Med Surg Quiz - 58 60 59 61 COPY

Question 1

What is the priority intervention in the emergency department for the patient with a stroke?

a. Intravenous fluid replacement
b. Administration of osmotic diuretics to reduce cerebral edema
c. Initiation of hypothermia to decrease the oxygen needs of the brain
d. Maintenance of respiratory function with patent airway and oxygen administration

Answer 1

d. Maintenance of respiratory function with patent airway and oxygen administration

The first priority in acute management of the patient with a stroke is the preservation of life. Because the patient of a stroke may be unconscious or have a reduced gag reflex, it is most important to maintain a patent airway for the patient and provide oxygen if respiratory effort is impaired. IV fluid replacement, treatment with osmotic diuretics, and avoiding hyperthermia may be used for further treatment.

Question 2

During the acute phase of a stroke, the nurse assesses the patient’s vital signs and neurologic status every 4 hours. What is a cardiovascular sign that the nurse would see as a body attempts to increase cerebral blood flow?

a. Hypertension
b. Fluid overload
c. Cardiac dysrhythmias
d. S3 and S4 heart sounds

Answer 2

a. Hypertension

The body responds to the vasospasm and decreased circulation to the brain that occurs with a stroke by increasing the BP, frequently resulting in hypertension. The other options are important cardiovascular factors to assess but they do not result from impaired cerebral blood flow.

Question 3

What is a nursing intervention that is indicated for the patient with hemiplegia?

a. The use of a footboard to prevent plantar flexion
b. Immobilization of the affected arm against the chest with a sling
c. Positioning the patient in bed with each joint lower than the joint proximal to it
d. Having the patient perform passive range of motion (ROM) of the affected limb with the unaffected limb

Answer 3

d. Having the patient perform passive range of motion (ROM) of the affected limb with the unaffected limb

Active range of motion (ROM) should be initiated on the unaffected side as soon as possible and passive ROM of the affected side should be started on the first day. Having the patient actively exercise the unaffected side provides the patient with active and passive ROM as needed. Use of footboards is controversial because they stimulate plantar flexion. The unaffected arm should be supported but immobilization may precipitate a painful shoulder-hand syndrome. The patient should be positioned with each joint higher than the joint proximal to it to prevent dependent edema.

Question 4

A newly admitted patient diagnosed with right-sided brain stroke has a nursing diagnosis of disturbed visual sensory perception related to homonymous hemianopsia. Early in the care of the patient, what should the nurse do?

a. Place objects on the right side within the patient’s field of vision.
b. Approach the patient from the left side to encourage the patient to turn the head.
c. Place objects on the patient’s left side to assess the patient’s ability to compensate.
d. Patch the affected eye to encourage the patient to turn the head to scan the environment.

Answer 4

a. Place objects on the right side within the patient’s field of vision.

The presence of homonymous hemianopia in a patient with right hemisphere brain damage causes a loss of vision in the left field bilaterally. Early in the care of the patient, objects should be placed on the right side of the patient in the field of vision and the nurse should approach the patient from the right side. Later in treatment, patients should be taught to turn the head and scan the environment and should be approached from the affected side to encourage head turning. Eye patches are used if patients have diplopia (double vision).

Question 5

Four days following a stroke, a patient is to start oral fluids and feedings. Before feeding the patient, what should the nurse do first?

a. Check the patient’s gag reflex.
b. Order a soft diet for the patient.
c. Raise the head of the bed to a sitting position.
d. Evaluate the patient’s ability to swallow small amounts of crushed ice or ice water.

Answer 5

a. Check the patient’s gag reflex.

Usually the speech therapist will have completed a swallowing study before a diet is ordered. The first step in providing oral feedings for a patient with a stroke is ensuring that the patient has an intact gag reflex because oral feedings will not be provided if the gag reflex is impaired. After placing the patient in an upright position, the nurse should then evaluate the patient’s ability to swallow ice chips or ice water.

Question 6

What is an appropriate food for a patient with a stroke who has mild dysphagia?

a. Fruit juices
b. Pureed meat
c. Scrambled eggs
d. Fortified milkshakes

Answer 6

c. Scrambled eggs

Soft foods that promote enough texture, flavor, and bulk to stimulate swallowing should be used for the patient with dysphagia. Thin liquids are difficult to swallow and patients may not be able to control them in the mouth. Pureed foods are often too bland and too smooth and milk products should be avoided because they tend to increase the viscosity of mucus and increase salivation.

Question 7

A patient’s wife asks the nurse why her husband did not receive the clot busting medication (tissue plasminogen activator [tPA] she has been reading about. Her husband is diagnosed with a hemorrhagic stroke. What is the best response by the nurse to the patient’s wife?

a. “He didn’t arrive within the timeframe for that therapy.”
b. “Not everyone is eligible for this drug. Has he had surgery lately?”
c. “You should discuss the treatment of your husband with his doctor.”
d. “The medication you are talking about dissolves clots and could cause more bleeding in your husband’s brain.”

Answer 7

d. “The medication you are talking about dissolves clots and could cause more bleeding in your husband’s brain.”

Recombinant tissue plasminogen activator (tPA) dissolves clots and increases the risk for bleeding. It is not used with hemorrhagic strokes. If the patient had a thrombotic or embolic stroke, the timeframe of 3 to 4.5 hours after onset of clinical signs of the stroke would be important as well as a history of surgery. The nurse should answer the question as accurately as possible and then encourage the wife to talk with the physician if she has further questions.

Question 8

The rehabilitation nurse assesses the patient, caregiver, and family before planning the rehabilitation program for this patient. What needs to be included in this assessment (select all that apply)?

a. Cognitive status of the family
b. Patient resources and support
c. Rehabilitation potential of the patient
d. Body strength remaining after the stroke
e. Physical status of body systems affected by the stroke
f. Patient and caregiver expectations of the rehabilitation

Answer 8

a. Cognitive status of the family
d. Body strength remaining after the stroke
e. Physical status of body systems affected by the stroke
f. Patient and caregiver expectations of the rehabilitation

The patient’s rehabilitation potential and expectations of the patient and caregiver related to the rehabilitation program will have a big impact on planning and carrying out the rehabilitation plan. The other things the rehabilitation nurse will assess are the physical status of all the patient’s body systems, presence of complications caused by the stroke or other chronic conditions, the cognitive status of the patient, and the family (including the patient and caregiver) resources and support.

Question 9

What is an appropriate nursing intervention to promote communication during rehabilitation of the patient with aphasia?

a. Use gestures, pictures, and music to stimulate patient responses.
b. Talk about activities of daily living (ADLs) that are familiar to the patient.
c. Structure statements so that the patient does not have to respond verbally.
d. Use flashcards with simple words and pictures to promote recall of language.

Answer 9

b. Talk about activities of daily living (ADLs) that are familiar to the patient.

During rehabilitation, the patient with aphasia needs frequent, meaningful verbal stimulation that has relevance for him or her. Conversation by the nurse and family should address activities of daily living (ADLs) that are familiar to the patient. Gestures, pictures, and simple statements are more appropriate in the acute phase, when patients may be overwhelmed by verbal stimuli. Flashcards are often perceived by the patient as childish and meaningless. Not responding verbally does not promote communication.

Question 10

A patient with a right hemisphere stroke has a nursing diagnosis of unilateral neglect related to sensory-perceptual deficits. During the patient’s rehabilitation, what nursing intervention is important for the nurse to do?

a. Avoid positioning the patient on the affected side.
b. Place all objects for care on the patient’s unaffected side.
c. Teach the patient to care consciously for the affected side.
d. Protect the affected side from injury with pillows and supports.

Answer 10

c. Teach the patient to care consciously for the affected side.

Unilateral neglect, or neglect syndrome, occurs when the patient with a stroke is unaware of the affected side of the body, which puts the patient at risk for injury. During the acute phase, the affected side is cared for by the nurse with positioning and support but during rehabilitation the patient is taught to care consciously for and attend to the affected side of the body to protect it from injury. Patients may be positioned on the affected side for up to 30 minutes.

Question 11

A patient with a stroke has a right-sided hemiplegia. What does the nurse teach the family to prepare them to cope with the behavior changes seen with this type of stroke?

a. Ignore undesirable behaviors manifested by the patient.
b. Provide directions to the patient verbally in small steps.
c. Distract the patient from inappropriate emotional responses.
d. Supervise all activities before allowing the patient to pursue them independently.

Answer 11

c. Distract the patient from inappropriate emotional responses.

Patients with left-brain damage from stroke often experience emotional lability, inappropriate emotional responses, mood swings, and uncontrolled tears or laughter disproportionate to or out of context with the situation. The behavior is upsetting and embarrassing to both the patient and the family and the patient should be distracted to minimize its presence. Maintaining a calm environment and avoiding shaming or scolding the patient is important. Patients with right-brain damage often have impulsive, rapid behavior that requires supervision and direction.

Question 12

The nurse can assist the patient and family in coping with the long-term effects of a stroke by doing what?

a. Informing family members that the patient will need assistance with almost all ADLs
b. Explaining that the patient’s prestroke behavior will return as improvement progresses
c. Encouraging the patient and family members to seek assistance from family therapy or stroke support groups
d. Helping the patient and family to understand the significance of residual stroke damage to promote problem solving and planning

Answer 12

d. Helping the patient and family to understand the significance of residual stroke damage to promote problem solving and planning

The patient and family need accurate and complete information about the effects of the stroke to problem-solve and make plans for the chronic care of the patient. It is uncommon for patients with major strokes to return completely to prestroke function, behaviors, and role and both the patient and family will mourn these losses. The patient’s specific needs for care must be identified and rehabilitation efforts should be continued at home. Family therapy and support groups may be helpful for some patients and families.

Question 13

For a patient who is suspected of having a stroke, one of the most important pieces of information that the nurse can obtain is

a. time of the patient’s last meal.
b. time at which stroke symptoms first appeared.
c. patient’s hypertension history and management.
d. family history of stroke and other cardiovascular diseases.

Answer 13

b. time at which stroke symptoms first appeared.

During initial evaluation, the most important point in the patient’s history is the time since onset of stroke symptoms. If the stroke is ischemic, recombinant tissue plasminogen activator (tPA) must be administered within 3 to 4.5 hours of the onset of clinical signs of ischemic stroke; tPA reestablishes blood flow through a blocked artery and prevents brain cell death in patients with acute onset of ischemic stroke.

Question 14

Bladder training in a male patient who has urinary incontinence after a stroke includes

a. limiting fluid intake.
b. keeping a urinal in place at all times.
c. assisting the patient to stand to void.
d. catheterizing the patient every 4 hours.

Answer 14

c. assisting the patient to stand to void.

In the acute stage of stroke, the primary urinary problem is poor bladder control and incontinence. Nurses should promote normal bladder function and avoid the use of indwelling catheters. A bladder retraining program consists of (1) adequate fluid intake, with most fluids administered between 7:00 AM and 7:00 PM; (2) scheduled toileting every 2 hours with the use of a bedpan, commode, or bathroom; and (3) noting signs of restlessness, which may indicate the need for urination. Intermittent catheterization may be used for urinary retention (not urinary incontinence). During the rehabilitation phase after a stroke, nursing interventions focused on urinary continence include (1) assessment for bladder distention by palpation; (2) offering the bedpan, urinal, commode, or toilet every 2 hours during waking hours and every 3 to 4 hours at night; (3) using a direct command to help the patient focus on the need to urinate; (4) assistance with clothing and mobility; (5) scheduling most fluid intake between 7:00 AM and 7:00 PM; and (6) encouraging the usual position for urinating (i.e., standing for men and sitting for women).

Question 15

Common psychosocial reactions of the stroke patient to the stroke include (select all that apply)

a. depression.
b. disassociation.
c. intellectualization.
d. sleep disturbances.
e. denial of severity of stroke.

Answer 15

a. depression.
d. sleep disturbances.
e. denial of severity of stroke.

The patient with a stroke may experience many losses, including sensory, intellectual, communicative, functional, role behavior, emotional, social, and vocational losses. Some patients experience long-term depression, manifesting symptoms such as anxiety, weight loss, fatigue, poor appetite, and sleep disturbances. The time and energy required to perform previously simple tasks can result in anger and frustration. Frustration and depression are common in the first year after a stroke. A stroke is usually a sudden, extremely stressful event for the patient, caregiver, family, and significant others. The family is often affected emotionally, socially, and financially as their roles and responsibilities change. Reactions vary considerably but may involve fear, apprehension, denial of the severity of stroke, depression, anger, and sorrow.

Question 16

A female patient has left-sided hemiplegia following an ischemic stroke that she experienced 4 days earlier. How should the nurse best promote the health of the patient’s integumentary system?

a. Position the patient on her weak side the majority of the time.
b. Alternate the patient’s positioning between supine and side-lying.
c. Avoid the use of pillows in order to promote independence in positioning.
d. Establish a schedule for the massage of areas where skin breakdown emerges.

Answer 16

b. Alternate the patient’s positioning between supine and side-lying.

A position change schedule should be established for stroke patients. An example is side-back-side, with a maximum duration of 2 hours for any position. The patient should be positioned on the weak or paralyzed side for only 30 minutes. Pillows may be used to facilitate positioning. Areas of skin breakdown should never be massaged.

Question 17

The patient with diabetes mellitus has had a right-sided stroke. Which nursing intervention should the nurse plan to provide for this patient related to expected manifestations of this stroke?

a. Safety measures
b. Patience with communication
c. Mobility assistance on the right side
d. Place food in the left side of patient’s mouth.

Answer 17

a. Safety measures

A patient with a right-sided stroke has spatial-perceptual deficits, tends to minimize problems, has a short attention span, is impulsive, and may have impaired judgment. Safety is the biggest concern for this patient. Hemiplegia occurs on the left side of this patient’s body. The patient with a left-sided stroke has hemiplegia on the right, is more likely to have communication problems, and needs mobility assistance on the right side with food placed on the left side if the patient needs to be fed after a swallow evaluation has taken place.

Question 18

The nurse is planning psychosocial support for the patient and family of the patient who suffered a stroke. What factor will most likely have the greatest impact on positive family coping with the situation?

a. Specific patient neurologic deficits
b. The patient’s ability to communicate
c. Rehabilitation potential of the patient
d. Presence of complications of a stroke

Answer 18

c. Rehabilitation potential of the patient

Although a patient’s neurologic deficit might initially be severe after a stroke, the ability of the patient to recover is most likely to positively impact the family’s coping with the situation. Providing explanations and emotional support beginning in the acute phase through the rehabilitation phase will facilitate coping. Emphasizing successes will offer the most realistic hope for the patient’s rehabilitation and helps maintain hope for the patient’s future abilities.

Question 19

Dementia is defined as a

a. syndrome that results only in memory loss.
b. disease associated with abrupt changes in behavior.
c. disease that is always due to reduced blood flow to the brain.
d. syndrome characterized by cognitive dysfunction and loss of memory.

Answer 19

d. syndrome characterized by cognitive dysfunction and loss of memory.

Dementia is a syndrome characterized by dysfunction in or loss of memory, orientation, attention, language, judgment, and reasoning. Personality changes and behavioral problems such as agitation, delusions, and hallucinations may result.

Question 20

Vascular dementia is associated with

a. transient ischemic attacks.
b. bacterial or viral infection of neuronal tissue.
c. cognitive changes secondary to cerebral ischemia.
d. abrupt changes in cognitive function that are irreversible.

Answer 20

c. cognitive changes secondary to cerebral ischemia.

Vascular dementia is the loss of cognitive function that results from ischemic, ischemic-hypoxic, or hemorrhagic brain lesions caused by cardiovascular disease. In this type of dementia, narrowing and blocking of arteries that supply the brain causes a decrease in blood supply.

Question 21

The clinical diagnosis of dementia is based on

a. CT or MRS.
b. brain biopsy.
c. electroencephalogram.
d. patient history and cognitive assessment.

Answer 21

d. patient history and cognitive assessment.

The diagnosis of dementia depends on determining the cause. A thorough physical examination is performed to rule out other potential medical conditions. Cognitive testing (e.g., Mini-Mental State Examination) is focused on evaluating memory, ability to calculate, language, visual-spatial skills, and degree of alertness. Diagnosis of dementia related to vascular causes is based on the presence of cognitive loss, the presence of vascular brain lesions demonstrated by neuroimaging techniques, and the exclusion of other causes of dementia. Structural neuroimaging with computed tomography (CT) or magnetic resonance imaging (MRI) is used in the evaluation of patients with dementia. A psychologic evaluation is also indicated to determine the presence of depression.

Question 22

Which statement(s) accurately describe(s) mild cognitive impairment (select all that apply)?

a. Always progresses to AD
b. Caused by a variety of factors and may progress to AD
c. Should be aggressively treated with acetylcholinesterase drugs
d. Caused by vascular infarcts that, if treated, will delay progression to AD
e. Patient is usually not aware that there is a problem with his or her memory

Answer 22

b. Caused by a variety of factors and may progress to AD

Although some individuals with mild cognitive impairment (MCI) revert to normal cognitive function or do not go on to develop Alzheimer’s disease (AD), those with MCI are at high risk for AD. No drugs have been approved for the treatment of MCI. A person with MCI is often aware of a significant change in memory.

Question 23

The early stage of AD is characterized by

a. no noticeable change in behavior.
b. memory problems and mild confusion.
c. increased time spent sleeping or in bed.
d. incontinence, agitation, and wandering behavior.

Answer 23

b. memory problems and mild confusion.

An initial sign of AD is a subtle deterioration in memory.

Question 24

A major goal of treatment for the patient with AD is to

a. maintain patient safety.
b. maintain or increase body weight.
c. return to a higher level of self-care.
d. enhance functional ability over time.

Answer 24

a. maintain patient safety.

The overall management goals are that the patient with AD will (1) maintain functional ability for as long as possible, (2) be maintained in a safe environment with a minimum of injuries, (3) have personal care needs met, and (4) have dignity maintained. The nurse should place emphasis on patient safety while planning and providing nursing care.

Question 25

Creutzfeldt-Jakob disease is characterized by

a. remissions and exacerbations over many years.
b. memory impairment, muscle jerks, and blindness.
c. parkinsonian symptomsin, including muscle rigidity and tremors at rest.
d. increased intracranial pressure secondary to decreased CSF drainage.

Answer 25

b. memory impairment, muscle jerks, and blindness.

Creutzfeldt-Jakob disease (CJD) is a fatal brain disorder caused by a prion protein. The earliest symptom of the disease may be memory impairment and behavioral changes. The disease progresses rapidly, with mental deterioration, involuntary movements (i.e., muscle jerks), weakness in the limbs, blindness, and eventually coma.

Question 26

Which patient is most at risk for developing delirium?

a. A 50-year-old woman with cholecystitis
b. A 19-year-old man with a fractured femur
c. A 42-year-old woman having an elective hysterectomy
d. A 78-year-old man admitted to the medical unit with complications related to heart failure

Answer 26

d. A 78-year-old man admitted to the medical unit with complications related to heart failure

Risk factors that can precipitate delirium include age of 65 years or older, male gender, and severe acute illness (e.g., heart failure). The 78-year-old man has the most risk factors for delirium (see Table 60-14).

Question 27

What manifestations of cognitive impairment are primarily characteristic of delirium (select all that apply)?

a. Reduced awareness
b. Impaired judgments
c. Words difficult to find
d. Sleep/wake cycle reversed
e. Distorted thinking and perception
f. Insidious onset with prolonged duration

Answer 27

a. Reduced awareness
d. Sleep/wake cycle reversed
e. Distorted thinking and perception

Manifestations of delirium include cognitive impairment with reduced awareness, reversed sleep/wake cycle, and distorted thinking and perception. The other options are characteristic of dementia.

Question 28

Which statement accurately describes dementia?

a. Overproduction of B-amyloid protein causes all dementias.
b. Demential resulting from neurodegenerative causes can be prevented.
c. Dementia caused by hepatic or renal encephalopathy cannot be reversed.
d. Vascular dementia can be diagnosed by brain lesions identified with neuroimaging.

Answer 28

d. Vascular dementia can be diagnosed by brain lesions identified with neuroimaging.

The diagnosis of vascular dementia can be aided by neuroimaging studies showing vascular brain lesions along with exclusion of other causes of dementia. Overproduction of B-amyloid protein contributes to Alzheimer’s disease (AD). Vascular dementia can be prevented or slowed by treating underlying diseases (e.g., diabetes mellitus, cardiovascular disease). Dementia caused by hepatic or renal encephalopathy potentially can be reversed.

Question 29

A patient with Alzheimer’s disease (AD) dementia has manifestations of depression. The nurse knows that treatment of the patient with antidepressants will most likely do what?

a. Improve cognitive function
b. Not alter the course of either condition
c. Cause interactions with the drugs used to treat the dementia
d. Be contraindicated because of the central nervous system (CNS)-depressant effect of antidepressants

Answer 29

a. Improve cognitive function

Depression is often associated with AD, especially early in the disease when the patient has awareness of the diagnosis and the progression of the disease. When dementia and depression occur together, intellectual deterioration may be more extreme. Depression is treatable and use of antidepressants often improves cognitive function.

Question 30

For what purpose would the nurse use the Mini-Mental State Examination to evaluate a patient with cognitive impairment?

a. It is a good tool to determine the etiology of dementia.
b. It is a good tool to evaluate mood and thought processes.
c. It can help to document the degree of cognitive impairment in delirium and dementia.
d. It is useful for initial evaluation of mental status but additional tools are needed to evaluate changes in cognition over time.

Answer 30

c. It can help to document the degree of cognitive impairment in delirium and dementia.

The Mini-Mental State Examination is a tool to document the decree of cognitive impairment and it can be used to determine a baseline from which changes over time can be evaluated. It does not evaluate mood or thought processes but can detect dementia and delirium and differentiate these from psychiatric mental illness. It cannot help to determine etiology.

Question 31

During assessment of a patient with dementia, the nurse determines that the condition is potentially reversible when finding out what about the patient?

a. Has long-standing abuse of alcohol
b. Has a history of Parkinson’s disease
c. Recently developed symptoms of hypothyroidism
d. Was infected with human immunodeficiency virus (HIV) 10 years ago

Answer 31

c. Recently developed symptoms of hypothyroidism

Hypothyroidism can cause dementia but it is a treatable condition if it has not been long standing. The other conditions are causes of irreversible dementia.

Question 32

The husband of a patient is complaining that his wife’s memory has been decreasing lately. When asked for examples of her memory loss, the husband says that she is forgetting the neighbors’ names and forgot their granddaughter’s birthday. What kind of loss does the nurse recognize this to be?

a. Delirium
b. Memory loss in AD
c. Normal forgetfulness
d. Memory loss in mild cognitive impairment

Answer 32

d. Memory loss in mild cognitive impairment

In mild cognitive impairment people frequently forget people’s names and begin to forget important events. Delirium changes usually occur abruptly. In Alzheimer’s disease the patient may not remember knowing a person and loses the sense of time and which day it is. Normal forgetfulness includes momentarily forgetting names and occasionally forgetting to run an errand.

Question 33

The wife of a patient who is manifesting deterioration in memory asks the nurse whether her husband has AD. The nurse explains that a diagnosis of AD is usually made when what happens?

a. A urine test indicates elevated levels of isoprostanes
b. All other possible causes of dementia have been eliminated
c. Blood analysis reveals increased amounts of B-amyloid protein
d. A computed tomography (CT) scan of the brain indicates brain atrophy

Answer 33

b. All other possible causes of dementia have been eliminated

The only definitive diagnosis of AD can be made on examination of brain tissue during an autopsy but a clinical diagnosis is made when all other possible causes of dementia have been eliminated. Patients with AD may be B-amyloid proteins in the blood, brain atrophy, or isoprostanes in the urine but these findings are not exclusive to those with AD.

Question 34

The newly admitted patient has moderate AD. What does the nurse know this patient will need help with?

a. Eating
b. Walking
c. Dressing
d. Self-care activities

Answer 34

c. Dressing

In the moderate stage of AD, the patient may need help with getting dressed. In the severe stage, patients will be unable to dress or feed themselves and are usually incontinent.

Question 35

What is one focus of collaborative care of patients with AD?

a. Replacement of deficient acetylcholine in the brain
b. Drug therapy for cognitive problems and undesirable behaviors
c. The use of memory-enhancing techniques to delay disease progression
d. Prevention of other chronic diseases that hasten the progression of AD

Answer 35

b. Drug therapy for cognitive problems and undesirable behaviors

Because there is no cure for AD, collaborative management is aimed at controlling the decline in cognition, controlling the undesirable manifestations that the patient may exhibit, and providing support for the family caregiver. Anticholinesterase agents help to increase acetylcholine (ACh) in the brain but a variety of other drugs are also used to control behavior. Memory-enhancing techniques have little or no effect in patients with AD, especially as the disease progresses. Patients with AD have limited ability to communicate health symptoms and problems, leading to a lack of professional attention for acute and other chronic illnesses.

Question 36

A patient with AD in a long-term care facility is wandering the halls very agitated, asking for her “mommy” and crying. What is the best response by the nurse?

a. Ask the patient, “Why are you behaving this way?”
b. Tell the patient, “Let’s go get a snack in the kitchen.”
c. Ask the patient, “Wouldn’t you like to lie down now?”
d. Tell the patient, “Just take some deep breaths and calm down.”

Answer 36

b. Tell the patient, “Let’s go get a snack in the kitchen.”

Patients with moderate to severe AD frequently become agitated but because their short-term memory loss is so pronounced, distraction is a very good way to calm them. “Why” questions are upsetting to them because they don’t know the answer and they cannot respond to normal relaxation techniques.

Question 37

The sister of a patient with AD asks the nurse whether prevention of the disease is possible. In responding, the nurse explains that there is no known way to prevent AD but there are ways to keep the brain healthy. What is included in the ways to keep the brain healthy (select all that apply)?

a. Avoid trauma to the brain.
b. Recognize and treat depression early.
c. Avoid social gatherings to avoid infections.
d. Do not overtax the brain by trying to learn new skills.
e. Daily wine intake will increase circulation to the brain.
f. Exercise regularly to decrease the risk for cognitive decline.

Answer 37

a. Avoid trauma to the brain.
b. Recognize and treat depression early.
f. Exercise regularly to decrease the risk for cognitive decline.

Avoiding trauma to the brain, treating depression early, and exercising regularly can maintain cognitive function. Staying socially active, avoiding intake of harmful substances, and challenging the brain to keep its connections active and create new ones also help to keep the brain healthy.

Question 38

The son of a patient with early-onset AD asks if he will get AD. What should the nurse tell this man about the genetics of AD?

a. The risk of early-onset AD for the children of parents with it is about 50%.
b. Women get AD more often than men do, so his chances of getting AD are slim.
c. The blood test for the ApoE gene to identify this type of AD can predict who will develop it.
d. This type of AD is not as complex as regular AD, so he does not need to worry about getting AD.

Answer 38

a. The risk of early-onset AD for the children of parents with it is about 50%.

The risk of early-onset AD for the children of parents with it is 50%. Women do get AD more often than men but that is more likely related to women living longer than men than to the type of AD. ApoE gene testing is used for research with late-onset AD but does not predict who will develop the disease. Late-onset AD is more genetically complex than early-onset AD and is more common in those over age 60 but because his parent has early-onset AD he is at a 50% risk of getting it.

Question 39

A patient with moderate AD has a nursing diagnosis of impaired memory related to effects of dementia. What is an appropriate nursing intervention for this patient?

a. Post clocks and calendars in the patient’s environment.
b. Establish and consistently follow a daily schedule with the patient.
c. Monitor the patient’s activities to maintain a safe patient environment.
d. Stimulate thought processes by asking the patient questions about recent activities.

Answer 39

b. Establish and consistently follow a daily schedule with the patient.

Adhering to a regular, consistent daily schedule helps the patient to avoid confusion and anxiety and is important both during hospitalization and at home. Clocks and calendars may be useful in early AD but they have little meaning to a patient as the disease progresses. Questioning the patient about activities and events they cannot remember is threatening and may because severe anxiety. Maintaining a safe environment for the patient is important but does not change the disturbed thought processes.

Question 40

The family caregiver for a patient with AD expresses an inability to make decisions, concentrate, or sleep. The nurse determines what about the caregiver?

a. The caregiver is also developing signs of AD.
b. The caregiver is manifesting symptoms of caregiver role strain.
c. The caregiver needs a period of respite from care of the patient.
d. The caregiver should ask other family members to participate in the patient’s care.

Answer 40

b. The caregiver is manifesting symptoms of caregiver role strain.

Family caregiver role strain is characterized by such symptoms of stress as the inability to sleep, make decisions, or concentrate. It is frequently seen in family members who are responsible for the care of the patient with AD. Assessment of the caregiver may reveal a need for assistance to increase coping skills, effectively use community resources, or maintain social relationships. Eventually the demands on a caregiver exceed the resources and the person with AD may be placed in an institutional setting.

Question 41

The wife of a man with moderate AD has a nursing diagnosis of social isolation related to diminishing social relationships and behavioral problems of the patient with AD. What is a nursing intervention that should be appropriate to provide respite care and allow the wife to have satisfactory contact with significant others?

a. Help the wife to arrange adult day care for the patient.
b. Encourage permanent placement of the patient in the Alzheimer’s unit of a long-term care facility.
c. Refer the wife to a home health agency to arrange for daily home nursing visits to assist with the patient’s care.
d. Arrange for the hospitalization of the patient for 3 to 4 days so that the wife can visit out-of-town friends and relatives.

Answer 41

a. Help the wife to arrange adult day care for the patient.

Adult dare care is an option to provide respite for caregivers and a protective environment for the patient during the early and middle stages of AD. There are also in-home respite care providers. The respite from the demands of care allows the caregiver to maintain social contacts, perform normal tasks of living, and be more responsive to the patient’s needs. Visits by home health nurses involve the caregiver and cannot provide adequate respite. Institutional placement is not always an acceptable option at earlier stages of AD, nor is hospitalization available for respite care.

Question 42

A 72-year-old woman is hospitalized in the intensive care unit (ICU) with pneumonia resulting from chronic obstructive pulmonary disease (COPD). She has a fever, productive cough, and adventitious breath sounds throughout her lungs. In the past 24 hours her fluid intake was 1000 mL and her urine output was 700 mL. She was diagnosed with early-stage AD 6 months ago but has been able to maintain her activities of daily living (ADLs) with supervision. Identify at least six risk factors for the development of delirium in this patient.

Answer 42

a. age
b. infection
c. hypoxemia (lung disease)
d. intensive care unit (ICU) hospitalization (change in environment, sensory overload)
e. preexisting dementia
f. dehydration
g. hyperthermia
h. potentially medications to treat COPD
i. pneumonia

Question 43

A 68-year-old man is admitted to the emergency department with multiple blunt trauma following a one-vehicle car accident. He is restless; disoriented to person, place, and time; and agitated. He resists attempts at examination and calls out the name “Janice.” Why should the nurse suspect delirium rather than dementia in this patient?

a. The fact that he wouldn’t have been allowed to drive if he had dementia
b. His hyperactive behavior, which differentiates his condition from the hypoactive behavior of dementia
c. The report of emergency personnel that he was noncommunicative when they arrived at the accident scene
d. The report of his family that although he has heart disease and is “very hard of hearing,” this behavior is unlike him

Answer 43

d. The report of his family that although he has heart disease and is “very hard of hearing,” this behavior is unlike him

Delirium is an acute problem that usually has a rapid onset in response to a precipitating event, especially when the patient has underlying health problems, such as heart disease and sensory limitations. In the absence of prior cognitive impairment, a sudden onset of confusion, disorientation, and agitation is usually delirium. Delirium may manifest with both hypoactive and hyperactive symptoms.

Question 44

What should be included in the management of a patient with delirium?

a. The use of restraints to protect the patient from injury
b. The use of short-acting benzodiazepines to sedate the patient
c. Identification and treatment of underlying causes when possible
d. Administration of high doses of an antipsychotic drug such as haloperidol (Haldol)

Answer 44

c. Identification and treatment of underlying causes when possible

Care of the patient with delirium is focused on identifying and eliminating precipitating factors if possible. Treatment of underlying medical conditions, changing environmental conditions, and discontinuing medications that induce delirium are important. Drug therapy is reserved for those patients with severe agitation because the drugs themselves may worsen delirium.

Question 45

When caring for a patient in the severe stage of AD, what diversion or distraction activities would be appropriate?

a. Watching TV
b. Playing games
c. Books to read
d. Mobiles or dangling ribbons

Answer 45

d. Mobiles or dangling ribbons

In the severe stage of AD, the patient is at a developmental level of 15 months or less; therefore appropriate distractions would be infant toys. Watching TV and playing games are more appropriate in the mild stage. Books to read would need to be at developmentally appropriate levels to be used as a diversion.

Question 46

When providing community health care teaching regarding the early warning signs of Alzheimer’s disease, which signs should the nurse advise family members to report (select all that apply)?

a. Misplacing car keys
b. Losing sense of time
c. Difficulty performing familiar tasks
d. Problems with performing basic calculations
e. Becoming lost in a usually familiar environment

Answer 46

b. Losing sense of time
c. Difficulty performing familiar tasks
d. Problems with performing basic calculations
e. Becoming lost in a usually familiar environment

Difficulty performing familiar tasks, problems with performing basic calculations, losing sense of time, and becoming lost in a usually familiar environment are all part of the early warning signs of Alzheimer’s disease. Misplacing car keys is a normal frustrating event for many people.

Question 47

Which nursing intervention is most appropriate when caring for patients with dementia?

a. Avoid direct eye contact.
b. Lovingly call the patient “honey” or “sweetie.”
c. Give simple directions, focusing on one thing at a time.
d. Treat the patient according to his or her age-related behavior.

Answer 47

c. Give simple directions, focusing on one thing at a time.

When dealing with patients with dementia, tasks should be simplified, giving directions using gestures or pictures and focusing on one thing at a time. It is best to treat these patients as adults, with respect and dignity, even when their behavior is childlike. The nurse should use gentle touch and direct eye contact. Calling the patient “honey” or “sweetie” can be condescending and does not demonstrate respect.

Question 48

Which statement by the wife of a patient with Alzheimer’s disease (AD) demonstrates an accurate understanding of her husband’s medication regimen?

a. “I’m really hoping his medications will slow down his mental losses.”
b. “We’re both holding out hope that this medication will cure his disease.”
c. “I know that this won’t cure him, but we learned that it might prevent a bodily decline while he declines mentally.”
d. “I learned that if we are vigilant about his medication schedule, he may not experience the physical effects of his disease.”

Answer 48

a. “I’m really hoping his medications will slow down his mental losses.”

There is presently no cure for Alzheimer’s disease, and drug therapy aims at improving or controlling decline in cognition. Medications do not directly address the physical manifestations of AD.

Question 49

Which patient may face the greatest risk of developing delirium?

a. A patient with fibromyalgia whose chronic pain has recently worsened
b. A patient with a fracture who has spent the night in the emergency department
c. An older patient whose recent computed tomography (CT) shows brain atrophy
d. An older patient who takes multiple medications to treat various health problems

Answer 49

d. An older patient who takes multiple medications to treat various health problems

Polypharmacy is implicated in many cases of delirium, and this phenomenon is especially common among older adults. Brain atrophy, if associated with cognitive changes, is indicative of dementia. Alterations in sleep and environment, as well as pain, may cause delirium, but this is less of a risk than in an older adult who takes multiple medications.

Question 50

For which patient should the nurse prioritize an assessment for depression?

a. A patient in the early stages of Alzheimer’s disease
b. A patient who is in the final stages of Alzheimer’s disease
c. A patient experiencing delirium secondary to dehydration
d. A patient who has become delirious following an atypical drug response

Answer 50

a. A patient in the early stages of Alzheimer’s disease

Patients in the early stages of Alzheimer’s disease are particularly susceptible to depression, since the patient is acutely aware of his or her cognitive changes and the expected disease trajectory. Delirium is typically a shorter-term health problem that does not typically pose a heightened risk of depression.

Question 51

The patient has been diagnosed with the mild cognitive impairment stage of Alzheimer’s disease. What nursing interventions should the nurse expect to use with this patient?

a. Treat disruptive behavior with antipsychotic drugs.
b. Use a calendar and family pictures as memory aids.
c. Use a writing board to communicate with the patient.
d. Use a wander guard mechanism to keep the patient in the area.

Answer 51

b. Use a calendar and family pictures as memory aids.

The patient with mild cognitive impairment will have problems with memory, language, or another essential cognitive function that is severe enough to be noticeable to others but does not interfere with activities of daily living. A calendar and family pictures for memory aids will help this patient. This patient should not yet have disruptive behavior or get lost easily. Using a writing board will not help this patient with communication.

Question 52

The patient is having some increased memory and language problems. What diagnostic tests will be done before this patient is diagnosed with Alzheimer’s disease (select all that apply)?

a. Urinalysis
b. MRI of the head
c. Liver function tests
d. Neuropsychologic testing
e. Blood urea nitrogen and serum creatinine

Answer 52

All of the above.

Because there is no definitive diagnostic test for Alzheimer’s disease, and many conditions can cause manifestations of dementia, testing must be done to eliminate any other causes of cognitive impairment. These include urinalysis to eliminate a urinary tract infection, an MRI to eliminate brain tumors, liver function tests to eliminate encephalopathy, BUN and serum creatinine to rule out renal dysfunction, and neuropsychologic testing to assess cognitive function.

Question 53

A 59-year-old female patient, who has frontotemporal lobar degeneration, has difficulty with verbal expression. One day she walks out of the house and goes to the gas station to get a soda but does not understand that she needs to pay for it. What is the best thing the nurse can suggest to this patient’s husband to keep the patient safe during the day while the husband is at work?

a. Assisted living
b. Adult day care
c. Advance directives
d. Monitor for behavioral changes

Answer 53

b. Adult day care

To keep this patient safe during the day while the husband is at work, an adult day care facility would be the best choice. This patient would not need assisted living. Advance directives are important but are not related to her safety. Monitoring for behavioral changes will not keep her safe during the day.

Question 54

A 50-year-old man complains of recurring headaches. He describes these as sharp, stabbing, and located around his left eye. He also resports that his left eye seems to swell and get teary when these headaches occur. Based on this history, you suspect that he has

a. cluster headaches.
b. tension headaches.
c. migraine headaches.
d. medication overuse headaches.

Answer 54

a. cluster headaches.

Cluster headaches involve repeated headaches that can occur for weeks to months, followed by periods of remission. The pain of cluster headache is sharp and stabbing; the intense pain lasts a few minutes to 3 hours. Cluster headaches can occur every other day and as often as eight times a day. The clusters occur with regularity, usually occurring at the same time each day and during the same seasons of the year. Typically, a cluster lasts 2 weeks to 3 months, and the patient then goes into remission for months to years. The pain usually is located around the eye and radiates to the temple, forehead, cheek, nose, or gums. Other manifestations may include swelling around the eye, lacrimation (tearing), facial flushing or pallor, nasal congestion, and constriction of the pupil. During the headache, the patient is often agitated and restless, unable to sit still or relax.

Question 55

A 65-year-old woman was just diagnosed with Parkinson’s disease. The priority nursing intervention is

a. searching the Internet for educational videos.
b. evaluating the home for environmental safety.
c. promoting physical exercise and a well-balanced diet.
d. designing an exercise program to strengthen and stretch specific muscles.

Answer 55

c. promoting physical exercise and a well-balanced diet.

Promotion of physical exercise and a well-balanced diet are major concerns of nursing care for patients with Parkinson’s disease.

Question 56

The nurse finds that an 87-year-old woman with Alzheimer’s disease is continually rubbing, flexing, and kicking out her legs throughout the day. The night shift reports that this same behavior escalates at night, preventing her from obtaining her required sleep. The next step the nurse should take is to

a. ask the physician for a daytime sedative for the patient.
b. request soft restraints to prevent her from falling out of bed.
c. ask the physician for a nighttime sleep medication for the patient.
d. assess the patient more closely, suspecting a disorder such as restless legs syndrome.

Answer 56

d. assess the patient more closely, suspecting a disorder such as restless legs syndrome.

The severity of sensory symptoms of restless legs syndrome (RLS) ranges from infrequent, minor discomfort (paresthesias, including numbness, tingling, and “pins and needles” sensation) to severe pain. The discomfort occurs when the patient is sedentary and is most common in the evening or at night. The pain at night can disrupt sleep and is often relieved by physical activity, such as walking, stretching, rocking, or kicking. In the most severe cases, patients sleep only a few hours at night, which results in daytime fatigue and disruption of the daily routine. The motor abnormalities associated with RLS consist of voluntary restlessness and stereotyped, periodic, involuntary movements. The involuntary movements usually occur during sleep. Symptoms are aggravated by fatigue.

Question 57

Social effects of a chronic neurologic disease include (select all that apply)

a. divorce.
b. job loss.
c. depression.
d. role changes.
e. loss of self-esteem.

Answer 57

All of the above.

Social problems related to chronic neurologic disease may include changes in roles and relationships (e.g., divorce, job loss, role changes); other psychologic problems (e.g., depression, loss of self-esteem) also may have social effects.

Question 58

The nurse is reinforcing teaching with a newly diagnosed patient with amyotrophic lateral sclerosis. Which statement would be appropriate to include in the teaching?

a. “ALS results from an excess chemical in the brain, and the symptoms can be controlled with medication.”
b. “Even though the symptoms you are experiencing are severe, most people recover with treatment.”
c. “You need to consider advance directives now, since you will lose cognitive function as the disease progresses.”
d. “This is a progressing disease that eventually results in a permanent paralysis, though you will not lose any cognitive function.”

Answer 58

d. “This is a progressing disease that eventually results in a permanent paralysis, though you will not lose any cognitive function.”

The disease results in destruction of the motor neurons in the brainstem and spinal cord, causing gradual paralysis. Cognitive function is maintained. Because there is no cure for amyotrophic lateral sclerosis (ALS), collaborative care is palliative and based on symptom relief. Death usually occurs within 3-6 years after diagnosis.

Question 59

Which characteristic of a patient’s recent seizure is consistent with a focal seizure?

a. The patient lost consciousness during the seizure.
b. The seizure involved lip smacking and repetitive movements.
c. The patient fell to the ground and became stiff for 20 seconds.
d. The etiology of the seizure involved both sides of the patient’s brain.

Answer 59

b. The seizure involved lip smacking and repetitive movements.

The most common complex focal seizure involves lip smacking and automatisms (repetitive movements that may not be appropriate). Loss of consciousness, bilateral brain involvement, and a tonic phase are associated with generalized seizure activity.

Question 60

Which measure should the nurse prioritize when providing care for a patient with a diagnosis of multiple sclerosis (MS)?

a. Vigilant infection control and adherence to standard precautions
b. Careful monitoring of neurologic assessment and frequent reorientation
c. Maintenance of a calorie count and hourly assessment of intake and output
d. Assessment of blood pressure and monitoring for signs of orthostatic hypotension

Answer 60

a. Vigilant infection control and adherence to standard precautions

Infection control is a priority in the care of patients with MS, since infection is the most common cause of an exacerbation of the disease. Decreases in cognitive function are less likely, and MS does not typically result in malnutrition, hypotension, or fluid volume excess or deficit.

Question 61

A male patient with a diagnosis of Parkinson’s disease (PD) has been admitted recently to a long-term care facility. Which action should the health care team take in order to promote adequate nutrition for this patient?

a. Provide multivitamins with each meal.
b. Provide a diet that is low in complex carbohydrates and high in protein.
c. Provide small, frequent meals throughout the day that are easy to chew and swallow.
d. Provide the patient with a minced or pureed diet that is high in potassium and low in sodium.

Answer 61

c. Provide small, frequent meals throughout the day that are easy to chew and swallow.

Nutritional support is a priority in the care of individuals with PD. Such patients may benefit from meals that are smaller and more frequent than normal and that are easy to chew and swallow. Multivitamins are not necessary at each meal, and vitamin intake, along with protein intake, must be monitored to prevent contraindications with medications. It is likely premature to introduce a minced or pureed diet, and a low carbohydrate diet is not indicated.

Question 62

Which nursing diagnosis is likely to be a priority in the care of a patient with myasthenia gravis (MG)?

a. Acute confusion
b. Bowel incontinence
c. Activity intolerance
d. Disturbed sleep pattern

Answer 62

c. Activity intolerance

The primary feature of MG is fluctuating weakness of skeletal muscle. Bowel incontinence and confusion are unlikely signs of MG, and although sleep disturbance is likely, activity intolerance is usually of primary concern.

Question 63

A female patient complains of a throbbing headache. When her history is obtained, the nurse discovers that the patient has had this type of headache before and experienced photophobia before the headache occurred. The nurse should know that what is probably the cause of this patient’s headache?

a. Polycythemia vera
b. A cluster headache
c. A migraine headache
d. A hemorrhagic stroke

Answer 63

c. A migraine headache

Although a headache may occur with any of these options, a migraine headache is the only one that has a throbbing headache with an aura (the photophobia). Headache from polycythemia vera is from erythrocytosis. The cluster headache pain is sharp and stabbing, and the headache with a hemorrhagic stroke has a sudden onset and is not recurrent.

Question 64

The patient with type 1 diabetes mellitus with hypoglycemia is having a seizure. Which medication should the nurse anticipate administering to stop the seizure?

a. IV dextrose solution
b. IV diazepam (Valium)
c. IV phenytoin (Dilantin)
d. Oral carbamazepine (Tegretol)

Answer 64

a. IV dextrose solution

This patient’s seizure is caused by low blood glucose, so IV dextrose solution should be given first to stop the seizure. IV diazepam, IV phenytoin, and oral carbamazepine would be used to treat seizures from other causes such as head trauma, drugs, and infections.

Question 65

A 50-year-old male patient has been diagnosed with amyotrophic lateral sclerosis (ALS). What nursing intervention is most important to help prevent a common cause of death for patients with ALS?

a. Reduce fat intake.
b. Reduce the risk of aspiration.
c. Decrease injury related to falls.
d. Decrease pain secondary to muscle weakness.

Answer 65

b. Reduce the risk of aspiration.

Reducing the risk of aspiration can help prevent respiratory infections that are a common cause of death from deteriorating muscle function. Reducing fat intake may reduce cardiovascular disease, but this is not a common cause of death for patients with ALS. Decreasing injury related to falls and decreasing pain secondary to muscle weakness are important nursing interventions for patients with ALS but are unrelated to causes of death for these patients.

Question 66

When establishing a diagnosis of MS, the nurse should teach the patient about what diagnostic studies (select all that apply)?

a. EEG
b. CT scan
c. Carotid duplex scan
d. Evoked response testing
e. Cerebrospinal fluid analysis

Answer 66

b. CT scan
d. Evoked response testing
e. Cerebrospinal fluid analysis

There is no definitive diagnostic test for MS. CT scan, evoked response testing, cerebrospinal fluid analysis, and MRI along with history and physical examination are used to establish a diagnosis for MS. EEG and carotid duplex scan are not used for diagnosing MS.

Question 67

A 48-year-old man was just diagnosed with Huntington’s disease. His 20-year-old son is upset about his father’s diagnosis. How can the nurse best help this young man?

a. Provide emotional and psychologic support.
b. Encourage him to get diagnostic genetic testing done.
c. Tell him the cognitive deterioration will be treated with counseling.
d. Tell him the chorea and psychiatric disorders can be treated with haloperidol (Haldol).

Answer 67

a. Provide emotional and psychologic support.

The patient’s son will first need emotional and psychologic support. He should be taught about diagnostic genetic testing for himself but should decide for himself with a genetic counselor if and when he wants this done. The treatment plan for his father will be determined depending on his father’s needs.

Question 68

Which type of headache is suspected when the headaches are unilateral and throbbing, preceded by a prodrome of photophobia, and associated with a family history of this type of headache?

a. Cluster
b. Migraine
c. Frontal-type
d. Tension-type

Answer 68

b. Migraine

Migraine headaches are frequently unilateral and usually throbbing. They may be preceded by a prodrome and frequently there is a family history. Cluster headaches are also unilateral with severe bone-crushing pain but there is no prodrome or family history. Frontal-type headache is not a functional type of headache. Tension-type headache are bilateral with constant, squeezing tightness without prodrome or family history.

Question 69

A patient is diagnosed with cluster headaches. The nurse knows that which characteristics are associated with this type of headache (select all that apply)?

a. Family history
b. Alcohol is the only dietary trigger
c. Abrupt onset lasting 5 to 180 minutes
d. Severe, sharp, penetrating head pain
e. Bilateral pressure or tightness sensation
f. May be accompanied by unilateral ptosis or lacrimation

Answer 69

b. Alcohol is the only dietary trigger
c. Abrupt onset lasting 5 to 180 minutes
d. Severe, sharp, penetrating head pain
f. May be accompanied by unilateral ptosis or lacrimation

Cluster headaches have only alcohol as a dietary trigger and have an abrupt onset lasting 5 minutes to 3 hours with severe, sharp, penetrating pain. Cluster headaches may be accompanied by unilateral ptosis, lacrimation, rhinitis, facial flushing or pallor and commonly recur several times each day for several weeks, with months or years between clustered attacks. Family history and nausea, vomiting, or irritability may be seen with migraine headaches. Bilateral pressure occurring between migraine headaches and intermittent occurrence over long periods of time are characteristics of tension-type headaches.

Question 70

What is the most important method of diagnosing functional headaches?

a. CT scan
b. Electromyography (EMG)
c. Cerebral blood flow studies
d. Thorough history of the headache

Answer 70

d. Thorough history of the headache

The primary way to diagnose and differentiate between headaches is with a careful history of the headaches, requiring assessment of specific details related to the headache. Electromyelography (EMG) may reveal contraction of the neck, scalp, or facial muscles in tension-type headaches but this is not seen in all patients. CT scans and cerebral angiography are used to rule out organic causes of the headaches.

Question 71

What drug therapy is included for acute migraine and cluster headaches that appears to alter the pathophysiologic process for these headaches?

a. B-Adrenergic blockers such as propanolol (Inderal)
b. Serotonin antagonists such as methysergide (Sansert)
c. Tricyclic antidepressants such as amitriptyline (Elavil)
d. Specific serotonin receptor agonists such as sumatriptan (Imitrex)

Answer 71

d. Specific serotonin receptor agonists such as sumatriptan (Imitrex)

Triptans (sumatriptan [Imitrex]) affect selected serotonin receptors that decrease neurogenic inflammation of the cerebral blood vessels and produce vasoconstriction. Both migraine headaches and cluster headaches appear to be related to vasodilation are useful in treatment of migraine and cluster headaches. Methysergide blocks serotonin receptors in the central and peripheral nervous systems and is used for prevention of migraine and cluster headaches. B-adrenergic blockers and tricyclic antidepressants are used prophylactically for migraine headaches but are not effective for cluster headaches.

Question 72

What is a nursing intervention that is appropriate for the patient with a nursing diagnosis of anxiety related to lack of knowledge of the etiology and treatment of headache?

a. Help the patient to examine lifestyle patterns and precipitating factors.
b. Administer medications as ordered to relieve pain and promote relaxation.
c. Provide a quiet, dimly lit environment to reduce stimuli that increase muscle tension and anxiety.
d. Support the patient’s use of counseling or psychotherapy to enhance conflict resolution and stress reduction.

Answer 72

a. Help the patient to examine lifestyle patterns and precipitating factors.

When the anxiety is related to a lack of knowledge about the etiology and treatment of a headache, helping the patient to identify stressful lifestyle patterns and other precipitating factors and ways of avoiding them are appropriate nursing interventions for the anxiety. Interventions that teach alternative therapies to supplements drug therapy also give the patient some control over pain and are appropriate teaching regarding treatment of the headache. The other interventions may help to reduce anxiety generally but they do not address the etiologic factor of the anxiety.

Question 73

The nurse is preparing to admit a newly diagnosed patient experiencing tonic-clonic seizures. What could the nurse delegate to unlicensed assistive personnel (UAP)?

a. Complete the admission assessment.
b. Explain the call system to the patient.
c. Obtain the suction equipment from the supply cabinet.
d. Place a padded tongue blade on the wall above the patient’s bed.

Answer 73

c. Obtain the suction equipment from the supply cabinet.

The unlicensed assistive personnel (UAP) is able to obtain equipment from the supply cabinet or department. The RN may need to provide a list of necessary equipment and should set up the equipment and ensure proper functioning. The RN is responsible for the initial history and assessment as well as teaching the patient about the room’s call system. Padded tongue blades are no longer used and no effort should be made to place anything in the patient’s mouth during a seizure.

Question 74

How do generalized seizures differ from focal seizures?

a. Focal seizures are confined to one side of the brain and remain focal in nature.
b. Generalized seizures result in loss of consciousness whereas focal seizures do not.
c. Generalized seizures result in temporary residual deficits during the postictal phase.
d. Generalized seizures have bilateral synchronous epileptic discharges affecting the whole brain at onset of the seizure.

Answer 74

d. Generalized seizures have bilateral synchronous epileptic discharges affecting the whole brain at onset of the seizure.

Generalized seizures have bilateral synchronous epileptic discharge affecting the entire brain at onset of the seizure. Loss of consciousness is also characteristic but many focal seizures also include an altered consciousness. Focal seizures begin in one side of the brain but may spread to involve the entire brain. Focal seizures that start with a local focus and spread to the entire brain, causing a secondary generalized seizure, are associated with a transient residual neurologic deficit postictally known as Todd’s paralysis.

Question 75

Which type of seizure occurs in children, is also known as a petit mal seizure, and consists of a staring spell that lasts for a few seconds?

a. Atonic
b. Simple focal
c. Typical absence
d. Atypical absence

Answer 75

c. Typical absence

The typical absence seizure is also known as petit mal and the child has staring spells that last for a few seconds. Atonic seizures occur when the patient falls from loss of muscle tone accompanied by brief unconsciousness. Simple focal seizures have focal motor, sensory, or autonomic symptoms related to the area of the brain involved without loss of consciousness. Staring spells in atypical absence seizures last longer than those in typical absence seizures and are accompanied by peculiar behavior during the seizure or confusion after the seizure.

Question 76

The patient is diagnosed with complex focal seizures. Which characteristics are related to complex focal seizures (select all that apply)?

a. Formerly known as grand mal seizure
b. Often accompanied by incontinence or tongue or cheek biting
c. Psychomotor seizures with repetitive behaviors and lip smacking
d. Altered memory, sexual sensations, and distortions of visual or auditory sensations
e. Loss of consciousness and stiffening of the body with subsequent jerking of extremities
f. Often involves behavioral, emotional, and cognitive functions with altered consciousness

Answer 76

c. Psychomotor seizures with repetitive behaviors and lip smacking
d. Altered memory, sexual sensations, and distortions of visual or auditory sensations
f. Often involves behavioral, emotional, and cognitive functions with altered consciousness

Complex focal seizures are psychomotor seizures with automatisms such as lip smacking. They cause altered consciousness or loss of consciousness producing a dreamlike state and may involve behavioral, emotional, or cognitive experiences without memory of what was done during the seizure. In generalized tonic-clonic seizures (previously known as grand mal seizures) there is a loss of consciousness and stiffening of the body with subsequent jerking of extremities. Incontinence or tongue or cheek biting may also occur.

Question 77

Which type of seizure is most likely to cause death for the patient?

a. Subclinical seizures
b. Myoclonic seizures
c. Psychogenic seizures
d. Tonic-clonic status epilepticus

Answer 77

d. Tonic-clonic status epilepticus

Tonic-clonic status epilepticus is most dangerous because the continuous seizing can cause respiratory insufficiency, hypoxemia, cardiac dysrhythmia, hyperthermia, and systemic acidosis, which can all be fatal. Subclinical seizures may occur in a patient who is sedated, so there is no physical movement. Myoclonic seizures may occur in clusters and have a sudden, excessive jerk of the body that may hurl the person to the ground. Psychogenic seizures are psychiatric in origin and diagnosed with video-electroencephalography (EEG) monitoring. They occur in patients with a history of emotional abuse or a specific traumatic episode.

Question 78

A patient admitted to the hospital following a generalized tonic-clonic seizure asks the nurse what caused the seizure. What is the best response by the nurse?

a. “So many factors can cause epilepsy that it is impossible to say what caused your seizure.”
b. “Epilepsy is an inherited disorder. Does anyone else in your family have a seizure disorder?”
c. “In seizures, some type of trigger causes sudden, abnormal bursts of electrical brain activity.”
d. “Scar tissue in the brain alters the chemical balance, creating uncontrolled electrical discharges.”

Answer 78

c. “In seizures, some type of trigger causes sudden, abnormal bursts of electrical brain activity.”

A seizure is a paroxysmal, uncontrolled discharge of neurons in the brain, which interrupts normal function, but the factor that causes the abnormal firing is not clear. Seizures may be precipitated by many factors and although scar tissue may make the brain neurons more likely to fire, it is not the usual cause of seizures. Epilepsy is established only by a pattern of spontaneous, recurring seizures.

Question 79

A patient with a seizure disorder is being evaluated for surgical treatment of seizures. The nurse recognizes that what is one of the requirements for surgical treatment?

a. Identification of scar tissue that is able to be removed
b. An adequate trial of drug therapy that had unsatisfactory results
c. Development of toxic syndromes from long-term use of antiseizure drugs
d. The presence of symptoms of cerebral degeneration from repeated seizures

Answer 79

b. An adequate trial of drug therapy that had unsatisfactory results

Most patients with seizures disorders maintain seizure control with medications but if surgery is considered, three requirements must be met: the diagnosis of epilepsy must be confirmed, there must have been an adequate trial with drug therapy without satisfactory results, and the electroclinical syndrome must be defined. The focal point must be localized but the presence of scar tissue is not required.

Question 80

The nurse teaches the patient taking antiseizure drugs that this method is most commonly used to measure compliance and measure for toxicity.

a. A daily seizure log
b. Urine testing for drug levels
c. Blood testing for drug levels
d. Monthly electroencephalography (EEG)

Answer 80

c. Blood testing for drug levels

Serum levels of antiseizure drugs are monitored regularly to maintain therapeutic levels of the drug, above which patients are likely to experience toxic effects and below which seizures are likely to occur. Many newer drugs do not require drug level monitoring because of large therapeutic ranges. A daily seizure log and urine testing for drug levels will not measure compliance or monitor for toxicity. EEGs have limited value in diagnosis of seizures and even less value in monitoring seizure control.

Question 81

When teaching a patient with a seizure disorder about the medication regimen, what is it most important for the nurse to emphasize?

a. The patient should increase the dosage of the medication if stress is increased.
b. Most over-the-counter and prescription drugs are safe to take with antiseizure drugs.
c. Stopping the medication abruptly may increase the intensity and frequency of seizures.
d. If gingival hypertrophy occurs, the drug should be stopped and the health care provider notified.

Answer 81

c. Stopping the medication abruptly may increase the intensity and frequency of seizures.

If antiseizure drugs are discontinued abruptly, seizures can be precipitated. Missed doses should be made up if the omission is remembered within 24 hours and patients should not adjust medications without professional guidance because this can also increase seizure frequency and may cause status epilepticus. Antiseizure drugs have numerous interactions with other drugs and the use of other medications should be evaluated by health professionals. If side effects occur, the physician should be notified and drug regimens evaluated.

Question 82

The nurse finds a patient in bed having a tonic-clonic seizure. During the seizure activity, what actions should the nurse take (select all that apply)?

a. Loosen restrictive clothing.
b. Turn the patient to the side.
c. Protect the patient’s head from injury.
d. Place a padded tongue blade between the patient’s teeth.
e. Restrain the patient’s extremities to prevent soft tissue and bone injury.

Answer 82

a. Loosen restrictive clothing.
b. Turn the patient to the side.
c. Protect the patient’s head from injury.

The focus is on maintaining a patent airway and preventing patient injury. The nurse should not place objects in the patient’s mouth or restrain the patient.

Question 83

Following a generalized tonic-clonic seizure, the patient is tired and sleepy. What care should the nurse provide?

a. Suction the patient before allowing him to rest.
b. Allow the patient to sleep as long as he feels sleepy.
c. Stimulate the patient to increase his level of consciousness.
d. Check the patient’s level of consciousness every 15 minutes for an hour.

Answer 83

b. Allow the patient to sleep as long as he feels sleepy.

In the postictal phase of generalized tonic-clonic seizures, patients are usually very tired and may sleep for several hours and the nurse should allow the patient to sleep for as long as necessary. Suctioning is performed only if needed and decreased level of consciousness is not a problem postictally unless a head injury has occurred during the seizure.

Question 84

During the diagnosis and long-term management of a seizure disorder, what should the nurse recognize as one of the major needs of the patient?

a. Managing the complicated drug regimen of seizure control
b. Coping with the effects of negative social attitudes toward epilepsy
c. Adjusting to the very restricted lifestyle required by a diagnosis of epilepsy
d. Learning to minimize the effect of the condition in order to obtain employment

Answer 84

b. Coping with the effects of negative social attitudes toward epilepsy

One of the most common complications of a seizure disorder is the effect it has on the patient’s lifestyle. This is because of the social stigma attached to seizures, which causes patients to hide their diagnosis and to prefer not to be identified as having epilepsy. Medication regimens usually require only once-or twice-daily dosing and the major restrictions of the lifestyle usually involve driving and high-risk environments. Job discrimination against the handicapped is prevented by federal and state laws and patients only need to identify their disease in case of medical emergencies.

Question 85

A patient at the clinic for a routine health examination mentions that she is exhausted because her legs bother her so much at night that she cannot sleep. The nurse questions the patient further about her leg symptoms with what knowledge about restless legs syndrome?

a. The condition can be readily diagnosed with EMG.
b. Other more serious nervous system dysfunctions may be present.
c. Dopaminergic agents are often effective in managing the symptoms.
d. Symptoms can be controlled by vigorous exercise of the legs during the day.

Answer 85

c. Dopaminergic agents are often effective in managing the symptoms.

Restless legs syndrome that is not related to other pathologic processes, such as diabetes mellitus or rheumatic disorders, may be caused by a dysfunction in the basal ganglia circuits that use the neurotransmitter dopamine, which controls movements. Dopamine precursors and dopamine agonists, such as those used for parkinsonism, are effective in managing sensory and motor symptoms. Polysomnography studies during sleep are the only tests that have diagnostic value and although exercise should be encouraged, excessive leg exercise does not have an effect on the symptoms.

Question 86

Which chronic neurologic disorder involves a deficiency of the neurotransmitters acetylcholine and y-aminobutyric acid (GABA) in the basal ganglia and extrapyramidal system?

a. Myasthenia gravis
b. Parkinson’s disease
c. Huntington’s disease
d. Amyotrophic lateral sclerosis (ALS)

Answer 86

c. Huntington’s disease

Huntington’s disease (HD) involves deficiency of acetylcholine and y-aminobutyric acid (GABA) in the basal ganglia and extrapyramidal system that causes the opposite symptoms of parkinsonism. Myasthenia gravis involves autoimmune antibody destruction of cholinergic receptors at the neuromuscular junction. Amyotrophic lateral sclerosis (ALS) involves degeneration of motor neurons in the brainstem and spinal cord.

Question 87

A 38-year-old woman has newly diagnosed multiple sclerosis (MS) and asks the nurse what is going to happen to her. Which is the best response by the nurse?

a. “You will have either periods of attacks and remissions or progression of nerve damage over time.”
b. “You need to plan for a continuous loss of movement, sensory functions, and mental capabilities.”
c. “You will most likely have a steady course of chronic progressive nerve damage that will change your personality.”
d. “It is common for people with MS to have an acute attack of weakness and then not to have any other symptoms for years.”

Answer 87

a. “You will have either periods of attacks and remissions or progression of nerve damage over time.”

Most patients with multiple sclerosis (MS) have remissions and exacerbations of neurologic dysfunction or a relapsing-remitting initial course followed by progression with or without occasional relapses, minor remissions, and plateaus that progressively cause loss of motor, sensory, and cerebellar functions. Intellectual function generally remains intact but patients may experience anger, depression, or euphoria. A few people have chronic progressive deterioration and some may experience only occasional and mild symptoms for several years after onset.

Question 88

During assessment of a patient admitted to the hospital with an acute exacerbation of MS, what should the nurse expect to find?

a. Tremors, dysphasia, and ptosis
b. Bowel and bladder incontinence and loss of memory
c. Motor impairment, visual disturbances, and parathesias
d. Excessive involuntary movements, hearing loss, and ataxia

Answer 88

c. Motor impairment, visual disturbances, and parathesias

Specific neurologic dysfunction of MS is caused by destruction of myelin and replacement with glial scar tissue at specific areas in the nervous system. Motor, sensory, cerebellar, and emotional dysfunctions, including parasthesias as well as patchy blindness, blurred vision, pain radiating along the dermatome of the nerve, ataxia, and severe fatigue, are the most common manifestations of MS. Constipation and bladder dysfunctions, short-term memory loss, sexual dysfunction, anger, and depression or euphoria may also occur. Excessive involuntary movements and tremors are not seen in MS.

Question 89

The nurse explains to a patient newly diagnosed with MS that the diagnosis is made primarily by

a. spinal x-ray findings.
b. T-cell analysis of the blood.
c. analysis of cerebrospinal fluid.
d. history and clinical manifestations.

Answer 89

d. history and clinical manifestations.

There is no specific diagnostic test for MS. A diagnosis is made primarily by history and clinical manifestations. Certain dianostic tests may be used to help establish a diagnosis of MS. Positive findings on MRI include evidence of at least two inflammatory demyelinating lesions in at least two different locations within the central nervous system (CNS). Cerebrospinal fluid (CSF) may have increased immunoglobin G and the presence of oligoclonal banding. Evoked potential responses are often delayed in persons with MS.

Question 90

Mitoxantrone (Novatrone) is being considered as treatment for a patient with progressive-relapsing MS. The nurse explains that the disadvantage of this drug compared with other drugs used for MS is what?

a. It must be given subcutaneously every day.
b. It has a lifetime dose limit because of cardiac toxicity.
c. It is an anticholinergic agent that causes urinary incontinence.
d. It is an immunosuppressant agent that increases the risk for infection.

Answer 90

b. It has a lifetime dose limit because of cardiac toxicity.

Mitoxantrone (Novantrone) cannot be used for more than 2 to 3 years because it is an antineoplastic drug that causes cardiac toxicity, leukemia, and infertility. It is a monoclonal antibody given IV monthly when patients have inadequate responses to other drugs. It increases the risk of progressive multifocal leukoencephalopathy.

Question 91

A patient with MS has a nursing diagnosis of self-care deficit related to muscle spasticity and neuromuscular deficits. In providing care for the patient, what is most important for the nurse to do?

a. Teach the family members how to care adequately for the patient’s needs.
b. Encourage the patient to maintain social interactions to prevent social isolation.
c. Promote the use of assistive devices so the patient can participate in self-care activities.
d. Perform all activities of daily living (ADLs) for the patent to conserve the patient’s energy.

Answer 91

c. Promote the use of assistive devices so the patient can participate in self-care activities.

The main goal in care of the patient with MS is to keep the patient active and maximally functional and promote self-care as much as possible to maintain independence. Assistive devices encourage independence while preserving the patient’s energy. No care activity that the patient can do for himself or herself should be performed by others. Involvement of the family in the patient’s care and maintenance of social interactions are also important but are not the priority in care.

Question 92

A patient with newly diagnosed MS has been hospitalized for evaluation and initial treatment of the disease. Following discharge teaching, the nurse realizes that additional instruction is needed when the patient says what?

a. “It is important for me to avoid exposure to people with upper respiratory infections.”
b. “When I begin to feel better, I should stop taking the prednisone to prevent side effects.”
c. “I plan to use vitamin supplements and a high-protein diet to help manage my condition.”
d. “I must plan with my family how we are going to manage my care if I become more incapacitated.”

Answer 92

b. “When I begin to feel better, I should stop taking the prednisone to prevent side effects.”

Corticosteroids used in treating acute exacerbations of MS should not be abruptly stopped by the patient because adrenal insufficiency may result and prescribed tapering doses should be followed. Infections may exacerbate symptoms and should be avoided and high-protein diets with vitamin supplements are advocated. Long-term planning for increasing disability is also important.

Question 93

The classic triad of manifestations associated with Parkinson’s disease is tremor, rigidity, and bradykinesia. What is a consequence related to rigidity?

a. Shuffling gait
b. Impaired handwriting
c. Lack of postural stability
d. Muscle soreness and pain

Answer 93

d. Muscle soreness and pain

The degeneration of dopamine-producing neurons in the substantia nigra of midbrain and basal ganglia lead to this triad of signs. Muscle soreness, pain, and slowness of movement are patient function consequences related to rigidity. Shuffling gait, lack of postural stability, absent arm swing while walking, absent blinking, masked facial expression, and difficulty initiating movement are all related bradykinesia. Impaired handwriting and hand activities are related to the tremor of Parkinson’s disease (PD).

Question 94

A patient with a tremor is being evaluated for Parkinson’s disease. The nurse explains to the patient that Parkinson’s disease can be confirmed by

a. CT and MRI scans.
b. relief of symptoms with administration of dopaminergic agents.
c. the presence of tremors that increase during voluntary movement.
d. cerebral angiogram that reveals the presence of cerebral atherosclerosis.

Answer 94

b. relief of symptoms with administration of dopaminergic agents.

Although clinical manifestations are characteristic in PD, no laboratory or diagnostic tests are specific for the condition. A diagnosis is made when at least two of the three signs of the classic triad are present and it is confirmed with a positive response to antiparkinsonian medication. Research regarding the role of genetic testing and MRI to diagnose PD is ongoing. Essential tremors increase during voluntary movement whereas the tremors of PD are more prominent at rest.

Question 95

Which observation of the patient made by the nurse is most indicative of Parkinson’s disease?

a. Large, embellished handwriting
b. Weakness of one leg resulting in a limping walk
c. Difficulty rising from a chair and beginning to walk
d. Onset of muscle spasms occurring with voluntary movement

Answer 95

c. Difficulty rising from a chair and beginning to walk

The bradykinesia of PD prevents automatic movements and activities such as beginning to walk, rising from a chair, or even swallowing of saliva cannot be executed unless they are consciously willed. Handwriting is affected by the tremor and results in the writing trailing off at the end of words. Specific limb weakness and muscle spasms are not characteristic of PD.

Question 96

A patient with Parkinson’s disease is started on levodopa. What should the nurse explain about this drug?

a. It stimulates dopamine receptors in the basal ganglia.
b. It promotes the release of dopamine from brain neurons.
c. It is a precursor of dopamine that is converted to dopamine in the brain.
d. It prevents the excessive breakdown of dopamine in the peripheral tissues.

Answer 96

c. It is a precursor of dopamine that is converted to dopamine in the brain.

Peripheral dopamine does not cross the blood-brain barrier but its precursor, levodopa, is able to enter the brain, where it is converted to dopamine, increasing the supply that is deficient in PD. Other drugs used to treat PD include bromocriptine, which stimulates dopamine receptors in the basal ganglia, and amantadine, which blocks the reuptake of dopamine in presynaptic neurons. Carbidopa is an agent that is usually administered with levodopa to prevent the levodopa from being metabolized in peripheral tissues before it can reach the brain.

Question 97

To reduce the risk for falls in the patient with Parkinson’s disease, what should the nurse teach the patient to do?

a. Use an elevated toilet seat.
b. Use a walker or cane for support.
c. Consciously lift the toes when stepping.
d. Rock side to side to initiate leg movements.

Answer 97

c. Consciously lift the toes when stepping.

The shuffling gait of PD causes the patient to be off balance and at risk for falling. Teaching the patient to use a wide stance with the feet apart, to lift the toes when walking, and to look ahead helps promote a more balanced gait. Use of an elevated toilet seat and rocking from side to side will enable a patient to initiate movement. Canes and walkers are difficult for patients with PD to maneuver and may make the patient more prone to injury.

Question 98

A patient with myasthenia gravis is admitted to the hospital with respiratory insufficiency and severe weakness. When is a diagnosis of cholinergic crisis made?

a. The patient’s respiration is impaired because of muscle weakness.
b. Administration of edrophonium (Tensilon) increases muscle weakness.
c. Administration of edrophonium (Tensilon) results in improved muscle contractility.
d. EMG reveals decreased response to repeated stimulation of muscles.

Answer 98

b. Administration of edrophonium (Tensilon) increases muscle weakness.

The reduction of acetylcholine (ACh) effect in myasthenia gravis (MG) is treated with anticholinesterase drugs, which prolong the action of ACh at the neuromuscular synapse, but too much of these drugs will cause a cholingergic crisis with symptoms very similar to those of MG. To determine whether the patient’s manifestations are due to a deficiency of ACh or too much anticholinesterase drug, the anticholinesterase drug edrophonium chloride (Tensilon) is administered. If the patient is in cholinergic crisis, the patient’s symptoms will worsen; if the patient is in a myasthenic crisis, the patient will improve.

Question 99

During care of a patient in myasthenic crisis, maintenance of what is the nurse’s first priority for the patient?

a. Mobility
b. Nutrition
c. Respiratory function
d. Verbal communication

Answer 99

c. Respiratory function

The patient in myasthenic crisis has severe weakness and fatigability of all skeletal muscles, affecting the patient’s ability to breathe, swallow, talk and move. However, the priority of nursing care is monitoring and maintaining adequate ventilation.

Question 100

When providing care for a patient with ALS, the nurse recognizes what as one of the most distressing problems experienced by the patient?

a. Painful spasticity of the face and extremities
b. Retention of cognitive function with total degeneration of motor function
c. Uncontrollable writhing and twisting movements of the face, limbs, and body
d. Knowledge that there is a 50% chance the disease has been passed to any offspring

Answer 100

b. Retention of cognitive function with total degeneration of motor function

In ALS there is gradual degeneration of motor neurons with extreme muscle wasting from lack of stimulation and use. However, cognitive function is not impaired and patients feel trapped in a dying body. Chorea manifested by writhing, involuntary movements is characteristic of HD. As an autosomal dominant genetic disease, HD also has a 50% chance of being passed off to each offspring.

Question 101

In providing care for patients with chronic, progressive neurologic disease, what is the major goal of treatment that the nurse works toward?

a. Meet the patient’s personal care needs.
b. Return the patient to normal neurologic function.
c. Maximize neurologic functioning for as long as possible.
d. Prevent the development of additional chronic diseases.

Answer 101

c. Maximize neurologic functioning for as long as possible.

Many chronic neurologic diseases involve progressive deterioration in physical or mental capabilities and have no cure, with devastating results for patients and families. Health care providers can only attempt to alleviate physical symptoms, prevent complications, and assist patients in maximizing function and self-care abilities for as long as possible.

Question 102

A patient is diagnosed with Bell’s palsy. What information should the nurse teach the patient about Bell’s palsy (select all that apply)?

a. Bell’s palsy affects the motor branches of the facial nerve.
b. Antiseizure drugs are the drugs of choice for treatment of Bell’s palsy.
c. Nutrition and avoidance of hot foods or beverages are special needs of this patient.
d. Herpes simplex virus 1 is strongly associated as a precipitating factor in the development of Bell’s palsy.
e. Moist heat, gentle massage, electrical stimulation of the nerve, and exercises are prescribed to treat Bell’s palsy.
f. An inability to close the eyelid, with an upward movement of the eyeball when closure is attempted, is evident.

Answer 102

a. Bell’s palsy affects the motor branches of the facial nerve.
d. Herpes simplex virus 1 is strongly associated as a precipitating factor in the development of Bell’s palsy.
e. Moist heat, gentle massage, electrical stimulation of the nerve, and exercises are prescribed to treat Bell’s palsy.
f. An inability to close the eyelid, with an upward movement of the eyeball when closure is attempted, is evident.

Bell’s palsy affects the motor branches of the facial nerve. It is treated with corticosteroids, usually prednisone. Herpes simplex virus 1 may be a precipitating factor. Moist heat, gentle massage, electrical nerve stimulation, and exercises are prescribed. Care must be taken to protect the eye with sunglasses, artificial tears or gel, and possibly taping the eyelid closed at night. Oral hygiene is important but avoidance of hot foods is not needed.

Question 103

When planning care for the patient with trigeminal neuralgia, which patient outcome should the nurse set as the highest priority?

a. Relief of pain
b. Protection of the cornea
c. Maintenance of nutrition
d. Maintenance of positive body image

Answer 103

a. Relief of pain

The pain of trigeminal neuralgia is excruciating and it may occur in clusters that continue for hours. The condition is considered benign with no major effects except the pain. Corneal exposure is a problem in Bell’s palsy or it may occur following surgery for the treatment of trigeminal neuralgia. Maintenance of nutrition is important but not urgent because chewing may trigger trigeminal neuralgia and patients then avoid eating. Except during an attack, there is no change in facial appearance in a patient with trigeminal neuralgia and body image is more disturbed in response to the paralysis typical of Bell’s palsy.

Question 104

Surgical intervention is being considered for a patient with trigeminal neuralgia. The nurse recognizes that which procedure has the least residual effects with a positive outcome?

a. Glycerol rhizotomy
b. Gamma knife radiosurgery
c. Microvascular decompression
d. Percutaneous radiofrequency rhizotomy

Answer 104

a. Glycerol rhizotomy

Although percutaneous radiofrequency and microvascular decompression provide the greatest relief of pain, glycerol rhizotomy causes less sensory loss and fewer sensory aberrations with comparable pain relief and less danger. Gamma knife radiosurgery provides precise high doses of radiation useful for persistent pain after other surgery.

Question 105

What should the nurse do when providing care for a patient with an acute attack of trigeminal neuralgia?

a. Carry out all hygiene and oral care for the patient.
b. Use conversation to distract the patient from pain.
c. Maintain a quiet, comfortable, draft-free environment.
d. Have the patient examine the mouth after each meal for residual food.

Answer 105

c. Maintain a quiet, comfortable, draft-free environment.

Because attacks of trigeminal neuralgia may be precipitated by hot or cold air movement on the face, jarring movements, or talking, the environment should be of moderate temperature and free of drafts and patients should not be expected to converse during the acute period. Patients offer prefer to carry out their own care because they are afraid someone may inadvertently injure them or precipitate an attack. The nurse should stress that oral hygiene be performed because patients often avoid it but residual food in the mouth after eating occurs more frequently with Bell’s palsy.

Question 106

A patient is admitted to the hospital with Guillain-Barre syndrome. She had weakness in her feet and ankles that has progressed to weakness with numbness and tingling in both legs. During the acute phase of the illness, what should the nurse know about Guillain-Barre syndrome?

a. The most important aspect of care is to monitor the patient’s respiratory rate and depth and vital capacity.
b. Early treatment with corticosteroids can suppress the immune response and prevent ascending nerve damage.
c. The most serious complication of this condition is ascending demyelination of the peripheral nerves and the cranial nerves.
d. Although voluntary motor neurons are damaged by the inflammatory response, the autonomic nervous system is unaffected by the disease.

Answer 106

a. The most important aspect of care is to monitor the patient’s respiratory rate and depth and vital capacity.

The most serious complication of Guillain-Barre syndrome is respiratory failure and it is essential that respiratory rate and depth and vital capacity are monitored to detect involvement of the autonomic nerves that affect respiration. Corticosteroids may be used in treatment but do not appear to have an effect on the prognosis or duration of the disease. Rather, plasmapheresis or administration of high-dose immunoglobin does result in shortening recovery time. The peripheral nerves of both the sympathetic and the parasympathetic nervous systems are involved in the disease and may lead to orthostatic hypotension, hypertension, and abnormal vagal responses affecting the heart. Guillain-Barre syndrome may affect the lower brainstem and cranial nerves (CNs) VII, VI, III, XII, V, and X, affecting facial, eye, and swallowing functions.

Question 107

A patient with Guillain-Barre syndrome asks whether he is going to die as the paralysis spreads toward his chest. In responding to the patient, what should the nurse know to be able to answer this question?

a. Patients who require ventilatory support almost always die.
b. Death occurs when nerve damage affects the brain and meninges.
c. Most patients with Guillain-Barre syndrome make a complete recovery.
d. If death can be prevented, residual paralysis and sensory impairment are usually permanent.

Answer 107

c. Most patients with Guillain-Barre syndrome make a complete recovery.

As the nerve involvement ascends, it is very frightening for the patient but 85% to 95% of patients with Guillain-Barre syndrome recover completely with care, although 30% may have a residual weakness. Patients also recover if ventilatory support is provided during respiratory failure. Guillain-Barre syndrome only affects peripheral nerves and does not affect the brain.

Question 108

Which condition is transmitted through wound contamination, causes painful tonic spasms or seizures, and can be prevented by immunization?

a. Tetanus
b. Botulism
c. Neurosyphilis
d. Systemic inflammatory response syndrome

Answer 108

a. Tetanus

Question 109

Which statements describe neurosyphilis (select all that apply)?

a. Occurs 10 to 20 years after bacterial infection
b. Infection can affect any part of the nervous system
c. Descending paralysis with cranial nerve involvement
d. Degenerative changes in the spinal cord and brainstem
e. Inhibits transmission of acetylcholine at myoneural junction
f. Initially manifests with GI symptoms with subsequent absorption of neurotoxin

Answer 109

a. Occurs 10 to 20 years after bacterial infection
b. Infection can affect any part of the nervous system
d. Degenerative changes in the spinal cord and brainstem