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The Client with Neurologic Health ProblemsThe Client with a Head Injury■ The Client with Seizures■ The Client with a Stroke■ The Client with Parkinson’s Disease■ The Client with Multiple Sclerosis■ The Unconscious Client■ The Client in Pain■ Managing Care Quality and Safety■ Answers, Rationales, and Test Taking StrategiesThe Client with a Head Injury1. Following a craniotomy, a client has beenadmitted to the neurologic intensive care unit. Thenurse has established a goal to maintain intracranialpressure (ICP) within the normal range. Whatshould the nurse do? Select all that apply.■ 1. Encourage the client to cough and take deepbreaths.■ 2. Elevate the head of the bed 15 to 30 degrees.■ 3. Contact the health care provider if ICP isgreater than 20 mm Hg.■ 4. Monitor neurologic status using the GlasgowComa Scale.■ 5. Stimulate the client with active range-of-motionexercises.2. The nurse is monitoring a client withincreased intracranial pressure (ICP). What indicatorsare the most critical for the nurse to monitor?Select all that apply.■ 1. Systolic blood pressure.■ 2. Urine output.■ 3. Breath sounds.■ 4. Cerebral perfusion pressure.■ 5. Level of pain.3. A nurse is assessing a client with increasingintracranial pressure. What is a client’s mean arterialpressure (MAP) in mm Hg when blood pressure (BP)is 120/60 mm Hg?_____________________ mm Hg.4. A client with a contusion has been admittedfor observation following a motor vehicle accidentwhen he was driving his wife to the hospital todeliver their child. The next morning, instead ofasking about his wife and baby, he asked to see thefootball game on television that he thinks is startingin 5 minutes. He is agitated that the nurse will notturn on the television. What should the nurse donext? Select all that apply.■ 1. Find a television so the client can view thefootball game.■ 2. Determine if the client’s pupils are equal andreact to light.■ 3. Ask the client if he has a headache.■ 4. Arrange for the client to be with his wife andbaby.■ 5. Administer a sedative.5. An unconscious client with multiple injuriesarrives in the emergency department. Which nursingintervention receives the highest priority?■ 1. Establishing an airway.■ 2. Replacing blood loss.■ 3. Stopping bleeding from open wounds.■ 4. Checking for a neck fracture.6. A client is at risk for increased intracranialpressure (ICP). Which of the following would be thepriority for the nurse to monitor?■ 1. Unequal pupil size.■ 2. Decreasing systolic blood pressure.■ 3. Tachycardia.■ 4. Decreasing body temperature.7. What should the nurse do fi rst when a clientwith a head injury begins to have clear drainagefrom his nose?■ 1. Compress the nares.■ 2. Tilt the head back.■ 3. Give the client tissues to collect the fl uid.■ 4. Administer an antihistamine for postnasaldrip.8. Which of the following respiratory patternsindicates increasing intracranial pressure in thebrain stem?■ 1. Slow, irregular respirations.■ 2. Rapid, shallow respirations.■ 3. Asymmetric chest excursion.■ 4. Nasal fl aring.9. Which of the following nursing interventionsis appropriate for a client with an increased intracranialpressure (ICP) of 20 mm Hg?■ 1. Give the client a warming blanket.■ 2. Administer low-dose barbiturates.■ 3. Encourage the client to hyperventilate.■ 4. Restrict fl uids.10. The nurse is assessing a client with increasingintracranial pressure (ICP). The nurse shouldnotify the health care provider about which of thefollowing changes in the client’s condition?■ 1. Widening pulse pressure.■ 2. Decrease in the pulse rate.■ 3. Dilated, fi xed pupils.■ 4. Decrease in level of consciousness (LOC).11. The client has a sustained increased intracranialpressure (ICP) of 20 mm Hg. Which clientposition would be most appropriate?■ 1. The head of the bed elevated 30 to 45 degrees.■ 2. Trendelenburg’s position.■ 3. Left Sims position.■ 4. The head elevated on two pillows.12. The nurse administers mannitol (Osmitrol)to the client with increased intracranial pressure.Which parameter requires close monitoring?■ 1. Muscle relaxation.■ 2. Intake and output.■ 3. Widening of the pulse pressure.■ 4. Pupil dilation.13. A client is being admitted with a spinal cordtransection at C7. Which of the following assessmentstake priority upon the client’s arrival? Selectall that apply.■ 1. Refl exes.■ 2. Bladder function.■ 3. Blood pressure.■ 4. Temperature.■ 5. Respirations.14. The nurse is assessing a client for movementafter halo traction placement for a C8 fracture.The nurse should document which of thefollowing?■ 1. The client’s shoulders shrug against downwardpressure of the examiner’s hands.■ 2. The client’s arm pulls up from a resting positionagainst resistance.■ 3. The client’s arm straightens out from a fl exedposition against resistance.■ 4. The client’s hand-grasp strength is equal.15. Four days after surgery for internal fi xation ofa C3 to C4 fracture, a nurse is moving a client fromthe bed to the wheelchair. The nurse is checkingthe wheelchair for correct features for this client.Which of the following features of the wheelchairare appropriate for the needs of this client? Selectall that apply.■ 1. Back at the level of the client’s scapula.■ 2. Back and head that are high.■ 3. Seat that is lower than normal.■ 4. Seat with fi rm cushions.■ 5. Chair controlled by the client’s breath.16. A male client with a head injury regains consciousnessafter several days. Which of the followingnursing statements is most appropriate as theclient awakens?■ 1. “I’ll get your family.”■ 2. “Can you tell me your name and where youlive?”■ 3. “I’ll bet you’re a little confused right now.”■ 4. “You are in the hospital. You were in an accidentand unconscious.”17. A client who is regaining consciousnessafter a craniotomy becomes restless and attempts topull out the I.V. line. Which nursing interventionprotects the client without increasing her increasedintracranial pressure (ICP)?■ 1. Place her in a jacket restraint.■ 2. Wrap her hands in soft “mitten” restraints.■ 3. Tuck her arms and hands under thedrawsheet.■ 4. Apply a wrist restraint to each arm.18. Which activity should the nurse encouragethe client to avoid when there is a risk for increasedintracranial pressure (ICP)?■ 1. Deep breathing.■ 2. Turning.■ 3. Coughing.■ 4. Passive range-of-motion (ROM) exercises.19. Which of the following is most effective inassessing the client suspected of developing diabetesinsipidus?■ 1. Taking vital signs every 2 hours.■ 2. Measuring urine output hourly.■ 3. Assessing arterial blood gas values everyother day.■ 4. Checking blood glucose levels.20. A client who had a serious head injury withincreased intracranial pressure is to be dischargedto a rehabilitation facility. Which of the followingrehabilitation outcomes would be appropriate forthe client? The client will:■ 1. Exhibit no further episodes of short-termmemory loss.■ 2. Be able to return to his construction job in3 weeks.■ 3. Actively participate in the rehabilitationprocess as appropriate.■ 4. Be emotionally stable and display pre-injurypersonality traits.21. Which of the following describes decerebrateposturing?■ 1. Internal rotation and adduction of arms withfl exion of elbows, wrists, and fi ngers.■ 2. Back hunched over, rigid fl exion of all fourextremities with supination of arms and plantarfl exion of feet.■ 3. Supination of arms, dorsifl exion of the feet.■ 4. Back arched, rigid extension of all fourextremities.22. A client receiving vent-assisted mode ventilationbegins to experience cluster breathing afterrecent intracranial occipital bleeding. The nurseshould:■ 1. Count the rate to be sure that ventilations aredeep enough to be suffi cient.■ 2. Notify the physician of the client’s breathingpattern.■ 3. Increase the rate of ventilations.■ 4. Increase the tidal volume on the ventilator.23. In planning the care for a client who has hada posterior fossa (infratentorial) craniotomy, whichof the following is contraindicated when positioningthe client?■ 1. Keeping the client fl at on one side or theother.■ 2. Elevating the head of the bed to 30 degrees.■ 3. Logrolling or turning as a unit when turning.■ 4. Keeping the neck in a neutral position.The Client with Seizures24. The nurse sees a client walking in the hallwaywho begins to have a seizure. The nurse shoulddo which of the following in priority order?2. Record the seizure activity observed.3. Ease the client to the fl oor.4. Obtain vital signs.1. Maintain a patent airway.25. Which of the following is contraindicated fora client with seizure precautions?■ 1. Encouraging him to perform his own personalhygiene.■ 2. Allowing him to wear his own clothing.■ 3. Assessing oral temperature with a glass thermometer.■ 4. Encouraging him to be out of bed.26. Which of the following will the nurseobserve in the client in the ictal phase of a generalizedtonic-clonic seizure?■ 1. Jerking in one extremity that spreads graduallyto adjacent areas.■ 2. Vacant staring and abruptly ceasing allactivity.■ 3. Facial grimaces, patting motions, and lipsmacking.■ 4. Loss of consciousness, body stiffening, andviolent muscle contractions.27. It is the night before a client is to have a computedtomography (CT) scan of the head withoutcontrast. The nurse should tell the client?■ 1. “You must shampoo your hair tonight toremove all oil and dirt.”■ 2. “You may drink fl uids until midnight, butafter that drink nothing until the scan iscompleted.”■ 3. “You will have some hair shaved to attach thesmall electrode to your scalp.”■ 4. “You will need to hold your head very stillduring the examination.”28. For breakfast on the morning a client is tohave an electroencephalogram (EEG), the clientis served a soft-boiled egg, toast with butter andmarmalade, orange juice, and coffee. Which of thefollowing should the nurse do?■ 1. Remove all the food.■ 2. Remove the coffee.■ 3. Remove the toast, butter, and marmalade only.■ 4. Substitute vegetable juice for the orange juice.29. A 20-year-old who hit his head while playingfootball has a tonic-clonic seizure. Upon awakeningfrom the seizure, the client asks the nurse,“What caused me to have a seizure? I’ve never hadone before.” Which cause should the nurse includein the response as a primary cause of tonic-clonicseizures in adults older than age 20?■ 1. Head trauma.■ 2. Electrolyte imbalance.■ 3. Congenital defect.■ 4. Epilepsy.30. Which of the following should the nurseinclude in the teaching plan for a client with seizureswho is going home with a prescription forgabapentin (Neurontin)?■ 1. Take all the medication until it is gone.■ 2. Notify the physician if vision changes occur.■ 3. Store gabapentin in the refrigerator.■ 4. Take gabapentin with an antacid to protectagainst ulcers.31. What is the priority nursing intervention inthe postictal phase of a seizure?■ 1. Reorient the client to time, person, and place.■ 2. Determine the client’s level of sleepiness.■ 3. Assess the client’s breathing pattern.■ 4. Position the client comfortably.32. Which intervention is most effective in minimizingthe risk of seizure activity in a client who isundergoing diagnostic studies after having experiencedseveral episodes of seizures?■ 1. Maintain the client on bed rest.■ 2. Administer butabarbital sodium (phenobarbital)30 mg P.O., three times per day.■ 3. Close the door to the room to minimizestimulation.■ 4. Administer carbamazepine (Tegretol) 200 mgP.O., twice per day.33. What nursing assessments should be documentedat the beginning of the ictal phase of aseizure?■ 1. Heart rate, respirations, pulse oximeter, andblood pressure.■ 2. Last dose of anticonvulsant and circumstancesat the time.■ 3. Type of visual, auditory, and olfactory aurathe client experienced.■ 4. Movement of the head and eyes and musclerigidity.34. The nurse is assessing a client in the postictalphase of generalized tonic-clonic seizure. The nurseshould determine if the client has?■ 1. Drowsiness.■ 2. Inability to move.■ 3. Paresthesia.■ 4. Hypotension.35. When preparing to teach a client aboutphenytoin sodium (Dilantin) therapy, the nurseshould urge the client not to stop the drug suddenlybecause:■ 1. Physical dependency on the drug developsover time.■ 2. Status epilepticus may develop.■ 3. A hypoglycemic reaction develops.■ 4. Heart block is likely to develop.36. A client states that she is afraid she will notbe able to drive again because of her seizures. Whichresponse by the nurse would be best?■ 1. A person with a history of seizures can driveonly during daytime hours.■ 2. A person with evidence that the seizures areunder medical control can drive.■ 3. A person with evidence that seizures occurno more often than every 12 months candrive.■ 4. A person with a history of seizures can driveif he carries a medical identifi cation card.37. The nurse is teaching a client to recognize anaura. The nurse should instruct the client to note:■ 1. A postictal state of amnesia.■ 2. An hallucination that occurs during a seizure.■ 3. A symptom that occurs just before a seizure.■ 4. A feeling of relaxation as the seizure begins tosubside.38. Which statement by a client with a seizuredisorder taking topiramate (Topamax) indicates theclient has understood the nurse’s instruction?■ 1. “I will take the medicine before going to bed.”■ 2. “I will drink 6 to 8 glasses of water a day.”■ 3. “I will eat plenty of fresh fruits.”■ 4. “I will take the medicine with a meal or snack.”39. Which clinical manifestation is a typicalreaction to long-term phenytoin sodium (Dilantin)therapy?■ 1. Weight gain.■ 2. Insomnia.■ 3. Excessive growth of gum tissue.■ 4. Deteriorating eyesight.40. A 21-year-old female client takes clonazepam(Klonopin). What should the nurse ask this clientabout? Select all that apply.■ 1. Seizure activity.■ 2. Pregnancy status.■ 3. Alcohol use.■ 4. Cigarette smoking.■ 5. Intake of caffeine and sugary drinks.The Client with a Stroke41. A client is being monitored for transientischemic attacks. She is oriented, can open her eyesspontaneously, and follows commands. What is herGlasgow Coma Scale score?________________________ points.42. The nurse is teaching a client about takingprophylactic warfarin sodium (Coumadin). Whichstatement indicates that the client understands howto take the drug? Select all that apply.■ 1. “The drug’s action peaks in 2 hours.”■ 2. “Maximum dosage is not achieved until 3 to4 days after starting the medication.”■ 3. “Effects of the drug continue for 4 to 5 daysafter discontinuing the medication.”■ 4. “Protamine sulfate is the antidote forwarfarin.”■ 5. “I should have my blood levels testedperiodically.”43. Regular oral hygiene is essential for the clientwho has had a stroke. Which of the following nursingmeasures is not appropriate when providing oralhygiene?■ 1. Placing the client on the back with a smallpillow under the head.■ 2. Keeping portable suctioning equipment at thebedside.■ 3. Opening the client’s mouth with a paddedtongue blade.■ 4. Cleaning the client’s mouth and teeth with atoothbrush.44. A client arrives in the emergency departmentwith an ischemic stroke and receives tissue plasminogenactivator (t-PA) administration. The nurseshould fi rst:■ 1. Ask what medications the client is taking.■ 2. Complete a history and health assessment.■ 3. Identify the time of onset of the stroke.■ 4. Determine if the client is scheduled for anysurgical procedures.45. During the fi rst 24 hours after thrombolytictreatment for an ischemic stroke, the primary goalis to control the client’s:■ 1. Pulse.■ 2. Respirations.■ 3. Blood pressure.■ 4. Temperature.46. What is a priority nursing assessment in thefi rst 24 hours after admission of the client with athrombotic stroke?■ 1. Cholesterol level.■ 2. Pupil size and pupillary response.■ 3. Bowel sounds.■ 4. Echocardiogram.47. A client with a hemorrhagic stroke is slightlyagitated, heart rate is 118, respirations are 22, bilateralrhonchi are auscultated, SpO2 is 94%, bloodpressure is 144/88, and oral secretions are noted.What order of interventions should the nurse followwhen suctioning the client to prevent increasedintracranial pressure (ICP) and maintain adequatecerebral perfusion?2. Hyperoxygenate.3. Suction the mouth.4. Provide sedation.1. Suction the airway.48. In planning care for the client who has had astroke, the nurse should obtain a history of the client’sfunctional status before the stroke because?■ 1. The rehabilitation plan will be guided by it.■ 2. Functional status before the stroke will helppredict outcomes.■ 3. It will help the client recognize his physicallimitations.■ 4. The client can be expected to regain much ofhis functioning.49. Which of the following techniques does thenurse avoid when changing a client’s position inbed if the client has hemiparalysis?■ 1. Rolling the client onto the side.■ 2. Sliding the client to move up in bed.■ 3. Lifting the client when moving the client upin bed.■ 4. Having the client help lift off the bed using atrapeze.50. Which nursing intervention has been foundto be the most effective means of preventing plantarfl exion in a client who has had a stroke with residualparalysis?■ 1. Place the client’s feet against a fi rm footboard.■ 2. Reposition the client every 2 hours.■ 3. Have the client wear ankle-high tennis shoesat intervals throughout the day.■ 4. Massage the client’s feet and ankles regularly.51. The nurse is planning the care of a hemiplegicclient to prevent joint deformities of the armand hand. Which of the following positions areappropriate?■ 1. Placing a pillow in the axilla so the arm isaway from the body.■ 2. Inserting a pillow under the slightly fl exedarm so the hand is higher than the elbow.■ 3. Immobilizing the extremity in a sling.■ 4. Positioning a hand cone in the hand so thefi ngers are barely fl exed.■ 5. Keeping the arm at the side using a pillow.52. For the client who is experiencing expressiveaphasia, which nursing intervention is most helpfulin promoting communication?■ 1. Speaking loudly.■ 2. Using a picture board.■ 3. Writing directions so client can read them.■ 4. Speaking in short sentences.53. The nurse is teaching the family of a clientwith dysphagia about decreasing the risk of aspirationwhile eating. Which of the following strategiesis not appropriate?■ 1. Maintaining an upright position.■ 2. Restricting the diet to liquids until swallowingimproves.■ 3. Introducing foods on the unaffected side ofthe mouth.■ 4. Keeping distractions to a minimum.54. Which food-related behaviors are expected ina client who has had a stroke that has left him withhomonymous hemianopia?■ 1. Increased preference for foods high in salt.■ 2. Eating food on only half of the plate.■ 3. Forgetting the names of foods.■ 4. Inability to swallow liquids.55. A nurse is teaching a client who had a strokeabout ways to adapt to a visual disability. Whichdoes the nurse identify as the primary safety precautionto use?■ 1. Wear a patch over one eye.■ 2. Place personal items on the sighted side.■ 3. Lie in bed with the unaffected side towardthe door.■ 4. Turn the head from side to side when walking.56. A client is experiencing mood swings after astroke and often has episodes of tearfulness that aredistressing to the family. Which is the best techniquefor the nurse to instruct family members to trywhen the client experiences a crying episode?■ 1. Sit quietly with the client until the episode isover.■ 2. Ignore the behavior.■ 3. Attempt to divert the client’s attention.■ 4. Tell the client that this behavior is unacceptable.57. The client who has had a stroke with residualphysical handicaps becomes discouraged by hisphysical appearance. What approach to the client isbest for the nurse to use to help the client overcomehis negative self-concept? Select all that apply.■ 1. Helpfulness.■ 2. Charity.■ 3. Firmness.■ 4. Encouragement.■ 5. Patience.58. When communicating with a client who hasaphasia, which of the following nursing interventionsis not appropriate?■ 1. Present one thought at a time.■ 2. Encourage the client not to write messages.■ 3. Speak with normal volume.■ 4. Make use of gestures.59. What is the expected outcome of thrombolyticdrug therapy for stroke?■ 1. Increased vascular permeability.■ 2. Vasoconstriction.■ 3. Dissolved emboli.■ 4. Prevention of hemorrhage.The Client with Parkinson’s Disease60. A health care provider has ordered carbidopa-levodopa (Sinemet) four times per day for aclient with Parkinson’s disease. The client statesthat he wants “to end it all now that the Parkinson’sdisease has progressed.” What should the nurse do?Select all that apply.■ 1. Explain that the new prescription for Sinemetwill treat his depression.■ 2. Encourage the client to discuss his feelings asthe Sinemet is being administered.■ 3. Contact the health care provider beforeadministering the Sinemet.■ 4. Determine if the client is on antidepressantsor monoamine oxidase (MAO) inhibitors.■ 5. Determine if the client is at risk for suicide.61. Which of the following is an initial sign ofParkinson’s disease?■ 1. Rigidity.■ 2. Tremor.■ 3. Bradykinesia.■ 4. Akinesia.62. The nurse develops a teaching plan for aclient newly diagnosed with Parkinson’s disease.Which of the following topics that the nurse plansto discuss is the most important?■ 1. Maintaining a balanced nutritional diet.■ 2. Enhancing the immune system.■ 3. Maintaining a safe environment.■ 4. Engaging in diversional activity.63. The nurse observes that a client’s upper armtremors disappear as he unbuttons his shirt. Whichstatement best guides the nurse’s analysis of thisobservation about the client’s tremors?■ 1. The tremors are probably psychological andcan be controlled at will.■ 2. The tremors sometimes disappear with purposefuland voluntary movements.■ 3. The tremors disappear when the client’sattention is diverted by some activity.■ 4. There is no explanation for the observation; itis probably a chance occurrence.64. At what time of day should the nurse encouragea client with Parkinson’s disease to schedule themost demanding physical activities to minimize theeffects of hypokinesia?■ 1. Early in the morning, when the client’s energylevel is high.■ 2. To coincide with the peak action of drugtherapy.■ 3. Immediately after a rest period.■ 4. When family members will be available.65. Which goal is the most realistic and appropriatefor a client diagnosed with Parkinson’s disease?■ 1. To cure the disease.■ 2. To stop progression of the disease.■ 3. To begin preparations for terminal care.■ 4. To maintain optimal body function.66. What is the primary goal collaborativelyestablished by the client with Parkinson’s disease,nurse, and physical therapist?■ 1. To maintain joint fl exibility.■ 2. To build muscle strength.■ 3. To improve muscle endurance.■ 4. To reduce ataxia.67. A client with Parkinson’s disease is prescribedlevodopa (L-dopa) therapy. Improvement inwhich of the following indicates effective therapy?■ 1. Mood.■ 2. Muscle rigidity.■ 3. Appetite.■ 4. Alertness.68. A client is being switched from levodopa(L-dopa) to carbidopa-levodopa (Sinemet). The nurseshould monitor for which of the following possiblecomplications during medication changes and dosageadjustment?■ 1. Euphoria.■ 2. Jaundice.■ 3. Vital sign fl uctuation.■ 4. Signs and symptoms of diabetes.69. A new medication regimen is ordered for aclient with Parkinson’s disease. At which time shouldthe nurse make certain that the medication is taken?■ 1. At bedtime.■ 2. All at one time.■ 3. Two hours before mealtime70. A client with Parkinson’s disease needs along time to complete her morning hygiene, but shebecomes annoyed when the nurse offers assistanceand refuses all help. Which action is the nurse’s bestinitial response in this situation?■ 1. Tell the client fi rmly that she needs assistanceand help her with her care.■ 2. Praise the client for her desire to be independentand give her extra time and encouragement.■ 3. Tell the client that she is being unrealisticabout her abilities and must accept the factthat she needs help.■ 4. Suggest to the client that if she insists on selfcare,she should at least modify her routine.71. A client with Parkinson’s disease asks thenurse to explain to his nephew “what the doctorsaid the pallidotomy would do.” The nurse’s bestresponse includes stating that the main goal for theclient after pallidotomy is improved:■ 1. Functional ability.■ 2. Emotional stress.■ 3. Alertness.■ 4. Appetite.The Client with Multiple Sclerosis72. The nurse is reviewing the care plan of aclient with Multiple Sclerosis. Which of the followingnursing diagnoses should receive furthervalidation?■ 1. Impaired mobility related to spasticity andfatigue.■ 2. Risk for falls related to muscle weakness andsensory loss.■ 3. Risk for seizures related to muscle tremorsand loss of myelin.■ 4. Impaired skin integrity related bowel andbladder incontinence.73. The nurse is teaching a client with bladder dysfunctionfrom multiple sclerosis (MS) about bladdertraining at home. Which instructions should the nurseinclude in the teaching plan? Select all that apply.■ 1. Restrict fl uids to 1,000 mL/24 hours.■ 2. Drink 400 to 500 mL with each meal.■ 3. Drink fl uids midmorning, midafternoon, andlate afternoon.■ 4. Attempt to void at least every 2 hours.■ 5. Use intermittent catheterization as needed.74. Which of the following is not a typical clinicalmanifestation of multiple sclerosis (MS)?■ 1. Double vision.■ 2. Sudden bursts of energy.■ 3. Weakness in the extremities.■ 4. Muscle tremors.75. A client with multiple sclerosis (MS) isreceiving baclofen (Lioresal). The nurse determinesthat the drug is effective when it achieves which ofthe following?■ 1. Induces sleep.■ 2. Stimulates the client’s appetite.■ 3. Relieves muscular spasticity.■ 4. Reduces the urine bacterial count.76. A client has had multiple sclerosis (MS) for15 years and has received various drug therapies.What is the primary reason why the nurse hasfound it diffi cult to evaluate the effectiveness of thedrugs that the client has used?■ 1. The client exhibits intolerance to many drugs.■ 2. The client experiences spontaneous remissionsfrom time to time.■ 3. The client requires multiple drugs simultaneously.■ 4. The client endures long periods of exacerbationbefore the illness responds to a particular drug.77. When the nurse talks with a client withmultiple sclerosis who has slurred speech, whichnursing intervention is contraindicated?■ 1. Encouraging the client to speak slowly.■ 2. Encouraging the client to speak distinctly.■ 3. Asking the client to repeat indistinguishablewords.■ 4. Asking the client to speak louder when tired.78. The right hand of a client with multiplesclerosis trembles severely whenever she attempts avoluntary action. She spills her coffee twice at lunchand cannot get her dress fastened securely. Which isthe best legal documentation in nurses’ notes of thechart for this client assessment?■ 1. “Has an intention tremor of the right hand.”■ 2. “Right-hand tremor worsens with purposefulacts.”■ 3. “Needs assistance with dressing and eatingdue to severe trembling and clumsiness.”■ 4. “Slight shaking of right hand increases tosevere tremor when client tries to button herclothes or drink from a cup.”79. A client with multiple sclerosis (MS) is experiencingbowel incontinence and is starting a bowelretraining program. Which strategy is inappropriate?■ 1. Eating a diet high in fi ber.■ 2. Setting a regular time for elimination.■ 3. Using an elevated toilet seat.■ 4. Limiting fl uid intake to 1,000 mL/day.80. Which of the following is not a realisticoutcome to establish with a client who has multiplesclerosis (MS)? The client will:■ 1. Develop joint mobility.■ 2. Develop muscle strength.■ 3. Develop cognition.■ 4. Develop mood elevation.81. The nurse is preparing a client with multiplesclerosis (MS) for discharge from the hospital tohome. The nurse should tell the client:■ 1. “You will need to accept the necessity for aquiet and inactive lifestyle.”■ 2. “Keep active, use stress reduction strategies,and avoid fatigue.”■ 3. “Follow good health habits to change thecourse of the disease.”■ 4. “Practice using the mechanical aids that youwill need when future disabilities arise.”82. Which of the following should the nurseinclude in the discharge plan for a client withmultiple sclerosis who has an impaired peripheralsensation? Select all that apply.■ 1. Carefully test the temperature of bathwater.■ 2. Avoid kitchen activities because of the risk ofinjury.■ 3. Avoid hot water bottles and heating pads.■ 4. Inspect the skin daily for injury or pressurepoints.■ 5. Wear warm clothing when outside in coldtemperatures.83. Which intervention should the nurse suggestto help a client with multiple sclerosis avoid episodesof urinary incontinence?■ 1. Limit fl uid intake to 1,000 mL/day.■ 2. Insert an indwelling urinary catheter.■ 3. Establish a regular voiding schedule.■ 4. Administer prophylactic antibiotics, asordered.84. A client with multiple sclerosis (MS) liveswith her daughter and 3-year-old granddaughter.The daughter asks the nurse what she can do athome to help her mother. Which of the followingmeasures would be most benefi cial?■ 1. Psychotherapy.■ 2. Regular exercise.■ 3. Day care for the granddaughter.■ 4. Weekly visits by another person with MS.The Unconscious Client85. A client is brought to the emergency departmentunconscious. An empty bottle of aspirin wasfound in his car, and a drug overdose is suspected.Which of the following medications should the nursehave available for further emergency treatment?■ 1. Vitamin K.■ 2. Dextrose 50%.■ 3. Activated charcoal powder.■ 4. Sodium thiosulfate.86. Which clinical manifestations should thenurse expect to assess in a client diagnosed with anoverdose of a cholinergic agent? Select all that apply.■ 1. Dry mucous membranes.■ 2. Urinary incontinence.■ 3. Central nervous system (CNS) depression.■ 4. Seizures.■ 5. Skin rash.87. The wife and sister of a client who hadattempted suicide with an overdose are distraughtabout his comatose condition and the possibilitythat he took an intentional drug overdose. Which ofthe following would be an appropriate initial nursingintervention with this family?■ 1. Explain that because the client was found onhospital property, he was probably asking forhelp and did not intentionally overdose.■ 2. Give the wife and sister a big hug and assurethem that the client is in good hands.■ 3. Encourage the wife and sister to express theirfeelings and concerns, and listen carefully.■ 4. Allow the wife and sister to help care for theclient by rubbing his back when he is turned.88. Which of the following is a priority duringthe fi rst 24 hours of hospitalization for a comatoseclient with suspected drug overdose?■ 1. Educate regarding drug abuse.■ 2. Minimize pain.■ 3. Maintain intact skin.■ 4. Increase caloric intake.89. An unconscious intubated client does nothave increased intracranial pressure. Which nursingintervention would be essential?■ 1. Monitoring the oral temperature, keep theroom temperature at 70° F (21.1° C), and placethe client on a cooling blanket if the client’stemperature is higher than 101° F (38.3° C).■ 2. Cleaning the mouth carefully, applying a thincoat of petroleum jelly, and moving the endotrachealtube to the opposite side daily.■ 3. Positioning the client in the supine positionwith the head to the side and slightly elevatedon two pillows.■ 4. Turning the client with a drawsheet and placinga pillow behind the back and one betweenthe legs.90. The client is to be placed in a right side-lyingposition. The nurse should intervene when observinga client in which of the following positions?■ 1. The head is placed on a small pillow.■ 2. The right leg is extended without pillowsupport.■ 3. The left arm is rested on the mattress with theelbow fl exed.■ 4. The left leg is supported on a pillow with theknee fl exed.91. The nursing team has been performingpassive range-of-motion (ROM) exercises on anunconscious client? Which of the following indicatethe exercises have been successful?■ 1. Preservation of muscle mass.■ 2. Prevention of bone demineralization.■ 3. Increase in muscle tone.■ 4. Maintenance of joint mobility.92. When the nurse performs oral hygiene for anunconscious client, which nursing intervention isthe priority?■ 1. Keep a suction machine available.■ 2. Place the client in a prone position.■ 3. Wear sterile gloves while brushing the client’steeth.■ 4. Use gauze wrapped around the fi ngers toclean the client’s gums.93. The nurse observes that the right eye ofan unconscious client does not close completely.Which nursing intervention is most appropriate?■ 1. Have the client wear eyeglasses at alltimes.■ 2. Lightly tape the eyelid shut.■ 3. Instill artifi cial tears once every shift.■ 4. Clean the eyelid with a washcloth everyshift.94. Which sign is an early indicator of hypoxiain the unconscious client?■ 1. Cyanosis.■ 2. Decreased respirations.■ 3. Restlessness.■ 4. Hypotension.95. When administering intermittent enteralfeeding to an unconscious client, the nurseshould:■ 1. Heat the formula in a microwave.■ 2. Place the client in a semi-Fowler’s position.■ 3. Obtain a sterile gavage bag and tubing.■ 4. Weigh the client before administering thefeeding.96. The client is to receive 200 mL of tube feedingevery 4 hours. The nurse checks for the client’sgastric residual before administering the next scheduledfeeding and obtains 40 mL of gastric residual.The nurse should:■ 1. Withhold the tube feeding and notify thephysician.■ 2. Dispose of the residual and continue withthe feeding.■ 3. Delay feeding the client for 1 hour and thenrecheck the residual.■4. Readminister the residual to the client andcontinue with the feeding.catheter care, which should have the highestpriority?■ 1. Cleaning the area around the urethralmeatus.■ 2. Clamping the catheter periodically to maintainmuscle tone.■ 3. Irrigating the catheter with several ouncesof normal saline solution.■ 4. Changing the location where the catheteris taped to the client’s leg.98. A client has been pronounced brain dead.Which fi ndings should the nurse document? Selectall that apply.■ 1. Decerebrate posturing.■ 2. Nonreactive dilated pupils.■ 3. Deep tendon refl exes.■ 4. Absent corneal refl ex.■ 5. Blink refl ex.The Client in Pain99. The physician orders Morphine Sulfate2-4 mg IV push every 2 hours prn pain for a clientwho has postoperative pain following abdominalsurgery. Prior to performing an abdominal dressingchange with packing at 10 AM, the nurse assessesthe client’s pain level as 1 on a scale of 0 = no pain to10 = the worst pain. The client is awake and orientedand vital signs are within normal limits. The nursereviews the pain medication record (see chart).The nurse should:■ 1. Perform the dressing change.■ 2. Administer Morphine 2 mg IV before thedressing change.■ 3. Administer Morphine 4 mg IV after the dressingchange.■ 4. Call the physician for a new medicationorder.Medication RecordTime Pain Level Intervention7 AM 8 Morphine 4 mg IV9 AM 4 Morphine 2 mg IV10 AM 1100. A 34-year-old Chinese man is admitted withmultiple injuries from a motor vehicle accident.He complains of severe pain and requests frequentmedication. One of the assistive nursing personnelexpresses surprise, saying, “I thought Asian peoplewere very stoic about pain.” Which is the nurse’sbest response about pain?■ 1. Expression and perception of pain varywidely from person to person.■ 2. Tolerance of pain is the same in all people.■ 3. Tolerance of pain is determined by a person’sgenetic makeup.■ 4. Pain perception is the same in all people.101. The nurse fi nds it diffi cult to relieve a client’spain satisfactorily. Which of the following measuresshould the nurse take next when continuing effortsto promote comfort?■ 1. Improve the nurse-client relationship.■ 2. Enlist the help of the client’s family.■ 3. Allow the client additional time to workthrough his or her own responses to pain.■ 4. Arrange to have the client share a room witha client who has little pain.102. The client’s physician decides to change theanalgesia medication from meperidine hydrochloride(Demerol) 75 mg I.M. every 4 hours as neededto meperidine hydrochloride by the oral route. Whatdosage of oral meperidine is required to provide anequivalent analgesic dose?■ 1. 25 to 50 mg.■ 2. 75 to 100 mg.■ 3. 125 to 150 mg.■ 4. 250 to 300 mg.103. After administering meperidine hydrochloride(Demerol), the nurse determines its effectivenessas an analgesic was related to its ability to:■ 1. Reduce the perception of pain.■ 2. Decrease the sensitivity of pain receptors.■ 3. Interfere with pain impulses traveling alongsensory nerve fi bers.■ 4. Block the conduction of pain impulses alongthe central nervous system.104. A client is arousing from a coma and keepssaying, “Just stop the pain.” The nurse respondsbased on the knowledge that the human bodytypically and automatically responds to pain fi rstwith attempts to:■ 1. Tolerate the pain.■ 2. Decrease the perception of pain.■ 3. Escape the source of pain.■ 4. Divert attention from the source of pain.105. Ergotamine tartrate (Gynergen) is prescribedfor a client’s migraine headaches. The client’s reportof which of the following indicates effectiveness?■ 1. Prevention of the migraine.■ 2. Reduced severity of the developing migraine.■ 3. Relief from the sleeplessness experienced inthe past after a migraine.■ 4. Relief from the vision problems experiencedin the past after a migraine.106. The nurse explains to the client with painthat the purpose of biofeedback is to enable him toexert control over his physiologic processes by:■ 1. Regulating the body processes through electricalcontrol.■ 2. Shocking himself when an undesirableresponse is elicited.■ 3. Monitoring the body processes for the therapistto interpret.■ 4. Translating the signals of his body processesinto observable forms.107. The nurse explains to the client that themain reason a back rub is used as therapy to relievepain is because the massage:■ 1. Blocks pain impulses from the spinal cord tothe brain.■ 2. Blocks pain impulses from the brain to thespinal cord.■ 3. Stimulates the release of endorphins.■ 4. Distracts the client’s focus on the source ofthe pain.108. Nursing responsibilities for the client witha patient-controlled analgesia (PCA) system shouldinclude:■ 1. Reassuring the client that pain will berelieved.■ 2. Documenting the client’s response to painmedication on a routine basis.■ 3. Instructing the client to continue pressing thesystem’s button whenever pain occurs.■ 4. Titrating the client’s pain medication until theclient is free from pain.109. A client has an epidural catheter inserted forpostoperative pain management. The client rateshis pain at 4 on a 0-to-5 pain scale. What should thenurse do fi rst?■ 1. Check the patient-controlled analgesia (PCA)pump function.■ 2. Adjust the epidural catheter.■ 3. Assess vital signs.■ 4. Notify the physician.110. The nurse using healing touch affects a client’spain primarily through:■ 1. Energy fi elds.■ 2. Touch therapy.3. Massage.■ 4. Hypnosis.Managing Care Quality and Safety111. A nursing assistant is providing care to a clientwith left-sided paralysis. Which of the followingactions by the nursing assistant requires the nurse toprovide further instruction?■ 1. Providing passive range of motion exercisesto the left extremities during the bed bath.■ 2. Elevating the foot of the bed to reduce edema.■ 3. Pulling up the client under the left shoulderwhen getting out of bed to a chair.■ 4. Putting high top tennis shoes on the clientafter bathing.112. The nurse notices that a client with Parkinson’sdisease is coughing frequently when eating.Which one of the following interventions should thenurse consider?■ 1. Have the client hyperextend the neck whenswallowing.■ 2. Tell the client to place the chin fi rmly againstthe chest when eating.■ 3. Thicken all liquids before offering to the client.■ 4. Place the client on a clear liquid diet.113. The nurse has asked the nursing assistantto ambulate a client with Parkinson’s disease. Thenurse observes the nursing assistant pulling on theclient’s arms to get the client to walk forward. Thenurse should:■ 1. Have the nursing assistant keep a steady pullon the client to promote forward ambulation.■ 2. Explain how to overcome a freezing gait bytelling the client to march in place.■ 3. Assist the nursing assistant with getting theclient back in bed.■ 4. Give the client a muscle relaxant.114. Which pressure point area(s) should thenurse monitor for an unconscious client positionedon the left side (see fi gure)? Choose all that apply.■ 1. Ankles.■ 2. Ear.■ 3. Greater trochanter.■ 4. Heels.■ 5. Occiput.■ 6. Sacrum.■ 7. Shoulder.discrepancyin the records of use of a controlled substancefor a client who is taking large doses of narcoticpain medication. The nurse should do which of thefollowing next?■ 1. Notify the Drug Enforcement Agency (DEA).■ 2. Contact the Director of Quality and Risk Management/Legal Department.■ 3. Notify the pharmacy technician who deliveredthe controlled substance.■ 4. Notify the nursing supervisor of the clinicalunit.Answers, Rationales, and Test Taking StrategiesThe answers and rationales for each question followbelow, along with keys ( ) to the client need(CN) and cognitive level (CL) for each question.Use these keys to further develop your test-takingskills. For additional information about test-takingskills and strategies for answering questions, refer topages 10–21, and pages 25–26 in Part 1 of this book.The Client with a Head Injury1. 2, 3, 4. The nurse should maintain ICP byelevating the head of the bed and monitoring neurologicstatus. An ICP greater than 20 mm Hg indicatesincreased ICP, and the nurse should notify thehealth care provider. Coughing and range-of-motionexercises will increase ICP and should be avoided inthe early postoperative : Physiological adaptation;CL: Synthesize2. 1, 4. The nurse must monitor the systolic anddiastolic blood pressure to obtain the mean arterialpressure (MAP), which represents the pressureneeded for each cardiac cycle to perfuse the brain.The nurse must also monitor the cerebral perfusionpressure (CPP), which is obtained from the ICPand the MAP. The nurse should also monitor urineoutput, respirations, and pain; however, crucialmeasurements needed to maintain CPP are ICP andMAP. When ICP equals MAP, there is no : Management of care;CL: Analyze3. 80 mm HgTo obtain the MAP, use this formula:MAP = [systolic BP + (2 × diastolic BP)] ÷ 3MAP = [120 + (2 × 60)] ÷ 3MAP = 240 ÷ 3 = : Management of care; CL: Apply4. 2, 3. The nurse should determine if the client’spupils are equal and react to light, and ask theclient if he has a headache. Confusion, agitation,and restlessness are subtle clinical manifestations ofincreased intracranial pressure (ICP). At this time, itis not appropriate for the nurse to fi nd a televisionor arrange for the client to see his wife and baby.Administering a sedative at this time will obscureassessment of increased : Management of care; CL: Synthesize5. 1. The highest priority for a client withmultiple injuries is to establish an open airway foreffective ventilation and oxygenation. Unless theclient has a patent airway, other care measures willbe futile. Replacing blood loss, stopping bleedingfrom open wounds, and checking for a neck fractureare important nursing interventions to be completedafter the airway and ventilation are : Safety and infection control;CL: Synthesize6. 1. Increasing ICP causes unequal pupils as aresult of pressure on the third cranial nerve. IncreasingICP causes an increase in the systolic pressure,which refl ects the additional pressure needed to perfusethe brain. It increases the pressure on the vagusnerve, which produces bradycardia, and it causesan increase in body temperature from : Reduction of risk potential;CL: Analyze7. 3. The clear drainage must be analyzed todetermine whether it is nasal drainage or cerebrospinalfl uid (CSF). The nurse should not give theclient tissues because it is important to know howmuch leakage of CSF is occurring. Compressing thenares will obstruct the drainage fl ow. It is inappropriateto tilt the head back, which would allow thefl uid to drain down the throat and not be collectedfor a sample. It is inappropriate to administer anantihistamine because the drainage may not be frompostnasal drip.the brain stem. Deterioration and pressure produceirregular respiratory patterns. Rapid, shallow respirations,asymmetric chest movements, and nasalfl aring are more characteristic of respiratory distressor : Physiological adaptation;CL: Apply9. 3. Normal ICP is 15 mm Hg or less for 15 to30 seconds or longer. Hyperventilation causes vasoconstriction,which reduces cerebrospinal fl uid andblood volume, two important factors for reducinga sustained ICP of 20 mm Hg. A cooling blanket isused to control the elevation of temperature becausea fever increases the metabolic rate, which in turnincreases ICP. High doses of barbiturates may beused to reduce the increased cellular metabolicdemands. Fluid volume and inotropic drugs areused to maintain cerebral perfusion by supportingthe cardiac output and keeping the cerebral perfusionpressure greater than 80 mm : Physiological adaptation;CL: Synthesize10. 4. A decrease in the client’s LOC is an earlyindicator of deterioration of the client’s neurologicstatus. Changes in level of consciousness, such asrestlessness and irritability, may be subtle. Wideningof the pulse pressure, decrease in the pulse rate,and dilated, fi xed pupils occur later if the increasedICP is not : Physiological adaptation;CL: Analyze11. 1. The client’s ICP is elevated, and the clientshould be positioned to avoid extreme neck fl exionor extension. The head of the bed is usually elevated30 to 45 degrees to drain the venous sinuses andthus decrease the ICP. Trendelenburg’s positionplaces the client’s head lower than the body, whichwould increase ICP. The Sims position (side lying)and elevating the head on two pillows may extendor fl ex the neck, which increases : Reduction of risk potential;CL: Synthesize12. 2. After administering mannitol, the nurseclosely monitors intake and output because mannitolpromotes diuresis and is given primarily to pullwater from the extracellular fl uid of the edematousbrain. Mannitol can cause hypokalemia and maylead to muscle contractions, not muscle relaxation.Signs and symptoms, such as widening pulse pressureand pupil dilation, should not occur becausemannitol serves to decrease : Pharmacological and parenteraltherapies; CL: Analyze13. 3, 4, 5. The nurse should assess the client forspinal shock, which is the immediate response tospinal cord transection. Hypotension occurs and thebody loses core temperature to environmental temperature.The nurse must treat the client immediatelyto manage hypotension and hypothermia. Thenurse should also ensure that there is an adequateairway and respirations; there may be respiratorycompromise due to intercostal muscle involvement.Once the client is stable, the nurse should conducta complete neurologic check. The nurse should takeall precautions to keep the client’s head, neck, andspine position in straight alignment. If the clientis conscious, the nurse should briefl y assess majorrefl exes, such as the Achilles, patellar, biceps, andtriceps tendons, and sensation of the perineum forbladder : Management of care; CL: Analyze14. 4. The correct motor function test for C8 isa hand-grasp check. The motor function check forC4 to C5 is shoulders shrugging against downwardpressure of the examiner’s hands. The motor functioncheck for C5 to C6 is an arm pulling up from aresting position against resistance. The motor functioncheck for C7 is an arm straightening out from afl exed position against : Management of care; CL: Analyze15. 2, 3, 5. The client with a C3 to C4 fracture hasneck control but may tire easily using sore musclesaround the incision area to hold up his head. Therefore,the head and neck of his wheelchair should behigh. The seat of the wheelchair should be lowerthan normal to facilitate transfer from the bed to thewheelchair. When a client can use his hands andarms to move the wheelchair, the placement of theback to the client’s scapula is necessary. This clientcannot use his arms and will need an electric chairwith breath, chin, or voice control to manipulatemovement of the chair. A fi rm or hard cushion addspressure to bony prominences; the cushion shouldinstead be padded to reduce the risk of : Basic care and comfort;CL: Synthesize16. 4. It is important to fi rst explain where a clientis to orient him to time, person, and place. Offeringto get his family and asking him questions todetermine whether he is oriented are important, butthe fi rst comments should let the client know wherehe is and what happened to him. It is useful to beempathetic to the client, but making a comment suchas “I’ll bet you’re a little confused” when he fi rstawakens is not helpful and may cause him : Psychosocial adaptation;CL: Synthesizehelp prevent the client from pulling on the I.V.without causing additional agitation. Using a jacketor wrist restraint or tucking the client’s arms andhands under the drawsheet restrict movement andadd to feelings of being confi ned, all of which wouldincrease her agitation and increase : Physiological adaptation;CL: Synthesize18. 3. Coughing is contraindicated for a client atrisk for increased ICP because coughing increasesICP. Deep breathing can be continued. Turning andpassive ROM exercises can be continued with carenot to extend or fl ex the : Reduction of risk potential;CL: Synthesize19. 2. Diabetes insipidus results from defi ciencyof antidiuretic hormone (ADH). The condition mayoccur in conjunction with head injuries as well aswith other disorders. In ADH defi ciency, the clientis extremely thirsty and excretes large amounts ofhighly diluted urine. Measuring the urine outputto detect excess amount and checking the specifi cgravity of urine samples to determine urine concentrationare appropriate measures to determine theonset of diabetes insipidus. The client may be tachycardicand hypotensive from fl uid defi cit; however,altered vital signs in a client with a head injury mayoccur for other reasons as well. Blood gas analysisand blood glucose levels will not reveal : Physiological adaptation;CL: Analyze20. 3. Recovery from a serious head injury is along-term process that may continue for months oryears. Depending on the extent of the injury, clientswho are transferred to rehabilitation facilities mostlikely will continue to exhibit cognitive and mobilityimpairments as well as behavior and personalitychanges. The client would be expected to participatein the rehabilitation efforts to the extent he iscapable. Family members and signifi cant others willneed long-term support to help them cope with thechanges that have occurred in the : Physiological adaptation;CL: Evaluate21. 4. Decerebrate posturing occurs in clientswith damage to the upper brain stem, midbrain, orpons and is demonstrated clinically by arching ofthe back, rigid extension of the extremities, pronationof the arms, and plantar fl exion of the feet.Internal rotation and adduction of arms with fl exionof elbows, wrists, and fi ngers describes decorticate posturing, which indicates damage to corticospinaltracts and cerebral : Physiological adaptation;CL: Apply22. 2. Cluster breathing consists of clusters ofirregular breaths followed by periods of apnea onan irregular basis. A lesion in the upper medulla orlower pons is usually the cause of cluster breathing.Because the client had a bleed in the occipital lobe,which is just superior and posterior to the pons andmedulla, clinical manifestations that indicate a newlesion are monitored very closely in case anotherbleed ensues. The nurse should notify the physicianimmediately so that treatment can begin before respirationscease. The client is not obtaining suffi cientoxygen and the depth of breathing is assisted by theventilator. The health care provider will determinechanges in the ventilator : Physiological adaptation;CL: Synthesize23. 2. Elevating the head of the bed to 30 degreesis contraindicated for infratentorial craniotomiesbecause it could cause herniation of the brain downonto the brain stem and spinal cord, resulting insudden death. Elevation of the head of the bed to30 degrees with the head turned to the side oppositethe incision, if not contraindicated by the increasedintracranial pressure, is used for : Physiological adaptation;CL: SynthesizeThe Client with Seizures24.1. Maintain a patent airway.4. Obtain vital signs.2. Record the seizure activity observed.3. Ease the client to the fl oor.To protect the client from falling, the nurse fi rstshould ease the client to the fl oor. It is importantto protect the head and maintain a patent airwaysince altered breathing and excessive salivation canoccur. The assessment of the postictal period shouldinclude level of consciousness and vital signs. Thenurse should record details of the seizure once theclient is stable. The events preceding the seizure,timing with descriptions of each phase, body parts affected and sequence of involvement, and autonomicsigns should be : Safety and infection control;CL: Synthesize25. 3. Temperatures are not assessed orally witha glass thermometer because the thermometer couldbreak and cause injury if a seizure occurred. Theclient can perform personal hygiene. There is noclinical reason to discourage the client from wearinghis own clothes. As long as there are no otherlimitations, the client should be encouraged to beout of : Physiological adaptation;CL: Synthesize26. 4. A generalized tonic-clonic seizure involvesboth a tonic phase and a clonic phase. The tonicphase consists of loss of consciousness, dilatedpupils, and muscular stiffening or contraction,which lasts about 20 to 30 seconds. The clonicphase involves repetitive movements. The seizureends with confusion, drowsiness, and resumption ofrespiration. A partial seizure starts in one region ofthe cortex and may stay focused or spread (e.g., jerkingin the extremity spreading to other areas of thebody). An absence seizure usually occurs in childrenand involves a vacant stare with a brief loss ofconsciousness that often goes unnoticed. A complexpartial seizure involves facial grimacing with pattingand : Physiological adaptation;CL: Analyze27. 4. The client will be asked to hold the headvery still during the examination, which lasts about30 to 60 minutes. In some instances, food and fl uidsmay be withheld for 4 to 6 hours before the procedureif a contrast medium is used because theradiopaque substance sometimes causes nausea.There is no special preparation for a CT scan, so ashampoo the night before is not required. The clientmay drink fl uids until 4 hours before the scan isscheduled. Electrodes are not used for a CT scan,nor is the head : Physiological adaptation;CL: Synthesize28. 2. Beverages containing caffeine, such as coffee,tea, and cola drinks, are withheld before an EEGbecause of the stimulating effects of the caffeineon the brain waves. A meal should not be omittedbefore an EEG because low blood sugar could alterbrain wave patterns; the client can have the entiremeal except for the : Physiological adaptation;CL: Synthesize29. 1. Trauma is one of the primary causes ofbrain damage and seizure activity in adults. Othercommon causes of seizure activity in adults includeneoplasms, withdrawal from drugs and alcohol, andvascular disease. Given the history of head injury,electrolyte imbalance is not the cause of the seizure.There is no information to indicate that the seizureis related to a congenital defect. Epilepsy is usuallydiagnosed in younger : Physiological adaptation;CL: Apply30. 2. Gabapentin (Neurontin) may impairvision. Changes in vision, concentration, or coordinationshould be reported to the physician. Gabapentinshould not be stopped abruptly because of thepotential for status epilepticus; this is a medicationthat must be tapered off. Gabapentin is to be storedat room temperature and out of direct light.It should not be taken with : Pharmacological and parenteraltherapies; CL: Synthesize31. 3. A priority for the client in the postictalphase (after a seizure) is to assess the client’s breathingpattern for effective rate, rhythm, and depth.The nurse should apply oxygen and ventilation tothe client as appropriate. Other interventions, to becompleted after the airway has been established,include reorientation of the client to time, person,and place. Determining the client’s level of sleepinessis useful, but it is not a priority. Positioningthe client comfortably promotes rest but is of lessimportance than ascertaining that the airway : Reduction of risk potential;CL: Synthesize32. 4. Carbamazepine (Tegretol) is an anticonvulsantthat helps prevent further seizures. Bed rest,sedation (phenobarbital), and providing privacy donot minimize the risk of : Pharmacological and parenteraltherapies; CL: Synthesize33. 4. During a seizure, the nurse should notemovement of the client’s head and eyes and musclerigidity, especially when the seizure fi rst begins, toobtain clues about the location of the trigger focusin the brain. Other important assessments wouldinclude noting the progression and duration of theseizure, respiratory status, loss of consciousness,pupil size, and incontinence of urine and stool. It istypically not possible to assess the client’s pulse andblood pressure during a tonic-clonic seizure becausethe muscle contractions make assessment diffi -cult to impossible. The last dose of anticonvulsant medication can be evaluated later. The nurse shouldfocus on maintaining an open airway, preventinginjury to the client, and assessing the onset andprogression of the seizure to determine the type ofbrain activity involved. The type of aura should beassessed in the preictal phase of the : Physiological adaptation;CL: Analyze34. 1. The nurse should expect a client in thepostictal phase to experience drowsiness to somnolencebecause exhaustion results from the abnormalspontaneous neuron fi ring and tonic-clonic motorresponse. An inability to move a muscle part isnot expected after a tonic-clonic seizure because alack of motor function would be related to a complication,such as a lesion, tumor, or stroke, inthe correlating brain tissue. A change in sensationwould not be expected because this would indicatea complication such as an injury to the peripheralnerve pathway to the corresponding part from thecentral nervous system. Hypotension is not typicallya problem after a : Physiological adaptation;CL: Analyze35. 2. Anticonvulsant drug therapy should neverbe stopped suddenly; doing so can lead to lifethreateningstatus epilepticus. Phenytoin sodiumdoes not carry a risk of physical dependency or leadto hypoglycemia. Phenytoin has antiarrhythmicproperties, and discontinuation does not cause : Pharmacological and parenteraltherapies; CL: Apply36. 2. Specifi c motor vehicle regulations andrestrictions for people who experience seizures varylocally. Most commonly, evidence that the seizuresare under medical control is required before theperson is given permission to drive. Time of dayis not a consideration when determining drivingrestrictions related to seizures. The amount of timea person has been seizure-free is a consideration forlifting driving restrictions; however, the time frameis usually 2 years. It is recommended, not required,that a person who is subject to seizures carry a cardor wear an identifi cation bracelet describing the illnessto facilitate quick identifi cation in the event ofan : Reduction of risk potential;CL: Synthesize37. 3. An aura is a premonition of an impendingseizure. Auras usually are of a sensory nature (e.g.,an olfactory, visual, gustatory, or auditory sensation);some may be of a psychic nature. Evaluatingan aura may help identify the area of the brain fromwhich the seizure originates. Auras occur before a seizure, not during or after (postictal). They are notsimilar to hallucinations or amnesia or related : Physiological adaptation;CL: Synthesize38. 2. Toxic effects of topiramate (Topamax)include nephrolithiasis, and clients are encouragedto drink 6 to 8 glasses of water a day to dilutethe urine and fl ush the renal tubules to avoid stoneformation. Topiramate is taken in divided dosesbecause it produces drowsiness. Although eatingfresh fruits is desirable from a nutritional standpoint,this is not related to the topiramate. The drugdoes not have to be taken with : Pharmacological and parenteraltherapies; CL: Evaluate39. 3. A common adverse effect of long-termphenytoin therapy is an overgrowth of gingival tissues.Problems may be minimized with good oralhygiene, but in some cases, overgrown tissues mustbe removed surgically. Phenytoin does not causeweight gain, insomnia, or deteriorating : Pharmacological and parenteraltherapies; CL: Evaluate40. 1, 2, 3. The nurse should assess the numberand type of seizures the client has experienced sincestarting clonazepam monotherapy for seizure control.The nurse should also determine if the clientmight be pregnant because clonazepam crosses theplacental barrier. The nurse should also ask aboutthe client’s use of alcohol because alcohol potentiatesthe action of clonazepam. Although the nursemay want to check on the client’s diet or use of cigarettesfor health maintenance and promotion, suchinformation is not specifi cally related to : Pharmacological and parenteraltherapies; CL: EvaluateThe Client with a Stroke41. 15 pointsThe Glasgow Coma Scale provides three objectiveneurologic assessments: spontaneity of eye opening,best motor response, and best verbal response on ascale of 3 to 15. The client who scores the best on allthree assessments scores 15 : Management of care; CL: Apply42. 2, 3, 5. The maximum dosage of warfarinsodium (Coumadin) is not achieved until 3 to 4 daysafter starting the medication, and the effects of thedrug continue for 4 to 5 days after discontinuing themedication. The client should have his blood levels tested periodically to make sure that the desiredlevel is maintained. Warfarin has a peak actionof 9 hours. Vitamin K is the antidote for warfarin;protamine sulfate is the antidote for : Pharmacological and parenteraltherapies; CL: Evaluate43. 1. A helpless client should be positioned onthe side, not on the back, with the head on a smallpillow. A lateral position helps secretions escapefrom the throat and mouth, minimizing the risk ofaspiration. It may be necessary to suction the clientif he aspirates. Suction equipment should be nearby.It is safe to use a padded tongue blade, and theclient should receive oral care, including brushingwith a : Reduction of risk potential;CL: Synthesize44. 3. Studies show that clients who receiverecombinant t-PA treatment within 3 hours after theonset of a stroke have better outcomes. The timefrom the onset of a stroke to t-PA treatment is critical.A complete health assessment and history isnot possible when a client is receiving emergencycare. Upcoming surgical procedures may need tobe delayed because of the administration of t-PA,which is a priority in the immediate treatment ofthe current stroke. While the nurse should identifywhich medications the client is taking, it is moreimportant to know the time of the onset of thestroke to determine the course of action for administeringt-: Pharmacological and parenteraltherapies; CL: Synthesize45. 3. Control of blood pressure is critical duringthe fi rst 24 hours after treatment because an intracerebralhemorrhage is the major adverse effect ofthrombolytic therapy. Vital signs are monitored, andblood pressure is maintained as identifi ed by thephysician and specifi c to the client’s ischemic tissueneeds and risk of bleeding from treatment. The othervital signs are important, but the priority is to monitorblood : Reduction of risk potential;CL: Synthesize46. 2. It is crucial to monitor the pupil size andpupillary response to indicate changes around thecranial nerves. The cholesterol level is not a priorityassessment, although it may be an assessment to beaddressed for long-term healthy lifestyle rehabilitation.Bowel sounds need to be assessed because anileus or constipation can develop, but this is not apriority in the fi rst 24 hours, when the primary concernsare cerebral hemorrhage and increased intracranialpressure. An echocardiogram is not needed for the client with a thrombotic stroke without : Physiological adaptation;CL: Analyze47.2. Hyperoxygenate.1. Suction the airway.3. Suction the mouth.4. Provide sedation.Increased agitation with suctioning will increaseintracranial pressure (ICP), therefore sedationshould be provided fi rst. The client should behyperoxygenated before and after suctioning toprevent hypoxia since hypoxia causes vasodilationof the cerebral vessels and increases ICP. The airwayshould then be suctioned for no more than 10 seconds.The mouth can be suctioned once the airwayis clear to remove oral secretions. Once the mouth issuctioned the suction catheter should be : Physiological adaptation;CL: Synthesize48. 1. The primary reason for the nursing assessmentof a client’s functional status before and after astroke is to guide the plan. The assessment does nothelp to predict how far the rehabilitation team canhelp the client to recover from the residual effectsof the stroke, only what plans can help a client whohas moved from one functional level to another. Thenursing assessment of the client’s functional statusis not a motivating : Physiological adaptation; CL: Apply49. 2. Sliding a client on a sheet causes frictionand is to be avoided. Friction injures skin andpredisposes to pressure ulcer formation. Rolling theclient is an acceptable method to use when changingpositions as long as the client is maintained inanatomically neutral positions and her limbs areproperly supported. The client may be lifted as longas the nurse has assistance and uses proper bodymechanics to avoid injury to himself or herself orthe client. Having the client help lift herself off thebed with a trapeze is an acceptable means to move aclient without causing friction burns or skin : Reduction of risk potential;CL: Synthesize50. 3. The use of ankle-high tennis shoes hasbeen found to be most effective in preventing plantar fl exion (footdrop) because they add supportto the foot and keep it in the correct anatomicposition. Footboards stimulate spasms and are notroutinely recommended. Regular repositioning andrange-of-motion exercises are important interventions,but the client’s foot needs to be in the correctanatomic position to prevent overextension ofthe muscle and tendon. Massaging does not preventplantar fl exion and, if rigorous, could : Reduction of risk potential;CL: Synthesize51. 1, 2, 4. Placing a pillow in the axilla so thearm is away from the body keeps the arm abductedand prevents skin from touching skin to avoid skinbreakdown. Placing a pillow under the slightlyfl exed arm so the hand is higher than the elbowprevents dependent edema. Positioning a handcone (not a rolled washcloth) in the hand preventshand contractures. Immobilization of the extremitymay cause a painful shoulder-hand syndrome.Flexion contractures of the hand, wrist, and elbowcan result from immobility of the weak or paralyzedextremity. It is better to extend the arms to : Reduction of risk potential;CL: Synthesize52. 2. Expressive aphasia is a condition in whichthe client understands what is heard or written butcannot say what he or she wants to say. A communicationor picture board helps the client communicatewith others in that the client can point toobjects or activities that he or she : Physiological adaptation;CL: Synthesize53. 2. A client with dysphagia (diffi culty swallowing)commonly has the most diffi culty ingestingthin liquids, which are easily aspirated. Liquidsshould be thickened to avoid aspiration. Maintainingan upright position while eating is appropriatebecause it minimizes the risk of aspiration. Introducingfoods on the unaffected side allows theclient to have better control over the food bolus. Theclient should concentrate on chewing and swallowing;therefore, distractions should be : Safety and infection control;CL: Synthesize54. 2. Homonymous hemianopia is blindness inhalf of the visual fi eld; therefore, the client wouldsee only half of his plate. Eating only the food onhalf of the plate results from an inability to coordinatevisual images and spatial relationships. Theremay be an increased preference for foods high insalt after a stroke, but this would not be related tohomonymous hemianopia. Forgetting the names of foods would be aphasia, which involves a cerebralcortex lesion. Being unable to swallow liquidsis dysphagia, which involves motor pathways ofcranial nerves IX and X, including the lower : Physiological adaptation;CL: Analyze55. 4. To expand the visual fi eld, the partiallysighted client should be taught to turn the head fromside to side when walking. Neglecting to do so mayresult in accidents. This technique helps maximizethe use of remaining sight. Covering an eye with apatch will limit the fi eld of vision. Personal itemscan be placed within sight and reach, but mostaccidents occur from tripping over items that cannotbe seen. It may help the client to see the door, butwalking presents the primary safety : Reduction of risk potential;CL: Synthesize56. 3. A client who has brain damage may beemotionally labile and may cry or laugh for noexplainable reason. Crying is best dealt with byattempting to divert the client’s attention. Ignoringthe behavior will not affect the mood swing or thecrying and may increase the client’s sense of isolation.Telling the client to stop is : Psychosocial adaptation;CL: Synthesize57. 4, 5. When offering emotional support to aclient who is discouraged and has a negative selfconceptbecause of physical handicaps, the nurseshould approach the client with encouragementand patience. The client should be praised whenhe or she shows progress in efforts to overcomehandicaps. An attitude of helpfulness and sympathyallows the client to assume a role of someone notordinary, someone who is not like others. Regardlessof the handicap, the client still feels the same on theinside and has the same innate needs for his or hergrowth and developmental age-group. An attitude ofcharity tends to make the client feel like a “charitycase” or like someone who is given something freebecause of his “condition.” The client feels unequalto his peers or unable to fulfi ll the role relationshipsthat were obtained before the stroke. An approachusing fi rmness is inappropriate because it impliesthat the client can do better if he just tries harderand leaves no room for softness in the approach toovercoming a negative self-: Psychosocial adaptation;CL: Synthesize58. 2. The nurse should encourage the clientto write messages or use alternative forms of communicationto avoid frustration. Presenting onethought at a time decreases stimuli that may distract the client, as does speaking in a normal volume andtone. The nurse should ask the client to “show me”and should encourage the use of gestures to assist ingetting the message across with minimal frustrationand exhaustion for the : Psychosocial adaptation;CL: Synthesize59. 3. Thrombolytic enzyme agents are used forclients with a thrombotic stroke to dissolve emboli,thus reestablishing cerebral perfusion. They do notincrease vascular permeability, cause vasoconstriction,or prevent further : Pharmacological and parenteraltherapies; CL: EvaluateThe Client with Parkinson’s Disease60. 3, 4, 5. The nurse should contact the healthcare provider before administering Sinemet becausethis medication can cause further symptoms ofdepression. Suicide threats in clients with chronicillness should be taken seriously. The nurse shouldalso determine if the client is on an MAO inhibitorbecause concurrent use with Sinemet can cause ahypertensive crisis. Sinemet is not a treatment fordepression. Having the client discuss his feelings isappropriate when the prescription is fi : Pharmacological and parenteraltherapies; CL: Synthesize61. 2. The fi rst sign of Parkinson’s disease isusually tremors. The client commonly is the fi rst tonotice this sign because the tremors may be minimalat fi rst. Rigidity is the second sign, and bradykinesiais the third sign. Akinesia is a later stage : Physiological adaptation;CL: Analyze62. 3. The primary focus is on maintaining a safeenvironment because the client with Parkinson’sdisease usually has a propulsive gait, characterizedby a tendency to take increasingly quicker stepswhile walking. This type of gait commonly causesthe client to fall or to have trouble stopping. Theclient should maintain a balanced diet, enhance theimmune system, and enjoy diversional activities;however, safety is the primary : Reduction of risk potential;CL: Synthesize63. 2. Voluntary and purposeful movementsoften temporarily decrease or stop the tremorsassociated with Parkinson’s disease. In some clients,however, tremors may increase with voluntaryeffort. Tremors associated with Parkinson’s disease are not psychogenic but are related to an imbalancebetween dopamine and acetylcholine. Tremors cannotbe reduced by distracting the : Physiological adaptation;CL: Analyze64. 2. Demanding physical activity should beperformed during the peak action of drug therapy.Clients should be encouraged to maintain independencein self-care activities to the greatest extentpossible. Although some clients may have moreenergy in the morning or after rest, tremors are managedwith drug : Physiological adaptation;CL: Synthesize65. 4. Helping the client function at his or herbest is most appropriate and realistic. There is noknown cure for Parkinson’s disease. Parkinson’s diseaseprogresses in severity, and there is no knownway to stop its progression. Many clients live foryears with the disease, however, and it would notbe appropriate to start planning terminal care at : Physiological adaptation;CL: Synthesize66. 1. The primary goal of physical therapy andnursing interventions is to maintain joint fl exibilityand muscle strength. Parkinson’s diseaseinvolves a degeneration of dopamine-producingneurons; therefore, it would be an unrealistic goalto attempt to build muscles or increase endurance.The decrease in dopamine neurotransmitters resultsin ataxia secondary to extrapyramidal motor systemeffects. Attempts to reduce ataxia through physicaltherapy would not be : Physiological adaptation;CL: Synthesize67. 2. Levodopa is prescribed to decrease severemuscle rigidity. Levodopa does not improve mood,appetite, or alertness in a client with Parkinson’: Pharmacological and parenteraltherapies; CL: Evalulate68. 3. Vital signs should be monitored, especiallyduring periods of adjustment. Changes, such asorthostatic hypotension, cardiac irregularities, palpitations,and light-headedness, should be reportedimmediately. The client may actually experiencesuicidal or paranoid ideation instead of euphoria.The nurse should monitor the client for elevatedliver enzyme levels, such as lactate dehydrogenase,aspartate aminotransferase, alanine aminotransferase,blood urea nitrogen, and alkaline phosphatase,but the client should not be jaundiced. Theclient should not experience signs and symptoms of diabetes or a low serum glucose level, but the nurseshould check the hemoglobin and hematocrit : Pharmacological and parenteraltherapies; CL: Analyze69. 4. While the client is hospitalized for adjustmentof medication, it is essential that the medicationsbe administered exactly at the scheduledtime, for accurate evaluation of effectiveness. Forexample, levodopa-carbidopa (Sinemet) is taken individed doses over the day, not all at one time, foroptimum : Pharmacological and parenteraltherapies; CL: Apply70. 2. Ongoing self-care is a major focus forclients with Parkinson’s disease. The client shouldbe given additional time as needed and praised forher efforts to remain independent. Firmly telling theclient that she needs assistance will undermine herself-esteem and defeat her efforts to be independent.Telling the client that her perception is unrealisticdoes not foster hope in her ability to care for herself.Suggesting that the client modify her routine seemsto put the hospital or the nurse’s time schedulebefore the client’s needs. This will only decrease theclient’s self-esteem and her desire to try to continueself-care, which is obviously important to : Psychosocial adaptation;CL: Synthesize71. 1. The goal of a pallidotomy is to improvefunctional ability for the client with Parkinson’sdisease. This is a priority. The pallidotomy createslesions in the globus pallidus to control extrapyramidaldisorders that affect control of movementand gait. If functional ability is improved by thepallidotomy, the client may experience a secondaryresponse of an improved emotional response, butthis is not the primary goal of the surgical procedure.The procedure will not improve alertness : Basic care and comfort; CL: ApplyThe Client with Multiple Sclerosis72. 3. Symptoms that can occur with multiplesclerosis are muscle spasticity and weakness,fatigue, visual disturbances, hearing loss, and boweland bladder incontinence. Seizures are not associatedwith myelin : Management of care; CL: Evaluate73. 2, 3, 4, 5. Maintaining urinary function in aclient with neurogenic bladder dysfunction fromMS is an important goal. The client should ideallydrink 400 to 500 mL with each meal; 200 mL attempt to void at least every 2 hours to preventinfection and stone formation. The client may needto catheterize herself to drain residual urine in thebladder. Restricting fl uids during the day will notproduce suffi cient urine. However, in bladder trainingfor nighttime continence, the client may restrictfl uids for 1 to 2 hours before going to bed. The clientshould drink at least 2,000 mL every 24 : Physiological adaptation; CL: Create74. 2. With MS, hyperexcitability and euphoriamay occur, but because of muscle weakness, suddenbursts of energy are unlikely. Visual disturbances,weakness in the extremities, and loss of muscle toneand tremors are common symptoms of : Physiological adaptation;CL: Analyze75. 3. Baclofen is a centrally acting skeletal musclerelaxant that helps relieve the muscle spasmscommon in MS. Drowsiness is an adverse effect, anddriving should be avoided if the medication producesa sedative effect. Baclofen does not stimulatethe appetite or reduce bacteria in the : Pharmacological and parenteraltherapies; CL: Evaluate76. 2. Evaluating drug effectiveness is diffi cultbecause a high percentage of clients with MS exhibitunpredictable episodes of remission, exacerbation,and steady progress without apparent cause. Clientswith MS do not necessarily have increased intoleranceto drugs, nor do they endure long periods ofexacerbation before the illness responds to a particulardrug. Multiple drug use is not what makesevaluation of drug effectiveness diffi : Physiological adaptation;CL: Analyze77. 4. Asking a client to speak louder even whentired may aggravate the problem. Asking the clientto speak slowly and distinctly and to repeat hard-tounderstandwords helps the client to : Psychosocial adaptation;CL: Synthesize78. 4. The nurses’ notes should be concise,objective, clearly stated, and relevant. This clienttrembles when she attempts voluntary actions, suchas drinking a beverage or fastening clothing. Thisactivity should be described exactly as it occursso that others reading the note will have no doubtabout the nurse’s observation of the client’s behavior.Identifying the “intentional” activity of daily livingwill help the interdisciplinary team individualizethe client’s plan of care. Clarifying what is meantby “worsening” with a purposeful act will facilitate the inter-rater reliability of the team. It is better tostate what the client did than to give vague nursingorders in the nurses’ : Management of care; CL: Apply79. 4. Limiting fl uid intake is likely to aggravaterather than relieve symptoms when a bowel retrainingprogram is being implemented. Furthermore,water imbalance, as well as electrolyte imbalance,tends to aggravate the signs and symptoms of MS. Adiet high in fi ber helps keep bowel movements regular.Setting a regular time each day for eliminationhelps train the body to maintain a schedule. Usingan elevated toilet seat facilitates transfer of the clientfrom the wheelchair to the toilet or from a standingto a sitting : Physiological adaptation;CL: Synthesize80. 3. MS is a progressive, chronic neurologicdisease characterized by patchy demyelinationthroughout the central nervous system. This interfereswith the transmission of electrical impulsesfrom one nerve cell to the next. MS affects speech,coordination, and vision, but not cognition. Care forthe client with MS is directed toward maintainingjoint mobility, preventing deformities, maintainingmuscle strength, rehabilitation, preventing and treatingdepression, and providing client : Reduction of risk potential;CL: Synthesize81. 2. The nurse’s most positive approach is toencourage a client with MS to keep active, use stressreduction strategies, and avoid fatigue because itis important to support the immune system whileremaining active. A quiet, inactive lifestyle is notnecessarily indicated. Good health habits are notlikely to alter the course of the disease, althoughthey may help minimize complications. Practicingusing aids that will be needed for future disabilitiesmay be helpful but also can be : Physiological adaptation;CL: Synthesize82. 1, 3, 4, 5. A client with impaired peripheralsensation does not feel pain as readily as someonewhose sensation is unimpaired; therefore, watertemperatures should be tested carefully. The clientshould be advised to avoid using hot water bottlesor heating pads and to protect against cold temperatures.Because the client cannot rely on minorpain as an indicator of damaged skin or sore spots,the client should carefully inspect the skin daily tovisualize any injuries that he cannot feel. The clientshould not be instructed to avoid kitchen activitiesout of fear of injury; independence and selfcareare also important. However, the client shouldmeet with an occupational therapist to learn about assistive devices and techniques that can reduceinjuries, such as burns and cuts that are common inkitchen : Reduction of risk potential;CL: Create83. 3. Maintaining a regular voiding patternis the most appropriate measure to help the clientavoid urinary incontinence. Fluid intake is notrelated to incontinence. Incontinence is related tothe strength of the detrusor and urethral sphinctermuscles. Inserting an indwelling catheter would bea treatment of last resort because of the increasedrisk of infection. If catheterization is required, intermittentself-catheterization is preferred because ofits lower risk of infection. Antibiotics do not infl uenceurinary : Physiological adaptation;CL: Synthesize84. 2. An individualized regular exercise programhelps the client to relieve muscle spasms. Theclient can be trained to use unaffected muscles topromote coordination because MS is a progressive,debilitating condition. The data do not indicate thatthe client needs psychotherapy, day care for thegranddaughter, or visits from other : Physiological adaptation;CL: SynthesizeThe Unconscious Client85. 3. Activated charcoal powder is administeredto absorb remaining particles of salicylate. VitaminK is an antidote for warfarin sodium (Coumadin).Dextrose 50% is used to treat hypoglycemia.Sodium thiosulfate is an antidote for : Pharmacological and parenteraltherapies; CL: Synthesize86. 2, 3, 4. An excess of cholinergic agentsproduce urinary and fecal incontinence, increasedsalivation, diarrhea, and diaphoresis. In a severeoverdose, CNS depression, seizures and musclefasciculations, bradycardia or tachycardia, weakness,and respiratory arrest due to respiratorymuscle paralysis occur. Anticholinergics producedry mucous membranes. Skin rash is not a sign ofoverdose with a cholinergic : Pharmacological and parenteraltherapies; CL: Analyze87. 3. The initial response to crisis is highanxiety. Anxiety must dissipate before a personcan deal with the actual situation. Allowing familymembers to ventilate their feelings can help diffusetheir anxiety. The reasons for the client’s actions are unknown; assumptions must be validated beforethey become facts. Touch can be appropriate but notwhen it is used as false reassurance. Helping withthe client’s care is appropriate at a later : Psychosocial adaptation;CL: Synthesize88. 3. Maintaining intact skin is a priority forthe unconscious client. Unconscious clients needto be turned every hour to prevent complicationsof immobility, which include pressure ulcers andstasis pneumonia. The unconscious client cannot beeducated at this time. Pain is not a concern. Duringthe fi rst 24 hours, the unconscious client will mostlylikely be on nothing-by-mouth : Reduction of risk potential;CL: Synthesize89. 2. The nurse must clean the unconsciousclient’s mouth carefully, apply a thin coat of petroleumjelly, and move the endotracheal tube to theopposite side daily to prevent dryness, crusting,infl ammation, and parotiditis. The unconsciousclient’s temperature should be monitored by a routeother than the oral route (e.g., rectal, tympanic)because oral temperatures will be inaccurate. Theclient should be positioned in a lateral or semiproneposition, not a supine position, to allow for drainageof secretions and for the jaw and tongue to fallforward. The client should not be dragged whenturned, as may happen when a drawsheet is used.Care should be taken to lift the client’s heels, buttocks,arms, and head off of the sheets when turning.Trochanter rolls, splints, foam boot aids, specialtybeds, and so on—not just two pillows—should beused to keep the client in correct body position andto decrease pressure on bony : Reduction of risk potential;CL: Synthesize90. 3. The client is not in proper body alignmentif, when in the right side-lying position, the client’sleft arm rests on the mattress with the elbow fl exed.This positioning of the arm pulls the left shoulderout of good alignment, restricting respiratory movements.The arm should be supported on a pillow.The client’s head also should be placed on a smallpillow to keep it in alignment with the body. Theright leg should be extended on the mattress withouta pillow to avoid hyperrotation of the hip. Apillow should be placed between the left and rightlegs with the left knee fl exed so that on no parts ofthe legs is skin touching : Physiological adaptation;CL: Synthesize91. 4. The goal of performing passive ROM exercisesis to maintain joint mobility. Active exercise isneeded to preserve bone and muscle mass. Passive ROM movements do not prevent bone demineralizationor have a positive effect on the client’s : Physiological adaptation;CL: Evaluate92. 1. Maintaining a patent airway is the priority.Therefore, the nurse should keep suction equipmentavailable to remove secretions. The clientshould be placed in a side-lying, not prone, position.Performing oral hygiene is a clean procedure;therefore, the nurse wears clean gloves, not sterilegloves. The nurse should never place any fi ngers inan unconscious client’s mouth; the client may bitedown. Padded tongue blades, swabs, or a toothbrushshould be used instead; but maintaining the airwayis the : Physiological adaptation;CL: Synthesize93. 2. When the blink refl ex is absent or the eyesdo not close completely, the cornea may become dryand irritated. Corneal abrasion can occur. Tapingthe eye closed will prevent injury. Having the clientwear eyeglasses or cleaning the eyelid will not protectthe cornea from dryness or irritation. Artifi cialtears instilled once per shift are not frequent enoughfor preventing : Reduction of risk potential;CL: Synthesize94. 3. Restlessness is an early indicator ofhypoxia. The nurse should suspect hypoxia in theunconscious client who becomes restless. The mostaccurate method for determining the presence ofhypoxia is to evaluate the pulse oximeter value orarterial blood gas values. Cyanosis and decreasedrespirations are late indicators of hypoxia. Hypertension,not hypotension, is a sign of : Physiological adaptation;CL: Apply95. 2. The client should be placed in a semi-Fowler’s position to reduce the risk of aspiration.The formula should be at room temperature, notheated. Administering enteral tube feedings is aclean procedure, not a sterile one; therefore, sterilesupplies are not required. Clients receiving enteralfeedings should be weighed regularly, but not necessarilybefore each : Reduction of risk potential;CL: Synthesize96. 4. Gastric residuals are checked beforeadministration of enteral feedings to determinewhether gastric emptying is delayed. A residualof less than 50% of the previous feeding volumeis usually considered acceptable. In this case, theamount is not excessive and the nurse should reinstill the aspirate through the tube and thenadminister the feeding. If the amount of gastricresidual is excessive, the nurse should notify thephysician and withhold the feeding. Disposing ofthe residual can cause electrolyte and fl uid : Reduction of risk potential;CL: Synthesize97. 1. Good catheter care, including meticulouscleaning of the area around the urethral meatus, isthe highest priority for the client with an indwellingcatheter. Clamping an indwelling catheter isnot recommended. Irrigation of the catheter, whichrequires breaking the closed system, is not recommended.Manipulation of the catheter taped to theclient’s leg causes trauma to the urethral meatus,which can predispose the client to an infection andis also not : Reduction of risk potential;CL: Synthesize98. 2, 3, 4. A client who is brain dead typicallydemonstrates nonreactive dilated pupils and nonreactiveor absent corneal and gag refl exes. The clientmay still have spinal refl exes, such as deep tendonand Babinski refl exes, in brain death. Decerebrateor decorticate posturing would not be seen. Clientswho are brain dead do not have a blink refl : Physiological adaptation;CL: ApplyThe Client in Pain99. 2. Morphine 2 mg was given 1 hour agoand the client can have up to 4 mg every 2 hours.Although the pain level is at 1, the nurse shouldgive medication prior to the dressing change withpacking that is likely to cause discomfort. A 4 mgdose of morphine would exceed the 2 hour limitand, if given after the dressing change, would notmanage pain during the procedure. The client hasbeen responding to the pain medication dosing anda new order is not required at this : Management of care;CL: Synthesize100. 1. Pain perception is an individual experience.Research indicates that pain tolerance andperception vary widely among individuals, evenwithin : Psychosocial adaptation;CL: Synthesize101. 1. Experience has demonstrated that clientswho feel confi dence in the persons who are caringfor them do not require as much therapy for painrelief as those who have less confi dence. Without the client’s confi dence, developed in an effectivenurse-client relationship, other interventions may beless effective. The client’s family can be an importantsource of support, but it is the nurse who plansstrategies for pain relief. The client may require timeto adjust to the pain, but the nurse and client cancollaborate to try to evaluate a variety of pain reliefstrategies. Arranging for the client to share a roomwith another client who has little pain may havenegative effects on the client who has pain that isdiffi cult to : Basic care and comfort;CL: Synthesize102. 4. Although meperidine hydrochloride canbe given orally, it is more effective when given intramuscularly.The equianalgesic dose of oral meperidineis up to four times the I.M. dose (75 × 4 = 300).CN: Pharmacological and parenteraltherapies; CL: Apply103. 1. Opioid analgesics relieve pain by reducingor altering the perception of pain. Meperidinehydrochloride does not decrease the sensitivity ofpain receptors, interfere with pain impulses travelingalong sensory nerve fi bers, or block the conductionof pain impulses in the central nervous : Pharmacological and parenteraltherapies; CL: Evaluate104. 3. The client’s innate responses to pain aredirected initially toward escaping from the source ofpain. Variations in tolerance and perception of painare apparent only in conscious clients, and onlyconscious clients can employ distraction to helprelieve : Physiological adaptation; CL: Apply105. 1. Ergotamine tartrate is used to help abort amigraine attack. It should be taken as soon as prodromalsymptoms appear. Reduced migraine severityand relief from sleeplessness and vision problemsaddress symptoms that occur after the migrainehas occurred and are not effects of : Pharmacological and parenteraltherapies; CL: Evaluate106. 4. Biofeedback translates body processesinto observable signs so that the client can developsome control over certain body processes. Biofeedbackdoes not involve electrical stimulation. Use ofunpleasant stimuli such as electrical shock is a formof aversion therapy. Biofeedback does not involvemonitoring body processes for the therapist to interpret;rather, it is a self-directed, self-care activitythat reinforces learning because the client can seethe results of his : Psychosocial adaptation; CL: Apply107. 1. A back rub stimulates the large-diametercutaneous fi bers, which block transmission ofpain impulses from the spinal cord to the brain. Itdoes not block the transmission of pain impulsesor stimulate the release of endorphins. A back rubmay distract the client, but the physiologic processof fi ber stimulation is the main reason a back rub isused as therapy for pain : Basic care and comfort;CL: Apply108. 2. It is essential that the nurse document theclient’s response to pain medication on a routine,systematic basis. Reassuring the client that pain willbe relieved is often not realistic. A client who continuallypresses the PCA button may not be gettingadequate pain relief, but through careful assessmentand documentation, the effectiveness of pain reliefinterventions can be evaluated and modifi ed. Painmedication is not titrated until the client is free frompain but rather until an acceptable level of painmanagement is : Pharmacological and parenteraltherapies; CL: Synthesize109. 1. An epidural catheter is used for postoperativepain management to block the pain sensationbelow the point of insertion. If the client is ratingpain high, the PCA pump may be malfunctioning,the catheter may have become misplaced, or theamount of medication may not be suffi cient. Thenurse should fi rst check the PCA pump to determineif it is functioning properly. Assessing vital signswould be important to provide additional data aboutthe possible cause of pain. The catheter placement,including removing the dressing or manipulatingthe catheter, and drug dosage are the responsibilityof the physician, usually an anesthesiologist, whoinserted the catheter. This person should be contactedif the PCA pump is functioning appropriately.The epidural catheter lies just above the dura of thespinal space. Infection, hypotension, and loss ofmental alertness are just a few of the complicationsthat can occur if the catheter is pushed through : Pharmacological and parenteraltherapies; CL: Synthesize110. 1. The nurse using healing touch affects a client’spain primarily through assessing and directingthe fl ow of energy fi elds. Healing touch can involvetouching, but it does not have to involve body contact.Massage and hypnosis are not parts of : Physiological adaptation;CL: ApplyManaging Care Quality and Safety111. 3. Pulling the client up under the arm cancause shoulder displacement. A belt around thewaist should be used to move the client. Passiverange of motion exercises prevents contractures andatrophy. Raising the foot of the bed assists in venousreturn to reduce edema. High top tennis shoes areused to prevent foot : Management of care; CL: Synthesize112. 3. Clients with Parkinson’s disease can experiencedysphagia. Thickening liquids assists withswallowing, preventing aspiration. Hyperextendingthe neck opens the airway and can increase riskof aspiration. Pressing the chin fi rmly on the chestmakes swallowing more diffi cult. The chin shouldbe slightly tucked to promote swallowing. The nurseshould suggest a speech therapy consult for evaluationof the client’s ability to : Safety and infection control;CL: Synthesize113. 2. Clients with Parkinson’s disease may experiencea freezing gait when they are unable to moveforward. Instructing the client to march in place,step over lines in the fl ooring, or visualize steppingover a log allows them to move forward. It is importantto ambulate the client and not keep them onbedrest. A muscle relaxant is not : Management of care; CL: Synthesize114. 1, 2, 3, 7. Pressure points in the side-lyingposition include the ears, shoulders, ribs, greatertrochanter, medial or lateral condyles, and ankles.The sacrum, occiput, and heels are pressure pointareas affected in the supine : Safety and infection control;CL: Analyze115. 4. All health care facilities in which controlledmedications (Schedules II, III, and IV) arestored for dispensing and/or administration to clientsare required to follow procedures for the propermaintenance of narcotic inventory. Narcotic inventorymaintenance includes, but is not limited to, alldiscrepancies will have thorough and appropriatedocumentation with accompanying reasons (.i.e.,tablet/amp/vial breakage, additional medicationvolume, etc.), timely resolution of inventory discrepancies,and timely notifi cation regarding controlledsubstance inventory discrepancies of personsin oversight areas (i.e., Pharmacy, Security, NursingHouse Supervisor). In the event of a signifi cant incident,the proper external authorities will be notifi ed(i.e., DEA, local police department) by the Qualityand Risk Management/Legal : Pharmacological and parenteraltherapies; CL: Synthesize ................
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