NURSING 4764/ATI NEURO PRACTICE QUESTIONS and ANSWERS
-A nurse is caring for a client who has global aphasia. Which of the following actions should
... [Show More] the nurse take?
CORRECT ANSWER = Speak to the client about one idea at a time
RATIONALE = The nurse should speak using sentences that contain one clear thought or idea for better communication and understanding.
Incorrect: Ask the client to multi-task.
The nurse use simple one-step directions, rather than ask the client to multi-task.
Incorrect: Limit questions to yes and no answers.
The nurse should avoid asking questions that stimulate "yes" and "no" responses because the client might give automatic responses that are not correct.
Incorrect: Focus on a single form of communication.
The nurse should include a variety of aids to assist with communication.
-A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?
Incorrect: Gradual onset of several hours
A client who has a thrombotic (ischemic) stroke will have a gradual onset of manifestations occurring over several minutes to hours. A client who has had a hemorrhagic stroke tends to have an acute onset.
CORRECT ANSWER = Manifestations preceded by a severe headache
RATIONALE = A hemorrhagic stroke is caused by bleeding into the brain tissues, ventricles, or subarachnoid space. It can be caused by hypertension, an aneurysm, or an arteriovenous malformation. A sudden, severe headache is an expected initial manifestation of a hemorrhagic stroke.
Incorrect: Maintains consciousness
A client who has an ischemic stroke maintains a level of consciousness. A client who has a hemorrhagic stroke has a decreased level of consciousness, extending from stupor to coma.
Incorrect: History of neurologic deficits lasting less than 1 hr
A client who has an ischemic stroke might have experienced transient ischemic attacks that caused neurologic deficits lasting for short periods of time before. These transient attacks are not present in a client who has had a hemorrhagic stroke.
-A nurse is caring for a client who has Parkinson’s disease and is taking diphenhydramine 25 mg PO TID. Which of the following therapeutic outcomes should the nurse expect to see?
Incorrect: Delay in disease progression
Diphenhydramine may be helpful in controlling symptoms in the early stage of the disease; however, it will not delay disease progression.
Incorrect: Improved bladder function
Antihistamines, like diphenhydramine, have a mild anticholinergic effect and may cause urinary retention.
Incorrect: Relief of depression
Relief of depression is not associated with the use of antihistamines or anticholinergics.
CORRECT ANSWER = Decreased tremors
RATIONALE = Clients who have Parkinson's disease often experience trembling, muscle rigidity, difficulty walking, and problems with balance and coordination. Antihistamines, like diphenhydramine, have a mild anticholinergic effect and may be helpful in controlling tremors in the early stage of the disease.
-A nurse is teaching a client who is taking benztropine to treat Parkinson’s disease. The nurse should instruct the client to report which of the following adverse effects?
Incorrect: Excess salivation
Dry mouth is an adverse effect of benztropine, due to the anticholinergic response of the medication.
CORRECT ANSWER = Difficulty voiding
RATIONALE = The nurse should instruct the client to report difficulty voiding, which may indicate urinary retention, as an adverse effect of benztropine. Benztropine is an anticholinergic medication that helps decrease the rigidity and tremors of Parkinson’s disease.
Incorrect: Diarrhea
Constipation is an adverse effect of benztropine, which is due to the anticholinergic response of the medication that slows peristalsis.
Incorrect: Slow pulse
Tachycardia is an adverse effect of benztropine, which is due to the anticholinergic response of the medication.
-A nurse who is off duty finds a woman who has collapsed and has right-sided weakness and slurred speech. Which of the following actions should the nurse take?
Incorrect: Obtain the telephone number of the client's provider.
This action could delay treatment and result in further injury and disability.
Incorrect: Find a location for the client to sit.
The nurse should support the client where she is and try to make her comfortable while ensuring airway patency. But she should not attempt to move her.
CORRECT ANSWER = Call emergency services.
RATIONALE = The client might have had a stroke, and if she has, she needs emergency medical intervention and transport to a stroke center.
Incorrect: Drive the client to the nearest emergency department.
The nurse should support the client where she is and try to make her comfortable while ensuring airway patency. But she should not attempt to move her, as doing so could cause additional injury and disability.
-A nurse is planning care for a client who has a cerebral aneurysm. Which of the following actions should the nurse plan to take?
Incorrect: Elevate the head of bed to 45°.
The nurse should elevate the head of the client's bed no higher than 30° to support venous return and lower intracranial pressure. In some cases, the bed should remain flat to increase cerebral perfusion.
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CORRECT ANSWER = Maintain the client on absolute bed rest.
The nurse should place the client on absolute bed rest in a quiet environment. Activity can elevate blood pressure and increase the risk for bleeding.
Incorrect: Administer a cleansing enema.
The nurse should not administer an enema because straining or discomfort can elevate the client's blood pressure and increase intracranial pressure.
Incorrect: Place the client in a room near the nurses' station.
The nurse should maintain the client on bed rest in a quiet, non-stressful environment.
-A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take?
Incorrect: Provide a nonskid mat to alleviate plate movement.
The nurse should provide a nonskid mat to alleviate plate movement, but this action does not resolve the problem of homonymous hemianopsia.
Incorrect: Encourage the client to use his right hand when feeding himself.
The nurse should encourage the client to use his right hand when feeding himself, but this action does not resolve the problem of homonymous hemianopsia.
CORRECT ANSWER = Remind the client to look for food on the left side of the tray.
RATIONALE =The nurse's action to remind the client to look for food on the left side of the tray will train the client to scan the tray by moving his head and eyes, which will help to resolve the problem of homonymous hemianopsia.
Incorrect: Encourage the use of the wide grip utensils.
The nurse should encourage the client to use wide grip utensils, but this action does not resolve the problem of homonymous hemianopsia.
-A nurse is caring for a client who is scheduled to have a MRI scan. The client askes the nurse what to expect during the procedure. Which of the following statements should the nurse make?
Incorrect: "An MRI scan is not distorted by movement, so you do not have to lie still."
An MRI scan is distorted by movement. It is important that the client is informed of the need to lie still during the procedure.
Incorrect:"An MRI scan is a short procedure and should take no longer than 30 minutes." An MRI scan is a lengthy procedure that lasts between 60 and 90 min.
Incorrect: "The MRI contrast dye contains iodine and can cause your skin to itch."
MRI contrast dye does not contain iodine and therefore is not subject to hypersensitivity reactions like contrast dye used in a traditional CT scan.
CORRECT ANSWER = "An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner."
RATIONALE = The nurse should instruct the client that many clients report being disconcerted by the loud thumping and humming noises produced by the scanner, and for that reason, earplugs are offered to reduce the discomfort.
-A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow coma scale score of 3 for eye opening, 5 for verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?
Incorrect: The client can follow simple motor commands.
The client's ability to follow commands would require a score of 6 for best motor response.
Incorrect: The client is unable to make vocal sound.
The inability of the client to make vocal sounds would result in a score of 1 for best verbal response.
Incorrect: The client is unconscious.
The unconscious client would have a score of 1 for eye opening and a 1 for best verbal response.
CORRECT ANSWER = The client opens his eyes when spoken to.
A GCS of 3-5-5 indicates that the client opens his eyes in response to speech, is oriented, and is able to localize pain.
-A nurse is shopping and finds a woman who has collapsed with right sided weakness and slurred speech. Which of the following actions should the nurse take?
Incorrect: Provide the client with water to test the gag reflex.
The nurse should not give the client anything to eat or drink in case the client's gag reflex is impaired, as this could cause aspiration. Assessment of swallowing ability can be performed when the client is stable and equipment to suction the client's airway is available.
Incorrect: Perform carotid massage.
The nurse should understand carotid massage is used to correct atrioventricular tachycardia. The technique will not improve the client's condition and could cause harm if the client has carotid stenosis.
CORRECT ANSWER = Notify emergency management services.
The client is exhibiting manifestations of a stroke and a rapid diagnosis is vital to administering appropriate treatment; therefore, the nurse should call the emergency management services.
Incorrect: Drive the client to the nearest medical facility.
The nurse should not attempt to drive the client away from the scene. The nurse should position the client to maintain an open airway.
-A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? Select all that apply.
CORRECT ANSWER = Loosen restrictive clothing.
RATIONALE: Loosening clothing, such as a belt or collar, aids in respiratory and abdominal expansion. The client should not be restrained.
Incorrect: Insert a bite stick into the client's mouth.
A bite stick or padded tongue blade can cause an obstruction in the client's airway or further injury if teeth are broken as a result of the jaw clamping down on the bite stick.
Incorrect: Place the client into a supine position.
If it is possible to do without causing injury to the client, the nurse should assist the client who is having a seizure into a lateral position. This position assists with the drainage of saliva and mucus, preventing aspiration, and allows the tongue to fall forward, preventing airway obstruction.
CORRECT ANSWER = Place a pillow under the client's head.
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Incorrect: Apply restraints.
The nurse should not restrict movement of a client who is having a seizure. Instead, the nurse should guide the client's movements to prevent injury and, if possible, assist the client into a lateral position.
- A nurse is providing teaching to the family of a client who has Parkinson’s disease. Which of the following information should the nurse include in the teaching?
CORRECT ANSWER = Provide client supervision.
RATIONALE : Because the client's voluntary motor control is affected by the disease, the nurse should recommend that the family provide client supervision to create a safe and respectful environment.
Incorrect: Limit client physical activity.
The nurse should recommend an exercise program, alternated with periods of rest, to improve the client's mobility.
Incorrect: Speak loudly to the client.
The speech patterns of clients who have Parkinson's disease are often affected with slurring or hesitation, but not their hearing.
Incorrect: Leave the television on continuously.
The nurse should recommend decreasing excess environmental stimuli to increase the client's ability to concentrate on listening.
- A nurse is caring for a client who has increased intracranial pressure. Which of the following intervention should the nurse take?
Incorrect: Teach controlled coughing and deep breathing.
The nurse should instruct the client to avoid coughing which increases intracranial pressure.
Incorrect: Provide a brightly lit environment.
The nurse should provide the client with a nonstimulating environment to limit the risk of seizure activity.
CORRECT ANSWER = Elevate the head of the bed 20°.
RATIONALE = The nurse should elevate the head of the bed less than 25° to promote reduction of intracranial pressure.
Incorrect: Encourage a minimum intake of 2000 mL (67.6 oz) of clear fluids per day.
The nurse should place the client on a fluid restriction to avoid increasing intracranial pressure.
- A nurse at a rehabilitation center is planning care for a client who has a left hemispheric cerebral accident CVA three weeks ago. Which of the following goals should the nurse include in the clients rehabilitation program?
CORRECT ANSWER = Establish the ability to communicate effectively.
RATIONALE = A CVA is an interruption of the blood supply to any part of the brain, resulting in damaged brain tissue. The left hemisphere is usually dominant for language. Because this client had a left-side CVA, the nurse should anticipate the client will have some degree of aphasia and will require speech therapy to establish communication.
Incorrect: Compensate for loss of depth perception.
A client who has a right-sided lesion experiences a loss of depth perception, proprioception (recognition of body position), and spatial deficits. The client who has a left-sided lesion will have an inability to discriminate between words and letters leading to problems reading.
Incorrect: Learn to control impulsive behavior.
A client with a right-side lesion is likely to be impulsive. Clients with left-side lesions are typically cautious.
Incorrect: Improve left-side motor function.
A client with a left-side lesion will demonstrate hemiplegia of the right side due to the fact that the pyramidal pathway crosses over at the base of the brain.
- A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instruction should the nurse include in the teaching?
Incorrect: "Insert a padded tongue blade into the client's mouth."
The nurse should instruct the family not to insert anything into the client's mouth during a seizure to prevent causing injuring to the client.
Incorrect: "Restrain the client."
The nurse should instruct the family not to restrain the client to reduce the risk of causing injury to the client.
Incorrect: "Place the client on his back."
The nurse should instruct the family to place the client on his side to decrease the risk for aspiration.
CORRECT ANSWER ="Move objects away from the client."
RATIONALE = The nurse should instruct the family to move objects away from the client to reduce the risk of injury to the client.
- A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?
CORRECT ANSWER = Decreased level of consciousness
RATIONALE = As intracranial pressure increases, cerebral perfusion, and therefore level of consciousness, decrease. Other manifestations include severe headache, irritability, and pupils that are slow to react or are unreactive to light.
Incorrect: Tachypnea
As intracranial pressure increases, the respiratory rate decreases or becomes erratic.
Incorrect: Bilateral weakness of extremities
As intracranial pressure increases, one-sided weakness of an extremity is a common early manifestation.
Incorrect: Hypotension
As intracranial pressure increases, blood pressure also increases.
- A nurse enters a clients room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?
Incorrect: Insert a tongue blade in the client's mouth.
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CORRECT ANSWER = Place the client on his side.
RATIONALE = The nurse should place the client on his side. This position drops the tongue to the side of the client's mouth and prevents the client's airway from being obstructed.
Incorrect: Hold the client's arms and legs from moving.
The nurse should not try to restrain the client from moving because this could injure the client.
Incorrect: Place the client back in bed.
The nurse should remove all furniture out of the way from the client during the seizure and place the client‘s head on a pillow or lap. However, the nurse should avoid moving the client back into bed until the seizure is completed.
- A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations and function should the nurse expect?
Incorrect: Difficulty reading
The left hemisphere is the center for language, mathematic skills and thinking analytically. A client who is unable to read following a stroke would have involvement of the left hemisphere.
CORRECT ANSWER = Inability to recognize his family members
RATIONALE = The right hemisphere is involved with visual and spatial awareness. A client who is unable to recognize faces would have involvement with the right hemisphere.
Incorrect: Right hemiparesis
The motor nerve fibers of the brain cross in the medulla, and a motor deficit on one side of the body reflects damage to the upper motor neurons on the opposite side of the brain. A client who has right hemiparesis would have involvement of the left hemisphere.
Incorrect: Aphasia
The left hemisphere is the center for language, mathematic skills and thinking analytically. A client who is unable to speak or understand language following a stroke would have involvement of the left hemisphere.
- A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client’s ability to safely ambulate?
Incorrect: Observe for the presence of Kernig's sign.
The nurse should check for Kernig’s sign in a client who has possible meningitis.
CORRECT ANSWER = Perform a Romberg's test.
RATIONALE = The nurse should perform a Romberg’s test to check the client’s ability to maintain an upright position without swaying when standing with feet close together, with eyes open and with eyes closed. The nurse must stand close enough to prevent the client from falling.
Incorrect: Check the function of cranial nerve V.
The nurse should check cranial nerve V to assess sensory nerve function of the face.
Incorrect: Inspect for the presence of clubbing.
The nurse should inspect for the presence of digital clubbing in clients who have chronic cardiopulmonary disorders.
- A nurse is in a client’s room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?
CORRECT ANSWER = Turn the client's head to the side.
The first action the nurse should take when using the airway, breathing, circulation approach to client care is to turn the client's head to the side. This action keeps the client's airway clear of secretion to prevent aspiration.
Incorrect: Check the client's motor strength.
The nurse should check the client's motor strength as part of a neurovascular assessment following the seizure; however, there is another action the nurse should take first.
Incorrect: Loosen the clothing around the client's waist.
The nurse should loosen the clothing around the client's waist to protect the client from injury; however, there is another action the nurse should take first.
Incorrect: Document the time the seizure began.
The nurse should document the time the seizure began and ended to provide information to the provider about the severity of the seizure; however, there is another action the nurse should take first.
-A nurse is modifying the diet have a client who has Parkinson’s disease and it’s prescribed Selegiline, an MAOI. Which of the following foods should the nurse eliminate?
Incorrect: Fresh fish
The nurse does not need to eliminate fresh fish from the diet of a client prescribed selegiline. Cured meats that contain tyramine should be eliminated.
CORRECT ANSWER = Cheddar cheese
RATIONALE = The nurse should eliminate aged cheeses from the diet of a client who is prescribed selegiline. Cheddar cheese contains tyramine, which can cause a hypertensive crisis.
Incorrect: Cherries
The nurse does not need to eliminate cherries from the diet of a client prescribed selegiline.
Incorrect: Chicken
The nurse does not need to eliminate chicken from the diet of a client prescribed selegiline. Cured meats that contain tyramine should be eliminated.
- A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure ICP?
Incorrect: Tachycardia
Alterations in vital signs, including increased systolic pressure, widening pulse pressure and bradycardia (termed Cushing’s triad) are signs of increased ICP.
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The client who has a traumatic brain injury may experience a loss of consciousness along with a lack of memory of events prior to or following the injury, but does not indicate an increase in ICP.
Incorrect: Hypotension
Alterations in vital signs, including increased systolic pressure, widening pulse pressure and bradycardia (termed Cushing’s triad) are signs of increased ICP.
CORRECT ANSWER = Restlessness
RATIONALE = Increased intracranial pressure is a condition in which the pressure of the cerebrospinal fluid or brain matter within the skull exceeds the upper limits for normal. Signs of increasing ICP include restlessness, irritability and confusion along with a change in level of consciousness, or a change in speech pattern.
- A nurse enters a client’s room and find him on the floor in the clinic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?
Incorrect: Insert a padded tongue blade into the client's mouth.
The nurse should avoid placing anything in the client’s mouth during a seizure due to the risk for injury and airway occlusion.
CORRECT ANSWER = Place a pillow under the client's head.
RATIONALE = The nurse should place a small pillow or other soft padding under the client’s head to protect the client from injury during the seizure, and turn his head to the side to keep the airway clear.
Incorrect: Gently restrain the client's extremities.
The nurse should avoid restraining the client’s extremities during a seizure due to the risk for injury.
Incorrect: Apply a face mask for oxygen administration.
The nurse should avoid placing anything on the client during a seizure due to the risk for injury. During the postictal phase the nurse should assess the client’s oxygenation status and administer supplemental oxygen if necessary.
- A nurse is instructing a clients family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instruction should the nurse include?
Incorrect: Encourage brief exercise before meals to promote appetite.
The nurse should instruct the family members to have the client rest for 30 min before meals to preserve energy for appropriate eating and swallowing.
Incorrect: Place food in the affected side of the mouth.
The nurse should instruct the family members to place food on the client's unaffected or stronger side of the mouth to facilitate appropriate swallowing.
CORRECT ANSWER = Encourage the client to take small bites.
RATIONALE = The family members should encourage the client to take small bites and chew food thoroughly in order to prevent choking.
Incorrect: Place the client with the head reclined back to facilitate swallowing.
The nurse should instruct the family members to have the client sit upright at 90°, and to place the chin in a downward position to facilitate swallowing.
- A nurse is implementing precautions for a client who has a cerebral aneurysm. Which of the following nursing intervention should the nurse implement?
Incorrect: Allow bathroom privileges.
The nurse should not allow bathroom privileges. Activity can cause an increase in blood pressure, resulting in a rupture of the aneurysm.
CORRECT ANSWER = Encourage exhaling through mouth during defecation.
RATIONALE = The nurse should encourage the client to exhale through her mouth when defecating to decrease strain.
Incorrect: Allow natural sunlight in the room.
The nurse should not allow natural sunlight in the room because the client might have photophobia.
Incorrect: Encourage visitation from family and friends.
The nurse should not encourage visitors because excess stimulation can increase blood pressure and intracranial pressure.
- A nurse is providing discharge teaching to a female client who has neuropathy and a new prescription for gabapentin. Which of the following statements should the nurse include in the teaching?
Incorrect: “Take this medication with an antacid to reduce gastric irritation."
The nurse should instruct the client that gabapentin and antacids should be taken 2 hr apart.
CORRECT ANSWER = "You may experience drowsiness while taking this medication."
RATIONALE = The nurse should instruct the client that drowsiness can occur while taking this medication and to exercise caution while performing activities that require alertness.
Incorrect: "You should take this medication with meals."
The nurse should instruct the client that this medication can be taken without regard to meals.
Incorrect: "You may continue to breastfeed while taking this medication."
The nurse should instruct the client to avoid breastfeeding while taking this medication.
- A nurse is presenting discharge instructions to a client who has multiple sclerosis MS. The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate?
Incorrect: “Wear an eye patch on the right eye at all times.”
The nurse should instruct the client to alternate every two hours an eye patch to improve diplopia, not leave on the right eye continually.
Incorrect: "Plan to relax in a hot tub spa each day."
The nurse should instruct the client to avoid extreme temperature changes because they can exacerbate the manifestations of MS.
Incorrect: "Engage in a vigorous exercise program."
The nurse should instruct the client to develop a tolerable exercise program. A vigorous exercise program can exacerbate the manifestations of MS.
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RATIONALE = The nurse should assist the client in developing a schedule that includes periods of exercise followed by periods of rest to maintain muscle strength and coordination.
- A nurse is monitoring a client who has a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure?
Incorrect: Hypotension
The nurse should identify hypertension as a manifestation of increased intracranial pressure.
Incorrect: Tachycardia
The nurse should identify bradycardia as a manifestation of increased intracranial pressure.
CORRECT ASNWER = Irritability
RATIONALE = The nurse should monitor the client for behavioral changes, such as confusion, restlessness, and irritability as manifestations of increased intracranial pressure.
Incorrect: Tinnitus
The nurse should identify changes in pupillary response as a manifestation of increased intracranial pressure.
- A nurse is caring for a client who has aphasia following a stroke. A family member ask the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate?
CORRECT ASNWER = “Incorporate nonverbal cues in the conversation."
RATIONALE = Nonverbal cues enhance the client's ability to comprehend and use language.
Incorrect: "Ask multiple choice questions as part of the conversation."
Simple questions requiring yes and no responses are better understood by the client.
Incorrect: "Use a higher-pitched tone of voice when speaking."
Tone of voice is understood by clients who have aphasia, unless they have a hearing impairment.
Incorrect: "Use simple, child-like statements when speaking."
It is important to respect the client and use age-appropriate communication.
- A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority?
Incorrect: Perform passive range of motion on each extremity.
The nurse should perform passive range of motion for the client who is unconscious, to help prevent complications of impaired physical mobility; however, this is not the highest priority intervention according to the safety and risk reduction priority setting framework.
Incorrect: Monitor the client's electrolyte levels.
The nurse should monitor the electrolyte levels for the client who is unconscious, to help identify complications of increased intracranial pressure and to limit the risk of cardiac dysrhythmia; however, this is not the highest priority intervention according to the safety and risk reduction priority setting framework.
CORRECT ASNWER = Suction saliva from the client's mouth.
RATIONALE = The unconscious client is unable to independently maintain a clear airway and is at risk for ineffective airway clearance. According to the safety and risk reduction priority setting framework, maintaining the client’s airway, breathing, and circulation is the highest priority.
Incorrect: Record the client's intake and output.
The nurse should record the intake and output for the client who is unconscious, to help identify complications of altered neurological status and increased intracranial pressure; however, this is not the highest priority intervention according to the safety and risk reduction priority setting framework.
-A nurse is teaching the family of a client who has Alzheimer’s disease about donepezil. Which of the following information should the nurse include in the teaching?
CORRECT ASNWER = "Syncope episodes may occur when taking this medication."
RATIONALE = The nurse should inform the family to monitor for syncope, which places the client at risk for falling.
Incorrect: "This medication may cause tachycardia."
The nurse should inform the family the medication may cause bradycardia, which places the client at risk for falling.
Incorrect: "You should administer the medication each morning."
The nurse should instruct the family to administer the medication at bedtime, not in the morning, to avoid daytime sedation and improve effectiveness.
Incorrect: "You will need to monitor for constipation."
The nurse should inform the family to monitor for diarrhea because of the cholinergic effect, not constipation.
-A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident CVA. Which of the following parameters should the nurse he is first in order to assess the clients pain level?
Incorrect: pulse and blood pressure findings
The nurse should assess the client's pain level routinely along with vital signs. A pain assessment should also be completed if the client has a change in condition, such as a new onset of chest pain, or following a procedure which can be uncomfortable for the client, such as x-rays which require the client to lay on a hard surface for extended periods of time. A hierarchical method of pain assessment is recommended when caring for clients who may have difficulty expressing themselves. Although vital signs can be used as a physiologic indicator, monitoring them is an objective method of evaluating pain and may not be a reliable means of assessing pain levels. Evidence-based practice indicates the nurse should use a different parameter first.
Incorrect: behavioral indicators and effect
A hierarchical method of pain assessment is recommended when caring for clients who may have difficulty expressing themselves. Although behavioral indicators can be used, the nurse should recognize that pain behaviors are unique to each patient. Evidence-based practice indicates the nurse should use a different parameter first.
Incorrect: scheduled treatments and client illness
A hierarchical method of pain assessment is recommended when caring for clients who may have difficulty expressing themselves. Although treating a client based upon the client’s condition or based upon the client’s scheduled, potentially painful procedure will yield effective results at assessing pain levels,
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CORRECT ASNWER = a self-report pain rating scale
RATIONALE = Expressive aphasia results from damage to an area of the frontal lobe and is a motor speech problem. The client who has expressive aphasia is able to understand what is said but is unable to communicate verbally. However, this does not necessarily mean that a client is unable to reliably report pain. Evidence-based practice indicates the nurse should first attempt to obtain the client’s self- report of pain. When assessing a client for pain, the nurse should utilize the hierarchy of pain measures which begins with self-report. It is always better to use a subjective method, such as a client report, instead of an objective method, such as something that is observable by the nurse, which is much less reliable.
-A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following intervention should the nurse include? Select all that apply.
CORRECT ASNWER = Provide a suction setup at the bedside.
RATIONALE = The nurse should provide a suction setup at the bedside to provide oral suctioning as needed following the seizure to prevent aspiration.
CORRECT ASNWER = Elevate the side rails near the head when the client is in bed.
RATIONALE = The nurse should raise the side rails near the head of the bed to help keep the client in the bed. The nurse should check the facility policy for specific guidelines because raising all side rails can be considered a restraint. Elevate the rails of the bed to prevent a fall during a seizure.
CORRECT ASNWER = Place the bed in the lowest position.
RATIONALE = The nurse should place the bed in the lowest position to prevent injury if a fall should occur during a seizure.
CORRECT ASNWER = Keep an oxygen setup at the bedside.
RATIONALE = The nurse should monitor the client's oxygen saturation during a seizure and provide supplemental oxygen as prescribed.
Incorrect: Furnish restraints at the bedside.
The nurse should not plan to restrain a client during a seizure, as this can cause harm to the client's muscles and limbs.
-A nurse is assessing a client who has Parkinson’s disease. Which of the following manifestation should the nurse expect?
Incorrect: Pruritus
The nurse should expect to find oily skin, which results from autonomic dysfunction, rather than pruritus, which results from dry skin. Incorrect: Hypertension
The nurse should expect to find orthostatic hypotension, which results from autonomic dysfunction.
CORRECT ASNWER = Bradykinesia
RATIONALE = The nurse should expect to find bradykinesia or difficulty moving in a client who has Parkinson's disease.
Incorrect: Xerostomia
The nurse should expect to find uncontrolled drooling, especially at night, instead of xerostomia or dry mouth in a client who has Parkinson's disease.
-A nurse working on a medical unit is caring for a client who is prescribe seizure precautions. Which of the following intervention should the nurse include in the client’s plan of care?
CORRECT ANSWER = Obtain IV access.
RATIONALE = The nurse should obtain IV access as a precaution so the client can receive IV medications in the event of a seizure.
Incorrect: Keep the lights on when the client is sleeping.
An important part of seizure precautions and management is to allow the client to rest. Illumination may interfere with the client’s ability to rest and sleep.
Incorrect: Place the client's bed in the high position.
Placing the client's bed in the lowest position will protect the client from injuries if he falls out of bed during a seizure. Placing a mattress on the floor can also project the client from injury during a seizure.
Incorrect: Keep a padded tongue blade available at the client's bedside.
The nurse should not use padded tongue blades or force anything into the client's mouth during a seizure. This can chip the client's teeth and place the client at risk for aspirating tooth fragments. This also can block the client's airway.
-A nurse is assessing a client who has a score of six on the Glasgow coma scale. The nurse should expect which of the following outcomes based on the score?
CORRECT ANSWER = The client needs total nursing care.
RATIONALE = A client who has a score of 6 on the Glasgow Coma Scale is in a comatose state and will require total nursing care.
Incorrect: The client is alert and oriented.
A client who has a score of 6 on the Glasgow Coma Scale is in a comatose state.
Incorrect: The client is in a deep coma.
A client who has a score of 3 on the Glasgow Coma Scale is in a deep coma or is completely unresponsive.
Incorrect: Indicates stable neurologic status
A client who has a score of 6 on the Glasgow Coma Scale is in a comatose state
- A nurse is caring for a client who has an intracranial pressure ICP reading of 40 mmHg. Which of the following findings should the nurse identify as a late sign of ICP? Select all that apply.
Incorrect: Confusion
A change in the level of consciousness is an early sign of neurologic status. This is often manifested as restlessness, irritability, and confusion.
CORRECT ANSWER = Bradycardia
Bradycardia is one of three findings of Cushing's triad, which is a late sign of increased intracranial pressure. A client who has hypovolemic shock is more likely to have tachycardia.
Incorrect: Hypotension
Severe hypertension is one of three findings of Cushing's triad, which is a late sign of increased intracranial pressure. A client who has hypovolemic shock is more likely to have hypotension.
CORRECT ASNWER = Nonreactive dilated pupils
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Incorrect: Slurred speech
Slowed speech can be an early sign of increased intracranial pressure. Late manifestations include stupor, progressing to coma, and abnormal motor responses, including decorticate and decerebrate posturing.
-A nurse is teaching a client who has a new diagnosis of atrial fibrillation. The nurse should instruct the client to monitor which of the following complications?
Incorrect: Bradycardia
The client who has atrial fibrillation has an irregular heartbeat with a rapid ventricular response.
CORRECT ASNWER = Pulmonary embolism
RATIONALE = Altered atrial contractions can cause blood pooling and thrombus formation. The client is at risk for developing a pulmonary embolism or embolic stroke. The client should monitor and report immediately manifestations, such as shortness of breath, or neurological changes.
Incorrect: Peripheral vascular disease
The client who has atrial fibrillation is at risk for developing heart failure because of decrease ventricular filling and decreased cardiac output.
Incorrect:
A client who has hypertension is at risk for developing atrial fibrillation.
-A nurse is caring for a client who has an intracranial aneurysms and requires aneurysm precautions. Which of the following intervention should the nurse take?
Incorrect:
Place the client in protective isolation.
Protective isolation is for clients who are at high risk for infection. This client is at risk for rupture of the aneurysm.
CORRECT ANSWER = Minimize environmental stimuli.
RATIONALE = A client who has a cerebral aneurysm is at risk for rupture and should avoid any stimulation that could cause anxiety, such as noise or bright lights.
Incorrect: Elevate the head of the client's bed 45°.
The nurse should elevate the head of the client's bed 15° to 30° to promote venous return and to reduce intracranial pressure.
Incorrect: Limit the client's ambulation to once a day.
A client who has a cerebral aneurysm should remain on bed rest. [Show Less]