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Test Bank
MULTIPLE CHOICE
1. The nurse assesses a client who has trauma to the cerebrum. Which clinical
manifestation does the nurse expect to observe?
a. Poor coordination
b. Memory loss
c. Hyperthermia
d. Slurred speech
ANS: B
The cerebrum is the largest part of the brain and controls intelligence, creativity, and
memory. Poor coordination, hyperthermia, and slurred speech are caused by other
parts of the brain.
2. The nurse is assessing a client with a frontal lobe brain injury. Which clinical
manifestation does the nurse expect to see?
a. Inability to interpret taste sensations
b. Inability to interpret sound
c. Impaired judgment
d. Impaired learning
ANS: C
The frontal lobe is responsible for many functions, including judgment, reasoning,
voluntary eye movement, and motor functions. The other clinical manifestations are
not associated with the frontal lobe.
ANS: D
The temporal lobe contains the auditory center for sound interpretation. The clients
hearing will be impaired in the left ear. The nurse should sit on the clients right side
and speak to the right ear. The other interventions do not address the clients left
temporal lobe damage.
4. After performing a physical assessment on a 75-year-old client, the nurse notes that
the client has a hypoactive response to a test of deep tendon reflexes. Which
intervention does the nurse include in this clients plan of care?
ANS: A
The older adult experiences certain neurologic changes associated with aging.
Hypoactive deep tendon reflexes and loss of vibration sense can impair balance and
coordination, predisposing the client to falls. The nurse or assistive personnel should
assist this client with ambulation to prevent injury. The other interventions do not
address the clients problem.
TOP: Client Needs Category: Health Promotion and Maintenance (Aging Process)
Older clients with decreased sensation are at risk of injury from the inability to sense
changes in terrain when walking. To compensate for this loss, the client is instructed
to look at the placement of her or his feet when walking. The client also should wear
sturdy shoes for ambulation. Throw rugs can slip and increase fall risk. Bath water
that is too warm places the client at risk for thermal injury.
6. A client admitted the previous day for a suspected neurologic disorder becomes
increasingly lethargic. Which is the best nursing action?
a. Promote a quiet atmosphere for sleep and rest to treat the clients sleep
deprivation.
b. Explain to the family that this is a normal age-related decline in mental
processing.
c. Consult a psychiatrist to treat the clients hospital-acquired depression.
d. Complete a full neurologic assessment and notify the neurologist.
ANS: D
7. The nurse is assessing a clients remote memory. Which statement by the client
confirms that remote memory is intact?
ANS: B
Asking clients about certain facts from the past that can be verified assesses remote,
or long-term, memory. The clients ability to make up a rhyme tests not memory, but
rather a higher level of cognition. The other statements indicate immediate and recent
memory.
ANS: A
The client who sways with eyes closed (positive Rombergs sign) but not with eyes
open most likely has a disorder of proprioception and uses vision to compensate for it.
The other options do not explain a positive Rombergs sign.
9. The nurse is assessing the deep tendon reflexes of a client with long-standing
diabetes mellitus. Which clinical manifestation does the nurse expect to see?
ANS: A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
10. During a neurologic assessment of a client, the nurse notes that the clients arms,
wrists, and fingers have become flexed, and internal rotation and plantar flexion of the
legs are evident. How does the nurse document these findings?
a. Decorticate posturing
b. Decerebrate posturing
c. Atypical hyperreflexia
d. Spinal cord degeneration
ANS: A
11. The nurse is evaluating a clients physical assessment with the medical history and
treatment plan. The nurse notes that the clients right pupil appears dilated, with a
sluggish pupillary response to light. Which disorder and related treatment does this
physical finding correlate with?
ANS: C
Clients with glaucoma who are being treated with eyedrops have unequal pupils,
especially if only one eye is being treated. The pupillary reaction to light is slowed by
the use of eyedrops for glaucoma. The other disorders and treatments do not correlate
with the clinical assessment.
12. Before electroencephalography, a client asks, Why will I be asked to take deep
breaths during the procedure? How does the nurse respond?
ANS: B
13. The nurse is caring for a client post-cerebral angiography via the clients right
femoral artery. Which intervention does the nurse implement?
ANS: A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Diagnostic Tests/Treatments/Procedures)
14. The nurse is preparing a client for magnetic resonance angiography. Which
question is a priority at this time?
ANS: B
Allergies to iodine and/or shellfish need to be explored because the client may have a
similar reaction to the dye used in the procedure. In some cases, the client may need to
be medicated with antihistamines or steroids before the test is given. The other
conditions would not affect the angiography.
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection
ControlAccident/Injury Prevention) MSC: Integrated Process: Nursing Process (Assessment)
15. The nurse is caring for a client who had a computed tomography (CT) scan of the
head with contrast medium. Which priority intervention does the nurse implement?
a. Maintain bedrest with the head of the bed elevated less than 30 degrees.
b. Apply a pressure dressing to the site of injection.
c. Increase fluid intake after the procedure.
d. Maintain sedation for 8 hours postprocedure.
ANS: C
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Diagnostic Tests/Treatments/Procedures)
16. The nurse is obtaining the health history of a client scheduled for magnetic
resonance imaging (MRI). Which condition requires the nurse to cancel the MRI?
a. Amputated leg
b. Internal insulin pump
c. Intrauterine device
d. Atrioventricular (AV) graft
ANS: B
Metal devices such as pacemakers and prostheses interfere with the accuracy of the
image and can become displaced by the magnetic force generated by an MRI
procedure. An intrauterine device and an AV graft do not contain any metal.
TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)
17. Which priority instruction or precaution does the nurse teach a client who is
scheduled for a positron emission tomography scan of the brain?
ANS: A
Caffeine-containing liquids and foods are central nervous system stimulants and may
alter the test results. No contrast is used; therefore the client does not need to increase
fluid intake. The test does not require MRI, so metal does not have to be removed.
The client should take cardiac medications as prescribed.
TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)
a. Caring for your children is a priority. You may not want to ask for help,
but you have to.
b. Our community has resources that may help you with some household
tasks so you have energy to care for your children.
c. You seem distressed. Would you like to talk to a psychologist about
adjusting to your changing status?
d. Give me more information about what worries you, so we can see if we
can do something to make adjustments.
ANS: D
19. The nurse is planning care for an 83-year-old client with age-related changes to his
sensory perception. Which nursing action does the nurse implement to ensure the
clients safety?
ANS: C
Dementia and confusion are not common phenomena in older adults. However,
physical impairment related to illness can be expected. Providing opportunities for
hazard-free ambulation will maintain strength and mobility (and ensure safety). The
other actions are not a priority.
a. Peptic ulcers
b. Smoking history
c. Liver failure
d. Currently breast feeding
ANS: D
A SPECT test uses radiopharmaceutical agents that enable radioisotopes to cross the
blood-brain barrier. This test is contraindicated in women who are breast-feeding.
Having a history of smoking, peptic ulcers, or liver failure should not interfere with
the client having this test.
a. I need to stay away from heavy metals for the next 48 hours.
b. My urine will be radioactive for the next 48 hours.
c. I must increase my fluids because of the dye used for the MRI.
d. I can return to my usual activities immediately after the MRI.
ANS: D
No postprocedure restrictions are imposed after MRI. The client can return to normal
activities after the test is complete.
22. While assessing pain discrimination, a client correctly identifies, with eyes closed,
a sharp sensation on the right hand when touched with a pin. How does the nurse then
proceed with the examination?
ANS: A
If testing is begun on the hand and the client correctly identifies the pain stimulus,
testing more proximal parts of that extremity is not necessary because, if the distal
tract is intact, so are the proximal areas. Temperature discrimination is not necessary
because the same tract transmits both pain and temperature sensation.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 915
23. The nurse is assessing a client scheduled for a lumbar puncture. Which clinical
manifestation assessed by the nurse complicates the lumbar puncture procedure?
ANS: C
Clients must be able to hold still during the procedure. If a client is restless or
agitated, assistance may be needed to ensure that the procedure is completed safely.
Lumbar puncture is not performed on clients with severely high intracranial pressure.
Allergies to iodine and shellfish or eating lunch 2 hours before the procedure have no
effect on the procedure.
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Diagnostic Tests/Treatments/Procedures)
24. On assessment of the left plantar reflexes of an adult client, the nurse notes the
response shown in the photograph below. What action does the nurse take after
assessing this new finding?
a. Relay this abnormal finding to other members of the health care team.
b. Anticipate the need for cerebral angiography to determine the cause.
c. Examine the family history for a potential genetic disorder.
d. Document the finding and continue the assessment.
ANS: A
This finding is a positive Babinski reflex. In clients older than 2 years of age, a
positive Babinski reflex is considered abnormal and indicates central nervous system
disease. The nurse should notify the health care provider and other members of the
health care team because further investigation is warranted.
MULTIPLE RESPONSE
1. In a client with an injury to the medulla, the nurse monitors for which clinical
manifestations secondary to damage of cranial nerves that emerge from the medulla?
(Select all that apply.)
a. Loss of smell
b. Impaired swallowing
c. Blink reflex
d. Visual changes
e. Inability to shrug shoulders
f. Loss of gag reflex
ANS: B, E, F
2. The nurse is assessing a client with a temporal lobe injury. Which clinical
manifestations correlate with this injury? (Select all that apply.)
a. Memory loss
b. Personality changes
c. Loss of temperature regulation
d. Difficulty with sound interpretation
e. Speech difficulties
f. Impaired taste
ANS: A, D, E
Wernickes area (language area) is located in the temporal lobe and enables processing
of words into coherent thought and understanding of written or spoken words. The
temporal lobe also is responsible for the auditory centers interpretation of sound and
complicated memory patterns. Personality changes are related to damage to frontal
lobe injury. Loss of temperature regulation is seen with damage to the hypothalamus,
and impaired taste is associated with injury to the parietal lobe.
ANS: B, D
COMPLETION
1. Immediately after a lumbar puncture, the client begins to vomit and an IV is started
with normal saline (0.9% NS). The provider orders a 200-mL bolus over 15 minutes.
Using an infusion pump that delivers mL/hr, the rate at which the nurse sets the pump
is _____ mL.
ANS:
800
x = 800 mL
Test Bank
MULTIPLE CHOICE
1. The nurse is caring for a client experiencing migraine headaches who is receiving a
beta blocker to help manage this disorder. When preparing a teaching plan, which
instruction does the nurse plan to provide?
a. Take this drug only when you have prodromal symptoms indicating the
onset of a migraine headache.
b. Take this drug as ordered, even when feeling well, to prevent vascular
changes associated with migraine headaches.
c. This drug will relieve the pain during the aura phase soon after a
headache has started.
d. This medication will have no effect on your heart rate or blood pressure
because you are taking it for migraines.
ANS: B
Beta blockers are prescribed as prophylactic treatment to prevent the vascular changes
that initiate migraine headaches. Heart rate and blood pressure will also be affected,
and the client should monitor these side effects. The other responses do not discuss an
appropriate use of the medication.
a. Vertigo
b. Lethargy
c. Visual disturbances
d. Numbness of the tongue
ANS: C
Early warning of impending migraine with aura usually consists of visual changes,
flashing lights, or diplopia. The other manifestations are not associated with an
impending migraine with aura.
ANS: C
4. The nurse is assessing a client with a cluster headache. Which clinical manifestation
does the nurse expect to find?
ANS: A
5. A client with epilepsy develops stiffening of the muscles of the arms and legs,
followed by an immediate loss of consciousness and jerking of all extremities. How
does the nurse document this seizure activity?
a. Atonic seizure
b. Absence seizure
c. Myoclonic seizure
d. Tonic-clonic seizure
ANS: D
Seizure activity that begins with stiffening of the arms and legs, followed by loss of
consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure.
The other seizures do not manifest in this manner.
6. The nurse is assessing a client with a history of absence seizures. Which clinical
manifestation does the nurse assess for?
a. Automatisms
b. Intermittent rigidity
c. Sudden loss of muscle tone
d. Brief jerking of the extremities
ANS: A
Automatisms are characteristic of absence seizures. These behaviors consist of lip
smacking, patting, and picking at clothing. The other manifestations do not correlate
with absence seizures.
7. The nurse is caring for a client with a history of epilepsy who suddenly begins to
experience a tonic-clonic seizure and loses consciousness. What is the nurses priority
action?
ANS: B
The nurse should turn the clients head to the side to prevent aspiration and allow
drainage of secretions. The client should not be restrained nor an airway placed in his
or her mouth during the seizure because these actions increase seizure activity and can
harm the client. Vital signs are measured in the postictal phase of the seizure.
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
ANS: B
ANS: D
10. The nurse is teaching a client who is newly diagnosed with epilepsy. Which
statement by the client indicates a need for further teaching concerning the drug
regimen?
ANS: D
The nurse must emphasize that antiepileptic drugs must be taken even if seizure
activity has stopped. Discontinuing the medication can predispose the client to seizure
activity and status epilepticus. The client should not drink alcohol while taking seizure
medications. The client should wear a medical alert bracelet and should make the
doctor aware of all medications to prevent complications of polypharmacy.
11. The nurse assesses for which clinical manifestations in the client with suspected
encephalitis?
ANS: D
Nuchal rigidity is associated with meningeal irritation and is frequently present in
clients with encephalitis. The other manifestations are not associated with
encephalitis.
12. The nurse is taking the health history of a client suspected of having bacterial
meningitis. Which question is most important for the nurse to ask?
ANS: A
TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)
13. The nurse is talking to the family of a client who has Parkinsons disease. Which
statement indicates that the family has a good understanding of the changes in motor
movement associated with this disease?
a. I can never tell what shes thinking. She hides behind a frozen face.
b. She drools all the time so I just cant take her out anywhere.
c. I think this disease makes her nervous. She perspires all the time.
d. She has trouble chewing so I will offer bite-sized portions.
ANS: D
A masklike face, drooling, and excess perspiration are common in clients with
Parkinsons disease. Changes in facial expression or a masklike facies in a Parkinsons
disease client can be misinterpreted. Because chewing and swallowing can be
problematic, small frequent meals and a supplement are better for meeting the clients
nutritional needs. The other statements indicate poor understanding of the disease
process.
14. The nurse is caring for a client with Parkinsons disease. Which intervention does
the nurse implement to prevent respiratory complications in the client?
ANS: D
Elevation of the back rest will help prevent aspiration. The other options will not
prevent aspiration, which is the greatest respiratory complication of Parkinsons
disease.
15. The daughter of a client with Alzheimers disease asks, Will the medication my
mother is taking improve her dementia? How does the nurse respond?
ANS: D
Drug therapy is not effective for treating dementia or halting the advancement of
Alzheimers disease. However, certain drugs may help suppress emotional
disturbances and psychiatric manifestations.
16. A client with Alzheimers disease is admitted to the hospital. Which psychosocial
assessment is most important for the nurse to complete?
ANS: C
As the disease progresses, the client experiences changes in emotional and behavioral
affect. The nurse should be alert to the clients reaction to a change in environment,
such as being hospitalized, because the client may exhibit an exaggerated response,
such as aggression, to the event. The other assessments should be completed but are
not as important for a client with Alzheimers disease.
17. The nurse is caring for a hospitalized client with Alzheimers disease who has a
history of agitation. Which intervention does the nurse implement to help prevent
agitation and aggressive behavior in this client?
ANS: A
Fatigue from disturbed sleep increases confusion and behavioral manifestations, such
as aggression and agitation. Reality orientation is inappropriate for clients in a later
stage of the disease. Constant noise from the TV most likely would agitate the client.
Sedation should be used as a last resort.
a. I see you are still hungry. I will get you some toast.
b. You are confused about mealtimes this morning.
c. You ate your breakfast 30 minutes ago.
d. You look tired. Maybe a nap will help.
ANS: A
19. A client is prescribed levetiracetam (Keppra). Which laboratory tests does the
nurse monitor for potential adverse effects of this medication?
ANS: B
20. The caregiver of a client with advanced Alzheimers disease states, She is always
wandering off. What can I do to manage this restless behavior? How does the nurse
respond?
ANS: B
Several strategies may be used to cope with restlessness and wandering. Taking the
client for frequent walks may decrease restless behavior. Another strategy is to engage
the client in structured activities. The other options would not be as helpful.
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection
ControlAccident/Injury Prevention)
21. A client who has Alzheimers disease is being discharged home. What safety
instructions does the nurse include in the teaching plan for the clients caregiver?
ANS: C
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection
ControlAccident/Injury Prevention) MSC: Integrated Process: Teaching/Learning
22. The nurse is assessing a client with Huntingtons disease. Which motor changes
does the nurse monitor for in this client?
a. Shuffling gait
b. Jerky hand movements
c. Continuous chewing motions
d. Tremors of the hands during fine motor tasks
ANS: B
23. The nurse is planning to bathe a client diagnosed with meningococcal meningitis.
In addition to gloves, what personal protective equipment does the nurse use?
a. Particulate respirator
b. Isolation gown
c. Shoe covers
d. Surgical mask
ANS: D
Meningeal meningitis is spread via saliva and droplets. Caregivers should wear a
surgical mask when within 6 feet of the client and should continue to use Standard
Precautions. A particulate respirator, an isolation gown, and shoe covers are not
necessary for Droplet Precautions.
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection
ControlStandard Precautions/Transmission-Based Precautions/Surgical Asepsis)
24. A client diagnosed with the Huntington gene but who has no symptoms asks for
options related to family planning. Which is the nurses best response?
a. Most clients with the Huntington gene do not pass on Huntington disease
to their children.
b. I understand that they can diagnose this disease in embryos. Therefore
you could select a healthy embryo from your fertilized eggs for
implantation to avoid passing on Huntington disease.
c. The need for family planning is limited because one of the hallmarks of
Huntington disease is infertility.
d. Tell me more specifically what information you need about family
planning so that I can direct you to the right information or health care
provider.
ANS: D
The presence of the Huntington gene means that the trait will be passed on to all
offspring of the affected person. Understanding options for contraception and
conception (e.g., surrogate mother options) and implications for children may require
the expertise of a genetic counselor or a reproductive specialist. The other options are
not accurate.
25. The nurse is caring for a client who has chronic migraine headaches. Which
complementary health therapy does the nurse suggest?
ANS: C
At the onset of a migraine attack, the client may be able to alleviate pain by lying
down and darkening the room. He or she may want both eyes covered and a cool cloth
on the forehead. If the client falls asleep, he or she should remain undisturbed until
awakening. The other options are not recognized therapies for migraines.
MULTIPLE RESPONSE
1. The nurse is planning care for a client with epilepsy. Which precautions does the
nurse implement to ensure the safety of the client while in the hospital? (Select all that
apply.)
ANS: A, D, F
The bed rails should be up at all times while the client is in the bed to prevent injury
from a fall if the client has a seizure. Padded tongue blades may pose a danger to the
client during a seizure. Be sure that oxygen and suctioning equipment with an airway
are readily available. If the client does not have an IV access, insert a saline lock,
especially for those clients who are at significant risk for generalized tonic-clonic
seizures. The saline lock provides ready access if IV drug therapy must be given to
stop the seizure.
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection
ControlAccident/Injury Prevention)
2. The nurse is teaching a client with chronic headaches about headache triggers.
Which statements does the nurse include in the clients teaching plan? (Select all that
apply.)
a. Increase your intake of caffeinated beverages.
b. Increase your intake of fruits and vegetables.
c. Avoid all alcoholic beverages.
d. Avoid drinking red wine.
e. Incorporate physical exercise into your daily routine.
f. Incorporate an occasional fast into your plan.
ANS: B, D, E
Triggers for headaches include caffeine, smoking, and ingestion of pickled foods.
Clients are taught to eat a balanced diet and to get adequate exercise and rest.
3. The nurse is assessing the results of diagnostic tests on a clients cerebrospinal fluid
(CSF). Which values and observations does the nurse correlate as most indicative of
viral meningitis? (Select all that apply.)
a. Clear
b. Cloudy
c. Normal protein level
d. Increased protein level
e. Normal glucose level
f. Decreased glucose level
ANS: A, D, E
Viral meningitis does not cause cloudiness or increased turbidity of CSF. Protein
levels are slightly increased, and glucose levels are normal. In bacterial meningitis,
the presence of bacteria and white blood cells causes the fluid to be cloudy.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
Test Bank
MULTIPLE CHOICE
ANS: A
Exercise can strengthen back muscles, reducing the incidence of low back pain. The
other options will not prevent low back pain.
2. The nurse is caring for a client who has low back pain (LBP) from a work-related
injury. Which measures does the nurse incorporate into the clients plan of care?
ANS: C
Heat increases blood flow to the affected area and promotes healing of injured nerves.
However, continuous application of moist heat can promote skin breakdown.
a. You should begin an exercise routine which includes walking every day.
b. You must sleep in a supine position until the bandage is removed.
c. You may feel numbness or tingling in the legs for 24 hours.
d. You will need to wear a lumbar brace for 1 week.
ANS: A
After this minimally invasive surgery, clients typically go home the same day or the
day after surgery. Clients should be taught to begin the prescribed exercise program
immediately after discharge, which includes walking every day. The client should not
be restricted to one sleeping position. Clients generally have less pain with this
procedure and do not experience numbness or tingling. The client may have a clear or
gauze dressing but will not need to wear a lumbar brace.
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
4. The nurse is assessing a client who had a discectomy 6 hours ago. Which client
complaint requires priority action by the nurse?
a. I am feeling tired.
b. My mouth is so dry.
c. I cant seem to relax and rest.
d. I am unable to urinate.
ANS: D
Inability to void may indicate damage to the sacral spinal nerves. The other symptoms
require the nurse to provide care but are not the priority or a complication of the
procedure.
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
ANS: D
The finding of clear fluid on the dressing after a laminectomy strongly suggests a
cerebrospinal fluid leak, which constitutes an emergency. The client has in increased
risk of meningitis with a spinal fluid leak. Pain, redness, and itching at the site are
normal. The client should be encouraged to eat a healthy diet but does not need to
return to the hospital for a decreased appetite.
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
6. The nurse is caring for a client who has undergone a spinal fusion. Which specific
postoperative instructions does the nurse give this client?
ANS: B
Clients who undergo spinal fusion are fitted with a brace that they need to wear
throughout the healing process (usually 3 to 6 months) whenever they are out of bed.
The client does not need to remain on bedrest for the first 48 hours, should not lift
anything, and will not take steroids for rejection prevention.
7. A client who suffered a spinal cord injury at level T5 several months ago develops a
flushed face and blurred vision. On taking vital signs, the nurse notes the blood
pressure to be 184/95 mm Hg. Which is the nurses first action?
ANS: A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
8. Emergency medical services arrive to the emergency department with a client who
has a cervical spinal cord injury. Which priority assessment does the emergency
department nurse perform at this time?
ANS: D
The first priority for a client with a spinal cord injury is assessment of respiratory
status and airway patency. Clients with cervical spine injuries are particularly prone to
respiratory compromise and may even require intubation. The other assessments
should be performed after airway and breathing are assessed.
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
9. The nurse is caring for a client who has a vertebral fracture. Which intervention
does the nurse implement to prevent deterioration of the clients neurologic status?
ANS: C
The nurse keeps the client in optimal body alignment at all times, avoiding flexion
and extension at the site of vertebral injury, to prevent further cord injury or
irritability from bone fragments. A brace, traction, or external fixation may be used
for this purpose. The other interventions would not prevent deterioration of the clients
neurologic status. Assessments would assist with the recognition of neurologic
changes but would not prevent them.
10. A client who experienced a spinal cord injury 1 hour ago is brought to the
emergency department. Which prescribed medication does the nurse prepare to
administer to this client?
ANS: B
11. The nurse is assessing a client with a spinal cord injury at the T5 level. Which
clinical manifestation alerts the nurse to the presence of a complication of this injury?
ANS: B
Clients with injuries at or above the T6 vertebra are especially at risk for respiratory
complications caused by impaired intercostal muscles. The development of fever and
cough should alert the nurse to the possibility of pneumonia. The other manifestations
are not related to complications from this type of injury.
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
12. The nurse notes reddened areas over the hips and sacrum of a client with
paraplegia from a spinal cord injury. Which action does the nurse implement?
ANS: C
Reddened areas should not be rubbed because this action could cause more extensive
damage to the already fragile capillary system. ROM exercises are used to prevent
contractures. The reddened areas should be assessed for blanching. If the skin does
not blanch, the area is vulnerable to breakdown. Appropriate interventions to relieve
pressure on these areas through positioning, assistive devices, and skin protection
should then be used.
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
ANS: D
In clients with lower motor neuron problems, such as spinal cord injury, performing a
Valsalva maneuver or tightening the abdominal muscles are interventions that can
initiate voiding. The other interventions do not initiate voiding.
14. A client who has a lower motor neuron injury experiences a flaccid bowel
elimination pattern. Which action does the nurse implement to assist in relieving this
clients constipation?
ANS: D
For the client with a lower motor neuron injury, the resulting flaccid bowel may
require a bowel program for the client, which includes stool softeners, increased fluid
intake, a high-fiber diet, and a consistent elimination time. The other interventions do
not assist this client.
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
ANS: C
ANS: A
Often, the person with a spinal cord injury will have weak intercostal muscles and is
at higher risk for developing atelectasis and stasis pneumonia. Using an incentive
spirometer every 2 hours helps the client expand her or his lungs more fully and
prevents atelectasis. Clients should drink fluids that they can tolerate; usually thick
fluids are easy to tolerate. The client should be encouraged to cough and clear
secretions. Clients should be placed in high Fowlers position to prevent aspiration.
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
17. The nurse assesses for which clinical manifestation in a client with multiple
sclerosis (MS) of the relapsing type?
ANS: B
The classic picture of relapsing-remitting MS is characterized by increasingly frequent
attacks. The other manifestations do not correlate with a relapsing type of MS.
18. The nurse is assessing a client with an early onset of multiple sclerosis (MS).
Which clinical manifestation does the nurse expect to see?
a. Hyperresponsive reflexes
b. Excessive somnolence
c. Nystagmus
d. Heat intolerance
ANS: C
Early signs and symptoms of MS include changes in motor skills, vision, and
sensation. The other manifestations are later signs of MS.
a. Baclofen (Lioresal)
b. Interferon beta-1b (Betaseron)
c. Dantrolene sodium (Dantrium)
d. Methylprednisolone (Medrol)
ANS: D
Methylprednisolone is the drug of choice for acute exacerbations of the disease. The
other medications are not appropriate.
20. A client with multiple sclerosis is being treated with fingolimod (Gilenya). Which
clinical manifestation alerts the nurse to an adverse effect of this medication?
a. Periorbital edema
b. Black tarry stools
c. Bradycardia
d. Vomiting after meals
ANS: C
21. The nurse is preparing a client who has multiple sclerosis (MS) for discharge home
from a rehabilitation center. The client has been prescribed cyclophosphamide
(Cytoxan) and methylprednisolone (Medrol). Which instruction does the nurse include
in the teaching plan for the client?
ANS: B
The client should be taught to avoid people with any type of upper respiratory illness
because these medications are immunosuppressive. Warm baths will exacerbate the
MS symptoms, assistive devices may be required for safe ambulation, and medication
should not be stopped.
22. Early manifestations of amyotrophic lateral sclerosis (ALS) and multiple sclerosis
(MS) are somewhat similar. Which clinical feature of ALS distinguishes it from MS?
a. Dysarthria
b. Dysphagia
c. Muscle weakness
d. Impairment of respiratory muscles
ANS: D
23. Which neurologic test or procedure requires the nurse to determine whether an
informed consent has been obtained from the client before the test or procedure?
ANS: C
TOP: Client Needs Category: Safe and Effective Care Environment (Management of
CareInformed Consent)
24. A client is scheduled for magnetic resonance imaging (MRI). Which action does
the nurse implement before the test?
a. Ensure that the person does not eat for 8 hours before the procedure.
b. Discontinue all neuroactive medications 3 hours before the procedure.
c. Make sure that the client has an identification bracelet that cannot be
removed.
d. Replace the clients gown with metal snaps with one that has cloth ties.
ANS: D
Metal objects are a hazard because of the magnetic field used in the MRI procedure.
The other actions are not necessary for MRI.
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection
ControlAccident/Injury Prevention)
25. The nurse is teaching a client who has an unstable thoracic vertebral fracture and is
being treated with immobilization before surgery. Which statement does the nurse
include in the clients teaching?
a. You will need to apply an immobilizing brace snugly around your waist
when out of bed.
b. You will remain strapped to the transport back board until the surgical
room is ready.
c. Keep your spine in alignment by not sitting up, arching your back, or
twisting in bed.
d. An incentive spirometer will prevent you from having atelectasis and
pneumonia after surgery.
ANS: C
The client with a thoracic vertebral fracture is at risk for spinal cord injury, especially
with flexion, extension, or rotation of the trunk. The client will be moved to a more
comfortable bed to wait for surgery and will remain on bedrest. Although teaching
about how to use an incentive spirometer is important for surgical clients, the
incentive spirometer alone does not prevent atelectasis and pneumonia; it only assists
the client to breathe deeply.
26. The nurse is planning care for a client who has a spinal cord injury. Which
interdisciplinary team member does the nurse consult with to assist the client with
activities of daily living?
a. Social worker
b. Physical therapist
c. Occupational therapist
d. Case manager
ANS: C
The occupational therapist instructs the client in the correct use of all adaptive
equipment. In collaboration with the therapists, the nurse instructs family members or
the caregiver about transfer skills, feeding, bathing, dressing, positioning, and skin
care. The other team members are consulted to assist the client with unrelated issues.
TOP: Client Needs Category: Safe and Effective Care Environment (Management of
CareConsultation with Interdisciplinary Team)
27. The nurse is discussing advanced directives with a client who has amyotrophic
lateral sclerosis (ALS). The client states, I do not want to be placed on a mechanical
ventilator. How does the nurse respond?
a. You will need to discuss that with your family and health care provider.
b. Why are you afraid of being placed on a breathing machine?
c. What would you like to be done if you begin to have difficulty
breathing?
d. You will be on the ventilator only until your muscles get stronger.
ANS: C
TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEthical
Practice) MSC: Integrated Process: Communication and Documentation
MULTIPLE RESPONSE
1. The nurse is assessing a clients coping strategies after suffering a traumatic spinal
cord injury. Which information related to this assessment is important for the nurse to
obtain? (Select all that apply.)
ANS: A, C, D, F
Information about the clients preinjury psychosocial status, usual methods of coping
with illness, difficult situations, and disappointments should be obtained. Determine
the clients level of independence or dependence and his or her comfort level in
discussing feelings and emotions with family members or close friends. Clients who
are emotionally secure and have a positive self-image, a supportive family, and
financial and job security often adapt to their injury. Information about the clients
spiritual and religious beliefs or cultural background also assists the nurse in
developing the plan of care. The other options do not supply as much information
about coping.
2. The nurse is teaching a client with a spinal cord tumor about the treatment plan.
Which statements indicate that the client correctly understands the teaching? (Select
all that apply.)
ANS: B, C, E
Although surgery may relieve symptoms by reducing pressure on the spine and
debulking the tumor, some motor and sensory deficits may remain. Spinal tumors
usually cause disability but are not usually fatal.
3. The nurse is teaching a male client with a spinal cord injury at T4 (thoracic) about
the sexual effects of this injury. Which statement by the client indicates correct
understanding of the teaching? (Select all that apply.)
ANS: B, D, E
Men with injuries above T6 often are able to have erections by stimulating reflex
activity. For example, stroking the penis will cause an erection. Ejaculation is less
predictable and may be mixed with urine. However, urine is sterile, so the clients
partner will not get an infection.
TOP: Client Needs Category: Health Promotion and Maintenance (Health and Wellness)
Test Bank
MULTIPLE CHOICE
ANS: B
In Guillain-Barr syndrome, the immune system destroys the myelin sheath, causing
segmental demyelination. Nerve impulses are transmitted more slowly but remain in
place. Antibodies are not developed. The nerves do not degenerate and retract.
2. The nurse assesses a client who has Guillain-Barr syndrome. Which clinical
manifestation does the nurse expect to find in this client?
ANS: C
The most common clinical pattern of Guillain-Barr syndrome is the ascending variety.
Weakness and paresthesia begin in the lower extremities and progress upward. The
other manifestations are not associated with Guillain-Barr syndrome.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 987
3. The nurse reviews laboratory data for a client who has Guillain-Barr syndrome
(GBS). Which result does the nurse correlate with this disease process?
ANS: A
A lumbar puncture is performed to evaluate the CSF. An increased CSF protein level
without increased cell count is a distinguishing feature of GBS. The other results are
not associated with GBS.
4. The intensive care nurse is caring for a client who has Guillain-Barr syndrome. The
nurse notes that the clients vital capacity has declined to 12 mL/kg, and the client is
having difficulty clearing secretions. Which is the nurses priority action?
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
ANS: C
Nursing care of the client undergoing plasmapheresis includes care of the shunt. The
nurse checks for bruits every 2 to 4 hours for patency. Pulse and extremity
assessments do not provide information related to shunt patency. Pressure within the
shunt is not tested before treatment to determine patency.
a. Tachycardia
b. Hypovolemia
c. Hyperkalemia
d. Hemorrhage
ANS: B
The client undergoing plasmapheresis is at risk for hypovolemia. The nurse monitors
fluid status, assesses vital signs, and administers replacement fluid, as indicated. The
other manifestations are not complications of plasmapheresis.
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Diagnostic Tests/Treatments/Procedures)
7. The nurse teaches a client with Guillain-Barr syndrome (GBS) about the recovery
rate of this disorder. Which statement indicates that the client correctly understands
the teaching?
ANS: B
Most clients make a full recovery from GBS. Recovery can take as long as 6 months
to 2 years. Fatigue is a major lingering symptom for most of those diagnosed with this
disorder. Clients are not permanently paralyzed. They are in an acute care
environment during the acute phase of the disorder.
8. The nurse assesses a client who has myasthenia gravis. Which clinical manifestation
does the nurse expect to observe in this client?
ANS: A
The most common assessment finding in more than 90% of clients with myasthenia
gravis is involvement of the extraocular muscles. The nurse observes for inability or
difficulty with tests of extraocular function, such as the cardinal positions of gaze.
Ptosis and incomplete eye closure also may be observed. Altered hearing and absent
reflexes are not common in myasthenia gravis.
9. The nurse is assessing laboratory results for a client with myasthenia gravis (MG).
Which results does the nurse correlate with this disease process?
a. Elevated serum calcium level
b. Decreased thyroid hormone level
c. Decreased complete blood count
d. Elevated acetylcholine receptor antibody levels
ANS: D
10. A client suspected to have myasthenia gravis is scheduled for the Tensilon
(edrophonium chloride) test. Which prescribed medication does the nurse prepare to
administer if complications of this test occur?
a. Epinephrine
b. Atropine sulfate
c. Diphenhydramine
d. Neostigmine bromide
ANS: B
Tensilon increases cholinergic responses and can slow the heart rate down so that
ectopic beats dominate, causing cardiac fibrillation or arrest. Atropine sulfate is an
anticholinergic drug. The other medications are not appropriate for complications of
this test.
11. The nurse is caring for a client who has myasthenia gravis. Which nursing
intervention does the nurse implement to reduce muscle weakness in this client?
ANS: B
The hallmark of myasthenia gravis is muscle weakness that increases with fatigue.
The nurse provides assistance with ADLs to prevent fatigue. The nurse collaborates
with the physical therapist in teaching the client energy conservation techniques.
Therapeutic massage, passive range of motion, and repositioning will not reduce
muscle weakness.
12. The nurse is assessing a client who is experiencing a myasthenia crisis. Which
diagnostic test does the nurse anticipate being ordered?
ANS: B
The Tensilon test in an important procedure for a client in myasthenic crisis.
Cholinesterase-inhibiting drugs should be withheld because they increase respiratory
secretions, which enhance the manifestations of a myasthenic crisis. A Babinski reflex
and caloric reflex test would not be appropriate for this client.
13. A client who has myasthenia gravis is receiving atropine for a cholinergic crisis.
Which intervention does the nurse implement for this client?
ANS: A
Atropine can cause thickening of secretions and formation of mucous plugs. The
client is maintained on a ventilator during the crisis. Measures to remove secretions to
prevent the buildup of secretions and the possibility of pneumonia are most important.
The other interventions do not relate to the administration of atropine.
14. The nurse instructs a client who has myasthenia gravis to take prescribed
medications on time and to eat meals 45 to 60 minutes after taking anticholinesterase
drugs. The client asks why the timing of meals is so important. Which is the nurses
best response?
a. This timing allows the drug to have maximum effect, so it is easier for
you to chew, swallow, and not choke.
b. This timing prevents your blood sugar level from dropping too low and
causing you to be at risk for falling.
c. These drugs are very irritating to your stomach and could cause ulcers if
taken too long before meals.
d. These drugs cause nausea and vomiting. By waiting a while after you
take the medication, you are less likely to vomit.
ANS: A
Skeletal muscle weakness extends to the ability to chew and swallow. Clients who
have myasthenia gravis are at risk for aspiration during meals. Timing the medication
so that most of the meal is eaten when the drugs have produced their peak effect
enables the client to chew and swallow more easily. The medication has no effect on
blood glucose levels, ulcers, or nausea.
15. A client who has myasthenia gravis is recovering after a thymectomy. Which
complication does the nurse monitor for in this client?
ANS: A
The complication to be alert for is pneumothorax or hemothorax. The nurse monitors
the client for chest pain, sudden onset of shortness of breath, diminished chest wall
expansion, decreased breath sounds, restlessness, and changes in vital signs. The other
symptoms are not likely to occur or are not related to removal of the thymus.
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
16. A client with myasthenia gravis is preparing for discharge. Which instructions
does the nurse include when educating the clients family members or caregiver?
ANS: D
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
17. The nurse teaches a client who has autonomic dysfunction about injury prevention.
Which statement indicates that the client correctly understands the teaching?
a. I will change positions slowly.
b. I will avoid wearing cotton socks.
c. I will use an electric razor.
d. I will use a heating pad on my feet.
ANS: A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
18. The nurse is planning discharge teaching for a client who has peripheral
neuropathy of the lower extremities. Which instruction does the nurse include in the
teaching plan?
a. Cut all calluses and corns from your feet as soon as you notice them.
b. Your balance will be steadier if you go barefoot while at home.
c. Use a thermometer to check the temperature of bath water.
d. Avoid using lotion on the feet and legs.
ANS: C
The client with neuropathy has loss of sensation in the lower extremities, which can
predispose the client to thermal injury. The client should be instructed to use a
thermometer to check the temperature of the bath water to avoid a burn. Checking the
water with the hands is not recommended because neuropathy may have a stocking
and glove distribution that could also affect the hands. The client should be taught to
wear shoes at all times, to assess feet and legs daily, to keep skin moist and clean, and
not to cut calluses or corns from the feet.
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
19. The nurse is caring for a client who has undergone peripheral nerve repair. Which
priority assessment does the nurse perform postoperatively?
ANS: B
The nurse assesses the skin surrounding the cast hourly for tightness, warmth, and
color. If the cast is too tight, the nurse notifies the provider immediately. The other
assessments should be completed after a circulatory assessment.
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
20. The nurse is assessing a client with trigeminal neuralgia. Which clinical
manifestation does the nurse expect to observe?
a. Excruciating pain
b. Decreased mobility
c. Controllable facial twitching
d. Increased talkativeness
ANS: C
Signs of trigeminal neuralgia are excruciating pain and uncontrollable facial twitching
which causes the client to avoid talking, smiling, eating, or attending to hygienic
needs. Sensory and mobility deficits are not associated with trigeminal neuralgia.
21. The nurse is assessing a client who had a dissection of all branches of the right
trigeminal nerve. When asked to wrinkle his forehead, the client wrinkles only the left
side. Which is the nurses best action?
ANS: B
Loss of motor and sensory function after complete trigeminal nerve dissection is
normal. No intervention is necessary.
a. The surgeon will cut the connection between the cranial nerves.
b. The surgeon will use an electrode to bypass the trigeminal nerve
conduction.
c. An incision is made into the nerve itself, and an anesthetic is applied to
the area.
d. A small artery compressing the nerve will be relocated.
ANS: D
In some clients, a small artery compresses the nerve as it enters the pons. By
relocating this nerve, pain relief is obtained and sensation is spared. The other
responses do not answer the clients question appropriately.
23. The nurse is teaching a client who is receiving carbamazepine (Tegretol) for
chronic trigeminal neuralgia. Which statement indicates that the client correctly
understands the teaching?
a. This drug will prevent seizures, which can occur because of trigeminal
disease.
b. I expect to have surgery soon, so I can stop taking this drug now.
c. This medication is very successful in relieving pain. I am glad to be
taking it.
d. I will avoid drinking alcohol because it can add to the side effects of this
medicine.
ANS: D
Carbamazepine is thought to interfere with the transmission of pain through slow
fibers. It may decrease the paroxysmal afferent impulse that causes trigeminal pain.
Trigeminal disease does not cause seizures. Drowsiness, dizziness, confusion, and risk
for falls are adverse effects of this medication. Alcohol consumption increases these
risks; therefore the client should not drink alcohol when taking this medication.
Seizure disorders may occur in clients who stop taking this medication. The dose
should be decreased gradually. Pain relief varies with the person; some people find
that this medication provides at least some relief.
24. The nurse teaches a client who has Guillain-Barr syndrome (GBS) about pain
management. Which statement indicates that the client correctly understands the
teaching?
a. I can use the button on the pump as often as I want to get more pain
medication.
b. Aspirin will provide the best relief from my pain associated with this
disease.
c. A combination of morphine and distraction helps bring me relief right
now.
d. I should not have any pain as a result of impaired motor and sensory
neurons.
ANS: C
Typical pain from GBS often is not relieved by medication other than opiates.
Distraction, repositioning, massage, heat, cold, and guided imagery may enhance the
opiate effects. Patient-controlled analgesia (PCA) pumps should be set with
appropriate doses and limits.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
25. The nurse is obtaining a health history for a 45-year-old woman with Guillain-Barr
syndrome (GBS). Which statement by the client does the nurse correlate with the
clients diagnosis?
ANS: B
The client with GBS often relates a history of acute illness, trauma, surgery, or
immunization 1 to 3 weeks before the onset of neurologic symptoms. The other
statements do not correlate with GBS.
MULTIPLE RESPONSE
1. A client has just undergone surgery for peripheral nerve trauma. Which
interventions does the nurse include in the clients plan of care? (Select all that apply.)
ANS: A, C, D
Care for the client with peripheral nerve trauma includes immobilization before and
after surgery, and skin care to prevent skin breakdown and promote healing. The
client may likely require physical or occupations therapy during the recovery process.
The client will have decreased sensation, so cold and heat therapy should not be used.
The client will require a diet high in protein to promote healing.
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
2. The nurse is preparing a staff in-service program related to restless legs syndrome
(RLS). Which potential risk factors of this syndrome does the nurse include? (Select
all that apply.)
a. Skin rashes
b. Polyneuropathies
c. Muscle atrophy
d. Diabetes mellitus type 2
e. Hypercalcemia
ANS: B, D
Risk factors for RLS include a possible genetic basis, history of type 2 diabetes
mellitus, advanced kidney failure, vitamin and mineral deficiencies, polyneuropathies,
peripheral nerve disease, age, lack of exercise, and pinched nerve. Rashes, muscle
atrophy, and hypercalcemia are not related.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 999
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
3. The nurse is preparing to send a cerebrospinal fluid sample to the laboratory. Which
actions does the nurse implement during this procedure? (Select all that apply.)
ANS: A, D, E
The Standard Precautions approach is based on the premise that a medical history and
a physical examination cannot reliably identify all those infected by pathogens.
Consequently, health care workers should consider all human blood and body fluids
as potentially infectious and must use appropriate protective measures to prevent
possible exposure. Specimens should be labeled appropriately and transported in a
sealed bag displaying the biohazard symbol. The nurse should use Standard
Precautions when handling the specimen. The nurse should also confirm the
identification of the client and the specimen. The nurse does not need sterile gloves,
and the specimen should not be iced.
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection
ControlHandling Hazardous and Infectious Materials)
Test Bank
MULTIPLE CHOICE
1. The nurse is obtaining a health history for a client admitted to the hospital after
experiencing a brain attack. Which disorder does the nurse identify as a predisposing
factor for an embolic stroke?
a. Seizures
b. Psychotropic drug use
c. Atrial fibrillation
d. Cerebral aneurysm
ANS: C
TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)
ANS: A
3. The nurse is caring for an 80-year-old client who presented to the emergency
department in a coma. Which question does the nurse ask the clients family to help
determine whether the coma is related to a brain attack?
ANS: D
Conditions such as drug or alcohol intoxication, as well as hypoxemia and metabolic
disturbances, can cause profound changes in level of consciousness (LOC) when
accompanied by a brain attack. Alcohol abuse and medication toxicity can be
especially problematic in older adults. The other manifestations are related to a stroke
but would not increase the clients risk of coma.
4. The nurse is assessing a client who had a stroke in the right cerebral hemisphere.
Which neurologic deficit does the nurse assess for in this client?
a. Impaired proprioception
b. Aphasia
c. Agraphia
d. Impaired olfaction
ANS: A
A stroke to the right cerebral hemisphere causes impaired visual and spatial
awareness. The client may present with impaired proprioception and may be
disoriented as to time and place. The right cerebral hemisphere does not control
speech, smell, or the clients ability to write.
5. A client who had a stroke combs her hair only on the right side of her head and
washes only the right side of her face. How does the nurse interpret these actions?
a. Poor left-sided motor control
b. Paralysis or contractures on the right side
c. Limited visual perception of the left fields
d. Unawareness of the existence of her left side
ANS: D
Clients who have experienced a right hemisphere stroke often have neglect syndrome,
in which they are unaware of the existence of the paralyzed side, or the left side. This
injury would not have an effect on the clients sight. This is not related to poor motor
control or paralysis.
6. The nurse notes that the left arm of a client who has experienced a brain attack is in
a contracted, fixed position. Which complication of this position does the nurse
monitor for in this client?
a. Shoulder subluxation
b. Flaccid hemiparesis
c. Pathologic fracture
d. Neglect syndrome
ANS: A
7. The nurse is caring for a client who has experienced a stroke. Which nursing
intervention for nutrition does the nurse implement to prevent complications from
cranial nerve IX impairment?
ANS: B
Cranial nerve IX, the glossopharyngeal nerve, controls the gag reflex. Clients with
impairment of this nerve are at great risk for aspiration. The client should be in high
Fowlers position and should drink thickened liquids if swallowing difficulties are
present. The client would not have vision problems. Turning the plate around would
not prevent a complication, nor would limiting the clients diet to clear liquids.
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
8. A client who had a brain attack was admitted to the intensive care unit yesterday.
The nurse observes that the client is becoming lethargic and is unable to articulate
words when speaking. What does the nurse do next?
ANS: B
The client is experiencing signs of increased intracranial pressure (ICP). Raising the
head of the bed would help decrease ICP. The health care provider should then be
notified immediately so that other interventions to reduce ICP can be instituted.
Assessing vital signs and white blood cell count is not the priority at this time.
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
9. The nurse is caring for a client who had a stroke. Which nursing intervention does
the nurse implement during the first 72 hours to prevent complications?
ANS: C
Early detection of neurologic, blood pressure, and heart rhythm changes offers an
opportunity to intervene in a timely fashion. Evidence is not yet sufficient to
recommend a specific back rest elevation after stroke. Analgesics are often held
during the first 72 hours to ensure that the clients neurologic status is not altered by
pain medications. Preventing fatigue is not a priority in the first 72 hours.
10. A client who first experienced symptoms related to a confirmed thrombotic stroke
2 hours ago is brought to the intensive care unit. Which prescribed medication does
the nurse prepare to administer?
ANS: A
The client who has had a thrombotic stroke has a 3-hour time frame from the onset of
symptoms to receive recombinant tissue plasminogen activator (rt-PA) to dissolve the
cerebral artery occlusion and re-establish blood flow. Clients must meet eligibility
criteria for administration of this therapy. The other medications do not assist in the
re-establishment of blood flow for a client with a confirmed thrombotic stroke.
11. A client who had a stroke is receiving clopidogrel (Plavix). Which adverse effect
does the nurse monitor for in this client?
a. Repeated syncope
b. New-onset confusion
c. Spontaneous ecchymosis
d. Abdominal distention
ANS: C
12. The nurse is caring for a client who is immobile from a recent stroke. Which
intervention does the nurse implement to prevent complications in this client?
ANS: B
To avoid complications of immobility, such as deep vein thrombosis, the nurse applies
sequential compression stockings or pneumatic compression boots. Efforts are made
to mobilize the client as much as possible, and the client should be repositioned
frequently. The other interventions will not prevent complications of immobility.
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
13. A client has experienced a stroke resulting in damage to Wernickes area. Which
clinical manifestation does the nurse monitor for?
ANS: A
The client with damage to Wernickes area cannot understand spoken or written words.
If the client speaks, the language is meaningless, with the client using made-up words.
Damage to Wernickes area does not cause slurred speech, nor will the client
communicate with habitual speech only.
14. A client who has had a stroke with left-sided hemiparesis has been referred to a
rehabilitation center. The client asks, Why do I need rehabilitation? How does the
nurse respond?
ANS: C
The goal of rehabilitation is to maximize the clients abilities in all aspects of life. The
other responses do not answer the clients question appropriately.
15. The nurse is teaching bladder training to a client who is incontinent after a stroke.
Which instruction does the nurse include in this clients teaching?
ANS: C
To begin a bladder training program, teach the client to use the commode, bedpan, or
urinal every 2 hours. If used frequently enough, this will prevent accidents and
establish a routine. Fluid intake should be restricted at night, and a Foley catheter
should be used only for urine retention. The client should empty his or her bladder
when the urge occurs and should not hold the bladder.
16. The nurse is caring for a client admitted to the intensive care unit after incurring a
basilar skull fracture. Which complication of this injury does the nurse monitor for?
a. Aspiration
b. Hemorrhage
c. Pulmonary embolus
d. Myocardial infarction
ANS: B
This type of fracture may cause hemorrhage from damage to the internal carotid
artery. The other problems are not complications of this injury.
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
17. A client who has a head injury is transported to the emergency department. Which
assessment does the emergency department nurse perform immediately?
a. Pupil response
b. Motor function
c. Respiratory status
d. Short-term memory
ANS: C
18. The nurse is caring for a client who has a moderate head injury. The clients sister
asks, Will my brother return to his normal functioning level when his brain heals?
How does the nurse respond?
a. You should expect a full recovery in all ways by the time of discharge.
b. Usually, someone with this type of injury returns to baseline within 6
months.
c. Your brother may experience many changes in personality and cognitive
abilities.
d. Learning complex new skills may be more difficult, but you can expect
other functions to return to normal.
ANS: C
Those with moderate to severe head injuries are never the same as before the injury.
They can experience changes in cognition such as memory loss, difficulty learning
new information, and limited concentration. Personality alterations such as outbursts
of temper and depression also may occur. The other responses do not correctly answer
the question and can give false hope.
19. A client who has a severe head injury is placed in a drug-induced coma. The
clients husband states, I do not understand. Why are you putting her into a coma?
How does the nurse respond?
a. These drugs will prevent her from experiencing pain when positioning or
suctioning is required.
b. This medication will help her remain cooperative and calm during the
painful treatments.
c. This medication will decrease the activity of her brain so that additional
damage does not occur.
d. This medication will prevent her from having a seizure and will reduce
the need for monitoring intracranial pressure.
ANS: C
ANS: A
21. A client with a head injury is being given midazolam (Versed) while on
mechanical ventilation. Which action does the nurse implement for this client?
ANS: D
22. The nurse is caring for a client who is disoriented as the result of a stroke. Which
action does the nurse implement to help orient this client?
ANS: A
For the client with disorientation, the nurse can request that the family bring in
pictures or objects that are familiar to the client. The nurse explains what the object or
picture represents in simple terms. These stimuli can be presented several times daily.
Visitors can also be familiar stimuli to reorient the client. Too much stimuli and
constant stimuli can lead to further confusion.
23. The nurse is planning the discharge of a client who has sustained a moderate head
injury and is experiencing personality and behavior changes. The clients wife states, I
am concerned about how different he is. What can I do to help with the transition back
to our home? How does the nurse respond?
ANS: C
24. The nurse assesses periorbital edema and ecchymosis around both eyes of a client
who is 6 hours postoperative for craniotomy. Which intervention does the nurse
implement for this client?
ANS: B
Periorbital edema and ecchymosis are expected after a craniotomy. The nurse should
attempt to increase the clients comfort by reducing the swelling with application of
ice. The provider does not need to be notified. Lowering the head of the bed and
assessing blood pressure will not decrease inflammation.
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
25. The nurse is assessing a client who was recently diagnosed with a meningioma.
Which statement indicates that the client correctly understands the diagnosis?
a. This is the worst type of brain tumor, and surgery is not an option.
b. My tumor can be removed, but I can still have damage because of
pressure in my brain.
c. Even after the surgery, I will need chemotherapy to decrease the spread
of the tumor.
d. Radiation is never used on brain tumors because of possible nerve
damage.
ANS: B
Meningiomas arise from the coverings of the brain (the meninges) and are the most
common type of benign tumor. This tumor is encapsulated, globular, and well
demarcated, and causes compression and displacement of nearby brain tissue.
Although complete removal of the tumor is possible, it tends to recur and causes
irreversible damage to the brain. The tumor is not treated by chemotherapy or
radiation.
MULTIPLE RESPONSE
a. Hemiplegia
b. Aphasia
c. Hearing loss
d. Behavior changes
e. Nystagmus
ANS: A, B, D
If the tumor affects the cerebral hemispheres, hemiplegia, aphasia, and behavioral
changes are common. Hearing loss and nystagmus are found with brainstem lesions.
COMPLETION
ANS:
80
15x = 1200
x = 80 mL/hr