Nursing Care of Patients With Central Nervous System Disorders

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____ 1. The nurse is caring for a patient brought to the emergency department after an automobile accident. The patient is fully conscious. For what early signs of increased intracranial pressure (ICP) should the nurse be alert?
a. Bradycardia
b. Hypothermia
c. Pinpoint pupils
d. Decreased level of consciousness
____ 2. The vital signs for a client with a possible head injury were on admission: blood pressure 128/72 mm Hg, pulse 90 beats/min, and respirations 66 breaths/min. Which vital sign assessment conducted four hours later most likely indicates the presence of increased intracranial pressure (ICP)?
a. Blood pressure 172/68 mm Hg, pulse 42 beats/min, respirations 10 breaths/min
b. Blood pressure 160/90 mm Hg, pulse 112 beats/min, respirations 16 breaths/min
c. Blood pressure 130/72 mm Hg, pulse 50 beats/min, respirations 24 breaths/min
d. Blood pressure 100/70 mm Hg, pulse 120 beats/min, respirations 30 breaths/min
____ 3. A patient who was in an industrial accident has had a sudden increase in intracranial pressure and is being prepared for placement of an emergency subarachnoid bolt. Which action should the nurse make a priority at this time?
a. Find out how the accident happened.
b. Ensure the patient is bathed before surgery.
c. Have the patient’s next of kin sign a consent form.
d. Send the patient’s belongings home with a family member.
____ 4. A patient with a severe headache due to viral meningitis requests an opioid analgesic. What explanation about opioids should the nurse provide?
a. “Opioid analgesics increase intracranial pressure.”
b. “Opioid analgesics are used as a last resort for headaches.”
c. “Opioid analgesics are contraindicated in patients with meningitis.”
d. “Acetaminophen (Tylenol) is more effective in treating meningitis-related headaches.”
____ 5. The nurse concludes that a patient’s meningitis is improving. What activity did the patient perform for the nurse to come to this conclusion?
a. Dorsiflex both feet.
b. Sit up and drink water.
c. Touch the chin to the chest.
d. Maintain a side-lying position in bed.
____ 6. The nurse is assisting with teaching a patient about tension headaches. Which explanation of tension headaches should the nurse provide?
a. “Tension headaches result from release of pain mediators in the periphery.”
b. “Tension headaches are caused by stress, which causes cerebral vessel constriction.”
c. “Tension headaches are a result of stress and sustained muscle contraction of the head and neck.”
d. “Tension headaches are caused by blood sugar fluctuations that result from excessive stress.”
____ 7. The nurse is determining care for a patient with acute migraine headaches. What should the nurse teach the patient to do first in order to determine a plan of care for the headaches?
a. Keep a headache diary.
b. Avoid sugar and caffeine.
c. Avoid bright light and noise.
d. Avoid taking analgesics until the cause has been determined.
____ 8. The nurse administers an analgesic to a patient with a headache. How should the nurse assess the patient’s response to the medication?
a. Observe the patient’s behavior.
b. Ask the patient to describe the pain.
c. Monitor the patient’s blood pressure and pulse.
d. Have the patient rate the pain on a scale of 0 to 10.
____ 9. A student under a great deal of stress develops a severe tension headache and goes to the school clinic. What strategy should the nurse teach the student for dealing with the onset of headaches in the future?
a. Aerobic exercise
b. Relaxation exercises
c. Use of vitamin C and zinc
d. Use of distraction techniques
____ 10. While walking to the bathroom a patient begins having a generalized tonic-clonic seizure. What should the nurse do first?
a. Reduce external stimuli.
b. Maintain the patient’s airway.
c. Maintain the patient’s privacy.
d. Perform a brief neurological assessment.
____ 11. A patient recovering from surgery to remove a brain tumor is found jerking rhythmically in the bed and unresponsive to verbal stimuli. What should the nurse do first?
a. Call the physician.
b. Find another nurse to assist.
c. Hold the patient firmly to keep the patient from injuring someone.
d. Protect the patient from injury and observe the sequence of events.
____ 12. A patient is incontinent during a seizure and sleeps for several hours afterward. What type of seizure did the patient most likely experience?
a. Absence
b. Tonic-clonic
c. Simple partial
d. Status epilepticus
____ 13. A patient in the post-ictal period after a seizure remembers smelling something like dead fish prior to the seizure. Which response by the nurse is best?
a. “Today is Friday; the hospital always cooks fish on Fridays.”
b. “You were probably hallucinating; I will ask for an order for an anti-hallucinatory agent.”
c. “The smell of dead fish might be your aura; you should call for help immediately if you smell it again.”
d. “Most people see a flash of light before a seizure; if this occurs, you should get to safety immediately.”
____ 14. A patient with a newly diagnosed seizure disorder is being prepared for discharge. What medication should the nurse anticipate will be prescribed for the patient to prevent recurrent seizures?
a. Selegiline (Eldepryl)
b. Haloperidol (Haldol)
c. Gabapentin (Neurontin)
d. Dexamethasone (Decadron)
____ 15. A patient who has had a seizure is crying, saying life is over, and that working and driving will no longer be possible. Which response by the nurse is most appropriate?
a. “With good seizure control, you should be able to work and drive again.”
b. “Maybe the social worker can help you identify some alternative activities.”
c. “You may be able to work again in time; you can use public transportation.”
d. “You should be able to discontinue your medication within a month and return to work.”
____ 16. The nurse is assessing a patient recovering from a tonic-clonic seizure. Which finding indicates a need for immediate nursing intervention?
a. The patient is difficult to arouse.
b. The patient has been incontinent of urine.
c. The patient has frothy sputum in the pharynx and gurgling respirations.
d. The patient becomes belligerent when the nurse does neurological assessments.
____ 17. A 17-year-old patient with a new onset of seizures is diagnosed with epilepsy. What should the nurse include in the patient teaching?
a. Aspirin can inhibit the action of anticonvulsants.
b. Sudden withdrawal of anticonvulsants can lead to status epilepticus.
c. Anticonvulsants must be taken frequently during the day to prevent seizures.
d. When the seizures have been controlled, the medications can be discontinued.
____ 18. A patient arriving in the emergency department with a bullet wound to the left frontal lobe is comatose. What should the nurse make a priority for this patient?
a. Evaluate fluid balance.
b. Maintain an open airway.
c. Maintain body temperature.
d. Evaluate neurological status.
____ 19. The nurse is caring for a patient admitted to the emergency department with massive trauma to the right frontal lobe of the brain. Which data should the nurse collect related to the location of the injury?
a. Presence of intact smell
b. Presence of intact pupillary reflex
c. Ability to remember the name of the current president
d. Ability to use extraocular muscles (EOMs) of the eyes
____ 20. A patient with a cerebral injury is experiencing increased intracranial pressure (ICP). Which intervention should the nurse use to help prevent further increasing intracranial pressure?
a. Avoid touching the patient as much as possible.
b. Provide stimulation such as radio and television for 12 hours each day.
c. Provide as much nursing care at one time as possible to allow the patient to rest.
d. Space nursing care at intervals so that necessary care is distributed evenly throughout a shift.
____ 21. The nurse is caring for a patient with a traumatic brain injury. Which assessment finding alerts the nurse to possible diabetes insipidus?
a. Headache
b. Confusion
c. Frequent urination
d. Elevated blood glucose
____ 22. The physician prescribes intravenous mannitol for a patient who has a head injury and increased intracranial pressure (ICP). Which assessment finding indicates to the nurse that the patient is having a therapeutic response to the mannitol?
a. Return of the gag reflex
b. Increased blood glucose
c. Increased urinary output
d. Decreased Glasgow Coma Scale (GCS) score
____ 23. A teen is experiencing a headache and dizziness after falling of a bicycle and hitting the head. The physician diagnoses a concussion. What explanation should the nurse provide to the patient’s mother?
a. The patient may lose consciousness before beginning to recover.
b. The patient has had some intracranial bleeding but should recover in time.
c. The patient has had a minor head trauma and should recover spontaneously.
d. The patient may need to have surgery to relieve increased intracranial pressure.
____ 24. A patient is recovering from an epidural bleed. In which part of the brain should the nurse explain to the family that this bleed occurred?
a. Circle of Willis
b. Spinal meninges
c. Space below the dura
d. Space between the dura and the skull
____ 25. The nurse is assisting with teaching family members about a patient’s epidural bleed. Which information about an epidural bleed should guide the nurse’s teaching?
a. It is usually venous and absorbs in time.
b. It is within the brain tissue, so residual effects are likely.
c. It usually causes quadriplegia, and rehabilitation will be necessary.
d. It is usually arterial and may lead to death without rapid intervention.
____ 26. The nurse is preparing to assess a patient with a head injury. Which data should the nurse include in this routine neurological nursing assessment?
a. Vital signs, lung sounds, and pedal pulses
b. Glasgow Coma Scale, pupil response, and vital signs
c. Range of motion, deep tendon reflexes, and capillary refill
d. Romberg test, Babinski reflex, and cranial nerve assessment
____ 27. The nurse notes that a patient with a head injury has a widening pulse pressure. Which action should the nurse take at this time?
a. Give an extra dose of diuretic.
b. Lay the bed flat and check pupil response.
c. Raise the head of the bed and notify the registered nurse (RN).
d. None; this is an expected finding after a head injury.
____ 28. A patient with a newly diagnosed brain tumor receives dexamethasone (Decadron) IV, which completely relieves the patient’s symptoms. What should the nurse explain to the family about the patient’s response to the medication?
a. “The brain is such a unique organ; we never really know what will happen.”
b. “By dilating the arteries in the brain, blood flow is improved and symptoms improve.”
c. “The Decadron works to reduce swelling in the brain caused by the tumor; we often see remarkable improvement.”
d. “Decadron regenerates neurons in the central nervous system, so the patient should continue to get even better over the next week or so.”
____ 29. The nurse suspects a patient with a spinal cord injury is experiencing spinal shock. What did the nurse assess to come to this conclusion?
a. Flaccid paralysis and lack of sensation below the level of the injury
b. Loss of voluntary motor control, but presence of reflex activity below the level of the injury
c. Falling blood pressure and rising pulse accompanied by reduced level of consciousness
d. Loss of motor control below the level of the injury with sensations of touch and position intact
____ 30. A patient with quadriplegia from a C5 injury is wearing a Halo vest and begins to experience a throbbing headache and nausea. What should the nurse do first?
a. Check the patient’s blood pressure.
b. Do a digital rectal examination for the presence of an impaction.
c. Notify the charge nurse or physician immediately of the patient’s headache.
d. Advise the patient that sitting in the wheelchair will help relieve the headache.
____ 31. A patient with suspected spinal cord and head injuries has a Glasgow Coma Scale score of 15; blood pressure 130/82 mm Hg, pulse 102 beats/min, respirations 20 breaths/min, and temperature 98°F (36.6°C). What is the most important nursing intervention during the initial care of the patient?
a. Avoid moving the patient.
b. Check the extremities for range of motion.
c. Turn the patient to the side to avoid aspiration.
d. Keep the head of the bed elevated 30 degrees.
____ 32. The spouse of a patient with a C7 spinal cord injury provides all care for the patient in addition to caring for three children. Which outcome criteria should the nurse identify as relevant for a nursing diagnosis of Caregiver Role Strain for this patient’s plan of care?
a. Caregiver maintains patient’s health.
b. Caregiver accepts constructive criticism.
c. Caregiver accepts responsibility for own actions.
d. Caregiver identifies resources available to assist with care.
____ 33. An adolescent sustains an injury while swimming in a river. Friends bring the adolescent to the riverbank and note that the adolescent is conscious and breathing but not moving any extremities. What should the friends do next?
a. Immobilize the boy, and call for help.
b. Push on his stomach to rid his lungs of water.
c. Use a four-man carry to take the boy to safety.
d. Turn him onto his stomach to allow water to drain from his lungs.
____ 34. A patient with a spinal cord injury is unable to move the extremities. In which area should the nurse suspect that this client’s injury occurred?
a. L1–L4
b. C4–C8
c. T8–T11
d. Above C4
____ 35. A patient is unable to move the extremities after experiencing a spinal cord injury. What term should the nurse use to document paralysis of all four extremities?
a. Paraplegia
b. Hemiparesis
c. Quadriplegia
d. Quadriparesis
____ 36. The nurse is caring for a patient who has had Parkinson’s disease for 15 years. What symptoms should the nurse anticipate when assisting with a routine assessment?
a. Cough, fever, and impaired airway clearance
b. Intention tremor, flaccid muscles, and tachykinesia
c. Hemiparesis, tremor of the head, and blurred vision
d. Slow shuffling gait, difficulty swallowing, and pill-rolling tremor
____ 37. A patient newly diagnosed with Parkinson’s disease is prescribed carbidopa/levodopa (Sinemet). Which patient statement indicates teaching about the medication has been effective?
a. “The medication causes urinary retention and a dry mouth.”
b. “Sinemet reduces inflammation in the central nervous system.”
c. “I should take this medication when my hand tremors bother me.”
d. “This medication converts to dopamine in the brain so my symptoms should improve.”
____ 38. A patient with Parkinson’s disease has difficulty tying shoes. What nursing intervention would be the most helpful?
a. Tie the shoes for the patient.
b. Reteach the patient to tie shoes.
c. Have a family member purchase shoes with Velcro fasteners.
d. Explain to the patient that as the disease progresses, there will be many things that will require assistance.
____ 39. The nurse is caring for residents on an Alzheimer’s unit. Which assessment finding indicates that a patient is in early stages of the disease?
a. Agitation
b. Forgetfulness
c. Combativeness
d. Increased intracranial pressure (ICP)
____ 40. The nurse is planning care for a patient with advancing Alzheimer’s disease. Which nursing diagnosis should be the priority for this patient?
a. Risk for Injury
b. Noncompliance
c. Bathing Self-Care Deficit
d. Ineffective Role Performance
____ 41. A nursing home resident with Alzheimer’s disease appears extremely distressed after breakfast. On which understanding should the nurse base interventions for this patient?
a. The patient needs an increase in antipsychotic medications.
b. The patient could quickly become more anxious and dysfunctional.
c. The patient would benefit from external stimuli and diversionary activities.
d. This is part of the sundowning syndrome associated with Alzheimer’s disease.
____ 42. The nurse caring for patients with dementia. Which intervention would be least helpful when coordinating care for patients who are experiencing confusion?
a. Providing finger foods
b. Monitoring cognitive functioning
c. Using soft restraints when the patient is left alone
d. Providing structured rest periods to prevent fatigue
____ 43. A patient is prescribed phenytoin (Dilantin) for seizure activity. What should the nurse include when teaching the patient about this medication?
a. “Be sure to brush and floss your teeth daily.”
b. “Be sure to arrange for regular checkups for potassium levels.”
c. “You may notice some vision changes while taking this drug.”
d. “You may experience shortness of breath as a side effect of the drug.”
____ 44. The nurse is notes that a patient recovering from a craniotomy has a pink spot with a yellow ring around it on the pillow. What should the nurse do?
a. Change the patient’s pillowcase.
b. Do a basic neurological assessment.
c. Notify the charge nurse immediately.
d. Change the patient’s cranial dressing.
____ 45. A patient is diagnosed with increased intracranial pressure. What pressure measurement should the nurse expect to be associated with this diagnosis?
a. 3
b. 5
c. 8
d. 17
____ 46. The nurse is observing a patient to determine if seizure activity is status epilepticus. For what length of time should seizure activity occur for this diagnosis to be appropriate for the patient?
a. 1 minute
b. 5 minutes
c. 20 minutes
d. 30 minutes
____ 47. A patient recovering from a brain injury is having difficulty completing activities of daily living. What should the nurse suggest to help this patient recover independence with self-care?
a. Occupational therapy consultation
b. Transfer to a rehabilitation facility
c. Hire long-term private care assistance
d. Cognitive stimulation to keep on track
Multiple Response
Identify one or more choices that best complete the statement or answer the question.

____ 48. The nurse is caring for an individual who has a tension headache. Which interventions should be included in the patient’s plan of care? (Select all that apply.)
a. Massage
b. Moist heat
c. Ergotamine
d. Dark glasses
e. Aerobic exercise
f. Cold compresses
____ 49. The nurse is planning care for a patient with a migraine headache. Which actions should the nurse include in this plan of care? (Select all that apply.)
a. Rest
b. White noise
c. A dark, quiet room
d. Sumatriptan (Imitrex)
e. Acetaminophen (Tylenol)
f. Pseudoephedrine (Sudafed)
____ 50. The nurse is caring for a patient with an acute brain injury. Which interventions should the nurse use to prevent increased intracranial pressure in this patient? (Select all that apply.)
a. Avoid hip flexion.
b. Administer stool softeners.
c. Keep head of bed elevated 30 degrees.
d. Encourage deep breathing and coughing.
e. Administer opioid analgesics for headache.
____ 51. A patient is experiencing a new onset of a seizure. What should the nurse include in this patient’s plan of care? (Select all that apply.)
a. Suction if necessary.
b. Monitor vital signs when possible.
c. Place the patient in a supine position.
d. Restrain the patient to prevent injury.
e. Observe and document progression of symptoms.
f. Protect the patient from injury by removing nearby objects.
____ 52. The nurse suspects that a patient is experiencing increasing intracranial pressure. What observations did the nurse make to come to this conclusion? (Select all that apply.)
a. Headache
b. Rising temperature
c. Decreasing systolic pressure
d. Dilated pupil on affected side
e. Decreasing level of consciousness (LOC)
____ 53. A patient is diagnosed with a benign familial tremor. Which characteristics of this tremor should the nurse expect to observe? (Select all that apply.)
a. Resting tremor
b. Intention tremor
c. Pill-rolling tremor
d. Head/voice tremor
e. Relieved by beta blocker drugs
____ 54. A patient has been prescribed the dopamine agonist pramipexole (Mirapex) for Parkinson’s disease. Which are important for the nurse to include when teaching about this medication? (Select all that apply.)
a. “Take it at noon each day.”
b. “Increase fluids and fiber in your diet.”
c. “Taking the medication with food may reduce nausea.”
d. “You may experience sudden bouts of excessive sleepiness.”
e. “Do not drive until the effects of this drug on you are fully known.”
f. “Because this drug may interact with some painkillers, be sure to tell health care providers that you are taking Mirapex.”
____ 55. A patient with a spinal cord injury at T3–T4 experiences a sudden increase in blood pressure (BP) and has cool, pale, gooseflesh skin on the lower extremities. What should the nurse do while awaiting physician orders? (Select all that apply.)
a. Monitor BP every 5 minutes.
b. Place the patient in supine position.
c. Place elastic stockings on the patient’s legs.
d. Check to see if the indwelling catheter is patent.
e. Perform a rectal examination to determine if impaction is present.
____ 56. The nurse is caring for a patient diagnosed with bacterial meningitis. Which medications should the nurse expect to be prescribed for this patient? (Select all that apply.)
a. Analgesics
b. Antibiotics
c. Antipyretics
d. Anticoagulants
e. Anti-inflammatory agents
____ 57. A patient with bacterial meningitis has an elevated temperature. Which actions should the nurse take to reduce this patient’s temperature? (Select all that apply.)
a. Use tepid sponge baths as needed
b. Monitor temperature every 4 hours
c. Apply ice to the groin every 2 hours
d. Administer antipyretics as prescribed
e. Place on a cooling blanket if available
____ 58. A patient with a brain injury is not able to respond appropriately to sensory stimulation. What should the nurse do to ensure that this patient does not develop skin breakdown? (Select all that apply.)
a. Protect bony prominences
b. Assess the skin every 2 hours
c. Moisturize the skin as needed
d. Apply paper tape over wounds
e. Turn and reposition every 2 hours
____ 59. After collecting data the nurse determines that a patient is experiencing cluster headaches. What information did the nurse use to come to this conclusion? (Select all that apply.)
a. Throbbing and excruciating pain
b. Bright sunlight causes severe eye pain
c. Sudden onset at the same time during the night
d. Pain that affects one side of the nose, eye and forehead
e. The eye on the side of the headache is bloodshot and tearing

Chapter 48. Nursing Care of Patients With Central Nervous System Disorders
Answer Section

MULTIPLE CHOICE

1. ANS: D
Initial symptoms of increased ICP include restlessness, irritability, and decreased level of consciousness, because cerebral cortex function is impaired. If not intubated, the patient may hyperventilate, causing vasoconstriction as the body attempts to compensate. As the pressure increases, the oculomotor nerve may be compressed on the side of the impairment. C. Compression of the outermost fibers of the oculomotor nerve results in diminished reactivity and dilation of the pupil. As the fibers become increasingly compressed, the pupil stops reacting to light. If the compression continues, and the brain tissue exerts pressure on the opposite side of the brain from the injury, both pupils become fixed and dilated. B. Hypothermia is not a sign of IICP. A. Vital sign changes are a late indication of increasing ICP.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

2. ANS: A
Vital sign changes are a late indication of increasing ICP. Cushing’s response is a classic late sign of increased ICP. Cushing’s response (or Cushing’s triad) is characterized by bradycardia, bradypnea, and arterial hypertension (increasing systolic blood pressure while diastolic blood pressure remains the same), resulting in widening pulse pressure. B. These vital signs indicate tachycardia. C. These vital signs indicate tachypnea. C. These vital signs indicate both tachycardia and tachypnea.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis|

3. ANS: C
The patient is unlikely to be able to sign a consent form, and it must be signed for surgery to begin. B. Bathing is not a priority. A. D. Belongings and further questioning can be taken care of after the patient is in surgery.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level: Application

4. ANS: B
Opioids are habit forming and are used only as a last resort for headaches. A. C. They do not increase intracranial pressure, and they are not contraindicated for other reasons. D. Tylenol is much less effective than an opioid.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

5. ANS: C
Ability to touch the chin to the chest indicates improvement in nuchal rigidity. A. B. D. An improvement in the patient’s condition is not associated with the ability to dorsiflex the feet, sit up, drink water, or maintain a side-lying position in bed.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Evaluation

6. ANS: C
Persistent contraction of the scalp, facial, cervical, and upper thoracic muscles can cause tension headaches. A cycle of muscle tension, muscle tenderness, and further muscle tension is established. B. A migraine headache is believed to be caused by cerebral vasoconstriction followed by vasodilation. A. Pain mediators in the periphery are associated with peripheral pain, not headaches. D. Blood sugar fluctuations can cause headaches related to diabetes, not stress.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

7. ANS: A
The patient can identify aggravating factors by keeping a headache diary for a time, recording the time of day the headache occurs, foods eaten or other aggravating factors, description of the pain, identification of associated symptoms such as nausea or visual disturbances, and other factors related to headache symptoms. B. C. Avoiding foods or lights and noise might be helpful, but they do not help identify factors causing headaches. D. Avoiding analgesics is unrealistic.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

8. ANS: D
A pain rating scale is the most objective measure of the patient’s pain. A, B, and C may also be helpful but are not the primary data needed. Blood pressure and pulse may increase with acute pain but not with chronic pain.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

9. ANS: B
Relaxation exercises help treat and may help stop a headache before it becomes severe. D. Distraction is good for some types of pain but less so for headaches. C. Vitamin C and zinc are good for wound healing. A. Aerobic exercise may promote general health and help the student to deal with stress but will not help once the headache has begun.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

10. ANS: B
The prime objective in caring for a patient experiencing a seizure is to prevent injury. Maintain a patent airway, and if possible, turn the patient on his or her side to prevent aspiration if vomiting occurs. Do not force an airway or anything else into the patient’s mouth once the seizure has begun. C. D. Assessment and privacy are important, but airway always takes priority. A. Reducing stimuli will not help once the seizure has begun.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

11. ANS: D
The prime objective in caring for a patient experiencing a seizure is to prevent injury to the patient. A. B. Once the patient’s safety has been assured, another nurse can be called to assist and the physician can be notified if necessary. C. Holding the patient increases the risk of injury.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

12. ANS: B
Generalized tonic-clonic seizures follow a typical progression. Aura and loss of consciousness may or may not occur. The patient is often incontinent. Patients who experience a generalized seizure may sleep deeply for 30 minutes to several hours. A. C. Absence and simple partial seizures are not generally associated with incontinence. D. A patient in status epilepticus may be incontinent but would still be having a seizure and not sleeping.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

13. ANS: C
Some patients experience an aura or sensation that warns the patient that a seizure is about to occur. An aura may be a visual distortion, a noxious odor, or an unusual sound. Patients who experience an aura may have enough time to sit or lie down before the seizure starts, thereby minimizing the chance of injury. B. Treating the aura as a hallucination does not help the patient to get to safety. A. Commenting on a food item on the menu is not appropriate. D. Flashes of light can occur however a noxious odor can also be an aura.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

14. ANS: C
Gabapentin is an anticonvulsant agent. D. Dexamethasone is a steroid. B. Haloperidol is an antipsychotic agent. A. Selegiline is used to treat Parkinson’s disease.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

15. ANS: A
Patients with poorly controlled seizures should not operate motor vehicles. If seizures can be well controlled with medication, then driving is possible. B. C. These are inappropriate statements until it is known how the patient responds to medication. D. Discontinuing the medication may be done after an extended seizure-free period but not after a month.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

16. ANS: C
Gurgling respirations and frothy sputum indicate aspiration, and a clear airway is a priority. A. B. Difficulty arousing and incontinence of urine are not uncommon findings after a tonic-clonic seizure. D. Belligerence is a concern but is not life threatening.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

17. ANS: B
Sudden discontinuance of a medication can result in status epilepticus. A. Aspirin does not interfere with anticonvulsants—each drug has different interactions that should be checked and communicated to the patient. C. The schedule is also dependent on the drug—some may be needed only once or twice a day. D. Medications for epilepsy will most likely be needed lifelong.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

18. ANS: B
Remember the ABCs: airway is always the first priority. A. C. D. Fluid balance, body temperature, and neurological status are important however are not helpful if the patient does not have a patent airway.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

19. ANS: C
The cerebral cortex, and therefore the frontal lobe, is involved in thinking, learning, and memory. A. B. D. Olfactory sense, pupils, and EOMs are controlled by cranial nerves.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

20. ANS: D
The nurse should space care activities to provide rest between each disturbance. C. Clustering care may raise ICP. B. Stimulation can also raise ICP. A. Avoiding touch is not necessary.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

21. ANS: C
Edema or direct injury affects the posterior portion of the pituitary gland or hypothalamus. Inadequate release of antidiuretic hormone results in polyuria and, if the patient is awake, polydipsia. Fluid replacement and intravenous vasopressin are used to maintain fluid and electrolyte balance. A. B. Headache and confusion are symptoms of intracranial pressure (ICP). D. Elevated glucose is a sign of diabetes mellitus, not insipidus.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

22. ANS: C
If ICP remains elevated despite drainage of cerebrospinal fluid, the next step is use of an osmotic diuretic. The most commonly used drug is intravenous mannitol (Osmitrol). Mannitol utilizes osmosis to pull fluid into the intravascular space and eliminate it via the renal system. D. The GCS score should increase, not decrease. A. B. Blood glucose and gag reflex are not affected by mannitol.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Evaluation

23. ANS: C
Cerebral concussion is considered a mild brain injury. If there is a loss of consciousness, it is for 5 minutes or less. Concussion is characterized by headache, dizziness, or nausea and vomiting. The patient may complain of amnesia of events before or after the trauma. On clinical examination, there is no skull or dura injury and no abnormality detected by computed tomography (CT) or magnetic resonance imaging (MRI). A. B. D. These statements explain more serious head injuries.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

24. ANS: D
An epidural hematoma is a collection of blood between the dura mater and skull, is usually arterial in nature, and is often associated with skull fracture. A subdural hematoma is typically venous in nature and accumulates between the dura and arachnoid membranes. A. B. C. An epidural bleed does not occur within the Circle of Willis, spinal meninges or the space below the dura.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level: Application

25. ANS: D
An epidural bleed is usually arterial in nature. Arterial bleeding can cause the hematoma to become large very quickly. The patient will die without rapid intervention. A. Subdural bleeds are more likely venous. B. A contusion is bruising of brain tissue. C. Paralysis depends on the area of central nervous system (CNS) injured.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

26. ANS: B
Assessment of neurological status minimally includes Glasgow Coma Scale score, pupil responses, muscle strength, and vital signs. A. C. Additional assessment of body systems are important but are not part of a neurological assessment. D. Romberg, Babinski, and cranial nerve assessment is more advanced and not routine.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

27. ANS: C
Widening pulse pressure or falling blood pressure are signs of increased intracranial pressure (ICP) and should be reported promptly. B. Raising the head of the bed 30 degrees may help reduce ICP. D. Increased ICP is not unexpected, but it is not normal and must be reported. A. A diuretic would only be given with a physician’s order.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

28. ANS: C
Dexamethasone is a steroid that may reduce brain swelling. A. B. D. Dexamethasone is not a vasodilator, and it does not regenerate nerve tissue.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

29. ANS: A
Immediately following a spinal cord injury, the cord below the injury stops functioning completely. This leads to a loss of motor and sensory functions as well as reflexes. B. C. D. Falling blood pressure and rising pulse indicate shock from blood loss or cardiovascular cause.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

30. ANS: A
The patient has symptoms of autonomic dysreflexia, which can occur in patients with injuries above the T6 level. B. Once blood pressure is checked and under control, then further assessment can be done to find the source of the problem. D. Sitting will not fix the problem. C. The physician or charge nurse can be notified as needed once further assessment and intervention are completed.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

31. ANS: A
The first priority is prevention of further spinal cord injury, so the patient must be kept flat without movement of the trunk. B. C. D. Checking range of motion, turning, or elevating the head could cause further injury.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

32. ANS: D
The spouse needs help, and the nurse can help identify resources to assist her. A. B. C. These outcome statements do not address the caregiver role strain diagnosis.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

33. ANS: A
He has a possible spinal cord injury and should be immobilized and not moved to prevent further injury. B. D. Since he is breathing, providing respiratory interventions can wait until emergency personnel are present. C. The patient should not be moved.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

34. ANS: B
Cervical cord injuries can affect all four extremities, causing paralysis and paresthesias, impaired respiration, and loss of bowel and bladder control. D. If the injury is at C3 or above, the injury is usually fatal because muscles used for breathing are paralyzed. An injury at the fourth or fifth cervical vertebrae affects breathing and may necessitate some type of ventilatory support. A. C. Thoracic and lumbar injuries affect the legs, bowel, and bladder.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

35. ANS: C
Paralysis of all four extremities is called quadriplegia. D. Weakness of all extremities is called quadriparesis. A. Paraplegia is paralysis of the lower extremities. B. Hemiparesis is weakness of one side.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

36. ANS: D
Slow shuffling gait, difficulty swallowing, and pill-rolling tremor are typical of Parkinson’s disease. B. Intention tremor is more common with a familial tremor. C. Hemiparesis is most common with stroke or brain injury. A. Cough and fever are signs of respiratory illness.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

37. ANS: D
Levodopa/carbidopa (Sinemet) converts to dopamine in the brain. Carbidopa prevents peripheral breakdown of levodopa, so more is available in the central nervous system (CNS). A/ Urine retention and dry mouth are associated with anticholinergic medications such as Trihexyphenidyl (Artane). C. Sinemet should be taken consistently, not on a prn schedule. B Sinemet does not affect inflammation.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Analysis

38. ANS: C
Providing Velcro fasteners allows the patient to remain independent as long as possible. B. Re-teaching is not appropriate: The patient has not forgotten how to tie his shoes; he is unable because of motor difficulties. A. Typing the patient’s shoes takes away his independence. D. Explaining that the patient will need more assistance as the disease progresses does not address the current issue of not being able to tie the shoes.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

39. ANS: B
The signs and symptoms of Alzheimer’s disease are typically broken down into three stages. The early stage, stage one, lasts 2 to 4 years and is characterized by increasing forgetfulness. A. C. D. Behavior changes occur later, and increased ICP is not associated with Alzheimer’s.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

40. ANS: A
According to Maslow’s hierarchy, safety needs come before higher-level needs. In addition, injury is the most life- and health-threatening problem. B. C. D. These nursing diagnoses can be addressed after the Risk for Injury has been addressed.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

41. ANS: B
Stress may increase dysfunctional behaviors. D. Sundowning is confusion that occurs at sundown, not in the morning; it has not been validated. A. Increasing medications is inappropriate if simple environment alterations can keep the patient calm. C. Stimuli make dysfunction worse, not better.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

42. ANS: C
Restraints can increase the risk of agitation and injury. A. B. D. Finger foods, structured rest periods, and monitoring are all helpful when caring for a patient with confusion.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

43. ANS: A
Regular dental care is important because of risk for gingival hyperplasia. B. C. D. Shortness of breath, vision changes, and potassium imbalance are not associated with phenytoin therapy.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

44. ANS: C
Drainage that is blood-tinged in the center with a yellowish ring around it may be cerebrospinal fluid (CSF) leakage. A suspected CSF leak should be reported to the charge nurse or physician immediately. A. B. These actions can be completed after the charge nurse has been notified. D. The dressing is changed only with a physician’s order.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

45. ANS: D
Normal ICP is 0 to 15 mm Hg. This pressure fluctuates with normal physiological changes, such as arterial pulsations, changes in position, and increases in intrathoracic pressure. A. B. C. These are considered normal intracranial pressure measurements.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

46. ANS: D
Status epilepticus is characterized by at least 30 minutes of repetitive seizure activity without a return to consciousness. This is a medical emergency and requires prompt intervention to prevent irreversible neurological damage. A. B. C. Seizure activity must occur for longer than 1, 5 or 20 minutes before being identified as status epilepticus.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

47. ANS: A
For the patient having difficulty completing self-care actions, an occupational therapy consultation might be needed. An occupational therapist is trained to assist patients to manage ADLs within health limitations. B. The patient does not need to be transferred to a rehabilitation facility. C. Long-term private care assistance is not needed while the patient is still hospitalized. This might need to be an option once discharged to home. D. Cognitive stimulation is not an option for this type of health problem.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level: Application

MULTIPLE RESPONSE

48. ANS: A, B
Symptom management may include the use of relaxation techniques, massage of the affected muscles, rest, localized heat application, nonnarcotic analgesics, and appropriate counseling. F. Heat, not cold, will relax muscles. C. Ergotamine may be helpful for a migraine headache. E. Rest, not exercise, may help. D. Photophobia is not typically associated with a tension headache.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

49. ANS: A, C, D
A dark room and rest help reduce stimulation during a migraine headache. Sumatriptan is a medication available used for migraine relief. E. F. Acetaminophen and decongestants may be helpful for sinus headaches. B. Stimulation (noise and light) may worsen a migraine.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

50. ANS: A, B, C
Elevation of the head of the bed may help reduce intracranial pressure (ICP). Stool softeners prevent straining, which can increase ICP. Hip flexion may also increase ICP. D. E. Coughing can increase ICP, and opioid analgesics make neurological assessment difficult.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

51. ANS: A, B, E, F
The patient should be protected from injury. Vital signs are monitored when able, if it will not injure the patient. Observing symptom progression can help diagnose the type of seizure, and suction may be necessary to prevent aspiration. C. The patient should be placed in a side-lying position if possible, not supine, to prevent aspiration. D. Restraining the patient increases the risk for injury.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

52. ANS: A, B, D, E
Headache, increasing systolic pressure, decreasing LOC, dilated pupil on affected side, and rising temperature are all signs of increased ICP. C. Decreasing systolic blood pressure is not associated with increased intracranial pressure.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

53. ANS: B, D, E
Patients with familial tremor experience an intention tremor and head and voice tremors; symptoms may be improved with beta blockers. A. C. A resting, pill-rolling tremor is common with Parkinson’s disease.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

54. ANS: C, D, E
Patients may fall asleep suddenly when taking this medication. The patient should be cautioned to avoid driving until effects are known. Giving with meals may reduce nausea. B. It is unknown if this medication causes constipation. A. F. Selegiline, not pramipexole, should be given at noon and interacts with meperidine (Demerol).

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

55. ANS: A, D, E
The patient is experiencing autonomic dysreflexia, which can cause hypertension and bradycardia. The nurse should monitor BP and then check for catheter patency and impaction, both of which can cause dysreflexia. B. C. The patient should be placed in high Fowler’s position, and elastic stockings should be removed to allow blood to pool and reduce BP.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

56. ANS: A, B, C, E
Analgesics are given to lessen head and neck pain. Antibiotics are administered for bacterial meningitis. Antipyretics such as acetaminophen are used to control the fever. Anti-inflammatory agents are given to decrease swelling. D. Anticoagulants are not routinely administered in the treatment of bacterial meningitis.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

57. ANS: A, B, D, E
To help reduce hyperthermia associated with bacterial meningitis the nurse should use tepid sponge baths as needed, monitor the temperature every 4 hours, administer antipyretics as prescribed, and place on a cooling blanket if available. C. Ice should not be applied to the groin because shivering could occur.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

58. ANS: A, B, C, E
To protect the skin of a patient with an alteration in sensation, the nurse should protect bony prominences, assess the skin every 2 hours, moisturize the skin as needed, and turn and reposition the patient every 2 hours. D. Paper tape can adhere to delicate skin tissue and cause tears.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care Environment—Management of Care | Cognitive Level: Application

59. ANS: A, C, D, E
Manifestations of cluster headaches include throbbing and excruciating pain, sudden onset typically at the same time of night, pain that is be unilateral, affecting the nose, eye, and forehead, and a bloodshot, teary appearance of the affected eye. B. Photophobia is not a manifestation of cluster headaches.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis