Central Nervous System (CNS) p.1968
https://quizlet.com/396855847/chapter-65-assessment-of-neurologic-function-flash-cards/
Infectious meningitis/encephalitis, p. 2088
A client with increased intracranial pressure (ICP) has a ventriculostomy for
monitoring ICP. The nurse's most recent assessment reveals that the client is now
exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the
presence of what complication?
A. Encephalitis
B. Cerebral spinal fluid leak
C. Meningitis
D. Catheter occlusion
Complications of a ventriculostomy include ventricular infectious meningitis
and problems with the monitoring system. Nuchal rigidity and photophobia are clinical
manifestations of meningitis, but are not suggestive of encephalitis, a cerebral spinal
fluid (CSF) leak, or an occluded catheter.
A client with possible bacterial meningitis is admitted to the ICU. What assessment
finding would the nurse expect for a client with this diagnosis?
A. Pain upon ankle dorsiflexion of the foot
B. Neck flexion produces flexion of knees and hips
C. Inability to stand with eyes closed and arms extended without swaying
D. Numbness and tingling in the lower extremities
Clinical manifestations of bacterial meningitis include a positive Brudzinski
sign. Neck flexion producing flexion of knees and hips correlates with a positive
Brudzinski sign. Positive Homan sign (pain upon dorsiflexion of the foot) and negative
Romberg sign (inability to stand with eyes closed and arms extended) are not expected
assessment findings for the client with bacterial meningitis. Peripheral neuropathy
manifests as numbness and tingling in the lower extremities. Again, this would not be an
initial assessment to rule out bacterial meningitis.
A client presents to the clinic reporting a headache. The nurse notes that the client is
guarding the neck and tells the nurse about stiffness in the neck area. The nurse suspects
the client may have meningitis. What is another well-recognized sign of this infection?
A. Negative Brudzinski sign
B. Positive Kernig sign
C. Hyperpatellar reflex
D. Sluggish pupil reaction
Rationale: Meningeal irritation results in a number of well-recognized signs commonly
seen in meningitis, such as a positive Kernig sign, a positive Brudzinski sign, and
photophobia. Hyperpatellar reflex and a sluggish pupil reaction are not commonly
recognized signs of meningitis.
A 69-year-old client is brought to the ED by ambulance because a family member
found the client lying on the floor disoriented and lethargic. The health care provider
suspects bacterial meningitis and admits the client to the ICU. What interventions should
the nurse perform? Select all that apply.
A. Obtain a blood type and cross-match.
B. Administer antipyretics as prescribed.
C. Perform frequent neurologic assessments.
D. Monitor pain levels and administer analgesics.
E. Place the client in positive pressure isolation.
Rationale: Clients with meningitis require antipyretics and analgesia to treat fever and
pain. The client’s neurologic status must be monitored closely. Transfusions are not
anticipated. Infection control precautions are implemented, but positive pressure
isolation is not necessary because the client is not immunocompromised.
(Start 10th Ed)
A patient with suspected meningitis is scheduled for a lumbar puncture. Before the procedure,
the nurse will plan to:
a.enforce NPO status for 4 hours.
b.transfer the patient to radiology.
c.administer a sedative medication.
d.help the patient to a lateral position.
For a lumbar puncture, the patient lies in the lateral recumbent position. The procedure
does not usually require a sedative, is done in the patient room, and has no risk for
aspiration.
A 42-year-old patient who has bacterial meningitis is disoriented and anxious. Which nursing
action will be included in the plan of care?
a.Encourage family members to remain at the bedside.
b.Apply soft restraints to protect the patient from injury.
c.Keep the room well-lighted to improve patient orientation.
d.Minimize contact with the patient to decrease sensory input
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 public health nurse is planning a program to decrease the incidence of meningitis in
adolescents and young adults. Which action is most important?
a.Encourage adolescents and young adults to avoid crowds in the winter.
b.Vaccinate 11- and 12-year-old children against Haemophilus influenzae.
c.Immunize adolescents and college freshmen against Neisseria meningitidis.
d.Emphasize the importance of hand washing to prevent the spread of infection.
The Neisseria meningitidis 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 isn't 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.
A patient has been admitted with meningococcal meningitis. Which observation by the nurse
requires action?
a.The bedrails at the head and foot of the bed are both elevated.
b.The patient receives a regular diet from the dietary department.
c.The lights in the patient's room are turned off and the blinds are shut.
d.Unlicensed assistive personnel enter the patient's room without a mask
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 foot 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 53-year-old patient with bacterial meningitis, the nurse obtains the following
data. Which Finding should be reported immediately to the health care provider?
a.The patient exhibits nuchal rigidity.
b.The patient has a positive Kernig's sign.
c.The patient's temperature is 101 F (38.3 C).
d.The patient's blood pressure is 88/42 mm Hg.
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 asthma hypotension.
Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a
registered nurse (RN) who has floated from the medical unit?
a.A 45-year-old receiving IV antibiotics for meningococcal meningitis
b.A 25-year-old admitted with a skull fracture and craniotomy the previous day
c.A 55-year-old who has increased intracranial pressure (ICP) and is receiving
hyperventilation therapy
d.A 35-year-old with ICP monitoring after a head injury last week
An RN who works on a medical unit will be familiar with administration of IV antibiotics
and with meningitis.The post craniotomy 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 being admitted with bacterial meningitis has a temperature of 102.5 F (39.2 C) and a
severe headache. Which order for collaborative intervention should the nurse implement first?
a.Administer ceftizoxime (Cefizox) 1 g IV.
b.Give acetaminophen (Tylenol) 650 mg PO.
c.Use a cooling blanket to lower temperature.
d.Swab the nasopharyngeal mucosa for cultures.
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.
A patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture was
performed in the emergency department. Which action prescribed by the health care provider
should the nurse question?
a.Elevate the head of the bed 20 degrees.
b.Restrict oral fluids to 1000 mL daily.
c.Administer ceftriaxone (Rocephin) 1 g IV every 12 hours.
d.Give ibuprofen (Motrin) 400 mg every 6 hours as needed for headache.
The patient with meningitis has increased fluid needs, so oral fluids should be
encouraged. The other actions are appropriate. Slight elevation of the head of the bed
will decrease headache without causing leakage of cerebrospinal fluid from the lumbar
puncture site. Antibiotics should be administered until bacterial meningitis is ruled out by
the cerebrospinal fluid analysis.
Encephalitis
A client with herpes simplex virus encephalitis (HSV) has been admitted to the ICU.
What medication would the nurse expect the health care provider to order for the
treatment of this disease process?
A. Cyclosporine
B. Acyclovir
C. Cyclobenzaprine
D. Ampicillin
Antiviral agents, acyclovir and ganciclovir, are the medications of choice in the
treatment of HSV. The mode of action is the inhibition of viral DNA replication. To
prevent
relapse, treatment would continue for up to 3 weeks. Cyclosporine is an
immunosuppressant and antirheumatic. Cyclobenzaprine is a centrally acting skeletal
muscle relaxant. Ampicillin, an antibiotic, is ineffective against viruses.
A client is being admitted to the neurologic ICU with suspected herpes simplex virus
encephalitis. What nursing action best addresses the client's reported headache?
A. Initiating a client-controlled analgesia (PCA) of morphine sulfate
B. Administering hydromorphone IV as needed
C. Dimming the lights and reducing stimulation
D. Distracting the client with activity
Comfort measures to reduce headache include dimming the lights, limiting
noise and visitors, grouping nursing interventions, and administering analgesic agents.
Opioid analgesic medications may mask neurologic symptoms; therefore, they are used
cautiously. Nonopioid analgesics may be preferred. Distraction is unlikely to be effective,
and may exacerbate the client's pain.
A client is admitted through the ED with suspected St. Louis encephalitis. The unique
clinical feature of St. Louis encephalitis will make what nursing action a priority?
A. Serial assessments of hemoglobin levels
B. Blood glucose monitoring
C. Close monitoring of fluid balance
D. Assessment of pain along dermatomes
A unique clinical feature of St. Louis encephalitis is SIADH with hyponatremia.
As such, it is important to monitor the client's intake and output closely.
(Start 10th)
Which action will the public health nurse take to reduce the incidence of epidemic encephalitis in
a community?
a.Encourage the use of effective insect repellents during mosquito season.
b.Remind patients that most cases of viral encephalitis can be cared for at home.
c.Teach about the importance of prophylactic antibiotics after exposure to encephalitis.
d.Arrange for screening of school-age children for West Nile virus during the school
year.
Epidemic encephalitis is usually spread by mosquitoes and ticks. Use of insect repellent
is effective in reducing risk. Encephalitis frequently requires that the patient be
hospitalized in an intensive care unit during the initial stages. Antibiotic prophylaxis is not
used to prevent encephalitis because most encephalitis is viral. West Nilevirus is most
common in adults over age 50 during the summer and early fall
Tuberculosis (TB) p 546
A client has tested positive for tuberculosis (TB). While providing client teaching, which
information should the nurse prioritize?
A. The importance of adhering closely to the prescribed medication regimen
B. The disease being a lifelong, chronic condition that will affect ADLs
C. TB being self-limiting but taking up to 2 years to resolve
D. The need to work closely with the occupational and physical therapists
Rationale: Successful treatment of TB is highly dependent on careful adherence to the
medication regimen. The disease is not self-limiting; occupational and physical therapy
are not necessarily indicated. TB is curable.
A client on the medical unit is found to have pulmonary tuberculosis (TB). What is the
most appropriate precaution for the staff to take to prevent transmission of this disease?
A. Standard precautions only
B. Droplet precautions
C. Standard and contact precautions
D. Standard and airborne precautions
Rationale: Airborne precautions are required for proven or suspected pulmonary TB.
Standard precaution techniques are used in conjunction with the transmission-based
precautions, regardless of the client's diagnosis. Droplet and contact precautions are
insufficient.
(Start 10th)
The nurse plans health care for a community with a large number of recent immigrants from
Vietnam.Which intervention is the most important for the nurse to implement?
a.Hepatitis testing
b.Tuberculosis screening
c.Contraceptive teaching
d.Colonoscopy information
Tuberculosis (TB) is endemic in many parts of Asia, and the incidence of TB is much
higher in immigrantsfrom Vietnam than in the general U.S. population. Teaching about
contraceptive use, colonoscopy, and testing for hepatitis may also be appropriate for
some patients but is not generally indicated for all members of this community.
The registered nurse (RN) caring for an HIV-positive patient admitted with tuberculosis can
delegate which action to unlicensed assistive personnel (UAP)?
a.Teach the patient about how to use tissues to dispose of respiratory secretions.
b.Stock the patients room with all the necessary personal protective equipment.
c.Interview the patient to obtain the names of family members and close contacts.
d.Tell the patient's family members the reason for the use of airborne precautions.
A patient diagnosed with tuberculosis would be placed on airborne precautions. Because
all healthcare workers are taught about the various types of infection precautions used in
the hospital, the UAP can safely stock the room with personal protective equipment.
Obtaining contact information and patient teaching are higher-level skills that require RN
education and scope of practice
The health care provider writes an order for bacteriologic testing for a patient who has a positive
tuberculosis skin test. Which action should the nurse take?
a.Teach about the reason for the blood tests.
b.Schedule an appointment for a chest x-ray.
c.Teach about the need to get sputum specimens for 2 to 3 consecutive days.
d.Instruct the patient to expectorate three specimens as soon as possible.
Sputum specimens are obtained on 2 to 3 consecutive days for bacteriologic testing for
M. tuberculosis. The patient should not provide all the specimens at once. Blood cultures
are not used for tuberculosis testing. Chest x-ray is not bacteriologic testing. Although
the findings on chest x-ray examination are important, it is not possible to make a
diagnosis of TB solely based on chest x-ray findings because other diseases can mimic
the appearance of TB.
A patient is admitted with active tuberculosis (TB). The nurse should question a health care
provider's order to discontinue airborne precautions unless which assessment finding is
documented?
a.Chest x-ray shows no upper lobe infiltrates.
b.TB medications have been taken for 6 months.
c.Mantoux testing shows an induration of 10 mm.
d.Three sputum smears for acid-fast bacilli are negative.
Negative sputum smears indicate that Mycobacterium tuberculosis is not present in the
sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays
are not used to determine whether treatment has been successful. Taking medications
for 6 months is necessary, but the multidrug-resistant forms of the disease might not be
eradicated after 6 months of therapy. Repeat Mantoux testing would not be done
because the result will not change even with effective treatment.
The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which
statement, if made by the patient, indicates that teaching was effective?
a.I will avoid being outdoors whenever possible.
b.My husband will be sleeping in the guest bedroom.
c.I will take the bus instead of driving to visit my friends.
d.I will keep the windows closed at home to contain the germs.
Teach the patient how to minimize exposure to close contacts and household members.
Homes should be well ventilated, especially the areas where the infected person spends
a lot of time. While still infectious, the patient should sleep alone, spend as much time as
possible outdoors, and minimize time in congregate settings or on public transportation.
A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having
orange discolored urine and tears. Which is the best response by the nurse?
a.Ask if the patient is experiencing shortness of breath, hives, or itching.
b.Ask the patient about any visual abnormalities such as red-green color discrimination.
c.Explain that orange discolored urine and tears are normal while taking this
medication.
d.Advise the patient to stop the drug and report the symptoms to the health care
provider.
Orange-colored body secretions are a side effect of rifampin. The patient does not have
to stop taking the medication. The findings are not indicative of an allergic reaction.
Alterations in red-green color discrimination commonly occurs when taking ethambutol
(Myambutol), which is a different TB medication.
11. An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse
should notify the health care provider if the patient exhibits which finding?
a.Yellow-tinged skin
b.Orange-colored sputum
c.Thickening of the fingernails
d.Difficulty hearing high-pitched voices
Noninfectious hepatitis is a toxic effect of isoniazid (INH), rifampin, and pyrazinamide,
and patients who develop hepatotoxicity will need to use other medications. Changes in
hearing and nail thickening are not expected with the four medications used for initial TB
drug therapy. Presbycusis is an expected finding in the older adult patient. Orange
discoloration of body fluids is an expected side effect of rifampin and not an indication to
call the health care provider.
An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which
intervention by the nurse will be most effective in ensuring adherence with the treatment
regimen?
a.Arrange for a friend to administer the medication on schedule.
b.Give the patient written instructions about how to take the medications.
c.Teach the patient about the high risk for infecting others unless treatment is followed.
d.Arrange for a daily noon meal at a community center where the drug will be
administered.
Directly observed therapy is the most effective means for ensuring compliance with the
treatment regimen, and arranging a daily meal will help ensure that the patient is
available to receive the medication. The other nursing interventions may be appropriate
for some patients but are not likely to be as helpful for this patient
After 2 months of tuberculosis (TB) treatment with isoniazid (INH), rifampin (Rifadin),
pyrazinamide(PZA), and ethambutol, a patient continues to have positive sputum smears for
acid-fast bacilli (AFB). Which action should the nurse take next?
a.Teach about treatment for drug-resistant TB treatment.
b.Ask the patient whether medications have been taken as directed.
c.Schedule the patient for directly observed therapy three times weekly.
d.Discuss with the health care provider the need for the patient to use an injectable
antibiotic.
The first action should be to determine whether the patient has been compliant with drug
therapy because negative sputum smears would be expected if the TB bacillus is
susceptible to the medications and if the medications have been taken correctly.
Assessment is the first step in the nursing process. Depending on whether the patient
has been compliant or not, different medications or directly observed therapy may be
indicated. The other options are interventions based on assumptions until an
assessment has been completed
Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a
negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no
symptoms of TB. Which information should the occupational health nurse plan to teach the staff
nurse?
a.Standard four-drug therapy for TB
b.Need for annual repeat TB skin testing
c.Use and side effects of isoniazid (INH)
d.Bacille Calmette-Gurin (BCG) vaccine
The nurse is considered to have a latent TB infection and should be treated with INH
daily for 6 to 9 months.The four-drug therapy would be appropriate if the nurse had
active TB. TB skin testing is not done for individuals who have already had a positive
skin test. BCG vaccine is not used in the United States for TB and would not be helpful
for this individual, who already has a TB infection.
When caring for a patient who is hospitalized with active tuberculosis (TB), the nurse observes a
student nurse who is assigned to take care of a patient. Which action, if performed by the
student nurse, would require intervention by the nurse?
a.The patient is offered a tissue from the box at the bedside.
b.A surgical face mask is applied before visiting the patient.
c.A snack is brought to the patient from the unit refrigerator.
d.Hand washing is performed before entering the patients room.
A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical
mask, should be used when entering the patient's room because the HEPA mask can
filter out 100% of small airborne particles. Hand Washing before entering the patient's
room is appropriate. Because anorexia and weight loss are frequent problems in patients
with TB, bringing food to the patient is appropriate. The student nurse should perform
hand washing after handling a tissue that the patient has used, but no precautions are
necessary when giving the patient an unused tissue.
A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis
(TB)disease. Which information obtained by the nurse is most important to communicate to the
health care provider?
a.The Mantoux test had an induration of 7 mm.
b.The chest-x-ray showed infiltrates in the lower lobes.
c.The patient is being treated with antiretrovirals for HIV infection.
d.The patient has a cough that is productive of blood-tinged mucus.
Drug interactions can occur between the antiretrovirals used to treat HIV infection and
the medications used to treat TB. The other data are expected in a patient with HIV and
TB.
The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have
immigrated to the United States. Which question is most important for the nurse to ask before
the skin test?
a.Is there any family history of TB?
b.How long have you lived in the United States?
c.Do you take any over-the-counter (OTC) medications?
d.Have you received the BCG vaccine for TB?
Patients who have received the BCG vaccine will have a positive Mantoux test. Another
method for screening(such as a chest x-ray) will need to be used in determining whether
the patient has a TB infection. The other information also may be valuable but is not as
pertinent to the decision about doing TB skin testing
Brain tumors p.2113
A nurse is assessing a client with an acoustic neuroma who has been recently admitted
to an oncology unit. What symptoms is the nurse likely to find during the initial
assessment?
A. Loss of hearing, tinnitus, and vertigo
B. Loss of vision, change in mental status, and hyperthermia
C. Loss of hearing, increased sodium retention, and hypertension
D. Loss of vision, headache, and tachycardia
Rationale: An acoustic neuroma is a tumor of the eighth cranial nerve, the cranial nerve
most responsible for hearing and balance. The client with an acoustic neuroma usually
experiences loss of hearing, tinnitus, and episodes of vertigo and staggering gait.
Acoustic neuromas do not cause loss of vision, increased sodium retention, or
tachycardia.
A client is diagnosed with an acoustic neuroma. When assessing this client, which
manifestation would the nurse expect to find? Select all that apply.
A. tinnitus
B. vertigo
C. staggering gait
D. seizures
E. headache
Rationale: An acoustic neuroma is a slow-growing tumor and attains considerable size
before it is correctly diagnosed. The client usually experiences loss of hearing, tinnitus,
episodes of vertigo, and staggering gait. As the tumor becomes larger, painful
sensations of the face may occur on the same side. Headaches and seizures are more
common with other types of brain tumors.
A client diagnosed with a pituitary adenoma has arrived in the neurologic unit. When
planning the client's care, the nurse should be aware that the effects of the tumor will
primarily depend on what variable?
A. Whether the tumor utilizes aerobic or anaerobic respiration
B. The specific hormones secreted by the tumor
C. The client's pre-existing health status
D. Whether the tumor is primary or the result of metastasis
Rationale: Functioning pituitary tumors can produce one or more hormones normally
produced by the anterior pituitary and the effects of the tumor depend largely on the
identity of these hormones. This variable is more significant than the client's health
status or whether the tumor is primary versus secondary. Anaerobic and aerobic
respiration are not relevant.
The nurse is with a client who has learned that they have glioblastoma multiforme, a
brain tumor associated with an exceptionally poor prognosis. The client’s heart rate
increases, eyes dilate, and blood pressure increases. The nurse recognizes these changes
as being attributable to what response?
A. Part of the limbic system response
B. Sympathetic nervous response
C. Hypothalamic–pituitary response
D. Local adaptation syndrome
Rationale: The sympathetic nervous system responds rapidly to stress; norepinephrine
is released at nerve endings, causing the organs to respond (i.e., heart rate increases,
eyes dilate, and blood pressure increases). The limbic system is a mediator of emotions
and behavior that are critical to survival during times of stress. The hypothalamic–
pituitary response regulates the cortisol-induced metabolic effect that results in elevated
blood sugars during stressful situations. Local adaptation syndrome is a tissue-specific
inflammatory reaction.
The nurse learns that a computed tomography scan a client underwent to investigate
new seizure activity revealed a brain tumor. When the client later asks about the results
of the scan, which therapeutic response should the nurse give the client?
A. “No, I have not seen the report.”
B. “What is your understanding of your condition?”
C. “Yes, but I can’t discuss the results with you.”
D. “Try not to worry; the doctor will be in later to talk with you.”
Rationale: By asking what the client knows, the nurse conveys acknowledgement of the
client’s question and establishes a baseline of knowledge for further discussion. Telling
the client that the nurse has not seen the report is not therapeutic or supportive of the
client and violates the tenet of veracity. Telling the client that the nurse knows the results
but cannot discuss it, while true, is not therapeutic. Telling the client not to worry is
dismissive of the client’s feelings and is not therapeutic.
The nurse is caring for a client with a brain tumor and is aware that the normal
compensation measures to keep ICP (intracranial pressure) within normal limits may no
longer be effective. What are the normal compensation measures for the brain? Select all
that apply.
A. Displacing or shifting cerebral spinal fluid (CSF)
B. Decreasing cerebral perfusion
C. Increasing the absorption of CSF
D. Shifting brain tissue
E. Decreasing cerebral blood volume
Rationale: The Monro–Kellie hypothesis explains the dynamic equilibrium of cranial
contents. This hypothesis states that because of the limited space for expansion within
the skull, an increase in any one of the components causes a change in the volume of
the others. The brain typically compensates for these changes by displacing or shifting
CSF, increasing the absorption or diminishing the production of CSF, or decreasing
cerebral blood volume. Without such changes, ICP begins to rise. A decrease in cerebral
perfusion and shifting brain tissue are not normal compensatory events. An increase in
ICP can occur because of a brain tumor. Increased ICP from any cause would result in a
decrease in cerebral perfusion which stimulates further edema and may shift brain
tissue. A shift in brain tissue results in herniation which is a dire and frequently fatal
event.
The nurse is caring for a client with a brain tumor. What drug would the nurse expect
to be prescribed to reduce the edema surrounding the tumor?
A. Solumedrol
B. Dextromethorphan
C. Dexamethasone
D. Furosemide
If a brain tumor is the cause of the increased ICP, corticosteroids (e.g.,
dexamethasone) help reduce the edema surrounding the tumor. Solumedrol, a steroid,
and furosemide, a loop diuretic, are not the drugs of choice in this instance.
Dextromethorphan is used in cough medicines.
A client has been admitted to the neurologic unit for the treatment of a newly
diagnosed brain tumor. The client has just exhibited seizure activity for the first time.
What is the nurse's priority response to this event?
A. Identify the triggers that precipitated the seizure.
B. Implement precautions to ensure the client's safety.
C. Teach the client's family about the relationship between brain tumors and
seizure activity.
D. Ensure that the client is housed in a private room.
Rationale: Clients with seizures are carefully monitored and protected from injury. Client
safety is a priority over health education, even though this is appropriate and necessary.
Specific triggers may or may not be evident; identifying these are not the highest
priority. A private room is preferable, but not absolutely necessary.
A client with a metastatic brain tumor of the frontal lobe experiences a generalized
seizure for the first time. The nurse should prepare for what action?
A. Intubation
B. STAT computed tomography (CT) health care provider
C. A STAT MRI
D. Administration of anticonvulsants
Rationale: Seizure activity necessitates anticonvulsants. In most cases, the development
seizure activity does not require immediate diagnostic imaging. Intubation is
unnecessary except in cases of respiratory failure.
The nurse is caring for a client with a brain tumor who is experiencing symptoms due
to compression and infiltration of normal tissue. The pathophysiologic changes that result
can cause what manifestations? Select all that apply.
A. Intracranial hemorrhage
B. Infection of cerebrospinal fluid
C. Increased ICP
D. Focal neurologic signs
E. Altered pituitary function
Rationale: The effects of neoplasms are caused by the compression and infiltration of
tissue. A variety of physiologic changes result, causing any or all of the following
pathophysiologic events: increased ICP and cerebral edema, seizure activity and focal
neurologic signs, hydrocephalus, and altered pituitary function.
The nurse is caring for a client newly diagnosed with a primary brain tumor. The client
asks the nurse where the tumor came from. What would be the nurse's best response?
A. "Your tumor originated from somewhere outside the CNS."
B. "Your tumor likely started out in one of your glands."
C. "Your tumor originated from cells within your brain itself."
D. "Your tumor is from nerve tissue somewhere in your body."
Rationale: Primary brain tumors originate from cells and structures within the brain.
Secondary brain tumors are metastatic tumors that originate somewhere else in the
body. The scenario does not indicate that the client's tumor is a pituitary tumor or a
neuroma.
A gerontologic nurse is advocating for diagnostic testing of an 81-year-old client who
is experiencing personality changes. The nurse is aware of what factor that is known to
affect the diagnosis and treatment of brain tumors in older adults?
A. The effects of brain tumors are often attributed to the cognitive effects of aging.
B. Brain tumors in older adults do not normally produce focal effects.
C. Older adults typically have numerous benign brain tumors by the eighth decade
of life.
D. Brain tumors cannot normally be treated in clients over age 75.
Rationale: In older adult clients, early signs and symptoms of intracranial tumors can be
easily overlooked or incorrectly attributed to cognitive and neurologic changes
associated with normal aging. Brain tumors are not normally benign and they produce
focal effects in all clients. Treatment options are not dependent primarily on age.
A client who has been experiencing numerous episodes of unexplained headaches
and vomiting has subsequently been referred for testing to rule out a brain tumor. What
characteristic of the client's vomiting is most consistent with a brain tumor?
A. The client's vomiting is accompanied by epistaxis.
B. The client's vomiting does not relieve his nausea.
C. The client's vomiting is unrelated to food intake.
D. The client's emesis is blood-tinged.
Rationale: Vomiting is often unrelated to food intake if caused by a brain tumor. The
presence or absence of blood is not related to the possible etiology and vomiting may or
may not relieve the client's nausea.
A client has been admitted to the neurologic ICU with a diagnosis of a brain tumor.
The client is scheduled to have a tumor resection/removal in the morning. Which of the
following assessment parameters should the nurse include in the initial assessment?
A. Gag reflex
B. Deep tendon reflexes
C. Abdominal girth
D. Hearing acuity
Rationale: Preoperatively, the gag reflex and ability to swallow are evaluated. In clients
with diminished gag response, care includes teaching the client to direct food and fluids
toward the unaffected side, having the client sit upright to eat, offering a semisoft diet,
and having suction readily available. Deep tendon reflexes, abdominal girth, and hearing
acuity are less commonly affected by brain tumors and do not affect the risk for
aspiration.
A client with a brain tumor has begun to exhibit signs of cachexia. What subsequent
assessment should the nurse prioritize?
A. Assessment of peripheral nervous function
B. Assessment of cranial nerve function
C. Assessment of nutritional status
D. Assessment of respiratory status
Rationale: Cachexia is a wasting syndrome of weight loss, muscle atrophy, fatigue,
weakness, and significant loss of appetite. Consequently, nutritional assessment is
paramount.
A client with an inoperable brain tumor has been told that the client has a short life
expectancy. On what aspects of assessment and care should the home health nurse
focus? Select all that apply.
A. Pain control
B. Management of treatment complications
C. Interpretation of diagnostic tests
D. Assistance with self-care
E. Administration of treatments
Rationale: Home care needs and interventions focus on four major areas: palliation of
symptoms and pain control, assistance in self-care, control of treatment complications,
and administration of specific forms of treatment, such as parenteral nutrition.
Interpretation of diagnostic tests is normally beyond the purview of the nurse.
A nurse is reading a journal article about brain tumors and the various types that can
occur. The nurse demonstrates understanding of the article by identifying which type as
being classified as an intracerebral tumor? Select all that apply.
A. meningioma
B. schwannoma
C. glioblastoma
D. astrocytoma
E. medulloblastoma
Rationale: Intracerebral tumors include glioblastomas, astrocytomas, and
medulloblastomas. Meningiomas and schwannomas are tumors that arise from
supporting structures.
A nurse is conducting an assessment of a client who is suspected of having a brain
tumor. Assessment reveals reports of a headache, for which the nurse gathers additional
information. The nurse determines that these reports support the suspicion of a brain
tumor when the client reports that the headache occurs:
A. early in the morning.
B. around lunchtime.
C. in the middle of the afternoon.
D. at bedtime.
Rationale: Headache, although not always present, is most common in the early morning
and improves during the day. Pain is made worse by coughing, straining, or sudden
movement. Headache is thought to be caused by the tumor invading, compressing, or
distorting the pain-sensitive structures, or by edema that accompanies the tumor.
(Start 10th)
Several patients have been hospitalized for diagnosis of neurologic problems. Which patient will
the nurse assess first?
a.Patient with a transient ischemic attack (TIA) returning from carotid duplex studies
b.Patient with a brain tumor who has just arrived on the unit after a cerebral
angiogram
c.Patient with a seizure disorder who has just completed an electroencephalogram
(EEG)
d.Patient prepared for a lumbar puncture whose health care provider is waiting for
assistance
Because cerebral angiograms require insertion of a catheter into the femoral artery,
bleeding is a possible complication. The nurse will need to check the pulse, blood
pressure, and the catheter insertion site in the groin as soon as the patient arrives.
Carotid duplex studies and EEG are noninvasive. The nurse will need to assist with the
lumbar puncture as soon as possible, but monitoring for hemorrhage after cerebral
angiogram has a higher priority.
The charge nurse observes an inexperienced staff nurse caring for a patient who has had a
craniotomy for resection of a brain tumor. Which action by the inexperienced nurse requires the
charge nurse to intervene?
a.The staff nurse assesses neurologic status every hour.
b.The staff nurse elevates the head of the bed to 30 degrees.
c.The staff nurse suctions the patient routinely every 2 hours.
d.The staff nurse administers an analgesic before turning the patient.
Suctioning increases intracranial pressure, and should only be done when the patient's
respiratory condition indicates it is needed. The other actions by the staff nurse are
appropriate.
Spinal cord injury p. 2070
The nurse is planning to teach tracheostomy care to a client who will be
discharged home following a spinal cord injury. When preparing to teach, which
component of the teaching plan should the nurse prioritize?
A. Citing the evidence that underlies each of the teaching points
B. Alleviating the client's guilt associated with not knowing appropriate self-care
C. Determining the client's readiness to learn new information
D. Including several nursing colleagues in the planning process
Rationale: Assessment in the teaching–learning process is directed toward the
systematic collection of data about the person and family's learning needs and
readiness to learn. Client readiness is critical to accepting and integrating new
information. Unless the client is ready to accept new information, client teaching
will be ineffective. Citing the evidence base will not likely enhance learning. Client
guilt cannot be alleviated until the client understands the intricacies of the condition
and their physiologic response to the disease. Inclusion of colleagues can be
beneficial, but this does not determine the success or failure of teaching.
A client with a spinal cord injury is being assessed by the nurse prior to being
discharged from the rehabilitation facility. The nurse is planning care through the lens of
the interface model of disability. Within this model, the nurse will plan care based on what
belief?
A. The client has the potential to function effectively despite the disability.
B. The client's condition does not have to affect their lifestyle.
C. The client will not require care from professional caregivers in the home setting.
D. The client's disability is the most significant aspect of the client’s personal
identity.
Rationale: The interface model does not ignore the condition or its disabling effects;
Instead, it promotes the view that people with disabilities are capable, responsible
people who are able to function effectively despite having a disability. This does not
mean that the client will not require care, however, or that it will not affect their lifestyle.
A person's disability is not their identity.
A client is being treated in the ICU for neurogenic shock secondary to a spinal cord
injury. Despite aggressive interventions, the client's mean arterial pressure (MAP) has
fallen to 55 mm Hg. The nurse should assess for the onset of acute kidney injury by
referring to what laboratory findings? Select all that apply.
A. Blood urea nitrogen (BUN) level
B. Urine specific gravity
C. Alkaline phosphatase level
D. Creatinine level
E. Serum albumin le-vel
Rationale: Acute kidney injury (AKI) is characterized by an increase in BUN and serum
creatinine levels, fluid and electrolyte shifts, acid–base imbalances, and a loss of the
renal–hormonal regulation of BP. Urine specific gravity is also affected. Alkaline
phosphatase and albumin levels are related to hepatic function.
A client has a flaccid bladder secondary to a spinal cord injury. The nurse recognizes
this client's high risk for urinary retention and should implement what intervention in the
client's plan of care?
A. Relaxation techniques
B. Sodium restriction
C. Lower abdominal massage
D. Double voiding
Rationale: To enhance emptying of a flaccid bladder, the client may be taught to "double
void." After each voiding, the client is instructed to remain on the toilet, relax for 1 to 2
minutes, and then attempt to void again in an effort to further empty the bladder.
Relaxation does not affect the neurologic etiology of a flaccid bladder. Sodium restriction
and massage are similarly ineffective.
A client is brought to the trauma center by ambulance after sustaining a high cervical
spinal cord injury 1.5 hours ago. Endotracheal intubation has been deemed necessary
and the nurse is preparing to assist. What nursing diagnosis should the nurse associate
with this procedure?
A. Risk for impaired skin integrity
B. Risk for injury
C. Risk for autonomic dysreflexia
D. Risk for suffocation
Rationale: If endotracheal intubation is necessary, extreme care is taken to avoid flexing
or extending the client's neck, which can result in extension of a cervical injury.
Intubation does not directly cause autonomic dysreflexia and the threat to skin integrity
is not a primary concern. Intubation does not carry the potential to cause suffocation.
The staff educator is precepting a nurse new to the critical care unit when a client with
a T2 spinal cord injury is admitted. The client is soon exhibiting manifestations of
neurogenic shock. In addition to monitoring the client closely, what would be the nurse's
most appropriate action?
A. Prepare to transfuse packed red blood cells.
B. Prepare for interventions to increase the client's BP.
C. Place the client in the Trendelenburg position.
D. Prepare an ice bath to lower core body temperature.
Rationale: Manifestations of neurogenic shock include decreased BP and heart rate.
Cardiac markers would be expected to rise in cardiogenic shock. Transfusion,
repositioning, and ice baths are not indicated interventions.
An ED nurse has just received a call from EMS that they are transporting a 17-year-old
client who has just sustained a spinal cord injury (SCI). The nurse recognizes that the
the most common cause of this type of injury is what event?
A. Syncope (fainting)
B. Suicide attempts
C. Workplace injuries
D. Motor vehicle accidents
Rationale: The most common causes of SCIs are motor vehicle crashes, falls, violence,
and sports.
A nurse has a client with a spinal cord injury and is tailoring their care plan to prevent
the major causes of death for this client. The nurse’s care plan includes assisted coughing
techniques, a sequential compression device, and prevention of pressure injuries. Which
are the most likely possible causes of death for this client?
A. Pneumonia, pulmonary embolism, and sepsis
B. Cardiac tamponade, hypoxia, and malnutrition
C. Oxygen toxicity in paralytic ileus and electrolyte imbalances
D. Seizures, osteomyelitis, and urinary tract infections
Rationale: The nurse is assisting the client with assisted coughing to prevent
pneumonia. Pulmonary infections are managed and prevented by frequent coughing,
turning, and deep breathing exercises and chest physiotherapy; aggressive respiratory
care and suctioning of the airway if a tracheostomy is present; assisted coughing as
needed; and adequate hydration. Low-dose anticoagulation therapy usually is initiated to
prevent DVT (deep vein thrombosis) and PE (pulmonary embolism), along with the use
of anti-embolism stockings or sequential pneumatic compression devices (SCDs).
Pressure injuries have the potential complication of sepsis, osteomyelitis, and fistulas.
All of the other listed causes may occur in clients with SCI but are not the main causes
of death. The interventions discussed above directly assist in the prevention of
pneumonia, pulmonary embolism osteomyelitis and sepsis.
A client who suffered a spinal cord injury is experiencing an exaggerated autonomic
response. What aspect of the client's current health status is most likely to have
precipitated this event?
A. The client received a blood transfusion.
B. The client's analgesia regimen was recently changed.
C. The client was not repositioned during the night shift.
D. The client's urinary catheter became occluded.
Rationale: A distended bladder is the most common cause of autonomic dysreflexia.
Infrequent positioning is a less likely cause, although pressure ulcers or tactile
stimulation can cause it. Changes in medications or blood transfusions are unlikely
causes.
A client with a C5 spinal cord injury has tetraplegia. After being moved out of the ICU,
the client reports a severe throbbing headache. What should the nurse do first?
A. Check the client's indwelling urinary catheter for kinks to ensure patency.
B. Lower the HOB to improve perfusion.
C. Administer PRN analgesia as prescribed.
D. Reassure the client that headaches are expected during recovery from spinal
cord injuries.
Rationale: A severe throbbing headache is a common symptom of autonomic
dysreflexia, which occurs after injuries to the spinal cord above T6. The syndrome is
usually brought on by sympathetic stimulation, such as bowel and bladder distention.
Lowering the HOB can increase ICP. Before administering analgesia, the nurse should
check the client's catheter, record vital signs, and perform an abdominal assessment. A
severe throbbing headache is a dangerous symptom in this client and is not expected.
A client is admitted to the neurologic ICU with a spinal cord injury. When assessing
the client the nurse notes there is a sudden depression of reflex activity in the spinal cord
below the level of injury. What should the nurse suspect?
A. Epidural hemorrhage
B. Hypertensive emergency
C. Spinal shock
D. Hypovolemia
Rationale: In spinal shock, the reflexes are absent, BP and heart rate fall, and
respiratory failure can occur. Hypovolemia, hemorrhage, and hypertension do not cause
this sudden change in neurologic function.
The nurse is assessing a client with a spinal cord injury that reports a severe
headache with a rapid onset. The nurse knows that this could be a symptom of which
complication of a spinal cord injury?
A. Autonomic dysreflexia
B. Spinal shock
C. Retinal hemorrhage
D. Myocardial infarction
Rationale: The client is likely suffering from an episode of autonomic dysreflexia which
triggers an autonomic–hyper-response. Autonomic dysreflexia occurs after spinal shock,
not due to it. Retinal hemorrhage and MI occur if autonomic dysreflexia is not resolved.
Following a spinal cord injury, a client is placed in halo traction. While performing pin
site care, the nurse notes that one of the traction pins has become detached. The nurse
would be correct in implementing what priority nursing action?
A. Complete the pin site care to decrease risk of infection.
B. Notify the neurosurgeon of the occurrence.
C. Stabilize the head in a lateral position.
D. Reattach the pin to prevent further head trauma.
Rationale: If one of the pins became detached, the head is stabilized in neutral position
by one person while another notifies the neurosurgeon. Reattaching the pin as a nursing
intervention would not be done due to risk of increased injury. Pin site care would not be
a priority in this instance. Prevention of neurologic injury is the priority
The nurse is caring for a client whose spinal cord injury has caused recent muscle
spasticity. What medication should the nurse expect to be prescribed to control this?
A. Baclofen
B. Dexamethasone
C. Mannitol
D. Phenobarbital
Rationale: Baclofen is classified as an antispasmodic agent in the treatment of muscle
spasms related to spinal cord injury. Decadron is an anti-inflammatory medication used
to decrease inflammation in both SCI and head injury. Mannitol is used to decrease
cerebral edema in clients with head injury. Phenobarbital is an anticonvulsant that is
used in the treatment of seizure activity.
The nurse is planning the care of a client with a T1 spinal cord injury. The nurse has
identified the diagnosis of "risk for impaired skin integrity." How can the nurse best
address this risk?
A. Change the client's position frequently.
B. Provide a high-protein diet.
C. Provide light massage at least daily.
D. Teach the client deep breathing and coughing exercises.
Rationale: Frequent position changes are among the best preventative measures
against pressure ulcers. A high-protein diet can benefit wound healing, but does not
necessarily prevent skin breakdown. Light massage and deep breathing do not protect
or restore skin integrity.
A client with a spinal cord injury has experienced several hypotensive episodes. How
can the nurse best address the client's risk for orthostatic hypotension?
A. Administer an IV bolus of normal saline prior to repositioning.
B. Maintain bed rest until normal BP regulation returns.
C. Monitor the client's BP before and during position changes.
D. Allow the client to initiate repositioning.
Rationale: To prevent hypotensive episodes, close monitoring of vital signs before and
during position changes is essential. Prolonged bed rest carries numerous risks and it is
not possible to provide a bolus before each position change. Following the client's lead
may or may not help regulate BP.
A nurse on the neurologic unit is providing care for a client who has spinal cord injury
at the level of C4. When planning the client's care, what aspect of the client's neurologic
and functional status should the nurse consider?
A. Inability to use a wheelchair
B. Unable to swallow liquid and solid food
C. Incontinent in bowel movements
D. Requires full assistance for elimination
Rationale: Clients with a lesion at C4 are fully dependent for elimination. The client is
dependent for feeding, but is able to swallow. The client will be capable of using an
electric wheelchair.
The nurse caring for a client with a spinal cord injury notes that the client is exhibiting
early signs and symptoms of disuse syndrome. Which of the following is the most
appropriate nursing action?
A. Limit the amount of assistance provided with ADLs.
B. Collaborate with the physical therapist and immobilize the client's extremities
temporarily.
C. Increase the frequency of ROM exercises.
D. Educate the client about the importance of frequent position changes.
Rationale: To prevent disuse syndrome, ROM exercises must be provided at least four
times a day, and care is taken to stretch the Achilles tendon with exercises. The client is
repositioned frequently and is maintained in proper body alignment whether in bed or in
a wheelchair. The client must be repositioned by caregivers, not just taught about
repositioning. It is inappropriate to limit assistance for the sole purpose of preventing
disuse syndrome.
Splints have been prescribed for a client who is at risk of developing foot drop
following a spinal cord injury. When should the nurse remove and reapply the splints?
A. At the client's request
B. Each morning and evening
C. Every 2 hours
D. One hour prior to mobility exercises
Rationale: The feet are prone to foot drop; therefore, various types of splints are used to
prevent foot drop. When used, the splints are removed and reapplied every 2 hours.
A male client who is being treated in the hospital for a spinal cord injury (SCI) is
advocating for the removal of the urinary catheter, stating that they want to try to
resume normal elimination. What principle should guide the care team's decision
regarding this intervention?
A. Urinary catheter use often leads to urinary tract infections (UTIs).
B. Urinary function is permanently lost following an SCI.
C. Urinary catheters should not remain in place for more than 7 days.
D. Overuse of urinary catheters can exacerbate nerve damage.
Rationale: Catheter use does not cause nerve damage, although it is a major risk factor
for UTIs. Bladder distention, a major cause of autonomic dysreflexia, can also cause
trauma. For this reason, removal of a urinary catheter must be considered with caution.
Extended use of urinary catheterization is often necessary following SCI. The effect of a
spinal cord lesion on urinary function depends on the level of the injury.
A client with spinal cord injury is ready to be discharged home. A family member asks
the nurse to review potential complications one more time. What are the potential
complications that should be monitored for this client? Select all that apply.
A. Orthostatic hypotension
B. Autonomic dysreflexia
C. DVT
D. Salt-wasting syndrome
E. Increased ICP
Rationale: For a spinal cord-injured client, based on the assessment data, potential
complications that may develop include DVT, orthostatic hypotension, and autonomic
dysreflexia. Salt-wasting syndrome and increased ICP are not typical complications
following the immediate recovery period.
A client is admitted to the neurologic ICU with a C4 spinal cord injury. When writing
the plan of care for this client, which of the following nursing diagnoses would the nurse
prioritize in the immediate care of this client?
A. Risk for impaired skin integrity related to immobility and sensory loss
B. Impaired physical mobility related to loss of motor function
C. Ineffective breathing patterns related to weakness of the intercostal muscles
D. Urinary retention related to inability to void spontaneously
Rationale: A nursing diagnosis related to breathing pattern would be the priority for this
client. A C4 spinal cord injury will require ventilatory support, due to the diaphragm and
intercostals being affected. The other nursing diagnoses would be used in the care plan,
but not designated as a higher priority than ineffective breathing patterns.
The nurse recognizes that a client with a SCI is at risk for muscle spasticity. How can the nurse
best prevent this complication of an SCI?
A. Position the client in a high-Fowler position when in bed.
B. Support the knees with a pillow when the client is in bed.
C. Perform passive ROM exercises as prescribed.
D. Administer NSAIDs as prescribed.
Rationale: Passive ROM exercises can prevent muscle spasticity following SCI. NSAIDs
are not used for this purpose. Pillows and sitting upright do not directly address the
client's risk of muscle spasticity.
(Start 10th)
A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic
bladder. Which action will the nurse include in the plan of care?
a.Teach the patient the Cred method.
b.Instruct the patient how to self-catheterize.
c.Catheterize for residual urine after voiding.
d.Assist the patient to the toilet every 2 hours.
Because the patients bladder is spastic and will empty in response to overstretching of
the bladder wall, themost appropriate method is to avoid incontinence by emptying the
bladder at regular intervals throughintermittent catheterization. Assisting the patient to
the toilet will not be helpful because the bladder will not empty. The Cred method is
more appropriate for a bladder that is flaccid, such as occurs with areflexic neurogenic
bladder. Catheterization after voiding will not resolve the patients incontinence.
When the nurse is developing a rehabilitation plan for a 30-year-old patient with a C6 spinal
cord injury, an appropriate goal is that the patient will be able to
a.drive a car with powered hand controls.
b.push a manual wheelchair on a flat surface.
c.turn and reposition independently when in bed.
d.transfer independently to and from a wheelchair.
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 20-year-old patient who sustained a T2 spinal cord injury 10 days ago angrily tells the nurse I
want to be transferred to a hospital where the nurses know what they are doing! Which action
by the nurse is best?
a.Clarify that abusive language will not be tolerated.
b.Request that the patient provide input for the plan of care.
c.Perform care without responding to the patients comments.
d.Reassure the patient about the competence of the nursing staff.
The patient is demonstrating behaviors consistent with the anger phase of the grief
process, and the nurse should allow expression of anger and seek the patient's input
into care. Expression of anger is appropriate at this stage, and should be accepted by
the nurse. Reassurance about the competency of the staff will not be helpful in
responding to the patient's anger. Ignoring the patient's comments will increase the
patient's anger and sense of helplessness.
A 38-year-old patient has returned home following rehabilitation for a spinal cord injury. The
home care nurse notes that the spouse is performing many of the activities that the patient had
been managing unassisted during rehabilitation. The most appropriate action by the nurse at
this time is to
a.remind the patient about the importance of independence in daily activities.
b.tell the spouse to stop because the patient is able to perform activities independently.
c.develop a plan to increase the patients independence in consultation with the
patient and the spouse.
d.recognize that it is important for the spouse to be involved in the patients care and
encourage the participation.
The best action by the nurse will be to involve all the parties in developing an optimal
plan of care. Becausefamily members who will be assisting with the patient's ongoing
care need to feel that their input is important,telling the spouse that the patient can
perform activities independently is not the best choice. Reminding the patient about the
importance of independence may not change the behaviors of the spouse. Supporting
the activities of the spouse will lead to ongoing dependency by the patient.
Which nursing action has the highest priority for a patient who was admitted 16 hours previously
with a C5spinal cord injury?
a.Cardiac monitoring for bradycardia
b.Assessment of respiratory rate and effort
c.Application of pneumatic compression devices to legs
d.Administration of methylprednisolone (Solu-Medrol) infusion
Edema around the area of injury may lead to damage above the C4 level, so the highest
priority is assessment of the patient's respiratory function. Methylprednisolone (SoluMedrol) is no longer recommended for the treatment of spinal cord injuries. The other
actions also are appropriate but are not as important as assessment of respiratory effort.
A patient who had a C7 spinal cord injury a week ago has a weak cough effort and audible
rhonchi. The Initial intervention by the nurse should be to
a.administer humidified oxygen by mask.
b.suction the patients mouth and nasopharynx.
c.push upward on the epigastric area as the patient coughs.
d.encourage incentive spirometry every 2 hours during the day.
Because the cough effort is poor, the initial action should be to use assisted coughing
techniques to improve the ability to mobilize secretions. Administration of oxygen will
improve oxygenation, but the data do not indicate hypoxemia. The use of the spirometer
may improve respiratory status, but the patient's ability to take deep breaths is limited by
the loss of intercostal muscle function. Suctioning may be needed if the patient is unable
to expel secretions by coughing but should not be the nurses first action.
A patient admitted with dermal ulcers who has a history of a T3 spinal cord injury tells the nurse,
I have a pounding headache and I feel sick to my stomach. Which action should the nurse take
first?
a.Check for a fecal impaction.
b.Give the prescribed analgesic.
c.Assess the blood pressure (BP).
d.Notify the health care provider.
The BP should be assessed immediately in a patient with an injury at the T6 level or
higher who complains of headache to determine whether autonomic dysreflexia is
occurring. Notification of the patient's health care provider is appropriate after the BP is
obtained. Administration of an antiemetic is indicated after autonomicdysreflexia is ruled
out as the cause of the nausea. After checking the BP, the nurse may assess for a fecal
impaction using lidocaine jelly to prevent further increased BP.
Following a cauda equina spinal cord injury, which action will the nurse include in the plan of
care?
a.Catheterize patient every 3 to 4 hours.
b.Assist patient to ambulate several times daily.
c.Administer medications to reduce bladder spasm
d.Stabilize the neck when repositioning the patient.
Patients with cauda equina syndrome have areflexic bladder, and intermittent
catheterization will be used foremptying the bladder. Because the bladder is flaccid,
antispasmodic medications will not be used. The legs areflaccid with cauda equina
syndrome and the patient will be unable to ambulate. The head and neck will notneed to
be stabilized following a cauda equina injury, which affects the lumbar and sacral nerve
roots.
A 33-year-old patient with a T4 spinal cord injury asks the nurse whether he will be able to be
sexuallyactive. Which initial response by the nurse is best?
a.Reflex erections frequently occur, but orgasm may not be possible.
b.Sildenafil (Viagra) is used by many patients with spinal cord injury.
c.Multiple options are available to maintain sexuality after spinal cord injury.
d.Penile injection, prostheses, or vacuum suction devices are possible options
Although sexuality will be changed by the patients spinal cord injury, there are options
for expression ofsexuality and for fertility. The other information also is correct, but the
choices will depend on the degrees ofinjury and the patients individual feelings about
sexuality.
A 19-year-old patient with massive trauma and possible spinal cord injury is admitted to the
emergency department (ED). Which assessment finding by the nurse will help confirm a
diagnosis of neurogenic shock?
a.Inspiratory crackles.
b.Cool, clammy extremities.
c.Apical heart rate 45 beats/min.
d.Temperature 101.2 F (38.4 C).
Neurogenic shock is characterized by hypotension and bradycardia. The other findings
would be more consistent with other types of shock
A nurse is assigned as a case manager for a hospitalized patient with a spinal cord injury. The
patient can expect the nurse functioning in this role to perform which activity?
a.Care for the patient during hospitalization for the injuries.
b.Assist the patient with home care activities during recovery.
c.Determine what medical care the patient needs for optimal rehabilitation.
d.Coordinate the services that the patient receives in the hospital and at home.
The role of the case manager is to coordinate the patient's care through multiple settings
and levels of care to allow the maximum patient benefit at the least cost. The case
manager does not provide direct care in either the acute or home setting. The case
manager coordinates and advocates for care but does not determine what medical care
is needed; that would be completed by the health care provider or other provider.
START OF WEEK II
Multiple Sclerosis (MS) p. 2094
The nurse is preparing discharge teaching for an adult client diagnosed with
urinary retention secondary to multiple sclerosis. The nurse will teach the client to
self-catheterize at home upon discharge. What teaching method is most likely to
be effective for this client?
A. A list of clear instructions written at a sixth-grade level
B. A short video providing useful information and demonstrations
C. An audio-recorded version of discharge instructions that can be accessed at
home
D. A discussion and demonstration between the nurse and the client
A client with a recent diagnosis of which condition would most likely benefit
from health education that emphasizes adherence?
A. Colonization with methicillin-resistant Staphylococcus aureus (MRSA)
B. Small bowel obstruction
C. Multiple sclerosis
D. A fractured humerus
A 37-year-old client with multiple sclerosis is married and has three children. The
nurse has worked extensively with the client and family to plan appropriate care. What is
the nurse's most important role with this client?
A. Ensure the client adheres to all treatments.
B. Provide the client with advice on alternative treatment options.
C. Provide a detailed plan of activities of daily living (ADLs) for the client.
D. Help the client develop strategies to implement treatment regimens.
A 55-year-old woman with multiple sclerosis is deficient in completing health
screening and health promotion tests. Based on the information provided, and statistical
data, what is the most likely test that the client missed?
A. Yearly physical
B. Pelvic examination
C. Colonoscopy
D. Hearing test
The nurse is caring for a young mother who has a longstanding diagnosis of multiple
sclerosis (MS). The parent was admitted with a postpartum infection 3 days ago, and the
plan is to discharge the client home when the client has finished 5 days of IV antibiotic
therapy. What information would be most useful for the nurse to provide at discharge?
A. A long discussion and overview of postpartum infections
B. How the response to infection never differs in clients with MS
C. The same information you would provide to a client without a chronic condition
D. Information on effective management of MS in the home setting
A client has a diagnosis of multiple sclerosis. The nurse is aware that neuromuscular
disorders such as multiple sclerosis may lead to a decreased vital capacity. What does
vital capacity measure?
A. The volume of air inhaled and exhaled with each breath
B. The volume of air in the lungs after a maximal inspiration
C. The maximal volume of air inhaled after normal expiration
D. The maximal volume of air exhaled from the point of maximal inspiration
The nurse is providing care for a client who has multiple sclerosis. The nurse
recognizes the autoimmune etiology of this disease and the potential benefits of what
Treatment?
A. Stem cell transplantation
B. Serial immunizations
C. Immunosuppression
D. Genetic engineering
A client is admitted to the medical unit with an exacerbation of multiple sclerosis.
When assessing this client, the nurse has the client stick out the tongue and move it back
and forth. What is the nurse assessing?
A. Function of the hypoglossal nerve
B. Function of the vagus nerve
C. Function of the spinal nerve
D. Function of the trochlear nerve
The nurse is caring for a client with multiple sclerosis (MS). The client tells the nurse
the hardest thing to deal with is the fatigue. When teaching the client how to reduce
fatigue, what action should the nurse suggest?
A. Taking a hot bath at least once daily
B. Resting in an air-conditioned room whenever possible
C. Increasing the dose of muscle relaxants
D. Avoiding naps during the day
10TH EDITION QUESTIONS
When obtaining a health history and physical assessment for a 36-year-old female patient with
possible multiple sclerosis (MS), the nurse should
a.assess for the presence of chest pain.
b.inquire about urinary tract problems.
c.inspect the skin for rashes or discoloration.
d.ask the patient about any increase in libido.
A 31-year-old woman who has multiple sclerosis (MS) asks the nurse about risks associated
with pregnancy.Which response by the nurse is accurate?
a.MS symptoms may be worse after the pregnancy.
b.Women with MS frequently have premature labor.
c.MS is associated with an increased risk for congenital defects.
d.Symptoms of MS are likely to become worse during pregnancy.
A 49-year-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate
(Copaxone).Which information will the nurse include in patient teaching?
a.Recommendation to drink at least 4 L of fluid daily
b.Need to avoid driving or operating heavy machinery
c.How to draw up and administer injections of the medication
d.Use of contraceptive methods other than oral contraceptives
Which action will the nurse plan to take for a 40-year-old patient with multiple sclerosis (MS)
who has urinary retention caused by a flaccid bladder?
a.Decrease the patient's evening fluid intake.
b.Teach the patient how to use the Cred method.
c.Suggest the use of adult incontinence briefs for nighttime only.
d.Assist the patient to the commode every 2 hours during the day.
Acute Myeloid Leukemia p. 951
***SAID THIS ? IN CLASS***
A nurse is caring for a client with acute myeloid leukemia who is preparing to undergo
induction therapy. In preparing a plan of care for this client, the nurse should assign the
highest priority to which nursing diagnosis?
A. Activity intolerance
B. Risk for infection
C. Acute confusion
D. Risk for spiritual distress
***SAID THIS ? IN CLASS***
A client diagnosed with acute myeloid leukemia has just been admitted to the
oncology unit. When writing this client's care plan, which potential complication should
the nurse address?
A. Pancreatitis
B. Hemorrhage
C. Arteritis
D. Liver dysfunction
Diagnostic testing has resulted in a diagnosis of acute myeloid leukemia (AML) in an
adult client who is otherwise healthy. The client and the care team have collaborated and
the client will soon begin induction therapy. The nurse should prepare the client for:
A. daily treatment with targeted therapy medications.
B. radiation therapy on a daily basis.
C. hematopoietic stem cell transplantation.
D. an aggressive course of chemotherapy.
A client with a diagnosis of acute myeloid leukemia (AML) is being treated with
induction therapy on the oncology unit. What nursing action should be prioritized in the
client's care plan?
A. Protective isolation and vigilant use of standard precautions
B. Provision of a high-calorie, low-texture diet and appropriate oral hygiene
C. Including the family in planning the client's activities of daily living
D. Monitoring and treating the client's pain
A 68-year-old woman with acute myelogenous leukemia (AML) asks the nurse whether the
planned chemotherapy will be worth undergoing. Which response by the nurse is appropriate?
a.If you do not want to have chemotherapy, other treatment options include stem cell
transplantation.
b.The side effects of chemotherapy are difficult, but AML frequently goes into
remission with chemotherapy.
c.The decision about treatment is one that you and the doctor need to make rather than
asking what I Would do.
d.You don't need to make a decision about treatment right now because leukemias in
adults tend to progress quite slowly
A 54-year-old woman with acute myelogenous leukemia (AML) is considering treatment with
hematopoietic stem cell transplant (HSCT). The best approach for the nurse to assist the patient
with a treatment decision is to
a.emphasize the positive outcomes of a bone marrow transplant.
b.discuss the need for adequate insurance to cover post-HSCT care.
c.ask the patient whether there are any questions or concerns about HSCT.
d.explain that a cure is not possible with any other treatment except HSCT.
A 30-year-old man with acute myelogenous leukemia develops an absolute neutrophil count of
850/L while receiving outpatient chemotherapy. Which action by the outpatient clinic nurse is
most appropriate?
a.Discuss the need for hospital admission to treat the neutropenia.
b.Teach the patient to administer filgrastim (Neupogen) injections.
c.Plan to discontinue the chemotherapy until the neutropenia resolves.
d.Order a high-efficiency particulate air (HEPA) filter for the patient's home.
Guillain- Barre p. 2013
The nurse in the medical intensive care unit is caring for a client who is in respiratory
acidosis due to inadequate ventilation. Which diagnosis could the client have that could
cause inadequate ventilation?
A. Endocarditis
B. Multiple myeloma
C. Guillain–Barré syndrome
D. Overdose of amphetamines
A client with Guillain-Barré syndrome has experienced a sharp decline in vital capacity.
What is the nurse's most appropriate action?
A. Administer bronchodilators as ordered.
B. Remind the client of the importance of deep breathing and coughing exercises.
C. Prepare to assist with intubation.
D. Administer supplementary oxygen by nasal cannula.
The nurse planning caring for a client diagnosed with Guillain-Barré syndrome. The
nurse's communication with the client should reflect the possibility of which sign or
symptom of the disease?
A. Intermittent hearing loss
B. Tinnitus
C. Tongue enlargement
D. Vocal paralysis
The nurse is developing a plan of care for a client with Guillain-Barré syndrome.
Which of the following interventions should the nurse prioritize for this client?
A. Using the incentive spirometer as prescribed
B. Maintaining the client on bed rest
C. Providing aids to compensate for loss of vision
D. Assessing frequently for loss of cognitive function
The nurse caring for a client in ICU diagnosed with Guillain-Barré syndrome should
prioritize monitoring for what potential complication?
A. Impaired skin integrity
B. Cognitive deficits
C. Hemorrhage
D. Autonomic dysfunction
The nurse is teaching a client with Guillain-Barré syndrome about the disease. The
client asks how the client can ever recover if demyelination of the nerves is occurring.
What would be the nurse's best response?
A. "Guillain-Barré spares the Schwann cell, which allows for remyelination in the
recovery phase of the disease."
B. "In Guillain-Barré, Schwann cells replicate themselves before the disease
destroys them, so remyelination is possible."
C. "I know you understand that nerve cells do not remyelinate, so the health care
provider is the best one to answer your question."
D. "For some reason, in Guillain-Barré, Schwann cells become activated and take
over the remyelination process."
Which assessment data for a patient who has Guillain-Barre syndrome will require the nurses
most immediate action?
a.The patients triceps reflexes are absent
b.The patient is continuously drooling saliva
c.The patient complains of severe pain in the feet.
d.The patient's blood pressure (BP) is 150/82 mm Hg.
A 68-year-old patient hospitalized with a new diagnosis of Guillain-Barre syndrome has
numbness and weakness of both feet. The nurse will anticipate teaching the patient about
a.intubation and mechanical ventilation
b.administration of corticosteroid drugs.
c.insertion of a nasogastric (NG) feeding tube.
d.infusion of immunoglobulin (Sandoglobulin).
A 27-year-old patient is hospitalized with new onset of Guillain-Barre syndrome. The most
essential assessment for the nurse to carry out is
a.determining level of consciousness.
b.checking strength of the extremities.
c.observing respiratory rate and effort.
d.monitoring the cardiac rate and rhythm.
Which of these nursing actions for a 64-year-old patient with Guillain-Barre syndrome is most
appropriate for the nurse to delegate to an experienced unlicensed assistive personnel (UAP)?
a.Nasogastric tube feeding q4hr
b.Artificial tear administration q2hr
c.Assessment for bladder distention q2hr
d.Passive range of motion to extremities q4hr
Increase Intracranial Pressure (IICP) p. 2004
A nurse in the neurologic ICU has received a prescription to infuse a hypertonic
solution into a client with increased intracranial pressure. This solution will increase the
number of dissolved particles in the client's blood, creating pressure for fluids in the
tissues to shift into the capillaries and increase the blood volume. This process is best
described with which of the following terms?
A. Hydrostatic pressure
B. Osmosis and osmolality
C. Diffusion
D. Active transport
A client with increased intracranial pressure (ICP) has a ventriculostomy for
monitoring ICP. The nurse's most recent assessment reveals that the client is now
exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the
presence of what complication?
A. Encephalitis
B. Cerebral spinal fluid leak
C. Meningitis
D. Catheter occlusion
***SAID THIS ? IN CLASS***
The neurologic ICU nurse is admitting a client with increased intracranial pressure.
How should the nurse best position the client?
A. Position the client supine.
B. Maintain head of bed (HOB) elevated at 30 to 45 degrees.
C. Position client in prone position.
D. Maintain bed in Trendelenburg position
The nurse is caring for a client with increased intracranial pressure (ICP) caused by a
traumatic brain injury. Which of the following clinical manifestations would suggest that
the client may be experiencing increased brain compression causing brain stem damage?
A. Hyperthermia
B. Tachycardia
C. Hypertension
D. Bradypnea
***SAID THIS ? IN CLASS*** - CUSHING TRIAD (SAID SHE LOVES IT)!
A client is exhibiting late signs of increased intracranial pressure. Which finding would
the nurse most likely assess? Select all that apply.
A. Hypertension
B. Bradycardia
C. Respiratory depression
D. Headache
E. Papilledema
A patient has increased intracranial pressure and a ventriculostomy after a head injury. Which
action can the nurse delegate to unlicensed assistive personnel (UAP) who regularly work in the
intensive care unit?
a.Document intracranial pressure every hour.
b.Turn and reposition the patient every 2 hours.
c.Check capillary blood glucose level every 6 hours.
d.Monitor cerebrospinal fluid color and volume hourly.
Amyotrophic Lateral Sclerosis p. 2131
A client with amyotrophic lateral sclerosis (ALS) is being visited by the home health
nurse who is creating a care plan. Which of the following nursing diagnoses is most likely
for a client with this condition?
A. Chronic confusion
B. Impaired urinary elimination
C. Impaired verbal communication
D. Bowel incontinence
A client with a new diagnosis of amyotrophic lateral sclerosis (ALS) is overwhelmed
by the diagnosis and the known complications of the disease. How can the client best
make known their wishes for care as the disease progresses?
A. Prepare an advance directive.
B. Designate a most responsible health care provider (MRP) early in the course of
the disease.
C. Collaborate with representatives from the Amyotrophic Lateral Sclerosis
Association.
D. Ensure that witnesses are present when he provides instruction
A 64-year-old patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with
pneumonia. Whichnursing action will be included in the plan of care?
a.Assist with active range of motion (ROM).
b.Observe for agitation and paranoia.
c.Give muscle relaxants as needed to reduce spasms.
d.Use simple words and phrases to explain procedures.
Myasthenia Gravis
A new client has been admitted with a diagnosis of stage IV breast cancer. The client
has a comorbidity of myasthenia gravis. During the initial assessment, the client states
that they felt the lump in the breast about 9 months ago. The nurse asks the client why
they did not see the health care provider when first finding the lump in breast. What
would be a factor that is known to influence the client in seeking health care services?
A. Lack of insight due to the success of self-managing a chronic condition
B. Lack of knowledge about treatment options
C. Overly sensitive client reactions to health care services
D. Unfavorable interactions with healthcare providers
A client has been recently diagnosed with myasthenia gravis. Which is indicative of a
person diagnosed with myasthenia gravis?
A. Excessive serotonin activity in the brain
B. Decreased dopamine activity in the brain
C. Impairment of acetylcholine binding to muscle cells
D. Defects in the expression of acetylcholine receptors
The nurse is preparing to provide care for a client diagnosed with myasthenia gravis.
The nurse should know that the signs and symptoms of the disease are the result of what
Issue?
A. Genetic dysfunction
B. Upper and lower motor neuron lesions
C. Decreased conduction of impulses in an upper motor neuron lesion
D. A lower motor neuron lesion
A nurse is planning the care of a 28-year-old client hospitalized with a diagnosis of
myasthenia gravis. What approach would be most appropriate for the care and
scheduling of diagnostic procedures for this client?
A. All at one time, to provide a longer rest period
B. Before meals, to stimulate the client’s appetite
C. In the morning, with frequent rest periods
D. Before bedtime, to promote rest
The clinic nurse is caring for a client with a recent diagnosis of myasthenia gravis. The
client has begun treatment with pyridostigmine bromide. What change in status would
most clearly suggest a therapeutic benefit of this medication?
A. Increased muscle strength
B. Decreased pain
C. Improved GI function
D. Improved cognition
A client diagnosed with myasthenia gravis has been hospitalized to receive
therapeutic plasma exchange (TPE) for a myasthenic exacerbation. The nurse should
anticipate what therapeutic response?
A. Permanent improvement after 4 to 6 months of treatment
B. Symptom improvement that lasts a few weeks after TPE ceases
C. Permanent improvement after 60 to 90 treatments
D. Gradual improvement over several months
Which assessment is most important for the nurse to make regarding a patient with myasthenia
gravis?
a.Pupil size
b.Grip strength
c.Respiratory effort
d.Level of consciousness
Following a thymectomy, a 62-year-old male 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?
a.Auscultate the patient's bowel sounds.
b.Notify the patient's health care provider.
c.Administer the prescribed PRN antiemetic drug.
d.Give the scheduled dose of prednisone (Deltasone).
After change-of-shift report, which patient should the nurse assess first?
a.Patient with myasthenia gravis who is reporting increased muscle weakness
b.Patient with a bilateral headache described as like a band around my head
c.Patient with seizures who is scheduled to receive a dose of phenytoin (Dilantin)
d.Patient with Parkinson's disease who has developed cogwheel rigidity of the arms
The nurse advises a patient with myasthenia gravis (MG) to
a.perform physically demanding activities early in the day.
b.anticipate the need for weekly plasmapheresis treatments.
c.do frequent weight-bearing exercise to prevent muscle atrophy.
d.protect the extremities from injury due to poor sensory perception
QSEN
The nurse caring for an older adult client with osteoarthritis is reviewing the client's
chart. This client is on a variety of medications prescribed by different care providers in
the community. In light of the QSEN competency of safety, what is the nurse most
concerned about this client?
A. Depression
B. Chronic illness
C. Inadequate pain control
D. Drug interactions
The nurse documenting the patient's progress in the care plan in the electronic health record
before an interdisciplinary discharge conference is demonstrating competency in which QSEN
category?
a.Patient-centered care
b.Quality improvement
c.Evidence-based practice
d.Informatics and technology