MSS Ch 2: Neurological Disorders Practice Questions Flashcards
A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? 1. Prepare to administer recombinant tissue plasminogen activator (rt-PA).
- Discuss the precipitating factors that caused the symptoms.
- Schedule for a STAT computed tomography (CT) scan of the head.
- Notify the speech pathologist for an emergency consult.
- The drug rt-PA may be administered, but a cerebrovascular accident (CVA) must be verified by diagnostic tests prior to administering it. rt-PA helps dissolve a blood clot, and it may be administered if an ischemic CVA is verified; rt-PA is not given if the client is experiencing a hemorrhagic stroke.
- Teaching is important to help prevent another CVA, but it is not the priority intervention on admission to the emergency department. Slurred speech indicates problems that may interfere with teaching.
- A CT scan will determine if the client is having a stroke or has a brain tumor or another neurological disorder. If a CVA is diagnosed, the CT scan can determine if it is a hemorrhagic or ischemic accident and guide treatment.
- The client may be referred for speech deficits and/or swallowing difficulty, but referrals are not priority in the emergency department.
The nurse is assessing a client experiencing motor loss as a result of a left-sided cere- brovascular accident (CVA). Which clinical manifestations would the nurse document? 1. Hemiparesis of the client’s left arm and apraxia.
- Paralysis of the right side of the body and ataxia.
- Homonymous hemianopsia and diplopia.
- Impulsive behavior and hostility toward family.
- A left-sided CVA will result in right-sided motor deficits; hemiparesis is weakness of one half of the body, not just the upper extremity. Apraxia, the inability to perform a previously learned task, is a communica- tion loss, not a motor loss.
- The most common motor dysfunction of a CVA is paralysis of one side of the body, hemiplegia; in this case with a left-sided CVA, the paralysis would affect the right side. Ataxia is an impaired ability to coordinate movement.
- Homonymous hemianopsia (loss of half of the visual field of each eye) and diplopia (double vision) are visual field deficits that a client with a CVA may experience, but they are not motor losses.
- Personality disorders occur in clients with a right-sided CVA and are cognitive deficits; hostility is an emotional deficit.
Which client would the nurse identify as being most at risk for experiencing a CVA?
- A 55-year-old African American male.
- An 84-year-old Japanese female.
- A 67-year-old Caucasian male.
- A 39-year-old pregnant female.
- African Americans have twice the rate of CVAs as Caucasians and men have a higher incidence than women; African Americans suffer more extensive damage from a CVA than do people of other cul- tural groups.
- Females are less likely to have a CVA than males, but advanced age does increase the risk for CVA. The Oriental population has a lower risk, possibly as a result of their relatively high intake of omega-3 fatty acids, antioxidants found in fish.
- Caucasians have a lower risk of CVA than do African Americans, Hispanics, and Native Pacific Islanders.
- Pregnancy is a minimal risk for having a CVA.
The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply.
- Position the client to prevent shoulder adduction.
- Turn and reposition the client every shift.
- Encourage the client to move the affected side.
- Perform quadriceps exercises three (3) times a day. 5. Instruct the client to hold the fingers in a fist.
- Placing a small pillow under the shoulder will prevent the shoulder from adducting toward the chest and developing a contracture.
- The client should be repositioned at least every two (2) hours to prevent contractures, pneumonia, skin breakdown, and other complications of immobility.
- The client should not ignore the paralyzed side, and the nurse must encourage the client to move it as much as possible; a written schedule may assist the client in exercising.
- These exercises are recommended, but they must be done at least five (5) times a day for 10 minutes to help strengthen the muscles for walking.
- The fingers are positioned so that they are barely flexed to help prevent contracture of the hand.
The nurse is planning care for a client experiencing agnosia secondary to a cerebrovas- cular accident. Which collaborative intervention will be included in the plan of care?
- Observe the client swallowing for possible aspiration.
- Position the client in a semi-Fowler’s position when sleeping.
- Place a suction setup at the client’s bedside during meals.
- Refer the client to an occupational therapist for evaluation.
- Agnosia is the failure to recognize familiar objects; therefore, observing the client for possible aspiration is not appropriate.
- A semi-Fowler’s position is appropriate for sleeping, but agnosia is the failure to recognize familiar objects; therefore, this intervention is inappropriate.
- Placing suction at the bedside will help if the client has dysphagia (difficulty swallowing), not agnosia, which is failure to recognize familiar objects.
- A collaborative intervention is an intervention in which another health-care discipline—in this case, occupational therapy—is used in the care of the client.
The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene?
- The assistant places a gait belt around the client’s waist prior to ambulating.
- The assistant places the client on the back with the client’s head to the side.
- The assistant places a hand under the client’s right axilla to move up in bed.
- The assistant praises the client for attempting to perform ADLs independently.
- Placing a gait belt prior to ambulating is an appropriate action for safety and would not require the nurse to intervene.
- Placing the client in a supine position with the head turned to the side is not a problem position, so the nurse does not need to intervene.
- This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; the client should be pulled up by placing the arm underneath the back or using a lift sheet.
- The client should be encouraged and praised for attempting to perform any activities independently, such as combing hair or brushing teeth.
The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge?
- An oral anticoagulant medication.
- A beta blocker medication.
- An anti-hyperuricemic medication.
- A thrombolytic medication.
- The nurse would anticipate an oral anticoagulant, warfarin (Coumadin), to be prescribed to help prevent thrombi formation in the atria secondary to atrial fibrillation. The thrombi can become embolic and may cause a TIA or CVA (stroke).
- Beta blockers slow the heart rate and decrease blood pressure but would not be an anticipated medication to help prevent a TIA secondary to atrial fibrillation.
- An anti-hyperuricemic medication is administered for a client experiencing gout and decreases the formation of tophi.
- A thrombolytic medication is administered to dissolve a clot, and it may be ordered during the initial presentation for a client with a CVA, but not on discharge.
The client has been diagnosed with a cerebrovascular accident (stroke). The client’s wife is concerned about her husband’s generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge?
- Obtain a rubber mat to place under the dinner plate.
- Purchase a long-handled bath sponge for showering.
- Purchase clothes with Velcro closure devices.
- Obtain a raised toilet seat for the client’s bathroom.
- The rubber mat will stabilize the plate and prevent it from slipping away from the client learning to feed himself, but this does not address generalized weakness.
- A long-handled bath sponge will assist
- the client when showering hard-to-reach areas, but it is not a home modification, nor will it help with generalized weakness. Clothes with Velcro closures will make dressing easier, but they do not constitute a home modification and do not address gen- eralized weakness.
- Raising the toilet seat is modifying the home and addresses the client’s weakness in being able to sit down and get up without straining muscles or requiring lifting assistance from the wife.
The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care?
- Potential for injury.
- Powerlessness.
- Disturbed thought processes.
- Sexual dysfunction.
- Potential for injury is a physiological problem, not a psychosocial problem.
- Expressive aphasia means that the client cannot communicate thoughts but understands what is being communicated; this leads to frustration, anger, depression, and the inability to verbalize needs, which, in turn, causes the client to have a lack of control and feel powerless.
- A disturbance in thought processes is a cognitive problem; with expressive aphasia the client’s thought processes are intact.
- Sexual dysfunction can have a psychosocial component or a physical component, but it is not related to expressive aphasia.
Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?
- A blood glucose level of 480 mg/dL.
- A right-sided carotid bruit.
- A blood pressure of 220/120 mm Hg.
- The presence of bronchogenic carcinoma.
- This glucose level is elevated and could predispose the client to ischemic neurologi- cal changes due to blood viscosity, but it is not a risk factor for a hemorrhagic stroke.
- A carotid bruit predisposes the client to an embolic or ischemic stroke but not to a hemorrhagic stroke.
- Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured blood vessel inside the cranium.
- Cancer is not a precursor to developing a hemorrhagic stroke.
The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first?
- Administer a nonnarcotic analgesic.
- Prepare for STAT magnetic resonance imaging (MRI).
- Start an intravenous infusion with D5W at 100 mL/hr.
- Complete a neurological assessment.
- The nurse should not administer any medication to a client without first assessing the cause of the client’s complaint or problem.
- An MRI scan may be needed, but the nurse must determine the client’s neurological status prior to diagnostic tests.
- Starting an IV infusion is appropriate, but it is not the action the nurse should implement when assessing pain, and 100 mL/hr might be too high a rate for an 85-year-old client.
- The nurse must complete a neurological assessment to help determine the cause of the headache before taking any further action.
A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement?
- Administer a stool softener b.i.d.
- Encourage the client to cough hourly.
- Monitor neurological status every shift.
- Maintain the dopamine drip to keep BP at 160/90.
- The client is at risk for increased intracranial pressure whenever performing the Valsalva maneuver, which will occur when straining during defecation. Therefore, stool softeners would be appropriate.
- Coughing increases intracranial pressure and is discouraged for any client who has had a craniotomy. The client is encour- aged to turn and breathe deeply, but not to cough.
- Monitoring the neurological status is appropriate for this client, but it should be done much more frequently than every shift.
- Dopamine is used to increase blood pres- sure or to maintain renal perfusion, and a BP of 160/90 is too high for this client.
The client diagnosed with a mild concussion is being discharged from the emergency department. Which discharge instruction should the nurse teach the client’s significant other?
- Awaken the client every two (2) hours.
- Monitor for increased intracranial pressure.
- Observe frequently for hypervigilance.
- Offer the client food every three (3) to four (4) hours.
- Awakening the client every two (2) hours allows the identification of headache, dizziness, lethargy, irritability, and anxiety—all signs of postconcussion syndrome—that would warrant the significant other’s taking the client back to the emergency department.
- The nurse should monitor for signs of increased intracranial pressure (ICP), but a layman, the significant other, would not know what these signs and medical terms mean.
- Hypervigilance, increased alertness and super-awareness of the surroundings, is a sign of amphetamine or cocaine abuse, but it would not be expected in a client with a head injury.
- The client can eat food as tolerated, but feeding the client every three (3) to four (4) hours does not affect the development of postconcussion syndrome, the signs of which are what should be taught to the significant other.
The resident in a long-term care facility fell during the previous shift and has a lacer- ation in the occipital area that has been closed with Steri-Strips. Which signs/ symptoms would warrant transferring the resident to the emergency department?
- A 4-cm area of bright red drainage on the dressing.
- A weak pulse, shallow respirations, and cool pale skin.
- Pupils that are equal, react to light, and accommodate. 4. Complaints of a headache that resolves with medication.
- The scalp is a very vascular area and a moderate amount of bleeding would be expected.
- These signs/symptoms—weak pulse, shallow respirations, cool pale skin— indicate increased intracranial pressure from cerebral edema secondary to the fall, and they require immediate attention.
- This is a normal pupillary response and would not warrant intervention.
- A headache that resolves with medication is not an emergency situation, and the nurse would expect the client to have a headache after the fall; a headache not relieved with Tylenol would warrant further investigation.
The nurse is caring for the following clients. Which client would the nurse assess first after receiving the shift report?
1. The 22-year-old male client diagnosed with a concussion who is complaining
someone is waking him up every two (2) hours.
2. The 36-year-old female client admitted with complaints of left-sided weakness
who is scheduled for a magnetic resonance imaging (MRI) scan.
3. The 45-year-old client admitted with blunt trauma to the head after a motorcycle
accident who has a Glasgow Coma Scale score of 6.
4. The 62-year-old client diagnosed with a cerebrovascular accident (CVA) who has
expressive aphasia.
- A client with a head injury must be awakened every two (2) hours to determine alertness; decreasing level of consciousness is the first indicator of increased intracranial pressure.
- A diagnostic test, MRI, would be an expected test for a client with left-sided weakness and would not require immediate attention.
- The Glasgow Coma Scale is used to determine a client’s response to stimuli (eye-opening response, best verbal response, and best motor response) secondary to a neurological problem; scores range from 3 (deep coma) to 15 (intact neurological function). A client with a score of 6 should be assessed first by the nurse.
- The nurse would expect a client diagnosed with a CVA (stroke) to have some sequelae of the problem, including the inability to speak.
The client has sustained a severe closed head injury and the neurosurgeon is deter- mining if the client is “brain dead.” Which data support that the client is brain dead?
- When the client’s head is turned to the right, the eyes turn to the right.
- The electroencephalogram (EEG) has identifiable waveforms.
- There is no eye activity when the cold caloric test is performed.
- The client assumes decorticate posturing when painful stimuli are applied.
- This is an oculocephalic test (doll’s eye movement) that determines brain activity. If the eyes move with the head, it means the brainstem is intact and there is no brain death.
- Waveforms on the EEG indicate that there is brain activity.
- The cold caloric test, also called the oculovestibular test, is a test used to determine if the brain is intact or dead. No eye activity indicates brain death. If the client’s eyes moved, that would indicate that the brainstem is intact.
- Decorticate posturing after painful stimuli are applied indicates that the brainstem is intact; flaccid paralysis is the worse neuro- logical response when assessing a client with a head injury.
The client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority?
- Assess neurological status.
- Monitor pulse, respiration, and blood pressure.
- Initiate an intravenous access.
- Maintain an adequate airway.
- Assessing the neurological status is important, but ensuring an airway is priority over assessment.
- Monitoring vital signs is important, but maintaining an adequate airway is higher priority.
- Initiating an IV access is an intervention the nurse can implement, but it is not the priority intervention.
- The most important nursing goal in the management of a client with a head injury is to establish and maintain an adequate airway.
The client diagnosed with a closed head injury is admitted to the rehabilitation department. Which medication order would the nurse question?
- A subcutaneous anticoagulant.
- An intravenous osmotic diuretic.
- An oral anticonvulsant.
- An oral proton pump inhibitor.
- The client in rehabilitation is at risk for the development of deep vein thrombosis; therefore, this is an appropriate medication.
- An osmotic diuretic would be ordered in the acute phase to help decrease cerebral edema, but this medication would not be expected to be ordered in a rehabilitation unit.
- Clients with head injuries are at risk for post-traumatic seizures; thus an oral anticonvulsant would be administered for seizure prophylaxis.
- The client is at risk for a stress ulcer; therefore, an oral proton pump inhibitor would be an appropriate medication.
The client diagnosed with a gunshot wound to the head assumes decorticate posturing when the nurse applies painful stimuli. Which assessment data obtained three (3) hours later would indicate the client is improving?
- Purposeless movement in response to painful stimuli.
- Flaccid paralysis in all four extremities.
- Decerebrate posturing when painful stimuli are applied.
- Pupils that are 6 mm in size and nonreactive on painful stimuli.
- Purposeless movement indicates that the client’s cerebral edema is decreasing. The best motor response is purposeful movement, but purposeless movement indicates an improvement over decorticate movement, which, in turn, is an improvement over decerebrate movement or flaccidity.
- Flaccidity would indicate a worsening of the client’s condition.
- Decerebrate posturing would indicate a worsening of the client’s condition.
- The eyes respond to light, not painful stimuli, but a 6-mm nonreactive pupil indicates severe neurological deficit.
The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply.
- Maintain the head of the bed at 60 degrees of elevation.
- Administer stool softeners daily.
- Ensure that pulse oximeter reading is higher than 93%. 4. Perform deep nasal suction every two (2) hours.
- Administer mild sedatives.
- The head of the bed should be elevated no more than 30 degrees to help decrease cerebral edema by gravity.
- Stool softeners are initiated to prevent the Valsalva maneuver, which increases intracranial pressure.
- Oxygen saturation higher than 93% ensures oxygenation of the brain tissues; decreasing oxygen levels increase cerebral edema.
- Noxious stimuli, such as suctioning, increase intracranial pressure and should be avoided.
- Mild sedatives will reduce the client’s agitation; strong narcotics would not be administered because they decrease the client’s level of consciousness.
The client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first?
- Notify the health-care provider immediately.
- Prepare to administer an antihistamine.
- Test the drainage for presence of glucose.
- Place 2 × 2 gauze under the nose to collect drainage.
- Prior to notifying the HCP, the nurse should always make sure that all the needed assessment information is available to discuss with the HCP.
- With head injuries, any clear drainage may indicate a cerebrospinal fluid leak; the nurse should not assume the drainage is secondary to allergies and administer an antihistamine.
- The presence of glucose in drainage from the nose or ears indicates cerebrospinal fluid, and the HCP should be notified immediately once this is determined.
- This would be appropriate, but it is not the first intervention. The nurse must determine where the fluid is coming from.
The nurse is enjoying a day at the lake and witnesses a water skier hit the boat ramp. The water skier is in the water not responding to verbal stimuli. The nurse is the first health-care provider to respond to the accident. Which intervention should be implemented first?
- Assess the client’s level of consciousness.
- Organize onlookers to remove the client from the lake. 3. Perform a head-to-toe assessment to determine injuries.
- Stabilize the client’s cervical spine.
- Assessment is important, but with clients with head injury the nurse must assume spinal cord injury until it is ruled out with x-ray; therefore, stabilizing the spinal cord is priority.
- Removing the client from the water is an appropriate intervention, but the nurse must assume spinal cord injury until it is ruled out with x-ray; therefore, stabilizing the spinal cord is priority.
- Assessing the client for further injury is appropriate, but the first intervention is to stabilize the spine because the impact was strong enough to render the client unconsciousness.
- The nurse should always assume that a client with traumatic head injury may have sustained spinal cord injury. Mov- ing the client could further injure the spinal cord and cause paralysis; there- fore, the nurse should stabilize the cer- vical spinal cord as best as possible prior to removing the client from the water.
The client is diagnosed with a closed head injury and is in a coma. The nurse writes the client problem as “high risk for immobility complications.” Which intervention would be included in the plan of care?
- Position the client with the head of the bed elevated at intervals.
- Perform active range-of-motion exercises every four (4) hours.
- Turn the client every shift and massage bony prominences.
- Explain all procedures to the client before performing them.
- The head of the client’s bed should be elevated to help the lungs expand and prevent stasis of secretions that could lead to pneumonia, a complication of immobility.
- Active range-of-motion exercises require that the client participate in the activity. This is not possible because the client is in a coma.
- The client is at risk for pressure ulcers and should be turned more frequently than every shift, and research now shows that massaging bony prominences can increase the risk for tissue breakdown.
- The nurse should always talk to the client, even if he or she is in a coma, but this will not address the problem of immobility.
The 29-year-old client who was employed as a forklift operator sustains a traumatic brain injury secondary to a motor-vehicle accident. The client is being discharged from the rehabilitation unit after three (3) months and has cognitive deficits. Which goal would be most realistic for this client?
- The client will return to work within six (6) months.
- The client is able to focus and stay on task for 10 minutes.
- The client will be able to dress self without assistance.
- The client will regain bowel and bladder control.
- The client is at risk for seizures and does not process information appropriately. Allowing him to return to his occupation as a forklift operator is a safety risk for him and other employees. Vocational training may be required.
- “Cognitive” pertains to mental processes of comprehension, judgment, memory, and reasoning. Therefore, an appropriate goal would be for the client to stay on task for 10 minutes.
- The client’s ability to dress self addresses self-care problems, not a cognitive problem.
- The client’s ability to regain bowel and bladder control does not address cognitive deficits.
The nurse arrives at the site of a one-car motor-vehicle accident and stops to render aid. The driver of the car is unconscious. After stabilizing the client’s cervical spine, which action should the nurse take next?
- Carefully remove the driver from the car.
- Assess the client’s pupils for reaction.
- Assess the client’s airway.
- Attempt to wake the client up by shaking him.
- The nurse should stabilize the client’s neck prior to removal from the car.
- The nurse must stabilize the client’s neck before doing any further assessment. Most nurses don’t carry penlights, and the client’s pupil reaction can be determined after stabilization.
- The nurse must maintain a patent air- way. Airway is the first step in resuscitation.
- Shaking the patient could cause further damage, possibly leading to paralysis.
In assessing a client with a T12 SCI, which clinical manifestations would the nurse expect to find to support the diagnosis of spinal shock?
- No reflex activity below the waist.
- Inability to move upper extremities.
- Complaints of a pounding headache.
- Hypotension and bradycardia.
- Spinal shock associated with SCI represents a sudden depression of reflex activity below the level of the injury. T12 is just above the waist; therefore, no reflex activity below the waist would be expected.
- Assessment of the movement of the upper extremities would be more appropriate with a higher level injury; an injury in the cervical area might cause an inability to move the upper extremities.
- Complaints of a pounding headache are not typical of a T12 spinal injury.
- Hypotension (low blood pressure) and tachycardia (rapid heart rate) are signs of hypovolemic or septic shock, but these do not occur in spinal shock.
The rehabilitation nurse caring for the client with an L1 SCI is developing the nursing care plan. Which intervention should the nurse implement?
- Keep oxygen via nasal cannula on at all times.
- Administer low-dose subcutaneous anticoagulants.
- Perform active lower extremity ROM exercises.
- Refer to a speech therapist for ventilator-assisted speech.
- Oxygen is administered initially to maintain a high arterial partial pressure of oxygen (PaO2) because hypoxemia can worsen a neurological deficit to the spinal cord initially, but this client is in the rehabilitation department and thus not in the initial stages of the injury.
- Deep vein thrombosis (DVT) is a potential complication of immobility, which can occur because the client cannot move the lower extremities as a result of the L1 SCI. Low-dose anticoagulation therapy (Lovenox) helps prevent blood from coagulating, thereby preventing DVTs.
- The client is unable to move the lower extremities. The nurse should do passive ROM exercises.
- A client with a spinal injury at C4 or above would be dependent on a ventilator for breathing, but a client with an L1 SCI would not.
The nurse in the neurointensive care unit is caring for a client with a new C6 SCI who is breathing independently. Which nursing interventions should be implemented? Select all that apply.
- Monitor the pulse oximetry reading.
- Provide pureed foods six (6) times a day.
- Encourage coughing and deep breathing.
- Assess for autonomic dysreflexia.
- Administer intravenous corticosteroids.
- Oxygen is administered initially to prevent hypoxemia, which can worsen the spinal cord injury; therefore, the nurse should determine how much oxygen is reaching the periphery.
- A C6 injury would not affect the client’s ability to chew and swallow, so pureed food is not necessary.
- Breathing exercises are supervised by the nurse to increase the strength and endurance of inspiratory muscles, especially those of the diaphragm.
- Autonomic dysreflexia occurs during the rehabilitation phase, not the acute phase.
- Corticosteroids are administered to decrease inflammation, which will decrease edema, and help prevent edema from ascending up the spinal cord, causing breathing difficulties.
The home health nurse is caring for a 28-year-old client with a T10 SCI who says, “I can’t do anything. Why am I so worthless?” Which statement by the nurse would be the most therapeutic?
- “This must be very hard for you. You’re feeling worthless?”
- “You shouldn’t feel worthless—you are still alive.”
- “Why do you feel worthless? You still have the use of your arms.”
- “If you attended a work rehab program you wouldn’t feel worthless.”
- Therapeutic communication addresses the client’s feelings and attempts to allow the client to verbalize feelings; the nurse should be a therapeutic listener.
- This is belittling the client’s feelings.
- The client does not owe the nurse an explanation of his feelings; “why” is never therapeutic.
- This is advising the client and is not therapeutic.
The client is diagnosed with an SCI and is scheduled for a magnetic resonance imaging (MRI) scan. Which question would be most appropriate for the nurse to ask prior to taking the client to the diagnostic test?
- “Do you have trouble hearing?”
- “Are you allergic to any type of dairy products?”
- “Have you eaten anything in the last eight (8) hours?”
- “Are you uncomfortable in closed spaces?”
- The machine is very loud and the technician will offer the client ear plugs, but hearing difficulty will not affect the MRI scan.
- Allergies to dairy products will not affect the MRI scan.
- The client does not need to be NPO for this procedure.
- MRI scans are often done in a very confined space; many people who have claustrophobia must be medicated or even rescheduled for the procedure in an open MRI machine, which may be available if needed.
The client with a C6 SCI is admitted to the emergency department complaining of a severe pounding headache and has a BP of 180/110. Which intervention should the emergency department nurse implement?
- Keep the client flat in bed.
- Dim the lights in the room.
- Assess for bladder distention.
- Administer a narcotic analgesic.
- This action will not address the client’s pounding headache and hypertension.
- Dimming the lights will not help the client’s condition.
- This is an acute emergency caused by exaggerated autonomic responses to stimuli and only occurs after spinal shock has resolved in the client with a spinal cord injury above T6. The most common cause is a full bladder.
- The nurse should always assess the client before administering medication.
The client with a cervical fracture is being discharged in a halo device. Which teaching instruction should the nurse discuss with the client?
- Discuss how to correctly remove the insertion pins.
- Instruct the client to report reddened or irritated skin areas.
- Inform the client that the vest liner cannot be changed.
- Encourage the client to remain in the recliner as much as possible.
- The halo device is applied by inserting pins into the skull, and the client cannot remove them; the pins should be checked for signs of infection.
- Reddened areas, especially under the brace, must be reported to the HCP because pressure ulcers can occur when wearing this appliance for an extended period.
- The vest liner should be changed for hygiene reasons, but the halo part is not removed.
- The client should be encouraged to ambulate to prevent complications of immobility.
The intensive care nurse is caring for a client with a T1 SCI. When the nurse elevates the head of the bed 30 degrees, the client complains of lightheadedness and dizziness. The client’s vital signs are T 99.2 ̊F, P 98, R 24, and BP 84/40. Which action should the nurse implement?
- Notify the health-care provider ASAP.
- Calm the client down by talking therapeutically.
- Increase the IV rate by 50 mL/hour.
- Lower the head of the bed immediately.
- This is not an emergency; therefore, the nurse should not notify the health-care provider.
- A physiological change in the client requires more than a therapeutic conversation.
- Increasing the IV rate will not address the cause of the problem.
- For the first two (2) weeks after an SCI above T7, the blood pressure tends to be unstable and low; slight elevations of the head of the bed can cause profound hypotension; therefore, the nurse should lower the head of the bed immediately.
The nurse on the rehabilitation unit is caring for the following clients. Which client should the nurse assess first after receiving the change-of-shift report?
1. The client with a C6 SCI who is complaining of dyspnea and has crackles in the
lungs.
2. The client with an L4 SCI who is crying and very upset about being discharged
home.
3. The client with an L2 SCI who is complaining of a headache and feeling very hot.
4. The client with a T4 SCI who is unable to move the lower extremities
- This client has signs/symptoms of a respiratory complication and should be assessed first.
- This is a psychosocial need and should be addressed, but it does not have priority over a physiological problem.
- A client with a lower SCI would not be at risk for autonomic dysreflexia; therefore, a complaint of headache and feeling hot would not be priority over an airway problem.
- The client with a T4 SCI would not be expected to move the lower extremities.
Which nursing task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel?
- Teach Credé’s maneuver to the client needing to void.
- Administer the tube feeding to the client who is quadriplegic.
- Assist with bowel training by placing the client on the bedside commode.
- Observe the client demonstrating self-catheterization technique.
- The nurse cannot delegate assessment or teaching.
- Tube feedings should be treated as if they were medications, and this task cannot be delegated.
- The assistant can place the client on the bedside commode as part of bowel training; the nurse is responsible for the training but can delegate this task.
- Evaluating the client’s ability to self- catheterize must be done by the nurse.
The 34-year-old male client with an SCI is sharing with the nurse that he is worried about finding employment after being discharged from the rehabilitation unit. Which intervention should the nurse implement?
- Refer the client to the American Spinal Cord Injury Association (ASIA).
- Refer the client to the state rehabilitation commission.
- Ask the social worker about applying for disability.
- Suggest that the client talk with his significant other about this concern.
- The ASIA is an appropriate referral for liv- ing with this condition, but it does not help find gainful employment after the injury.
- The rehabilitation commission of each state will help evaluate and determine if the client can receive training or education for another occupation after injury.
- The client is not asking about disability; he is concerned about employment. Therefore, the nurse needs to make a referral to the appropriate agency.
- This does not address the client’s concern about gainful employment.
The male client is sitting in the chair and his entire body is rigid with his arms and legs contracting and relaxing. The client is not aware of what is going on and is making guttural sounds. Which action should the nurse implement first?
- Push aside any furniture.
- Place the client on his side.
- Assess the client’s vital signs.
- Ease the client to the floor.
- The nurse needs to protect the client from injury. Moving furniture would help ensure that the client would not hit something accidentally, but this is not done first.
- This is done to help keep the airway patent, but it is not the first intervention in this specific situation.
- Assessment is important but, when the client is having a seizure, the nurse should not touch him or her.
- The client should not remain in the chair during a seizure. He should be brought safely to the floor so that he will have room to move the extremities.
The occupational health nurse is concerned about preventing occupation-related acquired seizures. Which intervention should the nurse implement?
- Ensure that helmets are worn in appropriate areas.
- Implement daily exercise programs for the staff.
- Provide healthy foods in the cafeteria.
- Encourage employees to wear safety glasses.
- Head injury is one of the main reasons for epilepsy that can be prevented through occupational safety precautions and highway safety programs.
- Sedentary lifestyle is not a cause of epilepsy.
- Dietary concerns are not a cause of epilepsy.
- Safety glasses will help prevent eye injuries, but such injuries are not a cause of epilepsy.
The client is scheduled for an electroencephalogram (EEG) to help diagnose a seizure disorder. Which preprocedure teaching should the nurse implement?
- Tell the client to take any routine antiseizure medication prior to the EEG.
- Tell the client not to eat anything for eight (8) hours prior to the procedure.
- Instruct the client to stay awake for 24 hours prior to the EEG.
- Explain to the client that there will be some discomfort during the procedure.
- Antiseizure drugs, tranquilizers, stimulants, and depressants are withheld before an EEG because they may alter the brain wave patterns.
- Meals are not withheld because altered blood glucose level can cause changes in brain wave patterns.
- The goal is for the client to have a seizure during the EEG. Sleep deprivation, hyperventilating, or flashing lights may induce a seizure.
- Electrodes are placed on the client’s scalp, but there are no electroshocks or any type of discomfort.
The nurse enters the room as the client is beginning to have a tonic-clonic seizure. What action should the nurse implement first?
- Note the first thing the client does in the seizure.
- Assess the size of the client’s pupils.
- Determine if the client is incontinent of urine or stool.
- Provide the client with privacy during the seizure.
- Noticing the first thing the client does during a seizure provides information and clues as to the location of the seizure in the brain. It is important to document whether the beginning of the seizure was observed.
- Assessment is important, but during the seizure the nurse should not attempt to restrain the head to assess the eyes; muscle contractions are strong, and restraining the client could cause injury.
- This should be done, but it is not the first intervention when walking into a room where the client is beginning to have a seizure.
- The client should be protected from onlookers, but the nurse should always address the client first.
The client who just had a three (3)-minute seizure has no apparent injuries and is oriented to name, place, and time but is very lethargic and just wants to sleep. Which intervention should the nurse implement?
- Perform a complete neurological assessment.
- Awaken the client every 30 minutes.
- Turn the client to the side and allow the client to sleep. 4. Interview the client to find out what caused the seizure.
- The client is exhausted from the seizure and should be allowed to sleep.
- Awakening the client every 30 minutes possibly could induce another seizure as a result of sleep deprivation.
- During the postictal (after-seizure) phase, the client is very tired and should be allowed to rest quietly; placing the client on the side will help prevent aspiration and maintain a patent airway.
- The client must rest, and asking questions about the seizure will keep the client awake and may induce another seizure as a result of sleep deprivation.
The unlicensed assistive personnel (UAP) is attempting to put an oral airway in the mouth of a client having a tonic-clonic seizure. Which action should the primary nurse take?
- Help the UAP to insert the oral airway in the mouth.
- Tell the UAP to stop trying to insert anything in the mouth.
- Take no action because the UAP is handling the situation.
- Notify the charge nurse of the situation immediately.
- Once the seizure has started, no one should attempt to put anything in the client’s mouth.
- The nurse should tell the UAP to stop trying to insert anything in the mouth of the client experiencing a seizure. Broken teeth and injury to the lips and tongue may result from trying to place anything in the clenched jaws of a client having a tonic-clonic seizure.
- The primary nurse is responsible for the action of the UAP and should stop the UAP from doing anything potentially dangerous to the client. No one should attempt to pry open the jaws that are clenched in a spasm to insert anything.
- The primary nurse must correct the action of the UAP immediately, prior to any injury occurring to the client and before notifying the charge nurse.
The client is prescribed phenytoin (Dilantin), an anticonvulsant, for a seizure disorder. Which statement indicates the client understands the discharge teaching concerning this medication?
- “I will brush my teeth after every meal.”
- “I will check my Dilantin level daily.”
- “My urine will turn orange while on Dilantin.”
- “I won’t have any seizures while on this medication.”
- Thorough oral hygiene after each meal, gum massage, daily flossing, and regular dental care are essential to prevent or control gingival hyperplasia, which is a common occurrence in clients taking Dilantin.
- A serum (venipuncture) Dilantin level is checked monthly at first and then, after a therapeutic level is attained, every six (6) months.
- Dilantin does not turn the urine orange.
- The use of Dilantin does not ensure that the client will not have any seizures, and in some instances, the dosage may need to be adjusted or another medication may need to be used.
The client is admitted to the intensive care department (ICD) experiencing status epilepticus. Which collaborative intervention should the nurse anticipate?
- Assess the client’s neurological status every hour.
- Monitor the client’s heart rhythm via telemetry.
- Administer an anticonvulsant medication by intravenous push.
- Prepare to administer a glucocorticosteroid orally.
- Assessment is an independent nursing action, not a collaborative one.
- All clients in the ICD will be placed on telemetry, which does not require an order by another health-care provider or collaboration with one.
- Administering an anticonvulsant medication by intravenous push requires the nurse to have an order or confer with another member of the health-care team.
- A glucocorticoid is a steroid and is not used to treat seizures.
The client has been newly diagnosed with epilepsy. Which discharge instructions should be taught to the client? Select all that apply.
- Keep a record of seizure activity.
- Take tub baths only; do not take showers.
- Avoid over-the-counter medications.
- Have anticonvulsant medication serum levels checked regularly. 5. Do not drive alone; have someone in the car.
- Keeping a seizure and medication chart will be helpful when keeping follow-up appointments with the health-care provider and in identifying activities that may trigger a seizure.
- The client should take showers, rather than tub baths, to avoid drowning if a seizure occurs. The nurse should also instruct the client never to swim alone.
- Over-the-counter medications may contain ingredients that will interact with antiseizure medications or, in some cases, as with use of stimulants, possibly cause a seizure.
- Most of the anticonvulsant medications have therapeutic serum levels that should be maintained, and regular checks of the serum levels help to ensure the correct level.
- A newly diagnosed client would have just been put on medication, which may cause drowsiness. Therefore, the client should avoid activities that require alertness and coordination and should not be driving at all until after the effects of the medication have been evaluated.
Which statement by the female client indicates that the client understands factors that may precipitate seizure activity?
- “It is all right for me to drink coffee for breakfast.”
- “My menstrual cycle will not affect my seizure disorder.”
- “I am going to take a class in stress management.”
- “I should wear dark glasses when I am out in the sun.”
- The client with a seizure disorder should avoid stimulants, such as caffeine.
- The onset of menstruation can cause seizure activity in the female client.
- Tension states, such as anxiety and frustration, induce seizures in some clients, so stress management may be helpful in preventing seizures.
- Bright flickering lights, television viewing, and some other photic (light) stimulation may cause seizures, but sunlight does not. Wearing dark glasses or covering one eye during potential seizure-stimulating activities may help prevent seizure.
The nurse asks the male client with epilepsy if he has auras with his seizures. The client says, “I don’t know what you mean. What are auras?” Which statement by the nurse would be the best response?
- “Some people have a warning that the seizure is about to start.”
- “Auras occur when you are physically and psychologically exhausted.”
- “You’re concerned that you do not have auras before your seizures?”
- “Auras usually cause you to be sleepy after you have a seizure.”
- An aura is a visual, auditory, or olfactory occurrence that takes place prior to a seizure and warns the client a seizure is about to occur. The aura often allows time for the client to lie down on the floor or find a safe place to have the seizure.
- An aura is not dependent on the client being physically or psychologically exhausted.
- This is a therapeutic response, reflecting feelings, which is not an appropriate response when answering a client’s question.
- Sleepiness after a seizure is very common, but the aura does not itself cause the sleepiness.
The nurse educator is presenting an in-service on seizures. Which disease process is the leading cause of seizures in the elderly?
- Alzheimer’s disease.
- Parkinson’s disease.
- Cerebral vascular accident (stroke).
- Brain atrophy due to aging.
- Alzheimer’s disease does not lead to seizures.
- Parkinson’s disease does not cause seizures.
- A CVA (stroke) is the leading cause of seizures in the elderly; increased intracranial pressure associated with the stroke can lead to seizures.
- Brain atrophy is not associated with seizures.