Ignatavicius Ch 42: Care of Patients with Problems of the CNS: The Brain

Question 1

A nurse is teaching a client who experiences migraine headaches and is prescribed a beta blocker. Which statement should the nurse include in this clients teaching?

a. Take this drug only when you have prodromal symptoms indicating the onset of a migraine headache.
b. Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches.
c. This drug will relieve the pain during the aura phase soon after a headache has started.
d. This medication will have no effect on your heart rate or blood pressure because you are taking it for migraines.

Answer 1

b. Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches.

Beta blockers are prescribed as prophylactic treatment to prevent the vascular changes that initiate migraine headaches. Heart rate and blood pressure will also be affected, and the client should monitor these side effects. The other responses do not discuss appropriate uses of the medication.

Question 2

A nurse assesses a client who has a history of migraines. Which clinical manifestation should the nurse identify as an early sign of a migraine with aura?

a. Vertigo
b. Lethargy
c. Visual disturbances
d. Numbness of the tongue

Answer 2

c. Visual disturbances

Early warning of impending migraine with aura usually consists of visual changes, flashing lights, or diplopia. The other manifestations are not associated with an impending migraine with aura.

Question 3

A nurse obtains a health history on a client prior to administering prescribed sumatriptan succinate (Imitrex) for migraine headaches. Which condition should alert the nurse to hold the medication and contact the health care provider?

a. Bronchial asthma
b. Prinzmetals angina
c. Diabetes mellitus
d. Chronic kidney disease

Answer 3

b. Prinzmetals angina

Sumatriptan succinate effectively reduces pain and other associated symptoms of migraine headache by binding to serotonin receptors and triggering cranial vasoconstriction. Vasoconstrictive effects are not confined to the cranium and can cause coronary vasospasm in clients with Prinzmetals angina. The other conditions would not affect the clients treatment.

Question 4

A nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How should the nurse document this activity?

a. Atonic seizure
b. Tonic-clonic seizure
c. Myoclonic seizure
d. Absence seizure

Answer 4

b. Tonic-clonic seizure

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

Question 5

A nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. Which action should the nurse take?

a. Start fluids via a large-bore catheter.
b. Turn the clients head to the side.
c. Administer IV push diazepam.
d. Prepare to intubate the client.

Answer 5

b. Turn the clients head to the side.

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

Question 6

A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication should the nurse prepare to administer?

a. Atenolol (Tenormin)
b. Lorazepam (Ativan)
c. Phenytoin (Dilantin)
d. Lisinopril (Prinivil)

Answer 6

b. Lorazepam (Ativan)

Initially, intravenous lorazepam is administered to stop motor movements. This is followed by the administration of phenytoin. Atenolol, a beta blocker, and lisinopril, an angiotensin-converting enzyme inhibitor, are not administered for seizure activity. These medications are typically administered for hypertension and heart failure.

Question 7

After teaching a client who is diagnosed with new-onset status epilepticus and prescribed phenytoin (Dilantin), the nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching?

a. To prevent complications, I will drink at least 2 liters of water daily.
b. This medication will stop me from getting an aura before a seizure.
c. I will not drive a motor vehicle while taking this medication.
d. Even when my seizures stop, I will continue to take this drug.

Answer 7

d. Even when my seizures stop, I will continue to take this drug.

Discontinuing antiepileptic drugs can lead to the recurrence of seizures or status epilepticus. The client does not need to drink more water and can drive while taking this medication. The medication will not stop an aura before a seizure.

Question 8

8. After teaching a client newly diagnosed with epilepsy, the nurse assesses the clients understanding. Which statement by the client indicates a need for additional teaching?
   a. I will wear my medical alert bracelet at all times.
   b. While taking my epilepsy medications, I will not drink any alcoholic beverages.
   c. I will tell my doctor about my prescription and over-the-counter medications.
   d. If I am nauseated, I will not take my epilepsy medication.

Answer 8

d. If I am nauseated, I will not take my epilepsy medication.

The nurse must emphasize that antiepileptic drugs must be taken even if the client is nauseous. Discontinuing the medication can predispose the client to seizure activity and status epilepticus. The client should not drink alcohol while taking seizure medications. The client should wear a medical alert bracelet and should make the doctor aware of all medications to prevent complications of polypharmacy.

Question 9

A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question should the nurse ask?

a. Do you live in a crowded residence?
b. When was your last tetanus vaccination?
c. Have you had any viral infections recently?
d. Have you traveled out of the country in the last month?

Answer 9

a. Do you live in a crowded residence?

Meningococcal meningitis tends to occur in multiple outbreaks. It is most likely to occur in areas of high- density population, such as college dormitories, prisons, and military barracks. A tetanus vaccination would not place the client at increased risk for meningitis or protect the client from meningitis. A viral infection would not lead to bacterial meningitis but could lead to viral meningitis. Simply knowing if the client traveled out of the country does not provide enough information. The nurse should ask about travel to specific countries in which the disease is common, for example, sub-Saharan Africa.

Question 10

After teaching the wife of a client who has Parkinson disease, the nurse assesses the wifes understanding. Which statement by the clients wife indicates she correctly understands changes associated with this disease?

a. His masklike face makes it difficult to communicate, so I will use a white board.
b. He should not socialize outside of the house due to uncontrollable drooling.
c. This disease is associated with anxiety causing increased perspiration.
d. He may have trouble chewing, so I will offer bite-sized portions.

Answer 10

d. He may have trouble chewing, so I will offer bite-sized portions.

Because chewing and swallowing can be problematic, small frequent meals and a supplement are better for meeting the clients nutritional needs. A masklike face and drooling are common in clients with Parkinson disease. The client should be encouraged to continue to socialize and communicate as normally as possible. The wife should understand that the clients masklike face can be misinterpreted and additional time may be needed for the client to communicate with her or others. Excessive perspiration is also common in clients with Parkinson disease and is associated with the autonomic nervous systems response.

Question 11

A nurse plans care for a client with Parkinson disease. Which intervention should the nurse include in this clients plan of care?

a. Ambulate the client in the hallway twice a day.
b. Ensure a fluid intake of at least 3 liters per day.
c. Teach the client pursed-lip breathing techniques.
d. Keep the head of the bed at 30 degrees or greater.

Answer 11

d. Keep the head of the bed at 30 degrees or greater.

Elevation of the head of the bed will help prevent aspiration. The other options will not prevent aspiration, which is the greatest respiratory complication of Parkinson disease, nor do these interventions address any of the complications of Parkinson disease. Ambulation in the hallway is usually implemented to prevent venous thrombosis. Increased fluid intake flushes out toxins from the clients blood. Pursed-lip breathing increases exhalation of carbon dioxide.

Question 12

A nurse is teaching the daughter of a client who has Alzheimers disease. The daughter asks, Will the medication my mother is taking improve her dementia? How should the nurse respond?

a. It will allow your mother to live independently for several more years.
b. It is used to halt the advancement of Alzheimers disease but will not cure it.
c. It will not improve her dementia but can help control emotional responses.
d. It is used to improve short-term memory but will not improve problem solving.

Answer 12

c. It will not improve her dementia but can help control emotional responses.

Drug therapy is not effective for treating dementia or halting the advancement of Alzheimers disease. However, certain drugs may help suppress emotional disturbances and psychiatric manifestations. Medication therapy may not allow the client to safely live independently.

Question 13

A nurse assesses a client with Alzheimers disease who is recently admitted to the hospital. Which psychosocial assessment should the nurse complete?

a. Assess religious and spiritual needs while in the hospital.
b. Identify the clients ability to perform self-care activities.
c. Evaluate the clients reaction to a change of environment.
d. Ask the client about relationships with family members.

Answer 13

c. Evaluate the clients reaction to a change of environment.

As Alzheimers disease progresses, the client experiences changes in emotional and behavioral affect. The nurse should be alert to the clients reaction to a change in environment, such as being hospitalized, because the client may exhibit an exaggerated response, such as aggression, to the event. The other assessments should be completed but are not as important as assessing the clients reaction to environmental change.

Question 14

A nurse witnesses a client with late-stage Alzheimers disease eat breakfast. Afterward the client states, I am hungry and want breakfast. How should the nurse respond?

a. I see you are still hungry. I will get you some toast.
b. You ate your breakfast 30 minutes ago.
c. It appears you are confused this morning.
d. Your family will be here soon. Lets get you dressed.

Answer 14

a. I see you are still hungry. I will get you some toast.

Use of validation therapy with clients who have Alzheimers disease involves acknowledgment of the clients feelings and concerns. This technique has proved more effective in later stages of the disease, when using reality orientation only increases agitation. Telling the client that he or she already ate breakfast may agitate the client. The other statements do not validate the clients concerns.

Question 15

A nurse assesses a client after administering prescribed levetiracetam (Keppra). Which laboratory tests should the nurse monitor for potential adverse effects of this medication?

a. Serum electrolyte levels
b. Kidney function tests
c. Complete blood cell count
d. Antinuclear antibodies

Answer 15

b. Kidney function tests

Adverse effects of levetiracetam include coordination problems and renal toxicity. The other laboratory tests are not affected by levetiracetam.

Question 16

A nurse cares for a client with advanced Alzheimers disease. The clients caregiver states, She is always wandering off. What can I do to manage this restless behavior? How should the nurse respond?

a. This is a sign of fatigue. The client would benefit from a daily nap.
b. Engage the client in scheduled activities throughout the day.
c. It sounds like this is difficult for you. I will consult the social worker.
d. The provider can prescribe a mild sedative for restlessness.

Answer 16

b. Engage the client in scheduled activities throughout the day.

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

Question 17

A nurse prepares to discharge a client with Alzheimers disease. Which statement should the nurse include in the discharge teaching for this clients caregiver?

a. Allow the client to rest most of the day.
b. Place a padded throw rug at the bedside.
c. Install deadbolt locks on all outside doors.
d. Provide a high-calorie and high-protein diet.

Answer 17

c. Install deadbolt locks on all outside doors.

Clients with Alzheimers disease have a tendency to wander, especially at night. If possible, alarms should be installed on all outside doors to alert family members if the client leaves. At a minimum, all outside doors should have deadbolt locks installed to prevent the client from going outdoors unsupervised. The client should be allowed to exercise within his or her limits. Throw rugs are a slip and fall hazard and should be removed. The client should eat a well-balanced diet. There is no need for a high-calorie or high-protein diet.

Question 18

A nurse assesses a client with Huntington disease. Which motor changes should the nurse monitor for in this client?

a. Shuffling gait
b. Jerky hand movements
c. Continuous chewing motions
d. Tremors of the hands

Answer 18

b. Jerky hand movements

An imbalance between excitatory and inhibitory neurotransmitters leads to uninhibited motor movements, such as brisk, jerky, purposeless movements of the hands, face, tongue, and legs. Shuffling gait, continuous chewing motions, and tremors are associated with Parkinson disease.

Question 19

A nurse cares for a client who has been diagnosed with the Huntington gene but has no symptoms. The client asks for options related to family planning. What is the nurses best response?

a. Most clients with the Huntington gene do not pass on Huntington disease to their children.
b. I understand that they can diagnose this disease in embryos. Therefore, you could select a healthy embryo from your fertilized eggs for implantation to avoid passing on Huntington disease.
c. The need for family planning is limited because one of the hallmarks of Huntington disease is infertility.
d. Tell me more specifically what information you need about family planning so that I can direct you to the right information or health care provider.

Answer 19

d. Tell me more specifically what information you need about family planning so that I can direct you to the right information or health care provider.

The presence of the Huntington gene means that the trait will be passed on to all offspring of the affected person. Understanding options for contraception and conception (e.g., surrogacy options) and implications for children may require the expertise of a genetic counselor or a reproductive specialist. The other statements are not accurate.

Question 20

A nurse is teaching a client with chronic migraine headaches. Which statement related to complementary therapy should the nurse include in this clients teaching?

a. Place a warm compress on your forehead at the onset of the headache.
b. Wear dark sunglasses when you are in brightly lit spaces.
c. Lie down in a darkened room when you experience a headache.
d. Set your alarm to ensure you do not sleep longer than 6 hours at one time.

Answer 20

c. Lie down in a darkened room when you experience a headache.

At the onset of a migraine attack, the client may be able to alleviate pain by lying down and darkening the room. He or she may want both eyes covered and a cool cloth on the forehead. If the client falls asleep, he or she should remain undisturbed until awakening. The other options are not recognized therapies for migraines.

Question 21

A nurse delegates care for a client with Parkinson disease to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this clients care?

a. Allow the client to be as independent as possible with activities.
b. Assist the client with frequent and meticulous oral care.
c. Assess the clients ability to eat and swallow before each meal.
d. Schedule appointments early in the morning to ensure rest in the afternoon.

Answer 21

a. Allow the client to be as independent as possible with activities.

Clients with Parkinson disease do not move as quickly and can have functional problems. The client should be encouraged to be as independent as possible and provided time to perform activities without rushing. Although oral care is important for all clients, instructing the UAP to provide frequent and meticulous oral is not a priority for this client. This statement would be a priority if the client was immune-compromised or NPO. The nurse should assess the clients ability to eat and swallow; this should not be delegated. Appointments and activities should not be scheduled early in the morning because this may cause the client to be rushed and discourage the client from wanting to participate in activities of daily living.

Question 22

A nurse delegates care for a client with early-stage Alzheimers disease to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this clients care?

a. If she is confused, play along and pretend that everything is okay.
b. Remove the clock from her room so that she doesnt get confused.
c. Reorient the client to the day, time, and environment with each contact.
d. Use validation therapy to recognize and acknowledge the clients concerns.

Answer 22

c. Reorient the client to the day, time, and environment with each contact.

Clients who have early-stage Alzheimers disease should be reoriented frequently to person, place, and time. The UAP should reorient the client and not encourage the clients delusions. The room should have a clock and white board with the current date written on it. Validation therapy is used with late-stage Alzheimers disease.

Question 23

A nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions should the nurse include in this clients plan of care? (Select all that apply.)

a. Have suction equipment at the bedside.
b. Place a padded tongue blade at the bedside.
c. Permit only clear oral fluids.
d. Keep bed rails up at all times.
e. Maintain the client on strict bedrest.
f. Ensure that the client has IV access.

Answer 23

a. Have suction equipment at the bedside.
d. Keep bed rails up at all times.
f. Ensure that the client has IV access.

Oxygen and suctioning equipment with an airway must be readily available. The bed rails should be up at all times while the client is in the bed to prevent injury from a fall if the client has a seizure. If the client does not have an IV access, insert a saline lock, especially for those clients who are at significant risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV drug therapy must be given to stop the seizure. Padded tongue blades may pose a danger to the client during a seizure and should not be used. Dietary restrictions and strict bedrest are not interventions associated with epilepsy. The client should be encouraged to eat a well-balanced diet and ambulate while in the hospital.

Question 24

A nurse is teaching a client who has chronic headaches. Which statements about headache triggers should the nurse include in this clients plan of care? (Select all that apply.)

a. Increase your intake of caffeinated beverages.
b. Incorporate physical exercise into your daily routine.
c. Avoid all alcoholic beverages.
d. Participate in a smoking cessation program.
e. Increase your intake of fruits and vegetables.

Answer 24

b. Incorporate physical exercise into your daily routine.
d. Participate in a smoking cessation program.
e. Increase your intake of fruits and vegetables.

Triggers for headaches include caffeine, smoking, and ingestion of pickled foods, so these factors should be avoided. Clients are taught to eat a balanced diet and to get adequate exercise and rest. Alcohol does not trigger chronic headaches but can enhance headaches during the headache period.

Question 25

A nurse evaluates the results of diagnostic tests on a clients cerebrospinal fluid (CSF). Which fluid results alerts the nurse to possible viral meningitis? (Select all that apply.)

a. Clear
b. Cloudy
c. Increased protein level
d. Normal glucose level
e. Bacterial organisms present f. Increased white blood cells

Answer 25

a. Clear
c. Increased protein level
d. Normal glucose level

In viral meningitis, CSF fluid is clear, protein levels are slightly increased, and glucose levels are normal. Viral meningitis does not cause cloudiness or increased turbidity of CSF. In bacterial meningitis, the presence of bacteria and white blood cells causes the fluid to be cloudy.

Question 26

A nurse assesses a client who is experiencing a cluster headache. Which clinical manifestations should the nurse expect to find? (Select all that apply.)

a. Ipsilateral tearing of the eye
b. Miosis
c. Abrupt loss of consciousness
d. Neck and shoulder tenderness
e. Nasal congestion
f. Exophthalmos

Answer 26

a. Ipsilateral tearing of the eye
b. Miosis
e. Nasal congestion

Cluster headache is usually accompanied by ipsilateral tearing, miosis, rhinorrhea or nasal congestion, ptosis, eyelid edema, and facial sweating. Abrupt loss of consciousness, neck and shoulder tenderness, and exophthalmos are not associated with cluster headaches.

Question 27

A nurse assesses a client who is experiencing an absence seizure. For which clinical manifestations should the nurse assess? (Select all that apply.)

a. Intermittent rigidity
b. Lip smacking
c. Sudden loss of muscle tone
d. Brief jerking of the extremities
e. Picking at clothing
f. Patting of the hand on the leg

Answer 27

b. Lip smacking
e. Picking at clothing
f. Patting of the hand on the leg

Automatisms are characteristic of absence seizures. These behaviors consist of lip smacking, picking at clothing, and patting. Rigidity of muscles is associated with the tonic phase of a seizure, and jerking of the extremities is associated with the clonic phase of a seizure. Loss of muscle tone occurs with atonic seizures.

Question 28

A nurse prepares to provide perineal care to a client with meningococcal meningitis. Which personal protective equipment should the nurse wear? (Select all that apply.)

a. Particulate respirator
b. Isolation gown
c. Shoe covers
d. Surgical mask
e. Gloves

Answer 28

d. Surgical mask
e. Gloves

Meningeal meningitis is spread via saliva and droplets, and Droplet Precautions are necessary. Caregivers should wear a surgical mask when within 6 feet of the client and should continue to use Standard Precautions, including gloves. A particulate respirator, an isolation gown, and shoe covers are not necessary for Droplet Precautions.

Question 29

A nurse assesses clients on a medical-surgical unit. Which clients should the nurse identify as at risk for secondary seizures? (Select all that apply.)

a. A 26-year-old woman with a left temporal brain tumor
b. A 38-year-old male client in an alcohol withdrawal program
c. A 42-year-old football player with a traumatic brain injury
d. A 66-year-old female client with multiple sclerosis
e. A 72-year-old man with chronic obstructive pulmonary disease

Answer 29

a. A 26-year-old woman with a left temporal brain tumor
b. A 38-year-old male client in an alcohol withdrawal program
c. A 42-year-old football player with a traumatic brain injury

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

Question 30

A nurse assesses a client who is recovering from the implantation of a vagal nerve stimulation device. For which clinical manifestations should the nurse assess as common complications of this procedure? (Select all that apply.)

a. Bleeding
b. Infection
c. Hoarseness
d. Dysphagia
e. Seizures

Answer 30

c. Hoarseness
d. Dysphagia

Complications of surgery to implant a vagal nerve stimulation device include hoarseness (most common), dyspnea, neck pain, and dysphagia. The device is tunneled under the skin with an electrode connected to the vagus nerve to control simple or complex partial seizures. Bleeding is not a common complication of this procedure, and infection would not occur during the recovery period.

Question 31

A nurse is caring for a client with meningitis. Which laboratory values should the nurse monitor to identify potential complications of this disorder? (Select all that apply.)

a. Sodium level
b. Liver enzymes
c. Clotting factors
d. Cardiac enzymes
e. Creatinine level

Answer 31

a. Sodium level
c. Clotting factors

Inflammation associated with meningitis can stimulate the hypothalamus and result in excessive production of antidiuretic hormone. The nurse should monitor sodium levels for early identification of syndrome of inappropriate antidiuretic hormone. A systemic inflammatory response (SIR) can also occur with meningitis. A SIR can result in a coagulopathy that leads to disseminated intravascular coagulation. The nurse should monitor clotting factors to identify this complication. The other laboratory values are not specific to complications of meningitis.

Question 32

A nurse assesses a client who has encephalitis. Which manifestations should the nurse recognize as signs of increased intracranial pressure (ICP), a complication of encephalitis? (Select all that apply.)

a. Photophobia
b. Dilated pupils
c. Headache
d. Widened pulse pressure
e. Bradycardia

Answer 32

b. Dilated pupils
d. Widened pulse pressure
e. Bradycardia

Increased ICP is a complication of encephalitis. The nurse should monitor for signs of increased ICP, including dilated pupils, widened pulse pressure, bradycardia, irregular respirations, and less responsive pupils. Photophobia and headache are not related to increased ICP.