Questions
2. The nurse is teaching a female client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to:
a. take a hot bath.
b. rest in an air-conditioned room
c. increase the dose of muscle relaxants.
d. avoid naps during the day
3. A male client is having a tonic-clonic seizures. What should the nurse do first?
a. Elevate the head of the bed.
b. Restrain the client’s arms and legs.
c. Place a tongue blade in the client’s mouth.
d. Take measures to prevent injury.
4. A female client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?
a. “You may have difficulty believing this, but the paralysis caused by this disease is temporary.”
b. “You’ll have to accept the fact that you’re permanently paralyzed. However, you won’t have any sensory loss.”
c. “It must be hard to accept the permanency of your paralysis.”
d. “You’ll first regain use of your legs and then your arms.”
5. The nurse is working on a surgical floor. The nurse must logroll a male client following a:
a. laminectomy.
b. thoracotomy.
c. hemorrhoidectomy.
d. cystectomy.
6. A female client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test?
a. Immobilize the neck before the client is moved onto a stretcher.
b. Determine whether the client is allergic to iodine, contrast dyes, or shellfish.
c. Place a cap over the client’s head.
d. Administer a sedative as ordered.
7. During a routine physical examination to assess a male client’s deep tendon reflexes, the nurse should make sure to:
a. use the pointed end of the reflex hammer when striking the Achilles tendon.
b. support the joint where the tendon is being tested.
c. tap the tendon slowly and softly
d. hold the reflex hammer tightly.
8. A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority in this client’s plan of care?
a. Disturbed sensory perception (visual)
b. Self-care deficient: Dressing/grooming
c. Impaired verbal communication
d. Risk for injury
9. A female client with amyotrophic lateral sclerosis (ALS) tells the nurse, “Sometimes I feel so frustrated. I can’t do anything without help!” This comment best supports which nursing diagnosis?
a. Anxiety
b. Powerlessness
c. Ineffective denial
d. Risk for disuse syndrome
10. For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to:
a. prevent respiratory alkalosis.
b. lower arterial pH.
c. promote carbon dioxide elimination.
d. maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg
12. The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use which plan to use which of the following to test the client’s peripheral response to pain?
a. Sternal rub
b. Nail bed pressure
c. Pressure on the orbital rim
d. Squeezing of the sternocleidomastoid muscle
13. A female client admitted to the hospital with a neurological problem asks the nurse whether magnetic resonance imaging may be done. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the client’s history of:
a. Hypertension
b. Heart failure
c. Prosthetic valve replacement
d. Chronic obstructive pulmonary disorder
14. A male client is having a lumbar puncture performed. The nurse would plan to place the client in which position?
a. Side-lying, with a pillow under the hip
b. Prone, with a pillow under the abdomen
c. Prone, in slight-Trendelenburg’s position
d. Side-lying, with the legs pulled up and head bent down onto chest.
15. The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid?
a. Head mildline
b. Head turned to the side
c. Neck in neutral position
d. Head of bed elevated 30 to 45 degrees
16. A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid:
a. Is clear and tests negative for glucose
b. Is grossly bloody in appearance and has a pH of 6
c. Clumps together on the dressing and has a pH of 7
d. Separates into concentric rings and test positive of glucose
Answers/Rationale
2. Answer B. Fatigue is a common symptom in clients with multiple sclerosis. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness and fatigue. Planning for frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with multiple sclerosis include treating depression, using occupational therapy to learn energy conservation techniques, and reducing spasticity.
3. Answer D. Protecting the client from injury is the immediate priority during a seizure. Elevating the head of the bed would have no effect on the client’s condition or safety. Restraining the client’s arms and legs could cause injury. Placing a tongue blade or other object in the client’s mouth could damage the teeth.
4. Answer A. The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs.
5. Answer A. The client who has had spinal surgery, such as laminectomy, must be logrolled to keep the spinal column straight when turning. The client who has had a thoracotomy or cystectomy may turn himself or may be assisted into a comfortable position. Under normal circumstances, hemorrhoidectomy is an outpatient procedure, and the client may resume normal activities immediately after surgery.
6. Answer B. Because CT commonly involves use of a contrast agent, the nurse should determine whether the client is allergic to iodine, contrast dyes, or shellfish. Neck immobilization is necessary only if the client has a suspected spinal cord injury. Placing a cap over the client’s head may lead to misinterpretation of test results; instead, the hair should be combed smoothly. The physician orders a sedative only if the client can’t be expected to remain still during the CT scan.
7. Answer B. To prevent the attached muscle from contracting, the nurse should support the joint where the tendon is being tested. The nurse should use the flat, not pointed, end of the reflex hammer when striking the Achilles tendon. (The pointed end is used to strike over small areas, such as the thumb placed over the biceps tendon.) Tapping the tendon slowly and softly wouldn’t provoke a deep tendon reflex response. The nurse should hold the reflex hammer loosely, not tightly, between the thumb and fingers so it can swing in an arc.
8. Answer D. Because the client is disoriented and restless, the most important nursing diagnosis is risk for injury. Although the other options may be appropriate, they’re secondary because they don’t immediately affect the client’s health or safety.
9. Answer B. This comment best supports a nursing diagnosis of Powerlessness because ALS may lead to locked-in syndrome, characterized by an active and functioning mind locked in a body that can’t perform even simple daily tasks. Although Anxiety and Risk for disuse syndrome may be diagnoses associated with ALS, the client’s comment specifically refers to an inability to act autonomously. A diagnosis of Ineffective denial would be indicated if the client didn’t seem to perceive the personal relevance of symptoms or danger.
10. Answer C. The goal of treatment is to prevent acidemia by eliminating carbon dioxide. That is because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP. Preventing respiratory alkalosis and lowering arterial pH may bring about acidosis, an undesirable condition in this case. It isn’t necessary to maintain a PaO2 as high as 80 mm Hg; 60 mm Hg will adequately oxygenate most clients.
11. Answer C. If a neck injury is suspected, the jaw thrust maneuver is used to open the airway. The head tilt–chin lift maneuver produces hyperextension of the neck and could cause complications if a neck injury is present. A flexed position is an inappropriate position for opening the airway.
12. Answer B. Motor testing in the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. Cerebral responses to pain are tested using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.
13. Answer C. The client having a magnetic resonance imaging scan has all metallic objects removed because of the magnetic field generated by the device. A careful history is obtained to determine whether any metal objects are inside the client, such as orthopedic hardware, pacemakers, artificial heart valves, aneurysm clips, or intrauterine devices. These may heat up, become dislodged, or malfunction during this procedure. The client may be ineligible if significant risk exists.
14. Answer D. The client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen and the head bent down onto the chest. This position helps open the spaces between the vertebrae.
15. Answer B. The head of the client with increased intracranial pressure should be positioned so the head is in a neutral midline position. The nurse should avoid flexing or extending the client’s neck or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure down.
16. Answer D. Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.
Resource: http://nclexreviews.com
Earliest to late: 5 signs and symptoms of increased ICP
1. Altered LOC
2. Behavior Change
3. Blurred Vision/Decreased visual acuity/Diplopia
4. Headache
5. Papilledema
6. Vomiting
7. Cushind Triad: Increased systolic BP with unchanged diastolic BP, widening pulse pressure, and reflex bradycardia
Positions Contraindicated in a patient with Increased ICP
1. HOB higher than 30°
2. Extreme hip and neck flexion
3. Trendelenberg position
2. The nurse is teaching a female client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to:
a. take a hot bath.
b. rest in an air-conditioned room
c. increase the dose of muscle relaxants.
d. avoid naps during the day
3. A male client is having a tonic-clonic seizures. What should the nurse do first?
a. Elevate the head of the bed.
b. Restrain the client’s arms and legs.
c. Place a tongue blade in the client’s mouth.
d. Take measures to prevent injury.
4. A female client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?
a. “You may have difficulty believing this, but the paralysis caused by this disease is temporary.”
b. “You’ll have to accept the fact that you’re permanently paralyzed. However, you won’t have any sensory loss.”
c. “It must be hard to accept the permanency of your paralysis.”
d. “You’ll first regain use of your legs and then your arms.”
5. The nurse is working on a surgical floor. The nurse must logroll a male client following a:
a. laminectomy.
b. thoracotomy.
c. hemorrhoidectomy.
d. cystectomy.
6. A female client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test?
a. Immobilize the neck before the client is moved onto a stretcher.
b. Determine whether the client is allergic to iodine, contrast dyes, or shellfish.
c. Place a cap over the client’s head.
d. Administer a sedative as ordered.
7. During a routine physical examination to assess a male client’s deep tendon reflexes, the nurse should make sure to:
a. use the pointed end of the reflex hammer when striking the Achilles tendon.
b. support the joint where the tendon is being tested.
c. tap the tendon slowly and softly
d. hold the reflex hammer tightly.
8. A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority in this client’s plan of care?
a. Disturbed sensory perception (visual)
b. Self-care deficient: Dressing/grooming
c. Impaired verbal communication
d. Risk for injury
9. A female client with amyotrophic lateral sclerosis (ALS) tells the nurse, “Sometimes I feel so frustrated. I can’t do anything without help!” This comment best supports which nursing diagnosis?
a. Anxiety
b. Powerlessness
c. Ineffective denial
d. Risk for disuse syndrome
10. For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to:
a. prevent respiratory alkalosis.
b. lower arterial pH.
c. promote carbon dioxide elimination.
d. maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg
12. The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use which plan to use which of the following to test the client’s peripheral response to pain?
a. Sternal rub
b. Nail bed pressure
c. Pressure on the orbital rim
d. Squeezing of the sternocleidomastoid muscle
13. A female client admitted to the hospital with a neurological problem asks the nurse whether magnetic resonance imaging may be done. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the client’s history of:
a. Hypertension
b. Heart failure
c. Prosthetic valve replacement
d. Chronic obstructive pulmonary disorder
14. A male client is having a lumbar puncture performed. The nurse would plan to place the client in which position?
a. Side-lying, with a pillow under the hip
b. Prone, with a pillow under the abdomen
c. Prone, in slight-Trendelenburg’s position
d. Side-lying, with the legs pulled up and head bent down onto chest.
15. The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid?
a. Head mildline
b. Head turned to the side
c. Neck in neutral position
d. Head of bed elevated 30 to 45 degrees
16. A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid:
a. Is clear and tests negative for glucose
b. Is grossly bloody in appearance and has a pH of 6
c. Clumps together on the dressing and has a pH of 7
d. Separates into concentric rings and test positive of glucose
Answers/Rationale
2. Answer B. Fatigue is a common symptom in clients with multiple sclerosis. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness and fatigue. Planning for frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with multiple sclerosis include treating depression, using occupational therapy to learn energy conservation techniques, and reducing spasticity.
3. Answer D. Protecting the client from injury is the immediate priority during a seizure. Elevating the head of the bed would have no effect on the client’s condition or safety. Restraining the client’s arms and legs could cause injury. Placing a tongue blade or other object in the client’s mouth could damage the teeth.
4. Answer A. The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs.
5. Answer A. The client who has had spinal surgery, such as laminectomy, must be logrolled to keep the spinal column straight when turning. The client who has had a thoracotomy or cystectomy may turn himself or may be assisted into a comfortable position. Under normal circumstances, hemorrhoidectomy is an outpatient procedure, and the client may resume normal activities immediately after surgery.
6. Answer B. Because CT commonly involves use of a contrast agent, the nurse should determine whether the client is allergic to iodine, contrast dyes, or shellfish. Neck immobilization is necessary only if the client has a suspected spinal cord injury. Placing a cap over the client’s head may lead to misinterpretation of test results; instead, the hair should be combed smoothly. The physician orders a sedative only if the client can’t be expected to remain still during the CT scan.
7. Answer B. To prevent the attached muscle from contracting, the nurse should support the joint where the tendon is being tested. The nurse should use the flat, not pointed, end of the reflex hammer when striking the Achilles tendon. (The pointed end is used to strike over small areas, such as the thumb placed over the biceps tendon.) Tapping the tendon slowly and softly wouldn’t provoke a deep tendon reflex response. The nurse should hold the reflex hammer loosely, not tightly, between the thumb and fingers so it can swing in an arc.
8. Answer D. Because the client is disoriented and restless, the most important nursing diagnosis is risk for injury. Although the other options may be appropriate, they’re secondary because they don’t immediately affect the client’s health or safety.
9. Answer B. This comment best supports a nursing diagnosis of Powerlessness because ALS may lead to locked-in syndrome, characterized by an active and functioning mind locked in a body that can’t perform even simple daily tasks. Although Anxiety and Risk for disuse syndrome may be diagnoses associated with ALS, the client’s comment specifically refers to an inability to act autonomously. A diagnosis of Ineffective denial would be indicated if the client didn’t seem to perceive the personal relevance of symptoms or danger.
10. Answer C. The goal of treatment is to prevent acidemia by eliminating carbon dioxide. That is because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP. Preventing respiratory alkalosis and lowering arterial pH may bring about acidosis, an undesirable condition in this case. It isn’t necessary to maintain a PaO2 as high as 80 mm Hg; 60 mm Hg will adequately oxygenate most clients.
11. Answer C. If a neck injury is suspected, the jaw thrust maneuver is used to open the airway. The head tilt–chin lift maneuver produces hyperextension of the neck and could cause complications if a neck injury is present. A flexed position is an inappropriate position for opening the airway.
12. Answer B. Motor testing in the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. Cerebral responses to pain are tested using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.
13. Answer C. The client having a magnetic resonance imaging scan has all metallic objects removed because of the magnetic field generated by the device. A careful history is obtained to determine whether any metal objects are inside the client, such as orthopedic hardware, pacemakers, artificial heart valves, aneurysm clips, or intrauterine devices. These may heat up, become dislodged, or malfunction during this procedure. The client may be ineligible if significant risk exists.
14. Answer D. The client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen and the head bent down onto the chest. This position helps open the spaces between the vertebrae.
15. Answer B. The head of the client with increased intracranial pressure should be positioned so the head is in a neutral midline position. The nurse should avoid flexing or extending the client’s neck or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure down.
16. Answer D. Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.
Resource: http://nclexreviews.com
Earliest to late: 5 signs and symptoms of increased ICP
1. Altered LOC
2. Behavior Change
3. Blurred Vision/Decreased visual acuity/Diplopia
4. Headache
5. Papilledema
6. Vomiting
7. Cushind Triad: Increased systolic BP with unchanged diastolic BP, widening pulse pressure, and reflex bradycardia
Positions Contraindicated in a patient with Increased ICP
1. HOB higher than 30°
2. Extreme hip and neck flexion
3. Trendelenberg position