Neurological Disorders

Question 1

The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use which technique to test the client’s peripheral response to pain? 1. Sternal rub 2. Nail bed pressure 3. Pressure on the orbital rim 4. Squeezing of the sternocleidomastoid muscle

Answer 1

Nail Bed Pressure

Nail bed pressure tests a basic motor and sensory peripheral response.

Cerebral responses to pain are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

The nail beds are the most distal of all options and are therefore the most peripheral. Each of the other options may elicit a generalized response, but not a localized one.

Question 2

The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising?

1.

Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure

2.

Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure

3.

Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure

4.

Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

Answer 2

A change in vital signs may be a late sign of increased intracranial pressure.

Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur.

Question 3

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity?

1.

Blowing the nose

2.

Isometric exercises

3.

Coughing vigorously

4.

Exhaling during repositioning

Answer 3

Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure.

Some of these activities include isometric exercises, Valsalva’s maneuver, coughing, sneezing, and blowing the nose.

Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising.

Question 4

How can CSF be distinguished from other body fluids ?

Answer 4

CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.

Question 5

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present?

1.

Fluid is clear and tests negative for glucose.

2.

Fluid is grossly bloody in appearance and has a pH of 6.

3.

Fluid clumps together on the dressing and has a pH of 7.

4.

Fluid separates into concentric rings and tests positive for glucose.

Answer 5

Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.

Focus on the subject, the characteristics of CSF. Recall that CSF contains glucose, whereas other secretions, such as mucus, do not. Knowing that CSF separates into rings also will help you to answer this question

Question 6

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists?

1.

Hyperreflexia

2.

Positive reflexes

3.

Flaccid paralysis

4.

Reflex emptying of the bladder

Answer 6

Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, and reflex emptying of the bladder.

Recall that spinal shock is characterized by the loss of movement of skeletal muscles, loss of bowel or bladder wall function, and depressed reflex action.

Return of any of these indicates that spinal shock is beginning to resolve. Note that options 1, 2, and 4 are comparable or alike, indicating the presence of reflexes.

Question 7

What is spinal shock characterized by ?

Answer 7

the loss of movement of skeletal muscles, loss of bowel or bladder wall function, and depressed reflex action. Return of any of these indicates that spinal shock is beginning to resolve the loss of movement of skeletal muscles, loss of bowel or bladder wall function, and depressed reflex action. Return of any of these indicates that spinal shock is beginning to resolve

Question 8

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply.

1.

Loosening restrictive clothing

2.

Restraining the client’s limbs

3.

Removing the pillow and raising padded side rails

4.

Positioning the client to the side, if possible, with the head flexed forward

5.

Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist

Answer 8

Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising padded side rails in the bed, and placing the client on one side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage.

The limbs are never restrained because the strong muscle contractions could cause the client harm.

If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible; protects the head from injury; and moves furniture that may injure the client.

Think about ethical and legal issues to eliminate option 5. Next, evaluate this question from the perspective of causing possible harm. No harm can come to the client from any of the options except for restraining the limbs. Remember to avoid restraints.

Question 9

Aphasia

Answer 9

A language disorder that affects a person’s ability to communicate.

It can occur suddenly after a stroke or head injury, or develop slowly from a growing brain tumor or disease.

Aphasia affects a person’s ability to express and understand written and spoken language.

Once the underlying cause is treated, the main treatment for aphasia is speech therapy.

Question 10

a weakness of one side of the body that may occur after a stroke.

Answer 10

hemiparesis

It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic: unable to discriminate words and letters.

Question 11

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply.

1.

The client is aphasic.

2.

The client has weakness on the right side of the body.

3.

The client has complete bilateral paralysis of the arms and legs.

4.

The client has weakness on the right side of the face and tongue.

5.

The client has lost the ability to move the right arm but is able to walk independently.

6.

The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance

Answer 11

Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic: unable to discriminate words and letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.

Question 12

Homonymous hemianopsia is _____________. What nursing interventions should be done ?

Answer 12

loss of half of the visual field.

The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available.

Question 13

The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully?

1.

Gets angry with family if they interrupt a task

2.

Experiences bouts of depression and irritability

3.

Has difficulty with using modified feeding utensils

4.

Consistently uses adaptive equipment in dressing self

Answer 13

Clients are evaluated as coping successfully with lifestyle changes after a stroke if they make appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions.

Options 1 and 2 are not adaptive behaviors; option 3 indicates a not yet successful attempt to adapt.

Options 1 and 2 are behaviors that may be expected in the client with a stroke, but they are not adaptive responses. Instead, they are a result of the insult to the brain. Options 3 and 4 indicate that the client is trying to adapt, but the correct option has the best outcome.

Question 14

the common causes of myasthenic and cholinergic crises are __________________ and __________________,

Answer 14

undermedication and overmedication

Question 15

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective?

1.

Taking medications as scheduled

2.

Eating large, well-balanced meals

3.

Doing muscle-strengthening exercises

4.

Doing all chores early in the day while less fatigued

Answer 15

Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is important.

Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional stress.

Question 16

defined by slow movement and an impaired ability to move the body swiftly on command

Answer 16

Bradydyskinesia

Question 17

The client with Parkinson’s disease should be instructed regarding safety measures in the home. The client should use his or her _________as support to get to the bathroom because of bradykinesia. The client should sit down to put on pants and shoes to prevent __________. The client should exercise every day in the ____________when energy levels are highest.

The client should have all loose rugs in the home removed to prevent falling.

Answer 17

walker; falling; morning

Question 18

the pain of trigeminal neuralgia is triggered by mechanical or thermal stimuli. Very _________foods are likely to trigger the pain, not relieve it.

Answer 18

hot or cold

Question 19

The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement?

“I will wash my face with cotton pads.”

2.

“I’ll have to start chewing on my unaffected side.”

3.

“I should rinse my mouth if toothbrushing is painful.”

4.

“I’ll try to eat my food either very warm or very cold.”

Answer 19

Facial pain can be minimized by using cotton pads to wash the face and using room temperature water. The client should chew on the unaffected side of the mouth, eat a soft diet, and take in foods and beverages at room temperature. If brushing the teeth triggers pain, an oral rinse after meals may be helpful instead.

Recall that the pain of trigeminal neuralgia is triggered by mechanical or thermal stimuli. Very hot or cold foods are likely to trigger the pain, not relieve it.

Question 20

The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client most at risk for this disease?

1.

Meningitis or encephalitis during the last 5 years

2.

Seizures or trauma to the brain within the last year

3.

Back injury or trauma to the spinal cord during the last 2 years

4.

Respiratory or gastrointestinal infection during the previous month

Answer 20

Guillain-Barré syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves.

Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits. On occasion, the syndrome can be triggered by vaccination or surgery.

Question 21

The client with Guillain-Barré syndrome experiences fear and anxiety from the __________paralysis and ________onset of the disorder. The nurse can alleviate these fears by

Answer 21

ascending; sudden; providing accurate information about the client’s condition, giving expert care and positive feedback to the client, and encouraging relaxation and distraction. The family can become involved with selected care activities and provide diversion for the client as well.

Question 22

A client has a neurological deficit involving the limbic system. On assessment, which finding is specific to this type of deficit?

1.

Is disoriented to person, place, and time

2.

Affect is flat, with periods of emotional lability

3.

Cannot recall what was eaten for breakfast today

4.

Demonstrates inability to add and subtract; does not know who is the president of the United States

Answer 22

The limbic system is responsible for feelings (affect) and emotions.

Calculation ability and knowledge of current events relate to function of the frontal lobe.

The cerebral hemispheres, with specific regional functions, control orientation. Recall of recent events is controlled by the hippocampus.

Question 23

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client’s safety? Select all that apply.

1.

Padding the side rails of the bed

2.

Placing an airway at the bedside

3.

Placing the bed in the high position

4.

Putting a padded tongue blade at the head of the bed

5.

Placing oxygen and suction equipment at the bedside

6.

Flushing the intravenous catheter to ensure that the site is patent

Answer 23

Evaluate this question from the perspective of causing possible harm. No harm can come to the client from any of the options except for placing the bed in the high position and using a tongue blade.

Seizure precautions may vary from agency to agency, but they generally have some common features. Usually, an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if antiseizure medications must be administered, and as part of the routine assessment the nurse should be checking patency of the catheter. The use of padded tongue blades is highly controversial, and they should not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure more likely will harm the client who bites down during seizure activity. Risks include blocking the airway from improper placement, chipping the client’s teeth, and subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begins.

Question 24

A Glasgow Coma Scale score of 15 is

Answer 24

a perfect score and indicates that the client is awake and alert, with no neurological deficits.

Question 25

Signs of meningeal irritation compatible with meningitis include .............

Answer 25

nuchal rigidity, a positive Brudzinski's sign, and positive Kernig's sign.

Question 26

\_\_\_\_\_\_\_\_\_\_\_\_\_sign is positive when the client feels pain and spasm of the hamstring muscles when the leg is fully flexed at the knee and hip.

Answer 26

Kernig's

Question 27

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest

Answer 27

Brudzinski's

Question 28

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? ## Footnote 1. A negative Kernig's sign 2. Absence of nuchal rigidity 3. A positive Brudzinski's sign 4. A Glasgow Coma Scale score of 15

Answer 28

Signs of meningeal irritation compatible with meningitis include **nuchal rigidity, a positive Brudzinski's sign, and positive Kernig's sign**. You can eliminate options 1, 2, and 4 because they are comparable or alike and are normal findings. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is flexed. Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the leg is fully flexed at the knee and hip. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glasgow Coma Scale score of 15 is a perfect score and indicates that the client is awake and alert, with no neurological deficits.

Question 29

What is a halo device ?

Answer 29

A halo is a medical device used to stabilize the cervical spine after traumatic injuries to the neck, or after spine surgery. The apparatus consists of a halo vest, stabilization bars, and a metal ring encircling the patient's head and fixated to the skull with multiple pins.

Question 30

The nurse has completed discharge instructions for a client with application of a halo device. Which statement indicates that the client needs further clarification of the instructions? ## Footnote 1. "I will use a straw for drinking." 2. "I will drive only during the daytime." 3. "I will be careful because the device alters balance." 4. "I will wash the skin daily under the lamb's wool liner of the vest."

Answer 30

The client cannot drive at all because the device impairs the range of vision. The inability to turn the head without turning the torso would contraindicate driving. **The halo device alters balance and can cause fatigue because of its weight.** The client should cleanse the skin daily under the vest to protect the skin from ulceration and should avoid the use of powder or lotions. The liner should be changed if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin care is done as instructed.

Question 31

With an ascending paralysis, the client is at risk for involvement of \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Answer 31

respiratory muscles and subsequent respiratory failure.

Question 32

The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which most essential items into the client's room? 1. Nebulizer and pulse oximeter 2. Blood pressure cuff and flashlight 3. Flashlight and incentive spirometer 4. Electrocardiographic monitoring electrodes and intubation tray

Answer 32

The client with Guillain-Barré syndrome is ***at risk for respiratory failure because of ascending paralysis.*** **An intubation tray should be available for use** **. Another complication of this syndrome is cardiac dysrhythmias**, which necessitates the use of electrocardiographic monitoring. Because the client is immobilized, the nurse should assess for deep vein thrombosis and pulmonary embolism routinely. Although items in the incorrect options may be used in care, they are not the most essential items from the options provided. The correct option is the only one that includes an intubation tray, which would be needed if the client's status deteriorated to needing intubation and mechanical ventilation. This option most directly addresses the airway

Question 33

Use of proper positions promotes \_\_\_\_\_\_\_\_\_\_\_\_\_from the cranium to keep intracranial pressure from elevating.

Answer 33

venous drainage The head of the client at risk for or with increased intracranial pressure should be positioned so that it is in a neutral, midline position. The head of the bed should be raised to 30 to 45 degrees. The nurse should avoid flexing or extending the client's neck or turning the client's head from side to side.

Question 34

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply. 1. Head midline 2. Neck in neutral position 3. Head of bed elevated 30 to 45 degrees 4. Head turned to the side when flat in bed 5. Neck and jaw flexed forward when opening the mouth

Answer 34

Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure from elevating. The head of the client at risk for or with increased intracranial pressure should be positioned so that **it is in a neutral, midline position**. The **head of the bed should be raised to 30 to 45 degrees.** *T**he nurse should avoid flexing or extending the client's neck or turning the client's head from side to side.*** Visualize each of the positions identified in the options and identify those that will promote venous drainage from the cranium.

Question 35

The physical appearance of CSF drainage is that of a halo. TRUE OR FALSE

Answer 35

TRUE

Question 36

The nurse is assessing the nasal dressing on a client who had a transsphenoidal resection of the pituitary gland. The nurse notes a small amount of serosanguineous drainage that is surrounded by clear fluid on the nasal dressing. Which nursing action is most appropriate?

Answer 36

Notify the health care provider (HCP) ***Cerebrospinal fluid (CSF) leakage after cranial surgery may be detected by noting drainage that is serosanguineous surrounded by an area of straw-colored or pale drainage.*** The physical appearance of CSF drainage is that of a halo. If the nurse notes the presence of this type of drainage, the HCP needs to be notified. The remaining options are inappropriate nursing actions. Recalling the risk of CSF leakage after this type of surgery will direct you to the correct option.

Question 37

In Meniere's disease, what is the goal of treatment? And whiat dietary changes are sometimes prescribed for this?

Answer 37

***The goal of treatment is To reduce the endolymphatic fluid*** Dietary changes, such as salt and fluid restrictions, that reduce the amount of endolymphatic fluid are sometimes prescribed for the client with Ménière's disease**. The client should be instructed to consume a low-sodium diet and restrict fluids as prescribed**

Question 38

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_could indicate the presence of a cerebrospinal fluid leak

Answer 38

bloody or clear drainage

Question 39

The nurse in the neurological unit is caring for a client who was in a motor vehicle crash and sustained a blunt head injury. On assessment of the client, the nurse notes the presence of bloody drainage from the nose. Which nursing action is most appropriate? 1. Insert nasal packing. 2. Document the findings. 3. Contact the health care provider (HCP). 4. Monitor the client's blood pressure and check for signs of increased intracranial pressure.

Answer 39

***Bloody or clear drainage from either the nasal or the auditory canal after head trauma could indicate a cerebrospinal fluid leak.*** The appropriate nursing action is to notify the HCP, because **this finding requires immediate intervention**. The remaining options are inappropriate nursing actions in this situation Recalling that ***bloody or clear drainage could indicate the presence of a cerebrospinal fluid leak*** will assist in directing you to the correct option.

Question 40

Bloody or clear drainage from either the nasal or the auditory canal after head trauma could indicate a \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_. This requires \_\_\_\_\_\_\_\_\_intervention.

Answer 40

cerebrospinal fluid leak; immediate

Question 41

A client has dysfunction of the cochlear division of the vestibulocochlear nerve (cranial nerve VIII). The nurse should determine that the client is adequately adapting to this problem if he or she states a plan to obtain which item? 1. A walker 2. Eyeglasses 3. A hearing aid 4. A bath thermometer

Answer 41

The cochlear division of cranial nerve VIII is responsible for hearing. Clients with hearing difficulty may benefit from the use of a hearing aid. The vestibular portion of this nerve controls equilibrium; difficulty with balance caused by dysfunction of this division could be addressed with use of a walker. Eyeglasses would correct visual problems (cranial nerve II); a bath thermometer would be of use to clients with sensory deficits of peripheral nerves, such as with diabetic neuropathy. Focus on the subject, function of cranial nerve VIII. Knowing that this nerve has two parts may help you remember that it is involved with the two functions of the ear (hearing and balance). This will assist you in eliminating options 2 and 4. Regarding the remaining options, focus on the word cochlear, and recall that the cochlear division is responsible for hearing. This will direct you to the correct option.

Question 42

What are the two parts of the cranial nerve VIII, the vestibulocochlear nerve

Answer 42

Knowing that this nerve has two parts may help you remember that it is involved with the two functions of the ear **(hearing and balance).** the cochlear division is responsible for hearing. The vestibular division controls equilibrium. The cochlear division of cranial nerve VIII is responsible for hearing. Clients with hearing difficulty may benefit from the use of a hearing aid. The vestibular portion of this nerve controls equilibrium; difficulty with balance caused by dysfunction of this division could be addressed with use of a walker.

Question 43

The nurse is planning care for a client who displays confusion secondary to a neurological problem. Which approaches by the nurse would be helpful in assisting this client? Select all that apply. 1. Providing sensory cues 2. Giving simple, clear directions 3. Providing a stable environment 4. Keeping family pictures at the bedside 5. Encouraging family members to visit at the same time

Answer 43

Clients with cognitive impairment from neurological dysfunction respond best to **a stable environment that is limited in amount and type of sensory input**. The nurse can provide sensory cues and give clear, simple directions in a positive manner. **Confusion can be minimized by reducing environmental stimuli** (such as television or multiple visitors) and by keeping familiar personal articles (such as family pictures) at the bedside. Remember that the client who is confused can handle only limited amounts of information at one time.

Question 44

The nurse has determined that a client with a neurological disorder also has difficulty breathing. Which activities would be appropriate components of the care plan for this client? Select all that apply. 1. Keep suction equipment at the bedside. 2. Elevate the head of the bed 30 degrees. 3. Keep the client lying in a supine position. 4. Keep the head and neck in good alignment. 5. Administer prescribed respiratory treatments as needed.

Answer 44

**The nurse maintains a patent airway** for the client with difficulty breathing by keeping the head and neck in good alignment and elevating the head of the bed 30 degrees unless contraindicated. Suction equipment is kept at the bedside if secretions need to be cleared. The client should be kept in a side-lying position whenever possible to minimize the risk of aspiration. Focus on the subject, care of a client with difficulty breathing. **Remember that a client with respiratory difficulty can breathe easier if the head of the bed is elevated.** Next, select options 1 and 4 because these are safe nursing actions. In addition, option 1 addresses suctioning, which refers to maintaining a patent airway and option 5 addresses **keeping the airway patent**. This leaves option 3, which is an unsafe nursing action and is incorrect.

Question 45

The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention should the nurse plan to incorporate into the care routine for the client and family?

Answer 45

Families often need assistance to cope with the illness of a loved one. **The nurse should explain all equipment, treatments, and procedures and should supplement or reinforce information given by the health care provider.** Family members should be encouraged to touch and speak to the client and to become involved in the client's care to the extent they are comfortable. The nurse should allow the family to stay with the client to the extent possible and should encourage them to eat and sleep adequately to maintain strength. The nurse can help family members of an unconscious client by assisting them to work through their feelings of grief.

Question 46

Members of the family of an unconscious client with increased intracranial pressure are talking at the client's bedside. They are discussing the client's condition and wondering whether the client will ever recover. The nurse intervenes on the basis of which interpretation? 1. It is possible the client can hear the family. 2. The family needs immediate crisis intervention. 3. The client might have wanted a visit from the hospital chaplain. 4. The family could benefit from a conference with the health care provider.

Answer 46

***Some clients who have awakened from an unconscious state have remembered hearing specific voices and conversations*.** Family and staff should assume that the client's sense of hearing is intact and act accordingly. In addition, **positive outcomes are associated with coma stimulation–that is, speaking to and touching the client.** The remaining options are incorrect interpretations. Focus on the subject, psychosocial support measures for family. The nurse should not infer that the client wants a visit from the chaplain from observing the family speaking over the client at the bedside, so option 3 should be eliminated first. The family demonstrates no evidence of crisis and seems to be well informed; this eliminates options 2 and 4.

Question 47

Clients with cognitive deficits after head injury may benefit from referral to a \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, who specializes in evaluating and treating cognitive problems.

Answer 47

neuropsychologist The neuropsychologist plans an individual program of therapy and initiates counseling to help the client reach maximal potential. The neuropsychologist works in collaboration with other disciplines that are involved in the client's care and rehabilitation.

Question 48

The nurse is caring for a client who has undergone a craniotomy and has a supratentorial incision. The nurse should place the client in which position postoperatively? ## Footnote 1. Head of bed flat, head and neck midline 2. Head of bed flat, head turned to the nonoperative side 3. Head of bed elevated 30 to 45 degrees, head and neck midline 4. Head of bed elevated 30 to 45 degrees, head turned to the operative side

Answer 48

**After supratentorial surgery, the head is kept at a 30- to 45-degree angle. The head and neck should not be angled either anteriorly or laterally but rather should be kept in a neutral (midline) position. This promotes venous return through the jugular veins, which will help prevent a rise in intracranial pressure** Focus on the subject, client positioning following craniotomy. This question tests knowledge of differences in positioning of the craniotomy client with an infratentorial versus a supratentorial incision. **Remember that with supratentorial surgery the head is kept up and with infratentorial surgery the head is kept down**. Remember though that surgeon's prescriptions regarding positioning are always followed. Regarding the remaining choices, recalling how to position the head for optimal venous drainage will help you to select the correct option over option 4.

Question 49

with supratentorial surgery the head is kept \_\_\_\_\_\_\_\_\_\_\_\_\_and with infratentorial surgery the head is kept \_\_\_\_\_\_\_\_\_\_\_. Remember though that **surgeon's prescriptions regarding positioning are always followed**

Answer 49

up; down

Question 50

The nurse is assessing fluid balance in a client who has undergone a craniotomy. The nurse should assess for which finding as a sign of overhydration, which would aggravate cerebral edema? 1. Unchanged weight 2. Shift intake 950 mL, output 900 mL 3. Blood urea nitrogen (BUN) 10 mg/dL (3.6 mmol/L) 4. Serum osmolality 280 mOsm/kg H2O (280 mmol/kg)

Answer 50

After craniotomy **the goal is to keep the serum osmolality on the high side of normal to minimize excess body water and control cerebral edema.** The normal serum osmolality is **285 to 295 mOsm/kg H2O** (285 to 295 mmol/kg). *A higher value indicates dehydration*; *a lower value indicates overhydration*. Stable weight indicates that there is neither fluid excess nor fluid deficit. A difference of 50 mL in intake and output for an 8-hour shift is insignificant. The BUN of 10 mg/dL (3.6 mmol/L) is within normal range and does not indicate overhydration or underhydration.

Question 51

After craniotomy the goal is to keep the serum osmolality on the\_\_\_\_\_\_\_\_\_\_\_ side of normal to minimize excess body water and control cerebral edema. The normal serum osmolality is \_\_\_\_\_\_\_\_\_\_\_\_\_mOsm/kg H2O . A \_\_\_\_\_\_\_\_\_\_\_\_\_value indicates dehydration; a \_\_\_\_\_\_\_\_\_\_\_value indicates overhydration.

Answer 51

high; **285 to 295** mOsm/kg H2O (285 to 295 mmol/kg) higher; lower an easy way to remember serum osmolality trends is "high is dry." Because the converse also is true, a low value indicates excess body water (overhydration).

Question 52

The postcraniotomy client typically is sensitive to \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_-. Control of environmental noise by others will be helpful for this client. \_\_\_\_\_\_\_\_\_\_-are a potential complication that may occur for up to 1 year after surgery. For this reason, the client must diligently take anticonvulsant medications. The client and family are encouraged to keep track of the doses administered.

Answer 52

loud noises and can find them excessively irritating; Seizures The family should learn seizure precautions and should accompany the client during ambulation if dizziness or seizures tend to occur. The suture line is kept dry until sutures are removed to prevent infection.

Question 53

many clients after craniotomy have increased sensitivity to or are irritated by \_\_\_\_\_\_\_\_\_\_\_\_\_\_--

Answer 53

loud noises.

Question 54

The nurse has made a judgment that a client who had a craniotomy is experiencing a problem with body image. The nurse develops goals for the client but determines that the client has not met the outcome criteria by discharge if the client performs which action? 1. Wears a turban to cover the incision 2. Indicates that facial puffiness will be a permanent problem 3. Verbalizes that periorbital bruising will disappear over time 4. States an intention to purchase a hairpiece until hair has grown back

Answer 54

***Look for the option that indicates a maladaptive response.*** Options 1 and 4 both indicate adaptive responses and are therefore eliminated. Knowing that facial edema and bruising are temporary will help you to choose the correct option over option After craniotomy, clients may experience difficulty with altered personal appearance. The nurse can help by listening to the client's concerns and by **clarifying any misconceptions about facial edema, periorbital bruising, and hair loss (all of which are temporary).** The nurse can encourage the client to participate in self-grooming and use personal articles of clothing. Finally, the nurse can suggest the use of a turban, followed by a hairpiece, to **help the client adapt to the temporary change in appearance.**

Question 55

A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and suspects the presence of which problem? 1. Altered breathing pattern 2. Increased likelihood of injury 3. Ineffective oxygen consumption 4. Increased susceptibility to aspiration

Answer 55

***Altered breathing pattern indicates that the respiratory rate, depth, rhythm, timing, or chest wall movements are insufficient for optimal ventilation of the client***. This is a risk for clients with spinal cord injury in the lower cervical area. ***Ineffective oxygen consumption occurs when oxygenation or carbon dioxide elimination is altered at the alveolar-capillary membrane.*** Increased susceptibility to aspiration and increased likelihood of injury are unrelated to the subject of the question.

Question 56

NCLEX strategy The correct option is the only one that addresses the client's feelings.

Answer 56

Believe that you can do this

Question 57

a primary goal in aneurysm precautions is to limit the amount of \_\_\_\_\_\_\_\_\_\_\_\_\_-(in any form) that the client receives and prevent increased \_\_\_\_\_\_\_\_\_\_-(ICP).

Answer 57

stimulation; intracranial pressure

Question 58

The nurse is planning to put aneurysm precautions in place for a client with a cerebral aneurysm. Which nursing measures would be implemented? Select all that apply. 1. Provide physical aspects of care. 2. Prevent pushing or straining activities. 3. Limit caffeinated coffee to 1 cup per day. 4. Keeping the lights on in the client's room. 5. Maintain the head of the bed at 15 degrees.

Answer 58

Aneurysm precautions include **placing the client on bed rest (as prescribed) in a quiet setting**. **Stimulants such as caffeine and nicotine are prohibited;** decaffeinated coffee or tea may be used. **Lights are kept dim to minimize environmental stimulation**. A**ny activity that increases the blood pressure or impedes venous return from the brain is prohibited**, such as pushing, pulling, sneezing, coughing, or straining. ***The nurse provides physical care to minimize increases in blood pressure***. For the same reason, visitors, radio, television, and reading materials are prohibited or limited.

Question 59

\_\_\_\_\_\_\_\_\_\_\_\_\_\_ is a stabbing, burning, and often severe pain due to an irritated or damaged nerve

Answer 59

Neuralgia

Question 60

The nurse is caring for a client diagnosed with trigeminal neuralgia. The client asks the nurse, "Why do I have so much pain?" Which is the appropriate response by the nurse? 1. "It's a local reaction to nasal stuffiness." 2. "It's due to a hypoglycemic effect on the cranial nerve." 3. "Release of catecholamines with infection or stress leads to the pain." 4. "Pain is due to stimulation of the affected nerve by pressure and temperature."

Answer 60

***The paroxysms of pain that accompany this neuralgia are triggered by stimulation of the terminal branches of the trigeminal nerve.*** Symptoms can be **triggered by pressure** from washing the face, brushing the teeth, shaving, eating, or drinking. Symptoms also can be triggered by **thermal stimuli**, such as a draft of cold air.

Question 61

To manage constipation, the client should take in a \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_. A fluid intake of \_\_\_\_\_\_\_\_\_\_\_\_\_\_mL/day is recommended. The client should initiate a bowel movement on an \_\_\_\_\_\_\_\_\_\_\_\_\_basis and should sit on the toilet or commode. This should be done approximately \_\_\_\_\_\_\_\_\_\_minutes after the largest meal of the day to take advantage of the gastrocolic reflex. A glycerin suppository, bisacodyl suppository, or digital stimulation may be used to initiate the process. ____________ and \_\_\_\_\_\_\_\_\_\_\_\_should be avoided whenever possible because they lead to dependence.

Answer 61

high-fiber diet, bulk formers, and stool softeners; 2000; every-other-day; 45; Laxatives and enemas The gastrocolic reflex is a physiological reflex that controls the motility of the lower gastrointestinal tract following a meal. As a result of the gastrocolic reflex, the colon has increased motility in response to the stretch of the stomach with the ingestion of food.

Question 62

A client has a difficulty with the ability to flex the hips. The nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which item? 1. Walker 2. Slider board 3. Raised toilet seat 4. Adaptive eating utensils

Answer 62

***A raised toilet seat is useful if the client does not have the mobility or ability to flex the hips***. The cerebellum is responsible for balance and coordination. A walker would provide stability for the client during ambulation. A slider board is used in transferring a client from a bed to a stretcher or wheelchair. Adaptive eating utensils may be beneficial if the client has partial paralysis of the hand. Think about how each item in the options would be helpful to the client. **The walker would help the client maintain balance.** A slider board would help with transferring from one place to another, such as from a bed to a chair. Next, remember that adaptive eating utensils are used in clients with loss of fine motor coordination, such as those with stroke.

Question 63

The nurse is assessing the client's gait and notes it is unsteady and staggering. Which description should the nurse use when documenting the assessment finding? ## Footnote 1. Spastic 2. Ataxic 3. Festinating 4. Dystrophic or broad-based

Answer 63

**An ataxic gait is characterized by unsteadiness and staggering.** A spastic gait is characterized by stiff, short steps with the legs held together, hip and knees flexed, and toes that catch and drag. A festinating gait is best described as walking on the toes with an accelerating pace. A dystrophic or broad-based gait is seen as waddling, with the weight shifting from side to side and the legs far apart.

Question 64

An \_\_\_\_\_\_\_\_\_\_\_gait is characterized by unsteadiness and staggering.

Answer 64

ataxic

Question 65

A \_\_\_\_\_\_\_\_\_gait is characterized by stiff, short steps with the legs held together, hip and knees flexed, and toes that catch and drag.

Answer 65

spastic

Question 66

A \_\_\_\_\_\_\_\_\_\_\_\_\_--gait is best described as walking on the toes with an accelerating pace.

Answer 66

festinating

Question 67

A \_\_\_\_\_\_\_or \_\_\_\_\_\_\_\_\_\_\_gait is seen as waddling, with the weight shifting from side to side and the legs far apart.

Answer 67

dystrophic or broad-based

Question 68

A client with a neurological impairment experiences urinary incontinence. Which nursing action would be most helpful in assisting the client to adapt to this alteration? 1. Using adult diapers 2. Inserting a Foley catheter 3. Establishing a toileting schedule 4. Padding the bed with an absorbent cotton pad

Answer 68

**A bladder retraining program, such as use of a toileting schedule, may be helpful to clients experiencing urinary incontinence.** A Foley catheter should be used only when necessary because of the associated risk of infection. Use of diapers or pads is the least acceptable alternative because of the risk of skin breakdown. Because use of a Foley catheter carries the risk of infection and use of diapers or pads carries the risk of skin breakdown, the only acceptable option is the toileting schedule

Question 69

A client with a neurological problem is experiencing hyperthermia. Which measures would be appropriate for the nurse to use in trying to lower the client's body temperature? Select all that apply. 1. Giving tepid sponge baths 2. Applying a hypothermia blanket 3. Covering the client with blankets 4. Administering acetaminophen per protocol 5. Placing ice packs over the client's abdomen and in the axilla and groin

Answer 69

Focus on the subject, measures to lower client's body temperature. **It may be helpful to look at this question from the standpoint of the relative body surface area that would be benefited by each of the measures identified in the options.** Tepid sponge baths and a hypothermia blanket would affect **a good portion of the client's skin to reduce heat**. Acetaminophen is a medication that has an antipyretic effect. Ice packs are an incorrect option because they would affect the skin only in the areas of placement, providing less generalized cooling with increased risk of shivering. Standard measures to lower body temperature include removing bed covers, providing cool sponge baths, using an electric fan in the room, administering acetaminophen, and placing a hypothermia blanket under the client. Ice packs are not used because they could cause shivering, which increases cellular oxygen demands, with the potential for increased intracranial pressure.

Question 70

Standard measures to lower body temperature include \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Why are ice packs not used ?

Answer 70

removing bed covers, providing cool sponge baths, using an electric fan in the room, administering acetaminophen, and placing a hypothermia blanket under the client. Ice packs are not used because they could cause shivering, which increases cellular oxygen demands, with the potential for increased intracranial pressure.

Question 71

The MRI scanner is a hollow tube that gives some clients a feeling of \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_. \_\_\_\_\_\_\_\_\_\_\_\_objects must be removed before the procedure so that they are not drawn into the magnetic field. The client may eat and may take all prescribed medications before the procedure. If a contrast medium is used, the client may wish to eat lightly if he or she has a tendency to become nauseated easily. The client lies supine on a padded table that moves into the imager. The client must lie \_\_\_\_\_\_\_\_during the procedure. The imager makes tapping noises during the scanning. The client is alone in the imager, but the nurse can reassure the client that the technologist will be in voice communication with the client at all times during the procedure.

Answer 71

claustrophobia; Metal; still

Question 72

The unconscious client is positioned on \_\_\_\_\_\_\_\_\_\_\_\_\_\_-during mouth care to prevent \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

Answer 72

the side; aspiration

Question 73

The nurse is administering mouth care to an unconscious client. The nurse should perform which actions in the care of this person? Select all that apply. 1. Use products that contain alcohol. 2. Position the client on his or her side. 3. Brush the teeth with a small, soft toothbrush. 4. Cleanse the mucous membranes with soft sponges. 5. Use lemon glycerin swabs when performing mouth care.

Answer 73

The unconscious client is **positioned on the side** during mouth care to prevent aspiration. The teeth are brushed at least twice daily with a small toothbrush. The gums, tongue, roof of the mouth, and oral mucous membranes are **cleansed with soft sponges to avoid encrustation and infection**. The lips are coated with water-soluble lubricant to prevent drying, cracking, and encrustation. ***The use of products with alcohol and lemon glycerin swabs should be avoided because they have a drying effect.*** Standard mouth care procedures include use of a toothbrush and soft sponges, so these options may be selected first. Knowing that **the unconscious client is at risk for aspiration** tells you that option 2 also is correct. This leaves options 1 and 5 as incorrect because **repeated use of products containing alcohol or lemon glycerin products could dry and crack the oral mucous membranes.​**

Question 74

Increased risk for aspiration is a condition in which an individual is at risk for entry of gastrointestinal (GI) secretions, oropharyngeal secretions, or solids or fluids into tracheobronchial passages. Conditions that place the client at risk for aspiration include \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Answer 74

**reduced level of consciousness, depressed cough and gag reflexes, and feeding via a GI tube.**

Question 75

Which intervention should the nurse include in a postoperative teaching plan for a client who underwent a spinal fusion and will be wearing a brace? 1. Tell the client to inspect the environment for safety hazards. 2. Inform the client about the importance of sitting as much as possible. 3. Inform the client that lotions and body powders can be used for skin breakdown. 4. Instruct the client to tighten the brace during meals and to loosen it for the first 30 minutes after each meal.

Answer 75

***The client must inspect the environment for safety hazards. The client is instructed in the importance of avoiding prolonged sitting and standing.*** **Powders and lotions should not be used because they may irritate the skin.** ***The client should be taught to loosen the brace during meals and for 30 minutes after each meal.*** The client may have difficulty eating if the brace is too tight. Loosening the brace after each meal will allow adequate nutritional intake and promote comfort. note that the correct option addresses safety and is the umbrella option.

Question 76

The nurse is preparing to care for a client **after a lumbar puncture.** The nurse should plan to place the client in which **best position following the procedure?** 1. Prone in semi Fowler's position 2. Supine in semi Fowler's position 3. Prone with a small pillow under the abdomen 4. Lateral with the head slightly lower than the rest of the body

Answer 76

***After the procedure, the client assumes a flat position. If the client is able, a prone position with a pillow under the abdomen is the best position.*** This position helps reduce cerebrospinal fluid leakage and decreases the likelihood of post–lumbar puncture headache

Question 77

The student nurse develops a plan of care for a client after a lumbar puncture. The nursing instructor corrects the student if the student documents which incorrect intervention in the plan? 1. Maintain the client in a flat position. 2. Restrict fluid intake for a period of 2 hours. 3. Assess the client's ability to void and move the extremities. 4. Inspect the puncture site for swelling, redness, and drainage.

Answer 77

**After the lumbar puncture the client remains flat in bed for at least 2 hours,** depending on the health care provider's prescriptions. **A liberal fluid intake is encouraged to replace the cerebrospinal fluid removed during the procedure,** unless contraindicated by the client's condition. The nurse checks the puncture site for redness and drainage and assesses the client's ability to void and move the extremities. Recalling that **cerebrospinal fluid is removed during this procedure and recalling the importance of fluid intake after the procedure** will direct you to the correct option

Question 78

What is a myelogram?

Answer 78

a type of radiographic examination that uses a contrast medium to detect pathology of the spinal cord, including the location of a spinal cord injury, cysts, and tumors.

Question 79

The nurse is monitoring a client who has returned to the nursing unit after a myelogram. Which client complaint would indicate the need to notify the health care provider (HCP)? 1. Backache 2. Headache 3. Neck stiffness 4. Feelings of fatigue

Answer 79

Headache is relatively common after the procedure, but **neck stiffness, especially on flexion, and pain should be reported because they signal meningeal irritation**. The client also is monitored for evidence of allergic reactions to the dye such as confusion, dizziness, tremors, and hallucinations. Feelings of fatigue may be normal, and back discomfort may occur because of the positions required for the procedure.

Question 80

The normal intracranial pressure is \_\_\_\_\_\_\_\_\_\_\_\_mm Hg.

Answer 80

**5 to 15**

Question 81

a widening pulse pressure and bradycardia are signs of \_\_\_\_\_\_\_\_\_\_\_\_\_\_reflex.

Answer 81

Cushing's

Question 82

The nurse in the neurological unit is monitoring a client for signs of increased intracranial pressure (ICP). The nurse reviews the assessment findings for the client and notes documentation of the presence of Cushing's reflex. The nurse determines that the presence of this reflex is obtained by assessing which item?

Answer 82

Cushing's reflex is a late sign of increased ICP and consists of **a widening pulse pressure (systolic pressure rises faster than diastolic pressure) and bradycardia.**

Question 83

Cushing's reflex is a\_\_\_\_\_\_\_\_\_\_\_\_\_ sign of increased ICP and consists of a \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Answer 83

late; widening pulse pressure (systolic pressure rises faster than diastolic pressure) and bradycardia.

Question 84

The nurse is assisting the neurologist in performing an assessment on a client who is unconscious after sustaining a head injury. The nurse understands that the neurologist would avoid performing the oculocephalic response (doll's eyes maneuver) if which condition is present in the client? 1. Dilated pupils 2. Lumbar trauma 3. A cervical cord injury 4. Altered level of consciousness

Answer 84

**A cervical cord injury** **In an unconscious client, eye movements are an indication of brainstem activity and are tested by the oculocephalic response.** When the doll's eyes maneuver is intact, the eyes move in the opposite direction when the head is turned. Abnormal responses include movement of the eyes in the same direction as that for the head and maintenance of a midline position of the eyes when the head is turned. An abnormal response indicates a disruption in the processing of information through the brainstem. Contraindications to performing this test include cervical-level spinal cord injuries and severely increased intracranial pressure.

Question 85

In an unconscious client, \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_are an indication of brainstem activity and are tested by the **oculocephalic response**. When the doll's eyes maneuver is intact, the eyes move in the ____________ direction when the head is turned. Abnormal responses include movement of the eyes in the same direction as that for the head and maintenance of a midline position of the eyes when the head is turned. **An abnormal response indicates a disruption in the processing of information through the brainstem**. Contraindications to performing this test include \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Answer 85

eye movements; opposite; cervical-level spinal cord injuries and severely increased intracranial pressure.

Question 86

recall that with a cervical injury, the head is not turned but maintained in a \_\_\_\_\_\_\_\_\_\_\_\_\_position.

Answer 86

midline

Question 87

The nurse is performing the **oculocephalic response** (doll's eyes maneuver) on an unconscious client. The nurse turns the client's head and notes movement of the eyes in the same direction as the head. How should the nurse document these findings?

Answer 87

Abnormal In an unconscious client, eye movements are an indication of brainstem activity and are tested by the oculocephalic response. When the doll's eyes maneuver is intact, the eyes move in the opposite direction when the head is turned. Abnormal responses include movement of the eyes in the same direction as the head and maintenance of a midline position of the eyes when the head is turned. **An abnormal response indicates a disruption in the processing of information through the brainstem.**

Question 88

What does an abnormal response to the oculocephalic response (dool's eye maneuver) indicate?

Answer 88

An abnormal response indicates **a disruption in the processing of information through the brainstem.**

Question 89

The nurse is performing a neurological assessment on a client and is assessing the function of cranial nerves III, IV, and VI. Assessment of which aspect of function will yield the best information about these cranial nerves? 1. Eye movements 2. Response to verbal stimuli 3. Affect, feelings, or emotions 4. Insight, judgment, and planning

Answer 89

**Eye movements are under the control of cranial nerves III, IV, and VI**. ***Level of consciousness (response to verbal stimuli) is controlled by the reticular activating system and both cerebral hemispheres.*** Feelings are part of the role of the limbic system and involve both hemispheres. Insight, judgment, and planning are part of the function of the frontal lobe in conjunction with association fibers that connect to other areas of the cerebrum.

Question 90

The nurse is reviewing the medical records of a client admitted to the nursing unit with a diagnosis of a thrombotic brain attack (stroke). The nurse would expect to note that which is documented in the assessment data section of the record? 1. **Sudden** loss of consciousness occurred. 2. Signs and symptoms occurred **suddenly**. 3. The client experienced paresthesias a few days before admission to the hospital. 4. The client complained of a severe headache, which was followed by **sudden** onset of paralysis.

Answer 90

**Cerebral thrombosis does not occur suddenly.** ***In the few hours or days preceding a thrombotic brain attack (stroke), the client may experience a transient loss of speech, hemiplegia, or paresthesias on 1 side of the body***. Signs and symptoms of thrombotic brain attack (stroke) vary but may include dizziness, cognitive changes, or seizures. Headache is rare, but some clients with stroke (brain attack) experience signs and symptoms similar to those of cerebral embolism or intracranial hemorrhage.

Question 91

Divalproex sodium is what type of medication ? it can cause fatal \_\_\_\_\_\_\_\_\_\_\_\_\_\_

Answer 91

An anticonvulsant; heptatotoxicity

Question 92

The nurse in the health care clinic is providing medication instructions to a client with a seizure disorder who will be taking divalproex sodium. The nurse should instruct the client about the importance of returning to the clinic for monitoring of which laboratory study? 1. Electrolyte panel 2. Liver function studies 3. Renal function studies 4. Blood glucose level determination

Answer 92

Divalproex sodium, an anticonvulsant, can cause fatal hepatotoxicity. **The nurse should instruct the client about the importance of monitoring the results of liver function studies** and ammonia level determination

Question 93

Trigeminal neuralgia is characterized by spasms of \_\_\_\_\_\_\_\_\_\_that start \_\_\_\_\_\_\_\_\_\_\_and last for seconds to minutes. The pain often is characterized as \_\_\_\_\_\_\_\_\_or as similar to an electric shock. It is accompanied by spasms of facial ____________ that cause twitching of parts of the face or mouth, or closure of the eye.

Answer 93

pain; suddenly; stabbing; muscles

Question 94

The home care nurse is performing an assessment on a client with a diagnosis of Bell's palsy. Which assessment question will elicit specific information regarding this client's disorder? 1. "Do your eyes feel dry?" 2. "Do you have any spasms in your throat?" 3. "Are you having any difficulty chewing food?" 4. "Do you have any tingling sensations around your mouth?"

Answer 94

Bell's palsy is a one-sided facial paralysis caused by compression of the facial nerve. Manifestations include facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and speech or chewing difficulties.

Question 95

What is Bell's Palsy ?

Answer 95

Bell's palsy is a one-sided facial paralysis caused by compression of the facial nerve. Manifestations include facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and **speech or chewing difficulties.**

Question 96

Auditory association and storage areas are located in the \_\_\_\_\_\_\_\_\_\_\_\_\_\_lobe and relate to understanding spoken language. The \_\_\_\_\_\_\_\_\_\_\_\_\_lobe contains areas related to vision. The \_\_\_\_\_\_\_\_\_\_\_\_\_controls voluntary muscle activity, including speech, and an impairment can result in expressive aphasia. The \_\_\_\_\_\_\_\_\_\_\_\_lobe contains association areas for concept formation, abstraction, spatial orientation, body and object size and shape, and tactile sensation.

Answer 96

temporal; occipital; frontal; parietal

Question 97

The nurse develops a plan of care for a client with a brain aneurysm who will be placed on aneurysm precautions. Which interventions should be included in the plan? Select all that apply. 1. Leave the lights on in the client's room at night. 2. Place a blood pressure cuff at the client's bedside. 3. Close the shades in the client's room during the day. 4. Allow the client to drink 1 cup of caffeinated coffee a day. 5. Allow the client to ambulate 4 times a day with assistance

Answer 97

Read each option in terms of whether it would cause stimulation or increased intracranial pressure, which can lead to rupture. ***Aneurysm precautions include placing the client on bed rest in a quiet setting***. The use of lights is kept to a minimum to prevent environmental stimulation. The nurse should monitor the blood pressure and note any changes that could indicate rupture. **Any activity, such as pushing, pulling, sneezing, or straining, that increases the blood pressure or impedes venous return from the brain is prohibited.** The nurse provides physical care to minimize increases in blood pressure. Visitors, radio, television, and reading materials are restricted or limited. **Stimulants, such as nicotine and coffee and other caffeine-containing products, are prohibited.** Decaffeinated coffee or tea may be used.

Question 98

The nurse is providing instructions to a client who will be taking phenytoin. Which statement, if made by the client, would indicate an understanding of the information about this medication? 1. "I need to perform good oral hygiene, including flossing and brushing my teeth." 2. "I should try to avoid alcohol, but if I'm not able to, I can drink alcohol in moderation." 3. "I should take my medication before coming to the laboratory to have a blood level drawn." 4. "I should monitor for side effects and adjust my medication dose depending on how severe the side effects are."

Answer 98

gingival hyperplasia is a side effect of this medication **Phenytoin is an anticonvulsant used to treat seizure disorders.** The client also should see a dentist at regularly scheduled times because **gingival hyperplasia is a side effect of this medication. The client should perform good oral hygiene, including flossing and brushing the teeth.** The client should avoid alcohol while taking this medication. The client should also be instructed that follow-up serum blood levels are important and that, ***on the day of the scheduled laboratory test, the client should avoid taking the medication before the specimen is drawn.*** The client should not adjust medication dosages.

Question 99

cerebral thrombosis does not occur \_\_\_\_\_\_\_\_\_\_\_\_\_-, and in the few days or hours preceding the thrombotic stroke, the client may experience a

Answer 99

suddenly ; transient loss of speech, hemiparesis, or paresthesias on 1 side of the body.

Question 100

The nurse is performing an assessment on a client with a diagnosis of thrombotic stroke (brain attack). Which assessment question would elicit data specific to this type of stroke? 1. "Have you had any headaches in the past few days?" 2. "Have you recently been having difficulty with seeing at nighttime?" 3. "Have you had any sudden episodes of passing out in the past few days?" 4. "Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?"

Answer 100

**Cerebral thrombosis (thrombotic stroke) does not occur suddenly.** In the few days or hours preceding the thrombotic stroke, the client may experience a transient loss of speech, hemiparesis, or paresthesias on 1 side of the body. Signs and symptoms of this type of stroke vary but may also include dizziness, cognitive changes, or seizures. ***Headache is rare, but some clients with stroke experience signs and symptoms similar to those of cerebral embolism or intracranial hemorrhage.*** The client does not complain of difficulty with night vision as part of this clinical problem. In addition, most clients do not have repeated episodes of loss of consciousness.

Question 101

The nurse is creating a plan of care for a client with dysphagia following a stroke (brain attack). Which should the nurse include in the plan? 1. Thicken liquids. 2. Assist the client with eating. 3. Assess for the presence of a swallow reflex. 4. Place the food on the affected side of the mouth. 5. Provide ample time for the client to chew and swallow.

Answer 101

**Liquids are thickened to prevent aspiration.** The nurse should assist the client with eating and place food on the unaffected side of the mouth. The nurse should assess for gag and swallowing reflexes before the client with dysphagia is started on a diet. The client should be allowed ample time to chew and swallow to prevent choking.

Question 102

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_is a loss of half of the visual field.

Answer 102

Homonymous hemianopsia

Question 103

What medication class if used to treat trigeminal neuralgia ?

Answer 103

Trigeminal neuralgia is characterized by spasms of pain that start suddenly and last from seconds to minutes. The pain often is described as either stabbing or similar to an electric shock. It is accompanied by spasms of the facial muscles that cause twitching of parts of the face or mouth, or closure of the eye. **It is treated by giving antiseizure medications, such as gabapentin, and sometimes tricyclic antidepressants. These medications work by stabilizing the neuronal membrane and blocking the nerve.** **antiseizure medications work in this condition by blocking the nerve​**

Question 104

The nurse is providing instructions to the client with trigeminal neuralgia regarding measures to take to prevent the episodes of pain. Which should the nurse instruct the client to do? 1. Prevent stressful situations. 2. Avoid activities that may cause fatigue. 3. Avoid contact with people with an infection. 4. Avoid activities that may cause pressure near the face.

Answer 104

The pain that accompanies trigeminal neuralgia is triggered by stimulation of the trigeminal nerve. Symptoms can be triggered by pressure such as from washing the face, brushing the teeth, shaving, eating, or drinking. Symptoms also can be triggered by stimulation by a draft or cold air.

Question 105

Assessment findings for Bell's Palsy

Answer 105

Bell's palsy is a one-sided facial paralysis caused by the compression of the facial nerve (cranial nerve VII). Assessment findings include **facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and speech or chewing difficulty.**

Question 106

Desired outcomes for nursing interventions to prevent cold discomfort and the development of accidental hypothermia include the following: hands and limbs are \_\_\_\_\_\_\_\_; body is\_\_\_\_\_\_\_\_ and not curled; body temperature is greater than \_\_\_\_\_\_\_°F (36.1°C); the client is not \_\_\_\_\_\_; and the client has no complaints of feeling \_\_\_\_.

Answer 106

warm; relaxed; 97; shivering; cold

Question 107

The nurse is preparing a plan of care for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On assessment, the nurse notes that the client is severely dysphagic. Which intervention should be included in the care plan for this client? Select all that apply. 1. Provide oral hygiene after each meal. 2. Assess swallowing ability frequently. 3. Allow the client sufficient time to eat. 4. Maintain a suction machine at the bedside. 5. Provide a full liquid diet for ease in swallowing.

Answer 107

A client who is severely dysphagic is at risk for aspiration. Swallowing is assessed frequently. The client should be given a sufficient amount of time to eat. Semisoft foods are easiest to swallow and require less chewing. Oral hygiene is necessary after each meal. Suctioning should be available for clients who experience dysphagia and are at risk for aspiration. Recall that liquids are most difficult to swallow in the client with dysphagia.

Question 108

TRUE OR FALSE liquids are most difficult to swallow in the client with dysphagia.

Answer 108

TRUE Semisoft foods are easiest to swallow and require less chewing

Question 109

The nurse is reviewing the record for a client seen in the health care clinic and notes that the health care provider has documented a diagnosis of amyotrophic lateral sclerosis (ALS). Which initial clinical manifestation of this disorder should the nurse expect to see documented in the record? 1. Muscle wasting 2. Mild clumsiness 3. Altered mentation 4. Diminished gag reflex

Answer 109

**The initial symptom of ALS is a mild clumsiness**, usually noted in the distal portion of one extremity. The client may complain of tripping and drag one leg when the lower extremities are involved. Mentation and intellectual function usually are normal. Diminished gag reflex and muscle wasting are not initial clinical manifestations.

Question 110

The nurse in the neurological unit is caring for a client with a supratentorial lesion. The nurse assesses which measurement as the most critical index of central nervous system (CNS) dysfunction? 1. Temperature 2. Blood pressure 3. Ability to speak 4. Level of consciousness

Answer 110

**Level of consciousness is the most critical index of CNS dysfunction. Changes in level of consciousness can indicate clinical improvement or deterioration.** Although blood pressure, temperature, and ability to speak may be components of the assessment, the client's level of consciousness is the most critical index of CNS dysfunction.

Question 111

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_is the most critical index of CNS dysfunction.

Answer 111

Level of consciousness. . Changes in level of consciousness can indicate clinical improvement or deterioration

Question 112

The nurse is caring for a client after a craniotomy and monitors the client for signs of increased intracranial pressure (ICP). Which finding, if noted in the client, would indicate an early sign of increased ICP? 1. Confusion 2. Bradycardia 3. Sluggish pupils 4. A widened pulse pressure

Answer 112

Early manifestations of increased ICP are subtle and often may be transient, lasting for only a few minutes in some cases. **These early clinical manifestations include episodes of confusion, drowsiness, and slight pupillary and breathing changes**. Later manifestations include a further decrease in the level of consciousness, a widened pulse pressure, and bradycardia. Cheyne-Stokes respiratory pattern, or a hyperventilation respiratory pattern, and pupillary sluggishness and dilatation appear in the late stages.

Question 113

Early manifestations of increased ICP are \_\_\_\_\_\_\_\_\_\_\_and often may be \_\_\_\_\_\_\_\_, lasting for only a few minutes in some cases. These early clinical manifestations include episodes of \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_- Later manifestations include a further decrease in the level of consciousness, a widened pulse pressure, and \_\_\_\_\_\_\_\_\_\_\_cardia. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_-respiratory pattern, or a hyperventilation respiratory pattern, and pupillary sluggishness and dilatation appear in the late stages.

Answer 113

subtle; transient; confusion, drowsiness, and slight pupillary and breathing changes; bradycardia; Cheyne-Stokes

Question 114

the earliest indicator of increased ICP is changes in \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_---

Answer 114

level of consciousness

Question 115

The nurse is planning discharge teaching for a client started on **acetazolamide** for a supratentorial lesion. Which information about the primary action of the medication should be included in the client's education?

Answer 115

It decreases cerebrospinal fluid production. Acetazolamide is a **carbonic anhydrase inhibitor and a diuretic.** It is used in the client with or at risk for increased intracranial pressure to decrease cerebrospinal fluid production.

Question 116

Acetazolamide

Answer 116

a carbonic anhydrase inhibitor and a diuretic. ***It is used in the client with or at risk for increased intracranial pressure to decrease cerebrospinal fluid production.***

Question 117

TRUE OR FALSE Objects such as tongue blades are safe to put in the client's mouth during a seizure

Answer 117

FALSE ## Footnote ***Objects such as tongue blades are contraindicated and should never be placed in the client's mouth during a seizure***

Question 118

objects should not be placed in the client's \_\_\_\_\_\_\_\_\_\_during a seizure.

Answer 118

mouth

Question 119

Full \_\_\_\_\_\_\_\_\_\_\_precautions include bed rest with padded side rails in a raised position, a suction machine at the bedside, having diazepam or lorazepam available, and providing an oxygen source.

Answer 119

seizure

Question 120

Selegiline hydrochloride is an \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_medication.

Answer 120

antiparkinsonian The medication **increases dopaminergic action**, assisting in the reduction of tremor, akinesia, and the rigidity of parkinsonism.

Question 121

The nurse is reviewing the record of a client with a suspected diagnosis of Huntington's disease. The nurse should expect to note documentation of which early symptom of this disease? 1. Aphasia 2. Agnosia 3. Difficulty with swallowing 4. Balance and coordination problems

Answer 121

Early symptoms of Huntington's disease include restlessness, **forgetfulness**, clumsiness, falls, **balance and coordination problems**, altered speech, and altered handwriting. Difficulty with swallowing occurs in the later stages. Aphasia and agnosia do not occur.

Question 122

Oxybutynin -what kind of medication is it and what is it used for ?

Answer 122

Oxybutynin is an **antispasmodic used to relieve symptoms of urinary urgency, frequency, nocturia, and incontinence in clients with uninhibited or reflex neurogenic bladder.** Expected effects include improved urinary control and decreased urinary frequency, incontinence, and nocturia.

Question 123

The nurse is preparing for the admission of a client with a suspected diagnosis of Guillain-Barré syndrome. When the client arrives at the nursing unit, the nurse reviews the health care provider's documentation. The nurse expects to note documentation of which hallmark clinical manifestation of this syndrome? 1. Multifocal seizures 2. Altered level of consciousness 3. Abrupt onset of a fever and headache 4. Development of progressive muscle weakness

Answer 123

A hallmark clinical manifestation of Guillain-Barré syndrome is progressive muscle weakness that develops rapidly. Seizures are not normally associated with this disorder. The client does not have symptoms such as a fever or headache. Cerebral function, level of consciousness, and pupillary responses are normal.

Question 124

A hallmark clinical manifestation of Guillain-Barré syndrome is progressive \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_--that develops rapidly.

Answer 124

**muscle weakness** Seizures are not normally associated with this disorder. The client does not have symptoms such as a fever or headache. Cerebral function, level of consciousness, and pupillary responses are normal.

Question 125

A thymectomy accomplished via a median sternotomy approach is performed in a client with a diagnosis of myasthenia gravis. The nurse creates a postoperative plan of care for the client that should include which intervention? 1. Monitor the chest tube drainage. 2. Restrict visitors for 24 hours postoperatively. 3. Maintain intravenous infusion of lactated Ringer's solution. 4. Avoid administering pain medication to prevent respiratory depression.

Answer 125

**The thymus has played a role in the development of myasthenia gravis**. ***A thymectomy is the surgical removal of the thymus gland and may be used for management of clients with myasthenia gravis to improve weakness.*** The procedure is performed through a median sternotomy or a transcervical approach. **Postoperatively the client will have a chest tube in the mediastinum**. Lactated intravenous solutions usually are avoided because they can increase weakness. Pain medication is administered as needed, but the client is monitored closely for respiratory depression. There is no reason to restrict visitors.

Question 126

The nurse is caring for a client with a diagnosis of right (nondominant) hemispheric stroke. The nurse notes that the client is alert and oriented to time and place. On the basis of these assessment findings, the nurse should make which interpretation? 1. Had a very mild stroke 2. Most likely suffered a transient ischemic attack 3. May have difficulty with language abilities only 4. Is likely to have perceptual and spatial disabilities

Answer 126

The client with a right (nondominant) hemispheric stroke may be alert and oriented to time and place. These signs of apparent wellness often suggest that the client is less disabled than is the case. However, impulsivity and confusion in carrying out activities may be very real problems for these clients as a result of perceptual and spatial disabilities. **The right hemisphere is considered specialized in sensory-perceptual and visual-spatial processing and awareness of body space.** The left hemisphere is dominant for language abilities.

Question 127

perceptual and spatial disabilities occur in the client with a\_\_\_\_\_\_\_\_\_\_\_\_\_ hemispheric stroke.

Answer 127

right

Question 128

anosognosia

Answer 128

in anosognosia the client neglects the affected side of the body.

Question 129

The nurse is creating a plan of care for a client with a diagnosis of stroke (brain attack). On reviewing the client's record, the nurse notes an assessment finding of anosognosia. The nursing care plan should address which manifestation related to this finding? 1. The client will be easily fatigued. 2. The client will have difficulty speaking. 3. The client will have difficulty swallowing. 4. The client will exhibit neglect of the affected side.

Answer 129

**In anosognosia, the client neglects the affected side of the body.** The client either may ignore the presence of the affected side (often creating a safety hazard as a result of potential injuries) or may state that the involved arm or leg belongs to someone else. The remaining options are not associated with anosognosia

Question 130

global aphasia is associated with poor \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_--.

Answer 130

comprehension

Question 131

The nurse is creating a plan of care for a client with a stroke (brain attack) who has global aphasia. The nurse should incorporate communication strategies into the plan of care because of which expected characteristic of the client's speech? 1. Intact 2. Rambling 3. Characterized by literal paraphasia 4. Associated with poor comprehension

Answer 131

**Global aphasia is a condition in which the affected person has few language skills as a result of extensive damage to the left hemisphere**. The speech is nonfluent and is associated with poor comprehension and limited ability to name objects or repeat words. The client with conduction aphasia has difficulty repeating words spoken by another, and speech is characterized by literal paraphasia with intact comprehension. The client with Wernicke's aphasia may exhibit a rambling type of speech.

Question 132

The nurse is creating a plan of care for a client with a diagnosis of stroke (brain attack) with anosognosia. To meet the needs of the client with this deficit, the nurse should include activities that will achieve which outcome? 1. Encourage communication. 2. Provide a consistent daily routine. 3. Promote adequate bowel elimination. 4. Increase the client's awareness of the affected side.

Answer 132

***In anosognosia, the client exhibits neglect of the affected side of the body.*** ***The nurse will plan care activities that remind the client to perform actions that require looking at the affected arm or leg, as well as activities that will increase the client's awareness of the affected side.*** The remaining options are not associated with this deficit.

Question 133

The nurse is caring for a client who sustained a spinal cord injury. During administration of morning care, the client begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action should the nurse take? 1. Elevate the head of the bed. 2. Examine the rectum digitally. 3. Assess the client's blood pressure. 4. Place the client in the prone position.

Answer 133

Autonomic dysreflexia is a serious complication that can occur in the spinal cord–injured client. **Once the syndrome is identified, the nurse elevates the head of the client's bed and then examines the client for the source of noxious stimuli.** The nurse also assesses the client's blood pressure, but t**he initial action would be to elevate the head of the bed.** *The client would not be placed in the prone position;* lying flat will increase the client's blood pressure.

Question 134

The home care nurse is visiting a client with a diagnosis of Parkinson's disease. The client is taking benztropine mesylate orally daily. The nurse provides information to the spouse regarding the side effects of this medication and should tell the spouse to report which side effect if it occurs? 1. Shuffling gait 2. Inability to urinate 3. Decreased appetite 4. Irregular bowel movements

Answer 134

**Benztropine mesylate is an anticholinergic, which causes urinary retention as a side effect.** The nurse would instruct the client or spouse about the need to monitor for difficulty with urinating, a distended abdomen, infrequent voiding in small amounts, and overflow incontinence.

Question 135

benztropine mesylate is an \_\_\_\_\_\_\_\_\_\_\_\_-and that these types of medications cause urinary \_\_\_\_\_\_\_\_\_\_

Answer 135

anticholinergic; retention

Question 136

The nurse is documenting nursing observations in the record of a client who experienced a tonic-clonic seizure. Which clinical manifestation did the nurse most likely note in the clonic phase of the seizure? 1. Body stiffening 2. Spasms of the entire body 3. Sudden loss of consciousness 4. Brief flexion of the extremities

Answer 136

***The clonic phase of a seizure is characterized by alternating spasms and momentary muscular relaxation of the entire body, accompanied by strenuous hyperventilation***. The face is contorted and the eyes roll. Excessive salivation results in frothing from the mouth. The tongue may be bitten, the client sweats profusely, and the pulse is rapid. The clonic jerking subsides by slowing in frequency and losing strength of contractions over a period of 30 seconds. Body stiffening, sudden loss of consciousness, and brief flexion of the extremities are associated with the tonic phase of a seizure.

Question 137

The clonic phase of a seizure is characterized by.

Answer 137

**alternating spasms and momentary muscular relaxation of the entire body**, accompanied by strenuous hyperventilation. ***The face is contorted and the eyes roll***. Excessive salivation results in frothing from the mouth. The tongue may be bitten, the client sweats profusely, and the pulse is rapid. The clonic jerking subsides by slowing in frequency and losing strength of contractions over a period of 30 seconds

Question 138

Body stiffening, sudden loss of consciousness, and brief flexion of the extremities are associated with the \_\_\_\_\_\_\_\_\_-phase of a seizure.

Answer 138

tonic

Question 139

The most common cause of autonomic dysreflexia is \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, such as with blockage of urinary drainage or with constipation. Barring these, other causes include **noxious mechanical and thermal stimuli**, particularly\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ and \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_. For this reason, the nurse ensures that the client is positioned with no pinching or pressure on paralyzed body parts and that the client will be sufficiently \_\_\_\_\_\_\_\_-.

Answer 139

visceral stimuli; pressure and overchilling; warm

Question 140

A client who had cranial surgery 5 days earlier to remove a brain tumor has a few cognitive deficits and does not seem to be progressing as quickly as the client or family had hoped. The nurse plans to implement which approach as most helpful to the client and family at this time? 1. Emphasize progress in a realistic manner. 2. Set high goals to give the client something to "aim for." 3. Tell the family to be extremely optimistic with the client. 4. Inform the client and family of standardized goals of care.

Answer 140

The most helpful approach by the nurse is to **emphasize progress that is being made in a realistic manner.** The nurse does not offer false hope but does provide factual information in a clear and positive manner. The nurse encourages the family to be realistic in their expectations and attitudes. The plan of care should be individualized for each client.

Question 141

At 8:00 a.m., A client who has had a stroke (brain attack) was awake and alert with vital signs of temperature 98°F (37.2°C) orally, pulse 80 beats/min, respirations 18 breaths/min, and blood pressure 138/80 mm Hg. At noon, the client is confused and only responsive to tactile stimuli, and vital signs are temperature 99°F (36.7°C) orally, pulse 62 beats/min, respirations 20 breaths/min, and blood pressure 166/72 mm Hg. The nurse should take which action? 1. Reorient the client. 2. Retake the vital signs. 3. Call the health care provider (HCP). 4. Administer an antihypertensive PRN (as needed).

Answer 141

The important nursing action is to **call the HCP**. ***The deterioration in neurological status, decreasing pulse, and increasing blood pressure with a widening pulse pressure all indicate that the client is experiencing increased intracranial pressure, which requires immediate treatment to prevent further complications and possible death.*** The nurse should retake the vital signs and reorient the client to surroundings. If the client's blood pressure falls within parameters for PRN antihypertensive medication, the medication also should be administered. However, options 1, 2, and 4 are secondary nursing actions.

Question 142

The client should avoid the intake of alcohol when taking seizure medications. TRUE OR FALSE

Answer 142

TRUE Alcohol could interact with the client's seizure medications, or it could precipitate seizure activity

Question 143

A client had a transsphenoidal resection of the pituitary gland. The nurse notes drainage on the nasal dressing. Suspecting cerebrospinal fluid (CSF) leakage, the nurse should look for drainage that is of which characteristic? 1. Serosanguineous only 2. Bloody with very small clots 3. Sanguineous only with no clot formation 4. Serosanguineous, surrounded by clear to straw-colored fluid

Answer 143

***CSF leakage after cranial surgery may be detected by noting drainage that is serosanguineous (from the surgery) and surrounded by an area of clear or straw-colored drainage***. The typical appearance of CSF drainage is that of a "halo." The nurse also would further verify actual CSF drainage by testing the drainage for glucose, which would be positive.

Question 144

A client arrives in the hospital emergency department with a closed head injury to the right side of the head caused by an assault with a baseball bat. The nurse assesses the client neurologically, looking primarily for motor response deficits that involve which area 1. The left side of the body 2. The right side of the body 3. Both sides of the body equally 4. Cranial nerves only, such as speech and pupillary response

Answer 144

**Motor responses such as weakness and decreased movement will be seen on the side of the body that is opposite an area of head injury**. Contralateral deficits result from compression of the cortex of the brain or the pyramidal tracts. Depending on the severity of the injury, the client may have a variety of neurological deficits.

Question 145

Motor responses such as weakness and decreased movement will be seen on the side of the body that is \_\_\_\_\_\_\_\_\_\_\_\_an area of head injury

Answer 145

opposite

Question 146

The nurse has a prescription to begin aneurysm precautions for a client with a subarachnoid hemorrhage secondary to aneurysm rupture. The nurse would plan to incorporate which intervention in controlling the environment for this client? 1. Keep the window blinds open. 2. Turn on a small spotlight above the client's head. 3. Make sure the door to the room is open at all times. 4. Prohibit or limit the use of a radio or television and reading.

Answer 146

Environmental stimuli are kept to a minimum with subarachnoid precautions **to prevent or minimize increases in intracranial pressure.** For this reason, lighting is reduced by closing window blinds and keeping the door to the client's room shut. Overhead lighting also is avoided for the same reason. **T****he nurse prohibits television, radio, and reading unless this is so stressful for the client that it would be counterproductive. In that instance, minimal amounts of stimuli by these means** T are allowed with approval of the health care provider.

Question 147

With aneurysm precautions, any activity that could raise the client's \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_--is avoided. For this reason, activities such as \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_are avoided whenever possible

Answer 147

intracranial pressure (ICP) straining, coughing, blowing the nose, and even sneezing

Question 148

The nurse is caring for a client who is on bed rest as part of aneurysm precautions. The nurse should avoid doing which action when giving respiratory care to this client? 1. Encouraging hourly coughing 2. Assisting with incentive spirometer 3. Encouraging hourly deep breathing 4. Repositioning gently side to side every 2 hours

Answer 148

With aneurysm precautions, any activity that could raise the client's intracranial pressure (ICP) is avoided. For this reason, activities such as straining, coughing, blowing the nose, and even sneezing are avoided whenever possible. ## Footnote **The other interventions (repositioning, deep breathing, and incentive spirometry) do not provide added risk of increasing ICP and are beneficial in reducing the respiratory complications of bed rest.**

Question 149

At the end of the work shift, the nurse is reviewing the respiratory status of a client admitted with a stroke (brain attack) earlier in the day. The nurse determines that the client's airway is patent if which data are identified? 1. Respiratory rate 24 breaths/min, oxygen saturation 94%, breath sounds clear 2. Respiratory rate 18 breaths/min, oxygen saturation 98%, breath sounds clear 3. Respiratory rate 16 breaths/min, oxygen saturation 85%, wheezes bilaterally 4. Respiratory rate 20 breaths/min, oxygen saturation 92%, diminished breath sounds in lung bases

Answer 149

The client's airway is most protected if all of the respiratory parameters measured fall within normal limits. Therefore, the respiratory rate should ideally be 16 to 20 breaths/min, the oxygen saturation should be greater than 95%, and the breath sounds should be clear. The correct option is the only one that meets all 3 criteria.

Question 150

At the beginning of the work shift, the nurse assesses the status of the client wearing a halo device. The nurse determines that which assessment finding requires intervention? 1. Tightened screws 2. Red skin areas under the jacket 3. Clean and dry lamb's wool jacket lining 4. Finger-width space between the jacket and the skin

Answer 150

**Red skin areas under the jacket indicate that the jacket is too tight.** The resulting pressure could lead to altered skin integrity and needs to be relieved by loosening the jacket. The screws all should be properly tightened. A clean, dry lamb's wool lining should be in place underneath the jacket, and there should be a finger-width space between the jacket and the skin. In addition, the client should wear a clean white cotton T-shirt next to the skin to help prevent itching.

Question 151

A client who has a spinal cord injury that resulted in paraplegia experiences a sudden onset of severe headache and nausea. The client is diaphoretic with piloerection and has flushing of the skin. The client's systolic blood pressure (BP) is 210 mm Hg. What should the nurse immediately suspect? 1. Return of spinal shock 2. Malignant hypertension 3. Impending brain attack (stroke) 4. Autonomic dysreflexia (hyperreflexia)

Answer 151

**Autonomic dysreflexia (hyperreflexia) results from sudden strong discharge of the sympathetic nervous system in response to a noxious stimulus.** Signs and symptoms include pounding headache, nausea, nasal stuffiness, flushed skin, piloerection, and diaphoresis. Severe hypertension can occur, with a systolic BP rising potentially as high as 300 mm Hg. It often is triggered by thermal or mechanical events such as a kinking of catheter tubing, constipation, urinary tract infection, or any variety of cutaneous stimuli. **The nurse must recognize this situation immediately and take corrective action to remove the stimulus**. If untreated, this medical emergency could result in stroke, status epilepticus, or possibly death.

Question 152

Autonomic dysreflexia (hyperreflexia) results from sudden strong discharge of the \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_nervous system in response to a \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_. Signs and symptoms include \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_-. Severe hypertension can occur, with a systolic BP rising potentially as high as 300 mm Hg. It often is triggered by ____________ or ____________ events such as a kinking of catheter tubing, constipation, urinary tract infection, or any variety of cutaneous stimuli. The nurse must recognize this situation immediately and take corrective action to remove the stimulus. **If untreated, this medical emergency could result in stroke, status epilepticus, or possibly death.**

Answer 152

sympathetic; noxious stimulus pounding headache, nausea, nasal stuffiness, flushed skin, piloerection, and diaphoresis thermal or mechanical

Question 153

A client who had a stroke (brain attack) has right-sided hemianopsia. What should the nurse plan to do to help the client adapt to this problem? 1. Teach the client to scan the environment. 2. Place all objects within the left visual field. 3. Place all objects within the right visual field. 4. Ensure that the family brings the client's eyeglasses to hospital.

Answer 153

The correct option teaches the client a response to overcome this visual deficit. Recalling that **hemianopsia is blindness in one half of the field of vision** will direct you to the correct option. **Hemianopsia is blindness in half of the visual field.** The client with hemianopsia is taught to scan the environment. This allows the client to take in the entirety of the visual field, which is necessary for proper functioning within the environment and helps to prevent injury to the client. Options 2 and 3 will not help the client adapt to this visual impairment. Eyeglasses are useful if the client already wears them, but they will not correct this visual field deficit.

Question 154

The nurse is assisting with caloric testing of the oculovestibular reflex in an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left, followed by eye movement back to midline. The nurse understands that this finding indicates which situation? 1. Brain death 2. A cerebral lesion 3. A temporal lesion 4. An intact brainstem

Answer 154

***Caloric testing provides information about differentiating between cerebellar and brainstem lesions***. After determining patency of the ear canal, cold or warm water is injected into the auditory canal. A normal response that indicates intact function of cranial nerves III, VI, and VIII is conjugate eye movements toward the side being irrigated, followed by eye movement back to midline. **Absent or dysconjugate eye movements indicate brainstem damage.** Remember that this test is used as an adjunct to determine brain death. This would limit the choices to option 1 or the correct option. In addition, note that options 1, 2, and 3 are comparable or alike in that they all indicate abnormal findings.

Question 155

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_is necessary after spinal cord injury to prevent further damage and insult to the spinal cord.

Answer 155

Spinal immobilization

Question 156

The nurse is caring for a client who is brought to the hospital emergency department with a spinal cord injury. The nurse minimizes the risk of compounding the injury by performing which action? 1. Keeping the client on a stretcher 2. Logrolling the client onto a soft mattress 3. Logrolling the client onto a firm mattress 4. Placing the client on a bed that provides spinal immobilization

Answer 156

**Spinal immobilization** is necessary after spinal cord injury to prevent further damage and insult to the spinal cord. ***Whenever possible, the client is placed on a special bed, such as a Stryker frame, which allows the nurse to turn the client to prevent complications of immobility while maintaining alignment of the spine.*** If a Stryker frame is not available, a firm mattress with a bed board under it should be used. The remaining options are incorrect and potentially harmful interventions

Question 157

The nurse is assessing a client who is experiencing seizure activity. The nurse understands that it is necessary to determine information about which items as part of routine assessment of seizures? Select all that apply. 1. Postictal status 2. Duration of the seizure 3. Changes in pupil size or eye deviation 4. Seizure progression and type of movements 5. What the client ate in the 2 hours preceding seizure activity

Answer 157

Typically seizure assessment includes **the time the seizure began, parts of the body affected, type of movements and progression of the seizure, change in pupil size or eye deviation or nystagmus, client condition during the seizure, and postictal status.** Determining what the client ate 2 hours prior to the seizure is not a component of seizure assessment.

Question 158

A client with myasthenia gravis is having difficulty with airway clearance and difficulty with maintaining an effective breathing pattern. The nurse should keep which most important items available at the client's bedside? 1. Oxygen and metered-dose inhaler 2. Ambu bag and suction equipment 3. Pulse oximeter and cardiac monitor 4. Incentive spirometer and cough pillow

Answer 158

The client with myasthenia gravis may experience episodes of respiratory distress if excessively fatigued or with development of myasthenic or cholinergic crisis. For this reason, an Ambu bag, intubation tray, and suction equipment should be available at the bedside. Knowing that the client with myasthenia gravis is at risk for aspiration and respiratory failure will help you select the correct choice over the others. In addition, the correct option addresses the maintenance of a patent airway.

Question 159

Lifting the head opens the airway, which decreases the risk of aspiration during drinking or eating. TRUE OR FALSE

Answer 159

FALSE Lifting the head opens the airway, which **INCREASES** the risk of aspiration during drinking or eating.

Question 160

A client with recent-onset Bell's palsy is upset and crying about the change in facial appearance. The nurse plans to support the client emotionally by making which statement to the client? 1. "This is not a stroke, and many clients recover in 3 to 5 weeks." 2. "This is caused by a small tumor, which can be removed easily." 3. "This is similar to a stroke, but all symptoms will reverse without treatment." 4. "This is a temporary problem, with treatment similar to that for migraine headaches."

Answer 160

***Clients with Bell's palsy should be reassured that they have not experienced stroke a (brain attack) and that symptoms often disappear spontaneously in 3 to 5 weeks***. The client is given supportive treatment for symptoms. Bell's palsy usually is not caused by a tumor, and the treatment is not similar to that for migraine headaches.

Question 161

The nurse has instructed a client with myasthenia gravis about strategies for self-management at home. The nurse determines a need for further teaching if the client makes which statement? 1. "Here's the MedicAlert bracelet I obtained." 2. "I should take my medications an hour before mealtime." 3. "Going to the beach will be a nice, relaxing form of activity." 4. "I've made arrangements to get a portable resuscitation bag and home suction equipment."

Answer 161

Most ongoing treatment for myasthenia gravis is done in outpatient settings, and the client must be aware of the lifestyle changes needed to maintain independence. The client should carry medical identification about the presence of the condition. **Taking medications an hour before mealtime gives greater muscle strength for chewing and is indicated**. The client should have portable suction equipment and a portable resuscitation bag available in case of respiratory distress. ***The client should avoid situations and other factors, including stress, infection, heat, surgery, and alcohol, that could worsen the symptoms.*** recall that premedication given 1 hour before meals restores strength to the muscles (for chewing and swallowing) and that heat and infection (exposure to crowds places the client at risk for infection) trigger myasthenic crisis.

Question 162

A client is admitted with an exacerbation of multiple sclerosis. The nurse is assessing the client for possible precipitating risk factors. Which factor, if reported by the client, should the nurse identify as being unrelated to the exacerbation? 1. Annual influenza vaccination 2. Ingestion of increased fruits and vegetables 3. An established routine of walking 2 miles each evening 4. A recent period of extreme outside ambient temperatures

Answer 162

The onset or exacerbation of multiple sclerosis can be preceded by a number of different factors, including physical stress (e.g., vaccination, excessive exercise), emotional stress, fatigue, infection, physical injury, pregnancy, extremes in environmental temperature, and high humidity. **No methods of primary prevention are known. *Intake of fruits and vegetables is a healthy and an unrelated item.***

Question 163

Multiple sclerosis is a chronic, nonprogressive, noncontagious degenerative disease of the central nervous system characterized by \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_of the neurons.

Answer 163

demyelination

Question 164

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_helps the client with a neurogenic bladder to establish regular times for successful voiding. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_after the evening meal minimizes incontinence or the need to empty the bladder during the night.

Answer 164

Spacing fluid intake over the day; Omitting intake

Question 165

The nurse has taught a client with a herniated lumbar disk about proper body mechanics and other items pertinent to low back care. The nurse determines that further teaching is needed if the client states the need to take which action? 1. Bend at the knees to pick up objects. 2. Increase fiber and fluid intake in the diet. 3. Strengthen the back muscles by swimming or walking. 4. Get out of bed by sitting straight up and swinging the legs over the side of the bed.

Answer 165

***The client is taught to get out of bed by sliding near the edge of the mattress. The client then rolls onto 1 side and pushes up from the bed using 1 or both arms. The client keeps the back straight and swings the legs over the side.*** Proper body mechanics includes bending at the knees, not the waist, to lift objects. ***Increasing fluid intake and dietary fiber helps prevent straining at stool, thereby preventing increases in intraspinal pressure.*** Walking and swimming are excellent exercises for strengthening lower back muscles.

Question 166

the client with low back pain should avoid maneuvers that increase \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_pressure.

Answer 166

intraspinal

Question 167

Which cranial nerve is responsible for the ability to chew food ?

Answer 167

The motor branch of cranial nerve V (trigeminal nerve) is responsible for the ability to chew food.

Question 168

Which assessment finding should the nurse expect to note in the client hospitalized with a diagnosis of stroke who has difficulty chewing food? 1. Dysfunction of vagus nerve (cranial nerve X) 2. Dysfunction of trigeminal nerve (cranial nerve V) 3. Dysfunction of hypoglossal nerve (cranial nerve XII) 4. Dysfunction of spinal accessory nerve (cranial nerve XI)

Answer 168

The motor branch of cranial nerve V is responsible for the ability to chew food. The vagus nerve is active in parasympathetic functions of the autonomic nervous system. **The hypoglossal nerve aids in swallowing.** The spinal accessory nerve is responsible for shoulder movement, among other things.

Question 169

The nurse has applied a hypothermia blanket to a client with a fever. The nurse should inspect the skin frequently to detect which condition that is a complication of hypothermia blanket use? 1. Frostbite 2. Skin breakdown 3. Arterial insufficiency 4. Venous insufficiency

Answer 169

***When a hypothermia blanket is used, the skin is inspected frequently for pressure points, which over time could lead to skin breakdown.*** The hypothermia blanket decreases the blood flow to pressure areas and can cause numbness, making it so that the client is not aware of damage to the skin. The temperature of the blanket is not cold enough to cause frostbite. Arterial insufficiency and venous insufficiency are not complications of hypothermia blanket use.

Question 170

The location of the brain's thermoregulatory center is where ?

Answer 170

In the hypothalamus

Question 171

The nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs of infection. On the basis of these findings the nurse suspects dysfunction in which area of the brain? 1. Cerebrum 2. Cerebellum 3. Hippocampus 4. Hypothalamus

Answer 171

**Hypothalamic damage causes persistent hyperthermia, which also may be called central fever.** It is characterized by a persistent high fever with no diurnal variation. Another characteristic feature is absence of sweating. Hyperthermia would not result from damage to the cerebrum, cerebellum, or hippocampus.

Question 172

Chlorpromazine is used to control\_\_\_\_\_\_\_\_\_\_\_\_\_\_- in hyperthermic states.

Answer 172

shivering It is a phenothiazine and has antiemetic and antipsychotic uses, especially when psychosis is accompanied by increased psychomotor activity.

Question 173

The nurse has a prescription to administer a medication to a client who is experiencing shivering as a result of hyperthermia. Which medication should the nurse anticipate to be prescribed? ## Footnote 1. Buspirone 2. Fluphenazine 3. Chlorpromazine 4. Prochlorperazine

Answer 173

**Chlorpromazine is used to control shivering in hyperthermic states.** It is a phenothiazine and has antiemetic and antipsychotic uses, especially when psychosis is accompanied by increased psychomotor activity. Buspirone is an anxiolytic. Prochlorperazine is a phenothiazine that is an antiemetic and antipsychotic. Fluphenazine is a phenothiazine that is used as an antipsychotic.

Question 174

The nurse is caring for a client with an intracranial pressure (ICP) monitoring device. The nurse should become most concerned if the ICP readings drifted to and stayed in the vicinity of which finding? 1. 5 mm Hg 2. 8 mm Hg 3. 14 mm Hg 4. 22 mm Hg

Answer 174

Normal ICP readings range from 5 to 15 mm Hg pressure. ***Pressures greater than 20 mm Hg are considered to represent increased ICP, which seriously impairs cerebral perfusion.***

Question 175

The nurse is caring for a client with intracranial pressure (ICP) monitoring. Which intervention is appropriate to include in the plan of care? 1. Place the client in Sims' position. 2. Change the drainage tubing every 48 hours. 3. Level the transducer at the lowest point of the ear. 4. Use strict aseptic technique when touching the monitoring system.

Answer 175

**Because there is a foreign body embedded in the client's brain, vigilant aseptic technique should be implemented**. Sims' is a side-lying, flat position. **With a client who has increased ICP, the head of the bed should be elevated at least 30 degrees to improve jugular outflow.** The drainage tubing should not be routinely changed. It should remain for the duration of the monitoring. **To obtain accurate ICP pressure readings, the transducer is zeroed at the level of the foramen of Monro, which is approximated by placing the transducer 1 inch above the level of the ear.** Serial ICP readings should be done with the client's head in the same position.

Question 176

Carbon dioxide is a very potent \_\_\_\_\_\_\_\_\_\_\_\_\_that can contribute to increases in ICP.

Answer 176

vasodilator

Question 177

A client with a traumatic brain injury is on mechanical ventilation. The nurse promotes normal intracranial pressure (ICP) by ensuring that the client's arterial blood gas (ABG) results are within which ranges? 1. PaO2 60 to 100 mm Hg (60 to 100 mm Hg), PaCo2 25 to 30 mm Hg (25 to 30 mm Hg) 2. PaO2 60 to 100 mm Hg (60 to 100 mm Hg), PaCo2 30 to 35 mm Hg (30 to 35 mm Hg) 3. PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCo2 25 to 30 mm Hg (25 to 30 mm Hg) 4. PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCo2 35 to 38 mm Hg (35 to 38 mm Hg)

Answer 177

Th**e goal is to maintain the partial pressure of arterial carbon dioxide (PaCo2) at 35 to 38 mm Hg (35 to 38 mm Hg**). Carbon dioxide is a very potent vasodilator that can contribute to increases in ICP. **The PaO2 is not allowed to fall below 80 mm Hg (80 mm Hg), to prevent cerebral vasodilation from hypoxemia,** which can also result in an increase in ICP. Therefore, the remaining options are incorrect.

Question 178

The nurse is providing care to a client with increased intracranial pressure (ICP). Which approach is beneficial in controlling the client's ICP from an environmental viewpoint? 1. Reduce environmental noise. 2. Allow visitors as desired by the client and family. 3. Awaken the client every 2 to 3 hours to monitor mental status. 4. Cluster nursing activities to reduce the number of interruptions.

Answer 178

**Nursing interventions to control ICP include maintaining a calm, quiet, and restful environment.** **Environmental noise should be kept at a minimum.** Visiting should be monitored to avoid emotional stress and interruption of sleep. Interventions should be spaced out over the shift to minimize the risk of a sustained rise in ICP. his question tests the concept that stimulation raises the ICP. If you know and understand this concept, you will be able to eliminate each of the incorrect options.

Question 179

sequela

Answer 179

a condition which is the consequence of a previous disease or injury.

Question 180

The home care nurse is making extended follow-up visits to a client discharged from the hospital after a moderately severe head injury. The family states that the client is behaving differently than before the accident. The client is more fatigued and irritable and has some memory problems. The client, who was previously very even tempered, is prone to outbursts of temper now. The nurse determines that these behaviors are indicative of which problem? 1. Intracranial pressure changes 2. A long-term sequela of the injury 3. A worsening of the original injury 4. A short-term problem that will resolve in about 1 month

Answer 180

**Clients with moderate to severe head injury usually have residual physical and cognitive disabilities; these include personality changes, increased fatigue and irritability, mood alterations, and memory changes.** The client also may require frequent to constant supervision. The nurse assesses the family's ability to cope and makes appropriate referrals to respite services, support groups, and state or local chapters of the National Head Injury Foundation. The question states that the client had a moderately severe head injury. Knowing that deficits remain with this level of head injury will help you to eliminate options 1, 3, and 4. Because the injury was more than minor, the correct option is the most reasonable one.

Question 181

A client was seen and treated in the hospital emergency department for a concussion. The nurse determines that the family needs further teaching if they verbalize to call the health care provider (HCP) for which client sign or symptom? 1. Vomiting 2. Minor headache 3. Difficulty speaking 4. Difficulty awakening

Answer 181

A concussion after head injury is a temporary loss of consciousness (from a few seconds to a few minutes) without evidence of structural damage. After concussion, the family is taught to monitor the client and call the HCP or return the client to the emergency department for signs and symptoms such as confusion, difficulty awakening or speaking, one-sided weakness, vomiting, and severe headache. **Minor headache is expected.** Note the strategic words, needs further teaching. These words indicate a negative event query and the need to select the incorrect sign or symptom. Focusing on the client's diagnosis and recalling the signs of increased intracranial pressure will direct you to the correct option. Also, note the word minor in the correct option.

Question 182

A client with a spinal cord injury expresses little interest in food and is very particular about the choice of meals that are actually eaten. How should the nurse interpret this information? 1. Anorexia is a sign of clinical depression, and a referral to a psychologist is needed. 2. The client has compulsive habits that should be ignored as long as they are not harmful. 3. The client probably has a naturally slow metabolism, and the decreased nutritional intake will not matter. 4. Meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable.

Answer 182

Depression frequently may be seen in the client with spinal cord injury and may be exhibited as a loss of appetite. **However, the client should be allowed to choose the types of food eaten and when they are eaten as much as is feasible because it is one of the few areas of control that the client has left.** There is no information in the question that would indicate that the client is anorexic or obsessive-compulsive or has a slow metabolism.

Question 183

The nurse is teaching a client with paraplegia measures to maintain skin integrity. Which instruction will be most helpful to the client? ## Footnote 1. Shift weight every 2 hours while in a wheelchair. 2. Change bed sheets every other week to maintain cleanliness. 3. Place a pillow on the seat of the wheelchair to provide extra comfort. 4. Use a mirror to inspect for redness and skin breakdown twice a week.

Answer 183

**To maintain skin integrity, the client should shift weight in the wheelchair every 2 hours and use a pressure relief pad.** ***A pillow is not sufficient to relieve the pressure.*** While the client is in bed, the bottom sheet should be free of wrinkles and wetness. Sheets should be changed as needed and more frequently than every other week. **The client should use a mirror to inspect the skin twice daily (morning and evening) to assess for redness, edema, and breakdown**. General additional measures include a nutritious diet and meticulous skin care.

Question 184

The nurse is caring for a client with an intracranial aneurysm who has been alert. Which signs and symptoms are an early indication that the level of consciousness (LOC) is deteriorating? Select all that apply. 1. Mild drowsiness 2. Drooping eyelids 3. Ptosis of the left eyelid 4. Slight slurring of speech 5. Less frequent spontaneous speech

Answer 184

***Early changes in LOC relate to orientation, alertness, and verbal responsiveness***. **Mild drowsiness, slight slurring of speech, and less frequent spontaneous speech are early signs of decreasing LOC**. Ptosis (drooping) of the eyelid is caused by pressure on and dysfunction of cranial nerve III. Once ptosis occurs, it is ongoing; it does not relate to LOC.

Question 185

Early changes in LOC relate to\_\_\_\_\_\_\_\_\_\_\_\_, _______ and \_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_are early signs of decreasing LOC.

Answer 185

orientation, alertness, and verbal responsiveness. Mild drowsiness, slight slurring of speech, and less frequent spontaneous speech

Question 186

TRUE OR FALSE medication should not be adjusted or changed by the client

Answer 186

TRUE

Question 187

The nurse has provided instructions to a client with a diagnosis of myasthenia gravis about home care measures. Which client statement indicates the need for further teaching? 1. "I will rest each afternoon after my walk." 2. "I should cough and deep breathe many times during the day." 3. "I can change the time of my medication on the mornings when I feel strong." 4. "If I get abdominal cramps and diarrhea, I should call my health care provider."

Answer 187

The client with myasthenia gravis and the family should be taught information about the disease and its treatment. They should be aware of the side and adverse effects of anticholinesterase medications and corticosteroids and should be taught that timing of anticholinesterase medication is critical. **It is important to instruct the client to administer the medication on time to maintain a chemical balance at the neuromuscular junction. If it is not given on time, the client may become too weak to even swallow.** ***Resting after a walk, coughing and deep-breathing many times during the day, and calling the health care provider when experiencing abdominal cramps and diarrhea indicate a correct understanding*** of home care instructions to maintain health with this neurological degenerative disease.

Question 188

The client with myasthenia gravis and the family should be taught information about the disease and its treatment. They should be aware of the side and adverse effects of\_\_\_\_\_\_\_\_\_\_\_\_\_\_ medications and corticosteroids and should be taught that timing of anticholinesterase medication is critical. It is important to instruct the client to administer the medication on time to maintain a chemical balance at the\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ junction. If it is not given on time, the client may become too weak to even \_\_\_\_\_\_\_\_\_\_\_ Resting after a walk, coughing and deep-breathing many times during the day, and calling the health care provider when experiencing abdominal cramps and diarrhea indicate a correct understanding of home care instructions to maintain health with this neurological degenerative disease.

Answer 188

anticholinesterase; neuromuscular; swallow

Question 189

A client is diagnosed with Bell's palsy. The nurse assessing the client expects to note which symptom? 1. A symmetrical smile 2. Difficulty closing the eyelid on the affected side 3. Narrowing of the palpebral fissure on the affected side 4. Paroxysms of excruciating pain in the lips and cheek on the affected side

Answer 189

The **facial drooping** associated with Bell's palsy makes it difficult for the client to close the eyelid on the affected side. **A widening of the palpebral fissure (the opening between the eyelids) and an asymmetrical smile are seen with Bell's palsy.** Paroxysms of excruciating pain are characteristic of trigeminal neuralgia

Question 190

\_\_\_\_\_\_\_\_\_\_\_ compromise is a major concern in clients with Guillain-Barré syndrome

Answer 190

Respiratory

Question 191

the greatest volume of air that can be expelled from the lungs after taking the deepest possible breath.

Answer 191

Vital Capacity

Question 192

The nurse is performing an assessment on a client with Guillain-Barré syndrome. The nurse determines that which finding would be of most concern? ## Footnote 1. Difficulty articulating words 2. Lung vital capacity of 10 mL/kg 3. Paralysis progressing from the toes to the waist 4. A blood pressure (BP) decrease from 110/78 mm Hg to 102/70 mm Hg

Answer 192

**Respiratory compromise is a major concern** in clients with Guillain-Barré syndrome. **Clients often are intubated and mechanically ventilated when the vital capacity is less than 15 mL/kg**. Difficulty articulating words and paralysis progressing from the toes to the waist are expected, depending on the degree of paralysis that occurs. Although orthostatic hypotension is a problem with these clients, the BP drop in option 4 is less than 10 mm Hg and is not significant.

Question 193

A client with multiple sclerosis tells a home health care nurse that she is having increasing difficulty in transferring from the bed to a chair. What is the initial nursing action? 1. Observe the client demonstrating the transfer technique. 2. Start a restorative nursing program before an injury occurs. 3. Seize the opportunity to discuss potential nursing home placement. 4. Determine the number of falls that the client has had in recent weeks.

Answer 193

Observation of the client's transfer technique is the initial intervention. Starting a restorative program is important but not unless an assessment has been completed first. Discussing nursing home placement would be inappropriate in view of the information provided in the question. Determining the number of falls is another important intervention, but observing the transfer technique should be done first. Note the strategic word, initial. **Use the steps of the nursing process to answer this question. Remember that assessment is the first step.**

Question 194

In \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, the upper extremities (arms, wrists, and fingers) are flexed with adduction of the arms. The lower extremities are extended with internal rotation and plantar flexion. This indicates a hemispheric lesion of the cerebral cortex.

Answer 194

decorticate rigidity

Question 195

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_is prolonged arching of the back with the head and heels bent backward. This indicates meningeal irritation. I

Answer 195

Opisthotonos

Question 196

In \_\_\_\_\_\_\_\_\_\_\_\_\_rigidity, the upper extremities are stiffly extended and adducted with internal rotation and pronation of the palms. The lower extremities are stiffly extended with plantar flexion. The teeth are clenched, and the back is hyperextended. This type of rigidity indicates a lesion in the brainstem at the midbrain or upper pons.

Answer 196

decerebrate

Question 197

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_-is complete loss of muscle tone and paralysis of all four extremities, indicating a completely nonfunctional brainstem.

Answer 197

Flaccid quadriplegia

Question 198

in \_\_\_\_\_\_\_\_\_\_\_\_rigidity the client flexes the upper extremities toward the core of the body.

Answer 198

decorticate

Question 199

flexion of the upper extremities occurs in \_\_\_\_\_\_\_\_\_\_\_rigidity

Answer 199

decorticate

Question 200

An older client is brought to the hospital emergency department by a neighbor who heard the client talking and found him wandering in the street at 3 a.m. The nurse should first determine which data about the client? His insurance status 2. Blood toxicology levels 3. Whether he ate his evening meal 4. Whether this is a change in usual level of orientation

Answer 200

The nurse should first determine whether this behavior represents a change in the client's neurological status. The next item to determine is when the client last ate. Blood toxicology levels may or may not be needed, but the health care provider would likely prescribe these. Insurance information must be obtained at some point but is not the priority from a clinical care viewpoint.

Question 201

An older client in an acute state of disorientation is brought to the hospital emergency department by the client's daughter. The daughter states that the client was "clear as a bell this morning." The nurse determines from this piece of information that which is an unlikely cause of the disorientation? 1. Hypoglycemia 2. Alzheimer's disease 3. Medication dosage error 4. Impaired circulation to the brain

Answer 201

Alzheimer's disease is a chronic disease with progression of memory deficits over time. The situation presented in the question represents an acute problem. **Evaluation is necessary to determine whether hypoglycemia, medication use, or impaired cerebral circulation has had a role in causing the client's current symptoms**

Question 202

The nurse is evaluating a function of the limbic system as a part of the neurological status of a client. What should the nurse assess? 1. Experience of pain 2. Affect or emotions 3. Response to verbal stimuli 4. Insight, judgment, and planning

Answer 202

Focus on the subject, the function of the limbic system. To answer this question correctly, you must be familiar with the different areas of the brain and the control they have over various areas of function. Remember that **affect and emotions are part of the role of the limbic system**. **Affect and emotions are part of the role of the limbic system and involve both hemispheres of the brain**. Pain is a complex experience involving several areas of the central nervous system. The response to verbal stimuli is part of the level of consciousness, which is under the control of the reticular activating system and both cerebral hemispheres. **Insight, judgment, and planning are part of the functions of the frontal lobes of the brain in conjunction with association fibers connecting to other areas of the cerebrum.**

Question 203

insomnia, agitation, mania, and delirium are caused by excessive arousal of the \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_activating system in conjunction with the cerebral hemispheres.

Answer 203

reticular

Question 204

The nurse is caring for a client with a neurological deficit involving the hippocampus. On assessment of the client, which signs and symptoms would most likely be noted? 1. Disoriented to client, place, and time 2. Affect flat, with periods of emotional lability 3. Cannot recall what was eaten for breakfast today 4. Unable to add and subtract; does not know who is president

Answer 204

**Recall of recent events and the storage of memories are controlled by the hippocampus, which is a limbic system structure**. The cerebral hemispheres, with specific regional functions, control orientation. The limbic system, overall, is responsible for feelings, affect, and emotions. Calculation ability and knowledge of current events are under the control of the frontal lobes of the cerebrum.

Question 205

A client has sustained damage to Wernicke's area from a stroke (brain attack). On assessment of the client, which sign or symptom would be noted? 1. Difficulty speaking 2. Problem with understanding language 3. Difficulty controlling voluntary motor activity 4. Problem with articulating events from the remote past

Answer 205

**Wernicke's area consists of a small group of cells in the temporal lobe whose function is the understanding of language**. Damage to Broca's area is responsible for aphasia. The motor cortex in the precentral gyrus controls voluntary motor activity. The hippocampus is responsible for the storage of memory.

Question 206

the function of \_\_\_\_\_\_\_\_\_\_\_\_\_\_-area is the understanding of language

Answer 206

Wernicke's

Question 207

Damage to Broca's area is responsible for \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_-

Answer 207

aphasia.

Question 208

A client with a traumatic brain injury is able, with eyes closed, to identify a set of keys placed in his or her hands. On the basis of this assessment finding, the nurse determines that there is appropriate function of which lobe of the brain?

Answer 208

The ability to distinguish an object by touch is called stereognosis, which is **a function of the right parietal area. *The parietal lobe of the brain is responsible for spatial orientation and awareness of sizes and shapes.*** The left parietal area is responsible for mathematics and right-left orientation. The other lobes of the brain are not responsible for this function

Question 209

The \_\_\_\_\_\_\_\_\_\_\_\_\_-l lobe is responsible for reception of vision and contains visual association areas. This area of the brain helps the individual to visually recognize and understand the surroundings.

Answer 209

occipital

Question 210

A client has suffered damage to Broca's area of the brain. Which priority assessment should the nurse perform? 1. Speech 2. Hearing 3. Balance 4. Level of consciousness

Answer 210

**Broca's area in the brain is responsible for the motor aspects of speech**, through coordination of the muscular activity of the tongue, mouth, and larynx. The term assigned to damage in this area is aphasia.

Question 211

\_\_\_\_\_\_\_\_\_\_\_\_\_area is responsible for the motor aspects of speech.

Answer 211

Broca's

Question 212

The \_\_\_\_\_\_\_\_\_\_\_\_-activating system is responsible for the sleep-wake cycle.

Answer 212

recticular

Question 213

The nurse notes that a client who has suffered a brain injury has an adequate heart rate, blood pressure, fluid balance, and body temperature. Based on these clinical findings, the nurse determines that which brain area is functioning properly? 1. Thalamus 2. Hypothalamus 3. Limbic system 4. Reticular activating system

Answer 213

**The hypothalamus is responsible for autonomic nervous system functions, such as heart rate, blood pressure, temperature, and fluid and electrolyte balance (among others)**. The thalamus acts as a relay station for sensory and motor information. The limbic system is responsible for emotions. The reticular activating system is responsible for the sleep-wake cycle.

Question 214

the hypothalamus is responsible for autonomic nervous system functions. TRUE OR FALSE

Answer 214

TRUE

Question 215

high CO2 levels cause \_\_\_\_\_\_\_\_\_\_\_\_\_\_-

Answer 215

vasodilation.

Question 216

A client has a high level of carbon dioxide (CO2) in the bloodstream, as measured by arterial blood gases. The nurse anticipates that which underlying pathophysiology can occur as a result of this elevated CO2? 1. It will cause arteriovenous shunting. 2. It will cause vasodilation of blood vessels in the brain. 3. It will cause blood vessels in the circle of Willis to collapse. 4. It will cause hyperresponsiveness of blood vessels in the brain.

Answer 216

**CO2 is one of the metabolic end products that can alter the tone of the blood vessels in the brain. High CO2 levels cause vasodilation**, which may cause headache, whereas low CO2 levels cause vasoconstriction, which may cause lightheadedness. The statements included in the other options are incorrect effects.

Question 217

CO2 is one of the metabolic end products that can alter the tone of the\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_in the brain. High CO2 levels cause vaso\_\_\_\_\_, which may cause\_\_\_\_\_\_\_\_\_\_, whereas low CO2 levels cause vaso\_\_\_\_\_\_\_\_\_\_, which may cause \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

Answer 217

blood vessels; vasodilation; headache; vasoconstriction; lightheadedness

Question 218

A client is anxious about an upcoming diagnostic procedure. The client's pupils are dilated, and the respiratory rate, heart rate, and blood pressure are increased from baseline. The nurse determines that the client's clinical manifestations are due to what type of physiologic response? 1. Vagal 2. Peripheral nervous system 3. Sympathetic nervous system 4. Parasympathetic nervous system

Answer 218

The sympathetic nervous system is responsible for the so-called fight or flight response, which is characterized by dilated pupils, increases in heart rate and cardiac output, and increases in respiratory rate and blood pressure. The sympathetic nervous system response affects some type of change in most systems of the body. The responses stated in the other options do not produce these effects.

Question 219

A client who is experiencing an inferior wall myocardial infarction has had a drop in heart rate into the range of 50 to 56 beats/minute. The client also is complaining of nausea. On the basis of these findings, the nurse determines that the client is experiencing parasympathetic stimulation of which cranial nerve?

Answer 219

**The vagus nerve is responsible for sensations in the thoracic and abdominal viscera. It also is responsible for the decrease in heart rate because approximately 75% of all parasympathetic stimulation is carried by the vagus nerve.** CN XII is responsible for tongue movement. CN XI is responsible for neck and shoulder movement. CN IX is responsible for taste in the posterior two thirds of the tongue, pharyngeal sensation, and swallowing.

Question 220

Remember that the \_\_\_\_\_\_\_\_\_\_\_\_\_\_nerve is responsible for sensations in the thoracic and abdominal viscera and for much of the parasympathetic response.

Answer 220

vagus . It also is responsible for the decrease in heart rate because approximately 75% of all parasympathetic stimulation is carried by the vagus nerve.

Question 221

The nurse overhears a neurologist saying that a client has an aneurysm located in the circle of Willis. The nurse understands that which blood vessels are part of the circle of Willis? Select all that apply. 1. Basilar artery 2. Vertebral artery 3. Anterior cerebral artery 4. Internal carotid arteries 5. Posterior cerebral artery

Answer 221

**The circle of Willis is a ring of blood vessels located at the base of the brain**. **It is referred to as the anterior circulation to the brain and is composed of the anterior and middle cerebral arteries, posterior cerebral arteries, posterior communicating arteries, internal carotid arteries, and anterior communicating branches.** The basilar artery and vertebral artery are not part of the circle of Willis. Rather, they are part of the vertebral-basilar system, which is known as the posterior circulation to the brain. Other parts of the posterior circulation are the posterior inferior cerebellar artery and the spinal arteries.

Question 222

What is the Circle of Willis and which blood vessels are part of it? What is it also referred to as?

Answer 222

**The circle of Willis is a ring of blood vessels located at the base of the brain.** **It is referred to as the anterior circulation to the brain** and is composed of the anterior and middle cerebral arteries, posterior cerebral arteries, posterior communicating arteries, internal carotid arteries, and anterior communicating branches. s.

Question 223

Alzheimer's disease is characterized by changes in the \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_of the neurons. The decrease in the number and composition of the \_\_\_\_\_\_\_\_\_\_\_\_is responsible for the symptoms of the disease

Answer 223

dendrites; dendrites Alzheimer's disease is caused by problems in the central nervous system

Question 224

Correct positioning of the client following cranial surgery is important to avoid increased \_\_\_\_\_\_\_\_\_\_\_\_\_\_pressure and to promote optimal \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_perfusion.

Answer 224

intracranial; cerebral tissue

Question 225

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_--position is contraindicated in the postoperative phase following cranial surgery.

Answer 225

Trendelenburg's

Question 226

To promote optimal cerebral tissue perfusion in the postoperative phase following cranial surgery, the nurse should place the client with an incision in the anterior or middle fossa, in which position? 1. 15 degrees of Trendelenburg's 2. Side-lying with the head of the bed flat 3. With the head of the bed elevated at least 30 degrees 4. With the head of the bed elevated no more than 10 degrees

Answer 226

Correct positioning of the client following cranial surgery is important to avoid increased intracranial pressure and to promote optimal cerebral tissue perfusion**. The surgeon's prescription for positioning is always followed.** **The client with an incision in the anterior or middle fossa should be positioned with the head of bed (HOB) elevated at least 30 degrees**. If the incision is in the posterior fossa or burr holes have been made, the client is positioned flat, or with the HOB elevated no more than 10 to 15 degrees. If a craniectomy (bone flap) is performed, the client should not be positioned to the operative side. Trendelenburg's position is contraindicated in the postoperative phase following cranial surgery. Recall the importance of positioning to promote cerebral tissue perfusion in the client with cranial surgery. Remember that the client with an incision in the anterior or middle fossa should be positioned with the HOB elevated. But also remember that surgeon's prescriptions are always followed.

Question 227

The nurse is caring for a client diagnosed with a hydrocephalus. Which should the nurse anticipate as being the cause of this disorder? 1. Closure of cranial sutures 2. Small aqueduct of Sylvius 3. Enlarged foramen of Monro 4. Increased number of arachnoid villi

Answer 227

**The closure of cranial sutures during childhood prevents expansion of the cranial vault when hydrocephalus occurs in the adult.** This leads to increased neurological changes with lesser degrees of hydrocephalus compared with hydrocephalus during early childhood. The other structures identified in the remaining options are associated with cerebrospinal fluid formation and circulation, but are not responsible for hydrocephalus.

Question 228

the withdrawal reflex is one of the \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_reflexes.

Answer 228

spinal It is an abrupt withdrawal of a body part in response to painful or injurious stimuli.

Question 229

The nurse is testing the spinal reflexes of a client during neurological assessment. Which assessment by the nurse would help to determine the adequacy of the spinal reflex? ## Footnote 1. Cough reflex 2. Withdrawal reflex 3. Munro-Kellie reflex 4. Accommodation reflex

Answer 229

The withdrawal reflex is one of the spinal reflexes. It is an abrupt withdrawal of a body part in response to painful or injurious stimuli. The cough reflex is a brainstem-associated reflex. Accommodation reflex is associated with cranial nerve III and is part of the ocular motor system. Munro-Kellie is not a reflex; it is a doctrine or a hypothesis addressing the cerebral volume relationships among the brain, the cerebrospinal fluid, and intracranial blood and their cumulative impact on intracranial pressure.

Question 230

A client with neck and upper extremity pain has been diagnosed with cervical radiculitis. What does the nurse anticipate as being the cause of these clinical manifestations? 1. Pressure on a spinous process 2. Pressure on a spinal nerve root 3. Pressure on a central spinal cord 4. Pressure on a posterior facet joints

Answer 230

**Radiculitis is a term used to describe spinal nerve root compression at the intervertebral foramen**. Radiculitis can be caused by a number of factors, such as whiplash or ruptured intervertebral disk. In many cases, it is caused by malalignment that occurs with degenerative disease or bone spur formation.

Question 231

A client brought to the emergency department had a seizure 1 hour ago. Family members were present during the episode and reported that the client's jaw was moving as though grinding food. In helping to determine the origin of this seizure, what should the nurse include in the client's assessment? 1. Loss of consciousness 2. Presence of diaphoresis 3. History of prior trauma 4. Rotating eye movements

Answer 231

Seizures that originate with specific motor phenomena are considered focal and are indicative of a focal structural lesion in the brain, often caused by trauma, infection, or medication consumption. The remaining options address signs, rather than an origin of the seizure. ocus on the subject, origin of a seizure. **Options 1, 2, and 4 address signs**. The correct option is the only one that addresses a possible origin.

Question 232

Because mild tactile stimulation of the face can trigger pain in trigeminal neuralgia, the client needs to eat or drink lukewarm, nutritious foods that are \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_to chew. \_\_\_\_\_\_\_\_\_\_\_\_\_of temperature will cause trigeminal nerve pain.

Answer 232

soft and easy; Extremes

Question 233

Assessing the \_\_\_\_\_\_\_\_\_\_\_\_\_--status is the priority for a client with a brainstem injury.

Answer 233

respiratory

Question 234

The nurse is assessing a client with a brainstem injury. In addition to obtaining the client's vital signs and determining the Glasgow Coma Scale score, what priority intervention should the nurse plan to implement? 1. Check cranial nerve functioning. 2. Determine the cause of the accident. 3. Draw blood for arterial blood gas analysis. 4. Perform a pulmonary wedge pressure measurement.

Answer 234

Assessment should be specific to the area of the brain involved. The respiratory center is located in the brainstem. Assessing the respiratory status is the priority for a client with a brainstem injury. The actions in the remaining options are not priorities, although they may be a component in the assessment process, depending on the injury and client condition. Recall the anatomical location of the respiratory center to direct you to the correct option. Remember that the respiratory center is located in the brainstem. Additionally, the correct option also relates to the ABCs–airway, breathing, and circulation.

Question 235

The nurse is performing an assessment on a client with the diagnosis of Brown-Séquard syndrome. The nurse would expect to note which assessment finding? 1. Bilateral loss of pain and temperature sensation 2. Ipsilateral paralysis and loss of touch and vibration 3. Contralateral paralysis and loss of touch, pressure, and vibration 4. Complete paraplegia or quadriplegia, depending on the level of injury

Answer 235

Brown-Séquard syndrome results from hemisection of the spinal cord, resulting in ipsilateral paralysis and loss of touch, pressure, vibration, and proprioception. Contralaterally, pain and temperature sensation are lost because these fibers decussate after entering the cord

Question 236

The nurse reviews the health care provider's (HCP's) prescriptions for a client with Guillain-Barré syndrome. Which prescription written by the HCP should the nurse question? 1. Clear liquid diet 2. Bilateral calf measure 3. Monitor vital signs frequently 4. Passive range-of-motion (ROM) exercises

Answer 236

***Clients with Guillain-Barré syndrome have dysphagia. Clients with dysphagia are more likely to aspirate clear liquids than thick or semisolid foods***. Passive ROM exercises can help prevent contractures, and assessing calf measurements can help detect deep vein thrombosis, for which these clients are at risk. Because clients with Guillain-Barré syndrome are at risk for hypotension or hypertension, bradycardia, and respiratory depression, frequent monitoring of vital signs is required.

Question 237

Myasthenia Gravis clients with **cholinergic crisis** have experienced \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_of medication

Answer 237

overdosage

Question 238

A client with myasthenia gravis arrives at the hospital emergency department in suspected crisis. The health care provider plans to administer edrophonium to differentiate between myasthenic and cholinergic crises. The nurse ensures that which medication is available in the event that the client is in cholinergic crisis? 1. Atropine sulfate 2. Morphine sulfate 3. Protamine sulfate 4. Pyridostigmine bromide

Answer 238

***Clients with cholinergic crisis have experienced overdosage of medication***. Edrophonium will exacerbate symptoms in cholinergic crisis to the point at which the client may need intubation and mechanical ventilation. **Intravenous atropine sulfate is used to reverse the effects of these anticholinesterase medications.** Morphine sulfate and pyridostigmine bromide would worsen the symptoms of cholinergic crisis. Protamine sulfate is the antidote for heparin.

Question 239

breath sounds will be \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_-if respiratory muscles are weakened or paralyzed.

Answer 239

dminished

Question 240

A client admitted to the nursing unit from the hospital emergency department has a C4 spinal cord injury. In conducting the admission assessment, what is the nurse's priority action? 1. Take the temperature. 2. Listen to breath sounds. 3. Observe for dyskinesias. 4. Assess extremity muscle strength.

Answer 240

**Because compromise of respiration is a leading cause of death in cervical cord injury, respiratory assessment is the highest priority**. Assessment of temperature and strength can be done after adequate oxygenation is ensured. Because dyskinesias occur in cerebellar disorders, this is not as important a concern as in cord-injured clients unless head injury is suspected.

Question 241

To assess the function of cranial nerve XII (the hypoglossal nerve), the nurse would assess the client's ability to extend the \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Answer 241

tongue

Question 242

The nurse is caring for a client who has just been admitted to the hospital with a diagnosis of a hemorrhagic stroke. The nurse should place the client in which position? 1. Prone 2. Supine 3. Semi Fowler's with the hip and the neck flexed 4. Head of the bed elevated 30 degrees with the head in midline position

Answer 242

The health care provider's prescriptions are always followed with regard to positioning the client after stroke. ***Clients with hemorrhagic stroke usually have the head of the bed elevated to 30 degrees to reduce intracranial pressure that can occur from the hemorrhage.*** The head should be in a midline, neutral position to facilitate venous drainage from the brain. Extreme hip and neck flexion should be avoided to prevent an increase in intrathoracic pressure and to promote venous drainage from the brain. **For clients with ischemic stroke, the head of the bed usually is kept flat to ensure adequate blood flow and thus oxygenation to the brain**. Prone, supine, and hip and neck flexion are incorrect positions for clients with hemorrhagic stroke.

Question 243

The nurse is preparing to care for a client who had a **supratentorial craniotomy**. The nurse should plan to place the client in which position? 1. Prone 2. Supine 3. Side-lying 4. Semi Fowler's

Answer 243

**After supratentorial surgery (surgery above the tentorium of the brain), the head of the client's bed usually is elevated 30 degrees** to promote venous outflow through the jugular veins. Prone, supine, and side-lying denote incorrect positions after this surgery, and **these positions could result in edema at the surgical site and increased intracranial pressure**. The health care provider's prescriptions are always followed with regard to positioning the client. Recall knowledge of supratentorial surgery and craniotomy to answer this question. Eliminate options 1, 2, and 3 because they are comparable or alike. Also, a helpful strategy is to remember that with supratentorial surgery, head up positioning. Remember though that the health care provider's prescriptions are always followed with regard to positioning the client.

Question 244

The nurse is admitting a client to the hospital emergency department from a nursing home. The client is unconscious with an apparent frontal head injury. A medical diagnosis of epidural hematoma is suspected. Which question is of the highest priority for the emergency department nurse to ask of the transferring nurse at the nursing home? ## Footnote 1. "When did the injury occur?" 2. "Was the client awake and talking right after the injury?" 3. "What medications has the client received since the fall?" 4. "What was the client's level of consciousness before the injury?"

Answer 244

**Epidural hematomas frequently are characterized by a "lucid interval" that lasts for minutes to hours, during which the client is awake and talking.** ***After this lucid interval, signs and symptoms progress rapidly, with potentially catastrophic intracranial pressure increase.*** Epidural hematomas are medical emergencies. It is important for the nurse to assist in the differentiation between epidural hematoma and other types of head injuries.

Question 245

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_frequently are characterized by a "lucid interval" that lasts for minutes to hours, during which the client is awake and talking. After this lucid interval, signs and symptoms progress rapidly, with potentially catastrophic intracranial pressure increase. Epidural hematomas are medical emergencies. It is important for the nurse to assist in the differentiation between epidural hematoma and other types of head injuries.

Answer 245

Epidural hematomas

Question 246

The client who is at risk for or who has increased ICP should be positioned so that the head is in a _______________ position. The nurse should avoid flexing or extending the client's neck or turning the head from side to side. The head of the bed should be raised to \_\_\_\_\_\_\_\_\_\_\_\_\_degrees. Use of proper positions promotes venous drainage from the cranium to keep ICP down.

Answer 246

neutral, midline; 30 to 45

Question 247

The nurse is caring for a client who is at risk for increased intracranial pressure (ICP) after a stroke. Which activities performed by the nurse will assist with preventing increases in ICP? Select all that apply. 1. Clustering nursing activities 2. Hyperoxygenating before suctioning 3. Maintaining 20 degree flexion of the knees 4. Maintaining the head and neck in midline position 5. Maintaining the head of the bed (HOB) at 30 degrees elevation

Answer 247

Measures aimed at preventing increased ICP in the poststroke client include **hyperoxgenating before suctioning to avoid transient hypoxemia and resultant ICP elevation from dilation of cerebral arteries; maintaining the head in a midline, neutral position to help promote venous drainage from the brain; and keeping the HOB elevated to between 25 and 30 degrees to prevent a decreased blood flow to the brain**. Clustering activities can be stressful for the client and increase ICP. Maintaining 20 degree flexion of the knees increases intraabdominal pressure and consequently ICP.

Question 248

The nurse is trying to communicate with a client who had a stroke and has aphasia. Which actions by the nurse would be most helpful to the client? Select all that apply. 1. Speaking to the client at a slower rate 2. Allowing plenty of time for the client to respond 3. Completing the sentences that the client cannot finish 4. Looking directly at the client during attempts at speech 5. Shouting words if it seems as though the client has difficulty understanding

Answer 248

Clients with aphasia after brain attack often fatigue easily and have a short attention span. **General guidelines when trying to communicate with the aphasic client include speaking more slowly and allowing adequate response time, listening to and watching attempts to communicate, and trying to put the client at ease with a caring and understanding manner.** The nurse would avoid shouting (because the client is not deaf), appearing rushed for a response, and letting family members provide all responses for the client.

Question 249

The nurse has given the client with Bell's palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs further teaching if the client makes which statements? 1. "I will perform facial exercises." 2. "I will expose my face to cold to decrease the pain." 3. "I will massage my face with a gentle upward motion." 4. "I will wrinkle my forehead, blow out my cheeks, and whistle frequently."

Answer 249

***Exposure to cold or drafts is avoided in Bell's palsy because it can cause discomfort.*** Prevention of muscle atrophy with Bell's palsy is accomplished with facial massage, facial exercises, and electrical nerve stimulation. Local application of heat to the face may improve blood flow and provide comfort.

Question 250

The client with a cervical spine injury has cervical tongs applied in the emergency department. What should the nurse include when planning care for this client? Select all that apply. 1. Using a RotoRest bed 2. Ensuring that weights hang freely 3. Removing the weights to reposition the client 4. Assessing the integrity of the weights and pulleys 5. Comparing the amount of prescribed traction with the amount in use

Answer 250

Cervical tongs are applied after drilling holes in the client's skull under local anesthesia. Weights are attached to the tongs, which exert pulling pressure on the longitudinal axis of the cervical spine. Serial x-rays of the cervical spine are taken, with weights being added gradually until the x-ray reveals that the vertebral column is realigned. After that, weights may be reduced gradually to a point that maintains alignment. T**he client with cervical tongs is placed on a Stryker frame or RotoRest bed. The nurse ensures that weights hang freely and the amount of weight matches the current prescription. The nurse also inspects the integrity and position of the ropes and pulleys**. The nurse does not remove the weights to administer care. Recalling the basics related to the care of a client in traction will direct you to the correct options. **Remember that weights are not removed or adjusted without a health care provider's prescription.**

Question 251

The nurse is caring for the client who suffered a spinal cord injury 48 hours ago. What should the nurse assess for when monitoring for gastrointestinal complications? 1. A history of diarrhea 2. A flattened abdomen 3. Hyperactive bowel sounds 4. Hematest-positive nasogastric tube drainage

Answer 251

**Development of a stress ulcer also can occur after spinal cord injury and can be detected by Hematest-positive nasogastric tube aspirate or stool.** The client is also at risk for paralytic ileus, which is characterized by the absence of bowel sounds and abdominal distention. A history of diarrhea is irrelevant.

Question 252

The client has an impairment of cranial nerve II. Specific to this impairment, what should the nurse plan to do to ensure client safety? 1. Speak loudly to the client. 2. Test the temperature of the shower water. 3. Check the temperature of the food on the dietary tray. 4. Provide a clear path for ambulation without obstacles.

Answer 252

**Cranial nerve II is the optic nerve, which governs vision**. The nurse can provide safety for the visually impaired client by clearing the path of obstacles when ambulating. Speaking loudly may help overcome a deficit of cranial nerve VIII (vestibulocochlear). Testing the shower water temperature would be useful if there was an impairment of peripheral nerves. Cranial nerves VII (facial) and IX (glossopharyngeal) control taste from the anterior two thirds and posterior third of the tongue, respectively.

Question 253

Transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with pain, and the nurse instructs the client about the purpose of the TENS unit. Which statement by the client indicates the need for further teaching? ## Footnote 1. "The unit relieves pain." 2. "Electrodes are attached to the skin." 3. "The unit will reduce the need for analgesics." 4. "Hospitalization is required because the unit is not portable."

Answer 253

The TENS unit is portable and the client controls the system for relieving pain and reducing the need for analgesics. It is attached to the skin of the body by electrodes. Hospitalization is not required. You should be directed to the correct option because it would not be a cost-effective pain management technique if the client required hospitalization.

Question 254

The client with a head injury opens eyes to sound, has no verbal response, and localizes to painful stimuli when applied to each extremity. How should the nurse document the Glasgow Coma Scale (GCS) score? 1. GCS = 3 2. GCS = 6 3. GCS = 9 4. GCS = 11

Answer 254

**The GCS is a method for assessing neurological status**. The highest possible GCS score is 15. A **score lower than 8 indicates that coma is present.** **Motor response** points are as follows: Obeys a simple response = 6; Localizes painful stimuli = 5; Normal flexion (withdrawal) = 4; Abnormal flexion (decorticate posturing) = 3; Extensor response (decerebrate posturing) = 2; No motor response to pain = 1. **Verbal response** points are as follows: Oriented = 5; Confused conversation = 4; Inappropriate words = 3; Responds with incomprehensible sounds = 2; No verbal response = 1. **Eye opening** points are as follows: Spontaneous = 4; In response to sound = 3; In response to pain = 2; No response, even to painful stimuli = 1. Using the GCS, a score of 3 is given when the client opens the eyes to sound. Localization to pain is scored as 5. When there is no verbal response the score is 1. The total score is then equal to 9.

Question 255

The client with a spinal cord injury at the level of T4 is experiencing a severe throbbing headache with a blood pressure of 180/100 mm Hg. What is the priority nursing intervention? 1. Notify the health care provider (HCP). 2. Loosen tight clothing on the client. 3. Place the client in a sitting position. 4. Check the urinary catheter tubing for kinks or obstruction.

Answer 255

*The client is demonstrating clinical manifestations of autonomic dysreflexia, which is a neurological emergency.* **The first priority is to place the client in a sitting position to prevent hypertensive stroke.** Loosening tight clothing and checking the urinary catheter can then be done, and the HCP can be notified once initial interventions are done.

Question 256

The nurse is caring for a client who is in the chronic phase of stroke (brain attack) and has a right-sided hemiparesis. The nurse identifies that the client is unable to feed self. Which is the appropriate nursing intervention? 1. Assist the client to eat with the left hand to build strength. 2. Provide a pureed diet that is easy for the client to swallow. 3. Inform the client that a feeding tube will be placed if progress is not made. 4. Provide a variety of foods on the meal tray to stimulate the client's appetite.

Answer 256

**Right-sided hemiparesis is weakness of the right arm and leg. The nurse should teach the client to use both sides of the body to increase strength and build endurance.** Providing a pureed diet is incorrect. The question does not mention swallowing difficulty, so there is no need to puree the food. Informing the client that a feeding tube may need to be placed is incorrect. That information would come from the health care provider. Providing a variety of foods is also incorrect because the problem is not the food selection but the client's ability to eat the food independently. Noting the word hemiparesis, which indicates weakness on one side, and recalling that maintaining independence is a goal will direct you to the correct option.

Question 257

paralysis of one side of the body.

Answer 257

hemiplegia or hemiparesis

Question 258

A client is newly admitted to the hospital with a diagnosis of stroke (brain attack) manifested by complete hemiplegia. Which item in the medical history of the client should the nurse be most concerned about? 1. Glaucoma 2. Emphysema 3. Hypertension 4. Diabetes mellitus

Answer 258

***The nurse should be most concerned about emphysema. The respiratory system is the priority in the acute phase of a stroke. The client with a stroke is vulnerable to respiratory complications such as atelectasis and pneumonia***. **Because the client has complete hemiplegia (is unable to move) and has emphysema, these risks are very significant**. Although the other conditions of glaucoma, hypertension, and diabetes mellitus are important, they are not as significant as emphysema. Use of the ABCs–airway, breathing, and circulation–will direct you to option 2.

Question 259

The nurse is caring for a client with Parkinson's disease. Which finding about gait should the nurse expect to note in the client? 1. Walking on the toes 2. Unsteady and staggering 3. Shuffling and propulsive 4. Broad-based and waddling

Answer 259

***The parkinsonian gait is characterized by short, accelerating, shuffling steps***. The client leans forward with the head, hips, and knees flexed and has difficulty starting and stopping. An ataxic gait is unsteady and staggering. A dystrophic gait is broad-based and waddling. Walking on the toes can occur from shortened Achilles tendons. Focus on the subject, the parkinsonian gait. **Recall that the client has difficulty in initiating movement and bradykinesia**. The gait is difficult to start, but it accelerates once it has begun. This will assist in eliminating options 2 and 4. From the remaining choices, recall that the client with Parkinson's disease shuffles but does not walk on the toes.

Question 260

A client with a history of myasthenia gravis presents at a clinic with bilateral ptosis and is drooling, and myasthenic crisis is suspected. The nurse assesses the client for which precipitating factor? 1. Getting too little exercise 2. Taking excess medication 3. Omitting doses of medication 4. Increasing intake of fatty foods

Answer 260

**Myasthenic crisis often is caused by undermedication and responds to the administration of cholinergic medications**. Cholinergic crisis (the opposite problem) is caused by excess medication and responds to withholding of medications. Too little exercise and excessive fatty food intake are incorrect. Overexertion and overeating possibly could trigger myasthenic crisis.

Question 261

The nurse is positioning a client who has increased intracranial pressure. Which position should the nurse avoid? ## Footnote 1. Head midline 2. Head turned to the side 3. Neck in neutral position 4. Head of bed elevated 30 to 45 degrees

Answer 261

The head of a client with increased intracranial pressure should be kept in a neutral midline position. **The nurse should avoid flexing or extending the client's neck or turning the head from side to side.** The head of the bed should be raised to 30 to 45 degrees. **Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure down.** Select the position that interferes with arterial circulation to the brain or with venous drainage from the brain. The only position that meets one of those criteria is option 2.

Question 262

A client who has had a stroke (brain attack) has residual dysphagia. When a diet prescription is initiated, the nurse should take which actions? Select all that apply. 1. Giving the client thin liquids 2. Thickening liquids to the consistency of oatmeal 3. Placing food on the unaffected side of the mouth 4. Allowing plenty of time for chewing and swallowing 5. Leave the client alone so that the client will gain independence by feeding self

Answer 262

The client with dysphagia is started on a diet only after the gag and swallow reflexes have returned. The client is assisted with meals as needed and is given ample time to chew and swallow. Food is placed on the unaffected side of the mouth. **Liquids are thickened to avoid aspiration**. The client is not left alone because of the risk of aspiration. **Remember that thickened liquids are easier for clients with impaired facial motion and impaired swallowing ability to manage.** Knowing this enables you to eliminate option 1 and select option 2. Option 3 is correct because the client has better sensation and motion on the unaffected side of the mouth. Option 4 is generally a good action for all clients. Finally eliminate option 5 because of the client's risk for aspiration.

Question 263

thickened liquids are easier for clients with impaired facial motion and impaired swallowing ability to manage. TRUE OR FALSE

Answer 263

TRUE

Question 264

A postoperative craniotomy client who sustained a severe head injury is admitted to the neurological unit. What nursing intervention is necessary for this client? 1. Take and record vital signs every 4 to 8 hours. 2. Prophylactically hyperventilate during the first 24 hours. 3. Treat a central fever with the administration of antipyretic medications such as acetaminophen. 4. Keep the head of the bed elevated at least 30 degrees, and position the client to avoid extreme flexion or extension of the neck and head.

Answer 264

**Avoiding extreme flexion and extension of the neck can enhance venous drainage and help prevent increased intracranial pressure.** As a general rule, hyperventilation is avoided during the first 24 hours postoperatively because it may produce ischemia caused by cerebral vasoconstriction. Vital signs need to be taken and recorded at least every 1 to 2 hours. **Central fevers caused by hypothalamic damage respond better to cooling (hypothermia blankets, sponge baths) than to the administration of antipyretic medications.**

Question 265

The \_\_\_\_\_\_\_\_\_\_\_\_\_\_--is responsible for balance and coordination.

Answer 265

cerebellum

Question 266

A client has a cerebellar lesion. The nurse would plan to obtain which item for use by this client? 1. Walker 2. Slider board 3. Raised toilet seat 4. Adaptive eating utensils

Answer 266

**The cerebellum is responsible for balance and coordination. A walker provides stability for the client during ambulation.** A raised toilet seat is useful if the client has sufficient mobility or ability to flex the hips. A slider board is used in transferring a client with weak or paralyzed legs from a bed to stretcher or wheelchair. Adaptive eating utensils are beneficial if the client has partial paralysis of the hand. To answer this question correctly, it is essential to recall that the cerebellum controls balance and coordination. This would help you eliminate options 2 and 3 first. To help you choose between the remaining 2 options, recall that adaptive eating utensils are useful with loss of fine motor coordination, such as with stroke. The walker would help the client maintain balance.

Question 267

The nurse is caring for a client who was admitted for a stroke (brain attack) of the temporal lobe. Which clinical manifestations should the nurse expect to note in the client? 1. The client will be unable to recall past events. 2. The client will have difficulty understanding language. 3. The client will demonstrate difficulty articulating words. 4. The client will have difficulty moving 1 side of the body.

Answer 267

**Wernicke's area consists of a small group of cells in the temporal lobe, the function of which is the understanding of language**. The hippocampus is responsible for the storage of memory (the client will be unable to recall past events). **Damage to Broca's area is responsible for aphasia (the client will demonstrate difficulty articulating words)**. The motor cortex in the precentral gyrus controls voluntary motor activity (the client will have difficulty moving one side of the body).

Question 268

\_\_\_\_\_\_\_\_\_\_\_\_\_--area in the temporal lobe is responsible for understanding language.

Answer 268

Wernicke's

Question 269

The nurse is caring for a client with bacterial meningitis. The nurse should anticipate that an antibiotic with which characteristics will be prescribed for the client? 1. One that has a long half-life 2. One that acts within minutes to hours 3. One that can be easily excreted in the urine 4. One that is able to cross the blood-brain barrier

Answer 269

**A primary consideration regarding medications to treat bacterial meningitis is the ability of the medication to cross the blood-brain barrier**. **If the medication cannot cross, it will not be effective.** The duration, onset, and excretion of the medication are also of general concern but apply to all medications and not specifically to those that are used to treat meningitis.

Question 270

CN \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_is responsible for taste in the posterior two thirds of the tongue, pharyngeal sensation, and swallowing.

Answer 270

**IX hypoglossal**

Question 271

The nurse is assessing a client's muscle strength and notes that when asked, the client cannot maintain the hands in a supinated position with the arms extended and eyes closed. How should the nurse correctly document this finding on the medical record? 1. Client is demonstrating ataxia. 2. Client is exhibiting pronator drift. 3. Client appears to have nystagmus. 4. Client examination reveals hyperreflexia.

Answer 271

**Pronator drift occurs when a client cannot maintain the hands in a supinated position with the arms extended and eyes closed.** *This assessment may be done to detect small changes in muscle strength that might not otherwise be noted*. Ataxia is a disturbance in gait. Nystagmus is characterized by fine, involuntary eye movements. It can occur with neurological disease or as a side effect of selected medications. Hyperreflexia is an excessive reflex action.

Question 272

The nurse caring for a client following craniotomy who has a supratentorial incision understands that the client should most likely be maintained in which position? 1. Prone position 2. Supine position 3. Semi Fowler's position 4. Dorsal recumbent position

Answer 272

**In supratentorial surgery (surgery above the brain's tentorium), the client's head is usually elevated 30 degrees to promote venous outflow through the jugular veins**. ***The client's head or the head of the bed is not lowered in the acute phase of care after supratentorial surgery.*** An exception to this is the client who has undergone evacuation of a chronic subdural hematoma, but a health care provider's (HCP's) prescription is required for positions other than those involving head elevation. In addition, the HCP's prescription regarding positioning is always checked and agency procedures are always followed.

Question 273

with supratentorial surgery the head should be kept \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Answer 273

up.

Question 274

The nurse is planning to perform an assessment of the client's level of consciousness using the Glasgow Coma Scale. Which assessments should the nurse include in order to calculate the score? Select all that apply. 1. Eye opening 2. Reflex response 3. Best verbal response 4. Best motor response 5. Pupil size and reaction

Answer 274

the 3 categories included are eye opening, best verbal response, and best motor response. Pupil assessment and reflex response is a necessary part of a total assessment of the neurological status of a client but is not part of this particular scale.

Question 275

A client with a traumatic closed head injury shows signs of secondary brain injury. What are some manifestations of secondary brain injury? Select all that apply. 1. Fever 2. Seizures 3. Hypoxia 4. Ischemia 5. Hypotension 6. Increased intracranial pressure (ICP)

Answer 275

**Secondary brain injury can occur several hours to days after the initial brain injury** and is a major concern when managing brain trauma. Nursing management of the client with an acute intracranial problem must include management of secondary injury. **Manifestations of secondary injury includes hypoxia, ischemia, hypotension, and increased ICP** that follows primary injury. It does not include fever or seizures. Eliminate option 1 because fever is indicative of infection but not one of the secondary brain injury factors. Also, eliminate option 2 because seizures may occur but are also not considered one of the factors of secondary brain injury.

Question 276

Manifestations of secondary bran injury includes \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_----

Answer 276

hypoxia, ischemia, hypotension, and increased ICP Secondary brain injury can occur several hours to days after the initial brain injury and is a major concern when managing brain trauma.

Question 277

The nurse cares for a client immediately following a lumbar laminectomy procedure. The client reports numbness and tingling down the left lateral thigh and knee. What is the next action for the nurse to take? 1. Document the assessment. 2. Contact the health care provider (HCP). 3. Inform the client that this is to be expected. 4. Question the client about preoperative symptoms.

Answer 277

**After spinal surgery the client requires frequent neurological assessments**. *Movement of the arms and the legs and assessment of sensation should be unchanged when compared with the preoperative status*. **Thus, the correct option is 4**. Although the assessment finding should be documented, option 1 is incorrect, as that is not the next thing the nurse should do. Option 2 is incorrect, as more assessment data are needed before calling the HCP. Option 3 is incorrect because this is an unexpected finding except if these findings were present before surgery; however, that preoperative information hasn't been gathered yet.