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Mental Health

1. A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states “I want to go outside now and smoke it takes forever to get anything done here”. What intervention is best for the PN to implement?

a. Encourage client to us nicotine patchb. Reassure pt that it is almost time for another breakc. Have the pt leave the unit with another staffd. Review the schedule of outdoor breaks with the client? (correct)

Answer: I will review the schedule of outdoor breaks with the client; Review the plan

2. A client is admitted to a psychiatric unit and tells the LVN that he is a FBI agent and his cover is Charles Bronson. The LVN should recognize that these thought patterns are examples of which condition:

a. delusions of grandiosity (correct)b. obsessive compulsive disorderc. a panic attackd. post traumatic stress disorder

Rationale: The client is delusional which is the holding of false beliefs or opinions. Obsessive compulsive disorder (b) is anxiety associated with repetitive thoughts obsession or irresistible impulsesor compulsion to perform a certain action like hand washing. A panic attack (c) is an unrealistic fear which the client recognized as excessive but can’t help it. Post traumatic stress disorder (D) is severe anxiety resulting from a traumatic experience.

3. The PN is brings a scheduled dose of valproate Acid -Depakote to amale client who has a history of seizure activity the client tells the

PN that has he has not had a seizure in several months and does not believe he needs the medication nurse response.

a. Hold the dose and document that the client believes that he does not need the medication

b. Reassure the client that this medication has other actions besides seizure control

c. Notify the charge nurse of the client’s refusal to take the scheduled medication

d. Review the need for taking the medication even when no seizure activity occurs. (correct)

Rational: assessing the clients understand of the risks of noncompliance d is important before attempting to intervene asking whooften leads to defensiveness b and c clues for intervening with the client but may seems patronizing to the client

4. The PN is reviewing the discharge medication instructions with a client for disulfiram (Antabuse). Which instruction should the PN reinforce with the client?

a. Have weekly blood tests to determine therapeutic drug levels andserum sodiumb. Avoid all sources of alcohol while taking this drug, including cough syrups (correct) c. Stop the drug if nausea, vomiting and or prostration occurd. The medication should be taken at the same time each day.

Rationale: Over the counter medications especially cold meds often contain alcohol and should not be taken while on antabuse therapy. Antabuse is used as an aversion therapy for alcoholics and will cause extreme nausea and vomiting when even a small amount of alcohol is ingested. Weekly blood tests are important for clients taking lithium carbonate not Antabuse.

5. A male client attends a community support program for mentally impaired and chemical abusing clients. The client tells the practical nurse PN that his drugs of choice are cocaine and heroin. What is the greatest health risk for this client?

a. Hypertensionb. Diabetes

c. Hepatitis (correct) d. Glaucoma

Rationale: Hepatitis is the greatest risk for this client because of the potential use of contaminated shared needles for drug administration.

6. A highly successful businessman presents to the community mental health center complaining of sleeplessness and anxiety over his financial status. What action should the practical nurse take to assist this client in diminishing his anxiety?

a. Reinforce the reality of his financial situationb. Teach him to limit sugar and caffeine intake. (correct) c. Direct him to drink a glass of red wine at bedtime.d. Encourage him to initiate daily rituals

7. A female client approaches the PN a states that she wants to talk about recent stresses. While they sit at a table talking, the client leans over puts her head down and states I feel like I’m having an anxiety attack. Client begins to hyperventilate. What should the PN do?

a. Find a peer to remain with the clientsb. Refocus the client’s attention to televisionc. Take the client to the self esteem groupd. Provide the client with verbal reassurance (correct)

Rational: PN should remain quiet and calm and should provide a reassurance to the client. Finding a peer may cause more anxiety; may leave client with feelings of abandonment. So the PN should remain with the patient.

8. A client is diagnosed with terminal cancer and tells the PN “the doctor told me I have cancer and I don’t have long to live”. Which response is most appropriate for the PN?

a. Would you like me to call your Chaplinb. Yes your condition is serious (correct)c. That’s correct, you don’t have lone to lived. There always hope, so don’t give up

Rationale: (b) is the most appropriate statement because it reflects what the client stated and confirms his statement. (c) is insensitive.(a) Might be appropriate after the PN has offered support. (d) Could promote denial.

9. The PN observes a male client diagnosed with schizophrenia sittingall alone and talking quietly. What action should the PN take?

a. Have the UAP escort the client to his roomb. Record the event but do not disturb the clientc. Ask the client if he is hearing voices?d. Administer a p.r.n. dose of Thorazine

10. A 16 yr old client is hospitalized following a head injury and is having a seizure. What action should the PN first take?a. Pull the emergency call light to notify the RNb. Place a padded tongue blade between the teethc. Hold the client’s arms to prevent injuryd. Place pillows around the side rails- (correct)

Rationale-placing pillows around the side rails will prevent the client from possibility incurring injury from hitting the side rails while seizing

11. A 30 year old female client with chronic major depressive disorder reports to the PN nurse working in the outpatient psychiatric clinic that she has recently stopped taking her medications. Which response is best for the PN to provide? a. What is it going to take to get you to stay on your medication regimen?b. Why did you decide to stop taking your medication?c. How will going off you medication help you?d. Has anyone discussed with you the risks of stopping your medication? (correct)

Neurological Nursing

12. A client has a nursing diagnose of altered sleep patterns related to nocturia. Which client instruction is important for the practical nurse to provide?

a. Decrease intake of fluids after the evening meal (correct)b. Drink a glass of cranberry juice every day

c. Drink a glass of warm decaffeinated beverage at bedtimed. Consult the healthcare provider about a sleeping pill

13. The nurse is preparing to administer a scheduled dose of benztropine Cogentin to a male client with Parkinson. The client reports that his moth is very dry. What action should nurse take?

a) Hold the doseb) Inform the charge nurse of the patient’s complaintc) Administer the scheduled dosed) Give the patient hard candy

Answer: Administer the scheduled medication and provide oral care or give candy to suck on.

Rationale: Cogentin is an anticholinergic medication used in the management of Parkinson’s disease. Dry mouth is a common side effect of anticholinergic so the nurse should administer the medication and provide care to relieve the dry mouth. There is no reason to withhold the medication or review the serum drug level before administering thedrug.

An anticholinergic agent is a substance that blocks the neurotransmitter acetylcholine in the central and the peripheral nervous system. An example of an anticholinergic is dicyclomine, and the classic example is atropine. Anticholinergics are administered to reduce the effects mediated by acetylcholine on acetylcholine receptors in neurons through competitive inhibition. Therefore, their effects are reversible.

Anticholinergics are a class of medications that inhibit parasympathetic nerve impulses by selectively blocking the binding of the neurotransmitter acetylcholine to its receptor in nerve cells. Thenerve fibers of the parasympathetic system are responsible for the involuntary movements of smooth muscles present in the gastrointestinal tract, urinary tract, lungs, etc. Anticholinergics are divided into three categories in accordance with their specific targets in the central and/or peripheral nervous system: antimuscarinic agents, ganglionic blockers, and neuromuscular blockers.

14. A granddaughter reports that her grandmother, who is a recent widow has become confused, has lost weight and motor activity has become impaired. The granddaughter asks the LVN what could the

problem? The client is now hospitalized and the LVN’s response to the family member should be based on what factual information

a. His exhibiting symptom of dementia and because of his age is probably permanent.

b. Her delirium may be due to depression and is possible reversible (correct)

c. Delirium is often a sign of underlying mental illness and institutionalization is often necessary.

d. If the dementia is a result of Alzheimer’s it is often reversibleeven in the late stages.

Rational: Delirium can be caused by depression or fluid and electrolyte disturbances caused by not eating as a result of depression. Since the client is recently widowed and may be depressed and accustomed to self-care his delirium is probably reversible if the depression can be successfully treated. Delirium does not necessarily involve mental illness in the elderly. This client appears to have delirium not dementia. Alzheimer’s disease is not reversible.

Deligation/Legal

15. A PN sees a colleague taking drugs from the hospital unit. What action should the PN take?

a. Report the colleague to the peer review committee of the hospitalb. Notify the hospital security staff to retrieve the drugs from the colleaguec. Report the incident to the person in charge of the unit or nursing supervisor (correct) d. Confront the colleague and tell him to take the drugs back to the unit

16. The PN is assigning care for residents on a 12 bed unit in an extended care facility. The staff consists of one UAP and one certified medication aide (CMA). Which task should the PN perform?

a. Administer medications and formula to a client with a gastrostomy tube. (correct)b. Provide self=catheterization equipment for a client with paraplegia

c. Charge a hydrocolloid dressing for a client with a stage II pressure ulcerd. Ambulate a client who has left hemiplegia and uses a cane

17. The PN is in charge of the evening shift of a 16 bed nursing home. Two unlicensed people assistive personnel UAP are also assigned to the unit. Which factor is most important for the PN to consider when making assignments?

a. The UAP’s preference for assignmentb. Which UAP has had a day off most recentlyc. The UAP that the clients compliments oftend. Who cared for which clients the evening before (correct)

Rationale: Previous assignments should be most important to consider when making assignments in order to provide consistency of care for anelderly population. The correct an answer or correct choice would always be who cared for which clients the evening before.

Trauma/Emergency Nursing

18. During CPR, when attempting to ventilate a client’s lungs, the PN notes that the chest is not rising. What action should the PN take first?

a. Inflate the lungs with more breaths and air pressureb. Reposition the head to ensure an open airway (correct) c. Finger sweep for a foreign body lodged in the oral cavityd. Reposition hands on chest and continue compressions

Rationale: The most frequent cause of inadequate aeration of the client’s lungs during CPR is improper positioning of the head resulting in occlusion of the airway.

19. A client reports that she was raped within the last 2 hours. How should the PN prepare the client for a physical examination?

a. Immediately position the client for a pelvic examination to obtain evidence and verify that the client was rapedb. Assist the client in removing as many contaminants as possible by providing Betadine to scrub the genital areac. Assist the client with a shower and observe for contusions, skin tears bleeding and other injuries.

d. Have the client remove all her clothing and instruct her not toeat drink or wash until after she is examined (correct)

Rationale: Have the client remove all her clothing and instruct her tonot to eat or drink. The client should remove contaminated clothing and not eat drink or wash. Specimen collections are taken from the victims clothing, skin surfaces and folds under fingernails, oral cavity, vaginal, rectal and perineal areas for the presence of evidence such as perpetrator’s semen, skin cells & hair victims fingernails oral cavity

Chapter 69 Black and Hawk Multiple ChoiceIdentify the choice that best completes the statement or answers the question.

____ 1. When doing an ophthalmologic examination the nurse practitioner assesses papilledema, which the practitioner recognizes as an indication ofa. compression of the second cranial nerve.b. increased intraocular pressure.c. migraine headache.d. impending stroke.ANS: A Papilledema, the swelling of the optic disc, occurs when there is increased intracranial pressure. The optic nerve, cranial nerve II,is compressed as well as intracerebral vessels. The most probable cause of the pressure is brain tumor. REF: p. 1823

____ 2. A week after a client experienced a ruptured cerebral aneurysm, he becomes extremely indecisive and has frequent episodes of incontinence. The nurse reports these events as probablea. vasospasm.b. automatisms.c. focal seizures.d. early-stage dementia.ANS: A Vasospasm, a complication of ruptured aneurysm, occurs 4 to 15 days following the rupture. The manifestations of vasospasm are dependent on the area of the brain involved. p. 1831

____ 3. The intraoperative nurse caring for a client having brain surgery to remove a tumor would be particularly careful abouta. inserting the IVs in the nondominant hand.b. padding and assessing the skin under the head frame.c. placing the client in straight alignment.d. using a catheter bag with a urimeter.

ANS: B The frames to help immobilize a client during intracranial surgery can cause pressure on the skin, edema of the face, and postoperative muscle soreness, especially in the neck. The nurse needsto take special precautions so as not to injure the client’s face. REF: p. 1824

____ 4. The nurse institutes seizure precautions for a client with a history of epilepsy. Which action is inconsistent with seizure precautions?a. Keeping oxygen and suction equipment nearbyb. Keeping the side rails up while the client is in bedc. Padding the side rails of the bed d. Taking an oral temperature when doing vital signsANS: D Clients with a history of seizures or epilepsy should have axillary or rectal temperatures taken. REF: p. 1817

____ 5. Three days following intracranial surgery a client develops fever, nuchal rigidity, and headache. The nurse would suspecta. cerebral emboli.b. extradural hematoma.c. increased ICP.d. meningitis.ANS: D The classic manifestations of meningitis are nuchal rigidity (rigidity of the neck), Brudzinski’s sign and Kernig’s sign, and photophobia. Intracranial surgery places the client at high risk of developing meningitis. REF: pp. 1835-1836

____ 6. When the client experiences convulsive movement beginning in the hand and progressing to the arm and face, the nurse recognizes this as being consistent witha. clonic seizure.b. complex partial seizure.c. partial seizure with motor signs.d. temporal lobe seizure.ANS: C The observation of the “jacksonian march” identifies this seizure activity as a partial seizure with motor signs. REF: pp. 1812-1813

____ 7. A client with epilepsy has the nursing diagnosis Risk for Impaired Adjustment. Which statement by the client would indicate movement towards positive resolution of this diagnosis?a. “Before activities, I should ask myself ‘What would

happen if I had a seizure?’”b. “Do you know how to apply for food stamps since I can’t

work?”

c. “I feel so sad that so many activities are off-limits for me now.”

d. “I have decided to sell my car since I will never be able to drive again.”

ANS: A Activity restrictions will vary among clients, but the key question the client should ask of him/herself is “What would happen ifI had a seizure while doing this activity?” Clients with epilepsy can and do work. There are five major types of activity restrictions to discuss with clients, and only a few things will truly be off-limits for clients with well-controlled seizures. State regulations regardingdriving vary; generally no driving is allowed for 6-12 months after a seizure, but many clients are able to drive again. REF: p. 1817

____ 8. The nurse clarifies that a generalized seizure, unlike a partial seizure, involvesa. areas of special senses.b. both hemispheres.c. only one hemisphere.d. the autonomic system.ANS: B A generalized seizure involves both hemispheres. REF: p. 1813

____ 9. A nurse is teaching a newly diagnosed epileptic client about anticonvulsant medications. The nurse should include information toa. help the client learn to control stress in his/her

life.b. limit heavy exercise and aerobic activities.c. stop medications if seizures are controlled for several

months.d. take an extra dose of medication if a seizure is

beginning.ANS: A Seizure activity is closely related to increasing stress. Clients should not alter their medication dosages without instruction and supervision of their prescriber. Exercise and aerobic activities are part of a healthy lifestyle and should be encouraged. REF: p. 1817

____10. The nurse caring for a client receiving phenytoin (Dilantin) should assess fora. anorexia, numbness, and tingling of extremities.b. ataxia, nausea, and bleeding tendency.c. headache, myalgias, and arthralgias.d. unsteady gait, slurred speech, and blurred vision.

ANS: D Serious adverse outcomes of antiseizure medications are unsteady gait, slurred speech, extreme fatigue, blurred vision, or feelings of suicide. REF: p. 1816

____11. An important age-related consideration the nurse should include in thecare plan for an elderly client with a seizure disorder isa. a decreased serum albumin level can increase the free

plasma level of medications.b. fortunately, seizure medications have very few drug-

drug interactions.c. older adults have very few choices when it comes to

seizure medications.d. the elderly rarely have seizure disorders, so community

support for them is poor.

ANS: A Protein-calorie malnutrition is common among elders and the subsequent decreased serum albumin level can lead to increased plasma levels of the drug, making them prone to drug toxicities. Many seizuremedications do have multiple drug-drug interactions, but all are available for use in this population. The frequency of seizures being diagnosed in the elderly population is increasing.REF: p. 1818

____12. The cerebrospinal (CSF) fluid laboratory finding the nurse would expect in a client with bacterial meningitis isa. clear color.b. decreased glucose level.c. decreased protein level.d. negative nitrates.ANS: B Clients with bacterial meningitis show the following: elevatedCSF pressures, elevated CSF protein, decreased CSF glucose, and usually increased cell count with predominantly polymorphonuclear leukocytes. REF: p. 1836

____13. The nurse should observe a client with bacterial meningitis fora. changes in sensorium.b. high blood pressure.c. hypothermia.d. muscle spasms.ANS: A Other general manifestations related to infection are also present, such as fever, tachycardia, headache, prostration, chills, fever, nausea, and vomiting. The client may be irritable at first, butas the infection progresses, the sensorium often becomes clouded, and coma may develop. REF: p. 1836 In the mental status exam, which is part of

any psychological evaluation, the sensorium refers to the person's grasp on time, place and person, all of which are functions of perception and memory.So, the sensorium is a person's immediate, short-, and long-term memory, especially to the extent to which this impacts whether or not they have a good handle on who they are and where they are located in place and time.

____14. The nurse assesses for the most common manifestations of a post-traumatic brain abscess, which area. headache and lethargy.b. photophobia and dizziness.c. muscle spasms and tingling.d. sluggish pupillary reactions.ANS: A Headache and lethargy are the most common manifestations. Manifestations of infection are present about half the time. REF:

p. 1837

____15. A client has been diagnosed with epilepsy and is going home. The client has received extensive teaching on the disease, medications, and lifestyle changes that are required. What else should the nurse include in the discharge plan?a. A referral to a support groupb. Easy-to-prepare menu guidec. Psychiatry clinic informationd. The city’s bus scheduleANS: A Clients with epilepsy often have poor self-image, feelings ofinferiority, self-consciousness, guilt, anger, depression, and other emotional problems. While any of the above options might be needed by a particular client, a referral to a self-help group or support group can best help the client learn to adapt to the new diagnosis and incorporate it into a healthy self-image.REF: p. 1820

____16. The client with epilepsy asks the nurse if he will have to take antispasmodic medication for the rest of his life. The nurse’s most helpful response would bea. “Maybe. You might be able to stop medication if you are

seizure free for 2 years.” b. “No. After a stable pattern is recognized, you can take

it sporadically.”c. “Yes. Epilepsy requires compliance to a regimen of

lifelong medication.”d. “Yes. Stopping a med after you take it a while makes

seizure activity worse.”ANS: A Many physicians allow their patients to stop antispasmodic

medication if they have been seizure-free for 2 years. Other physicians prefer a seizure-free period of 5 years. REF: p. 1816

____17. A nurse is reviewing leisure time activities with a client who has epilepsy. An important self-care measure the nurse teaches the client is to avoid a. alcoholic beverages.b. driving a motor vehicle.c. hiking and camping.d. light sports.

ANS: A Alcoholic beverages are contraindicated for two reasons. First, alcohol lowers the seizure threshold, and second, alcohol is detoxified by the liver. Most anticonvulsant medications are also detoxified by the liver. Although certain dangerous activities should be avoided or performed with special safeguards (e.g., swimming or horseback riding), a wide range of activities can still be enjoyed. Driving motor vehicles depends on state laws and the client’s medical control of seizures, with driving restrictions ranging from 3 months to 2 years. REF: p. 1819

____18. The nurse gives diazepam to a client in status epilepticus to stop theseizure because prolonged seizure activity can causea. brain injury.b. cardiac dysrhythmias.c. muscle and tendon damage.d. respiratory arrest.ANS: A Prolonged seizure activity exhausts the body’s supply of oxygen and glucose and can result in brain injury. REF: p. 1820

___ 19. A client is being worked up for a possible brain tumor. An important intervention the nurse would include in the nursing care plan specificto this client isa. documenting manifestations.b. preparing the client for tests.c. seizure precautions.d. supporting the client and family.

____20. For a client who had a transsphenoidal resection of a pituitary tumor,the nurse plans toa. assess the “mustache” dressing for drainage.b. do minimal mouth care for the first 2 days.c. encourage the use of straws when drinking.

d. provide heated mist and humidified oxygen.

____21. A client who has had intracranial surgery develops urine output in excess of 200 ml per hour. The nurse reports the findings, suspectinga. diabetes insipidus.b. fluid volume excess.c. hyponatremia.d. hyperkalemia.

ANS: A A fairly common effect of pituitary surgery is the development of transient diabetes insipidus (DI) as a result of decreased secretion of antidiuretic hormone. The main clinical manifestations of DI are polyuria and polydipsia, with 2 to 5 L per day of dilute urine that has a specific gravity of 1.005 or less. REF: p. 1829 *Diabetes Insipidus (DI) is a disorder in which there is an abnormal increase in urine output, fluid intake and often thirst.  It causes symptoms such as urinary frequency, nocturia (frequent awakening at night to urinate) or enuresis (involuntary urination during sleep or "bedwetting").  Urine output is increased because it is not concentrated normally.  Consequently, instead of being a yellow color, the urine is pale, colorless or watery in appearance and the measuredconcentration (osmolality or specific gravity) is low. Diabetes Insipidus isdivided into four types, each of which has a different cause and must be treated differently.  The most common type of DI is caused by a lack of vasopressin, a hormone that normally acts upon the kidney to reduce urine output by increasing the concentration of the urine.  This type of DI is usually due to the destruction of the back or "posterior" part of the pituitary gland where vasopressin is normally produced.  Hence, it is commonly called pituitary DI.   It is also known as central or neurogenic DI. NormalSG values are between 1.002 to 1.028. Normal specific gravity is usually between 1.002 and 1.035 on a random sample. Specific gravity (SG) is mostly used to determine hydration status. The numbers provided lose accuracy if the urine's SG exceeds below 1.010 or above 1.025 - Most laboratory will report "normal" ranges between 1.010 and 1.030.

____22. When a client is admitted to the hospital in an unconscious state following subarachnoid hemorrhage resulting from a ruptured intracranial aneurysm, the nurse anticipates that the manifestations that preceded the loss of consciousness werea. generalized weakness and fatigue accompanied by

anorexia.b. gradual loss of speech or vision.c. sudden severe headache accompanied by vomiting.d. weakness, fever, nausea, and vomiting.

____23. The nurse explains that an epidural blood patch may be used to treat aheadache that has resulted from a

a. brain tumor. b. concussion.c. lumbar puncture.d. migraine.

____24. The nurse observes for manifestations of typical migraine headaches, which includea. aura, visual disturbances, and nausea.b. bilateral pain, abrupt onset, and tinnitus.c. diarrhea, nasal congestion, and eye redness.d. scalp tenderness, sensation of pressure, and nighttime

onset.ANS: A The client may feel transient neurologic disturbances, including visual phenomena (flashes of light, bright spots, distorted vision, diplopia, transitory impaired vision), vertigo, nausea, diarrhea, abdominal pain, paresthesias (numbness or tingling of lips, face, or extremities), or transient hemiparesis. It gradually increases in severity. The pain is usually unilateral. REF: p. 1839

____25. A client has cyclical headaches accompanied by constricted pupils, unilateral lacrimation, and rhinorrhea. The nurse is exploring ways toprevent these headaches with the client. The nurse could focus questions and interventions on modifying the client’sa. daily level of stress.b. family history of brain tumors.c. pattern of caffeine consumption.d. usual alcohol intake.

____26. Following surgery for a pituitary tumor, when the client develops diabetes insipidus, the nurse explains that the drug that will be helpful to remedy the manifestations isa. atropine.b. desmopressin.c. diazepam (Valium).d. NPH insulin.ANS: B Clients who have diabetes insipidus after pituitary surgery often require IV vasopressin (Pitressin) or desmopressin (DDAVP). REF:

p. 1829

Desmopressin is a man-made form of a hormone that occurs naturally in the pituitary gland. This hormone is important for many functions including blood flow, blood pressure, kidney function, and regulating how the body uses water. Desmopressin is used to treat bed-wetting, central cranial diabetes insipidus, and increased thirst and urinationcaused by head surgery or head trauma.

What is the most important information I should know about oral desmopressin?

It is very important to reduce your intake of water and other fluids while you are taking desmopressin. Drinking too much water can cause your body to lose sodium, which may lead to a serious, life-threatening electrolyte imbalance.

Fluid restriction is especially important in children and older adultstaking desmopressin. Follow your doctor's instructions about the type and amount of liquids you should drink.

You should not use this medication if you have severe kidney disease or if you have ever had hyponatremia (low sodium levels in your body).

____27. The nurse explains to a newly diagnosed epileptic client that the basic pathophysiology of epilepsy is related toa. a period of hypoxia from sleep apnea.b. brain waves losing amplitude.c. excitation of neurons discharging in the brain stem.d. specific metabolic disturbances.ANS: C Epilepsy occurs when neurons fire with greater frequency and amplitude, spreading to adjacent neurons that ultimately discharge in the brain stem, causing muscle contractures and possible unconsciousness. REF: p. 1812

____28. The clinic nurse recommends to a client with cluster headaches that toabate the manifestations associated with an attack, he should inhalea. 100% oxygen for 15 minutes.b. deeply for 5 minutes.c. oil of cloves for 5 minutes.d. warm mist for 10 minutes.ANS: A Inhalation of 100% oxygen for 15 minutes has been found effective in combating the manifestations of cluster headache attack. REF: p. 1839 What Is A Cluster Headache?

A cluster headache is a rare type of headache that is more common in men. Cluster headaches start suddenly. The pain is usually behind or around one eye and is very severe. The eye and nose on the same side as the pain may become red, swollen and runny. Cluster headaches also cause restlessness. These headaches can be frightening to the suffererand his or her family. A cluster headache can last a few minutes or several hours, but it usually lasts for 45 to 90 minutes. Cluster headaches typically occur at the same time each day for several weeks,

until the "cluster period" is over. The most common times for cluster headaches seem to be between 1:00 a.m. and 2:00 a.m., 1:00 p.m. and 3:00 p.m. and around 9:00 p.m. Cluster periods usually last 4 to 8 weeks and may occur every few months.

Multiple Response- Identify one or more choices that best complete the statement or answer the question.

____29. A nurse is teaching a client preventive strategies for migraine headaches. The nurse would evaluate that teaching goals have been met when the client says (Select all that do not apply)a. “Do you know where I can learn relaxation techniques

like yoga?”b. “Eating on a regular schedule may help prevent some

migraines.”c. “I should keep a headache diary to see if I can

identify headache triggers.”d. “Small amounts of alcohol should not cause any

headaches.”e. “There may be some foods that trigger my headaches that

I should avoid.”ANS: D Alcohol temporarily increases the diameter of the blood vessels, which may trigger migraines. Some foods, such as chocolate, cheese, citrus fruits, coffee, pork, and dairy products, contain substances that may trigger migraines. Low food intake may lead to a low blood glucose level that can trigger migraines. Eating smaller, more frequent meals will decrease this risk. Getting enough sleep is essential, as is learning a stress management technique like yoga. REF: p. 1839

____30. When a client suffers a tonic-clonic seizure, the nurse should (Selectall that do not apply)a. insert an oral airway into the client’s mouth.b. move objects out of the client’s way.c. observe and document characteristics of the seizure.d. place a pillow or some padding under the client’s head.e. turn the client gently on one side.ANS: A A person having a seizure needs protection from the environment. The nurse should move objects out of the way, place some type of padding under the client’s head, loosen clothing that is tightaround the client’s neck, turn the client to one side to facilitate draining saliva, and observe the characteristics of the seizure. Nothing should be forced into the client’s mouth. p. 1815

Chapter 69 Black and Hawk

Multiple ChoiceIdentify the choice that best completes the statement or answers the question.

____ 1. When doing an ophthalmologic examination the nurse practitioner assesses papilledema, which the practitioner recognizes as an indication ofa. compression of the second cranial nerve.b. increased intraocular pressure.c. migraine headache.d. impending stroke.

____ 2. A week after a client experienced a ruptured cerebral aneurysm, he becomes extremely indecisive and has frequent episodes of incontinence. The nurse reports these events as probablea. vasospasm.b. automatisms.c. focal seizures.d. early-stage dementia.

____ 3. The intraoperative nurse caring for a client having brain surgery to remove a tumor would be particularly careful abouta. inserting the IVs in the nondominant hand.b. padding and assessing the skin under the head frame.c. placing the client in straight alignment.d. using a catheter bag with a urimeter.

____ 4. The nurse institutes seizure precautions for a client with a history of epilepsy. Which action is inconsistent with seizure precautions?a. Keeping oxygen and suction equipment nearbyb. Keeping the side rails up while the client is in bedc. Padding the side rails of the bed d. Taking an oral temperature when doing vital signs

____ 5. Three days following intracranial surgery a client develops fever, nuchal rigidity, and headache. The nurse would suspecta. cerebral emboli.b. extradural hematoma.c. increased ICP.d. meningitis.

____ 6. When the client experiences convulsive movement beginning in the hand and progressing to the arm and face, the nurse recognizes this as being consistent witha. clonic seizure.b. complex partial seizure.

c. partial seizure with motor signs.d. temporal lobe seizure.

____ 7. A client with epilepsy has the nursing diagnosis Risk for Impaired Adjustment. Which statement by the client would indicate movement towards positive resolution of this diagnosis?a. “Before activities, I should ask myself ‘What would

happen if I had a seizure?’”b. “Do you know how to apply for food stamps since I can’t

work?” c. “I feel so sad that so many activities are off-limits

for me now.”d. “I have decided to sell my car since I will never be

able to drive again.”____ 8. The nurse clarifies that a generalized seizure, unlike a partial

seizure, involvesa. areas of special senses.b. both hemispheres.c. only one hemisphere.d. the autonomic system.

____ 9. A nurse is teaching a newly diagnosed epileptic client about anticonvulsant medications. The nurse should include information toa. help the client learn to control stress in his/her

life.b. limit heavy exercise and aerobic activities.c. stop medications if seizures are controlled for several

months.d. take an extra dose of medication if a seizure is

beginning.____10. The nurse caring for a client receiving phenytoin (Dilantin) should

assess fora. anorexia, numbness, and tingling of extremities.b. ataxia, nausea, and bleeding tendency.c. headache, myalgias, and arthralgias.d. unsteady gait, slurred speech, and blurred vision.

____11. An important age-related consideration the nurse should include in thecare plan for an elderly client with a seizure disorder isa. a decreased serum albumin level can increase the free

plasma level of medications.b. fortunately, seizure medications have very few drug-

drug interactions.c. older adults have very few choices when it comes to

seizure medications.d. the elderly rarely have seizure disorders, so community

support for them is poor.____12. The cerebrospinal (CSF) fluid laboratory finding the nurse would

expect in a client with bacterial meningitis isa. clear color.b. decreased glucose level.c. decreased protein level.d. negative nitrates.

____13. The nurse should observe a client with bacterial meningitis fora. changes in sensorium.b. high blood pressure.c. hypothermia.d. muscle spasms.

____14. The nurse assesses for the most common manifestations of a post-traumatic brain abscess, which area. headache and lethargy.b. photophobia and dizziness.c. muscle spasms and tingling.d. sluggish pupillary reactions.

____15. A client has been diagnosed with epilepsy and is going home. The client has received extensive teaching on the disease, medications, and lifestyle changes that are required. What else should the nurse include in the discharge plan?a. A referral to a support groupb. Easy-to-prepare menu guidec. Psychiatry clinic informationd. The city’s bus schedule

____16. The client with epilepsy asks the nurse if he will have to take antispasmodic medication for the rest of his life. The nurse’s most helpful response would bea. “Maybe. You might be able to stop medication if you are

seizure free for 2 years.” b. “No. After a stable pattern is recognized, you can take

it sporadically.”c. “Yes. Epilepsy requires compliance to a regimen of

lifelong medication.”d. “Yes. Stopping a med after you take it a while makes

seizure activity worse.”____17. A nurse is reviewing leisure time activities with a client who has

epilepsy. An important self-care measure the nurse teaches the client is to avoid a. alcoholic beverages.b. driving a motor vehicle.c. hiking and camping.

d. light sports.____18. The nurse gives diazepam to a client in status epilepticus to stop the

seizure because prolonged seizure activity can causea. brain injury.b. cardiac dysrhythmias.c. muscle and tendon damage.d. respiratory arrest.

____19. A client is being worked up for a possible brain tumor. An important intervention the nurse would include in the nursing care plan specificto this client isa. documenting manifestations.b. preparing the client for tests.c. seizure precautions.d. supporting the client and family.

____20. For a client who had a transsphenoidal resection of a pituitary tumor,the nurse plans toa. assess the “mustache” dressing for drainage.b. do minimal mouth care for the first 2 days.c. encourage the use of straws when drinking.d. provide heated mist and humidified oxygen.

____21. A client who has had intracranial surgery develops urine output in excess of 200 ml per hour. The nurse reports the findings, suspectinga. diabetes insipidus.b. fluid volume excess.c. hyponatremia.d. hyperkalemia.

____22. When a client is admitted to the hospital in an unconscious state following subarachnoid hemorrhage resulting from a ruptured intracranial aneurysm, the nurse anticipates that the manifestations that preceded the loss of consciousness werea. generalized weakness and fatigue accompanied by

anorexia.b. gradual loss of speech or vision.c. sudden severe headache accompanied by vomiting.d. weakness, fever, nausea, and vomiting.

____23. The nurse explains that an epidural blood patch may be used to treat aheadache that has resulted from aa. brain tumor. b. concussion.c. lumbar puncture.d. migraine.

____24. The nurse observes for manifestations of typical migraine headaches, which includea. aura, visual disturbances, and nausea.b. bilateral pain, abrupt onset, and tinnitus.c. diarrhea, nasal congestion, and eye redness.d. scalp tenderness, sensation of pressure, and nighttime

onset.____25. A client has cyclical headaches accompanied by constricted pupils,

unilateral lacrimation, and rhinorrhea. The nurse is exploring ways toprevent these headaches with the client. The nurse could focus questions and interventions on modifying the client’sa. daily level of stress.b. family history of brain tumors.c. pattern of caffeine consumption.d. usual alcohol intake.

____26. Following surgery for a pituitary tumor, when the client develops diabetes insipidus, the nurse explains that the drug that will be helpful to remedy the manifestations isa. atropine.b. desmopressin.c. diazepam (Valium).d. NPH insulin.

____27. The nurse explains to a newly diagnosed epileptic client that the basic pathophysiology of epilepsy is related toa. a period of hypoxia from sleep apnea.b. brain waves losing amplitude.c. excitation of neurons discharging in the brain stem.d. specific metabolic disturbances.

____28. The clinic nurse recommends to a client with cluster headaches that toabate the manifestations associated with an attack, he should inhalea. 100% oxygen for 15 minutes.b. deeply for 5 minutes.c. oil of cloves for 5 minutes.d. warm mist for 10 minutes.

Multiple ResponseIdentify one or more choices that best complete the statement or answer the question.

____29. A nurse is teaching a client preventive strategies for migraine headaches. The nurse would evaluate that teaching goals have been met when the client says (Select all that apply)a. “Do you know where I can learn relaxation techniques

like yoga?”

b. “Eating on a regular schedule may help prevent some migraines.”

c. “I should keep a headache diary to see if I can identify headache triggers.”

d. “Small amounts of alcohol should not cause any headaches.”

e. “There may be some foods that trigger my headaches thatI should avoid.”

____30. When a client suffers a tonic-clonic seizure, the nurse should (Selectall that apply)a. insert an oral airway into the client’s mouth.b. move objects out of the client’s way.c. observe and document characteristics of the seizure.d. place a pillow or some padding under the client’s head.e. turn the client gently on one side.

Chapter 69 Black and Hawk Answer Section MULTIPLE CHOICE

1. ANS: APapilledema, the swelling of the optic disc, occurs when there is increasedintracranial pressure. The optic nerve, cranial nerve II, is compressed as well as intracerebral vessels. The most probable cause of the pressure is brain tumor.

PTS: 1 DIF: Analysis/Analyzing REF: p. 1823OBJ: AssessmentMSC: Physiological Integrity Physiological Adaptation-Pathophysiology

2. ANS: AVasospasm, a complication of ruptured aneurysm, occurs 4 to 15 days following the rupture. The manifestations of vasospasm are dependent on thearea of the brain involved.

PTS: 1 DIF: Analysis/Analyzing REF: p. 1831OBJ: AssessmentMSC: Physiological Integrity Physiological Adaptation-Pathophysiology

3. ANS: BThe frames to help immobilize a client during intracranial surgery can cause pressure on the skin, edema of the face, and postoperative muscle soreness, especially in the neck. The nurse needs to take special precautions so as not to injure the client’s face.

PTS: 1 DIF: Application/Applying REF: p. 1824OBJ: InterventionMSC: Safe, Effective Care Environment Safety and Infection Control-Safe Use of Equipment

4. ANS: DClients with a history of seizures or epilepsy should have axillary or rectal temperatures taken.

PTS: 1 DIF: Application/Applying REF: p. 1817OBJ: InterventionMSC: Safe, Effective Care Environment Safety and Infection Control-Injury Prevention

5. ANS: DThe classic manifestations of meningitis are nuchal rigidity (rigidity of the neck), Brudzinski’s sign and Kernig’s sign, and photophobia. Intracranial surgery places the client at high risk of developing meningitis.

PTS: 1 DIF: Analysis/Analyzing REF: pp. 1835-1836OBJ: AssessmentMSC: Physiological Integrity Physiological Adaptation-

Pathophysiology6. ANS: C

The observation of the “jacksonian march” identifies this seizure activity as a partial seizure with motor signs.

PTS: 1 DIF: Analysis/Analyzing REF: pp. 1812-1813OBJ: AssessmentMSC: Physiological Integrity Physiological Adaptation-Pathophysiology

7. ANS: AActivity restrictions will vary among clients, but the key question the client should ask of him/herself is “What would happen if I had a seizure while doing this activity?” Clients with epilepsy can and do work. There are five major types of activity restrictions to discuss with clients, and only a few things will truly be off-limits for clients with well-controlledseizures. State regulations regarding driving vary; generally no driving isallowed for 6-12 months after a seizure, but many clients are able to driveagain.

PTS: 1 DIF: Evaluation/Evaluating REF: p. 1817OBJ: EvaluationMSC: Psychosocial Integrity Coping and Adaptation-Situational Role Changes

8. ANS: BA generalized seizure involves both hemispheres.

PTS: 1 DIF: Comprehension/Understanding REF: p. 1813OBJ: Intervention MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

9. ANS: ASeizure activity is closely related to increasing stress. Clients should not alter their medication dosages without instruction and supervision of their prescriber. Exercise and aerobic activities are part of a healthy lifestyle and should be encouraged.

PTS: 1 DIF: Application/Applying REF: p. 1817OBJ: Intervention MSC: Psychosocial Integrity Coping and Adaptation-Stress Management

10. ANS: DSerious adverse outcomes of antiseizure medications are unsteady gait, slurred speech, extreme fatigue, blurred vision, or feelings of suicide.

PTS: 1 DIF: Application REF: p. 1816 OBJ: AssessmentMSC: Physiological Integrity Pharmacological and Parenteral Therapies-Adverse Effects/Contraindications

11. ANS: A

Protein-calorie malnutrition is common among elders and the subsequent decreased serum albumin level can lead to increased plasma levels of the drug, making them prone to drug toxicities. Many seizure medications do have multiple drug-drug interactions, but all are available for use in thispopulation. The frequency of seizures being diagnosed in the elderly population is increasing.

PTS: 1 DIF: Application/Applying REF: p. 1818OBJ: InterventionMSC: Health Promotion and Maintenance Growth and Development Through the Lifespan-Age Related Changes

12. ANS: BClients with bacterial meningitis show the following: elevated CSF pressures, elevated CSF protein, decreased CSF glucose, and usually increased cell count with predominantly polymorphonuclear leukocytes.

PTS: 1 DIF: Knowledge/Remembering REF: p. 1836OBJ: AssessmentMSC: Physiological Integrity Reduction of Risk Potential-DiagnosticTests

13. ANS: AOther general manifestations related to infection are also present, such asfever, tachycardia, headache, prostration, chills, fever, nausea, and vomiting. The client may be irritable at first, but as the infection progresses, the sensorium often becomes clouded, and coma may develop.

PTS: 1 DIF: Application/Applying REF: p. 1836OBJ: AssessmentMSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

14. ANS: AHeadache and lethargy are the most common manifestations. Manifestations ofinfection are present about half the time.

PTS: 1 DIF: Application/Applying REF: p. 1837OBJ: AssessmentMSC: Physiological Integrity Physiological Adaptation-Pathophysiology

15. ANS: AClients with epilepsy often have poor self-image, feelings of inferiority, self-consciousness, guilt, anger, depression, and other emotional problems.While any of the above options might be needed by a particular client, a referral to a self-help group or support group can best help the client learn to adapt to the new diagnosis and incorporate it into a healthy self-image.

PTS: 1 DIF: Knowledge/Remembering REF: p. 1820

OBJ: Intervention MSC: Psychosocial Integrity Coping and Adaptation-Coping Mechanisms

16. ANS: AMany physicians allow their patients to stop antispasmodic medication if they have been seizure-free for 2 years. Other physicians prefer a seizure-free period of 5 years.

PTS: 1 DIF: Comprehension/Understanding REF: p. 1816OBJ: Intervention MSC: Physiological Integrity Physiological Adaptation-Illness Management

17. ANS: AAlcoholic beverages are contraindicated for two reasons. First, alcohol lowers the seizure threshold, and second, alcohol is detoxified by the liver. Most anticonvulsant medications are also detoxified by the liver. Although certain dangerous activities should be avoided or performed with special safeguards (e.g., swimming or horseback riding), a wide range of activities can still be enjoyed. Driving motor vehicles depends on state laws and the client’s medical control of seizures, with driving restrictions ranging from 3 months to 2 years.

PTS: 1 DIF: Application/Applying REF: p. 1819OBJ: InterventionMSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Self Care

18. ANS: AProlonged seizure activity exhausts the body’s supply of oxygen and glucoseand can result in brain injury.

PTS: 1 DIF: Knowledge/Remembering REF: p. 1820OBJ: Intervention MSC: Physiological Integrity Physiological Adaptation-Medical Emergencies

19. ANS: COptions a, b, and d are always important interventions for the client who is being worked up for a medical condition. But the specific care this client needs is seizure precautions, because seizures are a common manifestation in clients with brain tumors.

PTS: 1 DIF: Application/Applying REF: p. 1823OBJ: InterventionMSC: Safe, Effective Care Environment Safety and Infection Control-Injury Prevention

20. ANS: A

Postoperative care after pituitary surgery using a transsphenoidal approachincludes prohibition of the use of straws for drinking any fluid, to prevent trauma to the oral/gingival incision site. Frequent oral hygiene isprovided, and a cool mist vaporizer may be used to keep oral mucous membranes moist. The nasal drip pad (“mustache” dressing pad) is assessed frequently for bloody and/or clear CSF.

PTS: 1 DIF: Application/Applying REF: p. 1829OBJ: InterventionMSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

21. ANS: AA fairly common effect of pituitary surgery is the development of transientdiabetes insipidus (DI) as a result of decreased secretion of antidiuretic hormone. The main clinical manifestations of DI are polyuria and polydipsia, with 2 to 5 L per day of dilute urine that has a specific gravity of 1.005 or less.

PTS: 1 DIF: Analysis/Analyzing REF: p. 1829OBJ: AssessmentMSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

22. ANS: CThe onset of a subarachnoid hemorrhage is sudden. The client experiences a sudden, severe headache, often accompanied by vomiting, often describing the headache as “the worst headache I have ever had.”

PTS: 1 DIF: Knowledge/Remembering REF: p. 1831OBJ: AssessmentMSC: Physiological Integrity Physiological Adaptation-Pathophysiology

23. ANS: CFor a post-lumbar puncture headache, an epidural blood patch accomplished by injection of 15 ml of autologous whole blood rarely fails for those who do not respond to caffeine.

PTS: 1 DIF: Comprehension/Understanding REF: p. 1840OBJ: InterventionMSC: Physiological Integrity Pharmacological and Parenteral Therapies-Blood and Blood Products

24. ANS: A

The client may feel transient neurologic disturbances, including visual phenomena (flashes of light, bright spots, distorted vision, diplopia, transitory impaired vision), vertigo, nausea, diarrhea, abdominal pain, paresthesias (numbness or tingling of lips, face, or extremities), or transient hemiparesis. It gradually increases in severity. The pain is usually unilateral.

PTS: 1 DIF: Application/Applying REF: p. 1839OBJ: AssessmentMSC: Physiological Integrity Physiological Adaptation-Pathophysiology

25. ANS: DThe client is experiencing cluster headaches, which are frequently associated with drinking alcohol.

PTS: 1 DIF: Application/Applying REF: pp. 1838-1839OBJ: AssessmentMSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Lifestyle Choices

26. ANS: BClients who have diabetes insipidus after pituitary surgery often require IV vasopressin (Pitressin) or desmopressin (DDAVP).

PTS: 1 DIF: Comprehension/Understanding REF: p. 1829OBJ: InterventionMSC: Physiological Integrity Pharmacological and Parenteral Therapies-Pharmacological Agents/Actions

27. ANS: CEpilepsy occurs when neurons fire with greater frequency and amplitude, spreading to adjacent neurons that ultimately discharge in the brain stem, causing muscle contractures and possible unconsciousness.

PTS: 1 DIF: Comprehension/Understanding REF: p. 1812OBJ: Intervention MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

28. ANS: AInhalation of 100% oxygen for 15 minutes has been found effective in combating the manifestations of cluster headache attack.

PTS: 1 DIF: Comprehension/Understanding REF: p. 1839OBJ: Intervention MSC: Physiological Integrity Physiological Adaptation-Disease Management

MULTIPLE RESPONSE

29. ANS: A, B, C, E

Alcohol temporarily increases the diameter of the blood vessels, which may trigger migraines. Some foods, such as chocolate, cheese, citrus fruits, coffee, pork, and dairy products, contain substances that may trigger migraines. Low food intake may lead to a low blood glucose level that can trigger migraines. Eating smaller, more frequent meals will decrease this risk. Getting enough sleep is essential, as is learning a stress managementtechnique like yoga.

PTS: 1 DIF: Evaluation/Evaluating REF: p. 1839OBJ: InterventionMSC: Health Promotion Prevention and/or Early Detection of Health Problems-Self Care

30. ANS: B, C, D, EA person having a seizure needs protection from the environment. The nurse should move objects out of the way, place some type of padding under the client’s head, loosen clothing that is tight around the client’s neck, turnthe client to one side to facilitate draining saliva, and observe the characteristics of the seizure. Nothing should be forced into the client’s mouth.

PTS: 1 DIF: Application/Applying REF: p. 1815OBJ: InterventionMSC: Safe, Effective Care Environment Safety and Infection Control-Injury Prevention

Neurological Nursing1) A 75 yr old male client with Alzheimer’s disease is admitted to an extended care facility. What intervention should the practical nurse include in this clients nursing care plan?

a. Plan to have the same nursing staff provide care for the client whenever possible (correct) b. Introduce the client to the nursing staff and other residents as soon as possiblec. Encourage the client to remain on the unit for three weeks, until he is oriented to his new surroundingsd. Describe the activities available to residents and encourage him to choose theones he prefers

___ 2) On the second postoperative day following herniated disk surgery, the client says, “My legs are numb. I thought surgery was going to fix my problems.” The nurse’s best response to explain the continued pain isa. “Because of the surgery, there is some swelling, which

should subside.” b. “This pain is from the anesthesia and will subside by this

afternoon.”c. “This pain is positional and will subside if you roll over

on your side.”d. “You are probably moving around too much. I will raise the

knee gatch.”

ANS: A Following spinal surgery, the nurse should question the client about pain and paresthesias. New paresthesias are probably related to swelling from the surgery, but the surgeon should be notified about their development. If progressive weakness or paralysis of the lower extremities, loss of sphincter control, anal numbness, or urinary retention occurs, emergency surgical decompression may be required. p. 1877

3) The spouse of a client who suffers from chronic back pain is exasperated by the client’s crankiness and sarcastic way of talking. The nurse should base a response to the spouse based on the knowledge thata. chronic pain can lead to depression and personality changes.b. clients with back pain often become addicted to narcotics.c. often spouses are not supportive and this frustrates the

clients.d. when clients are non-compliant with treatment plans, they

often act out.

ANS: A Research shows that clients with chronic back pain are often frustrated because there is no cut-and-dried approach to this condition, as opposed to otherconditions where treatment plans are well-known. Living in chronic pain combined with no clear diagnosis and no cure in sight often leads to depression and personality changes. DIF: Comprehension/Understanding REF: p. 1875

4) In performing a neurologic evaluation of a client who had lumbar surgery 36 hours ago, it is important that the nurse assessa. ability to move shoulders.b. leg movement.c. level of consciousness.d. reflex response.

ANS: B Assess neurologic function by asking the client to move his or her legs andthen comparing the results with those of the baseline evaluation. DIF: Application/Applying REF: p. 1877

5) On the first postoperative day, a client who had a cervical surgery requeststhe bedpan often, but cannot void. Based on these observations, the nurse shoulda. assess for bladder distention.

b. assess for manifestations of urinary tract infection.c. document this outcome as normal.d. increase fluid intake.

ANS: A Cervical surgery may affect the parasympathetic chain, causing urinary retention.DIF: Analysis/Analyzing REF: p. 1882

6) Before the administration of the first dose of carbamazepine (Tegretol) to aclient with trigeminal neuralgia, the nurse shoulda. assess the client’s deep tendon reflexes.b. check the client’s blood pressure.c. determine if the client abuses alcohol.d. remind the client to remain in bed for 20 minutes after

receiving the drug.

ANS: C Liver impairment may result from administration of both carbamazepine and phenytoin. Liver enzymes must be monitored before and during therapy. These medications should be used cautiously in clients with a history of alcohol abuse.DIF: Application/Applying REF: p. 1885

7) A client with Bell’s palsy tells the nurse that s/he is very depressed abouthaving the disease. The most informative response from the nurse would bea. “Bell’s palsy can be treated successfully with medication.”b. “I understand how you feel; it is difficult to live with a

chronic disease.” c. “Surgery has been very successful in improving the problem.”d. “The symptoms are likely to disappear or get better within a

few weeks.”

ANS: D Most clients recover from Bell’s palsy within a few weeks without residual manifestations. Medications can be used if needed and include analgesics, corticosteroids, and acyclovir. Giving the client information helps the client tofeel more in control and assists in coping. REF:p. 1886

8) The nurse should assess a client who has had unrelieved trigeminal neuralgiafor the past 6 months fora. alcohol consumption.b. suicidal ideation.c. vocational rehabilitation.d. weight gain.

ANS: B Unrelieved pain from trigeminal neuralgia is so intense that clients oftenconsider suicide. Because of the pain, they do not eat and neglect oral hygiene. REF: p. 1885

9) The nurse would question a client with suspected trigeminal neuralgia about facial pain that isa. characterized by intermittent episodes of severe pain with

gradual onset.b. characterized by intermittent episodes of severe pain with

sudden onset.c. constant and aching or burning in nature. d. constant, severe, and sharp in nature.

ANS: B Trigeminal neuralgia is characterized by intermittent episodes of intense pain of sudden onset. REF: p. 1885

10) The nurse would instruct a client who has undergone microvascular decompression surgery of the trigeminal nerve toa. chew on the affected side of the mouth.b. eat foods that are very warm or very cold for better taste.c. resume a full diet immediately.d. use a water jet device instead of a toothbrush.

ANS: D If facial anesthesia is present after surgery, clients must learn to test the temperature of food before putting it into their mouth. They should chew on the unaffected side and inspect mucous membranes for irritation. Assess for aspiration and advance the diet slowly. Teach the client to use a water jet device instead of a toothbrush for dental hygiene. REF: p. 1886

11) The nurse points out the physical therapy modality that would be avoided inthe treatment for a client with Bell’s palsy isa. cold packs.b. facial nerve stimulation with faradic current.c. gentle massage.d. moist heat.ANS: A Palliative measures include physiotherapy, moist heat, gentle massage, and stimulation of the facial nerve with faradic current. REF: p. 1886

_ 12) Important discharge instructions for the client with a cervical disk problem being discharged with a cervical collar includea. ambulate carefully to avoid falls.b. perform active range-of-motion exercises four times daily.c. release the Velcro strap every 2 hours while awake.d. wash the collar with mild soap and water daily.ANS: A Safety awareness is important to prevent falls in the client who is wearinga cervical collar because s/he cannot look down at the feet. This vision limitation is a safety concern. The other three options are not recommended for this client. REF: p. 1881

13) An 75 yr old client is admitted to the hospital for a CVA. Following surgical placement of a VP shunt, a footboard is placed at the client’s feet. When the family visits the patient, what reason will the LVN offer concerning thefootboard if the family asks? The footboard is used to

a. promote moving in bedb. promote early ambulationc. prevent hip dislocationd. prevent foot drop (correct)

Rationale: The footboard supports the feet in dorsiflexion and helps to prevent foot drop.

14) The PN can also refer to the external ear as what other known name?

a. Malleusb. Pinna (correct) c. Incusd. Cochlea

15) When providing oral care to a comatose unconscious client who is a mouth breather and does not swallow the action most important for the LVN to implement would be?

a. Inspect the oral cavity using gloved fingersb. Use an oral suction catheter in the buccal cavity (correct)c. Perform oral cleansing with a sponge toothetted. Apply a petroleum-based lubricant to the client’s lips

16) A family member of a dying client asks the PN if the client is aware that her family is at the bedside. The PN explains that which of the five senses persists the longest during the dying process?

a. Touchb. Hearing (correct)c. Visiond. Smell

17) The PN is using Glasgow coma scale to perform a neurological assessment. Acomatose client winces and pulls away from a painful stimulus. What action shouldthe nurse take?

a. Report this finding to the physician immediatelyb. Open the patient’s airwayc. Stop the assessment d. Document that the client responds to painful stimulus. (correct)

Answer: Document that the client responds to painful stimulus!

18) After administering carbamazepine (Tegretol) to a client with trigeminal neuralgia, which finding indicates to the practical nurse that the medication has produced the desired outcome? No pain!

a. The patient no longer has seizuresb. The twitching stopsc. The patient can fall asleepd. Client denies pain (correct)

Rationale: Client denies pain; Tegretol is administered to the client with trigeminal neuralgia to alleviate the severe pain. CN-V Trigeminal nerve is affected V-Trigeminal neuralgia CNVII Facial nerve paralysis-Bell’s Palsy Facial nerve paralysis

Trigeminal neuralgia (TN) or tic douloureux (also known as prosopalgia) is a neuropathic condition. Unfortunately, the symptoms of trigeminal neuralgia are often falsely attributed to a pathology of dental origin. "Rarely do patients come to the surgeon without having many removed, and not infrequently all, teeth on the affected side or both sides." Extractions do not help. The pain is originating in the trigeminal nerve itself - often in its roots - and not in an individual nerve of a tooth, but real tooth pain may be referred to the same areas of the face as that of trigeminal neuralgia. Because of this difficulty, many patients may go untreated for long periods of time before a correct diagnosis is made.

19) The PN is preparing a client with seizure for discharge the clients spouse tells PN, “I am afraid something is going to happen during a seizure and I won’t know what to do? What information should the PN offer?

a. Keep the phone numbers of an ambulance service posted near every phone in the house

b. Check the medication bottle everyday to make sure a dose of the anticonvulsant has not been omitted

c. If a seizure occurs, turn the client to the side lying position and stay with him (correct)

d. Call your friends and neighbors so they will come to help

Rationale: Positioning the client in the side lying position will help protect the airway and a client having a seizure should not be left alone. Transferring the patient via ambulance after a seizure is not indicated unless the client has status epilepticus or another complication. Although noncompliance to the medicalregime is a common cause of a seizure in clients with seizing disorders B is not the answer. B does not answer the spouse’s question. Many people are embarrassed

by diagnosis of seizure and would not want friends and neighbors to know. Their arrival may be delayed.

20) A PN assigns a UAP to obtain the VS of a 14 yr old girl who has a subdural hematoma that may be the result of physical abuse by her boyfriend. What instructions should the nurse provide the UAP?a. observe the boyfriend’s interactions with the clientb. allow only relatives to stay with the clientsc. Implement seizure precautionsd. Report any increase in restlessness or sleepiness

21) In caring for a client who requires seizure precautions the PN should ensure the ready availability of which equipment to perform which procedure?a. Insert a nasogastric tubeb. Apply soft restraintsc. Suction the trachea (correct)d. Insert a urinary catheter

22) Which action should the PN implement in caring for a client following an electroencephalogram EEG?

a. Monitor vital b. Instruct to rest for at least 8 hoursc. Monitor patient for potential headaches d. Wash any paste from the client’s hair and scalp (correct)

Rational during an EEG, electrodes are secured to the client’s scalp with paste which should be washed out after procedure. There is no activity restriction. Following in EEG there is no need to monitor vital signs. ANS wash any paste from the client’s hair scalp.

23) The care plan for a male client with amyotrophic lateral sclerosis (ALS) includes the nursing diagnosis decisional conflict related to concerns about mechanical ventilation. When assigned to care for this client what interventions should the practical nurse implement based on this diagnosis?

a.Ask a hospice nurse to visit with the client to discuss his options for care if he chooses not to undergo mechanical ventilation

b.Encourage the client to discuss his feeling and concerns related to the use of mechanical ventilation (correct)

c.Provide an opportunity for the client to meet with survivors of the disease who have undergone mechanical ventilation

d.Remind the client that a mechanical ventilator is usually only needed for a short period of time.

Rationale: The PN should encourage the client to discuss hi concerns regarding this decision. ALS is a terminal illness; once mechanical ventilation is implemented the life expectancy is very limited.

24) The PN and UAP are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere. What action should the PN implement?

a. Carefully observe the interaction between the client and family membersb. Instruct the UAP to protect the client’s left side when transferring to a

chair (correct)c. Demonstrate to the UAP how to approach the client from the client’s left

sided. Ask the UAP to leave the room and assess the client’s body for bruises

Rational: Neglect syndrome occurs following a stroke. It is important that caregivers protect the affected side, since the patient has lost this awareness. Neglect syndrome is not related to abuse or neglect.

25) The practical nurse observes that a client with Huntington’s disease is experiencing rapid jerky movements of the hands, legs and facial muscles while the client’s family is present in the room what action should the PN implement?

a. Offer emotional support to the family (correct)b. Place a mask on patient’s face, pt is having a seizurec. Encourage pt to deep breath and try to relaxd. Notify charge nurse that patient is having a seizure

Rationale: Offer emotional support to the family. Huntington’s disease is characterized by choreiform movements, rapid jerky movements of the limbs, trunk and facial muscles. This uncontrollable movement may be stressful for the family to observe, so the nurse should offer the family emotional support. This movementis not seizure activity and does not require oxygen via nasal cannula nor notifying the charge nurse of the behavior. The client cannot control this movement, so relaxation exercises don’t help.

26) The PN and UAP are caring for pt undergoing bladder retraining following stroke. What action should the PN implement?

a. Insert an indwelling catheter and assign the UAP to empty it q 4 hrb. Advise the client to limit oral fluids intake until bladder tone is

reestablishedc. Perform a straight catheterization daily at the same time each day.d. Assign the UAP to take the client to the bathroom to void @ q 2 hours

(correct)

Rationale: Voiding on a regular schedule promotes bladder tone and is a useful technique in bladder retraining. The PN should assign the UAP to take the client to BR every 2 hours

27) Following a cerebral vascular accident CVA a client has difficulty swallowing and R sided weakness. What

Equipment is most important to have available for the client? a. Pulse oximetry deviceb. Automatic blood pressure devicec. Padded side railsd. Oral suction device (correct)

28) The PN begins administration of a daily dose of enteric coated aspirin 82 mg p.o. to an 80 year old client who is admitted with transient ischemic attack (TIA). The client tells the PN that he does not have a headache and does not need to take the aspirin. The PN should describe which purpose of administering the aspirin?

a. Slow blood clotting to prevent a stroke (correct)b. Prevent a headache caused by the mini-strokec. Reduce brain inflammation from the TIA episoded. Decrease fever associated with the mini-stroke

29) The 14 year old male with a spinal cord injury SCI T-10 is admitted for rehabilitation. During the morning daily assessment the practical nurse determines that the adolescent’s face is flushed, his forehead is sweating, his heart rate is 54 bpm his blood pressure is 198/118. What action should the nurse implement first?

A 14 yr old with T-10 SCI admitted for rehabilitation blood pressure is 198/118

a. Administer an antihypertensive agentb. Determine if the urinary bladder is distended (correct) must assess first!c. Review the temperature graph for the last dayd. Irrigate the indwelling urinary catheter.

Rationale: Children with mid-thoracic SCI are susceptible to autonomic dysreflexia, which results from sensory stimuli that activates a sympathetic reflex and is manifested by a flushed face, sweating forehead, papillary constriction, headache, bradycardia, and marked hypertension. Bladder distention is the usually precipitating cause of hypertension associated with autonomic dysreflexia. If symptoms persist after bladder or bowel pressure is relieved (a) administer an antihypertensive agent is indicated. If an obstructed urinary catheter is identified, then (d) irrigate the indwelling urinary catheter is indicated to drain the bladder. If there is a fever (c) review the temperature

graph for the last day and a fever may reveal an infection, however, the visceralstimuli should be indentified and relieved first.

30) The PN is assisting a client to bathroom after R cataract extraction. (The client has a eye shield over the R eye) How should the PN assist the client during ambulation?

a. place the client in front of the nurse while both walk to bathroomb. walk on the client’s left side while assisting the client to the bathroomc. support the client on the R side while walking to the bathroom (correct)d. stand in front of the client and lead the client forward to the bathroom

Rationale: The eye shield on the right eye limits the clients field of vision to the right, so the PN should support the clients on the right. Correct to protect the right side from injury during initial ambulation all otheroptions can be frightening and uncomfortable and unsafe.

31) The PN is monitoring the neuro vital signs of a client with a recent closed Head injury. What vital sign trends indicate increased intracranial pressure and should be reported to the charge nurse

a. bradycardia, irregular respiratory patterns, widening pulse pressure (correct)

b. thread rapid pulse, trembling, perspiration, weakness and irritabilityc. heart rate above 100 beats per min, elevated respiratory rate and

hypotensiond. bounding pulse rate, groaning respiratory effort, and elevated blood

pressure

32) The Glasgow coma scale is being used to monitor a client in the critical careunit. The scale is used to evaluate what client status?

a. Ability to communicateb. Level of consciousness (correct)c. Mental statusd. Cranial nerve status

33) What action should the PN implement in caring for a client who is experiencing a migraine headache with photophobia and nausea?

a. Reinforce teaching about the avoidance of triggersb. Provide a calm, quiet, and darkened room environment (correct)c. Encourage the client to participate in self-care activitiesd. Withhold oral medications until the symptoms are relieved

Rationale: Clients with a migraine headache and photophobia also experience sensitivity to light. Therefore they are more comfortable in a calm quiet and darkened room environment B is answer

34) In performing a routine assessment of a bedfast client who has bilateral cataracts, the PN observes that the

client’s pupils appear milky-white. What action should the PN take next?a. Ask the client about any changes in vision (correct)b. Notify the charge nurse of the finding c. Assess the client using the Glasgow coma scaled. Assist the client to a Semi-Fowler’s position

Rationale: In cataracts lens opacity causes a milky-white appearance over the pupil of the eye. This opacity also

causes blurred vision, diplopia and reduced visual acuity. Rational: A. these changes should be assessed because

they increase the clients risk for injury.

35) An older client is transferred to the rehabilitation unit with the diagnosis of cerebrovascular accident with left sided hemiplegia. The PN addresses the client from the right side and the client points to the left leg and states, “there is a leg in my bed”? What is the best response by the PN?

a. Please explain to me that you think happened to your leg?b. Your stroke has impaired your ability to recognize your paralyzed leg (correct)c. Look as your legs and you will see that they both belong to youd. I know you think there is an extra leg in your bed, but I do not see it.

Rationale: Anosognosia is the inability to recognize a physical deficit or perceive the body parts and results from

damage to the right hemisphere of the brain. The best response is the pn’s validation that the leg is indeed part of him

or herself and the misconception is a result of the stroke B.

36) A 85 yr old patient has bilateral cataracts he still loves to read. To enhance his reading ability which intervention would be appropriate?

a. Dim the light slightly to prevent glare (correct)b. Provide sunlight as a light sourcec. Encourage him to obtain books on taped. Reduce environmental stimuli

Rationale: dimming the light A causes the pupils to dilate widely and will often improve the vision of a person with cataracts. Cataract is the development of opacity in the lens of the eye. The resulting vision problem is fussy or clouded vision. B) is not helpful to cataracts clients who often develop light sensitivity and must wear tinted or dark lenses. C) is not necessary she can readif the lights are dimmed. D) will not help problems associated with cataracts.

37) The nurse is preparing to administer a scheduled dose of benztropine (Cogentin) to a male client with Parkinson’s disease. The client reports that his mouth is very dry. What action should nurse take?a. Observe the client’s gums for signs of tissue overgrowthb. Withhold the scheduled drug and notify the charge nursec. Review the serum drug level before administering the drugd. Administer the scheduled medication and provide oral care (correct)