Question 1

A patient newly diagnosed with Parkinson's disease receives a prescription for carbidopa/levodopa (Sinemet). Which of the following statements indicates teaching has been effective?

Accepted Answer

Option B is the correct answer as it accurately describes the mechanism of action of carbidopa/levodopa (Sinemet). It is converted to dopamine in the brain and helps relieve symptoms of Parkinson's disease. Options A, C, and D are incorrect statements and indicate a need for further teaching.

Question 2

The nurse is caring for a patient with a traumatic brain injury. Which of the following assessment findings alerts the nurse to possible diabetes insipidus?

Accepted Answer

Frequent urination is a symptom of diabetes insipidus, which can occur as a result of a traumatic brain injury. Headache and confusion are non-specific symptoms that can occur with various conditions, and elevated blood glucose is a finding suggestive of diabetes mellitus, which is a different condition.

Question 3

A woman cares for her husband with a C7 spinal cord injury. The patient requires frequent turning, help with all activities of daily living, catheterization every 3 hours around the clock, and daily wound care for a pressure ulcer. They have three children ages 5 to 12. The wife is exhausted, cannot sleep at night, and has no one to help her. Which of the following outcome criteria would be relevant to a nursing diagnosis of Caregiver Role Strain for this patient's plan of care?

Accepted Answer

This option is relevant as it addresses the need for the caregiver to identify resources available to assist with care. It can be helpful for the caregiver to have support from others to ease the burden of care. The other options are not relevant to the nursing diagnosis of Caregiver Role Strain.

Question 4

The physician prescribes intravenous mannitol for a patient who has a head injury and increased intracranial pressure (ICP). Which assessment finding would best indicate to the nurse that the patient is having a therapeutic response to the mannitol?

Accepted Answer

Intravenous mannitol is a diuretic that helps to reduce ICP by decreasing cerebral edema. Increased urinary output would indicate that the mannitol is working and reducing the patient's ICP. The decreased GCS score, increased blood glucose levels, and return of the gag reflex are not related to the therapeutic response to mannitol.

Question 5

Which data should be included in a routine neurological nursing assessment of a patient who has experienced a head injury?

Accepted Answer

A routine neurological nursing assessment of a patient who has experienced a head injury should include assessment of the Glasgow Coma Scale, pupil response, and vital signs. These are crucial indicators of neurologic functioning and can help detect any changes that may require immediate intervention. The other options listed are important assessments for overall patient care but are not as specific to neurological function after a head injury.

Question 6

What term should the nurse use to document paralysis of all four extremities?

Accepted Answer

Quadriplegia refers to paralysis of all four limbs. Paraplegia refers to paralysis of the lower extremities, hemiparesis refers to weakness on one side of the body, and quadriparesis refers to weakness in all four limbs but not necessarily complete paralysis.

Question 7

A patient with a spinal cord injury arrives in the emergency department. The nurse assesses motor and sensory function and finds the patient without sensation or movement in all four extremities. The injury is most likely in what area?

Accepted Answer

The answer of A patient with a spinal cord injury...

Question 8

The nurse is caring for residents on an Alzheimer's unit. What assessment findings indicate that a patient is in early stages of the disease?

Accepted Answer

Forgetfulness is a hallmark early sign of Alzheimer's disease. Increased ICP, combativeness, and agitation are not typical early signs of the disease.

Question 9

A patient with Parkinson's disease has difficulty tying shoes. What nursing intervention would be most helpful?

Accepted Answer

Having a family member purchase shoes with Velcro fasteners would be most helpful because it would eliminate the need for the patient to tie their shoes. This is a practical solution that can improve the patient's overall quality of life and independence. Option A may be informative but does not provide a practical solution. Option B may be helpful in the short term but does not promote independence. Option C may be appropriate in some cases but assumes that the patient is capable of learning the skill again, which may not always be the case with Parkinson's disease.

Question 10

What nursing diagnosis should take priority for a patient with advancing Alzheimer's disease?

Accepted Answer

Patients with advancing Alzheimer's disease often experience increased risks for falls and other injuries due to impaired judgment, balance, and coordination. This makes Risk for Injury the most important nursing diagnosis to address in this patient population. While the other options may also be relevant, they do not pose as immediate of a threat to the patient's safety.

Question 11

A teen is brought to the emergency department with a headache and complaints of feeling dizzy after a head injury resulting from falling off a bicycle. The physician diagnoses a concussion. What explanation should the nurse provide to the patient's mother?

Accepted Answer

A concussion is a mild traumatic brain injury that is characterized by headache, dizziness, confusion, and other symptoms. It usually resolves on its own within a few days to a few weeks. There is no need for surgery or concern about intracranial bleeding in most cases. The best course of action is to monitor the patient's symptoms and provide supportive care.

Question 12

A patient is admitted to the stepdown unit after 3 days in the intensive care unit recovering from an epidural bleed. The nurse explains to the family that an epidural bleed occurs in which part of the brain?

Accepted Answer

An epidural bleed occurs in the space between the dura and the skull.

Question 13

A quadriplegic patient with a C5 injury has return of function of the lower motor neurons and is beginning rehabilitation. The patient is in a halo vest. As the nurse prepares to transfer the patient to a wheelchair, the patient complains of a throbbing headache and nausea, and the nurse notes that the patient's face looks flushed. What should the nurse do first?

Accepted Answer

The symptoms described are indicative of autonomic dysreflexia, a condition that can occur in patients with spinal cord injuries above T6. It is characterized by a sudden and severe increase in blood pressure, which can present with symptoms such as a throbbing headache, flushing of the face, and nausea. Checking the patient's blood pressure is the first step in identifying this potentially life-threatening condition.

Question 14

The nurse is caring for a nursing home resident who has had Parkinson's disease for 15 years. What symptoms does the nurse anticipate when assisting with a routine assessment?

Accepted Answer

Parkinson's disease presents with a variety of motor and non-motor symptoms. Common motor symptoms include slow shuffling gait, difficulty swallowing, and pill-rolling tremor, which would be expected in this resident who has had Parkinson's for 15 years. Option B describes symptoms of cerebellar dysfunction, which is not typically seen in Parkinson's disease. Option C describes symptoms that may occur in a stroke or brain injury. Option D describes symptoms of a respiratory infection, which would not be specifically related to Parkinson's disease.

Question 15

The nurse is caring for a patient admitted to a neurological unit with new-onset mild confusion and a headache. Magnetic resonance imaging confirms the physician's suspicion of brain tumor. The physician orders dexamethasone (Decadron) IV, which completely relieves the patient's symptoms. The patient's family is convinced this is a miracle. Which of the following statements by the nurse is best?

Accepted Answer

Dexamethasone (Decadron) is a corticosteroid that works to reduce swelling in the brain caused by the tumor. This reduction in inflammation can lead to remarkable improvement in symptoms, as seen in this patient. The other options are not accurate or supported by evidence.

Question 16

The nurse is caring for a patient involved in a motorcycle accident. After admission to the intensive care unit, the nurse assesses the patient for symptoms of spinal shock. Which of the following findings indicates the presence of spinal shock?

Accepted Answer

Spinal shock is characterized by flaccid paralysis and lack of sensation below the level of the injury. This occurs due to a temporary loss of reflex activity and is often present immediately following a spinal cord injury. Options A and C are indicative of incomplete spinal cord injuries, while option D is suggestive of neurogenic shock.

Question 17

The nurse is assisting with teaching family members about a patient's epidural bleed. Which understanding about an epidural bleed should guide the nurse's teaching?

Accepted Answer

An epidural bleed is typically arterial and can be life-threatening if not quickly addressed.

Question 18

A teen and his friends are drinking beer and swimming in a river near their neighborhood. The teen climbs a tree and dives headfirst into the river. After a few seconds, his friends realize something is wrong. They pull him onto the riverbank. He is conscious and breathing but unable to move. What should they do first?

Accepted Answer

The first priority should be to immobilize the boy and call for help. It is important to keep the boy still to prevent any further damage to his neck or spine. Additionally, professional medical help will be necessary to properly assess his injuries and provide appropriate treatment.

Question 19

A patient is admitted to the hospital after a head injury. The nurse notes a widening pulse pressure. Which of the following actions is most appropriate?

Accepted Answer

Widening pulse pressure, which is the difference between the systolic and diastolic blood pressures, can indicate increased intracranial pressure (ICP) and can be a sign of cerebral herniation. Raising the head of the bed can help decrease ICP, and notifying the RN will allow for further assessment and potential interventions such as administering medications or ordering imaging studies. Lay the bed flat and checking pupil response is not effective in treating widening pulse pressure. Giving an extra dose of diuretic is not appropriate without further assessment and can potentially worsen the patient's condition.

Question 20

A patient with suspected spinal cord and head injuries is brought into the emergency department on a backboard after a car accident. The Glasgow Coma Scale score is 15; vital signs are blood pressure 130/82 mm Hg, pulse 102 beats/min, respirations 20 breaths/min, and temperature 98°F (36.6°C). What is the most important nursing intervention during initial care of the patient?

Accepted Answer

In a patient with suspected spinal cord injury and head injury, it is crucial to avoid any unnecessary movement of the patient. This is to prevent any further damage to the spinal cord or brain. Therefore, the most important nursing intervention during initial care of the patient is to avoid moving the patient. Checking the extremities for range of motion or turning the patient to the side to avoid aspiration may be appropriate interventions but only after it has been determined that it is safe to do so. Keeping the head of the bed elevated 30 degrees may also be important for certain patients, but in this case, it is not the most important intervention.

Quiz 48: Nursing Care of Patients With Central Nervous System Disorders

A patient newly diagnosed with Parkinson's disease receives a prescription for carbidopa/levodopa (Sinemet) . Which of the following statements indicates teaching has been effective?