Question 1

A patient comes to the community clinic complaining of having a fever. Which clinical manifestations does the nurse correlate with a possible diagnosis of meningitis? Select all that apply.

Accepted Answer

Photophobia, opisthotonos, and nuchal rigidity are clinical manifestations commonly associated with meningitis. Photophobia is a sensitivity to light, opisthotonos is a severe muscle spasm causing the back to arch, and nuchal rigidity is stiffness in the neck, all of which can indicate inflammation of the meninges.

Question 2

A patient is suspected of having Alzheimer's disease. The nurse correlates the results from which diagnostic evaluation to a presumptive diagnosis of this disorder?

Accepted Answer

History and physical examination are crucial for diagnosing Alzheimer's disease, as there is no single test for its diagnosis. It involves assessing cognitive impairment and ruling out other causes of dementia through a comprehensive medical history and physical examination.

Question 3

The nurse suspects that a patient is in the premonitory phase of a migraine headache. What findings did the nurse use to make this clinical decision? Select all that apply.

Accepted Answer

The premonitory phase of a migraine can include various non-painful symptoms that precede the headache by hours or days. These symptoms can include yawning, food cravings, and increased urine output, which are indicative of changes in the body leading up to a migraine. Confusion and flashing lights are not typically associated with the premonitory phase; flashing lights are more commonly associated with the aura phase of a migraine.

Question 4

The nurse monitors for which clinical manifestation as indication that a patient's Alzheimer's disease is progressing?

Accepted Answer

Inability to recall the word for "car" indicates a progression in Alzheimer's disease as it reflects worsening language and memory deficits, which are characteristic of the disease's advancement.

Question 5

A patient with a seizure disorder is prescribed a 1,900-calorie ketogenic diet of which 80% should be consumed as fat. How many calories should the patient consume as fat? Record your answer as a whole number. _____

Accepted Answer

The answer of A patient with a seizure disorder is...

Question 6

The staff development trainer is preparing orientation materials for new staff hired to care for patients with seizure disorders. Which data are included in this presentation? Select all that apply.

Accepted Answer

C) Myoclonic seizures are characterized by sudden, brief, involuntary muscle contractions, which is accurate.D) Tonic seizures involve sustained muscle contractions, typically lasting from a few seconds to minutes, which is correct.E) Tonic-clonic seizures indeed start with a phase of muscle rigidity (tonic phase) followed by a phase of jerking movements (clonic phase), which is accurate.

Question 7

In monitoring a patient recovering from a craniotomy for treatment of a brain tumor, which assessment findings require the nurse to notify the surgeon? Select all that apply.

Accepted Answer

Bradycardia (A), irregular and slow respiratory rate (C), and high systolic blood pressure (E) can indicate increased intracranial pressure or other complications, requiring immediate attention.

Question 8

During morning rounds, the nurse notes that the unlicensed assistive personnel is assisting a patient with Parkinson's disease with breakfast. Which observation requires an immediate intervention?

Accepted Answer

Raising the head of the bed to only 30 degrees may not be sufficient to prevent aspiration in a patient with Parkinson's disease, especially during eating or drinking. Patients with Parkinson's disease often have difficulty swallowing (dysphagia), and a higher elevation, typically 45 to 90 degrees, is recommended during meals to reduce the risk of aspiration.

Question 9

The nurse provides care to a patient who is diagnosed with Parkinson's disease (PD). Which patient data support the implementation of fall precautions in the plan of care? Select all that apply.

Accepted Answer

Patients with Parkinson's disease (PD) often experience rigidity and tremors, which can impair their balance and coordination, increasing the risk of falls. Orthostatic hypotension, a common non-motor symptom in PD, can lead to dizziness or fainting upon standing, further elevating the risk of falls. Mask-like face and difficulty swallowing are symptoms of PD but do not directly contribute to fall risk.

Question 10

The nurse monitors for which clinical manifestations of increased intracranial pressure in the patient diagnosed with a brain tumor? Select all that apply.

Accepted Answer

Increased intracranial pressure (ICP) due to a brain tumor can manifest as ataxia (impaired balance or coordination), papilledema (swelling of the optic disc), vomiting, and headache. Diarrhea is not typically associated with increased ICP.

Question 11

During a home visit the nurse is concerned that the patient with Alzheimer's disease is deteriorating. What patient observation caused the nurse to have this concern?

Accepted Answer

No recognition of bowel incontinence indicates a deterioration in the patient's condition, as it shows a lack of awareness of basic bodily functions, which is a sign of advancing Alzheimer's disease.

Quiz 36: Coordinating Care for Patients With Brain Disorders