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

Question 1

A patient arrives in the emergency department with a bullet wound to the left frontal lobe. The patient is comatose on arrival. What is the nursing care priority at this time?

A)Evaluate neurological status.
B)Maintain an open airway.
C)Maintain body temperature.
D)Evaluate fluid balance.

Answer 1

Maintain an open airway.

Question 2

A 17-year-old patient is admitted with a new onset of seizures and is diagnosed with epilepsy. Which of the following would the nurse include in the patient teaching?

A)Aspirin can inhibit the action of anticonvulsants.
B)Anticonvulsants must be taken frequently during the day to prevent seizures.
C)Sudden withdrawal of anticonvulsants can lead to status epilepticus.
D)When the seizures have been controlled, the medications can be discontinued.

Answer 2

Sudden withdrawal of anticonvulsants can lead to status epilepticus.

Question 3

The nurse administers an analgesic to a patient with a headache. What is the best way for the nurse to assess the patient's response to the medication?

A)Ask the patient to describe the pain.
B)Observe the patient's behavior.
C)Monitor the patient's blood pressure and pulse.
D)Have the patient rate the pain on a scale of 0 to 10.

Answer 3

Have the patient rate the pain on a scale of 0 to 10.

Question 4

The nurse is caring for a patient brought to the emergency department after an automobile accident. The patient is fully conscious. What early signs of increased intracranial pressure (ICP) should the nurse be alert for?

A)Bradycardia
B)Hypothermia
C)Decreased level of consciousness
D)Pinpoint pupils

Question 5

A patient is incontinent during a seizure and sleeps for several hours afterward. What type of seizure did the patient most likely have?

A)Absence
B)Simple partial
C)Status epilepticus
D)Tonic-clonic

Question 6

The nurse is caring for a patient in the emergency department with a severe headache due to viral meningitis. The patient requests an opioid analgesic. What explanation about opioids should the nurse provide?

A)"Opioid analgesics may make assessment of mental status changes difficult."
B)"Opioid analgesics increase intracranial pressure."
C)"Opioid analgesics are contraindicated in patients with meningitis."
D)"Acetaminophen (Tylenol) is more effective in treating meningitis-related headaches."

Question 7

The nurse is caring for a patient following surgery for a brain tumor. Three days after surgery, the LVN enters the room and finds the patient jerking rhythmically in the bed. The patient does not respond to the LVN's questions. What should the nurse do first?

A)Go find the RN to assist.
B)Hold the patient firmly to keep the patient from injuring someone.
C)Call the physician.
D)Protect the patient from injury and observe the sequence of events.

Question 8

A patient with a newly diagnosed seizure disorder is being prepared for discharge. What medication does the nurse anticipate the patient being discharged on to prevent recurrent seizures?

A)Dexamethasone (Decadron)
B)Gabapentin (Neurontin)
C)Haloperidol (Haldol)
D)Selegiline (Eldepryl)

Question 9

The nurse is assisting with teaching a clinic patient who is diagnosed with tension headaches. Which explanation of tension headaches should the nurse provide?

A)"Tension headaches are caused by stress, which causes cerebral vessel constriction."
B)"Tension headaches result from release of pain mediators in the periphery."
C)"Tension headaches are a result of stress and sustained muscle contraction of the head and neck."
D)"Tension headaches are caused by blood sugar fluctuations that result from excessive stress."

Question 10

The nurse is caring for a patient during a post-ictal period. The patient remembers smelling something like dead fish prior to the seizure. Which of the following responses by the nurse is best?

A)"Today is Friday; the hospital always cooks fish on Fridays."
B)"You were probably hallucinating; I will ask for an order for an antihallucinatory agent."
C)"The smell of dead fish might be your aura; you should call for help immediately if you smell it again."
D)"Most people see a flash of light before a seizure; if this occurs, you should get to safety immediately."

Question 11

The nurse is assessing a patient who just had a tonic-clonic seizure. Which finding most indicates a need for immediate nursing intervention?

A)The patient is difficult to arouse.
B)The patient has frothy sputum in the pharynx and gurgling respirations.
C)The patient has been incontinent of urine.
D)The patient becomes belligerent when the nurse does neurological assessments.

Question 12

The nurse is caring for a patient who has had a seizure and is crying, saying life is over, and that working and driving will no longer be possible. Which response by the nurse is most appropriate?

A)"Maybe the social worker can help you identify some alternative activities."
B)"You may be able to work again in time; you can use public transportation."
C)"With good seizure control, you should be able to work and drive again."
D)"You should be able to discontinue your medication within a month and return to work."

Question 13

The nurse concludes that a patient's meningitis is improving when the patient can perform which of the following activities?

A)Maintain a side-lying position in bed.
B)Sit up and drink water.
C)Touch the chin to the chest.
D)Dorsiflex both feet.

Question 14

The nurse is walking a patient to the bathroom when the patient begins a generalized tonic-clonic seizure. What should the nurse do first?

A)Perform a brief neurological assessment.
B)Maintain the patient's privacy.
C)Reduce external stimuli.
D)Maintain the patient's airway.

Question 15

A patient who was in an industrial accident has had a sudden increase in intracranial pressure and is being prepared for placement of an emergency subarachnoid bolt. What would be the most important function of the nurse at this time?

A)Ensure the patient is bathed before surgery.
B)Send the patient's belongings home with a family member.
C)Find out how the accident happened.
D)Have the patient's next of kin sign a consent form.

Question 16

The nurse is caring for a patient admitted to the emergency department with massive trauma to the right frontal lobe of the brain. Which data should the nurse collect related to the location of the injury?

A)Presence of intact pupillary reflex
B)Presence of intact smell
C)Ability to remember the name of the current president
D)Ability to use extraocular muscles (EOMs) of the eyes

Question 17

The nurse is caring for a patient admitted to the hospital with a fractured femur and possible head injury. Vital signs on admission were blood pressure 128/72 mm Hg, pulse 90 beats/min, and respirations 66 breaths/min. Four hours after admission, the nurse is checking vital signs as part of the hourly assessment. Which of the following vital signs most likely indicate the presence of increased intracranial pressure (ICP)?

A)Blood pressure 172/68 mm Hg, pulse 42 beats/min, respirations 10 breaths/min
B)Blood pressure 160/90 mm Hg, pulse 112 beats/min, respirations 16 breaths/min
C)Blood pressure 130/72 mm Hg, pulse 50 beats/min, respirations 24 breaths/min
D)Blood pressure 100/70 mm Hg, pulse 120 beats/min, respirations 30 breaths/min

Question 18

The nurse is caring for a patient with a cerebral injury with increased intracranial pressure (ICP). Which intervention can help prevent further increasing intracranial pressure?

A)Provide as much nursing care at one time as possible to allow the patient to rest.
B)Space nursing care at intervals so that necessary care is distributed evenly throughout a shift.
C)Provide stimulation such as radio and television for 12 hours each day.
D)Avoid touching the patient as much as possible.

Question 19

A student is under a great deal of stress, develops a severe tension headache, and goes to a school clinic. What strategy can the nurse teach the student for dealing with the onset of headaches in the future?

A)Use of distraction techniques
B)Use of vitamin C and zinc
C)Aerobic exercise
D)Relaxation exercises

Question 20

The nurse is caring for a patient being seen at a walk-in clinic for an acute migraine headache. The patient winces every time the light is turned on in the examining room. The patient is unable to identify what triggered the headache. What should the nurse teach the patient to do first in order to determine a plan of care for the headaches?

A)Keep a headache diary.
B)Avoid sugar and caffeine.
C)Avoid bright light and noise.
D)Avoid taking analgesics until the cause has been determined.

Question 21

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?

A)"The medication causes urinary retention and a dry mouth."
B)"This medication converts to dopamine in the brain so my symptoms should improve."
C)"I should take this medication when my hand tremors bother me."
D)"Sinemet reduces inflammation in the central nervous system."

Question 22

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?

A)Headache
B)Elevated blood glucose
C)Frequent urination
D)Confusion

Question 23

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?

A)Caregiver maintains patient's health.
B)Caregiver accepts constructive criticism.
C)Caregiver accepts responsibility for own actions.
D)Caregiver identifies resources available to assist with care.

Question 24

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?

A)Increased urinary output
B)Decreased Glasgow Coma Scale (GCS) score
C)Increased blood glucose
D)Return of the gag reflex

Question 25

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

A)Vital signs, lung sounds, and pedal pulses
B)Glasgow Coma Scale, pupil response, and vital signs
C)Range of motion, deep tendon reflexes, and capillary refill
D)Romberg test, Babinski reflex, and cranial nerve assessment

Question 26

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

A)Paraplegia
B)Quadriparesis
C)Hemiparesis
D)Quadriplegia

Question 27

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?

A)Above C4
B)C4-C8
C)T8-T11
D)L1-L4

Question 28

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?

A)Increased intracranial pressure (ICP)
B)Forgetfulness
C)Combativeness
D)Agitation

Question 29

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

A)Explain to the patient that as the disease progresses, there will be many things that will require assistance.
B)Tie the shoes for the patient.
C)Reteach the patient to tie shoes.
D)Have a family member purchase shoes with Velcro fasteners.

Question 30

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

A)Ineffective Role Performance
B)Risk for Injury
C)Bathing Self-Care Deficit
D)Noncompliance

Question 31

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?

A)The patient has had a minor head trauma and should recover spontaneously.
B)The patient may need to have surgery to relieve increased intracranial pressure.
C)The patient may lose consciousness before beginning to recover.
D)The patient has had some intracranial bleeding but should recover in time.

Question 32

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?

A)Space below the dura
B)Circle of Willis
C)Space between the dura and the skull
D)Spinal meninges

Question 33

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?

A)Check the patient's blood pressure.
B)Do a digital rectal examination for the presence of an impaction.
C)Advise the patient that sitting in the wheelchair will help relieve the headache.
D)Notify the RN or physician immediately of the patient's headache.

Question 34

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?

A)Slow shuffling gait, difficulty swallowing, and pill-rolling tremor
B)Intention tremor, flaccid muscles, and tachykinesia
C)Hemiparesis, tremor of the head, and blurred vision
D)Cough, fever, and impaired airway clearance

Question 35

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?

A)"The brain is such a unique organ, we never really know what will happen."
B)"Decadron regenerates neurons in the central nervous system, so the patient should continue to get even better over the next week or so."
C)"By dilating the arteries in the brain, blood flow is improved and symptoms improve."
D)"The Decadron works to reduce swelling in the brain caused by the tumor; we often see remarkable improvement."

Question 36

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?

A)Loss of motor control below the level of the injury with sensations of touch and position intact
B)Flaccid paralysis and lack of sensation below the level of the injury
C)Loss of voluntary motor control, but presence of reflex activity below the level of the injury
D)Falling blood pressure and rising pulse accompanied by reduced level of consciousness

Question 37

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?

A)It is usually arterial and may lead to death without rapid intervention.
B)It is usually venous and absorbs in time.
C)It is within the brain tissue, so residual effects are likely.
D)It usually causes quadriplegia, and rehabilitation will be necessary.

Question 38

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?

A)Immobilize the boy, and call for help.
B)Turn him onto his stomach to allow water to drain from his lungs.
C)Push on his stomach to rid his lungs of water.
D)Use a four-man carry to take the boy to safety.

Question 39

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?

A)None; this is an expected finding after a head injury.
B)Lay the bed flat and check pupil response.
C)Raise the head of the bed and notify the RN.
D)Give an extra dose of diuretic.

Question 40

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?

A)Check the extremities for range of motion.
B)Avoid moving the patient.
C)Turn the patient to the side to avoid aspiration.
D)Keep the head of the bed elevated 30 degrees.

Question 41

The nurse is working on a dementia wing at an extended care facility. Which intervention would be least helpful when coordinating care for patients who are experiencing confusion?

A)Providing finger foods
B)Providing structured rest periods to prevent fatigue
C)Monitoring cognitive functioning
D)Using soft restraints when the patient is left alone

Question 42

Which of the following interventions are appropriate for a patient during the acute phase of a migraine headache? (Select all that apply.?

A)Acetaminophen (Tylenol)
B)A dark, quiet room
C)Sumatriptan (Imitrex)
D)White noise
E)Pseudoephedrine (Sudafed)
F)Rest

Question 43

Repetitive seizure activity without a return to consciousness that lasts for ________________minutes is documented as status epilepticus.

Question 44

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

A)Monitor BP every 5 minutes.
B)Place the patient in supine position.
C)Check to see if the indwelling catheter is patent.
D)Perform a rectal examination to determine if impaction is present.
E)Place elastic stockings on the patient's legs.Completion
Complete each statement.

Question 45

Intracranial pressure (ICP) greater than ________________mm Hg is considered above normal and necessitates further investigation.

Question 46

Which of the following are interventions used to prevent increased intracranial pressure in a patient who has had an acute brain injury? (Select all that apply.?

A)Keep head of bed elevated 30 degrees.
B)Administer stool softeners.
C)Encourage deep breathing and coughing.
D)Avoid hip flexion.
E)Administer opioid analgesics for headache.

Question 47

Which of the following are symptoms of benign familial (essential) tremor but not of Parkinson's disease? (Select all that apply.?

A)Resting tremor
B)Head/voice tremor
C)Pill-rolling tremor
D)Intention tremor
E)Relieved by beta blocker drugs

Question 48

The nurse is caring for a patient recovering from a craniotomy. The nurse assists the patient to turn and notes a pink spot with a yellow ring around it on the pillow. What should the nurse do?

A)Change the patient's cranial dressing.
B)Notify the RN immediately.
C)Change the patient's pillowcase.
D)Do a basic neurological assessment.

Question 49

Which of the following should be included in the nursing care of a patient having an epileptic seizure? (Select all that apply.?

A)Protect the patient from injury by removing nearby objects.
B)Place the patient in a supine position.
C)Monitor vital signs when possible.
D)Observe and document progression of symptoms.
E)Restrain the patient to prevent injury.
F)Suction if necessary.

Question 50

What should be included in the nurse's teaching for a patient prescribed phenytoin (Dilantin) to control seizures?

A)"You may experience shortness of breath as a side effect of the drug."
B)"You may notice some vision changes while taking this drug."
C)"Be sure to brush and floss your teeth daily."
D)"Be sure to arrange for regular checkups for potassium levels."

Question 51

The nurse is caring for an individual who has a tension headache. Which of the following would be included in the patient's plan of care? (Select all that apply.?

A)Dark glasses
B)Massage
C)Moist heat
D)Aerobic exercise
E)Cold compresses
F)Ergotomine

Question 52

A patient has been prescribed the dopamine agonist pramipexole (Mirapex) for Parkinson's disease. Which of the following are important for the nurse to include in teaching about the drug? (Select all that apply.?

A)"Do not drive until the effects of this drug on you are fully known."
B)"Take it at noon each day."
C)"Because this drug may interact with some painkillers, be sure to tell health-care providers that you are taking Mirapex."
D)"Increase fluids and fiber in your diet."
E)"You may experience sudden bouts of excessive sleepiness."
F)"Taking the medication with food may reduce nausea."

Question 53

Which of the following are signs and symptoms of increased intracranial pressure (ICP)? (Select all that apply.?

A)Headache
B)Decreasing systolic pressure
C)Decreasing level of consciousness (LOC)
D)Dilated pupil on affected side
E)Rising temperature

Question 54

A nursing home resident with Alzheimer's disease appears extremely distressed after breakfast. On which understanding does the nurse base intervention?

A)This is part of the sundowning syndrome associated with Alzheimer's disease.
B)The patient could quickly become more anxious and dysfunctional.
C)The patient needs an increase in antipsychotic medications.
D)The patient would benefit from external stimuli and diversionary activities.