MedSurg Neurological Disorders NCLEX Questions

Regular oral hygiene is an essential intervention for a client who has had a stroke. Which of the following nursing measures is inappropriate when providing oral hygiene?

A. Placing the client on the back with a small pillow under the head.

B. Keeping portable suctioning equipment at the bedside.

C. Opening the client's mouth with a padded tongue blade.

D. Cleaning the client's mouth and teeth with a toothbrush.

A.

client should be positioned on the side, not on the back. This lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration.

A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority?

A. Prepare to administer recombinant tissue plasminogen activator (rt-PA).

B. Discuss the precipitating factors that caused the symptoms.

C. Schedule for A STAT computer tomography (CT) scan of the head.

D. Notify the speech pathologist for an emergency consultation.

C.

A CT scan will determine if the client is having a stroke or has a brain tumour or another neurological disorder. This would also determine if it is a hemorrhagic or ischemic accident and guide the treatment because only an ischemic stroke can use tPA.

A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment?

A. Time of onset of current stroke

B. Complete physical and history

C. Current medications

D. Upcoming surgical procedures

A.

The time of onset of a stroke to t-PA administration is critical. Administration within 3 hours has better outcomes. Tissue plasminogen activator (tPA) is classified as a serine protease (enzymes that cleave peptide bonds in proteins). It is thus one of the essential components of the dissolution of blood clots. Its primary function includes catalyzing the conversion of plasminogen to plasmin, the primary enzyme involved in dissolving blood clots.

During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client's:

A. Pulse

B. Respirations

C. Blood pressure

D. Temperature

C.

Controlling the blood pressure is critical because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Blood pressure should be maintained according to the physician and is specific to the client's ischemic tissue needs and risks of bleeding from treatment.

What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?

A. Cholesterol level

B. Pupil size and pupillary response

C. Bowel sounds

D. Echocardiogram

B.

It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. Pupil reactions are regulated by the oculomotor (III) cranial nerve and are useful in determining whether the brain stem is intact. Pupil size and equality is determined by a balance between parasympathetic and sympathetic innervation. Response to light reflects the combined function of the optic (II) and oculomotor (III) cranial nerves.

What is the expected outcome of thrombolytic drug therapy?

A. Increased vascular permeability

B. Vasoconstriction

C. Dissolved emboli

D. Prevention of hemorrhage

C.

Thrombolytic therapy is used to dissolve emboli and reestablish cerebral perfusion. Thrombolytic treatment is also known as fibrinolytic or thrombolysis, to dissolve dangerous intravascular clots to prevent ischemic damage by improving blood flow. Thrombosis is a significant physiological response that limits hemorrhage caused by large or tiny vascular injury.

The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge?

A. A thrombolytic medication

B. A beta-blocker medication

C. An anti-hyperuricemic medication

D. An oral anticoagulant medication

D.

Thrombi form secondary to atrial fibrillation. Therefore, an anticoagulant would be anticipated to prevent thrombus formation; and oral (warfarin [Coumadin]) at discharge versus intravenous. Oral anticoagulation is indicated for patients with atrial fibrillation or other sources of cardioembolic sources of TIA.

Which client would the nurse identify as being most at risk for experiencing a CVA?

A. A 39-year-old pregnant female.

B. A 67-year-old Caucasian male.

C. An 84-year-old Japanese female.

D. A 55-year-old African American male.

D.

African Americans have twice the rate of CVAs as Caucasians; males are more likely to have strokes than females except in advanced years. Of all the risk factors, hypertension is the most common modifiable risk factor for stroke. Hypertension is most prevalent in African-Americans and also occurs earlier in life.

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?

A. A blood glucose level of 480 mg/dl.

B. A right-sided carotid bruit.

C. A blood pressure of 220/120 mmHg.

D. The presence of bronchogenic carcinoma.

C.

Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured blood vessel in the cranium. Hypertension is the most common cause of hemorrhagic stroke. Long standing hypertension produces degeneration of media, breakage of the elastic lamina, and fragmentation of smooth muscles of arteries.

The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene?

A. The assistant places a gait belt around the client's waist prior to ambulating.

B. The assistant places the client on the back with the client's head to the side.

C. The assistant places her hand under the client's right axilla to help him/her move up in bed.

D. The assistant praises the client for attempting to perform ADLs independently.

C.

This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; as always use a lift sheet for the client and nurse safety. Avoid pulling the affected arm. Place a hand behind the scapula when moving the upper extremity instead of pulling from the arm; Utilize a lift sheet during bed repositioning. When the patient is sitting provide the arm with a firm support surface

A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances?

A. Vomiting continues.

B. Intracranial pressure (ICP) is increased.

C. The client needs mechanical ventilation.

D. Blood is anticipated in the cerebrospinal fluid (CSF).

B.

Sudden removal of CSF results in pressures lower in the lumbar area than the brain and favours herniation of the brain; therefore, LP is contraindicated with increased ICP.

A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons?

A. To reduce intraocular pressure.

B. To prevent acute tubular necrosis.

C. To promote osmotic diuresis to decrease ICP.

D. To draw water into the vascular system to increase blood pressure.

C.

Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. Although mannitol is used for all the reasons described, the reduction of ICP in this client is a concern. The mannitol causes the cells in the brain to dehydrate mildly. The water inside the brain cells (intracellular water) leaves the cells and enters the bloodstream as the mannitol draws it out of the cells and into the bloodstream. Once in the bloodstream, the extra water is whisked out of the skull. When the mannitol gets to the kidneys, the kidneys filter the mannitol into the urine.

A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective?

A. Urine output increases.

B. Pupils are 8 mm and nonreactive.

C. Systolic blood pressure remains at 150 mm Hg.

D. BUN and creatinine levels return to normal.

A.

Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes. The mannitol causes the cells in the brain to dehydrate mildly. The water inside the brain cells (intracellular water) leaves the cells and enters the bloodstream as the mannitol draws it out of the cells and into the bloodstream. Once in the bloodstream, the extra water is whisked out of the skull. When the mannitol gets to the kidneys, the kidneys filter the mannitol into the urine.

Which of the following values is considered normal for ICP?

A. 0 to 15 mm Hg

B. 25 mm Hg

C. 35 to 45 mm Hg

D. 120/80 mm Hg

A.

Normal ICP is 0-15 mm Hg. Intracranial hypertension (IH) is a clinical condition that is associated with an elevation of the pressures within the cranium. The pressure in the cranial vault is measured in millimeters of mercury (mm Hg) and is normally less than 20 mm Hg.

Which of the following symptoms may occur with a phenytoin level of 32 mg/dl?

A. Ataxia and confusion

B. Sodium depletion

C. Tonic-clonic seizure

D. Urinary incontinence

A.

A therapeutic phenytoin level is 10 to 20 mg/dl. A level of 32 mg/dl indicates toxicity. Symptoms of toxicity include confusion and ataxia. The neurotoxic effects are concentration dependent and can range from mild nystagmus to ataxia, slurred speech, vomiting, lethargy and eventually coma and death. Paradoxically, at very high concentrations, phenytoin can lead to seizures.

Which of the following signs and symptoms of increased ICP after head trauma would appear first?

A. Bradycardia

B. Large amounts of very dilute urine

C. Restlessness and confusion

D. Widened pulse pressure

C.

The earliest symptom of elevated ICP is a change in mental status. Following the neurological exam closely is very important. Usually, there is an altered mental status and development of a fixed and dilated pupil. Patients presenting with findings suggestive of cerebral insult should undergo computed tomography (CT) scan of the brain; this can show the edema, which is visible as areas of low density and loss of gray/white matter differentiation, on an unenhanced image.

Problems with memory and learning would relate to which of the following lobes?

A. Frontal

B. Occipital

C. Parietal

D. Temporal

D.

The temporal lobe functions to regulate memory and learning problems because of the integration of the hippocampus. The hippocampus is responsible for creating declarative memories-those that can be consciously thought of and verbalized. Declarative memory can be episodic and semantic. Episodic memory is the ability to remember a specific occasion in the past in its specific time and place. Meanwhile, semantic memory is the ability to recall general facts about the world.

While cooking, your client couldn't feel the temperature of a hot oven. Which lobe could be dysfunctional?

A. Frontal

B. Occipital

C. Parietal

D. Temporal

C.

The parietal lobe regulates sensory function, which would include the ability to sense hot or cold objects.

The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain?

A. Sternal rub

B. Pressure on the orbital rim

C. Squeezing the sternocleidomastoid muscle

D. Nail bed pressure

D.

Motor testing on the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. Using peripheral pain to elicit a response isn't an effective test of brain function. A response may indicate that the patient feels the stimulus, but the response is from the spinal cord. If the patient didn't respond at all to central stimuli, apply a peripheral stimulus to all four extremities to establish a baseline. If all but one of his extremities responded to a central stimulus, test only the nonresponsive extremity. Pressing on his nail plate with a pencil is an acceptable technique.

The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure?

A. Side-lying, with legs pulled up and head bent down onto the chest.

B. Side-lying, with a pillow under the hip.

C. Prone, in a slight Trendelenburg's position.

D. Prone, with a pillow under the abdomen.

A.

The client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen, and with the head bent down onto the chest. This position helps to open the spaces between the vertebrae. The positioning of the patient in either a lateral recumbent position or sitting position may be used. The lateral recumbent position is preferred as it will allow an accurate measurement of opening pressure, and it also reduces the risk of post-lumbar puncture headache.

A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has:

A. A cerebral lesion

B. A temporal lesion

C. An intact brainstem

D. Brain death

C.

Caloric testing provides information about differentiating between cerebellar and brainstem lesions. After determining patency of the ear canal, cold or warm water is injected in the auditory canal. A normal response that indicates intact function of cranial nerves III, IV, and VIII is conjugate eye movements toward the side being irrigated, followed by rapid nystagmus to the opposite side. Absent or disconjugate eye movements indicate brainstem damage.

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

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

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

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

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

B.

A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may arise. Cushing triad is a clinical syndrome consisting of hypertension, bradycardia and irregular respiration and is a sign of impending brain herniation. This occurs when the ICP is too high the elevation of blood pressure is a reflex mechanism to maintain CPP.

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits:

A. A negative Kernig's sign.

B. A positive Brudzinski's sign.

C. Absence of nuchal rigidity.

D. A Glascow Coma Scale score of 15.

B.

Signs of meningeal irritation compatible with meningitis include nuchal rigidity, positive Brudzinski's sign, and positive Kernig's sign. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. Brudzinski's sign is characterized by reflexive flexion of the knees and hips following passive neck flexion. To elicit this sign, the examiner places one hand on the patient's chest and the other hand behind the patient's neck. The examiner then passively flexes the neck forward and assesses whether the knees and hips flex.

A client is arousing from a coma and keeps saying, "Just stop the pain." The nurse responds based on the knowledge that the human body typically and automatically responds to pain first with attempts to:

A. Tolerate the pain.

B. Decrease the perception of pain.

C. Escape the source of pain.

D. Divert attention from the source of pain.

C.

The client's innate responses to pain are directed initially toward escaping from the source of pain. For example, in sudden strong pain like that generated by pricking the finger, a reflex response occurs within the spinal cord. Motor neurons are activated and the muscles of the arm contract, moving the hand away from the sharp object. This occurs in a fraction of a second — before the signal has been relayed on to the brain — so the client will have pulled his arm away before even becoming conscious of the pain.

During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following would be most appropriate to institute?

A. Limiting conversation with the child.

B. Allowing the child to play in the bathtub.

C. Keeping extraneous noise to a minimum.

D. Performing treatments quickly

C.

A child in the acute stage of meningitis is irritable and hypersensitive to loud noise and light. Therefore, extraneous noise should be minimized and bright lights avoided as much as possible. Maintain a quiet environment and keep the lights dim. Prevents stimulation that can cause or precipitate an episode of convulsion.

Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation?

A. Hemorrhagic skin rash

B. Edema

C. Cyanosis

D. Dyspnea on exertion

A.

DIC is characterized by skin petechiae and a purpuric skin rash caused by spontaneous bleeding into the tissues. An abnormal coagulation phenomenon causes the condition. Disseminated intravascular coagulation (DIC) can be defined as a widespread hypercoagulable state that can lead to both microvascular and macrovascular clotting and compromised blood flow, ultimately resulting in multiple organ dysfunction syndrome or MODS. As this process begins consuming clotting factors and platelets in a positive feedback loop, hemorrhage can ensue, which may be the presenting symptom of a patient with DIC.

When interviewing the parents of a 2-year-old child, a history of which of the following illnesses would lead the nurse to suspect pneumococcal meningitis?

A. Bladder infection

B. Middle ear infection

C. Fractured clavicle

D. Septic arthritis

B.

Organisms that cause bacterial meningitis, such as pneumococci or meningococci, are commonly spread in the body by vascular dissemination from a middle ear infection. Meningitis may also be a direct extension from the paranasal and mastoid sinuses. The causative organism is a pneumococcus. A chronically draining ear is frequently also found.

The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate? Select all that apply.

A. Increased appetite

B. Vomiting

C. Polydipsia

D. Lethargy

E. Head tilt

F. Increased pulse

B, D, E

Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor. Tumors that develop in the brain are called primary tumors. Tumors that spread to the brain after forming in a different part of the body are called secondary tumors or metastatic tumors. This article focuses on primary tumors.

A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and determines which of the following results would verify the diagnosis?

A. Cloudy CSF, decreased protein, and decreased glucose.

B. Cloudy CSF, elevated protein, and decreased glucose.

C. Clear CSF, elevated protein, and decreased glucose.

D. Clear CSF, decreased pressure, and elevated protein.

B.

A diagnosis of meningitis is made by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure, turbid or cloudy CSF, elevated leukocytes, elevated protein, and decreased glucose levels.

A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which of the following would be included in the plan of care?

A. No precautions are required as long as antibiotics have been started.

B. Maintain enteric precautions.

C. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.

D. Maintain neutropenic precautions.

C.

A major priority of nursing care for a child suspected of having meningitis is to administer the prescribed antibiotic as soon as it is ordered. The child is also placed on respiratory isolation for at least 24 hours while culture results are obtained and the antibiotic is having an effect. Antibiotics are given to treat the underlying causes of inflammation and thus prevent the occurrence of seizure activity.

A nurse is reviewing the record of a child with increased ICP and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse would expect to note which of the following if this type of posturing was present?

A. Abnormal flexion of the upper extremities and extension of the lower extremities.

B. Rigid extension and pronation of the arms and legs.

C. Rigid pronation of all extremities.

D. Flaccid paralysis of all extremities.

B.

Decerebrate posturing is characterized by the rigid extension and pronation of the arms and legs. Synonymous terms for decerebrate posturing include abnormal extension, decerebrate rigidity, extensor posturing, or decerebrate response. Decerebrate posturing can be seen in patients with large bilateral forebrain lesions with progression caudally into the diencephalon and midbrain. It can also be caused by a posterior fossa lesion compressing the midbrain or rostral pons.

Which of the following assessment data indicated nuchal rigidity?

A. Positive Kernig's sign

B. Negative Brudzinski's sign

C. Positive homan's sign

D. Negative Kernig's sign

A.

A positive Kernig's sign indicated nuchal rigidity, caused by an irritative lesion of the subarachnoid space. Brudzinski's sign is also indicative of the condition. To elicit the Kernig sign, clinicians typically perform the exam with the patient lying supine with the thighs flexed on the abdomen, and the knees flexed. The examiner then passively extends the legs. In the presence of meningeal inflammation, the patient will resist leg extension or describe pain in the lower back or posterior thighs, which indicates a positive sign.

Meningitis occurs as an extension of a variety of bacterial infections due to which of the following conditions?

A. Congenital anatomic abnormality of the meninges.

B. Lack of acquired resistance to the various etiologic organisms.

C. Occlusion or narrowing of the CSF pathway.

D. Natural affinity of the CNS to certain pathogens.

B.

Extension of a variety of bacterial infections is a major causative factor of meningitis and occurs as a result of a lack of acquired resistance to the etiologic organisms. Preexisting CNS anomalies are factors that contribute to susceptibility. Meningitis can be caused by infectious and non-infectious processes (autoimmune disorders, cancer/paraneoplastic syndromes, drug reactions). The infectious etiologic agents of meningitis include bacteria, viruses, fungi, and less commonly parasites.

Which of the following pathologic processes is often associated with aseptic meningitis?

A. Ischemic infarction of cerebral tissue.

B. Childhood diseases of viral causation such as mumps.

C. Brain abscesses caused by a variety of pyogenic organisms.

D. Cerebral ventricular irritation from a traumatic brain injury.

B.

Aseptic meningitis is caused principally by viruses and is often associated with other diseases such as measles, mumps, herpes, and leukemia. Aseptic meningitis is a term used to define inflammation of the brain meninges due to various etiologies with negative cerebrospinal fluid (CSF) bacterial cultures. It is one of the most common, usually benign, inflammatory disorders of the meninges. Viruses are a common etiology, however, there are many other infective and non-infective causes. Therefore, the terms aseptic meningitis and viral meningitis are not interchangeable.

You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to LPN/LVN?

A. Complete admission assessment.

B. Place a padded tongue blade at the bedside.

C. Set up oxygen and suction equipment.

D. Pad the side rails before the patient arrives.

C.

The LPN/LVN can set up the equipment for oxygen and suctioning. Supportive care with attention to airway, breathing, and circulation issues are vital. Clear communication between team members is essential since patients' clinical status may abruptly change. Most patients will have a single, brief, uncomplicated event and return to full consciousness. Detection of any underlying cause of the seizure or seizures is important, so that appropriate therapy or counseling is available.

If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse would anticipate that the client has problems with:

A. Body temperature control

B. Balance and equilibrium

C. Visual acuity

D. Thinking and reasoning

A.

The body's thermostat is located in the hypothalamus; therefore, injury to that area can cause problems of body temperature control. The spinothalamic tract is the sensory pathway for pain, temperature and crude touch that originates in the spinal cord and feeds into the ventral posterolateral nucleus of the thalamus for further processing, while the ventral posteromedial nucleus receives sensory information from the trigeminal nerve about the face.

A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning?

A. phenytoin (Dilantin)

B. mannitol (Osmitrol)

C. lidocaine (Xylocaine)

D. furosemide (Lasix)

B.

Administering lidocaine via an endotracheal tube may minimize elevations in ICP caused by suctioning. Lidocaine use, both intravenous (IV) and laryngotracheal (LT), has been reported to blunt the ICP elevations during intubation. Though one would assume that the ICP mediated effects of lidocaine stem from its local anesthetic effect, there are other proposed mechanisms of ICP reduction via the IV route. Lidocaine injected IV has been shown in models to induce cerebral vasoconstriction leading to a decrease in cerebral blood volume and thus ICP. Furthermore, IV lidocaine leads to sodium channel inhibition and thus a reduction in cerebral activity and metabolic demands, as well as excitotoxicity, leading to a potential ICP reduction effect.

(Not mannitol as it can only been given IV)

After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client?

A. Give him a barbiturate.

B. Place him on mechanical ventilation.

C. Perform a lumbar puncture.

D. Elevate the head of his bed.

C.

The client's history and assessment suggest that he may have increased intracranial pressure (ICP). If this is the case, lumbar puncture shouldn't be done because it can quickly decompress the central nervous system and, thereby, cause additional damage. A head computed tomogram (CT) should be obtained before performing a lumbar puncture if there is a concern for increased intracranial pressure. Signs and symptoms of possible increased intracranial pressure include altered mental status, focal neurological deficits, new-onset seizure, papilledema, immunocompromised state, malignancy, history of focal CNS disease (stroke, focal infection, tumor), concern for mass CNS lesion and age greater than 60 years old.

When obtaining the health history from a male client with retinal detachment, the nurse expects the client to report:

A. Light flashes and floaters in front of the eye.

B. A recent driving accident while changing lanes.

C. Headaches, nausea, and redness of the eyes.

D. Frequent episodes of double vision.

A.

The sudden appearance of light flashes and floaters in front of the affected eye is characteristic of retinal detachment. Patients with a rhegmatogenous retinal detachment may present with a history of a large number of new-onset floaters. They may also have significant photopsia (flashes of light) in their vision.

Which nursing diagnosis takes highest priority for a client with Parkinson's crisis?

A. Imbalanced nutrition: Less than body requirements

B. Ineffective airway clearance

C. Impaired urinary elimination

D. Risk for injury

B.

In Parkinson's crisis, dopamine-related symptoms are severely exacerbated, virtually immobilizing the client. A client confined to bed during such a crisis is at risk for aspiration and pneumonia. Also, excessive drooling increases the risk of airway obstruction. Because of these concerns, the nursing diagnosis of Ineffective airway clearance takes highest priority. Although the other options also are appropriate, they aren't immediately life-threatening.

The nurse has given the male client with Bell's palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs additional information if the client states that he or she will:

A. Wrinkle the forehead, blow out the cheeks, and whistle.

B. Massage the face with a gentle upward motion.

C. Perform facial exercises.

D. Exposure to cold and drafts.

D.

Exposure to cold or drafts is avoided. Local application of heat to the face may improve blood flow and provide comfort. Facial pain is controlled with analgesic agents or heat applied to the involved side of the face.

A male client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure the client to ensure client safety?

A. Speak loudly to the client.

B. Test the temperature of the shower water.

C. Check the temperature of the food on the delivery tray.

D. Provide a clear path for ambulation without obstacles.

D.

Cranial nerve II is the optic nerve, which governs vision. The nurse can provide safety for the visually impaired client by clearing the path of obstacles when ambulating. Compromise of the optic nerve results in visual field defects and/or visual loss. The type of visual field defect depends on which region of the optic pathway is disrupted.

A female client has a neurological deficit involving the limbic system. Specific to this type of deficit, the nurse would document which of the following information related to the client's behavior.

A. Is disoriented to person, place, and time.

B. Affect is flat, with periods of emotional lability.

C. Cannot recall what was eaten for breakfast today.

D. Demonstrate inability to add and subtract; does not know who is the president.

B.

The limbic system is responsible for feelings (affect) and emotions. While the limbic system was initially suggested to be the sole neurological system involved in regulating emotion, it is now considered only one part of the brain to regulate visceral, autonomic processes. In general, the limbic system assists in various processes relating to cognition; including spatial memory, learning, motivation, emotional processing, and social processing.

A client is admitted with a diagnosis of Sturge-Weber syndrome. Which of the following information would you expect to find in this client?

A. It is a dysfunction of the trigeminal nerve causing a severe sharp pain in the nose, lips, gums, or across the cheeks.

B. It is a non-progressive neurological disorder of the seventh cranial nerve causing paralysis of one of the sides of the face.

C. It is a rare degenerative brain disorder characterized by sudden development of progressive neurological and neuromuscular symptoms.

D. It is a neurocutaneous disorder with angiomas causing abnormalities in the skin, brain, and eyes from birth.

D.

Sturge-Weber syndrome, also known as encephalofacial or encephalotrigeminal angiomatosis, is a neurocutaneous syndrome that is associated with a port-wine birthmark (facial port-wine stains in the trigeminal nerve distribution), vascular lesions in the ipsilateral brain and meninges, and eye problems such as glaucoma.

A client is admitted to the emergency room with a spinal cord injury. The client is complaining of lightheadedness, flushed skin above the level of the injury, and headache. The client's blood pressure is 160/90 mm Hg. Which of the following is a priority action for the nurse to take?

A. Loosen tight clothing or accessories

B. Assess for any bladder distention

C. Raise the head of the bed

D. Administer antihypertensive

C.

The client is experiencing an autonomic dysreflexia, a life-threatening medical emergency that affects individuals with spinal injuries. Usually an individual with SCI has a blood pressure reading of 20 mm to 40 mm Hg above baseline. If this condition is suspected, the priority nursing action is to raise the head of bed or place the client in high Fowler's position. This promotes adequate ventilation and prevents the occurrence of hypertensive stroke.

A client who had a stroke is seen bumping into things on the side and is having difficulty picking up the beginning of the next line of what he is reading. The client is experiencing which of the following conditions?

A. Visual neglect

B. Astigmatism

C. Blepharitis

D. Homonymous Hemianopsia

D.

Homonymous Hemianopsia is the loss of half of the visual field. It is usually caused by a stroke, brain tumor, and trauma. A client with hemianopia may bump into things on the side of the visual field defect and often lose their place in reading due to the visual field loss.

Which of the following medical treatments should the nurse anticipate administering to a client with increased intracranial pressure due to brain hemorrhage, except?

A. acetaminophen (Tylenol)

B. dexamethasone (Decadron)

C. mannitol (Osmitrol)

D. phenytoin (Dilantin)

E. nitroglycerin (Nitrostat)

E.

Decreasing blood pressure is essential to prevent exacerbation of intracerebral bleeding. However, BP medication such as nitroglycerin is avoided due to its vasodilating effects that increase cerebral blood volume and thus increases intracranial pressure.

Which of the following symptoms would you expect to a client with a phenytoin level of 35 mg/dL?

A. Ataxia

B. Potassium deficit

C. Neglect syndrome

D. Tetraplegia

A.

A therapeutic phenytoin level is 10 to 20 mg/dl. A level of 35 mg/dl signifies toxicity. Symptoms of this level of concentration include ataxia, tremor, slurred speech, nausea, and vomiting.

To encourage adequate nutritional intake for a female client with Alzheimer's disease, the nurse should:

A. Stay with the client and encourage him to eat.

B. Help the client fill out his menu.

C. Give the client privacy during meals.

D. Fill out the menu for the client.

A.

Staying with the client and encouraging him to feed himself will ensure adequate food intake. A client with Alzheimer's disease can forget how to eat. Offer sweet and salt substitutes. Helps satisfy desire for these tastes as taste buds decrease with aging without compromising diet. Allow for interaction during mealtime to promote interest in eating.

The nurse is performing a mental status examination on a male client diagnosed with a subdural hematoma. This test assesses which of the following?

A. Cerebellar function

B. Intellectual function

C. Cerebral function

D. Sensory function

C.

The mental status examination assesses functions governed by the cerebrum. Some of these are orientation, attention span, judgment, and abstract reasoning. Cerebrum is the largest part of the brain and is composed of right and left hemispheres. It performs higher functions like interpreting touch, vision, and hearing, as well as speech, reasoning, emotions, learning, and fine control of movement.

Shortly after admission to an acute care facility, a male client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium) 10 mg I.V. stat. How soon can the nurse administer the second dose of diazepam, if needed and prescribed?

A. In 30 to 45 seconds

B. In 10 to 15 minutes

C. In 30 to 45 minutes

D. In 1 to 2 hours

B.

When used to treat status epilepticus, diazepam may be given every 10 to 15 minutes, as needed, to a maximum dose of 30 mg. The nurse can repeat the regimen in 2 to 4 hours, if necessary, but the total dose shouldn't exceed 100 mg in 24 hours. It is crucial to monitor respiratory and cardiovascular status, blood pressure, heart rate, and symptoms of anxiety in patients taking diazepam.

Emergency medical technicians transport a 27-year-old ironworker to the emergency department. They tell the nurse, "He fell from a two-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has a compound fracture of his left femur and he's comatose. We intubated him and he's maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual resuscitation bag." Which intervention by the nurse has the highest priority?

A. Assessing the left leg.

B. Assessing the pupils.

C. Placing the client in Trendelenburg's position.

D. Assessing level of consciousness.

A.

In the scenario, airway and breathing are established so the nurse's next priority should be circulation. With a compound fracture of the femur, there is a high risk of profuse bleeding; therefore, the nurse should assess the site. Monitor vital signs. Note signs of general pallor, cyanosis, cool skin, changes in mentation. Inadequate circulating volume compromises systemic tissue perfusion.

An auto mechanic accidentally has battery acid splashed in his eyes. His coworkers irrigate his eyes with water for 20 minutes, and then take him to the emergency department of a nearby hospital, where he receives emergency care for the corneal injury. The physician prescribes dexamethasone (Maxidex Ophthalmic Suspension), two drops of 0.1% solution to be instilled initially into the conjunctival sacs of both eyes every hour; and polymyxin B sulfate (Neosporin Ophthalmic), 0.5% ointment to be placed in the conjunctival sacs of both eyes every 3 hours. Dexamethasone exerts its therapeutic effect by:

A. Increasing the exudative reaction of ocular tissue.

B. Decreasing leukocyte infiltration at the site of ocular inflammation.

C. Inhibiting the action of carbonic anhydrase.

D. Producing a miotic reaction by stimulating and contracting the sphincter muscles of the iris.

B.

Dexamethasone exerts its therapeutic effect by decreasing leukocyte infiltration at the site of ocular inflammation. This reduces the exudative reaction of diseased tissue, lessening edema, redness, and scarring. Dexamethasone is a widely prescribed drug by many healthcare professionals, including the nurse practitioner. However, it is essential to know that this potent steroid has many adverse effects, and patient monitoring is critical.

A female client who's paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis?

A. The client leaves the side rails down.

B. The client uses a mirror to inspect the skin.

C. The client repositions only after being reminded to do so.

D. The client hangs the left arm over the side of the wheelchair.

B.

Using a mirror enables the client to inspect all areas of the skin for signs of breakdown without the help of staff or family members. Inspect skin daily. Observe for pressure areas, and provide meticulous skincare. Teach the patient to inspect skin surfaces and to use a mirror to look at hard-to-see-areas. Altered circulation, loss of sensation, and paralysis potentiate pressure sore formation. This is a lifelong consideration.

A client, age 22, is admitted with bacterial meningitis. Which hospital room would be the best choice for this client?

A. A private room down the hall from the nurses' station.

B. An isolation room three doors from the nurses' station.

C. A semi-private room with a 32-year-old client who has viral meningitis.

D. A two-bedroom with a client who previously had bacterial meningitis.

B.

A client with bacterial meningitis should be kept in isolation for at least 24 hours after admission. Patients suspected of having meningococcal meningitis should be placed in droplet precautions until they have received 24 hours of antibiotics. Close contacts should also be treated prophylactically. Ciprofloxacin, rifampin, or ceftriaxone may be used. Close contacts are defined as people within 3 feet of the patient for more than 8 hours during the seven days before and 24 hours after receiving antibiotics. People exposed to the patient's oral secretions during this time should also be treated.

Nurse Marty is monitoring a client for adverse reactions to dantrolene (Dantrium). Which adverse reaction is most common?

A. Excessive tearing

B. Urine retention

C. Muscle weakness

D. Slurred speech

C.

The most common adverse reaction to dantrolene is muscle weakness. The drug also may depress liver function or cause idiosyncratic hepatitis. The intravenous administration of dantrolene in healthy volunteers has resulted in skeletal muscle weakness, dyspnea, respiratory muscle weakness, and decreased inspiratory capacity. These are expected symptoms given the mechanism of action of the medication.

The nurse is monitoring a male client for adverse reactions to atropine sulfate (Atropine Care) eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction?

A. Tachycardia

B. Increased salivation

C. Hypotension

D. Apnea

A.

Systemic absorption of atropine sulfate can cause tachycardia, palpitations, flushing, dry skin, ataxia, and confusion. To minimize systemic absorption, the client should apply digital pressure over the punctum at the inner canthus for 2 to 3 minutes after instilling the drops. Tachycardia is the most common side effect; titrate dose to effect when treating bradyarrhythmia in patients with coronary artery disease. Atropine may precipitate acute angle glaucoma, pyloric obstruction, urinary retention due to benign prostatic hyperplasia, or viscid plugs in patients with chronic lung diseases.

A male client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign the highest priority to which nursing diagnosis?

A. Impaired physical mobility

B. Ineffective breathing pattern

C. Disturbed sensory perception (tactile)

D. Self-care deficit: Dressing/grooming

B.

Because a cervical spine injury can cause respiratory distress, the nurse should take immediate action to maintain a patent airway and provide adequate oxygenation. Maintain patent airway: keep head in neutral position, elevate head of bed slightly if tolerated, use airway adjuncts as indicated. Patients with high cervical injury and impaired gag and cough reflexes require assistance in preventing aspiration and maintaining patient airway.

A male client has a history of painful, continuous muscle spasms. He has taken several skeletal muscle relaxants without experiencing relief. His physician prescribes diazepam (Valium), two (2) mg P.O. twice daily. In addition to being used to relieve painful muscle spasms, Diazepam also is recommended for:

A. Long-term treatment of epilepsy.

B. Postoperative pain management of laminectomy clients.

C. Postoperative pain management of diskectomy clients.

D. Treatment of spasticity associated with spinal cord lesions.

D.

Diazepam also is recommended for treatment of spasticity associated with spinal cord lesions. Diazepam's use is limited by its central nervous system effects and the tolerance that develops with prolonged use. It is a fast-acting, long-lasting benzodiazepine commonly used in the treatment of anxiety disorders, as well as alcohol detoxification, acute recurrent seizures, severe muscle spasm, and spasticity associated with neurologic disorders.

While reviewing a client's chart, the nurse notices that the female client has myasthenia gravis. Which of the following statements about neuromuscular blocking agents is true for a client with this condition?

A. The client may be less sensitive to the effects of a neuromuscular blocking agent.

B. Succinylcholine shouldn't be used; pancuronium may be used in a lower dosage.

C. Pancuronium shouldn't be used; succinylcholine may be used in a lower dosage.

D. Pancuronium and succinylcholine both require cautious administration.

D.

The nurse must cautiously administer pancuronium, succinylcholine, and any other neuromuscular blocking agent to a client with myasthenia gravis. Patients on NMDA are usually in the intensive care unit. Monitoring of patients on NMDA includes pulse oximetry for oxygen saturation, continuous end-tidal C02. The rise in the level of carbon dioxide might show the development of malignant hyperthermia.

A male client is color blind. The nurse understands that this client has a problem with:

A. Rods.

B. Cones.

C. Lens.

D. Aqueous humor.

B.

Cones provide daylight color vision, and their stimulation is interpreted as color. If one or more types of cones are absent or defective, color blindness occurs. Very few individuals are truly color blind, but instead, see a disrupted range of colors. The most common forms are protanopia and deuteranopia, conditions arising from loss of function of one of the cones, leading to dichromic vision.

A female client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain?

A. Diencephalon

B. Medulla

C. Midbrain

D. Cortex

C.

Decerebrate posturing, characterized by abnormal extension in response to painful stimuli, indicates damage to the midbrain. Decerebrate posturing can be seen in patients with large bilateral forebrain lesions with progression caudally into the diencephalon and midbrain. It can also be caused by a posterior fossa lesion compressing the midbrain or rostral pons.

The nurse is assessing a 37-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find?

A. Vision changes

B. Absent deep tendon reflexes

C. Tremors at rest

D. Flaccid muscles

A.

Vision changes, such as diplopia, nystagmus, and blurred vision, are symptoms of multiple sclerosis. Multiple sclerosis (MS) is a chronic autoimmune disease of the central nervous system (CNS) characterized by inflammation, demyelination, gliosis, and neuronal loss. Neurological symptoms vary and can include vision impairment, numbness and tingling, focal weakness, bladder and bowel incontinence, and cognitive dysfunction. Symptoms vary depending on lesion location.

The nurse is caring for a male client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?

A. Sit with the client for a few minutes.

B. Administer an analgesic.

C. Inform the nurse manager.

D. Call the physician immediately.

D.

A headache may be an indication that an aneurysm is leaking. The nurse should notify the physician immediately. Unruptured cerebral aneurysms are asymptomatic and are therefore unable to be detected based on history and physical exam alone. However, when ruptured, they commonly present with a sudden onset, severe headache. This is classically described as a "thunderclap headache" or "worst headache of my life." In 30% of patients, the pain is lateralized to the side of the aneurysm.

During recovery from a cerebrovascular accident (CVA), a female client is given nothing by mouth, to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once each shift. This assessment evaluates:

A. Cranial nerves I and II.

B. Cranial nerves III and V.

C. Cranial nerves VI and VIII.

D. Cranial nerves IX and X.

D.

Swallowing is a motor function of cranial nerves IX and X. Cranial nerve IX (glossopharyngeal nerve), is responsible for motor (SVE) innervation of the stylopharyngeus and the pharyngeal constrictor muscles by the nucleus ambiguus. Damage to the recurrent laryngeal branch of the vagus nerve can result in vocal hoarseness or acute dyspnea with bilateral avulsion.

A white female client is admitted to an acute care facility with a diagnosis of cerebrovascular accident (CVA). Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for CVA?

A. Caucasian race

B. Female sex

C. Obesity

D. Bronchial asthma

C.

Obesity is a risk factor for CVA. Other risk factors include a history of ischemic episodes, cardiovascular disease, diabetes mellitus, atherosclerosis of the cranial vessels, hypertension, polycythemia, smoking, hypercholesterolemia, oral contraceptive use, emotional stress, family history of CVA, and advancing age.

The nurse is teaching a female client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to:

A. Take a hot bath.

B. Rest in an air-conditioned room.

C. Increase the dose of muscle relaxants.

D. Avoid naps during the day.

B.

Fatigue is a common symptom in clients with multiple sclerosis. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. Other measures to reduce fatigue in the client with multiple sclerosis include treating depression, using occupational therapy to learn energy conservation techniques, and reducing spasticity.

A male client is having tonic-clonic seizures. What should the nurse do first?

A. Elevate the head of the bed.

B. Restrain the client's arms and legs.

C. Place a tongue blade in the client's mouth.

D. Take measures to prevent injury.

D.

Protecting the client from injury is the immediate priority during a seizure. Do not leave the patient during and after a seizure to promote safety measures. Maintain in lying position, flat surface; turn head to side during seizure activity. Helps in the drainage of secretions; prevents the tongue from obstructing the airway. Loosen clothing from neck or chest and abdominal areas to aid in breathing or chest expansion.

The nurse is working on a surgical floor. The nurse must log roll a male client following a:

A. Laminectomy.

B. Thoracotomy.

C. Hemorrhoidectomy.

D. Cystectomy.

A.

The client who has had spinal surgery, such as laminectomy, must be logrolled to keep the spinal column straight when turning. Laminectomy is among the most common procedures performed by spinal surgeons to decompress the spinal canal in various conditions. Preoperative and postoperative patient care is crucial to improve outcomes of laminectomy.

A female client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test?

A. Immobilize the neck before the client is moved onto a stretcher.

B. Determine whether the client is allergic to iodine, contrast dyes, or shellfish.

C. Place a cap on the client's head.

D. Administer a sedative as ordered.

B.

Because CT commonly involves the use of a contrast agent, the nurse should determine whether the client is allergic to iodine, contrast dyes, or shellfish. In some patients, contrast agents may cause allergic reactions, or in rare cases, temporary kidney failure. IV contrast agents should not be administered to patients with abnormal kidney function since they may induce a further reduction of kidney function, which may sometimes become permanent.

During a routine physical examination to assess a male client's deep tendon reflexes, the nurse should make sure to:

A. Use the pointed end of the reflex hammer when striking the Achilles' tendon.

B. Support the joint where the tendon is being tested.

C. Tap the tendon slowly and softly.

D. Hold the reflex hammer tightly.

B.

To prevent the attached muscle from contracting, the nurse should support the joint where the tendon is being tested. With clean hands on a fully relaxed joint, the tendon/target is struck with sufficient force to elicit the reflex while the clinician's eyes are focused on the proximal muscle group, looking for contraction, rather than the distal appendage, looking for movement.

A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority for this client's plan of care?

A. Disturbed sensory perception (visual)

B. Self-care deficit: Dressing/grooming

C. Impaired verbal communication

D. Risk for injury

D.

Because the client is disoriented and restless, the most important nursing diagnosis is risk for injury. Provide for safety needs (e.g., supervision, side rails, seizure precautions, placing call bell within reach, positioning needed items within reach/clearing traffic paths, ambulating with devices). This is to prevent untoward incidents and to promote safety.

For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to:

A. Prevent respiratory alkalosis.

B. Lower arterial pH.

C. Promote carbon dioxide elimination.

D. Maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg.

C.

The goal of treatment is to prevent acidemia by eliminating carbon dioxide. That is because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP. Hypercarbia lowers serum pH and can increase cerebral blood flow contributing to rising ICP, hence hyperventilation to lower pCO2 to around 30 mm Hg can be transiently used.

Nurse Mary witnesses a neighbor's husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to open the airway in this victim by using which method?

A. Flexed position

B. Head tilt-chin lift

C. Jaw-thrust maneuver

D. Modified head tilt-chin lift

C.

If a neck injury is suspected, the jaw thrust maneuver is used to open the airway. The jaw thrust maneuver more directly lifts the hyoid bone and tongue away from the posterior pharyngeal wall by subluxating the mandible forward onto the sliding part of the temporomandibular joint (mandibular advancement).

The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use which of the following to test the client's peripheral response to pain?

A. Sternal rub

B. Nail bed pressure

C. Pressure on the orbital rim

D. Squeezing of the sternocleidomastoid muscle

B.

Motor testing in the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. Motor responses can be purposeful, such as the patient pulling on an airway adjunct, or reflexive, including withdrawal, flexion, or extension responses.

A female client admitted to the hospital with a neurological problem asks the nurse whether magnetic resonance imaging may be done. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the client's history of:

A. Hypertension

B. Heart failure

C. Prosthetic valve replacement

D. Chronic obstructive pulmonary disorder

C.

The client having a magnetic resonance imaging scan has all metallic objects removed because of the magnetic field generated by the device. A careful history is obtained to determine whether any metal objects are inside the client, such as orthopedic hardware, pacemakers, artificial heart valves, aneurysm clips, or intrauterine devices. These may heat up, become dislodged, or malfunction during this procedure. The client may be ineligible if a significant risk exists.

The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid?

A. Head midline

B. Head turned to the side

C. Neck in neutral position

D. Head of bed elevated 30 to 45 degrees

B.

The head of the client with increased intracranial pressure should be positioned so the head is in a neutral midline position. The nurse should avoid flexing or extending the client's neck or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure down.

A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid:

A. Is clear and tests negative for glucose.

B. Is grossly bloody in appearance and has a pH of 6.

C. Clumps together on the dressing and has a pH of 7.

D. Separates into concentric rings and tests positive for glucose.

D.

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

A male client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?

A. Strict adherence to a bowel retraining program.

B. Keeping the linen wrinkle-free under the client.

C. Preventing unnecessary pressure on the lower limbs.

D. Limiting bladder catheterization to once every 12 hours.

D.

The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every four (4) to six (6) hours, and foley catheters should be checked frequently to prevent kinks in the tubing. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

The nurse is caring for the male client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated?

A. Loosening restrictive clothing.

B. Restraining the client's limbs.

C. Removing the pillow and raising padded side rails.

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

B.

The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible, protects the head from injury, and moves furniture that may injure the client. Other aspects of care are as described for the client who is in bed.

The nurse is assigned to care for a female client with complete right-sided hemiparesis. The nurse plans care knowing that this condition:

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

B. The client has weakness on the right side of the body, including the face and tongue.

C. The client has lost the ability to move the right arm but can walk independently.

D. The client has lost the ability to move the right arm but can walk independently.

B.

Hemiparesis is a weakness of one side of the body that may occur after a stroke. Complete hemiparesis is a weakness of the face and tongue, arm, and leg on one side. Complete bilateral paralysis does not occur in this condition.

The client with a brain attack (stroke) has residual dysphagia. When a diet order is initiated, the nurse avoids doing which of the following?

A. Giving the client thin liquids.

B. Thickening liquids to the consistency of oatmeal.

C. Placing food on the unaffected side of the mouth.

D. Allowing plenty of time for chewing and swallowing.

A.

Before the client with dysphagia is started on a diet, the gag and swallow reflexes must have returned. Review individual pathology and ability to swallow, noting extent of the paralysis: clarity of speech, tongue involvement, ability to protect airway, episodes of coughing, presence of adventitious breath sounds. Weigh periodically as indicated. Nutritional interventions and choices of feeding route are determined by these factors.

The nurse is assessing the adaptation of the female client to changes in functional status after a brain attack (stroke). The nurse assesses that the client is adapting most successfully if the client:

A. Gets angry with family if they interrupt a task.

B. Experiences bouts of depression and irritability.

C. Has difficulty with using modified feeding utensils.

D. Consistently uses adaptive equipment in dressing self.

D.

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

Nurse Kristine is trying to communicate with a client with brain attack (stroke) and aphasia. Which of the following actions by the nurse would be least helpful to the client?

A. Speaking to the client at a slower rate.

B. Allowing plenty of time for the client to respond.

C. Completing the sentences that the client cannot finish.

D. Looking directly at the client during attempts at speech.

C.

Clients with aphasia after brain attack (stroke) often fatigue easily and have a short attention span. The nurse would avoid shouting (because the client is not deaf), appearing rushed for a response, and letting family members provide all the responses for the client.

The nurse is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic crisis. The nurse tells the client that this is most effectively done by:

A. Eating large, well-balanced meals.

B. Doing muscle-strengthening exercises.

C. Doing all chores early in the day while less fatigued.

D. Taking medications on time to maintain therapeutic blood levels.

D.

Taking medications correctly to maintain blood levels that are not too low or too high is important. The complication of myasthenia gravis includes myasthenic crisis, usually secondary to infections, stress, or acute illnesses. Patients are advised to take their medications as directed and to avoid taking new medicines without checking with the medical provider.

A male client with Bell's Palsy asks the nurse what has caused this problem. The nurse's response is based on an understanding that the cause is:

A. Unknown, but possibly includes ischemia, viral infection, or an autoimmune problem.

B. Unknown, but possibly includes long-term tissue malnutrition and cellular hypoxia.

C. Primary genetic in origin, triggered by exposure to meningitis.

D. Primarily genetic in origin, triggered by exposure to neurotoxins.

A.

Bell's palsy is a one-sided facial paralysis from compression of the facial nerve. The exact cause is unknown but may include vascular ischemia, infection, exposure to viruses such as herpes zoster or herpes simplex, autoimmune disease, or a combination of these factors. BP is thought to result from compression of the seventh cranial nerve at the geniculate ganglion. The first portion of the facial canal, the labyrinthine segment, is the narrowest and it is here that most cases of compression occur. Due to the narrow opening of the facial canal, inflammation causes compression and ischemia of the nerve.

An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first?

A. Reposition the client to avoid neck flexion.

B. Administer 1 g Mannitol IV as ordered.

C. Increase the ventilator's respiratory rate to 20 breaths/minute.

D. Administer 100 mg of pentobarbital IV as ordered.

A.

The nurse should first attempt nursing interventions, such as repositioning the client to avoid neck flexion, which increases venous return and lowers ICP. Elevate the head of the bed to greater than 30 degrees. Keep the neck midline to facilitate venous drainage from the head. Nursing care must pay close attention to changes in neurologic status, any change in vitals such as an increasingly erratic heart rate, development of bradycardia, accurate and equal intake and output when having diuresis, and maintenance of proper blood pressure.

A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?

A. Therapeutic drug levels should be maintained between 20 to 30 mg/ml.

B. Rapid Dilantin administration can cause cardiac arrhythmias.

C. Dilantin should be mixed in dextrose in water before administration.

D. Dilantin should be administered through an IV catheter in the client's hand.

B.

Dilantin IV shouldn't be given at a rate exceeding 50 mg/minute. Rapid administration can depress the myocardium, causing arrhythmias. The drug is slowly administered intravenously directly into a large central or peripheral vein through an IV catheter less than 20 gauge, not exceeding a rate of 50 mg/minute.

A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?

A. Evaluate urine specific gravity.

B. Anticipate treatment for renal failure.

C. Provide emollients to the skin to prevent breakdown.

D. Slow down the IV fluids and notify the physician.

A.

Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce the antidiuretic hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration.

When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result?

A. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP).

B. Emergent; the client is poorly oxygenated.

C. Normal

D. Significant; the client has alveolar hypoventilation.

A.

A normal PaCO2 value is 35 to 45 mm Hg. CO2 has vasodilating properties; therefore, lowering PaCO2 through hyperventilation will lower ICP caused by dilated cerebral vessels. A subdural hematoma forms because of an accumulation of blood under the dura mater, one of the protective layers to the brain tissue under the calvarium.

A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first?

A. Assess full ROM to determine extent of injuries.

B. Call for an immediate chest x-ray.

C. Immobilize the client's head and neck.

D. Open the airway with the head-tilt-chin-lift maneuver.

C.

All clients with a head injury are treated as if a cervical spine injury is present until x-rays confirm their absence. The airway doesn't need to be opened since the client appears alert and not in respiratory distress. The management of patients with head trauma should always consider C-spine motion restriction. Hold the neck immobile in line with the body, apply a rigid or semi rigid cervical collar, and (unless the patient is very restless) secure the head to the trolley with sandbags and tape.

A client with a C6 spinal injury would most likely have which of the following symptoms?

A. Aphasia

B. Hemiparesis

C. Paraplegia

D. Tetraplegia

D.

Tetraplegia occurs as a result of cervical spine injuries. Cervical injuries lead to the same deficits as thoracic injuries and, also, may result in loss of function of the upper extremities leading to tetraplegia. Injuries above C5 may also cause respiratory compromise due to loss of innervation of the diaphragm.

A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority?

A. Bladder distension

B. Neurological deficit

C. Pulse ox readings

D. The client's feelings about the injury

C.

After a spinal cord injury, ascending cord edema may cause a higher level of injury. The diaphragm is innervated at the level of C4, so assessment of adequate oxygenation and ventilation is necessary. Maintain patent airway: keep head in neutral position, elevate head of bed slightly if tolerated, use airway adjuncts as indicated. Measure serial ABGs and pulse oximetry. Documents status of ventilation and oxygenation, identifies respiratory problems such as hypoventilation (low Pao2 and elevated Paco2) and pulmonary complications.

While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions?

A. Autonomic dysreflexia

B. Hemorrhagic shock

C. Neurogenic shock

D. Pulmonary embolism

C.

Symptoms of neurogenic shock include hypotension, bradycardia, and warm, dry skin due to the loss of adrenergic stimulation below the level of the lesion. Neurogenic shock is a devastating consequence of spinal cord injury (SCI), also known as vasogenic shock. Injury to the spinal cord results in a sudden loss of sympathetic tone, which leads to the autonomic instability that is manifested in hypotension, bradyarrhythmia, and temperature dysregulation.

A client is admitted with a spinal cord injury at the level of T12. He has limited movement of his upper extremities. Which of the following medications would be used to control edema of the spinal cord?

A. acetazolamide (Diamox)

B. furosemide (Lasix)

C. methylprednisolone (Solu-Medrol)

D. sodium bicarbonate

C.

High doses of Solu-Medrol are used within 24 hours of spinal injury to reduce cord swelling and limit neurological deficit. The other drugs aren't indicated in this circumstance. Methylprednisolone and its derivatives, methylprednisolone acetate succinate, and methylprednisolone sodium, are intermediate-acting, synthetic glucocorticoids used mainly as anti-inflammatory or immunosuppressive agents. Methylprednisolone is five times more potent in its anti-inflammatory properties relative to hydrocortisone (cortisol), with minimal mineralocorticoid activities compared to the latter.

A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first?

A. Place the client flat in bed.

B. Assess patency of the indwelling urinary catheter.

C. Give one SL nitroglycerin tablet.

D. Raise the head of the bed immediately to 90 degrees.

D.

Anxiety, flushing above the level of the lesion, piloerection, hypertension, and bradycardia are symptoms of autonomic dysreflexia, typically caused by such noxious stimuli such as a full bladder, fecal impaction, or decubitus ulcer. Elevate head of bed to 45-degree angle or place patient in sitting position. Lowers BP to prevent intracranial hemorrhage, seizures, or even death. Note: Placing tetraplegic in sitting position automatically lowers BP.

A client with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons?

A. To hasten wound healing.

B. To immobilize the cervical spine.

C. To prevent autonomic dysreflexia.

D. To hold bony fragments of the skull together.

B.

Gardner-Wells, Vinke, and Crutchfield tongs immobilize the spine until surgical stabilization is accomplished. There are several uses for GWT, including the treatment of cervical spine fractures, patient positioning inside the operating room, and skeletal traction during spinal deformity surgery. Aside from GWT, different apparatuses have been utilized for skeletal traction, including Crutchfield's caliper, Cone's caliper, Blackburn's caliper, and halo traction.

Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury?

A. Insert an indwelling urinary catheter to straight drainage.

B. Schedule intermittent catheterization every 2 to 4 hours.

C. Perform a straight catheterization every 8 hours while awake.

D. Perform Crede's maneuver to the lower abdomen before the client voids.

B.

Intermittent catheterization should begin every 2 to 4 hours early in the treatment. When residual volume is less than 400 ml, the schedule may advance to every 4 to 6 hours. Begin bladder retraining per protocol when appropriate (fluids between certain hours, digital stimulation of trigger area, contraction of abdominal muscles, Credé's maneuver).

A client who is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions?

A. Laceration of the middle meningeal artery.

B. Rupture of the carotid artery.

C. Thromboembolism from a carotid artery.

D. Venous bleeding from the arachnoid space.

A.

Epidural hematoma or extradural hematoma is usually caused by laceration of the middle meningeal artery. Most epidural hematomas result from arterial bleeding from a branch of the middle meningeal artery. The anterior meningeal artery or dural arteriovenous (AV) fistula at the vertex may be involved.

A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first?

A. Position the client flat in bed.

B. Check the fluid for dextrose with a dipstick.

C. Suction the nose to maintain airway patency.

D. Insert nasal and ear packing with sterile gauze.

B.

Clear fluid from the nose or ear can be determined to be cerebral spinal fluid or mucous by the presence of dextrose. CSF Leak is a condition in which CSF is able to escape from the subarachnoid space through a hole in the surrounding dura. The volume of CSF lost in a leak is very variable, ranging from insignificant to very substantial amounts.