Question 1

An adult client with altered mental status and fever has suspected bacterial meningitis with sepsis. Blood pressure is 80/60 mm Hg. Which prescribed intervention should the nurse implement first?

Accepted Answer

Meningitis is an inflammation of the meninges covering the brain and spinal cord. The key clinical manifestations of bacterial meningitis include fever, severe headache, nausea/vomiting, and nuchal rigidity. Other symptoms include photophobia, altered mental status, and other signs of increased intracranial pressure (ICP). In a hypotensive client with sepsis, the priority of care is fluid resuscitation to increase the client's blood pressure (Option B). In addition to IV fluid administration, interventions and prescriptions for a client with sepsis and meningitis may include: Administer vasopressors. Obtain relevant labs and blood cultures prior to administering antibiotics. Administer empiric antibiotics, preferably within 30 minutes of admission (Option A). This client will continue to decline without antibiotic therapy. Prior to a lumbar puncture (LP), obtain a head CT scan as increased ICP or mass lesions may contraindicate a LP due to the risk of brain herniation (Option D). Assist with a LP for cerebrospinal fluid (CSF) examination and cultures (Option C). CSF is usually purulent and turbid in clients with bacterial meningitis. CSF cultures will allow for targeted antibiotic therapy. Educational objective: For bacterial meningitis with sepsis, fluid resuscitation is the priority. Blood cultures should be drawn before starting antibiotics. After a head CT scan is performed to rule out increased intracranial pressure and mass lesions, cerebrospinal fluid cultures should be drawn via lumbar puncture.

Question 2

A client was struck on the head by a baseball bat during a robbery attempt. The nurse gives this report to the oncoming nurse at shift change and conveys that the client's current Glasgow Coma Scale (GCS) score is a "10." Which client assessment is most important for the reporting nurse to include?

Accepted Answer

11ecbb05_ca2b_c75d_b433_6119a67032ea_MD0009_00 The GCS quantifies the level of consciousness in a client with acute brain injury by measuring eye opening (alertness), verbal response (orientation), and motor response (eg, obeying a command, frontal lobe function). The maximum score on the GCS is 15 and the lowest is 3. If a client is trending for deterioration, this should always be noted in neurological assessments. A numerical decline of a single number in 1 hour is significant. A criticism of the GCS score is that it is not that precise. (Option A) Orientation to place is part of the GCS score (under best verbal). The total score and the negative trend are more indicative of the client's condition than any individual GCS component. (Option C) This client's vital signs are within normal limits and are not significant. It would be more important to communicate if there is absence of Cushing's triad (bradycardia, bradypnea/Cheyne-Stokes, and widening pulse pressure) or to give a brief summary of overall vital signs (eg, "normal"); exact readings are accessible and can be recited if the oncoming nurse needs to know them. However, reporting the negative neurological trend in the GCS score is the priority. (Option D) Although it is important to be aware of allergies, the oncoming nurse can find that information on the chart if these medications are ordered. The main concern is blunt head trauma and not infection; therefore, it is unlikely that the oncoming nurse will be required to know this information and need to administer antibiotics. Educational objective: It is a priority to report a negative neurological trend as evidenced by GCS score in a client with blunt head trauma.

Question 3

The nurse is caring for a client with left-sided weakness from a stroke.  When assisting the client to a chair, what should the nurse do?

Accepted Answer

When transferring a client from bed to chair the following are recommended for client safety: Clients should wear nonskid shoes (first step)Make sure the bed and chair (wheelchair) brakes are lockedUse a transfer belt. A transfer belt worn around the client's waist allows the nurse to assist the client while maintaining proper body mechanics and safety.Transfer the client toward the stronger (not the weaker) side. If the client is weak on the left side, ask the client to pivot on the right side. Clients should wear nonskid shoes (first step) Make sure the bed and chair (wheelchair) brakes are locked Use a transfer belt. A transfer belt worn around the client's waist allows the nurse to assist the client while maintaining proper body mechanics and safety. Transfer the client toward the stronger (not the weaker) side. If the client is weak on the left side, ask the client to pivot on the right side. (Option A) Bending at the waist often requires the nurse to use the back for lifting, making for poor body mechanics. (Option B) The nurse should provide a wide body stance for more stability. Keeping the feet close together would not be good body mechanics and could cause injury. (Option C) The nurse using proper body mechanics would pivot on the foot distal to the chair. Educational objective: A transfer belt worn around the client's waist allows the nurse to assist the client while maintaining proper body mechanics and safety.

Question 4

A client with blunt head injury is admitted for observation, including hourly neurologic checks.  At 01:00 AM, the client reports a headache; the nurse obtains a normal neurologic assessment and administers the PRN acetaminophen.  At 02:00 AM, the client appears to be sleeping.  Which action should the nurse take?

Accepted Answer

Serial neurologic assessments are important as neurologic abnormalities are often initially subtle, making it important to note the trend. Interventions for neurologic issues are most effective when made early. A neurologic assessment includes: Glasgow Coma Scale (GCS)-best eye, verbal, and motor responses. Best verbal response assesses orientation to person, place, and time (time is the most sensitive). Pupils-equal, round, response to light, and accommodate (PERRLA) Motor-strength and movement in all four extremities Vital signs-especially any signs of Cushing's triad of bradycardia, bradypnea/abnormal breathing pattern and widening pulse pressure (the difference between systolic and diastolic blood pressure readings). The nurse is assessing for signs of increased intracranial pressure (ICP). This client is not admitted in the hospital to get a good night sleep. The client is admitted due to the need for serial neurologic assessments by a professional nurse, and that is the priority. (Option B) Although pain relief has probably been achieved, this option does not reflect any neurologic assessment. One of the early signs of increased ICP is change in level of consciousness. This option does not assess the client's arousability. (Option C) Checking the respiratory rate and characteristics is part of the neurologic assessment. However, this alone is insufficient for assessing a neurologic status after a blunt head injury. (Option D) It is good to awaken the client, but paresthesia is part of a neurovascular assessment. Neurovascular assessment, commonly known as the 5 Ps, consists of paresthesia, pain, pallor, paralysis, and pulselessness. A neurovascular assessment is used when circulation is a primary concern. It is not the primary neurologic assessment needed in a closed head injury. Educational objective: Clients must be awakened for a prescribed, necessary neurologic assessment. A neurologic assessment consists of GCS, PERRLA, movement and strength of the extremities, and vital signs.

Question 5

The nurse is caring for a client with absence seizures. The unlicensed assistive personnel (UAP) asks if the client will "shake and jerk" when having a seizure. Which response from the nurse is the most helpful?

Accepted Answer

Absence seizures typically occur in children. The presentation is classic and includes the following: Daydreaming episodes or brief (<10 seconds) staring spells Absence of warning and postictal phases Absence of other forms of epileptic activity (no myoclonus or tonic-clonic activity) Unresponsiveness during the seizure No memory of the seizure The most helpful response by the nurse is one that corrects while educating the UAP (Option A). The UAP may be present when a client has a seizure, and understanding of what to expect will aid client care. (Options B and D) Although it is not the responsibility of the UAP to monitor the client, the UAP may witness a seizure and call for help if needed. (Option C) Seizures may include tonic (body stiffening), clonic (muscle jerking), atonic (loss of muscle tone or "drop attack"), myoclonic (brief muscle jerk), or tonic-clonic (alternating stiffening and jerking) body motions. Absence seizures do not typically involve these body motions. Educational objective: Absence seizures are brief periods of staring; there is no evidence of tonic-clonic activity or postictal confusion. The UAP should be educated about absence seizures when involved in the care of such clients.

Question 6

The clinic nurse is assessing a previously healthy 60-year-old client when the client says, "My hand has been shaking when I try to cut food. I did some research online. Could I have Parkinson's disease?" Which response from the nurse is the most helpful?

Accepted Answer

11ecbb05_ca2a_19ab_b433_756f35f111ff_MD0009_00 Parkinson's disease (PD) is a chronic, progressive neurodegenerative disorder that involves degeneration of the dopamine-producing neurons. Damage to dopamine neurons makes it difficult to control muscles through smooth movement. PD is characterized by a delay in initiation of movement (bradykinesia), increased muscle tone (rigidity), resting tremor, and shuffling gait. The most helpful response by the nurse is the one that acknowledges the concern of the client and also asks for more information. The nurse should assess for additional information and perform a more focused physical assessment given this new information (Option D). (Option A) It is incorrect to say that the client is too young to have PD although it is usually seen after age 60; about 15% of PD cases are diagnosed before age 50. (Option B) Although the nurse should encourage the client and family to discuss concerns with the health care provider, this is not the most helpful response. (Option C) Although the typical parkinsonian tremor occurs at rest and not during purposeful movement, it is not helpful to dismiss a concern without probing for more information. Educational objective: Therapeutic communication includes acknowledging concerns and probing for additional information as part of an assessment.

Question 7

The nurse is preparing to discharge a client who is stable following a head injury. Which statement by the client indicates a need for further discharge instructions?

Accepted Answer

Opioid pain medications should be avoided following a head injury; therefore, the nurse should clarify what medication the client has at home (Option A). Any change in level of consciousness, dizziness, nausea, or other side effects of opioids could be misinterpreted as symptoms of a worsening condition related to the head injury. Clients are typically advised to use non-narcotic or nonsteroidal anti-inflammatory pain medications. A client with a head injury should be taught the following: Notify the health care provider if you experience increased drowsiness, nausea or vomiting, worsening headache, seizures, vision changes, behavioral changes, weakness or numbness, or difficulty with balance or walking Avoid alcohol and other central nervous system (CNS) depressants (eg, benzodiazepines) (Option B) Have someone stay with you (Option D) Avoid driving, using heavy machinery, playing contact sports, or taking hot baths for 1-2 days (Option C) Educational objective: Clients should avoid opioid pain medications and CNS depressants (eg, alcohol) when recovering from a head injury. They should also avoid driving, using heavy machinery, playing contact sports, or taking hot baths for 1-2 days.

Question 8

The nurse is caring for a client with increased intracranial pressure (ICP). Which statement by the unlicensed assistive personnel would require immediate intervention by the nurse?

Accepted Answer

Clients with elevated ICP should avoid anything that increases intrathoracic or intraabdominal pressure as these also indirectly increase ICP. These activities include straining, coughing, and blowing the nose. Respiratory interventions, if needed, may include deep breathing and incentive spirometry in the absence of coughing. The head of the bed should be maintained at 30 degrees, high enough to allow for cerebrospinal fluid drainage, but low enough to maintain cerebral perfusion pressure. Clients should have minimal stimuli, including no bright lights or multiple visitors, as stimulation can increase ICP. (Option A) The head of the bed should be raised to 30 degrees and maintained. This may require follow-up, but not immediate intervention, by the nurse. (Option B) Turning down the lights is appropriate as clients with ICP benefit from a quiet, nonstimulating environment. (Option C) Bringing items closer to the client prevents straining from reaching and is appropriate. Educational objective: Clients with increased ICP should be encouraged not to cough, strain, or increase abdominal or thoracic pressure. The head of the bed should be maintained at 30 degrees, and stimulation in the room should be minimized.

Question 9

The home health nurse teaches an elderly client with dysphagia some strategies to help limit repeated hospitalizations for aspiration pneumonia. Which statement indicates that the client needs further teaching?

Accepted Answer

Dysphagia increases the risk for aspiration of oropharyngeal secretions, gastric content, food, and/or fluid into the lungs. Aspiration of foreign material into the lungs increases the risk for developing aspiration pneumonia. Interventions to help decrease aspiration and resulting aspiration pneumonia in susceptible clients (eg, elderly, neurologic dysfunction, decreased cough or gag reflexes, decreased immunity, chronic disease), include the following: Swallowing 2 times before taking another bite of food. This clears food from the pharynx. Thickening liquids to assist swallowing Avoiding over-the-counter cold medications. Antihistamine cold preparation medications also have some anticholinergic properties, such as causing drowsiness, decreasing saliva (xerostomia) production, and making the mouth dry. Saliva is a lubricant, and it helps bind food together to facilitate swallowing. Sitting upright for at least 30-40 minutes after meals. This uses gravity to move food or fluid through the alimentary tract, decreases gastroesophageal reflux, and helps decrease risk for aspiration. Brushing teeth and using antiseptic mouthwash before and after meals. This reduces the bacterial count before eating because bacteria as well as food can be aspirated. After-meal use removes particles of food that can be aspirated later. Smoking cessation. Smoking decreases mucociliary clearance and increases bacterial count in the mouth. (Option A) Positioning the chin slightly downward toward the neck (chin-tuck) when swallowing can be effective in some clients with dysphagia due to its facilitating closure of the epiglottis to help prevent tracheal aspiration. Educational objective: Teaching clients who are susceptible to aspiration about swallowing techniques, positioning, avoidance of over-the-counter cold preparation medications (cause drowsiness and dry mouth), oral care, and smoking cessation can decrease the risk for aspiration pneumonia

Question 10

A client is brought to the emergency department by emergency medical services with a flaccid right arm and leg and lack of verbal response. The stroke alert team is initiated. The nurse takes which priority action?

Accepted Answer

A flaccid extremity and change in verbal ability are symptoms of a stroke, which is considered an emergency. Clients with stroke symptoms are immediately triaged using a special team and set of tools to determine the correct course of action with the goal of preventing further brain damage. In any emergency, the first priority nursing action is to maintain a patent airway (Option C). Depending on the mechanism of injury, the symptoms may include changes in airway clearance, which is a priority. The nurse, or another member of the emergency department or stroke alert team, will prepare the client for an immediate head CT scan to rule out a hemorrhagic stroke and determine the location and extent of the injury (Option D). This person will also ensure that the client has 2 large-bore IV lines for rapid infusion of fluids or medications as needed (Option B). (Option A) It is vital to determine the onset of symptoms as thrombolytic medications are used in a short time frame (typically within 4.5 hours of onset). Thrombolytic medications are used only in ischemic strokes, so the head CT must be completed to confirm the type of stroke (ischemic versus hemorrhagic). With all of these interventions, the priority nursing actions remain the same: ABC - airway, breathing, and circulation. Educational objective: In any emergency, the primary nursing interventions are the ABCs. A patent airway should be maintained while other care is provided and throughout the emergency treatment process.

Question 11

Assessment of a client with a history of stroke reveals that the client understands and follows commands but answers questions with incorrect word choices.  The nurse documents the presence of which communication deficit?

Accepted Answer

11ecbb05_ca28_44ea_b433_2f916599b45a_MD0009_00 Aphasia refers to impaired communication due to a neurological condition (eg, stroke, traumatic brain injury). The term aphasia is interchangeable with dysphasia, although aphasia is used more commonly. Receptive aphasia refers to impaired comprehension of speech and writing. A client with receptive aphasia may speak full sentences, but the words do not make sense. The nurse should speak clearly, ask simple "yes" or "no" questions, and use gestures and pictures to increase understanding. Expressive aphasia refers to impaired speech and writing. A client with expressive aphasia may be able to speak short phrases but will have difficulty with word choice (Option A). The nurse should listen without interrupting and give the client time to form words. A client may have one type of aphasia or a combination of both, and the severity will vary with the individual. (Option B) Apraxia refers to loss of the ability to perform a learned movement (eg, whistling, clapping, dressing) due to neurological impairment. (Option C) Dysarthria is weakness of the muscles used for speech. Pronunciation and articulation are affected. Comprehension and the meaning of words are intact, but speech is difficult to understand (eg, mumble, lisp). (Option D) Dysphagia refers to difficulty swallowing. The term dysphagia is often confused with dysphasia. Clients with motor deficits after a stroke may have dysphagia, which requires swallowing precautions to prevent aspiration. Educational objective: Aphasia refers to a neurological impairment of communication. Clients may have impaired speech and writing, impaired comprehension of words, or a combination of both.

Question 12

The nurse is caring for a client admitted for a seizure disorder. The nurse witnesses the client having a tonic-clonic seizure with increasing salivation. Which actions should the nurse take? Select all that apply.

Accepted Answer

Safety is the immediate priority in a client experiencing a seizure. Nursing interventions include: Nursing interventions Remain at the client's bedside while noting duration and symptoms of the seizureCall for help so that other team members can assist with care of the client (Option A)Protect client from hitting hard surfaces by padding the side railsTurn client on the side if possible to allow for drainage of secretions and prevent the tongue from occluding the airway (Option E)Loosen clothing around the neck and chest to promote ventilationUse suction equipment after the seizure subsides as needed to maintain a patent airway (Option D) Remain at the client's bedside while noting duration and symptoms of the seizure Call for help so that other team members can assist with care of the client (Option A) Protect client from hitting hard surfaces by padding the side rails Turn client on the side if possible to allow for drainage of secretions and prevent the tongue from occluding the airway (Option E) Loosen clothing around the neck and chest to promote ventilation Use suction equipment after the seizure subsides as needed to maintain a patent airway (Option D) The client should not be restrained as this could cause an injury (Option B). Oral airways should be kept at the bedside for postictal airway management and recovery, but during an active seizure it is dangerous to attempt to insert anything in the client's mouth, especially if the teeth are clenched (Option C). Educational objective: During an active seizure, the nurse should call for additional help, turn the client on the side if possible, and have suction equipment ready to clear any excessive secretions that may block the airway. The nurse should not restrain the client or force anything into the client's mouth.

Question 13

The nurse is caring for a client diagnosed with Guillain-Barré syndrome (GBS) after a recent gastrointestinal (GI) illness. Monitoring for which of the following is a nursing care priority for this client?

Accepted Answer

GBS is an acute, immune-mediated polyneuropathy that is most often accompanied by ascending muscle weakness and absent deep-tendon reflexes. Many clients have a history of antecedent respiratory tract or GI infection. Lower-extremity weakness progresses over hours to days to involve the thorax, arms, and cranial nerves. However, neuromuscular respiratory failure is the most life-threatening complication. Early signs indicating impending respiratory failure include: Inability to cough Shallow respirations Dyspnea and hypoxia Inability to lift the head or eye brows Assessing the client's pulmonary function by serial spirometry is also recommended. Measurement of forced vital capacity (FVC) is the gold standard for assessing ventilation; a decline in FVC indicates impending respiratory arrest requiring endotracheal intubation. (Option A) Severe autonomic dysfunction can present as diaphoresis and facial flushing. (Option B) The client with GBS is also at risk for paralytic ileus, which is related to either immobility or nerve damage. As a result, the nurse should monitor for the presence hypoactive/absent bowel sounds. (Option D) Clients with GBS are at risk of developing deep venous thrombosis due to lack of ambulation and should receive pharmacologic prophylaxis (heparin) and support stockings. Although symptoms in Options A, B, and D represent a progressive illness and are important to communicate to the health care provider promptly, they are not the highest priority compared to impending respiratory failure. Educational objective: Respiratory distress is a potential complication of progressing paralysis in clients with Guillain-Barré syndrome. The nurse should prioritize and monitor for the presence of this complication. Measurement of serial spirometry (FVC) is the gold standard for assessing ventilation.

Question 14

The nurse is caring for a client with Bell palsy. Which of the following assessment findings does the nurse expect? Select all that apply.

Accepted Answer

11ecbb05_ca2a_8edc_b433_dff78e191e14_MD0009_00 Bell palsy is peripheral, unilateral facial paralysis characterized by inflammation of the facial nerve (cranial nerve VII) in the absence of a stroke or other causative agent/disease. Paralysis of the motor fibers innervating the facial muscles results in flaccidity on the affected side. cranial nerve VII Manifestations of Bell palsy include: Inability to completely close the eye on the affected side Alteration in tear production (eg, decreased tearing with extreme dryness, excessive tearing) due to weakness of the lower eyelid muscle (Option A) Flattening of the nasolabial fold on the side of the paralysis (Option C) Inability to smile or frown symmetrically (Option D) Alteration in the sensory fibers can cause loss of taste on the anterior two-thirds of the tongue. (Options B and E) Electric shock-like pain in the lips and gums and severe pain along the cheekbone are symptoms of trigeminal neuralgia (cranial nerve V). With Bell palsy, the trigeminal nerve may become hypersensitive and cause facial pain, but this is uncommon and typically more indicative of trigeminal neuralgia. Educational objective: Bell palsy is unilateral facial paralysis due to inflammation of the facial nerve that is characterized by inability to close the affected eye completely, changes in tear production, facial droop, and asymmetrical smile or frown.

Question 15

The nurse is caring for a client who has homonymous hemianopsia following an acute stroke. Which nursing diagnosis is the most appropriate for this client?

Accepted Answer

11ecbb05_ca27_a8a9_b433_b5eb2af37af7_MD0009_00 Cerebral vascular accidents (strokes) can cause visual and perceptual deficits depending on which part of the brain is affected. Clients with changes in visual field or perception of their body in space can be at risk for safety-related injuries. Homonymous hemianopsia is a loss in half of the visual field on the same side. For example, the client may lose the left side of the visual field in both eyes. A client unable to see the left side of the body is at a higher risk for neglecting that side or being unable to eat food placed on the left side of a plate. These clients are at higher risk for injury because they are unable to incorporate full visual field input. They are taught to turn the head and scan to the side with the visual field deficit to reduce the risk for injury and self-neglect. (Option A) Clients with a reduced visual field are not at a higher risk for ineffective airway maintenance. (Option B) Clients with a reduced visual field are at risk for knowledge deficit and should be taught to turn the head and scan the area with the deficit. However, this risk is not more important than client safety and the risk of self-neglect. (Option C) Clients with a reduced visual field are not specifically at higher risk for reduced fluid intake. Food and fluids should be kept within the client's field of vision to encourage intake as appropriate. Educational objective: Homonymous hemianopsia is the loss of one half of the field of vision on the same side in both eyes. Clients are taught to turn their heads and scan the area that has a visual deficit to reduce the risk of injury and self-neglect. Food and fluids should be kept within the client's field of vision to encourage intake as appropriate.

Question 16

The nurse is caring for a client with a history of tonic-clonic seizures.  After a seizure lasting 25 seconds, the nurse notes that the client is confused for 20 minutes.  The client does not know the current location, does not know the current season, and has a headache.  The nurse documents the confusion and headache as which phase of the client's seizure activity?

Accepted Answer

A seizure is an uncontrolled electrical discharge of neurons in the brain that interrupts normal function. Seizure manifestations generally are classified into 4 phases: The prodromal phase is the period with warning signs that precede the seizure (before the aural phase). The aural phase is the period before the seizure when the client may experience visual or other sensory changes. Not all clients experience or can recognize a prodromal or aural phase before the seizure. The ictal phase is the period of active seizure activity. During the postictal phase, the client may experience confusion while recovering from the seizure. The client may also experience a headache. Postictal confusion can help identify clients by differentiating seizures from syncope. In syncope, there will be only a brief loss of consciousness without prolonged post-event confusion. Educational objective: Clients may experience confusion after a seizure during the postictal phase. The client should be observed for safety and abnormalities documented before and during this phase.

Question 17

The nurse is caring for a client after a motor vehicle accident. The client's injuries include 2 fractured ribs and a concussion. The nurse notes which of the following as expected neurological changes for the client with a concussion? Select all that apply.

Accepted Answer

11ecbb05_ca25_acd8_b433_7bf611568db7_MD0009_00 A concussion is considered a minor traumatic brain injury and results from blunt force or an acceleration/deceleration head injury. Typical signs of concussion include: A brief disruption in level of consciousness Amnesia regarding the event (retrograde amnesia) Headache These clients should be observed closely by family members and not participate in strenuous or athletic activities for 1-2 days. Rest and a light diet are encouraged during this time. (Options A and D) The following manifestations indicate more serious brain injury and are not expected with simple concussion: Worsening headaches and vomiting (indicate high intracranial pressure) Sleepiness and/or confusion (indicate high intracranial pressure) Visual changes Weakness or numbness of part of the body Educational objective: Expected neurological changes with a concussion include brief loss of consciousness, retrograde amnesia, and headache. These clients should be observed closely by family members and not participate in strenuous or athletic activities for 1-2 days.

Question 18

A client comes to the emergency department with diplopia and recent onset of nausea.  Which statement by the client would indicate to the nurse that this is an emergency?

Accepted Answer

A ruptured cerebral aneurysm is a surgical emergency with a high mortality rate. Cerebral aneurysms are usually asymptomatic unless they rupture; they are often called "silent killers" as they may go undetected for many years before rupturing without warning signs. The distinctive description of a cerebral aneurysm rupture is the abrupt onset of "the worst headache of my life" that is different from previous headaches (including migraines). Immediate evaluation for a possible ruptured aneurysm is critical for any client experiencing a severe headache with changes in or loss of consciousness, neurologic deficits, diplopia, seizures, vomiting, or a stiff neck. Early identification and prompt surgical intervention help increase the chance for survival. (Options A, B, and C) A change in level of consciousness, increased blood pressure, or a feeling of illness should be investigated but alone does not indicate an emergency. Educational objective: Sudden onset of a severe headache described as "the worst headache of my life" is characteristic of a ruptured cerebral aneurysm and should be treated as an emergency.

Question 19

The nurse is caring for a client with an acute ischemic stroke who has a blood pressure of 178/95 mm Hg. The health care provider prescribes as-needed antihypertensives to be given if the systolic pressure is >200 mm Hg. Which action by the nurse is most appropriate?

Accepted Answer

An ischemic stroke is a loss of brain tissue perfusion due to blockage in blood flow. Elevated blood pressure is common and permitted after a stroke and may be a compensatory mechanism to maintain cerebral perfusion distal to the area of blockage. This permissive hypertension usually autocorrects within 24-48 hours and does not require treatment unless the hypertension is extreme (systolic blood pressure >220 mm Hg or diastolic blood pressure >120 mm Hg) or contraindicated due to the presence of another illness requiring strict blood pressure control (eg, active ischemic coronary disease, heart failure, aortic dissection). A blood pressure of 178/95 mm Hg should be monitored, along with the client's other vital signs and status (Option B). (Option A) The elevated blood pressure may be a protective measure to ensure tissue perfusion; therefore, the antihypertensive drug should not be given unless indicated by the prescription parameters. (Options C and D) The as-needed prescription is appropriate in this case, so there is no reason to question it and call the health care provider. Educational objective: Elevated blood pressure in the presence of an acute ischemic stroke is an expected finding and may be a protective measure to maintain tissue perfusion.

Question 20

An 86-year-old client with diabetes and gastroparesis has had repeated hospitalizations for aspiration pneumonia following a stroke and is now hospitalized with altered level of consciousness. Which nursing action is most appropriate to decrease the client's risk for developing aspiration pneumonia?

Accepted Answer

Clients with decreased level of consciousness may not be alert enough to protect their own airways; therefore, a side lying or lateral position is used to decrease the risk for developing aspiration pneumonia. If vomiting were to occur, this position promotes drainage of emesis out of the mouth instead of down the pharynx where it can be aspirated into the lungs. Maintaining an upright position during and after meals will allow remaining food particles to clear from the pharynx. (Option A) Assessing breath sounds can help identify the presence of pneumonia (eg, diminished, bronchial, crackles) but does not prevent the client from aspirating. (Option C) Titrating oxygen to maintain saturation ≥93% provides for adequate oxygenation but does not prevent the client from aspirating. (Option D) Turning and repositioning every 2 hours helps to prevent stasis of secretions in the lungs but does not prevent the client from aspirating. Educational objective: Placing a client with a decreased level of consciousness in a position that uses gravity to help drain oropharyngeal and gastric secretions can be effective in preventing aspiration and reducing the risk for aspiration pneumonia.

Exam 1: Adult Health

An adult client with altered mental status and fever has suspected bacterial meningitis with sepsis. Blood pressure is 80/60 mm Hg. Which prescribed intervention should the nurse implement first?

A client was struck on the head by a baseball bat during a robbery attempt. The nurse gives this report to the oncoming nurse at shift change and conveys that the client's current Glasgow Coma Scale (GCS) score is a "10." Which client assessment is most important for the reporting nurse to include?

The nurse is caring for a client with left-sided weakness from a stroke. When assisting the client to a chair, what should the nurse do?

The nurse is caring for a client with absence seizures. The unlicensed assistive personnel (UAP) asks if the client will "shake and jerk" when having a seizure. Which response from the nurse is the most helpful?

The clinic nurse is assessing a previously healthy 60-year-old client when the client says, "My hand has been shaking when I try to cut food. I did some research online. Could I have Parkinson's disease?" Which response from the nurse is the most helpful?

The nurse is preparing to discharge a client who is stable following a head injury. Which statement by the client indicates a need for further discharge instructions?

The nurse is caring for a client with increased intracranial pressure (ICP) . Which statement by the unlicensed assistive personnel would require immediate intervention by the nurse?

The home health nurse teaches an elderly client with dysphagia some strategies to help limit repeated hospitalizations for aspiration pneumonia. Which statement indicates that the client needs further teaching?

A client is brought to the emergency department by emergency medical services with a flaccid right arm and leg and lack of verbal response. The stroke alert team is initiated. The nurse takes which priority action?

Assessment of a client with a history of stroke reveals that the client understands and follows commands but answers questions with incorrect word choices. The nurse documents the presence of which communication deficit?

The nurse is caring for a client admitted for a seizure disorder. The nurse witnesses the client having a tonic-clonic seizure with increasing salivation. Which actions should the nurse take? Select all that apply.

The nurse is caring for a client diagnosed with Guillain-Barré syndrome (GBS) after a recent gastrointestinal (GI) illness. Monitoring for which of the following is a nursing care priority for this client?

The nurse is caring for a client with Bell palsy. Which of the following assessment findings does the nurse expect? Select all that apply.

The nurse is caring for a client who has homonymous hemianopsia following an acute stroke. Which nursing diagnosis is the most appropriate for this client?

The nurse is caring for a client after a motor vehicle accident. The client's injuries include 2 fractured ribs and a concussion. The nurse notes which of the following as expected neurological changes for the client with a concussion? Select all that apply.

A client comes to the emergency department with diplopia and recent onset of nausea. Which statement by the client would indicate to the nurse that this is an emergency?

The nurse is caring for a client with an acute ischemic stroke who has a blood pressure of 178/95 mm Hg. The health care provider prescribes as-needed antihypertensives to be given if the systolic pressure is >200 mm Hg. Which action by the nurse is most appropriate?

An 86-year-old client with diabetes and gastroparesis has had repeated hospitalizations for aspiration pneumonia following a stroke and is now hospitalized with altered level of consciousness. Which nursing action is most appropriate to decrease the client's risk for developing aspiration pneumonia?