Question 1

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.)

Accepted Answer

Meningeal meningitis is spread via saliva and droplets,and Droplet Precautions are necessary.Caregivers should wear a surgical mask when within 6 feet of the client and should continue to use Standard Precautions,including gloves.A particulate respirator,an isolation gown,and shoe covers are not necessary for Droplet Precautions.

Question 2

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?

Accepted Answer

Clients who have early-stage Alzheimer's disease should be reoriented frequently to person,place,and time.The UAP should reorient the client and not encourage the client's delusions.The room should have a clock and white board with the current date written on it.Validation therapy is used with late-stage Alzheimer's disease.

Question 3

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.)

Accepted Answer

Inflammation associated with meningitis can stimulate the hypothalamus and result in excessive production of antidiuretic hormone.The nurse should monitor sodium levels for early identification of syndrome of inappropriate antidiuretic hormone.A systemic inflammatory response (SIR)can also occur with meningitis.A SIR can result in a coagulopathy that leads to disseminated intravascular coagulation.The nurse should monitor clotting factors to identify this complication.The other laboratory values are not specific to complications of meningitis.

Question 4

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

Accepted Answer

Automatisms are characteristic of absence seizures.These behaviors consist of lip smacking,picking at clothing,and patting.Rigidity of muscles is associated with the tonic phase of a seizure,and jerking of the extremities is associated with the clonic phase of a seizure.Loss of muscle tone occurs with atonic seizures.

Question 5

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.)

Accepted Answer

Complications of surgery to implant a vagal nerve stimulation device include hoarseness (most common),dyspnea,neck pain,and dysphagia.The device is tunneled under the skin with an electrode connected to the vagus nerve to control simple or complex partial seizures.Bleeding is not a common complication of this procedure,and infection would not occur during the recovery period.

Question 6

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.)

Accepted Answer

Clients at risk for secondary seizures include those with a brain lesion from a tumor or trauma,and those who are experiencing a metabolic disorder,acute alcohol withdrawal,electrolyte disturbances,and high fever.Clients with a history of stroke,heart disease,and substance abuse are also at risk.Clients with multiple sclerosis or chronic obstructive pulmonary disease are not at risk for secondary seizures.

Question 7

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.)

Accepted Answer

In viral meningitis,CSF fluid is clear,protein levels are slightly increased,and glucose levels are normal.Viral meningitis does not cause cloudiness or increased turbidity of CSF.In bacterial meningitis,the presence of bacteria and white blood cells causes the fluid to be cloudy.

Question 8

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

Accepted Answer

Cluster headache is usually accompanied by ipsilateral tearing,miosis,rhinorrhea or nasal congestion,ptosis,eyelid edema,and facial sweating.Abrupt loss of consciousness,neck and shoulder tenderness,and exophthalmos are not associated with cluster headaches.

Question 9

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.)

Accepted Answer

Oxygen and suctioning equipment with an airway must be readily available.The bed rails should be up at all times while the client is in the bed to prevent injury from a fall if the client has a seizure.If the client does not have an IV access,insert a saline lock,especially for those clients who are at significant risk for generalized tonic-clonic seizures.The saline lock provides ready access if IV drug therapy must be given to stop the seizure.Padded tongue blades may pose a danger to the client during a seizure and should not be used.Dietary restrictions and strict bedrest are not interventions associated with epilepsy.The client should be encouraged to eat a well-balanced diet and ambulate while in the hospital.

Question 10

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.)

Accepted Answer

Increased ICP is a complication of encephalitis.The nurse should monitor for signs of increased ICP,including dilated pupils,widened pulse pressure,bradycardia,irregular respirations,and less responsive pupils.Photophobia and headache are not related to increased ICP.

Question 11

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?

Accepted Answer

Clients with Parkinson disease do not move as quickly and can have functional problems.The client should be encouraged to be as independent as possible and provided time to perform activities without rushing.Although oral care is important for all clients,instructing the UAP to provide frequent and meticulous oral is not a priority for this client.This statement would be a priority if the client was immune-compromised or NPO.The nurse should assess the client's ability to eat and swallow; this should not be delegated.Appointments and activities should not be scheduled early in the morning because this may cause the client to be rushed and discourage the client from wanting to participate in activities of daily living.

Question 12

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.)

Accepted Answer

Triggers for headaches include caffeine,smoking,and ingestion of pickled foods,so these factors should be avoided.Clients are taught to eat a balanced diet and to get adequate exercise and rest.Alcohol does not trigger chronic headaches but can enhance headaches during the headache period.

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

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 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?