TEST 11: The Client with Neurologic Health Problems

Question 1

The Client with a Head Injury
1. The nurse has established a goal to maintain intracranial pressure (ICP) within the normal
range for a client who had a craniotomy 12 hours ago. What should the nurse do? Select all that apply.
1. Encourage the client to cough to expectorate secretions.
2. Elevate the head of the bed 15 to 30 degrees.
3. Contact the health care provider if ICP is greater than 20 mm Hg.
4. Monitor neurologic status using the Glasgow Coma Scale.
5. Stimulate the client with active range-of-motion exercises.

Answer 1

The Client with a Head Injury
1. 2, 3, 4. The nurse should maintain ICP by elevating the head of the bed and monitoring
neurologic status. An ICP greater than 20 mm Hg indicates increased ICP, and the nurse should notify
the health care provider. Coughing and range-of-motion exercises will increase ICP and should be
avoided in the early postoperative stage.
CN: Physiological adaptation; CL: Synthesize

Question 2

2. The nurse is monitoring a client with increased intracranial pressure (ICP). What indicators
   are the most critical for the nurse to monitor? Select all that apply.
3. Systolic blood pressure.
4. Urine output.
5. Breath sounds.
6. Cerebral perfusion pressure.
7. Level of pain.

Answer 2

2. 1, 4. The nurse must monitor the systolic and diastolic blood pressure to obtain the mean
   arterial pressure (MAP), which represents the pressure needed for each cardiac cycle to perfuse the
   brain. The nurse must also monitor the cerebral perfusion pressure (CPP), which is obtained from the
   ICP and the MAP. The nurse should also monitor urine output, respirations, and pain; however,
   crucial measurements needed to maintain CPP are ICP and MAP. When ICP equals MAP, there is no
   CPP.
   CN: Management of care; CL: Analyze

Question 3

A nurse is assessing a client with increasing intracranial pressure. What is a client’s mean arterial
pressure (MAP) in mm Hg when blood pressure (BP) is 120/60 mm Hg?
__________________________ mm Hg.

Answer 3

3. 80 mm Hg
   MAP = SBP + (2XDBP) ] / 3
   MAP = [120 + (2X 60 )] / 3
   MAP = 240 / 3 = 80

To obtain the MAP, use this formula:
CN: Management of care; CL: Apply

Question 4

4. A client with a contusion has been admitted for observation following a motor vehicle
   accident when he was driving his wife to the hospital to deliver their child. The next morning, instead
   of asking about his wife and baby, he asked to see the football game on television that he thinks is
   starting in 5 minutes. He is agitated because the nurse will not turn on the television. What should the
   nurse do next? Select all that apply.
5. Find a television so the client can view the football game.
6. Determine if the client’s pupils are equal and react to light.
7. Ask the client if he has a headache.
8. Arrange for the client to be with his wife and baby.
9. Administer a sedative.

Answer 4

4. 2, 3. The nurse should determine if the client’s pupils are equal and react to light, and ask the
   client if he has a headache. Confusion, agitation, and restlessness are subtle clinical manifestations of
   increased intracranial pressure (ICP). At this time, it is not appropriate for the nurse to find a
   television or arrange for the client to see his wife and baby. Administering a sedative at this time will
   obscure assessment of increased ICP.
   CN: Management of care; CL: Synthesize

Question 5

5. The nurse is assessing the level of consciousness in a client with a head injury who has been
   unresponsive for the last 8 hours. Using the Glasgow Coma Scale the nurse notes that the client opens
   the eyes only as a response to pain, responds with sounds that are not understandable, and has
   abnormal extension of the extremities. The nurse should:
6. Attempt to arouse the client.
7. Reposition the client with the extremities in normal alignment.
8. Chart the client’s level of consciousness as coma.
9. Notify the physician.

Answer 5

5. 3. The client has a score of 6 (eye opening to pain = 2; verbal response, incomprehensible
      sounds = 2; best motor response, abnormal extension = 2); a score less than 7 is indicative of coma.
      While the nurse should continue to speak to the client, at this time the client will not be able to be
      aroused. The nurse should continue to provide skin care and appropriate alignment, but the client will
      continue to have a motor response of limb extension. It is not necessary to notify the physician as this
      assessment does not represent a significant change in neurological status.
      CN: Physiological adaptation; CL: Analyze

Question 6

6. An unconscious client with multiple injuries arrives in the emergency department. Which
   nursing intervention receives the highest priority?
7. Establishing an airway.
8. Replacing blood loss.
9. Stopping bleeding from open wounds.
10. Checking for a neck fracture.

Answer 6

6. 1. The highest priority for a client with multiple injuries is to establish an open airway for
      effective ventilation and oxygenation. Unless the client has a patent airway, other care measures will
      be futile. Replacing blood loss, stopping bleeding from open wounds, and checking for a neck
      fracture are important nursing interventions to be completed after the airway and ventilation are
      established.
      CN: Safety and infection control; CL: Synthesize

Question 7

7. A client has delirium following a head injury. The client is disoriented and agitated. In which
   order from first to last should the nurse do the following as a part of a plan to care for this client?1. Request a prescription for haloperidol (Haldol).
8. Maintain a quiet environment.
9. Assure client’s safety.
10. Approach the client using short sentences.

Answer 7

7.
4. Approach the client using short sentences.
3. Assure client’s safety.
2. Maintain a quiet environment.
1. Request a prescription for haloperidol (Haldol).
The first step in providing care for a client with delirium is to approach the client calmly,
introduce oneself, and use short sentences when explaining the care given. The nurse should also
assure the client’s safety by protecting the client from injury. Maintaining a quiet and calm
environment by removing extraneous noises will prevent overstimulation. Pharmacologic intervention
is used only when other plans for care are not effective. When the underlying problems related to the
head injury are resolved, the delirium likely will improve.
CN: Physiological adaptation; CL: Synthesize

Question 8

8. A client is at risk for increased intracranial pressure (ICP). Which of the following would be
the priority for the nurse to monitor?
1. Unequal pupil size.
2. Decreasing systolic blood pressure.
3. Tachycardia.
4. Decreasing body temperature.

Answer 8

8. 1. Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve.
      Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure
      needed to perfuse the brain. It increases the pressure on the vagus nerve, which produces
      bradycardia, and it causes an increase in body temperature from hypothalamic damage.
      CN: Reduction of risk potential; CL: Analyze

Question 9

9. What should the nurse do first when a client with a head injury begins to have clear drainage
   from the nose?
10. Compress the nares.
11. Tilt the head back.
12. Give the client tissues to collect the fluid.
13. Administer an antihistamine for postnasal drip.

Answer 9

9. 3. The clear drainage must be analyzed to determine whether it is nasal drainage or
      cerebrospinal fluid (CSF). The nurse should not give the client tissues because it is important to know
      how much leakage of CSF is occurring. Compressing the nares will obstruct the drainage flow. It is
      inappropriate to tilt the head back, which would allow the fluid to drain down the throat and not be
      collected for a sample. It is inappropriate to administer an antihistamine because the drainage may not
      be from postnasal drip.
      CN: Reduction of risk potential; CL: Synthesize

Question 10

10. Which of the following respiratory patterns indicates increasing intracranial pressure in the
brain stem?
1. Slow, irregular respirations.
2. Rapid, shallow respirations.
3. Asymmetric chest excursion.
4. Nasal flaring.

Answer 10

10. 1. Neural control of respiration takes place in the brain stem. Deterioration and pressure
       produce irregular respiratory patterns. Rapid, shallow respirations, asymmetric chest movements, and
       nasal flaring are more characteristic of respiratory distress or hypoxia.
       CN: Physiological adaptation; CL: Apply

Question 11

11. Which of the following nursing interventions is appropriate for a client with an increased
    intracranial pressure (ICP) of 20 mm Hg?
12. Give the client a warming blanket.
13. Administer low-dose barbiturates.
14. Encourage the client to hyperventilate.
15. Restrict fluids.

Answer 11

11. 3. Normal ICP is 15 mm Hg or less for 15 to 30 seconds or longer. Hyperventilation causes
       vasoconstriction, which reduces cerebrospinal fluid and blood volume, two important factors for
       reducing a sustained ICP of 20 mm Hg. A cooling blanket is used to control the elevation of
       temperature because a fever increases the metabolic rate, which in turn increases ICP. High doses of
       barbiturates may be used to reduce the increased cellular metabolic demands. Fluid volume and
       inotropic drugs are used to maintain cerebral perfusion by supporting the cardiac output and keeping
       the cerebral perfusion pressure greater than 80 mm Hg.
       CN: Physiological adaptation; CL: Synthesize

Question 12

12. The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should
    notify the health care provider about which of the following changes in the client’s condition?1. Widening pulse pressure.
13. Decrease in the pulse rate.
14. Dilated, fixed pupils.
15. Decrease in level of consciousness (LOC).

Answer 12

12. 4. A decrease in the client’s LOC is an early indicator of deterioration of the client’s
       neurologic status. Changes in LOC, such as restlessness and irritability, may be subtle. Widening of
       the pulse pressure, decrease in the pulse rate, and dilated, fixed pupils occur later if the increased
       ICP is not treated.
       CN: Physiological adaptation; CL: Analyze

Question 13

13. The client has a sustained increased intracranial pressure (ICP) of 20 mm Hg. Which client
    position would be most appropriate?
14. The head of the bed elevated 30 to 45 degrees.
15. Trendelenburg’s position.
16. Left Sims’ position.
17. The head elevated on two pillows.

Answer 13

13. 1. The client’s ICP is elevated, and the client should be positioned to avoid extreme neck
       flexion or extension. The head of the bed is usually elevated 30 to 45 degrees to drain the venous
       sinuses and thus decrease the ICP. Trendelenburg’s position places the client’s head lower than the
       body, which would increase ICP. Sims’ position (side lying) and elevating the head on two pillows
       may extend or flex the neck, which increases ICP.
       CN: Reduction of risk potential; CL: Synthesize

Question 14

14. The nurse administers mannitol (Osmitrol) to the client with increased intracranial pressure.
    Which parameter requires close monitoring?
15. Muscle relaxation.
16. Intake and output.
17. Widening of the pulse pressure.
18. Pupil dilation.

Answer 14

14. 2. After administering mannitol, the nurse closely monitors intake and output because mannitol
       promotes diuresis and is given primarily to pull water from the extracellular fluid of the edematous
       brain. Mannitol can cause hypokalemia and may lead to muscle contractions, not muscle relaxation.
       Signs and symptoms, such as widening pulse pressure and pupil dilation, should not occur because
       mannitol serves to decrease ICP.
       CN: Pharmacological and parenteral therapies; CL: Analyze

Question 15

15. The nurse is assessing a client for movement after halo traction placement for a C8 fracture.
    The nurse should document which of the following?
16. The client’s shoulders shrug against downward pressure of the examiner’s hands.
17. The client’s arm pulls up from a resting position against resistance.
18. The client’s arm straightens out from a flexed position against resistance.
19. The client’s hand-grasp strength is equal.

Answer 15

15. 4. The correct motor function test for C8 is a hand-grasp check. The motor function check for
C4 to C5 is shoulders shrugging against downward pressure of the examiner's hands. The motor
function check for C5 to C6 is an arm pulling up from a resting position against resistance. The motor
function check for C7 is an arm straightening out from a flexed position against resistance.
CN: Management of care; CL: Analyze

Question 16

16. A client who is regaining consciousness after a craniotomy becomes restless and attempts to
    pull out the IV line. Which nursing intervention protects the client without increasing the intracranial
    pressure (ICP)?
17. Place in a jacket restraint.
18. Wrap the hands in soft “mitten” restraints.
19. Tuck the arms and hands under the drawsheet.
20. Apply a wrist restraint to each arm.

Answer 16

16. 2. It is best for the client to wear mitts, which help prevent the client from pulling on the IV
       without causing additional agitation. Using a jacket or wrist restraint or tucking the client’s arms and
       hands under the drawsheet restrict movement and add to feelings of being confined, all of which
       would increase her agitation and increase ICP.
       CN: Physiological adaptation; CL: Synthesize

Question 17

17. Which activity should the nurse encourage the client to avoid when there is a risk for
    increased intracranial pressure (ICP)?
18. Deep breathing.
19. Turning.
20. Coughing.
21. Passive range-of-motion (ROM) exercises.

Answer 17

17. 3. Coughing is contraindicated for a client at risk for increased ICP because coughing
       increases ICP. Deep breathing can be continued. Turning and passive ROM exercises can be
       continued with care not to extend or flex the neck.
       CN: Reduction of risk potential; CL: Synthesize

Question 18

18. A client who had a serious head injury with increased intracranial pressure is to be
    discharged to a rehabilitation facility. Which of the following rehabilitation outcomes would be
    appropriate for the client? The client will:
19. Exhibit no further episodes of short-term memory loss.
20. Be able to return to his construction job in 3 weeks.
21. Actively participate in the rehabilitation process as appropriate.
22. Be emotionally stable and display preinjury personality traits.

Answer 18

18. 3. Recovery from a serious head injury is a long-term process that may continue for months oryears. Depending on the extent of the injury, clients who are transferred to rehabilitation facilities
       most likely will continue to exhibit cognitive and mobility impairments as well as behavior and
       personality changes. The client would be expected to participate in the rehabilitation efforts to the
       extent he is capable. Family members and significant others will need long-term support to help them
       cope with the changes that have occurred in the client.
       CN: Physiological adaptation; CL: Evaluate

Question 19

19. Which of the following describes decerebrate posturing?
20. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers.
21. Back hunched over, rigid flexion of all four extremities with supination of arms and plantar
    flexion of feet.
22. Supination of arms, dorsiflexion of the feet.
23. Back arched, rigid extension of all four extremities.

Answer 19

19. 4. Decerebrate posturing occurs in clients with damage to the upper brain stem, midbrain, or
       pons and is demonstrated clinically by arching of the back, rigid extension of the extremities,
       pronation of the arms, and plantar flexion of the feet. Internal rotation and adduction of arms with
       flexion of elbows, wrists, and fingers describes decorticate posturing, which indicates damage to
       corticospinal tracts and cerebral hemispheres.
       CN: Physiological adaptation; CL: Apply

Question 20

20. A client receiving vent-assisted mode ventilation begins to experience cluster breathing after
    recent intracranial occipital bleeding. The nurse should:
21. Count the rate to be sure that ventilations are deep enough to be sufficient.
22. Notify the physician of the client’s breathing pattern.
23. Increase the rate of ventilations.
24. Increase the tidal volume on the ventilator.

Answer 20

20. 2. Cluster breathing consists of clusters of irregular breaths followed by periods of apnea on
       an irregular basis. A lesion in the upper medulla or lower pons is usually the cause of cluster
       breathing. Because the client had a bleed in the occipital lobe, which is just superior and posterior to
       the pons and medulla, clinical manifestations that indicate a new lesion are monitored very closely in
       case another bleed ensues. The nurse should notify the physician immediately so that treatment can
       begin before respirations cease. The client is not obtaining sufficient oxygen and the depth of
       breathing is assisted by the ventilator. The health care provider will determine changes in the
       ventilator settings.
       CN: Physiological adaptation; CL: Synthesize

Question 21

21. In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy,
    which of the following is contraindicated when positioning the client?
22. Keeping the client flat on one side or the other.
23. Elevating the head of the bed to 30 degrees.
24. Logrolling or turning as a unit when turning.
25. Keeping the neck in a neutral position.

Answer 21

21. 2. Elevating the head of the bed to 30 degrees is contraindicated for infratentorial
       craniotomies because it could cause herniation of the brain down onto the brain stem and spinal cord,
       resulting in sudden death. Elevation of the head of the bed to 30 degrees with the head turned to the
       side opposite the incision, if not contraindicated by the increased intracranial pressure, is used for
       supratentorial craniotomies.
       CN: Physiological adaptation; CL: Synthesize

Question 22

22. When evaluating an arterial blood gas report from a client with a subdural hematoma who
    had surgery and is now on a ventilator, the nurse notes the PaCO 2 is 35 mm Hg (4.7 kPa). The
    ventilator settings are: TV 400, respiration rate 24, FIO 2 100%. What should the nurse do first?
23. Ask the respiratory technician to decrease the respiration rate on the ventilator to 18.
24. Position the client with the head of bed elevated.
25. Continue to monitor the client.
26. Inform the charge nurse of the results of the report.

Answer 22

22. 1. CO 2 has vasodilating properties; therefore, lowering PaCO 2 through hyperventilation will
       lower ICP caused by dilated cerebral vessels. Since the client’s PaCO 2 level is normal (35 to 45 mm
       Hg or 4.7 to 6.0 kPa), paging the respiratory technician to change the respiration rate is an
       appropriate action. Elevating the head of the client’s bed is contradicted with this client’s condition:
       that would lower blood pressure and care of these patients involves maintenance of a flat position in
       bed for 24 hours after surgery. Continuing to monitor the client is inappropriate because the PaCO 2
       level is normal and the respiratory technician needs to adjust the hyperventilation setting to normal on
       the ventilator since the lab indicates that PaCo 2 is normal. Informing the charge nurse about the
       change in ventilator settings is not necessary at this time because this is expected care for this client.
       CN: Physiological Integrity; CL: Synthesize

Question 23

23. A client with a head injury regains consciousness after several days. Which of the following
    nursing statements is most appropriate as the client awakens?
24. “I’ll get your family.”
25. “Can you tell me your name and where you live?”
26. “I’ll bet you’re a little confused right now.”
27. “You are in the hospital. You were in an accident and unconscious.”

Answer 23

23. 4. It is important to first explain where a client is to orient him or her to time, person, and
       place. Offering to get the family and asking questions to determine orientation are important, but the
       first comments should let the client know where he or she is and what has happened. It is useful to be
       empathetic to the client, but making a comment such as “I’ll bet you’re a little confused” is not helpfuland may cause anxiety.
       CN: Psychosocial adaptation; CL: Synthesize

Question 24

The Client with Seizures
24. The nurse sees a client walking in the hallway who begins to have a seizure. The nurse
should do which of the following in priority order?
1. Maintain a patent airway.
2. Record the seizure activity observed.
3. Ease the client to the floor.
4. Obtain vital signs.

Answer 24

The Client with Seizures
24.
3. Ease the client to the floor.
1. Maintain a patent airway.
4. Obtain vital signs.
2. Record the seizure activity observed.
To protect the client from falling, the nurse first should ease the client to the floor. It is important
to protect the head and maintain a patent airway since altered breathing and excessive salivation can
occur. The assessment of the postictal period should include level of consciousness and vital signs.
The nurse should record details of the seizure once the client is stable. The events preceding the
seizure, timing with descriptions of each phase, body parts affected and sequence of involvement, and
autonomic signs should be recorded.
CN: Safety and infection control; CL: Synthesize

Question 25

25. Which of the following is contraindicated for a client with seizure precautions?
26. Encouraging him to perform his own personal hygiene.
27. Allowing him to wear his own clothing.
28. Assessing his oral temperature with a glass thermometer.
29. Encouraging him to be out of bed.

Answer 25

25. 3. Temperatures are not assessed orally with a glass thermometer because the thermometer
       could break and cause injury if a seizure occurred. The client can perform personal hygiene. There is
       no clinical reason to discourage the client from wearing his own clothes. As long as there are no
       other limitations, the client should be encouraged to be out of bed.
       CN: Physiological adaptation; CL: Synthesize

Question 26

26. Which of the following will the nurse observe in the client in the ictal phase of a generalized
    tonic-clonic seizure?
27. Jerking in one extremity that spreads gradually to adjacent areas.
28. Vacant staring and abruptly ceasing all activity.
29. Facial grimaces, patting motions, and lip smacking.
30. Loss of consciousness, body stiffening, and violent muscle contractions.

Answer 26

26. 4. A generalized tonic-clonic seizure involves both a tonic phase and a clonic phase. The
       tonic phase consists of loss of consciousness, dilated pupils, and muscular stiffening or contraction,
       which lasts about 20 to 30 seconds. The clonic phase involves repetitive movements. The seizure
       ends with confusion, drowsiness, and resumption of respiration. A partial seizure starts in one region
       of the cortex and may stay focused or spread (eg, jerking in the extremity spreading to other areas of
       the body). An absence seizure usually occurs in children and involves a vacant stare with a brief loss
       of consciousness that often goes unnoticed. A complex partial seizure involves facial grimacing with
       patting and smacking.
       CN: Physiological adaptation; CL: Analyze

Question 27

27. It is the night before a client is to have a computed tomography (CT) scan of the head without
    contrast. The nurse should tell the client:
28. “You must shampoo your hair tonight to remove all oil and dirt.”
29. “You may drink fluids until midnight, but after that drink nothing until the scan is completed.”
30. “You will have some hair shaved to attach the small electrode to your scalp.”
31. “You will need to hold your head very still during the examination.”

Answer 27

27. 4. The client will be asked to hold the head very still during the examination, which lasts
       about 30 to 60 minutes. In some instances, food and fluids may be withheld for 4 to 6 hours before the
       procedure if a contrast medium is used because the radiopaque substance sometimes causes nausea.
       There is no special preparation for a CT scan, so a shampoo the night before is not required. The
       client may drink fluids until 4 hours before the scan is scheduled. Electrodes are not used for a CTscan, nor is the head shaved.
       CN: Physiological adaptation; CL: Synthesize

Question 28

28. The client will have an electroencephalogram (EEG) in the morning. The nurse should
    instruct the client to have which of the following for breakfast?
29. No food or fluids.
30. Only coffee or tea if needed.3. A full breakfast as desired without coffee, tea, or energy drinks.
31. A liquid breakfast of fruit juice, oatmeal, or smoothie

Answer 28

28. 3. Beverages containing caffeine, such as coffee, tea, cola, and energy drinks, are withheld
       before an EEG because of the stimulating effects of the caffeine on the brain waves. A meal should
       not be omitted before an EEG because low blood sugar could alter brain wave patterns; the client can
       have the entire meal except for the coffee. The client does not need to be on a liquid diet or NPO.
       CN: Physiological adaptation; CL: Synthesize

Question 29

29. The client is scheduled to receive phenytoin (Dilantin) through a nasogastric tube (NGT) and
    has a tube-feeding supplement running continuously. The head of the bed is elevated to 30 degrees.
    Prior to administering the medication, the nurse should:
30. Elevate the head of the bed to 60 degrees.
31. Draw blood to determine the Dilantin level after giving the morning dose in order to determine
    if client has toxic blood level.
32. Stop the tube feeding 1 hour before giving Dilantin and hold tube feeding for 1 hour after
    giving Dilantin.
33. Flush the NGT with 150 mL of water before and after giving the Dilantin.

Answer 29

29. 3. In order for Dilantin to be properly absorbed and provide maximum benefit to the client,
       nutritional supplements must be stopped before and after delivery. The head of the bed is elevated 30
       degrees since this client has a tube feeding infusing; it is not necessary to elevate the bed any further.
       Blood levels are usually drawn before giving a dose of Dilantin, not after. It is not necessary to flush
       with such a large amount of water (150 mL) before and after Dilantin.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 30

30. A 22-year-old who hit his head while playing football has a tonic-clonic seizure. Upon
    awakening from the seizure, the client asks the nurse, “What caused me to have a seizure? I’ve never
    had one before.” Which cause should the nurse include in the response as a primary cause of tonic-
    clonic seizures in adults older than age 20?
31. Head trauma.
32. Electrolyte imbalance.
33. Congenital defect.
34. Epilepsy.

Answer 30

30. 1. Trauma is one of the primary causes of brain damage and seizure activity in adults. Other
       common causes of seizure activity in adults include neoplasms, withdrawal from drugs and alcohol,
       and vascular disease. Given the history of head injury, electrolyte imbalance is not the cause of the
       seizure. There is no information to indicate that the seizure is related to a congenital defect. Epilepsy
       is usually diagnosed in younger clients.
       CN: Physiological adaptation; CL: Apply

Question 31

31. Which of the following should the nurse include in the teaching plan for a client with seizures
    who is going home with a prescription for gabapentin (Neurontin)?
32. Take all the medication until it is gone.
33. Notify the physician if vision changes occur.
34. Store gabapentin in the refrigerator.
35. Take gabapentin with an antacid to protect against ulcers.

Answer 31

31. 2. Gabapentin (Neurontin) may impair vision. Changes in vision, concentration, or
       coordination should be reported to the physician. Gabapentin should not be stopped abruptly because
       of the potential for status epilepticus; this is a medication that must be tapered off. Gabapentin is to be
       stored at room temperature and out of direct light. It should not be taken with antacids.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 32

32. What is the priority nursing intervention in the postictal phase of a seizure?
33. Reorient the client to time, person, and place.
34. Determine the client’s level of sleepiness.
35. Assess the client’s breathing pattern.
36. Position the client comfortably.

Answer 32

32. 3. A priority for the client in the postictal phase (after a seizure) is to assess the client’s
       breathing pattern for effective rate, rhythm, and depth. The nurse should apply oxygen and ventilation
       to the client as appropriate. Other interventions, to be completed after the airway has been
       established, include reorientation of the client to time, person, and place. Determining the client’s
       level of sleepiness is useful, but it is not a priority. Positioning the client comfortably promotes rest
       but is of less importance than ascertaining that the airway is patent.
       CN: Reduction of risk potential; CL: Synthesize

Question 33

33. Which intervention is most effective in minimizing the risk of seizure activity in a client who
    is undergoing diagnostic studies after having experienced several episodes of seizures?
34. Maintain the client on bed rest.
35. Administer butabarbital sodium 30 mg PO, three times per day.
36. Close the door to the room to minimize stimulation.
37. Administer carbamazepine 200 mg PO, twice per day.

Answer 33

33. 4. Carbamazepine is an anticonvulsant that helps prevent further seizures. Bed rest, sedation
       (phenobarbital), and providing privacy do not minimize the risk of seizures.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 34

34. What nursing assessments should be documented at the beginning of the ictal phase of a
    seizure?
35. Heart rate, respirations, pulse oximeter, and blood pressure.
36. Last dose of anticonvulsant and circumstances at the time.
37. Type of visual, auditory, and olfactory aura the client experienced.
38. Movement of the head and eyes and muscle rigidity.

Answer 34

34. 4. During a seizure, the nurse should note movement of the client’s head and eyes and muscle
       rigidity, especially when the seizure first begins, to obtain clues about the location of the trigger focus
       in the brain. Other important assessments would include noting the progression and duration of the
       seizure, respiratory status, loss of consciousness, pupil size, and incontinence of urine and stool. It is
       typically not possible to assess the client’s pulse and blood pressure during a tonic-clonic seizure
       because the muscle contractions make assessment difficult to impossible. The last dose ofanticonvulsant medication can be evaluated later. The nurse should focus on maintaining an open
       airway, preventing injury to the client, and assessing the onset and progression of the seizure to
       determine the type of brain activity involved. The type of aura should be assessed in the preictal
       phase of the seizure.
       CN: Physiological adaptation; CL: Analyze

Question 35

35. The nurse is assessing a client in the postictal phase of generalized tonic-clonic seizure. The
    nurse should determine if the client has:
36. Drowsiness.
37. Inability to move.
38. Paresthesia.
39. Hypotension.

Answer 35

35. 1. The nurse should expect a client in the postictal phase to experience drowsiness to
       somnolence because exhaustion results from the abnormal spontaneous neuron firing and tonic-clonic
       motor response. An inability to move a muscle part is not expected after a tonic-clonic seizure
       because a lack of motor function would be related to a complication, such as a lesion, tumor, or
       stroke, in the correlating brain tissue. A change in sensation would not be expected because this
       would indicate a complication such as an injury to the peripheral nerve pathway to the corresponding
       part from the central nervous system. Hypotension is not typically a problem after a seizure.
       CN: Physiological adaptation; CL: Analyze

Question 36

36. When preparing to teach a client about phenytoin sodium (Dilantin) therapy, the nurse should
    urge the client not to stop the drug suddenly because:
37. Physical dependency on the drug develops over time.
38. Status epilepticus may develop.
39. A hypoglycemic reaction develops.
40. Heart block is likely to develop.

Answer 36

36. 2. Anticonvulsant drug therapy should never be stopped suddenly; doing so can lead to life-
       threatening status epilepticus. Phenytoin sodium does not carry a risk of physical dependency or lead
       to hypoglycemia. Phenytoin has antiarrhythmic properties, and discontinuation does not cause heart
       block.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 37

37. A client who has had seizures asks the nurse about being able to drive because of the
    seizures. Which response by the nurse is best?
38. A person with a history of seizures can drive only during daytime hours.
39. A person with evidence that the seizures are under medical control can drive.
40. A person with evidence that seizures occur no more often than every 12 months can drive.
41. A person with a history of seizures can drive if he or she carries a medical identification card

Answer 37

37. 2. Specific motor vehicle regulations and restrictions for people who experience seizures
       vary locally. Most commonly, evidence that the seizures are under medical control is required before
       the person is given permission to drive. Time of day is not a consideration when determining driving
       restrictions related to seizures. The amount of time a person has been seizure-free is a consideration
       for lifting driving restrictions; however, the time frame is usually 2 years. It is recommended, not
       required, that a person who is subject to seizures carry a card or wear an identification bracelet
       describing the illness to facilitate quick identification in the event of an emergency.
       CN: Reduction of risk potential; CL: Synthesize

Question 38

38. The nurse is teaching a client to recognize an aura. The nurse should instruct the client to
    note:
39. A postictal state of amnesia.
40. A hallucination that occurs during a seizure.
41. A symptom that occurs just before a seizure.
42. A feeling of relaxation as the seizure begins to subside.

Answer 38

38. 3. An aura is a premonition of an impending seizure. Auras usually are of a sensory nature (eg,
       an olfactory, visual, gustatory, or auditory sensation); some may be of a psychic nature. Evaluating an
       aura may help identify the area of the brain from which the seizure originates. Auras occur before a
       seizure, not during or after (postictal). They are not similar to hallucinations or amnesia or related to
       relaxation.
       CN: Physiological adaptation; CL: Synthesize

Question 39

39. Which statement by a client with a seizure disorder taking topiramate (Topamax) indicates the
    client has understood the nurse’s instruction?
40. “I will take the medicine before going to bed.”
41. “I will drink six to eight glasses of water a day.”
42. “I will eat plenty of fresh fruits.”
43. “I will take the medicine with a meal or snack.”

Answer 39

39. 2. Toxic effects of topiramate (Topamax) include nephrolithiasis, and clients are encouraged
       to drink six to eight glasses of water a day to dilute the urine and flush the renal tubules to avoid stone
       formation. Topiramate is taken in divided doses because it produces drowsiness. Although eating
       fresh fruits is desirable from a nutritional standpoint, this is not related to the topiramate. The drug
       does not have to be taken with meals.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 40

40. Which clinical manifestation is a typical reaction to long-term phenytoin sodium (Dilantin)
therapy?
1. Weight gain.
2. Insomnia.
3. Excessive growth of gum tissue.
4. Deteriorating eyesight.

Answer 40

40. 3. A common adverse effect of long-term phenytoin therapy is an overgrowth of gingival
       tissues. Problems may be minimized with good oral hygiene, but in some cases, overgrown tissues
       must be removed surgically. Phenytoin does not cause weight gain, insomnia, or deterioratingeyesight.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 41

41. A 21-year-old female client takes clonazepam. What should the nurse ask this client about?
    Select all that apply.
42. Seizure activity.
43. Pregnancy status.
44. Alcohol use.
45. Cigarette smoking.5. Intake of caffeine and sugary drinks.

Answer 41

41. 1, 2, 3. The nurse should assess the number and type of seizures the client has experienced
    since starting clonazepam monotherapy for seizure control. The nurse should also determine if the
    client might be pregnant because clonazepam crosses the placental barrier. The nurse should also ask
    about the client’s use of alcohol because alcohol potentiates the action of clonazepam. Although the
    nurse may want to check on the client’s diet or use of cigarettes for health maintenance and promotion,
    such information is not specifically related to clonazepam therapy.
    CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 42

The Client with a Stroke
A client is being monitored for transient ischemic attacks. The client is oriented, can open the eyes
spontaneously, and follows commands. What is the Glasgow Coma Scale score?
______________________ points.

Answer 42

The Client with a Stroke
42. 15 points
The Glasgow Coma Scale provides three objective neurologic assessments: spontaneity of eye
opening, best motor response, and best verbal response on a scale of 3 to 15. The client who scores
the best on all three assessments scores 15 points.
CN: Management of care; CL: Apply

Question 43

43. The nurse is teaching a client about taking prophylactic warfarin sodium (Coumadin). Which
    statement indicates that the client understands how to take the drug? Select all that apply.
44. “The drug’s action peaks in 2 hours.”
45. “Maximum dosage is not achieved until 3 to 4 days after starting the medication.”
46. “Effects of the drug continue for 4 to 5 days after discontinuing the medication.”
47. “Protamine sulfate is the antidote for warfarin.”
48. “I should have my blood levels tested periodically.”

Answer 43

43. 2, 3, 5. The maximum dosage of warfarin sodium (Coumadin) is not achieved until 3 to 4 days
    after starting the medication, and the effects of the drug continue for 4 to 5 days after discontinuing the
    medication. The client should have blood levels tested periodically to make sure that the desired
    level is maintained. Warfarin has a peak action of 9 hours. Vitamin K is the antidote for warfarin;
    protamine sulfate is the antidote for heparin.
    CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 44

44. Which of the following nursing measures is not appropriate when providing oral hygiene for
    a client who has had a stroke?
45. Placing the client on the back with a small pillow under the head.
46. Keeping portable suctioning equipment at the bedside.
47. Opening the client’s mouth with a padded tongue blade.
48. Cleaning the client’s mouth and teeth with a toothbrush.

Answer 44

44. 1. A helpless client should be positioned on the side, not on the back, with the head on a small
       pillow. A lateral position helps secretions escape from the throat and mouth, minimizing the risk of
       aspiration. It may be necessary to suction the client if he aspirates. Suction equipment should be
       nearby. It is safe to use a padded tongue blade, and the client should receive oral care, including
       brushing with a toothbrush.
       CN: Reduction of risk potential; CL: Synthesize

Question 45

45. A client arrives in the emergency department with an ischemic stroke and receives tissue
    plasminogen activator (t-PA) administration. The nurse should first:
46. Ask what medications the client is taking.
47. Complete a history and health assessment.
48. Identify the time of onset of the stroke.
49. Determine if the client is scheduled for any surgical procedures.

Answer 45

45. 3. Studies show that clients who receive recombinant t-PA treatment within 3 hours after the
       onset of a stroke have better outcomes. The time from the onset of a stroke to t-PA treatment is
       critical. A complete health assessment and history is not possible when a client is receiving
       emergency care. Upcoming surgical procedures may need to be delayed because of the administration
       of t-PA, which is a priority in the immediate treatment of the current stroke. While the nurse should
       identify which medications the client is taking, it is more important to know the time of the onset of
       the stroke to determine the course of action for administering t-PA.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 46

46. During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal
is to control the client's:
1. Pulse.
2. Respirations.
3. Blood pressure.
4. Temperature.

Answer 46

46. 3. Control of blood pressure is critical during the first 24 hours after treatment because an
       intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Vital signs are
       monitored, and blood pressure is maintained as identified by the physician and specific to the client’s
       ischemic tissue needs and risk of bleeding from treatment. The other vital signs are important, but the
       priority is to monitor blood pressure.CN: Reduction of risk potential; CL: Synthesize

Question 47

47. What is a priority nursing assessment in the first 24 hours after admission of the client with a
thrombotic stroke?
1. Cholesterol level.
2. Pupil size and pupillary response.
3. Bowel sounds.
4. Echocardiogram.

Answer 47

47. 2. It is crucial to monitor the pupil size and pupillary response to indicate changes around the
       cranial nerves. The cholesterol level is not a priority assessment, although it may be an assessment to
       be addressed for long-term healthy lifestyle rehabilitation. Bowel sounds need to be assessed
       because an ileus or constipation can develop, but this is not a priority in the first 24 hours, when the
       primary concerns are cerebral hemorrhage and increased intracranial pressure. An echocardiogram is
       not needed for the client with a thrombotic stroke without heart problems.
       CN: Physiological adaptation; CL: Analyze

Question 48

48. A client with a hemorrhagic stroke is slightly agitated, heart rate is 118, respirations are 22,
    bilateral rhonchi are auscultated, SpO 2 is 94%, blood pressure is 144/88, and oral secretions are
    noted. What order of interventions should the nurse follow when suctioning the client to prevent
    increased intracranial pressure (ICP) and maintain adequate cerebral perfusion?1. Suction the airway.
49. Hyperoxygenate.
50. Suction the mouth.
51. Provide sedation.

Answer 48

48.
4. Provide sedation.
2. Hyperoxygenate.
1. Suction the airway.
3. Suction the mouth.
Increased agitation with suctioning will increase ICP; therefore, sedation should be provided
first. The client should be hyperoxygenated before and after suctioning to prevent hypoxia since
hypoxia causes vasodilation of the cerebral vessels and increases ICP. The airway should then be
suctioned for no more than 10 seconds. The mouth can be suctioned once the airway is clear to
remove oral secretions. Once the mouth is suctioned, the suction catheter should be discarded.
CN: Physiological adaptation; CL: Synthesize

Question 49

49. In planning care for the client who has had a stroke, the nurse should obtain a history of the
    client’s functional status before the stroke because:
50. The rehabilitation plan will be guided by it.
51. Functional status before the stroke will help predict outcomes.
52. It will help the client recognize physical limitations.
53. The client can be expected to regain most functional status.

Answer 49

49. 1. The primary reason for the nursing assessment of a client’s functional status before and after
       a stroke is to guide the plan. The assessment does not help to predict how far the rehabilitation team
       can help the client to recover from the residual effects of the stroke, only what plans can help a client
       who has moved from one functional level to another. The nursing assessment of the client’s functional
       status is not a motivating factor.
       CN: Physiological adaptation; CL: Apply

Question 50

50. Which of the following techniques is not appropriate when the nurse changes a client’s
    position in bed if the client has hemiparalysis?
51. Rolling the client onto the side.
52. Sliding the client to move up in bed.
53. Lifting the client when moving the client up in bed.
54. Having the client help lift off the bed using a trapeze.

Answer 50

50. 2. Sliding a client on a sheet causes friction and is to be avoided. Friction injures skin and
       predisposes to pressure ulcer formation. Rolling the client is an acceptable method to use when
       changing positions as long as the client is maintained in anatomically neutral positions and the limbs
       are properly supported. The client may be lifted as long as the nurse has assistance and uses proper
       body mechanics to avoid injury to himself or herself or the client. Having the client help lift off the
       bed with a trapeze is an acceptable means to move a client without causing friction burns or skin
       breakdown.
       CN: Reduction of risk potential; CL: Synthesize

Question 51

The nurse is caring for a client who is paraplegic as the result of a stroke. At home, the client uses a
wheel chair for mobility and can transfer independently. The client is now being treated with IV
antibiotics for a sacral wound via a peripherally inserted central catheter. The client is alert and
oriented and has no previous history of falling. Using the Morse Fall Scale (see exhibit), what is this
client’s total score?

ITEM / SCALE
History of falling; immedicate or within 3 months

No - 0
Yes - 25

Secondary diagnosis
No - 0
Yes 15

Ambulatory Aid
Bed Rest/Nurse assist - 0
Crutches/Cane/walker - 15
Furniture - 30

IV/Heparin Lock
No - 0
Yes - 20

Gait Transferring
Normal/Bedrest - 0
Immobile Weak - 10
Impaired - 20

Mental Status
Oriented to own ability - 0
Forgets limitations - 15

_______________________ Fall risk score.

Answer 51

51. 35. This client has a fall risk score of 35 and is at medium fall risk due to the client’ssecondary diagnosis (15) and IV access (20). Though paraplegic, this does not affect the client’s fall
        risk assessment as the client will either be in bed or in a wheelchair; the client therefore is not
        assessed points on the fall risk for “ambulatory aid” or “gait.”
        CN: Safety and infection control; CL: Evaluate

Question 52

52. Which of the following is the most effective means of preventing plantar flexion in a client
    who has had a stroke with residual paralysis?
53. Place the client’s feet against a firm footboard.
54. Reposition the client every 2 hours.
55. Have the client wear ankle-high tennis shoes at intervals throughout the day.
56. Massage the client’s feet and ankles regularly.

Answer 52

52. 3. The use of ankle-high tennis shoes has been found to be most effective in preventing plantar
       flexion (footdrop) because they add support to the foot and keep it in the correct anatomic position.
       Footboards stimulate spasms and are not routinely recommended. Regular repositioning and range-of-
       motion exercises are important interventions, but the client’s foot needs to be in the correct anatomic
       position to prevent overextension of the muscle and tendon. Massaging does not prevent plantar
       flexion and, if rigorous, could release emboli.
       CN: Reduction of risk potential; CL: Synthesize

Question 53

53. The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm
    and hand. Which of the following positions are appropriate?
54. Placing a pillow in the axilla so the arm is away from the body.
55. Inserting a pillow under the slightly flexed arm so the hand is higher than the elbow.
56. Immobilizing the extremity in a sling.
57. Positioning a hand cone in the hand so the fingers are barely flexed.
58. Keeping the arm at the side using a pillow.

Answer 53

53. 1, 2, 4. Placing a pillow in the axilla so the arm is away from the body keeps the arm
    abducted and prevents skin from touching skin to avoid skin breakdown. Placing a pillow under the
    slightly flexed arm so the hand is higher than the elbow prevents dependent edema. Positioning a hand
    cone (not a rolled washcloth) in the hand prevents hand contractures. Immobilization of the extremity
    may cause a painful shoulder-hand syndrome. Flexion contractures of the hand, wrist, and elbow can
    result from immobility of the weak or paralyzed extremity. It is better to extend the arms to prevent
    contractures.
    CN: Reduction of risk potential; CL: Synthesize

Question 54

54. For the client who is experiencing expressive aphasia, which nursing intervention is most
    helpful in promoting communication?
55. Speaking loudly and slowly.
56. Using a “picture board” for the client to point to pictures.3. Writing directions so client can read them.
57. Speaking in short sentences

Answer 54

54. 2. Expressive aphasia is a condition in which the client understands what is heard or written
       but cannot say what he or she wants to say. A communication or picture board helps the client
       communicate with others in that the client can point to objects or activities that he or she desires.
       CN: Physiological adaptation; CL: Synthesize

Question 55

55. The nurse is teaching the family of a client with dysphagia about decreasing the risk of
    aspiration while eating. Which of the following strategies should the nurse include in the teaching
    plan. Check all that apply.
56. Maintaining an upright position while eating.
57. Restricting the diet to liquids until swallowing improves.
58. Introducing foods on the unaffected side of the mouth.
59. Keeping distractions to a minimum.
60. Cutting food into large pieces of finger food.

Answer 55

55. 1, 3, 4. A client with dysphagia (difficulty swallowing) commonly has the most difficulty
    ingesting thin liquids, which are easily aspirated. Liquids should be thickened to avoid aspiration.
    Maintaining an upright position while eating is appropriate because it minimizes the risk of
    aspiration. Introducing foods on the unaffected side allows the client to have better control over the
    food bolus. The client should concentrate on chewing and swallowing; therefore, distractions should
    be avoided. Large pieces of food could cause choking; the food should be cut into bite-sized pieces.
    CN: Safety and infection control; CL: Synthesize

Question 56

56. The nurse is assisting a client with a stroke who has homonymous hemianopia. The nurse
    should understand that the client will:
57. Have a preference for foods high in salt.
58. Eat food on only half of the plate.
59. Forget the names of foods.
60. Not be able to swallow liquids.

Answer 56

56. 2. Homonymous hemianopia is blindness in half of the visual field; therefore, the client would
       see only half of the plate. Eating only the food on half of the plate results from an inability to
       coordinate visual images and spatial relationships. There may be an increased preference for foods
       high in salt after a stroke, but this would not be related to homonymous hemianopia. Forgetting the
       names of foods is a sign of aphasia, which involves a cerebral cortex lesion. Being unable to
       swallow liquids is dysphagia, which involves motor pathways of cranial nerves IX and X, including
       the lower brain stem.
       CN: Physiological adaptation; CL: Analyze

Question 57

57. A nurse is teaching a client who had a stroke about ways to adapt to a visual disability.
    Which does the nurse identify as the primary safety precaution to use?
58. Wear a patch over one eye.
59. Place personal items on the sighted side.
60. Lie in bed with the unaffected side toward the door.
61. Turn the head from side to side when walking.

Answer 57

57. 4. To expand the visual field, the partially sighted client should be taught to turn the head from
       side to side when walking. Neglecting to do so may result in accidents. This technique helps
       maximize the use of remaining sight. Covering an eye with a patch will limit the field of vision.Personal items can be placed within sight and reach, but most accidents occur from tripping over
       items that cannot be seen. It may help the client to see the door, but walking presents the primary
       safety hazard.
       CN: Reduction of risk potential; CL: Synthesize

Question 58

58. A client is experiencing mood swings after a stroke and often has episodes of tearfulness that
    are distressing to the family. Which is the best technique for the nurse to instruct family members to
    try when the client experiences a crying episode?
59. Sit quietly with the client until the episode is over.
60. Ignore the behavior.
61. Attempt to divert the client’s attention.
62. Tell the client that this behavior is unacceptable.

Answer 58

58. 3. A client who has brain damage may be emotionally labile and may cry or laugh for no
       explainable reason. Crying is best dealt with by attempting to divert the client’s attention. Ignoring the
       behavior will not affect the mood swing or the crying and may increase the client’s sense of isolation.
       Telling the client to stop is inappropriate.
       CN: Psychosocial adaptation; CL: Synthesize

Question 59

59. When communicating with a client who has aphasia, which of the following are helpful?
    Select all that apply.
60. Present one thought at a time.
61. Avoid writing messages.
62. Speak with normal volume.
63. Make use of gestures.
64. Encourage pointing to the needed object.

Answer 59

59. 1, 3, 4, 5. The goal of communicating with a client with aphasia is to minimize frustration and
    exhaustion. The nurse should encourage the client to write messages or use alternative forms of
    communication to avoid frustration. Presenting one thought at a time decreases stimuli that may
    distract the client, as does speaking in a normal volume and tone. The nurse should ask the client to
    point to objects and encourage the use of gestures to assist in communicating.
    CN: Psychosocial adaptation; CL: Synthesize

Question 60

60. What is the expected outcome of thrombolytic drug therapy for stroke?
61. Increased vascular permeability.
62. Vasoconstriction.
63. Dissolved emboli.
64. Prevention of hemorrhage.

Answer 60

60. 3. Thrombolytic enzyme agents are used for clients with a thrombotic stroke to dissolve
       emboli, thus reestablishing cerebral perfusion. They do not increase vascular permeability, cause
       vasoconstriction, or prevent further hemorrhage.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 61

The Client with Parkinson’s Disease
61. A health care provider has prescribed carbidopa-levodopa (Sinemet) four times per day for a
client with Parkinson’s disease. The client wants “to end it all now that the Parkinson’s disease has
progressed.” What should the nurse do? Select all that apply.
1. Explain that the new prescription for Sinemet will treat the depression.
2. Encourage the client to discuss feelings as the Sinemet is being administered.
3. Contact the health care provider before administering the Sinemet.
4. Determine if the client is on antidepressants or monoamine oxidase (MAO) inhibitors.
5. Determine if the client is at risk for suicide.

Answer 61

The Client with Parkinson’s Disease
61. 3, 4, 5. The nurse should contact the health care provider before administering Sinemet
because this medication can cause further symptoms of depression. Suicide threats in clients with
chronic illness should be taken seriously. The nurse should also determine if the client is on an MAO
inhibitor because concurrent use with Sinemet can cause a hypertensive crisis. Sinemet is not a
treatment for depression. Having the client discuss feelings is appropriate when the prescription is
finalized.
CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 62

62. Which of the following is an initial sign of Parkinson’s disease?
63. Rigidity.
64. Tremor.
65. Bradykinesia.
66. Akinesia.

Answer 62

62. 2. The first sign of Parkinson’s disease is usually tremors. The client commonly is the first to
       notice this sign because the tremors may be minimal at first. Rigidity is the second sign, and
       bradykinesia is the third sign. Akinesia is a later stage of bradykinesia.
       CN: Physiological adaptation; CL: Analyze

Question 63

63. The nurse develops a teaching plan for a client newly diagnosed with Parkinson’s disease.
    Which of the following topics that the nurse plans to discuss is the most important?
64. Maintaining a balanced nutritional diet.
65. Enhancing the immune system.
66. Maintaining a safe environment.
67. Engaging in diversional activity.

Answer 63

63. 3. The primary focus is on maintaining a safe environment because the client with Parkinson’s
       disease usually has a propulsive gait, characterized by a tendency to take increasingly quicker steps
       while walking. This type of gait commonly causes the client to fall or to have trouble stopping. The
       client should maintain a balanced diet, enhance the immune system, and enjoy diversional activities;
       however, safety is the primary concern.
       CN: Reduction of risk potential; CL: Synthesize

Question 64

64. The nurse observes that a when a client with Parkinson’s disease unbuttons the shirt, the
    upper arm tremors disappear. Which statement best guides the nurse’s analysis of this observation
    about the client’s tremors?
65. The tremors are probably psychological and can be controlled at will.
66. The tremors sometimes disappear with purposeful and voluntary movements.
67. The tremors disappear when the client’s attention is diverted by some activity.
68. There is no explanation for the observation; it is a chance occurrence.

Answer 64

64. 2. Voluntary and purposeful movements often temporarily decrease or stop the tremors
       associated with Parkinson’s disease. In some clients, however, tremors may increase with voluntaryeffort. Tremors associated with Parkinson’s disease are not psychogenic but are related to an
       imbalance between dopamine and acetylcholine. Tremors cannot be reduced by distracting the client.
       CN: Physiological adaptation; CL: Analyze

Question 65

65. At what time of day should the nurse encourage a client with Parkinson’s disease to schedule
    the most demanding physical activities to minimize the effects of hypokinesia?
66. Early in the morning, when the client’s energy level is high.
67. To coincide with the peak action of drug therapy.
68. Immediately after a rest period.
69. When family members will be available.

Answer 65

65. 2. Demanding physical activity should be performed during the peak action of drug therapy.
       Clients should be encouraged to maintain independence in self-care activities to the greatest extent
       possible. Although some clients may have more energy in the morning or after rest, tremors are
       managed with drug therapy.
       CN: Physiological adaptation; CL: Synthesize

Question 66

66. Which goal is the most realistic for a client diagnosed with Parkinson’s disease?
67. To cure the disease.
68. To stop progression of the disease.
69. To begin preparations for terminal care.
70. To maintain optimal body function.

Answer 66

66. 4. Helping the client function at his or her best is most appropriate and realistic. There is no
       known cure for Parkinson’s disease. Parkinson’s disease progresses in severity, and there is no known
       way to stop its progression. Many clients live for years with the disease, however, and it would not
       be appropriate to start planning terminal care at this time.
       CN: Physiological adaptation; CL: Synthesize

Question 67

67. Which of the following goals is collaboratively established by the client with Parkinson’s
    disease, nurse, and physical therapist?1. To maintain joint flexibility.
68. To build muscle strength.
69. To improve muscle endurance.
70. To reduce ataxia.

Answer 67

67. 1. The primary goal of physical therapy and nursing interventions is to maintain joint
       flexibility and muscle strength. Parkinson’s disease involves a degeneration of dopamine-producing
       neurons; therefore, it would be an unrealistic goal to attempt to build muscles or increase endurance.
       The decrease in dopamine neurotransmitters results in ataxia secondary to extrapyramidal motor
       system effects. Attempts to reduce ataxia through physical therapy would not be effective.
       CN: Physiological adaptation; CL: Synthesize

Question 68

68. A client with Parkinson’s disease is prescribed levodopa ( L -dopa) therapy. Improvement in
    which of the following indicates effective therapy?
69. Mood.
70. Muscle rigidity.
71. Appetite.
72. Alertness.

Answer 68

68. 2. Levodopa is prescribed to decrease severe muscle rigidity. Levodopa does not improve
       mood, appetite, or alertness in a client with Parkinson’s disease.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 69

69. A client is being switched from levodopa ( L -dopa) to carbidopa-levodopa (Sinemet). The
    nurse should monitor for which of the following possible complications during medication changes
    and dosage adjustment?
70. Euphoria.
71. Jaundice.
72. Vital sign fluctuation.
73. Signs and symptoms of diabetes.

Answer 69

69. 3. Vital signs should be monitored, especially during periods of adjustment. Changes, such as
       orthostatic hypotension, cardiac irregularities, palpitations, and light-headedness, should be reported
       immediately. The client may actually experience suicidal or paranoid ideation instead of euphoria.
       The nurse should monitor the client for elevated liver enzyme levels, such as lactate dehydrogenase,
       aspartate aminotransferase, alanine aminotransferase, blood urea nitrogen, and alkaline phosphatase,
       but the client should not be jaundiced. The client should not experience signs and symptoms of
       diabetes or a low serum glucose level, but the nurse should check the hemoglobin and hematocrit
       levels.
       CN: Pharmacological and parenteral therapies; CL: Analyze

Question 70

70. A new medication regimen is prescribed for a client with Parkinson’s disease. At which time
    should the nurse make certain that the medication is taken?
71. At bedtime.
72. All at one time.
73. Two hours before mealtime.
74. At the time scheduled.

Answer 70

70. 4. While the client is hospitalized for adjustment of medication, it is essential that the
       medications be administered exactly at the scheduled time, for accurate evaluation of effectiveness.
       For example, levodopa-carbidopa (Sinemet) is taken in divided doses over the day, not all at one
       time, for optimum effectiveness.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 71

71. A client with Parkinson’s disease needs a long time to complete morning care, but becomes
    annoyed when the nurse offers assistance and refuses all help. Which action is the nurse’s best initial
    response in this situation?
72. Tell the client firmly that he or she needs assistance and help with the morning care.
73. Praise the client for the desire to be independent and give extra time and encouragement.
74. Tell the client that he or she is being unrealistic about the abilities and must accept the fact that
    he or she needs help.
75. Suggest to the client to at least modify the morning care routine if he or she insists on self-care.

Answer 71

71. 2. Ongoing self-care is a major focus for clients with Parkinson’s disease. The client should
       be given additional time as needed and praised for efforts to remain independent. Firmly telling the
       client that he or she needs assistance will undermine self-esteem and defeat efforts to be independent.
       Telling the client that perception of the situation is unrealistic does not foster hope in the ability toperform self-care measures. Suggesting that the client modify the morning routine seems to put the
       hospital or the nurse’s time schedule before the client’s needs. This will only decrease the client’s
       self-esteem and the desire to try to continue self-care, which is obviously important to the client.
       CN: Psychosocial adaptation; CL: Synthesize

Question 72

72. Which of the following is an expected outcome for a client with Parkinson's disease who has
a pallidotomy improved?
1. Functional ability.
2. Emotional stress.
3. Alertness.
4. Appetite.

Answer 72

72. 1. The goal of a pallidotomy is to improve functional ability for the client with Parkinson’s
       disease. This is a priority. The pallidotomy creates lesions in the globus pallidus to control
       extrapyramidal disorders that affect control of movement and gait. If functional ability is improved by
       the pallidotomy, the client may experience a secondary response of an improved emotional response,
       but this is not the primary goal of the surgical procedure. The procedure will not improve alertness or
       appetite.
       CN: Basic care and comfort; CL: Apply

Question 73

The Client with Multiple Sclerosis
73. The nurse should conduct a focused assessment with the client with multiple sclerosis for risk
of which of the following? Select all that apply.
1. Dehydration.
2. Falls.
3. Seizures.
4. Skin breakdown.
5. Fatigue.

Answer 73

The Client with Multiple Sclerosis
73. 2, 4, 5. The client with multiple sclerosis is at risk for falls due to muscle weakness, skin
breakdown due to bowel and bladder incontinence, and fatigue. The client is not at risk for
dehydration; seizures are not associated with myelin destruction.
CN: Physiological integrity; CL: Analyze

Question 74

74. The nurse is teaching a client with bladder dysfunction from multiple sclerosis (MS) about
    bladder training at home. Which instructions should the nurse include in the teaching plan? Select all
    that apply.
75. Restrict fluids to 1,000 mL/24 hours.
76. Drink 400 to 500 mL with each meal.
77. Drink fluids midmorning, midafternoon, and late afternoon.
78. Attempt to void at least every 2 hours.
79. Use intermittent catheterization as needed.

Answer 74

74. 2, 3, 4, 5. Maintaining urinary function in a client with neurogenic bladder dysfunction from
    MS is an important goal. The client should ideally drink 400 to 500 mL with each meal; 200 mL
    midmorning, midafternoon, and late afternoon; and attempt to void at least every 2 hours to prevent
    infection and stone formation. The client may need to catheterize herself to drain residual urine in the
    bladder. Restricting fluids during the day will not produce sufficient urine. However, in bladder
    training for nighttime continence, the client may restrict fluids for 1 to 2 hours before going to bed.
    The client should drink at least 2,000 mL every 24 hours.
    CN: Physiological adaptation; CL: Create

Question 75

75. Which of the following is not a typical clinical manifestation of multiple sclerosis (MS)?
76. Double vision.
77. Sudden bursts of energy.
78. Weakness in the extremities.
79. Muscle tremors.

Answer 75

75. 2. With MS, hyperexcitability and euphoria may occur, but because of muscle weakness,
       sudden bursts of energy are unlikely. Visual disturbances, weakness in the extremities, and loss of
       muscle tone and tremors are common symptoms of MS.
       CN: Physiological adaptation; CL: Analyze

Question 76

76. A client with multiple sclerosis (MS) is receiving baclofen (Lioresal). The nurse determines
    that the drug is effective when it achieves which of the following?
77. Induces sleep.
78. Stimulates the client’s appetite.
79. Relieves muscular spasticity.
80. Reduces the urine bacterial count.

Answer 76

76. 3. Baclofen is a centrally acting skeletal muscle relaxant that helps relieve the muscle spasms
       common in MS. Drowsiness is an adverse effect, and driving should be avoided if the medication
       produces a sedative effect. Baclofen does not stimulate the appetite or reduce bacteria in the urine.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 77

7. A client has had multiple sclerosis (MS) for 15 years and has received various drug
   therapies. What is the primary reason why the nurse has found it difficult to evaluate the effectiveness
   of the drugs that the client has used?
8. The client exhibits intolerance to many drugs.
9. The client experiences spontaneous remissions from time to time.
10. The client requires multiple drugs simultaneously.
11. The client endures long periods of exacerbation before the illness responds to a particular
    drug

Answer 77

77. 2. Evaluating drug effectiveness is difficult because a high percentage of clients with MS
       exhibit unpredictable episodes of remission, exacerbation, and steady progress without apparent
       cause. Clients with MS do not necessarily have increased intolerance to drugs, nor do they endure
       long periods of exacerbation before the illness responds to a particular drug. Multiple drug use is not
       what makes evaluation of drug effectiveness difficult.
       CN: Physiological adaptation; CL: Analyze

Question 78

78. When the nurse talks with a client with multiple sclerosis who has slurred speech, which
    nursing intervention is contraindicated?
79. Encouraging the client to speak slowly.
80. Encouraging the client to speak distinctly.
81. Asking the client to repeat indistinguishable words.
82. Asking the client to speak louder when tired.

Answer 78

78. 4. Asking a client to speak louder even when tired may aggravate the problem. Asking theclient to speak slowly and distinctly and to repeat hard-to-understand words helps the client to
       communicate effectively.
       CN: Psychosocial adaptation; CL: Synthesize

Question 79

79. The right hand of a client with multiple sclerosis trembles severely whenever she attempts a
    voluntary action. She spills her coffee twice at lunch and cannot get her dress fastened securely.
    Which is the best legal documentation in nurses’ notes of the chart for this client assessment?
80. “Has an intention tremor of the right hand.”
81. “Right-hand tremor worsens with purposeful acts.”
82. “Needs assistance with dressing and eating due to severe trembling and clumsiness.”
83. “Slight shaking of right hand increases to severe tremor when client tries to button her clothes
    or drink from a cup.”

Answer 79

79. 4. The nurses’ notes should be concise, objective, clearly stated, and relevant. This client
       trembles when she attempts voluntary actions, such as drinking a beverage or fastening clothing. This
       activity should be described exactly as it occurs so that others reading the note will have no doubt
       about the nurse’s observation of the client’s behavior. Identifying the “intentional” activity of daily
       living will help the interdisciplinary team individualize the client’s plan of care. Clarifying what is
       meant by “worsening” with a purposeful act will facilitate the interrater reliability of the team. It is
       better to state what the client did than to give vague nursing orders in the nurses’ notes.
       CN: Management of care; CL: Apply

Question 80

80. A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a
    bowel retraining program. Which strategy is not appropriate?
81. Eating a diet high in fiber.
82. Setting a regular time for elimination.
83. Using an elevated toilet seat.
84. Limiting fluid intake to 1,000 mL/day.

Answer 80

80. 4. Limiting fluid intake is likely to aggravate rather than relieve symptoms when a bowel
       retraining program is being implemented. Furthermore, water imbalance, as well as electrolyte
       imbalance, tends to aggravate the signs and symptoms of MS. A diet high in fiber helps keep bowel
       movements regular. Setting a regular time each day for elimination helps train the body to maintain a
       schedule. Using an elevated toilet seat facilitates transfer of the client from the wheelchair to the
       toilet or from a standing to a sitting position.
       CN: Physiological adaptation; CL: Synthesize

Question 81

81. Which of the following is not a realistic outcome to establish with a client who has multiple
sclerosis (MS)? The client will develop:
1. Joint mobility.
2. Muscle strength.
3. Cognition.
4. Mood elevation.

Answer 81

81. 3. MS is a progressive, chronic neurologic disease characterized by patchy demyelination
       throughout the central nervous system. This interferes with the transmission of electrical impulses
       from one nerve cell to the next. MS affects speech, coordination, and vision, but not cognition. Care
       for the client with MS is directed toward maintaining joint mobility, preventing deformities,
       maintaining muscle strength, rehabilitation, preventing and treating depression, and providing client
       motivation.
       CN: Reduction of risk potential; CL: Synthesize

Question 82

82. The nurse is preparing a client with multiple sclerosis (MS) for discharge from the hospital
    to home. The nurse should tell the client:
83. “You will need to accept the necessity for a quiet and inactive lifestyle.”
84. “Keep active, use stress reduction strategies, and avoid fatigue.”
85. “Follow good health habits to change the course of the disease.”
86. “Practice using the mechanical aids that you will need when future disabilities arise.”

Answer 82

82. 2. The nurse’s most positive approach is to encourage a client with MS to keep active, use
       stress reduction strategies, and avoid fatigue because it is important to support the immune system
       while remaining active. A quiet, inactive lifestyle is not necessarily indicated. Good health habits are
       not likely to alter the course of the disease, although they may help minimize complications.
       Practicing using aids that will be needed for future disabilities may be helpful but also can be
       discouraging.
       CN: Physiological adaptation; CL: Synthesize

Question 83

83. Which of the following should the nurse include in the discharge plan for a client with
    multiple sclerosis who has an impaired peripheral sensation? Select all that apply.
84. Carefully test the temperature of bath water.
85. Avoid kitchen activities because of the risk of injury.
86. Avoid hot water bottles and heating pads.
87. Inspect the skin daily for injury or pressure points.
88. Wear warm clothing when outside in cold temperatures.

Answer 83

83. 1, 3, 4, 5. A client with impaired peripheral sensation does not feel pain as readily as
    someone whose sensation is unimpaired; therefore, water temperatures should be tested carefully.
    The client should be advised to avoid using hot water bottles or heating pads and to protect against
    cold temperatures. Because the client cannot rely on minor pain as an indicator of damaged skin or
    sore spots, the client should carefully inspect the skin daily to visualize any injuries that he cannot
    feel. The client should not be instructed to avoid kitchen activities out of fear of injury; independence
    and self-care are also important. However, the client should meet with an occupational therapist to
    learn about assistive devices and techniques that can reduce injuries, such as burns and cuts that are
    common in kitchen activities.CN: Reduction of risk potential; CL: Create

Question 84

84. Which intervention should the nurse suggest to help a client with multiple sclerosis avoid
    episodes of urinary incontinence?
85. Limit fluid intake to 1,000 mL/day.
86. Insert an indwelling urinary catheter.
87. Establish a regular voiding schedule.
88. Administer prophylactic antibiotics, as prescribed.

Answer 84

84. 3. Maintaining a regular voiding pattern is the most appropriate measure to help the client
       avoid urinary incontinence. Fluid intake is not related to incontinence. Incontinence is related to the
       strength of the detrusor and urethral sphincter muscles. Inserting an indwelling catheter would be a
       treatment of last resort because of the increased risk of infection. If catheterization is required,
       intermittent self-catheterization is preferred because of its lower risk of infection. Antibiotics do not
       influence urinary incontinence.
       CN: Physiological adaptation; CL: Synthesize

Question 85

85. A client with multiple sclerosis (MS) lives with her daughter and 3-year-old granddaughter.
    The daughter asks the nurse what she can do at home to help her mother. Which of the following
    measures would be most beneficial?
86. Psychotherapy.
87. Regular exercise.
88. Day care for the granddaughter.
89. Weekly visits by another person with MS.

Answer 85

85. 2. An individualized regular exercise program helps the client to relieve muscle spasms. The
       client can be trained to use unaffected muscles to promote coordination because MS is a progressive,
       debilitating condition. The data do not indicate that the client needs psychotherapy, day care for the
       granddaughter, or visits from other clients.
       CN: Physiological adaptation; CL: Synthesize

Question 86

The Client with Myasthenia Gravis
86. When caring for a client with myasthenia gravis, the nurse should assess the client for which
of the following manifestations of cholinergic crisis? Select all that apply.
1. Ptosis.
2. Fasciculation.
3. Abdominal cramps.
4. Increased heart rate.
5. Decreased secretions and saliva.
6. Respiratory rate of 6 and irregular rhythm.

Answer 86

The Client with Myasthenia Gravis
86. 1, 2, 6. Cholinergic crisis is caused by overstimulation at the neuromuscular junction due to
increased acetylcholine. The crisis affects the muscles that control eye and eyelid movement, causing
fasciculation, ptosis (drooping eyelids) and difficulty chewing, talking, and swallowing. The muscles
that control breathing and neck and limb movements are also affected, and respirations become
slowed. Salivation is increased. The crisis is reversed with atropine.
CN: Physiological Integrity; CL: Analyze

Question 87

87. A client with refractory myasthenia gravis (MG) undergoes plasmapheresis therapy. The
    nurse determines that the therapy was effective if the client demonstrates improvement in:
88. Vital capacity.
89. Leg strength.
90. Ptosis.
91. Diplopia.

Answer 87

7. 1. Plasmapheresis therapy removes the antibodies that cause MG; therefore, the lung muscles
      will function with greater strength delivering more vital capacity. MG affects the upper limbs, and an
      increase in leg strength is not an outcome of plasmapheresis. Once the MG client has symptoms of
      ptosis and diplopia, they will not be reversed by plasmapheresis therapy.
      CN: Physiological Integrity; CL: Evaluate

Question 88

88. After teaching a client about myasthenia gravis, the nurse would judge that the client has
    formed a realistic concept of her health problem when she says that by taking her medication and
    pacing her activities:
89. She will live longer, but ultimately the disease will cause her death.
90. Her symptoms will be controlled, and eventually the disease will be cured.
91. She should be able to control the disease and enjoy a healthy lifestyle.
92. Her fatigue will be relieved, but she should expect occasional periods of muscle weakness.

Answer 88

88. 3. With a well-managed regimen, a client with myasthenia gravis should be able to control
       symptoms, maintain a normal lifestyle, and achieve a normal life expectancy. Myasthenia gravis can
       be controlled and need not be a fatal disease. Myasthenia gravis can be controlled, not cured.
       Episodes of increased muscle weakness should not occur if treatment is well managed.
       CN: Physiological adaptation; CL: Evaluate

Question 89

The Unconscious Client
89. A client is brought to the emergency department unconscious. An empty bottle of aspirin was
found in the car, and a drug overdose is suspected. Which of the following medications should the
nurse have available for further emergency treatment?
1. Vitamin K.
2. Dextrose 50%.
3. Activated charcoal powder.
4. Sodium thiosulfate.

Answer 89

The Unconscious Client
89. 3. Activated charcoal powder is administered to absorb remaining particles of salicylate.
Vitamin K is an antidote for warfarin sodium (Coumadin). Dextrose 50% is used to treat
hypoglycemia. Sodium thiosulfate is an antidote for cyanide.
CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 90

90. Which clinical manifestations should the nurse expect to assess in a client diagnosed with an
    overdose of a cholinergic agent? Select all that apply.
91. Dry mucous membranes.
92. Urinary incontinence.
93. Central nervous system (CNS) depression.
94. Seizures.
95. Skin rash.

Answer 90

90. 2, 3, 4. An excess of cholinergic agents produces urinary and fecal incontinence, increased
    salivation, diarrhea, and diaphoresis. In a severe overdose, CNS depression, seizures and muscle
    fasciculations, bradycardia or tachycardia, weakness, and respiratory arrest due to respiratory muscle
    paralysis occur. Anticholinergics produce dry mucous membranes. Skin rash is not a sign of overdosewith a cholinergic agent.
    CN: Pharmacological and parenteral therapies; CL: Analyze

Question 91

91. The wife and sister of a client who had attempted suicide with an overdose are distraught
    about his comatose condition and the possibility that he took an intentional drug overdose. Which of
    the following would be an appropriate initial nursing intervention with this family?
92. Explain that because the client was found on hospital property, he was probably asking for
    help and did not intentionally overdose.
93. Give the wife and sister a big hug and assure them that the client is in good hands.
94. Encourage the wife and sister to express their feelings and concerns, and listen carefully.
95. Allow the wife and sister to help care for the client by rubbing his back when he is turned

Answer 91

91. 3. The initial response to crisis is high anxiety. Anxiety must dissipate before a person can
       deal with the actual situation. Allowing family members to ventilate their feelings can help diffuse
       their anxiety. The reasons for the client’s actions are unknown; assumptions must be validated before
       they become facts. Touch can be appropriate but not when it is used as false reassurance. Helping
       with the client’s care is appropriate at a later time.
       CN: Psychosocial adaptation; CL: Synthesize

Question 92

92. Which of the following is a priority during the first 24 hours of hospitalization for a
    comatose client with suspected drug overdose?
93. Educate regarding drug abuse.
94. Minimize pain.
95. Maintain intact skin.
96. Increase caloric intake.

Answer 92

92. 3. Maintaining intact skin is a priority for the unconscious client. Unconscious clients need to
       be turned every hour to prevent complications of immobility, which include pressure ulcers and stasis
       pneumonia. The unconscious client cannot be educated at this time. Pain is not a concern. During the
       first 24 hours, the unconscious client will mostly likely be on nothing-by-mouth status.
       CN: Reduction of risk potential; CL: Synthesize

Question 93

93. An unconscious intubated client does not have increased intracranial pressure. Which nursing
    intervention would be essential?
94. Monitoring the oral temperature, keep the room temperature at 70°F (21.1°C), and place the
    client on a cooling blanket if the client’s temperature is higher than 101°F (38.3°C).
95. Cleaning the mouth carefully, applying a thin coat of petroleum jelly, and moving the
    endotracheal tube to the opposite side daily.
96. Positioning the client in the supine position with the head to the side and slightly elevated on
    two pillows.
97. Turning the client with a drawsheet and placing a pillow behind the back and one between the
    legs.

Answer 93

93. 2. The nurse must clean the unconscious client’s mouth carefully, apply a thin coat of
       petroleum jelly, and move the endotracheal tube to the opposite side daily to prevent dryness,
       crusting, inflammation, and parotiditis. The unconscious client’s temperature should be monitored by
       a route other than the oral (eg, rectal, tympanic) because oral temperatures will be inaccurate. The
       client should be positioned in a lateral or semiprone position, not a supine position, to allow for
       drainage of secretions and for the jaw and tongue to fall forward. The client should not be dragged
       when turned, as may happen when a drawsheet is used. Care should be taken to lift the client’s heels,
       buttocks, arms, and head off of the sheets when turning. Trochanter rolls, splints, foam boot aids,
       specialty beds, and so on—not just two pillows—should be used to keep the client in correct body
       position and to decrease pressure on bony prominences.
       CN: Reduction of risk potential; CL: Synthesize

Question 94

94. The unconscious client is to be placed in a right side-lying position. The nurse should
    intervene when observing a client in which of the following positions?1. The head is placed on a small pillow.
95. The right leg is extended without pillow support.
96. The left arm is rested on the mattress with the elbow flexed.
97. The left leg is supported on a pillow with the knee flexed.

Answer 94

94. 3. The client is not in proper body alignment if, when in the right side-lying position, the
       client’s left arm rests on the mattress with the elbow flexed. This positioning of the arm pulls the left
       shoulder out of good alignment, restricting respiratory movements. The arm should be supported on a
       pillow. The client’s head also should be placed on a small pillow to keep it in alignment with the
       body. The right leg should be extended on the mattress without a pillow to avoid hyperrotation of the
       hip. A pillow should be placed between the left and right legs with the left knee flexed so that on no
       parts of the legs is skin touching skin.
       CN: Physiological adaptation; CL: Synthesize

Question 95

95. Which of the following indicate that performing passive range-of-motion (ROM) exercises on
    an unconscious client has been successful?
96. Preservation of muscle mass.
97. Prevention of bone demineralization.
98. Increase in muscle tone.
99. Maintenance of joint mobility.

Answer 95

95. 4. The goal of performing passive ROM exercises is to maintain joint mobility. Active
       exercise is needed to preserve bone and muscle mass. Passive ROM movements do not prevent bone
       demineralization or have a positive effect on the client’s muscle tone.
       CN: Physiological adaptation; CL: Evaluate

Question 96

96. When the nurse performs oral hygiene for an unconscious client, which nursing intervention is
    the priority?
97. Keep a suction machine available.
98. Place the client in a prone position.
99. Wear sterile gloves while brushing the client’s teeth.
100. Use gauze wrapped around the fingers to clean the client’s gums.

Answer 96

96. 1. Maintaining a patent airway is the priority. Therefore, the nurse should keep suction
       equipment available to remove secretions. The client should be placed in a side-lying, not prone,
       position. Performing oral hygiene is a clean procedure; therefore, the nurse wears clean gloves, not
       sterile gloves. The nurse should never place any fingers in an unconscious client’s mouth; the client
       may bite down. Padded tongue blades, swabs, or a toothbrush should be used instead; but maintainingthe airway is the priority.
       CN: Physiological adaptation; CL: Synthesize

Question 97

97. The nurse observes that the right eye of an unconscious client does not close completely.
    Which nursing intervention is most appropriate?
98. Have the client wear eyeglasses at all times.
99. Lightly tape the eyelid shut.
100. Instill artificial tears once every shift.
101. Clean the eyelid with a washcloth every shift.

Answer 97

97. 2. When the blink reflex is absent or the eyes do not close completely, the cornea may become
       dry and irritated. Corneal abrasion can occur. Taping the eye closed will prevent injury. Having the
       client wear eyeglasses or cleaning the eyelid will not protect the cornea from dryness or irritation.
       Artificial tears instilled once per shift are not frequent enough for preventing dryness.
       CN: Reduction of risk potential; CL: Synthesize

Question 98

98. Which sign is an early indicator of hypoxia in the unconscious client?
99. Cyanosis.
100. Decreased respirations.
101. Restlessness.
102. Hypotension.

Answer 98

98. 3. Restlessness is an early indicator of hypoxia. The nurse should suspect hypoxia in the
       unconscious client who becomes restless. The most accurate method for determining the presence of
       hypoxia is to evaluate the pulse oximeter value or arterial blood gas values. Cyanosis and decreased
       respirations are late indicators of hypoxia. Hypertension, not hypotension, is a sign of hypoxia.
       CN: Physiological adaptation; CL: Apply

Question 99

99. When administering intermittent enteral feeding to an unconscious client, the nurse should:
100. Heat the formula in a microwave.
101. Place the client in a semi-Fowler’s position.
102. Obtain a sterile gavage bag and tubing.
103. Weigh the client before administering the feeding

Answer 99

99. 2. The client should be placed in a semi-Fowler’s position to reduce the risk of aspiration.
       The formula should be at room temperature, not heated. Administering enteral tube feedings is a clean
       procedure, not a sterile one; therefore, sterile supplies are not required. Clients receiving enteral
       feedings should be weighed regularly, but not necessarily before each feeding.
       CN: Reduction of risk potential; CL: Synthesize

Question 100

100. The unconscious client is to receive 200 mL of tube feeding every 4 hours. The nurse checks
     for the client’s gastric residual before administering the next scheduled feeding and obtains 40 mL of
     gastric residual. The nurse should:
101. Withhold the tube feeding and notify the physician.
102. Dispose of the residual and continue with the feeding.
103. Delay feeding the client for 1 hour and then recheck the residual.
104. Readminister the residual to the client and continue with the feeding.

Answer 100

100. 4. Gastric residuals are checked before administration of enteral feedings to determine
        whether gastric emptying is delayed. A residual of less than 50% of the previous feeding volume is
        usually considered acceptable. In this case, the amount is not excessive and the nurse should reinstill
        the aspirate through the tube and then administer the feeding. If the amount of gastric residual is
        excessive, the nurse should notify the physician and withhold the feeding. Disposing of the residual
        can cause electrolyte and fluid losses.
        CN: Reduction of risk potential; CL: Synthesize

Question 101

The Client in Pain
The physician prescribes morphine sulfate 2 to 4 mg IV push every 2 hours PRN pain for a client who
has postoperative pain following abdominal surgery. Prior to performing an abdominal dressing
change with packing at 10 AM , the nurse assesses the client’s pain level as 1 on a scale of 0 = no pain
to 10 = the worst pain. The client is awake and oriented, and vital signs are within normal limits. The
nurse reviews the pain medication record (see chart).
The nurse should:

TIME PAIN LEVEL INTERVENTION
7 am 8 Morphine 4 mg IV
9 am 4 Morphine 2 mg IV
10 am 1

1. Perform the dressing change.
2. Administer morphine 2 mg IV before the dressing change.
3. Administer morphine 4 mg IV after the dressing change.
4. Call the physician for a new medication prescription.

Answer 101

The Client in Pain
101. 2. Morphine 2 mg was given 1 hour ago and the client can have up to 4 mg every 2 hours.
Although the pain level is at 1, the nurse should give medication prior to the dressing change with
packing that is likely to cause discomfort. A 4-mg dose of morphine would exceed the 2-hour limit
and, if given after the dressing change, would not manage pain during the procedure. The client has
been responding to the pain medication dosing and a new prescription is not required at this time.
CN: Management of care; CL: Synthesize

Question 102

102. Which of the following is true about pain?
103. Expression and perception of pain vary widely from person to person.
104. Tolerance of pain is the same in all people.
105. Tolerance of pain is determined by a person’s genetic makeup.
106. Pain perception is the same in all people.

Answer 102

102. 1. Pain perception is an individual experience. Research indicates that pain tolerance and
        perception vary widely among individuals, even within cultures.
        CN: Psychosocial adaptation; CL: Synthesize

Question 103

103. The nurse finds it difficult to relieve a client’s pain satisfactorily. Which of the following
     measures should the nurse take next when continuing efforts to promote comfort?
104. Increase the client’s confidence in the nurse.
105. Enlist the help of the client’s family.
106. Allow the client additional time to work through his or her own responses to pain.
107. Arrange to have the client share a room with a client who has little pain.

Answer 103

103. 1. Experience has demonstrated that clients who feel confidence in the persons who are
        caring for them do not require as much therapy for pain relief as those who have less confidence.
        Without the client’s confidence, developed in an effective nurse-client relationship, other
        interventions may be less effective. The client’s family can be an important source of support, but it is
        the nurse who plans strategies for pain relief. The client may require time to adjust to the pain, but thenurse and client can collaborate to try to evaluate a variety of pain relief strategies. Arranging for the
        client to share a room with another client who has little pain may have negative effects on the client
        who has pain that is difficult to relieve.
        CN: Basic care and comfort; CL: Synthesize

Question 104

104. The client’s physician changes the analgesia medication from meperidine hydrochloride
     (Demerol) 75 mg IM every 4 hours as needed to meperidine hydrochloride by the oral route. What
     dosage of oral meperidine is required to provide an equivalent analgesic dose?
105. 25 to 50 mg.
106. 75 to 100 mg.
107. 125 to 150 mg.
108. 250 to 300 mg.

Answer 104

104. 4. Although meperidine hydrochloride can be given orally, it is more effective when given
        intramuscularly. The equianalgesic dose of oral meperidine is up to four times the IM dose (75 × 4 =
        300).
        CN: Pharmacological and parenteral therapies; CL: Apply

Question 105

105. After administering meperidine hydrochloride (Demerol), the nurse determines itseffectiveness as an analgesic was related to its ability to:
106. Reduce the perception of pain.
107. Decrease the sensitivity of pain receptors.
108. Interfere with pain impulses traveling along sensory nerve fibers.
109. Block the conduction of pain impulses along the central nervous system.

Answer 105

105. 1. Opioid analgesics relieve pain by reducing or altering the perception of pain. Meperidine
        hydrochloride does not decrease the sensitivity of pain receptors, interfere with pain impulses
        traveling along sensory nerve fibers, or block the conduction of pain impulses in the central nervous
        system.
        CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 106

106. A client is arousing from a coma and keeps saying, “Just stop the pain.” The nurse responds
     based on the knowledge that the client’s first response to pain will be to:
107. Tolerate the pain.
108. Decrease the perception of pain.
109. Escape the source of pain.
110. Divert attention from the source of pain.

Answer 106

106. 3. The client’s innate responses to pain are directed initially toward escaping from the
        source of pain. Variations in tolerance and perception of pain are apparent only in conscious clients,
        and only conscious clients can employ distraction to help relieve pain.
        CN: Physiological adaptation; CL: Apply

Question 107

107. Ergotamine tartrate is prescribed for a client’s migraine headaches. Which of the following
     is an expected outcome of the use of this drug?
108. Prevention of the migraine.
109. Reduced severity of the developing migraine.
110. Relief from the sleeplessness experienced in the past after a migraine.
111. Relief from the vision problems experienced in the past after a migraine.

Answer 107

107. 1. Ergotamine tartrate is used to help abort a migraine attack. It should be taken as soon as
        prodromal symptoms appear. Reduced migraine severity and relief from sleeplessness and vision
        problems address symptoms that occur after the migraine has occurred and are not effects of
        ergotamine.
        CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 108

108. The purpose of biofeedback is to enable a client to exert control over physiologic processes
     by:
109. Regulating the body processes through electrical control.
110. Shocking the client when an undesirable response is elicited.
111. Monitoring the body processes for the therapist to interpret.
112. Translating the signals of body processes into observable forms.

Answer 108

108. 4. Biofeedback translates body processes into observable signs so that the client can
        develop some control over certain body processes. Biofeedback does not involve electrical
        stimulation. Use of unpleasant stimuli such as electrical shock is a form of aversion therapy.
        Biofeedback does not involve monitoring body processes for the therapist to interpret; rather, it is a
        self-directed, self-care activity that reinforces learning because the client can see the results of his
        actions.
        CN: Psychosocial adaptation; CL: Apply

Question 109

109. The nurse explains to the client that the main reason a back rub is used as therapy to relieve
     pain is because the massage:
110. Blocks pain impulses from the spinal cord to the brain.
111. Blocks pain impulses from the brain to the spinal cord.
112. Stimulates the release of endorphins.
113. Distracts the client’s focus on the source of the pain.

Answer 109

109. 1. A back rub stimulates the large-diameter cutaneous fibers, which block transmission of
        pain impulses from the spinal cord to the brain. It does not block the transmission of pain impulses or
        stimulate the release of endorphins. A back rub may distract the client, but the physiologic process of
        fiber stimulation is the main reason a back rub is used as therapy for pain relief.
        CN: Basic care and comfort; CL: Apply

Question 110

110. Nursing responsibilities for the client with a patient-controlled analgesia (PCA) system
     should include:
111. Reassuring the client that pain will be relieved.
112. Documenting the client’s response to pain medication.
113. Instructing the client to continue pressing the system’s button whenever pain occurs.
114. Titrating the client’s pain medication until the client is free from pain.

Answer 110

110. 2. It is essential that the nurse document the client’s response to pain medication on a routine,
        systematic basis. Reassuring the client that pain will be relieved is often not realistic. A client who
        continually presses the PCA button may not be getting adequate pain relief, but through careful
        assessment and documentation, the effectiveness of pain relief interventions can be evaluated and
        modified. Pain medication is not titrated until the client is free from pain but rather until an acceptable
        level of pain management is reached.CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 111

111. A client has an epidural catheter inserted for postoperative pain management. The client
     rates his pain at 4 on a 0-to-5 pain scale. What should the nurse do first?
112. Check the patient-controlled analgesia (PCA) pump function.
113. Adjust the epidural catheter.
114. Assess vital signs.
115. Notify the physician.

Answer 111

111. 1. An epidural catheter is used for postoperative pain management to block the pain
        sensation below the point of insertion. If the client is rating pain high, the PCA pump may be
        malfunctioning, the catheter may have become misplaced, or the amount of medication may not be
        sufficient. The nurse should first check the PCA pump to determine if it is functioning properly.
        Assessing vital signs would be important to provide additional data about the possible cause of pain.
        The catheter placement, including removing the dressing or manipulating the catheter, and drug dosage
        are the responsibility of the physician, usually an anesthesiologist, who inserted the catheter. This
        person should be contacted if the PCA pump is functioning appropriately. The epidural catheter lies
        just above the dura of the spinal space. Infection, hypotension, and loss of mental alertness are just a
        few of the complications that can occur if the catheter is pushed through the dura.
        CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 112

112. The nurse using healing touch affects a client’s pain primarily through:1. Energy fields.
113. Touch therapy.
114. Massage.
115. Hypnosis.

Answer 112

112. 1. The nurse using healing touch affects a client’s pain primarily through assessing and
        directing the flow of energy fields. Healing touch can involve touching, but it does not have to involve
        body contact. Massage and hypnosis are not parts of healing touch.
        CN: Physiological adaptation; CL: Apply

Question 113

113. When a nurse is assessing a client for pain, what finding is most significant? The client:
114. Protects a specific area of the body.
115. Tells the nurse about experiencing pain.
116. Has a change in vital signs.
117. Appears to be uncomfortable.

Answer 113

113. 2. Pain is whatever the client perceives it is; using a pain scale is the best way to have the
        client quantify the amount of pain. The fact that the client is protecting an area of the body, the client’s
        vital signs, and the client’s appearance of discomfort are objective rather than subjective findings; the
        nurse should confirm the meaning of these changes before assuming the client has pain.
        CN: Basic care and comfort; CL Analyze

Question 114

Managing Care Quality and Safety
114. A nursing assistant is providing care to a client with left-sided paralysis. Which of the
following actions by the nursing assistant requires the nurse to provide further instruction?
1. Providing passive range-of-motion exercises to the left extremities during the bed bath.
2. Elevating the foot of the bed to reduce edema.
3. Pulling up the client under the left shoulder when getting the client out of bed to a chair.
4. Putting high top tennis shoes on the client after bathing.

Answer 114

Managing Care Quality and Safety
114. 3. Pulling the client up under the arm can cause shoulder displacement. A belt around the
waist should be used to move the client. Passive range-of-motion exercises prevents contractures and
atrophy. Raising the foot of the bed assists in venous return to reduce edema. High top tennis shoes
are used to prevent foot drop.
CN: Management of care; CL: Synthesize

Question 115

115. The nurse notices that a client with Parkinson’s disease is coughing frequently when eating.
     Which one of the following interventions should the nurse consider?
116. Have the client hyperextend the neck when swallowing.
117. Tell the client to place the chin firmly against the chest when eating.
118. Thicken all liquids before offering to the client.
119. Place the client on a clear liquid diet.

Answer 115

115. 3. Clients with Parkinson’s disease can experience dysphagia. Thickening liquids assists
        with swallowing, preventing aspiration. Hyperextending the neck opens the airway and can increase
        risk of aspiration. Pressing the chin firmly on the chest makes swallowing more difficult. The chin
        should be slightly tucked to promote swallowing. The nurse should suggest a speech therapy consult
        for evaluation of the client’s ability to swallow.
        CN: Safety and infection control; CL: Synthesize

Question 116

116. After receiving a change-of-shift report at 7:00 AM , the nurse should assess which of these
     clients first?
117. A 23-year-old with a migraine headache who has severe nausea associated with retching.
118. A 45-year-old who is scheduled for a craniotomy in 30 minutes and needs preoperative
     teaching.
119. A 59-year-old with Parkinson’s disease who will need a swallowing assessment before
     breakfast.
120. A 63-year-old with multiple sclerosis who has an oral temperature of 101.8°F (38.8°C) and
     flank pain.

Answer 116

116. 4. Urinary tract infections are a frequent complication in clients with multiple sclerosis
        because of the effect on bladder function; therefore, that client should been seen first by the nurse. The
        elevated temperature and flank pain suggest that this patient may have pyelonephritis. The physician
        should be notified immediately so that antibiotic therapy can be started quickly. The other clients
        should be assessed soon, but do not have needs as urgent as this client.
        CN: Management of care; CL: Synthesize

Question 117

117. The nurse has asked the nursing assistant to ambulate a client with Parkinson’s disease. The
     nurse observes the nursing assistant pulling on the client’s arms to get the client to walk forward. The
     nurse should:
118. Have the nursing assistant keep a steady pull on the client to promote forward ambulation.
119. Explain how to overcome a freezing gait by telling the client to march in place.
120. Assist the nursing assistant with getting the client back in bed.
121. Give the client a muscle relaxant.

Answer 117

117. 2. Clients with Parkinson’s disease may experience a freezing gait when they are unable to
        move forward. Instructing the client to march in place, step over lines in the flooring, or visualize
        stepping over a log allows them to move forward. It is important to ambulate the client and not keep
        them on bedrest. A muscle relaxant is not indicated.
        CN: Management of care; CL: Synthesize

Question 118

118. Which pressure point area(s) should the nurse monitor for an unconscious client positioned
on the left side (see figure)? Choose all that apply.1. Ankles.
2. Ear.
3. Greater trochanter.
4. Heels.
5. Occiput.
6. Sacrum.
7. Shoulder.

Answer 118

118. 1, 2, 3, 7. Pressure points in the side-lying position include the ears, shoulders, ribs, greater
     trochanter, medial or lateral condyles, and ankles. The sacrum, occiput, and heels are pressure point
     areas affected in the supine position.
     CN: Safety and infection control; CL: Analyze

Question 119

119. The nurse ascertains that there is a discrepancy in the records of use of a controlled
     substance for a client who is taking large doses of narcotic pain medication. The nurse should do
     which of the following next?
120. Notify the police.
121. Contact the hospital’s administration or legal department.
122. Notify the pharmacy technician who delivered the controlled substance.
123. Notify the nursing supervisor of the clinical unit.

Answer 119

119. 4. All health care facilities in which controlled medications are stored for dispensing and/or
        administration to clients are required to follow procedures for the proper maintenance of narcotic
        inventory. Narcotic inventory maintenance includes, but is not limited to, all discrepancies will have
        thorough and appropriate documentation with accompanying reasons (ie, tablet/amp/vial breakage,
        additional medication volume, etc.), timely resolution of inventory discrepancies, and timely
        notification regarding controlled substance inventory discrepancies of persons in oversight areas (ie,
        Pharmacy, Security, Nursing House Supervisor). In the event of a significant incident, the proper
        external authorities will be notified by the Quality and Risk Management/Legal Department.
        CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 120

120. The nurse is caring for a client who is confused about time and place. The client has
     intravenous fluid infusing. After attempting to reorient the client, the client remains unable to
     demonstrate appropriate use of the call light. In order to maintain client safety, the nurse should first:
121. Ask the family to stay with the client.
122. Contact the physician and request a prescription for soft wrist restraints.
123. Increase the frequency of client observation.
124. Administer a sedative.

Answer 120

120. 3. The first intervention for a confused client is to increase the frequency of observation,
        moving the client closer to the nurses’ station if possible and/or delegating the nursing assistant to
        check on the client more frequently. If the family is able to stay with the client, that is an option, but it
        is the nurse’s responsibility, not the family’s, to keep the client safe. Wrist restraints are not used
        simply because a client is confused; there is no mention of this client pulling at intravenous lines,
        which is one of the main reasons to use wrist restraints. Administering a sedative simply because a
        client is confused is not appropriate nursing care and may actually potentiate the problem.
        CN: Safety and infection control; CL: Synthesize

Question 121

121. The nurse finds a confused client with soft wrist restraints in place (see figure). The nurse
     should first:
122. Assess and document the condition of the client’s skin beneath the restraint.
123. Untie the restraint and resecure to the bedframe using a quick-release knot.
124. Release the restraint and perform passive range of motion.
125. Ask if the client needs to use the restroom.

Answer 121

121. 2. To ensure the client’s safety when using restraints, the restraint must be secured to the
        bedframe (not the siderail) using a quick-release slip knot (not a square knot). Assessing and
        documenting skin should be done regularly when restraints are in use, but safety is first priority.
        Regularly releasing restraints and performing range of motion is essential but not priority in this case.
        Providing for the client’s basic needs while in restraints (ie, toileting) is important but not first
        priority.
        CN: Safety and infection control; CL: Synthesize