chapter 61

Question 1

The nurse is teaching a client about management of migraine headaches. Which of the following client statements indicates that the teaching has been effective?
a. “I will take the topiramate as soon as any headaches start.”
b. “I should avoid taking Aspirin and sumatriptan at the same time.”
c. “I will try to lie down someplace dark and quiet when the headaches begin.”
d. “A glass of wine might help me relax and prevent headaches from developing.”

Answer 1

c. “I will try to lie down someplace dark and quiet when the headaches begin.”

Question 2

Which of the following parameters should the nurse assess when caring for a client who is experiencing a cluster headache?
a. Nuchal rigidity
b. Projectile vomiting
c. Unilateral eyelid swelling
d. Throbbing, bilateral facial pain

Answer 2

c. Unilateral eyelid swelling

Question 3

A client has a tonic–clonic seizure while the nurse is in the client’s room. Which of the following actions should the nurse take?
a. Insert an oral airway during the seizure to maintain a patent airway.
b. Restrain the client’s arms and legs to prevent injury during the seizure.
c. Avoid touching the client to prevent further nervous system stimulation.
d. Time and observe and record the details of the seizure and postictal state.

Answer 3

d. Time and observe and record the details of the seizure and postictal state.

Question 4

An elementary teacher who has just been diagnosed with epilepsy after having a generalized tonic–clonic seizure tells the nurse, “I cannot teach anymore, it will be too upsetting if I have a seizure at work.” Which of the following responses by the nurse is
best?
a. “You may want to contact the Epilepsy Foundation for assistance.”
b. “You might benefit from some psychological counselling at this time.”
c. “The Department of Vocational Rehabilitation can help with work retraining.”
d. “Half of all clients with epilepsy are well controlled with antiseizure drugs.”

Answer 4

d. “Half of all clients with epilepsy are well controlled with antiseizure drugs.”

Question 5

Which action will the nurse take when evaluating a client who is taking phenytoin for adverse effects of the medication?
a. Inspect the oral mucosa.
b. Listen to the lung sounds.
c. Auscultate the bowel tones.
d. Check pupil reaction to light.

Answer 5

a. Inspect the oral mucosa.

Question 6

A client found in a tonic–clonic seizure reports afterward that the seizure was preceded by numbness and tingling of the arm. Which of the following types of seizures should the nurse document based upon this finding?
a. Atonic
b. Partial
c. Absence
d. Myoclonic

Answer 6

b. Partial

Question 7

The nurse is obtaining a health history and physical assessment from a client with possible multiple sclerosis (MS). Which of the following assessments should the nurse include?
a. Assess for the presence of chest pain.
b. Inquire about any urinary tract problems.
c. Inspect the skin for rashes or discoloration.
d. Question the client about any increase in libido.

Answer 7

b. Inquire about any urinary tract problems.

Question 8

A female client who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which of the following responses by the nurse is accurate?
a. “MS symptoms may be worse after the pregnancy.”
b. “Women with MS frequently have premature labour.”
c. “Symptoms of MS are likely to become worse during pregnancy.”
d. “MS is associated with a slightly increased risk for congenital defects.”

Answer 8

a. “MS symptoms may be worse after the pregnancy.”

Question 9

The nurse is caring for a client with multiple sclerosis (MS) who is to begin treatment with glatiramer acetate. Which of the following information should the nurse include in client teaching?
a. Recommendation to drink at least 3–4 L of water daily
b. Need to avoid driving or operating heavy machinery
c. How to draw up and administer injections of the medication
d. Use of contraceptive methods other than oral contraceptives

Answer 9

c. How to draw up and administer injections of the medication

Question 10

The nurse is caring for a client with epilepsy. Which of the following laboratory results should the nurse expect?
a. Increased blood glucose
b. Decreased BUN
c. Increased creatinine
d. Decreased liver function tests

Answer 10

c. Increased creatinine

Question 11

The nurse is caring for a client with multiple sclerosis (MS) who has urinary retention caused by a flaccid bladder. Which of the following actions should the nurse plan to take?
a. Teach the client how to perform self-catheterization.
b. Decrease the client’s fluid intake in the evening.
c. Suggest the use of incontinence briefs for nighttime use only.
d. Assist the client to the commode every 2 hours during the day.

Answer 11

a. Teach the client how to perform self-catheterization.

Question 12

A client with Parkinson’s disease has a nursing diagnosis of impaired physical mobility related to bradykinesia. Which of the following actions should the nurse include in the plan of care?
a. Instruct the client in activities that can be done while lying or sitting.
b. Suggest that the client rock from side to side to initiate leg movement.
c. Have the client take small steps in a straight line directly in front of the feet.
d. Teach the client to keep the feet in contact with the floor and slide them forward.

Answer 12

b. Suggest that the client rock from side to side to initiate leg movement.

Question 13

A client has a new prescription for bromocriptine mesylate to control symptoms of Parkinson’s disease. Which of the following information obtained by the nurse may indicate a need for a decrease in the dose?
a. The client has a chronic dry cough.
b. The client has four loose stools in a day.
c. The client develops a deep vein thrombosis.
d. The client’s blood pressure is 90/46 mm Hg.

Answer 13

d. The client’s blood pressure is 90/46 mm Hg.

Question 14

The nurse is providing teaching to a client with myasthenia gravis (MG) about management of the disease? Which of the following information should the nurse include in the teaching plan?
a. Perform physically demanding activities in the morning.
b. Anticipate the need for weekly plasmapheresis treatments.
c. Do frequent weight-bearing exercise to prevent muscle atrophy.
d. Protect the extremities from injury due to poor sensory perception.

Answer 14

a. Perform physically demanding activities in the morning.

Question 15

The nurse is assessing a client in the outpatient clinic who has restless legs syndrome. Which of the following over-the-counter medications that the client is taking routinely should the nurse discuss with the client?
a. Multivitamin
b. Acetaminophen
c. Ibuprofen
d. Diphenhydramine

Answer 15

d. Diphenhydramine

Question 16

The nurse is caring for a client with amyotrophic lateral sclerosis (ALS) who is hospitalized with pneumonia. Which of the following actions should be included in the plan of care?
a. Assist with active range of motion.
b. Observe for agitation and paranoia.
c. Give muscle relaxants as needed to reduce spasms.
d. Use simple words and phrases to explain procedures.

Answer 16

a. Assist with active range of motion.

Question 17

The nurse is caring for a client who is diagnosed with early Huntington’s disease (HD). Which of the following information should the nurse include in the teaching plan for the client, partner, and children?
a. Use of levodopa–carbidopa to help reduce HD symptoms.
b. Need to take prophylactic antibiotics to decrease the risk for pneumonia.
c. Lifestyle changes such as increased exercise that delay disease progression.
d. Availability of genetic testing to determine the HD risk for the client’s children.

Answer 17

d. Availability of genetic testing to determine the HD risk for the client’s children.

Question 18

The nurse assesses a client in the health clinic who has symptoms of a stooped posture, shuffling gait, and pill rolling-type tremor. Which of the following topics should the nurse include in the plan of care?
a. Oral corticosteroids
b. Antiparkinsonian drugs
c. The purpose of electroencephalogram (EEG) testing
d. Preparation for magnetic resonance imaging (MRI)

Answer 18

b. Antiparkinsonian drugs

Question 19

The nurse is assessing a client at the health clinic who has a severe migraine headache and tells the nurse about having four similar headaches in the last 3 months. Which of the following actions should the nurse take initially?
a. Refer the client for stress counselling.
b. Ask the client to keep a headache diary.
c. Suggest the use of muscle-relaxation techniques.
d. Teach about the effectiveness of the triptan drugs.

Answer 19

b. Ask the client to keep a headache diary.

Question 20

The nurse is caring for a hospitalized client who has a moderate bilateral headache that radiates from the base of the skull. Which of the following prescribed PRN medications should the nurse administer initially?
a. Lorazepam
b. Acetaminophen
c. Morphine sulphate
d. Butalbital and Aspirin

Answer 20

b. Acetaminophen

Question 21

A client tells the nurse about using acetaminophen several times every day for recurrent bilateral headaches. Which of the following actions should the nurse take first?
a. Discuss the need to stop taking the acetaminophen.
b. Suggest the use of biofeedback for headache control.
c. Teach the client about magnetic resonance imaging (MRI).
d. Describe the use of botulism toxin (BOTOX) for headaches.

Answer 21

a. Discuss the need to stop taking the acetaminophen.

Question 22

The health care provider is considering the use of sumatriptan for a client with migraine headaches. Which of the following information obtained by the nurse is most important to report to the health care provider?
a. The client has at least 1–2 cups of coffee daily.
b. The client has had migraine headaches for 30 years.
c. The client has a history of a recent acute myocardial infarction.
d. The client has been taking topiramate for 2 months.

Answer 22

c. The client has a history of a recent acute myocardial infarction.

Question 23

The nurse witnesses a client with a seizure disorder as the client suddenly jerks the arms and legs, falls to the floor, and regains consciousness immediately. Which of the following actions is priority for the nurse to take initially?
a. Assess the client for a possible head injury.
b. Give the scheduled dose of divalproex.
c. Document the timing and description of the seizure.
d. Notify the client’s health care provider about the seizure.

Answer 23

a. Assess the client for a possible head injury.

Question 24

Which of the following prescribed interventions will the nurse implement first for a hospitalized client who is experiencing continuous tonic–clonic seizures?
a. Give phenytoin 100 mg IV.
b. Monitor level of consciousness.
c. Obtain computed tomography scan.
d. Administer lorazepam 4 mg IV.

Answer 24

d. Administer lorazepam 4 mg IV.

Question 25

The partner of a client with Parkinson’s disease (PD) is upset and asks the nurse why he is no longer able to read the affectionate notes that the client writes for him. Which of the following information is the basis for the nurse’s response?
a. Characteristic slow speech makes it difficult for the client with PD to put his or her
thoughts on paper.
b. Cogwheel rigidity makes it hard for the client to hold a pen.
c. Micrographia is common in clients with PD.
d. Depression often seen in PD leads to denying affectionate feelings.

Answer 25

c. Micrographia is common in clients with PD.

Question 26

Which of the following information about a client who is being treated with carbidopa/levodopa for Parkinson’s disease is most important for the nurse to report to the health care provider?
a. Shuffling gait
b. Tremor at rest
c. Cogwheel rigidity of limbs
d. Uncontrolled head movement

Answer 26

d. Uncontrolled head movement

Question 27

The nurse is caring for a client with Parkinson’s disease who has decreased tongue mobility and an inability to move the facial muscles. Which of the following nursing
diagnoses is of highest priority?
a. Activity intolerance related to immobility
b. Toileting self-care deficit related to impaired mobility
c. Ineffective health management related to difficulty managing complex treatment regimen
d. Imbalanced nutrition: less than body requirements related to insufficient dietary intake

Answer 27

d. Imbalanced nutrition: less than body requirements related to insufficient dietary intake

Question 28

The nurse is assessing a client with myasthenia gravis. Which of the following parameters is most important for the nurse to assess?
a. Check pupillary size.
b. Monitor grip strength.
c. Observe respiratory effort.
d. Assess level of consciousness.

Answer 28

c. Observe respiratory effort.

Question 29

The nurse is caring for a client with myasthenia gravis who has had a thymectomy and receives the usual dose of pyridostigmine. An hour later, the client has nausea and severe abdominal cramps. Which of the following actions should the nurse take first?
a. Auscultate the client’s bowel sounds.
b. Notify the client’s health care provider.
c. Administer the prescribed PRN antiemetic drug.
d. Give the scheduled dose of prednisone.

Answer 29

b. Notify the client’s health care provider.

Question 30

The nurse is caring for a client with a history of cluster headache who awakens during the night with a severe stabbing headache. Which of the following actions should the nurse take first?
a. Start the prescribed PRN oxygen at 8 L/minute.
b. Put a moist hot pack on the client’s neck.
c. Give the prescribed PRN acetaminophen.
d. Notify the client’s health care provider immediately.

Answer 30

a. Start the prescribed PRN oxygen at 8 L/minute.

Question 31

The nurse is teaching a client with Parkinson’s disease preventive measures to reduce the risk of a fall. Which of the following instructions should the nurse include in the teaching session?
a. Point the toes downward when stepping.
b. Take two steps backward and three steps forward.
c. Rock from front to back when walking.
d. Drop rice kernels and step over them.

Answer 31

d. Drop rice kernels and step over them.