An early sign of increased ICP that the nurse should assess for is
A) Cushing's triad.
B) unexpected vomiting.
C) decreasing level of consciousness (LOC).
D) dilated pupil with sluggish response to light.
The nurse recognizes the presence of Cushing's triad in the patient with which vital sign changes?
A) Increased pulse, irregular respiration, increased BP
B) Decreased pulse, increased respiration, decreased systolic BP
C) Decreased pulse, irregular respiration, widened pulse pressure
D) Increased pulse, decreased respiration, widened pulse pressure
Increased ICP in the left cerebral cortex caused by intracranial bleeding causes displacement of brain tissue to the right hemisphere beneath the falx cerebri. The nurse knows that this is referred to as what?
A) Uncal herniation
B) Tentorial herniation
C) Cingulate herniation
D) Temporal lobe herniation
Priority Decision: A patient has ICP monitoring with an intraventricular catheter. What is a priority nursing intervention for the patient?
A) Aseptic technique to prevent infection
B) Constant monitoring of ICP waveforms
C) Removal of CSF to maintain normal ICP
D) Sampling CSF to determine abnormalities
When using intraventricular ICP monitoring, what should the nurse be aware of to prevent inaccurate readings?
A) The P2 wave is higher than the P1 wave.
B) CSF is leaking around the monitoring device.
C) The stopcock of the drainage device is open to drain the CSF fluid.
D) The transducer of the ventriculostomy monitor is at the level of the upper ear.
The patient is being monitored long term with a brain tissue oxygenation catheter. What range for the pressure of oxygen in brain tissue (PbtO2) will maintain cerebral oxygen supply and demand?
A) 55% to 75%
B) 20 to 40 mm Hg
C) 70 to 150 mm Hg
D) 80 to 100 mm Hg
Which drug treatment helps to decrease ICP by expanding plasma and the osmotic effect to move fluid?
B) Oxygen administration
C) Pentobarbital (Nembutal)
D) Mannitol (Osmitrol) (25%)
How are the metabolic and nutritional needs of the patient with increased ICP best met?
A) Enteral feedings that are low in sodium
B) Simple glucose available in D5W IV solutions
C) Fluid restriction that promotes a moderate dehydration
D) Balanced, essential nutrition in a form that the patient can tolerate
Why is the Glasgow Coma Scale (GCS) used?
A) To quickly assess the LOC
B) To assess the patient's ability to communicate
C) To assess the patient's ability to respond to commands
D) To assess the patient's coordination with motor responses
A patient with an intracranial problem does not open his eyes to any stimulus, has no verbal response except moaning and muttering when stimulated, and flexes his arm in response to painful stimuli. What should the nurse record as the patient's GCS score?
Priority Decision: When assessing the body functions of a patient with increased ICP, what should the nurse assess first?
A) Corneal reflex testing
B) Pupillary reaction to light
C) Extremity strength testing
D) Circulatory and respiratory status
How is cranial nerve (CN) III, originating in the midbrain, assessed by the nurse for an early indication of pressure on the brain stem?
A) Assess for nystagmus
B) Test the corneal reflex
C) Test pupillary reaction to light
D) Test for oculocephalic (doll's eyes) reflex
A patient has a nursing diagnosis of risk for ineffective cerebral tissue perfusion related to cerebral edema. What is an appropriate nursing intervention for the patient?
A) Avoid positioning the patient with neck and hip flexion.
B) Maintain hyperventilation to a PaCO2 of 15 to 20 mm Hg.
C) Cluster nursing activities to provide periods of uninterrupted rest.
D) Routinely suction to prevent accumulation of respiratory secretions.
An unconscious patient with increased ICP is on ventilatory support. Which arterial blood gas (ABG) measurement should prompt the nurse to notify the HCP?
A) pH of 7.43
B) SaO2 of 94%
C) PaO2 of 70 mm Hg
D) PaCO2 of 35 mm Hg
Priority Decision: While the nurse performs range of motion (ROM) on an unconscious patient with increased ICP, the patient experiences severe decerebrate posturing reflexes. What should the nurse do first?
A) Use restraints to protect the patient from injury while posturing.
B) Perform the exercises less frequently because posturing indicates increased ICP.
C) Administer central nervous system (CNS) depressants to lightly sedate the patient.
D) Continue the exercises because they are necessary to maintain musculoskeletal function.
The patient has been diagnosed with a cerebral concussion. What should the nurse expect to see in this patient?
A) Deafness, loss of taste, and CSF otorrhea
B) CSF otorrhea, vertigo, and Battle's sign with a dural tear
C) Boggy temporal muscle because of extravasation of blood
D) Headache, retrograde amnesia, and transient reduction in LOC
The patient comes to the emergency department (ED) with cortical blindness and visual field defects. Which type of head injury does the nurse suspect?
A) Cerebral contusion
B) Orbital skull fracture
C) Posterior fossa fracture
D) Frontal lobe skull fracture
The patient has a depressed skull fracture and scalp lacerations with communication to the intracranial cavity. Which type of injury should the nurse record?
A) Linear skull fracture
B) Depressed skull fracture
C) Compound skull fracture
D) Comminuted skull fracture
A patient with a head injury has bloody drainage from the ear. What should the nurse do to determine if CSF is present in the drainage?
A) Examine the tympanic membrane for a tear.
B) Test the fluid for a halo sign on a white dressing.
C) Test the fluid with a glucose-identifying strip or stick.
D) Collect 5 mL of fluid in a test tube and send it to the laboratory for analysis.
The nurse suspects the presence of an arterial epidural hematoma in the patient who experiences
A) failure to regain consciousness following a head injury.
B) a rapid deterioration of neurologic function within 24 to 48 hours following a head injury.
C) nonspecific, nonlocalizing progression of alteration in LOC occurring over weeks or months.
D) unconsciousness at the time of a head injury with a brief period of consciousness followed by a decrease in LOC.
Skull x-rays and a CT scan provide evidence of a depressed parietal fracture with a subdural hematoma in a patient admitted to the ED following an automobile accident. In planning care for the patient, what should the nurse anticipate?
A) The patient will receive life support measures until the condition stabilizes.
B) Immediate burr holes will be made to rapidly decompress the intracranial cavity.
C) The patient will be treated conservatively with close monitoring for changes in neurologic status.
D) The patient will be taken to surgery for a craniotomy for evacuation of blood and decompression of the cranium.
A 54-yr-old man is recovering from a skull fracture with a subacute subdural hematoma that caused unconsciousness. He has return of motor control and orientation but appears apathetic and has reduced awareness of his environment. When planning discharge of the patient, what should the nurse explain to the patient and family?
A) The patient is likely to have long-term emotional and mental changes that may require professional help.
B) Continuous improvement in the patient's condition should occur until he has returned to pre trauma status.
C) The patient's complete recovery may take years, and the family should plan for his long-term dependent care.
D) Role changes in family members will be necessary because the patient will be dependent on his family for care and support.
The patient is suspected of having a new brain tumor. Which test will the nurse expect to be ordered to detect a small tumor?
A) CT scan
C) Electroencephalography (EEG)
D) Positron emission tomography (PET) scan
Assisting the family to understand what is happening to the patient is an especially important role of the nurse when the patient has a tumor in which part of the brain?
B) Frontal lobe
C) Parietal lobe
D) Occipital lobe
Which cranial surgery would require the patient to learn how to protect the surgical area from trauma?
A) Burr holes
What is the best explanation of stereotactic radiosurgery?
A) Radioactive seeds are implanted in the brain.
B) Very precisely focused radiation destroys tumor cells.
C) Tubes are placed to redirect CSF from one area to another.
D) The cranium is opened with removal of a bone flap to open the dura.
For the patient undergoing a craniotomy, when should the nurse provide information about the use of wigs and hairpieces or other methods to disguise hair loss?
A) During preoperative teaching
B) If the patient asks about their use
C) In the immediate postoperative period
D) When the patient expresses negative feelings about his or her appearance
What would best indicate successful achievement of outcomes for the patient with cranial surgery?
A) Ability to return home in 6 days
B) Ability to meet all self-care needs
C) Acceptance of residual neurologic deficits
D) Absence of signs and symptoms of increased ICP
On physical examination of a patient with headache and fever, the nurse should suspect a brain abscess when the patient has
B) nuchal rigidity.
C) focal symptoms.
D) signs of increased ICP.
A patient is admitted to the hospital with possible bacterial meningitis. During the initial assessment, the nurse questions the patient about a recent history of what?
A) Mosquito or tick bites
B) Chickenpox or measles
C) Cold sores or fever blisters
D) An upper respiratory infection
What are the key manifestations of bacterial meningitis?
A) Papilledema and psychomotor seizures
B) High fever, nuchal rigidity, and severe headache
C) Behavioral changes with memory loss and lethargy
D) Jerky eye movements, loss of corneal reflex, and hemiparesis
Vigorous control of fever in the patient with meningitis is required to prevent complications of increased cerebral edema, seizure frequency, neurologic damage, and fluid loss. What nursing care should be included?
A) Administer analgesics as ordered.
B) Monitor LOC related to increased brain metabolism.
C) Rapidly decrease temperature with a cooling blanket.
D) Assess for peripheral edema from rapid fluid infusion.
In promoting health maintenance for prevention of strokes, the nurse understands that the highest risk for the most common type of stroke is present in which people?
A) African Americans
B) Women who smoke
C) Individuals with hypertension and diabetes
D) Those who are obese with high dietary fat intake
A thrombus that develops in a cerebral artery does not always cause a loss of neurologic function because
A) the body can dissolve atherosclerotic plaques as they form.
B) some tissues of the brain do not require constant blood supply to prevent damage.
C) circulation via the Circle of Willis may provide blood supply to the affected area of the brain.
D) neurologic deficits occur only when major arteries are occluded by thrombus formation around atherosclerotic plaque.
Patient-Centered Care: A patient comes to the emergency department (ED) immediately after experiencing numbness of the face and an inability to speak, but while the patient awaits examination, the symptoms disappear and the patient requests discharge. Why should the nurse emphasize that it is important for the patient to be treated before leaving?
A) The patient has probably experienced an asymptomatic lacunar stroke.
B) The symptoms are likely to return and progress to worsening neurologic deficit in the next 24 hours.
C) Neurologic deficits that are transient occur most often as a result of small hemorrhages that clot off.
D) The patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebrovascular disease.
Which type of stroke is associated with endocardial disorders, has a rapid onset, and is likely to occur during activity?
C) Intracerebral hemorrhage
D) Subarachnoid hemorrhage
What primarily determines the neurologic functions that are affected by a stroke?
A) The amount of tissue area involved
B) The rapidity of the onset of symptoms
C) The brain area perfused by the affected artery
D) The presence or absence of collateral circulation
The patient has a lack of comprehension of both verbal and written language. Which type of communication difficulty does this patient have?
B) Fluent dysphasia
C) Receptive aphasia
D) Expressive aphasia
A patient is admitted to the hospital with a left hemiplegia. To determine the size and location and to ascertain whether a stroke is ischemic or hemorrhagic, what will the nurse anticipate that the HCP will request?
A) Lumbar puncture
B) Cerebral angiography
C) Magnetic resonance imaging (MRI)
D) Computed tomography (CT) scan with contrast
A carotid endarterectomy is being considered as treatment for a patient who has had several TIAs. What should the nurse explain to the patient about this surgery?
A) It involves intracranial surgery to join a superficial extracranial artery to an intracranial artery.
B) It is used to restore blood circulation to the brain following an obstruction of a cerebral artery.
C) It involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke.
D) It is used to open a stenosis in a carotid artery with a balloon and stent to restore cerebral circulation.
The incidence of ischemic stroke in patients with TIAs and other risk factors is reduced with the administration of which medication?
B) Furosemide (Lasix)
C) Warfarin (Coumadin)
D) Daily low-dose aspirin
Priority Decision: What is the priority intervention in the ED for the patient with a stroke?
A) IV fluid replacement
B) Administration of osmotic diuretics to reduce cerebral edema
C) Initiation of hypothermia to decrease the oxygen needs of the brain
D) Maintenance of respiratory function with a patent airway and oxygen administration
A diagnosis of a ruptured cerebral aneurysm has been made in a patient with manifestations of a stroke. The nurse anticipates which treatment option that would be considered for the patient?
A) Hyperventilation therapy
B) Surgical clipping of the aneurysm
C) Administration of hyperosmotic agents
D) Administration of thrombolytic therapy
During the acute phase of a stroke, the nurse assesses the patient's vital signs and neurologic status at least every 4 hours. What is a cardiovascular sign that the nurse would see as the body attempts to increase cerebral blood flow?
B) Fluid overload
C) Cardiac dysrhythmias
D) S3 and S4 heart sounds
What is a nursing intervention that is indicated for the patient with hemiplegia?
A) The use of a footboard to prevent plantar flexion
B) Immobilization of the affected arm against the chest with a sling
C) Positioning the patient in bed with each joint lower than the joint proximal to it
D) Having the patient perform passive range of motion (ROM) of the affected limb with the unaffected limb
A newly admitted patient diagnosed with a right-sided brain stroke has a nursing diagnosis of disturbed visual sensory perception related to homonymous hemianopsia. Early in the care of the patient, what should the nurse do?
A) Place objects on the right side within the patient's field of vision.
B) Approach the patient from the left side to encourage the patient to turn the head.
C) Place objects on the patient's left side to assess the patient's ability to compensate.
D) Patch the affected eye to encourage the patient to turn the head to scan the environment.
Four days following a stroke, a patient is to start oral fluids and feedings. Before feeding the patient, what should the nurse do first?
A) Check the patient's gag reflex.
B) Order a soft diet for the patient.
C) Raise the head of the bed to a sitting position.
D) Evaluate the patient's ability to swallow small amounts of crushed ice or ice water.
What is an appropriate food for a patient with a stroke who has mild dysphagia?
A) Fruit juices
B) Pureed meat
C) Scrambled eggs
D) Fortified milkshakes
A patient's wife asks the nurse why her husband did not receive the
clot busting medication (tissue plasminogen activator [tPA]) she has
been reading about. Her husband is diagnosed with a hemorrhagic
stroke. What is the best response by the
nurse to the patient's wife?
A) “He didn't arrive within the timeframe for that therapy.”
B) “Not everyone is eligible for this drug. Has he had surgery lately?”
C) “You should discuss the treatment of your husband with his doctor.”
D) “The medication you are talking about dissolves clots and could cause more bleeding in your husband's brain.”
What is an appropriate nursing intervention to promote communication during rehabilitation of the patient with aphasia?
A) Allow time for the individual to complete his/her thoughts.
B) Use gestures, pictures, and music to stimulate patient responses.
C) Structure statements so that the patient does not have to respond verbally.
D) Use flashcards with simple words and pictures to promote recall of language.
Patient-Centered Care: A patient with a right hemisphere stroke has a nursing diagnosis of unilateral neglect related to sensory-perceptual deficits. During the patient's rehabilitation, what nursing intervention is important for the nurse to do?
A) Avoid positioning the patient on the affected side.
B) Place all objects for care on the patient's unaffected side.
C) Teach the patient to care consciously for the affected side.
D) Protect the affected side from injury with pillows and supports.
A patient with a stroke has a right-sided hemiplegia. What does the nurse teach the family to prepare them to cope with the behavior changes seen with this type of stroke?
A) Ignore undesirable behaviors manifested by the patient.
B) Provide directions to the patient verbally in small steps.
C) Distract the patient from inappropriate emotional responses.
D) Supervise all activities before allowing the patient to pursue them independently.
The nurse can best assist the patient and family in coping with the long-term effects of a stroke by doing what?
A) Informing family members that the patient will need assistance with almost all ADLs
B) Explaining that the patient's prestroke behavior will return as improvement progresses
C) Encouraging the patient and family members to seek assistance from family therapy or stroke support groups
D) Helping the patient and family to understand the significance of residual stroke damage to promote problem solving and planning
Teamwork and Collaboration: Which intervention should the nurse delegate to the licensed practical nurse (LPN) when caring for a patient following an acute stroke?
A) Assess the patient's neurologic status.
B) Assess the patient's gag reflex before beginning feeding.
C) Administer ordered antihypertensives and platelet inhibitors.
D) Teach the patient's caregivers strategies to minimize unilateral neglect.
Which type of headache is suspected when the headaches are unilateral and throbbing, preceded by a premonitory symptom of photophobia, and associated with a family history of this type of headache?
What is the most important method of diagnosing functional headaches?
A) CT scan
B) Electromyography (EMG)
C) Cerebral blood flow studies
D) Thorough history of the headache
Which drug therapy is included for acute migraine and cluster headaches that appears to alter the pathophysiologic process for these headaches?
A) Tricyclic antidepressants such as amitriptyline
B) Nonsteroidal antiinflammatory drugs (NSAIDs)
C) β-adrenergic blockers such as propranolol (Inderal)
D) Specific serotonin receptor agonists such as sumatriptan (Imitrex)
Patient-Centered Care: What is a nursing intervention that is appropriate for the patient with a nursing diagnosis of anxiety related to lack of knowledge of the etiology and treatment of headache?
A) Help the patient to examine lifestyle patterns and precipitating factors.
B) Administer medications as ordered to relieve pain and promote relaxation.
C) Provide a quiet, dimly lit environment to reduce stimuli that increase muscle tension and anxiety.
D) Support the patient's use of counseling or psychotherapy to enhance conflict resolution and stress reduction.
Teamwork and Collaboration: The nurse is preparing to admit a newly diagnosed patient experiencing tonic-clonic seizures. What could the nurse delegate to unlicensed assistive personnel (UAP)?
A) Complete the admission assessment.
B) Assess the details of the seizure event.
C) Obtain the suction equipment from the supply cabinet.
D) Place a padded tongue blade on the wall above the patient's bed.
How do generalized seizures differ from focal seizures?
A) Focal seizures are confined to one side of the brain and remain focal in nature.
B) Generalized seizures result in loss of consciousness, whereas focal seizures do not.
C) Generalized seizures result in temporary residual deficits during the postictal phase.
D) Generalized seizures have bilateral synchronous epileptic discharges affecting the whole brain at onset of the seizure.
Which type of seizure occurs in children, is also known as a petit mal seizure, and consists of a staring spell that lasts for a few seconds?
B) Simple focal
C) Typical absence
D) Atypical absence
Which type of seizure is most likely to cause death for the patient?
A) Status epilepticus
B) Myoclonic seizures
C) Subclinical seizures
D) Psychogenic seizures
A patient admitted to the hospital following a generalized tonic-clonic seizure asks the nurse what caused the seizure. What is the best response by the nurse?
A) “So many factors can cause epilepsy that it is impossible to say what caused your seizure.”
B) “Epilepsy is an inherited disorder. Does anyone else in your family have a seizure disorder?”
C) “In seizures, some type of trigger causes sudden, abnormal bursts of electrical brain activity.”
D) “Scar tissue in the brain alters the chemical balance, creating uncontrolled electrical discharges.”
A patient with a seizure disorder is being evaluated for surgical treatment of the seizures. The nurse recognizes that what is one of the requirements for surgical treatment?
A) Identification of scar tissue that is able to be removed
B) An adequate trial of drug therapy that had unsatisfactory results
C) Development of toxic syndromes from long-term use of antiseizure drugs
D) The presence of symptoms of cerebral degeneration from repeated seizures
The nurse teaches the patient taking antiseizure drugs that this method is most commonly used to measure compliance and monitor for toxicity.
A) A daily seizure log
B) Urine testing for drug levels
C) Blood testing for drug levels
D) Monthly electroencephalography (EEG)
Priority Decision: When teaching a patient with a seizure disorder about the medication regimen, what is it most important for the nurse to emphasize?
A) The patient should increase the dosage of the medication if stress is increased.
B) Most over-the-counter and prescription drugs are safe to take with antiseizure drugs.
C) Stopping the medication abruptly may increase the intensity and frequency of seizures.
D) If gingival hypertrophy occurs, the HCP should be notified and the drug may be changed.
Following a generalized tonic-clonic seizure, the patient is tired and sleepy. What care should the nurse provide?
A) Suction the patient before allowing him to rest.
B) Allow the patient to sleep as long as he feels sleepy.
C) Stimulate the patient to increase his level of consciousness.
D) Check the patient's level of consciousness every 15 minutes for an hour.
During the diagnosis and long-term management of a seizure disorder, what should the nurse recognize as one of the major needs of the patient?
A) Managing the complicated drug regimen of seizure control
B) Coping with the effects of negative social attitudes toward epilepsy
C) Adjusting to the very restricted lifestyle required by a diagnosis of epilepsy
D) Learning to minimize the effect of the condition in order to obtain employment
A patient at the clinic for a routine health examination mentions that she is exhausted because her legs bother her so much at night that she cannot sleep. The nurse questions the patient further about her leg symptoms with what knowledge about restless legs syndrome?
A) The condition can be readily diagnosed with EMG.
B) Other more serious nervous system dysfunctions may be present.
C) Dopaminergic agents are often effective in managing the symptoms.
D) Symptoms can be controlled by vigorous exercise of the legs during the day.
Which chronic neurologic disorder involves a deficiency of the neurotransmitters acetylcholine and γ-aminobutyric acid (GABA) in the basal ganglia and extrapyramidal system?
A) Myasthenia gravis
B) Parkinson's disease
C) Huntington's disease
D) Amyotrophic lateral sclerosis (ALS)
A 38-yr-old woman has newly diagnosed multiple sclerosis (MS) and asks the nurse what is going to happen to her. What is the best response by the nurse?
A) “You will have either periods of attacks and remissions or progression of nerve damage over time.”
B) “You need to plan for a continuous loss of movement, sensory functions, and mental capabilities.”
C) “You will most likely have a steady course of chronic progressive nerve damage that will change your personality.”
D) “It is common for people with MS to have an acute attack of weakness and then not to have any other symptoms for years.”
During assessment of a patient admitted to the hospital with an acute exacerbation of MS, what should the nurse expect to find?
A) Tremors, dysphasia, and ptosis
B) Bowel and bladder incontinence and loss of memory
C) Motor impairment, visual disturbances, and paresthesias
D) Excessive involuntary movements, hearing loss, and ataxia
The nurse explains to a patient newly diagnosed with MS that the diagnosis is made primarily by
A) spinal x-ray findings.
B) T-cell analysis of the blood.
C) analysis of cerebrospinal fluid.
D) history and clinical manifestations.
Mitoxantrone is being considered as treatment for a patient with progressive relapsing MS. The nurse explains that a disadvantage of this drug compared with other drugs used for MS is what?
A) It must be given subcutaneously every day.
B) It has a lifetime dose limit because of cardiac toxicity.
C) It is a muscle relaxant that increases the risk for drowsiness.
D) It is an anticholinergic agent that causes urinary incontinence.
Priority Decision: A patient with MS has a nursing diagnosis of self-care deficit related to muscle spasticity and neuromuscular deficits. In providing care for the patient, what is most important for the nurse to do?
A) Teach the family members how to care adequately for the patient's needs.
B) Encourage the patient to maintain social interactions to prevent social isolation.
C) Promote the use of assistive devices so that the patient can participate in self-care activities.
D) Perform all activities of daily living (ADLs) for the patient to conserve the patient's energy.
A patient with newly diagnosed MS has been hospitalized for evaluation and initial treatment of the disease. Following discharge teaching, the nurse realizes that additional instruction is needed when the patient says what?
A) “It is important for me to avoid exposure to people with upper respiratory infections.”
B) “When I begin to feel better, I should stop taking the prednisone to prevent side effects.”
C) “I plan to use vitamin supplements and a diet high in fiber to help manage my condition.”
D) “I must plan with my family how we are going to manage my care if I become more Incapacitated.”
The classic manifestations associated with Parkinson's disease is tremor, rigidity, akinesia, and postural instability. What is a consequence related to rigidity?
A) Shuffling gait
B) Impaired handwriting
C) Lack of postural stability
D) Muscle soreness and pain
A patient with a tremor is being evaluated for Parkinson's disease. The nurse explains to the patient that Parkinson's disease can be confirmed by
A) CT and MRI scans.
B) relief of symptoms with administration of dopaminergic agents.
C) the presence of tremors that increase during voluntary movement.
D) cerebral angiogram that reveals the presence of cerebral atherosclerosis.
Which observation of the patient made by the nurse is most indicative of Parkinson's disease?
A) Large, embellished handwriting
B) Weakness of one leg resulting in a limping walk
C) Difficulty rising from a chair and beginning to walk
D) Onset of muscle spasms occurring with voluntary movement
A patient with Parkinson's disease is started on levodopa. What should the nurse explain about this drug?
A) It stimulates dopamine receptors in the basal ganglia.
B) It promotes the release of dopamine from brain neurons.
C) It is a precursor of dopamine that is converted to dopamine in the brain.
D) It prevents the excessive breakdown of dopamine in the peripheral tissues.
To reduce the risk for falls in the patient with Parkinson's disease, what is the best thing the nurse should teach the patient to do?
A) Use an elevated toilet seat.
B) Use a wheelchair for mobility.
C) Use a walker or cane for support.
D) Consciously lift the toes when stepping.
A patient with myasthenia gravis is admitted to the hospital with respiratory insufficiency and severe weakness. What confirms a diagnosis of myasthenia gravis?
A) History and physical examination reveal weakness.
B) Serum acetylcholine receptor antibodies are present.
C) The patient's respiration is impaired because of muscle weakness.
D) EMG reveals an increased response with repeated stimulation of muscles.
Priority Decision: During care of a patient in myasthenic crisis, maintenance of what is the nurse's first priority for the patient?
C) Respiratory function
D) Verbal communication
When providing care for a patient with ALS, the nurse recognizes what as one of the most distressing problems experienced by the patient?
A) Painful spasticity of the face and extremities
B) Retention of cognitive function with total degeneration of motor function
C) Uncontrollable writhing and twisting movements of the face, limbs, and body
D) Knowledge that there is a 50% chance the disease has been passed to any offspring
In providing care for patients with chronic, progressive neurologic disease, what is the major goal of treatment that the nurse works toward?
A) Meet the patient's personal care needs.
B) Return the patient to normal neurologic function.
C) Maximize neurologic functioning for as long as possible.
D) Prevent the future development of additional chronic diseases.
Which statement most accurately describes dementia?
A) Overproduction of β-amyloid protein causes all dementias.
B) Dementia resulting from neurodegenerative causes can be prevented.
C) Dementia caused by hepatic or renal encephalopathy cannot be reversed.
D) Vascular dementia can be diagnosed by brain lesions identified with neuroimaging.
A patient with Alzheimer's disease (AD) dementia has manifestations of depression. The nurse knows that treatment of the patient with antidepressants will most likely do what?
A) Improve cognitive function
B) Not alter the course of either condition
C) Cause interactions with the drugs used to treat the dementia
D) Be contraindicated because of the central nervous system (CNS)–depressant effect of antidepressants
For what purpose would the nurse use the Mini-Mental State Examination to evaluate a patient with cognitive impairment?
A) It is a good tool to determine the etiology of dementia.
B) It is a good tool to evaluate mood and thought processes.
C) It can help to document the degree of cognitive impairment in delirium and dementia.
D) It is useful for initial evaluation of mental status, but additional tools are needed to evaluate changes in cognition over time.
During assessment of a patient with dementia, the nurse determines that the condition is potentially reversible when finding out what about the patient?
A) Has long-standing abuse of alcohol
B) Has a history of Parkinson's disease
C) Recently developed symptoms of hypothyroidism
D) Was infected with human immunodeficiency virus (HIV) 15 years ago
The husband of a patient is complaining that his wife's memory has been decreasing lately. When asked for examples of her memory loss, the husband says that she is forgetting the neighbors' names and forgot their granddaughter's birthday. What kind of loss does the nurse recognize this to be?
B) Memory loss in AD
C) Normal forgetfulness
D) Memory loss in mild cognitive impairment
The wife of a patient who is manifesting deterioration in memory asks the nurse whether her husband has AD. The nurse explains that a diagnosis of AD is usually made when what happens?
A) A urine test indicates elevated levels of isoprostanes.
B) All other possible causes of dementia have been eliminated.
C) Blood analysis reveals increased amounts of β-amyloid protein.
D) A computed tomography (CT) scan of the brain indicates brain atrophy.
The newly admitted patient has moderate AD. What does the nurse know this patient will need help with?
D) Self-care activities
What is one focus of interprofessional care of patients with AD?
A) Replacement of deficient acetylcholine in the brain
B) Drug therapy for cognitive problems and undesirable behaviors
C) The use of memory-enhancing techniques to delay disease progression
D) Prevention of other chronic diseases that hasten the progression of AD
The patient is receiving donepezil (Aricept), lorazepam (Ativan), risperidone (Risperdal), and sertraline (Zoloft) for the management of AD. What benzodiazepine medication is being used to help manage this patient's behavior?
A) Sertraline (Zoloft)
B) Donepezil (Aricept)
C) Lorazepam (Ativan)
D) Risperidone (Risperdal)
What N-methyl-D-aspartate (NMDA) receptor antagonist is frequently used for a patient with AD who is experiencing decreased memory and cognition?
A) Zolpidem (Ambien)
B) Olanzapine (Zyprexa)
C) Rivastigmine (Exelon)
D) Memantine (Namenda)
A patient with AD in a long-term care facility is wandering the halls very agitated, asking for her “mommy” and crying. What is the best response by the nurse?
A) Ask the patient, “Why are you behaving this way?”
B) Tell the patient, “Let's go get a snack in the kitchen.”
C) Ask the patient, “Wouldn't you like to lie down now?”
D) Tell the patient, “Just take some deep breaths and calm down.”
The son of a patient with early onset AD asks if he will get AD. What should the nurse tell this man about the genetics of AD?
A) The risk for it is higher for the children of parents of early onset AD.
B) Women get AD more often than men do, so his chances of getting AD are slim.
C) The blood test for the ApoE gene to identify this type of AD can predict who will develop it.
D) This type of AD is not as complex as regular AD, so he does not need to worry about getting AD.
A patient with moderate AD has a nursing diagnosis of impaired memory related to effects of dementia. What is an appropriate nursing intervention for this patient?
A) Post clocks and calendars in the patient's environment.
B) Establish and consistently follow a daily schedule with the patient.
C) Monitor the patient's activities to maintain a safe patient environment.
D) Stimulate thought processes by asking the patient questions about recent activities.
The family caregiver for a patient with AD expresses an inability to make decisions, concentrate, or sleep. The nurse determines what about the caregiver?
A) The caregiver is also developing signs of AD.
B) The caregiver is manifesting symptoms of caregiver role strain.
C) The caregiver needs a period of respite from care of the patient.
D) The caregiver should ask other family members to participate in the patient's care
Patient-Centered Care: The wife of a man with moderate AD has a nursing diagnosis of social isolation related to diminishing social relationships and behavioral problems of the patient with AD. What is a nursing intervention that would be appropriate to provide respite care and allow the wife to have satisfactory contact with significant others?
A) Help the wife to arrange for adult day care for the patient.
B) Encourage permanent placement of the patient in the Alzheimer's unit of a long term care facility.
C) Refer the wife to a home health agency to arrange daily home nursing visits to assist with the patient's care.
D) Arrange for hospitalization of the patient for 3 or 4 days so that the wife can visit out-of-town friends and relatives.
A 68-yr-old man is admitted to the ED with multiple blunt trauma following a one vehicle car accident. He is restless; disoriented to person, place, and time; and agitated. He resists attempts at examination and calls out the name “Janice.” Why should the nurse suspect delirium rather than dementia in this patient?
A) The fact that he should not have been allowed to drive if he had dementia
B) His hyperactive behavior, which differentiates his condition from the hypoactive behavior of dementia
C) The report of emergency personnel that he was noncommunicative when they arrived at the accident scene
D) The report of his family that, although he has heart disease and is “very hard of hearing,” this behavior is unlike him
What should be included in the management of a patient with delirium?
A) The use of restraints to protect the patient from injury
B) The use of short-acting benzodiazepines to sedate the patient
C) Identification and treatment of underlying causes when possible
D) Administration of high doses of an antipsychotic drug such as haloperidol (Haldol)
When caring for a patient in the severe stage of AD, the nurse would use what diversion or distraction activities?
A) Watching TV
B) Books to read
C) Playing games
D) Mobiles or dangling ribbons
In planning community education for prevention of spinal cord injuries, the nurse should target what group?
A) Older men
B) Teenage girls
C) Elementary school-age children
D) Adolescent and young adult men
A 70-yr-old patient is admitted after falling from his roof. He has a spinal cord injury (SCI) at the C7 level. What findings during the assessment identify the presence of spinal shock?
A) Paraplegia with a flaccid paralysis
B) Tetraplegia with total sensory loss
C) Total hemiplegia with sensory and motor loss
D) Spastic tetraplegia with loss of pressure sensation
Which syndrome of incomplete SCI is described as cord damage common in the cervical region resulting in greater weakness in upper extremities than lower?
A) Central cord syndrome
B) Anterior cord syndrome
C) Posterior cord syndrome
D) Cauda equina and conus medullaris syndromes
The patient is diagnosed with Brown-Séquard syndrome after a knife wound to the spine. Which description accurately describes this syndrome?
A) Damage to the most distal cord and nerve roots, resulting in flaccid paralysis of the lower limbs and areflexic bowel and bladder
B) Spinal cord damage resulting in ipsilateral motor paralysis and contralateral loss of pain and sensation below the level of the injury
C) Rare cord damage resulting in loss of proprioception below the lesion level with retention of motor control and temperature and pain sensation
D) Often caused by flexion injury with acute compression of cord resulting in complete motor paralysis and loss of pain and temperature sensation below the level of injury
What causes an initial incomplete SCI to result in complete cord damage?
A) Edematous compression of the cord above the level of the injury
B) Continued trauma to the cord resulting from damage to stabilizing ligaments
C) Infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites
D) Mechanical transection of the cord by sharp vertebral bone fragments after the initial injury
A patient with SCI has spinal shock. The nurse plans care for the patient based on what knowledge?
A) Rehabilitation measures cannot be initiated until spinal shock has resolved.
B) The patient will need continuous monitoring for hypotension, tachycardia, and hypoxemia.
C) Resolution of spinal shock is manifested by spasticity, reflex return, and neurogenic bladder.
D) Patient will have complete loss of motor and sensory functions below the level of the injury, but autonomic functions are not affected.
Patient-Centered Care: Two days following SCI, a patient asks continually about the extent of impairment that will result from the injury. What is the best response by the nurse?
A) “You will have more normal function when spinal shock resolves and the reflex arc returns.”
B) “The extent of your injury cannot be determined until the secondary injury to the cord is resolved.”
C) “When your condition is more stable, MRI will be done to reveal the extent of the cord damage.”
D) “Because long-term rehabilitation can affect the return of function, it will be years before we can tell what the complete effect will be.”
Priority Decision: The patient was in a traffic collision and is experiencing loss of function below C4. Which effect must the nurse be aware of to provide priority care for the patient?
A) Respiratory diaphragmatic breathing
B) Loss of all respiratory muscle function
C) Decreased response of the sympathetic nervous system
D) GI hypomotility with paralytic ileus and gastric distention
A patient is admitted to the emergency department (ED) with SCI at the level of T2. Which finding is of most concern to the nurse?
A) SpO2 of 92%
B) Heart rate of 42 bpm
C) Blood pressure of 88/60 mm Hg
D) Loss of motor and sensory function in arms and legs
The patient's SCI is at T4. What is the highest-level goal of rehabilitation that is realistic for this patient to have?
A) Indoor mobility in manual wheelchair
B) Ambulate with crutches and leg braces
C) Be independent in self-care and wheelchair use
D) Completely independent ambulation with short leg braces and canes
What is one indication for early surgical therapy of the patient with SCI?
A) There is incomplete cord lesion involvement.
B) The ligaments that support the spine are torn.
C) A high cervical injury causes loss of respiratory function.
D) Evidence of continued compression of the cord is apparent.
Priority Decision: A patient is admitted to the ED with a possible cervical SCI following an automobile crash. During admission of the patient, what is the highest priority for the nurse?
A) Maintaining a patent airway
B) Assessing the patient for head and other injuries
C) Maintaining immobilization of the cervical spine
D) Assessing the patient's motor and sensory function
Before surgical stabilization, what method of immobilization for the patient with a cervical SCI should the nurse expect to be used?
A) Kinetic beds
B) Hard cervical collar
C) Skeletal traction with skull tongs
D) Sternal-occipital-mandibular immobilizer brace
The health care provider has prescribed IV norepinephrine (Levophed) for a patient in the ED with SCI. The nurse determines that the drug is having the desired effect when what is observed in patient assessment?
A) Heart rate of 68 bpm
B) Respiratory rate of 24
C) Temperature of 96.8° F (36.0° C)
D) Blood pressure of 106/82 mm Hg
Priority Decision: During assessment of a patient with SCI, the nurse determines that the patient has a poor cough with diaphragmatic breathing. Based on this finding, what should be the nurse's first action?
A) Institute frequent turning and repositioning.
B) Use tracheal suctioning to remove secretions.
C) Assess lung sounds and respiratory rate and depth.
D) Prepare the patient for endotracheal intubation and mechanical ventilation.
Following a T2 spinal cord injury, the patient develops paralytic ileus. While this condition is present, what should the nurse anticipate that the patient will need?
A) IV fluids
B) Tube feedings
C) Parenteral nutrition
D) Nasogastric suctioning
How is urinary function maintained during the acute phase of SCI?
A) An indwelling catheter
B) Intermittent catheterization
C) Insertion of a suprapubic catheter
D) Use of incontinent pads to protect the skin
A week following SCI at T2, a patient experiences movement in his leg and tells the nurse that he is recovering some function. What is the nurse's best response to the patient?
A) “It is really still too soon to know if you will have a return of function.”
B) “That could be a really positive finding. Can you show me the movement?”
C) “That's wonderful. We will start exercising your legs more frequently now.”
D) “I'm sorry but the movement is only a reflex and does not indicate normal function.”
A patient with paraplegia has developed an irritable bladder with reflex emptying. Along with possible use of medications, what will be most helpful for the nurse to teach the patient?
A) Hygiene care for an indwelling urinary catheter
B) How to perform intermittent self-catheterization
C) To empty the bladder with manual pelvic pressure in coordination with reflex voiding patterns
D) That a urinary diversion, such as an ileal conduit, is the easiest way to handle urinary elimination
In counseling patients with SCIs regarding sexual function, how should the nurse advise a male patient with a complete lower motor neuron lesion?
A) He may have uncontrolled reflex erections, but orgasm and ejaculation are usually not possible.
B) He is most likely to have reflex erections and may experience orgasm if S2-S4 nerve pathways are intact.
C) He has a lesion with the greatest possibility of successful psychogenic erection with ejaculation and orgasm.
D) He will probably be unable to have either psychogenic or reflexogenic erections and no ejaculation or orgasm.
During the patient's process of grieving for the losses resulting from SCI, what should the nurse do?
A) Help the patient to understand that working through the grief will be a lifelong process.
B) Assist the patient to move through all stages of the mourning and grief process to acceptance.
C) Let the patient know that anger directed at the staff or the family is not a positive coping mechanism.
D) Facilitate the grieving process so that it is completed by the time the patient is discharged from rehabilitation.
A patient with a metastatic tumor of the spinal cord is scheduled for removal of the tumor by a laminectomy. In planning postoperative care for the patient, what should the nurse recognize?
A) Most cord tumors cause autodestruction of the cord as in traumatic injuries.
B) Metastatic tumors are commonly extradural lesions that are treated palliatively.
C) Radiation therapy is routinely administered following surgery for all malignant spinal cord tumors.
D) Because complete removal of intramedullary tumors is not possible, the surgery is considered palliative.
Priority Decision: When planning care for the patient with trigeminal neuralgia, which patient outcome should the nurse set as the highest priority?
A) Relief of pain
B) Protection of the cornea
C) Maintenance of nutrition
D) Maintenance of positive body image
Surgical intervention is being considered for a patient with trigeminal neuralgia. The nurse recognizes that which procedure has the least residual effects with a positive outcome?
A) Glycerol rhizotomy
B) Gamma knife radiosurgery
C) Microvascular decompression
D) Percutaneous radiofrequency rhizotomy
What should the nurse do when providing care for a patient with an acute attack of trigeminal neuralgia?
A) Carry out all hygiene and oral care for the patient.
B) Use conversation to distract the patient from pain.
C) Maintain a quiet, comfortable, draft-free environment.
D) Have the patient examine the mouth after each meal for residual food.
Patient-Centered Care: A patient is admitted to the hospital with Guillain-Barré syndrome. She had weakness in her feet and ankles that has progressed to weakness with numbness and tingling in both legs. During the acute phase of the illness, what should the nurse know about Guillain-Barré syndrome?
A) The most important aspect of care is to monitor the patient's respiratory rate and depth and vital capacity.
B) Early treatment with corticosteroids can suppress the immune response and prevent ascending nerve damage.
C) The most serious complication of this condition is ascending demyelination of the peripheral nerves and the cranial nerves.
D) Although voluntary motor neurons are damaged by the inflammatory response, the autonomic nervous system is unaffected by the disease.
A patient with Guillain-Barré syndrome asks whether he is going to die as the paralysis spreads toward his chest. In responding to the patient, what should the nurse know to be able to best answer this question?
A) Patients who require ventilatory support almost always die.
B) Death occurs when nerve damage affects the brain and meninges.
C) Most patients with Guillain-Barré syndrome do not die, but recover.
D) If death can be prevented, residual paralysis and sensory impairment are usually permanent.
The patient is diagnosed with chronic inflammatory demyelinating polyneuropathy (CIDP) after nerve conduction velocity test. How will this patient with CIDP be treated differently than a patient with Guillain-Barré syndrome?
D) IV immunoglobulin
Which condition is transmitted through wound contamination, causes painful tonic spasms or seizures, and can be prevented by immunization?
D) Systemic inflammatory response syndrome