LA #10 (Neurological) Chapters 58, 59, 60, 61 Flashcards
1
Q
A patient with a deep, large laceration of the left forearm, which has damaged nerve fibres as well as other tissue, asks the nurse to explain what the effect of the nerve damage will be. What is the best response to the patient?
a.
Nerve cells cannot regenerate, and the sensory and motor loss will be permanent.
b.
He will probably have return of normal motor and sensory function because peripheral nerve cells can regenerate.
c.
Only nerve fibres within the central nervous system are capable of regeneration, and the nerve loss he has distal to his injury will be permanent.
d.
There is a chance that some nervous function will return because peripheral nerve fibres can slowly regenerate if cell bodies have not been damaged.
A
D
In the peripheral nervous system, regeneration of injured nerve fibres is possible if the cell body is intact. The final result depends on the connections the axon sprouts make with end-organs and other nerves.
2
Q
When interviewing an acutely confused patient who has a head injury, which question will provide the most useful information?
a.
“Have you ever been hospitalized for a neurological problem?”
b.
“Do you have any pain at the present time?”
c.
“What have you had to eat in the last 24 hours?”
d.
“Can you describe your usual pattern for coping with injury?”
A
B
The acutely confused patient will be able to state whether he currently has pain. The patient may not be able to provide accurate information about his history of hospitalization, 24-hour dietary recall, or usual coping patterns.
3
Q
When the nurse administers a drug that increases the synaptic release of γ-aminobutyric acid (GABA), what is the effect the nurse would expect?
a.
Widespread increases in nervous system activity
b.
Suppression of nervous system activity
c.
Increased patient alertness and arousal
d.
Excitation of the affected postsynaptic neurons
A
B
GABA is a neurotransmitter that has inhibitory activity on action-potential generation and decreases nervous system activity.
4
Q
For a patient who has a corticospinal tract lesion, the nurse should assess for which of the following?
a.
Extremity movement and strength
b.
Cranial nerve function
c.
Peripheral sensitivity to pain
d.
Level of consciousness
A
A
The corticospinal tract carries impulses from the cortex to the peripheral nerves that control voluntary muscle movement.
5
Q
A patient has a lesion that affects lower motor neurons. During assessment of the patient’s lower extremities, what does the nurse expect to find?
a.
Spasticity
b.
Flaccidity
c.
Hyperreflexia
d.
Loss of sensation
A
B
Because the cell bodies of lower motor neurons are located in the spinal cord, damage to the neuron will decrease motor activity of the affected muscles, and the nurse would assess flaccidity.
6
Q
Which of the following assessment findings would the nurse expect when examining a patient with a lesion of the left posterior temporal lobe?
a.
Inability to reason or problem solve
b.
Loss of sensation on the left side of the body
c.
Inability to comprehend written or oral language
d.
Inability to voluntarily move the right side of the body
A
C
The posterior temporal lobe integrates the visual and auditory input for language comprehension.
7
Q
What is the path of intervention with cranial nerve VI (abducens nerve) that is connected to the brain via the pons?
a.
Motor path
b.
Sensory path
c.
Sympathetic path
d.
Parasympathetic path
A
A
Cranial nerve VI (abducens nerve) that is connected to the brain via the pons has a motor path of intervention.
8
Q
When obtaining a health history from a patient with a neurological problem, the nurse is likely to elicit the most valid response from the patient by asking the patient which of the following questions?
a.
“Do you ever have any nausea or dizziness?”
b.
“Does the pain radiate from your back into your legs?”
c.
“Do you have any sensations of pins and needles in your feet?”
d.
“Can you describe the sensations you are having in your chest?”
A
D
The most useful and valid information is obtained through the use of open-ended questions that allow the patient to describe symptoms.
9
Q
When admitting a patient with acute confusion to the hospital, the nurse will interview the patient about health problems and health history primarily for which of the following reasons?
a.
To determine the patient’s motivation for self-care
b.
To include the patient in health care decisions
c.
To use the information given by the patient to guide care
d.
To assess the patient’s baseline cognitive abilities
A
D
The appropriateness of the patient’s response and the patient’s use of language will help the nurse assess the baseline cognitive abilities of the patient.
10
Q
A 71-year-old patient reports a change in sleep patterns occurring over the past 2 to 3 years. Based on knowledge of the effects of aging on the reticular activating system, what would the nurse expect the patient to exhibit?
a.
Increased rapid-eye-movement sleep
b.
Longer cycles of sleep
c.
Increased sleep apnea
d.
Increased spontaneous awakening
A
D
Normal changes in the reticular activating system and autonomic nervous system lead to more spontaneous awakening and less sleep time in older adults.
11
Q
To assess the functioning of the optic nerve (cranial nerve II), what should the nurse do?
a.
Apply a cotton wisp strand to the cornea.
b.
Perform a confrontational test for visual fields.
c.
Evaluate pupil response to light and accommodation.
d.
Ask the patient to follow a finger with the eyes as it is moved vertically, horizontally, and diagonally.
A
B
The optic nerve is responsible for visual fields and visual acuity.
12
Q
Neurological testing of the patient by the nurse indicates impaired functioning of the left glossopharyngeal nerve (cranial nerve IX) and the vagus nerve (cranial nerve X). Based on these findings, what should the nurse plan to do?
a.
Insert an oral airway.
b.
Withhold oral fluid or foods.
c.
Provide highly seasoned foods.
d.
Apply artificial tears to protect the cornea.
A
B
The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex. A patient with impaired function of these nerves is at risk for aspiration.
13
Q
The following orders are received for a patient who is unconscious after a head injury caused by an automobile accident. Which one should the nurse question?
a.
Perform neurological checks every 15 minutes.
b.
Prepare the patient for lumbar puncture.
c.
Obtain X-ray films of the skull and spine.
d.
Do computed tomography scanning with and without contrast.
A
B
After a head injury, the patient may be experiencing intracranial bleeding and increased intracranial pressure, which could lead to herniation of the brain with lumbar puncture.
14
Q
The charge nurse is observing a new staff nurse who is assessing a patient with a possible spinal cord lesion for sensation. Which action by the new nurse indicates a need for further teaching about neurological assessment?
a.
Tests for light touch before testing for pain
b.
Has the patient close the eyes during testing
c.
Tells the patient, “You may feel a pinprick now.”
d.
Uses an irregular pattern to test for intact touch
A
C
When performing a sensory assessment, the nurse should not provide verbal or visual clues.
15
Q
To prepare a patient who is to have a lumbar puncture performed for analysis of cerebrospinal fluid, what should the nurse inform him about?
a.
He will be given a mild sedative to help control muscle spasms.
b.
He should cough as soon as he feels the needle enter the spinal canal.
c.
He may be required to lie flat on his back for 24 hours following the test.
d.
He will be positioned on his side with his knees drawn to the chest and his head flexed to the chest.
A
D
For a lumbar puncture, the patient lies in the lateral recumbent position, with the knees drawn to the chest and the head flexed to the chest to separate the vertebrae.
16
Q
When reviewing the results of a patient’s cerebrospinal fluid analysis obtained from a lumbar puncture, which of the following does the nurse identify as abnormal?
a.
pH 7.35
b.
White blood cell count 4 cells/microlitre (0.004 cells/L)
c.
Protein 0.30 g/L (30 mg/dL)
d.
Glucose 1.7 mmol/L (30 mg/dL)
A
D
The glucose level is low.
17
Q
Which of the following is an age-related change in the nervous system?
a.
Increased efficiency of temperature-regulating mechanism
b.
Decreased size of ventricles in the brain
c.
Decrease in electrical activity
d.
Increase in deep-tendon reflexes
A
C
A normal age-related change is a decrease in electrical activity. The temperature-regulating mechanism is decreased in efficiency in aging. The size of the ventricles increases with age. The deep-tendon reflexes either remain the same or decrease in aging.
18
Q
During the neurological assessment, the patient cooperates with the nurse’s directions to grip with the hands and to move the feet, but does not respond to the nurse’s questions. The nurse will suspect which of the following?
a.
A temporal lobe lesion
b.
Injury to the cerebellum
c.
A brainstem lesion
d.
Damage to the frontal lobe
A
D
Expressive speech is controlled by Broca’s area in the frontal lobe.
19
Q
Which neurotransmitter is involved in emotions, moods, and regulating motor control?
a.
Serotonin
b.
Epinephrine
c.
Dopamine
d.
Substance P
A
C
Dopamine is involved in emotions, moods, and regulating motor activity. Serotonin is also involved with moods and emotions but has no relevance to regulating motor control.
20
Q
Which internal structure arises from the basilar and two internal carotid arteries?
a.
Reticular formation
b.
Blood–brain barrier
c.
Circle of Willis
d.
Anterior communicating centre
A
C
The circle of Willis arises from the basilar and two internal carotid arteries.
21
Q
Which area of the cerebrum would the nurses suspect is injured when the patient is unable to understand spoken words?
a.
Broca’s area
b.
Precentral gyrus
c.
Wernicke’s area
d.
Postcentral gyrus
A
C
The function of Wernicke’s area is to integrate auditory language, that is, understanding of spoken words.
22
Q
The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include
a.
prophylactic clipping of cerebral aneurysms.
b.
heparin via continuous intravenous infusion.
c.
oral administration of low dose aspirin therapy.
d.
therapy with tissue plasminogen activator (tPA).
A
C
The patient’s symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient’s symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.
23
Q
Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the health care provider before giving the aspirin?
a.
The patient has dysphasia.
b.
The patient has atrial fibrillation.
c.
The patient states, “My symptoms started with a terrible headache.”
d.
The patient has a history of brief episodes of right-sided hemiplegia.
A
C
A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer the aspirin.
24
Q
A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When admitting the patient, which clinical manifestation will the nurse expect to find?
a.
Impulsive behavior
b.
Right-sided neglect
c.
Hyperactive left-sided reflexes
d.
Difficulty in understanding commands
A
D
Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side stroke.
25
The nurse receives a verbal report that a patient has an occlusion of the left posterior cerebral artery. The nurse will anticipate that the patient may have
a.
dysphasia.
b.
confusion.
c.
visual deficits.
d.
poor judgment.
C
Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion.
26
The health care provider prescribes clopidogrel (Plavix) for a patient with cerebral atherosclerosis. When teaching about the new medication, the nurse will tell the patient
a.
to monitor and record the blood pressure daily.
b.
to call the health care provider if stools are tarry.
c.
that Plavix will dissolve clots in the cerebral arteries.
d.
that Plavix will reduce cerebral artery plaque formation.
B
Plavix inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots.
27
The health care provider recommends a carotid endarterectomy for a patient with carotid atherosclerosis and a history of transient ischemic attacks (TIAs). The patient asks the nurse to describe the procedure. Which response by the nurse is appropriate?
a.
“The carotid endarterectomy involves surgical removal of plaque from an artery in the neck.”
b.
“The diseased portion of the artery in the brain is removed and replaced with a synthetic graft.”
c.
“A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed.”
d.
“A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque.”
A
In a carotid endarterectomy, the carotid artery is incised and the plaque is removed. The response beginning, “The diseased portion of the artery in the brain is removed” describes an arterial graft procedure. The answer beginning, “A catheter with a deflated balloon is positioned at the narrow area” describes an angioplasty. The final response beginning, “A wire is threaded through the artery” describes the MERCI procedure.
28
When assessing a patient with a possible stroke, the nurse finds that the patient’s aphasia started 3.5 hours previously and the blood pressure is 170/92 mm Hg. Which of these orders by the health care provider should the nurse question?
a.
Infuse normal saline at 75 mL/hr.
b.
Keep head of bed elevated at least 30 degrees.
c.
Administer tissue plasminogen activator (tPA) per protocol.
d.
Titrate labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg.
D
Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if mean arterial pressure (MAP) is \>130 mm Hg or systolic pressure is \>220 mm Hg. Fluid intake should be 1500 to 2000 mL daily to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees, unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use.
29
A patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. The nurse anticipates the need to prepare the patient for
a.
surgical endarterectomy.
b.
transluminal angioplasty.
c.
intravenous heparin administration.
d.
tissue plasminogen activator (tPA) infusion.
D
The patient’s history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke.
30
The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. An appropriate nursing intervention to help the patient communicate is to
a.
have the patient practice facial and tongue exercises.
b.
ask simple questions that the patient can answer with “yes” or “no.”
c.
develop a list of words that the patient can read and practice reciting.
d.
prevent embarrassing the patient by changing the subject if the patient does not respond.
B
Communication will be facilitated and less frustrating to the patient when questions that require a “yes” or “no” response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.
31
A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the effects of right brain damage, the nurse establishes a nursing diagnosis of
a.
impaired physical mobility related to right hemiplegia.
b.
risk for injury related to denial of deficits and impulsiveness.
c.
impaired verbal communication related to speech-language deficits.
d.
ineffective coping related to depression and distress about disability.
B
Right-sided brain damage typically causes denial of any deficits and poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability.
32
When caring for a patient with left-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care during the acute period of the stroke?
a.
Apply an eye patch to the left eye.
b.
Approach the patient from the left side.
c.
Place objects needed for activities of daily living on the patient’s right side.
d.
Reassure the patient that the visual deficit will resolve as the stroke progresses.
C
During the acute period, the nurse should place objects on the patient’s unaffected side. Since there is a visual defect in the left half of each eye, an eye patch is not appropriate. The patient should be approached from the right side. The visual deficit may not resolve, although the patient can learn to compensate for the defect.
33
The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a patient with right-sided hemiplegia. Which intervention should be included in the plan of care?
a.
Provide a wide variety of food choices.
b.
Provide oral care before and after meals.
c.
Assist the patient to eat with the left hand.
d.
Teach the patient the “chin-tuck” technique.
C
Because the nursing diagnosis indicates that the patient’s imbalanced nutrition is related to the right-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use the left hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition.
34
A 32-year-old patient has a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan?
a.
Applying intermittent pneumatic compression stockings
b.
Assisting to dangle on edge of bed and assess for dizziness
c.
Encouraging patient to cough and deep breathe every 4 hours
d.
Inserting an oropharyngeal airway to prevent airway obstruction
A
The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboemboism (VTE). Activities such as coughing and sitting up that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.
35
A patient who has had a stroke has a new order to attempt oral feedings. The nurse should assess the gag reflex and then
a.
order a varied pureed diet.
b.
assess the patient’s appetite.
c.
assist the patient into a chair.
d.
offer the patient a sip of juice.
C
The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted regardless.
36
A patient who has right-sided weakness after a stroke is attempting to use the left hand for feeding and other activities. The patient’s wife insists on feeding and dressing him, telling the nurse, “I just don’t like to see him struggle.” Which nursing diagnosis is most appropriate for the patient?
a.
Situational low self-esteem related to increasing dependence on others
b.
Interrupted family processes related to effects of illness of a family member
c.
Disabled family coping related to inadequate understanding by patient’s spouse
d.
Impaired nutrition: less than body requirements related to hemiplegia and aphasia
C
The information supports the diagnosis of disabled family coping because the wife does not understand the rehabilitation program. There are no data supporting low self-esteem, and the patient is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. There is no indication that the patient has impaired nutrition.
37
Several weeks after a stroke, a patient has urinary incontinence resulting from an impaired awareness of bladder fullness. For an effective bladder training program, which nursing intervention will be best to include in the plan of care?
a.
Limit fluid intake to 1200 mL daily to reduce urine volume.
b.
Assist the patient onto the bedside commode every 2 hours.
c.
Perform intermittent catheterization after each voiding to check for residual urine.
d.
Use an external “condom” catheter to protect the skin and prevent embarrassment.
B
Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1200 mL fluid restriction may lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke but should not be considered solutions for long-term management because of the risks for urinary tract infection (UTI) and skin breakdown.
38
A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering the medications, the patient says, “I don’t need the aspirin today. I don’t have any aches or pains.” Which action should the nurse take?
a.
Document that the aspirin was refused by the patient.
b.
Tell the patient that the aspirin is used to prevent aches.
c.
Explain that the aspirin is ordered to decrease stroke risk.
d.
Call the health care provider to clarify the medication order.
C
Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patient’s refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The aspirin is not ordered to prevent aches and pains.
39
A patient is admitted to the hospital with dysphasia and right-sided weakness that resolves in a few hours. The nurse will anticipate teaching the patient about
a.
alteplase (tPA).
b.
aspirin (Ecotrin).
c.
warfarin (Coumadin).
d.
nimodipine (Nimotop).
B
Following a TIA, patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Coumadin is usually used for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage.
40
A patient with a left-sided brain stroke suddenly bursts into tears when family members visit. The nurse should
a.
use a calm voice to ask the patient to stop the crying behavior.
b.
explain to the family that depression is normal following a stroke.
c.
have the family members leave the patient alone for a few minutes.
d.
teach the family that emotional outbursts are common after strokes.
D
Patients who have left-sided brain stroke are prone to emotional outbursts, which are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient’s outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient’s control and asking the patient to stop will lead to embarrassment.
41
The nurse obtains all of the following information about a 65-year-old patient in the clinic. When developing a plan to decrease stroke risk, which risk factor is most important for the nurse to address?
a.
The patient has a daily glass of wine to relax.
b.
The patient is 25 pounds above the ideal weight.
c.
The patient works at a desk and relaxes by watching television.
d.
The patient’s blood pressure (BP) is usually about 180/90 mm Hg.
D
Hypertension is the single most important modifiable risk factor and this patient’s hypertension is at the stage 2 level. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not so much as hypertension.
42
A patient with sudden-onset right-sided weakness has a CT scan and is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?
a.
The patient’s speech is difficult to understand.
b.
The patient’s blood pressure is 144/90 mm Hg.
c.
The patient takes a diuretic because of a history of hypertension.
d.
The patient has atrial fibrillation and takes warfarin (Coumadin).
D
The use of warfarin will have contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient’s care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.
43
A patient with right-sided weakness that started 90 minutes earlier is admitted to the emergency department and all these diagnostic tests are ordered. Which test should be done first?
a.
Electrocardiogram (ECG)
b.
Complete blood count (CBC)
c.
Chest radiograph (Chest x-ray)
d.
Noncontrast computed tomography (CT) scan
D
Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the smaller the area of brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.
44
A patient with a stroke has progressive development of neurologic deficits with increasing weakness and decreased level of consciousness (LOC). Which nursing diagnosis has the highest priority for the patient?
a.
Impaired physical mobility related to weakness
b.
Disturbed sensory perception related to brain injury
c.
Risk for impaired skin integrity related to immobility
d.
Risk for aspiration related to inability to protect airway
D
Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses also are appropriate, but interventions to prevent aspiration are the priority at this time.
45
A patient who has had a subarachnoid hemorrhage is being cared for in the intensive care unit. Which information about the patient is most important to communicate to the health care provider?
a.
The patient’s blood pressure is 90/50 mm Hg.
b.
The patient complains about having a stiff neck.
c.
The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).
d.
The patient complains of an ongoing severe headache.
A
To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider.
46
Which of these nursing actions included in the care of a patient who has been experiencing stroke symptoms for 60 minutes can the nurse delegate to an LPN/LVN?
a.
Assess the patient’s gag and cough reflexes.
b.
Determine when the stroke symptoms began.
c.
Administer the prescribed clopidogrel (Plavix).
d.
Infuse the prescribed IV metoprolol (Lopressor).
C
Administration of oral medications is included in LPN education and scope of practice. The other actions require more education and scope of practice and should be done by the RN.
47
After receiving change-of-shift report on the following four patients, which patient should the nurse see first?
a.
A patient with right-sided weakness who has an infusion of tPA prescribed
b.
A patient who has atrial fibrillation and a new order for warfarin (Coumadin)
c.
A patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due
d.
A patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled
A
tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury. The other medications also should be given as quickly as possible, but timing of the medications is not as critical.
48
The nurse is caring for a patient with carotid artery narrowing who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse?
a.
The pulse rate is 104 beats/min.
b.
The patient has difficulty talking.
c.
The blood pressure is 142/88 mm Hg.
d.
There are fine crackles at the lung bases.
B
Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual because of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure; the nurse should have the patient take some deep breaths.
49
A patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?
a.
Check the respiratory rate.
b.
Monitor the blood pressure.
c.
Send the patient for a CT scan.
d.
Obtain the Glasgow Coma Scale score.
A
The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, circulation) are completed.
50
A 58-year-old patient who began experiencing right-sided arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? Put a comma and space between each answer choice (a, b, c, d, etc.) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
a. Obtain CT scan without contrast.
b. Infuse tissue plasminogen activator (tPA).
c. Administer oxygen to keep O2 saturation \>95%.
d. Use National Institute of Health Stroke Scale to assess patient.
C, D, A, B
The initial actions should be those that help with airway, breathing, and circulation. Baseline neurologic assessments should be done next. A CT scan will be needed to rule out hemorrhagic stroke before tPA can be administered.
51
A patient has a systemic blood pressure of 120/60 mm Hg and an intracranial pressure (ICP) of 24 mm Hg. What does the nurse determine that the cerebral perfusion pressure (CPP) of this patient indicates?
a.
High blood flow to the brain
b.
Normal ICP
c.
Impaired blood flow to the brain
d.
Adequate autoregulation of cerebral blood flow
C
The patient’s CPP is 56 mm Hg, below the normal of 70 to 100 mm Hg and approaching the level of ischemia and neuronal death.
52
ICP monitoring is instituted for a patient with a head injury. The patient’s arterial blood pressure is 92/50 mm Hg, and her ICP is 18 mm Hg. Which nursing action is most appropriate?
a.
Document and continue to monitor the parameters.
b.
Elevate the head of the patient’s bed.
c.
Notify the physician about the assessments.
d.
Check the patient’s pupillary response to light.
C
The patient’s CPP is only 46 mm Hg, which will rapidly lead to cerebral ischemia and neuronal death unless rapid action is taken to reduce ICP and increase arterial blood pressure, so the most appropriate action is to contact the physician.
53
Patient manifestations of a headache, CSF leakage, and cranial nerve deficit are signs of which one of the following indications for cranial surgery?
a.
Brain tumour
b.
Skull fracture
c.
Hydrocephalus
d.
Intracranial infection
B
Patient manifestations of a headache, CSF leakage, and cranial nerve deficit indicate a skull fracture, which requires cranial surgery.
54
A patient with a serum sodium level of 115 mmol/L has a decreasing level of consciousness (LOC) and complains of a headache. Which of the following orders should be the priority?
a.
Administer acetaminophen (Tylenol) 650 mg orally.
b.
Administer 5% hypertonic saline intravenously.
c.
Draw blood for arterial blood gases (ABGs).
d.
Send the patient to the radiology department for computed tomography of the head.
B
The patient’s low sodium indicates that hyponatremia may be causing the cerebral edema, and the nurse’s first action should be to correct the low sodium level.
55
The wife of a patient who is in a coma is optimistic about her husband’s recovery because he opens his eyes and appears to be awake. What is the most appropriate response to the wife’s comment?
a.
“Your husband’s behaviour is only a reflex and does not really show improvement in his condition.”
b.
“Sleep–wake cycles are encouraging signs of recovery, and you should be optimistic about your husband’s condition.”
c.
“You are right to be optimistic. When patients begin to recover from a coma, the first behaviours seen are those of wakefulness.”
d.
“Your husband may show sleep–wake patterns if the part of the brain responsible for arousal is not injured, but these patterns do not reflect activity of the higher brain centres.”
D
Arousal is controlled by the reticular activating system in the brainstem and will allow the patient to maintain wakefulness even though the damage to the cerebral cortex is severe.
56
When assessing a patient with a head injury, what will the nurse recognize as an early indication of increased ICP?
a.
Vomiting
b.
Headache
c.
Change in the LOC
d.
Sluggish pupillary response to light
C
LOC is the most sensitive indicator of the patient’s neurological status and possible changes in ICP.
57
A patient is admitted to the hospital with a head injury resulting from an automobile accident. On admission, the patient’s vital signs are temperature 37°C, blood pressure 128/68 mm Hg, pulse 110 beats/min, and respiration 26 breaths/min. One hour after admission, which of the following vital signs does the nurse note indicates the presence of Cushing’s triad?
a.
Blood pressure 140/60 mm Hg, pulse 60 beats/min, respiration 14 breaths/min
b.
Blood pressure 130/72 mm Hg, pulse 90 beats/min, respiration 24 breaths/min
c.
Blood pressure 148/78 mm Hg, pulse 112 beats/min, respiration 28 breaths/min
d.
Blood pressure 110/70 mm Hg, pulse 120 beats/min, respiration 30 breaths/min
A
Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing’s triad and indicate that the ICP has increased and brain herniation may be imminent unless immediate action is taken to reduce the ICP.
58
Which of the following assessment data of the oculomotor nerve make the nurse suspicious of a possible supratentorial herniation and compression of the brainstem?
a.
Absent corneal reflexes
b.
Development of nystagmus
c.
Right pupil does not react to light
d.
Left pupil is 10 mm in size
C
A dilated pupil on the ipsilateral side in a patient with an acute brain injury indicates herniation.
59
When the nurse applies a painful stimulus to an unconscious patient, the patient responds by stiffly extending and abducting the arms and hyperpronating the wrists. How should the nurse interpret this finding?
a.
Decorticate posturing indicating an interruption of voluntary motor tracts
b.
Decerebrate posturing indicating an interruption of voluntary motor tracts
c.
Decorticate posturing indicating a disruption of motor fibres in the midbrain and brainstem
d.
Decerebrate posturing indicating a disruption of motor fibres in the midbrain and brainstem
D
With decerebrate posturing, the arms are stiffly extended, adducted, and hyperpronated.
60
When a patient’s ICP is being monitored with an intraventricular catheter, what is a priority nursing intervention?
a.
Maintaining strict aseptic technique to prevent infection
b.
Maintaining the patient’s head in a fixed position
c.
Continuous monitoring of the ICP waveform
d.
Removing CSF to keep pressure at normal levels
A
Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters; therefore, a priority intervention would be strict aseptic technique at all times.
61
The charge nurse observes a new graduate nurse who is caring for a patient who has had a craniotomy for a brain tumour. Which action by the new graduate requires the charge nurse to intervene and provide additional teaching?
a.
The new nurse has the patient breathe deeply and cough.
b.
The new nurse assesses neurological status every hour.
c.
The new nurse elevates the head of the bed to 30 degrees.
d.
The new nurse administers an analgesic before turning the patient.
A
Coughing can increase ICP and is generally discouraged in patients at risk for increased ICP.
62
A patient is brought to the emergency department by ambulance after she was found unconscious on the bathroom floor by her husband. In admitting the patient, what is it most important for the nurse to assess first?
a.
Health history
b.
Airway patency
c.
Neurological status
d.
Status of bodily functions
B
Airway patency and breathing are the most vital functions and should be assessed first.
63
Mechanical ventilation with a rate and volume to maintain a mild hyperventilation is used for a patient with a head injury. Which of the following should the nurse do to evaluate the effectiveness of the therapy?
a.
Monitor oxygen saturation.
b.
Check ABGs.
c.
Monitor ICP.
d.
Assess the patient’s breath sounds.
C
The purpose of hyperventilation for a patient with a head injury is reduction of ICP, and ICP should be monitored to evaluate whether the therapy is effective.
64
The physician prescribes intravenous (IV) mannitol (Osmitrol) for an unconscious patient. What would the nurse expect the therapeutic effect of this drug to result in?
a.
Decreased seizure activity
b.
Decreased cerebral edema
c.
Decreased cerebral metabolism
d.
Decreased cerebral inflammation
B
Mannitol is an osmotic diuretic and will reduce cerebral edema and ICP.
65
A patient with a severe head injury has been maintained on IV fluids of 5% dextrose in water (D5W) at 50 mL/hour for 4 days. The nurse will anticipate the need for which of the following?
a.
Continue the D5W to provide the needed glucose for brain function.
b.
Decrease the rate of IV infusion to avoid increasing cerebral edema.
c.
Insert an enteral feeding tube to provide nutritional replacement.
d.
Administer IV 5% albumin to increase serum protein levels.
C
The patient is in a hypermetabolic and hypercatabolic state, and enteral feedings will provide nutrients for brain function and for healing and immune function. D5W does not provide adequate nutrition to meet patient needs and can lead to lower serum osmolarity and cerebral edema.
66
When assessing a patient with a head injury, which assessment information is of most concern to the nurse?
a.
The blood pressure increases from 120/54 to 136/62 mm Hg.
b.
The patient is more difficult to arouse.
c.
The patient complains of a headache at pain level 5 of a 10-point scale.
d.
The patient’s apical pulse is slightly irregular.
B
The change in the LOC is an indicator of increased ICP and suggests that action by the nurse is needed to prevent complications.
67
A patient with a head injury opens his eyes when his name is called, curses when he is stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. How should the nurse record the patient’s Glasgow Coma Scale score?
a.
9
b.
11
c.
13
d.
15
B
The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.
68
The nurse identifies a nursing diagnosis of ineffective breathing pattern related to loss of central nervous system integrative function for a patient who has post-traumatic brain swelling based on which of the following findings?
a.
Apneustic breathing
b.
Crackles on inspiration
c.
Glasgow Coma Scale score less than 8
d.
CPP less than 60 mm Hg
A
Apneustic breathing is caused by loss of central nervous system integration in the pons and is not effective in maximizing gas exchange.
69
A woman is admitted unconscious to the emergency department after striking her head on a boulder while hiking. Her husband and three teenaged children will not leave her side and constantly ask about the treatment being given. What is the best approach to the patient’s family?
a.
Call the family’s pastor or spiritual advisor to support them while initial care is given.
b.
Refer the family members to the hospital counselling service to deal with their anxiety.
c.
Allow the family to stay with the patient, and explain all procedures thoroughly to them.
d.
Ask the family to wait in the waiting room until the initial assessment can be completed and care can be started.
C
The need for information about the diagnosis and care is very high in family members of acutely ill patients, and the nurse should allow the family to observe care and explain the procedures.
70
An unconscious patient has a nursing diagnosis of ineffective tissue perfusion (cerebral) related to cerebral tissue swelling. What is an appropriate nursing intervention for this problem?
a.
Elevate the head of the bed 30 degrees.
b.
Provide a position of comfort with the knees and hips flexed.
c.
Cluster nursing interventions to provide uninterrupted periods of rest.
d.
Teach the patient to cough and breathe deeply to prevent the necessity for suctioning.
A
The patient with increased ICP should be maintained in the head-up position to help reduce ICP.
71
The nurse notes that a patient with a head injury has a clear nasal drainage. What is the most appropriate nursing action for this finding?
a.
Obtain a specimen of the fluid for culture and sensitivity.
b.
Check the nasal drainage for glucose with a Dextrostix or Tes-Tape.
c.
Take the patient’s temperature to determine whether a fever is present.
d.
Instruct the patient to blow his nose and then check the nares for inflammation.
B
If the drainage is CSF leakage from a dural tear, glucose will be present.
72
A patient was brought to the emergency department when he became faint and disoriented after being hit in the head with a baseball bat during a company picnic. On admission, he has a headache and cannot remember being hit, but he has no other signs of neurological deficit. What would the nurse expect treatment for the patient to include?
a.
Diagnostic testing with magnetic resonance imaging
b.
Hospitalization for observation for 24 hours
c.
Discharge with observation and monitoring instructions
d.
Administration of a narcotic for the headache, followed by observation for several hours
C
A patient with a minor head trauma is usually discharged with instructions about neurological monitoring and the need to return if neurological status deteriorates.
73
A victim of an automobile accident was found unconscious at the scene of the accident but regained consciousness during transport to the hospital. Shortly after admission, her Glasgow Coma Scale score is 8, and an acute epidural hematoma is suspected. The nurse plans care for the patient based on the expectation that which of the following treatments will be included?
a.
Immediate craniotomy
b.
Administration of IV furosemide (Lasix)
c.
Administration of IV corticosteroids
d.
Endotracheal intubation with mechanical ventilation
A
As the Glasgow Coma Scale indicates a severe head injury, the principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation; therefore, an immediate craniotomy is expected.
74
The nurse notes clear drainage from the nose of a patient with a frontal skull fracture and recognizes that which of the following interventions is absolutely contraindicated for this patient?
a.
Lying flat
b.
Eating solid food
c.
Inserting a nasogastric tube
d.
Cold packs for facial bruising
C
Rhinorrhea may indicate a dural tear with CSF leakage, and insertion of a nasogastric tube will increase the risk for infections such as meningitis.
75
In planning long-term care for the patient following brain trauma, what is the primary reason the nurse includes teaching and support for the family?
a.
Patients will always have some residual deficits of the brain damage.
b.
Most patients experience seizure disorders in the weeks or even years following head injury.
c.
Families become dysfunctional and unable to cope with the role reversals required during convalescence.
d.
Patients with head injuries with unconsciousness often have changes in personality with loss of concentration and memory processing.
D
Changes in personality, concentration, and memory are common after severe head injury and require anticipatory guidance for the patient and family.
76
During the assessment of a patient who has a tumour of the left frontal lobe, what would the nurse expect to find?
a.
Speech disturbances
b.
Ataxic gait and vertigo
c.
Personality and judgement changes
d.
Papilledema and vision disturbances
C
The frontal lobes control intellectual activities such as judgement.
77
A patient with increasing headaches who is having diagnostic testing for a brain tumour asks the nurse what type of treatment will be used if a tumour is discovered. Which response is most appropriate?
a.
“If the tumour is benign, treatment may not be necessary.”
b.
“Therapy to remove or reduce the tumour size will be recommended.”
c.
“Surgery will initially be used to reduce or remove the tumour.”
d.
“Chemotherapy is used to shrink the tumour, followed by craniotomy.”
B
Treatment is designed to reduce tumour size or remove the tumour.
78
Which one of the following types of cranial surgery is done to remove a bone flap?
a.
Burr hole
b.
Craniotomy
c.
Craniectomy
d.
Cranioplasty
C
A craniectomy is an excision into the cranium to cut away a bone flap.
79
Which one of the following can be caused by bacteria, fungi, a parasite, or a virus?
a.
Meningitis
b.
Brain abscess
c.
Encephalitis
d.
Brain hemorrhage
C
Encephalitis can be caused by bacteria, fungi, a parasite, or a virus.
80
Following a craniotomy with a craniectomy and left anterior fossa incision, the patient has a nursing diagnosis of ineffective protection related to decreased level of consciousness and weakness. What does an appropriate nursing intervention for the patient include?
a.
Assessing for changes in motor ability daily
b.
Performing range-of-motion exercises every 4 hours
c.
Turning and repositioning the patient side to side every 4 hours
d.
Eliminating extraneous noise to prevent sensory overload
B
Range-of-motion exercises will help prevent the complications of immobility.
81
Direct extension from a local infection in which of the following locations can be a primary cause of a brain abscess?
a.
Eye
b.
Ear
c.
Lung
d.
Endocardium
B
Direct extension from a local ear infection can be a primary cause of a brain abscess; others include tooth, mastoid, or sinus infection.
82
Rabies manifests as which of the following?
a.
Bacterial meningitis
b.
Viral encephalitis
c.
Viral meningitis
d.
Bacterial encephalitis
B
The cause of rabies is an RNA virus that produces an acute, progressive viral encephalitis.
83
A patient admitted with bacterial meningitis and a temperature of 38.9°C has orders for all of these collaborative interventions. Which one should the nurse accomplish first?
a.
IV ceftizoxime (Cefizox) 1 g now and every 6 hours
b.
IV dexamethasone (Decadron) 4 mg now
c.
Hypothermia blanket to keep the temperature less than 38.7°C
d.
Nasopharyngeal swab for culture and sensitivity
D
Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics are started.
84
The community health nurse is developing a program to decrease the incidence of meningitis in adolescents and young adults. Which nursing action is most important?
a.
Emphasize the importance of handwashing to prevent the spread of infection.
b.
Immunize adolescents and college freshmen against Neisseria meningitidis.
c.
Vaccinate 11- and 12-year-old children against Haemophilus influenzae.
d.
Encourage adolescents and young adults to avoid crowded areas in the winter.
B
The N. meningitidis vaccination is recommended for children ages 11 and 12, unvaccinated teens entering high school, and college/university freshmen.
85
After teaching a patient about management of migraine headaches, the nurse determines that the teaching has been effective when the patient says,
a.
“I will take the (Topamax) as soon as any headaches start.”
b.
“I should avoid taking aspirin and sumatriptan (Imitrex) 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.”
C
It is recommended that the patient with a migraine rest in a dark, quiet area. Topiramate (Topamax) is used to prevent migraines and must be taken for several months to determine effectiveness. Aspirin or other nonsteroidal anti-inflammatory medications can be taken with the triptans. Alcohol may precipitate migraine headaches.
86
When a patient is experiencing a cluster headache, the nurse will plan to assess for
a.
nuchal rigidity.
b.
projectile vomiting.
c.
unilateral eyelid swelling.
d.
throbbing, bilateral facial pain.
C
Unilateral eye edema, tearing, and ptosis are characteristic of cluster headaches. Nuchal rigidity suggests meningeal irritation, such as occurs with meningitis. Although nausea and vomiting may occur with migraine headaches, projectile vomiting is more consistent with increases in intracranial pressure (ICP). Unilateral sharp, stabbing pain, rather than throbbing pain, is characteristic of cluster headaches.
87
A patient has a tonic-clonic seizure while the nurse is in the patient’s room. Which action should the nurse take?
a.
Insert an oral airway during the seizure to maintain a patent airway.
b.
Restrain the patient’s arms and legs to prevent injury during the seizure.
c.
Avoid touching the patient to prevent further nervous system stimulation.
d.
Time and observe and record the details of the seizure and postictal state.
D
Because diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure.
88
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 response by the nurse is best?
a.
“You may want to contact the Epilepsy Foundation for assistance.”
b.
“You might benefit from some psychologic counseling at this time.”
c.
“The Department of Vocational Rehabilitation can help with work retraining.”
d.
“Most patients with epilepsy are well controlled with antiseizure medications.”
D
The nurse should inform the patient that most patients with seizure disorders are controlled with medication. The other information may be necessary if the patient seizures persist after treatment with antiseizure medications is implemented.
89
Which action will the nurse take when evaluating a patient who is taking phenytoin (Dilantin) 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.
A
Phenytoin can cause gingival hyperplasia, but does not affect bowel tones, lung sounds, or pupil reaction to light.
90
A patient found in a tonic-clonic seizure reports afterward that the seizure was preceded by numbness and tingling of the arm. The nurse knows that this finding indicates what type of seizure?
a.
Atonic
b.
Partial
c.
Absence
d.
Myoclonic
A
The initial symptoms of a partial seizure involve clinical manifestations that are localized to a particular part of the body or brain. Symptoms of an absence seizure are staring and a brief loss of consciousness. In an atonic seizure, the patient loses muscle tone and (typically) falls to the ground. Myoclonic seizures are characterized by a sudden jerk of the body or extremities.
91
When obtaining a health history and physical assessment for a patient with possible multiple sclerosis (MS), the nurse should
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 patient about any increase in libido.
B
Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS.
92
A 28-year-old woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which response by the nurse is accurate?
a.
“MS symptoms may be worse after the pregnancy.”
b.
“Women with MS frequently have premature labor.”
c.
“Symptoms of MS are likely to become worse during pregnancy.”
d.
“MS is associated with a slightly increased risk for congenital defects.”
A
During the postpartum period, women with MS are at greater risk for exacerbation of symptoms. There is no increased risk for congenital defects in infants born of mothers with MS. Symptoms of MS may improve during pregnancy. Onset of labor is not affected by MS.
93
A patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching?
a.
Recommendation to drink at least 3 to 4 L daily
b.
Need to avoid driving or operating heavy machinery
c.
How to draw up and administer injections of the medication
d.
Use of contraceptive methods other than oral contraceptives
C
Copaxone is administered by self-injection. Oral contraceptives are an appropriate choice for birth control. There is no need to avoid driving or drink large fluid volumes when taking glatiramer.
94
Which information about a patient with MS indicates that the nurse should consult with the health care provider before giving the prescribed dose of dalfampridine (Ampyra)?
a.
The patient has relapsing-remitting MS.
b.
The patient enjoys walking for relaxation.
c.
The patient has an increased creatinine level.
d.
The patient complains of pain with neck flexion.
C
Dalfampridine should not be given to patients with impaired renal function. The other information will not impact on whether the dalfampridine should be administered.
95
A patient with multiple sclerosis (MS) has urinary retention caused by a flaccid bladder. Which action will the nurse plan to take?
a.
Teach the patient how to use the Credé method.
b.
Decrease the patient’s fluid intake in the evening.
c.
Suggest the use of incontinence briefs for nighttime use only.
d.
Assist the patient to the commode every 2 hours during the day.
A
The Credé method can be used to improve bladder emptying. Decreasing fluid intake will not improve bladder emptying and may increase risk for urinary tract infection (UTI) and dehydration. The use of incontinence briefs and frequent toileting will not improve bladder emptying.
96
A patient with Parkinson’s disease has a nursing diagnosis of impaired physical mobility related to bradykinesia. Which action will the nurse include in the plan of care?
a.
Instruct the patient in activities that can be done while lying or sitting.
b.
Suggest that the patient rock from side to side to initiate leg movement.
c.
Have the patient take small steps in a straight line directly in front of the feet.
d.
Teach the patient to keep the feet in contact with the floor and slide them forward.
B
Rocking the body from side to side stimulates balance and improves mobility. The patient will be encouraged to continue exercising because this will maintain functional abilities. Maintaining a wide base of support will help with balance. The patient should lift the feet and avoid a shuffling gait.
97
A patient has a new prescription for bromocriptine (Parlodel) to control symptoms of Parkinson’s disease. Which information obtained by the nurse may indicate a need for a decrease in the dose?
a.
The patient has a chronic dry cough.
b.
The patient has four loose stools in a day.
c.
The patient develops a deep vein thrombosis.
d.
The patient’s blood pressure is 90/46 mm Hg.
D
Hypotension is an adverse effect of bromocriptine, and the nurse should check with the health care provider before giving the medication. Diarrhea, cough, and deep vein thrombosis are not associated with bromocriptine use.
98
When teaching a patient with myasthenia gravis (MG) about management of the disease, the nurse advises the patient to
a.
perform physically demanding activities in the morning.
b.
anticipate the need for weekly plasmapheresis treatments.
c.
do frequent weight-bearing exercise to prevent muscle atrophy.
d.
protect the extremities from injury due to poor sensory perception.
A
Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then. Plasmapheresis is not routinely scheduled but is used for myasthenia crisis or for situations in which corticosteroid therapy should be discontinued. There is no decrease in sensation with MG, and muscle atrophy does not occur because muscles are used during part of the day.
99
A patient who is seen in the outpatient clinic complains of restless legs syndrome. Which of the following over-the-counter medications that the patient is taking routinely should the nurse discuss with the patient?
a.
multivitamin (Stresstabs)
b.
acetaminophen (Tylenol)
c.
ibuprofen (Motrin, Advil)
d.
diphenhydramine (Benadryl)
D
Antihistamines can aggravate restless legs syndrome. The other medications will not contribute to the restless legs syndrome.
100
A patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?
a.
Assist with active range of motion.
b.
Observe for agitation and paranoia.
c.
Give muscle relaxants as needed to reduce spasms.
d.
Use simple words and phrases to explain procedures.
A
ALS causes progressive muscle weakness, but assisting the patient to perform active ROM will help to maintain strength as long as possible. Psychotic symptoms such as agitation and paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the patient’s ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations.
101
A 42-year-old patient who was adopted at birth is diagnosed with early Huntington’s disease (HD). When teaching the patient, spouse, and children about this disorder, the nurse will provide information about the
a.
use of levodopa-carbidopa (Sinemet) 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 patient’s children.
D
Genetic testing is available to determine whether an asymptomatic individual has the HD gene. The patient and family should be informed of the benefits and problems associated with genetic testing. Sinemet will increase symptoms of HD given that HD involves an increase in dopamine. Antibiotic therapy will not reduce the risk for aspiration. There are no effective treatments or lifestyle changes that delay the progression of symptoms in HD.
102
A patient is seen in the health clinic with symptoms of a stooped posture, shuffling gait, and pill rolling–type tremor. The nurse will anticipate teaching the patient about
a.
oral corticosteroids.
b.
antiparkinsonian drugs.
c.
the purpose of electroencephalogram (EEG) testing.
d.
preparation for magnetic resonance imaging (MRI).
B
The diagnosis of Parkinson’s is made when two of the three characteristic signs of tremor, rigidity, and bradykinesia are present. The confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered. This patient has symptoms of tremor and bradykinesia; the next anticipated step will be treatment with medications. MRI and EEG are not useful in diagnosing Parkinson’s disease, and corticosteroid therapy is not used to treat it.
103
A patient seen at the health clinic with a severe migraine headache tells the nurse about having four similar headaches in the last 3 months. Which initial action should the nurse take?
a.
Refer the patient for stress counseling.
b.
Ask the patient to keep a headache diary.
c.
Suggest the use of muscle-relaxation techniques.
d.
Teach about the effectiveness of the triptan drugs.
B
The initial nursing action should be further assessment of the precipitating causes of the headaches, quality, and location of pain, etc. Stress reduction, muscle relaxation, and the triptan drugs may be helpful, but more assessment is needed first.
104
A hospitalized patient complains of a moderate bilateral headache that radiates from the base of the skull. Which of these prescribed PRN medications should the nurse administer initially?
a.
lorazepam (Ativan)
b.
acetaminophen (Tylenol)
c.
morphine sulfate (Roxanol)
d.
butalbital and aspirin (Fiorinal)
B
The patient’s symptoms are consistent with a tension headache, and initial therapy usually involves a nonopioid analgesic such as acetaminophen, sometimes combined with a sedative or muscle relaxant. Lorazepam may be used in conjunction with acetaminophen but would not be appropriate as the initial monotherapy. Morphine sulfate and butalbital and aspirin would be more appropriate for a headache that did not respond to a nonopioid analgesic.
105
A patient tells the nurse about using acetaminophen (Tylenol) several times every day for recurrent bilateral headaches. Which action will the nurse plan to take first?
a.
Discuss the need to stop taking the acetaminophen.
b.
Suggest the use of biofeedback for headache control.
c.
Teach the patient about magnetic resonance imaging (MRI).
d.
Describe the use of botulism toxin (BOTOX) for headaches.
A
The headache description suggests that the patient is experiencing medication overuse headache. The initial action will be withdrawal of the medication. The other actions may be needed if headaches persist.
106
The health care provider is considering the use of sumatriptan (Imitrex) for a patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider?
a.
The patient has at least 1 to 2 cups of coffee daily.
b.
The patient has had migraine headaches for 30 years.
c.
The patient has a history of a recent acute myocardial infarction.
d.
The patient has been taking topiramate (Topamax) for 2 months.
C
The triptans cause coronary artery vasoconstriction and should be avoided in patients with coronary artery disease. The other information will be reported to the health care provider, but none of it is an indication that sumatriptan would be an inappropriate treatment.
107
The nurse witnesses a patient with a seizure disorder as the patient suddenly jerks the arms and legs, falls to the floor, and regains consciousness immediately. It will be most important for the nurse to
a.
assess the patient for a possible head injury.
b.
give the scheduled dose of divalproex (Depakote).
c.
document the timing and description of the seizure.
d.
notify the patient’s health care provider about the seizure.
A
The patient who has had a myoclonic seizure and fall is at risk for head injury and should be evaluated and treated for this possible complication first. Documentation of the seizure, notification of the seizure, and administration of antiseizure medications also are appropriate actions, but the initial action should be assessment for injury.
108
Which of these prescribed interventions will the nurse implement first for a hospitalized patient who is experiencing continuous tonic-clonic seizures?
a.
Give phenytoin (Dilantin) 100 mg IV.
b.
Monitor level of consciousness (LOC).
c.
Obtain computed tomography (CT) scan.
d.
Administer lorazepam (Ativan) 4 mg IV.
D
To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary. Phenytoin also will be administered, but it is not rapidly acting. Patients who are experiencing tonic-clonic seizures are nonresponsive, although the nurse should assess LOC after the seizure.
109
When the home health RN is planning care for a patient with a seizure disorder, which nursing action can be delegated to an LPN/LVN?
a.
Make referrals to appropriate community agencies.
b.
Place medications in the home medication organizer.
c.
Teach the patient and family how to manage seizures.
d.
Assess for use of medications that may precipitate seizures.
B
LPN/LVN education includes administration of medications. The other activities require RN education and scope of practice.
110
Which information about a patient who is being treated with carbidopa/levodopa (Sinemet) for Parkinson’s disease is most important for the nurse to report to the health care provider?
a.
Shuffling gait
b.
Tremor at rest
c.
Cogwheel rigidity of limbs
d.
Uncontrolled head movement
D
Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other findings are typical with Parkinson’s disease.
111
A patient with Parkinson’s disease has decreased tongue mobility and an inability to move the facial muscles. Which nursing diagnosis is of highest priority?
a.
Activity intolerance
b.
Self-care deficit: toileting
c.
Ineffective self-health management
d.
Imbalanced nutrition: less than body requirements
D
The data about the patient indicate that poor nutrition will be a concern because of decreased swallowing. The other diagnoses also may be appropriate for a patient with Parkinson’s disease, but the data do not indicate they are current problems for this patient.
112
When the nurse is assessing a patient with myasthenia gravis, which action will be most important to take?
a.
Check pupillary size.
b.
Monitor grip strength.
c.
Observe respiratory effort.
d.
Assess level of consciousness.
C
Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical.
113
Following a thymectomy, a patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first?
a.
Auscultate the patient’s bowel sounds.
b.
Notify the patient’s health care provider.
c.
Administer the prescribed PRN antiemetic drug.
d.
Give the scheduled dose of prednisone (Deltasone).
B
The patient’s history and symptoms indicate a possible cholinergic crisis. The health care provider should be notified immediately, and it is likely that atropine will be prescribed. The other actions will be appropriate if the patient is not experiencing a cholinergic crisis.
114
A hospitalized 24-year-old patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first?
a.
Start the ordered PRN oxygen at 6 L/min.
b.
Put a moist hot pack on the patient’s neck.
c.
Give the ordered PRN acetaminophen (Tylenol).
d.
Notify the patient’s health care provider immediately.
A
Acute treatment for cluster headache is administration of 100% oxygen at 6 to 8 L/min. If the patient obtains relief with the oxygen, there is no immediate need to notify the health care provider. Cluster headaches last only 60 to 90 minutes, so oral pain medications have minimal effect. Hot packs are helpful for tension headaches but are not as likely to reduce pain associated with a cluster headache.
115
When preparing to admit a patient who has been treated for status epilepticus in the emergency department, which equipment should the nurse have available in the room (select all that apply)?
a.
Siderail pads
b.
Tongue blade
c.
Oxygen mask
d.
Suction tubing
e.
Nasogastric tube
A, C, D
The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The bed’s side rails should be padded to minimize the risk for patient injury during a seizure. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. Use of tongue blades during a seizure is contraindicated.
116
A patient with Parkinson’s disease is admitted to the hospital for treatment of an acute infection. Which nursing interventions will be included in the plan of care (select all that apply)?
a.
Use an elevated toilet seat.
b.
Cut patient’s food into small pieces.
c.
Provide high protein foods at each meal.
d.
Place an arm chair at the patient’s bedside.
e.
Observe for sudden exacerbation of symptoms.
A, B, D
Since the patient with Parkinson’s has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High protein foods will decrease the effectiveness of L-dopa. Parkinson’s is a steadily progressive disease without acute exacerbations.
117
The nurse obtains all of the following information about a 65-year-old patient in the clinic. When developing a plan to decrease stroke risk, which risk factor is most important for the nurse to address?
a.
The patient smokes a pack of cigarettes daily.
b.
The patient’s blood pressure is chronically between 150/80 and 170/90 mm Hg.
c.
The patient works at a desk and relaxes by watching television.
d.
The patient is 11.3 kg above the ideal weight.
B
Hypertension is the most important modifiable risk factor.
118
A patient with right-sided weakness that started 1 hour ago is admitted to the emergency department, and the following diagnostic tests are ordered. Which order should the nurse act on first?
a.
Chest radiograph
b.
Electrocardiogram
c.
Complete blood count
d.
Noncontrast computed tomography (CT) scan
D
Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 3 hours of the onset of clinical manifestations of the stroke.
119
The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include which of the following treatments?
a.
Oral administration of clopidogrel (Plavix)
b.
Heparin via continuous intravenous (IV) infusion
c.
Prophylactic clipping of cerebral aneurysms
d.
Therapy with tPA
A
The patient’s symptoms are consistent with transient ischemic attack (TIA), and medications that inhibit platelet aggregation are prescribed after a TIA to prevent stroke.
120
Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the physician?
a.
The patient has atrial fibrillation.
b.
The patient has dysphasia.
c.
The patient states, “I suddenly developed a terrible headache.”
d.
The patient has a history of brief episodes of right hemiplegia.
C
A sudden-onset headache is typical of a subarachnoid hemorrhage and ruptured aneurysm; the physician should be notified immediately.
121
A patient with a stroke caused by thrombosis of the middle cerebral artery experiences left-sided paralysis of the upper and lower extremities and facial drooping on the left side. When obtaining admission assessment data about the patient’s clinical manifestations, it is most important for the nurse to assess which of the following?
a.
The patient’s ability to follow commands
b.
The patient’s visual fields
c.
The patient’s left-sided reflexes
d.
The patient’s emotional state
A
Because the patient with a right-sided brain stroke may have difficulty with comprehension and use of language, it is important to obtain baseline data about the ability to follow commands.
122
On the medical unit, the nurse receives a verbal report from the emergency department nurse that a patient has an occlusion of the left posterior cerebral artery. When admitting the patient to the medical floor, which of the following will the nurse anticipate that the patient may be experiencing?
a.
Visual deficits
b.
Dysphasia
c.
Confusion
d.
Poor judgement
A
Visual disturbances are expected with posterior cerebral artery occlusion.
123
Which one of the following manifestations would the nurse expect to assess on a patient with right-brain damage from a stroke?
a.
Right-sided hemiplegia
b.
Slow performance, cautiousness
c.
Aware of deficits, depression
d.
Impulsive behaviour
D
A patient with right-brain damage from a stroke would manifest impulsive behaviour, thus safety is a main priority of care.
124
The physician recommends a carotid endarterectomy for a patient with carotid atherosclerosis and a history of TIAs. The patient asks the nurse whether this procedure involves brain surgery. In responding to the patient, what should the nurse include information about?
a.
An endarterectomy involves brain surgery because plaques in arteries at the base of the brain are removed.
b.
This surgery involves resection of a diseased portion of the artery in the brain and replacing it with a synthetic graft.
c.
A carotid endarterectomy involves removal of plaques in an artery in the neck and does not involve surgery in the brain.
d.
In this surgery, a burr hole is drilled in the skull to connect an artery outside the skull to one inside the brain, bypassing a blockage.
C
In a carotid endarterectomy, the carotid artery is incised and the plaque is removed.
125
On initial assessment of a patient hospitalized following a stroke, the nurse finds the patient’s blood pressure to be 180/90 mm Hg. What should the nurse anticipate?
a.
IV fluids will be withheld until the blood pressure is within the normal range.
b.
Unless the blood pressure is lowered, the patient is at risk for another stroke.
c.
IV fluids will be administered to promote hydration to maintain cerebral perfusion.
d.
IV antihypertensive agents will be administered to maintain a mean arterial pressure of 140 mm Hg.
C
Fluid intake should be 1500 to 2000 mL daily to maintain cerebral blood flow.
126
A 68-year-old man has had several TIAs with temporary hemiparesis and dysarthria that have lasted up to an hour. The nurse encourages the patient to seek immediate medical assistance for any symptoms that last longer than an hour, explaining that permanent disability from a stroke may be reduced if therapy is initiated within 3 hours with the use of which of the following treatments?
a.
IV heparin
b.
Transluminal angioplasty
c.
A surgical endarterectomy
d.
tPA
D
The patient’s history and clinical manifestations suggest an acute ischemic stroke, and a patient who is seen within 3 hours of stroke onset is likely to receive tPA (after screening with a CT scan).
127
The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. What is an appropriate nursing intervention to help the patient communicate?
a.
Ask simple questions that can be answered with “yes” or “no.”
b.
Develop a list of simple words that she can read and practise reciting.
c.
Have her practise facial and tongue exercises to improve motor control necessary for speech.
d.
Prevent embarrassing her by changing the subject if she does not respond in a timely manner.
A
Communication will be facilitated and less frustrating to the patient when questions that require a “yes” or “no” response are used.
128
Twenty-four hours after admission, a patient with a stroke has progressive development of neurological deficits with increasing weakness and decreased level of consciousness. What is the primary goal of nursing management of the patient at this time?
a.
Protecting the skin from breakdown
b.
Monitoring for changes in neurological status
c.
Maintaining the patient’s respiratory function
d.
Preventing joint contractures and muscle atrophy
C
Protection of the airway is the priority of nursing care for a patient having an acute stroke.
129
Which classification of stroke is the most common one, representing approximately 80% of all strokes?
a.
Intercerebral stroke
b.
Ischemic stroke
c.
Hemorrhagic stroke
d.
Subarachnoid stroke
B
Ischemic strokes account for approximately 80% of all strokes.
130
A patient with homonymous hemianopsia resulting from a stroke has a nursing diagnosis of disturbed sensory perception related to hemianopsia. What is an appropriate nursing intervention that will help the patient learn to compensate for the deficit during the rehabilitation period?
a.
Apply an eye patch to the affected eye.
b.
Approach the patient on the unaffected side.
c.
Place objects necessary for activities of daily living on the affected side.
d.
Teach the patient to exercise the eye muscles with full range of motion at least twice a day.
C
During the rehabilitation period, placing objects on the affected side will encourage the patient to use the scanning technique to visualize the affected side.
131
During the acute phase of a patient with an ischemic stroke, the nurse monitors the patient’s neurological status closely with the knowledge that following a stroke, increased intracranial pressure from cerebral edema is most likely to peak in which of the following time periods?
a.
12 hours
b.
24 hours
c.
48 hours
d.
72 hours
D
Increased intracranial pressure from cerebral edema usually peaks in 72 hours and may cause brain herniation.
132
The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to inability to feed self for a patient with right-sided hemiplegia. What is an appropriate nursing intervention to help improve the patient’s nutrition?
a.
Assist the patient to eat with her left hand.
b.
Provide a puréed diet that is easy for the patient to swallow.
c.
Stroke the patient’s throat while feeding her to stimulate swallowing of food.
d.
Provide a wide variety of food choices on the meal tray to stimulate her appetite.
A
Because the nursing diagnosis indicates that the patient’s imbalanced nutrition is related to the right-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use the left hand for self-feeding.
133
The nurse is assisting the patient who is recovering from an acute stroke and has right-sided hemiplegia to transfer from the bed to the wheelchair. Which nursing action is appropriate?
a.
Positioning the wheelchair next to the bed on the patient’s right side
b.
Placing the wheelchair parallel to the bed on the patient’s left side
c.
Setting the wheelchair directly in front of the patient, who is sitting on the side of the bed
d.
Moving the wheelchair a few steps from the bed and having the patient walk to the chair
B
Placing the wheelchair on the patient’s left side will allow the patient to use the left hand to grasp the left arm of the chair to transfer. If the chair is placed on the patient’s right side or in front of the patient, it will be awkward to use the strong arm, and the patient will be at increased risk for a fall.
134
A 32-year-old patient has a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan?
a.
Encouraging the patient to cough and breathe deeply every 4 hours
b.
Inserting an oropharyngeal airway to prevent airway obstruction
c.
Assisting the patient to dangle on the edge of the bed and assessing for dizziness
d.
Applying intermittent pneumatic compression stockings
D
The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for deep-vein thrombosis.
135
When initiating oral feedings for a patient with a stroke, the nurse determines that the patient has an intact gag reflex and then does which of the following actions?
a.
Offers the patient a sip of juice
b.
Orders a varied puréed diet
c.
Assesses the patient’s appetite
d.
Assists the patient into a chair
D
The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk.
136
A patient has right-sided paresis and aphasia as a result of a stroke but is attempting to use his left hand for feeding and other activities. When his wife visits, she insists on doing everything for him. What is a nursing diagnosis that is most appropriate in this situation?
a.
Situational low self-esteem related to increasing dependence on others
b.
Interrupted family processes related to effects of illness of a family member
c.
Disabled family coping related to inadequate understanding by primary person
d.
Risk for ineffective therapeutic regimen management related to functional and communication limitations
C
The information supports the diagnosis of disabled family coping because the wife does not understand the rehabilitation program.
137
Following a stroke, a patient has urinary incontinence with an impaired impulse to void. What should a bladder retraining program for the patient include?
a.
Limiting fluid intake to 1000 mL/day to reduce urine volume
b.
Assisting the patient onto the bedpan or the bedside commode every 2 hours
c.
Performing intermittent catheterization after each voiding to check for residual urine
d.
Inserting an in-dwelling catheter and clamping and draining the catheter every 4 hours to re-establish bladder tone
B
Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder.
138
A 72-year-old man is being discharged home following a stroke. He is able to walk with assistance but needs help with hygiene, dressing, and eating. The patient’s 70-year-old wife has received instruction and practice in necessary areas of care. Which of the following statements by the patient’s wife indicates to the nurse that the outcomes for discharge planning have been met?
a.
“I can handle all of my husband’s needs with the instruction provided.”
b.
“I have arranged for a home health aide to provide all the care my husband will need.”
c.
“I can provide the care my husband needs if I use the support and resources available in the community.”
d.
“Because my husband will have continuous improvement in his condition, I won’t need outside assistance in his care for very long.”
C
The statement that community resources will be used indicates a realistic outcome. The patient is unlikely to continue to improve to the point of needing no assistance.
139
A patient who has a history of a TIA has an order for aspirin 160 mg daily. When the nurse is administering the medications, the patient says, “I don’t need the aspirin today. I don’t have any aches or pains.” Which action should the nurse take?
a.
Document that the aspirin was refused by the patient.
b.
Call the physician to clarify the medication order.
c.
Explain that the aspirin is ordered to decrease stroke risk.
d.
Tell the patient that the aspirin is used to prevent aches.
C
Aspirin is ordered to prevent stroke in patients who have experienced TIAs.
140
A patient is admitted to the hospital with dysphasia and right-sided weakness that resolves in a few hours. The nurse will anticipate teaching the patient about which of the following medications?
a.
Alteplase (tPA)
b.
Aspirin (Aggrenox)
c.
Warfarin (Coumadin)
d.
Nimodipine (Nimotop)
B
Following a TIA, patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk.
141
In order to assess a patient’s receptive speech, what should the nurse do?
a.
Ask the patient where she is right now.
b.
Show the patient three items, and ask the patient to name them.
c.
Instruct the patient to close the eyes, ask if a stone sinks in water, and get her to point to the ceiling.
d.
Ask the patient the time of day, what month, and what year it is.
C
Instructing the patient to close her eyes, asking if a stone sinks in water, and getting her to point to the ceiling is the assessment for receptive speech that the nurse would implement.
142
A patient with left-sided hemiparesis arrives by ambulance at the emergency department. Which action should the nurse take first?
a.
Obtain the Glasgow Coma Scale score.
b.
Check the respiratory rate.
c.
Monitor the blood pressure.
d.
Send the patient for a CT scan.
B
The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway.
143
Obesity is a modifiable risk factor for the prevention of stroke. What is the prevalence of obesity in Canada among those aged 18 years and older?
a.
30%
b.
50%
c.
60%
d.
75%
C
Over half (60%) of all Canadians aged 18 years and older are obese.
144
Which one of the following manifestations would the nurse expect to assess on a patient with left-brain damage from a stroke?
a.
Left-sided hemiplegia
b.
Spatial–perceptual deficits
c.
Impaired speech–language
d.
Impaired time concepts
C
A patient with left-brain damage will manifest impaired speech–language.
145
A patient who is hospitalized with pneumonia is disoriented and confused 2 days after admission. Which information obtained by the nurse about the patient indicates that the patient is experiencing delirium rather than dementia?
a.
The patient was oriented and alert when admitted.
b.
The patient’s speech is fragmented and incoherent.
c.
The patient is disoriented to place and time but oriented to person.
d.
The patient has a history of increasing confusion over several years.
A
The onset of delirium occurs acutely. The degree of disorientation does not differentiate between delirium and dementia. Increasing confusion for several years is consistent with dementia. Fragmented and incoherent speech may occur with either delirium or dementia.
146
When developing a plan of care for a hospitalized patient with moderate dementia, which intervention will the nurse include?
a.
Provide complete personal hygiene care for the patient.
b.
Remind the patient frequently about being in the hospital.
c.
Reposition the patient frequently to avoid skin breakdown.
d.
Place suction at the bedside to decrease the risk for aspiration.
B
The patient with moderate dementia will have problems with short- and long-term memory and will need reminding about the hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty with swallowing, self-care, and immobility.
147
When administering a mental status examination to a patient with delirium, the nurse should
a.
medicate the patient first to reduce any anxiety.
b.
give the examination when the patient is well-rested.
c.
reorient the patient as needed during the examination.
d.
choose a place without distracting environmental stimuli.
D
Because overstimulation by environmental factors can distract the patient from the task of answering the nurse’s questions, these stimuli should be avoided. The nurse will not wait to give the examination because action to correct the delirium should occur as soon as possible. Reorienting the patient is not appropriate during the examination. Antianxiety medications may increase the patient’s delirium.
148
To protect a patient from injury during an episode of delirium, the most appropriate action by the nurse is to
a.
secure the patient in bed using a soft chest restraint.
b.
ask the health care provider about ordering an antipsychotic drug.
c.
instruct family members to remain with the patient and prevent injury.
d.
assign a nursing assistant to stay with the patient and offer frequent reorientation.
D
The priority goal is to protect the patient from harm, and a staff member will be most experienced in providing safe care. Visits by family members are helpful in reorienting the patient, but families should not be responsible for protecting patients from injury. Antipsychotic medications may be ordered, but only if other measures are not effective because these medications have multiple side effects. Restraints are sometimes used but tend to increase agitation and disorientation.
149
Which action will the nurse in the outpatient clinic include in the plan of care for a patient with mild cognitive impairment (MCI)?
a.
Suggest a move into an assisted living facility.
b.
Schedule the patient for more frequent appointments.
c.
Ask family members to supervise the patient’s daily activities.
d.
Discuss the preventive use of acetylcholinesterase medications.
B
Ongoing monitoring is recommended for patients with MCI. MCI does not interfere with activities of daily living, acetylcholinesterase drugs are not used for MCI, and an assisted living facility is not indicated for MCI.
150
When administering a mental status examination to a patient, the nurse suspects depression when the patient responds with
a.
“I don’t know.”
b.
“Is that the right answer?”
c.
“Wait, let me think about that.”
d.
“Who are those people over there?”
A
Answers such as “I don’t know” are more typical of depression. The response “Who are those people over there?” is more typical of the distraction seen in a patient with delirium. The remaining two answers are more typical of a patient with dementia.
151
A 72-year-old patient is diagnosed with moderate dementia as a result of multiple strokes. During assessment of the patient, the nurse would expect to find
a.
excessive nighttime sleepiness.
b.
difficulty eating and swallowing.
c.
variable ability to perform simple tasks.
d.
loss of both recent and long-term memory.
D
Loss of both recent and long-term memory is characteristic of moderate dementia. Patients with dementia have frequent nighttime awakening. Dementia is progressive, and the patient’s ability to perform tasks would not have periods of improvement. Difficulty eating and swallowing is characteristic of severe dementia.
152
To determine whether a new patient’s confusion is caused by dementia or delirium, which action should the nurse take?
a.
Assess the patient using the Mini-Mental Status Exam.
b.
Obtain a list of the medications that the patient usually takes.
c.
Determine whether there is positive family history of dementia.
d.
Use the Confusion Assessment Method tool to assess the patient.
D
The Confusion Assessment Method tool has been extensively tested in assessing delirium. The other actions will be helpful in determining cognitive function or risk factors for dementia or delirium, but they will not be useful in differentiating between dementia and delirium.
153
A 62-year-old patient is brought to the clinic by a family member who is concerned about the patient’s inability to solve common problems. To obtain information about the patient’s current mental status, which question should the nurse ask the patient?
a.
“Where were you were born?”
b.
“Do you have any feelings of sadness?”
c.
“What did you have for breakfast?”
d.
“How positive is your self-image?”
C
This question tests the patient’s recent memory, which is decreased early in Alzheimer’s disease (AD) or dementia. Asking the patient about birthplace tests for remote memory, which is intact in the early stages. Questions about the patient’s emotions and self-image are helpful in assessing emotional status, but they are not as helpful in assessing mental state.
154
When teaching the children of a patient who is being evaluated for Alzheimer’s disease (AD) about the disorder, the nurse explains that
a.
the most important risk factor for AD is a family history of the disorder.
b.
new drugs have been shown to reverse AD dramatically in some patients.
c.
a diagnosis of AD can be made only when other causes of dementia have been ruled out.
d.
the presence of brain atrophy detected by MRI confirms the diagnosis of AD in patients with dementia.
C
The diagnosis of AD is one of exclusion. Age is the most important risk factor for development of AD. Drugs can slow the deterioration but do not dramatically reverse the effects of AD. Brain atrophy is a common finding in AD, but it can occur in other diseases as well and does not confirm an AD diagnosis.
155
A patient with mild dementia has a new prescription for donepezil (Aricept). Which nursing action will be most effective in ensuring compliance with the medication?
a.
Having the patient’s spouse administer the medication
b.
Setting the medications up weekly in a medication box
c.
Calling the patient daily with a reminder to take the medication
d.
Posting reminders to take the medications in the patient’s house
A
Because the patient with mild dementia will have difficulty with learning new skills and forgetfulness, the most appropriate nursing action is to have someone else administer the drug. The other nursing actions will not be as effective in ensuring that the patient takes the medications.
156
Which intervention will the nurse include in the plan of care for a patient who has late-stage Alzheimer’s disease (AD)?
a.
Encourage the patient to discuss events from the past.
b.
Maintain a consistent daily routine for the patient’s care.
c.
Reorient the patient to the date and time every 2 to 3 hours.
d.
Provide the patient with current newspapers and magazines.
B
Providing a consistent routine will decrease anxiety and confusion for the patient. In late-stage AD, the patient will not remember events from the past. Reorientation to time and place will not be helpful to the patient with late-stage AD, and the patient will not be able to read.
157
When assessing a patient with Alzheimer’s disease (AD) who is being admitted to a long-term care facility, the nurse learns that the patient has had several episodes of wandering away from home. Which nursing action will the nurse include in the plan of care?
a.
Place the patient in a room close to the nurses’ station.
b.
Ask the patient why the wandering episodes have occurred.
c.
Have the family bring in familiar items from the patient’s home.
d.
Reorient the patient to the new living situation several times daily.
A
Patients at risk for problems with safety require close supervision. Placing the patient near the nurse’s station will allow nursing staff to observe the patient more closely. The use of “why” questions is frustrating for patients with AD because they are unable to understand clearly or verbalize the reason for wandering behaviors. Because of the patient’s short-term memory loss, reorientation will not help prevent wandering behavior. Because the patient had wandering behavior at home, familiar objects will not prevent wandering.
158
During the morning change-of-shift report at the long-term care facility, the nurse learns that the patient with dementia has had sundowning. Which nursing action should the nurse take while caring for the patient?
a.
Provide hourly orientation to time of day.
b.
Move the patient to a quieter room at night.
c.
Keep blinds open during the daytime hours.
d.
Have the patient take a brief mid-morning nap.
C
The most likely cause of sundowning is a disruption in circadian rhythms and keeping the patient active and in daylight will help to reestablish a more normal circadian pattern. Moving the patient to a different room might increase confusion. Taking a nap will interfere with nighttime sleep. Hourly orientation will not be helpful in a patient with memory difficulties.
159
A long-term care patient with moderate dementia develops increased restlessness and agitation. The nurse’s initial action should be to
a.
reorient the patient to time, place, and person.
b.
administer the PRN dose of lorazepam (Ativan).
c.
assess for factors that might be causing discomfort.
d.
have a nursing assistant stay with the patient to ensure safety.
C
Increased motor activity in a patient with dementia is frequently the patient’s only way of responding to factors like pain, so the nurse’s initial action should be to assess the patient for any precipitating factors. Administration of sedative drugs may be indicated, but this should not be done until assessment for precipitating factors has been completed and any of these factors have been addressed. Reorientation is unlikely to be helpful for the patient with moderate dementia. Assigning a nursing assistant to stay with the patient also may be necessary, but any physical changes that may be causing the agitation should be addressed first.
160
The spouse of a male patient with early stage Alzheimer’s disease (AD) tells the nurse, “I am just exhausted from the constant worry. I don’t know what to do.” Which action is best for the nurse to take next (select all that apply)?
a.
Suggest that a long-term care facility be considered.
b.
Offer ideas for ways to distract or redirect the patient.
c.
Suggest that the spouse consult with the physician for antianxiety drugs.
d.
Educate the spouse about the availability of adult day care as a respite.
e.
Ask the spouse what she knows and has considered about dementia care options.
B, D, E
The stress of being a caregiver can be managed with a multicomponent approach. This includes respite care, learning ways to manage challenging behaviors, and further assessment of what the spouse may already have considered. The patient is in the early stages and does not need long-term placement. Antianxiety medications may be appropriate but other measures should be tried first.
161
A patient with a headache describes it as affecting both sides of his head with a moderate intensity that becomes worse when he is physically active. The nurse knows that the patient’s clinical manifestations are characteristic of which of the following disorders?
a.
Cluster headaches
b.
Migraine headaches
c.
Tension-type headaches
d.
Headaches associated with trigeminal neuralgia
C
The International Headache Society (2004) classification system defines tension-type headache as involving at least two of the following characteristics: pressure or tightness sensation, mild to moderate severity, bilateral location, or worsening with physical activity.
162
A 20-year-old woman is seen at the health clinic with a severe migraine headache. The headaches began 3 months ago, and she has had four headaches since that time. During assessment, the patient tells the nurse she is afraid to make social plans because she never knows when she will be incapacitated with the pain. What is the most appropriate nursing intervention in response to the patient’s comments?
a.
Refer the patient for counselling to assist her with conflict resolution and stress reduction.
b.
Suggest that the patient keep a diary of headache episodes to identify precipitating factors.
c.
Encourage the patient to learn the holistic techniques of meditation and biofeedback to minimize the pain.
d.
Reassure the patient that the headaches are not serious and the pain can be controlled with a variety of drugs.
B
The initial nursing action should be further assessment of the precipitating causes of the headaches, quality and location of pain, and so on, which can be accomplished by the patient keeping a diary of the headache episodes.
163
When teaching a patient about management of her migraine headaches, the nurse determines that teaching has been effective when the patient gives which of the following responses?
a.
“I will take the topiramate as soon as any headaches start.”
b.
“The sumatriptan will help increase the blood flow to my brain.”
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.”
C
It is recommended that the patient with a migraine rest in a dimly lit, quiet area.
164
What is the most important nursing tool in diagnosing a cluster headache?
a.
Magnetic resonance imaging (MRI) of the brain
b.
Electromyography
c.
The patient history
d.
Computed tomography (CT) imaging of the brain
C
Diagnosis of cluster headache is made primarily on the basis of the patient’s symptoms; therefore, a thorough patient history is required.
165
A patient experiences cluster headaches that occur about every year for 2 months. During assessment of the patient during an episode of the headache, what would the nurse expect to find?
a.
Nuchal rigidity
b.
Nausea and vomiting
c.
Unilateral eyelid edema and ptosis
d.
A severe, throbbing, bilateral headache
C
Unilateral eye edema, tearing, and ptosis are characteristic of cluster headaches.
166
Which one of the following should the nurse teach the patient to avoid because it may trigger a headache?
a.
Tylenol
b.
Popsicles
c.
Hot dogs
d.
Fried chicken
C
Patients should be taught to avoid foods containing amines, nitrates, vinegar, onions, or MSG. Hot dogs contain nitrates.
167
When caring for a patient with epilepsy who was hospitalized and successfully treated for status epilepticus, what is a precaution that the nurse should institute as part of the care?
a.
Placing oxygen and suction equipment at the bedside
b.
Assigning an assistant to stay with the patient at all times
c.
Keeping a tongue blade available to insert in case of a seizure
d.
Instructing the patient to stay in bed and call for assistance to go to the bathroom
A
Oxygen and suction equipment should be available at the bedside for a patient who has epilepsy.
168
A patient has a tonic–clonic seizure while the nurse is in the patient’s room. During the seizure, what is it important for the nurse to do?
a.
Insert an oral airway during the seizure to maintain a patent airway.
b.
Restrain the patient’s arms and legs to prevent injury during the seizure.
c.
Avoid touching the patient to prevent further stimulation of the nervous system.
d.
Time the seizure, and observe and record the details of the seizure and the postictal phase.
D
Because diagnosis and treatment of seizures are frequently based on the description of the seizure, recording the length and details of the seizure is important.
169
The nurse witnesses a patient with a seizure disorder as he suddenly jerks his arms and legs, falls to the floor, and regains consciousness immediately. What type of seizure is demonstrated by this patient that the nurse must document?
a.
An atonic seizure
b.
A myoclonic seizure
c.
A complex partial seizure with automatisms
d.
A simple partial seizure with motor symptoms
A
An atonic (“drop attack”) seizure involves either a tonic episode or a paroxysmal loss of muscle tone and begins suddenly with the person falling to the ground. Consciousness usually returns by the time the person hits the ground, and normal activity can be resumed immediately.
170
After experiencing a generalized tonic–clonic seizure in the classroom, a 25-year-old high school teacher is evaluated and diagnosed with idiopathic epilepsy. The patient cries when told of the diagnosis and tells the nurse that she can never go back to teaching after experiencing the seizure in front of her students. What is an appropriate nursing diagnosis for the patient?
a.
Anxiety related to loss of control during seizures
b.
Hopelessness related to diagnosis of chronic illness
c.
Disturbed body image related to new diagnosis of epilepsy
d.
Ineffective role performance related to misinformation about epilepsy
D
The data indicate that the patient has ineffective role performance caused by inadequate information about the disease because most patients are able to control seizures with medication.
171
Following recovery from a stroke, a 68-year-old patient developed complex partial seizures with motor symptoms beginning in the right arm with progression to unconsciousness. The physician prescribes phenytoin (Dilantin) for control of the seizures. Which of the following statements by the patient indicates understanding of what self-care related to this drug includes?
a.
“I should use soft swabs rather than a toothbrush to clean my mouth.”
b.
“If I have a seizure, I should call an ambulance to take me to the hospital.”
c.
“I will take the medication at the beginning of the seizure before I lose consciousness.”
d.
“As I start this medication, I will need to have my blood taken frequently to check the level of the drug.”
D
Serum levels of phenytoin may be checked to ascertain that a therapeutic level of the medication is achieved.
172
When a patient experiences a generalized tonic–clonic seizure in the emergency department after a head injury, all of the following orders are received. Which one will the nurse implement first?
a.
Send patient to radiology department for a CT scan.
b.
Administer midazolam (Versed).
c.
Check capillary blood glucose.
d.
Monitor level of consciousness.
B
To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines.
173
A patient found in a tonic–clonic seizure reports, after gaining consciousness, that the seizure was preceded by numbness and tingling of the arm. What does the nurse know that this finding indicates?
a.
An absence seizure
b.
A simple partial seizure
c.
A complex partial seizure
d.
A generalized myoclonic seizure
C
The initial symptoms of a complex partial seizure involve clinical manifestations that are localized to a particular part of the body or brain. In addition, an alteration in consciousness is always manifested.
174
A patient has newly diagnosed multiple sclerosis (MS) and asks many questions about the disease. When teaching the patient about MS, what should the nurse explain?
a.
MS is an untreatable viral disease that destroys the basal ganglia in the brain.
b.
Nerve impulses travel too quickly over nerves that have lost their myelin coat, overloading the brain.
c.
An autoimmune process causes gradual destruction of the myelin sheath of nerves in the brain and spinal cord.
d.
In MS, antibodies are produced against acetylcholine receptors, resulting in blocked muscle contraction.
C
The primary pathology in MS is an autoimmune process that leads to loss of the myelin sheath and results in decreased nerve transmission.
175
When the nurse is obtaining a health history from a patient undergoing diagnostic testing for MS, which of the following is a finding identified as characteristic of early MS?
a.
Memory lapses
b.
Intermittent fever
c.
Constipation
d.
Weakness of the legs
D
Extremity weakness or spasms are common motor symptoms of MS.
176
A 28-year-old woman has had MS for 3 years and wants to have children before her disease becomes worse. When she asks about the risks associated with pregnancy, the nurse should explain which of the following information?
a.
The stress of pregnancy is likely to accelerate the course of the disease.
b.
She may experience an acute, long-lasting exacerbation of the disease during pregnancy.
c.
Because MS is genetically transmitted, she should consider the risks to future generations.
d.
MS has no apparent effect on pregnancy and lactation, but the risk for an exacerbation after the pregnancy is increased.
D
During the postpartum period, women with MS are at greater risk for exacerbation of symptoms.
177
A patient with MS is to begin treatment with glatiramer acetate (Copaxone). In planning the patient teaching necessary with the use of the drug, the nurse recognizes the patient will need to be taught which of the following information?
a.
Self-injection techniques for subcutaneous injections
b.
To use contraceptive methods other than oral contraceptives for birth control
c.
To plan laboratory monitoring of complete blood count, chemistries, and liver function every 3 months
d.
That the drug will control symptoms but has no effect on the progression of the disease
A
Glatiramer acetate is administered by self-injection.
178
According to the International Classification of Seizure Disorders, what would be the classification of a clonic seizure?
a.
Simple partial
b.
Generalized
c.
Complex partial
d.
Unclassified
B
A clonic seizure is classified as a generalized seizure.
179
A patient with MS has a nursing diagnosis of urinary retention related to sensorimotor deficits. What is an appropriate nursing intervention for this problem?
a.
Decrease fluid intake in the evening.
b.
Teach the patient how to use the Credé manoeuvre.
c.
Suggest the use of incontinence briefs for nighttime use only.
d.
Assist the patient to the commode every 2 hours during the day.
B
The Credé manoeuvre can be used to improve bladder emptying.
180
The nurse identifies the nursing diagnosis of impaired physical mobility related to bradykinesia for a patient with Parkinson’s disease. To assist the patient to ambulate safely, what should the nurse do?
a.
Allow the patient to ambulate only with assistance.
b.
Teach the patient to rock back and forth to initiate leg movement.
c.
Have the patient take small steps in a straight line directly in front of the feet.
d.
Teach the patient to slide the feet forward with each step, always keeping the feet in contact with the floor.
B
Rocking the body from side to side stimulates balance and improves mobility.
181
For which classification of drug that is used in the treatment of MS does the nurse know to teach the patient about the importance of restricting their sodium intake?
a.
Cholinergics
b.
Acetylcholinesterase
c.
Corticosteroids
d.
Anticholinergics
C
Patient teaching with the administration of corticosteroids includes restricting salt intake, not stopping therapy abruptly, and being aware of drug interactions.
182
A patient with Parkinson’s disease has decreased tongue mobility and an inability to move his facial muscles. The nurse documents which of the following nursing diagnoses that reflects these impairments?
a.
Disuse syndrome related to loss of muscle control
b.
Self-care deficit related to bradykinesia and rigidity
c.
Impaired verbal communication related to difficulty swallowing
d.
Impaired oral mucous membranes related to inability to swallow saliva
C
The inability to use the tongue and facial muscles decreases the patient’s ability to socialize or communicate needs.
183
A patient with Parkinson’s disease tells the nurse that she is having increasing problems with constipation. The nurse explains that constipation occurring with Parkinson’s disease is most often a result of which of the following factors?
a.
Advanced age
b.
Decreased physical activity
c.
Side effects of dopaminergic agents
d.
Diminished nerve conduction to the bowel
B
Promotion of physical exercise and a well-balanced diet are major concerns for nursing care. Exercise for patients with Parkinson’s disease can limit the consequences of decreased mobility, such as muscle atrophy, contractures, and constipation.
184
Which of the following is a clinical manifestation of myasthenia gravis (MG)?
a.
Bulging eyes
b.
Scotoma
c.
Unstable gait
d.
Hypertension
C
A clinical manifestation of MG is unstable or unusual gait.
185
A patient with MG is admitted to the hospital with severe weakness and acute respiratory insufficiency. The physician performs a Tensilon test to distinguish between myasthenic crisis and cholinergic crisis. During the test, it will be most important to monitor which of the following?
a.
Pupillary size
b.
Muscle strength
c.
Respiratory function
d.
Level of consciousness
C
The Tensilon test in a patient with MG reveals improved muscle contractility after intravenous injection of the anticholinesterase agent edrophonium chloride (Tensilon); therefore, respiratory function must be monitored. (Anticholinesterase blocks the enzyme acetylcholinesterase.) This test also aids in the diagnosis of cholinergic crisis (secondary to overdose of anticholinesterase medication). In this condition, Tensilon does not improve muscle weakness but may actually increase it. Atropine, a cholinergic antagonist, should be readily available to counteract Tensilon effects when it is used diagnostically.
186
When teaching a patient with MG about management of the disease, the nurse advises the patient to do which of the following?
a.
Anticipate the need for weekly plasmapheresis treatments.
b.
Protect the extremities from injury due to poor sensory perception.
c.
Do frequent weight-bearing exercise to prevent muscle atrophy.
d.
Perform necessary physically demanding activities in the morning.
D
Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then.
187
A patient with MG has a nursing diagnosis of altered nutrition: less than body requirements related to impaired swallowing. To promote nutrition, the nurse suggests that before meals, the patient should avoid which of the following actions?
a.
Writing letters
b.
Talking on the telephone
c.
Typing on the computer
d.
Taking pyridostigmine (Mestinon)
B
The same muscles are used for talking and swallowing, so the patient should avoid fatiguing the muscles of the mouth and throat before meals.
188
A patient with restless legs syndrome (RLS) tells the nurse, “My leg pain and twitching keep me awake so much of the night, I am tired most of the day. Is there anything I can do?” Based on this information, which nursing diagnosis is most appropriate?
a.
Ineffective role performance related to fatigue
b.
Chronic pain related to RLS
c.
Anxiety related to lack of knowledge about RLS treatment
d.
Sleep deprivation related to leg pain and involuntary movement
D
The patient’s statement indicates that daytime fatigue caused by lack of sleep is the major concern.
189
A patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?
a.
Observing for agitation and paranoia
b.
Assisting the patient with active range of motion (ROM)
c.
Using simple words and phrases to explain procedures
d.
Administering muscle relaxants as needed for muscle spasms
B
ALS causes progressive muscle weakness, but assisting the patient to perform active ROM will help maintain strength as long as possible.
190
A 42-year-old patient who was adopted at birth is diagnosed with early Huntington’s disease. When teaching the patient and her family about this disorder, what should the nurse explain about Huntington’s disease?
a.
It is characterized by retarded voluntary and involuntary movement, resulting in immobility.
b.
Genetic testing is available to determine the risk for your children.
c.
It can be controlled by replacing the neurotransmitters acetylcholine and γ-aminobutyric acid.
d.
It will result in limited physical and mental deterioration, requiring some planning and support for care.
B
Genetic testing is available to determine whether an asymptomatic individual has the Huntington’s disease gene. The patient and family should be informed of the benefits and problems associated with genetic testing.
191
A hospitalized 24-year-old patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first?
a.
Notify the patient’s physician immediately.
b.
Start the ordered as-needed oxygen at 9 L/min.
c.
Give the ordered as-needed acetaminophen (Tylenol).
d.
Put a moist hot pack on the patient’s neck.
B
Acute treatment for cluster headache is administration of 100% oxygen at 7 to 9 L/min. If the patient obtains relief with the oxygen, there is no immediate need to notify the physician.
192
The patient tells the nurse that he has a constant, squeezing tightness at the base of his skull and that his neck is stiff. Which type of headache is the patient most likely experiencing?
a.
Migraine headache
b.
Cluster headache
c.
Ocular headache
d.
Tension-type headache
D
A tension-type headache manifests with constant, squeezing tightness, bandlike pressure at the base of the skull, in the face, or both.
193
A patient is seen in the health clinic with symptoms of a stooped posture, shuffling gait, and pill rolling–type tremor. The nurse will anticipate teaching the patient about which of the following?
a.
Preparation for an MRI scan
b.
The purpose of electroencephalographic testing
c.
Antiparkinsonian drugs
d.
Oral corticosteroids
C
The diagnosis of Parkinson’s diagnosis is made when two of the three characteristic signs of tremor, rigidity, and bradykinesia are present. The confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered.
194
When assessing a patient with newly diagnosed trigeminal neuralgia, the nurse will ask the patient about
a.
triggers that lead to facial pain.
b.
visual problems caused by ptosis.
c.
poor appetite caused by a loss of taste.
d.
weakness on the affected side of the face.
A
The major clinical manifestation of trigeminal neuralgia is severe facial pain that is triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and facial weakness are not characteristics of trigeminal neuralgia.
195
Which action should the nurse take when assessing a patient with trigeminal neuralgia?
a.
Examine the mouth and teeth thoroughly.
b.
Have the patient clench and relax the jaw and eyes.
c.
Identify trigger zones by lightly touching the affected side.
d.
Gently palpate the face to compare skin temperature bilaterally.
A
Oral hygiene is frequently neglected because of fear of triggering facial pain. Having the patient clench the facial muscles will not be useful because the sensory branches of the nerve are affected by trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided.
196
When evaluating a patient with trigeminal neuralgia who has had a glycerol rhizotomy, the nurse will
a.
ask whether the patient is using an eye shield at night.
b.
determine whether the patient is doing daily facial exercises.
c.
question the patient about social activities with family and friends.
d.
remind the patient to chew food on the unaffected side of the mouth.
C
Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, asking about social activities will help in evaluating whether the patient’s symptoms have improved. Glycerol rhizotomy does not damage the corneal reflex or motor functions of the trigeminal nerve, so there is no need to use an eye shield, do facial exercises, or take precautions with chewing.
197
Which action will the nurse include in the plan of care when caring for a patient who is experiencing trigeminal neuralgia?
a.
Teach facial and jaw relaxation techniques.
b.
Assess intake and output and dietary intake.
c.
Apply ice packs for no more than 20 minutes.
d.
Spend time at the bedside talking with the patient.
B
The patient with an acute episode of trigeminal neuralgia may be unwilling to eat or drink, so assessment of nutritional and hydration status is important. Because stimulation by touch is the precipitating factor for pain, relaxation of the facial muscles will not improve symptoms. Application of ice is likely to precipitate pain. The patient will not want to engage in conversation, which may precipitate attacks.
198
When teaching patients who are at risk for Bell’s palsy because of previous herpes simplex infection, which information should the nurse include?
a.
“Call the doctor if pain or herpes lesions occur near the ear.”
b.
“Treatment of herpes with antiviral agents prevents Bell’s palsy.”
c.
“You may be able to prevent Bell’s palsy by doing facial exercises regularly.”
d.
“Medications to treat Bell’s palsy work only if started before paralysis onset.”
A
Pain or herpes lesions near the ear may indicate the onset of Bell’s palsy and rapid corticosteroid treatment may reduce the duration of Bell’s palsy symptoms. Antiviral therapy for herpes simplex does not reduce the risk for Bell’s palsy. Corticosteroid therapy will be most effective in reducing symptoms if started before paralysis is complete but will still be somewhat effective when started later. Facial exercises do not prevent Bell’s palsy.
199
A patient with Bell’s palsy refuses to eat while others are present because of embarrassment about drooling. The best response by the nurse to the patient’s behavior is to
a.
respect the patient’s desire and arrange for privacy at mealtimes.
b.
teach the patient to chew food on the unaffected side of the mouth.
c.
offer the patient liquid nutritional supplements at frequent intervals.
d.
discuss the patient’s concerns with visitors who arrive at mealtimes.
A
The patient’s desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements will reduce the patient’s enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the patient’s embarrassment with visitors unless the patient wishes to share this information. Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food but will not decrease the drooling.
200
Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia in order to prevent autonomic dysreflexia?
a.
Assist with selection of a high protein diet.
b.
Use quad coughing to assist cough effort.
c.
Discuss options for sexuality and fertility.
d.
Teach the purpose of a prescribed bowel program.
D
Fecal impaction is a common stimulus for autonomic dysreflexia. The other actions may be included in the plan of care but will not reduce the risk for autonomic dysreflexia.
201
When caring for a patient who has Guillain-Barré syndrome, which assessment data obtained by the nurse will require the most immediate action?
a.
The patient has continuous drooling of saliva.
b.
The patient’s blood pressure (BP) is 106/50 mm Hg.
c.
The patient’s quadriceps and triceps reflexes are absent.
d.
The patient complains of severe tingling pain in the feet.
A
Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, and the BP requires ongoing monitoring, but these actions are not as urgently needed as maintenance of respiratory function. Absence of the reflexes should be documented, but this is a common finding in Guillain-Barré syndrome.
202
A patient who has numbness and weakness of both feet is hospitalized with Guillain-Barré syndrome. The nurse will anticipate the need to teach the patient about
a.
intubation and mechanical ventilation.
b.
administration of IV corticosteroid drugs.
c.
insertion of a nasogastric (NG) feeding tube.
d.
IV infusion of immunoglobulin (Sandoglobulin).
D
Because the Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and tube feedings may be used later in the progression of the syndrome but are not needed now. Corticosteroid use is not helpful in reducing the duration or symptoms of the syndrome.
203
A patient arrives at an urgent care center with a deep puncture wound after stepping on a nail that was lying on the ground. The patient reports having had a tetanus booster 7 years ago. The nurse will anticipate
a.
IV infusion of tetanus immune globulin (TIG).
b.
administration of the tetanus-diphtheria (Td) booster.
c.
intradermal injection of an immune globulin test dose.
d.
initiation of the tetanus-diphtheria immunization series.
B
If the patient has not been immunized within 5 years, administration of the Td booster is indicated because the wound is deep. Immune globulin administration is given by the IM route if the patient has no previous immunization. Administration of a series of immunization is not indicated. TIG is not indicated for this patient, and a test dose is not needed for immune globulin.
204
A patient with a neck fracture at the C5 level is admitted to the intensive care unit. During initial assessment of the patient, the nurse recognizes the presence of neurogenic shock on finding
a.
hypotension, bradycardia, and warm extremities.
b.
involuntary, spastic movements of the arms and legs.
c.
hyperactive reflex activity below the level of the injury.
d.
lack of movement or sensation below the level of the injury.
A
Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement and sensation indicate spinal cord injury, but not neurogenic shock.
205
A patient has an incomplete right spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which nursing action should be included in the plan of care?
a.
Assessment of the patient for left leg pain
b.
Assessment of the patient for left arm weakness
c.
Positioning the patient’s right leg when turning the patient
d.
Teaching the patient to look at the left leg to verify its position
C
The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the right leg. Pain sensation will be lost on the patient’s left leg. Left arm weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the left leg.
206
A patient with a T1 spinal cord injury is admitted to the intensive care unit. The nurse will teach the patient and family that
a.
use of the shoulders will be preserved.
b.
full function of the patient’s arms will be retained.
c.
total loss of respiratory function may occur temporarily.
d.
elevations in heart rate are common with this type of injury.
B
The patient with a T1 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Loss of respiratory function occurs with cervical spine injuries. Bradycardia is associated with injuries above the T6 level.
207
A patient with paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. Which action will the nurse include in the plan of care?
a.
Educate on the use of the Credé method.
b.
Teach the patient how to self-catheterize.
c.
Catheterize for residual urine after voiding.
d.
Assist the patient to the toilet every 2 hours.
B
Because the patient’s bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with a reflexic neurogenic bladder. Catheterization after voiding will not resolve the patient’s incontinence.
208
When the nurse is developing a rehabilitation plan for a patient with a C6 spinal cord injury, an appropriate patient goal is that the patient will be able to
a.
transfer independently to a wheelchair.
b.
drive a car with powered hand controls.
c.
turn and reposition independently when in bed.
d.
push a manual wheelchair on flat, smooth surfaces.
D
The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed.
209
A patient who sustained a spinal cord injury a week ago becomes angry, telling the nurse “I want to be transferred to a hospital where the nurses know what they are doing!” Which reaction by the nurse is best?
a.
Ask for the patient’s input into the plan for care.
b.
Clarify that abusive behavior will not be tolerated.
c.
Reassure the patient about the competence of the nursing staff.
d.
Continue to perform care without responding to the patient’s comments.
A
The patient is demonstrating behaviors consistent with the anger phase of the mourning process, and the nurse should allow expression of anger and seek the patient’s input into care. Expression of anger is appropriate at this stage and should be tolerated by the nurse. Reassurance about the competency of the staff will not be helpful in responding to the patient’s anger. Ignoring the patient’s comments will increase the patient’s anger and sense of helplessness.
210
After a 25-year-old patient has returned home following rehabilitation for a spinal cord injury, the home care nurse notes that the spouse is performing many of the activities that the patient had been managing during rehabilitation. The most appropriate action by the nurse at this time is to
a.
tell the spouse that the patient can perform activities independently.
b.
remind the patient about the importance of independence in daily activities.
c.
develop a plan to increase the patient’s independence in consultation with the patient and the spouse.
d.
recognize that it is important for the spouse to be involved in the patient’s care and support the spouse’s participation.
C
The best action by the nurse will be to involve all the parties in developing an optimal plan of care. Because family members who will be assisting with the patient’s ongoing care need to feel that their input is important, telling the spouse that the patient can perform activities independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviors of the spouse. Supporting the activities of the spouse will lead to ongoing dependency by the patient.
211
The health care provider prescribes these interventions for a patient with possible botulism poisoning. Which one will the nurse question?
a.
Maintain NPO status.
b.
Obtain lumbar puncture tray.
c.
Give magnesium citrate 8 oz now.
d.
Administer 1500-mL tap water enema.
C
Magnesium is contraindicated because it may worsen the neuromuscular blockade. The other orders are appropriate for the patient.
212
When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority?
a.
Assessment of respiratory rate and depth
b.
Continuous cardiac monitoring for bradycardia
c.
Application of pneumatic compression devices to both legs
d.
Administration of methylprednisolone (Solu-Medrol) infusion
A
Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient’s respiratory function. The other actions also are appropriate but are not as important as assessment of respiratory effort.
213
A 24-year-old patient is hospitalized with the onset of Guillain-Barré syndrome. During this phase of the patient’s illness, the most essential assessment for the nurse to carry out is
a.
monitoring the cardiac rhythm.
b.
determining level of consciousness.
c.
checking strength of the extremities.
d.
observing respiratory rate and effort.
D
The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments also will be included in nursing care, but they are not as important as respiratory assessment.
214
A patient admitted to the emergency department is diagnosed with botulism, and an order for botulinum antitoxin is received. Before administering the antitoxin, it is most important for the nurse to
a.
obtain the patient’s temperature.
b.
administer an intradermal test dose.
c.
ask the patient about a history of egg allergies.
d.
document the presence of neurologic symptoms.
B
To prevent allergic reactions, an intradermal test dose of the antitoxin should be administered. Although temperature, allergy history, and symptom assessment and documentation are appropriate, these assessments will not affect the decision to administer the antitoxin.
215
When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort and loose-sounding secretions, the initial intervention by the nurse should be to
a.
suction the patient’s oral and pharyngeal airway.
b.
administer oxygen at 7 to 9 L/min with a face mask.
c.
place the hands on the epigastric area and push upward when the patient coughs.
d.
encourage the patient to use an incentive spirometer every 2 hours during the day.
C
Since the cough effort is poor, the initial action should be to use assisted coughing techniques to improve the ability to mobilize secretions. Administration of oxygen will improve oxygenation, but the data do not indicate hypoxemia. The use of the spirometer may improve respiratory status, but the patient’s ability to take deep breaths is limited by the loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by coughing but should not be the nurse’s first action.
216
To evaluate the effectiveness of IV methylprednisolone (Solu-Medrol) given to a patient with a T4 spinal cord injury, which information is most important for the nurse to obtain?
a.
Leg strength and sensation
b.
Skin temperature and color
c.
Blood pressure and apical heart rate
d.
Respiratory effort and O2 saturation
A
The purpose of methylprednisolone administration is to help preserve motor function and sensation. Therefore the nurse will assess this patient for lower extremity function. The other data also will be collected by the nurse, but they do not reflect the effectiveness of the methylprednisolone.
217
A patient with a history of a T2 spinal cord injury tells the nurse, “I feel awful today. My head is throbbing, and I feel sick to my stomach.” Which action should the nurse take first?
a.
Assess for a fecal impaction.
b.
Give the prescribed antiemetic.
c.
Check the blood pressure (BP).
d.
Notify the health care provider.
C
The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is occurring. Notification of the patient’s health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. The nurse may assess for a fecal impaction, but this should be done after checking the BP and lidocaine jelly should be used to prevent further increases in the BP.
218
The nurse is assessing a patient who is being evaluated for a possible spinal cord tumor. Which finding by the nurse requires the most immediate action?
a.
The patient has new onset weakness of both legs.
b.
The patient complains of chronic severe back pain.
c.
The patient starts to cry and says, “I feel hopeless.”
d.
The patient expresses anxiety about having surgery.
A
The new onset of symptoms indicates cord compression, an emergency that requires rapid treatment to avoid permanent loss of function. The other patient assessments also indicate a need for nursing action but do not require intervention as rapidly as the new onset weakness.
219
Which of these nursing actions for a patient with Guillain-Barré syndrome is most appropriate for the nurse to delegate to an experienced nursing assistant?
a.
Nasogastric tube feeding q4hr
b.
Artificial tear administration q2hr
c.
Assessment for bladder distention q2hr
d.
Passive range of motion to extremities q8hr
D
Assisting a patient with movement is included in nursing assistant education and scope of practice. Administration of tube feedings, administration of ordered medications, and assessment are skills requiring more education and scope of practice, and the RN should perform these skills.
220
A 26-year-old patient with a T3 spinal cord injury asks the nurse about whether he will be able to be sexually active. Which initial response by the nurse is best?
a.
Reflex erections frequently occur, but orgasm may not be possible.
b.
Sildenafil (Viagra) is used by many patients with spinal cord injury.
c.
Multiple options are available to maintain sexuality after spinal cord injury.
d.
Penile injection, prostheses, or vacuum suction devices are possible options.
C
Although sexuality will be changed by the patient’s spinal cord injury, there are options for expression of sexuality and for fertility. The other information also is correct, but the choices will depend on the degrees of injury and the patient’s individual feelings about sexuality.
221
When caring for a patient who experienced a T1 spinal cord transsection 2 days ago, which collaborative and nursing actions will the nurse include in the plan of care (select all that apply)?
a.
Urinary catheter care
b.
Nasogastric (NG) tube feeding
c.
Continuous cardiac monitoring
d.
Avoidance of cool room temperature
e.
Administration of H2 receptor blockers
A, C, D, E
The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature. Gastrointestinal (GI) motility is decreased initially and NG suctioning is indicated. To avoid bladder distention, a urinary retention catheter is used during this acute phase. Stress ulcers are a common complication but can be avoided through the use of the H2 receptor blockers such as famotidine.
222
In which order will the nurse perform the following actions when caring for a patient with possible C6 spinal cord trauma who is admitted to the emergency department? Put a comma and space between each answer choice (a, b, c, d, etc.) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
a. Infuse normal saline at 150 mL/hr.
b. Monitor cardiac rhythm and blood pressure.
c. Administer O2 using a non-rebreather mask.
d. Transfer the patient to radiology for spinal computed tomography (CT).
e. Immobilize the patient’s head, neck, and spine.
E, C, B, A, D
The first action should be to prevent further injury by stabilizing the patient’s spinal cord. Maintenance of oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible complication, monitoring of heart rhythm and BP are indicated, followed by infusing normal saline for volume replacement. A CT scan to determine the extent and level of injury is needed once initial assessment and stabilization are accomplished.
