Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
729
Chapter 38: Assessment and Management of Patients With Rheumatic
Disorders
1.
A patient is suspected of having rheumatoid arthritis and her diagnostic regimen includes aspiration of
synovial fluid from the knee for a definitive diagnosis. The nurse knows that which of the following
procedures will be involved?
A)
Angiography
B)
Myelography
C)
Paracentesis
D)
Arthocentesis
Ans:
D
Feedback:
Arthrocentesis involves needle aspiration of synovial fluid. Angiography is an x-ray study of circulation
with a contrast agent injected into a selected artery. Myelography is an x-ray of the spinal subarachnoid
space taken after the injection of a contrast agent into the spinal subarachnoid space through a lumbar
puncture. Paracentesis is removal of fluid (ascites) from the peritoneal cavity through a small surgical
incision or puncture made through the abdominal wall under sterile conditions.
2.
A nurse is providing care for a patient who has just been diagnosed as being in the early stage of
rheumatoid arthritis. The nurse should anticipate the administration of which of the following?
A)
Hydromorphone (Dilaudid)
B)
Methotrexate (Rheumatrex)
C)
Allopurinol (Zyloprim)
D)
Prednisone
Ans:
B
Feedback:
In the past, a step-wise approach starting with NSAIDs was standard of care. However, evidence clearly
documenting the benefits of early DMARD (methotrexate [Rheumatrex], antimalarials, leflunomide
[Arava], or sulfasalazine [Azulfidine]) treatment has changed national guidelines for management. Now
it is recommended that treatment with the non-biologic DMARDs begin within 3 months of disease
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
730
onset. Allopurinol is used to treat gout. Opioids are not indicated in early RA. Prednisone is used in
unremitting RA.
3.
A nurse is performing the initial assessment of a patient who has a recent diagnosis of systemic lupus
erythematosus (SLE). What skin manifestation would the nurse expect to observe on inspection?
A)
Petechiae
B)
Butterfly rash
C)
Jaundice
D)
Skin sloughing
Ans:
B
Feedback:
An acute cutaneous lesion consisting of a butterfly-shaped rash across the bridge of the nose and cheeks
occurs in SLE. Petechiae are pinpoint skin hemorrhages, which are not a clinical manifestation of SLE.
Patients with SLE do not typically experience jaundice or skin sloughing.
4.
A clinic nurse is caring for a patient with suspected gout. While explaining the pathophysiology of gout
to the patient, the nurse should describe which of the following?
A)
Autoimmune processes in the joints
B)
Chronic metabolic acidosis
C)
Increased uric acid levels
D)
Unstable serum calcium levels
Ans:
C
Feedback:
Gout is caused by hyperuricemia (increased serum uric acid). Gout is not categorized as an autoimmune
disease and it does not result from metabolic acidosis or unstable serum calcium levels.
5.
A)
A nurse is planning the care of a patient who has a long history of chronic pain, which has only recently
been diagnosed as fibromyalgia. What nursing diagnosis is most likely to apply to this womans care
needs?
Ineffective Role Performance Related to Pain
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
B)
Risk for Impaired Skin Integrity Related to Myalgia
C)
Risk for Infection Related to Tissue Alterations
D)
Unilateral Neglect Related to Neuropathic Pain
Ans:
A
731
Feedback:
Typically, patients with fibromyalgia have endured their symptoms for a long period of time. The
neuropathic pain accompanying FM can often impair a patients ability to perform normal roles and
functions. Skin integrity is unaffected and the disease has no associated infection risk. Activity
limitations may result in neglect, but not of a unilateral nature.
6.
A patients decreased mobility is ultimately the result of an autoimmune reaction originating in the
synovial tissue, which caused the formation of pannus. This patient has been diagnosed with what health
problem?
A)
Rheumatoid arthritis (RA)
B)
Systemic lupus erythematosus
C)
Osteoporosis
D)
Polymyositis
Ans:
A
Feedback:
In RA, the autoimmune reaction results in phagocytosis, producing enzymes within the joint that break
down collagen, cause edema and proliferation of the synovial membrane, and ultimately form pannus.
Pannus destroys cartilage and bone. SLE, osteoporosis, and polymyositis do not involve pannus
formation.
7.
A nurse is performing the health history and physical assessment of a patient who has a diagnosis of
rheumatoid arthritis (RA). What assessment finding is most consistent with the clinical presentation of
RA?
A)
Cool joints with decreased range of motion
B)
Signs of systemic infection
C)
Joint stiffness, especially in the morning
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
D)
Visible atrophy of the knee and shoulder joints
Ans:
C
732
Feedback:
In addition to joint pain and swelling, another classic sign of RA is joint stiffness, especially in the
morning. Joints are typically swollen, not atrophied, and systemic infection does not accompany the
disease. Joints are often warm rather than cool.
8.
A patient has a diagnosis of rheumatoid arthritis and the primary care provider has now prescribed
cyclophosphamide (Cytoxan). The nurses subsequent assessments should address what potential adverse
effect?
A)
Infection
B)
Acute confusion
C)
Sedation
D)
Malignant hyperthermia
Ans:
A
Feedback:
When administering immunosuppressives such as Cytoxan, the nurse should be alert to manifestations
of bone marrow suppression and infection. Confusion and sedation are atypical adverse effects.
Malignant hyperthermia is a surgical complication and not a possible adverse effect.
9.
A)
B)
A clinic nurse is caring for a patient newly diagnosed with fibromyalgia. When developing a care plan
for this patient, what would be a priority nursing diagnosis for this patient?
Impaired Urinary Elimination Related to Neuropathy
Altered Nutrition Related to Impaired Absorption
C)
Disturbed Sleep Pattern Related to CNS Stimulation
D)
Fatigue Related to Pain
Ans:
D
Feedback:
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
733
Fibromyalgia is characterized by fatigue, generalized muscle aching, and stiffness. Impaired urinary
elimination is not a common manifestation of the disease. Altered nutrition and disturbed sleep pattern
are potential nursing diagnoses, but are not the priority.
10. A nurse is assessing a patient for risk factors known to contribute to osteoarthritis. What assessment
finding would the nurse interpret as a risk factor?
A)
The patient has a 30 pack-year smoking history.
B)
The patients body mass index is 34 (obese).
C)
The patient has primary hypertension.
D)
The patient is 58 years old.
Ans:
B
Feedback:
Risk factors for osteoarthritis include obesity and previous joint damage. Risk factors of OA do not
include smoking or hypertension. Incidence increases with age, but a patient who is 58 would not yet
face a significantly heightened risk.
11. A patient is undergoing diagnostic testing to determine the etiology of recent joint pain. The patient asks
the nurse about the difference between osteoarthritis (OA) and rheumatoid arthritis (RA). What is the
best response by the nurse?
A)
OA is a considered a noninflammatory joint disease. RA is characterized by inflamed, swollen
joints.
B)
OA and RA are very similar. OA affects the smaller joints such as the fingers, and RA affects the
larger, weight-bearing joints like the knees.
C)
OA originates with an infection. RA is a result of your bodys cells attacking one another.
D)
OA is associated with impaired immune function; RA is a consequence of physical damage.
Ans:
A
Feedback:
OA is a degenerative arthritis with a noninflammatory etiology, characterized by the loss of cartilage on
the articular surfaces of weight-bearing joints, with spur development. RA is characterized by
inflammation of synovial membranes and surrounding structures. The diseases are not distinguished by
the joints affected and neither has an infectious etiology.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
734
12. A patient with systemic lupus erythematosus (SLE) is preparing for discharge. The nurse knows that the
patient has understood health education when the patient makes what statement?
A)
Ill make sure I get enough exposure to sunlight to keep up my vitamin D levels.
B)
Ill try to be as physically active as possible between flare-ups.
C)
Ill make sure to monitor my body temperature on a regular basis.
D)
Ill stop taking my steroids when I get relief from my symptoms.
Ans:
C
Feedback:
Fever can signal an exacerbation and should be reported to the physician. Sunlight and other sources of
ultraviolet light may precipitate severe skin reactions and exacerbate the disease. Fatigue can cause a
flare-up of SLE. Patients should be encouraged to pace activities and plan rest periods. Corticosteroids
must be gradually tapered because they can suppress the function of the adrenal gland. As well, these
drugs should not be independently adjusted by the patient.
A patient with an exacerbation of systemic lupus erythematosus (SLE) has been hospitalized on the
13. medical unit. The nurse observes that the patient expresses angerand irritation when her call bell isnt
answered immediately. What would be the most appropriate response?
A)
You seem like youre feeling angry. Is that something that we could talk about?
B)
Try to remember that stress can make your symptoms worse.
C)
Would you like to talk about the problem with the nursing supervisor?
D)
I can see youre angry. Ill come back when youve calmed down.
Ans:
A
Feedback:
The changes and the unpredictable course of SLE necessitate expert assessment skills and nursing care,
as well as sensitivity to the psychological reactions of the patient. Offering to listen to the patient express
anger can help the nurse and the patient understand its cause and begin to deal with it. Although stress
can exacerbate the symptoms of SLE, telling the patient to calm down doesnt acknowledge her feelings.
Ignoring the patients feelings suggests that the nurse has no interest in what the patient has said. Offering
to get the nursing supervisor also does not acknowledge the patients feelings.
14. A nurse is caring for a 78-year-old patient with a history of osteoarthritis (OA). When planning the
patients care, what goal should the nurse include?
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
A)
The patient will express satisfaction with her ability to perform ADLs.
B)
The patient will recover from OA within 6 months.
C)
The patient will adhere to the prescribed plan of care.
D)
The patient will deny signs or symptoms of OA.
Ans:
A
735
Feedback:
Pain management and optimal functional ability are major goals of nursing interventions for OA. Cure is
not a possibility and it is unrealistic to expect a complete absence of signs and symptoms. Adherence to
the plan of care is highly beneficial, but this is not the priority goal of care.
15. A patient who has been newly diagnosed with systemic lupus erythematosus (SLE) has been admitted to
the medical unit. Which of the following nursing diagnoses is the most plausible inclusion in the plan of
care?
A)
Fatigue Related to Anemia
B)
Risk for Ineffective Tissue Perfusion Related to Venous Thromboembolism
C)
Acute Confusion Related to Increased Serum Ammonia Levels
D)
Risk for Ineffective Tissue Perfusion Related to Increased Hematocrit
Ans:
A
Feedback:
Patients with SLE nearly always experience fatigue, which is partly attributable to anemia. Ammonia
levels are not affected and hematocrit is typically low, not high. VTE is not one of the central
complications of SLE.
16. The nurse is preparing to care for a patient who has scleroderma. The nurse refers to resources that
describe CREST syndrome. Which of the following is a component of CREST syndrome?
A)
Raynauds phenomenon
B)
Thyroid dysfunction
C)
Esophageal varices
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
D)
Osteopenia
Ans:
A
736
Feedback:
The R in CREST stands for Raynauds phenomenon. Thyroid dysfunction, esophageal varices, and
osteopenia are not associated with scleroderma.
17. Allopurinol (Zyloprim) has been ordered for a patient receiving treatment for gout. The nurse caring for
this patient knows to assess the patient for bone marrow suppression, which may be manifested by
which of the following diagnostic findings?
A)
Hyperuricemia
B)
Increased erythrocyte sedimentation rate
C)
Elevated serum creatinine
D)
Decreased platelets
Ans:
D
Feedback:
Thrombocytopenia occurs in bone marrow suppression. Hyperuricemia occurs in gout, but is not caused
by bone marrow suppression. Increased erythrocyte sedimentation rate may occur from inflammation
associated with gout, but is not related to bone marrow suppression. An elevated serum creatinine level
may indicate renal damage, but this is not associated with the use of allopurinol.
18. A patient with rheumatic disease is complaining of stomatitis. The nurse caring for the patient should
further assess the patient for the adverse effects of what medications?
A)
Corticosteroids
B)
Gold-containing compounds
C)
Antimalarials
D)
Salicylate therapy
Ans:
B
Feedback:
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
737
Stomatitis is an adverse effect that is associated with gold therapy. Steroids, antimalarials, and
salicylates do not normally have this adverse effect.
19. A nurse is planning patient education for a patient being discharged home with a diagnosis of
rheumatoid arthritis. The patient has been prescribed antimalarials for treatment, so the nurse knows to
teach the patient to self-monitor for what adverse effect?
A)
Tinnitus
B)
Visual changes
C)
Stomatitis
D)
Hirsutism
Ans:
B
Feedback:
Antimalarials may cause visual changes; regular ophthalmologic examinations are necessary.Tinnitus is
associated with salicylate therapy, stomatitis is associated with gold therapy, and hirsutism is associated
with corticosteroid therapy.
20. A nurse is working with a patient with rheumatic disease who is being treated with salicylate therapy.
What statement would indicate that the patient is experiencing adverse effects of this drug?
A)
I have this ringing in my ears that just wont go away.
B)
I feel so foggy in the mornings and it takes me so long to wake up.
C)
When I eat a meal thats high in fat, I get really nauseous.
D)
I seem to have lost my appetite, which is unusual for me.
Ans:
A
Feedback:
Tinnitus is associated with salicylate therapy. Salicylates do not normally cause drowsiness, intolerance
of high-fat meals, or anorexia.
21. A patient has been admitted to a medical unit with a diagnosis of polymyalgia rheumatica (PMR). The
nurse should be aware of what aspects of PMR? Select all that apply.
A)
PMR has an association with the genetic marker HLA-DR4.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
B)
Immunoglobulin deposits occur in PMR.
C)
PMR is considered to be a wear-and-tear disease.
D)
Foods high in purines exacerbate the biochemical processes that occur in PMR.
E)
PMR occurs predominately in Caucasians.
Ans:
A, B, E
738
Feedback:
The underlying mechanism involved with polymyalgia rheumatica is unknown. This disease occurs
predominately in Caucasians and often in first-degree relatives. An association with the genetic marker
HLA-DR4 suggests a familial predisposition. Immunoglobulin deposits in the walls of inflamed
temporal arteries also suggest an autoimmune process. Purines are unrelated and it is not a result of
physical degeneration.
22. A nurse is providing care for a patient who has a recent diagnosis of giant cell arteritis (GCA). What
aspect of physical assessment should the nurse prioritize?
A)
Assessment for subtle signs of bleeding disorders
B)
Assessment of the metatarsal joints and phalangeal joints
C)
Assessment for thoracic pain that is exacerbated by activity
D)
Assessment for headaches and jaw pain
Ans:
D
Feedback:
Assessment of the patient with GCA focuses on musculoskeletal tenderness, weakness, and decreased
function. Careful attention should be directed toward assessing the head (for changes in vision,
headaches, and jaw claudication). There is not a particular clinical focus on the potential for bleeding,
hand and foot pain, or thoracic pain.
23. A nurse is educating a patient with gout about lifestyle modifications that can help control the signs and
symptoms of the disease. What recommendation should the nurse make?
A)
Ensuring adequate rest
B)
Limiting exposure to sunlight
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
C)
Limiting intake of alcohol
D)
Smoking cessation
Ans:
C
739
Feedback:
Alcohol and red meat can precipitate an acute exacerbation of gout. Each of the other listed actions is
consistent with good health, but none directly addresses the factors that exacerbate gout.
24. A patients rheumatoid arthritis (RA) has failed to respond appreciably to first-line treatments and the
primary care provider has added prednisone to the patients drug regimen. What principle will guide this
aspect of the patients treatment?
A)
The patient will need daily blood testing for the duration of treatment.
B)
The patient must stop all other drugs 72 hours before starting prednisone.
C)
The drug should be used at the highest dose the patient can tolerate.
D)
The drug should be used for as short a time as possible.
Ans:
D
Feedback:
Corticosteroids are used for shortest duration and at lowest dose possible to minimize adverse effects.
Daily blood work is not necessary and the patient does not need to stop other drugs prior to using
corticosteroids.
25. A nurse is caring for a patient who is suspected of having giant cell arteritis (GCA). What laboratory
tests are most useful in diagnosing this rheumatic disorder? Select all that apply.
A)
Erythrocyte count
B)
Erythrocyte sedimentation rate
C)
Creatinine clearance
D)
C-reactive protein
E)
D-dimer
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Ans:
740
B, D
Feedback:
Simultaneous elevation in the ESR and CRP have a sensitivity of 88% and a specificity of 98% in
making the diagnosis of GCA when coupled with clinical findings. Erythrocyte counts, creatinine
clearance, and D-dimer are not diagnostically useful.
26. A patient with SLE has come to the clinic for a routine check-up. When auscultating the patients apical
heart rate, the nurse notes the presence of a distinct scratching sound. What is the nurses most
appropriate action?
A)
Reposition the patient and auscultate posteriorly.
B)
Document the presence of S3 and monitor the patient closely.
C)
Inform the primary care provider that a friction rub may be present.
D)
Inform the primary care provider that the patient may have pneumonia.
Ans:
C
Feedback:
Patients with SLE are susceptible to developing a pericardial friction rub, possibly associated with
myocarditis and accompanying pleural effusions; this warrants prompt medical follow-up. This finding
is not characteristic of pneumonia and does not constitute S3. Posterior auscultation is unlikely to yield
additional meaningful data.
27. A community health nurse is performing a visit to the home of a patient who has a history of rheumatoid
arthritis (RA). On what aspect of the patients health should the nurse focus most closely during the visit?
A)
The patients understanding of rheumatoid arthritis
B)
The patients risk for cardiopulmonary complications
C)
The patients social support system
D)
The patients functional status
Ans:
D
Feedback:
The patients functional status is a central focus of home assessment of the patient with RA. The nurse
may also address the patients understanding of the disease, complications, and social support, but the
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
741
patients level of function and quality of life is a primary concern.
28. A 21-year-old male has just been diagnosed with a spondyloarthropathy. What will be a priority nursing
intervention for this patient?
A)
Referral for assistive devices
B)
Teaching about symptom management
C)
Referral to classes to stop smoking
D)
Setting up an exercise program
Ans:
B
Feedback:
Major nursing interventions in the spondyloarthropathies are related to symptom management and
maintenance of optimal functioning. This is a priority over the use of assistive devices, smoking
cessation, and exercise programs, though these topics may be of importance for some patients.
29. A patient with SLE asks the nurse why she has to come to the office so often for check-ups. What would
be the nurses best response?
A)
Taking care of you in the best way involves seeing you face to face.
B)
Taking care of you in the best way involves making sure you are taking your medication the way it
is ordered.
C)
Taking care of you in the best way involves monitoring your disease activity and how well the
prescribed treatment is working.
D)
Taking care of you in the best way involves drawing blood work every month.
Ans:
C
Feedback:
The goals of treatment include preventing progressive loss of organ function, reducing the likelihood of
acute disease, minimizing disease-related disabilities, and preventing complications from therapy.
Management of SLE involves regular monitoring to assess disease activity and therapeutic effectiveness.
Stating the benefit of face-to-face interaction does not answer the patients question. Blood work is not
necessarily drawn monthly and assessing medication adherence is not the sole purpose of visits.
A patient is diagnosed with giant cell arteritis (GCA) and is placed on corticosteroids. A concern for this
30. patient is that he will stop taking the medication as soon as he starts to feel better. Why must the nurse
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
742
emphasize the need for continued adherence to the prescribed medication?
A)
To avoid complications such as venous thromboembolism
B)
To avoid the progression to osteoporosis
C)
To avoid the progression of GCA to degenerative joint disease
D)
To avoid complications such as blindness
Ans:
D
Feedback:
The nurse must emphasize to the patient the need for continued adherence to the prescribed medication
regimen to avoid complications of giant cell arteritis, such as blindness. VTE, OP, and degenerative joint
disease are not among the most common complications for GCA.
31. A patient with polymyositisis experiencing challenges with activities of daily living as a result of
proximal muscle weakness. What is the most appropriate nursing action?
A)
Initiate a program of passive range of motion exercises
B)
Facilitate referrals to occupational and physical therapy
C)
Administer skeletal muscle relaxants as ordered
D)
Encourage a progressive program of weight-bearing exercise
Ans:
B
Feedback:
Patients with polymyositis may have symptoms similar to those of other inflammatory diseases.
However, proximal muscle weakness is characteristic, making activities such as hair combing, reaching
overhead, and using stairs difficult. Therefore, use of assistive devices may be recommended, and
referral to occupational or physical therapy may be warranted. The muscle weakness is a product of the
disease process, not lack of exercise. Skeletal muscle relaxants are not used in the treatment of
polymyositis.
32. A nurse is creating a teaching plan for a patient who has a recent diagnosis of scleroderma. What topics
should the nurse address during health education? Select all that apply.
A)
Surgical treatment options
B)
The importance of weight loss
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
C)
Managing Raynauds-type symptoms
D)
Smoking cessation
E)
The importance of vigilant skin care
Ans:
C, D, E
743
Feedback:
Patient teaching for the patient with scleroderma focuses on management of Raynauds phenomenon,
smoking cessation, and meticulous skin care. Surgical treatment options do not exist and weight loss is
not a central concern.
33. A 40-year-old woman was diagnosed with Raynauds phenomenon several years earlier and has sought
care because of a progressive worsening of her symptoms. The patient also states that many of her skin
surfaces are stiff, like the skin is being stretched from all directions. The nurse should recognize the need
for medical referral for the assessment of what health problem?
A)
Giant cell arteritis (GCA)
B)
Fibromyalgia (FM)
C)
Rheumatoid arthritis (RA)
D)
Scleroderma
Ans:
D
Feedback:
Scleroderma starts insidiously with Raynauds phenomenon and swelling in the hands. Later, the skin and
the subcutaneous tissues become increasingly hard and rigid and cannot be pinched up from the
underlying structures. This progression of symptoms is inconsistent with GCA, FM, or RA.
34. A patient with rheumatoid arthritis comes to the clinic complaining of pain in the joint of his right great
toe and is eventually diagnosed with gout. When planning teaching for this patient, what management
technique should the nurse emphasize?
A)
Take OTC calcium supplements consistently.
B)
Restrict consumption of foods high in purines.
C)
Ensure fluid intake of at least 4 liters per day.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
D)
Restrict weight-bearing on right foot.
Ans:
B
744
Feedback:
Although severe dietary restriction is not necessary, the nurse should encourage the patient to restrict
consumption of foods high in purines, especially organ meats. Calcium supplementation is not necessary
and activity should be maintained as tolerated. Increased fluid intake is beneficial, but it is not necessary
for the patient to consume more than 4 liters daily.
A clinic nurse is caring for a patient diagnosed with rheumatoid arthritis (RA). The patient tells the nurse
35. that she has not been taking her medication because she usually cannot remove the childproof
medication lids. How can the nurse best facilitate the patients adherence to her medication regimen?
A)
Encourage the patient to store the bottles with their tops removed.
B)
Have a trusted family member take over the management of the patients medication regimen.
C)
Encourage her to have her pharmacy replace the tops with alternatives that are easier to open.
D)
Have the patient approach her primary care provider to explore medication alternatives.
Ans:
C
Feedback:
The patients pharmacy will likely be able to facilitate a practical solution that preserves the patients
independence while still fostering adherence to treatment. There should be no need to change
medications, and storing open medication containers is unsafe. Delegating medications to a family
member is likely unnecessary at this point and promotes dependence.
36. A nurses plan of care for a patient with rheumatoid arthritis includes several exercise-based
interventions. Exercises for patients with rheumatoid disorders should have which of the following
goals?
A)
Maximize range of motion while minimizing exertion
B)
Increase joint size and strength
C)
Limit energy output in order to preserve strength for healing
D)
Preserve and increase range of motion while limiting joint stress
Ans:
D
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
745
Feedback:
Exercise is vital to the management of rheumatic disorders. Goals should be preserving and promoting
mobility and joint function while limiting stress on the joint and possible damage. Cardiovascular
exertion should remain within age-based limits and individual ability, but it is not a goal to minimize
exertion. Increasing joint size is not a valid goal.
37. A patient has just been told by his physician that he has scleroderma. The physician tells the patient that
he is going to order some tests to assess for systemic involvement. The nurse knows that priority systems
to be assessed include what?
A)
Hepatic
B)
Gastrointestinal
C)
Genitourinary
D)
Neurologic
Ans:
B
Feedback:
Assessment of systemic involvement with scleroderma requires a systems review with special attention
to gastrointestinal, pulmonary, renal, and cardiac systems. Liver, GU, and neurologic functions are not
central priorities.
38. A nurse is providing care for a patient who has a rheumatic disorder. The nurses comprehensive
assessment includes the patients mood, behavior, LOC, and neurologic status. What is this patients most
likely diagnosis?
A)
Osteoarthritis (OA)
B)
Systemic lupus erythematosus (SLE)
C)
Rheumatoid arthritis (RA)
D)
Gout
Ans:
B
Feedback:
SLE has a high degree of neurologic involvement, and can result in central nervous system changes. The
patient and family members are asked about any behavioral changes, including manifestations of
neurosis or psychosis. Signs of depression are noted, as are reports of seizures, chorea, or other central
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
746
nervous system manifestations. OA, RA, and gout lack this dimension.
39. A patient with rheumatoid arthritis comes into the clinic for a routine check-up. On assessment the nurse
notes that the patient appears to have lost some of her ability to function since her last office visit. Which
of the following is the most appropriate action?
A)
Arrange a family meeting in order to explore assisted living options.
B)
Refer the patient to a support group.
C)
Arrange for the patient to be assessed in her home environment.
D)
Refer the patient to social work.
Ans:
C
Feedback:
Assessment in the patients home setting can often reveal more meaningful data than an assessment in the
health care setting. There is no indication that assisted living is a pressing need or that the patient would
benefit from social work or a support group.
40. A nurse is assessing a patient with rheumatoid arthritis. The patient expresses his intent to pursue
complementary and alternative therapies. What fact should underlie the nurses response to the patient?
A)
New evidence shows CAM to be as effective as medical treatment.
B)
CAM therapies negate many of the benefits of medications.
C)
CAM therapies typically do more harm than good.
D)
Evidence shows minimal benefits from most CAM therapies.
Ans:
D
Feedback:
A recent systematic review of complementary and alternative medicine (CAM) examined the efficacy of
herbal medicine, acupuncture, Tai chi and biofeedback for the treatment of rheumatoid arthritis and
osteoarthritis. Although acupuncture treatment for pain management showed some promise, in all
modalities the evidence was ambiguous. There is not enough evidence of the effectiveness of CAM and
more rigorous research is needed.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1223
Chapter 65: Assessment of Neurologic Function
1.
A patient is brought to the ER following a motor vehicle accident in which he sustained head trauma.
Preliminary assessment reveals a vision deficit in the patients left eye. The nurse should associate this
abnormal finding with trauma to which of the following cerebral lobes?
A)
Temporal
B)
Occipital
C)
Parietal
D)
Frontal
Ans:
B
Feedback:
The posterior lobe of the cerebral hemisphere is responsible for visual interpretation. The temporal lobe
contains the auditory receptive areas. The parietal lobe contains the primary sensory cortex, and is
essential to an individuals awareness of the body in space, as well as orientation in space and spatial
relations. The frontal lobe functions in concentration, abstract thought, information storage or memory,
and motor function.
2.
A patient scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The
nurse who prepares the patient for the MRI should prioritize which of the following actions?
A)
Withholding stimulants 24 to 48 hours prior to exam
B)
Removing all metal-containing objects
C)
Instructing the patient to void prior to the MRI
D)
Initiating an IV line for administration of contrast
Ans:
B
Feedback:
Patient preparation for an MRI consists of removing all metal-containing objects prior to the
examination. Withholding stimulants would not affect an MRI; this relates to an electroencephalography
(EEG). Instructing the patient to void is patient preparation for a lumbar puncture. Initiating an IV line
for administration of contrast would be done if the patient was having a CT scan with contrast.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
3.
1224
A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, agerelated changes. Of what phenomenon should the nurse be aware?
A)
Hyperactive deep tendon reflexes
B)
Reduction in cerebral blood flow
C)
Increased cerebral metabolism
D)
Hypersensitivity to painful stimuli
Ans:
B
Feedback:
Reduction in cerebral blood flow (CBF) is a change that occurs in the normal aging process. Deep
tendon reflexes can be decreased or, in some cases, absent. Cerebral metabolism decreases as the patient
advances in age. Reaction to painful stimuli may be decreased with age. Because pain is an important
warning signal, caution must be used when hot or cold packs are used.
4.
The nurse has admitted a new patient to the unit. One of the patients admitting orders is for an
adrenergic medication. The nurse knows that this medication will have what effect on the circulatory
system?
A)
Thin, watery saliva
B)
Increased heart rate
C)
Decreased BP
D)
Constricted bronchioles
Ans:
B
Feedback:
The term adrenergic refers to the sympathetic nervous system. Sympathetic effects include an increased
rate and force of the heartbeat. Cholinergic effects, which correspond to the parasympathetic division of
the autonomic nervous system, include thin, watery saliva, decreased rate and force of heartbeat, and
decreased BP.
5.
A)
A nurse is assessing reflexes in a patient with hyperactive reflexes. When the patients foot is abruptly
dorsiflexed, it continues to beat two to three times before settling into a resting position. How would the
nurse document this finding?
Rigidity
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
B)
Flaccidity
C)
Clonus
D)
Ataxia
Ans:
C
1225
Feedback:
When reflexes are very hyperactive, a phenomenon called clonus may be elicited. If the foot is abruptly
dorsiflexed, it may continue to beat two to three times before it settles into a position of rest. Rigidity is
an increase in muscle tone at rest characterized by increased resistance to passive stretch. Flaccidity is
lack of muscle tone. Ataxia is the inability to coordinate muscle movements, resulting in difficulty
walking, talking, and performing self-care activities.
6.
The nurse is doing an initial assessment on a patient newly admitted to the unit with a diagnosis of
cerebrovascular accident (CVA). The patient has difficulty copying a figure that the nurse has drawn and
is diagnosed with visual-receptive aphasia. What brain region is primarily involved in this deficit?
A)
Temporal lobe
B)
Parietal-occipital area
C)
Inferior posterior frontal areas
D)
Posterior frontal area
Ans:
B
Feedback:
Difficulty copying a figure that the nurse has drawn would be considered visual-receptive aphasia,
which involves the parietal-occipital area. Expressive aphasia, the inability to express oneself, is often
associated with damage to the frontal area. Receptive aphasia, the inability to understand what someone
else is saying, is often associated with damage to the temporal lobe area.
7.
What term is used to describe the fibrous connective tissue that hugs the brain closely and extends into
every fold of the brains surface?
A)
Dura mater
B)
Arachnoid
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
C)
Fascia
D)
Pia mater
Ans:
D
1226
Feedback:
The term meninges describes the fibrous connective tissue that covers the brain and spinal cord. The
meninges have three layers, the dura mater, arachnoid, and pia mater. The pia mater is the innermost
membrane that hugs the brain closely and extends into every fold of the brains surface. The dura mater,
the outermost layer, covers the brain and spinal cord. The arachnoid, the middle membrane, is
responsible for the production of cerebrospinal fluid.
8.
The nurse is caring for a patient with an upper motor neuron lesion. What clinical manifestations should
the nurse anticipate when planning the patients neurologic assessment?
A)
Decreased muscle tone
B)
Flaccid paralysis
C)
Loss of voluntary control of movement
D)
Slow reflexes
Ans:
C
Feedback:
Upper motor neuron lesions do not cause muscle atrophy, flaccid paralysis, or slow reflexes. However,
upper motor neuron lesions normally cause loss of voluntary control.
9.
The nurse is admitting a patient to the unit who is diagnosed with a lower motor neuron lesion. What
entry in the patients electronic record is most consistent with this diagnosis?
A)
Patient exhibits increased muscle tone.
B)
Patient demonstrates normal muscle structure with no evidence of atrophy.
C)
Patient demonstrates hyperactive deep tendon reflexes.
D)
Patient demonstrates an absence of deep tendon reflexes.
Ans:
D
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1227
Feedback:
Lower motor neuron lesions cause flaccid muscle paralysis, muscle atrophy, decreased muscle tone, and
loss of voluntary control.
10. An elderly patient is being discharged home. The patient lives alone and has atrophy of his olfactory
organs. The nurse tells the patients family that it is essential that the patient have what installed in the
home?
A)
Grab bars
B)
Nonslip mats
C)
Baseboard heaters
D)
A smoke detector
Ans:
D
Feedback:
The sense of smell deteriorates with age. The olfactory organs are responsible for smell. This may
present a safety hazard for the patient because he or she may not smell smoke or gas leaks. Smoke
detectors are universally necessary, but especially for this patient.
11. The patient in the ED has just had a diagnostic lumbar puncture. To reduce the incidence of a postlumbar puncture headache, what is the nurses most appropriate action?
A)
Position the patient prone.
B)
Position the patient supine with the head of bed flat.
C)
Position the patient left side-lying.
D)
Administer acetaminophen as ordered.
Ans:
A
Feedback:
The lumbar puncture headache may be avoided if a small-gauge needle is used and if the patient remains
prone after the procedure. Acetaminophen is not administered as a preventative measure for post-lumbar
puncture headaches.
12. The nurse is conducting a focused neurologic assessment. When assessing the patients cranial nerve
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1228
function, the nurse would include which of the following assessments?
A)
Assessment of hand grip
B)
Assessment of orientation to person, time, and place
C)
Assessment of arm drift
D)
Assessment of gag reflex
Ans:
D
Feedback:
The gag reflex is governed by the glossopharyngeal nerve, one of the cranial nerves. Hand grip and arm
drifting are part of motor function assessment. Orientation is an assessment parameter related to a mental
status examination.
13. A nurse is caring for a patient diagnosed with Mnires disease. While completing a neurologic
examination on the patient, the nurse assesses cranial nerve VIII. The nurse would be correct in
identifying the function of this nerve as what?
A)
Movement of the tongue
B)
Visual acuity
C)
Sense of smell
D)
Hearing and equilibrium
Ans:
D
Feedback:
Cranial nerve VIII (acoustic) is responsible for hearing and equilibrium. Cranial nerve XII (hypoglossal)
is responsible for movement of the tongue. Cranial nerve II (optic) is responsible for visual acuity and
visual fields. Cranial nerve I (olfactory) functions in sense of smell.
14. A patient exhibiting an uncoordinated gait has presented at the clinic. Which of the following is the most
plausible cause of this patients health problem?
A)
Cerebellar dysfunction
B)
A lesion in the pons
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
C)
Dysfunction of the medulla
D)
A hemorrhage in the midbrain
Ans:
A
1229
Feedback:
The cerebellum controls fine movement, balance, position sense, and integration of sensory input.
Portions of the pons control the heart, respiration, and blood pressure. Cranial nerves IX through XII
connect to the brain in the medulla. Cranial nerves III and IV originate in the midbrain.
15. The nursing students are learning how to assess function of cranial nerve VIII. To assess the function of
cranial nerve VIII the students would be correct in completing which of the following assessment
techniques?
A)
Have the patient identify familiar odors with the eyes closed.
B)
Assess papillary reflex.
C)
Utilize the Snellen chart.
D)
Test for air and bone conduction (Rinne test).
Ans:
D
Feedback:
Cranial nerve VIII is the acoustic nerve. It functions in hearing and equilibrium. When assessing this
nerve, the nurse would test for air and bone conduction (Rinne) with a tuning fork. Assessment of
papillary reflex would be completed for cranial nerves III (oculomotor), IV (trochlear), and VI
(abducens). The Snellen chart would be used to assess cranial nerve II (optic).
16. A patient is being given a medication that stimulates her parasympathetic system. Following
administration of this medication, the nurse should anticipate what effect?
A)
Constricted pupils
B)
Dilated bronchioles
C)
Decreased peristaltic movement
D)
Relaxed muscular walls of the urinary bladder
Ans:
A
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1230
Feedback:
Parasympathetic stimulation results in constricted pupils, constricted bronchioles, increased peristaltic
movement, and contracted muscular walls of the urinary bladder.
17. A patient with lower back pain is scheduled for myelography using metrizamide (a water-soluble
contrast dye). After the test, the nurse should prioritize what action?
A)
Positioning the patient with the head of the bed elevated 45 degrees
B)
Administering IV morphine sulfate to prevent headache
C)
Limiting fluids for the next 12 hours
D)
Helping the patient perform deep breathing and coughing exercises
Ans:
A
Feedback:
After myelography, the patient lies in bed with the head of the bed elevated 30 to 45 degrees. The patient
is advised to remain in bed in the recommended position for 3 hours or as prescribed. Drinking liberal
amounts of fluid for rehydration and replacement of CSF may decrease the incidence of postlumbar
puncture headache. Deep breathing and coughing exercises are not normally necessary since there is no
consequent risk of atelectasis.
18. A patient is having a fight or flight response after receiving bad news about his prognosis. What affect
will this have on the patients sympathetic nervous system?
A)
Constriction of blood vessels in the heart muscle
B)
Constriction of bronchioles
C)
Increase in the secretion of sweat
D)
Constriction of pupils
Ans:
C
Feedback:
Sympathetic nervous system stimulation results in dilated blood vessels in the heart and skeletal muscle,
dilated bronchioles, increased secretion of sweat, and dilated pupils.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1231
19. The nurse educator is reviewing the assessment of cranial nerves. What should the educator identify as
the specific instances when cranial nerves should be assessed? Select all that apply.
A)
When a neurogenic bladder develops
B)
When level of consciousness is decreased
C)
With brain stem pathology
D)
In the presence of peripheral nervous system disease
E)
When a spinal reflex is interrupted
Ans:
B, C, D
Feedback:
Cranial nerves are assessed when level of consciousness is decreased, with brain stem pathology, or in
the presence of peripheral nervous system disease. Abnormalities in muscle tone and involuntary
movements are less likely to prompt the assessment of cranial nerves, since these nerves do not directly
mediate most aspects of muscle tone and movement.
20. A patient in the OR goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The
nurse knows that the area of the brain that regulates body temperature is which of the following?
A)
Cerebellum
B)
Thalamus
C)
Hypothalamus
D)
Midbrain
Ans:
C
Feedback:
The hypothalamus plays an important role in the endocrine system because it regulates the pituitary
secretion of hormones that influence metabolism, reproduction, stress response, and urine production. It
works with the pituitary to maintain fluid balance through hormonal release and maintains temperature
regulation by promoting vasoconstriction or vasodilatation. The cerebellum, thalamus, and midbrain and
not directly involved in temperature regulation.
21. The nurse is planning the care of a patient with Parkinsons disease. The nurse should be aware that
treatment will focus on what pathophysiological phenomenon?
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
A)
Premature degradation of acetylcholine
B)
Decreased availability of dopamine
C)
Insufficient synthesis of epinephrine
D)
Delayed reuptake of serotonin
Ans:
B
1232
Feedback:
Parkinsons disease develops from decreased availability of dopamine, not acetylcholine, epinephrine, or
serotonin.
22. A patient is admitted to the medical unit with an exacerbation of multiple sclerosis. When assessing this
patient, the nurse has the patient stick out her 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
Ans:
A
Feedback:
The hypoglossal nerve is the 12th cranial nerve. It is responsible for movement of the tongue. None of
the other listed nerves affects motor function in the tongue.
23. A trauma patient was admitted to the ICU with a brain injury. The patient had a change in level of
consciousness, increased vital signs, and became diaphoretic and agitated. The nurse should recognize
which of the following syndromes as the most plausible cause of these symptoms?
A)
Adrenal crisis
B)
Hypothalamic collapse
C)
Sympathetic storm
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
D)
Cranial nerve deficit
Ans:
C
1233
Feedback:
Sympathetic storm is a syndrome associated with changes in level of consciousness, altered vital signs,
diaphoresis, and agitation that may result from hypothalamic stimulation of the sympathetic nervous
system following traumatic brain injury. Alterations in cranial nerve or adrenal function would not have
this result.
24. Assessment is crucial to the care of patients with neurologic dysfunction. What does accurate and
appropriate assessment require? Select all that apply.
A)
The ability to select mediations for the neurologic dysfunction
B)
Understanding of the tests used to diagnose neurologic disorders
C)
Knowledge of nursing interventions related to assessment and diagnostic testing
D)
Knowledge of the anatomy of the nervous system
E)
The ability to interpret the results of diagnostic tests
Ans:
B, C, D
Feedback:
Assessment requires knowledge of the anatomy and physiology of the nervous system and an
understanding of the array of tests and procedures used to diagnose neurologic disorders. Knowledge
about the nursing implications and interventions related to assessment and diagnostic testing is also
essential. Selecting medications and interpreting diagnostic tests are beyond the normal scope of the
nurse.
25. When caring for a patient with an altered level of consciousness, the nurse is preparing to test cranial
nerve VII. What assessment technique would the nurse use to elicit a response from cranial nerve VII?
A)
Palpate trapezius muscle while patient shrugs should against resistance.
B)
Administer the whisper or watch-tick test.
C)
Observe for facial movement symmetry, such as a smile.
D)
Note any hoarseness in the patients voice.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Ans:
1234
C
Feedback:
Cranial nerve VII is the facial nerve. An appropriate assessment technique for this cranial nerve would
include observing for symmetry while the patient performs facial movements: smiles, whistles, elevates
eyebrows, and frowns. Palpating and noting strength of the trapezius muscle while the patient shrugs
shoulders against resistance would be completed to assess cranial nerve XI (spinal accessory). Assessing
cranial nerve VIII (acoustic) would involve using the whisper or watch-tick test to evaluate hearing.
Noting any hoarseness in the patients voice would involve assessment of cranial nerve X (vagus).
26. The nurse is caring for a patient who exhibits abnormal results of the Weber test and Rinne test. The
nurse should suspect dysfunction involving what cranial nerve?
A)
Trigeminal
B)
Acoustic
C)
Hypoglossal
D)
Trochlear
Ans:
B
Feedback:
Abnormal hearing can correlate with damage to cranial nerve VIII (acoustic). The acoustic nerve
functions in hearing and equilibrium. The trigeminal nerve functions in facial sensation, corneal reflex,
and chewing. The hypoglossal nerve moves the tongue. The trochlear nerve controls muscles that move
the eye.
27. The nurse caring for an 80 year-old patient knows that she has a pre-existing history of dulled tactile
sensation. The nurse should first consider what possible cause for this patients diminished tactile
sensation?
A)
Damage to cranial nerve VIII
B)
Adverse medication effects
C)
Age-related neurologic changes
D)
An undiagnosed cerebrovascular accident in early adulthood
Ans:
C
Feedback:
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1235
Tactile sensation is dulled in the elderly person due to a decrease in the number of sensory receptors.
While thorough assessment is necessary, it is possible that this change is unrelated to pathophysiological
processes.
28. A 72-year-old man has been brought to his primary care provider by his daughter, who claims that he
has been experiencing uncharacteristic lapses in memory. What principle should underlie the nurses
assessment and management of this patient?
A)
Loss of short-term memory is normal in older adults, but loss of long-term memory is pathologic.
B)
Lapses in memory in older adults are considered benign unless they have negative consequences.
C)
Gradual increases in confusion accompany the aging process.
D)
Thorough assessment is necessary because changes in cognition are always considered to be
pathologic.
Ans:
D
Feedback:
Although mental processing time decreases with age, memory, language, and judgment capacities
remain intact. Change in mental status should never be assumed to be a normal part of aging.
29. A gerontologic nurse educator is providing practice guidelines to unlicensed care providers. Because
reaction to painful stimuli is sometimes blunted in older adults, what must be used with caution?
A)
Hot or cold packs
B)
Analgesics
C)
Anti-inflammatory medications
D)
Whirlpool baths
Ans:
A
Feedback:
Reaction to painful stimuli may be decreased with age. Because pain is an important warning signal,
caution must be used when hot or cold packs are used. The older patient may be burned or suffer
frostbite before being aware of any discomfort. Any medication is used with caution in the elderly, but
not because of the decreased sense of heat or cold. Whirlpool baths are generally not a routine treatment
ordered for the elderly.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1236
30. A trauma patient in the ICU has been declared brain dead. What diagnostic test is used in making the
determination of brain death?
A)
Magnetic resonance imaging (MRI)
B)
Electroencephalography (EEG)
C)
Electromyelography (EMG)
D)
Computed tomography (CT)
Ans:
B
Feedback:
The EEG can be used in determining brain death. MRI, CT, and EMG are not normally used in
determining brain death.
31. A patient is scheduled for CT scanning of the head because of a recent onset of neurologic deficits. What
should the nurse tell the patient in preparation for this test?
A)
No metal objects can enter the procedure room.
B)
You need to fast for 8 hours prior to the test.
C)
You will need to lie still throughout the procedure.
D)
There will be a lot of noise during the test.
Ans:
C
Feedback:
Preparation for CT scanning includes teaching the patient about the need to lie quietly throughout the
procedure. If the patient were having an MRI, metal and noise would be appropriate teaching topics.
There is no need to fast prior to a CT scan of the brain.
32. A patient for whom the nurse is caring has positron emission tomography (PET) scheduled. In
preparation, what should the nurse explain to the patient?
A)
The test will temporarily limit blood flow through the brain.
B)
An allergy to iodine precludes getting the radio-opaque dye.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
C)
The patient will need to endure loud noises during the test.
D)
The test may result in dizziness or lightheadedness.
Ans:
D
1237
Feedback:
Key nursing interventions for PET scan include explaining the test and teaching the patient about
inhalation techniques and the sensations (e.g., dizziness, light-headedness, and headache) that may
occur. A PET scan does not impede blood flow through the brain. An allergy to iodine precludes the dye
for an MRI, and loud noise is heard in an MRI.
33. A patient is scheduled for a myelogram and the nurse explains to the patient that this is an invasive
procedure, which assesses for any lesions in the spinal cord. The nurse should explain that the
preparation is similar to which of the following neurologic tests?
A)
Lumbar puncture
B)
MRI
C)
Cerebral angiography
D)
EEG
Ans:
A
Feedback:
A myelogram is an x-ray of the spinal subarachnoid space taken after the injection of a contrast agent
into the spinal subarachnoid space through a lumbar puncture. Patient preparation for a myelogram
would be similar to that for lumbar puncture. The other listed diagnostic tests do not involve lumbar
puncture.
34. The physician has ordered a somatosensory evoked responses (SERs) test for a patient for whom the
nurse is caring. The nurse is justified in suspecting that this patient may have a history of what type of
neurologic disorder?
A)
Hypothalamic disorder
B)
Demyelinating disease
C)
Brainstem deficit
D)
Diabetic neuropathy
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Ans:
1238
B
Feedback:
SERs are used to detect deficits in the spinal cord or peripheral nerve conduction and to monitor spinal
cord function during surgical procedures. The test is also useful in the diagnosis of demyelinating
diseases, such as multiple sclerosis and polyneuropathies, where nerve conduction is slowed. The test is
not done to diagnose hypothalamic disorders, brainstem deficits, or diabetic neuropathies.
35. A patient had a lumbar puncture performed at the outpatient clinic and the nurse has phoned the patient
and family that evening. What does this phone call enable the nurse to determine?
A)
What are the patients and familys expectations of the test
B)
Whether the patients family had any questions about why the test was necessary
C)
Whether the patient has had any complications of the test
D)
Whether the patient understood accurately why the test was done
Ans:
C
Feedback:
Contacting the patient and family after diagnostic testing enables the nurse to determine whether they
have any questions about the procedure or whether the patient had any untoward results. The other listed
information should have been elicited from the patient and family prior to the test.
36. A patient is currently being stimulated by the parasympathetic nervous system. What effect will this
nervous stimulation have on the patients bladder?
A)
The parasympathetic nervous system causes urinary retention.
B)
The parasympathetic nervous system causes bladder spasms.
C)
The parasympathetic nervous system causes urge incontinence.
D)
The parasympathetic nervous system makes the bladder contract.
Ans:
D
Feedback:
The parasympathetic division of the nervous system causes contraction (stimulation) of the urinary
bladder muscles and a decrease (inhibition) in heart rate, whereas the sympathetic division produces
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1239
relaxation (inhibition) of the urinary bladder and an increase (stimulation) in the rate and force of the
heartbeat.
37. The nurse is performing a neurologic assessment of a patient whose injuries have rendered her unable to
follow verbal commands. How should the nurse proceed with assessing the patients level of
consciousness (LOC)?
A)
Assess the patients vital signs and correlate these with the patients baselines.
B)
Assess the patients eye opening and response to stimuli.
C)
Document that the patient currently lacks a level of consciousness.
D)
Facilitate diagnostic testing in an effort to obtain objective data.
Ans:
B
Feedback:
If the patient is not alert or able to follow commands, the examiner observes for eye opening; verbal
response and motor response to stimuli, if any; and the type of stimuli needed to obtain a response. Vital
signs and diagnostic testing are appropriate, but neither will allow the nurse to gauge the patients LOC.
Inability to follow commands does not necessarily denote an absolute lack of consciousness.
38. In the course of a focused neurologic assessment, the nurse is palpating the patients major muscle groups
at rest and during passive movement. Data gleaned from this assessment will allow the nurse to describe
which of the following aspects of neurologic function?
A)
Muscle dexterity
B)
Muscle tone
C)
Motor symmetry
D)
Deep tendon reflexes
Ans:
B
Feedback:
Muscle tone (the tension present in a muscle at rest) is evaluated by palpating various muscle groups at
rest and during passive movement. Data from this assessment do not allow the nurse to ascertain the
patients dexterity, reflexes, or motor symmetry.
39. The neurologic nurse is testing the function of a patients cerebellum and basal ganglia. What action will
most accurately test these structures?
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
A)
Have the patient identify the location of a cotton swab on his or her skin with the eyes closed.
B)
Elicit the patients response to a hypothetical problem.
C)
Ask the patient to close his or her eyes and discern between hot and cold stimuli.
D)
Guide the patient through the performance of rapid, alternating movements.
Ans:
D
1240
Feedback:
Cerebellar and basal ganglia influence on the motor system is reflected in balance control and
coordination. Coordination in the hands and upper extremities is tested by having the patient perform
rapid, alternating movements and point-to-point testing. The cerebellum and basal ganglia do not
mediate cutaneous sensation or judgment.
40. During the performance of the Romberg test, the nurse observes that the patient sways slightly. What is
the nurses most appropriate action?
A)
Facilitate a referral to a neurologist.
B)
Reposition the patient supine to ensure safety.
C)
Document successful completion of the assessment.
D)
Follow up by having the patient perform the Rinne test.
Ans:
C
Feedback:
Slight swaying during the Romberg test is normal, but a loss of balance is abnormal and is considered a
positive Romberg test. Slight swaying is not a significant threat to the patients safety. The Rinne test
assesses hearing, not balance.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1241
Chapter 66: Management of Patients with Neurologic Dysfunction
1.
A patient is being admitted to the neurologic ICU following an acute head injury that has resulted in
cerebral edema. When planning this patients care, the nurse would expect to administer what priority
medication?
A)
Hydrochlorothiazide (HydroDIURIL)
B)
Furosemide (Lasix)
C)
Mannitol (Osmitrol)
D)
Spirolactone (Aldactone)
Ans:
C
Feedback:
The osmotic diuretic mannitol is given to dehydrate the brain tissue and reduce cerebral edema. This
drug acts by reducing the volume of brain and extracellular fluid. Spirolactone, furosemide, and
hydrochlorothiazide are diuretics that are not typically used in the treatment of increased ICP resulting
from cerebral edema.
2.
The nurse is providing care for a patient who is unconscious. What nursing intervention takes highest
priority?
A)
Maintaining accurate records of intake and output
B)
Maintaining a patent airway
C)
Inserting a nasogastric (NG) tube as ordered
D)
Providing appropriate pain control
Ans:
B
Feedback:
Maintaining a patent airway always takes top priority, even though each of the other listed actions is
necessary and appropriate.
3.
The nurse is caring for a patient in the ICU who has a brain stem herniation and who is exhibiting an
altered level of consciousness. Monitoring reveals that the patients mean arterial pressure (MAP) is 60
mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurses most appropriate
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1242
action?
A)
Position the patient in the high Fowlers position as tolerated.
B)
Administer osmotic diuretics as ordered.
C)
Participate in interventions to increase cerebral perfusion pressure.
D)
Prepare the patient for craniotomy.
Ans:
C
Feedback:
The cerebral perfusion pressure (CPP) is 55 mm Hg, which is considered low. The normal CPP is 70 to
100 mm Hg. Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage. As
a result, interventions are necessary. A craniotomy is not directly indicated. Diuretics and increased
height of bed would exacerbate the patients condition.
4.
The nurse is caring for a patient who is postoperative following a craniotomy. When writing the plan of
care, the nurse identifies a diagnosis of deficient fluid volume related to fluid restriction and osmotic
diuretic use. What would be an appropriate intervention for this diagnosis?
A)
Change the patients position as indicated.
B)
Monitor serum electrolytes.
C)
Maintain NPO status.
D)
Monitor arterial blood gas (ABG) values.
Ans:
B
Feedback:
The postoperative fluid regimen depends on the type of neurosurgical procedure and is determined on an
individual basis. The volume and composition of fluids are adjusted based on daily serum electrolyte
values, along with fluid intake and output. Fluids may have to be restricted in patients with cerebral
edema. Changing the patients position, maintaining an NPO status, and monitoring ABG values do not
relate to the nursing diagnosis of deficient fluid volume.
5.
A)
A patient with a documented history of seizure disorder experiences a generalized seizure. What nursing
action is most appropriate?
Restrain the patient to prevent injury.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
B)
Open the patients jaws to insert an oral airway.
C)
Place patient in high Fowlers position.
D)
Loosen the patients restrictive clothing.
Ans:
D
1243
Feedback:
An appropriate nursing intervention would include loosening any restrictive clothing on the patient. No
attempt should be made to restrain the patient during the seizure because muscular contractions are
strong and restraint can produce injury. Do not attempt to pry open jaws that are clenched in a spasm to
insert anything. Broken teeth and injury to the lips and tongue may result from such an action. If
possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward
and facilitates drainage of saliva and mucus.
6.
A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of the
adverse of effects of this medication, the nurse should prioritize which of the following in the patients
plan of care?
A)
Monitoring of pulse oximetry
B)
Administration of a low-protein diet
C)
Administration of thorough oral hygiene
D)
Fluid restriction as ordered
Ans:
C
Feedback:
Gingival hyperplasia (swollen and tender gums) can be associated with long-term phenytoin (Dilantin)
use. Thorough oral hygiene should be provided consistently and encouraged after discharge. Fluid and
protein restriction are contraindicated and there is no particular need for constant oxygen saturation
monitoring.
7.
A nurse is admitting a patient with a severe migraine headache and a history of acute coronary
syndrome. What migraine medication would the nurse question for this patient?
A)
Rizatriptan (Maxalt)
B)
Naratriptan (Amerge)
C)
Sumatriptan succinate (Imitrex)
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
D)
Zolmitriptan (Zomig)
Ans:
C
1244
Feedback:
Triptans can cause chest pain and are contraindicated in patients with ischemic heart disease. Maxalt,
Amerge, and Zomig are triptans used in routine clinical use for the treatment of migraine headaches.
8.
The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing
diagnosis of ineffective cerebral tissue perfusion. What would be an expected outcome that the nurse
would document for this diagnosis?
A)
Copes with sensory deprivation.
B)
Registers normal body temperature.
C)
Pays attention to grooming.
D)
Obeys commands with appropriate motor responses.
Ans:
D
Feedback:
An expected outcome of the diagnosis of ineffective cerebral tissue perfusion in a patient with increased
intracranial pressure (ICP) would include obeying commands with appropriate motor responses. Vitals
signs and neurologic status are assessed every 15 minutes to every hour. Coping with sensory
deprivation would relate to the nursing diagnosis of disturbed sensory perception. The outcome of
registers normal body temperature relates to the diagnosis of potential for ineffective thermoregulation.
Body image disturbance would have a potential outcome of pays attention to grooming.
9.
A patient exhibiting an altered level of consciousness (LOC) due to blunt-force trauma to the head is
admitted to the ED. The physician determines the patients injury is causing increased intracranial
pressure (ICP). The nurse should gauge the patients LOC on the results of what diagnostic tool?
A)
Monro-Kellie hypothesis
B)
Glasgow Coma Scale
C)
Cranial nerve function
D)
Mental status examination
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Ans:
1245
B
Feedback:
LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma
Scale: eye opening, verbal response, and motor response. The Monro-Kellie hypothesis states that
because of the limited space for expansion within the skull, an increase in any one of the components
(blood, brain tissue, cerebrospinal fluid) causes a change in the volume of the others. Cranial nerve
function and the mental status examination would be part of the neurologic examination for this patient,
but would not be the priority in evaluating LOC.
10. While completing a health history on a patient who has recently experienced a seizure, the nurse would
assess for what characteristic associated with the postictal state?
A)
Epileptic cry
B)
Confusion
C)
Urinary incontinence
D)
Body rigidity
Ans:
B
Feedback:
In the postictal state (after the seizure), the patient is often confused and hard to arouse and may sleep
for hours. The epileptic cry occurs from the simultaneous contractions of the diaphragm and chest
muscles that occur during the seizure. Urinary incontinence and intense rigidity of the entire body are
followed by alternating muscle relaxation and contraction (generalized tonicclonic contraction) during
the seizure.
11. A patient with increased ICP has a ventriculostomy for monitoring ICP. The nurses most recent
assessment reveals that the patient is now exhibiting nuchal rigidity and photophobia. The nurse would
be correct in suspecting the presence of what complication?
A)
Encephalitis
B)
CSF leak
C)
Meningitis
D)
Catheter occlusion
Ans:
C
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1246
Feedback:
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 CSF leak, or an occluded catheter.
12. The nurse is participating in the care of a patient with increased ICP. What diagnostic test is
contraindicated in this patients treatment?
A)
Computed tomography (CT) scan
B)
Lumbar puncture
C)
Magnetic resonance imaging (MRI)
D)
Venous Doppler studies
Ans:
B
Feedback:
A lumbar puncture in a patient with increased ICP may cause the brain to herniate from the withdrawal
of fluid and change in pressure during the lumbar puncture. Herniation of the brain is a dire and
frequently fatal event. CT, MRI, and venous Doppler are considered noninvasive procedures and they
would not affect the ICP itself.
13. The nurse is caring for a patient who is in status epilepticus. What medication does the nurse know may
be given to halt the seizure immediately?
A)
Intravenous phenobarbital (Luminal)
B)
Intravenous diazepam (Valium)
C)
Oral lorazepam (Ativan)
D)
Oral phenytoin (Dilantin)
Ans:
B
Feedback:
Medical management of status epilepticus includes IV diazepam (Valium) and IV lorazepam (Ativan)
given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital)
are given later to maintain a seizure-free state. Oral medications are not given during status epilepticus.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1247
14. The nurse has created a plan of care for a patient who is at risk for increased ICP. The patients care plan
should specify monitoring for what early sign of increased ICP?
A)
Disorientation and restlessness
B)
Decreased pulse and respirations
C)
Projectile vomiting
D)
Loss of corneal reflex
Ans:
A
Feedback:
Early indicators of ICP include disorientation and restlessness. Later signs include decreased pulse and
respirations, projectile vomiting, and loss of brain stem reflexes, such as the corneal reflex.
15. The neurologic ICU nurse is admitting a patient following a craniotomy using the supratentorial
approach. How should the nurse best position the patient?
A)
Position the patient supine.
B)
Maintain head of bed (HOB) elevated at 30 to 45 degrees.
C)
Position patient in prone position.
D)
Maintain bed in Trendelenberg position.
Ans:
B
Feedback:
The patient undergoing a craniotomy with a supratentorial (above the tentorium) approach should be
placed with the HOB elevated 30 to 45 degrees, with the neck in neutral alignment. Each of the other
listed positions would cause a dangerous elevation in ICP.
16. A clinic nurse is caring for a patient diagnosed with migraine headaches. During the patient teaching
session, the patient questions the nurse regarding alcohol consumption. What would the nurse be correct
in telling the patient about the effects of alcohol?
A)
Alcohol causes hormone fluctuations.
B)
Alcohol causes vasodilation of the blood vessels.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
C)
Alcohol has an excitatory effect on the CNS.
D)
Alcohol diminishes endorphins in the brain.
Ans:
B
1248
Feedback:
Alcohol causes vasodilation of the blood vessels and may exacerbate migraine headaches. Alcohol has a
depressant effect on the CNS. Alcohol does not cause hormone fluctuations, nor does it decrease
endorphins (morphine-like substances produced by the body) in the brain.
17. A patient has developed diabetes insipidus after having increased ICP following head trauma. What
nursing assessment best addresses this complication?
A)
Vigilant monitoring of fluid balance
B)
Continuous BP monitoring
C)
Serial arterial blood gases (ABGs)
D)
Monitoring of the patients airway for patency
Ans:
A
Feedback:
Diabetes insipidus requires fluid and electrolyte replacement, along with the administration of
vasopressin, to replace and slow the urine output. Because of these alterations in fluid balance, careful
monitoring is necessary. None of the other listed assessments directly addresses the major
manifestations of diabetes insipidus.
18. What should the nurse suspect when hourly assessment of urine output on a patient postcraniotomy
exhibits a urine output from a catheter of 1,500 mL for two consecutive hours?
A)
Cushing syndrome
B)
Syndrome of inappropriate antidiuretic hormone (SIADH)
C)
Adrenal crisis
D)
Diabetes insipidus
Ans:
D
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1249
Feedback:
Diabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in patients after brain
surgery. Cushing syndrome is excessive glucocorticoid secretion resulting in sodium and water
retention. SIADH is the result of increased secretion of ADH; the patient becomes volume-overloaded,
urine output diminishes, and serum sodium concentration becomes dilute. Adrenal crisis is
undersecretion of glucocorticoids resulting in profound hypoglycemia, hypovolemia, and hypotension.
19. During the examination of an unconscious patient, the nurse observes that the patients pupils are fixed
and dilated. What is the most plausible clinical significance of the nurses finding?
A)
It suggests onset of metabolic problems.
B)
It indicates paralysis on the right side of the body.
C)
It indicates paralysis of cranial nerve X.
D)
It indicates an injury at the midbrain level.
Ans:
D
Feedback:
Pupils that are fixed and dilated indicate injury at the midbrain level. This finding is not suggestive of
unilateral paralysis, metabolic deficits, or damage to CN X.
20. Following a traumatic brain injury, a patient has been in a coma for several days. Which of the following
statements is true of this patients current LOC?
A)
The patient occasionally makes incomprehensible sounds.
B)
The patients current LOC will likely become a permanent state.
C)
The patient may occasionally make nonpurposeful movements.
D)
The patient is incapable of spontaneous respirations.
Ans:
C
Feedback:
Coma is a clinical state of unarousable unresponsiveness in which no purposeful responses to internal or
external stimuli occur, although nonpurposeful responses to painful stimuli and brain stem reflexes may
be present. Verbal sounds, however, are atypical. Ventilator support may or may not be necessary.
Comas are not permanent states.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1250
21. The nurse is caring for a patient with permanent neurologic impairments resulting from a traumatic head
injury. When working with this patient and family, what mutual goal should be prioritized?
A)
Achieve as high a level of function as possible.
B)
Enhance the quantity of the patients life.
C)
Teach the family proper care of the patient.
D)
Provide community assistance.
Ans:
A
Feedback:
The overarching goals of care are to achieve as high a level of function as possible and to enhance the
quality of life for the patient with neurologic impairment and his or her family. This goal encompasses
family and community participation.
22. The nurse is providing care for a patient who is withdrawing from heavy alcohol use. The nurse and
other members of the care team are present at the bedside when the patient has a seizure. In preparation
for documenting this clinical event, the nurse should note which of the following?
A)
The ability of the patient to follow instructions during the seizure.
B)
The success or failure of the care team to physically restrain the patient.
C)
The patients ability to explain his seizure during the postictal period.
D)
The patients activities immediately prior to the seizure.
Ans:
D
Feedback:
Before and during a seizure, the nurse observes the circumstances before the seizure, including visual,
auditory, or olfactory stimuli; tactile stimuli; emotional or psychological disturbances; sleep; and
hyperventilation. Communication with the patient is not possible during a seizure and physical restraint
is not attempted. The patients ability to explain the seizure is not clinically relevant.
23. The nurse is caring for a patient whose recent health history includes an altered LOC. What should be
the nurses first action when assessing this patient?
A)
Assessing the patients verbal response
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
B)
Assessing the patients ability to follow complex commands
C)
Assessing the patients judgment
D)
Assessing the patients response to pain
Ans:
A
1251
Feedback:
Assessment of the patient with an altered LOC often starts with assessing the verbal response through
determining the patients orientation to time, person, and place. In most cases, this assessment will
precede each of the other listed assessments, even though each may be indicated.
24. The nurse caring for a patient in a persistent vegetative state is regularly assessing for potential
complications. Complications of neurologic dysfunction for which the nurse should assess include which
of the following? Select all that apply.
A)
Contractures
B)
Hemorrhage
C)
Pressure ulcers
D)
Venous thromboembolism
E)
Pneumonia
Ans:
A, C, D, E
Feedback:
Based on the assessment data, potential complications may include respiratory distress or failure,
pneumonia, aspiration, pressure ulcer, deep vein thrombosis (DVT), and contractures. The
pathophysiology of decreased LOC does not normally create a heightened risk for hemorrhage.
25. The nurse is caring for a patient with a brain tumor. What drug would the nurse expect to be ordered to
reduce the edema surrounding the tumor?
A)
Solumedrol
B)
Dextromethorphan
C)
Dexamethasone
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
D)
Furosemide
Ans:
C
1252
Feedback:
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.
26. The nurse is caring for a patient who sustained a moderate head injury following a bicycle accident. The
nurses most recent assessment reveals that the patients respiratory effort has increased. What is the
nurses most appropriate response?
A)
Inform the care team and assess for further signs of possible increased ICP.
B)
Administer bronchodilators as ordered and monitor the patients LOC.
C)
Increase the patients bed height and reassess in 30 minutes.
D)
Administer a bolus of normal saline as ordered.
Ans:
A
Feedback:
Increased respiratory effort can be suggestive of increasing ICP, and the care team should be promptly
informed. A bolus of IV fluid will not address the problem. Repositioning the patient and administering
bronchodilators are insufficient responses, even though these actions may later be ordered.
27. A patient has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury.
As the patients ICP increases and condition worsens, the nurse knows to assess for indications of
approaching death. These indications include which of the following?
A)
Hemiplegia
B)
Dry mucous membranes
C)
Signs of internal bleeding
D)
Loss of brain stem reflexes
Ans:
D
Feedback:
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1253
Loss of brain stem reflexes, including pupillary, corneal, gag, and swallowing reflexes, is an ominous
sign of approaching death. Dry mucous membranes, hemiplegia, and bleeding must be promptly
addressed, but none of these is a common sign of impending death.
28. A patient has experienced a seizure in which she became rigid and then experienced alternating muscle
relaxation and contraction. What type of seizure does the nurse recognize?
A)
Unclassified seizure
B)
Absence seizure
C)
Generalized seizure
D)
Focal seizure
Ans:
C
Feedback:
Generalized seizures often involve both hemispheres of the brain, causing both sides of the body to
react. Intense rigidity of the entire body may occur, followed by alternating muscle relaxation and
contraction (generalized tonicclonic contraction). This pattern of rigidity does not occur in patients who
experience unclassified, absence, or focal seizures.
29. When caring for a patient with increased ICP the nurse knows the importance of monitoring for possible
secondary complications, including syndrome of inappropriate antidiuretic hormone (SIADH). What
nursing interventions would the nurse most likely initiate if the patient developed SIADH?
A)
Fluid restriction
B)
Transfusion of platelets
C)
Transfusion of fresh frozen plasma (FFP)
D)
Electrolyte restriction
Ans:
A
Feedback:
The nurse also assesses for complications of increased ICP, including diabetes insipidus, and SIADH.
SIADH requires fluid restriction and monitoring of serum electrolyte levels. Transfusions are
unnecessary.
30. The nurse is admitting a patient to the unit who is scheduled for removal of an intracranial mass. What
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1254
diagnostic procedures might be included in this patients admission orders? Select all that apply.
A)
Transcranial Doppler flow study
B)
Cerebral angiography
C)
MRI
D)
Cranial radiography
E)
Electromyelography (EMG)
Ans:
A, B, C
Feedback:
Preoperative diagnostic procedures may include a CT scan to demonstrate the lesion and show the
degree of surrounding brain edema, the ventricular size, and the displacement. An MRI scan provides
information similar to that of a CT scan with improved tissue contrast, resolution, and anatomic
definition. Cerebral angiography may be used to study a tumors blood supply or to obtain information
about vascular lesions. Transcranial Doppler flow studies are used to evaluate the blood flow within
intracranial blood vessels. Regular x-rays of the skull would not be diagnostic for an intracranial mass.
An EMG would not be ordered prior to intracranial surgery to remove a mass.
31. A patient is recovering from intracranial surgery performed approximately 24 hours ago and is
complaining of a headache that the patient rates at 8 on a 10-point pain scale. What nursing action is
most appropriate?
A)
Administer morphine sulfate as ordered.
B)
Reposition the patient in a prone position.
C)
Apply a hot pack to the patients scalp.
D)
Implement distraction techniques.
Ans:
A
Feedback:
The patient usually has a headache after a craniotomy as a result of stretching and irritation of nerves in
the scalp during surgery. Morphine sulfate may also be used in the management of postoperative pain in
patients who have undergone a craniotomy. Prone positioning is contraindicated due to the consequent
increase in ICP. Distraction would likely be inadequate to reduce pain and a hot pack may cause
vasodilation and increased pain.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1255
32. A patient is recovering from intracranial surgery that was performed using the transsphenoidal approach.
The nurse should be aware that the patient may have required surgery on what neurologic structure?
A)
Cerebellum
B)
Hypothalamus
C)
Pituitary gland
D)
Pineal gland
Ans:
C
Feedback:
The transsphenoidal approach (through the mouth and nasal sinuses) is often used to gain access to the
pituitary gland. This surgical approach would not allow for access to the pineal gland, cerebellum, or
hypothalamus.
33. A patient is postoperative day 1 following intracranial surgery. The nurses assessment reveals that the
patients LOC is slightly decreased compared with the day of surgery. What is the nurses best response to
this assessment finding?
A)
Recognize that this may represent the peak of post-surgical cerebral edema.
B)
Alert the surgeon to the possibility of an intracranial hemorrhage.
C)
Understand that the surgery may have been unsuccessful.
D)
Recognize the need to refer the patient to the palliative care team.
Ans:
A
Feedback:
Some degree of cerebral edema occurs after brain surgery; it tends to peak 24 to 36 hours after surgery,
producing decreased responsiveness on the second postoperative day. As such, there is not necessarily
any need to deem the surgery unsuccessful or to refer the patient to palliative care. A decrease in LOC is
not evidence of an intracranial hemorrhage.
34. A school nurse is called to the playground where a 6-year-old girl has been found unresponsive and
staring into space, according to the playground supervisor. How would the nurse document the girls
activity in her chart at school?
A)
Generalized seizure
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
B)
Absence seizure
C)
Focal seizure
D)
Unclassified seizure
Ans:
B
1256
Feedback:
Staring episodes characterize an absence seizure, whereas focal seizures, generalized seizures, and
unclassified seizures involve uncontrolled motor activity.
35. A neurologic nurse is reviewing seizures with a group of staff nurses. How should this nurse best
describe the cause of a seizure?
A)
Sudden electrolyte changes throughout the brain
B)
A dysrhythmia in the peripheral nervous system
C)
A dysrhythmia in the nerve cells in one section of the brain
D)
Sudden disruptions in the blood flow throughout the brain
Ans:
C
Feedback:
The underlying cause of a seizure is an electrical disturbance (dysrhythmia) in the nerve cells in one
section of the brain; these cells emit abnormal, recurring, uncontrolled electrical discharges. Seizures are
not caused by changes in blood flow or electrolytes.
36. The nurse is caring for a patient who has undergone supratentorial removal of a pituitary mass. What
medication would the nurse expect to administer prophylactically to prevent seizures in this patient?
A)
Prednisone
B)
Dexamethasone
C)
Cafergot
D)
Phenytoin
Ans:
D
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1257
Feedback:
Antiseizure medication (phenytoin, diazepam) is often prescribed prophylactically for patients who have
undergone supratentorial craniotomy because of the high risk of seizures after this procedure. Prednisone
and dexamethasone are steroids and do not prevent seizures. Cafergot is used in the treatment of
migraines.
37. A hospital patient has experienced a seizure. In the immediate recovery period, what action best protects
the patients safety?
A)
Place the patient in a side-lying position.
B)
Pad the patients bed rails.
C)
Administer antianxiety medications as ordered.
D)
Reassure the patient and family members.
Ans:
A
Feedback:
To prevent complications, the patient is placed in the side-lying position to facilitate drainage of oral
secretions. Suctioning is performed, if needed, to maintain a patent airway and prevent aspiration. None
of the other listed actions promotes safety during the immediate recovery period.
38. A nurse is caring for a patient who experiences debilitating cluster headaches. The patient should be
taught to take appropriate medications at what point in the course of the onset of a new headache?
A)
As soon as the patients pain becomes unbearable
B)
As soon as the patient senses the onset of symptoms
C)
Twenty to 30 minutes after the onset of symptoms
D)
When the patient senses his or her symptoms peaking
Ans:
B
Feedback:
A migraine or a cluster headache in the early phase requires abortive medication therapy instituted as
soon as possible. Delaying medication administration would lead to unnecessary pain.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1258
39. A nurse is collaborating with the interdisciplinary team to help manage a patients recurrent headaches.
What aspect of the patients health history should the nurse identify as a potential contributor to the
patients headaches?
A)
The patient leads a sedentary lifestyle.
B)
The patient takes vitamin D and calcium supplements.
C)
The patient takes vasodilators for the treatment of angina.
D)
The patient has a pattern of weight loss followed by weight gain.
Ans:
C
Feedback:
Vasodilators are known to contribute to headaches. Weight fluctuations, sedentary lifestyle, and vitamin
supplements are not known to have this effect.
40. An adult patient has sought care for the treatment of headaches that have become increasingly severe
and frequent over the past several months. Which of the following questions addresses potential
etiological factors? Select all that apply?
A)
Are you exposed to any toxins or chemicals at work?
B)
How would you describe your ability to cope with stress?
C)
What medications are you currently taking?
D)
When was the last time you were hospitalized?
E)
Does anyone else in your family struggle with headaches?
Ans:
A, B, C, E
Feedback:
Headaches are multifactorial, and may involve medications, exposure to toxins, family history, and
stress. Hospitalization is an unlikely contributor to headaches.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1259
Chapter 67: Management of Patients with Cerebrovascular Disorders
1.
A patient has had an ischemic stroke and has been admitted to the medical unit. What action should the
nurse perform to best prevent joint deformities?
A)
Place the patient in the prone position for 30 minutes/day.
B)
Assist the patient in acutely flexing the thigh to promote movement.
C)
Place a pillow in the axilla when there is limited external rotation.
D)
Place patients hand in pronation.
Ans:
C
Feedback:
A pillow in the axilla prevents adduction of the affected shoulder and keeps the arm away from the
chest. The prone position with a pillow under the pelvis, not flat, promotes hyperextension of the hip
joints, essential for normal gait. To promote venous return and prevent edema, the upper thigh should
not be flexed acutely. The hand is placed in slight supination, not pronation, which is its most functional
position.
2.
A patient diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy.
The nurse explains that this procedure will be done for what purpose?
A)
To decrease cerebral edema
B)
To prevent seizure activity that is common following a TIA
C)
To remove atherosclerotic plaques blocking cerebral flow
D)
To determine the cause of the TIA
Ans:
C
Feedback:
The main surgical procedure for select patients with TIAs is carotid endarterectomy, the removal of an
atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in
patients with occlusive disease of the extracranial arteries. An endarterectomy does not decrease cerebral
edema, prevent seizure activity, or determine the cause of a TIA.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
3.
1260
The nurse is discharging home a patient who suffered a stroke. He has a flaccid right arm and leg and is
experiencing problems with urinary incontinence. The nurse makes a referral to a home health nurse
because of an awareness of what common patient response to a change in body image?
A)
Denial
B)
Fear
C)
Depression
D)
Disassociation
Ans:
C
Feedback:
Depression is a common and serious problem in the patient who has had a stroke. It can result from a
profound disruption in his or her life and changes in total function, leaving the patient with a loss of
independence. The nurse needs to encourage the patient to verbalize feelings to assess the effect of the
stroke on self-esteem. Denial, fear, and disassociation are not the most common patient response to a
change in body image, although each can occur in some patients.
4.
When caring for a patient who had a hemorrhagic stroke, close monitoring of vital signs and neurologic
changes is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke of
which the nurse should be aware?
A)
Generalized pain
B)
Alteration in level of consciousness (LOC)
C)
Tonicclonic seizures
D)
Shortness of breath
Ans:
B
Feedback:
Alteration in LOC is the earliest sign of deterioration in a patient after a hemorrhagic stroke, such as
mild drowsiness, slight slurring of speech, and sluggish papillary reaction. Sudden headache may occur,
but generalized pain is less common. Seizures and shortness of breath are not identified as early signs of
hemorrhagic stroke.
5.
The nurse is performing stroke risk screenings at a hospital open house. The nurse has identified four
patients who might be at risk for a stroke. Which patient is likely at the highest risk for a hemorrhagic
stroke?
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
A)
White female, age 60, with history of excessive alcohol intake
B)
White male, age 60, with history of uncontrolled hypertension
C)
Black male, age 60, with history of diabetes
D)
Black male, age 50, with history of smoking
Ans:
B
1261
Feedback:
Uncontrolled hypertension is the primary cause of a hemorrhagic stroke. Control of hypertension,
especially in individuals over 55 years of age, clearly reduces the risk for hemorrhagic stroke. Additional
risk factors are increased age, male gender, and excessive alcohol intake. Another high-risk group
includes African Americans, where the incidence of first stroke is almost twice that as in Caucasians.
6.
A patient who just suffered a suspected ischemic stroke is brought to the ED by ambulance. On what
should the nurses primary assessment focus?
A)
Cardiac and respiratory status
B)
Seizure activity
C)
Pain
D)
Fluid and electrolyte balance
Ans:
A
Feedback:
Acute care begins with managing ABCs. Patients may have difficulty keeping an open and clear airway
secondary to decreased LOC. Neurologic assessment with close monitoring for signs of increased
neurologic deficit and seizure activity occurs next. Fluid and electrolyte balance must be controlled
carefully with the goal of adequate hydration to promote perfusion and decrease further brain activity.
7.
A patient with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure
(ICP). What nursing intervention would be most appropriate for this patient?
A)
Range-of-motion exercises to prevent contractures
B)
Encouraging independence with ADLs to promote recovery
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
C)
Early initiation of physical therapy
D)
Absolute bed rest in a quiet, nonstimulating environment
Ans:
D
1262
Feedback:
The patient is placed on immediate and absolute bed rest in a quiet, nonstressful environment because
activity, pain, and anxiety elevate BP, which increases the risk for bleeding. Visitors are restricted. The
nurse administers all personal care. The patient is fed and bathed to prevent any exertion that might raise
BP.
8.
A patient recovering from a stroke has severe shoulder pain from subluxation of the shoulder and is
being cared for on the unit. To prevent further injury and pain, the nurse caring for this patient is aware
of what principle of care?
A)
The patient should be fitted with a cast because use of a sling should be avoided due to adduction
of the affected shoulder.
B)
Elevation of the arm and hand can lead to further complications associated with edema.
C)
Passively exercising the affected extremity is avoided in order to minimize pain.
D)
The patient should be taught to interlace fingers, place palms together, and slowly bring scapulae
forward to avoid excessive force to shoulder.
Ans:
D
Feedback:
To prevent shoulder pain, the nurse should never lift a patient by the flaccid shoulder or pull on the
affected arm or shoulder. The patient is taught how to move and exercise the affected arm/shoulder
through proper movement and positioning. The patient is instructed to interlace the fingers, place the
palms together, and push the clasped hands slowly forward to bring the scapulae forward; he or she then
raises both hands above the head. This is repeated throughout the day. The use of a properly worn sling
when the patient is out of bed prevents the paralyzed upper extremity from dangling without support.
Range-of-motion exercises are still vitally important in preventing a frozen shoulder and ultimately
atrophy of subcutaneous tissues, which can cause more pain. Elevation of the arm and hand is also
important in preventing dependent edema of the hand.
9.
The patient has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make
the patients atmosphere more conducive to communication?
A)
Provide a board of commonly used needs and phrases.
B)
Have the patient speak to loved ones on the phone daily.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
C)
Help the patient complete his or her sentences.
D)
Speak in a loud and deliberate voice to the patient.
Ans:
A
1263
Feedback:
The inability to talk on the telephone or answer a question or exclusion from conversation causes anger,
frustration, fear of the future, and hopelessness. A common pitfall is for the nurse or other health care
team member to complete the thoughts or sentences of the patient. This should be avoided because it
may cause the patient to feel more frustrated at not being allowed to speak and may deter efforts to
practice putting thoughts together and completing a sentence. The patient may also benefit from a
communication board, which has pictures of commonly requested needs and phrases. The board may be
translated into several languages.
10. The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of a
stroke?
A)
Facial droop
B)
Dysrhythmias
C)
Periorbital edema
D)
Projectile vomiting
Ans:
A
Feedback:
Facial drooping or asymmetry is a classic abnormal finding on a physical assessment that may be
associated with a stroke. Facial edema is not suggestive of a stroke and patients less commonly
experience dysrhythmias or vomiting.
11. The nurse is caring for a patient diagnosed with an ischemic stroke and knows that effective positioning
of the patient is important. Which of the following should be integrated into the patients plan of care?
A)
The patients hip joint should be maintained in a flexed position.
B)
The patient should be in a supine position unless ambulating.
C)
The patient should be placed in a prone position for 15 to 30 minutes several times a day.
D)
The patient should be placed in a Trendelenberg position two to three times daily to promote
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1264
cerebral perfusion.
Ans:
C
Feedback:
If possible, the patient is placed in a prone position for 15 to 30 minutes several times a day. A small
pillow or a support is placed under the pelvis, extending from the level of the umbilicus to the upper
third of the thigh. This helps to promote hyperextension of the hip joints, which is essential for normal
gait, and helps prevent knee and hip flexion contractures. The hip joints should not be maintained in
flexion and the Trendelenberg position is not indicated.
12. A patient has been admitted to the ICU after being recently diagnosed with an aneurysm and the patients
admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate
into the patients plan of care?
A)
Elevate the head of the bed to 45 degrees.
B)
Maintain the patient on complete bed rest.
C)
Administer enemas when the patient is constipated.
D)
Avoid use of thigh-high elastic compression stockings.
Ans:
B
Feedback:
Cerebral aneurysm precautions are implemented for the patient with a diagnosis of aneurysm to provide
a nonstimulating environment, prevent increases in ICP, and prevent further bleeding. The patient is
placed on immediate and absolute bed rest in a quiet, nonstressful environment because activity, pain,
and anxiety elevate BP, which increases the risk for bleeding. Visitors, except for family, are restricted.
The head of the bed is elevated 15 to 30 degrees to promote venous drainage and decrease ICP. Some
neurologists, however, prefer that the patient remains flat to increase cerebral perfusion. No enemas are
permitted, but stool softeners and mild laxatives are prescribed. Thigh-high elastic compression
stockings or sequential compression boots may be ordered to decrease the patients risk for deep vein
thrombosis (DVT).
13. A nurse is caring for a patient diagnosed with a hemorrhagic stroke. When creating this patients plan of
care, what goal should be prioritized?
A)
Prevent complications of immobility.
B)
Maintain and improve cerebral tissue perfusion.
C)
Relieve anxiety and pain.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
D)
Relieve sensory deprivation.
Ans:
B
1265
Feedback:
Each of the listed goals is appropriate in the care of a patient recovering from a stroke. However,
promoting cerebral perfusion is a priority physiologic need, on which the patients survival depends.
14. The nurse is preparing health education for a patient who is being discharged after hospitalization for a
hemorrhagic stroke. What content should the nurse include in this education?
A)
Mild, intermittent seizures can be expected.
B)
Take ibuprofen for complaints of a serious headache.
C)
Take antihypertensive medication as ordered.
D)
Drowsiness is normal for the first week after discharge.
Ans:
C
Feedback:
The patient and family are provided with information that will enable them to cooperate with the care
and restrictions required during the acute phase of hemorrhagic stroke and to prepare the patient to
return home. Patient and family teaching includes information about the causes of hemorrhagic stroke
and its possible consequences. Symptoms of hydrocephalus include gradual onset of drowsiness and
behavioral changes. Hypertension is the most serious risk factor, suggesting that appropriate
antihypertensive treatment is essential for a patient being discharged. Seizure activity is not normal;
complaints of a serious headache should be reported to the physician before any medication is taken.
Drowsiness is not normal or expected.
15. A patient diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a
priority for the nurse?
A)
Sit with the patient for a few minutes.
B)
Administer an analgesic.
C)
Inform the nurse-manager.
D)
Call the physician immediately.
Ans:
D
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1266
Feedback:
A headache may be an indication that the aneurysm is leaking. The nurse should notify the physician
immediately. The physician will decide whether administration of an analgesic is indicated. Informing
the nurse-manager is not necessary. Sitting with the patient is appropriate, once the physician has been
notified of the change in the patients condition.
16. A patient is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse
caring for this patient is aware that an absolute contraindication for thrombolytic therapy is what?
A)
Evidence of hemorrhagic stroke
B)
Blood pressure of 180/110 mm Hg
C)
Evidence of stroke evolution
D)
Previous thrombolytic therapy within the past 12 months
Ans:
A
Feedback:
Thrombolytic therapy would exacerbate a hemorrhagic stroke with potentially fatal consequences.
Stroke evolution, high BP, or previous thrombolytic therapy does not contraindicate its safe and
effective use.
17. When caring for a patient who has had a stroke, a priority is reduction of ICP. What patient position is
most consistent with this goal?
A)
Head turned slightly to the right side
B)
Elevation of the head of the bed
C)
Position changes every 15 minutes while awake
D)
Extension of the neck
Ans:
B
Feedback:
Elevation of the head of the bed promotes venous drainage and lowers ICP; the nurse should avoid
flexing or extending the neck or turning the head side to side. The head should be in a neutral midline
position. Excessively frequent position changes are unnecessary.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1267
18. A patient who suffered an ischemic stroke now has disturbed sensory perception. What principle should
guide the nurses care of this patient?
A)
The patient should be approached on the side where visual perception is intact.
B)
Attention to the affected side should be minimized in order to decrease anxiety.
C)
The patient should avoid turning in the direction of the defective visual field to minimize shoulder
subluxation.
D)
The patient should be approached on the opposite side of where the visual perception is intact to
promote recovery.
Ans:
A
Feedback:
Patients with decreased field of vision should first be approached on the side where visual perception is
intact. All visual stimuli should be placed on this side. The patient can and should be taught to turn the
head in the direction of the defective visual field to compensate for this loss. The nurse should constantly
remind the patient of the other side of the body and should later stand at a position that encourages the
patient to move or turn to visualize who and what is in the room.
19. What should be included in the patients care plan when establishing an exercise program for a patient
affected by a stroke?
A)
Schedule passive range of motion every other day.
B)
Keep activity limited, as the patient may be over stimulated.
C)
Have the patient perform active range-of-motion (ROM) exercises once a day.
D)
Exercise the affected extremities passively four or five times a day.
Ans:
D
Feedback:
The affected extremities are exercised passively and put through a full ROM four or five times a day to
maintain joint mobility, regain motor control, prevent development of a contracture in the paralyzed
extremity, prevent further deterioration of the neuromuscular system, and enhance circulation. Active
ROM exercises should ideally be performed more than once per day.
20. A female patient is diagnosed with a right-sided stroke. The patient is now experiencing hemianopsia.
How might the nurse help the patient manage her potential sensory and perceptional difficulties?
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
A)
Keep the lighting in the patients room low.
B)
Place the patients clock on the affected side.
C)
Approach the patient on the side where vision is impaired.
D)
Place the patients extremities where she can see them.
Ans:
D
1268
Feedback:
The patient with homonymous hemianopsia (loss of half of the visual field) turns away from the affected
side of the body and tends to neglect that side and the space on that side; this is called amorphosynthesis.
In such instances, the patient cannot see food on half of the tray, and only half of the room is visible. It is
important for the nurse to remind the patient constantly of the other side of the body, to maintain
alignment of the extremities, and if possible, to place the extremities where the patient can see them.
Patients with a decreased field of vision should be approached on the side where visual perception is
intact. All visual stimuli (clock, calendar, and television) should be placed on this side. The patient can
be taught to turn the head in the direction of the defective visual field to compensate for this loss.
Increasing the natural or artificial lighting in the room and providing eyeglasses are important in
increasing vision. There is no reason to keep the lights dim.
The public health nurse is planning a health promotion campaign that reflects current epidemiologic
21. trends. The nurse should know that hemorrhagic stroke currently accounts for what percentage of total
strokes in the United States?
A)
43%
B)
33%
C)
23%
D)
13%
Ans:
D
Feedback:
Strokes can be divided into two major categories: ischemic (87%), in which vascular occlusion and
significant hypoperfusion occur, and hemorrhagic (13%), in which there is extravasation of blood into
the brain or subarachnoid space.
22. A patient who has experienced an ischemic stroke has been admitted to the medical unit. The patients
family in adamant that she remain on bed rest to hasten her recovery and to conserve energy. What
principle of care should inform the nurses response to the family?
A)
The patient should mobilize as soon as she is physically able.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
B)
To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks.
C)
The patient should remain on bed rest until she expresses a desire to mobilize.
D)
Lack of mobility will greatly increase the patients risk of stroke recurrence.
Ans:
A
1269
Feedback:
As soon as possible, the patient is assisted out of bed and an active rehabilitation program is started.
Delaying mobility causes complications, but not necessarily stroke recurrence. Mobility should not be
withheld until the patient initiates.
23. A patient has recently begun mobilizing during the recovery from an ischemic stroke. To protect the
patients safety during mobilization, the nurse should perform what action?
A)
Support the patients full body weight with a waist belt during ambulation.
B)
Have a colleague follow the patient closely with a wheelchair.
C)
Avoid mobilizing the patient in the early morning or late evening.
D)
Ensure that the patients family members do not participate in mobilization.
Ans:
B
Feedback:
During mobilization, a chair or wheelchair should be readily available in case the patient suddenly
becomes fatigued or feels dizzy. The family should be encouraged to participate, as appropriate, and the
nurse should not have to support the patients full body weight. Morning and evening activity are not
necessarily problematic.
24. A patient diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse
knows that teaching for the patient and family needs to begin as soon as the patient is settled on the unit
and will continue until the patient is discharged. What will family education need to include?
A)
How to differentiate between hemorrhagic and ischemic stroke
B)
Risk factors for ischemic stroke
C)
How to correctly modify the home environment
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
D)
Techniques for adjusting the patients medication dosages at home
Ans:
C
1270
Feedback:
For a patient with a hemorrhagic stroke, teaching addresses the use of assistive devices or modification
of the home environment to help the patient live with the disability. This is more important to the
patients needs than knowing about risk factors for ischemic stroke. It is not necessary for the family to
differentiate between different types of strokes. Medication regimens should never be altered without
consultation.
25. After a subarachnoid hemorrhage, the patients laboratory results indicate a serum sodium level of less
than 126 mEq/L. What is the nurses most appropriate action?
A)
Administer a bolus of normal saline as ordered.
B)
Prepare the patient for thrombolytic therapy as ordered.
C)
Facilitate testing for hypothalamic dysfunction.
D)
Prepare to administer 3% NaCl by IV as ordered.
Ans:
D
Feedback:
The patient may be experiencing syndrome of inappropriate antidiuretic hormone (SIADH) or cerebral
salt-wasting syndrome. The treatment most often is the use of IV hypertonic 3% saline. A normal saline
bolus would exacerbate the problem and there is no indication for tests of hypothalamic function or
thrombolytic therapy.
26. A community health nurse is giving an educational presentation about stroke and heart disease at the
local senior citizens center. What nonmodifiable risk factor for stroke should the nurse cite?
A)
Female gender
B)
Asian American race
C)
Advanced age
D)
Smoking
Ans:
C
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1271
Feedback:
Advanced age, male gender, and race are well-known nonmodifiable risk factors for stroke. High-risk
groups include people older than 55 years of age; the incidence of stroke more than doubles in each
successive decade. Men have a higher rate of stroke than that of women. Another high-risk group is
African Americans; the incidence of first stroke in African Americans is almost twice that as in
Caucasian Americans; Asian American race is not a risk factor. Smoking is a modifiable risk.
27. A family member brings the patient to the clinic for a follow-up visit after a stroke. The family member
asks the nurse what he can do to decrease his chance of having another stroke. What would be the nurses
best answer?
A)
Have your heart checked regularly.
B)
Stop smoking as soon as possible.
C)
Get medication to bring down your sodium levels.
D)
Eat a nutritious diet.
Ans:
B
Feedback:
Smoking is a modifiable and highly significant risk factor for stroke. The significance of smoking, and
the potential benefits of quitting, exceed the roles of sodium, diet, and regular medical assessments.
28. The nurse is reviewing the medication administration record of a female patient who possesses
numerous risk factors for stroke. Which of the womans medications carries the greatest potential for
reducing her risk of stroke?
A)
Naproxen 250 PO b.i.d.
B)
Calcium carbonate 1,000 mg PO b.i.d.
C)
Aspirin 81 mg PO o.d.
D)
Lorazepam 1 mg SL b.i.d. PRN
Ans:
C
Feedback:
Research findings suggest that low-dose aspirin may lower the risk of stroke in women who are at risk.
Naproxen, lorazepam, and calcium supplements do not have this effect.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1272
29. A nurse in the ICU is providing care for a patient who has been admitted with a hemorrhagic stroke. The
nurse is performing frequent neurologic assessments and observes that the patient is becoming
progressively more drowsy over the course of the day. What is the nurses best response to this
assessment finding?
A)
Report this finding to the physician as an indication of decreased metabolism.
B)
Provide more stimulation to the patient and monitor the patient closely.
C)
Recognize this as the expected clinical course of a hemorrhagic stroke.
D)
Report this to the physician as a possible sign of clinical deterioration.
Ans:
D
Feedback:
Alteration in LOC often is the earliest sign of deterioration in a patient with a hemorrhagic stroke.
Drowsiness and slight slurring of speech may be early signs that the LOC is deteriorating. This finding is
unlikely to be the result of metabolic changes and it is not expected. Stimulating a patient with an acute
stroke is usually contraindicated.
30. Following diagnostic testing, a patient has been admitted to the ICU and placed on cerebral aneurysm
precautions. What nursing action should be included in patients plan of care?
A)
Supervise the patients activities of daily living closely.
B)
Initiate early ambulation to prevent complications of immobility.
C)
Provide a high-calorie, low-protein diet.
D)
Perform all of the patients hygiene and feeding.
Ans:
A
Feedback:
The patient is placed on immediate and absolute bed rest in a quiet, nonstressful environment, because
activity, pain, and anxiety elevate BP, which increases the risk for bleeding. As such, independent ADLs
and ambulation are contraindicated. There is no need for a high-calorie or low-protein diet.
31. A preceptor is discussing stroke with a new nurse on the unit. The preceptor would tell the new nurse
which cardiac dysrhythmia is associated with cardiogenic embolic strokes?
A)
Ventricular tachycardia
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
B)
Atrial fibrillation
C)
Supraventricular tachycardia
D)
Bundle branch block
Ans:
B
1273
Feedback:
Cardiogenic embolic strokes are associated with cardiac dysrhythmias, usually atrial fibrillation. The
other listed dysrhythmias are less commonly associated with this type of stroke.
32. The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following
steps:
1. Change in pH
2. Blood flow decreases
3. A switch to anaerobic respiration
4. Membrane pumps fail
5. Cells cease to function
6. Lactic acid is generated
Put these steps in order in which they occur.
A)
635241
B)
352416
C)
236145
D)
162534
Ans:
C
Feedback:
The ischemic cascade begins when cerebral blood flow decreases to less than 25 mL per 100 g of blood
per minute. At this point, neurons are no longer able to maintain aerobic respiration. The mitochondria
must then switch to anaerobic respiration, which generates large amounts of lactic acid, causing a
change in the pH. This switch to the less efficient anaerobic respiration also renders the neuron incapable
of producing sufficient quantities of adenosine triphosphate (ATP) to fuel the depolarization processes.
The membrane pumps that maintain electrolyte balances begin to fail, and the cells cease to function.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1274
33. As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for
benefit and for harm. The nurse should be cognizant of what contraindications for thrombolytic therapy?
Select all that apply.
A)
INR above 1.0
B)
Recent intracranial pathology
C)
Sudden symptom onset
D)
Current anticoagulation therapy
E)
Symptom onset greater than 3 hours prior to admission
Ans:
B, D, E
Feedback:
Some of the absolute contraindications for thrombolytic therapy include symptom onset greater than 3
hours before admission, a patient who is anticoagulated (with an INR above 1.7), or a patient who has
recently had any type of intracranial pathology (e.g., previous stroke, head injury, trauma).
34. After a major ischemic stroke, a possible complication is cerebral edema. Nursing care during the
immediate recovery period from an ischemic stroke should include which of the following?
A)
Positioning to avoid hypoxia
B)
Maximizing PaCO2
C)
Administering hypertonic IV solution
D)
Initiating early mobilization
Ans:
A
Feedback:
Interventions during this period include measures to reduce ICP, such as administering an osmotic
diuretic (e.g., mannitol), maintaining the partial pressure of carbon dioxide (PaCO2) within the range of
30 to 35 mm Hg, and positioning to avoid hypoxia. Hypertonic IV solutions are not used unless sodium
depletion is evident. Mobilization would take place after the immediate threat of increased ICP has past.
35. The nurse is caring for a patient recovering from an ischemic stroke. What intervention best addresses a
potential complication after an ischemic stroke?
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
A)
Providing frequent small meals rather than three larger meals
B)
Teaching the patient to perform deep breathing and coughing exercises
C)
Keeping a urinary catheter in situ for the full duration of recovery
D)
Limiting intake of insoluble fiber
Ans:
B
1275
Feedback:
Because pneumonia is a potential complication of stroke, deep breathing and coughing exercises should
be encouraged unless contraindicated. No particular need exists to provide frequent meals and normally
fiber intake should not be restricted. Urinary catheters should be discontinued as soon as possible.
36. During a patients recovery from stroke, the nurse should be aware of predictors of stroke outcome in
order to help patients and families set realistic goals. What are the predictors of stroke outcome? Select
all that apply.
A)
National Institutes of Health Stroke Scale (NIHSS) score
B)
Race
C)
LOC at time of admission
D)
Gender
E)
Age
Ans:
A, C, E
Feedback:
It is helpful for clinicians to be knowledgeable about the relative importance of predictors of stroke
outcome (age, NIHSS score, and LOC at time of admission) to provide stroke survivors and their
families with realistic goals. Race and gender are not predictors of stroke outcome.
37. A nursing student is writing a care plan for a newly admitted patient who has been diagnosed with a
stroke. What major nursing diagnosis should most likely be included in the patients plan of care?
A)
B)
Adult failure to thrive
Post-trauma syndrome
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
C)
Hyperthermia
D)
Disturbed sensory perception
Ans:
D
1276
Feedback:
The patient who has experienced a stroke is at a high risk for disturbed sensory perception. Stroke is
associated with multiple other nursing diagnoses, but hyperthermia, adult failure to thrive, and posttrauma syndrome are not among these.
38. When preparing to discharge a patient home, the nurse has met with the family and warned them that the
patient may exhibit unexpected emotional responses. The nurse should teach the family that these
responses are typically a result of what cause?
A)
Frustration around changes in function and communication
B)
Unmet physiologic needs
C)
Changes in brain activity during sleep and wakefulness
D)
Temporary changes in metabolism
Ans:
A
Feedback:
Emotional problems associated with stroke are often related to the new challenges around ADLs and
communication. These challenges are more likely than metabolic changes, unmet physiologic needs, or
changes in brain activity, each of which should be ruled out.
39. A rehabilitation nurse caring for a patient who has had a stroke is approached by the patients family and
asked why the patient has to do so much for herself when she is obviously struggling. What would be the
nurses best answer?
A)
We are trying to help her be as useful as she possibly can.
B)
The focus on care in a rehabilitation facility is to help the patient to resume as much self-care as
possible.
C)
We arent here to care for her the way the hospital staff did; we are here to help her get better so she
can go home.
D)
Rehabilitation means helping patients do exactly what they did before their stroke.
Ans:
B
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1277
Feedback:
In both acute care and rehabilitation facilities, the focus is on teaching the patient to resume as much
self-care as possible. The goal of rehabilitation is not to be useful, nor is it to return patients to their
prestroke level of functioning, which may be unrealistic.
40. A patient with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue
plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the
patients cardiac and neurologic status, the nurse monitors the patient for signs of what complication?
A)
Acute pain
B)
Septicemia
C)
Bleeding
D)
Seizures
Ans:
C
Feedback:
Bleeding is the most common side effect of t-PA administration, and the patient is closely monitored for
any bleeding. Septicemia, pain, and seizures are much less likely to result from thrombolytic therapy.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1278
Chapter 68: Management of Patients with Neurologic Trauma
1.
The ED nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at
home. What physical assessment finding is suggestive of a basilar skull fracture?
A)
Epistaxis
B)
Periorbital edema
C)
Bruising over the mastoid
D)
Unilateral facial numbness
Ans:
C
Feedback:
An area of ecchymosis (bruising) may be seen over the mastoid (Battles sign) in a basilar skull fracture.
Numbness, edema, and epistaxis are not directly associated with a basilar skull fracture.
2.
A patient is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury
1 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
Ans:
B
Feedback:
If endotracheal intubation is necessary, extreme care is taken to avoid flexing or extending the patients
neck, which can result in extension of a cervical injury. Intubation does not directly cause autonomic
dysreflexia and the threat to skin integrity is a not a primary concern. Intubation does not carry the
potential to cause suffocation.
3.
A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations
would the nurse expect in this patient?
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
A)
Respiratory distress and projectile vomiting
B)
Bradycardia and hypertension
C)
Tachycardia and agitation
D)
Third-spacing and hyperthermia
Ans:
B
1279
Feedback:
Autonomic dysreflexia is characterized by a pounding headache, profuse sweating, nasal congestion,
piloerection (goose bumps), bradycardia, and hypertension. It occurs in cord lesions above T6 after
spinal shock has resolved; it does not result in vomiting, tachycardia, or third-spacing.
4.
The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain
injury. Which of the following clinical manifestations would suggest that the patient may be
experiencing increased brain compression causing brain stem damage?
A)
Hyperthermia
B)
Tachycardia
C)
Hypertension
D)
Bradypnea
Ans:
A
Feedback:
Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic BP, and
widening pulse pressure. As brain compression increases, respirations become rapid, BP may decrease,
and the pulse slows further. A rapid rise in body temperature is regarded as unfavorable. Hyperthermia
increases the metabolic demands of the brain and may indicate brain stem damage.
5.
A patient is brought to the ED by her family after falling off the roof. A family member tells the nurse
that when the patient fell she was knocked out, but came to and seemed okay. Now she is complaining of
a severe headache and not feeling well. The care team suspects an epidural hematoma, prompting the
nurse to prepare for which priority intervention?
A)
Insertion of an intracranial monitoring device
B)
Treatment with antihypertensives
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
C)
Emergency craniotomy
D)
Administration of anticoagulant therapy
Ans:
C
1280
Feedback:
An epidural hematoma is considered an extreme emergency. Marked neurologic deficit or respiratory
arrest can occur within minutes. Treatment consists of making an opening through the skull to decrease
ICP emergently, remove the clot, and control the bleeding. Antihypertensive medications would not be a
priority. Anticoagulant therapy should not be ordered for a patient who has a cranial bleed. This could
further increase bleeding activity. Insertion of an intracranial monitoring device may be done during the
surgery, but is not priority for this patient.
6.
The staff educator is precepting a nurse new to the critical care unit when a patient with a T2 spinal cord
injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. In addition to
monitoring the patient closely, what would be the nurses most appropriate action?
A)
Prepare to transfuse packed red blood cells.
B)
Prepare for interventions to increase the patients BP.
C)
Place the patient in the Trendelenberg position.
D)
Prepare an ice bath to lower core body temperature.
Ans:
B
Feedback:
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.
7.
An ED nurse has just received a call from EMS that they are transporting a 17-year-old man who has
just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type
of injury is what?
A)
Sports-related injuries
B)
Acts of violence
C)
Injuries due to a fall
D)
Motor vehicle accidents
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Ans:
1281
D
Feedback:
The most common causes of SCIs are motor vehicle crashes (46%), falls (22%), violence (16%), and
sports (12%).
8.
A patient with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the
increased the risk of deep vein thrombosis (DVT). Which of the following would be included as an
appropriate nursing intervention to prevent a DVT from occurring?
A)
Placing the patient on a fluid restriction as ordered
B)
Applying thigh-high elastic stockings
C)
Administering an antifibrinolyic agent
D)
Assisting the patient with passive range of motion (PROM) exercises
Ans:
B
Feedback:
It is important to promote venous return to the heart and prevent venous stasis in a patient with altered
mobility. Applying elastic stockings will aid in the prevention of a DVT. The patient should not be
placed on fluid restriction because a dehydrated state will increase the risk of clotting throughout the
body. Antifibrinolytic agents cause the blood to clot, which is absolutely contraindicated in this
situation. PROM exercises are not an effective protection against the development of DVT.
9.
Paramedics have brought an intubated patient to the RD following a head injury due to accelerationdeceleration motor vehicle accident. Increased ICP is suspected. Appropriate nursing interventions
would include which of the following?
A)
Keep the head of the bed (HOB) flat at all times.
B)
Teach the patient to perform the Valsalva maneuver.
C)
Administer benzodiazepines on a PRN basis.
D)
Perform endotracheal suctioning every hour.
Ans:
C
Feedback:
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1282
If the patient with a brain injury is very agitated, benzodiazepines are the most commonly used sedatives
and do not affect cerebral blood flow or ICP. The HOB should be elevated 30 degrees. Suctioning
should be done a limited basis, due to increasing the pressure in the cranium. The Valsalva maneuver is
to be avoided. This also causes increased ICP.
10. A patient who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing
care should include which of the following?
A)
Preparation for emergency craniotomy
B)
Watchful waiting and close monitoring
C)
Administration of inotropic drugs
D)
Fluid resuscitation
Ans:
B
Feedback:
Nondepressed skull fractures generally do not require surgical treatment; however, close observation of
the patient is essential. A craniotomy would not likely be needed if the fracture is nondepressed. Even if
treatment is warranted, it is unlikely to include inotropes or fluid resuscitation.
11. A patient who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What
aspect of the patients current health status is most likely to have precipitated this event?
A)
The patient received a blood transfusion.
B)
The patients analgesia regimen was recent changed.
C)
The patient was not repositioned during the night shift.
D)
The patients urinary catheter became occluded.
Ans:
D
Feedback:
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 mediations or blood
transfusions are unlikely causes.
12. A patient is admitted to the neurologic ICU with a spinal cord injury. In writing the patients care plan,
the nurse specifies that contractures can best be prevented by what action?
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
A)
Repositioning the patient every 2 hours
B)
Initiating range-of-motion exercises (ROM) as soon as the patient initiates
C)
Initiating (ROM) exercises as soon as possible after the injury
D)
Performing ROM exercises once a day
Ans:
C
1283
Feedback:
Passive ROM exercises should be implemented as soon as possible after injury. It would be
inappropriate to wait for the patient to first initiate exercises. Toes, metatarsals, ankles, knees, and hips
should be put through a full ROM at least four, and ideally five, times daily. Repositioning alone will
not prevent contractures.
13. A patient with a head injury has been increasingly agitated and the nurse has consequently identified a
risk for injury. What is the nurses best intervention for preventing injury?
A)
Restrain the patient as ordered.
B)
Administer opioids PRN as ordered.
C)
Arrange for friends and family members to sit with the patient.
D)
Pad the side rails of the patients bed.
Ans:
D
Feedback:
To protect the patient from self-injury, the nurse uses padded side rails. The nurse should avoid
restraints, because straining against them can increase ICP or cause other injury. Narcotics used to
control restless patients should be avoided because these medications can depress respiration, constrict
the pupils, and alter the patients responsiveness. Visitors should be limited if the patient is agitated.
14. A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the patient
complains of a severe throbbing headache. What should the nurse do first?
A)
Check the patients indwelling urinary catheter for kinks to ensure patency.
B)
Lower the HOB to improve perfusion.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
C)
Administer analgesia.
D)
Reassure the patient that headaches are expected after spinal cord injuries.
Ans:
A
1284
Feedback:
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 patients catheter, record vital signs, and perform an abdominal
assessment. A severe throbbing headache is a dangerous symptom in this patient and is not expected.
15. A patient is admitted to the neurologic ICU with a spinal cord injury. When assessing the patient 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
Ans:
C
Feedback:
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.
16. An elderly woman found with a head injury on the floor of her home is subsequently admitted to the
neurologic ICU. What is the best rationale for the following physician orders: elevate the HOB; keep the
head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion?
A)
To decrease cerebral arterial pressure
B)
To avoid impeding venous outflow
C)
To prevent flexion contractures
D)
To prevent aspiration of stomach contents
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Ans:
1285
B
Feedback:
Any activity or position that impedes venous outflow from the head may contribute to increased volume
inside the skull and possibly increase ICP. Cerebral arterial pressure will be affected by the balance
between oxygen and carbon dioxide. Flexion contractures are not a priority at this time. Stomach
contents could still be aspirated in this position.
17. A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding?
A)
Absence of reflexes along with flaccid extremities
B)
Positive Babinskis reflex along with spastic extremities
C)
Hyperreflexia along with spastic extremities
D)
Spasticity of all four extremities
Ans:
A
Feedback:
During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all
reflexes are absent and the extremities are flaccid. When spinal shock subsides, the patient demonstrates
a positive Babinskis reflex, hyperreflexia, and spasticity of all four extremities.
18. A nurse is reviewing the trend of a patients scores on the Glasgow Coma Scale (GCS). This allows the
nurse to gauge what aspect of the patients status?
A)
Reflex activity
B)
Level of consciousness
C)
Cognitive ability
D)
Sensory involvement
Ans:
B
Feedback:
The Glasgow Coma Scale (GCS) examines three responses related to LOC: eye opening, best verbal
response, and best motor response.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1286
19. The nurse is caring for a patient who is rapidly progressing toward brain death. The nurse should be
aware of what cardinal signs of brain death? Select all that apply.
A)
Absence of pain response
B)
Apnea
C)
Coma
D)
Absence of brain stem reflexes
E)
Absence of deep tendon reflexes
Ans:
B, C, D
Feedback:
The three cardinal signs of brain death upon clinical examination are coma, the absence of brain stem
reflexes, and apnea. Absences of pain response and deep tendon reflexes are not necessarily indicative of
brain death.
20. Following a spinal cord injury a patient 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.
Ans:
B
Feedback:
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.
21. The ED is notified that a 6-year-old is in transit with a suspected brain injury after being struck by a car.
The child is unresponsive at this time, but vital signs are within acceptable limits. What will be the
primary goal of initial therapy?
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
A)
Promoting adequate circulation
B)
Treating the childs increased ICP
C)
Assessing secondary brain injury
D)
Preserving brain homeostasis
Ans:
D
1287
Feedback:
All therapy is directed toward preserving brain homeostasis and preventing secondary brain injury,
which is injury to the brain that occurs after the original traumatic event. The scenario does not indicate
the child has increased ICP or a secondary brain injury at this point. Promoting circulation is likely
secondary to the broader goal of preserving brain homeostasis.
22. A patient is admitted to the neurologic ICU with a suspected diffuse axonal injury. What would be the
primary neuroimaging diagnostic tool used on this patient to evaluate the brain structure?
A)
MRI
B)
PET scan
C)
X-ray
D)
Ultrasound
Ans:
A
Feedback:
CT and MRI scans, the primary neuroimaging diagnostic tools, are useful in evaluating the brain
structure. Ultrasound would not show the brain nor would an x-ray. A PET scan shows brain function,
not brain structure.
23. A 13-year-old was brought to the ED, unconscious, after being hit in the head by a baseball. When the
child regains consciousness, 5 hours after being admitted, he cannot remember the traumatic event. MRI
shows no structural sign of injury. What injury would the nurse suspect the patient has?
A)
Diffuse axonal injury
B)
Grade 1 concussion with frontal lobe involvement
C)
Contusion
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
D)
Grade 3 concussion with temporal lobe involvement
Ans:
D
1288
Feedback:
In a grade 3 concussion there is a loss of consciousness lasting from seconds to minutes. Temporal lobe
involvement results in amnesia. Frontal lobe involvement can cause uncharacteristic behavior and a
grade 1 concussion does not involve loss of consciousness. Diagnostic studies may show no apparent
structural sign of injury, but the duration of unconsciousness is an indicator of the severity of the
concussion. Diffuse axonal injury (DAI) results from widespread shearing and rotational forces that
produce damage throughout the brainto axons in the cerebral hemispheres, corpus callosum, and brain
stem. In cerebral contusion, a moderate to severe head injury, the brain is bruised and damaged in a
specific area because of severe acceleration-deceleration force or blunt trauma.
24. An 82-year-old man is admitted for observation after a fall. Due to his age, the nurse knows that the
patient is at increased risk for what complication of his injury?
A)
Hematoma
B)
Skull fracture
C)
Embolus
D)
Stroke
Ans:
A
Feedback:
Two major factors place older adults at increased risk for hematomas. First, the dura becomes more
adherent to the skull with increasing age. Second, many older adults take aspirin and anticoagulants as
part of routine management of chronic conditions. Because of these factors, the patients risk of a
hematoma is likely greater than that of stroke, embolism, or skull fracture.
25. A neurologic flow chart is often used to document the care of a patient with a traumatic brain injury. At
what point in the patients care should the nurse begin to use a neurologic flow chart?
A)
When the patients condition begins to deteriorate
B)
As soon as the initial assessment is made
C)
At the beginning of each shift
D)
When there is a clinically significant change in the patients condition
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Ans:
1289
B
Feedback:
Neurologic parameters are assessed initially and as frequently as the patients condition requires. As soon
as the initial assessment is made, the use of a neurologic flowchart is started and maintained. A new
chart is not begun at the start of every shift.
26. The nurse planning the care of a patient with head injuries is addressing the patients nursing diagnosis of
sleep deprivation. What action should the nurse implement?
A)
Administer a benzodiazepine at bedtime each night.
B)
Do not disturb the patient between 2200 and 0600.
C)
Cluster overnight nursing activities to minimize disturbances.
D)
Ensure that the patient does not sleep during the day.
Ans:
C
Feedback:
To allow the patient longer times of uninterrupted sleep and rest, the nurse can group nursing care
activities so that the patient is disturbed less frequently. However, it is impractical and unsafe to provide
no care for an 8-hour period. The use of benzodiazepines should be avoided.
27. The nurse has implemented interventions aimed at facilitating family coping in the care of a patient with
a traumatic brain injury. How can the nurse best facilitate family coping?
A)
Help the family understand that the patient could have died.
B)
Emphasize the importance of accepting the patients new limitations.
C)
Have the members of the family plan the patients inpatient care.
D)
Assist the family in setting appropriate short-term goals.
Ans:
D
Feedback:
Helpful interventions to facilitate coping include providing family members with accurate and honest
information and encouraging them to continue to set well-defined, short-term goals. Stating that a
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1290
patients condition could be worse downplays their concerns. Emphasizing the importance of acceptance
may not necessarily help the family accept the patients condition. Family members cannot normally plan
a patients hospital care, although they may contribute to the care in some ways.
28. The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should the nurse
identify as prominent risk factors for SCI? Select all that apply.
A)
Young age
B)
Frequent travel
C)
African American race
D)
Male gender
E)
Alcohol or drug use
Ans:
A, D, E
Feedback:
The predominant risk factors for SCI include young age, male gender, and alcohol and drug use.
Ethnicity and travel are not risk factors.
29. The school nurse has been called to the football field where player is immobile on the field after landing
awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse
perform?
A)
Ensure that the player is not moved.
B)
Obtain the players vital signs, if possible.
C)
Perform a rapid assessment of the players range of motion.
D)
Assess the players reflexes.
Ans:
A
Feedback:
At the scene of the injury, the patient must be immobilized on a spinal (back) board, with the head and
neck maintained in a neutral position, to prevent an incomplete injury from becoming complete. This is a
priority over determining the patients vital signs. It would be inappropriate to test ROM or reflexes.
30. The nurse is caring for a patient whose spinal cord injury has caused recent muscle spasticity. What
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1291
medication should the nurse expect to be ordered to control this?
A)
Baclofen (Lioresal)
B)
Dexamethasone (Decadron)
C)
Mannitol (Osmitrol)
D)
Phenobarbital (Luminal)
Ans:
A
Feedback:
Baclofen is classified as an antispasmodic agent in the treatment of muscles 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 patients with head injury. Phenobarbital
is an anticonvulsant that is used in the treatment of seizure activity.
31. The nurse is planning the care of a patient 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 patients position frequently.
B)
Provide a high-protein diet.
C)
Provide light massage at least daily.
D)
Teach the patient deep breathing and coughing exercises.
Ans:
A
Feedback:
Frequent position changes are among the best preventative measures against pressure ulcers. A highprotein diet can benefit wound healing, but does not necessarily prevent skin breakdown. Light massage
and deep breathing do not protect or restore skin integrity.
32. A patient with a spinal cord injury has experienced several hypotensive episodes. How can the nurse
best address the patients risk for orthostatic hypotension?
A)
Administer an IV bolus of normal saline prior to repositioning.
B)
Maintain bed rest until normal BP regulation returns.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
C)
Monitor the patients BP before and during position changes.
D)
Allow the patient to initiate repositioning.
Ans:
C
1292
Feedback:
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 patients lead may or may not help regulate BP.
33. A nurse on the neurologic unit is providing care for a patient who has spinal cord injury at the level of
C4. When planning the patients care, what aspect of the patients neurologic and functional status should
the nurse consider?
A)
The patient will be unable to use a wheelchair.
B)
The patient will be unable to swallow food.
C)
The patient will be continent of urine, but incontinent of bowel.
D)
The patient will require full assistance for all aspects of elimination.
Ans:
D
Feedback:
Patients with a lesion at C4 are fully dependent for elimination. The patient is dependent for feeding, but
is able to swallow. The patient will be capable of using an electric wheelchair.
34. The nurse is providing health education to a patient who has a C6 spinal cord injury. The patient asks
why autonomic dysreflexia is considered an emergency. What would be the nurses best answer?
A)
The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel.
B)
The suddenness of the onset of the syndrome tells us the body is struggling to maintain its normal
state.
C)
Autonomic dysreflexia causes permanent damage to delicate nerve fibers that are healing.
D)
The sudden, severe headache increases muscle tone and can cause further nerve damage.
Ans:
A
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1293
Feedback:
The sudden increase in BP may cause a rupture of one or more cerebral blood vessels or lead to
increased ICP. Autonomic dysreflexia does not directly cause nerve damage.
35. The nurse caring for a patient with a spinal cord injury notes that the patient 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 patients extremities temporarily.
C)
Increase the frequency of ROM exercises.
D)
Educate the patient about the importance of frequent position changes.
Ans:
C
Feedback:
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 patient is repositioned frequently and is
maintained in proper body alignment whether in bed or in a wheelchair. The patient must be
repositioned by caregivers, not just taught about repositioning. It is inappropriate to limit assistance for
the sole purpose of preventing disuse syndrome.
36. Splints have been ordered for a patient who is at risk of developing footdrop following a spinal cord
injury. The nurse caring for this patient knows that the splints are removed and reapplied when?
A)
At the patients request
B)
Each morning and evening
C)
Every 2 hours
D)
One hour prior to mobility exercises
Ans:
C
Feedback:
The feet are prone to footdrop; therefore, various types of splints are used to prevent footdrop. When
used, the splints are removed and reapplied every 2 hours.
37. A patient who is being treated in the hospital for a spinal cord injury is advocating for the removal of his
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
1294
urinary catheter, stating that he wants to try to resume normal elimination. What principle should guide
the care teams decision regarding this intervention?
A)
Urinary retention can have serious consequences in patients with SCIs.
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.
Ans:
A
Feedback:
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. Catheter use does not cause nerve damage, although it is a major risk factor for UTIs.
38. A patient 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 in this patient? Select all that apply.
A)
Orthostatic hypotension
B)
Autonomic dysreflexia
C)
DVT
D)
Salt-wasting syndrome
E)
Increased ICP
Ans:
A, B, C
Feedback:
For a spinal cord-injured patient, based on the assessment data, potential complications that may develop
include DVT, orthostatic hypotension, and autonomic dysreflexia. Salt-wasting syndrome or increased
ICP are not typical complications following the immediate recovery period.
39. The nurse recognizes that a patient with a SCI is at risk for muscle spasticity. How can the nurse best
prevent this complication of an SCI?
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
A)
Position the patient in a high Fowlers position when in bed.
B)
Support the knees with a pillow when the patient is in bed.
C)
Perform passive ROM exercises as ordered.
D)
Administer NSAIDs as ordered.
Ans:
C
1295
Feedback:
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 patients risk of muscle spasticity.
40. A patient is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care
for this patient, which of the following nursing diagnoses would the nurse prioritize in the immediate
care of this patient?
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
Ans:
C
Feedback:
A nursing diagnosis related to breathing pattern would be the priority for this patient. 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.