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Neurologic System

October 21, 2010 Leave a comment Go to comments

Neurologic system

  1. A 15-year-old client recently had infectious mononucleosis and had begun to complain of muscle tenderness. This morning, the client was unable to move either leg and was admitted with the diagnosis of paralysis of unknown etiology. After a review of the history and assessment of symmetrical paralysis, a diagnosis of Guillain-Barre syndrome was made. The most characteristic feature of this syndrome is:

    • 1   –   progressive ascending flaccid paralysis.
    • 2   –   unilateral involvement of the dominant side.
    • 3   –   intermittent paralysis of the lower extremities.
    • 4   –   completely reversible asymmetrical paralysis.

    RATIONALE: Guillain-Barre syndrome is an acute episode of progressive ascending flaccid paralysis. The paralysis is classically symmetrical, and the client’s recovery is usually complete.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    COGNITIVE LEVEL: Knowledge

  2. A 16-year-old client received a severe head injury in a motor vehicle accident. He’s admitted to the neurologic unit and subsequently develops neurogenic diabetes insipidus. The physician prescribes vasopressin (Pitressin), 5 units subcutaneously twice a day. When vasopressin is given subcutaneously, it begins to act within:
    • 1   –   5 minutes.
    • 2   –   1 hour.
    • 3   –   2 hours.
    • 4   –   4 hours.

    RATIONALE: When vasopressin is given subcutaneously it begins to act within 1 hour. Its duration of action is 2 to 8 hours.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Knowledge

  3. A 3-year-old child has been diagnosed with lead poisoning. On admission, the child’s blood level concentration of lead was 100 mcg/dl. Which of the following nursing diagnoses would be given priority in the care plan for this child?

    • 1   –   Risk for injury related to lead encephalopathy
    • 2   –   Decreased cardiac output related to impaired membrane permeability
    • 3   –   Ineffective GI tissue perfusion related to ingestion of lead
    • 4   –   Ineffective renal tissue perfusion

    RATIONALE: Because the nervous system is affected by high lead levels, the child is at risk for seizures and permanent effects. Cardiac, nutritional, and renal effects also result from excessive lead ingestion, but these aren’t the priority.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Application

  4. A child with otitis media caused by Haemophilus influenzae is treated with antibiotics. Three weeks later the child is diagnosed with meningitis caused by the same pathogen. How was the organism spread?
    • 1   –   Metastasis
    • 2   –   Vascular dissemination
    • 3   –   Transient inflammatory process
    • 4   –   Ineffective antibiotic syndrome

    RATIONALE: Successful treatment of an infection depends on the type of antibiotic and the length of treatment. If either factor is ineffective, the pathogen invades the bloodstream and can appear in a different area. In metastasis, cancer cells spread from one area to another. An inflammatory process wouldn’t account for the vascular spread of this organism, and there’s no specific syndrome associated with ineffective antibiotic treatment.
    NURSING PROCESS STEP: Analysis
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Analysis

  5. A client admitted for a hysterectomy has a secondary diagnosis of Menicre’s disease. Which of the following nursing interventions should the nurse include in the client’s care plan to decrease the effects of tinnitus?
    • 1   –   Reduce the amount of glucose and cholesterol in the diet.
    • 2   –   Encourage the client to listen to the radio with earphones.
    • 3   –   Encourage a weight reduction diet.
    • 4   –   Administer antihypertensive medications as ordered.

    RATIONALE: Listening to the radio with earphones is one way to override the buzzing sound in the ears caused by tinnitus. Diet regulation may affect the occurrence of attacks of Menicre’s but not the effects of tinnitus. The client wouldn’t take antihypertensive medications for this disorder.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Application

  6. A client had a subarachnoid screw inserted to monitor intracranial pressure (ICP) after a fall from a Ferris wheel. Which of the following assessments would indicate that the client’s condition is improving?
    • 1   –   ICP of 13 mm Hg at 7 a.m.; ICP of 17 mm Hg at 8 a.m.
    • 2   –   Glasgow Coma Scale of 10 at 7 a.m. and 8 a.m.
    • 3   –   ICP of 17 mm Hg at 7 a.m.; ICP of 13 mm Hg at 8 a.m.
    • 4   –   Glasgow Coma Scale of 10 for 2 hours at 7 a.m. and 8 a.m.; ICP of 15 mm Hg for 2 hours at 7 a.m. and 8 a.m.

    RATIONALE: Decreasing, not increasing, ICP indicates improvement in the client’s condition. A Glasgow Coma Scale of 10 for 2 hours wouldn’t be indicative of improvement or worsening, as the baseline Glasgow Coma Scale isn’t available. An ICP of 15 mm Hg or above for a period of time is considered problematic; therefore, the client wouldn’t be considered to be improving.
    NURSING PROCESS STEP: Analysis
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Analysis

  7. A client has a circular rash on her leg, accompanied by malaise, fever, headache, and joint aches. Laboratory studies and physical examination findings confirm that she has Lyme disease. Her physician prescribes tetracycline (Achromycin), 500 mg by mouth four times daily. Which instruction should the nurse give the client about self-administration of tetracycline?

    • 1   –   “Take the drug on an empty stomach.”
    • 2   –   “Take the drug with food or milk.”
    • 3   –   “Take the drug with a magnesium-containing antacid to reduce irritability.”
    • 4   –   “Take the drug with an iron supplement.”

    RATIONALE: Tetracycline should be taken on an empty stomach because certain foods, such as dairy products, can bind with the drug, preventing its absorption. Additionally, the drug shouldn’t be taken with supplements containing calcium, magnesium, aluminum, or iron. These substances also bind with tetracycline, preventing its absorption.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Comprehension

  8. A client has just returned to the unit after having an astrocytoma removed. In what position should the nurse place a client immediately after an infratentorial craniotomy?
    • 1   –   Trendelenburg’s
    • 2   –   Prone
    • 3   –   Flat
    • 4   –   Semi-Fowler’s

    RATIONALE: Clients who’ve had an infratentorial craniotomy must remain flat for 24 hours because elevation of the head of the bed may cause detrimental pressure changes. Trendelenburg’s or prone positions would incur radical pressure changes. Semi-Fowler’s position would be selected if the client had a supratentorial craniotomy.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

  9. A client has left-sided paralysis. The clinical term for this condition is:
    • 1   –   monoplegia.
    • 2   –   hemiplegia.
    • 3   –   paraplegia.
    • 4   –   quadriplegia.

    RATIONALE: Hemiplegia refers to paralysis of one side of the body. Monoplegia refers to paralysis of one extremity; paraplegia, to paralysis of both lower limbs; andquadriplegia, to paralysis of all four extremities and, usually, the trunk.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    COGNITIVE LEVEL: Knowledge

  10. A client is transferred to a rehabilitation center after being treated in the hospital for a stroke. Because the client has a history of Cushing’s syndrome (hypercortisolism) and chronic obstructive pulmonary disease, the nurse formulates a nursing diagnosis of:
    • 1   –   Risk for deficient fluid volume related to excessive sodium loss.
    • 2   –   Risk for impaired skin integrity related to tissue catabolism secondary to cortisol hypersecretion.
    • 3   –   Ineffective health maintenance related to frequent hypoglycemic episodes secondary to Cushing’s syndrome.
    • 4   –   Decreased cardiac output related to hypotension secondary to Cushing’s syndrome.

    RATIONALE: Cushing’s syndrome causes tissue catabolism, resulting in thinning skin and connective tissue loss. Along with immobility related to stroke, these factors increase this client’s risk for impaired skin integrity. The exaggerated glucocorticoid activity in Cushing’s syndrome causes sodium and water retention, which in turn leads to edema and hypertension. Therefore, Risk for fluid volume deficit and Decreased cardiac output are inappropriate nursing diagnoses. Increased glucocorticoid activity also causes persistent hyperglycemia, eliminating Altered health maintenance related to frequent hypoglycemic episodes as an appropriate diagnosis.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Analysis

  11. A client newly diagnosed with migraine headaches is being discharged on propanolol hydrochloride (Inderal), a beta-adrenergic blocker. The nurse would know that the discharge teaching regarding this drug was effective if the client stated that the reason Inderal was ordered was to:
    • 1   –   control the nausea and vomiting associated with a migraine.
    • 2   –   control the dilation of blood vessels to exert an antimigraine effect.
    • 3   –   decrease blood pressure and intracranial pressure (ICP).
    • 4   –   decrease the response to pain and increase level of comfort.

    RATIONALE: Beta-adrenergic blockers, such as Inderal, halt the dilation of blood vessels, which exerts an antimigraine effect. Inderal doesn’t control nausea and vomiting, reduce blood pressure or ICP, or influence the pain response.
    NURSING PROCESS STEP: Evaluation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacologic and parenteral therapies
    COGNITIVE LEVEL: Analysis

  12. A client with a severe head injury is admitted after a motor vehicle accident. The admitting nurse reviews the emergency department nurse’s notes and finds the client’s Glasgow Coma Scale to be 6. The client is in which of the following neurologic states?

    • 1   –   Coma
    • 2   –   Locked-in syndrome
    • 3   –   Vegetative
    • 4   –   Drowsy but easily aroused

    RATIONALE: On the Glasgow Coma Scale, the highest score of 15 indicates the most responsive and a score of 7 or less is usually classified as coma. Locked-in and vegetative states don’t occur with an acute head injury. A drowsy-but-easily-aroused state would be indicated by a higher Glasgow Coma Scale.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Knowledge

  13. A neonate born 18 hours ago with myelomeningocele over the lumbosacral region is scheduled for corrective surgery. Preoperatively, what is the most important nursing goal?

    • 1   –   Preventing infection
    • 2   –   Ensuring adequate hydration
    • 3   –   Providing adequate nutrition
    • 4   –   Preventing contracture deformity

    RATIONALE: Preventing infection is the nurse’s primary preoperative goal for a neonate with myelomeningocele. Although the other options are relevant for this neonate, they’re secondary to preventing infection.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Safety and infection control
    COGNITIVE LEVEL: Application

  14. A neonate in the nursery has been diagnosed with a neural tube defect (myelomeningocele). The nurse would assess for which of the following as the chief urinary problem associated with this disorder?
    • 1   –   Nephrotic syndrome
    • 2   –   Acute renal failure
    • 3   –   Neurogenic bladder
    • 4   –   Renal calculi

    RATIONALE: The presence of a neurogenic bladder in a neonate with myelomeningocele depends on the level of the neural tube defect. Nephrotic syndrome, renal failure, and renal calculi are rarely associated with this congenital anomaly.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

  15. A nurse working the night shift reports that 6 hours after a craniotomy, a client is exhibiting signs of increasing papilledema, which may indicate increasing intracranial pressure. As a result, the nursing care plan would now include assessing for which kind of edema?
    • 1   –   Edema of the trigeminal nerve, causing severe facial pain
    • 2   –   Edema of the optic nerve, causing visual disturbances
    • 3   –   Edema of the brain stem, causing labile blood pressure
    • 4   –   Edema of the meninges, causing meningeal irritation

    RATIONALE: Papilledema is edema of the optic nerve.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

  16. A teenage girl has just been diagnosed with epilepsy and has been started on phenytoin (Dilantin). Which information should the nurse teach the client regarding this medication?
    • 1   –   Dilantin effects the efficacy of birth control pills.
    • 2   –   Dilantin may turn her urine orange.
    • 3   –   She should tell her ophthalmologist that she’s taking Dilantin.
    • 4   –   She should decrease the amount of sodium in her diet.

    RATIONALE: Dilantin may affect the efficiency of birth control pills, resulting in an unplanned pregnancy. Dilantin has been known to cause pink-tinged (not orange-tinged) urine in some clients. The client should notify her dentist because Dilantin may cause gingival hyperplasia. No dietary restrictions apply to clients taking Dilantin.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Application

  17. After a head injury, a child experiences enuresis, polydipsia, and weight loss. Based on these findings, the nurse should monitor closely for signs and symptoms of:
    • 1   –   hypercalcemia.
    • 2   –   hyperglycemia.
    • 3   –   hyponatremia.
    • 4   –   hypokalemia.

    RATIONALE: Enuresis, polydipsia, and weight loss suggest diabetes insipidus, a disorder that may result from a head injury that damages the neurohypophyseal structures. Diabetes insipidus places the child at risk for fluid volume depletion and hypokalemia. It doesn’t cause hypercalcemia, hyperglycemia, or hyponatremia.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Comprehension

  18. After a motor vehicle accident, a client is admitted with numerous fractures and a closed head injury. When reading the emergency department nurse’s notes, the nurse reads that the client has Battle’s sign present on the right side of the head. Thus, when seeing the client for the first time, the nurse would expect to find:

    • 1   –   ecchymosis behind or below the right ear.
    • 2   –   bilateral black eyes with no facial fractures.
    • 3   –   eyes deviated to the side of injury.
    • 4   –   decorticate posturing.

    RATIONALE: An area of bruising in this location usually indicates a basal skull fracture. The condition of bilateral black eyes with no facial fracture is usually called raccoon’s eyes. Eyes deviated to the side of injury usually indicates a lesion in the cerebral white matter. Decorticate posturing refers to the position the body may assume when there is injury to the cerebral cortex.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Application

  19. Alzheimer’s disease is the secondary diagnosis of a client admitted with a myocardial infarction. Which of the following nursing interventions should appear on this client’s care plan?
    • 1   –   Perform activities of daily living for the client to decrease frustration.
    • 2   –   Provide a stimulating environment.
    • 3   –   Establish and maintain a routine.
    • 4   –   Try to reason with the client as much as possible.

    RATIONALE: Establishing and maintaining a routine is essential to client care because it decreases extraneous stimuli. The client should participate in daily care as much as possible. Attempting to reason with such clients isn’t successful because they can’t think abstractly.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Application

  20. An 8-year-old child with suspected meningitis is admitted to the pediatric unit. Which of the following would be the best room assignment for this new client?
    • 1   –   A room with an 8-year-old with a perforated appendix
    • 2   –   A room with a child in sickle cell crisis
    • 3   –   A room with laminar air flow
    • 4   –   A single-bed room to decrease extraneous stimulation

    RATIONALE: A child with meningitis will probably have meningeal irritation, which may predispose the child to seizures. Placing this child in a room with one who has either a perforated appendix or sickle cell crisis would expose the already susceptible roommate to infection. Laminar air flow protects against infection, but wouldn’t help a client who already has an infection.
    NURSING PROCESS STEP: Analysis
    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Analysis

  21. An eight-year-old child weighing 66 lb is ordered to receive gentamicin (Garamycin) 6 mg/kg/day in three divided doses for meningitis. How many milligrams of gentamicin will the child receive in a single dose administered every 8 hours?
    • -

    RATIONALE: The nurse should use the following formula to determine the correct dose for the child:
    1 lb = 2.2 kg
    66 lb 9 2.2 = 30 kg
    30 kg x 6 mg = 180 mg 9 3 doses
    180 mg 9 3 doses = 60 mg
    1 dose = 60 mg
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Application

  22. An infant has been admitted with a closed head injury, possibly because of maltreatment. During assessment, which of the following clinical manifestations would the nurse note as an indicator of increased intracranial pressure (ICP) in an infant?

    • 1   –   High-pitched cry
    • 2   –   Presence of generalized tonic-clonic seizures
    • 3   –   Longer periods of alertness
    • 4   –   Low-pitched cry

    RATIONALE: As ICP increases, the child’s cry may change to a high-pitched or shrill cry. The presence of generalized tonic-clonic seizures would be a late indicator of increasing ICP. As ICP increases, the infant would become less, not more, responsive. A low-pitched cry wouldn’t indicate increased ICP.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Knowledge

  23. An infant has undergone surgery to remove a myelomeningocele. To detect increased intracranial pressure (ICP) as early as possible, the nurse should be alert for which of the following postoperative findings?
    • 1   –   Decreased urine output
    • 2   –   Increased heart rate
    • 3   –   Bulging fontanels
    • 4   –   Sunken eyeballs

    RATIONALE: Because an infant’s fontanels remain open, the skull may expand in response to increased ICP. Therefore, bulging fontanels are a cardinal sign of increased ICP in an infant. Decreased urine output and sunken eyeballs indicate dehydration, not increased ICP. With increased ICP, the heart rate decreases.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Knowledge

  24. An unconscious client was admitted with a severe head injury resulting from a motor vehicle accident. To facilitate rehabilitation when the client’s condition allows, the nurse should:

    • 1   –   Maintain his limbs in the position of function.
    • 2   –   Apply restraints to the client’s arms and legs to control spasms.
    • 3   –   Exercise just the arms because the legs maintain their tone longer.
    • 4   –   Notify physical therapy as soon as the physician orders passive range of motion.

    RATIONALE: Maintaining the client’s limbs in the position of function decreases the likelihood of contractures. There’s no evidence that the client is experiencing spasms. The nurse should exercise both arms and legs as long as injuries permit. The longer rehabilitation is delayed, the more difficult it becomes.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Safety and infection control
    COGNITIVE LEVEL: Application

  25. The client is ordered haloperidol (Haldol) 1.5 mg b.i.d. as needed for agitation. The nurse is preparing to administer the dose using the available 1-mg tablets. How may tablets will the nurse dispense?
    • -

    RATIONALE: The nurse should calculate the client’s dose using this method:
    (1 mg 9 1 tablet) = (1.5 mg 9 X)
    1X = 1.5
    X = 1.5 tablets
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Application

  26. The daughter of a client admitted with a stroke asks the nurse what caused her mother’s stroke. Which of the following would be the nurse’s best response?

    • 1   –   “A stroke occurs when circulation to part of the brain is interrupted by any of a variety of causes.”
    • 2   –   “Strokes are caused by a cerebral hemorrhage.”
    • 3   –   “Strokes are usually caused by abuse of prescription medications.”
    • 4   –   “A stroke may be the result of a transient ischemic attack.”

    RATIONALE: Strokes can be caused by a variety of conditions, including embolus, thrombus, or different types of bleeds. The cause of this client’s stroke must be determined by diagnostic testing; therefore, any of the other response to the client’s daughter would be inappropriate.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Knowledge

  27. The nurse is assessing an infant for signs of increased intracranial pressure (ICP). What’s the earliest sign of increased ICP in an infant?
    • 1   –   Vomiting
    • 2   –   Papilledema
    • 3   –   Headache
    • 4   –   Increased head circumference

    RATIONALE: Increased head circumference is the first sign of increased ICP in an infant. Vomiting occurs later. Papilledema is a late sign of increased ICP and may not be evident. Because the infant can’t speak, the nurse would have trouble determining if the infant has a headache.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Knowledge

  28. The nurse is caring for a client who’s about to undergo a lumbar puncture to assess for the presence of blood in the cerebrospinal fluid (CSF) and to measure CSF pressure. Which of the following results would indicate an abnormality?
    • 1   –   The presence of glucose in the CSF
    • 2   –   A pressure of 70 to 200 mm H2O
    • 3   –   The presence of red blood cells (RBCs) in the first specimen tube
    • 4   –   A pressure of 200 to 250 mm H2O

    RATIONALE: The normal pressure is 70 to 200 mm H2O, and pressures over 200 mm H2O are considered abnormal. The presence of glucose is an expected finding in CSF, and RBCs typically occur in the first specimen tube from the trauma caused by the procedure.
    NURSING PROCESS STEP: Analysis
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Analysis

  29. The nurse is formulating a teaching plan for a client who has just experienced a transient ischemic attack (TIA). Which of the following facts should the nurse include in the teaching plan?
    • 1   –   TIA symptoms may last 24 to 48 hours.
    • 2   –   Most clients have residual effects after having a TIA.
    • 3   –   TIA may be a warning that the client may have a stroke.
    • 4   –   The most common symptom of a TIA is the inability to speak.

    RATIONALE: TIA may be a warning that the client will experience a stroke in the near future. TIA symptoms last no longer than 24 hours and clients usually have complete recovery after TIA. The most common symptom of TIA is sudden, painless loss of vision (not speech) lasting up to 24 hours.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Application

  30. The parents of a child undergoing surgery for a severe closed head injury have just finished speaking with the neurosurgeon. When the nurse asks them if they have questions about anything the physician said, the mother questions what the neurosurgeon meant when he stated that one aspect of their child’s injury was “contrecoup.” The nurse should explain that contrecoup means:
    • 1   –   the point of impact on the skull.
    • 2   –   the point on the skull where the brain collided with it, located opposite the point on the skull where the external impact occurred.
    • 3   –   that the skull was fractured and the brain has been compressed.
    • 4   –   a low-grade subdural hematoma may be forming.

    RATIONALE: The brain responds to the force of injury as it changes shape to adapt to the trauma exerted on it. The point of initial impact on the skull is called coup, and the point on the skull directly opposite the point of initial impact (where the brain collides with the opposite side of the skull) is called the contrecoup. Nothing in this scenario indicates a fractured skull or subdural hematoma formation. Although a skull fracture or subdural hematoma may result from a severe head injury, these injuries aren’t part of the “coup” and “contrecoup” definition.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Application

  31. When doing a neurologic assessment of a client, the nurse will assess for a consensual response of the client’s eyes. This response would be present if the nurse assesses which of the following reactions?
    • 1   –   The eyes have no extraocular movements.
    • 2   –   The red reflex is present.
    • 3   –   The eyes deviate to the side of stimulation.
    • 4   –   When a light is shown in one eye, that pupil constricts, as does the unstimulated eye.

    RATIONALE: In a neurologically stable client, both eyes constrict when a light is shown in one or the other. This response is called consensual pupils. When eyes have extraocular movements, nystagmus may be diagnosed. The red reflex is a normal response in which the retina glows red when a light is shined on the pupil; it doesn’t refer to consensual response. The eyes don’t deviate to the side of stimulation in consensual response.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Application

  32. When performing a neurologic assessment on a client, the nurse finds that the client’s pupils are fixed and dilated. What does this assessment of the client’s eyes indicate?
    • 1   –   The client is permanently paralyzed.
    • 2   –   The client is going to be blind as a result of an injury.
    • 3   –   The client probably has meningitis.
    • 4   –   The client has received a significant brain injury.

    RATIONALE: When the client has received an injury to the midbrain, the pupils become fixed and dilated, an ominous sign. Paralysis, blindness, and meningitis have clinical manifestations other than fixed, dilated pupils.
    NURSING PROCESS STEP: Analysis
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Analysis

  33. When providing oral hygiene for an unconscious client, the nurse must take which essential action?
    • 1   –   Swab the client’s lips, teeth, and gums with lemon glycerin.
    • 2   –   Clean the client’s tongue with gloved fingers.
    • 3   –   Place the client in semi-Fowler’s position.
    • 4   –   Place the client in a side-lying position.

    RATIONALE: An unconscious client is at risk for aspiration. To decrease this risk, the nurse should place the client in a side-lying position when performing oral hygiene. Swabbing the client’s lips, teeth, and gums with lemon glycerin would promote tooth decay. Cleaning the tongue with gloved fingers wouldn’t be effective in removing oral secretions or debris in an unconscious client. Placing the client in semi-Fowler’s position would increase the risk of aspiration.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

  34. Which of the following tests would the nurse expect to see performed on a client with Guillain-Barre syndrome? Select all that apply.

    • 1   –   Electromyography (EMG) studies
    • 2   –   Lumbar puncture
    • 3   –   Cerebrospinal fluid (CSF) analysis
    • 4   –   Vital capacity
    • 5   –   X-rays of the cervical spine

    RATIONALE: EMG studies show a decreased nerve conduction velocity related to the loss of myelin. Lumbar puncture and CSF results may reveal elevated levels of proteins related to inflammation of the nerve root. Vital capacity findings provide the nurse with information related to the effects of motor weakness of the respiratory muscles. X-rays of the cervical spine aren’t clinically significant diagnostic studies for a client with this condition.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiologic adaptation
    COGNITIVE LEVEL: Comprehension

 

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