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Chapter 43: Assessment of the

Nervous System Nursing School


Test Banks
Chapter 43: Assessment of the Nervous System

Test Bank

MULTIPLE CHOICE

1. The nurse assesses a client who has trauma to the cerebrum. Which clinical
manifestation does the nurse expect to observe?

a. Poor coordination
b. Memory loss
c. Hyperthermia
d. Slurred speech

ANS: B

The cerebrum is the largest part of the brain and controls intelligence, creativity, and
memory. Poor coordination, hyperthermia, and slurred speech are caused by other
parts of the brain.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

2. The nurse is assessing a client with a frontal lobe brain injury. Which clinical
manifestation does the nurse expect to see?
a. Inability to interpret taste sensations
b. Inability to interpret sound
c. Impaired judgment
d. Impaired learning

ANS: C

The frontal lobe is responsible for many functions, including judgment, reasoning,
voluntary eye movement, and motor functions. The other clinical manifestations are
not associated with the frontal lobe.

DIF: Cognitive Level: Knowledge/Remembering REF: Table 43-1, p. 907

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

3. The nurse is planning to provide discharge teaching related to cardiac medications


to a client who has experienced damage to the left temporal lobe of the brain. What
does the nurse do to assist the client to understand the content of the instruction?

a. Use a larger print size for written materials.


b. Ensure that the client is wearing glasses.
c. Point out the color of the medication.
d. Sit on the clients right side.

ANS: D

The temporal lobe contains the auditory center for sound interpretation. The clients
hearing will be impaired in the left ear. The nurse should sit on the clients right side
and speak to the right ear. The other interventions do not address the clients left
temporal lobe damage.

DIF: Cognitive Level: Application/Applying or higher REF: N/A


TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

MSC: Integrated Process: Teaching/Learning

4. After performing a physical assessment on a 75-year-old client, the nurse notes that
the client has a hypoactive response to a test of deep tendon reflexes. Which
intervention does the nurse include in this clients plan of care?

a. Assist the client with ambulation.


b. Elevate the clients lower extremities.
c. Apply elastic support hose.
d. Massage the clients legs.

ANS: A

The older adult experiences certain neurologic changes associated with aging.
Hypoactive deep tendon reflexes and loss of vibration sense can impair balance and
coordination, predisposing the client to falls. The nurse or assistive personnel should
assist this client with ambulation to prevent injury. The other interventions do not
address the clients problem.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Aging Process)

MSC: Integrated Process: Nursing Process (Implementation)

5. The nurse is discharging an 80-year-old client with diminished touch sensation.


Which instruction does the nurse provide to promote client safety?

a. Walk barefoot only in your home.


b. Bathe in warm water to increase your circulation.
c. Look at the placement of your feet when walking.
d. Put throw rugs at the foot of your bed for cushioning.
ANS: C

Older clients with decreased sensation are at risk of injury from the inability to sense
changes in terrain when walking. To compensate for this loss, the client is instructed
to look at the placement of her or his feet when walking. The client also should wear
sturdy shoes for ambulation. Throw rugs can slip and increase fall risk. Bath water
that is too warm places the client at risk for thermal injury.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Principles of


Teaching/Learning)

MSC: Integrated Process: Teaching/Learning

6. A client admitted the previous day for a suspected neurologic disorder becomes
increasingly lethargic. Which is the best nursing action?

a. Promote a quiet atmosphere for sleep and rest to treat the clients sleep
deprivation.
b. Explain to the family that this is a normal age-related decline in mental
processing.
c. Consult a psychiatrist to treat the clients hospital-acquired depression.
d. Complete a full neurologic assessment and notify the neurologist.

ANS: D

A change in the clients level of consciousness (LOC) is the first indication of a


decline in central neurologic functioning. The nurse should conduct a thorough
assessment and then should notify the neurologist (or other provider). The other
interventions are inappropriate.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)


MSC: Integrated Process: Nursing Process (Analysis)

7. The nurse is assessing a clients remote memory. Which statement by the client
confirms that remote memory is intact?

a. Mary had a little lamb whose fleece was white as snow.


b. I was born on April 3, 1967, in Johnstown Community Hospital.
c. Apple, chair, and pencil are the words you just stated.
d. My sister brought me to the clinic for this appointment.

ANS: B

Asking clients about certain facts from the past that can be verified assesses remote,
or long-term, memory. The clients ability to make up a rhyme tests not memory, but
rather a higher level of cognition. The other statements indicate immediate and recent
memory.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction in Risk PotentialSystem-


Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment)

8. During a neurologic examination, a client demonstrates a positive Rombergs sign


with eyes closed, but not with eyes open. Which condition does the nurse associate
with this finding?

a. Difficulty with proprioception


b. Peripheral motor disorder
c. Impaired cerebellar function
d. Positive pronator drift

ANS: A
The client who sways with eyes closed (positive Rombergs sign) but not with eyes
open most likely has a disorder of proprioception and uses vision to compensate for it.
The other options do not explain a positive Rombergs sign.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

9. The nurse is assessing the deep tendon reflexes of a client with long-standing
diabetes mellitus. Which clinical manifestation does the nurse expect to see?

a. Bilateral hypoactive reflexes


b. Bilateral hyperactive reflexes
c. Asymmetric reflex response
d. Bilateral ankle clonus

ANS: A

Long-standing diabetes mellitus causes peripheral neuropathy. Hypoactive responses


or no response to stimulation of deep tendon reflexes is one manifestation of diabetes-
induced peripheral neuropathy. Other responses are not related to complications of
diabetes mellitus.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Assessment)

10. During a neurologic assessment of a client, the nurse notes that the clients arms,
wrists, and fingers have become flexed, and internal rotation and plantar flexion of the
legs are evident. How does the nurse document these findings?
a. Decorticate posturing
b. Decerebrate posturing
c. Atypical hyperreflexia
d. Spinal cord degeneration

ANS: A

The client is demonstrating decorticate posturing, which is seen with interruption in


the corticospinal pathway. This finding is abnormal and is a sign that the clients
condition has deteriorated. The physician, the charge nurse, and other health care team
members should be notified immediately of this change in status. Decerebrate
posturing consists of external rotation and extension of the extremities. The other two
options are inaccurate.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Communication and Documentation

11. The nurse is evaluating a clients physical assessment with the medical history and
treatment plan. The nurse notes that the clients right pupil appears dilated, with a
sluggish pupillary response to light. Which disorder and related treatment does this
physical finding correlate with?

a. Coronary artery disease and beta blockers


b. Diabetes mellitus and oral glycemic reducing agents
c. Glaucoma and intraocular pressurereducing eyedrops
d. Myopia and corrective laser surgery

ANS: C

Clients with glaucoma who are being treated with eyedrops have unequal pupils,
especially if only one eye is being treated. The pupillary reaction to light is slowed by
the use of eyedrops for glaucoma. The other disorders and treatments do not correlate
with the clinical assessment.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

12. Before electroencephalography, a client asks, Why will I be asked to take deep
breaths during the procedure? How does the nurse respond?

a. Hyperventilation causes cerebral vasodilatation and increases the


likelihood of seizure activity.
b. Hyperventilation causes cerebral vasoconstriction and increases the
likelihood of seizure activity.
c. Deep breathing will keep you relaxed and will lower the seizure
threshold.
d. Deep breathing will make you hypoxemic, which lowers the seizure
threshold.

ANS: B

Hyperventilation produces cerebral vasoconstriction and alkalosis, which increases


the likelihood of seizure activity. The client is asked to breathe deeply 20 to 30 times
for 3 minutes. The other responses are not appropriate.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialDiagnostic


Tests) MSC: Integrated Process: Teaching/Learning

13. The nurse is caring for a client post-cerebral angiography via the clients right
femoral artery. Which intervention does the nurse implement?

a. Check the right lower extremity pulses.


b. Measure orthostatic blood pressure.
c. Perform a funduscopic examination.
d. Assess the clients gag reflex.

ANS: A

Cerebral angiography is performed by threading a catheter through the femoral or


brachial artery. The extremity is kept immobilized after the procedure. The nurse
checks the extremity for adequate circulation by noting skin color and temperature,
presence and quality of pulses distal to the injection site, and capillary refill. Clients
usually are on bedrest; therefore orthostatic blood pressure cannot be performed. The
funduscopic examination would not be affected by cerebral angiography. The client is
given analgesics but not conscious sedation; therefore the clients gag reflex would not
be compromised.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Assessment)

14. The nurse is preparing a client for magnetic resonance angiography. Which
question is a priority at this time?

a. Have you had a recent blood transfusion?


b. Do you have allergies to iodine or shellfish?
c. Do you have a history of urinary tract infections?
d. Do you currently use oral contraceptives?

ANS: B

Allergies to iodine and/or shellfish need to be explored because the client may have a
similar reaction to the dye used in the procedure. In some cases, the client may need to
be medicated with antihistamines or steroids before the test is given. The other
conditions would not affect the angiography.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection
ControlAccident/Injury Prevention) MSC: Integrated Process: Nursing Process (Assessment)

15. The nurse is caring for a client who had a computed tomography (CT) scan of the
head with contrast medium. Which priority intervention does the nurse implement?

a. Maintain bedrest with the head of the bed elevated less than 30 degrees.
b. Apply a pressure dressing to the site of injection.
c. Increase fluid intake after the procedure.
d. Maintain sedation for 8 hours postprocedure.

ANS: C

If a contrast medium is used, intravenous fluid may be given to promote excretion of


the contrast medium. Contrast medium also may act as a diuretic, resulting in the need
for fluid replacement. The client will not be sedated for the procedure and will not
require bedrest. Contrast is injected through a peripheral IV.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Implementation)

16. The nurse is obtaining the health history of a client scheduled for magnetic
resonance imaging (MRI). Which condition requires the nurse to cancel the MRI?

a. Amputated leg
b. Internal insulin pump
c. Intrauterine device
d. Atrioventricular (AV) graft

ANS: B

Metal devices such as pacemakers and prostheses interfere with the accuracy of the
image and can become displaced by the magnetic force generated by an MRI
procedure. An intrauterine device and an AV graft do not contain any metal.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 921

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Nursing Process (Planning)

17. Which priority instruction or precaution does the nurse teach a client who is
scheduled for a positron emission tomography scan of the brain?

a. Avoid caffeine-containing substances for 12 hours before the test.


b. Drink at least 3 liters of fluid during the 24 hours after the test.
c. Do not take your cardiac medication on the morning of the test.
d. Remove your dentures and any metal before the test begins.

ANS: A

Caffeine-containing liquids and foods are central nervous system stimulants and may
alter the test results. No contrast is used; therefore the client does not need to increase
fluid intake. The test does not require MRI, so metal does not have to be removed.
The client should take cardiac medications as prescribed.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Nursing Process (Planning)


18. A female client with deteriorating neurologic function states, I am worried I will
not be able to care for my young children. How does the nurse respond?

a. Caring for your children is a priority. You may not want to ask for help,
but you have to.
b. Our community has resources that may help you with some household
tasks so you have energy to care for your children.
c. You seem distressed. Would you like to talk to a psychologist about
adjusting to your changing status?
d. Give me more information about what worries you, so we can see if we
can do something to make adjustments.

ANS: D

Investigate specific concerns about situational or role changes before providing


additional information. The nurse should tell the client what is or is not a priority for
her. Although community resources may be available, they may not be appropriate for
the client. Consulting a psychologist would not be appropriate.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

MSC: Integrated Process: Communication and Documentation

19. The nurse is planning care for an 83-year-old client with age-related changes to his
sensory perception. Which nursing action does the nurse implement to ensure the
clients safety?

a. Provide a call button that requires only minimal pressure to activate.


b. Use a clock and a calendar to orient and minimize onset of dementia.
c. Ensure that the path to the bathroom is free from equipment.
d. Admit the client to the room closest to the nursing station.

ANS: C
Dementia and confusion are not common phenomena in older adults. However,
physical impairment related to illness can be expected. Providing opportunities for
hazard-free ambulation will maintain strength and mobility (and ensure safety). The
other actions are not a priority.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Basic Care and


ComfortMobility/Immobility)

MSC: Integrated Process: Nursing Process (Implementation)

20. A client is scheduled for a single-photon emission computed tomography test.


Which condition in the clients history causes the nurse to contact the provider before
the test takes place?

a. Peptic ulcers
b. Smoking history
c. Liver failure
d. Currently breast feeding

ANS: D

A SPECT test uses radiopharmaceutical agents that enable radioisotopes to cross the
blood-brain barrier. This test is contraindicated in women who are breast-feeding.
Having a history of smoking, peptic ulcers, or liver failure should not interfere with
the client having this test.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Principles of


Teaching/Learning)

MSC: Integrated Process: Teaching/Learning


21. The nurse is teaching a client before magnetic resonance imaging (MRI). Which
statement indicates that the client understands the content of the education?

a. I need to stay away from heavy metals for the next 48 hours.
b. My urine will be radioactive for the next 48 hours.
c. I must increase my fluids because of the dye used for the MRI.
d. I can return to my usual activities immediately after the MRI.

ANS: D

No postprocedure restrictions are imposed after MRI. The client can return to normal
activities after the test is complete.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Principles of


Teaching/Learning)

MSC: Integrated Process: Teaching/Learning

22. While assessing pain discrimination, a client correctly identifies, with eyes closed,
a sharp sensation on the right hand when touched with a pin. How does the nurse then
proceed with the examination?

a. Touch the pin on the same area of the left hand.


b. Touch the pin on the right forearm.
c. Touch the pin on the right upper arm.
d. Touch the right hand with a drop of cold water.

ANS: A

If testing is begun on the hand and the client correctly identifies the pain stimulus,
testing more proximal parts of that extremity is not necessary because, if the distal
tract is intact, so are the proximal areas. Temperature discrimination is not necessary
because the same tract transmits both pain and temperature sensation.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 915

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialSystem-


Specific Assessments) MSC: Integrated Process: Nursing Process (Assessment)

23. The nurse is assessing a client scheduled for a lumbar puncture. Which clinical
manifestation assessed by the nurse complicates the lumbar puncture procedure?

a. Normal intracranial pressures


b. Allergy to iodine or shellfish
c. Restlessness and agitation
d. Eating lunch less than 2 hours ago

ANS: C

Clients must be able to hold still during the procedure. If a client is restless or
agitated, assistance may be needed to ensure that the procedure is completed safely.
Lumbar puncture is not performed on clients with severely high intracranial pressure.
Allergies to iodine and shellfish or eating lunch 2 hours before the procedure have no
effect on the procedure.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 925

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Assessment)

24. On assessment of the left plantar reflexes of an adult client, the nurse notes the
response shown in the photograph below. What action does the nurse take after
assessing this new finding?

a. Relay this abnormal finding to other members of the health care team.
b. Anticipate the need for cerebral angiography to determine the cause.
c. Examine the family history for a potential genetic disorder.
d. Document the finding and continue the assessment.

ANS: A

This finding is a positive Babinski reflex. In clients older than 2 years of age, a
positive Babinski reflex is considered abnormal and indicates central nervous system
disease. The nurse should notify the health care provider and other members of the
health care team because further investigation is warranted.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation-


Pathophysiology)

MSC: Integrated Process: Nursing Process (Implementation)

MULTIPLE RESPONSE

1. In a client with an injury to the medulla, the nurse monitors for which clinical
manifestations secondary to damage of cranial nerves that emerge from the medulla?
(Select all that apply.)

a. Loss of smell
b. Impaired swallowing
c. Blink reflex
d. Visual changes
e. Inability to shrug shoulders
f. Loss of gag reflex

ANS: B, E, F

Cranial nerves IX (glossopharyngeal), X (vagus), XI (accessory), and XII


(hypoglossal) emerge from the medulla, as do portions of cranial nerves VII (facial)
and VIII (acoustic). Damage to these nerves causes impaired swallowing, inability to
shrug shoulders, and loss of the gag reflex. The other manifestations are not
associated with damage to the medulla.

DIF: Cognitive Level: Knowledge/Remembering REF: Table 43-2, p. 908

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

2. The nurse is assessing a client with a temporal lobe injury. Which clinical
manifestations correlate with this injury? (Select all that apply.)

a. Memory loss
b. Personality changes
c. Loss of temperature regulation
d. Difficulty with sound interpretation
e. Speech difficulties
f. Impaired taste

ANS: A, D, E

Wernickes area (language area) is located in the temporal lobe and enables processing
of words into coherent thought and understanding of written or spoken words. The
temporal lobe also is responsible for the auditory centers interpretation of sound and
complicated memory patterns. Personality changes are related to damage to frontal
lobe injury. Loss of temperature regulation is seen with damage to the hypothalamus,
and impaired taste is associated with injury to the parietal lobe.

DIF: Cognitive Level: Knowledge/Remembering REF: Table 43-1, p. 907

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)


3. The nurse is administering a medication to a client that stimulates the sympathetic
division of the autonomic nervous system. Which clinical manifestations does the
nurse monitor for? (Select all that apply.)

a. Decreased heart rate


b. Increased heart rate
c. Decreased force of contraction
d. Increased force of contraction
e. Decreased respirations

ANS: B, D

Stimulation of the sympathetic nervous system initiates the fight-or-flight response,


increasing both the heart rate and the force of contraction. The other three options do
not occur with sympathetic nervous system stimulation.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

COMPLETION

1. Immediately after a lumbar puncture, the client begins to vomit and an IV is started
with normal saline (0.9% NS). The provider orders a 200-mL bolus over 15 minutes.
Using an infusion pump that delivers mL/hr, the rate at which the nurse sets the pump
is _____ mL.

ANS:

800

200 mL/15 min = x mL/60 min

200 mL/15 min = 800 mL/60 min


15x = 12,000

x = 800 mL

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral


TherapiesDosage Calculation)

MSC: Integrated Process: Nursing Process (Implementation)

Chapter 44: Care of Patients with


Problems of the Central Nervous System:
The Brain Nursing School Test Banks
Chapter 44: Care of Patients with Problems of the Central Nervous System: The
Brain

Test Bank

MULTIPLE CHOICE

1. The nurse is caring for a client experiencing migraine headaches who is receiving a
beta blocker to help manage this disorder. When preparing a teaching plan, which
instruction does the nurse plan to provide?

a. Take this drug only when you have prodromal symptoms indicating the
onset of a migraine headache.
b. Take this drug as ordered, even when feeling well, to prevent vascular
changes associated with migraine headaches.
c. This drug will relieve the pain during the aura phase soon after a
headache has started.
d. This medication will have no effect on your heart rate or blood pressure
because you are taking it for migraines.
ANS: B

Beta blockers are prescribed as prophylactic treatment to prevent the vascular changes
that initiate migraine headaches. Heart rate and blood pressure will also be affected,
and the client should monitor these side effects. The other responses do not discuss an
appropriate use of the medication.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral


TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Teaching/Learning

2. The nurse is assessing a client with a history of migraines. Which clinical


manifestation is an early sign of a migraine with aura?

a. Vertigo
b. Lethargy
c. Visual disturbances
d. Numbness of the tongue

ANS: C

Early warning of impending migraine with aura usually consists of visual changes,
flashing lights, or diplopia. The other manifestations are not associated with an
impending migraine with aura.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 928

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

3. The nurse is reviewing a clients prescription for sumatriptan succinate (Imitrex).


Which condition in this clients medical history does the nurse report to the health care
provider?
a. Bronchial asthma
b. Gonorrhea
c. Prinzmetals angina
d. Chronic kidney disease

ANS: C

Sumatriptan succinate effectively reduces pain and other associated symptoms of


migraine by binding to serotonin receptors and triggering cranial vasoconstriction.
Vasoconstrictive effects are not confined to the cranium and can cause coronary
vasospasm in clients with Prinzmetals angina. The other conditions would not affect
the clients treatment.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral


TherapiesAdverse Effects/Contraindications/Side Effects/Interactions)

MSC: Integrated Process: Nursing Process (Analysis)

4. The nurse is assessing a client with a cluster headache. Which clinical manifestation
does the nurse expect to find?

a. Ipsilateral tearing of the eye


b. Exophthalmos
c. Abrupt loss of consciousness
d. Neck and shoulder tenderness

ANS: A

Cluster headache is usually accompanied by ipsilateral tearing, rhinorrhea or nasal


congestion, ptosis, eyelid edema, facial sweating, and miosis. The other
manifestations are not associated with cluster headaches.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 931


TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

5. A client with epilepsy develops stiffening of the muscles of the arms and legs,
followed by an immediate loss of consciousness and jerking of all extremities. How
does the nurse document this seizure activity?

a. Atonic seizure
b. Absence seizure
c. Myoclonic seizure
d. Tonic-clonic seizure

ANS: D

Seizure activity that begins with stiffening of the arms and legs, followed by loss of
consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure.
The other seizures do not manifest in this manner.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 932

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Communication and Documentation

6. The nurse is assessing a client with a history of absence seizures. Which clinical
manifestation does the nurse assess for?

a. Automatisms
b. Intermittent rigidity
c. Sudden loss of muscle tone
d. Brief jerking of the extremities

ANS: A
Automatisms are characteristic of absence seizures. These behaviors consist of lip
smacking, patting, and picking at clothing. The other manifestations do not correlate
with absence seizures.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 932

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

7. The nurse is caring for a client with a history of epilepsy who suddenly begins to
experience a tonic-clonic seizure and loses consciousness. What is the nurses priority
action?

a. Restrain the clients extremities.


b. Turn the clients head to the side.
c. Take the clients blood pressure.
d. Place an airway into the clients mouth.

ANS: B

The nurse should turn the clients head to the side to prevent aspiration and allow
drainage of secretions. The client should not be restrained nor an airway placed in his
or her mouth during the seizure because these actions increase seizure activity and can
harm the client. Vital signs are measured in the postictal phase of the seizure.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

8. A client is actively experiencing status epilepticus. Which prescribed medication


does the nurse prepare to administer?
a. Atropine
b. Lorazepam (Ativan)
c. Phenytoin (Dilantin)
d. Morphine sulfate

ANS: B

Initially, intravenous lorazepam is administered to stop motor movements. This is


followed by the administration of phenytoin. Atropine and morphine are not
administered for seizure activity.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral


TherapiesExpected Actions/Outcomes)

MSC: Integrated Process: Nursing Process (Implementation)

9. A client with new-onset status epilepticus is prescribed phenytoin (Dilantin). After


teaching the client about this treatment regimen, the nurse assesses the clients
understanding. Which statement indicates that the client understands the teaching?

a. I must drink at least 2 liters of water daily.


b. This will stop me from getting an aura before a seizure.
c. I will not be able to be employed while taking this medication.
d. Even when my seizures stop, I will take this drug.

ANS: D

Discontinuing antiepileptic drugs can lead to the recurrence of seizures or status


epilepticus. The client does not need to drink more water and can continue to work
while taking this medication. The medication will not stop an aura before a seizure.

DIF: Cognitive Level: Application/Applying or higher REF: N/A


TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral
TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Teaching/Learning

10. The nurse is teaching a client who is newly diagnosed with epilepsy. Which
statement by the client indicates a need for further teaching concerning the drug
regimen?

a. I will not drink any alcoholic beverages.


b. I will wear a medical alert bracelet.
c. I will let my doctor know about all of my prescriptions.
d. I can skip a couple of pills if they make me ill.

ANS: D

The nurse must emphasize that antiepileptic drugs must be taken even if seizure
activity has stopped. Discontinuing the medication can predispose the client to seizure
activity and status epilepticus. The client should not drink alcohol while taking seizure
medications. The client should wear a medical alert bracelet and should make the
doctor aware of all medications to prevent complications of polypharmacy.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

11. The nurse assesses for which clinical manifestations in the client with suspected
encephalitis?

a. Fever of 101 F (38.3 C)


b. Nausea and vomiting
c. Hypoactive deep tendon reflexes
d. Pain on flexion of the neck

ANS: D
Nuchal rigidity is associated with meningeal irritation and is frequently present in
clients with encephalitis. The other manifestations are not associated with
encephalitis.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 940

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

12. The nurse is taking the health history of a client suspected of having bacterial
meningitis. Which question is most important for the nurse to ask?

a. Do you live in a crowded residence?


b. When was your last tetanus vaccination?
c. Have you had any viral infections recently?
d. Have you traveled out of the country in the last month?

ANS: A

Meningococcal meningitis tends to occur in outbreaks. It is most likely to occur in


areas of high-density population, such as college dormitories, prisons, and military
barracks. The other questions do not identify risk factors for bacterial meningitis.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Nursing Process (Assessment)

13. The nurse is talking to the family of a client who has Parkinsons disease. Which
statement indicates that the family has a good understanding of the changes in motor
movement associated with this disease?

a. I can never tell what shes thinking. She hides behind a frozen face.
b. She drools all the time so I just cant take her out anywhere.
c. I think this disease makes her nervous. She perspires all the time.
d. She has trouble chewing so I will offer bite-sized portions.

ANS: D

A masklike face, drooling, and excess perspiration are common in clients with
Parkinsons disease. Changes in facial expression or a masklike facies in a Parkinsons
disease client can be misinterpreted. Because chewing and swallowing can be
problematic, small frequent meals and a supplement are better for meeting the clients
nutritional needs. The other statements indicate poor understanding of the disease
process.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

MSC: Integrated Process: Teaching/Learning

14. The nurse is caring for a client with Parkinsons disease. Which intervention does
the nurse implement to prevent respiratory complications in the client?

a. Keep an oral airway at the bedside.


b. Ensure fluid intake of at least 3 L/day.
c. Teach the client pursed-lip breathing techniques.
d. Maintain the head of the bed at 30 degrees or greater.

ANS: D

Elevation of the back rest will help prevent aspiration. The other options will not
prevent aspiration, which is the greatest respiratory complication of Parkinsons
disease.

DIF: Cognitive Level: Application/Applying or higher REF: N/A


TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

15. The daughter of a client with Alzheimers disease asks, Will the medication my
mother is taking improve her dementia? How does the nurse respond?

a. It will help your mother live independently once more.


b. It is used to halt the advancement of Alzheimers disease but will not cure
it.
c. It will provide a steady improvement in memory but not in problem
solving.
d. It will not improve dementia but can help control emotional responses.

ANS: D

Drug therapy is not effective for treating dementia or halting the advancement of
Alzheimers disease. However, certain drugs may help suppress emotional
disturbances and psychiatric manifestations.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral


TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Evaluation)

16. A client with Alzheimers disease is admitted to the hospital. Which psychosocial
assessment is most important for the nurse to complete?

a. Ability to recall past events


b. Ability to perform self-care
c. Reaction to a change of environment
d. Relationship with close family members

ANS: C
As the disease progresses, the client experiences changes in emotional and behavioral
affect. The nurse should be alert to the clients reaction to a change in environment,
such as being hospitalized, because the client may exhibit an exaggerated response,
such as aggression, to the event. The other assessments should be completed but are
not as important for a client with Alzheimers disease.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Sensory/Perceptual Alterations)

MSC: Integrated Process: Nursing Process (Assessment)

17. The nurse is caring for a hospitalized client with Alzheimers disease who has a
history of agitation. Which intervention does the nurse implement to help prevent
agitation and aggressive behavior in this client?

a. Provide undisturbed sleep.


b. Orient the client to reality.
c. Leave the television turned on.
d. Administer hypnotic drugs as needed.

ANS: A

Fatigue from disturbed sleep increases confusion and behavioral manifestations, such
as aggression and agitation. Reality orientation is inappropriate for clients in a later
stage of the disease. Constant noise from the TV most likely would agitate the client.
Sedation should be used as a last resort.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness


Management) MSC: Integrated Process: Nursing Process (Implementation)
18. A hospitalized client with late-stage Alzheimers disease says that breakfast has not
been served. The nurse witnessed the client eating breakfast earlier. Which statement
made to this client is an example of validation therapy?

a. I see you are still hungry. I will get you some toast.
b. You are confused about mealtimes this morning.
c. You ate your breakfast 30 minutes ago.
d. You look tired. Maybe a nap will help.

ANS: A

Use of validation therapy involves acknowledgment of the clients feelings and


concerns. This technique has proved more effective in later stages of the disease,
when using reality orientation only increases agitation. Telling the client that he or she
already ate breakfast may agitate the client. The other statements do not validate the
clients concerns.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

MSC: Integrated Process: Nursing Process (Implementation)

19. A client is prescribed levetiracetam (Keppra). Which laboratory tests does the
nurse monitor for potential adverse effects of this medication?

a. Serum electrolyte levels


b. Kidney function tests
c. Complete blood cell count
d. Antinuclear antibodies

ANS: B

Adverse effects of levetiracetam (Keppra) include coordination problems and renal


toxicity. The other laboratory tests are not affected by levetiracetam.
DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral


TherapiesAdverse Effects/Contraindications/Side Effects/Interactions)

MSC: Integrated Process: Nursing Process (Assessment)

20. The caregiver of a client with advanced Alzheimers disease states, She is always
wandering off. What can I do to manage this restless behavior? How does the nurse
respond?

a. Allow for a 45-minute daytime nap.


b. Take the client for frequent walks throughout the day.
c. Using a Geri-chair may decrease agitation.
d. Give a mild sedative during periods of restlessness.

ANS: B

Several strategies may be used to cope with restlessness and wandering. Taking the
client for frequent walks may decrease restless behavior. Another strategy is to engage
the client in structured activities. The other options would not be as helpful.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection
ControlAccident/Injury Prevention)

MSC: Integrated Process: Nursing Process (Implementation)

21. A client who has Alzheimers disease is being discharged home. What safety
instructions does the nurse include in the teaching plan for the clients caregiver?

a. Keep exercise to a minimum.


b. Place a padded throw rug at the bedside.
c. Install deadbolt locks on all outside doors.
d. Keep the lights off in the bedroom at night.

ANS: C

Clients with Alzheimers disease have a tendency to wander, especially at night. If


possible, alarms should be installed on all outside doors to alert family members if the
client leaves. At a minimum, all outside doors should have deadbolt locks installed to
prevent the client from going outdoors unsupervised. The client should be allowed to
exercise within his or her limits. Throw rugs are a slip and fall hazard and should be
removed. The client may need or want lights on in the bedroom at night.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection
ControlAccident/Injury Prevention) MSC: Integrated Process: Teaching/Learning

22. The nurse is assessing a client with Huntingtons disease. Which motor changes
does the nurse monitor for in this client?

a. Shuffling gait
b. Jerky hand movements
c. Continuous chewing motions
d. Tremors of the hands during fine motor tasks

ANS: B

An imbalance between excitatory and inhibitory neurotransmitters leads to


uninhibited motor movements, such as brisk, jerky, purposeless movements of the
hands, face, tongue, and legs. Shuffling gait, continuous chewing motions, and
tremors are associated with Parkinsons disease.

DIF: Cognitive Level: Knowledge/Remembering REF: p. 956

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)


MSC: Integrated Process: Nursing Process (Assessment)

23. The nurse is planning to bathe a client diagnosed with meningococcal meningitis.
In addition to gloves, what personal protective equipment does the nurse use?

a. Particulate respirator
b. Isolation gown
c. Shoe covers
d. Surgical mask

ANS: D

Meningeal meningitis is spread via saliva and droplets. Caregivers should wear a
surgical mask when within 6 feet of the client and should continue to use Standard
Precautions. A particulate respirator, an isolation gown, and shoe covers are not
necessary for Droplet Precautions.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection
ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis)

MSC: Integrated Process: Nursing Process (Implementation)

24. A client diagnosed with the Huntington gene but who has no symptoms asks for
options related to family planning. Which is the nurses best response?

a. Most clients with the Huntington gene do not pass on Huntington disease
to their children.
b. I understand that they can diagnose this disease in embryos. Therefore
you could select a healthy embryo from your fertilized eggs for
implantation to avoid passing on Huntington disease.
c. The need for family planning is limited because one of the hallmarks of
Huntington disease is infertility.
d. Tell me more specifically what information you need about family
planning so that I can direct you to the right information or health care
provider.

ANS: D

The presence of the Huntington gene means that the trait will be passed on to all
offspring of the affected person. Understanding options for contraception and
conception (e.g., surrogate mother options) and implications for children may require
the expertise of a genetic counselor or a reproductive specialist. The other options are
not accurate.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Teaching/Learning

25. The nurse is caring for a client who has chronic migraine headaches. Which
complementary health therapy does the nurse suggest?

a. Place a hot compress on your forehead at the onset of the headache.


b. Wear dark sunglasses when you are in brightly lit spaces.
c. Lie down in a darkened room when you experience a headache.
d. Do not sleep longer than 6 hours at one time.

ANS: C

At the onset of a migraine attack, the client may be able to alleviate pain by lying
down and darkening the room. He or she may want both eyes covered and a cool cloth
on the forehead. If the client falls asleep, he or she should remain undisturbed until
awakening. The other options are not recognized therapies for migraines.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)


MSC: Integrated Process: Teaching/Learning

MULTIPLE RESPONSE

1. The nurse is planning care for a client with epilepsy. Which precautions does the
nurse implement to ensure the safety of the client while in the hospital? (Select all that
apply.)

a. Have suction equipment at the bedside.


b. Place a padded tongue at the bedside.
c. Permit only clear oral fluids.
d. Keep bed rails up at all times.
e. Maintain the client on strict bedrest.
f. Ensure that the client has IV access.

ANS: A, D, F

The bed rails should be up at all times while the client is in the bed to prevent injury
from a fall if the client has a seizure. Padded tongue blades may pose a danger to the
client during a seizure. Be sure that oxygen and suctioning equipment with an airway
are readily available. If the client does not have an IV access, insert a saline lock,
especially for those clients who are at significant risk for generalized tonic-clonic
seizures. The saline lock provides ready access if IV drug therapy must be given to
stop the seizure.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection
ControlAccident/Injury Prevention)

MSC: Integrated Process: Nursing Process (Implementation)

2. The nurse is teaching a client with chronic headaches about headache triggers.
Which statements does the nurse include in the clients teaching plan? (Select all that
apply.)
a. Increase your intake of caffeinated beverages.
b. Increase your intake of fruits and vegetables.
c. Avoid all alcoholic beverages.
d. Avoid drinking red wine.
e. Incorporate physical exercise into your daily routine.
f. Incorporate an occasional fast into your plan.

ANS: B, D, E

Triggers for headaches include caffeine, smoking, and ingestion of pickled foods.
Clients are taught to eat a balanced diet and to get adequate exercise and rest.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

3. The nurse is assessing the results of diagnostic tests on a clients cerebrospinal fluid
(CSF). Which values and observations does the nurse correlate as most indicative of
viral meningitis? (Select all that apply.)

a. Clear
b. Cloudy
c. Normal protein level
d. Increased protein level
e. Normal glucose level
f. Decreased glucose level

ANS: A, D, E

Viral meningitis does not cause cloudiness or increased turbidity of CSF. Protein
levels are slightly increased, and glucose levels are normal. In bacterial meningitis,
the presence of bacteria and white blood cells causes the fluid to be cloudy.
DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory


Values) MSC: Integrated Process: Nursing Process (Analysis)

Chapter 45: Care of Patients with


Problems of the Central Nervous System:
The Spinal Cord Nursing School Test
Banks
Chapter 45: Care of Patients with Problems of the Central Nervous System: The
Spinal Cord

Test Bank

MULTIPLE CHOICE

1. The nurse is providing health education at a community center. Which instruction


does the nurse include as part of client education for the prevention of low back pain?

a. Participate in a regular exercise program.


b. Purchase a soft mattress for sleeping comfort.
c. Wear high-heeled shoes only for special occasions.
d. Keep your weight within 20% of your ideal body weight.

ANS: A

Exercise can strengthen back muscles, reducing the incidence of low back pain. The
other options will not prevent low back pain.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)


MSC: Integrated Process: Teaching/Learning

2. The nurse is caring for a client who has low back pain (LBP) from a work-related
injury. Which measures does the nurse incorporate into the clients plan of care?

a. Apply moist heat continuously to the affected area.


b. Use ice packs or ice massage for 1 to 2 hours over the affected area.
c. Apply heat packs for 20 to 30 minutes at least four times daily.
d. Advise the client to avoid hot baths or showers.

ANS: C

Heat increases blood flow to the affected area and promotes healing of injured nerves.
However, continuous application of moist heat can promote skin breakdown.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 962

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness


Management) MSC: Integrated Process: Nursing Process (Implementation)

3. A client who has a herniated disk is being discharged after a percutaneous


endoscopic discectomy. Which postprocedure instructions does the nurse provide
before discharge?

a. You should begin an exercise routine which includes walking every day.
b. You must sleep in a supine position until the bandage is removed.
c. You may feel numbness or tingling in the legs for 24 hours.
d. You will need to wear a lumbar brace for 1 week.

ANS: A

After this minimally invasive surgery, clients typically go home the same day or the
day after surgery. Clients should be taught to begin the prescribed exercise program
immediately after discharge, which includes walking every day. The client should not
be restricted to one sleeping position. Clients generally have less pain with this
procedure and do not experience numbness or tingling. The client may have a clear or
gauze dressing but will not need to wear a lumbar brace.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Teaching/Learning

4. The nurse is assessing a client who had a discectomy 6 hours ago. Which client
complaint requires priority action by the nurse?

a. I am feeling tired.
b. My mouth is so dry.
c. I cant seem to relax and rest.
d. I am unable to urinate.

ANS: D

Inability to void may indicate damage to the sacral spinal nerves. The other symptoms
require the nurse to provide care but are not the priority or a complication of the
procedure.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Analysis)

5. The nurse is providing discharge teaching to a client after a lumbar laminectomy.


For which complication does the nurse instruct the client to return to the hospital?

a. Pain at the incision site


b. Decreased appetite
c. Slight redness and itching at the incision site
d. Clear drainage from the incision site

ANS: D

The finding of clear fluid on the dressing after a laminectomy strongly suggests a
cerebrospinal fluid leak, which constitutes an emergency. The client has in increased
risk of meningitis with a spinal fluid leak. Pain, redness, and itching at the site are
normal. The client should be encouraged to eat a healthy diet but does not need to
return to the hospital for a decreased appetite.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Teaching/Learning

6. The nurse is caring for a client who has undergone a spinal fusion. Which specific
postoperative instructions does the nurse give this client?

a. You may lift items up to 10 pounds.


b. Wear your brace when you are out of bed.
c. You must remain on bedrest for 48 hours after surgery.
d. You will need to take steroids to prevent rejection of the bone graft.

ANS: B

Clients who undergo spinal fusion are fitted with a brace that they need to wear
throughout the healing process (usually 3 to 6 months) whenever they are out of bed.
The client does not need to remain on bedrest for the first 48 hours, should not lift
anything, and will not take steroids for rejection prevention.

DIF: Cognitive Level: Application/Applying or higher REF: N/A


TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Teaching/Learning

7. A client who suffered a spinal cord injury at level T5 several months ago develops a
flushed face and blurred vision. On taking vital signs, the nurse notes the blood
pressure to be 184/95 mm Hg. Which is the nurses first action?

a. Palpate the area over the bladder for distention.


b. Place the client in the Trendelenburg position.
c. Administer oxygen via a nasal cannula.
d. Perform bilateral carotid massage.

ANS: A

The client is manifesting symptoms of autonomic dysreflexia. Common causes


include bladder distention, tight clothing, increased room temperature, and fecal
impaction. If persistent, the client could experience neurologic injury. Precipitating
conditions should be eliminated and the physician notified. The other actions would
not be appropriate.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

8. Emergency medical services arrive to the emergency department with a client who
has a cervical spinal cord injury. Which priority assessment does the emergency
department nurse perform at this time?

a. Level of consciousness and orientation


b. Heart rate and rhythm
c. Muscle strength and reflexes
d. Respiratory pattern and airway

ANS: D

The first priority for a client with a spinal cord injury is assessment of respiratory
status and airway patency. Clients with cervical spine injuries are particularly prone to
respiratory compromise and may even require intubation. The other assessments
should be performed after airway and breathing are assessed.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Assessment)

9. The nurse is caring for a client who has a vertebral fracture. Which intervention
does the nurse implement to prevent deterioration of the clients neurologic status?

a. Reorient the client to time, place, and person.


b. Administer the Mini-Mental State Examination.
c. Immobilize the affected portion of the spinal column.
d. Reposition the client every 2 hours.

ANS: C

The nurse keeps the client in optimal body alignment at all times, avoiding flexion
and extension at the site of vertebral injury, to prevent further cord injury or
irritability from bone fragments. A brace, traction, or external fixation may be used
for this purpose. The other interventions would not prevent deterioration of the clients
neurologic status. Assessments would assist with the recognition of neurologic
changes but would not prevent them.

DIF: Cognitive Level: Application/Applying or higher REF: N/A


TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationMedical
Emergencies) MSC: Integrated Process: Nursing Process (Implementation)

10. A client who experienced a spinal cord injury 1 hour ago is brought to the
emergency department. Which prescribed medication does the nurse prepare to
administer to this client?

a. Intrathecal baclofen (Lioresal)


b. Methylprednisolone (Medrol)
c. Atropine sulfate
d. Epinephrine (Adrenalin)

ANS: B

Methylprednisolone (Medrol) should be given within 8 hours of the injury. Clients


who receive this therapy usually show improvement in motor and sensory function.
The other medications are inappropriate for the client.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral


TherapiesExpected Actions/Outcomes)

MSC: Integrated Process: Nursing Process (Implementation)

11. The nurse is assessing a client with a spinal cord injury at the T5 level. Which
clinical manifestation alerts the nurse to the presence of a complication of this injury?

a. Rhinorrhea and epiphora


b. Fever and cough
c. Agitation and restlessness
d. Hip and knee pain

ANS: B
Clients with injuries at or above the T6 vertebra are especially at risk for respiratory
complications caused by impaired intercostal muscles. The development of fever and
cough should alert the nurse to the possibility of pneumonia. The other manifestations
are not related to complications from this type of injury.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Analysis)

12. The nurse notes reddened areas over the hips and sacrum of a client with
paraplegia from a spinal cord injury. Which action does the nurse implement?

a. Massage the reddened areas with a barrier cream.


b. Perform hip flexion and extension range-of-motion (ROM) exercises.
c. Reposition the client so that the reddened area does not bear weight.
d. Ensure that the client sits in a chair at least once each shift.

ANS: C

Reddened areas should not be rubbed because this action could cause more extensive
damage to the already fragile capillary system. ROM exercises are used to prevent
contractures. The reddened areas should be assessed for blanching. If the skin does
not blanch, the area is vulnerable to breakdown. Appropriate interventions to relieve
pressure on these areas through positioning, assistive devices, and skin protection
should then be used.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)


13. The nurse is caring for a client with a lower motor neuron lesion who wishes to
achieve bladder control. Which intervention does the nurse implement to effectively
stimulate the initiation of voiding for this client?

a. Stroking the inner aspect of the thigh


b. Intermittent catheterization
c. Digital anal stimulation
d. The Valsalva maneuver

ANS: D

In clients with lower motor neuron problems, such as spinal cord injury, performing a
Valsalva maneuver or tightening the abdominal muscles are interventions that can
initiate voiding. The other interventions do not initiate voiding.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness


Management) MSC: Integrated Process: Nursing Process (Implementation)

14. A client who has a lower motor neuron injury experiences a flaccid bowel
elimination pattern. Which action does the nurse implement to assist in relieving this
clients constipation?

a. Pouring warm water over the perineum


b. Tapping the abdomen from left to right
c. Administering daily tap water enemas
d. Implementing a consistent daily time for elimination

ANS: D

For the client with a lower motor neuron injury, the resulting flaccid bowel may
require a bowel program for the client, which includes stool softeners, increased fluid
intake, a high-fiber diet, and a consistent elimination time. The other interventions do
not assist this client.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

15. A client with paraplegia is scheduled to participate in a rehabilitation program. The


client states, I do not understand the need for rehabilitation; the paralysis will not go
away and it will not get better. How does the nurse respond?

a. If you do not want to participate in the rehabilitation program, I will


cancel the order.
b. Your doctor has helped many clients with your injury and has ordered a
rehabilitation program to help you.
c. The rehabilitation program will teach you how to maintain the functional
ability you have and prevent further disability.
d. When new discoveries are made regarding paraplegia, people in
rehabilitation programs will benefit first.

ANS: C

Participation in rehabilitation programs has many purposes, including prevention of


disability, maintenance of functional ability, and restoration of function. The other
responses do not meet the clients needs.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

MSC: Integrated Process: Nursing Process (Implementation)


16. The nurse is teaching a client who has a spinal cord injury how to prevent
respiratory problems at home. Which statement indicates that the client correctly
understands the teaching?

a. I will use my incentive spirometer every 2 hours while Im awake.


b. I will not drink thick fluids to prevent choking.
c. I will take cough medicine to prevent excessive coughing.
d. I will position myself on my right side so I dont aspirate.

ANS: A

Often, the person with a spinal cord injury will have weak intercostal muscles and is
at higher risk for developing atelectasis and stasis pneumonia. Using an incentive
spirometer every 2 hours helps the client expand her or his lungs more fully and
prevents atelectasis. Clients should drink fluids that they can tolerate; usually thick
fluids are easy to tolerate. The client should be encouraged to cough and clear
secretions. Clients should be placed in high Fowlers position to prevent aspiration.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Evaluation)

17. The nurse assesses for which clinical manifestation in a client with multiple
sclerosis (MS) of the relapsing type?

a. Absence of periods of remission


b. Attacks becoming increasingly frequent
c. Absence of active disease manifestations
d. Gradual neurologic symptoms without remission

ANS: B
The classic picture of relapsing-remitting MS is characterized by increasingly frequent
attacks. The other manifestations do not correlate with a relapsing type of MS.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 979

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

18. The nurse is assessing a client with an early onset of multiple sclerosis (MS).
Which clinical manifestation does the nurse expect to see?

a. Hyperresponsive reflexes
b. Excessive somnolence
c. Nystagmus
d. Heat intolerance

ANS: C

Early signs and symptoms of MS include changes in motor skills, vision, and
sensation. The other manifestations are later signs of MS.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 979

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

19. A client presents with an acute exacerbation of multiple sclerosis. Which


prescribed medication does the nurse prepare to administer?

a. Baclofen (Lioresal)
b. Interferon beta-1b (Betaseron)
c. Dantrolene sodium (Dantrium)
d. Methylprednisolone (Medrol)
ANS: D

Methylprednisolone is the drug of choice for acute exacerbations of the disease. The
other medications are not appropriate.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral


TherapiesExpected Actions/Outcomes)

MSC: Integrated Process: Nursing Process (Implementation)

20. A client with multiple sclerosis is being treated with fingolimod (Gilenya). Which
clinical manifestation alerts the nurse to an adverse effect of this medication?

a. Periorbital edema
b. Black tarry stools
c. Bradycardia
d. Vomiting after meals

ANS: C

Fingolimod (Gilenya) is an antineoplastic agent that can cause bradycardia, especially


within the first 6 hours after administration. The other manifestations are not adverse
effects of fingolimod.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral


TherapiesAdverse Effects/Contraindications//Side Effects/Interactions)

MSC: Integrated Process: Nursing Process (Implementation)

21. The nurse is preparing a client who has multiple sclerosis (MS) for discharge home
from a rehabilitation center. The client has been prescribed cyclophosphamide
(Cytoxan) and methylprednisolone (Medrol). Which instruction does the nurse include
in the teaching plan for the client?

a. Take warm baths to promote muscle relaxation.


b. Avoid crowds and people with colds.
c. Use physical aids such as walkers as little as possible.
d. Stop using these medications when your symptoms improve.

ANS: B

The client should be taught to avoid people with any type of upper respiratory illness
because these medications are immunosuppressive. Warm baths will exacerbate the
MS symptoms, assistive devices may be required for safe ambulation, and medication
should not be stopped.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

22. Early manifestations of amyotrophic lateral sclerosis (ALS) and multiple sclerosis
(MS) are somewhat similar. Which clinical feature of ALS distinguishes it from MS?

a. Dysarthria
b. Dysphagia
c. Muscle weakness
d. Impairment of respiratory muscles

ANS: D

In ALS, progressive muscle atrophy occurs until a flaccid quadriplegia develops.


Eventually, the respiratory muscles are involved, and this leads to respiratory
compromise.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 984

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

23. Which neurologic test or procedure requires the nurse to determine whether an
informed consent has been obtained from the client before the test or procedure?

a. Measurement of sensation using the pinprick method


b. Computed tomography of the cranial vault
c. Lumbar puncture for cerebrospinal fluid (CSF) sampling
d. Venipuncture for autoantibody analysis

ANS: C

A lumbar puncture is an invasive procedure with many potentially serious


complications. The other assessments or tests are considered noninvasive.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of
CareInformed Consent)

MSC: Integrated Process: Nursing Process (Implementation)

24. A client is scheduled for magnetic resonance imaging (MRI). Which action does
the nurse implement before the test?

a. Ensure that the person does not eat for 8 hours before the procedure.
b. Discontinue all neuroactive medications 3 hours before the procedure.
c. Make sure that the client has an identification bracelet that cannot be
removed.
d. Replace the clients gown with metal snaps with one that has cloth ties.
ANS: D

Metal objects are a hazard because of the magnetic field used in the MRI procedure.
The other actions are not necessary for MRI.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection
ControlAccident/Injury Prevention)

MSC: Integrated Process: Nursing Process (Implementation)

25. The nurse is teaching a client who has an unstable thoracic vertebral fracture and is
being treated with immobilization before surgery. Which statement does the nurse
include in the clients teaching?

a. You will need to apply an immobilizing brace snugly around your waist
when out of bed.
b. You will remain strapped to the transport back board until the surgical
room is ready.
c. Keep your spine in alignment by not sitting up, arching your back, or
twisting in bed.
d. An incentive spirometer will prevent you from having atelectasis and
pneumonia after surgery.

ANS: C

The client with a thoracic vertebral fracture is at risk for spinal cord injury, especially
with flexion, extension, or rotation of the trunk. The client will be moved to a more
comfortable bed to wait for surgery and will remain on bedrest. Although teaching
about how to use an incentive spirometer is important for surgical clients, the
incentive spirometer alone does not prevent atelectasis and pneumonia; it only assists
the client to breathe deeply.

DIF: Cognitive Level: Application/Applying or higher REF: N/A


TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Analysis)

26. The nurse is planning care for a client who has a spinal cord injury. Which
interdisciplinary team member does the nurse consult with to assist the client with
activities of daily living?

a. Social worker
b. Physical therapist
c. Occupational therapist
d. Case manager

ANS: C

The occupational therapist instructs the client in the correct use of all adaptive
equipment. In collaboration with the therapists, the nurse instructs family members or
the caregiver about transfer skills, feeding, bathing, dressing, positioning, and skin
care. The other team members are consulted to assist the client with unrelated issues.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of
CareConsultation with Interdisciplinary Team)

MSC: Integrated Process: Nursing Process (Planning)

27. The nurse is discussing advanced directives with a client who has amyotrophic
lateral sclerosis (ALS). The client states, I do not want to be placed on a mechanical
ventilator. How does the nurse respond?

a. You will need to discuss that with your family and health care provider.
b. Why are you afraid of being placed on a breathing machine?
c. What would you like to be done if you begin to have difficulty
breathing?
d. You will be on the ventilator only until your muscles get stronger.

ANS: C

ALS is an adult-onset upper and lower motor neuron disease, characterized by


progressive weakness, muscle wasting, and spasticity, eventually leading to paralysis.
Once muscles of breathing are involved, the client must include in the advance
directives what is to be done when breathing is no longer possible without
intervention. The other statements do not address the clients needs.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEthical
Practice) MSC: Integrated Process: Communication and Documentation

MULTIPLE RESPONSE

1. The nurse is assessing a clients coping strategies after suffering a traumatic spinal
cord injury. Which information related to this assessment is important for the nurse to
obtain? (Select all that apply.)

a. Spiritual or religious beliefs


b. Level of pain
c. Family support
d. Level of independence
e. Annual income
f. Previous coping strategies

ANS: A, C, D, F

Information about the clients preinjury psychosocial status, usual methods of coping
with illness, difficult situations, and disappointments should be obtained. Determine
the clients level of independence or dependence and his or her comfort level in
discussing feelings and emotions with family members or close friends. Clients who
are emotionally secure and have a positive self-image, a supportive family, and
financial and job security often adapt to their injury. Information about the clients
spiritual and religious beliefs or cultural background also assists the nurse in
developing the plan of care. The other options do not supply as much information
about coping.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Coping Mechanisms)

MSC: Integrated Process: Caring

2. The nurse is teaching a client with a spinal cord tumor about the treatment plan.
Which statements indicate that the client correctly understands the teaching? (Select
all that apply.)

a. Because my symptoms occurred so quickly, I am likely to be cured


quickly by surgery.
b. Radiation therapy can shrink the tumor but radiation can cause more
problems, too.
c. I am glad you are here to turn me. Lying in one position for a long time
makes my pain worse, even if turning is uncomfortable.
d. I have put my affairs in order and purchased a burial plot because this
type of cancer is almost always fatal.
e. My family is making some changes at home for me, including moving
my bedroom downstairs.

ANS: B, C, E

Although surgery may relieve symptoms by reducing pressure on the spine and
debulking the tumor, some motor and sensory deficits may remain. Spinal tumors
usually cause disability but are not usually fatal.

DIF: Cognitive Level: Application/Applying or higher REF: N/A


TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness
Management) MSC: Integrated Process: Teaching/Learning

3. The nurse is teaching a male client with a spinal cord injury at T4 (thoracic) about
the sexual effects of this injury. Which statement by the client indicates correct
understanding of the teaching? (Select all that apply.)

a. I will not be able to have an erection because of my injury.


b. Ejaculation may not be as predictable as before.
c. I will explore other ways besides intercourse to please my partner.
d. I may urinate with ejaculation but this will not cause an infection.
e. I should be able to have an erection with stimulation.

ANS: B, D, E

Men with injuries above T6 often are able to have erections by stimulating reflex
activity. For example, stroking the penis will cause an erection. Ejaculation is less
predictable and may be mixed with urine. However, urine is sterile, so the clients
partner will not get an infection.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Health and Wellness)

MSC: Integrated Process: Teaching/Learning

Chapter 46: Care of Patients with


Problems of the Peripheral Nervous
System Nursing School Test Banks
Chapter 46: Care of Patients with Problems of the Peripheral Nervous System

Test Bank
MULTIPLE CHOICE

1. The nurse recognizes which pathophysiologic feature as a hallmark of Guillain-Barr


syndrome?

a. Nerve impulses are not transmitted to skeletal muscle.


b. The immune system destroys the myelin sheath.
c. The distal nerves degenerate and retract.
d. Antibodies to acetylcholine receptor sites develop.

ANS: B

In Guillain-Barr syndrome, the immune system destroys the myelin sheath, causing
segmental demyelination. Nerve impulses are transmitted more slowly but remain in
place. Antibodies are not developed. The nerves do not degenerate and retract.

DIF: Cognitive Level: Knowledge/Remembering REF: p. 987

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

2. The nurse assesses a client who has Guillain-Barr syndrome. Which clinical
manifestation does the nurse expect to find in this client?

a. Ophthalmoplegia and diplopia


b. Progressive weakness without sensory involvement
c. Progressive, ascending weakness and paresthesia
d. Weakness of the face, jaw, and sternocleidomastoid muscles

ANS: C

The most common clinical pattern of Guillain-Barr syndrome is the ascending variety.
Weakness and paresthesia begin in the lower extremities and progress upward. The
other manifestations are not associated with Guillain-Barr syndrome.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 987

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

3. The nurse reviews laboratory data for a client who has Guillain-Barr syndrome
(GBS). Which result does the nurse correlate with this disease process?

a. Increased cerebrospinal fluid (CSF) protein level


b. Decreased serum protein electrophoresis results
c. Increased antinuclear antibodies
d. Decreased immune globulin G (IgG) levels

ANS: A

A lumbar puncture is performed to evaluate the CSF. An increased CSF protein level
without increased cell count is a distinguishing feature of GBS. The other results are
not associated with GBS.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 988

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

4. The intensive care nurse is caring for a client who has Guillain-Barr syndrome. The
nurse notes that the clients vital capacity has declined to 12 mL/kg, and the client is
having difficulty clearing secretions. Which is the nurses priority action?

a. Place the client in a high Fowlers position.


b. Prepare the client for elective intubation.
c. Administer oxygen via a nasal cannula.
d. Auscultate for breath sounds.
ANS: B

Deterioration in vital capacity to less than 15 mL/kg and an inability to clear


secretions are indications for elective intubation. The other interventions may assist
with breathing and oxygenation but would not reverse the deterioration in vital
capacity or help clear secretions.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

5. A client who has Guillain-Barr syndrome is scheduled for plasmapheresis. Before


the procedure, which clinical manifestation does the nurse use to determine patency of
the clients arteriovenous shunt?

a. Palpable distal pulses


b. A pink, warm extremity
c. The presence of a bruit
d. Shunt pressure higher than 25 mm Hg

ANS: C

Nursing care of the client undergoing plasmapheresis includes care of the shunt. The
nurse checks for bruits every 2 to 4 hours for patency. Pulse and extremity
assessments do not provide information related to shunt patency. Pressure within the
shunt is not tested before treatment to determine patency.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialTherapeutic


Procedures) MSC: Integrated Process: Nursing Process (Implementation)
6. The nurse assesses a client with Guillain-Barr syndrome during plasmapheresis.
Which complication does the nurse monitor for during this procedure?

a. Tachycardia
b. Hypovolemia
c. Hyperkalemia
d. Hemorrhage

ANS: B

The client undergoing plasmapheresis is at risk for hypovolemia. The nurse monitors
fluid status, assesses vital signs, and administers replacement fluid, as indicated. The
other manifestations are not complications of plasmapheresis.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Implementation)

7. The nurse teaches a client with Guillain-Barr syndrome (GBS) about the recovery
rate of this disorder. Which statement indicates that the client correctly understands
the teaching?

a. I need to see a lawyer because I do not expect to recover from this


disease.
b. I will have to take things slowly for several months after I leave the
hospital.
c. I expect to be able to return to work in construction soon after I get
discharged.
d. I wonder if my family will be able to manage my care now that I am
paralyzed.

ANS: B
Most clients make a full recovery from GBS. Recovery can take as long as 6 months
to 2 years. Fatigue is a major lingering symptom for most of those diagnosed with this
disorder. Clients are not permanently paralyzed. They are in an acute care
environment during the acute phase of the disorder.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Stress Management)

MSC: Integrated Process: Teaching/Learning

8. The nurse assesses a client who has myasthenia gravis. Which clinical manifestation
does the nurse expect to observe in this client?

a. Inability to perform the six cardinal positions of gaze


b. Lateralization to the affected side during the Weber test
c. Absent deep tendon reflexes
d. Impaired stereognosis

ANS: A

The most common assessment finding in more than 90% of clients with myasthenia
gravis is involvement of the extraocular muscles. The nurse observes for inability or
difficulty with tests of extraocular function, such as the cardinal positions of gaze.
Ptosis and incomplete eye closure also may be observed. Altered hearing and absent
reflexes are not common in myasthenia gravis.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 991

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

9. The nurse is assessing laboratory results for a client with myasthenia gravis (MG).
Which results does the nurse correlate with this disease process?
a. Elevated serum calcium level
b. Decreased thyroid hormone level
c. Decreased complete blood count
d. Elevated acetylcholine receptor antibody levels

ANS: D

Testing for acetylcholine receptor (AChR) antibodies is important because 80% to


90% of clients with the disease have elevated AChR antibody levels. The other
laboratory results are not associated with myasthenia gravis.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 992

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

10. A client suspected to have myasthenia gravis is scheduled for the Tensilon
(edrophonium chloride) test. Which prescribed medication does the nurse prepare to
administer if complications of this test occur?

a. Epinephrine
b. Atropine sulfate
c. Diphenhydramine
d. Neostigmine bromide

ANS: B

Tensilon increases cholinergic responses and can slow the heart rate down so that
ectopic beats dominate, causing cardiac fibrillation or arrest. Atropine sulfate is an
anticholinergic drug. The other medications are not appropriate for complications of
this test.

DIF: Cognitive Level: Application/Applying or higher REF: N/A


TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Implementation)

11. The nurse is caring for a client who has myasthenia gravis. Which nursing
intervention does the nurse implement to reduce muscle weakness in this client?

a. Administer a therapeutic massage.


b. Collaborate with the physical therapist.
c. Perform passive range-of-motion exercises.
d. Reposition the client every 2 hours.

ANS: B

The hallmark of myasthenia gravis is muscle weakness that increases with fatigue.
The nurse provides assistance with ADLs to prevent fatigue. The nurse collaborates
with the physical therapist in teaching the client energy conservation techniques.
Therapeutic massage, passive range of motion, and repositioning will not reduce
muscle weakness.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness


Management) MSC: Integrated Process: Nursing Process (Implementation)

12. The nurse is assessing a client who is experiencing a myasthenia crisis. Which
diagnostic test does the nurse anticipate being ordered?

a. Babinski reflex test


b. Tensilon test
c. Cholinesterase challenge test
d. Caloric reflex test

ANS: B
The Tensilon test in an important procedure for a client in myasthenic crisis.
Cholinesterase-inhibiting drugs should be withheld because they increase respiratory
secretions, which enhance the manifestations of a myasthenic crisis. A Babinski reflex
and caloric reflex test would not be appropriate for this client.

DIF: Cognitive Level: Knowledge/Remembering REF: p. 992

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness


Management) MSC: Integrated Process: Nursing Process (Analysis)

13. A client who has myasthenia gravis is receiving atropine for a cholinergic crisis.
Which intervention does the nurse implement for this client?

a. Suction the client to remove secretions.


b. Turn and reposition the client every 2 hours.
c. Measure urinary output every 30 minutes.
d. Administer prescribed anticholinergic drugs as needed.

ANS: A

Atropine can cause thickening of secretions and formation of mucous plugs. The
client is maintained on a ventilator during the crisis. Measures to remove secretions to
prevent the buildup of secretions and the possibility of pneumonia are most important.
The other interventions do not relate to the administration of atropine.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral


TherapiesAdverse Effects/Contraindications/Side Effects/Interactions)

MSC: Integrated Process: Nursing Process (Implementation)

14. The nurse instructs a client who has myasthenia gravis to take prescribed
medications on time and to eat meals 45 to 60 minutes after taking anticholinesterase
drugs. The client asks why the timing of meals is so important. Which is the nurses
best response?

a. This timing allows the drug to have maximum effect, so it is easier for
you to chew, swallow, and not choke.
b. This timing prevents your blood sugar level from dropping too low and
causing you to be at risk for falling.
c. These drugs are very irritating to your stomach and could cause ulcers if
taken too long before meals.
d. These drugs cause nausea and vomiting. By waiting a while after you
take the medication, you are less likely to vomit.

ANS: A

Skeletal muscle weakness extends to the ability to chew and swallow. Clients who
have myasthenia gravis are at risk for aspiration during meals. Timing the medication
so that most of the meal is eaten when the drugs have produced their peak effect
enables the client to chew and swallow more easily. The medication has no effect on
blood glucose levels, ulcers, or nausea.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

15. A client who has myasthenia gravis is recovering after a thymectomy. Which
complication does the nurse monitor for in this client?

a. Sudden onset of shortness of breath


b. Swelling of the lower extremities
c. Lower abdominal tenderness
d. Decreased urinary output

ANS: A
The complication to be alert for is pneumothorax or hemothorax. The nurse monitors
the client for chest pain, sudden onset of shortness of breath, diminished chest wall
expansion, decreased breath sounds, restlessness, and changes in vital signs. The other
symptoms are not likely to occur or are not related to removal of the thymus.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Assessment)

16. A client with myasthenia gravis is preparing for discharge. Which instructions
does the nurse include when educating the clients family members or caregiver?

a. Technique for therapeutic massage to the lower extremities


b. Administration of morphine sulfate via an IV pump
c. Instructions for preparing thin, pured foods
d. Cardiopulmonary resuscitation (CPR)

ANS: D

Respiratory compromise is a common occurrence with myasthenia gravis. The clients


family members are encouraged to learn CPR and to have resuscitation equipment
available in the home. The other interventions are not a priority.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Teaching/Learning

17. The nurse teaches a client who has autonomic dysfunction about injury prevention.
Which statement indicates that the client correctly understands the teaching?
a. I will change positions slowly.
b. I will avoid wearing cotton socks.
c. I will use an electric razor.
d. I will use a heating pad on my feet.

ANS: A

Autonomic dysfunction causes orthostatic hypotension. The client should change


positions slowly to prevent orthostatic hypotension. Autonomic dysfunction can cause
peripheral polyneuropathy, so the client should be taught to wear socks and shoes at
all times and not to use a heating pad. The disorder does not cause bleeding; therefore
the client can use any type of razor.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Evaluation)

18. The nurse is planning discharge teaching for a client who has peripheral
neuropathy of the lower extremities. Which instruction does the nurse include in the
teaching plan?

a. Cut all calluses and corns from your feet as soon as you notice them.
b. Your balance will be steadier if you go barefoot while at home.
c. Use a thermometer to check the temperature of bath water.
d. Avoid using lotion on the feet and legs.

ANS: C

The client with neuropathy has loss of sensation in the lower extremities, which can
predispose the client to thermal injury. The client should be instructed to use a
thermometer to check the temperature of the bath water to avoid a burn. Checking the
water with the hands is not recommended because neuropathy may have a stocking
and glove distribution that could also affect the hands. The client should be taught to
wear shoes at all times, to assess feet and legs daily, to keep skin moist and clean, and
not to cut calluses or corns from the feet.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Teaching/Learning

19. The nurse is caring for a client who has undergone peripheral nerve repair. Which
priority assessment does the nurse perform postoperatively?

a. Evaluate extremity mobility.


b. Assess the skin surrounding the cast.
c. Test distal extremities for sensation.
d. Auscultate bowel sounds.

ANS: B

The nurse assesses the skin surrounding the cast hourly for tightness, warmth, and
color. If the cast is too tight, the nurse notifies the provider immediately. The other
assessments should be completed after a circulatory assessment.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Assessment)

20. The nurse is assessing a client with trigeminal neuralgia. Which clinical
manifestation does the nurse expect to observe?
a. Excruciating pain
b. Decreased mobility
c. Controllable facial twitching
d. Increased talkativeness

ANS: C

Signs of trigeminal neuralgia are excruciating pain and uncontrollable facial twitching
which causes the client to avoid talking, smiling, eating, or attending to hygienic
needs. Sensory and mobility deficits are not associated with trigeminal neuralgia.

DIF: Cognitive Level: Knowledge/Remembering REF: p. 1000

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in


Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

21. The nurse is assessing a client who had a dissection of all branches of the right
trigeminal nerve. When asked to wrinkle his forehead, the client wrinkles only the left
side. Which is the nurses best action?

a. Place the client in high Fowlers position.


b. Document the finding.
c. Assess the corneal reflex.
d. Notify the health care provider.

ANS: B

Loss of motor and sensory function after complete trigeminal nerve dissection is
normal. No intervention is necessary.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)


22. A client with trigeminal neuralgia is about to undergo surgery for pain relief. The
client asks, How will this surgery relieve my pain? How does the nurse respond?

a. The surgeon will cut the connection between the cranial nerves.
b. The surgeon will use an electrode to bypass the trigeminal nerve
conduction.
c. An incision is made into the nerve itself, and an anesthetic is applied to
the area.
d. A small artery compressing the nerve will be relocated.

ANS: D

In some clients, a small artery compresses the nerve as it enters the pons. By
relocating this nerve, pain relief is obtained and sensation is spared. The other
responses do not answer the clients question appropriately.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness


Management) MSC: Integrated Process: Teaching/Learning

23. The nurse is teaching a client who is receiving carbamazepine (Tegretol) for
chronic trigeminal neuralgia. Which statement indicates that the client correctly
understands the teaching?

a. This drug will prevent seizures, which can occur because of trigeminal
disease.
b. I expect to have surgery soon, so I can stop taking this drug now.
c. This medication is very successful in relieving pain. I am glad to be
taking it.
d. I will avoid drinking alcohol because it can add to the side effects of this
medicine.

ANS: D
Carbamazepine is thought to interfere with the transmission of pain through slow
fibers. It may decrease the paroxysmal afferent impulse that causes trigeminal pain.
Trigeminal disease does not cause seizures. Drowsiness, dizziness, confusion, and risk
for falls are adverse effects of this medication. Alcohol consumption increases these
risks; therefore the client should not drink alcohol when taking this medication.
Seizure disorders may occur in clients who stop taking this medication. The dose
should be decreased gradually. Pain relief varies with the person; some people find
that this medication provides at least some relief.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Nursing Process (Evaluation)

24. The nurse teaches a client who has Guillain-Barr syndrome (GBS) about pain
management. Which statement indicates that the client correctly understands the
teaching?

a. I can use the button on the pump as often as I want to get more pain
medication.
b. Aspirin will provide the best relief from my pain associated with this
disease.
c. A combination of morphine and distraction helps bring me relief right
now.
d. I should not have any pain as a result of impaired motor and sensory
neurons.

ANS: C

Typical pain from GBS often is not relieved by medication other than opiates.
Distraction, repositioning, massage, heat, cold, and guided imagery may enhance the
opiate effects. Patient-controlled analgesia (PCA) pumps should be set with
appropriate doses and limits.
DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Nursing Process (Evaluation)

25. The nurse is obtaining a health history for a 45-year-old woman with Guillain-Barr
syndrome (GBS). Which statement by the client does the nurse correlate with the
clients diagnosis?

a. My neighbor also had Guillain-Barr syndrome.


b. I had a viral infection about 2 weeks ago.
c. I am an artist and work with oil paints.
d. I have a history of a cardiac dysrhythmia.

ANS: B

The client with GBS often relates a history of acute illness, trauma, surgery, or
immunization 1 to 3 weeks before the onset of neurologic symptoms. The other
statements do not correlate with GBS.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

MULTIPLE RESPONSE

1. A client has just undergone surgery for peripheral nerve trauma. Which
interventions does the nurse include in the clients plan of care? (Select all that apply.)

a. Immobilization of the affected area with a splint


b. Rotation of cold and heat therapy
c. Occupational therapy
d. Skin care, including hygiene and ointments
e. High-fat, low-protein diet

ANS: A, C, D

Care for the client with peripheral nerve trauma includes immobilization before and
after surgery, and skin care to prevent skin breakdown and promote healing. The
client may likely require physical or occupations therapy during the recovery process.
The client will have decreased sensation, so cold and heat therapy should not be used.
The client will require a diet high in protein to promote healing.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Planning)

2. The nurse is preparing a staff in-service program related to restless legs syndrome
(RLS). Which potential risk factors of this syndrome does the nurse include? (Select
all that apply.)

a. Skin rashes
b. Polyneuropathies
c. Muscle atrophy
d. Diabetes mellitus type 2
e. Hypercalcemia

ANS: B, D

Risk factors for RLS include a possible genetic basis, history of type 2 diabetes
mellitus, advanced kidney failure, vitamin and mineral deficiencies, polyneuropathies,
peripheral nerve disease, age, lack of exercise, and pinched nerve. Rashes, muscle
atrophy, and hypercalcemia are not related.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 999

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)

3. The nurse is preparing to send a cerebrospinal fluid sample to the laboratory. Which
actions does the nurse implement during this procedure? (Select all that apply.)

a. Use Standard Precautions.


b. Wear sterile gloves when handling the specimen.
c. Place the specimen on ice.
d. Send the specimen in a sealed bag displaying a biohazard symbol.
e. Confirm the specimen label with the clients identification band.

ANS: A, D, E

The Standard Precautions approach is based on the premise that a medical history and
a physical examination cannot reliably identify all those infected by pathogens.
Consequently, health care workers should consider all human blood and body fluids
as potentially infectious and must use appropriate protective measures to prevent
possible exposure. Specimens should be labeled appropriately and transported in a
sealed bag displaying the biohazard symbol. The nurse should use Standard
Precautions when handling the specimen. The nurse should also confirm the
identification of the client and the specimen. The nurse does not need sterile gloves,
and the specimen should not be iced.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection
ControlHandling Hazardous and Infectious Materials)

MSC: Integrated Process: Nursing Process (Implementation)


Chapter 47: Care of Critically Ill Patients
with Neurologic Problems Nursing
School Test Banks
Chapter 47: Care of Critically Ill Patients with Neurologic Problems

Test Bank

MULTIPLE CHOICE

1. The nurse is obtaining a health history for a client admitted to the hospital after
experiencing a brain attack. Which disorder does the nurse identify as a predisposing
factor for an embolic stroke?

a. Seizures
b. Psychotropic drug use
c. Atrial fibrillation
d. Cerebral aneurysm

ANS: C

Clients with a history of hypertension, heart disease, atrial fibrillation, diabetes,


obesity, and hypercoagulopathy are at risk for embolic stroke. The other disorders are
not risk factors for an embolic stroke.

DIF: Cognitive Level: Knowledge/Remembering REF: p. 1012

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Nursing Process (Assessment)


2. A client with aphasia presents to the emergency department with a suspected brain
attack. Which clinical manifestation leads the nurse to suspect that this client has had
a thrombotic stroke?

a. Two episodes of speech difficulties in the last month


b. Sudden loss of motor coordination
c. A grand mal seizure 2 months ago
d. Chest pain and nuchal rigidity

ANS: A

Thrombotic stroke is characterized by a gradual onset of symptoms that often are


preceded by transient ischemic attacks (TIAs), causing a focal neurologic dysfunction.
Two episodes of speech difficulties would correlate with TIAs. The other
manifestations are not related to a thrombotic stroke.

DIF: Cognitive Level: Comprehension/Understanding REF: Table 47-1, p. 1006

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

3. The nurse is caring for an 80-year-old client who presented to the emergency
department in a coma. Which question does the nurse ask the clients family to help
determine whether the coma is related to a brain attack?

a. How many hours does your mother usually sleep at night?


b. Did your mother complain recently of weakness in her lower
extremities?
c. Is any history of seizures known among your mothers immediate family?
d. Does your mother drink any alcohol or take any medications?

ANS: D
Conditions such as drug or alcohol intoxication, as well as hypoxemia and metabolic
disturbances, can cause profound changes in level of consciousness (LOC) when
accompanied by a brain attack. Alcohol abuse and medication toxicity can be
especially problematic in older adults. The other manifestations are related to a stroke
but would not increase the clients risk of coma.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

4. The nurse is assessing a client who had a stroke in the right cerebral hemisphere.
Which neurologic deficit does the nurse assess for in this client?

a. Impaired proprioception
b. Aphasia
c. Agraphia
d. Impaired olfaction

ANS: A

A stroke to the right cerebral hemisphere causes impaired visual and spatial
awareness. The client may present with impaired proprioception and may be
disoriented as to time and place. The right cerebral hemisphere does not control
speech, smell, or the clients ability to write.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

5. A client who had a stroke combs her hair only on the right side of her head and
washes only the right side of her face. How does the nurse interpret these actions?
a. Poor left-sided motor control
b. Paralysis or contractures on the right side
c. Limited visual perception of the left fields
d. Unawareness of the existence of her left side

ANS: D

Clients who have experienced a right hemisphere stroke often have neglect syndrome,
in which they are unaware of the existence of the paralyzed side, or the left side. This
injury would not have an effect on the clients sight. This is not related to poor motor
control or paralysis.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1011

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPotential for


Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Analysis)

6. The nurse notes that the left arm of a client who has experienced a brain attack is in
a contracted, fixed position. Which complication of this position does the nurse
monitor for in this client?

a. Shoulder subluxation
b. Flaccid hemiparesis
c. Pathologic fracture
d. Neglect syndrome

ANS: A

Hypertonia causing contracture or flaccidity can predispose the client to subluxation


of the shoulder. Contractures are stiff and immobilenot flaccid. Contractures are not
caused by fractures or neglect syndrome.

DIF: Cognitive Level: Application/Applying or higher REF: N/A


TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Analysis)

7. The nurse is caring for a client who has experienced a stroke. Which nursing
intervention for nutrition does the nurse implement to prevent complications from
cranial nerve IX impairment?

a. Turn the clients plate around halfway through the meal.


b. Place the client in high Fowlers position.
c. Order a clear liquid diet for the client.
d. Verbalize the placement of food on the clients plate.

ANS: B

Cranial nerve IX, the glossopharyngeal nerve, controls the gag reflex. Clients with
impairment of this nerve are at great risk for aspiration. The client should be in high
Fowlers position and should drink thickened liquids if swallowing difficulties are
present. The client would not have vision problems. Turning the plate around would
not prevent a complication, nor would limiting the clients diet to clear liquids.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

8. A client who had a brain attack was admitted to the intensive care unit yesterday.
The nurse observes that the client is becoming lethargic and is unable to articulate
words when speaking. What does the nurse do next?

a. Check the clients blood pressure and apical heart rate.


b. Elevate the back rest to 30 degrees and notify the health care provider.
c. Place the client in a supine position with a flat back rest, and observe.
d. Assess the clients white blood cell count and differential.

ANS: B

The client is experiencing signs of increased intracranial pressure (ICP). Raising the
head of the bed would help decrease ICP. The health care provider should then be
notified immediately so that other interventions to reduce ICP can be instituted.
Assessing vital signs and white blood cell count is not the priority at this time.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

9. The nurse is caring for a client who had a stroke. Which nursing intervention does
the nurse implement during the first 72 hours to prevent complications?

a. Administer prescribed analgesics to promote pain relief.


b. Cluster nursing procedures together to avoid fatiguing the client.
c. Monitor neurologic and vital signs closely to identify early changes in
status.
d. Position with the head of the bed flat to enhance cerebral perfusion.

ANS: C

Early detection of neurologic, blood pressure, and heart rhythm changes offers an
opportunity to intervene in a timely fashion. Evidence is not yet sufficient to
recommend a specific back rest elevation after stroke. Analgesics are often held
during the first 72 hours to ensure that the clients neurologic status is not altered by
pain medications. Preventing fatigue is not a priority in the first 72 hours.

DIF: Cognitive Level: Application/Applying or higher REF: N/A


TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Analysis)

10. A client who first experienced symptoms related to a confirmed thrombotic stroke
2 hours ago is brought to the intensive care unit. Which prescribed medication does
the nurse prepare to administer?

a. Tissue plasminogen activator


b. Heparin sodium
c. Gabapentin (Neurontin)
d. Warfarin (Coumadin)

ANS: A

The client who has had a thrombotic stroke has a 3-hour time frame from the onset of
symptoms to receive recombinant tissue plasminogen activator (rt-PA) to dissolve the
cerebral artery occlusion and re-establish blood flow. Clients must meet eligibility
criteria for administration of this therapy. The other medications do not assist in the
re-establishment of blood flow for a client with a confirmed thrombotic stroke.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral


TherapiesExpected Actions/Outcomes)

MSC: Integrated Process: Nursing Process (Implementation)

11. A client who had a stroke is receiving clopidogrel (Plavix). Which adverse effect
does the nurse monitor for in this client?

a. Repeated syncope
b. New-onset confusion
c. Spontaneous ecchymosis
d. Abdominal distention

ANS: C

Clopidogrel (Plavix) is an antiplatelet medication that can cause bleeding, bruising,


and liver dysfunction. The nurse should be alert for signs of bleeding, such as
ecchymosis, bleeding gums, and tarry stools. Plavix does not cause syncope,
confusion, or abdominal distention.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral


TherapiesAdverse Effects/Contraindications/Side Effects/Interactions)

MSC: Integrated Process: Nursing Process (Evaluation)

12. The nurse is caring for a client who is immobile from a recent stroke. Which
intervention does the nurse implement to prevent complications in this client?

a. Position the client with the unaffected side down.


b. Apply sequential compression stockings.
c. Instruct the client to turn the head from side to side.
d. Teach the client to touch and use both sides of the body.

ANS: B

To avoid complications of immobility, such as deep vein thrombosis, the nurse applies
sequential compression stockings or pneumatic compression boots. Efforts are made
to mobilize the client as much as possible, and the client should be repositioned
frequently. The other interventions will not prevent complications of immobility.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)

13. A client has experienced a stroke resulting in damage to Wernickes area. Which
clinical manifestation does the nurse monitor for?

a. Inability to comprehend spoken words


b. Communication with rote speech only
c. Slurred speech
d. Inability to make sounds

ANS: A

The client with damage to Wernickes area cannot understand spoken or written words.
If the client speaks, the language is meaningless, with the client using made-up words.
Damage to Wernickes area does not cause slurred speech, nor will the client
communicate with habitual speech only.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Sensory/Perceptual Alterations)

MSC: Integrated Process: Nursing Process (Analysis)

14. A client who has had a stroke with left-sided hemiparesis has been referred to a
rehabilitation center. The client asks, Why do I need rehabilitation? How does the
nurse respond?

a. Rehabilitation will reverse any physical deficits caused by the stroke.


b. If you do not have rehabilitation, you may never walk again.
c. Rehabilitation will help you function at the highest level possible.
d. Your doctor knows best and has ordered this treatment for you.

ANS: C
The goal of rehabilitation is to maximize the clients abilities in all aspects of life. The
other responses do not answer the clients question appropriately.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Principles of


Teaching/Learning)

MSC: Integrated Process: Teaching/Learning

15. The nurse is teaching bladder training to a client who is incontinent after a stroke.
Which instruction does the nurse include in this clients teaching?

a. Decrease your oral intake of fluids to 1 liter per day.


b. Use a Foley catheter at night to prevent accidents.
c. Plan to use the commode every 2 hours during the day.
d. Hold your bladder as long as possible to restore bladder tone.

ANS: C

To begin a bladder training program, teach the client to use the commode, bedpan, or
urinal every 2 hours. If used frequently enough, this will prevent accidents and
establish a routine. Fluid intake should be restricted at night, and a Foley catheter
should be used only for urine retention. The client should empty his or her bladder
when the urge occurs and should not hold the bladder.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness


Management) MSC: Integrated Process: Teaching/Learning

16. The nurse is caring for a client admitted to the intensive care unit after incurring a
basilar skull fracture. Which complication of this injury does the nurse monitor for?

a. Aspiration
b. Hemorrhage
c. Pulmonary embolus
d. Myocardial infarction

ANS: B

This type of fracture may cause hemorrhage from damage to the internal carotid
artery. The other problems are not complications of this injury.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Analysis)

17. A client who has a head injury is transported to the emergency department. Which
assessment does the emergency department nurse perform immediately?

a. Pupil response
b. Motor function
c. Respiratory status
d. Short-term memory

ANS: C

Respiratory derangements (e.g., hypoxemia, hypercarbia, alterations in pH) can


contribute to secondary brain injury in this scenario. Therefore, the important priority
is assessment of respiratory status so that secondary brain injury conditions are
avoided. The other assessments should be performed after effective respiratory
functions have been established.

DIF: Cognitive Level: Application/Applying or higher REF: N/A


TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Assessment)

18. The nurse is caring for a client who has a moderate head injury. The clients sister
asks, Will my brother return to his normal functioning level when his brain heals?
How does the nurse respond?

a. You should expect a full recovery in all ways by the time of discharge.
b. Usually, someone with this type of injury returns to baseline within 6
months.
c. Your brother may experience many changes in personality and cognitive
abilities.
d. Learning complex new skills may be more difficult, but you can expect
other functions to return to normal.

ANS: C

Those with moderate to severe head injuries are never the same as before the injury.
They can experience changes in cognition such as memory loss, difficulty learning
new information, and limited concentration. Personality alterations such as outbursts
of temper and depression also may occur. The other responses do not correctly answer
the question and can give false hope.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

MSC: Integrated Process: Nursing Process (Implementation)

19. A client who has a severe head injury is placed in a drug-induced coma. The
clients husband states, I do not understand. Why are you putting her into a coma?
How does the nurse respond?
a. These drugs will prevent her from experiencing pain when positioning or
suctioning is required.
b. This medication will help her remain cooperative and calm during the
painful treatments.
c. This medication will decrease the activity of her brain so that additional
damage does not occur.
d. This medication will prevent her from having a seizure and will reduce
the need for monitoring intracranial pressure.

ANS: C

When intracranial pressure cannot be controlled by other means, clients may be


placed in a barbiturate coma to decrease cerebral metabolic demands, decrease
formation of vasogenic edema, and produce a more uniform blood supply to the brain.
The other responses do not correctly explain the reason for a medication-induced
coma. Pain medication should be administered when the client is comatose.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness


Management) MSC: Integrated Process: Teaching/Learning

20. The nurse is preparing to administer prescribed mannitol (Osmitrol) to a client


with a severe head injury. Which precaution does the nurse take before administering
this medication?

a. Draw up the medication using a filtered needle.


b. Have injectable naloxone (Narcan) prepared and ready at the bedside.
c. Prepare to hyperventilate the client before drug administration.
d. Discontinue a barbiturate-induced coma before drug administration.

ANS: A

Mannitol (Osmitrol) must be drawn up using a filtered needle to eliminate


microscopic crystals. Narcan does not reverse the effects of mannitol.
Hyperventilation does not affect administration of this drug, and clients can be given
mannitol while in a barbiturate-induced coma.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral


TherapiesMedication Administration)

MSC: Integrated Process: Nursing Process (Implementation)

21. A client with a head injury is being given midazolam (Versed) while on
mechanical ventilation. Which action does the nurse implement for this client?

a. Monitor for seizures.


b. Assess for urinary output.
c. Provide a clear liquid diet.
d. Administer an analgesic.

ANS: D

Midazolam (Versed) is a benzodiazepine agent and has no analgesic effect. It should


be given with pain medication. This medication does not increase the risk of seizures
and does not decrease urinary output. Clients should not be fed when being
mechanically ventilated.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral


TherapiesExpected Actions/Outcomes)

MSC: Integrated Process: Nursing Process (Implementation)

22. The nurse is caring for a client who is disoriented as the result of a stroke. Which
action does the nurse implement to help orient this client?

a. Ask the family to bring in pictures familiar to the client.


b. Turn on the television to a 24-hour news station.
c. Maintain a calm and quite environment by minimizing visitors.
d. Provide auditory and visual stimulation simultaneously.

ANS: A

For the client with disorientation, the nurse can request that the family bring in
pictures or objects that are familiar to the client. The nurse explains what the object or
picture represents in simple terms. These stimuli can be presented several times daily.
Visitors can also be familiar stimuli to reorient the client. Too much stimuli and
constant stimuli can lead to further confusion.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness


Management) MSC: Integrated Process: Nursing Process (Implementation)

23. The nurse is planning the discharge of a client who has sustained a moderate head
injury and is experiencing personality and behavior changes. The clients wife states, I
am concerned about how different he is. What can I do to help with the transition back
to our home? How does the nurse respond?

a. Be firm and let him know when his behavior is unacceptable.


b. Minimizing the number of visitors will help stabilize his personality.
c. Developing a routine will help provide him with a structured
environment.
d. He will return to his normal emotional functioning in 6 to 12 months.

ANS: C

Developing a home routine that provides structure and repetition is recommended


because clients with personality and behavior problems respond best to this type of
environment. The clients personality and emotional functioning will never return to
normal. The client may be aggressive, and family members must be aware of potential
client reactions.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Family Dynamics)

MSC: Integrated Process: Teaching/Learning

24. The nurse assesses periorbital edema and ecchymosis around both eyes of a client
who is 6 hours postoperative for craniotomy. Which intervention does the nurse
implement for this client?

a. Position the client with the head of the bed flat.


b. Apply an ice pack to the affected area.
c. Assess arterial blood pressure.
d. Notify the health care provider.

ANS: B

Periorbital edema and ecchymosis are expected after a craniotomy. The nurse should
attempt to increase the clients comfort by reducing the swelling with application of
ice. The provider does not need to be notified. Lowering the head of the bed and
assessing blood pressure will not decrease inflammation.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

25. The nurse is assessing a client who was recently diagnosed with a meningioma.
Which statement indicates that the client correctly understands the diagnosis?

a. This is the worst type of brain tumor, and surgery is not an option.
b. My tumor can be removed, but I can still have damage because of
pressure in my brain.
c. Even after the surgery, I will need chemotherapy to decrease the spread
of the tumor.
d. Radiation is never used on brain tumors because of possible nerve
damage.

ANS: B

Meningiomas arise from the coverings of the brain (the meninges) and are the most
common type of benign tumor. This tumor is encapsulated, globular, and well
demarcated, and causes compression and displacement of nearby brain tissue.
Although complete removal of the tumor is possible, it tends to recur and causes
irreversible damage to the brain. The tumor is not treated by chemotherapy or
radiation.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

MSC: Integrated Process: Nursing Process (Evaluation)

MULTIPLE RESPONSE

1. A client is admitted for evaluation of a cerebral tumor. Which clinical


manifestations does the nurse assess this client for?

a. Hemiplegia
b. Aphasia
c. Hearing loss
d. Behavior changes
e. Nystagmus

ANS: A, B, D
If the tumor affects the cerebral hemispheres, hemiplegia, aphasia, and behavioral
changes are common. Hearing loss and nystagmus are found with brainstem lesions.

DIF: Cognitive Level: Comprehension/Understanding REF: Chart 47-10, p. 1032

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

COMPLETION

1. The nurse is preparing to administer a prescribed dose of intravenous


dexamethasone (Decadron) to a client after craniotomy. The pharmacy supplies
dexamethasone 40 mcg in 20 mL normal saline to be administered over 15 minutes.
The nurse sets the IV pump at a rate of _____ mL/hr.

ANS:

80

20 mL/15 min = x mL/60 min

15x = 1200

x = 80 mL/hr

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral


TherapiesDosage Calculation)

MSC: Integrated Process: Nursing Process (Implementation)