetiracetam is an anticonvulsant prescribed for seizure disorders. It may have depressing effects on the central nervous system (eg, drowsiness) as the body adjusts to therapy. Serious adverse effects include suicidal ideation and Stevens-Johnson syndrome. Clients with seizure disorders must meet the guidelines of their department of transportation and receive permission from their health care provider prior to legally operating a motor vehicle.

The nurse is caring for a client after a motor vehicle accident. The client's injuries include 2 fractured ribs and a concussion. The nurse notes which of the following as expected neurological changes for the client with a concussion? Select all that apply. 1. Asymmetrical pupillary constriction 2. Brief loss of consciousness 3. Headache 4. Loss of vision 5. Retrograde amnesia

2. Brief loss of consciousness 3. Headache 5. Retrograde amnesia 2, 3, 5 A concussion is considered a minor traumatic brain injury and results from blunt force or an acceleration/deceleration head injury. Typical signs of concussion include: A brief disruption in level of consciousness Amnesia regarding the event (retrograde amnesia) Headache These clients should be observed closely by family members and not participate in strenuous or athletic activities for 1-2 days. Rest and a light diet are encouraged during this time. (Options 1 and 4) The following manifestations indicate more serious brain injury and are not expected with simple concussion: Worsening headaches and vomiting (indicate high intracranial pressure) Sleepiness and/or confusion (indicate high intracranial pressure) Visual changes Weakness or numbness of part of the body Educational objective: Expected neurological changes with a concussion include brief loss of consciousness, retrograde amnesia, and headache. These clients should be observed closely by family members and not participate in strenuous or athletic activities for 1-2 days.

GOOD The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a client who had a craniotomy 12 hours ago. What should the nurse do? Select all that apply. 1. Encourage the client to cough to expectorate secretions. 2. Elevate the head of the bed 30 degrees. 3. Contact the HCP if ICP is >15 mmHg. 4. Monitor neurologic status using the Glasgow Coma Scale. 5. Stimulate the client with active range-of-motion exercises.

2. Elevate the head of the bed 15 - 20 degrees. 3. Contact the HCP if ICP is >15 mmHg. 4. Monitor neurologic status using the Glasgow Coma Scale. The nurse should maintain ICP by elevating the head of the bed 15 - 20 degrees and monitoring neurologic status. An ICP >15 mmHg with 20 to 25 mmHg as upper limits of normal indicates increased ICP, and the nurse should notify the HCP. Coughing and range of motion exercises will increase ICP and should be avoided in the early postoperative stage.

A client is admitted to the ambulatory care unit for an endoscopic procedure. The gastroenterologist administers midazolam (versed) 1 mg intravenously for sedation and titrates the dosage upward to 3.5 mg. The client becomes hypotensive (86/60 mm Hg), develops severe respiratory depression (SpO2 86%), and has periods of apnea. The nurse anticipates the administration of which antidote drug? 1. Benztropine 2. Flumazenil 3. Naloxone 4. Phentolamine

2. Flumazenil Educational objective: Flumazenil is a drug used to reverse the sedative effects of benzodiazepines such as midazolam. Midazolam (Versed) is a benzodiazepine commonly used to induce conscious sedation in clients undergoing endoscopic procedures. The initial dose is 1 mg and is titrated up slowly

A client is receiving scheduled doses of carbidopa-levodopa. The nurse evaluates the medication as having the intended effect if which finding is noted? 1. Improvement in short-term memory 2. Improvement in spontaneous activity 3. Reduction in number of visual hallucinations 4. Reduction of dizziness with standing

2. Improvement in spontaneous activity Parkinson disease is caused by low levels of dopamine in the brain. Levodopa is converted to dopamine in the brain, but much of this drug is metabolized before reaching the brain. Carbidopa helps prevent the breakdown of levodopa before it can reach the brain and take effect. This combination medication is particularly effective in treating bradykinesia (generalized slowing of movement). Tremor and rigidity may also improve to some extent. Carbidopa-levodopa (Sinemet) once started should never be stopped suddenly as this can lead to akinetic crisis (complete loss of movement). However, prolonged use can also result in dyskinesias (spontaneous involuntary movements) and on/off periods when the medication will start or stop working unpredictably.

GOOD The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? 1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2. Increasing temperature, decreasing pulse, decreasing respirations, decreasing blood pressure 3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

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

GOOD An adult client with altered mental status and fever has suspected bacterial meningitis with sepsis. Blood pressure is 80/60 mm Hg. Which prescribed intervention should the nurse implement first? 1. Administer IV antibiotics 2. Infuse bolus of IV normal saline 3. Prepare to assist with lumbar puncture 4. Transport client for head CT scan

2. Infuse bolus of IV normal saline Educational objective: For bacterial meningitis with sepsis, fluid resuscitation is the priority. Blood cultures should be drawn before starting antibiotics. After a head CT scan is performed to rule out increased intracranial pressure and mass lesions, cerebrospinal fluid cultures should be drawn via lumbar puncture. Meningitis is an inflammation of the meninges covering the brain and spinal cord. The key clinical manifestations of bacterial meningitis include fever, severe headache, nausea/vomiting, and nuchal rigidity. Other symptoms include photophobia, altered mental status, and other signs of increased intracranial pressure (ICP). In a hypotensive client with sepsis, the priority of care is fluid resuscitation to increase the client's blood pressure (Option 2). In addition to IV fluid administration, interventions and prescriptions for a client with sepsis and meningitis may include: Administer vasopressors. Obtain relevant labs and blood cultures prior to administering antibiotics. Administer empiric antibiotics, preferably within 30 minutes of admission (Option 1). This client will continue to decline without antibiotic therapy. Prior to a lumbar puncture (LP), obtain a head CT scan as increased ICP or mass lesions may contraindicate a LP due to the risk of brain herniation (Option 4). Assist with a LP for cerebrospinal fluid (CSF) examination and cultures (Option 3). CSF is usually purulent and turbid in clients with bacterial meningitis. CSF cultures will allow for targeted antibiotic therapy.

Four children are brought to the emergency department. Which child should be assessed first? 1. A 13-month-old who ingested an unknown quantity of children's multivitamins 2. A 15-month-old with a fever of 100.5 F (38.1 C) after being vaccinated 3. A 3-year-old with a forehead laceration and colorless nasal drainage 4. A 4-year-old with enlarged tonsillar lymph nodes who is crying in pain

3 Clear, colorless fluid draining from the nose or ears after head trauma is suspicious for cerebrospinal fluid (CSF) leakage (Option 3). When the drainage is clear, dextrose testing can be used to determine if the drainage is CSF. However, the presence of blood would make this test unreliable as blood also contains glucose. This child is at risk for intracerebral bleeding and meningitis. Vascular compromise may occur with even minimal head trauma; therefore, the nurse should evaluate any changes in level of consciousness and temperature as well as assess the head and neck for subcutaneous bleeding. The nurse should anticipate a CT scan of the head and neck and prophylactic antibiotics. (Option 1) Iron ingestion is the major concern with vitamin toxicity in children. However, children's formulations contain minimal or no iron. As a result, ingestion of an unknown quantity is unlikely to cause serious toxicity. This child should be seen second. (Option 2) A low-grade fever is common after immunizations; this child can be seen last. (Option 4) Although infection and pain are important, this child can be seen third. Educational objective: The child with head trauma who is leaking cerebrospinal fluid (CSF) is at risk for meningitis and intracerebral bleeding. If the drainage is clear, a dextrose test is used to determine if the drainage is CSF. The nurse should assess for signs of bleeding (eg, change in level of consciousness) and infection (eg, increased temperature) and anticipate a CT scan and prophylactic antibiotics.

What should the nurse do first when a client with a head injury begins to have clear drainage from the nose? 1. Compress the nares 2. Tilt the head back 3. Collect the drainage 4. Administer an antihistamine for postnasal drip

3. Collect the drainage The clear drainage must be analyzed to determine whether it is nasal drainage or CSF. The nurse should not give the client tissues because it is important to know how much leakage of CSF is occurring. Compressing the nares will obstruct the drainage flow. It is inappropriate to tilt the head back, which would allow the fluid to drain down the throat and not be collected for a sample. It is inappropriate to administer an antihistamine because the drainage may not be from postnasal drip.

What is the expected outcome of thrombolytic drug therapy for stroke? 1. Increased vascular permeability 2. Vasoconstriction 3. Dissolved emboli 4. Prevention of hemorrhage

3. Dissolved emboli Thrombolytic enzyme agents are used for clients with a thrombotic stroke to dissolve emboli, this reastablishing cerebral perfusion. They do not increase vascular permeability, cause vasoconstriction, or prevent further hemorrhage.

The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of priority from first to last? All options must be used. 1. Maintain a patent airway. 2. Record the seizure activity observed. 3. Ease the client to the floor. 4. Obtain vital signs.

3. Ease the client to the floor. 1. Maintain a patent airway. 4. Obtain vital signs. 2. Record the seizure activity observed. 3, 1, 4, 2 To protect the client from falling, the nurse first should ease the client to the floor. It is important to protect the head and maintain a patent airway since altered breathing and excessive salivation can occur. The assessment of the postictal period should include level of consciousness and vital signs. The nurse should record details of the seizure once the client is stable. The events preceding the seizure, timing with descriptions of each phase, body parts affected and sequence of involvement, and autonomic signs should be recorded.

A highly intoxicated client was brought to the emergency department after found lying on the sidewalk. On admission, the client is awake with a pulse of 70/min and blood pressure of 160/80 mm Hg. An hour later, the client is lethargic, pulse is 48/min, and blood pressure is 200/80 mm Hg. Which action does the nurse anticipate taking next? 1. Administer atropine for bradycardia 2. Administer nifedipine for hypertension 3. Have CT scan performed to rule out an intracranial bleed 4. Perform hourly neurologic checks with Glasgow coma scale (GCS)

3. Have CT scan performed to rule out an intracranial bleed Cushing's triad is related to increased intracranial pressure (ICP). Early signs include change in level of consciousness. Later signs include bradycardia, increased systolic blood pressure with a widening pulse pressure (difference between systolic and diastolic), and slowed irregular (Cheyne-Stokes) respirations. Cushing's triad is a later sign that does not appear until the ICP is increased for some time. It indicates brain stem compression. The skull cannot expand after the fontanels close at age 18 months, so anything taking up more space inside the skull (eg, hematoma, tumor, swelling, etc.) is a concern for causing pressure on the brain tissue/brain stem and potential herniation. In this scenario, hidden head trauma causing an intracranial bleed must be ruled out with diagnostic testing. The client's intoxication could blunt an accurate history or presentation of a head injury. (Option 1) Atropine is used to stimulate the sinoatrial node in bradycardia with systemic symptoms. An electrocardiogram (ECG) should be obtained prior to administering atropine. In this client, there is no evidence of a cardiac etiology or systemic symptoms of poor perfusion/circulation from the bradycardia. (Option 2) Nifedipine (Procardia) is a calcium channel blocker that is a potent vasodilator. However, all components must be considered in this scenario as to the etiology of the hypertension rather than just treating that sign. Ruling out a cerebral cause of the hypertension is most important. (Option 4) The nurse would continue to perform neurologic assessments (including GCS). However, it is more important to obtain appropriate diagnostic tests and initiate treatment for the changing neurologic symptoms than to just monitor and document. In addition, the nurse should be performing these assessments more frequently than hourly in this rapidly changing client. Educational objective: Cushing's triad/reflex indicates increased intercerebral pressure. Classic signs include bradycardia, rising systolic blood pressure, widening pulse pressure, and irregular respirations (such as Cheyne-Stokes).

The nurse is caring for a client who has undergone a craniotomy and has a supratentorial incision. The nurse should place the client in which position postoperatively? 1. Head of bed flat, head and neck midline. 2. Head of bed flat, head turned to the nonoperative side 3. Head of bed elevated 30 to 45 degrees, head and neck midline 4. Head of bed elevated 30 to 45 degrees, head turned to the operative side

3. Head of bed elevated 30 to 45 degrees, head and neck midline

GOOD A client is admitted to the hospital for severe headaches. The client has a history of increased intracranial pressure (ICP), which has required lumbar punctures to relieve the pressure by draining cerebrospinal fluid. The client suddenly vomits and states, "That's weird, I didn't even feel nauseated." Which action by the nurse is the most appropriate? 1. Document the amount of emesis 2. Lower the head of the bed 3. Notify the health care provider (HCP) 4. Offer anti-nausea medication

3. Notify the health care provider (HCP) Unexpected and projectile vomiting without nausea can be a sign of increased ICP, especially in the client with a history of increased ICP. The unexpected vomiting is related to pressure changes in the cranium. The vomiting can be associated with headache and gets worse with lowered head position. The most appropriate action is to obtain a full set of vital signs and contact the HCP immediately. (Option 1) Documentation is important, but it is not the priority action. (Option 2) The head of the bed should be raised, not lowered, for clients with suspected increased ICP. Raising the head of the bed to 30 degrees helps to drain the cerebrospinal fluid via the valve system without lowering the cerebral blood pressure. (Option 4) The vomiting is caused not by nausea but by pressure changes in the cranium. Anti-nausea medications are often not effective. Decreasing intracranial pressure will help the vomiting. Educational objective: Notify the HCP of signs/symptoms of increased ICP, including unexpected vomiting. The vomiting is often projectile, associated with headache, and gets worse with lowering the head position.

A nurse is evaluating an acutely ill client with suspected meningitis. The nurse should take what action first? 1. Check for Kernig's and Brudzinski's signs 2. Establish IV access 3. Place the client on droplet precautions 4. Prepare the client for lumbar puncture

3. Place the client on droplet precautions. 3 After a supratentorial surgery, the head is kept at a 30-45 degree angle. The head and neck should not be angled either anteriorly or laterally but rather should be kept in a neutral (midline) position. This promotes venous return through the jugular veins, which will help prevent a rise in intracranial pressure.

A client with seizure activity is receiving a continuous tube feeding via a small-bore enteral tube. The nurse prepares to administer phenytoin (Dilantin) oral suspension via the enteral route. What is the nurse's priority action before administering this medication? 1. Check renal function laboratory results 2. Flush tube with normal saline, not water 3. Stop the feeding for 1 to 2 hours 4. Take the blood pressure (BP)

3. Stop the feeding for 1 to 2 hours Educational objective: Phenytoin is an anticonvulsant drug commonly used to treat seizure disorders. Steady absorption is necessary to maintain a therapeutic dosage range and drug level to control seizure activity. Administration of phenytoin concurrent with certain drugs (eg, antacids, calcium) and/or enteral feedings can affect the absorption of phenytoin.

The health care provider (HCP) has prescribed amitriptyline 25 mg orally every morning for an elderly client with recent herpes zoster infection (shingles) and severe postherpetic neuralgia. What is the priority nursing action? 1. Encourage increased fluid intake 2. Provide frequent rest periods 3. Teach the client to get up slowly from the bed or a sitting position 4. Tell the client to wear sunglasses when outdoors

3. Teach the client to get up slowly from the bed or a sitting position Educational objective: The most common side effects experienced by clients taking tricyclic antidepressants include dizziness, drowsiness, dry mouth, constipation, photosensitivity, urinary retention, and blurred vision. The priority nursing action is to teach caution in changing positions due to the increased risk for falls from dizziness and orthostatic hypotension, especially in elderly clients.

A client comes to the emergency department with diplopia and recent onset of nausea. Which statement by the client would indicate to the nurse that this is an emergency? 1. "I am very tired, and it's hard for me to keep my eyes open." 2. "I don't feel good, and I want to be seen." 3. "I have not taken my blood pressure medicine in over a week." 4. "I have the worst headache I've ever had in my life."

4 A ruptured cerebral aneurysm is a surgical emergency with a high mortality rate. Cerebral aneurysms are usually asymptomatic unless they rupture; they are often called "silent killers" as they may go undetected for many years before rupturing without warning signs. The distinctive description of a cerebral aneurysm rupture is the abrupt onset of "the worst headache of my life" that is different from previous headaches (including migraines). Immediate evaluation for a possible ruptured aneurysm is critical for any client experiencing a severe headache with changes in or loss of consciousness, neurologic deficits, diplopia, seizures, vomiting, or a stiff neck. Early identification and prompt surgical intervention help increase the chance for survival. (Options 1, 2, and 3) A change in level of consciousness, increased blood pressure, or a feeling of illness should be investigated but alone does not indicate an emergency. Educational objective: Sudden onset of a severe headache described as "the worst headache of my life" is characteristic of a ruptured cerebral aneurysm and should be treated as an emergency.

GOOD The nurse receives report for 4 clients in the emergency department. Which client should be seen first? 1. 30-year-old with a spinal cord injury at L3 sustained in a motor cycle accident who reports lower abdominal pain and difficulty urinating 2. 33-year-old with a seizure disorder admitted with phenytoin toxicity who reports slurred speech and unsteady gait 3. 65-year-old with suspected brain tumor waiting to be admitted for biopsy who reports throbbing headache and had emesis of 250 mL 4. 70-year-old with atrial fibrillation and a closed-head injury waiting for brain imaging who reports a headache and had emesis of 200 mL

4. 70-year-old with atrial fibrillation and a closed-head injury waiting for brain imaging who reports a headache and had emesis of 200 mL Educational objective: Constant headache, decreased mental status, and sudden-onset emesis indicate increased intracranial pressure. A client with a neurological injury (eg, head trauma, stroke) is at risk for cerebral edema and increased intracranial pressure (ICP), a life-threatening situation. The client with atrial fibrillation may also be taking anticoagulants (eg, warfarin, rivaroxaban, apixaban, dabigatran), making a life-threatening intracranial bleed even more dangerous. The nurse should perform a neurologic assessment (eg, level of consciousness, pupil response, vital signs) immediately. (Option 1) Autonomic dysreflexia (eg, throbbing headache, flushing, hypertension) is a life-threatening condition caused by sensory stimulation that occurs in clients who have a spinal cord injury at T6 or higher. This is not the priority assessment as this client's injury is at L3. This client likely has acute urinary retention and needs catheterization. (Option 2) Phenytoin toxicity commonly presents with neurologic manifestations such as gait disturbance, slurred speech, and nystagmus. These are expected symptoms and therefore are not a priority. (Option 3) A brain tumor can also cause increased intracranial pressure; clients report morning headache, nausea, and vomiting. Dexamethasone (Decadron) can be prescribed short-term to decrease the surrounding edema. A tumor usually grows more slowly than a possible hematoma and is therefore not the priority assessment. Educational objective: Constant headache, decreased mental status, and sudden-onset emesis indicate increased intracranial pressure.

NEED TO KNOW? A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? 1. Fluid is clear and tests negative for glucose. 2. Fluid is grossly blood in appearance and has a pH of 6 3. Fluid clumps together on the dressing and had a pH of 7 4. Fluid separates into concentric rings and tests positive for glucose.

4. Fluid separates into concentric rings and tests positive for glucose. Leakage of cerebrospinal fluid from the ears or nose may accompany basilar skull fractures. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.

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

4. We need to remind him to turn his head to scan the lost visual field. 4 Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available.

2 Levetiracetam (Keppra) is a medication often used to treat seizures in various settings. It has minimal drug-drug interactions compared to phenytoin and is often the preferred antiepileptic medication. (Option 1) Chemotherapy and radiation therapy would kill tumor cells and reduce tumor size. (Option 3) Hospitalized clients and clients with malignancy are at higher risk for venous thromboembolism. These clients would benefit from anticoagulation (eg, heparin, enoxaparin, rivaroxaban, apixaban). (Option 4) Dexamethasone, a corticosteroid, is used to treat cerebral edema associated with a brain injury/tumor by decreasing inflammation. Educational objective: Levetiracetam (Keppra) is a medication often used to treat seizures in various settings. Corticosteroids are used to reduce inflammation and cerebral edema in clients with brain injury and tumors.

A client with a brain tumor is admitted for surgery. The health care provider prescribes levetiracetam. The client asks why. What is the nurse's response? 1. "It destroys tumor cells and helps shrink the tumor." 2. "It prevents seizure development." 3. "It prevents blood clots in legs." 4. "It reduces swelling around the tumor."

The nurse educates the caregiver of a client with Alzheimer disease about maintaining the client's safety. Current symptoms include occasional confusion and wandering. Which of the following responses by the caregiver show correct understanding? Select all that apply. a. Grab bars should be installed in the shower and beside the toilet b. I will place a safe return bracelet on all exterior doors c. Keyed deadbolts should be placed on all exterior doors d. Medications will be placed in a weekly pill dispenser e. Throw rugs and clutter will be removed from the floors

Alzheimer disease (AD) is a form of dementia that causes progressive decline of cognitive and physical abilities. The nurse should educate the client/caregiver to prepare for current and future safety needs. Interventions evolve to meet client needs at each stage of disease progression. Safety promotion for the client with moderate AD includes: Keyed deadbolts (with keys removed) and close supervision to provide a controlled environment for wandering (Option 3) Medical identification/location devices (eg, bracelets, shoe inserts) in case the client wanders outside the designated area (Option 2) Decreased water heater temperature and "hot" and "cold" labels on faucets to prevent burns Household hazards (eg, gas appliances, rugs, toxic chemicals) removed to prevent injury (Option 5) Grab bars installed in showers and tubs (Option 1) (Option 4) All medications should be out of the client's reach or locked away. A confused person may not remember the day of the week and take more or less medication than prescribed. Educational objective:For clients with moderate Alzheimer disease, caregivers should provide a controlled environment for safe wandering (eg, throw rugs and clutter removed, exterior doors secured), and the client should wear an identification/location device (eg, bracelet). All medications should be out of reach or locked away. Hazards (eg, gas appliances, rugs, toxic chemicals) should be removed. Grab bars should be installed in showers and tubs. Answers: A,B,C,E

The nurse is caring for a client who is taking riluzole for amyotrophic lateral sclerosis (ALS). The client asks, "There's no cure for ALS, so why should I keep taking this expensive drug?" What is the nurse's best response? a. It may be able to slow the progression of ALS b. It reduces the amount of glutamate in your brain c. The case manager may be able to find a program to assist with cost d. You have the right to refuse the medication

Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig disease, is a debilitating, progressive neurodegenerative disease with no cure. Clients develop fatigue and muscle weakness that progresses to paralysis, dysphagia, difficulty speaking, and respiratory failure. Most clients diagnosed with ALS survive only 3-5 years. Riluzole (Rilutek) is the only medication approved for ALS treatment. Riluzole, a glutamate antagonist, is thought to slow neuron degeneration by decreasing the production and activity of the neurotransmitter glutamate in the brain and spinal cord. In some clients, riluzole may slow disease progression and prolong survival by 3-6 months. The nurse should provide teaching about the purpose of the medication so that the client can make an informed decision about taking it (Option 1). (Option 2) Explaining the pharmacology of riluzole is not the best response for helping the client understand the purpose of taking the medication. (Option 3) It would be appropriate to consult the case manager if the client expresses concern about not having the appropriate resources to acquire a costly medication, but the nurse should first ensure that the client understands the medication's purpose. (Option 4) The client has the right to refuse any medication, but the nurse should first ensure that the client is informed and understands the purpose of the medication. Educational objective:Although there is no cure for amyotrophic lateral sclerosis, the medication riluzole may slow disease progression and prolong survival. Answer: A

The nurse is assessing a client with advanced amyotrophic lateral sclerosis. Which of the following assessment findings does the nurse expect? Select all that apply. a. Diarrhea b. Difficulty breathing c. Difficulty swallowing d. Muscle weakness e. Resting tremor

Amyotrophic lateral sclerosis (ALS, Lou Gehrig disease) is a debilitating neurodegenerative disease with no cure. ALS causes progressive degeneration of motor neurons in the brain and spinal cord. Physical symptoms include fatigue, progressive muscle weakness, twitching and muscle spasms, difficulty swallowing, difficulty speaking, and respiratory failure (Options 2, 3, and 4). Most clients survive only 3-5 years after the diagnosis as there is no cure. Treatment focuses on symptom management. Interventions include: Respiratory support with noninvasive positive pressure (eg, bilevel positive airway pressure [BiPAP]) or invasive mechanical ventilation (eg, via tracheostomy) Feeding tube for enteral nutrition Medications to decrease symptoms (eg, spasms, uncontrolled secretions, dyspnea) Mobility assistive devices (eg, walker, wheelchair) Communication assistive devices (eg, alphabet boards, specialized computers) (Option 1) Constipation due to decreased mobility is more common in ALS. Diarrhea is not seen. (Option 5) Resting tremor is characteristic of parkinsonism. Educational objective:Amyotrophic lateral sclerosis causes motor neuron degeneration that leads to progressive muscle weakness, twitching and muscle spasms, difficulty swallowing, difficulty speaking, and respiratory failure. There is no cure. Treatment focuses on symptom management. Answer: B,C,D

The nurse in the outpatient clinic is speaking with a client diagnosed with cerebral arteriovenous malformation. Which statement would be a priority for the nurse to report to the health care provider? a. I got short of breath this morning when I worked out b. I have cut down on smoking to 1/2 pack per day c. I haven't been feeling well, so I have been sleeping a lot d. I took an acetaminophen in the waiting room for this bad headache.

An arteriovenous malformation (AVM) is a tangle of veins and arteries that is believed to form during embryonic development. The tangled vessels do not have a capillary bed, causing them to become weak and dilated. AVMs are usually found in the brain and can cause seizures, headaches, and neurologic deficits. Treatment depends on the location of the AVM, but blood pressure control is crucial. Clients with AVMs are at high risk for having an intracranial bleed as the veins can easily rupture because they lack a muscular layer around their lumen. Any neurologic changes, sudden severe headache, nausea, and vomiting should be evaluated immediately as these are usually the first symptoms of a hemorrhage (Option 4). (Option 1) The report of dyspnea may prompt further evaluation depending on the type of exercise performed, but it is not the priority. Clients with AVMs should be discouraged from engaging in heavy exercise as it increases blood pressure. (Option 2) Clients with AVMs should avoid smoking to prevent hypertension. This client needs education on smoking cessation, but it is not the priority. (Option 3) Reports of not feeling well and sleeping a lot may be related to the headache and possible hemorrhage, but this alone would not prompt a call to the health care provider. Educational objective:An arteriovenous malformation is a congenital deformity of tangled blood vessels often occurring in the brain. These vessels may weaken and rupture, causing an intracranial hemorrhage. Any neurologic changes and severe headache need to be addressed immediately as these may indicate hemorrhage. Answer: D

A child is scheduled to have an electroencephalogram (EEG). Which statement by the parent indicates understanding of the teaching? a. I will let my child drink cocoa as usual the morning of the procedure. b. I will wash my child's hair using shampoo the morning of the procedure c. My child may have scalp tenderness where the electrodes were applied d. My child will not remember the procedure.

An electroencephalogram (EEG) is a diagnostic procedure used to evaluate the presence of abnormal electrical discharges in the brain, which may result in a seizure disorder. The EEG can be done in a variety of ways, such as with the child asleep or awake with or without stimulation. Teaching for the parent includes the following: Hair should be washed to remove oils and hair care products, and accessories such as ribbons or barrettes should be removed. Hair may need to be washed after the procedure to remove electrode gel. Avoid caffeine, stimulants, and central nervous system depressants prior to the test. The test is not painful, and no analgesia is required. (Option 1) Food and liquids are not restricted prior to an EEG except for caffeinated beverages. Cocoa contains caffeine. (Option 3) This test (EEG) is not painful as it only records brain electrical activity. Electrode gel is nonirritating to the skin. (Option 4) A routine EEG is not performed under sedation, and so the child should remember the procedure. Educational objective:An EEG is used to diagnose the presence of a seizure disorder. Electrodes are secured to the scalp to observe for abnormal electrical discharges in the brain. Preprocedure teaching includes avoiding stimulants and CNS depressants and washing the hair. Answer: B

A client is diagnosed with right-sided Bell's palsy. What instructions should the nurse give this client for care at home? Select all that apply. a. Apply a patch to the right eye at night b. Avoid driving c. Chew on the left side d. Maintain meticulous oral hygiene e. Use a cane on the left side

Bell's palsy is an inflammation of cranial nerve VII (facial) that causes motor and sensory alterations. Clients are usually managed as outpatients, with corticosteroids to reduce inflammation, and taught eye/oral care. In Bell's palsy, the eyelids do not close properly. This may result in eye dryness and risk of corneal abrasions. However, weakness of the lower eyelid may cause excessive tearing due to overflow in some clients. Facial muscle weakness results in poor chewing and food retention. Client teaching should include the following: Eye care: Use glasses during the day; wear a patch (or tape the eyelids) at night to protect the exposed eye. Use artificial tears during the day as needed to prevent excess drying of the cornea (Option 1). Oral care: Chew on the unaffected side to prevent food trapping; a soft diet is recommended. Maintain good oral hygiene after every meal to prevent problems from accumulated residual food (eg, parotitis, dental caries) (Options 3 and 4). (Options 2 and 5) Vision, balance, consciousness, and extremity motor function are not impaired with Bell's palsy. Educational objective:Bell's palsy is an inflammation of cranial nerve VII (facial) that results in facial muscle weakness and inability to close the eyelids. Eye care (patch at night, artificial tears as needed) and oral care (eating on the unaffected side, oral hygiene after meals) are vital for these clients. Answer A,C,D

A child with autism spectrum disorder is being admitted to an acute care unit. Which is the most important nursing action? a. Placing the child in a private room away from the nurses' station b. Placing the child in a private room near the playroom c. Placing the child in a semi private room near the nurses' station d. Placing the child in a semi-private room with another child with autism spectrum disorder

Children with autism spectrum disorder (ASD) often exhibit sensory processing problems; they may be hyper- or hypo-sensitive to sounds, lights, movement, touch, taste, and smells. A calming environment with minimal stimulation should be provided; a private room away from the nurses' station is the best location. The nurse can also facilitate a calming environment by: Using a quiet or monotone voice when speaking to the child Using eye contact and gestures carefully Moving slowly Limiting visual clutter Maintaining minimal lighting Providing the child with a single object to focus on (Option 2) A private room is an appropriate placement; however, the noise and activity from the playroom may be distracting to the child with ASD. (Option 3) A semi-private room near the nurses' station is likely to have a stimulating environment due to the noise, lighting, and work pace in the area. (Option 4) Placing the child in a semi-private room with another child with ASD does not promote a calming environment. Educational objective:Because children with autism spectrum disorder often exhibit sensory processing problems, they need a calming environment with minimal stimulation. Answer A

The nurse is planning care for an 8-year-old client with mild cognitive impairment who is hospitalized for diagnostic testing. Which of the following interventions are appropriate to include in the plan of care? Select all that apply. a. Consistently a ssign the same nurse and unlicensed assistive personnel to care for the client b. Give direct procedural education and explanations to the parent rather than the client c. Provide appropriate toys based on developmental level rather than chronological age d. Reinforce parental limit-setting measures for preventing self-injurious behaviour e. Use a picture board to facilitate communication and promote understanding of procedures.

Clients with cognitive impairment (intellectual disability) are diagnosed prior to adulthood and have limited levels of intellectual functioning and adaptive skills for their chronological age. Manifestations may include a decreased ability to perform abstract or logical reasoning, interpret complex ideas, and learn by experience. Cognitive impairment results in developmental delays of varying levels (eg, mild, moderate) and types (eg, cognitive, physical, social, emotional, behavioral) and requires the nurse to assess the client's skills and abilities and provide individualized care. Appropriate nursing interventions for a client with cognitive impairment include: Promoting the staff's understanding of client behavior/needs and maintaining a familiar environment for the client by consistently assigning the same staff (eg, nurse) for care (Option 1) Fostering playtime by providing toys that are developmentally appropriate, not necessarily age appropriate (Option 3) Preventing self-injury by reinforcing the parents' limit-setting measures (eg, time-outs) and positively reinforcing good behavior (Option 4) Facilitating communication and learning by using visual demonstration (eg, picture board) rather than complex explanations (Option 5) (Option 2) The nurse should involve parents in preprocedural education but avoid excluding the client; explaining procedures using methods appropriate for the client's cognitive ability is encouraged. Educational objective:Appropriate nursing interventions when caring for a pediatric client with cognitive impairment include providing consistency in staff assignments, providing toys appropriate for the client's developmental (not chronological) age, preventing self-injurious behavior (eg, reinforce parental limit setting), and using visual demonstration (eg, picture board) and simple explanations to facilitate communication and learning. Answers - A,C,D,E

The nurse completes a neurological examination on a client who has suffered a stroke to determine if damage has occurred to any of the cranial nerves. The nurse understands that damage has occurred to cranial nerve IX based on which assessment finding? a. A tongue blade is used to touch the client's pharynx; gag reflex is present b. Only one side of the mouth moves when the client is asked to smile and frown c. The absence of light touch and pain sensation on the left side of the client's face d. When the client shrugs against resistance, the left shoulder is weaker than the right.

Cranial nerves IX (glossopharyngeal) and X (vagus) are related to the movement of the pharynx and tongue. To evaluate cranial nerves IX and X, the nurse assesses for the presence of a gag reflex and symmetrical movements of the uvula and soft palate, and listens to voice quality. A tongue blade can be used to touch the posterior pharyngeal wall to assess for a gag reflex. Asking the client to say "ah" will allow assessment of the uvula and soft palate. Harsh or brassy voice quality indicates dysfunction with the vagus nerve (X) (Option 1). (Option 2) The facial nerve (VII) is assessed by observing for symmetrical movements during facial expressions (eg, smile, frown, close eyes). (Option 3) The trigeminal nerve (V) has both sensory and motor functions. The nurse assesses for equal jaw strength by palpating the masseter muscle while the client clenches the jaw. To assess sensory function, the nurse touches the client's face with the client's eyes closed to determine if sensations are equal. (Option 4) The spinal accessory nerve innervates the sternocleidomastoid and part of the trapezius muscles. The nurse applies resistance during shrugging and head turning and assesses for equal strength. Educational objective:Cranial nerves IX and X work together to create movement of the pharynx and tongue. An absent gag reflex, asymmetrical uvular and palate movement, or a change in voice quality indicates damage. Answer: A

The nurse is caring for a young adult who is considering becoming pregnant. The client expresses concern, stating, "One of my parents has Huntington disease, and I am afraid my child will get it." How should the nurse respond? a. Genetic counseling is recommended. You will receive a referral before you leave b. Huntington disease inheritance requires both biological parents to carry the gene c. There are other ways to grow your family. You should consider adoption d. This disease occurs spontaneously and is not likely to affect your children

Huntington disease (HD) is an incurable autosomal dominant hereditary disease that causes progressive nerve degeneration, which results in impaired movement, swallowing, speech, and cognitive abilities. Chorea (involuntary, tic-like movement) is a hallmark sign. The onset of active disease is usually at age 30-50, and death from neuromuscular and respiratory complications typically occurs within 20 years of diagnosis. HD is confirmed by genetic testing. Clients who have a parent with HD and are considering having biological children should receive genetic counseling (Option 1). (Option 2) Autosomal dominant traits require only one copy of the affected gene (from one carrier parent) to manifest (eg, cause disease). (Option 3) Although adoption may be considered, the nurse's opinion is not appropriate or therapeutic for the client. After genetic testing and further education from a genetic counselor, the client can make an informed decision about starting a family. (Option 4) HD is hereditary, not spontaneous. The offspring of a client with the HD gene have at least a 50% chance of inheritance. Educational objective:Huntington disease is an incurable autosomal dominant disease that causes progressive nerve degeneration, which impairs movement, swallowing, speech, and cognitive abilities. Death typically occurs within 20 years. Clients who have a parent with this disease should receive genetic counseling, especially when planning to start a family. Answer - A

The nurse is providing care for a client with Alzheimer disease who often becomes angry and agitated 20 minutes or more after eating. The client accuses the nurse of not providing food, saying, "I'm hungry. You didn't feed me." The nurse should take which action? a. Give the client gentle reminders that the client has already eaten b. Say that the client can have a snack in a couple of hours c. Serve the client half of the meal initially and offer the other half later d. Take a picture of the client having a meal and show it when the client becomes upset

Most clients with Alzheimer disease experience eating and nutritional problems throughout the course of their disease. During the earlier stages, it is common for clients to forget that they have eaten recently. The best approach is for caregivers to give clients something to eat when they say they are hungry. Smaller meals throughout the day, along with low-calorie snacks, are effective strategies for clients who forget that they have eaten. (Option 1) Reality orientation has been recommended in the past as a way to deal with confusion (eg, dementia, Alzheimer disease), but research has shown that it may cause anxiety and distress. Validation therapy is a newer and more therapeutic approach that validates and accepts the client's reality. (Option 2) Offering to provide a snack later does not address the client's stated need to eat now. Delay in giving food will only further increase the client's anger and frustration. (Option 4) Showing a picture of the client having a meal is confrontational and will have no meaning to the client. Educational objective:Clients with Alzheimer disease experience eating and nutritional problems throughout the course of the disease. During the earlier stages, it is common for them to forget that they have eaten recently. The best approach is for caregivers to give clients something to eat when they say they are hungry. Answer C

A newborn has a large myelomeningocele. What nursing intervention is priority? a. Assess the anus for muscle tone b. Cover the area with a sterile, moist dressing c. Measure the occipital frontal circumference d. Place the newborn supine with the HOB elevated

Myelomeningocele occurs when the neural tube fails to fuse properly during fetal development. An outpouching of spinal fluid, spinal cord, and nerves covered by only a thin membrane occurs, typically in the lumbar area. The newborn is at high risk for infection at this area. A priority nursing intervention is to cover the area with a sterile, moist dressing to decrease the risk of infection until surgical repair can occur. (Option 1) Assessing for an anal wink will assist in the assessment of the level of neurologic deficit but is not a priority intervention. (Option 3) Myelomeningocele may decrease the absorption of cerebrospinal fluid, which would place the newborn at risk for hydrocephalus from the excess cerebrospinal fluid. An occipital frontal circumference is needed as a baseline measurement but is not a priority. (Option 4) The newborn would be placed in the prone position (with face turned to the side) to prevent rupture of the myelomeningocele. Educational objective:The newborn with a myelomeningocele is at risk for infection. Covering the myelomeningocele with a sterile, moist dressing is indicated to decrease the risk of infection at the site. The infant should be placed on the abdomen (prone) with the face turned to the side. Answer: B

The home health nurse prepares to give benztropine to a 70-year-old client with Parkinson disease. Which client statement is most concerning and would warrant health care provider notification? a. I am going to repeat testing to confirm glaucoma b. I am not able to exercise as much as I used to. c. I started taking esomeprazole for heartburn d. My bowel movements are not regular

Parkinson disease (PD) is a progressive neurological disorder characterized by bradykinesia (loss of autonomic movements), rigidity, and tremors. Clients with PD have an imbalance between dopamine and acetylcholine in which dopamine is not produced in high enough quantities to inhibit acetylcholine. Anticholinergic medications (eg, benztropine, trihexyphenidyl) are commonly used to treat tremor in these clients. However, in clients with benign prostatic hyperplasia or glaucoma, caution must be taken as anticholinergic drugs can precipitate urinary retention and an acute glaucoma episode. As a result, such medications are contraindicated in these clients. (Option 2) Decreased ability to exercise is common in clients with PD due to tremors and bradykinesia, and they require physical and occupational therapy consultations. However, acute glaucoma can be sight threatening and is the priority. (Option 3) Esomeprazole is safe to take with benztropine and will not cause an adverse reaction. (Option 4) Constipation is a common side effect of benztropine. Due to the characteristic decreased mobility, PD can also cause constipation. The client should be instructed to increase dietary fiber intake and drink plenty of water. However, this is not the most concerning issue. Educational objective:Anticholinergic medications (eg, benztropine, trihexyphenidyl) are used to treat Parkinson disease tremor. However, they can precipitate acute glaucoma and urinary retention and are therefore contraindicated in susceptible clients (eg, those with glaucoma or benign prostatic hyperplasia). Answer: A

The clinic nurse is assessing a previously healthy 60-year-old client when the client says, "My hand has been shaking when I try to cut food. I did some research online. Could I have Parkinson's disease?" Which response from the nurse is the most helpful? a. It can't be Parkinson's disease because you aren't old enough b. Make sure you tell the physician about your concerns c. Parkinson's disease does not cause that kind of hand shaking d. Tell me more about your symptoms. When did they start?

Parkinson's disease (PD) is a chronic, progressive neurodegenerative disorder that involves degeneration of the dopamine-producing neurons. Damage to dopamine neurons makes it difficult to control muscles through smooth movement. PD is characterized by a delay in initiation of movement (bradykinesia), increased muscle tone (rigidity), resting tremor, and shuffling gait. The most helpful response by the nurse is the one that acknowledges the concern of the client and also asks for more information. The nurse should assess for additional information and perform a more focused physical assessment given this new information (Option 4). (Option 1) It is incorrect to say that the client is too young to have PD although it is usually seen after age 60; about 15% of PD cases are diagnosed before age 50. (Option 2) Although the nurse should encourage the client and family to discuss concerns with the health care provider, this is not the most helpful response. (Option 3) Although the typical parkinsonian tremor occurs at rest and not during purposeful movement, it is not helpful to dismiss a concern without probing for more information. Educational objective:Therapeutic communication includes acknowledging concerns and probing for additional information as part of an assessment. Answer- D

A nurse cares for a client with impairment of cranial nerve VIII. What instructions will the nurse provide the unlicensed assistive personnel prior to delegating interventions related to the client's activities of daily living? a. Be aware of the client's shoulder weakness and provide support as needed b. Ensure that the client sits upright and tucks the chin when swallowing food c. Explain all procedures in step-by-step detain before performing them d. Make sure the items needed by the client are within reach

The client has an impairment of cranial nerve (CN) VIII, the vestibulocochlear (or auditory) nerve. Symptoms of impairment may include loss of hearing, dizziness, vertigo, and motion sickness, which place the client at a high risk for falls. Therefore, when instructing the unlicensed assistive personnel (UAP) about helping the client with activities of daily living, the nurse emphasizes the need to keep items at the bedside within the client's reach (Option 4). (Option 1) Weakness of the shoulder muscle occurs with impairment of CN XI, the spinal accessory nerve. Impairment of CN VIII does not affect shoulder strength. (Option 2) Dysphagia may occur with impairment of CN IX (glossopharyngeal) and CN X (vagus), not CN VIII. Instructing the client to tuck the chin while eating is a technique for those who have difficulty swallowing. (Option 3) Impairment of visual acuity occurs with disorders affecting CN II (optic). Because impairment of CN VIII does not affect visual acuity, providing a detailed, step-by-step explanation of procedures may be helpful but is not the most appropriate instruction to give the UAP. Educational objective:Impairment of cranial nerve (CN) VIII, the vestibulocochlear or auditory nerve, may cause dizziness, vertigo, loss of hearing, and motion sickness. To assist the client with impairment of CN VIII, needed items should be placed nearby to decrease the risk of the client getting out of bed and falling. Answer: D

The daughter of an 80-year-old client recently diagnosed with Alzheimer disease (AD) says to the nurse, "I guess I can anticipate getting this disease myself at some point." What is an appropriate response by the nurse? a. Engaging in regular exercise decreases the risk of AD b. Having a family hx of AD is not a risk factor c. Try not to worry about this now as you can't do anything to prevent AD d. You should avoid aluminum cans and cookware to prevent AD

The development of Alzheimer disease (AD) is related to a combination of genetic, lifestyle, and environmental factors. Clients with AD are usually diagnosed at age ≥65. Early-onset AD is a rare form of the disease that develops before age 60 and is strongly related to genetics. Children of clients with early-onset AD have a 50% chance of developing the disease. For late-onset AD, the strongest known risk factor is advancing age. Having a first-degree relative (eg, parent, sibling) with late-onset AD also increases the risk of developing AD (Option 2). Trauma to the brain has been associated with the development of AD in the future. Brain trauma may be prevented by wearing seat belts and sports helmets and taking measures to prevent falls. Research suggests that healthy lifestyle choices (eg, smoking cessation, avoiding excessive alcohol intake, exercising regularly, participating in mentally challenging activities) reduce the risk for developing AD (Options 1 and 3). (Option 4) Research has failed to confirm that exposure to aluminum products (eg, cans, cookware, antiperspirant deodorant) is related to the development of AD. Educational objective:Research suggests that healthy lifestyle choices (eg, smoking cessation, avoiding excessive alcohol intake, exercising regularly, participating in mentally challenging activities) reduce the risk for developing Alzheimer disease. Answer A

The nurse is assessing the cranial nerves and begins testing the facial nerve (cranial nerve VII). Which direction should the nurse give the client to test this cranial nerve? a. Close your eyes and identify the smell b. Follow my finger with your eyes without moving your head c. Look straight ahead and let me know when you can see my finger d. Raise your eyebrows, smile and frown

The facial nerve, cranial nerve VII, is tested by assessing exaggerated facial movements. The client is directed to raise the eyebrows, furrow the eyebrows, draw up the cheeks in a large smile, pull the cheeks down in a frown, and open the lips to show the teeth. Any asymmetrical movements are documented, and if unexpected, the health care provider is notified. (Option 1) Cranial nerve I is the olfactory sensory nerve. This nerve is tested by having the client identify a readily recognized odor. (Option 2) Cranial nerve III is a motor nerve of the eye, which is tested by having the client track an object, such as a finger, through the fields of vision. (Option 3) Cranial nerve II is the optic nerve and is a sensory nerve. It is assessed by testing the fields of vision for the client's ability to see objects in the field. Educational objective:The facial nerve, cranial nerve VII, is tested by assessing exaggerated facial movements. The client is directed to raise the eyebrows, furrow the eyebrows, draw up the cheeks in a large smile, pull the cheeks down in a frown, and open the lips to show the teeth. Answer: D

The nurse receives new prescriptions for a 6-month-old client with bacterial meningitis. Which action is the priority of care? a. Administer 400 mg Ceftriaxone IV every 12 hours b. Apply padding to the crib side rails c. Implement low-stimulation environment d. Monitor head circumference daily

a. Administer 400 mg Ceftriaxone IV every 12 hours Educational objective :Bacterial meningitis is an inflammation of the membranes covering the brain and spinal cord that can lead to severe complications (eg, hearing loss, brain damage) or death without treatment. To reduce the risk of complications, the nurse should prioritize initiation of prescribed antibiotic therapy as soon as possible Bacterial meningitis is an inflammation of the membranes covering the brain and spinal cord (ie, meninges) caused by a bacterial infection. The inflammatory process and bacterial growth within the meninges lead to increased volumes of cerebrospinal fluid and, subsequently, increased intracranial pressure (ICP). Without intervention, increased ICP may lead to nerve ischemia, permanent functional impairment (eg, hearing loss, visual impairment, paralysis), brain damage, herniation, and death. The initial priority of nursing care is protecting other clients and staff from exposure, as bacterial meningitis is highly contagious and transmitted by droplets. After isolating the client, the nurse should initiate prescribed antibiotics as quickly as possible, as bacterial meningitis can progress rapidly and lead to death without treatment (Option 1). (Options 2 and 3) Clients with meningitis are at increased risk for seizures. Implementation of a low-stimulation environment (eg, low lighting, minimal noise, uninterrupted rest periods) and seizure precautions (eg, padded side rails) are important interventions. However, initiating antibiotic therapy is the priority. (Option 4) An increasing head circumference may indicate increasing volumes of cerebrospinal fluid and increased ICP. Monitoring for new or worsening signs of increased ICP is important but may be performed after initiating prescribed antibiotics. Educational objective :Bacterial meningitis is an inflammation of the membranes covering the brain and spinal cord that can lead to severe complications (eg, hearing loss, brain damage) or death without treatment. To reduce the risk of complications, the nurse should prioritize initiation of prescribed antibiotic therapy as soon as possible. Answer: A

The emergency department nurse receives several prescriptions for a client who was found unresponsive after drinking beer and consuming unidentified pills. Which prescription should the nurse implement first? Click on the exhibit button for additional information. VS: T- 96.4 F (35.8 C) P- 53/min R- 6/min BP- 90/62 O2 sat% - 92% a. Administer IVP naloxone once now b. Draw specimen for blood alcohol content testing STAT c. Initiate continuous LR solution infusion d. Obtain urine sample for drug abuse screening ASAP

a. Administer IVP naloxone once now Educational objective: Nurses providing emergency care to clients with suspected substance abuse who exhibit signs of central nervous system depression (eg, bradypnea, bradycardia) prioritize interventions according to the ABCs (ie, airway, breathing, circulation). Administration of naloxone is a priority action in the setting of respiratory depression from an unknown substance because it rapidly reverses the depressant effects of opioids. The goals of emergency care for the client with suspected substance abuse who exhibits signs of central nervous system depression (eg, altered level of consciousness, bradypnea, hypotension, bradycardia) are to promote adequate ventilation and oxygenation and preserve hemodynamic stability. Interventions are prioritized according to the ABCs (ie, airway, breathing, circulation). Initial actions involve maintaining patency of the client's airway, including appropriate positioning, oropharyngeal suctioning, and artificial airway placement (if needed). Respiratory depression occurring after the ingestion of an unknown substance (eg, depressants [opioids, benzodiazepines, barbiturates]) should initially be treated with administration of reversal agents (eg, naloxone, flumazenil). Naloxone rapidly reverses the effects of opioids and may restore spontaneous respiration and normal ventilatory pattern, averting initiation of mechanical ventilation, the possibility of respiratory arrest, and death (Option 1). (Options 2 and 4) Obtaining blood and urine for toxicology screening assists in guiding care decisions but should occur after interventions that support the client's airway, breathing, and circulation. (Option 3) Administration of IV fluids to support blood pressure and prevent dehydration should be performed after securing the client's airway and supporting effective breathing. Educational objective: Nurses providing emergency care to clients with suspected substance abuse who exhibit signs of central nervous system depression (eg, bradypnea, bradycardia) prioritize interventions according to the ABCs (ie, airway, breathing, circulation). Administration of naloxone is a priority action in the setting of respiratory depression from an unknown substance because it rapidly reverses the depressant effects of opioids. Answer - A

GOOD A hospitalized client develops acute hemorrhagic stroke and is transferred to the intensive care unit. Which nursing interventions should be included in the plan of care? Select all that apply. a. Administer PRN stool softeners daily b. Administer scheduled enoxaparin injection c. Implement seizure precautions d. Keep client NPO until swallow screen is performed e. Perform frequent neurological assessments

a. Administer PRN stool softeners daily c. Implement seizure precautions d. Keep client NPO until swallow screen is performed e. Perform frequent neurological assessments Educational objective: A hemorrhagic stroke occurs when a blood vessel ruptures in the brain and causes bleeding. The nurse should perform frequent neurological assessments, keep the client NPO, maintain seizure precautions and strict bed rest, and limit any activity that may increase bleeding (eg, anticoagulant administration) or intracranial pressure (eg, stimulation, straining during bowel movements). A hemorrhagic stroke occurs when a blood vessel ruptures in the brain and causes bleeding into the brain tissue or subarachnoid space. Seizure activity may occur due to increased intracranial pressure (ICP) (Option 3). During the acute phase, a client may develop dysphagia. To prevent aspiration, the client must remain NPO until a swallow function screen reveals no deficits (Option 4). The nurse should perform neurological assessments (eg, level of consciousness, pupillary response) at regular intervals and report any acute changes (Option 5). Preventing activities that increase ICP or blood pressure will minimize further bleeding. The nurse should: Reduce stimulation, maintain a quiet and dimly lit environment, limit visitors Administer stool softeners to reduce strain during bowel movements (Option 1) Reduce exertion, maintain strict bed rest, assist with activities of daily living Maintain head in midline position to improve jugular venous return to the heart (Option 2) Enoxaparin is an anticoagulant used to prevent venous thromboembolism (VTE). Anticoagulants are contraindicated in clients with hemorrhagic stroke; the nurse should question any prescriptions that increase risk for bleeding. A client with hemorrhagic stroke should instead receive nonpharmacologic interventions (eg, compression stockings) to prevent VTE. Educational objective: A hemorrhagic stroke occurs when a blood vessel ruptures in the brain and causes bleeding. The nurse should perform frequent neurological assessments, keep the client NPO, maintain seizure precautions and strict bed rest, and limit any activity that may increase bleeding (eg, anticoagulant administration) or intracranial pressure (eg, stimulation, straining during bowel movements). Answers: A,C,D,E

A client is admitted to the hospital with an exacerbation of myasthenia gravis. What are the appropriate nursing actions? Select all that apply. a. Administer an anticholinesterase drug AC b. Anticipate a need for anticholinergic drug c. Develop a bladder training schedule d. Encourage a semi-solid food consumption e. Teach the necessity for annual flu vaccination

a. Administer an anticholinesterase drug AC d. Encourage a semi-solid food consumption e. Teach the necessity for annual flu vaccination Myasthenia gravis is an autoimmune disease involving a decreased number of acetylcholine receptors at the neuromuscular junction. As a result, there is fluctuating weakness of skeletal muscles, most often presented as ptosis/diplopia, bulbar signs (difficulty speaking or swallowing), and difficulty breathing. Muscles are stronger in the morning and become weaker with the day's activity as the supply of available acetylcholine is depleted. Treatment includes anticholinesterase drugs (pyridostigmine [Mestinon]) that are administered before meals so that the client's ability to swallow is strongest during the meal (Option 1). Semi-solid foods (easily-chewed foods) are preferred over solid foods (to avoid stressing muscles involved in chewing and swallowing) or liquids (aspiration risk)(Option 4). All clients with a serious chronic co-morbidity should receive the annual flu vaccine (also the pneumonia vaccine if appropriate) as they are more likely to have a negative outcome if the illness is contracted. It is especially important in clients with myasthenia gravis as the flu (or pneumonia) would tax the already compromised respiratory muscles(Option 5). (Option 2) An anticholinergic drug, such as atropine, is used for treatment in a cholinergic crisis (eg, the medication is too high or there is excess acetylcholine). The need would not be anticipated during a myasthenic crisis (eg, exacerbation of myasthenia gravis), which is usually a result of too little medication related to noncompliance, illness, or surgery. (Option 3) The skeletal muscles are involved in myasthenia gravis; dysfunction of the reflexes or central nervous system affects bowel and bladder control. This issue is classic with multiple sclerosis. Educational objective:Myasthenia gravis involves reduction of acetylcholine receptors in the skeletal muscles; this decreases the strength of muscles used for eye and eyelid movements, speaking, swallowing, and breathing. Treatment includes administration of anticholinesterase drugs before meals, easily-chewed foods, and appropriate vaccinations. Answer - A,D,E

The office nurse, while reviewing a client's health information, notices that the client has recently started taking St. John's wort for symptoms of depression. What additional information is most important for the nurse to obtain? a. Ask if the client is currently taking any prescription antidepressant medications b. Ask if the client has been diagnosed by a mental health care provider c. Ask if the client takes a multivitamin with iron d. Ask if the client uses tanning beds

a. Ask if the client is currently taking any prescription antidepressant medications Educational objective: St. John's wort interferes with many prescription medications. It is a priority for the nurse to assess for concomitant use of St. John's wort with prescription SSRIs, MAOIs, or tricyclic antidepressants as such combinations can cause serotonin syndrome. St. John's wort is an herbal product commonly used by many clients to treat depression. However, it may interact with medications used to treat depression or other mood disorders, including tricyclic antidepressants, selective serotonin and/or norepinephrine receptor inhibitors (SSRIs/SNRIs), and monoamine oxidase inhibitors (MAOIs). Taking St. John's wort with these medications tends to increase side effects and could potentially lead to a dangerous condition called serotonin syndrome. Serotonin is a chemical produced by the body that is needed for the nerve cells and brain to function. Excessive serotonin causes symptoms that can range from mild (shivering and diarrhea) to severe (muscle rigidity, fever, and seizures). Severe serotonin syndrome can be fatal if it is not treated. (Option 2) The nurse can ask the client if a diagnosis of depression has been made by an HCP, but inquiring about possible medications that can interact with St. John's wort is more important at this time. (Option 3) St. John's wort may interfere with the absorption of iron and other minerals. This is a teaching point, but it is not the highest priority question to ask the client. (Option 4) St. John's wort can cause photosensitivity which could be exacerbated by use of tanning beds. However, this is not the highest priority question to ask the client. Educational objective: St. John's wort interferes with many prescription medications. It is a priority for the nurse to assess for concomitant use of St. John's wort with prescription SSRIs, MAOIs, or tricyclic antidepressants as such combinations can cause serotonin syndrome. Answer: A

The nurse is caring for a client who had a stroke two weeks ago and has moderate receptive aphasia. Which interventions should the nurse include in the plan of care to help the client follow simple commands regarding activities of daily living (ADL)? Select all that apply. a. Ask simple questions that require "yes" or "no" answers b. If the client becomes frustrated, seek a different care provider to complete ADL c. Remain calm and allow the client time to understand each instruction d. Show the client pictures of ADL (e.g. shower, toilet, and toothbrush) or use gestures e. Speak slowly but loudly while looking directly at the client

a. Ask simple questions that require "yes" or "no" answers c. Remain calm and allow the client time to understand each instruction d. Show the client pictures of ADL (e.g. shower, toilet, and toothbrush) or use gestures Educational objective: Receptive aphasia refers to impairment or loss of language comprehension. Appropriate interventions to aid communication include asking short, simple, "yes" or "no" questions; using hand gestures or pictures to demonstrate activities; and patiently allowing the client time to understand each instruction. Receptive aphasia refers to impairment or loss of language comprehension (ie, speech, reading) that is caused by a neurological condition (eg, stroke, traumatic brain injury). The terms "aphasia" and "dysphasia" can be used interchangeably as both refer to impaired communication; however, "aphasia" is more commonly used. When assisting a client with receptive aphasia to complete activities of daily living, the nurse should avoid completing tasks for the client and should instead encourage independence using appropriate communication techniques. Appropriate interventions to aid communication include: Ask short, simple, "yes" or "no" questions (Option 1). Use gestures or pictures (eg, communication board) to demonstrate activities (Option 4). Remain patient and calm, allowing the client time to understand each instruction (Option 3). (Option 2) Clients with aphasia often become frustrated due to inability to communicate effectively. Frustration does not result from the nurse's care, so reassigning the client to a different care provider is not an effective solution. (Option 5) Eye contact is important in all communication, but raising the voice will not help. Speaking loudly will not improve comprehension and may increase anxiety and confusion. Educational objective: Receptive aphasia refers to impairment or loss of language comprehension. Appropriate interventions to aid communication include asking short, simple, "yes" or "no" questions; using hand gestures or pictures to demonstrate activities; and patiently allowing the client time to understand each instruction. Answer: A,C,D

The nurse is planning care for a client being admitted with newly diagnosed quadriplegia (tetraplegia). Which intervention will the nurse prioritize? a. Assess vital capacity and tidal volume once per shift and PRN b. Perform passive range of motion exercises on affected joints every 4 hours c. Provide time during each shift for the client to express feelings d. Turn the client every 2 hours throughout the day and night

a. Assess vital capacity and tidal volume once per shift and PRN Quadriplegia (tetraplegia) occurs when the lower limbs are completely paralyzed and there is complete or partial paralysis of the upper limbs. This is usually due to injury of the cervical spinal cord. Depending on the area of injury and extent of cord edema, the airway can be adversely affected. The priority assessment for this client is the status of the airway and oxygenation. The nurse should frequently assess breath sounds, accessory muscle use, vital capacity, tidal volume, and arterial blood gas values (if prescribed). (Options 2, 3, and 4) This client will need passive range of motion exercises on affected joints to prevent contractures. Turning the client will be necessary to prevent skin breakdown over bony prominences. The client will need to express feelings and work through the grief process related to loss of function. Bladder and bowel training programs will be necessary. All of these interventions are important for this client but are not the priority over maintenance of adequate oxygenation. Educational objective:The priority assessment in a client newly diagnosed with quadriplegia (tetraplegia) is airway management and oxygenation. Answer: A

A client with Parkinson disease is prescribed carbidopa-levodopa. Which of the following instructions should the nurse include with the client's discharge teaching? Select all that apply. a. Change positions slowly, and sit on the side of the bed before standing b. This medication takes several weeks to reach maximum benefit c. You may experience some facial and eye twitching, but this is not harmful d. Your tremors should disappear completely while on this medication e. Your urine and saliva may turn reddish-brown, but this is not harmful

a. Change positions slowly, and sit on the side of the bed before standing b. This medication takes several weeks to reach maximum benefit e. Your urine and saliva may turn reddish-brown, but this is not harmful Parkinson disease (PD) is characterized by decreased dopamine levels, uncontrolled acetylcholine, and formation of abnormal protein clusters (Lewy bodies) in the brain. PD causes both physical and neurological (eg, mood alterations, dementia) symptoms. Carbidopa-levodopa is a combination antiparkinsonian medication used to reduce physical symptoms of PD by increasing dopamine levels in the brain. Levodopa is converted to dopamine in the brain but is largely metabolized before reaching the brain. Carbidopa does not have a therapeutic effect on PD but prevents breakdown of levodopa before reaching the brain, which makes levodopa more effective. Client teaching for carbidopa-levodopa includes: Implementing fall precautions (eg, changing positions slowly, removing rugs), as orthostatic hypotension is a common side effect (Option 1) Knowing that carbidopa-levodopa takes several weeks to reach its maximum effectiveness (Option 2) Understanding that harmless discoloration (eg, red, brown, black) of secretions (eg, urine, perspiration, saliva) may occur while taking carbidopa-levodopa (Option 5) Avoiding high-protein meals, which interfere with the absorption of carbidopa-levodopa (Option 3) Dyskinesia (eg, facial or eyelid twitching, tongue protrusion, facial grimacing) may indicate overdose or toxicity of carbidopa-levodopa and should be reported immediately to the health care provider. (Option 4) Carbidopa-levodopa often decreases, but does not eliminate, tremor and rigidity. Educational objective:Carbidopa-levodopa is a medication used to reduce symptoms of tremor and rigidity in clients with Parkinson disease. Teach clients that the medication takes several weeks to become effective; urine, perspiration, or saliva discoloration is a common side effect; and fall precautions should be implemented for client safety. Answer A,B,E

A client sustained a concussion after falling off a ladder. What are essential instructions for the nurse to provide when the client is discharged from the hospital? Select all that apply. a. Client should abstain from alcohol b. Client should remain awake all night c. Responsible adult should be taught neurological examination d. Responsible adult should stay with the client

a. Client should abstain from alcohol c. Responsible adult should be taught neurological examination d. Responsible adult should stay with the client An essential aspect of discharging a client with a head injury is ensuring that a responsible adult will check on the client as the level of consciousness can change (Option 5). Brain edema or increased intracranial pressure (IICP) may not be evident immediately. The client should return to the emergency department or notify the primary care provider if any of the following signs/symptoms are present in the next 2-3 days: Change in level of consciousness (eg, increased drowsiness, difficulty arousing, confusion) Worsening headache or stiff neck, especially if unrelieved by over-the-counter analgesics Visual changes (eg, blurring) Motor problems (eg, difficulty walking, slurred speech) (Option 3) Sensory disturbances Seizures Nausea/vomiting or bradycardia (indicates IICP) The client is also to abstain from alcohol, check before taking medications that can affect level of consciousness (eg, muscle relaxants, opioids), and avoid driving or operating heavy machinery (Option 1). (Option 2) It is not necessary to cause sleep deprivation by keeping the client awake. It is most important that the client can be easily aroused to an awake state. (Option 4) A neurological examination includes evaluation with the Glasgow Coma Scale, testing of pupils, and assessment of all 4 extremities for movement, strength, and sensation; this examination should be performed by a clinician. The responsible adult is taught the general indicative symptoms in the list above. Educational objective:A client sent home with a head injury requires the presence of a responsible adult. This person should observe for the signs/symptoms of increased intracranial pressure including change in level of consciousness, projectile vomiting, motor alteration (eg, ataxia), ipsilateral pupil dilation, and seizures. Answer: A,C,D

The home health nurse reviews the serum laboratory test results for a client with seizures. The phenytoin level is 27 mcg/mL. The client makes which statement that may indicate the presence of dose-related drug toxicity and prompt the nurse to notify the health care provider? a. I am feeling unsteady when I walk b. I am getting up to urinate about 4 times during the night c. I have a metallic taste in my mouth when I eat d. My gums are getting so puffy and red

a. I am feeling unsteady when I walk Phenytoin (Dilantin) is an anticonvulsant drug used to treat generalized tonic-clonic seizures. The therapeutic serum phenytoin reference range is between 10-20 mcg/mL. Levels are measured when therapy is initiated, periodically throughout treatment to guide dosing until a steady state is attained (3-12 months), and if seizure activity increases. Early signs of toxicity include horizontal nystagmus and gait unsteadiness. These may be followed by slurred speech, lethargy, confusion, and even coma. Bradyarrhythmias and hypotension are usually seen with intravenous phenytoin. (Option 2) Nocturia is an expected side effect of diuretics but not phenytoin. Nocturia is also seen with diabetes mellitus and benign prostatic hyperplasia. (Option 3) Metallic taste in the mouth is often seen with metronidazole but not with phenytoin. (Option 4) Gingival hyperplasia is a common expected side effect of phenytoin and does not indicate drug toxicity. It occurs more often in clients <23 years of age who are prescribed >500 mg/day. Good oral hygiene can limit symptoms. Educational objective:Phenytoin, an anticonvulsant drug, is used to treat generalized tonic-clonic seizures. Common symptoms of phenytoin drug-induced toxicity involve the central nervous system and include ataxia, nystagmus, slurred speech, and decreased alertness. Answer: A

The nurse is caring for a client with absence seizures. The unlicensed assistive personnel (UAP) asks if the client will "shake and jerk" when having a seizure. Which response from the nurse is the most helpful? a. No, abscense seizures can look like daydreaming or staring off into space b. No, you are wrong. Don't worry about that c. Yes, so please let me know if you see the client do that d. You don't have to monitor the client for seizures.

a. No, abscense seizures can look like daydreaming or staring off into space Absence seizures typically occur in children. The presentation is classic and includes the following: Daydreaming episodes or brief (<10 seconds) staring spells Absence of warning and postictal phases Absence of other forms of epileptic activity (no myoclonus or tonic-clonic activity) Unresponsiveness during the seizure No memory of the seizure The most helpful response by the nurse is one that corrects while educating the UAP (Option 1). The UAP may be present when a client has a seizure, and understanding of what to expect will aid client care. (Options 2 and 4) Although it is not the responsibility of the UAP to monitor the client, the UAP may witness a seizure and call for help if needed. (Option 3) Seizures may include tonic (body stiffening), clonic (muscle jerking), atonic (loss of muscle tone or "drop attack"), myoclonic (brief muscle jerk), or tonic-clonic (alternating stiffening and jerking) body motions. Absence seizures do not typically involve these body motions. Educational objective:Absence seizures are brief periods of staring; there is no evidence of tonic-clonic activity or postictal confusion. The UAP should be educated about absence seizures when involved in the care of such clients. Answer - A

GOOD The nurse assesses several clients using the Glasgow Coma Scale. Which scenario best demonstrates a correct application of this scale? a. The nurse applies pressure to the nail bed, and the client tries to push the nurse's hand away. The nurse scores motor response as "localization of pain" b. The nurse asks the client what day it is and the client says "banana". The nurse scores verbal response as "confused" c. The nurse speaks with client and then the client's eyes open. The nurse scores eye opening as "spontaneous". d. The nurse walks in the room and the client states "Hi honey. How are you?" The nurse scores verbal response as "oriented"

a. The nurse applies pressure to the nail bed, and the client tries to push the nurse's hand away. The nurse scores motor response as "localization of pain" Educational objective: The Glasgow Coma Scale is used to determine level of consciousness. The nurse follows a standardized assessment to determine the score of the client's eye opening response, verbal response, and ability to obey commands through a motor response The Glasgow Coma Scale is used to determine level of consciousness. The nurse follows a standardized assessment to determine the score of the client's eye opening response, verbal response, and ability to obey commands through a motor response. For the best motor response score, the nurse first verbally asks the client to obey a command. If there is no response, the nurse next uses noxious stimuli (eg, nail bed pressure) and records the physical response. If the client tries to remove the painful stimulus, it is recorded as "localizing" or moving toward the pain; whereas if the client retracts from the stimulus, it is recorded as "withdrawal" (Option 1). (Option 2) To ensure an accurate score in the verbal response category, the nurse must differentiate if the client is confused (eg, answers "1955" when asked the year) or if a client uses inappropriate words. (Option 3) To ensure an accurate eye opening score, the nurse must determine whether the client's eyes open spontaneously (eg, no prompting) or if a stimulus (eg, sound, pain) is needed. (Option 4) A social, verbal client is not necessarily oriented. The nurse must assess orientation by specifically asking clients to state their name, the time, and their location. Educational objective: The Glasgow Coma Scale is used to determine level of consciousness. The nurse follows a standardized assessment to determine the score of the client's eye opening response, verbal response, and ability to obey commands through a motor response. Answer A

The clinic nurse performs assessments on four infants. The nurse should alert the health care provider to see which client first? a. 3-month old whose posterior occiput appears flattened b. 4-month old who has sclera visible above the iris (sunset eyes) c. 6-month old who has vomited twice and has had 8 wet diapers in the last 24 hours d. 9-month old whose toes fan out and big toe dorsiflexes when plantar surface is stroked

b. 4-month old who has sclera visible above the iris (sunset eyes) Educational objective: The presence of sunset eyes (sclera visible above the iris) is a late sign of increased intracranial pressure and a priority to report to the health care provider Hydrocephalus is an increase in intracranial pressure (ICP) that results from obstruction of cerebrospinal fluid flow. Increased ICP can progress to brain damage and death. Signs of increased ICP in children include bulging fontanelles, increasing head circumference, and sunset eyes (or setting-sun sign) (sclera visible above the iris). Sunset eyes occur when periaqueductal structures are compressed from increased ICP, paralyzing the upward gaze. This is a late sign of increased ICP that requires timely treatment (eg, shunt placement) and is the priority (Option 2). (Option 1) Positional plagiocephaly (flat head syndrome) occurs when an infant is placed in the same position (eg, supine) for an extended period of time and the pliable skull molds to the surface (flattens). Parents can intervene to avoid or correct plagiocephaly (eg, periodically repositioning the head during sleep, tummy time). Minor skull deformation is not a priority. (Option 3) Eight wet diapers in 24 hours is within the normal range (6-10 diapers/day or approximately 1 diaper every 4 hours), indicating that the infant is likely producing >1 mL/kg/hr urine output and is not dehydrated, despite vomiting. (Option 4) The Babinski reflex (ie, toes fan outward and the big toe dorsiflexes with stimuli) is expected in infants and is a normal finding up to age 1 year. However, its presence beyond this age can indicate neurologic disease. Educational objective: The presence of sunset eyes (sclera visible above the iris) is a late sign of increased intracranial pressure and a priority to report to the health care provider. Answer: B

The nurse is caring for a client diagnosed with Broca aphasia due to a stroke. Which of the following deficits would the nurse correctly attribute to Broca aphasia? Select all that apply. a. Client coughs and gasps when swallowing food and liquids b. Client is easily frustrated while attempting to speak c. Client is unable to understand speech and is completely non verbal d. Client misunderstands and inappropriately responds to verbal instruction e. Client's speech is limited to short phrases that require effort

b. Client is easily frustrated while attempting to speak e. Client's speech is limited to short phrases that require effort Educational objective: Damage to the frontal lobe of the brain may cause Broca (expressive) aphasia. Clients with this condition demonstrate effortful and sensible speech characterized by short, limited sentences, with retained ability to comprehend speech. This impairment often causes clients with Broca aphasia to be frustrated when speaking. Broca (expressive) aphasia is a nonfluent aphasia resulting from damage to the frontal lobe. Clients with Broca aphasia can comprehend speech but demonstrate speech difficulties. The speech pattern often consists of short, limited phrases that make sense but display great effort and frequent omission of smaller words (eg, "and," "is," "the") (Option 5). Clients with Broca aphasia are aware of their deficits and can become frustrated easily (Option 2). In comparison, clients with Wernicke (receptive) aphasia are unaware of their speech impairment. (Option 1) Trouble swallowing, often identified by coughing and gasping when eating and drinking, is dysphagia, which is not related to Broca aphasia. (Option 3) Clients with damage to multiple language areas of the brain may develop global aphasia, resulting in the inability to read, write, or understand speech. This is the most severe form of aphasia. (Option 4) Clients with damage to the temporal portion of the brain may develop Wernicke (fluent) aphasia (ie, the inability to comprehend the spoken and/or written word) and exhibit a long, but meaningless, speech pattern. Educational objective: Damage to the frontal lobe of the brain may cause Broca (expressive) aphasia. Clients with this condition demonstrate effortful and sensible speech characterized by short, limited sentences, with retained ability to comprehend speech. This impairment often causes clients with Broca aphasia to be frustrated when speaking. Answers: B,E

A client was struck on the head by a baseball bat during a robbery attempt. The nurse gives this report to the oncoming nurse at shift change and conveys that the client's current Glasgow Coma Scale (GCS) score is a "10." Which client assessment is most important for the reporting nurse to include? a. Belief that the current surroundings are a racetrack b. GCS score was "11" one hour ago c. Recent vital signs show BP of 120/80 and HR 82 d. Reported allergy to penicillin and vancomycin

b. GCS score was "11" one hour ago Educational objective: It is a priority to report a negative neurological trend as evidenced by GCS score in a client with blunt head trauma. The GCS quantifies the level of consciousness in a client with acute brain injury by measuring eye opening (alertness), verbal response (orientation), and motor response (eg, obeying a command, frontal lobe function). The maximum score on the GCS is 15 and the lowest is 3. If a client is trending for deterioration, this should always be noted in neurological assessments. A numerical decline of a single number in 1 hour is significant. A criticism of the GCS score is that it is not that precise. (Option 1) Orientation to place is part of the GCS score (under best verbal). The total score and the negative trend are more indicative of the client's condition than any individual GCS component. (Option 3) This client's vital signs are within normal limits and are not significant. It would be more important to communicate if there is absence of Cushing's triad (bradycardia, bradypnea/Cheyne-Stokes, and widening pulse pressure) or to give a brief summary of overall vital signs (eg, "normal"); exact readings are accessible and can be recited if the oncoming nurse needs to know them. However, reporting the negative neurological trend in the GCS score is the priority. (Option 4) Although it is important to be aware of allergies, the oncoming nurse can find that information on the chart if these medications are ordered. The main concern is blunt head trauma and not infection; therefore, it is unlikely that the oncoming nurse will be required to know this information and need to administer antibiotics. Educational objective: It is a priority to report a negative neurological trend as evidenced by GCS score in a client with blunt head trauma. Answer: B

The nurse is reinforcing education to a client newly prescribed levetiracetam (Keppra) for seizures. Which statement made by the client indicates a need for further instruction? a. Drowsiness is a common side effect of this medication and will improve overtime b. I can begin driving again after I have been on this medication for a few weeks c. I need to immeidately report any new or increased anxiety when on this medication d. I need to immediately report any new rash when on this medication

b. I can begin driving again after I have been on this medication for a few weeks Levetiracetam (Keppra) is an anticonvulsant prescribed for seizure disorders. As with other antiseizure medications, levetiracetam has a depressing effect on the central nervous system (CNS), which may cause drowsiness, somnolence, and fatigue as clients adjust to the medication. Clients should be assured that this is common and typically improves within 4-6 weeks (Option 1). However, the CNS-depressing effects of levetiracetam may be enhanced if taken with other CNS-depressing substances (eg, alcohol) or medications. New or increased agitation, anxiety, and/or depression or mood changes should be reported immediately as levetiracetam is associated with suicidal ideation (Option 3). Like other anticonvulsants, levetiracetam can trigger Stevens-Johnson syndrome, a rare but life-threatening blistering reaction of the skin. Rash, blistering, muscle/joint pain, or conjunctivitis should be reported and assessed immediately (Option 4). (Option 2) Clients with seizure disorders should avoid driving or operating heavy machinery until they have permission from their health care provider and have met the requirements of their department of transportation. Typically, the client must be free from seizures for an allotted time period. Educational objective:Levetiracetam is an anticonvulsant prescribed for seizure disorders. It may have depressing effects on the central nervous system (eg, drowsiness) as the body adjusts to therapy. Serious adverse effects include suicidal ideation and Stevens-Johnson syndrome. Clients with seizure disorders must meet the guidelines of their department of transportation and receive permission from their health care provider prior to legally operating a motor vehicle. Answer: B

A client with a brain tumor is admitted for surgery. The health care provider prescribes levetiracetam (Keppra). The client asks why. What is the nurse's response? a. It destroys tumor cells and helps shrink the tumor b. It prevents seizure development c. It prevents blood clots in legs d. It reduces swelling around the tumor

b. It prevents seizure development Levetiracetam (Keppra) is a medication often used to treat seizures in various settings. It has minimal drug-drug interactions compared to phenytoin and is often the preferred antiepileptic medication. (Option 1) Chemotherapy and radiation therapy would kill tumor cells and reduce tumor size. (Option 3) Hospitalized clients and clients with malignancy are at higher risk for venous thromboembolism. These clients would benefit from anticoagulation (eg, heparin, enoxaparin, rivaroxaban, apixaban). (Option 4) Dexamethasone, a corticosteroid, is used to treat cerebral edema associated with a brain injury/tumor by decreasing inflammation. Educational objective: Levetiracetam (Keppra) is a medication often used to treat seizures in various settings. Corticosteroids are used to reduce inflammation and cerebral edema in clients with brain injury and tumors. Answer: B

GOOD EXPLINATION The nurse is caring for a client with an acute ischemic stroke who has a blood pressure of 178/95 mm Hg. The health care provider prescribes as-needed antihypertensives to be given if the systolic pressure is >200 mm Hg. Which action by the nurse is most appropriate? a. Give the antihypertensive medication b. Monitor the BP c. Notify the HCP d. Question the prescription

b. Monitor the BP Educational objective: Elevated blood pressure in the presence of an acute ischemic stroke is an expected finding and may be a protective measure to maintain tissue perfusion An ischemic stroke is a loss of brain tissue perfusion due to blockage in blood flow. Elevated blood pressure is common and permitted after a stroke and may be a compensatory mechanism to maintain cerebral perfusion distal to the area of blockage. This permissive hypertension usually autocorrects within 24-48 hours and does not require treatment unless the hypertension is extreme (systolic blood pressure >220 mm Hg or diastolic blood pressure >120 mm Hg) or contraindicated due to the presence of another illness requiring strict blood pressure control (eg, active ischemic coronary disease, heart failure, aortic dissection). A blood pressure of 178/95 mm Hg should be monitored, along with the client's other vital signs and status (Option 2). (Option 1) The elevated blood pressure may be a protective measure to ensure tissue perfusion; therefore, the antihypertensive drug should not be given unless indicated by the prescription parameters. (Options 3 and 4) The as-needed prescription is appropriate in this case, so there is no reason to question it and call the health care provider. Educational objective: Elevated blood pressure in the presence of an acute ischemic stroke is an expected finding and may be a protective measure to maintain tissue perfusion. Answer: B

GOOD The nurse is preparing for the admission of a 9-year-old client with new-onset tonic-clonic seizures. It is important for the nurse to ensure that what is in the room? Select all that apply. a. Oral bite prevention device b. Oxygen delivery system c. Padding on the bed side rails d. Soft arm and leg restraints e. Suction equipment

b. Oxygen delivery system c. Padding on the bed side rails e. Suction equipment Educational objective: Turning the client on the side, providing oxygen and suctioning as needed, and padding the siderails or removing objects that are near the client can decrease the risk for injury during a seizure. Avoid restraints. Client safety is a priority when caring for a client with seizure activity. Protecting the airway and improving oxygenation includes turning the client on the side and providing oxygen and oral suctioning as needed. Padding the bed siderails provides the client protection and decreases the potential for injury from the metal in the event that the head or extremities hit the siderails during seizure activity. (Option 1) During seizure activity, nothing should be placed in the client's mouth. Placing objects in the mouth could result in injury to the client or health care provider. Maintaining an open airway is important and can be accomplished by turning the client on the side and providing oral suctioning to the inside of the cheeks as necessary. (Option 4) A client should never be restrained during seizure activity. Restraints could cause muscle or tissue injury. Educational objective: Turning the client on the side, providing oxygen and suctioning as needed, and padding the siderails or removing objects that are near the client can decrease the risk for injury during a seizure. Avoid restraints. Answers: B,C,E

A nurse working in a neurology clinic receives the following telephone messages. Which client should the nurse call back first? a. Client prescribed sumatriptan who has a throbbing left temple pain preceded by an aura b. Client taking carbidopa-levodopa who has dizziness when rising from a sitting or lying position c. Client with Myasthenia Gravis who has a fever and increasing difficulty swallowing d. Client with trigeminal neuralgia who reports burning cheek pain after eating an ice cream

c. Client with Myasthenia Gravis who has a fever and increasing difficulty swallowing Myasthenia gravis is an autoimmune disease of the neuromuscular junction resulting in fluctuating muscle weakness. Autoantibodies are formed against the acetylcholine receptors, so fewer receptors are available for acetylcholine to bind. It is treated with pyridostigmine (Mestinon), which increases the amount of acetylcholine at the synaptic junction, augmenting neuromuscular signals and improving muscle strength. Infection, undermedication, and stress can precipitate a life-threatening myasthenic crisis, which is characterized by oropharyngeal and respiratory muscle weakness and respiratory failure. This client's infection and increasing difficulty swallowing indicate the need for immediate intervention. (Option 1) Sumatriptan is prescribed for moderate to severe, acute migraine headaches that are characterized by severe pulsatile, throbbing unilateral head pain with or without auras, photophobia, nausea, and vomiting. The client with uncontrolled migraine headaches requires a change in treatment regimen (eg, ergotamine). (Option 2) Carbidopa-levodopa is prescribed to decrease symptoms of Parkinson disease (eg, bradykinesia, tremor, rigidity). Orthostatic hypotension is an adverse effect of the drug and may also occur from disease-related autonomic nervous system dysfunction. This client should be taught to slowly change positions; this is not the priority action. (Option 4) Trigeminal neuralgia is characterized by intermittent severe, unilateral facial pain precipitated by light touch, hot or cold foods, chewing, and swallowing. This client may require a change in treatment regimen (eg, carbamazepine, gabapentin, baclofen) for improved pain relief. Educational objective:Myasthenia gravis is a chronic neurologic autoimmune disease in which acetylcholine receptors are blocked, causing muscle weakness. Infection, undermedication, and stress can lead to a myasthenic crisis, which is characterized by oropharyngeal and respiratory muscle weakness and respiratory failure. Answer C

The nurse is caring for an assigned team of clients. Which client is the priority for the nurse at this time? a. Client admitted with Guillain -Barré syndrome yesterday is paralyzed to the knees b. Client admitted with multiple sclerosis exacerbation had scanning speech c. Client with epilepsy puts on call light and reports having an aura d. Client with fibromyalgia reports pain in the neck and shoulders

c. Client with epilepsy puts on call light and reports having an aura Educational objective: An aura is a sensory warning that a complex or generalized seizure will occur. It is a priority over stable or expected findings such as point tenderness in fibromyalgia, low-level location of paralysis in Guillain-Barré syndrome, or scanning speech in multiple sclerosis. An aura is a sensory perception that occurs prior to a complex or generalized seizure. The client will most likely have a tonic-clonic seizure soon, and the nurse should attend to this client first to ensure safety measures (ie, seizure precautions) are in place. (Option 1) Guillain-Barré syndrome is an ascending symmetrical paralysis. It can move upward rapidly or relatively slowly (over days/weeks). Respiratory compromise is the worst complication. A client with paralysis at the level of the knee after 24 hours would not take priority over a client who will have a seizure in few minutes. (Option 2) Scanning speech is a dysarthria in which there are noticeable pauses between syllables and/or emphasis on unusual syllables. It is an expected finding with multiple sclerosis. (Option 4) Fibromyalgia involves neuroendocrine/neurotransmitter dysregulation. Clients experience widespread pain with point tenderness at multiple sites, including the neck and shoulders. This client is not a priority. Educational objective: An aura is a sensory warning that a complex or generalized seizure will occur. It is a priority over stable or expected findings such as point tenderness in fibromyalgia, low-level location of paralysis in Guillain-Barré syndrome, or scanning speech in multiple sclerosis. Answer: C

GOOD EXPLINATION A highly intoxicated client was brought to the emergency department after found lying on the sidewalk. On admission, the client is awake with a pulse of 70/min and blood pressure of 160/80 mm Hg. An hour later, the client is lethargic, pulse is 48/min, and blood pressure is 200/80 mm Hg. Which action does the nurse anticipate taking next? a. Administer atropine for bradycardia b. Administer nifedipine for HTN c. Have CT scan performed to rule out an intracranial bleed d. Perform hourly neurologic checks with Glasgow coma scale

c. Have CT scan performed to rule out an intracranial bleed Educational objective: Cushing's triad/reflex indicates increased intracerebral pressure. Classic signs include bradycardia, rising systolic blood pressure, widening pulse pressure, and irregular respirations (such as Cheyne-Stokes). Cushing's triad is related to increased intracranial pressure (ICP). Early signs include change in level of consciousness. Later signs include bradycardia, increased systolic blood pressure with a widening pulse pressure (difference between systolic and diastolic), and slowed irregular (Cheyne-Stokes) respirations. Cushing's triad is a later sign that does not appear until the ICP is increased for some time. It indicates brain stem compression. The skull cannot expand after the fontanels close at age 18 months, so anything taking up more space inside the skull (eg, hematoma, tumor, swelling, etc.) is a concern for causing pressure on the brain tissue/brain stem and potential herniation. In this scenario, hidden head trauma causing an intracranial bleed must be ruled out with diagnostic testing. The client's intoxication could blunt an accurate history or presentation of a head injury. (Option 1) Atropine is used to stimulate the sinoatrial node in bradycardia with systemic symptoms. An electrocardiogram (ECG) should be obtained prior to administering atropine. In this client, there is no evidence of a cardiac etiology or systemic symptoms of poor perfusion/circulation from the bradycardia. (Option 2) Nifedipine (Procardia) is a calcium channel blocker that is a potent vasodilator. However, all components must be considered in this scenario as to the etiology of the hypertension rather than just treating that sign. Ruling out a cerebral cause of the hypertension is most important. (Option 4) The nurse would continue to perform neurologic assessments (including GCS). However, it is more important to obtain appropriate diagnostic tests and initiate treatment for the changing neurologic symptoms than to just monitor and document. In addition, the nurse should be performing these assessments more frequently than hourly in this rapidly changing client. Educational objective: Cushing's triad/reflex indicates increased intracerebral pressure. Classic signs include bradycardia, rising systolic blood pressure, widening pulse pressure, and irregular respirations (such as Cheyne-Stokes). Answer - C

GOOD The nurse is planning care for a client with suspected stroke who has just arrived at the emergency department with slurred speech, facial drooping, and right arm weakness that began 1 hour ago. Which of the following interventions should the nurse anticipate including in the initial plan of care? Select all that apply. a. Arrange for a speech pathologist consult b. Discuss community resources with family c. Obtain a STAT CT scan of the head d. Perform a baseline neurologic assessment e. Prepare to initiate alteplase (Tissue plasminogen activator) within the next 3 hours

c. Obtain a STAT CT scan of the head d. Perform a baseline neurologic assessment e. Prepare to initiate alteplase (Tissue plasminogen activator) within the next 3 hours Strokes may be either ischemic or hemorrhagic. Ischemic stroke occurs when circulation to parts of the brain is interrupted by occlusion of cerebral blood vessels by a thrombosis or embolus. Hemorrhagic stroke occurs when a cerebral blood vessel ruptures and bleeds into the cranial vault. Both types of stroke result in brain tissue death without prompt treatment. A client with stroke symptoms must have an immediate CT scan or MRI of the head to determine the type and location of the stroke (Option 3). Determining exactly when symptoms began is essential for diagnosis and planning treatment. Thrombolytic therapy (eg, alteplase, tissue plasminogen activator [tPA]) is used to dissolve blood clots and restore perfusion to brain tissue in clients with an ischemic stroke unless contraindicated (eg, active bleeding, uncontrolled hypertension, aneurysm). It must be administered within 4.5 hours from onset of symptoms (Option 5). A baseline neurologic assessment is essential for tracking ongoing neurologic symptoms that indicate improvement or complications which guide later treatments (Option 4). (Options 1 and 2) Consultation with a speech pathologist and providing the family with information about community resources are important later but not during the initial (acute) phase of stroke management. Educational objective:The initial plan of care for a client with an acute stroke should include performing baseline neurologic assessment to begin monitoring neurologic status trend, obtaining an immediate CT scan of the head to determine stroke type, and anticipating administration of thrombolytics (if indicated) within 4.5 hours of symptom onset. Answer: C,D,E

The nurse taught the caregiver of a child with a ventriculoperitoneal (VP) shunt about when to contact the health care provider (HCP). The caregiver shows understanding of the instructions by contacting the HCP about which symptom? a. A temp of 99 F (37 C) that occurs during the evening b. The child cannot recall items eaten for lunch the previous day c. The child vomits after awakening from a nap and 1 hour later d. The VP shunt is palpated along the posterior-lateral portion of the skull

c. The child vomits after awakening from a nap and 1 hour later The caregiver of a child with a VP shunt must understand symptoms of increased intracranial pressure (ICP), which indicate shunt malfunction. Vomiting may be a sign of increased ICP and would require that the HCP be contacted. (Option 1) Fever may indicate shunt infection, but a temperature of 99 F (37 C) remains within acceptable parameters. Contacting the HCP is not indicated. (Option 2) Memory lapse or changes in mental status may indicate increased ICP. The inability to remember one meal would not indicate a change of mental status. (Option 4) A VP shunt is tunneled under the scalp and can be palpated. Educational objective:Increased ICP may occur with VP shunt malfunctions. The caregiver must recognize symptoms of vomiting, headaches, vision changes, and changes in mental status. Early intervention by the HCP will decrease the risk of damage to the brain tissue. Answer C

During shift report it was noted that the off-going nurse had given the client a PRN dose of morphine 2 mg every 2 hours for incisional pain. What current client assessment would most likely affect the oncoming nurse's decision to discontinue the administration every 2 hours? a. Client reports burning during injection into the IV line b. Client reports dizziness when getting up to use the bathroom c. Client's BP is 106/68 d. Client's RR is 11

d. Client's RR is 11 Morphine is an opioid analgesic that can be given intravenously for moderate to severe pain. An adverse reaction to morphine administration is respiratory depression. A respiratory rate <12/min would be a reason to hold morphine administration. The nurse should perform a more in-depth assessment of the client's pain and causes. The morphine dose may need to be decreased or the time between administrations may need to be increased. The nurse should not administer additional doses until the respiratory rate increases. (Option 1) Morphine can cause burning during IV administration. This can be reduced by diluting the morphine with normal saline and administering it slowly over 4-5 minutes. (Option 2) The nurse should instruct the client to call for help before getting up to go to use the bathroom to avoid falls caused by dizziness from the morphine. (Option 3) Morphine can lower blood pressure, and clients receiving it should have blood pressure monitored. This blood pressure reading is not severely low and is not a priority over the respiratory depression. Educational objective:Morphine administration can cause respiratory depression. The nurse should hold a dose of morphine for a client whose respiratory rate is <12/min. Answer: D

A client diagnosed with trigeminal neuralgia is given a prescription of carbamazepine (Tegretol) by the health care provider. Which intervention does the nurse add to this client's care plan? a. Encourage client to drink cold beverages b. Encourage client to eat high fiber diet c. Encourage client to perform facial massage d. Encourage client to report fever or sore throat

d. Encourage client to report fever or sore throat Trigeminal neuralgia is sudden, sharp pain along the distribution of the trigeminal nerve. The symptoms are usually unilateral and primarily in the maxillary and mandibular branches. Clients may experience chronic pain with periods of less severe pain, or "cluster attacks" of pain between long periods without pain. Triggers can include washing the face, chewing food, brushing teeth, yawning, or talking. Pain is severe, intense, burning, or electric shock-like. The primary intervention for trigeminal neuralgia is consistent pain control with medications and lifestyle changes. The drug of choice is carbamazepine. It is a seizure medication but is highly effective for neuropathic pain. Carbamazepine is associated with agranulocytosis (leukopenia) and infection risk. Clients should be advised to report any fever or sore throat. Behavioral interventions include the following: Oral care - use a small, soft-bristled toothbrush or a warm mouth wash Use lukewarm water; avoid beverages or food that are too hot or cold (Option 1) Room should be kept at an even and moderate temperature Avoid rubbing or facial massage. Use cotton pads to wash the face if necessary. Have a soft diet with high calorie content; avoid foods that are difficult to chew. Chew on the unaffected side of the mouth. (Option 2) A high-fiber diet is not required for a client with trigeminal neuralgia, and the additional chewing with higher-fiber foods may serve as a pain trigger. (Option 3) Clients with trigeminal neuralgia are encouraged not to massage the face as this can trigger pain. Educational objective:The primary intervention for trigeminal neuralgia includes pain control and limiting pain triggers. The drug of choice is carbamazepine. Triggers can include washing the face, chewing food, brushing teeth, yawning, or talking. Carbamazepine is associated with agranulocytosis (leukopenia) and infection risk. Clients should be advised to report any fever or sore throat. Answer: D

A client comes to the emergency department with diplopia and recent onset of nausea. Which statement by the client would indicate to the nurse that this is an emergency? a. I am very tired, and it's hard for me to keep my eyes open b. I don't feel good and I want to be seen c. I have not taken my BP medicine in over a week d. I have the worst headache I've ever had in my life

d. I have the worst headache I've ever had in my life Educational objective: Sudden onset of a severe headache described as "the worst headache of my life" is characteristic of a ruptured cerebral aneurysm and should be treated as an emergency. HEMORHAGIC CVA A ruptured cerebral aneurysm is a surgical emergency with a high mortality rate. Cerebral aneurysms are usually asymptomatic unless they rupture; they are often called "silent killers" as they may go undetected for many years before rupturing without warning signs. The distinctive description of a cerebral aneurysm rupture is the abrupt onset of "the worst headache of my life" that is different from previous headaches (including migraines). Immediate evaluation for a possible ruptured aneurysm is critical for any client experiencing a severe headache with changes in or loss of consciousness, neurologic deficits, diplopia, seizures, vomiting, or a stiff neck. Early identification and prompt surgical intervention help increase the chance for survival. (Options 1, 2, and 3) A change in level of consciousness, increased blood pressure, or a feeling of illness should be investigated but alone does not indicate an emergency. Educational objective: Sudden onset of a severe headache described as "the worst headache of my life" is characteristic of a ruptured cerebral aneurysm and should be treated as an emergency. Answer: D

The clinic nurse is caring for an elderly client who is overweight and being treated for hypertension. What is most important for the nurse to emphasize to prevent a stroke (acute brain attack)? a. Consume a low-fat, low-salt diet b. Do not smoke cigarettes c. Exercise and lose weight d. Take prescribed antihypertensive medications

d. Take prescribed antihypertensive medications Educational objective: The single most important factor in preventing strokes is controlling hypertension. Risk factors for stroke include diabetes, high cholesterol, hypertension, smoking, obesity (particularly in the abdomen), older age, and genetic susceptibility. The single most important modifiable risk factor is hypertension. Stroke risk can be reduced up to 50% with appropriate treatment of hypertension. Because clients often experience side effects from the antihypertensive medications and don't feel bad with untreated hypertension, they may not realize that it is essential to continue the medications. The nurse should therefore emphasize this point. (Option 1) A low-fat, low-salt diet is beneficial to the client, but managing hypertension with medications is most important. (Option 2) Smoking is also a major risk factor for stroke, and smoking cessation should be emphasized. However, hypertension is the single most important risk factor. (Option 3) Normal BMI is 18.5-24.9 kg/m2. Obesity increases the risk of ischemic stroke, but hypertension control is most important. In addition, it is not indicated if the client is slightly overweight or morbidly obese to make this the highest risk factor. Educational objective: The single most important factor in preventing strokes is controlling hypertension. Answer: D