MSS Ch 2: Neurological Disorders Comprehensive Exam

Question 1

The client is admitted with a diagnosis of trigeminal neuralgia. Which assessment data would the nurse expect to find in this client?

1. Joint pain of the neck and jaw.
2. Unconscious grinding of the teeth during sleep.
3. Sudden severe unilateral facial pain.
4. Progressive loss of calcium in the nasal septum.

Answer 1

1. Joint pain is usually associated with some type of arthritis.
2. Unconscious grinding of the teeth during sleep is usually associated with temporo- mandibular joint (TMJ) disorder.
3. Trigeminal neuralgia affects the 5th cranial nerve and is characterized by paroxysms of pain in the area innervated by the three branches of the nerve. The unilateral nature of the pain is an important diagnostic characteristic. The disorder is also known as tic douloureux.
4. The nasal structure is not made up of bone.

Question 2

The client recently has been diagnosed with trigeminal neuralgia. Which intervention is most important for the nurse to implement with the client?

1. Assess the client’s sense of smell and taste.
2. Teach the client how to care for the eyes.
3. Instruct the client to have carbamazepine (Tegretol) levels monitored regularly.
4. Assist the client to identify factors that trigger an attack.

Answer 2

1. The client’s sense of smell and taste are not affected.
2. The cornea is at risk for abrasions because of the twitching, which causes irritation. Therefore, the nurse must teach the client how to care for the eye, but the most impor- tant intervention is to prevent the attacks.
3. Tegretol is the treatment of choice for trigeminal neuralgia, but it is not the most important intervention when the client is first diagnosed with this condition.
4. Stimulating specific areas of the face, called trigger zones, many initiate the onset of pain. Therefore, the nurse should help the client identify situations that exacerbate the condition, such as chewing gum, eating, brushing the teeth, or being exposed to a draft of cold air.

Question 3

The client comes to the clinic and reports a sudden drooping of the left side of the face and complains of pain in that area. The nurse notes that the client cannot wrinkle the forehead or close the left eye. Which condition should the nurse suspect?

1. Bell’s palsy.
2. Right-sided stroke.
3. Tetany.
4. Mononeuropathy.

Answer 3

1. Bell’s palsy, called facial paralysis, is a disorder of the 7th cranial nerve (facial nerve) characterized by unilateral paralysis of facial muscles.
2. These are symptoms of a left-sided stroke.
3. Tetany is due to low calcium levels. In this disorder, the face twitches when touched; this is known as a positive Chvostek’s sign.
4. Mononeuropathy is limited to a single peripheral nerve and its branches and occurs because the trunk of the nerve is com- pressed, such as in carpal tunnel syndrome.

Question 4

The client comes to the clinic for treatment of a dog bite. Which intervention should the clinic nurse implement first?

1. Prepare the client for a series of rabies injections.
2. Notify the local animal control shelter.
3. Administer a tetanus toxoid in the deltoid.
4. Determine if the animal has had its vaccinations.

Answer 4

1. This may be needed if it is determined the dog has not had its shots or if the dog cannot be found, but it is not the first intervention.
2. This is an appropriate action if the client does not know who owns the dog, so that the dog can be found and quarantined.
3. If the client has not had a tetanus booster in the last 10 years, one must be administered, but it is usually the last action taken before the client is discharged from the clinic.
4. This is priority because, if the dog has had its vaccinations, the client will not have to undergo a series of very painful injections. The nurse must obtain information about the dog, which is assessment of the situation.

Question 5

The client has glossopharyngeal nerve (cranial nerve IX) paralysis secondary to a stroke. Which referral would be most appropriate for this client?

1. Hospice nurse.
2. Speech therapist.
3. Physical therapist.
4. Occupational therapist.

Answer 5

1. Clients are referred to hospice when there is a life expectancy of less than six (6) months. This client has difficulty swallow- ing, which is not life threatening.
2. Speech therapists address the needs of clients who have difficulty with the innervations and musculature of the face and neck. This includes the swallowing reflex.
3. The physical therapist assists the client to ambulate and transfer (e.g., from bed to chair) and with muscle strength training.
4. The occupational therapist focuses on cog- nitive disability and activities of daily living.

Question 6

Which assessment data would make the nurse suspect that the client has amyotrophic lateral sclerosis?

1. History of a cold or gastrointestinal upset in the last month.
2. Complaints of double vision and drooping eyelids.
3. Fatigue, progressive muscle weakness, and twitching. 4. Loss of sensation below the level of the umbilicus.

Answer 6

1. A history of a cold or gastrointestinal upset in the last month would be assessment data that would make the nurse suspect Guillain-Barré syndrome.
2. Complaints of double vision and drooping eyelids would make the nurse suspect myasthenia gravis.
3. Fatigue, progressive muscle weakness, and twitching are signs of ALS, a progressive neurological disease in which there is a loss of motor neurons. There is no cure, but recently a medica- tion to slow the deterioration of the motor neurons has been found.
4. Loss of sensation would make the nurse suspect some type of spinal cord injury.

Question 7

The client is scheduled for an MRI of the brain to confirm a diagnosis of Creutzfeldt- Jakob disease. Which intervention should the nurse implement prior to the procedure?

1. Determine if the client has claustrophobia.
2. Obtain a signed informed consent form.
3. Determine if the client is allergic to egg yolks. 4. Start an intravenous line in both hands.

Answer 7

1. For an MRI scan, the client is placed in a very narrow tube. If the client is claustrophobic, he or she may need medication or an open MRI machine may need to be considered.
2. An MRI scan is not an invasive procedure; therefore, informed consent is not needed.
3. The nurse would need to determine allergies to shellfish or iodine, not to egg yolks.
4. The client will need one saline lock, not two intravenous lines. Often the MRI tech is the person who inserts the IV line.

Question 8

Which should be the nurse’s first intervention with the client diagnosed with Bell’s palsy?

1. Explain that this disorder will resolve within a month.
2. Tell the client to apply heat to the involved side of the face.
3. Encourage the client to eat a soft diet.
4. Teach the client to protect the affected eye from injury.

Answer 8

1. This is correct information, but it is not priority when discussing Bell’s palsy.
2. Heat will help promote comfort and increase blood flow to the muscles, but safety of the client’s eye is priority.
3. The client may have difficulty chewing on the affected side, so a soft diet should be encouraged, but it is not priority teaching.
4. Teaching the client to protect the eye is priority because the eye does not close completely and the blink reflex is diminished, making the eye vulnerable to injury. The client should wear an eye patch at night and wraparound sunglasses or goggles during the day; he or she may also need artificial tears.

Question 9

The client asks the nurse, “What causes Creutzfeldt-Jakob disease?” Which state- ment would be the nurse’s best response?

1. “The person must have been exposed to an infected prion.”
2. “It is mad cow disease, and eating contaminated meat is the cause.”
3. “This disease is caused by a virus that is in stagnant water.”
4. “A fungal spore from the lungs infects the brain tissue.”

Answer 9

1. Would a layperson know what a prion is? This is using medical jargon, which is not the nurse’s best response.
2. This is the cause of this disease and would be the best response.
3. A virus is not the cause of Creutzfeldt-Jakob disease.
4. Fungal spores do not cause this disease.

Question 10

The client is diagnosed with Creutzfeldt-Jakob disease. Which referral would be the most appropriate?

1. Alzheimer’s Association.
2. Creutzfeldt-Jakob Disease Foundation.
3. Hospice Care.
4. A neurosurgeon.

Answer 10

1. Creutzfeldt-Jakob disease is not Alzheimer’s disease, although the presenting symptoms may mimic Alzheimer’s disease.
2. There is no foundation for Creutzfeldt- Jakob disease, but if there were, the significant other would not be referred to this organization because the disease progresses so rapidly that the client would not get any benefit from the organization.
3. This disease is usually fatal within a year, and the symptoms progress rapidly to dementia.
4. The nurse does not refer the client to a neurosurgeon and the primary HCP would not refer to a neurosurgeon because there is no surgical or medical treatment for this disease.

Question 11

The client is diagnosed with arboviral encephalitis. Which priority intervention should the nurse implement?

1. Place the client in strict isolation.
2. Administer IV antibiotics.
3. Keep the client in the supine position.
4. Institute seizure precautions.

Answer 11

1. Arboviral encephalitis is a viral infection transmitted by mosquito bites, and isolation is not required.
2. Antibiotics are prescribed for bacterial infections, not viral infections. There is no antiviral medication to treat this disease.
3. Keeping the client supine would increase intracranial pressure, which is a concern when caring for clients with brain diseases.
4. Seizure precautions should be instituted because any inflammation of the brain tissue will put the client at risk for seizures.

Question 12

The client is diagnosed with a brain abscess. Which sign/symptom is the most common?

1. Projectile vomiting.
2. Disoriented behavior.
3. Headaches, worse in the morning.
4. Petit mal seizure activity.

Answer 12

1. Vomiting may occur, but it is not projec- tile and it is not the most common.
2. Disoriented behavior may occur, but it is not the most common.
3. The most common and prevailing symptom of a brain abscess is a headache that is worse in the morning because of increased intracranial pressure as a result of lying flat (gravity).
4. The client with a brain abscess may have seizure activity, but it is usually tonic-clonic (grand mal) and it is not the most common.

Question 13

The client diagnosed with a brain abscess has become lethargic and difficult to arouse. Which intervention should the nurse implement first?

1. Implement seizure precautions.
2. Assess the client’s neurological status.
3. Close the drapes and darken the room.
4. Prepare to administer an IV steroid.

Answer 13

1. This is an appropriate intervention, but it is not the first.
2. Remember, assessment is the first step of the nursing process and should be implemented first whenever there is a change in the client’s behavior.
3. This helps prevent stimulation that could initiate a seizure, but it is not the first intervention.
4. Steroids may be administered to clients with brain abscesses to decrease inflamma- tion, but assessment is the first intervention.

Question 14

The client is diagnosed with Huntington’s chorea. Which interventions should the nurse implement with the family? Select all that apply.

1. Refer to the Huntington’s Chorea Foundation.
2. Explain the need for the client to wear football padding.
3. Discuss how to cope with the client’s messiness.
4. Provide three (3) meals a day and no between-meal snacks.
5. Teach the family how to perform chest percussion.

Answer 14

1. Foundations offer the family and client information about the disease, support groups, and up-to-date information on current research.
2. The use of padding will help prevent injury from the constant movement that occurs with this disease.
3. The constant movement causes the client to be messy when eating, dressing, or performing activities of daily living.
4. The constant movements expend more calories; therefore, the client should have three meals plus between-meal snacks.
5. The client is at risk for choking; therefore, teaching the Heimlich maneuver is appropriate, but teaching chest percussion is not.

Question 15

The nurse is discussing psychosocial implications of Huntington’s chorea with the adult child of a client diagnosed with the disease. Which psychosocial intervention should the nurse implement?

1. Refer the child for genetic counseling as soon as possible.
2. Teach the child to use a warming tray under the food during meals.
3. Discuss the importance of not abandoning the parent.
4. Allow the child to talk about the fear of getting the disease.

Answer 15

1. Referring the child is not a psychosocial intervention. The gene that determines if a client has Huntington’s chorea has been identified, and genetic counseling could rule out or confirm that the client’s child will develop Huntington’s chorea.
2. This is an appropriate intervention, but it is not a psychosocial intervention. (Read the stem closely.)
3. This is placing a lot of responsibility on the child concerning the parent’s debilitat- ing, chronic, and devastating disease. The client may need to be in a long-term care facility, and the child should not feel guilty if this is necessary.
4. The child will develop this disease if he or she inherited the gene. It can be frightening for children to watch a parent progress through this disease and understand that they too may get it.

Question 16

The client is undergoing post-thrombolytic therapy for a stroke. The health-care provider has ordered heparin to be infused at 1,000 units per hour. The solution comes as 25,000 units of heparin in 500 mL of D5W. At what rate will the nurse set the pump? ___________

Answer 16

20 mL/hr.

To arrive at the answer, the test taker must divide 25,000 units by 500 mL = 50 units in 1 mL. Divide 1,000 units by 50 units = 20 mL/hr.

Question 17

Which finding is considered to be one of the warning signs of developing Alzheimer’s disease?

1. Difficulty performing familiar tasks.
2. Problems with orientation to date, time, and place.
3. Having problems focusing on a task.
4. Atherosclerotic changes in the vessels.

Answer 17

1. The client may experience minor difficulty in work or social activities but has ade- quate cognitive ability to hide the loss and continue to function independently.
2. Disorientation to time and place is a warning sign.
3. Not being able to focus on a task is more likely a sign of attention deficit- hyperactivity disorder.
4. Atherosclerotic changes are not warning signs of Alzheimer’s disease. Amyloid protein plaques do appear to have something to do with the disease, but they are not found until autopsy.

Question 18

Which information should be shared with the client diagnosed with Stage I Alzheimer’s disease who is prescribed donepezil (Aricept), a cholinesterase inhibitor? 1. The client must continue taking this medication forever to maintain function.

2. The drug may delay the progression of the disease, but it does not cure it.
3. A serum drug level must be obtained monthly to evaluate for toxicity.
4. If the client develops any muscle aches, the HCP should be notified.

Answer 18

1. This is not a true statement. The client will be no longer be prescribed this medication as the disease progresses and it becomes ineffective.
2. This medication does not cure Alzheimer’s disease, and at some point it will become ineffective as the disease progresses.
3. There is no monthly drug level to be monitored. Toxicity includes jaundice and gastrointestinal distress.
4. Muscle aches are an adverse effect of the lipid-lowering medications, not of Aricept.

Question 19

The spouse of a recently retired man tells the nurse, “All my husband does is sit around and watch television all day long. He is so irritable and moody. I don’t want to be around him.” Which action should the nurse implement?

1. Encourage the wife to leave the client alone.
2. Tell the wife that he is probably developing Alzheimer’s disease.
3. Recommend that the client see an HCP for an antidepressant medication.
4. Instruct the wife to buy him some arts and crafts supplies.

Answer 19

1. If the wife could leave the client alone, she would not be sharing her concerns with the nurse. The nurse needs to address the wife’s concerns as well as the husband’s.
2. This is not the typical signs/symptoms of stage I Alzheimer’s disease.
3. This behavior indicates the client is depressed and should be treated with antidepressants. A major lifestyle change has occurred, and he may need short-term medication therapy, depending on how the client adjusts to retirement.
4. The client may not want to participate in arts and crafts.

Question 20

The nurse in a long-term care facility has noticed a change in the behavior of one of the clients. The client no longer participates in activities and prefers to stay in his room. Which intervention should the nurse implement first?

1. Insist the client go to the dining room for meals.
2. Notify the family of the change in behavior.
3. Determine if the client wants another roommate.
4. Complete a Geriatric Depression Scale.

Answer 20

1. The nurse cannot insist that the client do anything. The nurse can encourage, but remember, this is the client’s home.
2. The family may need to be notified, but the nurse should first assess what is happening that is causing this change in behavior.
3. There is nothing that indicates the client is unhappy with the roommate. In fact, the client wants to stay in the room, which does not indicate a need for a room change.
4. A change in behavior may indicate depression. The Geriatric Depression Scale measures satisfaction with life’s accomplishments. The elderly should be in Erikson’s generativity versus stagnation stage of life.

Question 21

A family member brings the client to the emergency department reporting that the 78-year-old father has suddenly become very confused and thinks he is living in 1942, that he has to go to war, and that someone is trying to poison him. Which question should the nurse ask the family member?

1. “Has your father been diagnosed with dementia?”
2. “What medication has your father taken today?”
3. “What have you given him that makes him think it’s poison?”
4. “Does your father like to watch old movies on television?”

Answer 21

1. Dementia involves behavior changes that are irreversible and occur over time. Delirium, however, occurs suddenly (as in this man’s symptom onset), is caused by an acute event, and is reversible.
2. Drug toxicity and interactions are common causes of delirium in the elderly.
3. This is blaming the family member for the client’s paranoid ideation.
4. Watching old movies on television will not cause delirium.

Question 22

The student nurse asks the nurse, “Why do you ask the client to identify how many fingers you have up when the client hit the front of the head, not the back?” The nurse would base the response on which scientific rationale?

1. This is part of the routine neurological examination.
2. This is done to determine if the client has diplopia.
3. This assesses the amount of brain damage.
4. This is done to indicate if there is a rebound effect on the brain.

Answer 22

1. This is part of the neurological examination, but this is not the scientific rationale for why it is done. The nurse must understand what is being assessed to interpret the data.
2. Diplopia, double vision, is a sign of head injury, but it is not the scientific rationale.
3. The procedure does assess for brain dam- age, but this answer does not explain why.
4. When the client hits the front of the head, there is a rebound effect known as “coup-contrecoup” in which the brain hits the back of the skull. The occipital lobe is in the back of the head, and an injury to it may be manifested by seeing double.

Question 23

The ambulance brings the client with a head injury to the emergency department. The client responds to painful stimuli by opening the eyes, muttering, and pulling away from the nurse. How would the nurse rate this client on the Glasgow Coma Scale?

1. 3
2. 8
3. 10
4. 15

Answer 23

1. A score of 3 is the lowest score and indicates deep coma and impending brain death.
2. A score of 8 indicates severe increased intracranial pressure, but with appropriate care the client may survive. The nurse would rate the client at an 8: 1 for opening the eyes; 3 for verbal response; and 4 for motor response.
3. A score of 10 indicates moderately increased intracranial pressure.
4. A score of 15 is the highest score a client can receive, indicating normal function.

Question 24

Which intervention has the highest priority for the client in the emergency department who has been in a motorcycle collision with an automobile and has a fractured left leg?

1. Assessing the neurological status.
2. Immobilizing the fractured leg.
3. Monitoring the client’s output.
4. Starting an 18-gauge saline lock.

Answer 24

1. Assessment is the first step in the nursing process, and a client with a motorcycle accident must be assessed for a head injury.
2. Neurological assessment is priority over a fractured leg.
3. The client’s urinary output is not priority over assessment.
4. An 18-gauge IV access should be started in case the client has to go to surgery, but it is not priority over an assessment.

Question 25

The nurse writes the nursing diagnosis “altered body temperature related to damaged temperature regulating mechanism” for a client with a head injury. Which would be the most appropriate goal?

1. Administer acetaminophen (Tylenol) for elevated temperature.
2. The client’s temperature will remain less than 100 ̊F.
3. Maintain the hypothermia blanket at 99 ̊F for 24 hours.
4. The basal metabolic temperature will fluctuate no more than two (2) degrees.

Answer 25

1. Administering acetaminophen is an intervention, which is not a goal.
2. This is an appropriate goal. It addresses the client, addresses the problem (temperature elevation), and is measurable.
3. Maintaining the blanket temperature is a nursing intervention, which should eliminate this as a possible answer.
4. The basal metabolic temperature is evaluated for a woman trying to get pregnant; it helps indicate ovulation.

Question 26

Which potential pituitary complication should the nurse assess for in the client diagnosed with a traumatic brain injury (TBI)?

1. Diabetes mellitus type 2 (DM 2).
2. Seizure activity.
3. Syndrome of inappropriate antidiuretic hormone (SIADH).
4. Cushing’s disease.

Answer 26

1. Diabetes mellitus type 2 is a pancreatic disease that has nothing to do with the pituitary gland or head injury.
2. Seizure activity is a possible complication of traumatic brain injury (TBI), but it is not a pituitary complication.
3. The pituitary gland produces vasopressin, the antidiuretic hormone (ADH), and any injury that causes increased intracranial pressure will exert pressure on the pituitary gland and can cause the syndrome of inappropriate antidiuretic hormone (SIADH).
4. Cushing’s disease is caused by an excess production of glucocorticoids and mineralocorticoids from the adrenal gland.

Question 27

The nurse is discussing seizure prevention with a female client who was just diagnosed with epilepsy. Which statement indicates the client needs more teaching?

1. “I will take calcium supplements daily and drink milk.”
2. “I will see my HCP to have my blood levels drawn regularly.”
3. “I should not drink any type of alcohol while taking the medication.”
4. “I am glad that my periods will not affect my epilepsy.”

Answer 27

1. Because of bone loss associated with long-term use of anticonvulsants, the client should increase calcium intake to reduce the risk of osteoporosis.
2. Anticonvulsant medications have a narrow range of therapeutic value and the levels should be checked regularly.
3. Alcohol interferes with anticonvulsant medication and should be avoided.
4. Women with epilepsy note an increase in the frequency of seizures during menses. This is thought to be linked to the increase in sex hormones that alter the excitability of the neurons in the brain.

Question 28

The unlicensed assistive personnel (UAP) is caring for a client who is having a seizure. Which action by the UAP would warrant immediate intervention by the nurse?

1. The assistant attempts to insert an oral airway.
2. The assistant turns the client on the right side.
3. The assistant has all the side rails padded and up.
4. The assistant does not leave the client’s bedside.

Answer 28

1. The nurse must intervene to stop the UAP because the client’s jaws are clenched. Attempting to insert anything into the mouth could cause injury to the client or to the UAP.
2. Side-lying positions help to prevent aspiration and are an appropriate intervention.
3. The client’s safety is priority, and this will help protect the client from injury.
4. Staying with the client is an appropriate behavior that would not warrant intervention by the nurse.

Question 29

The nurse is preparing the male client for an electroencephalogram (EEG). Which intervention should the nurse implement?

1. Explain that this procedure is not painful.
2. Premedicate the client with a benzodiazepine drug.
3. Instruct the client to shave all facial hair.
4. Tell the client it will cause him to see “floaters.”

Answer 29

1. This procedure is not painful, although electrodes are attached to the scalp. The client will need to wash the hair after the procedure.
2. Antianxiety medication would make the client drowsy and could cause a false EEG reading.
3. There is no reason for facial hair to be shaved.
4. This procedure measures the electrical conductivity in the brain and does not cause the client to see “floaters” (spots before the eyes). Flashing bright lights may be used in an attempt to evoke a seizure.

Question 30

Which assessment data indicate that the client with a traumatic brain injury (TBI) exhibiting decorticate posturing on admission is responding effectively to treatment?

1. The client has flaccid paralysis.
2. The client has purposeful movement.
3. The client has decerebrate posturing with painful stimuli.
4. The client does not move extremities.

Answer 30

1. Flaccid paralysis indicates a worsening of the increased intracranial pressure.
2. Purposeful movement indicates the client is getting better and is responding to the treatment.
3. Decerebrate positioning indicates a worsening of the increased intracranial pressure.
4. This is the same as flaccid paralysis and indicates a worsening of the increased intracranial pressure.

Question 31

Which assessment data indicate that the client with a traumatic brain injury (TBI) exhibiting decorticate posturing on admission is responding effectively to treatment?

1. The client has flaccid paralysis.
2. The client has purposeful movement.
3. The client has decerebrate posturing with painful stimuli.
4. The client does not move extremities.

Answer 31

1. Assessing for deep vein thrombosis, which is a complication of immobility, would be appropriate for this client.
2. Anticoagulants may cause bleeding; therefore, the client who has had surgery would not be prescribed this medication.
3. Monitoring of intake and output helps to detect possible complications of the pituitary gland, which include diabetes insipidus and syndrome of inappropri- ate antidiuretic hormone (SIADH).
4. The nurse should apply cool compresses to alleviate periocular edema.
5. The nurse does not want the client to be active and possibly increase intracranial pressure; therefore, the nurse should perform passive range-of-motion for the client.

Question 32

Which client should the nurse assess first after receiving the shift report?

1. The client diagnosed with a stroke who has right-sided paralysis.
2. The client diagnosed with meningitis who complains of photosensitivity.
3. The client with a brain tumor who has projectile vomiting.
4. The client with epilepsy who complains of tender gums.

Answer 32

1. Paralysis is an expected occurrence with a client who has had a stroke.
2. Photosensitivity is an expected sign of meningitis.
3. Projectile vomiting indicates that increased intracranial pressure is exerting pressure on the vomiting center of the brain.
4. Tender gums could be secondary to medication given for epilepsy. The client may need to see a dentist, but this client does not need to be assessed first.

Question 33

The client is reporting neck pain, fever, and a headache. The nurse elicits a positive Kernig’s sign. Which diagnostic test procedure should the nurse anticipate the HCP ordering to confirm a diagnosis?

1. A computed tomography (CT).
2. Blood cultures times two (2).
3. Electromyogram (EMG).
4. Lumbar puncture (LP).

Answer 33

1. The symptoms and a positive Kernig’s sign suggest meningitis, but a CT scan is not diagnostic of meningitis.
2. Blood cultures determine septicemia or infections of the bloodstream, not meningitis.
3. An electromyogram (EMG) evaluates electrical conductivity through the muscle.
4. The client’s symptoms, along with a positive Kernig’s sign, should make the nurse suspect meningitis. The definitive diagnostic test for meningitis is a lumbar puncture to obtain cerebrospinal fluid for culture.

Question 34

Which behavior is a risk factor for developing and spreading bacterial meningitis?

1. An upper respiratory infection.
2. Unprotected sexual intercourse.
3. Chronic alcohol consumption.
4. Use of tobacco products.

Answer 34

1. An upper respiratory infection (URI) is not a behavior. The question asked which behavior was a risk factor, so this option can be ruled out. However, a URI is a risk factor for developing and spreading bacterial meningitis because of increased droplet production.
2. Unprotected sexual intercourse is a risk factor for sexually transmitted diseases (STDs), but not for meningitis.
3. Chronic alcohol consumption can cause pancreatitis or hepatitis but not meningitis.
4. Tobacco use increases respiratory secretions and droplet production and thus is a risk factor for developing and spreading bacterial meningitis.

Question 35

Which assessment data should the nurse expect to observe for the client diagnosed with Parkinson’s disease?

1. Ascending paralysis and pain.
2. Masklike facies and pill rolling.
3. Diplopia and ptosis.
4. Dysphagia and dysarthria.

Answer 35

1. The spread of pain and paralysis are signs/ symptoms of Guillain-Barré syndrome.
2. Masklike facies and pill rolling are signs/symptoms of Parkinson’s disease, along with cogwheeling, postural instability, and stooped and shuffling gait.
3. Diplopia and ptosis are signs/symptoms of myasthenia gravis.
4. Dysphagia and dysarthria are signs/ symptoms of myasthenia gravis.

Question 36

The client diagnosed with Parkinson’s disease is prescribed carbidopa/levodopa (Sinemet). Which intervention should the nurse implement prior to administering the medication?

1. Discuss how to prevent orthostatic hypotension.
2. Take the client’s apical pulse for one (1) full minute.
3. Inform the client that this medication is for short-term use.
4. Tell the client to take the medication on an empty stomach.

Answer 36

1. Because carbidopa/levodopa has been linked to hypotension, teaching a client given the medication ways to help prevent a drop in blood pressure when standing—orthostatic hypotension— decreases the risks associated with hypotension and falling.
2. The medication will not cause the heart rate to change, so taking the client’s apical pulse for one (1) minute is not priority.
3. This medication is prescribed for the client the rest of his or her life unless the medication stops working or the client experiences adverse side effects.
4. The medication should be administered with food to help prevent gastrointestinal distress.

Question 37

The client diagnosed with amyotrophic lateral sclerosis (Lou Gehrig’s disease) is prescribed medications that require intravenous access. The HCP has ordered a primary intravenous line at a keep-vein-open (KVO) rate at 25 mL/hr. The drop factor is 10 gtts/mL. At what rate should the nurse set the IV tubing? ___________

Answer 37

4 gtts/min.

The nurse must know the formula for regulating IV drips: the amount to infuse (25 mL/hr) times the drop factor (10 gtts/ mL) divided by the minutes. Thus,

25 × 10 = 250 ÷ 60 = 4.11 or 4 gtts/min.

Question 38

Which intervention should the nurse take with the client recently diagnosed with amyotrophic lateral sclerosis (Lou Gehrig’s disease)?

1. Discuss a percutaneous gastrostomy tube.
2. Explain how a fistula is accessed.
3. Provide an advance directive.
4. Refer to a physical therapist for leg braces.

Answer 38

1. The client was diagnosed recently and at some point may need a percutaneous endoscopic gastrostomy (PEG) tube, but it is too early for this discussion.
2. A fistula is used for hemodialysis, and ALS does not cause renal dysfunction.
3. It is never too early to discuss advance directives with a client diagnosed with a terminal illness.
4. A client with ALS does not have leg braces as part of the therapeutic regimen.

Question 39

The public health nurse is discussing St. Louis encephalitis with a group in the community. Which instruction should the nurse provide to help prevent an outbreak?

1. Yearly vaccinations for the disease.
2. Advise that the city should spray for mosquitoes.
3. The use of gloves when gardening.
4. Not going out at night.

Answer 39

1. There is no vaccine for preventing encephalitis.
2. Mosquitoes are the vectors that spread the disease, and spraying to kill mosquito larvae will help prevent an outbreak in the community.
3. Gloves will not protect a person from being bitten by a mosquito.
4. Mosquitoes are more prevalent at night, but this is an unrealistic intervention and will not help prevent an outbreak.

Question 40

The husband of a client who is an alcoholic tells the nurse, “I don’t know what to do. I don’t know how to deal with my wife’s problem.” Which response would be most appropriate by the nurse?

1. “It must be difficult. Maybe you should think about leaving.”
2. “I think you should attend Alcoholics Anonymous.”
3. “I think that Alanon might be very helpful for you.”
4. “You should not enable your wife’s alcoholism.”

Answer 40

1. This advice might be appropriate at some point from a professional counselor but not from the nurse.
2. Alcoholics Anonymous is the support group that alcoholics—in this case, the wife, not the husband—should attend.
3. Alanon is the support group for signifi- cant others of alcoholics. Al-A-Teen is for teenage children of alcoholics.
4. This statement is making a judgment that is not given in the stem and is not applica- ble to all husbands of alcoholic wives.

Question 41

The client is brought to the emergency department by the police for public disorderliness. The client reports feeling no pain and is unconcerned that the police have arrested him. The nurse notes the client has epistaxis and nasal congestion. Which substance should the nurse suspect the client has abused?

1. Marijuana
2. Heroin.
3. Ecstasy.
4. Cocaine.

Answer 41

1. Symptoms of marijuana use are apathy, delayed time, and not wanting to eat.
2. Heroin symptoms include pupil changes and respiratory depression.
3. Ecstasy is a hallucinogen that is an “upper.”
4. Disorderly behavior and the symptoms of epistaxis and nasal congestion would make the nurse suspect cocaine abuse.

Question 42

The client with a history of migraine headaches comes to the clinic and reports that a migraine is coming because the client is experiencing bright spots before the eyes. Which phase of migraine headaches is the client experiencing?

1. Prodrome phase.
2. Aura phase.
3. Headache phase.
4. Recovery phase.

Answer 42

1. The prodrome phase occurs hours to days before the migraine headache.
2. This is the aura phase, which is characterized by focal neurological symptoms.
3. The headache phase occurs when vasodilation occurs in the brain, along with a decline in serotonin levels, causing a throbbing headache.
4. The recovery phase is when the pain begins to gradually subside.

Question 43

The client with a history of migraine headaches comes to the emergency department complaining of a migraine headache. Which collaborative treatment should the nurse anticipate?

1. Administer an injection of sumatriptan (Imitrex), a triptan.
2. Prepare for a computed tomography (CT) of the head. 3. Place the client in a quiet room with the lights off.
3. Administer propranolol (Inderal), a beta blocker.

Answer 43

1. Sumatriptan is a medication of choice for migraine headaches. It constricts blood vessels and reduces inflamma- tion. The nurse administering the medication is part of a collaborative effort because the nurse must act on the order or prescription of a physician or other health-care provider who has prescriptive authority.
2. This is a collaborative intervention, but it is not routinely ordered because the client reports having a history of migraine headaches.
3. This is an appropriate independent nursing intervention.
4. Propranolol is not used for acute migraine headaches; it is prescribed for long-term prophylaxis of migraines, so the nurse should not anticipate its use in this situation.

Question 44

Which assessment data would make the nurse suspect that the client with a C7 spinal cord injury is experiencing autonomic dysreflexia?

1. Abnormal diaphoresis.
2. A severe throbbing headache.
3. Sudden loss of motor function.
4. Spastic skeletal muscle movement.

Answer 44

1. Sweating is not a sign of autonomic dysreflexia.
2. A throbbing headache is the classic sign of autonomic dysreflexia, which is caused by a stimulus such as a full bladder.
3. Sudden loss of motor function occurs with the original injury. Autonomic dysreflexia does not occur until spinal shock has resolved; it usually occurs in the rehabilitation phase.
4. Spastic skeletal muscle movement could be secondary to the reflex arc in lower motor neuron injuries.

Question 45

The nurse stops at the scene of a motor-vehicle accident and provides emergency first aid at the scene. Which law protects the nurse as a first responder?

1. The First Aid Law.
2. Ombudsman Act.
3. Good Samaritan Act.
4. First Responder Law.

Answer 45

1. There is no such law known as the First Aid Law.
2. The Ombudsman Act addresses many areas, such as advance directives, elderly advocacy, and several other areas.
3. The Good Samaritan Act protects nurses from judgment against them when in an emergency situation in which the nurse is not receiving com- pensation for the skills and expertise rendered. The nurse is held to a differ- ent standard than a layperson; the nurse must act as any reasonable and prudent nurse would in the same situation.
4. There is no such law known as the First Responder Law.

Question 46

The nurse writes the problem “high risk for impaired skin integrity” for the client with an L5-6 spinal cord injury. Which intervention should the nurse include in the plan of care?

1. Perform active range-of-motion exercise.
2. Massage the legs and trochanters every shift.
3. Arrange for a Roho cushion in the wheelchair.
4. Apply petroleum-based lotion to the extremities.

Answer 46

1. A patient with an L5-6 spinal cord injury is paralyzed and cannot perform active ROM exercises.
2. Massaging bony prominences can cause trauma to the underlying blood vessels and will increase the risk for skin breakdown.
3. The nurse must realize that the client is at risk for skin breakdown even when sitting in the chair. A Roho cushion is an air-filled cushion that provides reduced pressure on the ischium.
4. Lotion will not prevent skin breakdown and should be water based, not petroleum based.

Question 47

The nurse is preparing to administer acetaminophen (Tylenol) to a client diagnosed with a stroke who is complaining of a headache. Which intervention should the nurse implement first?

1. Administer the medication in pudding.
2. Check the client’s armband.
3. Crush the tablet and dissolve in juice.
4. Have the client sip some water.

Answer 47

1. The medication can be administered in pudding, but it is not the first intervention.
2. The armband should be checked but not before determining if the client can swallow.
3. Tylenol comes in liquid form, and the nurse should request this before crushing a very bitter tablet.
4. Asking the client to sip some water assesses the client’s ability to swallow, which is priority when placing anything in the mouth of the client who has had a stroke.

Question 48

Which client would be most at risk for experiencing a stroke?

1. A 92-year-old client who is an alcoholic.
2. A 54-year-old client diagnosed with hepatitis.
3. A 60-year-old client who has a Greenfield filter.
4. A 68-year-old client with chronic atrial fibrillation.

Answer 48

1. An alcoholic is not at risk for having a stroke anymore than someone in the general population.
2. A client with hepatitis is not at risk for having a stroke anymore than someone in the general population.
3. A Greenfield filter is positioned in the inferior vena cava to prevent an embolism resulting from deep vein thrombosis; these filters prevent strokes and pulmonary emboli.
4. A client with atrial fibrillation is at high risk to have a stroke and is usually given oral anticoagulants to prevent a stroke.

Question 49

The charge nurse is making client assignments for a neuro-medical floor. Which client should be assigned to the most experienced nurse?

1. The elderly client who is experiencing a stroke in evolution.
2. The client diagnosed with a transient ischemic attack 48 hours ago.
3. The client diagnosed with Guillain-Barré syndrome who complains of leg pain.
4. The client with Alzheimer’s disease who is wandering in the halls.

Answer 49

1. This client is experiencing a progress- ing stroke, is at risk for dying, and should be cared for by the most experienced nurse.
2. A TIA by definition lasts less than 24 hours, so this client should be stable at this time.
3. Pain is expected in clients with Guillain- Barré syndrome, and symptoms are on the lower half of the body, which does not affect the airway. Therefore, a less experienced nurse could care for this client.
4. The charge nurse could delegate much of the care of this client to a UAP.

Question 50

The nurse is assessing a client who is experiencing anosmia on a neurological floor. Which area should the nurse assess for cranial nerve I that is pertinent to anosmia?

1. A
2. B
3. C
4. D

Answer 50

1. The eyes, indicated by A, would be assessed if checking cranial nerves II, III, IV, or VI.
2. The tongue located in the mouth, indicated by B, would be assessed if checking cranial nerves IX, X, or XII.
3. The cheek, indicated by C, would be assessed if checking for cranial nerve V, the trigeminal nerve.
4. Anosmia, the loss of the sense of smell, would require the nurse to assess for cranial nerve I, the olfactory nerve, indicated by D.

Question 51

The nurse arrives at the scene of a motor-vehicle accident and the car is leaking gasoline. The client is in the driver’s seat of the car complaining of not being able to move the legs. Which actions should the nurse implement? List in order of priority.

1. Move the client safely out of the car.
2. Assess the client for other injuries.
3. Stabilize the client’s neck.
4. Notify the emergency medical system.
5. Place client in a functional anatomical position.

Answer 51

In order of priority: 3, 2, 1, 5, 4.

3. Stabilizing the client’s neck is priority action to prevent further injury to the client, and it must be done prior to moving the client.
4. The nurse should assess for any other injuries prior to moving the client from the vehicle.
5. Because the vehicle is leaking fuel and there is potential for an explosion or fire, the client should be moved to an area of safety.
6. Placing the client in a functional anatomical position is an attempt to prevent further spinal cord injury.
7. Because the vehicle is leaking fuel, the priority is to remove the client and then obtain emergency medical assistance.

Question 52

The elderly male client diagnosed with Parkinson’s disease has undergone a minor surgical procedure and is receiving cefazolin (Ancef) IV piggyback q 6 hr. Which laboratory data should the nurse report to the health-care provider?

Answer 52

1. These values are within normal range for a male client.
2. These values are within normal range.
3. These values are slightly above range for the client but not alarmingly so.
4. The wound has methicillin-resistant Staph. aureus (MRSA) in it, and the client is receiving an antibiotic that the MRSA is resistant to; the nurse should notify the HCP for a medication change to Vancomycin.