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1

Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia at the T4 level in order to prevent autonomic dysreflexia?

a. Support selection of a high-protein diet.
b. Discuss options for sexuality and fertility.
c. Assist in planning a prescribed bowel program.
d. Use quad coughing to strengthen cough efforts.

ANS: Can

c. Assist in planning a prescribed bowel program.

Fecal impaction is a common stimulus for autonomic dysreflexia. Dietary protein, coughing, and discussing sexuality/fertility should be included in the plan of care but will not reduce the risk for autonomic dysreflexia.

2

Which type of seizures involves both hemispheres of the brain?

a. Focal
b. Partial
c. Generalized
d. Acquired

ANS: C

c. Generalized

Feedback
A Focal seizures may arise from any area of the cerebral cortex, but the frontal, temporal, and parietal lobes are most commonly affected.
B Partial seizures are caused by abnormal electric discharges from epileptogenic foci limited to a circumscribed region of the cerebral cortex.
C Clinical observations of generalized seizures indicate that the initial involvement is from both hemispheres.
D A seizure disorder that is acquired is a result of a brain injury from a variety of factors; it does not specify the type of seizure.

3

Which change in status should alert the nurse to increased intracranial pressure (ICP) in a child with a head injury?

a. Rapid, shallow breathing
b. Irregular, rapid heart rate
c. Increased diastolic pressure with narrowing pulse pressure
d. Confusion and altered mental status

ANS: D

d. Confusion and altered mental status

Feedback
A Respiratory changes occur with ICP. One pattern that may be evident is Cheyne-Stokes respiration. This pattern of breathing is characterized by increasing rate and depth, then decreasing rate and depth, with a pause of variable length.
B Temperature elevation may occur in children with ICP.
C Changes in blood pressure occur, but the diastolic pressure does not increase, nor is there a narrowing of pulse pressure.
D The child with a head injury may have confusion and altered mental status, a change in vital signs, retinal hemorrhaging, hemiparesis, and papilledema.

4

After a tonic-clonic seizure, it would not be unusual for a child to display

a. Irritability and hunger
b. Lethargy and confusion
c. Nausea and vomiting
d. Nervousness and excitability

ANS: B

b. Lethargy and confusion

Feedback
A Neither irritability nor hunger is typical of the period after a tonic-clonic seizure.
B In the period after a tonic-clonic seizure, the child may be confused and
lethargic. Some children may sleep for a period of time.
C Nausea and vomiting are not expected reactions in the postictal period.
D The child will more likely be confused and lethargic after a tonic-clonic seizure.

5

A patient diagnosed with schizophrenia and auditory hallucinations anxiously tells the nurse, “The voice is telling me to do things.” Select the nurse’s priority assessment question.

a. “How long has the voice been directing your behavior?”

b. “Does what the voice tell you to do frighten you?”

c. “Do you recognize the voice speaking to you?’

d. “What is the voice telling you to do?”

ANS: D

d. “What is the voice telling you to do?”

Learning what a command hallucination is telling the patient to do is important because the command often places the patient or others at risk for harm. Command hallucinations can be terrifying and may pose a psychiatric emergency. The incorrect questions are of lesser importance than identifying the command.

6

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?

a. The patient’s speech is difficult to understand.

b. The patient’s blood pressure is 144/90 mm Hg.

c. The patient takes a diuretic because of a history of hypertension.

d. The patient has atrial fibrillation and takes warfarin (Coumadin).

ANS: D

d. The patient has atrial fibrillation and takes warfarin (Coumadin).

The use of warfarin probably contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient’s care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.

7

A newly admitted patient diagnosed with schizophrenia says, “The voices are bothering me. They yell and tell me I am bad. I have got to get away from them.” Select the nurse’s most helpful reply.

a. “Do you hear the voices often?”

b. “Do you have a plan for getting away from the voices?”

c. “I’ll stay with you. Focus on what we are talking about, not the voices. ”

d. “Forget the voices and ask some other patients to play cards with you.”

ANS: C

c. “I’ll stay with you. Focus on what we are talking about, not the voices. ”

Staying with a distraught patient who is hearing voices serves several purposes: ongoing observation, the opportunity to provide reality orientation, a means of helping dismiss the voices, the opportunity of forestalling an action that would result in self-injury, and general support to reduce anxiety. Asking if the patient hears voices is not particularly relevant at this point. Asking if the patient plans to “get away from the voices” is relevant for assessment purposes but is less helpful than offering to stay with the patient while encouraging a focus on their discussion. Suggesting playing cards with other patients shifts responsibility for intervention from the nurse to the patient and other patients.

8

A patient took trifluoperazine 30 mg po daily for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patient’s neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect?

a. Agranulocytosis
b. Tardive dyskinesia
c. Tourette’s syndrome
d. Anticholinergic effects

ANS: B

b. Tardive dyskinesia

Tardive dyskinesia is a neuroleptic-induced condition involving the face, trunk, and limbs. Involuntary movements, such as tongue thrusting; licking; blowing; irregular movements of the arms, neck, and shoulders; rocking; hip jerks; and pelvic thrusts, are seen. These symptoms are frequently not reversible even when the drug is discontinued. The scenario does not present evidence consistent with the other disorders mentioned. Agranulocytosis is a blood disorder. Tourette’s syndrome is a condition in which tics are present. Anticholinergic effects include dry mouth, blurred vision, flushing

9

Withdrawn patients diagnosed with schizophrenia:

a. are usually violent toward caregivers.

b. universally fear sexual involvement with therapists.

c. exhibit a high degree of hostility as evidenced by rejecting behavior.

d. avoid relationships because they become anxious with emotional closeness.

ANS: D

d. avoid relationships because they become anxious with emotional closeness.

When an individual is suspicious and distrustful and perceives the world and the people in it as potentially dangerous, withdrawal into an inner world can be a defense against uncomfortable levels of anxiety. When someone attempts to establish a relationship with such a patient, the patient’s anxiety rises until trust is established. There is no evidence that withdrawn patients with schizophrenia universally fear sexual involvement with therapists. In most cases, it is untrue that withdrawn patients with schizophrenia are commonly violent or exhibit a high degree of hostility by demonstrating rejecting behavior.

10

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take?

a. Insert an oral airway during the seizure to maintain a patent airway.

b. Restrain the patient’s arms and legs to prevent injury during the seizure.

c. Time and observe and record the details of the seizure and postictal state.

d. Avoid touching the patient to prevent further nervous system stimulation.

ANS: C

c. Time and observe and record the details of the seizure and postictal state.

Because the diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure.

11

An acutely violent patient diagnosed with schizophrenia receives several doses of haloperidol (Haldol). Two hours later the nurse notices the patient’s head rotated to one side in a stiffly fixed position, the lower jaw thrust forward, and drooling. Which intervention by the nurse is indicated?

a. Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record.

b. Reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient.

c. Give trihexyphenidyl (Artane) 5 mg orally at the next regularly scheduled medication administration time.

d. Administer atropine sulfate 2 mg subcut from the PRN medication administration record.

ANS: A

a. Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record.

Diphenhydramine, trihexyphenidyl, benztropine, and other anticholinergic medications may be used to treat dystonias. Swallowing will be difficult or impossible; therefore, oral medication is not an option. Medication should be administered immediately, so the intramuscular route is best. In this case, the best option given is diphenhydramine.

12

A client who suffered a spinal cord injury at level T5 several months ago develops a flushed face and blurred vision. On taking vital signs, the nurse notes the blood pressure to be 184/95 mm Hg. Which is the nurse's first action?

a. Palpate the area over the bladder for distention.
b. Place the client in the Trendelenburg position.
c. Administer oxygen via a nasal cannula.
d. Perform bilateral carotid massage.

ANS: A

a. Palpate the area over the bladder for distention.

The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury. Precipitating conditions should be eliminated and the physician notified. The other actions would not be appropriate.

13

A 23-year-old patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse plan to take?

a. Administer IV furosemide (Lasix).
b. Prepare the patient for craniotomy.
c. Initiate high-dose barbiturate therapy.
d. Type and crossmatch for blood transfusion.

ANS: B

b. Prepare the patient for craniotomy.

The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If intracranial pressure (ICP) is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but these will not be of benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries, and transfusion is usually not necessary.

14

A 56-year-old patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for

a. surgical endarterectomy.
b. transluminal angioplasty.
c. intravenous heparin administration.
d. tissue plasminogen activator (tPA) infusion.

ANS: D

d. tissue plasminogen activator (tPA) infusion.

The patient’s history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke.

Dysarthria: difficult or unclear articulation of speech that is otherwise linguistically normal.

15

A patient’s care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating?

a. Detachment and overconfidence
b. Darting eyes, tilted head, mumbling to self
c. Euphoric mood, hyperactivity, distractibility
d. Foot tapping and repeatedly writing the same phrase

ANS: B

b. Darting eyes, tilted head, mumbling to self

Clues to hallucinations include eyes looking around the room as though to find the speaker, tilting the head to one side as though listening intently, and grimacing, mumbling, or talking aloud as though responding conversationally to someone.

16

A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care?

a. Encourage coughing and deep breathing.
b. Position the patient with knees and hips flexed.
c. Keep the head of the bed elevated to 30 degrees.
d. Cluster nursing interventions to provide rest periods.

ANS: C

c. Keep the head of the bed elevated to 30 degrees.

The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP. Extreme flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP

17

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, the nurse reports the response as

a. flexion withdrawal.
b. localization of pain.
c. decorticate posturing.
d. decerebrate posturing.

ANS: C

c. decorticate posturing.

Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal

18

A patient diagnosed with schizophrenia was hospitalized after arguing with co-workers and threatening to harm them. The patient is aloof, suspicious, and says, “Two staff members I saw talking were plotting to kill me.” Based on data gathered at this point, which nursing diagnoses relate?
Select all that apply.

a. Risk for other-directed violence
b. Disturbed thought processes
c. Risk for loneliness
d. Spiritual distress
e. Social isolation

ANS: A, B

a. Risk for other-directed violence
b. Disturbed thought processes


Delusions of persecution and ideas of reference support the nursing diagnosis of disturbed thought processes. Risk for other-directed violence is substantiated by the patient’s feeling endangered by persecutors. Fearful individuals may strike out at perceived persecutors or attempt self-harm to get away from persecutors. Data are not present to support the other diagnoses.

19

A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The patient states, “I saw two doctors talking in the hall. They were plotting to kill me.” The nurse may correctly assess this behavior as:

a. echolalia.
b. an idea of reference.
c. a delusion of infidelity.
d. an auditory hallucination.

b. an idea of reference.

Ideas of reference are misinterpretations of the verbalizations or actions of others that give special personal meanings to these behaviors; for example, when seeing two people talking, the individual assumes they are talking about him or her. The other terms do not correspond with the scenario.

20

A patient diagnosed with schizophrenia says, “My co-workers are out to get me. I also saw two doctors plotting to kill me.” How does this patient perceive the environment?

a. Disorganized
b. Dangerous
c. Supportive
d. Bizarre

b. Dangerous

The patient sees the world as hostile and dangerous. This assessment is important because the nurse can be more effective by using empathy to respond to the patient. Data are not present to support any of the other options.

21

An unconscious 39-year-old male patient is admitted to the emergency department (ED) with a head injury. The patient’s spouse and teenage children stay at the patient’s side and ask many questions about the treatment being given. What action is best for the nurse to take?

a. Ask the family to stay in the waiting room until the initial assessment is completed.

b. Allow the family to stay with the patient and briefly explain all procedures to them.

c. Refer the family members to the hospital counseling service to deal with their anxiety.

d. Call the family’s pastor or spiritual advisor to take them to the chapel while care is given.

b. Allow the family to stay with the patient and briefly explain all procedures to them.

The need for information about the diagnosis and care is very high in family members of acutely ill patients. The nurse should allow the family to observe care and explain the procedures unless they interfere with emergent care needs. A pastor or counseling service can offer some support, but research supports information as being more effective. Asking the family to stay in the waiting room will increase their anxiety.

22

The nurse is caring for a client who has a moderate head injury. The client's sister asks, "Will my brother return to his normal functioning level when his brain heals?" How does the nurse respond?

a. "You should expect a full recovery in all ways by the time of discharge."

b. "Usually, someone with this type of injury returns to baseline within 6 months."

c. "Your brother may experience many changes in personality and cognitive abilities."

d. "Learning complex new skills may be more difficult, but you can expect other functions to return to normal."

c. "Your brother may experience many changes in personality and cognitive abilities."

Those with moderate to severe head injuries are never the same as before the injury. They can experience changes in cognition such as memory loss, difficulty learning new information, and limited concentration. Personality alterations such as outbursts of temper and depression also may occur. The other responses do not correctly answer the question and can give false hope.

23

What is the most appropriate nursing action when a child is in the tonic phase of a generalized tonic-clonic seizure?

a. Guide the child to the floor if standing and go for help.

b. Turn the child’s body on the side.

c. Place a padded tongue blade between the teeth.

d. Quickly slip soft restraints on the child’s wrists.

ANS: B

b. Turn the child’s body on the side.

Feedback
A The child should be placed on a soft surface if he is not in bed; however, it is inappropriate to leave the child during the seizure.
B Positioning the child on his side will prevent aspiration.
C Nothing should be inserted into the child’s mouth during a seizure to prevent injury to the mouth, gums, or teeth.
D Restraints could cause injury. Sharp objects and furniture should be moved out of the way to prevent injury.

24

A nurse observes a catatonic patient standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon?

a. Echolalia
b. Waxy flexibility
c. Depersonalization
d. Thought withdrawal

b. Waxy flexibility

Waxy flexibility is the ability to hold distorted postures for extended periods of time, as though the patient were molded in wax. Echolalia is a speech pattern. Depersonalization refers to a feeling state. Thought withdrawal refers to an alteration in thinking.

25

A 68-year-old patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin?

a. The patient has dysphasia.

b. The patient has atrial fibrillation.

c. The patient reports that symptoms began with a severe headache.

d. The patient has a history of brief episodes of right-sided hemiplegia.

c. The patient reports that symptoms began with a severe headache.

A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer the aspirin.

26

A child is brought to the emergency department in generalized tonic-clonic status epilepticus. Which medication should the nurse expect to be given initially in this situation?

a. Clorazepate dipotassium (Tranxene)
b. Fosphenytoin (Cerebyx)
c. Phenobarbital
d. Lorazepam (Ativan)

ANS: D

d. Lorazepam (Ativan)

Feedback
A Clorazepate dipotassium (Tranxene) is indicated for cluster seizures. It can be given orally.
B Fosphenytoin can be given intravenously as a second round of medication if seizures continue.
C Phenobarbital can be given intravenously as a second round of medication if seizures continue.
D Lorazepam (Ativan) or diazepam (Valium) is given intravenously to control generalized tonic-clonic status epilepticus and may also be used for seizures lasting more than 5 minutes.

27

A nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurse’s best response.

a. “Why are you laughing?”
b. “Please share the joke with me.”
c. “I don’t think I said anything funny.”
d. “You’re laughing. Tell me what’s happening.”

d. “You’re laughing. Tell me what’s happening.”

The patient is likely laughing in response to inner stimuli, such as hallucinations or fantasy. Focus on the hallucinatory clue (the patient’s laughter) and then elicit the patient’s observation. The incorrect options are less useful in eliciting a response: no joke may be involved, “why” questions are difficult to answer, and the patient is probably not focusing on what the nurse said in the first place.

28

A patient diagnosed with schizophrenia has taken fluphenazine (Prolixin) 5 mg po bid for 3 weeks. The nurse now observes a shuffling propulsive gait, a mask-like face, and drooling. Which term applies to these symptoms?

a. Neuroleptic malignant syndrome
b. Hepatocellular effects
c. Pseudoparkinsonism
d. Akathisia

c. Pseudoparkinsonism

Pseudoparkinsonism induced by antipsychotic medication mimics the symptoms of Parkinson’s disease. It frequently appears within the first month of treatment and is more common with first-generation antipsychotic drugs. Hepatocellular effects would produce abnormal liver test results. Neuroleptic malignant syndrome is characterized by autonomic instability. Akathisia produces motor restlessness.

29

A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 1030. By 1200, the patient has difficulty swallowing and is drooling. By 1600, vital signs are 102.8° F; pulse 110; respirations 26; 150/90. The patient is diaphoretic. Select the nurse’s best analysis and action.

a. Agranulocytosis; institute reverse isolation.

b. Tardive dyskinesia; withhold the next dose of medication.

c. Cholestatic jaundice; begin a high-protein, high-cholesterol diet.

d. Neuroleptic malignant syndrome; notify health care provider stat.

d. Neuroleptic malignant syndrome; notify health care provider stat.

Taking an antipsychotic medication coupled with the presence of extrapyramidal symptoms, such as severe muscle stiffness and difficulty swallowing, hyperpyrexia, and autonomic symptoms (pulse elevation), suggest neuroleptic malignant syndrome, a medical emergency. The symptoms given in the scenario are not consistent with the medical problems listed in the incorrect options.

30

. A 41-year-old patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care?

a. Encourage coughing and deep breathing.

b. Position the patient with knees and hips flexed.

c. Keep the head of the bed elevated to 30 degrees.

d. Cluster nursing interventions to provide rest periods.

ANS: C

c. Keep the head of the bed elevated to 30 degrees.

The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP. Extreme flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP

31

The nurse is caring for a patient who has a head injury and fractured right arm after being assaulted. Which assessment information requires the most rapid action by the nurse?

a. The apical pulse is slightly irregular.

b. The patient complains of a headache.

c. The patient is more difficult to arouse.

d. The blood pressure (BP) increases to 140/62 mm Hg.

ANS: C

c. The patient is more difficult to arouse.

The change in level of consciousness (LOC) is an indicator of increased intracranial pressure (ICP) and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache and a slightly irregular apical pulse are not unusual in a patient after a head injury.

32

When admitting a 42-year-old patient with a possible brain injury after a car accident to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider?

a. The patient takes warfarin (Coumadin) daily.

b. The patient’s blood pressure is 162/94 mm Hg.

c. The patient is unable to remember the accident.

d. The patient complains of a severe dull headache.

ANS: A

a. The patient takes warfarin (Coumadin) daily.

The use of anticoagulants increases the risk for intracranial hemorrhage and should be immediately reported. The other information would not be unusual in a patient with a head injury who had just arrived in the ED.

33

. A 56-year-old patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for

a. surgical endarterectomy.
b. transluminal angioplasty.
c. intravenous heparin administration.
d. tissue plasminogen activator (tPA) infusion.

ANS: D

d. tissue plasminogen activator (tPA) infusion.

Rationale: The patient's history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 3 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy are not indicated for the patient who is having an acute ischemic stroke.

34

When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care?

a. Apply an eye patch to the right eye.
b. Approach the patient from the right side.
c. Place objects needed on the patient’s left side.
d. Teach the patient that the left visual deficit will resolve.

ANS: C

c. Place objects needed on the patient’s left side.

During the acute period, the nurse should place objects on the patient’s unaffected side. Because there is a visual defect in the right half of each eye, an eye patch is not appropriate. The patient should be approached from the left side. The visual deficit may not resolve, although the patient can learn to compensate for the defect.

35

A male patient who has right-sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activities. The nurse observes that when the patient’s wife is visiting, she feeds and dresses him. Which nursing diagnosis is most appropriate for the patient?

a. Interrupted family processes related to effects of illness of a family member

b. Situational low self-esteem related to increasing dependence on spouse for care

c. Disabled family coping related to inadequate understanding by patient’s spouse

d. Impaired nutrition: less than body requirements related to hemiplegia and aphasia

ANS: C

c. Disabled family coping related to inadequate understanding by patient’s spouse

Rationale: The information supports the diagnosis of disabled family coping because the wife does not understand the rehabilitation program. There are no data supporting low self-esteem, and the patient is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. The patient's attempts to use the left hand indicate that he is managing the therapeutic regimen appropriately.

36

Several weeks after a stroke, a 50-year-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention will be best to include in the initial plan for an effective bladder training program?

a. Limit fluid intake to 1200 mL daily to reduce urine volume.

b. Assist the patient onto the bedside commode every 2 hours.

c. Perform intermittent catheterization after each voiding to check for residual urine.

d. Use an external “condom” catheter to protect the skin and prevent embarrassment.

ANS: B

b. Assist the patient onto the bedside commode every 2 hours.

Rationale: Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1000-ml fluid intake is too restricted and will lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke but should not be considered solutions for long-term management because of the risks for urinary tract infection (UTI) and skin breakdown

37

A 58-year-old patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should

a. use a calm voice to ask the patient to stop the crying behavior.

b. explain to the family that depression is normal following a stroke.

c. have the family members leave the patient alone for a few minutes.

d. teach the family that emotional outbursts are common after strokes.

ANS: D

d. teach the family that emotional outbursts are common after strokes.

Rationale: Patients who have left-sided brain stroke are prone to emotional outbursts, which are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient's control and asking the patient to stop will lead to embarrassment.

38

A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?

a. Monitor the blood pressure.

b. Send the patient for a computed tomography (CT) scan.

c. Check the respiratory rate and effort.

d. Assess the Glasgow Coma Scale score.

ANS: C

c. Check the respiratory rate and effort.

The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, and circulation) are completed.

39

The nurse is planning discharge teaching for a patient taking clozapine (Clozaril). Which of the following is essential to include?

a. Caution about sunlight exposure

b. Reminder to call the clinic if fever, sore throat, or malaise develops

c. Instructions regarding dietary restrictions

d. A chart to record patient weight

ANS: B

b. Reminder to call the clinic if fever, sore throat, or malaise develops

Fever, sore throat, and malaise are symptoms of agranulocytosis, a serious side effect of taking clozapine. Weekly blood counts are necessary to monitor for the condition. Sunlight exposure is a risk for persons taking chlorpromazine hydrochloride (Thorazine). There are no dietary restrictions for persons taking clozapine. While weight gain may occur when taking antipsychotic medication, daily monitoring is not required.

Agranulocytosis: an acute condition involving a severe and dangerous leukopenia (lowered white blood cell count), most commonly of neutrophils causing a neutropenia in the circulating blood. It is a severe lack of one major class of infection-fighting white blood cells

40

What is a sign of increased intracranial pressure (ICP) in a 10-year-old child?

a. Headache
b. Bulging fontanel
c. Tachypnea
d. Increase in head circumference

ANS: A

a. Headache

Headaches are a clinical manifestation of increased ICP in children. A change in the child’s normal behavior pattern may be an important early sign of increased ICP.

41

What is the best response to a father who tells the nurse that his son “daydreams” at home and his teacher has observed this behavior at school?

a. “Your son must have an active imagination.”

b. “Can you tell me exactly how many times this occurs in one day?”

c. “Tell me about your son’s activity when you notice the daydreams.”

d. “He is probably overtired and needs more rest.”

ANS: C

c. “Tell me about your son’s activity when you notice the daydreams.”

The daydream episodes are suggestive of absence seizures, and data about activity associated with the daydreams should be obtained.

42

After a tonic-clonic seizure, it would not be unusual for a child to display

a. Irritability and hunger
b. Lethargy and confusion
c. Nausea and vomiting
d. Nervousness and excitability

ANS: B

b. Lethargy and confusion

Feedback
A Neither irritability nor hunger is typical of the period after a tonic-clonic seizure.
B In the period after a tonic-clonic seizure, the child may be confused and lethargic. Some children may sleep for a period of time.
C Nausea and vomiting are not expected reactions in the postictal period.
D The child will more likely be confused and lethargic after a tonic-clonic seizure.

43

A person has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today the person shouts, “They’re all plotting to destroy me. Isn’t that true?” Select the nurse’s most therapeutic response.

a. “Everyone here is trying to help you. No one wants to harm you.”

b. “Feeling that people want to destroy you must be very frightening.”

c. “That is not true. People here are trying to help you if you will let them.”

d. “Staff members are health care professionals who are qualified to help you.”

ANS B:

b. “Feeling that people want to destroy you must be very frightening.”

Resist focusing on content; instead, focus on the feelings the patient is expressing. This strategy prevents arguing about the reality of delusional beliefs. Such arguments increase patient anxiety and the tenacity with which the patient holds to the delusion. The other options focus on content and provide opportunity for argument.

44

When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol (Haldol) was prescribed. The patient now says, “I stopped taking those pills. They made me feel like a robot.” What are common side effects the nurse should validate with the patient?

a. Sedation and muscle stiffness

b. Sweating, nausea, and diarrhea

c. Mild fever, sore throat, and skin rash

d. Headache, watery eyes, and runny nose

ANS: A

a. Sedation and muscle stiffness

Typical antipsychotic drugs often produce sedation and extrapyramidal side effects such as stiffness and gait disturbance, effects the patient might describe as making him or her feel like a “robot.” The side effects mentioned in the other options are usually not associated with typical antipsychotic therapy or would not have the effect described by the patient.

45

A health care provider considers which antipsychotic medication to prescribe for a patient diagnosed with schizophrenia who has auditory hallucinations and poor social function. The patient is also overweight and hypertensive. Which drug should the nurse advocate?

a.Clozapine (Clozaril)

c.Olanzapine (Zyprexa)

b.Ziprasidone (Geodon)

d.Aripiprazole (Abilify)

ANS: D

d. Aripiprazole (Abilify)

Aripiprazole is a third-generation atypical antipsychotic effective against both positive and negative symptoms of schizophrenia. It causes little or no weight gain and no increase in glucose, high- or low-density lipoprotein cholesterol, or triglycerides, making it a reasonable choice for a patient with obesity or heart disease. Clozapine may produce agranulocytosis, making it a poor choice as a first-line agent. Ziprasidone may prolong the QT interval, making it a poor choice for a patient with cardiac disease. Olanzapine fosters weight gain.

46

A patient diagnosed with schizophrenia tells the nurse, “I eat skiller. Tend to end. Easter. It blows away. Get it?” Select the nurse’s best response.

a.“Nothing you are saying is clear.”

b.“Your thoughts are very disconnected.”

c. “Try to organize your thoughts and then tell me again.”

d. “I am having difficulty understanding what you are saying.”

ANS: D

d. “I am having difficulty understanding what you are saying.”

When a patient’s speech is loosely associated, confused, and disorganized, pretending to understand is useless. The nurse should tell the patient that he or she is having difficulty understanding what the patient is saying. If a theme is discernible, ask the patient to talk about the theme. The incorrect options tend to place blame for the poor communication with the patient. The correct response places the difficulty with the nurse rather than being accusatory. See relationship to audience response question.

47

A patient diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which patient needs are of priority importance?

a. Self-esteem

b. Psychosocial

c. Physiological

d. Self-actualization

ANS: C

c. Physiological

Physiological needs must be met to preserve life. A patient with waxy flexibility must be fed by hand or tube, toileted, given range-of-motion exercises, and so forth to preserve physiological integrity. Higher level needs are of lesser concern.

48

A nurse observes a catatonic patient standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon?

a. Echolalia

b. Waxy flexibility

c. Depersonalization

d. Thought withdrawal

ANS: B

b. Waxy flexibility

Waxy flexibility is the ability to hold distorted postures for extended periods of time, as though the patient were molded in wax. Echolalia is a speech pattern. Depersonalization refers to a feeling state. Thought withdrawal refers to an alteration in thinking.

49

An acutely violent patient diagnosed with schizophrenia receives several doses of haloperidol (Haldol). Two hours later the nurse notices the patient’s head rotated to one side in a stiffly fixed position, the lower jaw thrust forward, and drooling. Which intervention by the nurse is indicated?

a. Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record.

b. Reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient.

c. Give trihexyphenidyl (Artane) 5 mg orally at the next regularly scheduled medication administration time.

d. Administer atropine sulfate 2 mg subcut from the PRN medication administration record.

ANS: A

a. Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record.

Diphenhydramine, trihexyphenidyl, benztropine, and other anticholinergic medications may be used to treat dystonias. Swallowing will be difficult or impossible; therefore, oral medication is not an option. Medication should be administered immediately, so the intramuscular route is best. In this case, the best option given is diphenhydramine.

50

A patient took trifluoperazine 30 mg po daily for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patient’s neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect?

a. Agranulocytosis

b. Tardive dyskinesia

c. Tourette’s syndrome

d. Anticholinergic effects

ANS: B

b. Tardive dyskinesia

Tardive dyskinesia is a neuroleptic-induced condition involving the face, trunk, and limbs. Involuntary movements, such as tongue thrusting; licking; blowing; irregular movements of the arms, neck, and shoulders; rocking; hip jerks; and pelvic thrusts, are seen. These symptoms are frequently not reversible even when the drug is discontinued. The scenario does not present evidence consistent with the other disorders mentioned. Agranulocytosis is a blood disorder. Tourette’s syndrome is a condition in which tics are present. Anticholinergic effects include dry mouth, blurred vision, flushing, constipation, and dry eyes.

51

A nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurse’s best response.

a. “Why are you laughing?”

b. “Please share the joke with me.”

c. “I don’t think I said anything funny.”

d. “You’re laughing. Tell me what’s happening.”

ANS: D

d. “You’re laughing. Tell me what’s happening.”

The patient is likely laughing in response to inner stimuli, such as hallucinations or fantasy. Focus on the hallucinatory clue (the patient’s laughter) and then elicit the patient’s observation. The incorrect options are less useful in eliciting a response: no joke may be involved, “why” questions are difficult to answer, and the patient is probably not focusing on what the nurse said in the first place.

52

What assessment findings mark the prodromal stage of schizophrenia?

a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion

b. Auditory hallucinations, ideas of reference, thought insertion, and broadcasting

c. Stereotyped behavior, echopraxia, echolalia, and waxy flexibility

d. Loose associations, concrete thinking, and echolalia neologisms

ANS: A

a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion

Withdrawal, misinterpreting, poor concentration, and preoccupation with religion are prodromal symptoms, the symptoms that are present before the development of florid symptoms. The incorrect options each list the positive symptoms of schizophrenia that might be apparent during the acute stage of the illness.

53

A patient diagnosed with schizophrenia and auditory hallucinations anxiously tells the nurse, “The voice is telling me to do things.” Select the nurse’s priority assessment question.

a. “How long has the voice been directing your behavior?”

b. “Does what the voice tell you to do frighten you?”

c. “Do you recognize the voice speaking to you?’

d. “What is the voice telling you to do?”

ANS: D

d. “What is the voice telling you to do?”

Learning what a command hallucination is telling the patient to do is important because the command often places the patient or others at risk for harm. Command hallucinations can be terrifying and may pose a psychiatric emergency. The incorrect questions are of lesser importance than identifying the command.

54

A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 1030. By 1200, the patient has difficulty swallowing and is drooling. By 1600, vital signs are 102.8° F; pulse 110; respirations 26; 150/90. The patient is diaphoretic. Select the nurse’s best analysis and action.

a. Agranulocytosis; institute reverse isolation.

b. Tardive dyskinesia; withhold the next dose of medication.

c. Cholestatic jaundice; begin a high-protein, high-cholesterol diet.

d. Neuroleptic malignant syndrome; notify health care provider stat.

ANS: D

d. Neuroleptic malignant syndrome; notify health care provider stat.

Taking an antipsychotic medication coupled with the presence of extrapyramidal symptoms, such as severe muscle stiffness and difficulty swallowing, hyperpyrexia, and autonomic symptoms (pulse elevation), suggest neuroleptic malignant syndrome, a medical emergency. The symptoms given in the scenario are not consistent with the medical problems listed in the incorrect options.

55

A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse?

a. Blood pressure 156/60, pulse 55, respirations 12

b. Blood pressure 130/72, pulse 90, respirations 32

c. Blood pressure 148/78, pulse 112, respirations 28

d. Blood pressure 110/70, pulse 120, respirations 30

a. Blood pressure 156/60, pulse 55, respirations 12

56

Which parameter is best for the nurse to monitor to determine whether the prescribed IV mannitol (Osmitrol) has been effective for an unconscious patient?

a. Hematocrit

b. Blood pressure

c. Oxygen saturation

d. Intracranial pressure

ANS: D

d. Intracranial pressure

Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and increase blood pressure, but these are not the best parameters for evaluation of the effectiveness of the drug. Oxygen saturation will not directly improve as a result of mannitol administration.

57

A patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. The nurse records the patient’s Glasgow Coma Scale score as

a. 9.

b. 11.

c. 13.

d. 15.

ANS: B

b. 11.

The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor response.

Eye: 1=Does not open eyes
2=Opens eyes in response to painful stimuli
3=Opens eyes in response to voice
4=Opens eyes spontaneously

Verbal: 1=Makes no sounds
2=Incomprehensible sounds
3=Utters incoherent words
4=Confused, disoriented
5=Oriented, converses normally

Motor: 1=Makes no movements
2=Extension to painful stimuli (decerebrate
response)
3=Abnormal flexion to painful stimuli (decorticate
response)
4=Flexion / Withdrawal to painful stimuli
5=Localizes to painful stimuli
6=Obeys commands

58

A patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse plan to take?

a. Administer IV furosemide (Lasix).

b. Initiate high-dose barbiturate therapy.

c. Type and crossmatch for blood transfusion.

d. Prepare the patient for immediate craniotomy.

ANS: D

d. Prepare the patient for immediate craniotomy.

The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If intracranial pressure (ICP) is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but these will not be of benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries, and transfusion is usually not necessary.

59

When caring for a patient who has had a head injury, which assessment information requires the most rapid action by the nurse?

a. The patient is more difficult to arouse.

b. The patient’s pulse is slightly irregular.

c. The patient’s blood pressure increases from 120/54 to 136/62 mm Hg.

d. The patient complains of a headache at pain level 5 of a 10-point scale.

ANS: A

a. The patient is more difficult to arouse.

The change in level of consciousness (LOC) is an indicator of increased intracranial pressure (ICP) and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache and a slightly irregular apical pulse are not unusual in a patient after a head injury.

60

Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the health care provider before giving the aspirin?

a. The patient has dysphasia.

b. The patient has atrial fibrillation.

c. The patient states, “My symptoms started with a terrible headache.”

d. The patient has a history of brief episodes of right-sided hemiplegia.

ANS: C

c. The patient states, “My symptoms started with a terrible headache.”

A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer the aspirin.

61

A patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. The nurse anticipates the need to prepare the patient for

a. surgical endarterectomy.

b. transluminal angioplasty.

c. intravenous heparin administration.

d. tissue plasminogen activator (tPA) infusion.

ANS: D

d. tissue plasminogen activator (tPA) infusion.

Rationale: The patient's history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 3 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy are not indicated for the patient who is having an acute ischemic stroke.

62

When caring for a patient with left-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care during the acute period of the stroke?

a. Apply an eye patch to the left eye.

b. Approach the patient from the left side.

c. Place objects needed for activities of daily living on the patient’s right side.

d. Reassure the patient that the visual deficit will resolve as the stroke progresses.

AND: C

c. Place objects needed for activities of daily living on the patient’s right side.

During the acute period, the nurse should place objects on the patient's unaffected side. Because there is a visual defect in the right half of each eye, an eye patch is not appropriate. The patient should be approached from the left side. The visual deficit may not resolve, although the patient can learn to compensate for the defect.

63

A patient who has right-sided weakness after a stroke is attempting to use the left hand for feeding and other activities. The patient’s wife insists on feeding and dressing him, telling the nurse, “I just don’t like to see him struggle.” Which nursing diagnosis is most appropriate for the patient?

a. Situational low self-esteem related to increasing dependence on others

b. Interrupted family processes related to effects of illness of a family member

c. Disabled family coping related to inadequate understanding by patient’s spouse

d. Impaired nutrition: less than body requirements related to hemiplegia and aphasia

ANS: C

c. Disabled family coping related to inadequate understanding by patient’s spouse

Rationale: The information supports the diagnosis of disabled family coping because the wife does not understand the rehabilitation program. There are no data supporting low self-esteem, and the patient is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. The patient's attempts to use the left hand indicate that he is managing the therapeutic regimen appropriately.

64

A patient with sudden-onset right-sided weakness has a CT scan and is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?

a. The patient’s speech is difficult to understand.

b. The patient’s blood pressure is 144/90 mm Hg.

c. The patient takes a diuretic because of a history of hypertension.

d. The patient has atrial fibrillation and takes warfarin (Coumadin).

ANS: D

d. The patient has atrial fibrillation and takes warfarin (Coumadin).

Rationale: The use of warfarin will have contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.

65

A patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?

a. Check the respiratory rate.

b. Monitor the blood pressure.

c. Send the patient for a CT scan.

d. Obtain the Glasgow Coma Scale score.

ANS: A

a. Check the respiratory rate.

The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, and circulation) are completed.