kmn,n.pdf: Chapter 36 Introduction to the Nervous System PDF

Chapter 36: Introduction to the Nervous System 1. The nurse provides care for a client who is comatose and needs to collect motor response data. Which nursing action is appropriate? A. Using the Romberg test B. Observing the reaction of pupils to light C. Observing the client's response to painful s...

Chapter 36: Introduction to the Nervous System 1. The nurse provides care for a client who is comatose and needs to collect motor response data. Which nursing action is appropriate? A. Using the Romberg test B. Observing the reaction of pupils to light C. Observing the client's response to painful stimuli D. Monitoring the client's sensitivity to temperature, touch, and pain ANS: C Rationale: Assessment of motor function includes muscle movement, size, tone, strength, and coordination. The nurse evaluates motor response in the comatose or unconscious client by administering a painful stimulus to determine the client’s response. An appropriate response is for the client to reach toward or withdraw from the stimulus. The Romberg test is used to assess equilibrium in a noncomatose client. Observing the reaction of the client’s pupils to light is an oculomotor cranial nerve assessment. Monitoring sensitivity to temperature, touch, and pain assesses the sensory function of the client and not motor response. PTS: 1 REF: pp. 598-599, Motor Function NAT: Client Needs: Reduction of Risk Potential TOP: Chapter: 36 KEY: Integrated Process: Nursing Problem-Solving Process BLM: Cognitive Level: Apply NOT: Multiple Choice 2. A client undergoes a scheduled electroencephalogram (EEG). Which post-procedure activity is most appropriate? A. Measure the heart and the pulse rate. B. Provide the client with caffeine-rich drinks. C. Allow the client to wash hair and rest. D. Measure the level of consciousness (LOC) of the client. ANS: C Rationale: After an EEG, the nurse should ensure rest for the sleep-deprived client and allow the client to wash hair to remove the glue used to affix electrodes to the scalp. The client is advised not to take sedative drugs and caffeine-related drinks before the EEG; therefore, there is no reason to provide the client with them after the test. The nurse should not measure the LOC, the heart rate, or the pulse rate of the client unless advised by the health care provider. PTS: 1 REF: p. 602, Electroencephalogram NAT: Client Needs: Reduction of Risk Potential TOP: Chapter: 36 KEY: Integrated Process: Nursing Problem-Solving Process BLM: Cognitive Level: Apply NOT: Multiple Choice 3. The nurse is caring for a client who is undergoing single-photon emission computed tomography (SPECT). What is a potential side effect that this client may suffer? A. Headache and pain in the neck B. Claustrophobia C. Allergic reaction to the imaging material D. Allergic reaction to radioactive rays ANS: C Rationale: SPECT obtains images of the brain after the client intravenously receives radiopharmaceuticals and radioisotopes approximately 1 hour before the test begins. A potential risk of SPECT is the client's allergic reaction to the imaging material. Headache is an aftereffect of a cisternal puncture, and claustrophobia is experienced by clients during a magnetic resonance imaging scan. PTS: 1 REF: p. 601, Single-Photon Emission Computed Tomography NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter: 36 KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 4. Which neurons transmit impulses from the CNS? A. Sensory B. Neurilemma C. Dendrites D. Motor ANS: D Rationale: Neurons are either sensory or motor. Sensory neurons transmit impulses to the CNS; motor neurons transmit impulses from the CNS. A membranous sheath called the neurilemma covers the myelin of axons in peripheral nerves. Dendrites are nerve fibers. PTS: 1 REF: p. 592, Anatomy And Physiology NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter: 36 KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 5. A critical care nurse is documenting the assessment of a client. The client is status postresection of a brain tumor. The nurse documents that the client is flaccid on the left. This means that the client: A. has an abnormal posture response to stimuli. B. is not responding to stimuli. C. is hyperresponsive on the left. D. is hyporesponsive on the left. ANS: B Rationale: Flaccidity is when the client has no motor response to stimuli. Flaccidity is a motor assessment. PTS: 1 REF: p. 599, Motor Function NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter: 36 KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 6. A nurse is caring for a client with an injury to the central nervous system. When caring for a client with a spinal cord insult that is slowing transmission of the motor neurons, in what would the nurse anticipate a delayed reaction? A. Identification of information due to slowed passages of information to brain. B. Cognitive ability to understand relayed information. C. Processing information transferred from the environment. D. Response due to interrupted impulses from the central nervous system ANS: D Rationale: The central nervous system is composed of the brain and the spinal cord. Motor neurons transmit impulses from the central nervous system. Slowing transmission in this area would slow the response of transmission leading to a delay in reaction. Sensory neurons transmit impulses from the environment to the central nervous system, allowing identification of a stimulus. Cognitive centers of the brain interpret the information. PTS: 1 REF: p. 592, Anatomy And Physiology NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter: 36 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 7. The nurse is instructing a community class when a student asks, "How does someone get super strength in an emergency?" The nurse should respond by describing the action of the: A. musculoskeletal system. B. sympathetic nervous system. C. parasympathetic nervous system. D. endocrine system. ANS: B Rationale: The division of the autonomic nervous system called the sympathetic nervous system regulates the expenditure of energy. The neurotransmitters of the sympathetic nervous system are called catecholamines. During an emergency situation or an intensely stressful event, the body adjusts to deliver blood flow and oxygen to the brain, muscles, and lungs that need to react in the situation. The musculoskeletal system benefits from the sympathetic nervous system as the fight-or-flight effects pump blood to the muscles. The parasympathetic nervous system works to conserve body energy not expend it during an emergency. The endocrine system regulates metabolic processes. PTS: 1 REF: p. 596, Sympathetic Nervous System NAT: Client Needs: Health Promotion and Maintenance | Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter: 36 KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 8. The nurse who is employed in a neurologist's office is performing a history and assessment on a client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of which cranial nerve? A. II B. VI C. VIII D. XI ANS: C Rationale: There are 12 pairs of cranial nerves. Cranial nerve VIII is the vestibulocochlear or auditory nerve responsible for hearing and balance. Cranial nerve II is the optic nerve. Cranial nerve VI is the abducens nerve responsible for eye movement. Cranial nerve XI is the accessory nerve and is involved with head and shoulder movement. PTS: 1 REF: p. 595, Cranial Nerves NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter: 36 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 9. The nurse is caring for a client in the emergency department with a diagnosis of head trauma secondary to a motorcycle accident. The nurse aide is assigned to clean the client's face and torso. Which action by the nurse aide would prompt the nurse to provide further instruction? A. Using mild soapy water to clean the face. B. Moving the client's head to clean behind the ears. C. Cleaning the eye area from the inner to outer eye area. D. Cleaning the neck and upper chest area. ANS: B Rationale: Further instruction would be provided to the nurse aide when the nurse aide attempted to move the client's head to clean behind the ears. There should be no movement of the client's head when there is a history of head trauma. Cleaning the client's face with soapy water, cleaning the eye area, and cleaning the neck and upper chest are all appropriate actions completed by the nurse aide. PTS: 1 REF: p. 597, Physical Examination NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter: 36 KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze NOT: Multiple Choice 10. Which diagnostic procedure would the nurse anticipate performing first if the goal was to obtain a thin “slice” of a muscular body area? A. Computed tomography (CT) B. Magnetic resonance imaging (MRI) C. Positron emission tomography (PET) D. Single-photon emission computed tomography (SPECT) ANS: A Rationale: A computer tomography scan uses x-rays and computer analysis to produce three-dimensional views of cross sections, or “slices,” of the body. An MRI uses radiofrequency waves to produce images of tissue. PET scans use radioactive substances to examine metabolic activity and organ involvement. SPECT is an imaging tool that examines cerebral blood flow. PTS: 1 REF: p. 601, Computed Tomography NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter: 36 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 11. The nurse assists the health care provider (HCP) in completing a lumbar puncture (LP). Which should the nurse note as a concern? A. The HCP maintains aseptic procedure. B. The pressure is noted to be 90 mm H20. C. The cerebrospinal fluid (CSF) is cloudy in nature. D. The HCP administers a drug by intrathecal injection. ANS: C Rationale: The CSF is normally clear and colorless; therefore, CSF that is cloudy would be noted by the nurse as a concern. The HCP is correct to maintain aseptic procedure. At 90 mm H20, the client’s CSF fluid pressure falls within normal limits (between 80 and 100 mm H20). Sometimes the HCP will administer medication via intrathecal injection during an LP, which should not be a cause for concern. PTS: 1 REF: p. 602, Lumbar Puncture NAT: Client Needs: Physiological Adaptation TOP: Chapter: 36 KEY: Integrated Process: Nursing Problem-Solving Process BLM: Cognitive Level: Apply NOT: Multiple Choice 12. A nurse is working in an outpatient studies unit administering neurological tests. The client is surprised that paste is used to secure an electroencephalogram and asks how it will be removed from the hair. With what substance does the nurse reply? A. Acetone B. A special soap C. Shampoo D. Warm water ANS: C Rationale: Shampoo is used to remove the paste, which attached the electrodes to the head. Acetone is not used on the hair. There is no special soap needed. More than warm water is needed to lift and remove the paste. PTS: 1 REF: p. 602, Electroencephalogram NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter: 36 KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 13. A nurse is noting from a client's neurologic assessment findings that the client's motor impulses are interrupted from the brain to the spinal cord. It also appears that the client lacks sensory impulses from the peripheral sensory neurons to the brain. Which area has the deficit? A. Midbrain B. Medulla oblongata C. Pons D. Subarachnoid space ANS: B Rationale: The medulla oblongata lies below the pons and transmits motor impulses from the brain to the spinal cord, and sensory impulses from the peripheral sensory neurons to the brain. The pons is part of the brainstem. The midbrain forms the forward part of the brainstem and connects the pons and the cerebellum with the two cerebral hemispheres. The subarachnoid space lies between the pie matter and the arachnoids membrane. PTS: 1 REF: pp. 593-594, Central Nervous System NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter: 36 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 14. A nurse is working in a neurologist's office. The physician orders a Romberg test. What should the nurse instruct the client to do? A. Touch nose with one finger. B. Close eyes and stand erect. C. Close eyes and discriminate between dull and sharp. D. Close eyes and jump on one foot. ANS: B Rationale: In the Romberg test, the client stands erect with the feet close together and eyes closed. If the client sways as if to fall, it is considered a positive Romberg test. All of the other options include components of neurologic tests, indicating neurologic deficits and balance. PTS: 1 REF: p. 598, Motor Function NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter: 36 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 15. The nurse is caring for a client newly diagnosed with multiple sclerosis who is overwhelmed by learning about the disease. The client indicates understanding that there is a disruption in the covering of axons but does not remember what the covering is called. What should the nurse tell the client? A. That it is not necessary to worry about the finer details of the disease. B. That because there is so much to learn, there will be another meeting to discuss it again. C. That the covering is called myelin and that it can be discussed further at the next meeting. D. That the disease process requires more research. ANS: C Rationale: Myelin is a fatty substance that covers some axons in the CNS and PNS. The nurse would be most correct in answering the question and then, if the client is tired, following up at the next meeting. It would also be appropriate to provide literature for the client to review at leisure. Discounting the client's need to know information about the disease process is belittling. Telling the client that more research needs to be done discounts the valuable information which is known. PTS: 1 REF: p. 593, Anatomy and Physiology NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter: 36 KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 16. A client is waiting in a triage area to learn the medical status of family members following a motor vehicle accident. The client is pacing, taking deep breaths, and handwringing. Considering the effects in the body systems, what does the nurse anticipate the liver will do? A. Cease function and shunt blood to the heart and lungs. B. Convert glycogen to glucose for immediate use. C. Produce a toxic by-product in relation to stress. D. Maintain a basal rate of functioning. ANS: B Rationale: When the body is under stress, the sympathetic nervous system is activated to ready the body for action. The effect of the body is to mobilize stored glycogen to glucose to provide additional energy for body action. PTS: 1 REF: p. 597, Table 36-1 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter: 36 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 17. The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly? A. Moving the head toward both sides B. Lightly tapping the lower portion of the neck to detect sensation C. Moving the head and chin toward the chest D. Gently pressing the bones on the neck ANS: C Rationale: The neck is examined for stiffness or abnormal position. The presence of rigidity is assessed by moving the head and chin toward the chest. The nurse should not maneuver the neck if a head or neck injury is suspected or known. The neck should also not be maneuvered if trauma to any part of the body is evident. Moving the head toward the sides or pressing the bones on the neck will not help assess for neck rigidity correctly. While assessing for neck rigidity, sensation at the neck area is not assessed. PTS: 1 REF: p. 601, Neck NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter: 36 KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 18. The critical care nurse is giving end-of-shift report on a client. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the oncoming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate? A. Comatose B. Somnolence C. Stupor D. Normal ANS: A Rationale: The GSC is used to measure the LOC. The scale consists of three parts: eye opening response, best verbal response, and best motor response. A normal response is 15. A score of 7 or less is considered comatose. Therefore, a score of 6 indicates the client is in a state of coma and not in any other state such as stupor or somnolence. The evaluations are recorded on a graphic sheet where connecting lines show an increase or decrease in the LOC. PTS: 1 REF: p. 600, Box 36-1 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter: 36 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 19. A client presents to the emergency department status postseizure. The health care provider wants to measure CSF pressure. What test might be ordered on this client? A. Lumbar puncture B. Echoencephalography C. Nerve conduction studies D. EMG ANS: A Rationale: Changes in CSF occur in many neurologic disorders. A lumbar puncture (spinal tap) is performed to obtain samples of CSF from the subarachnoid space for laboratory examination and to measure CSF pressure. Echoencephalography records the electrical impulses generated by the brain. Nerve conduction studies measure the speed with which the nerve impulse travels along the peripheral nerve. Electromyography studies the changes in the electrical potential of muscles and the nerves supplying the muscles. PTS: 1 REF: p. 602, Lumbar Puncture NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter: 36 KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 20. The nurse is assessing the throat of a client with throat pain. In asking the client to stick out the tongue, the nurse is also assessing which cranial nerve? A. Cranial nerve I B. Cranial nerve V C. Cranial nerve XI D. Cranial nerve XII ANS: D Rationale: Assessment of the movement of the tongue is related to cranial nerve XII, the hypoglossal nerve. Cranial nerve I is the olfactory nerve. Cranial nerve V is the trigeminal nerve responsible for sensation to the face and chewing. Cranial nerve XI is the spinal or accessory nerve responsible for head and shoulder and shoulder movement. PTS: 1 REF: p. 596, Cranial Nerves NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter: 36 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 21. The nurse is assessing the assigned client's level of consciousness during morning rounds. The nurse speaks the client's name, strokes the client's hand, and moves the client's shoulder. There is a delay, and then the client states, “What do you want?” Which level of consciousness should the nurse document? A. Conscious B. Semicomatose C. Somnolent D. Stuporous ANS: C Rationale: Somnolent or lethargy means that the client is drowsy or sleepy at inappropriate times. This is an improvement from the stuporous state, which includes arousing the client only with vigorous and repeated stimulation. A client that is conscious is alert and responds to stimulation immediately. A client is documented as semicomatose when the client only responds to superficial, relatively mild, painful stimuli. PTS: 1 REF: p. 599, Level of Consciousness NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter: 36 KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Analyze NOT: Multiple Choice 22. The nurse scores the client's level of consciousness (LOC) using the Glasgow Coma Scale. Which score should indicate to the nurse that the client needs emergency attention? A. a score of 9 B. A score of 11 C. A score of 12 D. A score of 15 ANS: A Rationale: A score of 9 indicates that the client needs emergency attention. Scores greater than or equal to 11 are considered within normal range. PTS: 1 REF: pp. 599-600, Glasgow Coma Scale NAT: Client Needs: Physiological Adaptation TOP: Chapter: 36 KEY: Integrated Process: Nursing Problem-Solving Process BLM: Cognitive Level: Apply NOT: Multiple Choice 23. The nurse is assessing the client's pupils following a sports injury. Which assessment finding(s) indicates a neurologic concern? Select all that apply. A. Unequal pupils B. Pupil reaction quick C. Pinpoint pupils D. Absence of pupillary response E. Pupil reacts to light ANS: A, C, D Rationale: Normal assessment findings include the pupils being equal and reactive to light. Pupils that are unequal, pinpoint in nature, or fail to respond indicate a neurologic impairment. PTS: 1 REF: pp. 599-600, Glasgow Coma Scale NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter: 36 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Select 24. The physician's office nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm? A. Myelogram B. Electroencephalogram C. Echoencephalography D. Cerebral angiography ANS: D Rationale: The nurse would anticipate a cerebral angiography, which detects distortion of the cerebral arteries and veins. A myelogram detects abnormalities of the spinal canal. An electroencephalogram records electrical impulses of the brain. An echoencephalography is an ultrasound of the structures of the brain. PTS: 1 REF: p. 602, Contrast Studies NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter: 36 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 25. The nurse is caring for a client with a significant allergy history to various medications and shellfish. Because the client needs to have a diagnostic study with contrast, which medication classification is anticipated? A. Bronchodilator B. Antihistamine C. Cardiotonic D. Antibiotic ANS: B Rationale: Clients with an allergy history are administered a pretest dose of an antihistamine. Antihistamines block histamine receptors and reduce the manifestations of an allergic reaction. The other options are not administered in the pretest period. PTS: 1 REF: p. 603, Nursing Process for the Client Undergoing Neurologic Testing NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter: 36 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 26. The nurse provides care for a client with a deteriorating neurologic status. The nurse collects data at the beginning of the shift that reveals a falling blood pressure (BP) and heart rate (HR), and the client makes no motor response to stimuli. Which documentation of neuromuscular status is most appropriate? A. Flaccidity B. Abnormal posture C. Weak muscular tone D. Decorticate posturing ANS: A Rationale: The nurse should document flaccidity when the client makes no motor response to stimuli. Clients with impaired cerebral function manifest abnormal posturing, which is documented by the nurse as either decorticate posturing (decorticate rigidity), a position in which the arms are flexed, fists are clenched, and the legs are extended or decerebrate posturing (decerebrate rigidity), when the extremities are stiff and rigid. Muscle tone is documented using a scale of 0 to 5; therefore, weak muscular tone is not the most appropriate documentation. PTS: 1 REF: pp. 598-599, Motor Function NAT: Client Needs: Reduction of Risk Potential TOP: Chapter: 36 KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 27. The nurse collects neurologic data and determines that the client has significant visual deficits. A brain tumor is considered. Which area of the brain does the nurse consider to be most likely to contain the neurologic deficit? A. Frontal B. Parietal C. Occipital D. Temporal ANS: C Rationale: The visual receiving area is in the occipital lobe; therefore, this is the area of the brain the nurse determines is affected for the client with significant visual deficits. The frontal lobe contains the written and motor speech areas. The parietal lobe is the primary sensory area of the brain. The temporal lobe is the auditory receiving and association area of the brain, and is responsible for speech comprehension (i.e., Wernicke area). PTS: 1 REF: p. 593, Figure 36-2 NAT: Client Needs: Physiological Adaptation TOP: Chapter: 36 KEY: Integrated Process: Nursing Problem-Solving Process BLM: Cognitive Level: Apply NOT: Multiple Choice 28. The nurse collects data regarding a client's ability to detect sensation in the upper extremity. Which nursing action(s) is appropriate? Select all that apply. A. Place a warm cotton ball on the client’s arm. B. Use a safety pin to stroke the client’s fingers. C. Use a needle to introduce a prick to the client’s skin. D. Drag a tube filled with cold water on the client’s arm. E. Place a tube filled with warm water on the client’s hand. ANS: A, B, D, E Rationale: The nurse evaluates the extremities for sensitivity to heat, cold, touch, and pain. Various objects can be used by the nurse for this purpose, including cotton balls and tubes filled with hot or cold water. Sharp objects may be used but should not pierce the skin; therefore, it is appropriate for the nurse to stroke the client’s fingers with a safety pin but not to prick the skin with a needle. PTS: 1 REF: p. 599, Sensory Function NAT: Client Needs: Reduction of Risk Potential TOP: Chapter: 36 KEY: Integrated Process: Nursing Problem-Solving Process BLM: Cognitive Level: Apply NOT: Multiple Choice 29. A client is weak and drowsy after a lumbar puncture. The nurse caring for the client knows that what priority nursing intervention should be provided after a lumbar puncture? A. Administer antihistamines to the client. B. Provide adequate caffeine-rich drinks to the client. C. Leave the client to rest and do not perform any assessments. D. Position the client flat as directed. ANS: D Rationale: A client who has undergone a lumbar puncture should be positioned flat and given adequate fluids. These measures help restore the cerebrospinal fluid volume extracted from the client and are priority activities. The client is administered antihistamines to manage any allergic reactions that may occur from the test. The nurse should assess the LOC or the pupil response of the client after a lumbar puncture. Parenteral administration of caffeine sodium benzoate may offset cerebral vasodilation. PTS: 1 REF: p. 604, Nursing Process for the Client Undergoing Neurologic Testing NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter: 36 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice Chapter 37: Caring for Clients With Central and Peripheral Nervous System Disorders 1. A client the nurse is caring for experiences a seizure. What would be a priority nursing action? A. Restrain the client during the seizure. B. Insert a tongue blade between the teeth. C. Protect the client from injury. D. Suction the mouth during the convulsion. ANS: C Rationale: The nursing action for a client experiencing a seizure should be to protect the client from being injured. To ensure this, the nurse should turn the client to one side and not restrain client's movements. Inserting a tongue blade between the teeth is not as important as protecting the client from injury. The mouth and the pharynx of the client should be suctioned only after the seizure. PTS: 1 REF: p. 635, Seizure Disorders NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter: 37 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 2. The nurse is caring for a client with an inoperable brain tumor. What is a major threat to this client? A. Increased intracranial pressure B. Decreased intracranial pressure C. Hypervolemia D. Hypovolemia ANS: A Rationale: Nursing management depends on the area of the brain affected, tumor type, treatment approach, and the client's signs and symptoms. If the tumor is inoperable or has expanded despite treatment, increased intracranial pressure (ICP) is a major threat. In this scenario, there are no indications that fluid volume either increasing or decreasing is an issue. PTS: 1 REF: p. 638, Brain Tumors NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter: 37 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 3. An older client complains of a constant headache. A physical examination shows papilledema. Based on these symptoms, what condition would the nurse suspect? A. Epilepsy B. Trigeminal neuralgia C. Hypostatic pneumonia D. Brain tumor ANS: D Rationale: Headache and papilledema are symptoms of a brain tumor, although these symptoms do appear less often in the older adult. Symptoms of epilepsy include seizure activity, whereas symptoms of trigeminal neuralgia would be pain in the jaws or facial muscles. Hypostatic pneumonia develops due to immobility or prolonged bed rest in older clients. The other options are not associated with papilledema or constant headache. PTS: 1 REF: p. 638, Brain Tumors NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter: 37 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 4. The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased intracranial pressure (ICP). What neurologic sequelae might this client develop? A. Damage to the nerves that facilitate vision and hearing B. Damage to the vagal nerve C. Damage to the olfactory nerve D. Damage to the facial nerve ANS: A Rationale: Neurologic sequelae in survivors include damage to the cranial nerves that facilitate vision and hearing. Sequelae to meningitis do not include damage to the vagal nerve, the olfactory nerve, or the facial nerve. PTS: 1 REF: p. 613, Infectious and Inflammatory Disorders of the Nervous System NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter: 37 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 5. The nurse is caring for a client hospitalized with a severe exacerbation of myasthenia gravis. When administering medications to this client, what is a priority nursing action? A. Assess client's reaction to new medication schedule. B. Administer medications at exact intervals ordered. C. Document medication given and dose. D. Give client plenty of fluids with medications. ANS: B Rationale: The nurse must administer medications at the exact intervals ordered to maintain therapeutic blood levels and prevent symptoms from returning. Assessing the client's reaction, documenting medication and dose, and giving the client plenty of fluids are not the priority nursing action for this client. PTS: 1 REF: p. 620, Neuromuscular Disorders NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter: 37 KEY: Integrated Process: Caring BLM: Cognitive Level: Apply NOT: Multiple Choice 6. A client diagnosed with Huntington disease is on a disease-modifying drug regimen and has a urinary catheter in place. Which potential complication is the highest priority for the nurse while monitoring the client? A. Severe depression B. Choreiform movements C. Urinary tract infection D. Emotional apathy ANS: C Rationale: Because all disease-modifying drug regimens for Huntington disease can decrease immune cells and infection protection, it is most important for the nurse to assess for acquired infections such as urinary tract infections, especially if the client is catheterized. Severe depression is common and can lead to suicide. Symptoms of Huntington disease develop slowly and include mental apathy and emotional disturbances, choreiform movements (uncontrollable writhing and twisting of the body), grimacing, difficulty chewing and swallowing, speech difficulty, intellectual decline, and loss of bowel and bladder control. Assessing for these other conditions is appropriate but not as important as assessing for urinary tract infection in the client on a disease-modifying drug regimen with a urinary catheter in place. PTS: 1 REF: p. 631, Huntington Disease NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter: 37 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 7. The school nurse notes a 6-year-old running across the playground with friends. The child stops in midstride, freezing for a few seconds. Then the child resumes running across the playground. The school nurse suspects what in this child? A. An absence seizure B. A myoclonic seizure C. A partial seizure D. A tonic-clonic seizure ANS: A Rationale: Absence seizures, formerly referred to as petit mal seizures, are more common in children. They are characterized by a brief loss of consciousness during which physical activity ceases. The person stares blankly; the eyelids flutter; the lips move; and slight movement of the head, arms, and legs occurs. These seizures typically last for a few seconds, and the person seldom falls to the ground. Because of their brief duration and relative lack of prominent movements, these seizures often go unnoticed. People with absence seizures can have them many times a day. Partial, or focal, seizures begin in a specific area of the cerebral cortex. Both myoclonic and tonicclonic seizures involve jerking movements. PTS: 1 REF: p. 632, Seizure Disorders NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter: 37 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 8. The nurse is caring for a client with mid-to-late stage of an inoperable brain tumor. What teaching is most important for the nurse to do with this client? A. Optimizing nutrition B. Managing muscle weakness C. Explaining hospice care and services D. Offering family support groups ANS: C Rationale: The nurse explains hospice care and services to clients with brain tumors that no longer are at a stage where they can be cured. Managing muscle weakness and offering family support groups are important, but explaining hospice is the best answer. Optimizing nutrition at this point is not a priority. PTS: 1 REF: p. 640, Brain Tumors NAT: Client Needs: Psychosocial Integrity TOP: Chapter: 37 KEY: Integrated Process: Caring BLM: Cognitive Level: Analyze NOT: Multiple Choice 9. A client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure? A. Blood pressure 100/60 mm Hg B. Lethargy C. Nausea D. Periorbital edema ANS: B Rationale: Decreasing level of consciousness is one of the earliest signs of increased intracranial pressure (ICP). Without a baseline for the blood pressure, it is difficult to determine whether this is a significant change for this client. Vomiting (usually without forewarning of nausea) when associated with a head injury suggests increasing ICP. Periorbital edema is more suggestive of fluid overload than ICP. PTS: 1 REF: p. 608, Increased Intracranial Pressure NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter: 37 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 10. The nurse is caring for a client with head trauma. Which assessment finding(s) would indicate an increasing intracranial pressure (ICP) in this client? Select all that apply. A. Stiff neck B. Generalized pain C. Glasgow Coma Scale of 15 D. Elevated systolic blood pressure E. Brisk pupil response F. Wide pulse pressure ANS: D, F Rationale: Elevated systolic blood pressure with widening pulse pressure is consistent with Cushing's triad, which occurs late in increasing ICP. Other signs of Cushing's triad include bradycardia and irregular breathing. Stiff neck is not a symptom associated with ICP. Generalized pain is not significant with ICP unless related to complaint of headache (especially upon awakening). Glasgow Coma Scale of 15 and brisk pupil response are normal findings. PTS: 1 REF: p. 608, Increased Intracranial Pressure NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter: 37 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Select 11. A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? A. Dextrose 5% in water (D5W) B. Half-normal saline (0.45% NSS) C. One-third normal saline (0.33% NSS) D. Lactated Ringer’s ANS: D Rationale: With increasing ICP, isotonic normal saline, lactated Ringer’s, or hypertonic (3%) saline solutions are used to decrease swelling in the brain cells. D5W, 0.45% NSS, and 0.33% NSS are all hypotonic solutions that will move more fluid into the cells, worsening the ICP. PTS: 1 REF: p. 609, Medical and Surgical Management NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter: 37 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 12. A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first? A. Elevate the head of the bed. B. Complete a head-to-toe assessment. C. Administer morning dose of anticonvulsant. D. Administer Percocet as ordered. ANS: A Rationale: The first action would be to elevate the head of the bed to promote venous drainage of blood and cerebral spinal fluid (CSF). Then, a neurological assessment would be completed to determine if any other assessment findings are significant of increasing intracranial pressure (ICP). The administering of routine ordered drugs is not a priority, and narcotic analgesics would be avoided in clients with ICP issues. PTS: 1 REF: p. 610, Increased Intracranial Pressure NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter: 37 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 13. The nurse is caring for a client with bacterial meningitis. Which assessment finding(s) is most important in determining nursing care for this client? Select all that apply. A. Cloudy cerebral spinal fluid B. Pain and stiffness of the extremities C. Purpura of hands and feet D. Low white blood cell (WBC) count E. Low red blood cell (RBC) count F. Low antidiuretic hormone (ADH) levels ANS: A, C Rationale: The cerebral spinal fluid (CSF) will be cloudy if bacterial meningitis is the causative agent. Purpura indicates a serious complication of bacterial meningitis (disseminated intravascular coagulation) is occurring and may place the client at risk for amputation of those parts. Pain and stiffness of the extremities is not indicative of meningitis. A rise in RBCs, WBCs, and ADH would be expected. PTS: 1 REF: p. 613, Infectious and Inflammatory Disorders of the Nervous System NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter: 37 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Select 14. The client presents to the walk-in clinic with fever, nuchal rigidity, and headache. Which assessment finding by the nurse would be most significant in the diagnosis of this client? A. Change in level of consciousness B. Vomiting C. Vector bites D. Seizures ANS: C Rationale: Possible exposure to mosquito bites can be beneficial in the diagnosing of encephalitis secondary to West Nile virus. Change in level of consciousness (LOC), vomiting, and seizures are all symptoms of increased intracranial pressure (ICP) and do not assist in the differentiating of cause, diagnosis, or establishing nursing care. PTS: 1 REF: p. 614, Infectious and Inflammatory Disorders of the Nervous System NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter: 37 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 15. A client is receiving baclofen for management of symptoms associated with multiple sclerosis. To evaluate the effectiveness of this medication, what does the nurse assess? A. Sleep pattern B. Mood and affect C. Appetite D. Muscle spasms ANS: D Rationale: Baclofen is a drug used to manage symptoms of muscle spasticity and rigidity in clients diagnosed with neuromuscular disorders. Because of the effects on the CNS, initially, baclofen may cause drowsiness, but sleep is not the intended goal for this therapy. Mood and appetite are not a factor in the administration of this drug. PTS: 1 REF: p. 618, Neuromuscular Disorders NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter: 37 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 16. The nurse is caring for a 30-year-old client diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse? A. “I will have progressive muscle weakness.” B. “I will lose strength in my arms.” C. “My children are at greater risk to develop this disease.” D. “I need to remain active for as long as possible.” ANS: C Rationale: There is no known cause for ALS, and no reason to suspect genetic inheritance. ALS usually begins with muscle weakness of the arms and progresses. The client is encouraged to remain active for as long as possible to prevent respiratory complications. PTS: 1 REF: p. 620, Amyotrophic Lateral Sclerosis NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter: 37 KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 17. The nurse is caring for a client with Bell palsy. Which of the following teaching points is a priority in the management of symptoms for this client? A. Avoid stimuli that trigger pain. B. Use ophthalmic lubricant and protect the eye. C. Encourage semiannual dental exams. D. Complete the course of antibiotics as prescribed. ANS: B Rationale: The VII cranial nerve supplies muscles to the face. In Bell palsy, the eye can be affected which results in incomplete closure and risk for injury. The eye can become dry and irritated unless eye moisturizing drops and ophthalmic ointment is applied. Avoiding stimuli that can trigger pain is specific to tic douloureux(cranial nerve V disorder). Encouraging dental exams is a part of care but not the priority. Antibiotics are not used in the treatment of Bell's palsy because it is thought to be caused by a virus. PTS: 1 REF: p. 625, Bell Palsy NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter: 37 KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 18. The nurse is caring for a client newly diagnosed with Parkinson disease. Which topic is most important for the nurse to include in the teaching plan for this client? ? A. Involvement with diversion activities B. Enhancement of the immune system C. Establishing balanced nutrition D. Maintaining a safe environment ANS: D Rationale: The primary focus in caring for Parkinson disease is on maintaining a safe environment. Parkinson disease often has a propulsive gait, characterized by a tendency to take increasingly quicker steps while walking and an inability to stop abruptly without losing balance. Prevention of communicable diseases and establishing a balanced nutrition is encouraged with any chronic disorder. Diversional activities can be helpful in times of stress but not a priority. PTS: 1 REF: p. 629, Parkinson Disease NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter: 37 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 19. A client adopted at birth recently discovers that Huntington disease is prevalent in the biological family history. The nurse is providing education to the client about the condition. Which statement(s) should the nurse include in the teaching? Select all that apply. A. “In the early stages, people with the disease can participate in most physical activities.” B. “The disease eventually leads to hallucinations, delusions, impaired judgment, and increased intensity of abnormal movements.” C. “Disease-modifying medications for Huntington disease can decrease immune cells and infection protection.” D. “There are specific tests that can be arranged to diagnose whether or not you have the disorder.” E. “Huntington disease is familial; it is not transmitted genetically.” ANS: A, B, C Rationale: In teaching the client about Huntington disease, the nurse will explain to the client that people with the disease can participate in most physical activities in the early stages, but that the disease eventually causes hallucinations, delusions, impaired judgment, and increased intensity of abnormal movements. The nurse will go on to inform the client that medications for Huntington disease can decrease immune cells and immune protection. There are no specific diagnostic tests for this disorder, and it is transmitted genetically; thus, the nurse will leave out these statements in the teaching. PTS: 1 REF: p. 631, Huntington Disease NAT: Client Needs: Health Promotion and Maintenance: Health Promotion and Maintenance TOP: Chapter: 37 KEY: Integrated Process: Caring BLM: Cognitive Level: Apply NOT: Multiple Select 20. A client falls to the floor in a generalized seizure with tonic-clonic movements. Which is the first action taken by the nurse? A. Insert an airway or bite block. B. Manually restrain the extremities. C. Turn client to side-lying position. D. Monitor vital signs. ANS: C Rationale: When a client begins to convulse, the highest priority is to maintain airway. This can best be accomplished by turning client to side-lying position, which allows saliva and emesis to drain from the mouth. Turning the client also allows the tongue to fall forward opening the airway. More damage can occur if a bite block is inserted after the seizure has begun. Manually restraining extremities is not recommended. Attempting to take blood pressure is not recommended and pulse rate and respirations during the event will not be beneficial. Monitor vital signs during the postictal phase. PTS: 1 REF: p. 635, Seizure Disorders NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter: 37 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 21. The nurse is caring for a client who has a generalized seizure. Which nursing assessment is a priority for detailing the event? A. Seizure began at 1300 hours. B. The client cried out before the seizure began. C. Seizure was 1 minute in duration including tonic-clonic activity. D. Sleeping quietly after the seizure ANS: C Rationale: Describing the length and the progression of the seizure is a priority nursing responsibility. During this time, the client will experience respiratory spasms, and the skin will appear cyanotic, indicating a period of lack of tissue oxygenation. Noting when the seizure began and presence of an aura are also valuable pieces of information. Postictal behavior should be documented along with vital signs, oxygen saturation, and assessment of tongue and oral cavity. PTS: 1 REF: p. 635, Seizure Disorders NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter: 37 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 22. A client is about to be discharged after undergoing surgery for the treatment of a brain tumor and has a referral in place for medical and radiation oncology. Which component(s) should be included in the discharge teaching for this client? Select all that apply. A. Medication regimen B. Appointments for chemotherapy or radiotherapy C. Adverse effects of chemotherapy or radiation and techniques for managing them D. Nutritional support E. Electromyography ANS: A, B, C, D Rationale: The nurse should include the medication regimen, appointments for chemotherapy and radiotherapy, adverse effects of chemotherapy or radiation and techniques for managing them, and nutritional support as components of the discharge teaching for this client. Electromyography is used in amyotrophic lateral sclerosis (ALS) to validate weakness in the affected muscles and should not be included for the client being discharged after surgery for a brain tumor. PTS: 1 REF: p. 639, Nursing Management NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter: 37 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Select 23. The nursing instructor gives students an assignment of making a plan of care for a client with Huntington disease. What would be important for the students to include in the teaching portion of the care plan? A. How to exercise B. How to perform household tasks C. How to take a bath D. How to facilitate tasks such as using both hands to hold a drinking glass ANS: D Rationale: The nurse demonstrates how to facilitate tasks such as using both hands to hold a drinking glass, using a straw to drink, and wearing slip-on shoes. The teaching portion of the care plan would not include how to exercise, perform household tasks, or take a bath. PTS: 1 REF: p. 631, Huntington Disease NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter: 37 KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 24. The nurse is caring for a client who continues to have increasingly high intracranial pressure. Which complication is expected unless intracranial pressure is resolved? A. Additional inflammation occurs in the brain. B. Blood vessels dilate circulating blood. PTS: 1 REF: p. 636, Nursing Process for the Client with a Seizure Disorder NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter: 37 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice Chapter 38: Caring for Clients With Cerebrovascular Disorders 1. The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has? A. Ischemic B. Hemorrhagic C. Right-sided D. Left-sided ANS: A Rationale: Ischemic strokes occur when a thrombus or embolus obstructs an artery carrying blood to the brain; about 80% of strokes are the ischemic variety. The other options are incorrect. PTS: 1 REF: p. 649, Cerebrovascular Accident (Stroke) NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter: 38 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 2. A client presents to the walk-in clinic complaining of a migraine. The client is prescribed an antileptic. What should the nurse suggest to the client? A. Avoid crowds. B. Take drugs only after meals at night. C. Avoid caffeine and alcohol. D. Use caution while driving or performing hazardous activities. ANS: D Rationale: A client who is prescribed an antileptic needs to exercise caution while driving and avoid performing hazardous activities. A client taking non-steroidal antiinflammatory drugs should be advised against taking caffeine and alcohol. The client need not take the drug only at night after meals or be instructed to avoid crowds. PTS: 1 REF: p. 645, Headache NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter: 38 KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 3. A client has just been diagnosed with a cerebral aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client? A. Avoid heavy lifting. B. Avoid fiber in the diet. C. Take an antacid frequently. D. Take an herbal form of feverfew. ANS: A Rationale: A client with an aneurysm should be advised to avoid heavy lifting, extreme emotional situations, or straining of stools because these activities increase intracranial pressure and thereby headaches and potential rupture of aneurysm. Avoidance of fiber may lead to constipation and straining with stools and would not be recommended. There would not be a recommendation for antacids or feverfew in the discharge teaching. PTS: 1 REF: p. 658, Cerebral Aneurysms NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter: 38 KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 4. A client has tension headaches. The nurse recommends massage as a treatment for tension headaches. How does massage help clients with tension headaches? A. Reduces hypotension B. Increases appetite C. Relaxes muscles D. Relieves migraines ANS: C Rationale: Massaging relaxes tense muscles, causes local dilation of blood vessels, and relieves headache. However, this approach is not likely to help a client with migraine or cluster headaches. Massage is not offered to clients with tension headaches to increase their appetite or reduce hypotension. PTS: 1 REF: p. 646, Headache NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter: 38 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 5. A client diagnosed with migraine headaches asks the nurse what to do to help control the headaches and minimize the number of attacks. What instructions should the nurse give this client? A. Identify and avoid factors that precipitate or intensify an attack. B. Keep a record of activities following an attack. C. When an attack occurs, stay in a brightly lit area. D. Write down any adverse drug effects. ANS: A Rationale: The nurse includes the following instructions: Follow the indications and dosage regimen for medication and notify the physician of any adverse drug effects. Identify and avoid factors that precipitate or intensify an attack. Keep a food diary, which may help identify foods that trigger attacks. Keep a record of the attacks, including activities before the attack and environmental or emotional circumstances that appear to bring on the attack. Lie down in a darkened room and avoid noise and movement when an attack occurs whenever possible. PTS: 1 REF: p. 646, Headache NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter: 38 KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 6. While making initial rounds after coming on shift, the nurse finds a client thrashing about in bed complaining of a severe headache. The client tells the nurse the pain is behind the right eye, which is red and tearing. What type of headache would the nurse suspect this client of having? A. Migraine B. Tension C. Cluster D. Sinus ANS: C Rationale: A person with a cluster headache has pain on one side of the head, usually behind the eye, accompanied by nasal congestion, rhinorrhea (watery discharge from the nose), and tearing and redness of the eye. The pain is so severe that the person is not likely to lie still; instead, the person may pace or thrash about. The symptoms in the scenario do not describe the other types of headaches listed. PTS: 1 REF: p. 643, Headache NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter: 38 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 7. A family member comes to the clinic to talk to the nurse about a client who has had a stroke on the right side of the brain. The family member is concerned because of the deficits the client is exhibiting. The nurse knows that when a client experiences a stroke on the right side of the brain, common deficits include what? Select all that apply. A. Left-sided hemiplegia B. Tendency to distractibility C. Impairment of long-term memory D. Hyperaware of deficits E. Neglect of objects and people on the left side ANS: A, B, E Rationale: Left-sided hemiplegia (stroke on right side of brain) may have the following neurologic deficits: spatial-perceptual defects; disregard for the deficits of the affected side require special safety considerations; tendency to distractibility; impulsive behavior, unaware of deficits; poor judgment; defects in left visual fields; misjudge distances; difficulty distinguishing upside-down and right-side up; impairment of shortterm memory; and neglect left side of body, objects and people on left side. PTS: 1 REF: p. 651, Cerebrovascular Accident (Stroke) NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter: 38 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Select 8. A family member brings a 76-year-old client to the clinic, stating that the client has had two transient ischemic attacks (TIAs) in the past week. The health care provider orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option(s) does the nurse expect the health care provider to offer this client to increase blood flow to the brain? Select all that apply. A. Balloon angioplasty of the carotid artery followed by stent placement B. Removal of the carotid artery C. Percutaneous transluminal coronary artery angioplasty D. Carotid endarterectomy E. Administration of tissue plasminogen activator ANS: A, D Rationale: If narrowing of the carotid artery by atherosclerotic plaques is the cause of the TIAs, a carotid endarterectomy (surgical removal of atherosclerotic plaque) could be performed. A balloon angioplasty of the carotid artery, a procedure similar to a percutaneous transluminal coronary artery angioplasty, may be performed alternatively to dilate the carotid artery and increase blood flow to the brain, followed by stent placement. The other options are not options to increase blood flow through the carotid artery to the brain. PTS: 1 REF: p. 648, Transient Ischemic Attacks NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter: 38 KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Select 9. A female client who complains of recurring headaches, accompanied by increased irritability, photophobia, and fatigue i