021290Neurologic Exam(Flash Card)

S E C T I O N O N E Neurological Disorders 3

Head Injury

1. The client has sustained a traumatic brain injury (TBI) secondary to a motor vehicle accident. Which signs/symptoms would the emergency department (ED) nurse expect the client to exhibit?

1. Blurred vision, nausea, and right-sided hemiparesis.

2. Increased urinary output, negative Babinski, and ptosis.

3. Autonomic dysreflexia, positive Brudzinski, and hyperpyrexia.

4. Negative dextrostik, nuchal rigidity, and nystagmus.

2. The intensive care nurse is caring for a client diagnosed with a closed head injury. Which data would warrant immediate intervention?

1. The client refuses to cough and deep-breathe.

2. The client’s Glasgow Coma Scale goes from 13 to 7.

3. The client complains of a frontal headache.

4. The client’s Mini-Mental Status Exam (MMSE) is 30.

3. The rehabilitation nurse is caring for the client with a closed head injury. Which cognitive goal would be most appropriate for this client?

1. The client will be able to feed himself/herself independently.

2. The client will attend therapy sessions 3 hours a day.

3. The client will interact appropriately with staff members.

4. The client will be able to stay on task for 15 minutes. A N S W E R S

Correct answer 1: Signs/symptoms of TBI include neurological deficits, among them blurred vision, nausea, and right-sided hemiparesis. A positive Babinski sign would also occur with head trauma. Autonomic dysreflexia would be found in a client with a spinal cord injury; a positive dextrostik for glucose would be found in someone with a cerebrospinal fluid leak; and a positive Brudzinski and nuchal rigidity are signs of meningitis. Content–Medical; Category of

Health Alteration–Neurological; Integrated Process– Assessment; Client Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level–Analysis.

Correct answer 2: A 15 on the Glasgow Coma Scale indicates the client is neurologically intact; a decrease to 7 indicates an increase in the intracranial pressure, which warrants immediate intervention. A 30 on the MMSE indicates the client is cognitively intact.

Content–Medical; Category of Health Alteration– Neurological; Integrated Process–Assessment; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.

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Correct answer 4: Cognitive is mental functioning; therefore, the ability to stay on task would be the client’s most appropriate cognitive goal. Content–

Medical; Category of Health Alteration–Neurological; Integrated Process–Planning; Client Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level– Synthesis.


4. The intensive care nurse is caring for a client diagnosed with a TBI who is exhibiting decorticate posturing. Three hours later the client has flaccid posturing. Which action should the nurse implement first?

1. Notify the client’s health-care provider (HCP) immediately.

2. Prepare to administer mannitol (Osmitrol), an osmotic diuretic.

3. Complete a thorough neurological assessment on the client.

4. Reassess the client in 1 hour, including calculating the Glasgow Coma Scale.

5. The emergency department nurse is entering the room of a client who was at a baseball game and was hit in the head with a bat. Which intervention should the nurse implement first?

1. Assess the client’s orientation to date, time, and place.

2. Ask the client to squeeze the nurse’s fingers.

3. Determine the client’s reaction to the door opening.

4. Request the client to move his lower legs.

6. The nurse is preparing the client diagnosed with a head injury for a magnetic resonance imaging (MRI). Which interventions should the nurse implement? Select all that apply.

1. Ask the client if he/she is claustrophobic.

2. Have the client sign a procedural permit.

3. Determine if the client is allergic to shellfish.

4. Check if the client has any prosthetic devices.

5. Ask the client to empty his/her bladder. A N S W E R S

Correct answer 1: Flaccid posturing is the worst-case scenario for a client with a TBI; therefore, the nurse should notify the HCP. Completing a neurological assessment, administering an osmotic diuretic, and reassessing the client are all plausible interventions, but they are not the first to be implemented. Content–

Medical; Category of Health Alteration–Neurological; Integrated Process–Assessment; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Analysis.

Correct answer 3: The nurse should first determine how alert the client is by noticing the reaction when the door opens. The best reaction is spontaneous opening of the eyes without verbal or noxious stimuli. The other three options are appropriate but should not be the nurse’s first intervention when entering the client’s room. Content–Medical; Category of

Health Alteration–Neurological; Integrated Process– Implementation; Client Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level–Application.

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Correct answer 1, 4, 5: The client is enclosed in an MRI tube for an extended period so the client cannot be claustrophobic or want to stop the procedure. An MRI cannot be completed on a client with a metal prosthesis unless it is made with titanium because the MRI may dislodge the prosthesis. The hospital admission permit covers the MRI, and because no contrast dye is now used in most MRIs, an allergy to shellfish is not pertinent. Content–Medical; Category of Health Alteration–Neurological; Integrated Process– Implementation; Client Needs–Physiological Integrity,

Reduction of Risk Potential; Cognitive Level–Application.


7. The client with increased intracranial pressure is receiving mannitol (Osmitrol), an osmotic diuretic. Which intervention should the nurse implement?

1. Monitor the client’s complete blood cell (CBC) count.

2. Do not administer the drug if the client’s apical pulse is less than 60.

3. Ensure that the client’s cardiac status is monitored by telemetry.

4. Use a filter needle when administering the medication.

8. The male client is being discharged from the ED after sustaining a minor head injury. Which statement indicates the wife understands the discharge teaching?

1. “My husband will be hard to wake up for a couple of days.”

2. “He doesn’t need any pain medication becauseI have some at home.”

3. “I should not give my husband anything to eat or drink for 12 hours.”

4. “I will bring my husband back to the emergency room if he starts vomiting.”

9. The nurse is discussing the TBI Act at a support group meeting. Which statement best explains the act?

1. It is a federal act that provides public policy regarding community living for clients with a TBI.

2. It ensures that all public buildings must have access for physically challenged clients.

3. This act ensures that all clients with a TBI have access to rehabilitation services.

4. It is a national policy that establishes guidelines for neurological rehabilitation centers.

10. The nurse is caring for a female client who sustained a closed head injury 8 days ago due to a motor vehicle accident. Which signs/symptoms would alert the nurse to a complication of the head injury?

1. The client reports having trouble sleeping due to having nightmares about the wreck.

2. The client tells the nurse she has a stuffy nose and green nasal drainage.

3. The client complains of extreme thirst and has an increased urine output.

4. The client informs the nurse that she has started her menstrual period. A N S W E R S

Correct answer 4: The nurse must use a filter needle when administering mannitol because crystals may form in the solution and syringe and be inadvertently injected into the client. The CBC and apical pulse are not affected by the medication. Mannitol is administered cautiously in clients with heart failure, but telemetry is not required routinely. Content–

Medical; Category of Health Alteration–Neurological; Integrated Process–Implementation; Client Needs– Physiological Integrity, Pharmacological and Parenteral Therapies; Cognitive Level–Application.

Correct answer 4: Vomiting indicates an increase in intracranial pressure, which is a complication of a head injury. The client should arouse easily, may eat and drink (not alcohol), and should not take any type of pain medication that would mask mental status.

Content–Medical; Category of Health Alteration– Neurological; Integrated Process–Evaluation; Client Needs–Health Promotion and Maintenance; Cognitive Level: Evaluation.

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Correct answer 1: The TBI Act is part of the Children’s Act of 2000 and is the only federal legislation designed for clients with a TBI. The Act provides for a balanced public policy for prevention, education, research, and community living for clients with a TBI and their families. Content–Medical;

Category of Health Alteration–Neurological; Integrated Process–Planning; Client Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level–Knowledge.

Correct answer 3: For 7–10 days post head injury, the client is at risk for developing diabetes insipidus, which is a lack of the antidiuretic hormone, resulting in increased urine output and increased thirst.

Content–Medical; Category of Health Alteration– Neurological; Integrated Process–Assessment; Client

Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level–Analysis.


Spinal Cord Injury

Which clinical manifestation would the nurse assess in the client with a T-12 spinal cord injury (SCI) who is experiencing spinal shock?l 1. Flaccid paralysis below the waist. l 2. Lower extremity muscle spasticity.

l 3. Complaints of a pounding headache. l 4. Hypertension and bradycardia.

The nurse is caring for a client who has a C-6 vertebral

fracture and is using Crutchfield tongs with 2-pound weights. Which data would the nurse expect the client to exhibit?

1. The client is on controlled mechanical ventilation at 12 respirations a minute.

2. The client has no movement of the lower extremities.

3. The client has 2 deep tendon reflexes in the lower extremities.

4. The client has loss of sensation below the C-6 vertebral fracture.

13. The rehabilitation nurse caring for the young client with a T-12 SCI is developing the nursing care plan. Which priority intervention should the nurse implement?

1. Monitor the client’s indwelling urinary catheter.

2. Insert a rectal stimulant at the same time every morning.

3. Encourage active lower extremity range of motion (ROM) exercises.

4. Refer the client to a vocational training assistance program.

14. The nurse is caring for a client with a C-6 SCI in the neurological intensive care unit. Which nursing intervention should be implemented?

1. Monitor the client’s heparin drip.

2. Assess the neurological status every shift.

3. Maintain the client’s ice saline infusion.

4. Administer corticosteroids intrathecally. A N S W E R S

Correct answer 1: Spinal shock is associated with an SCI. It is a sudden depression of reflex activity, a loss of sensation, and flaccid paralysis below the level of the injury. T-12 is just above the waist. Content–

Medical; Category of Health Alteration–Neurological; Integrated Process–Assessment; Client Needs– Physiological Integrity, Physiological Adaptation; Cognitive Level–Analysis.

Correct answer 3: The spinal cord has not been injured; therefore, normal body movement, responses, and reflexes should be intact. The Crutchfield tongs ensure that the cervical spine remains in alignment. Content–Medical; Category of

Health Alteration–Neurological; Integrated Process– Assessment; Client Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level–Analysis.

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Correct answer 2: The client’s bowel and bladder functions must be addressed; therefore, administering a daily rectal stimulant will ensure a daily bowel movement. Indwelling urinary catheters are discouraged due to the increased risk of infection associated with their use. Content–Medical; Category of Health Alteration–Neurological; Integrated Process– Implementation; Client Needs–Physiological Integrity, Basic Care and Comfort; Cognitive Level–Application.

Correct answer 3: Current treatment options that have proven efficacy in treating SCI is to decrease inflammation and edema by lowering the body temperature with ice saline solutions. Intravenous corticosteroid therapy is a standard of care but not intrathecal, into the spinal cord. Content–Medical;

Category of Health Alteration–Neurological; Integrated Process–Implementation; Client Needs–Physiological Integrity, Pharmacological and Parenteral Therapies; Cognitive Level–Application


15. The male client with a C-6 SCI tells the home health nurse he has had a severe pounding headache for the last 2 hours. Which intervention should the clinic nurse implement?

1. Determine when and how much the client last urinated.

2. Ask the client if he has taken any medication for the headache.

3. Inquire when the client had his last bowel movement.

4. Check the client’s respiratory rate reading immediately.

16. The client with a T-1 SCI complains of lightheadedness and dizziness when the head of the bed is elevated. The client’s B/P is 84/40. Which action should the nurse implement first?

1. Increase the client’s intravenous (IV) rate by50 mL/hr.

2. Administer dopamine, a vasopressor, via an IV pump.

3. Notify the HCP immediately.

4. Lower the client’s head of bed immediately.

17. The nurse caring for a client with a C-6 SCI determines the client has no plantar reflexes. Which area on the stick figure should the nurse document this finding? A N S W E R S 1215. Correct answer 1: The cause of the pounding 17. Correct answer: Content–Medical; Category of Healthheadache is most likely autonomic dysreflexia, a

Alteration–Neurological; Integrated Process–Assessment;result of exaggerated autonomic responses to stimuli.

Client Needs–Safe Effective Care, Management of Care;An elevated blood pressure would confirm this.

Cognitive Level–Analysis.The most common cause of autonomic dysreflexia

is a full bladder. All the other options could be

implemented, but confirming the autonomic

dysreflexia is priority. Content–Medical; Category

of Health Alteration–Neurological; Integrated

Process–Implementation; Client Needs–Safe Effective

Care Environment, Management of Care; Cognitive

Level–Analysis.

16. Correct answer 4: The blood pressure tends to be

very unstable and low for clients with an SCI of T-6

or above, and slight elevations of the head of the bed

can cause profound drops in the client’s vital signs.

Content–Medical; Category of Health Alteration–

Neurological; Integrated Process–Implementation;

Client Needs–Safe Effective Care Environment,

Management of Care; Cognitive Level–Application.

Copyright © 2010 F.A. Davis Company S E C T I O N O N E Neurological Disorders 13

18. The nurse on the rehabilitation unit is caring for the following clients with SCIs. Which client should the nurse assess first after receiving the change-of-shift report?

1. The client with a C-6 SCI who has a warm, reddened edematous gastrocnemius muscle.

2. The client with an L-4 SCI who is concerned about being able to live independently.

3. The client with an L-2 SCI who is complaining of a headache and nausea.

4. The client with a T-4 SCI who is unable to move the lower extremities.

19. The nurse is caring for clients on a rehabilitation unit. Which nursing task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?

1. Ask the UAP to hold the urinal while the client performs the Credé maneuver.

2. Discuss the proper method of administering tube feedings to the family member.

3. Assist with bowel training by inserting a suppository into the client’s rectum.

4. Observe the client demonstrating self-catheterization technique.

20. The 25-year-old client with an SCI is sharing with the nurse that he is worried about how his family will be able to survive financially until he can go back to work. Which intervention should the nurse implement?

1. Refer the client to the American Spinal Injury Association.

2. Refer the client to the state rehabilitation commission.

3. Refer the client to the social worker about applying for disability.

4. Refer the client to an occupational therapist for life skills training. A N S W E R S

Correct answer 1: The gastrocnemius muscle is the calf muscle, and warmth, redness, and swelling in the muscles indicate the client has a deep vein thrombosis (DVT), which requires immediate intervention. A client with an L-2 SCI (option 3) would not experience autonomic dysreflexia. A client with a T-4 SCI (option 4) would not be expected to be able to move the lower extremities. Content–

Medical; Category of Health Alteration–Neurological; Integrated Process–Assessment; Client Needs–Safe

Effective Care Environment, Management of Care; Cognitive Level–Analysis.

Correct answer 1: The UAP can hold a urinal for the client. The UAP cannot assess, teach, evaluate, administer medications, or care for an unstable client.

Content–Medical; Category of Health Alteration– Neurological: Integrated Process–Planning; Client Needs–Effective Care Management, Management of Care; Cognitive Level–Synthesis.

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Correct answer 3: The social worker is responsible for assisting the client with financial concerns. The ASIA assists clients to live with their SCI, and the rehabilitation commission can assist with employment.

Content–Medical; Category of Health Alteration– Neurological; Integrated Process–Implementation; Client Needs–Psychosocial Integrity; Cognitive Level–Application.


Seizures

The nurse walks into the room and notes the male client is lying supine, and the entire body is rigid with his arms and legs contracting and relaxing. The client is not aware of what is going on and is making guttural sounds. Which action should the nurse implement first?

l 1. Loosen constrictive clothing. l 2. Place padding on the side rails. l 3. Assess the client’s vital signs. l 4. Turn the client on his side.

The client newly diagnosed with epilepsy who works in

an office asks the nurse, “What can I do to prevent having seizures?” Which statement is the nurse’s best response?

1. “I recommend getting about 4 hours of sleep a night.”

2. “Ask your supervisor to have someone else make copies.”

3. “Request your employer to provide a work area with dim lighting.”

4. “You should get your serum blood level checked every month.”

23. The nurse observes a client having a tonic-clonic seizure. Which information should the nurse document in the client’s chart? Select all that apply.

1. Determine if the client is incontinent of urine or stool.

2. Document the client had privacy during the seizure.

3. Note the time and where the movement or stiffness began.

4. Note the circumstances before the client’s seizure activity began.

5. Note the results of a complete neurological assessment. A N S W E R S

Correct answer 4: Placing the client on his side helps keep the airway patent; therefore, it is the first intervention. All the other interventions may be done, but airway is priority. Content–Medical;

Category of Health Alteration–Neurological; Integrated Process–Implementation; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Analysis.

Correct answer 2: Flashing lights, such as occur with a copying machine, can evoke a seizure and should be avoided; other causes of seizures include stress, fatigue, and alcohol intake. Serum blood levels will not help prevent seizures, but they do indicate the serum drug level. Content–Medical; Category of

Health Alteration–Neurological; Integrated Process– Planning; Client Needs–Physiological Integrity, Reduction of Risk Potential; Cognitive Level–Synthesis.

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Correct answer 1, 3, 4: The nurse should assess the client before, during, and after seizure activity. Providing privacy is expected and would not be documented in the chart. The client in the postictal state needs rest; therefore, a complete neurological

assessment would not be appropriate. Content–Medical;

Category of Health Alteration–Neurological; Integrated Process–Implementation; Client Needs–Safe Effective Care

Environment, Management of Care; Cognitive Level–Application.


24. The UAP is holding the arms of a client who is having a tonic-clonic seizure. Which action should the nurse implement?

1. Help the UAP restrain the client’s upper extremities.

2. Instruct the UAP to release the client’s arms immediately.

3. Take no action because the assistant is handling the situation.

4. Notify the charge nurse of the situation immediately.

25. The client diagnosed with a seizure disorder is prescribed phenytoin (Dilantin), an anticonvulsant. Which statement indicates the client needs more teaching concerning this medication?

1. “I will brush my teeth after every meal.”

2. “I will get my Dilantin level checked regularly.”

3. “My urine will turn orange while on Dilantin.”

4. “This medication will help prevent my seizures.”

The client is admitted to the intensive care unit (ICU) experiencing status epilepiticus. Which intervention should the nurse anticipate implementing first?

l 1. Assess the client’s neurological status frequently. l 2. Monitor the client’s heart rhythm via telemetry. l 3. Administer diazepam (Valium), a benzodiazepine. l 4. Prepare to administer anticonvulsant medication.

The client is admitted to the ED after experiencing a

partial seizure. Which question would be most appropriate for the nurse to ask the client?

1. “Do you know if you lost consciousness during the seizure?”

2. “Are you feeling sleepy or very tired at this time?”

3. “When did you last take your seizure medication?”

4. “Were you feeling jittery or irritable prior to the seizure?” A N S W E R S

Correct answer 2: The client should be protected from injury but be allowed to move freely. Restraining the client’s extremities could result in orthopedic injury to the client. Content–Medical; Category of

Health Alteration–Neurological; Integrated Process– Implementation; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Application.

Correct answer 3: Dilantin does not turn the urine orange; therefore this statement indicates the client needs more teaching. Content–Medical; Category of

Health Alteration–Drug Administration; Integrated Process–Evaluation; Client Needs–Physiological Integrity, Pharmacological and Parenteral Therapies; Cognitive Level–Synthesis.

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Correct answer 3: The client is in distress; therefore, assessment is not priority. The nurse should first administer Valium to halt the seizure immediately to ensure adequate oxygen supply to the brain. Anticonvulsant medications are administered later to maintain a seizure-free state. Content–Medical;

Category of Health Alteration–Neurological; Integrated Process–Planning; Client Needs–Safe Effective Care, Management of Care; Cognitive Level–Analysis.

Correct answer 3: The nurse must determine if the client has been compliant with medication; therefore, this question is appropriate. The client does not

lose consciousness in a partial seizure and does not experience a postictal state. Hypoglycemia (feeling jittery or irritable) causes tonic-clonic seizures, not partial seizures. Content–Medical; Category of Health

Alteration–Neurological; Integrated Process–Assessment; Client Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level–Analysis.


28. Which statement by the female client indicates that the client understands factors that may precipitate seizure activity?

1. “I should not take birth control pills to prevent pregnancy.”

2. “I need to limit my intake of dairy products.”

3. “I should not participate in any contact sports.”

4. “My menstrual cycle may affect my seizure disorder.”

29. The clinic nurse is checking diagnostic test results. Which diagnostic test result would warrant notifying the client immediately?

1. The female client who is taking an anticonvulsant who has a low bone density scan.

2. The client who is diagnosed with epilepsy who has a phenytoin (Dilantin) level of 28 mcg/dL.

3. The client with a seizure disorder who has a carbamazepine (Tegretol) of 10 mcg/mL.

4. The client who has partial seizures who has a serum sodium level of 143 mEq/L.

30. The mother of a child who had a febrile seizure tells the pediatric clinic nurse, “I am so upset because now my child has epilepsy.” Which statement is the clinic nurse’s best response?

1. “Your child had a seizure due to a high fever, not due to epilepsy.”

2. “You are upset about your child having epilepsy. Let’s talk.”

3. “The Epilepsy Foundation of America provides good information.”

4. “I would recommend you attend the local epilepsy support group.” A N S W E R S

Correct answer 4: Because of the fluctuations in hormones that alter the excitability of neurons in the cerebral cortex, an increase in seizure frequency may occur during menses. Content–Medical; Category of Health Alteration–Neurological; Integrated Process– Evaluation; Client Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level–Evaluation.

Correct answer 2: The therapeutic Dilantin level is 10–20 mcg/dL; a level of 28 mcg/dL requires notifying the client. Content–Medical; Category of

Health Alteration–Neurological; Integrated Process–Assessment; Client Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level–Synthesis.

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Correct answer 1: A high fever in a child can cause a seizure, but it does not indicate the child has a seizure disorder. The nurse should provide information if at all possible instead of a therapeutic response that encourages the client to ventilate feelings. Content–Medical; Category of Health

Alteration–Neurological; Integrated Process–Evaluation; Client Needs–Health Promotion and Maintenance; Cognitive Level–Synthesis.


Cerebrovascular Accident(Stroke, Brain Attack)

31. The 88-year-old client is admitted to the ED with numbness and weakness of the left arm and slurred speech. The computed tomography (CT) scan was negative for bleeding. Which nursing intervention is priority?

1. Prepare to administer tissue plasminogen activator (TPA).

2. Discuss the precipitating factors that caused the symptoms.

3. Determine the exact time the symptoms occurred.

4. Notify the speech pathologist for an emergency consult.

32. The nurse is assessing the client experiencing a left-sided cerebrovascular accident (CVA). Which clinical manifestations would the nurse expect the client to exhibit?

1. Hemiparesis of the left arm and apraxia.

2. Paralysis of the right side of the body and aphasia.

3. Inability to recognize and use familiar objects.

4. Impulsive behavior and hostility toward family.

33. The HCP has discussed a carotid endarterectomy with the client who has experienced two transient ischemic attacks (TIAs). The client tells the nurse, “I really don’t understand why I need this procedure, and I don’t want to have it.” Which scientific rationale would support the nurse’s response?

1. This surgery is indicated for clients with symptoms of a TIA due to carotid artery stenosis.

2. This surgical procedure will ensure the client does not have a cerebrovascular accident.

3. This surgery will remove all atherosclerotic plaque from the carotid arteries.

4. This surgical procedure will increase the elasticity of the carotid arterial wall. A N S W E R S

Correct answer 3: The nurse must first determine when the symptoms started before administering TPA, a standard of care. TPA must be initiated within 3 hours of the start of symptoms because, after that time, revascularization of necrotic tissue, which occurs with the administration of TPA, increases the risk for cerebral edema and hemorrhage.

Content–Medical; Category of Health Alteration– Neurological; Integrated Process–Assessment; Client Needs–Reduction of Risk Potential; Cognitive Level–Analysis.

Correct answer 2: A left-sided CVA results in right-sided paralysis, right visual field deficit, aphasia (inability to speak), and altered intellectual ability. All other options are results of right-sided CVA.

Content–Medical; Category of Health Alteration– Neurological; Integrated Process–Assessment; Client Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level–Analysis.

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Correct answer 1: This is the rationale the nurse would utilize to encourage the client to have this surgical procedure. An endartectomy does not ensure the client will not have a CVA nor does it ensure that all atherosclerotic plaque will be removed or that the carotid artery wall will become more elastic.

Content–Medical; Category of Health Alteration– Neurological; Integrated Process–Planning; Client Needs–Physiological Adaptation, Reduction of Risk Potential; Cognitive Level–Synthesis.


34. Which client would the nurse identify as being least at risk for experiencing a CVA?

1. A 55-year-old African-American male who is obese.

2. A 73-year-old Japanese female who has essential hypertension.

3. A 67-year-old Caucasian male whose cholesterol level is below 200 mg/dL.

4. A 39-year-old female who is taking oral contraceptives.

35. The client diagnosed with a right-sided CVA is admitted to the rehabilitation unit. Which intervention should be included in the nursing care plan?

1. Turn and reposition the client every shift.

2. Place a small pillow under the client’s left shoulder.

3. Have the client perform quadriceps exercises three times a day.

4. Instruct the client to hold fingers in a fist.

The nurse is planning care for the client experiencing dysphagia secondary to a CVA. Which intervention should be included in the plan of care?l 1. Evaluate the client during mealtime.

l 2. Position the client in a semi-Fowler position. l 3. Administer oxygen during meals.

l 4. Refer the client to a physical therapist.

The nurse and a UAP are caring for a client with

right-sided paralysis. Which action by the UAP requires the nurse to intervene?

1. The UAP places the gait belt under the client’s axilla prior to ambulating.

2. The UAP places the client on the abdomen with the client’s head to the side.

3. The UAP uses a lift sheet when moving the client up in the bed.

4. The UAP praises the client for attempting to perform activities of daily life (ADLs) independently. A N S W E R S

Correct answer 3: Caucasians have a lower risk of CVA than African Americans, Hispanics, and Native Pacific Islanders. A high cholesterol level, being African American, hypertension, and oral contraceptive use are risk factors for developing a CVA. Content–Medical;Category of Health Alteration–Neurological; Integrated Process–Diagnosis; Client Needs–Health Promotion and Maintenance; Cognitive Level–Analysis.

Correct answer 2: Placing a small pillow under the left shoulder will prevent the shoulder from adducting toward the chest and developing a contracture. The client should be repositioned at least every 2 hours; quadricep exercises should be done for 10 minutes at least five times a day; and the fingers are positioned so that they are barely flexed. Content–Medical; Category of Health Alteration–Neurological; Integrated Process– Planning; Client Needs–Physiological Integrity, Basic Care and Comfort; Cognitive Level–Synthesis.

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Correct answer 1: Dysphagia (swallowing difficulty) puts the client at risk for aspiration, pneumonia, dehydration, and malnutrition; therefore, the nurse should evaluate the client during mealtime. The client should be in a high Fowler position or, preferably, in a chair. Content–Medical; Category of Health Alteration–

Neurological; Integrated Process–Planning; Client Needs– Physiological Integrity, Physiological Adaptation; Cognitive Level–Synthesis.

Correct answer 1: The gait belt should be around the waist because this is the client’s center of gravity. All other options are appropriate interventions for the UAP and would not require intervention.

Content–Medical; Category of Health Alteration– Neurological; Integrated Process–Implementation; Client Needs–Safe Effective Care Environment, Immobility; Cognitive Level–Synthesis.


38. The client diagnosed with chronic atrial fibrillation has experienced a transient TIA. Which discharge instruction should the nurse implement?

1. Keep nitroglycerin tablets in a dark-colored bottle.

2. Check the radial pulse prior to all medications.

3. Obtain International Normalized Ratio (INR) routinely.

4. Take over-the-counter vitamin K tablets daily.

39. The client diagnosed with a CVA has hemiparesis. Which problem would be priority for the client?

1. Impaired skin integrity.

2. Fluid volume overload.

3. High risk for aspiration.

4. High risk for injury.

40. The nurse has received the morning shift report. Which client should the nurse assess first?

1. The client who is complaining of a headache at a 3 on a scale of 1–10.

2. The client who has an apical pulse of 56 and a blood pressure of 210/116.

3. The client who is reporting not having a bowel movement in 3 days.

4. The client who is angry because the call light was not answered for 1 hour.

Brain Tumors

41. The client is being admitted with rule-out (R/O) brain tumor. Which signs/symptoms support the diagnosis of a brain tumor?

1. Widening pulse pressure, hypertension, and bradycardia.

2. Headache, vomiting, and diplopia.

3. Hypotension, tachycardia, and tachypnea.

4. Abrupt loss of motor function, diarrhea, and changes in taste.

A N S W E R S

Correct answer 3: An oral anticoagulant, warfarin (Coumadin), will be prescribed to help prevent the formation of thrombi in the atrium secondary to atrial fibrillation. The thrombi can become embolic, which may cause a TIA. The INR is the laboratory value used to determine therapeutic oral anticoagulant levels. Content–Medical; Category of Health Alteration–

Neurological; Integrated Process–Planning; Client Needs–Health Promotion and Maintenance; Cognitive Level–Synthesis

Correct answer 4: Hemiparesis is a weakness on one side of the body that may lead to falls; this makes high risk for injury the priority problem for this client. Content–Medical; Category of Health Alteration–

Neurological; Integrated Process–Diagnosis; Client Needs– Physiological Integrity, Reduction of Risk Potential; Cognitive Level–Analysis.

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Correct answer 2: This blood pressure is extremely high, and the pulse rate is decreased; therefore, this client should be assessed first. A 3 headache, no bowel movement, and an upset client would not be priority over a client who may be having a CVA.

Content–Medical; Category of Health Alteration– Neurological; Integrated Process–Assessment; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Analysis.

Correct answer 2: The classic triad of symptoms of a brain tumor includes a headache that is dull and unrelenting and worse in the morning, vomiting unrelated to food intake, and edema of the optic nerve (papilledema) causing diplopia. Option 1 is the Cushing triad, which indicates increased intracranial pressure that would not be seen initially on diagnosis; option 3 is signs/symptoms of hypovolemic shock.

Content–Medical; Category of Health Alteration– Neurological; Integrated Process–Assessment; Client Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level–Analysis.


The client is diagnosed with a frontal lobe brain tumor. Which sign/symptom would the nurse expect the client to exhibit?l 1. Ataxia.

l 2. Decreased visual acuity. l 3. Scanning speech.

l 4. Personality changes.

The male client diagnosed with a brain tumor is

having a closed magnetic resonance imaging (MRI) scan in 1 hour. The client tells the radiology nurse, “I don’t like small enclosed spaces.” Which action should the nurse implement?

1. Allow the client to express his feelings.

2. Discuss the procedure with the client.

3. Obtain an order for an anti-anxiety medication.

4. Reschedule the procedure for another day.

The client diagnosed with lung cancer has developed metastasis to the brain. Which problem would be priority for this client?l 1. Anticipatory grieving. l 2. Impaired gas exchange.

l 3. Altered nutritional status. l 4. Alteration in comfort.

The client diagnosed with a brain tumor was

admitted to the ICU with decorticate posturing. Which indicates that the client’s condition is improving?

1. The client has purposeful movement with painful stimuli.

2. The client assumes adduction of the upper extremities.

3. The client assumes the decerebrate posture upon painful stimuli.

4. The client has become flaccid and does not respond to stimuli. A N S W E R S

Correct answer 4: Personality changes occur in a client with a frontal lobe tumor. Ataxia or gait problems indicate a temporal lobe tumor. Decreased visual acuity is a symptom indicating papilledema, a general symptom of the majority of all brain tumors, not specifically a frontal lobe tumor. Scanning speech is symptomatic of multiple sclerosis. Content–

Medical; Category of Health Alteration–Neurologic; Integrated Process–Assessment; Client Needs–Physiological

Integrity, Physiological Adaptation; Cognitive Level– Analysis.

Correct answer 3: The client is claustrophobic and will need medications to help decrease the anxiety associated with small enclosed spaces. Ventilating feelings and discussing the procedure will not help claustrophobia. Reschedule for an open MRI, not another closed MRI. Content–Medical; Category of

Health Alteration–Neurological; Integrated Process– Planning; Client Needs–Physiological Integrity, Reduction of Risk Potential; Cognitive Level–Synthesis.

28

Correct answer 1: Anticipatory grieving is priority because brain metastasis is a terminal diagnosis, indicating death within 6 months or less. With the development of brain metastasis, the nurse must address death and dying issues, which is why this is priority over all the other client problems. Content–

Medical; Category of Health Alteration–Neurological; Integrated Process–Diagnosis; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Analysis.

Correct answer 1: Purposeful movement following painful stimuli would indicate an improvement in the client’s condition. Adducting the upper extremities while internally rotating the lower extremities is decorticate positioning; this would indicate the client’s condition had not changed. Decerebrate posturing and flaccid movement indicate a worsening of the condition. Content–Medical; Category of Health

Alteration–Neurological; Integrated Process–Evaluation; Client Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level–Evaluation.


The intensive care nurse is caring for a client following an infratentorial craniotomy. Which interventions should the nurse implement? Select all that apply.l 1. Keep the head of the bed elevated at 30 degrees. l 2. Keep a humidifier in the client’s room.

l 3. Do not put anything in the client’s mouth. l 4. Provide the client with a clear liquid diet.

l 5. Assess the client’s respiratory status every hour.

The client is diagnosed with a pituitary tumor and is

scheduled for a transsphenoidal hypophysectomy. Which postoperative instruction is important to discuss with the client?

1. Demonstrate to a family member how to change a turban dressing.

2. Explain to the client how to monitor urine output at home.

3. Tell the client not to blow his nose for 2 weeks after surgery.

4. Tell the client he will have to lie flat for 24 hours following the surgery.

48. The client has undergone a craniotomy for a brain tumor. Which data indicate a complication of this surgery?

1. The client complains of a headache at a 3–4 on a 1–10 scale.

2. The client has a urinary output of 250 mL over the last 24 hours.

3. The client has a serum sodium level of 137 mEq/L.

4. The client experiences dizziness when trying to get up too quickly. A N S W E R S

Correct answer 2, 4, 5: Humidified air would be provided; the client’s diet is started slowly; and the respiratory status is assessed because the centers that control respiration and vomiting are in the area of the brain affected by the surgery. The head of the bed would be flat, and caution with oral care is appropriate for a client with a transsphenoidal hypophysectomy, not with an infratentorial craniotomy. Content–Surgical; Category of Health

Alteration–Neurological; Integrated Process– Implementation; Client Needs–Physiological Integrity, Reduction of Risk Potential; Cognitive Level–Analysis.

Correct answer 3: Blowing the nose creates increased intracranial pressure and could result in a leak of cerebral spinal fluid. A transsphenoidal hypophysectomy is done by an incision above the gum line, and there is no turban dressing. The head of the bed is elevated to 30 degrees to allow for gravity to assist in draining the cerebrospinal fluid.

Content–Surgical; Category of Health Alteration– Neurological; Integrated Process–Planning; Client

30

Needs–Physiological Integrity, Physiological Adaptation;

Cognitive Level–Synthesis.

Correct answer 2: The decreased urinary output may indicate syndrome of inappropriate antidiuretic hormone (SIADH), which is a complication of a craniotomy. A headache after this surgery would be an expected occurrence. The sodium level is normal (135–145 mEq/L). Dizziness upon arising quickly would not be a complication of this surgery. Content–

Surgical; Category of Health Alteration–Neurological; Integrated Process–Assessment; Client Needs–Physiological Adaptation, Reduction of Risk Potential; Cognitive Level–Analysis.


The client diagnosed with a brain tumor is prescribed intravenous dexamethasone (Decadron), a steroid. Which intervention should the nurse implement when administering this medication?

l 1. Administer medication with normal saline only. l 2. Check the client’s white blood cell (WBC) count. l 3. Determine if the client has oral candidiasis.

l 4. Monitor the client’s glucose level.

The male client is scheduled for gamma knife

stereotactic surgery for a brain tumor. Which preoperative instruction should the nurse discuss with the client?

1. Instruct the client to avoid bright lights and wear sunscreen.

2. Tell the client he must sleep with the head of the bed elevated.

3. Explain there are no activity limitations after this procedure.

4. Encourage the client to take off at least 2 weeks from work.

Meningitis

The nurse is assessing the client diagnosed with bacterial meningitis. In addition to nuchal rigidity, which clinical manifestations would the nurse assess?l 1. Positive Cushing sign and ascending paralysis. l 2. Negative Kernig sign and facial tingling.

l 3. Positive Brudzinski sign and photophobia.l 4. Negative Trousseau sign and descending paralysis.

The nurse is admitting a client diagnosed with

meningococcal meningitis and notes lesions over the face and extremities. Which priority intervention should the nurse implement?

1. Initiate the intravenous antibiotics stat.

2. Obtain a skin biopsy for culture and sensitivity.

3. Perform a complete neurological assessment.

4. Close all the curtains in the room and turn off lights. A N S W E R S

Correct answer 4: Decadron, a glucocorticosteroid, will increase insulin resistance, which increases glucose levels; therefore, glucose levels should be monitored. Decadron is compatible with dextrose, so normal saline does not need to be used, and the WBC count and oral candidiasis would not be interventions pertinent to administering this medication. Content–Medical; Category of Health

Alteration–Drug Administration; Integrated Process– Implementation; Client Needs–Physiological Integrity, Pharmacological and Parenteral Therapies; Cognitive Level–Application.

Correct answer 3: This is a day-surgery procedure, and the client is usually discharged home 3–4 hours after the surgery and can resume normal activities.

Content–Medical; Category of Health Alteration– Surgical; Integrated Process–Planning; Client Needs– Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.

32

Correct answer 3: A positive Brudzinski sign (raise the client’s head, and the knees will come up) and photophobia due to meningeal irritation are key signs of meningitis. A positive Kernig sign (client is unable to extend leg when lying flat) would also be expected. Content–Medical; Category of Health

Alteration–Neurological; Integrated Process–Diagnosis; Client Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level–Analysis.

Correct answer 1: Purpuric lesions over the face and extremities are the signs of a fulminating infection in clients with meningococcal meningitis. The infection can lead to death within a few hours. The nurse should start the antibiotics immediately. Content–

Medical; Category of Health Alteration–Neurological; Integrated Process–Implementation; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Analysis.


Which type of precautions should the nurse implement for the client diagnosed with aseptic meningitis?

l 1. Standard precautions. l 2. Airborne precautions. l 3. Contact precautions. l 4. Droplet precautions.

A college student came to the university health clinic

and was diagnosed with bacterial meningitis and admitted to a local hospital. Which intervention should the university health clinic nurse implement?

1. Place the client’s dormitory under strict respiratory isolation.

2. Notify the parents of all students about the meningitis outbreak.

3. Arrange for students to receive the meningococcal vaccination.

4. Ensure dormitory roommates receive chemoprophylaxis using rifampin.

55. The nurse is preparing for a lumbar puncture for the client diagnosed with R/O meningitis. Which interventions should the nurse implement? Select all that apply.

1. Determine if the client has any allergies to iodine.

2. Do not let the client urinate 2 hours before the procedure.

3. Place the client in a prone position with the face turned to the side.

4. Instruct the client to take slow deep breaths during the procedure.

5. Label the specimen and send to the laboratory for cultures.

56. The client diagnosed with septic meningitis is admitted to the medical floor at 1200. Which HCP’s order would the nurse implement first?

1. Administer intravenous antibiotic.

2. Start the client’s intravenous line.

3. Provide a quiet, calm dark room.

4. Initiate seizure precautions. A N S W E R S

Correct answer 1: Aseptic meningitis is caused by a noninfectious agent or a virus and is not likely to be transmitted to other people; therefore, standard precautions would be expected. Septic meningitis would require droplet precautions for 24-48 hours after initiation of antibiotics. Content–Medical;

Category of Health Alteration–Neurological; Integrated Process–Implementation; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Application.

Correct answer 4: People in close contact with clients diagnosed with meningococcal meningitis, the most common type of infectious agent in group settings, should receive chemoprophylaxis for prevention of meningitis. The public health nurse or college administration would notify parents. It is too late for the vaccine. Content–Medical; Category of

Health Alteration–Infectious Disease; Integrated Process–Planning; Client Needs–Safe Effective Care Environment, Safety and Infection Control; Cognitive Level–Synthesis.

34

Correct answer 1, 4, 5: The lumbar area is cleansed with Betadine; therefore, iodine allergies should be noted. The client’s bladder should be empty for comfort during the procedure, and the client should be in a side-lying position with back arched for access to intravertebral space. Taking slow deep breaths will help calm the client, and specimens are sent to the laboratory. Content–Medical; Category of

Health Alteration–Neurological; Integrated Process– Implementation; Client Needs–Physiological Integrity, Reduction of Risk Potential; Cognitive Level–Application.

Correct answer 2: Intravenous antibiotics are of paramount importance, so the nurse must start an intravenous line first. Content–Medical; Category of

Health Alteration–Infectious Diseases; Integrated Process–Planning; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.


The nurse asks the UAP to help admit the client diagnosed with bacterial meningitis. Which nursing task is priority?l 1. Take the client’s vital signs.

l 2. Obtain the client’s height and weight.l 3. Prepare the room for respiratory isolation.l 4. Pull the drapes and make sure the room is dim.

The 18-year-old client is admitted to the medical

floor with a diagnosis of meningitis. Which priority intervention should the nurse assess?

1. Assess the client’s neurovascular status.

2. Assess the client’s cranial nerve IX function.

3. Assess the client’s brachioradialis reflex.

4. Assess the client’s neurological status.

59. The nurse is developing a plan of care for a client diagnosed with septic meningitis. Which client goal would be most appropriate for the client problem of “altered thermoregulation”?

1. The client will have no injury from using the hypothermia blanket.

2. The client will be protected from injury if seizure activity occurs.

3. The client will be afebrile for 48 hours prior to discharge.

4. The client will have serum electrolytes within normal limits.

60. The nurse is admitting a client diagnosed with meningitis who has AIDS. Which signs/symptoms would the nurse expect the client to exhibit?

1. A positive Babinski sign.

2. Diplopia and blurred vision.

3. Auditory deficits.

4. The client may be asymptomatic. A N S W E R S

Correct answer 3: Equipment needed for the staff to enter the client’s room safely is the priority nursing task that can be delegated. All other tasks could be safely delegated to the UAP, but they are not priority. Content–Medical; Category–Infectious

Diseases; Integrated Process–Planning; Client Needs– Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.

Correct answer 4: Meningitis directly affects the client’s brain; therefore, assessing the neurological status would have priority for this

client. Neurovascular assessment involves peripheral nerves and changes such as paralysis and skin temperature. Content–Medical; Category of Health

Alteration–Infectious Diseases; Integrated Process– Assessment; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Analysis.

36

Correct answer 3: The client with septic meningitis has a high fever; therefore, being afebrile for 48 hours would be an appropriate goal. Content–Medical; Cate-gory of Health Alteration–Infectious Diseases; Integrated Process–Planning; Client Needs–Physiological Integrity, Reduction of Risk Potential; Cognitive Level–Synthesis.

Correct answer 4: The client with AIDS may be asymptomatic or may exhibit atypical symptoms because of blunted inflammatory responses. Content–Medical; Category of Health Alteration–Infectious Diseases; Integrated Process–Assessment; Client Needs– Physiological Integrity, Physiological Adaptation; Cognitive Level–Analysis.


Parkinson Disease

Which clinical manifestations would the nurse expect to assess in the client diagnosed with Parkinson disease (PD)?l 1. Nausea, vomiting, and diarrhea.

l 2. Polyuria, polydipsia, and polyphagia.l 3. Dysphonia, dysphagia, and scanning speech. l 4. Tremors, rigidity, and bradykinesia.

The nurse caring for a client diagnosed with Parkinson

disease writes a problem of “Impaired Nutrition.” Which nursing intervention would be included in the plan of care?

1. Give the client a pureed diet.

2. Request a low-residue heart-healthy diet.

3. Provide an 1800-calorie American Diabetic Association diet.

4. Offer bite-sized foods on a plate warmer.

63. The nurse and the UAP are caring for clients on a medical surgical unit. Which task would be most appropriate to assign to the UAP?

1. Feed the client with Parkinson disease who has intention tremors of the hand.

2. Change the sterile pressure ulcer dressing for a client who is on bedrest.

3. Give the client who is having heartburn 30 mL of the antacid Maalox.

4. Obtain vital signs on a client with Parkinson disease who is hallucinating. A N S W E R S

Correct answer 4: Tremors, rigidity, and bradykinesia are the classic manifestations of PD. They are known as the triad of PD. Content–Medical; Category ofHealth Alteration–Neurological; Integrated Process– Assessment; Client Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level–Analysis.

Correct answer 4: Bite-sized foods require less energy from the client for chewing, and a plate warmer preserves the appeal of the food. Nothing in the stem of the question indicates that the client has diabetes, so the ADA diet would not be necessary. The client should have a high-residue (fiber) diet to prevent constipation. A pureed diet has baby-food consistency and should not be given to a client

who can chew. Content–Medical; Category of Health

Alteration–Neurological; Integrated Process–Planning; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.

38

Correct answer 1: The client with intention tremors is stable but cannot keep the food on the eating utensil to get it to the mouth; this task could be safely delegated to the UAP. UAP cannot assess, teach, evaluate, administer medications, or care for an unstable client. The client hallucinating is having a reaction to the Parkinson disease medications and is unstable. Content–Medical; Category of Health



64. The charge nurse is making assignments on a medical surgical unit. Which client should be assigned to the licensed practical nurse (LPN)?

1. The client with Parkinson disease who became disoriented throughout the night.

2. The client with aseptic meningitis who is complaining the light is bothersome.

3. The client newly diagnosed with Parkinson disease who is being discharged.

4. The client diagnosed with a brain tumor who had a seizure at the change of shift.

65. The nurse is planning the care for a client diagnosed with Parkinson disease. Which goal would be appropriate for the client problem of “impaired mobility”?

1. The client will experience periods of akinesia throughout the day.

2. The client will be able to turn from side to side in bed.

3. The client will be able to ambulate in the hall three times a day.

4. The client will be able to carry out ADLs.

66. The client diagnosed with Parkinson disease is being discharged. Which statement made by the client’s significant other indicates a need for more teaching?

1. “I know that my husband may have some emotional mood swings.”

2. “My spouse may experience hallucinations until the medication starts working.”

3. “I will schedule appointments late in the morning after his morning bath.”

4. “My spouse must take his medication at the same time every day.”

67. The client with Parkinson disease is admitted to the medical unit diagnosed with pneumonia. The nurse needs to administer ceftriaxone (Rocephin) 100 mg in 100 mL of normal saline to infuse over 30 minutes. Which rate should the nurse set the intravenous pump?

Answer: ____________________ A N S W E R S

Correct answer 2: Photophobia is an expected clinical manifestation of aseptic meningitis, so the LPN could be assigned to this client. New-onset disorientation indicates the client is unstable and would require the registered nurse (RN) to assess the client. The newly diagnosed client with PD requires extensive teaching. Seizure activity may indicate increasing intracranial pressure. Content–Medical; Category of Health


Correct answer 3: The goal of a client with impaired mobility would be to be mobile; walking in the hall would be an appropriate goal. Akinesia is lack of movement, and the client should not be allowed to stay in bed due to immobility complications. Ability to do ADLs would be appropriate for self-care deficit problem. Content–Medical; Category of Health

Alteration–Neurological; Integrated Process–Planning; Client Needs–Physiological Integrity, Basic Care and Comfort; Cognitive Level–Synthesis.

40

Correct answer 2: Hallucinations are a sign that the client is experiencing drug toxicity; therefore, this statement indicates that the significant other needs more teaching. The other statements indicate the client’s significant other understands the discharge teaching. Content–Medical; Category of Health

Alteration–Neurological; Integrated Process–Planning; Client Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level–Synthesis.

Correct answer 200 mL/hour: Intravenous pumps are set at an hourly rate; if 100 mL is infused in1 hour, the nurse should double the rate so that 100 mL would infuse in 30 minutes. Content–Medical;Category of Health Alteration–Drug Administration; Integrated Process–Implementation; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Application.


68. The home health nurse is caring for a client diagnosed with Parkinson disease. Which comment by the client’s significant other would suggest a common cognitive problem associated with Parkinson disease?

1. “My wife is never happy about anything I do for her.”

2. “All my wife does is sit on the porch and look at her garden.”

3. “My wife is becoming more forgetful about routine things.”

4. “My wife thinks the medication I give her is poison.”

69. The nurse is conducting a support group for clients diagnosed with PD and their significant others. Which information regarding physiological needs should be included in the discussion?

1. Remove all throw rugs and tack down all loose carpet.

2. Recommend the client completes an advance directive.

3. Explain the reason why the client has “pill rolling” tremors.

4. Give simple, short, concise directions to their loved one.

70. The client has been diagnosed with Parkinson disease for 12 years and has been taking levodopa (L-dopa) for the last 8 years. Which symptom would alert the nurse to a possible medication complication?

1. The client is unable to initiate voluntary movement.

2. The client has recently developed dyskinesia.

3. The client has masklike facies and cogwheel movements.

4. The client has excessive saliva production. A N S W E R S

Correct answer 3: Memory deficits are cognitive impairments; the client may also develop a dementia. Emotional liability, depression, and paranoia are psychosocial problems, not cognitive ones. Content–

Medical; Category of Health Alteration–Neurological; Integrated Process–Evaluation; Client Needs–Psychosocial Integrity; Cognitive Level–Evaluation.

Correct answer 1: The client’s safety is priority due to the physiological shuffling gait that makes the client high risk for injuries due to falls. Content–Medical;Category of Health Alteration–Neurological; Integrated Process–Planning; Client Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level–Synthesis.

42

Correct answer 2: Dyskinesia is abnormal involun-tary movement, including facial grimacing, rhythmic jerking movements, and head-bobbing. These move-ments indicate a complication of the L-dopa.

Content–Medical; Category of Health Alteration– Neurological; Integrated Process–Assessment; Client Needs–Physiological Integrity, Pharmacological and Parenteral Therapies; Cognitive Level–Analysis.


Sensory Deficits

The client is diagnosed with acute otitis media. Which statement would cause the nurse to suspect the client had a ruptured tympanic membrane?l 1. “I always have a lot of earwax buildup.”

l 2. “I have been running a fever with my ear pain.” l 3. “I had ear pain but then it went away on its own.”

l 4. “I had a sinus infection prior to getting the ear pain.”

The client is diagnosed with Ménière disease. Which

statement by the client supports that the client needs more teaching concerning the management for this disease?

1. “Surgery is the only cure for Ménière, but I may be deaf.”

2. “I will have to use a hearing aid for the rest of my life.”

3. “I must adhere to a low-sodium diet, 2000 mg/day.”

4. “When I get dizzy I need to lie down on my bed.”

73. The nurse is preparing to administer otic drops into the adult client’s right ear. Which action should the nurse implement?

1. Grasp the ear lobe and pull up and out when putting drops in the ear.

2. Insert the eardrops without touching the outside of the ear.

3. Place the applicator 1⁄4 inch into the outer ear canal.

4. Pull the auricle down and back prior to instilling drops. A N S W E R S

Correct answer 3: The pain associated with otitis media is relieved after spontaneous perforation or therapeutic incision of the tympanic membrane.Ear pain and fever are expected with otitis media.

Content–Medical; Category of Health Alteration– Neurosensory; Integrated Process–Assessment; Client Needs–Physiological Integrity, Reduction of Risk Potential; Cognitive Level–Analysis.

Correct answer 2: Ménière disease does not lead to deafness unless surgery is done, which may result in permanent deafness in the affected ear. Sodium regu-lates the balance of fluid within the body; therefore, a low-sodium diet is prescribed to help control the symptoms of Ménière disease. Content–Medical;

Category of Health Alteration–Neurosensory; Integrated Process–Evaluation; Client Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level–Evaluation.

44

Correct answer 4: Pulling the auricle down and back prior to instilling drops will straighten the ear canal so that the ear drops will enter the ear canal and drain toward the tympanic membrane (eardrum). Nothing should be placed in the outer ear canal.

Content–Medical; Category of Health Alteration–Drug Administration; Integrated Process–Implementation; Client Needs–Physiological Integrity, Pharmacological and Parenteral Therapies; Cognitive Level–Application.


74. The client is scheduled for right tympanoplasty. Which statement indicates the client understands the preoperative teaching concerning the surgery?

1. “If I have to sneeze or blow my nose, I will do it with my mouth open.”

2. “If I have any dizzy spells, I will contact my doctor immediately.”

3. “I will probably have permanent hearing loss in my right ear.”

4. “I can shampoo my hair the day after surgery as long as I am careful.”

75. The client diagnosed with osteoarthritis has been self-medicating with high doses of aspirin for the pain. Which comment by the client would warrant further evaluation by the nurse?

1. “I always take my medication with food.”

2. “I have noticed a buzzing sound in my ears.”

3. “I soak in a hot tub bath in the morning.”

4. “I will call my doctor if my gums bleed.”

The client is diagnosed with cataracts. Which symptom would the nurse expect the client to report? l 1. Halos around lights.

l 2. Floating spots in the eye.l 3. Everything has a yellow haze. l 4. Painless, blurry vision.

The 65-year-old client is diagnosed with macular

degeneration. Which statement indicates the client understands the discharge teaching concerning this diagnosis?

1. “I should use artificial tears three times a day.”

2. “I will look at my Amsler grid at least twice a week.”

3. “I am going to use low-watt lightbulbs in my house.”

4. “I will wear dark sunglasses when I go outside.” A N S W E R S

Correct answer 1: Leaving the mouth open when coughing or sneezing will minimize the pressure changes in the middle ear. Dizziness is expected after ear surgery. Tympanoplasty is a repair of the inner ear structure and will not cause permanent hearing loss. Shampooing is avoided to prevent contamination of the ear canal. Content–Surgical: Category of Health

Alteration–Neurosensory; Integrated Process–Evaluation; Client Needs–Physiological Integrity, Reduction of Risk Potential: Cognitive Level–Evaluation.

Correct answer 2: The “buzzing” should alert the nurse to possible tinnitus, which is a sign of aspirin toxicity and warrants further evaluation by the nurse.

Content–Medical; Category of Health Alteration–Drug Administration; Integrated Process–Implementation; Client Needs–Physiological Integrity, Pharmacological and Parenteral Therapies; Cognitive Level–Application.

46

Correct answer 4: A cataract is a lens opacity or cloudiness resulting in painless, blurry vision. The symptom in option 1 is characteristic of glaucoma; that in option 2 of retinal detachment; and that in option 3 of digoxin toxicity. Content–Medical;

Category of Health Alteration–Neurosensory; Integrated Process–Assessment; Client Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level–Analysis.

Correct answer 2: Amsler grids provide the earliest sign of worsening of the client’s macular degeneration. If the lines of the grid become distorted or faded,the client should call the ophthalmologist. Content–

Medical; Category of Health Alteration–Neurosensory; Integrated Process–Evaluation; Client Needs–Physiological Integrity, Physiological Adaptation; Cognitive Level–Evaluation.


78. The nurse is preparing to administer eyedrops to a client. To which area should the nurse apply pressure to prevent systemic absorption of the medication?

1. A

2. B

3. C

4. D

A D

B C

A male client is brought to the employee health clinic reporting some type of chemical was splashed in his eyes. Which action should the nurse implement first?

l 1. Arrange for transportation to the ophthalmologist. l 2. Perform a vision screening test on the client.

l 3. Flush the eye continuously with water.l 4. Complete an occurrence report for the situation.

The client with glaucoma is prescribed a miotic

cholinergic medication. Which data support the teaching for this medication has been effective?

1. The client reports taking the medication on vacations.

2. The client reports taking a stool softener every day.

3. The client places the medication in the inner canthus.

4. The client wears gloves when instilling the medication. A N S W E R S

Correct answer 4: The area marked A is known as the inner canthus; gentle pressure to this area will prevent systemic absorption of the medication.

Content–Medical; Category of Health Alteration–Drug Administration; Integrated Process–Implementation; Client Needs–Physiological Adaptation, Pharmacological and Parenteral Therapies; Cognitive Level–Synthesis.

Correct answer 3: The first and most important intervention is to flush the agent out of the eye. Then the nurse should refer the client to an ophthalmologist, maybe check vision, and then complete an occurrence report because the client was not wearing goggles. Content–Medical; Category of

Health Alteration–Neurosensory; Integrated Process– Implementation; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.

48

Correct answer 1: The client realizes that medication compliance is priority for glaucoma and consequently takes the medication while on vacation. The client should prevent constipation, but it has nothing to do with miotic medications. Medication should be placed in the conjunctiva. The client needs to wash the hands but not wear gloves. Content–Medical; Category of

Health Alteration–Drug Administration; Integrated Process–Evaluation; Client Needs–Health Promotion and Maintenance; Cognitive Level–Evaluation.


Management Issues

81. The nurse is caring for clients on a medical surgical floor. Which client should be assessed first?

1. The client diagnosed with epilepsy who reports over the intercom having an aura.

2. The client with an L-1 SCI who is complaining of shortness of breath while exercising.

3. The client diagnosed with Parkinson disease who is being discharged today.

4. The client diagnosed with a CVA who has resolving left hemiparesis.

82. The charge nurse in the medical/surgical department is making rounds at 0700. Which client should the nurse see first?

1. The client diagnosed with a brain tumor who is complaining of a headache.

2. The client diagnosed with meningitis who is complaining of a stiff neck.

3. The client diagnosed with diabetes who is reporting seeing spots in the eyes.

4. The client diagnosed with low back pain who has radiating pain down the left leg.

83. The registered nurse (RN), an LPN, and a UAP are caring for clients on a neurological unit. Which task would be most appropriate for the nurse to assign/delegate?

1. Instruct the LPN to complete the client’s admission assessment.

2. Request the UAP to change the central line dressing.

3. Assign the LPN to administer routine medications.

4. Tell the UAP to complete the Glasgow Coma Scale. A N S W E R S

Correct answer 1: The client with an aura is getting ready to have a seizure. This client should be seen first. Content–Medical; Category of Health Alteration–Neurological; Integrated Process–Assessment; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Analysis.

Correct answer 3: Seeing spots could indicate a retinal detachment, and this requires the nurse to assess this client first. If the signs/symptoms are expected for the disease process—such as headache with a brain tumor, a stiff neck with meningitis, and pain radiating down the leg in a client with low back pain—then the nurse should not assess that client first unless the symptom is life-threatening. Content–

Medical; Category of Health Alteration–Neurological; Integrated Process–Assessment; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Analysis.

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Correct answer 3: The LPN can administer routine medications. The RN should not delegate/assign assessment to an LPN or a UAP (options 1 and 4). The central line dressing change is a sterile dressing that should not be delegated to a UAP. Content–

Medical; Category of Health Alteration–Drug Administration; Integrated Process–Planning; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.


84. The nurse is caring for a client diagnosed with septic meningitis. The UAP reports T 101.6°F, P 128, R 32, B/P 96/46. Which action should the nurse implement first?

1. Notify the HCP.

2. Assess the client immediately.

3. Prepare to administer acetaminophen (Tylenol).

4. Check the chart for the culture and sensitivity report.

85. The nurse is preparing to administer dexamethasone (Decadron) intravenous push (IVP) to a client with an acute spinal cord injury. Which interventions should the nurse implement? Rank in order.

1. Administer the medication over 2 minutes.

2. Dilute the medication with normal saline.

3. Check the client’s medication administration record (MAR).

4. Check the client’s identification band.

5. Clamp the primary tubing distal to the port.

86. The 22-year-old client with a severe head injury is admitted to the critical care unit. Some of the client’s friends come to the nurse’s station requesting information. Which action would be most appropriate by the nurse?

1. Tell the friends to talk to the parents.

2. Discuss the client’s situation with the friends.

3. Allow the friends to visit the client for 10 minutes.

4. Explain that no information can be shared with the friends.

87. The male client diagnosed with a brain tumor who is receiving hospice care is admitted to the hospital and provides the nurse with a copy of his living will, stating he does not want any heroic measures. Which action should the nurse implement first?

1. Check the chart to make sure there is a do not resuscitate (DNR) order.

2. Inform the HCP that the client has a living will.

3. Place a copy of the living will in the front of the client’s chart.

4. Request the hospital chaplain to come and talk to the client. A N S W E R S

Correct answer 2: Whenever another health-care team member reports information to the nurse, assessment should be completed to confirm the data. Then the nurse should notify the HCP, administer Tylenol to decrease the fever, and check the chart, but the nurse must first realize this is potential septic shock, and the client should be assessed. Content–Medical; Category of

Health Alteration–Infectious Diseases; Integrated Process– Implementation; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Application.

Correct answer 3, 2, 4, 5, 1: First check the MAR to ensure the right medication, the right dose, at the right time. Diluting the medication saves the vein and decreases the client’s pain during administration. Check for the right client by checking the client’s identification band. Clamping the tubing will ensure the medication goes into the vein, and 2 minutes is the recommended administration time. Content–

Medical; Category of Health Alteration–Drug Administration; Integrated Process–Implementation;

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Cognitive Level–Safe Effective Care Environment,

Management of Care; Cognitive Level–Application.

Correct answer 4: The nurse cannot violate the client’s confidentiality according to the Health Information Privacy and Portability Act (HIPPA).

Content–Fundamentals; Category of Health Alteration– Neurological; Integrated Process–Planning; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Application.

Correct answer 1: This action should be implemented first to ensure the client’s wishes will be honored in case the client codes. All other actions could be taken, but the client’s wishes are priority. Content–Medical;

Category of Health Alteration–Neurological; Integrated Process–Implementation; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Application.


88. The charge nurse has received laboratory data for clients. Which situation requires the charge nurse’s intervention first?

1. The client with a brain tumor who has ABGs: ph 7.36, PaO2 95, PaCO2 38, HCO3 24.

2. The postoperative craniotomy client who has a serum sodium level of 153 mEq/L.

3. The client with septic meningitis who has a white blood cell count of 12,000 mm.

4. The client with epilepsy who has a serum phenytoin (Dilantin) level 15 mcg/mL.

89. The primary nurse in the neurological critical care unit is very busy. Which nursing task must be implemented first?

1. Assist the HCP with a sterile dressing change for a client who has a turban dressing.

2. Obtain a tracheostomy tray for a client with aC-4 SCI who is exhibiting air hunger.

3. Transcribe orders for a client who was transferred from the emergency department.

4. Administer the antibiotic therapy to the client diagnosed with meningitis.

90. The nurse and a UAP are caring for a client with right-sided paralysis secondary to a CVA. Which action by the UAP requires the nurse to intervene?

1. The UAP encourages the client to perform ROM exercises.

2. The UAP places the client on a side with a pillow between the legs.

3. The UAP leaves a urinal full of urine at the client’s bedside.

4. The UAP praises the client for attempting to get dressed alone. A N S W E R S

Correct answer 2: An elevated serum sodium level (normal is 135–145 mEq/L) indicates possible diabetes insipidus, which is a complication of brain surgery. The ABGs are within normal limits, the WBC count would be elevated in a client with meningitis, and the therapeutic Dilantin level is 10–20 mcg/mL. Content–Medical; Category of Health

Alteration–Surgical; Integrated Process–Implementation; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Synthesis.

Correct answer 2: The client with a C-4 SCI may have ascending edema that could cause respiratory compromise; therefore, the nurse should have a tracheostomy tray at the bedside. Content–Medical;

Category of Health Alteration–Neurological; Integrated Process–Planning; Client Needs–Safe Effective Care Environment, Management of Care; Cognitive Level–Evaluation.a

Documents

021290Neurologic Exam(Flash Card)