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56: Neurological System
PRACTICE QUESTIONS
1. A client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure client safety? 1. Provide a clear path for ambulation without obstacles. 2. Test the temperature of the shower water. 3. Speak loudly to the client. 4. Check the temperature of the food on the dietary tray. Answer: 1 Rationale: Cranial nerve II is the optic nerve, which governs vision. The nurse can provide safety for the visually impaired client by clearing the path of obstacles when ambulating. Testing the shower water temperature would be useful if there were impairment of peripheral nerves. Speaking loudly may help overcome a deficit of cranial nerve VIII (vestibulocochlear). Cranial nerves VII (facial) and IX (glossopharyngeal) control taste from the anterior two thirds and posterior one third of the tongue, respectively. Test-Taking Strategy: Focus on the issue, impairment of cranial nerves. Recalling that this is the optic nerve will direct you to option 1. Review these cranial nerves if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Adult Health/Neurological Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, pp. 974-975. 2. The client has a cerebellar lesion. The nurse determines that the client was adapting successfully to this problem if the client demonstrated proper use of which of the following items? 1. Adaptive eating utensils 2. Walker 3. Raised toilet seat 4. Slider board Answer: 2 Rationale: The cerebellum is responsible for balance and coordination. A walker would provide stability for the client during ambulation. Adaptive eating utensils may be beneficial when the client has partial paralysis of the hand. A raised toilet seat is useful when the client does not have the mobility or ability to flex the hips. A slider board is used in transferring a client from a bed to stretcher or wheelchair. Test-Taking Strategy: Use the process of elimination. Recall that the cerebellum controls balance and coordination. This will help you eliminate options 3 and 4. To choose between options 1 and 2, remember that adaptive eating utensils are used when there is loss of fine motor coordination, such as with a cerebrovascular accident. The walker would help the client

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maintain balance. Review care of the client with a cerebellar lesion if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 408, 426. 3. A nurse is planning care for a client who displays confusion secondary to a neurological problem. Which approach by the nurse would be least helpful in assisting this client? 1. Giving simple, clear directions 2. Providing a stable environment 3. Providing sensory cues 4. Encouraging multiple visitors at one time Answer: 4 Rationale: Clients with cognitive impairment from neurological dysfunction respond best to a stable environment, which is limited in the amounts and type of sensory input. The nurse can provide sensory cues and give clear, simple directions in a positive manner. Confusion and agitation can be minimized by reducing environmental stimuli (such as television, multiple visitors) and keeping familiar personal articles (such as family pictures) at the bedside. Test-Taking Strategy: Use the process of elimination, noting the key words, least helpful. These words indicate a false response question and that you need to select the incorrect action. The client who is confused can handle limited amounts of information at one time, which makes option 4 the correct answer to this question. Review care of the neurological client if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, pp. 615-616. 4. A client with a neurological impairment experiences urinary incontinence. Which nursing action would help the client adapt to this alteration? 1. Establishing a toileting schedule 2. Inserting a Foley catheter 3. Using adult diapers 4. Padding the bed with an absorbent cotton pad Answer: 1 Rationale: A bladder retraining program, such as use of a toileting schedule, may be helpful to clients experiencing urinary incontinence. A Foley catheter should be used only when necessary because of risk of infection. Use of diapers or pads is the least acceptable alternative, because the risk of skin breakdown exists. Test-Taking Strategy: This question can be answered most easily by looking at it from a client

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safety viewpoint. Because Foley catheters carry a risk of infection, and the use of diapers or pads carries the risk of skin breakdown, the only acceptable answer is the toileting schedule. Review care of the client with a neurological impairment if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 421. 5. The nurse has obtained a personal and family history from the client with a neurological disorder. Which finding in the client's history does not give the client added risk for neurological problems? 1. Previous back injury 2. Allergy to pollen 3. History of hypertension 4. History of headaches Answer: 2 Rationale: Previous neurological problems such as headaches or back injuries place the client more at risk for development of a neurological disorder. Chronic diseases such as hypertension and diabetes mellitus also place the client at greater risk. Assessment of allergies is a routine part of the health history, regardless of the nature of the client's problem. Additionally, an allergy to pollen would not place the client at risk for a neurological problem. Test-Taking Strategy: Note the key words, does not give. These words indicate a false response question and that you need to select the finding that is not associated with a neurological problem. Each of the incorrect options has an actual or potential neurological association. Allergies indicate a disturbance of the immune system. Review the risks associated with neurological problems if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 607. 6. A client with right leg hemiplegia has a nursing diagnosis of Impaired Physical Mobility. The nurse determines that the family needs reinforcement of teaching if the nurse observes which of the following being done by the family? 1. Encouraging the client to stand unassisted on the leg 2. Active range of motion (ROM) to the affected leg 3. Passive ROM to the affected leg 4. Application of a premolded splint Answer: 1 Rationale: The question is worded to elicit an unsafe action on the part of the family. Depending on the client's functional ability, either passive or active ROM is indicated to keep the joint

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moving freely. Application of a premolded splint would also keep the limb aligned and in good position. The client should not attempt to stand unsupported on a weak or paralyzed limb. The inability to bear weight will cause the client to fall. Test-Taking Strategy: Note the key words, needs reinforcement of teaching. These words indicate a false response question and that you need to select the incorrect action by the family. Noting that the client has hemiplegia of the leg will direct you to option 1. Review care of the client with hemiplegia if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Neurological References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, pp. 620-621. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 421. 7. A nurse is preparing a client who is scheduled to have cerebral angiography performed. The nurse would check the client for: 1. Allergy to salmon 2. Allergy to iodine or shellfish 3. Claustrophobia 4. Excessive weight Answer: 2 Rationale: The client undergoing cerebral angiography is assessed for possible allergy to the contrast dye, which can be determined by questioning the client about allergies to iodine or shellfish. Allergy to salmon is not associated with this procedure. Claustrophobia and excessive weight are areas of concern with magnetic resonance imaging. Test-Taking Strategy: Use the process of elimination. Recalling that a contrast dye is used in this procedure will direct you to option 2. Review this diagnostic test if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, p. 124. 8. A client admitted to the hospital with a neurological problem indicates to the nurse that magnetic resonance imaging (MRI) may be done. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the client's history of: 1. Hypertension 2. Chronic obstructive pulmonary disorder 3. Heart failure 4. Prosthetic valve replacement Answer: 4

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Rationale: The client having an MRI has all metallic objects removed, because of the magnetic field generated by the device. A careful history is done to determine if any metal objects are inside the client, such as orthopedic hardware, pacemakers, artificial heart valves, aneurysm clips, or intrauterine devices. These may heat up, become dislodged, or malfunction during this procedure. The client may be ineligible if there is significant risk. Test-Taking Strategy: Note the key word, ineligible. An important concept with regard to MRI is the avoidance of any metal objects in the vicinity of the machine. You will note that each of the incorrect options is a medical disorder. The correct answer is the name of a surgical procedure where an artificial valve (sometimes metal) is implanted. Review the contraindications related to this procedure if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, p. 606. 9. A client is having a lumbar puncture (LP) performed. The nurse would place the client in which position for the procedure? 1. Side-lying, with legs pulled up and head bent down onto the chest 2. Supine, in semi-Fowler’s 3. Prone, in slight Trendelenburg 4. Prone, with a pillow under the abdomen Answer: 1 Rationale: The client undergoing LP is positioned lying on the side, with the legs pulled up to the abdomen and the head bent down onto the chest. This position helps open the spaces between the vertebrae. Test-Taking Strategy: Use the process of elimination. Recalling that an LP is the introduction of a needle into the subarachnoid space, it is reasonable that the position of the client must facilitate this. The correct answer is the only position that flexes the vertebrae for easier needle insertion. Review positioning procedures for an LP if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Reference: Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, pp. 580-581. 10. The client is somewhat nervous about having magnetic resonance imaging (MRI). Which statement by the nurse would provide reassurance to the client about the procedure? 1. "It is necessary to remove any metal or metal-containing objects before having the MRI done to avoid the metal being drawn into the magnetic field." 2. "The MRI machine is a long, hollow narrow tube, and may make you feel somewhat claustrophobic." 3. "Even though you are alone in the scanner, you will be in voice communication with the

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technologist during the procedure." 4. "You will be able to eat before the procedure unless you get nauseous easily. If so, you should eat lightly." Answer: 3 Rationale: The MRI scanner is a hollow tube, which gives some clients a feeling of claustrophobia. Metal objects must be removed before the procedure, so they are not drawn into the magnetic field. The client may eat and take all prescribed medications before the procedure. If a contrast medium is used, the client may wish to eat lightly if the client has a tendency to get nauseated easily. The client lies supine on a padded table, which moves into the imager. The client must lie still during the procedure. The imager makes tapping noises while scanning. The client is alone in the imager, but the nurse can reassure the client that the technician is in voice communication with the client at all times during the procedure. Test-Taking Strategy: Use the process of elimination. The statements in each of the options are correct. However, the question asks which of them will provide reassurance to the client. Although all statements are factually true, the correct option is the only one that provides a measure of reassurance to the client. Review MRI if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Reference: Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, pp. 606-607. 11. A client has just undergone computerized tomography (CT) scanning with a contrast medium. The nurse determines that the client understands postprocedure care if the client verbalizes that he or she will: 1. Eat lightly for the remainder of the day. 2. Rest quietly for the remainder of the day. 3. Hold medications for at least 4 hours. 4. Drink extra fluids for the day. Answer: 4 Rationale: After CT scanning, the client may resume all usual activities. The client should be encouraged to take in extra fluids to replace those lost with diuresis from the contrast dye. Options 1, 2, and 3 are unnecessary. Test-Taking Strategy: Use the process of elimination. Recalling that there is no special aftercare following this procedure and noting the words “contrast medium” in the question will direct you to option 4. Review the procedure related to CT scanning if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Neurological Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 390-391, 404.

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12. A nurse is admitting the client to the ambulatory care unit following a myelogram. A water based contrast agent was used for the procedure. The nurse would plan which activity restriction for the client? 1. Bed rest for 6 to 8 hours, with the head of the bed elevated 15 to 30 degrees 2. Bed rest for 2 to 4 hours, with the head of the bed elevated 15 to 30 degrees 3. Bed rest for 6 to 8 hours, with the head of the bed flat 4. Bed rest for 2 to 4 hours, with the head of the bed flat Answer: 1 Rationale: Following myelography, the client is placed on bed rest for 6 to 8 hours after the procedure. When a water-based contrast medium is used, the client is positioned with the head of the bed elevated 15 to 30 degrees. With use of an oil-based medium, the head of the bed is positioned flat (even though the contrast is aspirated out after the procedure). Test-Taking Strategy: Note that a water-based contrast medium was used for the procedure. Also, note that this question is asking for knowledge of two separate items, length of bed rest and head position. With a myelographic procedure, remember that the longer the bed rest, the less likelihood of complications; this will assist in eliminating options 2 and 4. If you can remember that "oil rises, so keep the head low," you will be able to choose correctly from the remaining options. Review postprocedure care following myelography if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Content Area: Adult Health/Neurological Integrated Process: Nursing Process/Planning References: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 436. Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, p. 623. 13. A nurse is administering mouth care to an unconscious client. The nurse should avoid doing which of the following? 1. Positioning the client on the side 2. Using products with lemon or alcohol 3. Cleansing the mucous membranes with toothettes 4. Brushing the teeth with a small toothbrush Answer: 2 Rationale: The unconscious client is positioned on the side during mouth care to prevent aspiration. The teeth are brushed at least twice daily using a small toothbrush. The gums, tongue, roof of mouth, and oral mucous membranes are cleansed with toothettes to avoid encrustation and infection. The lips are coated with water-soluble lubricant to prevent drying, cracking, and encrustation. The use of products with lemon or alcohol should be avoided, because they have a drying effect. Test-Taking Strategy: Note the key word, avoid. This word indicates a false response question and that you need to select the incorrect nursing action. Standard mouth care procedures include use of toothbrush and toothettes, so options 3 and 4 are eliminated first. Recalling that the unconscious client is at risk of aspiration tells you that option 1 is a correct action also. This

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leaves option 2 as incorrect, because repeated use of these products could dry and crack the oral mucous membranes. Review care of the unconscious client if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 2061-2062. deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 290-291. 14. A nurse is trying to help the family of an unconscious client cope with the situation. Which intervention would the nurse plan to incorporate into the care routine for the client? 1. Discouraging the family from touching the client 2. Explaining equipment and procedures on an ongoing basis 3. Ensuring adherence to visiting hours to ensure client's rest 4. Encouraging the family not to "give in" to their feelings of grief Answer: 2 Rationale: Families often need assistance to cope with the sudden, severe illness of a loved one. The nurse can help the family of an unconscious client by assisting them to work through their feelings of grief. The nurse should explain all equipment, treatments, and procedures, and supplement or reinforce information given by the physician. The family should be encouraged to touch and speak to the client, and to become involved in the client's care to the extent that they are comfortable. The nurse should allow the family to stay with the client as much as possible, and should encourage them to eat and sleep adequately to maintain their strength. Test-Taking Strategy: Use the process of elimination and focus on the issue, assisting the family to cope. Each incorrect option either inhibits the family's coping or distances the family from the client or the client's care. Review the psychosocial needs of the family of an unconscious client if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 2065-2065. 15. The nurse is suctioning an unconscious client who has a tracheostomy. The nurse should avoid which action during this procedure? 1. Keeping a supply of suction catheters at the bedside 2. Auscultating breath sounds to determine need for suctioning 3. Hyperoxygenating the client before, during, and after suctioning 4. Making sure not to suction for longer than 30 seconds Answer: 4 Rationale: Suction equipment should be kept at the bedside of an unconscious client, regardless

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of whether or not an artificial airway is present. The nurse auscultates breath sounds every 2 to 4 hours, or more frequently if there is a need. The client should be hyperoxygenated before, during, and after suctioning to minimize cerebral hypoxia. The client should not be suctioned for longer than 10 seconds at one time to prevent cerebral hypoxia and an increase in intracranial pressure. Test-Taking Strategy: Use the process of elimination and note the key word, avoid. This word indicates a false response question and that you need to select the incorrect nursing action. Options 1, 2, and 3 are part of standard suctioning procedure. The only option that is different, and unsafe, is option 4. If you had difficulty with this question, review suctioning procedure. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 1100. 16. A nurse has applied a hypothermia blanket to a client with a fever. The nurse would inspect the skin frequently to detect which complication of hypothermia blanket use? 1. Skin breakdown 2. Frostbite 3. Arterial insufficiency 4. Venous insufficiency Answer: 1 Rationale: When a hypothermia blanket is used, the skin is inspected frequently for pressure points, which over time could lead to skin breakdown. Options 2, 3, and 4 are not complications of hypothermia blanket use. Test-Taking Strategy: Use the process of elimination. Options 3 and 4 may be eliminated first, because they are other health problems. The temperature of the blanket is not cold enough to produce frostbite. This leaves skin breakdown as the correct option. Review the complications associated with the use of a hypothermia blanket if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 779-780. 17. A nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs and symptoms of infection. The nurse understands that there may be damage to the client's thermoregulatory center in the: 1. Cerebrum 2. Cerebellum 3. Hippocampus 4. Hypothalamus Answer: 4

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Rationale: Hypothalamic damage causes hyperthermia, which may also be called "central fever." It is characterized by a persistent high fever with no diurnal variation. There is also an absence of sweating. Options 1, 2, and 3 are not associated with temperature regulation. Test-Taking Strategy: Knowledge of the location of the brain's thermoregulatory center is needed to answer this question. Eliminate options 1 and 2 first, because they are responsible for higher mental functions and balance, respectively. From the remaining options, remember that hyperthermia is affected by the hypothalamus. Review the anatomy and physiology of the brain if you had difficulty with this question. Level of Cognitive Ability: Knowledge Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 324-325. 18. A client seeking treatment for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client stated that he or she will: 1. Stay in a cool environment when possible. 2. Increase fluid intake for the next 24 hours. 3. Monitor voiding for adequacy of urine output. 4. Resume full activity level immediately. Answer: 4 Rationale: Discharge instructions for the client hospitalized for hyperthermia include prevention of heat-related disorders, increased fluid intake for 24 hours, self-monitoring of voiding, and the importance of staying in a cool environment and resting. Test-Taking Strategy: Note the key words, needs clarification of discharge instructions. These words indicate a false response question and that you need to select the incorrect client statement. Options 2 and 3 relate to maintaining and monitoring fluid balance, and are therefore eliminated. A cool environment is appropriate, so option 1 is eliminated also. Resumption of full activity is not helpful; rather, rest periods are indicated. Review home care instructions for the client with hyperthermia if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Neurological References: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, p. 329. Potter, P., & Perry, A. (2003). Essentials for practice (5th ed.). St. Louis: Mosby, p. 187. 19. A nurse is caring for a client with an increased intracranial pressure (ICP). The nurse would monitor for which of the following trends in vital signs that would occur if the intracranial pressure is rising? 1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure (BP)

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2. Increasing temperature, decreasing pulse, decreasing respirations, increasing BP 3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing BP 4. Decreasing temperature, increasing pulse, decreasing respirations, increasing BP Answer: 2 Rationale: A change in vital signs may be a late sign of increased ICP. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities may also arise. Test-Taking Strategy: Use the process of elimination. This question looks complex, but can be logically answered. If you remember that temperature rises, then you are able to eliminate options 3 and 4. If you know that the client becomes bradycardic, or know that the BP rises, you are able to select the correct option. Review the signs of increased intracranial pressure if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 382-383. 20. A nurse is positioning the client with increased intracranial pressure (ICP). Which position would the nurse avoid? 1. Head turned to the side 2. Head midline 3. Neck in neutral position 4. Head of bed elevated 30 to 45 degrees Answer: 1 Rationale: The head of the client with increased ICP should be positioned so that the head is in a neutral, midline position. The nurse should avoid flexing or extending the neck or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure down. Test-Taking Strategy: Note the key word, avoid. This word indicates a false response question and that you need to select the incorrect position. This would be one that interferes with arterial circulation to the brain or with venous drainage from the brain. The only position that meets one of those criteria is option 1. Review client positioning with ICP if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 383. 21. A client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which of the following activities?

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1. Exhaling during repositioning 2. Isometric exercises 3. Blowing the nose 4. Coughing vigorously Answer: 1 Rationale: Activities that increase intrathoracic and intraabdominal pressures cause indirect elevation of the ICP. Some of these activities include isometric exercises, Valsalva maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising. Test-Taking Strategy: Use the process of elimination. Evaluate each option in terms of the tension it puts on the body. Doing so will help you eliminate each of the incorrect options. Review the measures that will reduce or prevent increased intracranial pressure if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Neurological References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 2195. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 390. 22. A family of an unconscious client with increased intracranial pressure is talking at the client's bedside. They are discussing the gravity of the client's condition, and wondering if the client will ever recover. The nurse intervenes, based on the understanding that: 1. The family needs immediate crisis intervention. 2. The family could benefit from a conference with the physician. 3. It is possible the client can hear the family. 4. The client might have wanted a visit from the hospital chaplain. Answer: 3 Rationale: Some clients who have awakened from an unconscious state report that they remember hearing specific voices and conversations. Family and staff should assume that the client's sense of hearing is still intact, and act accordingly. Research has also demonstrated that positive outcomes are associated with coma stimulation—that is, speaking to and touching the client. Test-Taking Strategy: Use the process of elimination. The nurse would not infer that the client wants a visit from the chaplain based on the family speaking over the client at the bedside, so option 4 can be eliminated first. The family demonstrates no evidence of crisis, and they seem to be well informed. This eliminates options 1 and 2. Review care of the unconscious client if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for

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positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 2064-2065. 23. A nurse is providing care to a client with increased intracranial pressure (ICP). Which approach may not be beneficial in controlling the client's ICP from an environmental viewpoint? 1. Maintaining a calm atmosphere 2. Reducing environmental noise 3. Clustering nursing activities to be done all at once 4. Allowing the client uninterrupted time for sleep Answer: 3 Rationale: Nursing interventions should be spaced out over the shift to minimize the risk of a rise in ICP. If possible, activities known to raise ICP should be avoided when possible. Other interventions to control the ICP include maintaining a calm, quiet environment and avoiding emotional stress and interruption of sleep. Test-Taking Strategy: Focus on the issue, controlling ICP. Recalling that stimulation raises the ICP will direct you to option 3. Review nursing care of the client with increased intracranial pressure if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 619. 24. A client has clear fluid leaking from the nose following a basilar skull fracture. The nurse determines that this is cerebrospinal fluid (CSF) if the fluid: 1. Clumps together on the dressing and has a pH of 7 2. Separates into concentric rings and tests positive for glucose 3. Is grossly bloody in appearance and has a pH of 6 4. Is clear in appearance and tests negative for glucose Answer: 2 Rationale: Leakage of CSF from the ears or nose may accompany basilar skull fracture. It can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, which is known as the halo sign. It also tests positive for glucose. Options 1, 3, and 4 are not characteristics of ICP. Test-Taking Strategy: Use the process of elimination. Recalling that CSF contains glucose, whereas other secretions such as mucus do not, will direct you to option 2. Also, remember that CSF separates into rings. Review testing for CSF fluid if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Neurological References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, pp. 609, 649. Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, pp. 1506-1507.

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Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 194. 25. A client is admitted to the hospital for observation with a probable minor head injury after an automobile accident. The nurse would plan on leaving the cervical collar in place until: 1. The physician makes rounds. 2. The family comes to visit. 3. The result of spinal x-rays are known. 4. The nurse needs to do physical care. Answer: 3 Rationale: There is a significant association between cervical spine injury and head injury. For this reason, the nurse leaves any form of spinal immobilization in place until lateral cervical spine x-rays rule out fracture or other damage. Test-Taking Strategy: Focus on the data in the question and note the client’s injury. Remember that the reason for spinal immobilization is to protect the spine from movement, which could cause further damage if the cervical spine were injured. If x-ray results are negative, there is no reason to leave the collar in place. Review emergency care of the client with a suspected cervical injury if this question was difficult. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, pp. 2148-2149. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 194-195. 26. A client was seen and treated in the emergency room for treatment of a concussion. The nurse determines that the family needs reinforcement of the discharge instructions if they verbalize to call the physician for which of the client’s signs and symptoms? 1. Difficulty speaking 2. Difficulty awakening 3. Vomiting 4. Minor headache Answer: 4 Rationale: A concussion after head injury is a temporary loss of consciousness (from a few seconds to a few minutes) without evidence of structural damage. After concussion, the family is taught to monitor the client and call the physician or return the client to the emergency room if certain signs and symptoms are noted. These include confusion, difficulty awakening or speaking, one-sided weakness, vomiting, or severe headache. Minor headache is expected. Test-Taking Strategy: Note the key words, needs reinforcement of the discharge instructions. These words indicate a false response question and that you need to select the incorrect family statement. Noting the word “minor” in option 4 will direct you to this option. Review care of the client with a concussion if you had difficulty with this question. Level of Cognitive Ability: Analysis

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Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Neurological Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, pp. 648-649. 27. A nurse is caring for a client who has undergone craniotomy with a supratentorial incision. The nurse would plan to place the client in which position postoperatively? 1. Head of bed flat, head and neck midline 2. Head of bed flat, head turned to the nonoperative side 3. Head of bed elevated 30 to 45 degrees, head and neck midline 4. Head of bed elevated 30 to 45 degrees, head turned to the operative side Answer: 3 Rationale: Following supratentorial surgery, the head is kept at a 30- to 45-degree angle. The head and neck should not be angled either anteriorly or laterally, but rather should be kept in a neutral (midline) position. This will promote venous return through the jugular veins, which will help prevent a rise in intracranial pressure. Test-Taking Strategy: This question tests knowledge of differences in positioning the craniotomy client with an infratentorial versus supratentorial incision. If you remember that with supra- one should “keep the head up,” and with infra- one should “keep the head down,” options 1 and 2 can be eliminated. Knowing how to position the head for optimal venous drainage helps you select option 3 over option 4. Review client positioning following craniotomy if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 382. 28. A nurse is preparing to give the postcraniotomy client medication for incisional pain. The family asks the nurse why the client is receiving codeine sulfate and not “something stronger.” In formulating a response, the nurse incorporates the understanding that codeine: 1. Is one of the strongest narcotic analgesics available 2. Cannot lead to physical or psychological dependence 3. Does not cause gastrointestinal upset or constipation as do other narcotics 4. Does not alter respirations or mask neurological signs as do other narcotics Answer: 4 Rationale: Codeine sulfate is the narcotic analgesic often used for clients after craniotomy. It is frequently combined with a non-narcotic analgesic such as acetaminophen for added effect. It does not alter the respiratory rate or mask neurological signs as do other narcotics. Side effects of codeine include gastrointestinal upset and constipation. The medication can lead to physical and psychological dependence with chronic use. It is not the strongest narcotic analgesic available. Test-Taking Strategy: Use the process of elimination. General knowledge about narcotic

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analgesics helps you eliminate options 2 and 3. Because codeine is not the strongest narcotic available, eliminate option 1 next. This leaves the correct option, which is codeine's advantage of not masking neurological signs. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W. B. Saunders, p. 254. McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 279. 29. A nurse reinforces home care instructions to the postcraniotomy client. Which statement by the client indicates the need for further instructions? 1. “A tub bath or shower is permitted, but I need to keep my scalp dry until the sutures are removed.” 2. “I need to use a check-off system for my anticonvulsant medications to avoid missing doses.” 3. “I will not hear sounds clearly unless they are loud.” 4. “If I tend to have seizures or gets dizzy spells, someone should be with me while walking.” Answer: 3 Rationale: Seizures are a potential complication that can occur for up to 1 year after surgery. For this reason, the client must diligently take anticonvulsant medications. The client and family are encouraged to keep track of doses administered. The family should learn seizure precautions, and accompany the client while ambulating if dizziness or seizures tend to occur. The suture line is kept dry until sutures are removed to prevent infection. The postcraniotomy client is typically sensitive to loud noises and can find them irritating (e.g., loud television). Awareness control of environmental noise by others is helpful to this client. Test-Taking Strategy: Note the key words, need for further instructions. These words indicate a false response question and that you need to select the incorrect client statement. Begin to answer this question by eliminating option 1 first, because it is a general measure after many types of surgery. If you know that seizures are a potential postoperative risk up to 1 year after surgery, this eliminates options 2 and 4 as well. This leaves option 3 as the correct answer. Many clients after craniotomy have sensitivity to or are irritated by loud noises. Review home care instructions following craniotomy if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Neurological Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 2091. 30. A nurse notes documentation of a nursing diagnosis of Disturbed Body Image for a client after craniotomy. The nurse determines that the client has not met the outcome criteria by discharge if the client:

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1. Wears a turban to cover the incision 2. States an intention to purchase a hairpiece until the hair has grown back 3. Verbalizes that periorbital bruising will disappear over time 4. Indicates that facial puffiness will be a permanent problem Answer: 4 Rationale: After craniotomy, clients may experience difficulty with his or her altered personal appearance. The nurse can help by listening to client concerns and by clarifying any misconceptions about facial edema, periorbital bruising, and hair loss (which are temporary). The nurse can encourage the client to participate in self-grooming and use personal articles of clothing. Finally, the nurse can suggest the use of a turban, followed by a hairpiece, to help the client adapt to the temporary change in appearance. Test-Taking Strategy: Note the key words, has not met. These words indicate a false response question and that you need to select the maladaptive response. Options 1 and 2 both indicate adaptive responses and are therefore eliminated. From the remaining options, recalling that facial edema and bruising are temporary will direct you to option 4. Review care of the client following craniotomy if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Neurological References: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 1517. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, 390. 31. A client with a cervical spine injury has Crutchfield tongs applied in the emergency room. The nurse would avoid which of the following when planning care for this client? 1. Use of a Stryker frame bed 2. Assessment of the integrity of the weights and pulleys 3. Comparing the amount of ordered traction with the amount in use 4. Removing the weights to reposition the client Answer: 4 Rationale: Crutchfield tongs are applied after drilling holes in the client's skull under local anesthesia. Weights are attached to the tongs, which exert pulling pressure on the longitudinal axis of the cervical spine. Serial x-rays of the cervical spine are taken, with weights being gradually added until radiography reveals that the vertebral column is realigned. Weights may then be gradually reduced to a point that maintains alignment. The client with Crutchfield tongs is placed on a Stryker frame or RotoRest bed. The nurse ensures that weights hang freely and the amount of weight matches the current order. The nurse also inspects the integrity and position of the ropes and pulleys. The nurse does not remove the weights to administer care. Test-Taking Strategy: Note the key word, avoid. This word indicates a false response question and that you need to select the item that would be contraindicated. Recalling the basics of traction and recalling that weights are not removed will direct you to option 4. Review nursing care related to the client with cervical tongs if you had difficulty with this question. Level of Cognitive Ability: Application

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Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 441-442. 32. A client with spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. The nurse should: 1. Advise the client that rehabilitation progresses more quickly with cooperation. 2. Acknowledge the client's anger and continue to encourage participation in care. 3. Leave the client alone until ready to participate. 4. Ask the family to deliver the care. Answer: 2 Rationale: Adjusting to paralysis is difficult both physically and psychosocially for the client and family. The nurse recognizes that the client goes through the grieving process in adjusting to the loss, and may move back and forth among the stages of grief. The nurse acknowledges the client's feelings while continuing to meet the client's physical needs and encouraging independence. Test-Taking Strategy: Use the process of elimination. This question can be answered easily by examining the impact or outcome of each of the options. The nurse cannot neglect the client until the client is ready (option 3), so this can be eliminated first. The family is also in crisis and needs the nurse's support (option 4), and should not be relied on for care. Option 1 represents a factual but noncaring approach to the client, which is not therapeutic. This leaves option 2 as the answer. Also, option 2 acknowledges the client's feelings. Review the psychosocial needs of a client with a spinal cord injury if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 448. 33. A nurse has completed reinforcing discharge instructions with a client with an application of a halo device. The nurse determines that the client needs further clarification of the instructions if the client states that he or she will: 1. Use caution, because the device alters balance. 2. Wash the skin daily under the lamb's wool liner of the vest. 3. Use a straw for drinking. 4. Drive only during the daytime. Answer: 4 Rationale: The halo device alters balance and can cause fatigue due to its weight. The client should cleanse the skin daily under the vest or the device to protect the skin from ulceration, and should use powder or lotions sparingly or not at all. The wool liner should be changed if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin care is done as instructed. The client should not drive, because the

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device impairs the range of vision. Test-Taking Strategy: Note the key words, needs further clarification. These words indicate a false response question and that you need to select the incorrect client statement. Recall that a halo device is used to allow mobility for the client who needs continuous cervical traction; it maintains the head and spine in a neutral position. With this in mind, it will be easy to select option 4 as the correct answer to the question as stated. The inability to turn the head without turning the torso would make driving contraindicated. Review client teaching points related to a halo device if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Neurological Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medicalsurgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, pp. 1414-1413, 1477. 34. A client with a spinal cord injury expresses little interest in food, and is very particular about the choice of meals that are actually eaten. The nurse interprets that: 1. Meal choices represent an area of client control, and should be encouraged as much as is nutritionally reasonable. 2. Anorexia is a sign of clinical depression, and a referral to a psychologist is needed. 3. The client has compulsive habits, which should be ignored as long as they are not harmful. 4. The client probably has a naturally slow metabolism, and the decreased nutritional intake won’t matter. Answer: 1 Rationale: Depression is frequently seen in the client with spinal cord injury, and may be exhibited as a loss of appetite. The client should be allowed to choose the types of food eaten and to eat as much as is feasible, because it is one of the few areas of control that the client has left. Test Testing Strategy: Use the process of elimination. The nurse does not make the diagnosis of clinical depression, which makes option 2 incorrect. For the same reason, option 3 should be eliminated. There is no information in the question to demonstrate that the client has a slow metabolic rate, so option 4 is eliminated next. Option 1 provides the client as much control as possible. Review the psychosocial needs of the client with a spinal cord injury if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 2218. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 448-449. 35. A nursing student is planning care for a client with paraplegia who has a Risk for Injury

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related to spasticity of his leg muscles. The registered nurse intervenes if the student plans to include which intervention to minimize the risk of injury to the client? 1. Removing potentially harmful objects near the spastic limbs 2. Performing range of motion to the affected limbs 3. Use of padded restraints to immobilize the limb 4. Use of PRN orders for muscle relaxants such as baclofen (Lioresal) Answer: 3 Rationale: Range-of-motion exercises are beneficial in stretching muscles, which may diminish spasticity. Removing potentially harmful objects is an important safety measure. Use of muscle relaxants is also indicated if the spasms cause discomfort to the client or pose a risk to the client’s safety. Use of limb restraints will not alleviate spasticity and could harm the client. Test-Taking Strategy: Note the key word, intervenes. This word indicates a false response question and that you need to select the action that is potentially harmful to the client. This will direct you to option 3. Remember, restraints should be avoided. Review the safety needs for the client with paraplegia if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 444, 449. 36. A nurse is teaching the paraplegic client measures to promote skin integrity. Which instruction will be least helpful to the client? 1. Shifting weight every 2 hours while in a wheelchair 2. Using a mirror to inspect for redness and breakdown twice a week 3. Checking the bottom sheet for wetness and wrinkles 4. Using a pressure relief pad while in a wheelchair Answer: 2 Rationale: To prevent pressure ulcers from developing, the paraplegic client should shift weight in the wheelchair every 2 hours and use a pressure relief pad. While in bed, the bottom sheet should be free of wrinkles and wetness. The client should use a mirror to inspect the skin twice a day (morning and evening) to assess for redness, edema, and breakdown. General measures include a nutritious diet and meticulous skin care. Test-Taking Strategy: Note the key words, least helpful. Each option appears reasonable on first inspection. With a closer look, however, you will notice that the time frame for inspecting the skin is much too infrequent, making this the correct option. Review care of the paraplegic client if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.), Philadelphia: W.B. Saunders, p. 449.

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37. A client who is paraplegic after spinal cord injury has been taught muscle strengthening exercises for the upper body. The nurse determines that the client will derive the least musclestrengthening benefit from which activity? 1. Doing push-ups in a prone position 2. Extending the arms while holding weights 3. Doing active range of motion to finger joints 4. Squeezing rubber balls Answer: 3 Rationale: Range-of-motion exercises of the finger joints prevent contractures, but do not actively strengthen muscle groups needed for self-mobilization with paraplegia. Other activities that are more effective include push-ups from a prone position, sit-ups from a sitting position, extending the arms while holding weights, and squeezing rubber balls or crumpling newspaper. Test-Taking Strategy: Use the process of elimination and note the key words, least musclestrengthening benefit. This question can be answered by thinking about the energy expenditure of the muscle groups involved in the activities listed in each option. The one that will involve the least energy expenditure (and therefore the least amount of muscle development) is the range-of-motion exercises, which makes it the correct answer to this question. Review care of the paraplegic client if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 449. 38. A nurse is caring for the client who has suffered spinal cord injury. The nurse further monitors the client for signs of autonomic dysreflexia and suspects this complication if which of the following is noted? 1. Severe, throbbing headache 2. Pallor of the face and neck 3. Sudden tachycardia 4. Severe and sudden hypotension Answer: 1 Rationale: The client with spinal cord injury above the level of T7 is at risk for autonomic dysreflexia. It is characterized by severe, throbbing headache, flushing of the face and neck, bradycardia, and sudden severe hypertension. Other signs include nasal stuffiness, blurred vision, nausea, and sweating. It is a life-threatening syndrome triggered by a noxious stimulus below the level of the injury. Test-Taking Strategy: Use the process of elimination. To answer this question correctly, it is necessary to know what causes autonomic dysreflexia. Remember, it results from the sudden exaggerated response of the sympathetic nervous system to a noxious stimulus. A massive sympathetic nervous system response causes severe hypertension. This would account for the throbbing headache (the correct answer), and cause flushing of the face and neck. Baroreceptors sense the sudden hypertension, causing a reflex bradycardia. Also, remember that the pulse and BP changes with autonomic dysreflexia are actually the opposite of what would occur with

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hypovolemic shock. Review the signs of autonomic dysreflexia if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 446-447. 39. A client with diplopia has been taught to use an eye patch to promote better vision and prevent injury. The nurse determines that the client understands how to use the patch if the client states that he or she will: 1. Use the patch only when vision is especially troublesome. 2. Wear the patch for 1 hour at a time. 3. Wear the patch continuously, alternating eyes each day. 4. Wear the patch continuously, alternating eyes each week. Answer: 3 Rationale: Placing an eye patch over one eye in the client with diplopia removes the second image and restores more normal vision. The patch is worn continuously and is alternated on a daily basis to maintain the strength of the extraocular muscles of the eyes. Test-Taking Strategy: Use the process of elimination. Knowing that an eye patch will help diplopia only while it is worn will assist in eliminating options 1 and 2. From the remaining options, recall that the extraocular muscles weaken with eye patch use. This will direct you to option 3, alternating the eye patch each day. Review care of the client with diplopia if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Neurological References: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 422. Swearingen, P. (2003). Manual of medical-surgical nursing care (5th ed.). St. Louis: Mosby, p. 404. 40. A client with spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which measure to minimize the risk of recurrence? 1. Strict adherence to a bowel retraining program 2. Limiting bladder catheterization to once every 12 hours 3. Keeping the linen wrinkle-free under the client 4. Avoiding unnecessary pressure on the lower limbs Answer: 2 Rationale: The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours, and Foley catheters should be checked frequently for kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from

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tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas. Test-Taking Strategy: Note the key word, avoid. Remember that autonomic dysreflexia is caused by noxious stimuli to the bowel, bladder, or skin. With this in mind, you can eliminate each of the incorrect options. Review the measures to minimize the risk of autonomic dysreflexia if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 447. 41. A client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking vital signs, the nurse immediately: 1. Lowers the head of the bed and administers an antihypertensive agent 2. Removes the noxious stimulus and administers an antihypertensive agent 3. Lowers the head of the bed and removes the noxious stimulus 4. Raises the head of the bed and removes the noxious stimulus Answer: 4 Rationale: Key nursing actions are to sit the client up in bed, remove the noxious stimulus, and bring the blood pressure under control with antihypertensive medication per protocol. The nurse can also clearly label the client's chart identifying the risk for autonomic dysreflexia. Client and family should be taught to recognize, and later manage, the signs and symptoms of this syndrome. Test-Taking Strategy: Note the key word, immediately, in the question. This is a clue that the first item in each option must be the first action. If you know to raise the head of the client's bed first (to try to minimize cerebral hypertension), then this eliminates each of the incorrect responses. Review immediate nursing interventions for the client experiencing autonomic dysreflexia, if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 446. 42. A nurse is planning care for the client in spinal shock. Which of the following actions would be least helpful in minimizing the effects of vasodilation below the level of the injury? 1. Monitoring vital signs before and during position changes 2. Using vasopressor medications, as prescribed 3. Moving the client quickly as one unit 4. Applying Teds or compression stockings Answer: 3 Rationale: Reflex vasodilation below the level of spinal cord injury places the client at risk of orthostatic hypotension, which may be profound. Measures to minimize this include measuring

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vital signs before and during position changes, use of a tilt table in early mobilization, and changing the client's position slowly. Venous pooling can be reduced by using Teds or compression stockings. Vasopressor medications are used as per protocol and as prescribed. Test-Taking Strategy: Note the key words, least helpful, and recall that reflex vasodilation below the level of the injury causes hypotension. Venous compression (option 4 ) is helpful and is eliminated. Options 1 and 2 are helpful and are eliminated next. Knowing that quick position changes and movement would aggravate hypotension helps you be sure that you have selected the correct option. Review care of the client with spinal shock if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 2218. Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 650. 43. A nurse is caring for a client with an intracranial aneurysm who was previously alert. Which finding would be an early indication that the level of consciousness (LOC) is deteriorating? 1. Clear speech 2. Ptosis of the left eyelid 3. Drowsiness 4. Frequent spontaneous speech Answer: 3 Rationale: Ptosis of the eyelid is due to pressure on and dysfunction of cranial nerve III and does not relate to LOC. Early changes in LOC relate to alertness and verbal responsiveness. Less frequent speech, slight slurring of speech, and mild drowsiness are early signs of decreasing LOC. Test-Taking Strategy: Use the process of elimination. Recalling that LOC includes orientation, awareness, and verbal responsiveness will direct you to option 3. Review the early signs of decreasing LOC if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 371. 44. A nurse is planning to put aneurysm precautions in place for the client with a cerebral aneurysm. Which item would be included as part of the precautions? 1. Allowing out of bed activities as tolerated 2. Maintaining the head of bed at 15 degrees 3. Limiting cigarettes to three per day 4. Allowing one cup of caffeinated coffee per day Answer: 2

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Rationale: Aneurysm precautions include placing the client on bed rest with the head of the bed elevated in a quiet setting. Lights are kept dim to minimize environmental stimulation. Any activity that increases blood pressure (BP) or impedes venous return from the brain is prohibited, such as pushing, pulling, sneezing, coughing, or straining. The nurse provides all physical care to minimize increases in BP. For the same reason, visitors, radio, television, and reading materials are prohibited or limited. Stimulants such as caffeine and nicotine are prohibited; decaffeinated coffee or tea may be given. Test-Taking Strategy: Use the process of elimination. Recall that a global principle in aneurysm precautions is to limit the amount of stimulation (in any form) that the client receives, and to prevent increased intracranial pressure (ICP). This will direct you to option 2. Review aneurysm precautions if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medicalsurgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 1385. 45. A nursing instructor asks a nursing student about the points to document if the client has had a seizure. The instructor determines that the student needs to read about seizures and documentation points if the student stated that it is important to document: 1. Duration of the seizure 2. What the client ate in the 2 hours preceding seizure activity 3. Seizure progression and type of movements 4. Changes in pupil size or eye deviation Answer: 2 Rationale: Typically, seizure assessment includes the time the seizure began, part(s) of the body affected, the type of movements and progression of the seizure, changes in pupil size, eye deviation or nystagmus, client condition during the seizure, and postictal status. Test-Taking Strategy: Note the key words, needs to read. These words indicate a false response question and that you need to select the incorrect student statement. Note that options 1, 3, and 4 relate to seizures and neurological assessment whereas option 2 does not. Review nursing assessment during a seizure if you had difficulty answering this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 386-387. 46. A nurse is planning to institute seizure precautions for a client who is being admitted from the Emergency Department. Which of the following measures would the nurse avoid in planning for the client's safety? 1. Placing an airway, oxygen, and suction equipment at the bedside 2. Padding the side rails of the bed

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3. Putting a padded tongue blade at the head of the bed 4. Having intravenous (IV) equipment ready for insertion of IV access Answer: 3 Rationale: Seizure precautions may vary somewhat from agency to agency, but they generally have some commonalities. Usually an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has a IV access in place to have a readily accessible route if IV anticonvulsant medications must be administered. The use of padded tongue blades is highly controversial, and they should not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure will more likely harm the client who bites down during seizure activity. Other risks include blocking the airway from improper placement, chipping the client's teeth, and subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begins. Test-Taking Strategy: Note the key word, avoid. This word indicates a false response question and that you need to select the action that is contraindicated. No harm can come to the client from any of the options except for the tongue blade. Review seizure precautions if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 387. 47. A nurse is caring for a client who begins to experience seizure activity while in bed. Which action by the nurse would be contraindicated? 1. Loosening restrictive clothing 2. Removing the pillow and raising the padded side rails 3. Restraining the client's limbs 4. Positioning the client to the side, if possible, with head flexed forward Answer: 3 Rationale: Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising the padded side rails in bed, and placing the client on one side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained, because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible, protects the head against injury, and moves furniture that may injure the client. Test-Taking Strategy: Note the key word, contraindicated. This word indicates a false response question and that you need to select the harmful action. No harm can come to the client from any of the options, except for restraining the limbs. Remember to avoid restraints. Review care of a client during a seizure if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation

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Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 397. 48. A nurse has given medication instructions to the client receiving phenytoin (Dilantin). The nurse determines that the client understands the instructions if the client states: 1. The medication dose may be self-adjusted, depending on side effects. 2. Alcohol is not contraindicated while taking this medication. 3. Good oral hygiene is needed, including brushing and flossing. 4. The morning dose of the medication should be taken before a sample for a serum drug level is drawn. Answer: 3 Rationale: Typical anticonvulsant medication instructions include taking the dose daily to keep the blood level of the drug constant; having a serum drug level drawn before taking the morning dose; avoiding abruptly stopping the medication; avoiding alcohol; checking with the physician before taking over-the-counter medications; avoiding activities where alertness and coordination are required until medication effects are known; providing good oral hygiene and getting regular dental care; and carrying a Medic-Alert bracelet or tag. Test-Taking Strategy: Use the process of elimination. Options 1 and 2 can be eliminated using general medication administration guidelines. From the remaining options, remember that medications are not generally taken just before drawing samples for checking therapeutic serum levels, because the results would be artificially high. This leaves oral hygiene as the correct answer, because of the risk of gingival hyperplasia associated with this medication. Review client teaching related to phenytoin (Dilantin) if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Neurological Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W. B. Saunders, p. 858. 49. A nurse is planning care for the client with hemiparesis of the right arm and leg. The nurse incorporates in the care plan placement of objects: 1. Within the client's reach, on the right side 2. Within the client's reach, on the left side 3. Just out of the client's reach, on the right side 4. Just out of the client's reach, on the left side Answer: 2 Rationale: Hemiparesis is a weakness of the face, arm, and leg on one side. The client with onesided hemiparesis benefits from having objects placed on the unaffected side and within reach. Other helpful activities with hemiparesis include range-of-motion exercises to the affected side and muscle strengthening exercises to the unaffected side. Test-Taking Strategy: Focus on the client’s diagnosis. Begin to answer this question by eliminating options 3 and 4, because they are hazardous to the client. This question also tests your ability to distinguish between hemiparesis and unilateral neglect. The client with

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hemiparesis has weakness on one side, and therefore objects should be place on the stronger side. With unilateral neglect, objects are placed on the affected side to train the client to attend to that part of the environment. Knowing this, you would select option 2 as the correct answer. Review care of the client with hemiparesis if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 382. 50. A client with a cerebrovascular accident (CVA) has residual dysphagia. When a diet order is initiated, the nurse avoids doing which of the following? 1. Giving the client thin liquids 2. Thickening liquids to the consistency of oatmeal 3. Placing food on the unaffected side of the mouth 4. Allowing plenty of time for chewing and swallowing Answer: 1 Rationale: Before the client with dysphagia is started on a diet, the gag and swallow reflexes must have returned. The client is assisted with meals as needed, and is given ample time to chew and swallow. Food is placed on the unaffected side of the mouth. Liquids are thickened to avoid aspiration. Test-Taking Strategy: Note the key word, avoid. This indicates a false response question and that you need to select the incorrect action. Option 4 is generally a good action for all clients. Option 3 is appropriate because the client has better sensation and motion on the unaffected side of the mouth. This narrows your options to two opposing concepts, thin versus thick liquids. Thickened liquids are easier for the client with impaired facial motion and swallowing ability to manage. Knowing this enables you to select option 1 as the action to avoid. Review care of the client with residual dysphagia if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 415. 51. A nurse has instructed the family of a cerebrovascular accident (CVA) client who has homonymous hemianopsia about measures to help the client overcome the deficit. The nurse determines that the family understands the measures to use if they state that they will: 1. Place objects in the client's impaired field of vision. 2. Approach the client from the impaired field of vision. 3. Remind the client to turn the head to scan the lost visual field. 4. Discourage the client from wearing own eyeglasses. Answer: 3 Rationale: Homonymous hemianopsia is loss of half of the visual field. The client with

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homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available. Test-Taking Strategy: To answer this question accurately, you need to be able to distinguish between homonymous hemianopsia and unilateral neglect. Clients are approached differently with these two deficits. Remember that the similarity is that the client must be taught to scan the environment, which is the answer to this question. Review care of the client with homonymous hemianopsia if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 416. 52. A nurse is trying to communicate with a cerebrovascular accident (CVA) client with aphasia. Which action by the nurse would be least helpful to the client? 1. Speaking to the client at a slower rate 2. Completing the sentences that the client cannot finish 3. Looking directly at the client during attempts at speech 4. Allowing plenty of time for the client to respond Answer: 2 Rationale: Clients with aphasia after CVA often fatigue easily and have a short attention span. General guidelines when trying to communicate with the aphasic client include speaking more slowly and allowing adequate response time, listening to and watching attempts to communicate, and trying to put the client at ease with a caring and understanding manner. The nurse should avoid shouting (because the client is not deaf), appearing rushed for a response, and letting family members give all the responses for the client. Test-Taking Strategy: Note the key words, least helpful. These words indicate a false response question and that you need to select the inappropriate nursing action. Visualizing each action will direct you to option 2. If this question was difficult, review these communication strategies. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 414-415. 53. A family of a spinal cord–injured client rushes to the nursing station, saying that the client needs immediate help. On entering the room, the nurse notes that the client is diaphoretic, with a flushed face and neck, and complains of a severe headache. The pulse is 40 beats per minute and the blood pressure (BP) is 230/100 mm Hg. The nurse acts quickly, knowing that the client is experiencing: 1. Spinal shock

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2. Malignant hypertension 3. Pulmonary embolism 4. Autonomic dysreflexia Answer: 4 Rationale: The client with spinal cord injury above the level of T7 is at risk for autonomic dysreflexia. It is characterized by severe, throbbing headache, flushing of the face and neck, bradycardia, and sudden severe hypertension. Other signs include nasal stuffiness, blurred vision, nausea, and sweating. It is a life-threatening syndrome triggered by a noxious stimulus below the level of the injury. Test-Taking Strategy: Use the process of elimination. Begin to answer this question by eliminating options 1 and 3. The client in spinal shock would be hypotensive (not hypertensive), and the client's clinical picture does not match pulmonary embolism. (It may be useful to know also that autonomic dysreflexia does not occur until spinal shock resolves.) The word hypertension may have caught your eye in option 2, but knowing that malignant hypertension occurs with anesthesia will help you eliminate this option as well. Review the signs of autonomic dysreflexia if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 446. 54. A client receives a dose of edrophonium (Tensilon) intravenously. The client shows improvement in muscle strength for a period of time following the injection. The nurse interprets that this finding is compatible with: 1. Multiple sclerosis 2. Amyotrophic lateral sclerosis 3. Myasthenia gravis 4. Muscular dystrophy Answer: 3 Rationale: Myasthenia gravis can often be diagnosed based on clinical signs and symptoms. The diagnosis can be confirmed by injecting the client with a dose of Tensilon. This medication inhibits the breakdown of an enzyme in the neuromuscular junction, so more acetylcholine binds to receptors. If the muscle is strengthened for 3 to 5 minutes after this injection, it confirms a diagnosis of myasthenia gravis. Another medication, neostigmine (Prostigmin), may also be used because its effect lasts for 1 to 2 hours, providing a better analysis. For either medication, atropine sulfate should be available as the antidote. Test-Taking Strategy: Knowledge of the purpose and expected findings of the Tensilon test is needed to answer this question. Remember, the Tensilon test is used in diagnosing myasthenia gravis. Review this test if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology

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Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, pp. 1035-1036. 55. A client with myasthenia gravis is having difficulty speaking. The client’s speech is dysarthritic and has a nasal tone. The nurse would avoid using which communication strategy when working with this client? 1. Repeating what the client said to verify the message 2. Encouraging the client to speak quickly 3. Using a communication board when necessary 4. Asking yes and no questions when able Answer: 2 Rationale: The client has speech that is nasal in tone and dysarthritic because of cranial nerve involvement of the muscles governing speech. The nurse listens attentively and verbally, verifies what the client has said, asks questions requiring a yes or no response, and develops alternative communication methods (e.g., letter board, picture board, pen and paper, flash cards). Encouraging the client to speak quickly is an unsuccessful communication strategy and is counterproductive. Test-Taking Strategy: Note the key word, avoid. This word indicates a false response question and that you need to select the incorrect communication strategy. There are some techniques that are useful in communicating with clients with speech impairment, regardless of the specific cause of the difficulty. Options 3 and 4 are examples of alternative communication methods that are useful, so eliminate these options as strategies to avoid. From the remaining options, remember that speaking quickly is difficult for a client with a speech impairment. Review these communication strategies if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Adult Health/Neurological Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 640. 56. A client has experienced an episode of myasthenic crisis. The nurse collects data to determine whether the client has precipitating factors such as: 1. Too little exercise 2. Increased intake of fatty foods 3. Omitted doses of medication 4. Increased doses of medication Answer: 3 Rationale: Myasthenic crisis is often caused by undermedication and responds to administration of cholinergic medications such as neostigmine (Prostigmin) and pyridostigmine (Mestinon). Cholinergic crisis (the opposite problem) is caused by excess medication and responds to withholding of medications. Too little exercise and fatty food intake are incorrect options. Overexertion and overeating could possibly trigger myasthenic crisis. Test-Taking Strategy: Focus on the client’s diagnosis and recall that myasthenic crisis is treated with medication. Remember, undermedication is a cause of myasthenic crisis. Review the

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causes of this type of crisis if you are unfamiliar with them. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 403-404. 57. A nurse is teaching the client with myasthenia gravis about prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by: 1. Doing all chores early in the day while less fatigued 2. Taking medications on time to maintain therapeutic blood levels 3. Doing muscle-strengthening exercises 4. Eating large, well-balanced meals Answer: 2 Rationale: Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. It is very important to take medications correctly to maintain blood levels that are not too low or too high. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as well as exposure to heat, crowds, erratic sleep habits, and emotional stress. Test-Taking Strategy: Use the process of elimination and note the key words, most effectively. If you know that common causes of myasthenic and cholinergic crises are undermedication and overmedication, respectively, you should be able to eliminate each of the incorrect options easily. Remember, it is extremely important that these clients take medications on time to maintain therapeutic blood levels. Review measures to prevent myasthenic and cholinergic crises if you are unfamiliar with them. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 404. 58. A nurse has instructed the client with myasthenia gravis about ways to manage his or her own health at home. The nurse determines that the client needs more information if the client makes which of the following statements? 1. "I should take my medications an hour before mealtime." 2. "I've made arrangements to get a portable resuscitation bag and home suction equipment." 3. "Going to the beach will be a nice, relaxing form of activity." 4. "Here's the Medic-Alert bracelet I obtained." Answer: 3 Rationale: Most ongoing treatment for myasthenia gravis is done in outpatient settings, and the client needs to be aware of the lifestyle changes needed to maintain independence. Taking medications 1 hour before mealtime gives greater muscle strength for chewing, and is indicated. The client should have portable suction equipment and a portable resuscitation bag available in

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case of respiratory distress. The client should carry medical identification about the condition. The client should avoid activities that could worsen the symptoms, including stress, infection, heat, surgery, or alcohol. Test-Taking Strategy: Note the key words, needs more information. These words indicate a false response question and that you need to select the incorrect client statement. Options 2 and 4 are reasonable courses of action and are eliminated first. To select from the remaining options, you would need to know that premedication 1 hour before meals gives strength to the muscles (for chewing and swallowing), and that heat and infection (crowds at the beach) trigger myasthenic crisis. Review client education points with myasthenia gravis if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 404. 59. A client with Parkinson's disease is embarrassed about the symptoms of the disorder, and is bored and lonely. The nurse would plan which approach as most therapeutic in assisting the client to cope with the disease? 1. Plan only a few activities for the client during the day 2. Assist the client with activities of daily living (ADLs) as much as possible 3. Encourage and praise perseverance in exercising and performing ADLs 4. Cluster activities at the end of the day when the client is most bored Answer: 3 Rationale: The client with Parkinson's disease tends to become withdrawn and depressed, and should become an active participant in his or her own care to prevent this. There should be planned activities throughout the day to inhibit daytime sleeping and boredom. The nurse gives the client encouragement and praises the client for perseverance. Exercise helps prevent progression of the disease and self-care improves self-esteem. Test-Taking Strategy: Use the process of elimination. Eliminate option 1 because of the absolute word “only.” Option 2 is well-intentioned, but is not therapeutic in helping the client cope with the disease and promotes dependence. From the remaining options, eliminate option 4 because it will promote fatigue. Review care of the client with Parkinson's disease if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 398. 60. A client with Parkinson's disease is experiencing a parkinsonian crisis. The nurse would immediately place the client: 1. In a quiet, dim room with respiratory and cardiac support available

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2. In a high-Fowler's position, with a nasogastric tube at the bedside 3. In a room near the nursing station, which is near the code cart 4. In a bed with padded side rails, with limb restraints nearby Answer: 1 Rationale: Parkinsonian crisis can occur with emotional trauma or sudden withdrawal of medications. The client exhibits severe tremors, rigidity, and bradykinesia. The client also displays anxiety, is diaphoretic, and has tachycardia and hyperpnea. The client should be placed in a quiet, dim room and respiratory and cardiac support should be available. Test-Taking Strategy: Use the process of elimination. Option 4 is not indicated and is eliminated first. Option 3 is not an immediate concern and is also eliminated. From the remaining options, note that there is nothing about parkinsonian crisis that warrants placement of a nasogastric tube. This leaves the correct option, which is to put the client in a dim, quiet room and provide for support of cardiac and respiratory symptoms. Also, use of the ABCs—airway, breathing, and circulation—will direct you to the correct option. Review nursing care for parkinsonian crisis if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Neurological Reference: Swearingen, P. (2003). Manual of medical-surgical nursing care (5th ed.). St. Louis: Mosby, p. 305. 61. A nurse has given instructions to the client with Parkinson's disease about maintaining mobility. The nurse determines that the client understands the directions if the client states that he or she will: 1. Exercise in the evening to combat fatigue. 2. Rock back and forth to start movement with bradykinesia. 3. Sit in soft, deep chairs. 4. Buy clothes with many buttons to maintain finger dexterity. Answer: 2 Rationale: The client with Parkinson's disease should exercise in the morning, when energy levels are highest. The client should avoid sitting in soft, deep chairs, because they are difficult to get up from. The client can rock back and forth to initiate movement. The client should buy clothes with Velcro fasteners and slide-locking buckles to support the ability to dress herself or himself. Test-Taking Strategy: Use the process of elimination. Option 1 is not useful to clients with fatigue from any disorder, so this option can be eliminated first. Knowing that the client with Parkinson's has difficulty with movement and dexterity helps you eliminate options 3 and 4 next. Review client teaching points with Parkinson’s disease if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Neurological Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 378.

Silvestri, 3/e, ISBN 1-1460-0052-6 Chapter 056 (edited file)—"Neurological System" 10/14/08, Page 35 of 36, 4 Figure(s), 1 Table(s), 18 Box(es)

62. A nurse has given suggestions to the client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs reinforcement of information if the client made which of the following statements? 1. "I will wash my face with cotton pads." 2. "I'll have to start chewing on the unaffected side." 3. "I should rinse my mouth sometimes if toothbrushing is painful." 4. "I'll try to eat my food either very warm or very cold." Answer: 4 Rationale: Facial pain can be minimized by using cotton pads to wash the face, using room temperature water. The client should chew on the unaffected side of the mouth, eat a soft diet, and take in foods and beverages at room temperature. If toothbrushing triggers pain, sometimes an oral rinse after meals is helpful instead. Test-Taking Strategy: Note the key words, needs reinforcement of information. These words indicate a false response question and that you need to select the incorrect client statement. Recalling that the pain of trigeminal neuralgia is triggered by mechanical or thermal stimuli will direct you to the correct option. Remember, very hot or cold foods are likely to trigger the pain, not relieve it. Review these client teaching points if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Neurological References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 643. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 405. <AQ>63. The client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client’s vital signs, list the nurse’s actions in order of priority. (Number 1 is the first priority action and number 5 is the last priority action.) ____Check for bladder distention and catheterize if present. ____Raise the head of the bed. ____Contact the physician. ____Loosen tight clothing on the client. ____Administer an antihypertensive medication, as prescribed. Answer: 31425 Rationale: Autonomic dysreflexia is characterized by severe hypertension, bradycardia, severe headache, nasal stuffiness, and flushing. The cause is a noxious stimulus, most often a distended bladder or constipation. It is a neurological emergency and must be treated promptly to prevent a hypertensive stroke. Immediate nursing actions are to sit the client up in bed in a high-Fowler’s position and remove the noxious stimulus. The nurse would loosen any tight clothing, and check for bladder distention, and catheterize the client if distention is present. If the client has a Foley catheter, the nurse would check for kinks in the tubing. The nurse would also check for a fecal impaction and disimpact the client, if necessary. The physician is contacted if these actions do not relieve the signs and symptoms. Antihypertensive medication may be prescribed by the

Silvestri, 3/e, ISBN 1-1460-0052-6 Chapter 056 (edited file)—"Neurological System" 10/14/08, Page 36 of 36, 4 Figure(s), 1 Table(s), 18 Box(es)

physician to minimize cerebral hypertension. Test-Taking Strategy: Recalling that this syndrome causes severe hypertension will assist in determining that elevating the head of the bed is the first action. Next, recalling that the syndrome is caused by a noxious stimulus will assist in determining that loosening tight clothing, checking for bladder distention, and catheterizing if necessary would be the next actions. Because loosening any tight clothing would take less time than checking for bladder distention and catheterizing, this action would be taken next. Antihypertensives require a physician’s order; therefore, calling the physician would be the next action. Review immediate nursing interventions for the client experiencing autonomic dysreflexia if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing References: Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders, p. 988. Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 1625.

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