1.

If Peter Maingatkanaba experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse would anticipate that the client has problems with: a. b. c. d. body temperature control. balance and equilibrium. visual acuity. thinking and reasoning

mechanical ventilation may be required if breathing deteriorates; and elevating the head of the bed may be used to reduce ICP. 3. Shortly after admission to an acute care facility, Francis Didumadale with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium) 10 mg I.V. stat. How soon can the nurse administer a second dose of diazepam, if needed and prescribed? a. b. c. d. In 30 to 45 seconds In 10 to 15 minutes In 30 to 45 minutes In 1 to 2 hours

Answer A. The bodys thermostat is located in the hypothalamus; therefore, injury to that area can cause problems of body temperature, a young man e control. Balance and equilibrium problems are related to cerebellar damage. Visual acuity problems would occur following occipital or optic nerve injury. Thinking and reasoning problems 2. After striking his head on a tree while falling from a ladder Jeuel Jhon Agila-Lilipadna, age 18 is admitted to the emergency department. Hes unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client? a. b. c. d. Give him a barbiturate. Place him on mechanical ventilation. Perform a lumbar puncture. Elevate the head of his bed.

Answer B. When used to treat status epilepticus, diazepam may be given every 10 to 15 minutes, as needed, to a maximum dose of 30 mg. The nurse can repeat the regimen in 2 to 4 hours, if necessary, but the total dose shouldnt exceed 100 mg in 24 hours. The nurse must not administer I.V. diazepam faster than 5 mg/minute. Therefore, the dose cant be repeated in 30 to 45 seconds because the first dose wouldnt have been administered completely by that time. Waiting longer than 15 minutes to repeat the dose would increase the clients risk of complications associated with status epilepticus. 4. A male client in the emergency department has a suspected neurologic disorder. To assess gait, nurse Camela Chupchup asks the client to take a few steps; with each step, the clients feet make a half circle. To document the clients gait, the nurse should use which term? a. b. Ataxic Dystrophic

Answer C. The clients history and assessment suggest that he may have increased intracranial pressure (ICP). If this is the case, lumbar puncture shouldnt be done because it can quickly decompress the central nervous system and, thereby, cause additional damage. After a head injury, barbiturates may be given to prevent seizures;

c. d.

Helicopod Steppage

a. The client may be less sensitive to the effects of a neuromuscular blocking agent. b. Succinylcholine shouldnt be used; pancuronium may be used in a lower dosage.

Answer C. A helicopod gait is an abnormal gait in which the clients feet make a half circle with each step. An ataxic gait is staggering and unsteady. In a dystrophic gait, the client waddles with the legs far apart. In a steppage gait, the feet and toes raise high off the floor and the heel comes down heavily with each step. 5. A physician diagnoses Peter North Balba with myasthenia gravis, prescribing pyridostigmine (Mestinon), 60 mg P.O. every 3 hours. Before administering this anticholinesterase agent, the nurse reviews the clients history. Which preexisting condition would contraindicate the use of pyridostigmine? a. b. c. d. Ulcerative colitis Blood dyscrasia Intestinal obstruction Spinal cord injury

c. Pancuronium shouldnt be used; succinylcholine may be used in a lower dosage. d. Pancuronium and succinylcholine both require cautious administration. Answer D. The nurse must cautiously administer pancuronium, succinylcholine, and any other neuromuscular blocking agent to a client with myasthenia gravis. Such a client isnt less sensitive to the effects of a neuromuscular blocking agent. Either succinylcholine or pancuronium can be administered in the usual adult dosage to a client with myasthenia gravis. 7. Marianne Ozawa, a call center agent, comes to the emergency department complaining of sudden onset of sharp, severe pain in the lumbar region, which radiates around the side and toward the bladder. The client also reports nausea and vomiting and appears pale, diaphoretic, and anxious. The physician tentatively diagnoses renal calculi and orders flat-plate abdominal X-rays. Renal calculi can form anywhere in the urinary tract. What is their most common formation site? a. b. c. d. Kidney Ureter Bladder Urethra

Answer C. Anticholinesterase agents such as pyridostigmine are contraindicated in a client with a mechanical obstruction of the intestines or urinary tract, peritonitis, or hypersensitivity to anticholinesterase agents. Ulcerative colitis, blood dyscrasia, and spinal cord injury dont contraindicate use of the drug. 6. While reviewing Karen Tubillos chart, nurse Dumadamuvs Alyssa notices that the female client has myasthenia gravis. Which of the following statements about neuromuscular blocking agents is true for a client with this condition?

Answer A. The most common site of renal calculi formation is the kidney. Calculi may travel down the urinary tract with or without causing damage and may lodge anywhere along the tract or may stay within the kidney. The ureter, bladder, and urethra are less common sites of renal calculi formation. 8. Ralph Machopapa Llanes with acute renal failure is undergoing dialysis for the first time. Jessica Seksibadi, the nurse in charge monitors the client closely for dialysis equilibrium syndrome, a complication that is most common during the first few dialysis sessions. Typically, dialysis equilibrium syndrome causes: a. b. c. d. confusion, headache, and seizures. acute bone pain and confusion. weakness, tingling, and cardiac arrhythmias. hypotension, tachycardia, and tachypnea.

a. b. c. d.

Caucasian race Female sex Obesity Bronchial asthma

Answer C. Obesity is a risk factor for CVA. Other risk factors include a history of ischemic episodes, cardiovascular disease, diabetes mellitus, atherosclerosis of the cranial vessels, hypertension, polycythemia, smoking, hypercholesterolemia, oral contraceptive use, emotional stress, family history of CVA, and advancing age. The clients race, sex, and bronchial asthma arent risk factors for CVA. 10. Nurse Jean Trentaminuto - Sabanyo is teaching a female client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to: a. take a hot bath. rest in an air-conditioned room increase the dose of muscle relaxants. avoid naps during the day

Answer A. Dialysis equilibrium syndrome causes confusion, a decreasing level of consciousness, headache, and seizures. These findings, which may last several days, probably result from a relative excess of interstitial or intracellular solutes caused by rapid solute removal from the blood. The resultant organ swelling interferes with normal physiologic functions. To prevent this syndrome, many dialysis centers keep first-time sessions short and use a reduced blood flow rate. Acute bone pain and confusion are associated with aluminum intoxication, another potential complication of dialysis. Weakness, tingling, and cardiac arrhythmias suggest hyperkalemia, which is associated with renal failure. Hypotension, tachycardia, and tachypnea signal hemorrhage, another dialysis complication. 9. Nancy Snowie is admitted to an acute care facility with a diagnosis of cerebrovascular accident (CVA). Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for CVA?

b. c. d.

Answer B. Fatigue is a common symptom in clients with multiple sclerosis. Lowering the body temperature by resting in an airconditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness and fatigue. Planning for frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with multiple sclerosis include treating depression, using occupational therapy to learn energy conservation techniques, and reducing spasticity.

11. Gummy Kho is having a tonic-clonic seizures. What should nurse Hayy Kim do first? a. b. c. d. Elevate the head of the bed. Restrain the clients arms and legs. Place a tongue blade in the clients mouth. Take measures to prevent injury.

imaging may be done. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the clients history of: a. b. c. d. Hypertension Heart failure Prosthetic valve replacement Chronic obstructive pulmonary disorder

Answer D. Protecting the client from injury is the immediate priority during a seizure. Elevating the head of the bed would have no effect on the clients condition or safety. Restraining the clients arms and legs could cause injury. Placing a tongue blade or other object in the clients mouth could damage the teeth. 12. Client Kimmydora with Guillain-Barr syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks nurse Mutya Godonghae about the paralysis, how should the nurse respond? a. You may have difficulty believing this, but the paralysis caused by this disease is temporary. b. Youll have to accept the fact that youre permanently paralyzed. However, you wont have any sensory loss. c. d. It must be hard to accept the permanency of your paralysis. Youll first regain use of your legs and then your arms.

Answer C. The client having a magnetic resonance imaging scan has all metallic objects removed because of the magnetic field generated by the device. A careful history is obtained to determine whether any metal objects are inside the client, such as orthopedic hardware, pacemakers, artificial heart valves, aneurysm clips, or intrauterine devices. These may heat up, become dislodged, or malfunction during this procedure. The client may be ineligible if significant risk exists. 14. Gian Lakasapil with a spinal cord injury is prone to experiencing automatic dysreflexia. Nurse Lawrence Walakapala would avoid which of the following measures to minimize the risk of recurrence? a. b. c. d. Strict adherence to a bowel retraining program Keeping the linen wrinkle-free under the client Preventing unnecessary pressure on the lower limbs Limiting bladder catheterization to once every 12 hours

Answer A. The nurse should inform the client that the paralysis that accompanies Guillain-Barr syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs. 13. M SpeysialBoi was admitted to the hospital with a neurological problem asks nurse Lyka Pon-Da whether magnetic resonance

Answer D. The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours, and foley catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes

include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas. 15. Jeuel Higopking is caring for the male client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated? a. b. c. Loosening restrictive clothing Restraining the clients limbs Removing the pillow and raising padded side rails

d.

Taking medications on time to maintain therapeutic blood levels

Answer D. Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is important. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional stress. 17. A male client SupeohJunioh with Bells palsy asks nurse Ayu LeeDonghae what has caused this problem. The nurses response is based on an understanding that the cause is: a. Unknown, but possibly includes ischemia, viral infection, or an autoimmune problem b. Unknown, but possibly includes long-term tissue malnutrition and cellular hypoxia c. d. Primary genetic in origin, triggered by exposure to meningitis Primarily genetic in origin, triggered by exposure to neurotoxins

d. Positioning the client to side, if possible, with the head flexed forward Answer B. Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising side rails in the bed, and placing the client on one side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible, protects the head from injury, and moves furniture that may injure the client. Other aspects of care are as described for the client who is in bed. 16. Nurse Kim Kyuhyun is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by: a. b. c. Eating large, well-balanced meals Doing muscle-strengthening exercises

Answer A. Bells palsy is a one-sided facial paralysis from compression of the facial nerve. The exact cause is unknown, but may include vascular ischemia, infection, exposure to viruses such as herpes zoster or herpes simplex, autoimmune disease, or a combination of these factors. 18. Nurse Jean Dermaking has given the male client with Bells palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs additional information if the client states that he or she will: a. Exposure to cold and drafts

Doing all chores early in the day while less fatigued

b. c. d.

Massage the face with a gentle upward motion Perform facial exercises Wrinkle the forehead, blow out the cheeks, and whistle

a. Giving client full control over care decisions and restricting visitors b. Providing positive feedback and encouraging active range of motion c. Providing information, giving positive feedback, and encouraging relaxation d. Providing intravaneously administered sedatives, reducing distractions and limiting visitors Answer C. The client with Guillain-Barr syndrome experiences fear and anxiety from the ascending paralysis and sudden onset of the disorder. The nurse can alleviate these fears by providing accurate information about the clients condition, giving expert care and positive feedback to the client, and encouraging relaxation and distraction. The family can become involved with selected care activities and provide diversion for the client as well.

Answer A. Prevention of muscle atrophy with Bells palsy is accomplished with facial massage, facial exercises, and electrical stimulation of the nerves. Exposure to cold or drafts is avoided. Local application of heat to the face may improve blood flow and provide comfort. 19. Female client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. Nurse Lyka Jisiks inquires during the nursing admission interview if the client has history of: a. b. c. Seizures or trauma to the brain Meningitis during the last 5 years Back injury or trauma to the spinal cord

d. Respiratory or gastrointestinal infection during the previous month. Answer D. Guillain-Barr syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits. Occasionally, the syndrome can be triggered by vaccination or surgery. 20. A female client Wagkang Atribida with Guillian-Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which of the following strategies would nurse Lawrence incorporate in the plan of care to help the client cope with this illness?