NEUROLOGICAL DISORDERS NCLEX
QUESTIONS AND ANSWERS 2022
After teaching a patient about management of migraine headaches, the nurse
determines that the
... [Show More] teaching has been effective when the patient says,
_____________ - ANS- "I will try to lie down someplace dark and quiet when the
headaches begin."
rational: It is recommended that the patient with a migraine rest in a dark, quiet area.
Topiramate (Topamax) is used to prevent migraines and must be taken for several
months to determine effectiveness. Aspirin or other nonsteroidal anti-inflammatory
medications can be taken with the triptans. Alcohol may precipitate migraine
headaches.
When a patient is experiencing a cluster headache, the nurse will plan to assess for
_______________ - ANS- unilateral eyelid swelling.
rational: Unilateral eye edema, tearing, and ptosis are characteristic of cluster
headaches. Nuchal rigidity suggests meningeal irritation, such as occurs with
meningitis. Although nausea and vomiting may occur with migraine headaches,
projectile vomiting is more consistent with increases in intracranial pressure (ICP).
Unilateral sharp, stabbing pain, rather than throbbing pain, is characteristic of cluster
headaches.
A patient has a tonic-clonic seizure while the nurse is in the patient's room. Which
action should the nurse take? - ANS- Time and observe and record the details of the
seizure and postictal state.
rational: Because diagnosis and treatment of seizures frequently are based on the
description of the seizure, recording the length and details of the seizure is
important. Insertion of an oral airway and restraining the patient during the seizure
are contraindicated. The nurse may need to move the patient to decrease the risk of
injury during the seizure.
An elementary teacher who has just been diagnosed with epilepsy after having a
generalized tonic-clonic seizure tells the nurse, "I cannot teach anymore, it will be too
upsetting if I have a seizure at work." Which response by the nurse is best? - ANS-
"Most patients with epilepsy are well controlled with antiseizure medications."
rational: The nurse should inform the patient that most patients with seizure
disorders are controlled with medication. The other information may be necessary if
the patient seizures persist after treatment with antiseizure medications is
implemented.
Which action will the nurse take when evaluating a patient who is taking phenytoin
(Dilantin) for adverse effects of the medication? - ANS- Inspect the oral mucosa.
rational: Phenytoin can cause gingival hyperplasia, but does not affect bowel tones,
lung sounds, or pupil reaction to light.
A patient found in a tonic-clonic seizure reports afterward that the seizure was
preceded by numbness and tingling of the arm. The nurse knows that this finding
indicates what type of seizure? - ANS- Atonic
rational: The initial symptoms of a partial seizure involve clinical manifestations that
are localized to a particular part of the body or brain. Symptoms of an absence
seizure are staring and a brief loss of consciousness. In an atonic seizure, the
patient loses muscle tone and (typically) falls to the ground. Myoclonic seizures are
characterized by a sudden jerk of the body or extremities.
When obtaining a health history and physical assessment for a patient with possible
multiple sclerosis (MS), the nurse should _____________ - ANS- inquire about any
urinary tract problems.
rational: Urinary tract problems with incontinence or retention are common
symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease
in libido is common with MS.
A 28-year-old woman who has multiple sclerosis (MS) asks the nurse about risks
associated with pregnancy. Which response by the nurse is accurate? - ANS- "MS
symptoms may be worse after the pregnancy."
rational: During the postpartum period, women with MS are at greater risk for
exacerbation of symptoms. There is no increased risk for congenital defects in
infants born of mothers with MS. Symptoms of MS may improve during pregnancy.
Onset of labor is not affected by MS.
A patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate
(Copaxone). Which information will the nurse include in patient teaching? - ANSHow to draw up and administer injections of the medication
rational: Copaxone is administered by self-injection. Oral contraceptives are an
appropriate choice for birth control. There is no need to avoid driving or drink large
fluid volumes when taking glatiramer.
Which information about a patient with MS indicates that the nurse should consult
with the health care provider before giving the prescribed dose of fampridine
(Ampyra)? - ANS- The patient has an increased creatinine level.
rational: Fampridine should not be given to patients with impaired renal function. The
other information will not impact on whether the fampridine should be administered.
A patient with multiple sclerosis (MS) has urinary retention caused by a flaccid
bladder. Which action will the nurse plan to take? - ANS- Teach the patient how to
use the Credé method.
rational: The Credé method can be used to improve bladder emptying. Decreasing
fluid intake will not improve bladder emptying and may increase risk for urinary tract
infection (UTI) and dehydration. The use of incontinence briefs and frequent toileting
will not improve bladder emptying.
A patient with Parkinson's disease has a nursing diagnosis of impaired physical
mobility related to bradykinesia. Which action will the nurse include in the plan of
care? - ANS- Suggest that the patient rock from side to side to initiate leg movement.
rational: Rocking the body from side to side stimulates balance and improves
mobility. The patient will be encouraged to continue exercising because this will
maintain functional abilities. Maintaining a wide base of support will help with
balance. The patient should lift the feet and avoid a shuffling gait.
A patient has a new prescription for bromocriptine (Parlodel) to control symptoms of
Parkinson's disease. Which information obtained by the nurse may indicate a need
for a decrease in the dose? - ANS- The patient's blood pressure is 90/46 mm Hg.
rational: Hypotension is an adverse effect of bromocriptine, and the nurse should
check with the health care provider before giving the medication. Diarrhea, cough,
and deep vein thrombosis are not associated with bromocriptine use.
When teaching a patient with myasthenia gravis (MG) about management of the
disease, the nurse advises the patient to ______________ - ANS- perform physically
demanding activities in the morning.
rational: Muscles are generally strongest in the morning, and activities involving
muscle activity should be scheduled then. Plasmapheresis is not routinely scheduled
but is used for myasthenia crisis or for situations in which corticosteroid therapy
should be discontinued. There is no decrease in sensation with MG, and muscle
atrophy does not occur because muscles are used during part of the day.
A patient who is seen in the outpatient clinic complains of restless legs syndrome.
Which of the following over-the-counter medications that the patient is taking
routinely should the nurse discuss with the patient? - ANS- diphenhydramine
(Benadryl)
rational: Antihistamines can aggravate restless legs syndrome. The other
medications will not contribute to the restless legs syndrome.
A patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia.
Which nursing action will be included in the plan of care? - ANS- Assist with active
range of motion.
rational: ALS causes progressive muscle weakness, but assisting the patient to
perform active ROM will help to maintain strength as long as possible. Psychotic
symptoms such as agitation and paranoia are not associated with ALS. Cognitive
function is not affected by ALS, and the patient's ability to understand procedures will
not be impaired. Muscle relaxants will further increase muscle weakness and
depress respirations.
A 42-year-old patient who was adopted at birth is diagnosed with early Huntington's
disease (HD). When teaching the patient, spouse, and children about this disorder,
the nurse will provide information about the ______________ - ANS- availability of
genetic testing to determine the HD risk for the patient's children.
rational: Genetic testing is available to determine whether an asymptomatic
individual has the HD gene. The patient and family should be informed of the
benefits and problems associated with genetic testing. Sinemet will increase
symptoms of HD given that HD involves an increase in dopamine. Antibiotic therapy
will not reduce the risk for aspiration. There are no effective treatments or lifestyle
changes that delay the progression of symptoms in HD.
A patient is seen in the health clinic with symptoms of a stooped posture, shuffling
gait, and pill rolling-type tremor. The nurse will anticipate teaching the patient about
_______________ - ANS- antiparkinsonian drugs.
rational: The diagnosis of Parkinson's is made when two of the three characteristic
signs of tremor, rigidity, and bradykinesia are present. The confirmation of the
diagnosis is made on the basis of improvement when antiparkinsonian drugs are
administered. This patient has symptoms of tremor and bradykinesia; the next
anticipated step will be treatment with medications. MRI and EEG are not useful in
diagnosing Parkinson's disease, and corticosteroid therapy is not used to treat it.
A patient seen at the health clinic with a severe migraine headache tells the nurse
about having four similar headaches in the last 3 months. Which initial action should
the nurse take? - ANS- Ask the patient to keep a headache diary.
rational: The initial nursing action should be further assessment of the precipitating
causes of the headaches, quality, and location of pain, etc. Stress reduction, muscle
relaxation, and the triptan drugs may be helpful, but more assessment is needed
first.
A hospitalized patient complains of a moderate bilateral headache that radiates from
the base of the skull. Which of these prescribed PRN medications should the nurse
administer initially? - ANS- acetaminophen (Tylenol)
rational: The patient's symptoms are consistent with a tension headache, and initial
therapy usually involves a nonopioid analgesic such as acetaminophen, sometimes
combined with a sedative or muscle relaxant. Lorazepam may be used in
conjunction with acetaminophen but would not be appropriate as the initial
monotherapy. Morphine sulfate and butalbital and aspirin would be more appropriate
for a headache that did not respond to a nonopioid analgesic.
A patient tells the nurse about using acetaminophen (Tylenol) several times every
day for recurrent bilateral headaches. Which action will the nurse plan to take first? -
ANS- Discuss the need to stop taking the acetaminophen.
rational: The headache description suggests that the patient is experiencing
medication overuse headache. The initial action will be withdrawal of the medication.
The other actions may be needed if headaches persist.
The health care provider is considering the use of sumatriptan (Imitrex) for a patient
with migraine headaches. Which information obtained by the nurse is most important
to report to the health care provider? - ANS- The patient has a history of a recent
acute myocardial infarction.
rational: The triptans cause coronary artery vasoconstriction and should be avoided
in patients with coronary artery disease. The other information will be reported to the
health care provider, but none of it is an indication that sumatriptan would be an
inappropriate treatment.
The nurse witnesses a patient with a seizure disorder as the patient suddenly jerks
the arms and legs, falls to the floor, and regains consciousness immediately. It will
be most important for the nurse to
_________________ - ANS- assess the patient for a possible head injury.
rational: The patient who has had a myoclonic seizure and fall is at risk for head
injury and should be evaluated and treated for this possible complication first.
Documentation of the seizure, notification of the seizure, and administration of
antiseizure medications also are appropriate actions, but the initial action should be
assessment for injury.
Which of these prescribed interventions will the nurse implement first for a
hospitalized patient who is experiencing continuous tonic-clonic seizures? - ANSAdminister lorazepam (Ativan) 4 mg IV.
rational: To prevent ongoing seizures, the nurse should administer rapidly acting
antiseizure medications such as the benzodiazepines. A CT scan is appropriate, but
prevention of any seizure activity during the CT scan is necessary. Phenytoin also
will be administered, but it is not rapidly acting. Patients who are experiencing tonicclonic seizures are nonresponsive, although the nurse should assess LOC after the
seizure.
When the home health RN is planning care for a patient with a seizure disorder,
which nursing action can be delegated to an LPN/LVN? - ANS- Place medications in
the home medication organizer.
rational: LPN/LVN education includes administration of medications. The other
activities require RN education and scope of practice.
Which information about a patient who is being treated with carbidopa/levodopa
(Sinemet) for Parkinson's disease is most important for the nurse to report to the
health care provider? - ANS- Uncontrolled head movement
rational: Dyskinesia is an adverse effect of the Sinemet, indicating a need for a
change in medication or decrease in dose. The other findings are typical with
Parkinson's disease.
A patient with Parkinson's disease has decreased tongue mobility and an inability to
move the facial muscles. Which nursing diagnosis is of highest priority? - ANSImbalanced nutrition: less than body requirements
rational: The data about the patient indicate that poor nutrition will be a concern
because of decreased swallowing. The other diagnoses also may be appropriate for
a patient with Parkinson's disease, but the data do not indicate they are current
problems for this patient.
When the nurse is assessing a patient with myasthenia gravis, which action will be
most important to take? - ANS- Observe respiratory effort.
rational: Because respiratory insufficiency may be life threatening, it will be most
important to monitor respiratory function. The other data also will be assessed but
are not as critical.
Following a thymectomy, a patient with myasthenia gravis receives the usual dose of
pyridostigmine (Mestinon). An hour later, the patient complains of nausea and
severe abdominal cramps. Which action should the nurse take first? - ANS- Notify
the patient's health care provider.
rational: The patient's history and symptoms indicate a possible cholinergic crisis.
The health care provider should be notified immediately, and it is likely that atropine
will be prescribed. The other actions will be appropriate if the patient is not
experiencing a cholinergic crisis.
A hospitalized 24-year-old patient with a history of cluster headache awakens during
the night with a severe stabbing headache. Which action should the nurse take first?
- ANS- Start the ordered PRN oxygen at 6 L/min.
rational: Acute treatment for cluster headache is administration of 100% oxygen at 6
to 8 L/min. If the patient obtains relief with the oxygen, there is no immediate need to
notify the health care provider. Cluster headaches last only 60 to 90 minutes, so oral
pain medications have minimal effect. Hot packs are helpful for tension headaches
but are not as likely to reduce pain associated with a cluster headache.
When preparing to admit a patient who has been treated for status epilepticus in the
emergency department, which equipment should the nurse have available in the
room: - ANS- -Siderail pads
-Oxygen mask
-Suction tubing
rational: The patient is at risk for further seizures, and oxygen and suctioning may be
needed after any seizures to clear the airway and maximize oxygenation. The bed's
side rails should be padded to minimize the risk for patient injury during a seizure.
Insertion of a nasogastric (NG) tube is not indicated because the airway problem is
not caused by vomiting or abdominal distention. Use of tongue blades during a
seizure is contraindicated.
A patient with Parkinson's disease is admitted to the hospital for treatment of an
acute infection. Which nursing interventions will be included in the plan of care: -
ANS- -Use an elevated toilet seat
-Cut patient's food into small pieces
-Place an arm chair at the patient's bedside
rational: Since the patient with Parkinson's has difficulty chewing, food should be cut
into small pieces. An armchair should be used when the patient is seated so that the
patient can use the arms to assist with getting up from the chair. An elevated toilet
seat will facilitate getting on and off the toilet. High protein foods will decrease the
effectiveness of L-dopa. Parkinson's is a steadily progressive disease without acute
exacerbations.
When family members ask the nurse about the purpose of the ventriculostomy
system being used for intracranial pressure monitoring for a patient, which response
by the nurse is best? - ANS- "The monitoring system helps show whether blood flow
to the brain is adequate."
rational: Short and simple explanations should be given to patients and family
members. The other explanations are either too complicated to be easily understood
or may increase the family member's anxiety.
A patient with a head injury has admission vital signs of blood pressure 128/68,
pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after
admission, will be of most concern to the nurse? - ANS- Blood pressure 156/60,
pulse 55, respirations 12
rational: Systolic hypertension with widening pulse pressure, bradycardia, and
respiratory changes represent Cushing's triad and indicate that the intracranial
pressure (ICP) has increased, and brain herniation may be imminent unless
immediate action is taken to reduce ICP. The other vital signs may indicate the need
for changes in treatment, but they are not indicative of an immediately lifethreatening process.
When the nurse applies a painful stimulus to the nail beds of an unconscious patient,
the patient responds with internal rotation, adduction, and flexion of the arms. The
nurse documents this as _____________ - ANS- decorticate posturing.
rational: Internal rotation, adduction, and flexion of the arms in an unconscious
patient is documented as decorticate posturing. Extension of the arms and legs is
decerebrate posturing. Because the flexion is generalized, it does not indicate
localization of pain or flexion withdrawal.
Which parameter is best for the nurse to monitor to determine whether the
prescribed IV mannitol (Osmitrol) has been effective for an unconscious patient? -
ANS- Intracranial pressure
rational: Mannitol is an osmotic diuretic and will reduce cerebral edema and
intracranial pressure. It may initially reduce hematocrit and increase blood pressure,
but these are not the best parameters for evaluation of the effectiveness of the drug.
Oxygen saturation will not directly improve as a result of mannitol administration.
A patient with a head injury opens the eyes to verbal stimulation, curses when
stimulated, and does not respond to a verbal command to move but attempts to
remove a painful stimulus. The nurse records the patient's Glasgow Coma Scale
score as _______ - ANS- 11
rational: The patient has a score of 3 for eye opening, 3 for best verbal response,
and 5 for best motor response.
Following a head injury, an unconscious 32-year-old patient is admitted to the
emergency department (ED). The patient's spouse and children stay at the patient's
side and constantly ask about the treatment being given. What action is best for the
nurse to take? - ANS- Allow the family to stay with the patient and briefly explain all
procedures to them.
rational: The need for information about the diagnosis and care is very high in family
members of acutely ill patients, and the nurse should allow the family to observe
care and explain the procedures. A pastor or counseling service can offer some
support, but research supports information as being more effective. Asking the family
to stay in the waiting room will increase their anxiety.
An unconscious patient has a nursing diagnosis of ineffective cerebral tissue
perfusion related to cerebral tissue swelling. Which nursing intervention will be
included in the plan of care? - ANS- Keep the head of the bed elevated to 30
degrees.
rational: The patient with increased intracranial pressure (ICP) should be maintained
in the head-up position to help reduce ICP. Flexion of the hips and knees increases
abdominal pressure, which increases ICP. Because the stimulation associated with
nursing interventions increases ICP, clustering interventions will progressively
elevate ICP. Coughing increases intrathoracic pressure and ICP.
After noting that a patient with a head injury has clear nasal drainage, which action
should the nurse take? - ANS- Check the nasal drainage for glucose.
rational: Clear nasal drainage in a patient with a head injury suggests a dural tear
and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for
glucose. Fluid leaking from the nose will have normal nasal flora, so culture and
sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage.
A patient who has a head injury is diagnosed with a concussion. Which action will
the nurse plan to take? - ANS- Provide discharge instructions about monitoring
neurologic status.
rational: A patient with a minor head trauma is usually discharged with instructions
about neurologic monitoring and the need to return if neurologic status deteriorates.
MRI, hospital admission, or surgery are not indicated in a patient with a concussion.
A patient who is suspected of having an epidural hematoma is admitted to the
emergency department. Which action will the nurse plan to take? - ANS- Prepare the
patient for immediate craniotomy.
rational: The principal treatment for epidural hematoma is rapid surgery to remove
the hematoma and prevent herniation. If intracranial pressure (ICP) is elevated after
surgery, furosemide or high-dose barbiturate therapy may be needed, but these will
not be of benefit unless the hematoma is removed. Minimal blood loss occurs with
head injuries, and transfusion is usually not necessary.
While admitting a patient with a basal skull fracture, the nurse notes clear drainage
from the patient's nose. Which of these admission orders should the nurse question?
- ANS- Insert nasogastric tube.
rational: Rhinorrhea may indicate a dural tear with cerebrospinal fluid (CSF) leakage,
and insertion of a nasogastric tube will increase the risk for infections such as
meningitis. Turning the patient, elevating the head, and applying cold pack are
appropriate orders.
Which assessment information will the nurse collect to determine whether a patient
is developing postconcussion syndrome? - ANS- Short-term memory
rational: Decreased short-term memory is one indication of postconcussion
syndrome. The other data may be assessed but are not indications of
postconcussion syndrome.
When admitting a patient who has a tumor of the right frontal lobe, the nurse would
expect to find __________ - ANS- judgment changes
rational: The frontal lobes control intellectual activities such as judgment. Speech is
controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral
side from the tumor. Swallowing is controlled by the brainstem.
Which statement by a patient who is being discharged from the emergency
department (ED) after a head injury indicates a need for intervention by the nurse? -
ANS- "I am going to drive home and go to bed."
rational: Following a head injury, the patient should avoid operating heavy
machinery. Retrograde amnesia is common after a concussion. The patient can take
acetaminophen for headache and should return if symptoms of increased intracranial
pressure such as dizziness or nausea occur.
After having a craniectomy and left anterior fossae incision, a patient has a nursing
diagnosis of impaired physical mobility related to decreased level of consciousness
and weakness. An appropriate nursing intervention is to
______________ - ANS- perform range-of-motion (ROM) exercises every 4 hours.
rational: ROM exercises will help to prevent the complications of immobility. Patients
with anterior craniotomies are positioned with the head elevated. The patient with a
craniectomy should not be turned to the operative side. When the patient is weak,
clustering nursing activities may lead to more fatigue and weakness.
A patient who has bacterial meningitis is disoriented and anxious. Which nursing
action will be included in the plan of care? - ANS- Encourage family members to
remain at the bedside.
rational: Patients with meningitis and disorientation will be calmed by the presence of
someone familiar at the bedside. Restraints should be avoided because they
increase agitation and anxiety. The patient requires frequent assessment for
complications; the use of touch and a soothing voice will decrease anxiety for most
patients. The patient will have photophobia, so the light should be dim.
The community health nurse is developing a program to decrease the incidence of
meningitis in adolescents and young adults. Which nursing action is most important?
- ANS- Immunize adolescents and college freshman against Neisseria meningitides.
rational: The Neisseria meningitides vaccination is recommended for children ages
11 and 12, unvaccinated teens entering high school, and college freshmen. Hand
washing may help decrease the spread of bacteria, but it is not as effective as
immunization. Vaccination with Haemophilus influenzae is for infants and toddlers.
Because adolescents and young adults are in school or the workplace, avoiding
crowds is not realistic.
While caring for a patient who has just been admitted with meningococcal meningitis,
the RN observes all of the following. Which one requires action by the RN? - ANSThe nursing assistant goes into the patient's room without a mask.
rational: Meningococcal meningitis is spread by respiratory secretions, so it is
important to maintain respiratory isolation as well as standard precautions. Because
the patient may be confused and weak, bedrails should be elevated at both the food
and head of the bed. Low light levels in the room decrease pain caused by
photophobia. Nutrition is an important aspect of care in a patient with meningitis.
When assessing a patient with bacterial meningitis, the nurse obtains the following
data. Which finding should be reported immediately to the health care provider? -
ANS- The patient's blood pressure is 86/42 mm Hg.
rational: Shock is a serious complication of meningitis, and the patient's low blood
pressure indicates the need for interventions such as fluids or vasopressors. Nuchal
rigidity and a positive Kernig's sign are expected with bacterial meningitis. The nurse
should intervene to lower the temperature, but this is not as life threatening as the
hypotension.
A patient has a systemic BP of 108/51 mm Hg and an intracranial pressure (ICP) of
14 mm Hg. Which action should the nurse take first? - ANS- Report the BP and ICP
to the health care provider.
rational: The patient's cerebral perfusion pressure is 56 mm Hg, below the normal of
60 to 100 mm Hg and approaching the level of ischemia and neuronal death.
Immediate changes in the patient's therapy such as fluid infusion or vasopressor
administration are needed to improve the cerebral perfusion pressure. Adjustments
in the head elevation should only be done after consulting with the health care
provider. Continued monitoring and documentation also will be done, but they are
not the first actions that the nurse should take.
After suctioning, the nurse notes that the intracranial pressure for a patient with a
traumatic head injury has increased from 14 to 16 mm Hg. Which action should the
nurse take first? - ANS- Assure that the patient's neck is not in a flexed position.
rational: Since suctioning will cause a transient increase in intracranial pressure, the
nurse should initially check for other factors that might be contributing to the increase
and observe the patient for a few minutes. Documentation is needed, but this is not
the first action. There is no need to notify the health care provider about this
expected reaction to suctioning. Propofol is used to control patient anxiety or
agitation; there is no indication that anxiety has contributed to the increase in
intracranial pressure.
Which of these patients is most appropriate for the intensive care unit (ICU) charge
nurse to assign to an RN who has floated from the medical unit? - ANS- A 44-yearold receiving IV antibiotics for meningococcal meningitis
rational: An RN who works on a medical unit will be familiar with administration of IV
antibiotics and with meningitis. The postcraniotomy patient, patient with an ICP
monitor, and the patient on a ventilator should be assigned to an RN familiar with the
care of critically ill patients.
A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115
mmol/L) and a decreasing level of consciousness (LOC) and complains of a
headache. Which of these prescribed interventions should the nurse implement first?
- ANS- Administer 5% hypertonic saline intravenously.
rational: The patient's low sodium indicates that hyponatremia may be causing the
cerebral edema, and the nurse's first action should be to correct the low sodium
level. Acetaminophen (Tylenol) will have minimal effect on the headache because it
is caused by cerebral edema and increased intra-cranial pressure (ICP). Drawing
ABGs and obtaining a CT scan may add some useful information, but the low
sodium level may lead to seizures unless it is addressed quickly.
After the emergency department nurse has received a status report on the following
patients who have been admitted with head injuries, which patient should the nurse
assess first? - ANS- A patient whose right pupil is 10 mm and unresponsive to light
rational: The dilated and nonresponsive pupil may indicate an intracerebral
hemorrhage and increased intracranial pressure. The other patients are not at
immediate risk for complications such as herniation.
Which assessment finding in a patient who was admitted the previous day with a
basilar skull fracture is most important to report to the health care provider? - ANSTemperature of 101.5° F (38.6° C)
rational: Patients who have basilar skull fractures are at risk for meningitis, so the
elevated temperature should be reported to the health care provider. The other
findings are typical of a patient with a basilar skull fracture.
When a patient's intracranial pressure (ICP) is being monitored with an
intraventricular catheter, which information obtained by the nurse is most important
to communicate to the health care provider? - ANS- Oral temperature 101.6° F
rational: Infection is a serious consideration with ICP monitoring, especially with
intraventricular catheters. The temperature indicates the need for antibiotics or
removal of the monitor. The ICP, arterial pressure, and apical pulse are all borderline
high but require only ongoing monitoring at this time.
The charge nurse observes an inexperienced staff nurse who is caring for a patient
who has had a craniotomy for a brain tumor. Which action by the inexperienced
nurse requires the charge nurse to intervene? - ANS- The staff nurse suctions the
patient every 2 hours.
rational: Suctioning increases intracranial pressure and is done only when the
patient's respiratory condition indicates it is needed. The other actions by the staff
nurse are appropriate.
A patient is brought to the emergency department (ED) by ambulance after being
found unconscious on the bathroom floor by the spouse. Which action will the nurse
take first? - ANS- Obtain oxygen saturation.
rational: Airway patency and breathing are the most vital functions and should be
assessed first. The neurologic assessments should be accomplished next and the
health and medication history last.
The care plan for a patient who has increased intracranial pressure and a
ventriculostomy includes the following nursing actions. Which action can the nurse
delegate to nursing assistive personnel (NAP) who regularly work in the intensive
care unit? - ANS- Check capillary blood glucose level every 6 hours.
rational: Experienced NAP can obtain capillary blood glucose levels when they have
been trained and evaluated in the skill. Monitoring and documentation of
cerebrospinal fluid (CSF) color and intracranial pressure (ICP) require RN-level
education and scope of practice. Although repositioning patients is frequently
delegated to NAP, repositioning a patient with a ventriculostomy is complex and
should be done by the RN.
Which information about a patient who is hospitalized after a traumatic brain injury
requires the most rapid action by the nurse? - ANS- Pressure of oxygen in brain
tissue (PbtO2) is 14 mm Hg
rational: The PbtO2 should be 20 to 40 mm Hg. Lower levels indicate brain ischemia.
An intracranial pressure (ICP) of 15 mm Hg is at the upper limit of normal. CSF is
produced at a rate of 20 to 30 mL/hour. The reason for the sinus tachycardia should
be investigated, but the elevated heart rate is not as concerning as the decrease in
PbtO2.
When caring for a patient who has had a head injury, which assessment information
requires the most rapid action by the nurse? - ANS- The patient is more difficult to
arouse.
rational: The change in level of consciousness (LOC) is an indicator of increased
intracranial pressure (ICP) and suggests that action by the nurse is needed to
prevent complications. The change in BP should be monitored but is not an indicator
of a need for immediate nursing action. Headache is not unusual in a patient after a
head injury. A slightly irregular apical pulse is not unusual.
The nurse obtains these assessment findings for a patient who has a head injury.
Which finding should be reported rapidly to the health care provider? - ANS- Urine
output of 800 mL in the last hour
rational: The high urine output indicates that diabetes insipidus may be developing
and interventions to prevent dehydration need to be rapidly implemented. The other
data do not indicate a need for any change in therapy.
When admitting a patient with a possible coup-contracoup injury after a car accident
to the emergency department, the nurse obtains the following information. Which
finding is most important to report to the health care provider? - ANS- The patient
takes warfarin (Coumadin) daily.
rational: The use of anticoagulants increases the risk for intracranial hemorrhage and
should be immediately reported. The other information would not be unusual in a
patient with a head injury who had just arrived to the ED.
A patient admitted with bacterial meningitis and a temperature of 102° F (38.8° C)
has orders for all of these collaborative interventions. Which action should the nurse
take first? - ANS- Swap the nasopharyngeal mucosa for cultures.
rational: Antibiotic therapy should be instituted rapidly in bacterial meningitis, but
cultures must be done before antibiotics are started. As soon as the cultures are
done, the antibiotic should be started. Hypothermia therapy and acetaminophen
administration are appropriate but can be started after the other actions are
implemented.
An unconscious patient with a traumatic head injury has a blood pressure of 126/72
mm Hg, and an intracranial pressure of 18 mm Hg. The nurse will calculate the
cerebral perfusion pressure as ____________________. - ANS- 72 mm Hg
(The formula for calculation of cerebral perfusion pressure is [(Systolic pressure +
Diastolic blood pressure × 2)/3] = intracranial pressure.)
When assessing a patient with newly diagnosed trigeminal neuralgia, the nurse will
ask the patient about _______________ - ANS- triggers that lead to facial pain.
rational: The major clinical manifestation of trigeminal neuralgia is severe facial pain
that is triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and
facial weakness are not characteristics of trigeminal neuralgia.
Which action should the nurse take when assessing a patient with trigeminal
neuralgia? - ANS- Examine the mouth and teeth thoroughly.
rational: Oral hygiene is frequently neglected because of fear of triggering facial pain.
Having the patient clench the facial muscles will not be useful because the sensory
branches of the nerve are affected by trigeminal neuralgia. Light touch and palpation
may be triggers for pain and should be avoided.
When evaluating a patient with trigeminal neuralgia who has had a glycerol
rhizotomy, the nurse will ______________ - ANS- question the patient about social
activities with family and friends.
rational: Because withdrawal from social activities is a common manifestation of
trigeminal neuralgia, asking about social activities will help in evaluating whether the
patient's symptoms have improved. Glycerol rhizotomy does not damage the corneal
reflex or motor functions of the trigeminal nerve, so there is no need to use an eye
shield, do facial exercises, or take precautions with chewing.
Which action will the nurse include in the plan of care when caring for a patient who
is experiencing trigeminal neuralgia? - ANS- Assess intake and output and dietary
intake.
rational: The patient with an acute episode of trigeminal neuralgia may be unwilling
to eat or drink, so assessment of nutritional and hydration status is important.
Because stimulation by touch is the precipitating factor for pain, relaxation of the
facial muscles will not improve symptoms. Application of ice is likely to precipitate
pain. The patient will not want to engage in conversation, which may precipitate
attacks.
When teaching patients who are at risk for Bell's palsy because of previous herpes
simplex infection, which information should the nurse include? - ANS- "Call the
doctor if pain or herpes lesions occur near the ear."
rational: Pain or herpes lesions near the ear may indicate the onset of Bell's palsy
and rapid corticosteroid treatment may reduce the duration of Bell's palsy symptoms.
Antiviral therapy for herpes simplex does not reduce the risk for Bell's palsy.
Corticosteroid therapy will be most effective in reducing symptoms if started before
paralysis is complete but will still be somewhat effective when started later. Facial
exercises do not prevent Bell's palsy.
A patient with Bell's palsy refuses to eat while others are present because of
embarrassment about drooling. The best response by the nurse to the patient's
behavior is to _______________ - ANS- respect the patient's desire and arrange for
privacy at mealtimes.
rational: The patient's desire for privacy should be respected to encourage adequate
nutrition and reduce patient embarrassment. Liquid supplements will reduce the
patient's enjoyment of the taste of food. It would be inappropriate for the nurse to
discuss the patient's embarrassment with visitors unless the patient wishes to share
this information. Chewing on the unaffected side of the mouth will enhance nutrition
and enjoyment of food but will not decrease the drooling.
Which nursing action will the home health nurse include in the plan of care for a
patient with paraplegia in order to prevent autonomic dysreflexia? - ANS- Teach the
purpose of a prescribed bowel program.
rational: Fecal impaction is a common stimulus for autonomic dysreflexia. The other
actions may be included in the plan of care but will not reduce the risk for autonomic
dysreflexia.
When caring for a patient who has Guillain-Barré syndrome, which assessment data
obtained by the nurse will require the most immediate action? - ANS- The patient
has continuous drooling of saliva.
rational: Drooling indicates decreased ability to swallow, which places the patient at
risk for aspiration and requires rapid nursing and collaborative actions such as
suctioning and possible endotracheal intubation. The foot pain should be treated with
appropriate analgesics, and the BP requires ongoing monitoring, but these actions
are not as urgently needed as maintenance of respiratory function. Absence of the
reflexes should be documented, but this is a common finding in Guillain-Barré
syndrome.
A patient who has numbness and weakness of both feet is hospitalized with GuillainBarré syndrome. The nurse will anticipate the need to teach the patient about
_____________ - ANS- IV infusion of immunoglobulin (Sandoglobulin).
rational: Because the Guillain-Barré syndrome is in the earliest stages (as evidenced
by the symptoms), use of high-dose immunoglobulin is appropriate to reduce the
extent and length of symptoms. Mechanical ventilation and tube feedings may be
used later in the progression of the syndrome but are not needed now. Corticosteroid
use is not helpful in reducing the duration or symptoms of the syndrome.
A patient arrives at an urgent care center with a deep puncture wound after stepping
on a nail that was lying on the ground. The patient reports having had a tetanus
booster 7 years ago. The nurse will anticipate ______________ - ANSadministration of the tetanus-diphtheria (Td) booster.
rational: If the patient has not been immunized within 5 years, administration of the
Td booster is indicated because the wound is deep. Immune globulin administration
is given by the IM route if the patient has no previous immunization. Administration of
a series of immunization is not indicated. TIG is not indicated for this patient, and a
test dose is not needed for immune globulin.
A patient with a neck fracture at the C5 level is admitted to the intensive care unit.
During initial assessment of the patient, the nurse recognizes the presence of
neurogenic shock on finding ________________ - ANS- hypotension, bradycardia,
and warm extremities.
rational: Neurogenic shock is characterized by hypotension, bradycardia, and
vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes
do not occur at this stage of spinal cord injury. Lack of movement and sensation
indicate spinal cord injury, but not neurogenic shock.
A patient has an incomplete right spinal cord lesion at the level of T7, resulting in
Brown-Séquard syndrome. Which nursing action should be included in the plan of
care? - ANS- Positioning the patient's right leg when turning the patient
rational: The patient with Brown-Séquard syndrome has loss of motor function on the
ipsilateral side and will require the nurse to move the right leg. Pain sensation will be
lost on the patient's left leg. Left arm weakness will not be a problem for a patient
with a T7 injury. The patient will retain position sense for the left leg.
A patient with a T1 spinal cord injury is admitted to the intensive care unit. The nurse
will teach the patient and family that ______________ - ANS- full function of the
patient's arms will be retained.
rational: The patient with a T1 injury can expect to retain full motor and sensory
function of the arms. Use of only the shoulders is associated with cervical spine
injury. Loss of respiratory function occurs with cervical spine injuries. Bradycardia is
associated with injuries above the T6 level.
A patient with paraplegia resulting from a T10 spinal cord injury has a neurogenic
reflex bladder. Which action will the nurse include in the plan of care? - ANS- Teach
the patient how to self-catheterize.
rational: Because the patient's bladder is spastic and will empty in response to
overstretching of the bladder wall, the most appropriate method is to avoid
incontinence by emptying the bladder at regular intervals through intermittent
catheterization. Assisting the patient to the toilet will not be helpful because the
bladder will not empty. The Credé method is more appropriate for a bladder that is
flaccid, such as occurs with a reflexic neurogenic bladder. Catheterization after
voiding will not resolve the patient's incontinence.
When the nurse is developing a rehabilitation plan for a patient with a C6 spinal cord
injury, an appropriate patient goal is that the patient will be able to _____________ -
ANS- push a manual wheelchair on flat, smooth surfaces.
rational: The patient with a C6 injury will be able to use the hands to push a
wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is
minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car
with powered hand controls, or turn independently in bed.
A patient who sustained a spinal cord injury a week ago becomes angry, telling the
nurse "I want to be transferred to a hospital where the nurses know what they are
doing!" Which reaction by the nurse is best? - ANS- Ask for the patient's input into
the plan for care... [Show Less]