If a male client experienced a cerebrovascular accident (CVA) that damaged
the hypothalamus, the nurse ould anticipate that the client has problems ith! a. body temperature control. b. balance and e"uilibrium. c. visual acuity. d. thin#ing and reasoning. $. A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (IC%). &he client is intubated and placed on mechanical ventilation to help reduce IC%. &o prevent a further rise in IC% caused by suctioning, the nurse anticipates administering hich drug endotracheally before suctioning' a. phenytoin ((ilantin) b. mannitol ()smitrol) c. lidocaine (*ylocaine) d. furosemide (+asix) ,. After stri#ing his head on a tree hile falling from a ladder, a young man age 1- is admitted to the emergency department. .e/s unconscious and his pupils are nonreactive. 0hich intervention ould be the most dangerous for the client' a. 1ive him a barbiturate. b. %lace him on mechanical ventilation. c. %erform a lumbar puncture. d. 2levate the head of his bed. 3. 0hen obtaining the health history from a male client ith retinal detachment, the nurse expects the client to report! a. light flashes and floaters in front of the eye. b. a recent driving accident hile changing lanes. c. headaches, nausea, and redness of the eyes. d. fre"uent episodes of double vision. 4. 0hich nursing diagnosis ta#es highest priority for a client ith %ar#inson/s crisis' a. Imbalanced nutrition! +ess than body re"uirements b. Ineffective airay clearance c. Impaired urinary elimination d. 5is# for in6ury 7. &o encourage ade"uate nutritional inta#e for a female client ith Al8heimer/s disease, the nurse should! a. stay ith the client and encourage him to eat. b. help the client fill out his menu. c. give the client privacy during meals. d. fill out the menu for the client. 9. &he nurse is performing a mental status examination on a male client diagnosed ith subdural hematoma. &his test assesses hich of the folloing' a. Cerebellar function b. Intellectual function c. Cerebral function d. :ensory function -. :hortly after admission to an acute care facility, a male client ith a sei8ure disorder develops status epilepticus. &he physician orders dia8epam (Valium) 1; mg I.V. stat. .o soon can the nurse administer a second dose of dia8epam, if needed and prescribed' a. In ,; to 34 seconds b. In 1; to 14 minutes c. In ,; to 34 minutes d. In 1 to $ hours <. A female client complains of periorbital aching, tearing, blurred vision, and photophobia in her right eye. )phthalmologic examination reveals a small, irregular, nonreactive pupil = a condition resulting from acute iris inflammation (iritis). As part of the client/s therapeutic regimen, the physician prescribes atropine sulfate (Atropisol), to drops of ;.4> solution in the right eye tice daily. Atropine sulfate belongs to hich drug classification' a. %arasympathomimetic agent b. :ympatholytic agent c. Adrenergic bloc#er d. Cholinergic bloc#er 1;. 2mergency medical technicians transport a $9?year?old iron or#er to the emergency department. &hey tell the nurse, @.e fell from a to?story building. .e has a large contusion on his left chest and a hematoma in the left parietal area. .e has a compound fracture of his left femur and he/s comatose. 0e intubated him and he/s maintaining an arterial oxygen saturation of <$> by pulse oximeter ith a manual?resuscitation bag.A 0hich intervention by the nurse has the highest priority' a. Assessing the left leg b. Assessing the pupils c. %lacing the client in &rendelenburg/s position d. Assessing level of consciousness 11. An auto mechanic accidentally has battery acid splashed in his eyes. .is coor#ers irrigate his eyes ith ater for $; minutes, and then ta#e him to the emergency department of a nearby hospital, here he receives emergency care for corneal in6ury. &he physician prescribes dexamethasone (Baxidex )phthalmic :uspension), to drops of ;.1> solution to be instilled initially into the con6unctival sacs of both eyes every hourC and polymyxin D sulfate (Eeosporin )phthalmic), ;.4> ointment to be placed in the con6unctival sacs of both eyes every , hours. (examethasone exerts its therapeutic effect by! a. increasing the exudative reaction of ocular tissue. b. decreasing leu#ocyte infiltration at the site of ocular inflammation. c. inhibiting the action of carbonic anhydrase. d. producing a miotic reaction by stimulating and contracting the sphincter muscles of the iris. 1$. Eurse April is caring for a client ho underent a lumbar laminectomy $ days ago. 0hich of the folloing findings should the nurse consider abnormal' a. Bore bac# pain than the first postoperative day b. %aresthesia in the dermatomes near the ounds c. Frine retention or incontinence d. &emperature of <<.$G H (,9.,G C) 1,. After an eye examination, a male client is diagnosed ith open?angle glaucoma. &he physician prescribes pilocarpine ophthalmic solution (%ilocar), ;.$4> gtt i, )F ".i.d. Dased on this prescription, the nurse should teach the client or a family member to administer the drug by! a. instilling one drop of pilocarpine ;.$4> into both eyes daily. b. instilling one drop of pilocarpine ;.$4> into both eyes four times daily. c. instilling one drop of pilocarpine ;.$4> into the right eye daily. d. instilling one drop of pilocarpine ;.$4> into the left eye four times daily. 13. A female client ho/s paraly8ed on the left side has been receiving physical therapy and attending teaching sessions about safety. 0hich behavior indicates that the client accurately understands safety measures related to paralysis' a. &he client leaves the side rails don. b. &he client uses a mirror to inspect the s#in. c. &he client repositions only after being reminded to do so. d. &he client hangs the left arm over the side of the heelchair. 14. A male client in the emergency department has a suspected neurologic disorder. &o assess gait, the nurse as#s the client to ta#e a fe stepsC ith each step, the client/s feet ma#e a half circle. &o document the client/s gait, the nurse should use hich term' a. Ataxic b. (ystrophic c. .elicopod d. :teppage 17. A client, age $$, is admitted ith bacterial meningitis. 0hich hospital room ould be the best choice for this client' a. A private room don the hall from the nurses/ station b. An isolation room three doors from the nurses/ station c. A semiprivate room ith a ,$?year?old client ho has viral meningitis d. A to?bed room ith a client ho previously had bacterial meningitis 19. A physician diagnoses a client ith myasthenia gravis, prescribing pyridostigmine (Bestinon), 7; mg %.). every , hours. Defore administering this anticholinesterase agent, the nurse revies the client/s history. 0hich preexisting condition ould contraindicate the use of pyridostigmine' a. Flcerative colitis b. Dlood dyscrasia c. Intestinal obstruction d. :pinal cord in6ury 1-. A female client is admitted to the facility for investigation of balance and coordination problems, including possible BIniJre/s disease. 0hen assessing this client, the nurse expects to note! a. vertigo, tinnitus, and hearing loss. b. vertigo, vomiting, and nystagmus c. vertigo, pain, and hearing impairment. d. vertigo, blurred vision, and fever. 1<. A male client ith a conductive hearing disorder caused by an#ylosis of the stapes in the oval indo undergoes a stapedectomy to remove the stapes and replace the impaired bone ith a prosthesis. After the stapedectomy, the nurse should provide hich client instruction' a. @+ie in bed ith your head elevated, and refrain from bloing your nose for $3 hours.A b. @&ry to ambulate independently after about $3 hours.A c. @:hampoo your hair every day for 1; days to help prevent ear infection.A d. @(on/t fly in an airplane, climb to high altitudes, ma#e sudden movements, or expose yourself to loud sounds for ,; days.A $;. Eurse )liver is monitoring a client for adverse reactions to dantrolene ((antrium). 0hich adverse reaction is most common' a. 2xcessive tearing b. Frine retention c. Buscle ea#ness d. :lurred speech $1. &he nurse is monitoring a male client for adverse reactions to atropine sulfate (Atropine Care) eyedrops. :ystemic absorption of atropine sulfate through the con6unctiva can cause hich adverse reaction' a. &achycardia b. Increased salivation c. .ypotension d. Apnea $$. A male client is admitted ith a cervical spine in6ury sustained during a diving accident. 0hen planning this client/s care, the nurse should assign highest priority to hich nursing diagnosis' a. Impaired physical mobility b. Ineffective breathing pattern c. (isturbed sensory perception (tactile) d. :elf?care deficient! (ressingKgrooming $,. A male client has a history of painful, continuous muscle spasms. .e has ta#en several s#eletal muscle relaxants ithout experiencing relief. .is physician prescribes dia8epam (Valium), $ mg %.). tice daily. In addition to being used to relieve painful muscle spasms, dia8epam also is recommended for! a. long?term treatment of epilepsy. b. postoperative pain management of laminectomy clients. c. postoperative pain management of dis#ectomy clients d. treatment of spasticity associated ith spinal cord lesions. $3. A female client ho as found unconscious at home is brought to the hospital by a rescue s"uad. In the intensive care unit, the nurse chec#s the client/s oculocephalic (doll/s eye) response by! a. introducing ice ater into the external auditory canal. b. touching the cornea ith a isp of cotton. c. turning the client/s head suddenly hile holding the eyelids open. d. shining a bright light into the pupil. $4. 0hile revieing a client/s chart, the nurse notices that the female client has myasthenia gravis. 0hich of the folloing statements about neuromuscular bloc#ing agents is true for a client ith this condition' a. &he client may be less sensitive to the effects of a neuromuscular bloc#ing agent. b. :uccinylcholine shouldn/t be usedC pancuronium may be used in a loer dosage. c. %ancuronium shouldn/t be usedC succinylcholine may be used in a loer dosage. d. %ancuronium and succinylcholine both re"uire cautious administration. $7. A male client is color blind. &he nurse understands that this client has a problem ith! a. rods. b. cones. c. lens. d. a"ueous humor. $9. A female client ho as trapped inside a car for hours after a head?on collision is rushed to the emergency department ith multiple in6uries. (uring the neurologic examination, the client responds to painful stimuli ith decerebrate posturing. &his finding indicates damage to hich part of the brain' a. (iencephalon b. Bedulla c. Bidbrain d. Cortex $-. &he nurse is assessing a ,9?year?old client diagnosed ith multiple sclerosis. 0hich of the folloing symptoms ould the nurse expect to find' a. Vision changes b. Absent deep tendon reflexes c. &remors at rest d. Hlaccid muscles $<. &he nurse is caring for a male client diagnosed ith a cerebral aneurysm ho reports a severe headache. 0hich action should the nurse perform' a. :it ith the client for a fe minutes. b. Administer an analgesic. c. Inform the nurse manager. d. Call the physician immediately. ,;. (uring recovery from a cerebrovascular accident (CVA), a female client is given nothing by mouth, to help prevent aspiration. &o determine hen the client is ready for a li"uid diet, the nurse assesses the client/s salloing ability once each shift. &his assessment evaluates! a. cranial nerves I and II. b. cranial nerves III and V. c. cranial nerves VI and VIII. d. cranial nerves I* and *. 1. Answer A. &he body/s thermostat is located in the hypothalamusC therefore, in6ury to that area can cause problems of body temperature control. Dalance and e"uilibrium problems are related to cerebellar damage. Visual acuity problems ould occur folloing occipital or optic nerve in6ury. &hin#ing and reasoning problems are the result of in6ury to the cerebrum. $. Answer C. Administering lidocaine via an endotracheal tube may minimi8e elevations in IC% caused by suctioning. Although mannitol and furosemide may be given to reduce IC%, they/re administered parenterally, not endotracheally. %henytoin doesn/t reduce IC% directly but may be used to abolish sei8ures, hich can increase IC%. .oever, phenytoin isn/t administered endotracheally. ,. Answer C. &he client/s history and assessment suggest that he may have increased intracranial pressure (IC%). If this is the case, lumbar puncture shouldn/t be done because it can "uic#ly decompress the central nervous system and, thereby, cause additional damage. After a head in6ury, barbiturates may be given to prevent sei8uresC mechanical ventilation may be re"uired if breathing deterioratesC and elevating the head of the bed may be used to reduce IC%. 3. Answer A. &he sudden appearance of light flashes and floaters in front of the affected eye is characteristic of retinal detachment. (ifficulty seeing cars in another driving lane suggests gradual loss of peripheral vision, hich may indicate glaucoma. .eadache, nausea, and redness of the eyes are signs of acute (angle?closure) glaucoma. (ouble vision is common in clients ith cataracts. 4. Answer B. In %ar#inson/s crisis, dopamine?related symptoms are severely exacerbated, virtually immobili8ing the client. A client confined to bed during such a crisis is at ris# for aspiration and pneumonia. Also, excessive drooling increases the ris# of airay obstruction. Decause of these concerns, the nursing diagnosis of Ineffective airay clearance ta#es highest priority. Although the other options also are appropriate, they aren/t immediately life?threatening. 7. Answer A. :taying ith the client and encouraging him to feed himself ill ensure ade"uate food inta#e. A client ith Al8heimer/s disease can forget ho to eat. Alloing privacy during meals, filling out the menu, or helping the client to complete the menu doesn/t ensure ade"uate nutritional inta#e. 9. Answer C. &he mental status examination assesses functions governed by the cerebrum. :ome of these are orientation, attention span, 6udgment, and abstract reasoning. Intellectual functioning isn/t the only cerebral activity. Cerebellar function testing assesses coordination, e"uilibrium, and fine motor movement. :ensory function testing involves assessment of pain, light?touch sensation, and temperature discrimination. -. Answer B. 0hen used to treat status epilepticus, dia8epam may be given every 1; to 14 minutes, as needed, to a maximum dose of ,; mg. &he nurse can repeat the regimen in $ to 3 hours, if necessary, but the total dose shouldn/t exceed 1;; mg in $3 hours. &he nurse must not administer I.V. dia8epam faster than 4 mgKminute. &herefore, the dose can/t be repeated in ,; to 34 seconds because the first dose ouldn/t have been administered completely by that time. 0aiting longer than 14 minutes to repeat the dose ould increase the client/s ris# of complications associated ith status epilepticus. <. Answer D. Atropine sulfate is a cholinergic bloc#er. It isn/t a parasympathomimetic agent, a sympatholytic agent, or an adrenergic bloc#er. 1;. Answer A. In the scenario, airay and breathing are established so the nurse/s next priority should be circulation. 0ith a compound fracture of the femur, there is a high ris# of profuse bleedingC therefore, the nurse should assess the site. Eeurologic assessment is a secondary concern to airay, breathing, and circulation. &he nurse doesn/t have enough data to arrant putting the client in &rendelenburg/s position. 11. Answer B. (examethasone exerts its therapeutic effect by decreasing leu#ocyte infiltration at the site of ocular inflammation. &his reduces the exudative reaction of diseased tissue, lessening edema, redness, and scarring. (examethasone and other anti?inflammatory agents don/t inhibit the action of carbonic anhydrase or produce any type of miotic reaction. 1$. Answer C. Frine retention or incontinence may indicate cauda e"uina syndrome, hich re"uires immediate surgery. An increase in pain on the second postoperative day is common because the long?acting local anesthetic, hich may have been in6ected during surgery, ill ear off. 0hile paresthesia is common after surgery, progressive ea#ness or paralysis may indicate spinal nerve compression. A mild fever is also common after surgery but is considered significant only if it reaches 1;1G H (,-.,G C). 1,. Answer B. &he abbreviation LgttL stands for drop, LiL is the apothecary symbol for the number 1, )F signifies both eyes, and L".i.d.L means four times a day. &herefore, one drop of pilocarpine ;.$4> should be instilled into both eyes four times daily. 13. Answer B. Fsing a mirror enables the client to inspect all areas of the s#in for signs of brea#don ithout the help of staff or family members. &he client should #eep the side rails up to help ith repositioning and to prevent falls. &he paraly8ed client should ta#e responsibility for repositioning or for reminding the staff to assist ith it, if needed. A client ith left?side paralysis may not reali8e that the left arm is hanging over the side of the heelchair. .oever, the nurse should call this to the client/s attention because the arm can get caught in the heel spo#es or develop impaired circulation from being in a dependent position for too long. 14. Answer C. A helicopod gait is an abnormal gait in hich the client/s feet ma#e a half circle ith each step. An ataxic gait is staggering and unsteady. In a dystrophic gait, the client addles ith the legs far apart. In a steppage gait, the feet and toes raise high off the floor and the heel comes don heavily ith each step. 17. Answer B. A client ith bacterial meningitis should be #ept in isolation for at least $3 hours after admission and, during the initial acute phase, should be as close to the nurses/ station as possible to allo maximal observation. %lacing the client in a room ith a client ho has viral meningitis may cause harm to both clients because the organisms causing viral and bacterial meningitis differC either client may contract the other/s disease. Immunity to bacterial meningitis can/t be ac"uiredC therefore, a client ho previously had bacterial meningitis shouldn/t be put at ris# by rooming ith a client ho has 6ust been diagnosed ith this disease. 19. Answer C. Anticholinesterase agents such as pyridostigmine are contraindicated in a client ith a mechanical obstruction of the intestines or urinary tract, peritonitis, or hypersensitivity to anticholinesterase agents. Flcerative colitis, blood dyscrasia, and spinal cord in6ury don/t contraindicate use of the drug. 1-. Answer A. BIniJre/s disease, an inner ear disease, is characteri8ed by the symptom triad of vertigo, tinnitus, and hearing loss. &he combination of vertigo, vomiting, and nystagmus suggests labyrinthitis. BIniJre/s disease rarely causes pain, blurred vision, or fever. 1<. Answer D. Hor ,; days after a stapedectomy, the client should avoid air travel, sudden movements that may cause trauma, and exposure to loud sounds and pressure changes (such as from high altitudes). Immediately after surgery, the client should lie flat ith the surgical ear facing upardC nose bloing is permitted but should be done gently and on one side at a time. &he client/s first attempt at postoperative ambulation should be supervised to prevent falls caused by vertigo and light?headedness. &he client must avoid shampooing and simming to #eep the dressing and the ear dry. $;. Answer C. &he most common adverse reaction to dantrolene is muscle ea#ness. &he drug also may depress liver function or cause idiosyncratic hepatitis. Buscle ea#ness is rarely severe enough to cause slurring of speech, drooling, and enuresis. Although excessive tearing and urine retention are adverse reactions associated ith dantrolene use, they aren/t as common as muscle ea#ness $1. Answer A. :ystemic absorption of atropine sulfate can cause tachycardia, palpitations, flushing, dry s#in, ataxia, and confusion. &o minimi8e systemic absorption, the client should apply digital pressure over the punctum at the inner canthus for $ to , minutes after instilling the drops. &he drug also may cause dry mouth. It isn/t #non to cause hypotension or apnea. $$. Answer B. Decause a cervical spine in6ury can cause respiratory distress, the nurse should ta#e immediate action to maintain a patent airay and provide ade"uate oxygenation. &he other options may be appropriate for a client ith a spinal cord in6ury = particularly during the course of recovery = but don/t ta#e precedence over a diagnosis of Ineffective breathing pattern. $,. Answer D. In addition to relieving painful muscle spasms, dia8epam also is recommended for treatment of spasticity associated ith spinal cord lesions. (ia8epam/s use is limited by its central nervous system effects and the tolerance that develops ith prolonged use. &he parenteral form of dia8epam can treat status epilepticus, but the drug/s sedating properties ma#e it an unsuitable choice for long?term management of epilepsy. (ia8epam isn/t an analgesic agent. $3. Answer C. &o elicit the oculocephalic response, hich detects cranial nerve compression, the nurse turns the client/s head suddenly hile holding the eyelids open. Eormally, the eyes move from side to side hen the head is turnedC in an abnormal response, the eyes remain fixed. &he nurse introduces ice ater into the external auditory canal hen testing the oculovestibular responseC normally, the client/s eyes deviate to the side of ice ater introduction. &he nurse touches the client/s cornea ith a isp of cotton to elicit the corneal reflex response, hich reveals brain stem functionC blin#ing is the normal response. :hining a bright light into the client/s pupil helps evaluate brain stem and cranial nerve III functionsC normally, the pupil responds by constricting. $4. Answer D. &he nurse must cautiously administer pancuronium, succinylcholine, and any other neuromuscular bloc#ing agent to a client ith myasthenia gravis. :uch a client isn/t less sensitive to the effects of a neuromuscular bloc#ing agent. 2ither succinylcholine or pancuronium can be administered in the usual adult dosage to a client ith myasthenia gravis. $7. Answer B. Cones provide daylight color vision, and their stimulation is interpreted as color. If one or more types of cones are absent or defective, color blindness occurs. 5ods are sensitive to lo levels of illumination but can/t discriminate color. &he lens is responsible for focusing images. A"ueous humor is a clear atery fluid and isn/t involved ith color perception. $9. Answer C. (ecerebrate posturing, characteri8ed by abnormal extension in response to painful stimuli, indicates damage to the midbrain. 0ith damage to the diencephalon or cortex, abnormal flexion (decorticate posturing) occurs hen a painful stimulus is applied. (amage to the medulla results in flaccidity. $-. Answer A. Vision changes, such as diplopia, nystagmus, and blurred vision, are symptoms of multiple sclerosis. (eep tendon reflexes may be increased or hyperactive = not absent. Dabins#i/s sign may be positive. &remors at rest aren/t characteristic of multiple sclerosisC hoever, intentional tremors, or those occurring ith purposeful voluntary movement, are common in clients ith multiple sclerosis. Affected muscles are spastic, rather than flaccid. $<. Answer D. &he headache may be an indication that the aneurysm is lea#ing. &he nurse should notify the physician immediately. :itting ith the client is appropriate but only after the physician has been notified of the change in the client/s condition. &he physician ill decide hether or not administration of an analgesic is indicated. Informing the nurse manager isn/t necessary. ,;. Answer D. :alloing is a motor function of cranial nerves I* and *. Cranial nerves I, II, and VIII don/t possess motor functions. &he motor functions of cranial nerve III include extraocular eye movement, eyelid elevation, and pupil constriction. &he motor function of cranial nerve V is cheing. Cranial nerve VI controls lateral eye movement.