Question 1

The nurse is providing information to a patient with migraine headaches. Which information from the patient is least likely to be useful to the HCP when prescribing treatment?

Accepted Answer

The effectiveness of resting in a dark, quiet environment is more of a coping strategy rather than information that would influence the prescription of treatment. The other options provide valuable insights into the nature and triggers of the migraines, which are crucial for determining the most appropriate treatment plan.

Question 2

The nurse is planning care for a patient with a migraine headache. Which actions does the nurse include in this plan of care? (Select all that apply.)

Accepted Answer

Rest, a dark, quiet room, and Sumatriptan (Imitrex) are all effective treatments for migraine headaches.

Question 3

The nurse is caring for a patient with an acute brain injury. Which interventions does the nurse use to prevent increased intracranial pressure in this patient? (Select all that apply.)

Accepted Answer

Avoiding hip flexion, administering stool softeners, and keeping the head of the bed elevated 30 degrees are interventions aimed at preventing increased intracranial pressure. Hip flexion can increase abdominal and thoracic pressure, leading to increased intracranial pressure. Stool softeners prevent straining during bowel movements, which can also increase intracranial pressure. Elevating the head of the bed helps to promote venous drainage from the brain, reducing intracranial pressure.

Question 4

The nurse is providing care for a patient who was diagnosed with Parkinson disease 12 years prior. Which manifestation of the disease presents the nurse with the most likely risk for safety of this patient?

Accepted Answer

Shuffling gait is a common symptom of Parkinson's disease that significantly increases the risk of falls and injuries, making it a major safety concern for patients.

Question 5

The nurse is hired by a family to provide care for a family member diagnosed with stage 2 Alzheimer disease. Which action related to safety is most important for the nurse to implement?

Accepted Answer

Locking doors where potential risks exist is crucial for patient safety, especially in Alzheimer's disease, to prevent wandering and accidents.

Question 6

The nurse is working in a college infirmary when a student comes in and states, "I think I have a migraine. My head hurts, I cannot stand the light, and I feel sick to my stomach." Which additional data collected by the nurse causes concern for a different diagnosis?

Accepted Answer

A positive Brudzinski's sign could indicate meningitis, a serious condition, rather than a migraine. This sign is not associated with migraines but with irritation of the meninges.

Question 7

The nurse is assisting with the care of a patient with a brain tumor who is exhibiting ICP. Which nursing intervention is specifically initiated to provide safety for this patient?

Accepted Answer

Padding the bedside rails and relocating environmental objects are safety measures to prevent injury in patients with increased intracranial pressure (ICP) who may be at risk for seizures or confusion.

Question 8

The nurse is assisting with care for a patient in the ICU with an extreme head injury. The HCP reports that the patient has brain herniation. Which action does the nurse expect from the HCP?

Accepted Answer

The answer of The nurse is assisting with care for...

Question 9

The nurse suspects that a patient is experiencing increasing ICP. What observations cause the nurse to come to this conclusion? (Select all that apply.)

Accepted Answer

The answer of The nurse suspects that a patient is...

Question 10

The nurse is assisting with the care of a patient after a traumatic brain injury. The patient experiences a seizure and exhibits bilateral jerking of the extremities. Which type of seizure activity does the nurse recognize?

Accepted Answer

The bilateral jerking of the extremities is characteristic of generalized seizures, which involve both sides of the brain and result in widespread seizure activity.

Question 11

The nurse is assisting the RN in providing care for a patient with a potential for ICP. Which manifestation does the nurse recognize as needing to be reported to the RN?

Accepted Answer

Increased systolic blood pressure is a classic sign of increased intracranial pressure (ICP), indicating a potential for Cushing's triad (hypertension, bradycardia, and irregular respirations), which needs immediate attention.

Question 12

A patient with a spinal cord injury at T3-T4 experiences a sudden increase in BP and has cool, pale, gooseflesh skin on the lower extremities. Which action does the nurse perform while awaiting physician orders? (Select all that apply.)

Accepted Answer

The patient is likely experiencing autonomic dysreflexia, a condition common in individuals with spinal cord injuries above T6. The symptoms include a sudden increase in blood pressure and changes in skin condition. The nurse should monitor BP frequently (A) to track changes and intervene as necessary. Ensuring the indwelling catheter is patent (D) is crucial because a full bladder is a common trigger for autonomic dysreflexia. Performing a rectal examination (E) is also important to check for fecal impaction, another potential trigger. Placing the patient in a supine position (B) could worsen the hypertension, and while elastic stockings (C) might help with circulation, they do not address the immediate causes of autonomic dysreflexia.

Question 13

An older adult patient is experiencing the manifestation related to a neurocognitive disorder and is being transferred to a long-term care facility. Which condition will involve the nurse in reaching long-term goals related to this patient?

Accepted Answer

Suggesting the family attend a support group is crucial as it provides them with support and education, which can help in managing the patient's condition and reaching long-term care goals.

Question 14

A patient is prescribed the dopamine agonist pramipexole (Mirapex) for Parkinson disease. Which instructions are important for the nurse to include when teaching about this medication? (Select all that apply.)

Accepted Answer

The answer of A patient is prescribed the dopamine agonist...

Question 15

The nurse is providing care for a patient on a medical unit with a history of seizure activity. The patient exhibits the manifestations of a generalized seizure, which does not respond to prescribed treatment. Seizure activity has been continuous for over 30 minutes. Which prescription does the nurse prepare for the HCP?

Accepted Answer

The answer of The nurse is providing care for a...

Question 16

A patient is brought to the health care provider's office with a headache, lethargy, nausea, vomiting, and a fever, which has developed over the past few days. The nurse begins collecting data about the possible causes of the symptoms. Which information indicates a possible cause for encephalitis?

Accepted Answer

Encephalitis can be caused by viral infections, and camping could expose the patient to mosquito or tick bites, which are common vectors for viruses that cause encephalitis.

Question 17

A patient is diagnosed with bacterial encephalopathy. Which symptoms exhibited by the patient indicate late signs of the patient's diagnosis?

Accepted Answer

Late signs of bacterial encephalopathy include lack of involvement and lip smacking or chewing.

Question 18

The licensed practical nurse (LPN) is assigned to assist the registered nurse (RN) in providing care for a patient admitted for an inflammatory neurologic disorder. Which reassessment finding does the LPN report immediately to the RN?

Accepted Answer

The patient attempting to get out of bed to go to work could indicate confusion or a change in mental status, which is significant in the context of an inflammatory neurologic disorder and should be reported immediately to ensure patient safety and appropriate care adjustments.

Question 19

A patient is distressed to learn that a sibling is diagnosed with both neurologic and cognitive manifestations of Huntington disease. When the patient asks the nurse how to determine the incidence of the disease, which answer is most appropriate?

Accepted Answer

Huntington disease is an autosomal dominant genetic disorder, meaning that each child of an affected parent has a 50% chance of inheriting the faulty gene. Genetic testing is the most accurate way to determine if an individual carries the gene that causes Huntington disease. The other options do not accurately reflect how the disease is diagnosed or the genetic risk.

Question 20

A patient is brought to the emergency department after being hit by a baseball bat during a game. Which nursing intervention is immediately reported to the HCP or RN?

Accepted Answer

The answer of A patient is brought to the emergency...

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