Deck 42: Care of Patients with Problems of the Central Nervous System: The Brain

Question 1

A nurse assesses a client with Alzheimer's disease who is recently admitted to the hospital.Which psychosocial assessment should the nurse complete?

A) Assess religious and spiritual needs while in the hospital.
B) Identify the client's ability to perform self-care activities.
C) Evaluate the client's reaction to a change of environment.
D) Ask the client about relationships with family members.

Answer 1

Evaluate the client's reaction to a change of environment.

Question 2

A nurse obtains a health history on a client prior to administering prescribed sumatriptan succinate (Imitrex)for migraine headaches.Which condition should alert the nurse to hold the medication and contact the health care provider?

A) Bronchial asthma
B) Prinzmetal's angina
C) Diabetes mellitus
D) Chronic kidney disease

Answer 2

Prinzmetal's angina

Question 3

A nurse assesses a client with Huntington disease.Which motor changes should the nurse monitor for in this client?

A) Shuffling gait
B) Jerky hand movements
C) Continuous chewing motions
D) Tremors of the hands

Answer 3

Jerky hand movements

Question 4

A nurse assesses a client after administering prescribed levetiracetam (Keppra).Which laboratory tests should the nurse monitor for potential adverse effects of this medication?

A) Serum electrolyte levels
B) Kidney function tests
C) Complete blood cell count
D) Antinuclear antibodies

Question 5

A nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness.Which action should the nurse take?

A) Start fluids via a large-bore catheter.
B) Turn the client's head to the side.
C) Administer IV push diazepam.
D) Prepare to intubate the client.

Question 6

A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis.Which question should the nurse ask?

A) "Do you live in a crowded residence?"
B) "When was your last tetanus vaccination?"
C) "Have you had any viral infections recently?"
D) "Have you traveled out of the country in the last month?"

Question 7

A nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs,followed by an immediate loss of consciousness and jerking of all extremities.How should the nurse document this activity?

A) Atonic seizure
B) Tonic-clonic seizure
C) Myoclonic seizure
D) Absence seizure

Question 8

After teaching the wife of a client who has Parkinson disease,the nurse assesses the wife's understanding.Which statement by the client's wife indicates she correctly understands changes associated with this disease?

A) "His masklike face makes it difficult to communicate, so I will use a white board."
B) "He should not socialize outside of the house due to uncontrollable drooling."
C) "This disease is associated with anxiety causing increased perspiration."
D) "He may have trouble chewing, so I will offer bite-sized portions."

Question 9

A nurse cares for a client with advanced Alzheimer's disease.The client's caregiver states,"She is always wandering off.What can I do to manage this restless behavior?" How should the nurse respond?

A) "This is a sign of fatigue.The client would benefit from a daily nap."
B) "Engage the client in scheduled activities throughout the day."
C) "It sounds like this is difficult for you.I will consult the social worker."
D) "The provider can prescribe a mild sedative for restlessness."

Question 10

A nurse is teaching a client who experiences migraine headaches and is prescribed a beta blocker.Which statement should the nurse include in this client's teaching?

A) "Take this drug only when you have prodromal symptoms indicating the onset of a migraine headache."
B) "Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches."
C) "This drug will relieve the pain during the aura phase soon after a headache has started."
D) "This medication will have no effect on your heart rate or blood pressure because you are taking it for migraines."

Question 11

After teaching a client newly diagnosed with epilepsy,the nurse assesses the client's understanding.Which statement by the client indicates a need for additional teaching?

A) "I will wear my medical alert bracelet at all times."
B) "While taking my epilepsy medications, I will not drink any alcoholic beverages."
C) "I will tell my doctor about my prescription and over-the-counter medications."
D) "If I am nauseated, I will not take my epilepsy medication."

Question 12

A nurse is teaching a client with chronic migraine headaches.Which statement related to complementary therapy should the nurse include in this client's teaching?

A) "Place a warm compress on your forehead at the onset of the headache."
B) "Wear dark sunglasses when you are in brightly lit spaces."
C) "Lie down in a darkened room when you experience a headache."
D) "Set your alarm to ensure you do not sleep longer than 6 hours at one time."

Question 13

A nurse assesses a client who has a history of migraines.Which clinical manifestation should the nurse identify as an early sign of a migraine with aura?

A) Vertigo
B) Lethargy
C) Visual disturbances
D) Numbness of the tongue

Question 14

A nurse prepares to discharge a client with Alzheimer's disease.Which statement should the nurse include in the discharge teaching for this client's caregiver?

A) "Allow the client to rest most of the day."
B) "Place a padded throw rug at the bedside."
C) "Install deadbolt locks on all outside doors."
D) "Provide a high-calorie and high-protein diet."

Question 15

A nurse is teaching the daughter of a client who has Alzheimer's disease.The daughter asks,"Will the medication my mother is taking improve her dementia?" How should the nurse respond?

A) "It will allow your mother to live independently for several more years."
B) "It is used to halt the advancement of Alzheimer's disease but will not cure it."
C) "It will not improve her dementia but can help control emotional responses."
D) "It is used to improve short-term memory but will not improve problem solving."

Question 16

A nurse witnesses a client with late-stage Alzheimer's disease eat breakfast.Afterward the client states,"I am hungry and want breakfast." How should the nurse respond?

A) "I see you are still hungry.I will get you some toast."
B) "You ate your breakfast 30 minutes ago."
C) "It appears you are confused this morning."
D) "Your family will be here soon.Let's get you dressed."

Question 17

A nurse plans care for a client with Parkinson disease.Which intervention should the nurse include in this client's plan of care?

A) Ambulate the client in the hallway twice a day.
B) Ensure a fluid intake of at least 3 liters per day.
C) Teach the client pursed-lip breathing techniques.
D) Keep the head of the bed at 30 degrees or greater.

Question 18

A nurse cares for a client who is experiencing status epilepticus.Which prescribed medication should the nurse prepare to administer?

A) Atenolol (Tenormin)
B) Lorazepam (Ativan)
C) Phenytoin (Dilantin)
D) Lisinopril (Prinivil)

Question 19

A nurse cares for a client who has been diagnosed with the Huntington gene but has no symptoms.The client asks for options related to family planning.What is the nurse's best response?

A) "Most clients with the Huntington gene do not pass on Huntington disease to their children."
B) "I understand that they can diagnose this disease in embryos.Therefore, you could select a healthy embryo from your fertilized eggs for implantation to avoid passing on Huntington disease."
C) "The need for family planning is limited because one of the hallmarks of Huntington disease is infertility."
D) "Tell me more specifically what information you need about family planning so that I can direct you to the right information or health care provider."

Question 20

After teaching a client who is diagnosed with new-onset status epilepticus and prescribed phenytoin (Dilantin),the nurse assesses the client's understanding.Which statement by the client indicates a correct understanding of the teaching?

A) "To prevent complications, I will drink at least 2 liters of water daily."
B) "This medication will stop me from getting an aura before a seizure."
C) "I will not drive a motor vehicle while taking this medication."
D) "Even when my seizures stop, I will continue to take this drug."

Question 21

A nurse prepares to provide perineal care to a client with meningococcal meningitis.Which personal protective equipment should the nurse wear? (Select all that apply.)

A) Particulate respirator
B) Isolation gown
C) Shoe covers
D) Surgical mask
E) Gloves

Question 22

A nurse delegates care for a client with early-stage Alzheimer's disease to an unlicensed assistive personnel (UAP).Which statement should the nurse include when delegating this client's care?

A) "If she is confused, play along and pretend that everything is okay."
B) "Remove the clock from her room so that she doesn't get confused."
C) "Reorient the client to the day, time, and environment with each contact."
D) "Use validation therapy to recognize and acknowledge the client's concerns."

Question 23

A nurse is caring for a client with meningitis.Which laboratory values should the nurse monitor to identify potential complications of this disorder? (Select all that apply.)

A) Sodium level
B) Liver enzymes
C) Clotting factors
D) Cardiac enzymes
E) Creatinine level

Question 24

A nurse assesses a client who is experiencing an absence seizure.For which clinical manifestations should the nurse assess? (Select all that apply.)

A) Intermittent rigidity
B) Lip smacking
C) Sudden loss of muscle tone
D) Brief jerking of the extremities
E) Picking at clothing
F) Patting of the hand on the leg

Question 25

A nurse assesses a client who is recovering from the implantation of a vagal nerve stimulation device.For which clinical manifestations should the nurse assess as common complications of this procedure? (Select all that apply.)

A) Bleeding
B) Infection
C) Hoarseness
D) Dysphagia
E) Seizures

Question 26

A nurse assesses clients on a medical-surgical unit.Which clients should the nurse identify as at risk for secondary seizures? (Select all that apply.)

A) A 26-year-old woman with a left temporal brain tumor
B) A 38-year-old male client in an alcohol withdrawal program
C) A 42-year-old football player with a traumatic brain injury
D) A 66-year-old female client with multiple sclerosis
E) A 72-year-old man with chronic obstructive pulmonary disease

Question 27

A nurse evaluates the results of diagnostic tests on a client's cerebrospinal fluid (CSF).Which fluid results alerts the nurse to possible viral meningitis? (Select all that apply.)

A) Clear
B) Cloudy
C) Increased protein level
D) Normal glucose level
E) Bacterial organisms present

Question 28

A nurse assesses a client who is experiencing a cluster headache.Which clinical manifestations should the nurse expect to find? (Select all that apply.)

A) Ipsilateral tearing of the eye
B) Miosis
C) Abrupt loss of consciousness
D) Neck and shoulder tenderness
E) Nasal congestion

Question 29

A nurse plans care for a client with epilepsy who is admitted to the hospital.Which interventions should the nurse include in this client's plan of care? (Select all that apply.)

A) Have suction equipment at the bedside.
B) Place a padded tongue blade at the bedside.
C) Permit only clear oral fluids.
D) Keep bed rails up at all times.
E) Maintain the client on strict bedrest.
F) Ensure that the client has IV access.

Question 30

A nurse assesses a client who has encephalitis.Which manifestations should the nurse recognize as signs of increased intracranial pressure (ICP),a complication of encephalitis? (Select all that apply.)

A) Photophobia
B) Dilated pupils
C) Headache
D) Widened pulse pressure
E) Bradycardia

Question 31

A nurse delegates care for a client with Parkinson disease to an unlicensed assistive personnel (UAP).Which statement should the nurse include when delegating this client's care?

A) "Allow the client to be as independent as possible with activities."
B) "Assist the client with frequent and meticulous oral care."
C) "Assess the client's ability to eat and swallow before each meal."
D) "Schedule appointments early in the morning to ensure rest in the afternoon."

Question 32

A nurse is teaching a client who has chronic headaches.Which statements about headache triggers should the nurse include in this client's plan of care? (Select all that apply.)

A) "Increase your intake of caffeinated beverages."
B) "Incorporate physical exercise into your daily routine."
C) "Avoid all alcoholic beverages."
D) "Participate in a smoking cessation program."
E) "Increase your intake of fruits and vegetables."