Quiz #5 Neurological System

Question 1

Tonic-clonic seizure

Answer 1

Begins only for a few seconds with tonic episode (stiffening of muscles) and loss of consciousness.
A 1-2 min clonic episode (rhythmic jerking of the extremities)
Breathing can stop during the tonic phase and become irregular during the clonic phase
Incontinence can occur
Postictal phase, a period of confusion and sleepiness follows the seizure

Question 2

Seizure precautions- what to have at bedside

Answer 2

• Oxygen
• Oral airway
• Suction equipment
• Padding for side rails

*clients at high risk for generalized seizures should have saline lock in place for immediate IV access

Question 3

A nurse enters a client’s room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?

A. Insert a padded tongue blade into the client’s mouth.
B. Place a pillow under the client’s head.
C. Gently restrain the client’s extremities.
D. Apply a face mask for oxygen administration.

Answer 3

B. Place a pillow under the client’s head

Question 4

A nurse working on a medical unit is caring for a client who is prescribed seizure precautions. Which of the following interventions should the nurse include in the clients plan of care?

A. Obtain IV access.
B. Keep the lights on when the client is sleeping.
C. Place the client’s bed in the highest position.
D. Keep a padded tongue blade available at the client’s bedside.

Answer 4

A. Obtain IV access

Question 5

A nurse is in a clients room when the client begins having a tonic- clonic seizure. Which of the following actions should the nurse take first?

A. Turn the client’s head to the side.
B. Check the client’s motor strength.
C. Loosing the clothing around the client’s waste.
D. Document the time the seizure began.

Answer 5

A. Turn the client’s head to the side

Turning the client’s head to the side helps prevent aspiration in case of vomiting during the seizure, which is the immediate priority during a seizure episode.

Question 6

Actions during a seizure

Answer 6

Protect the clients privacy
move furniture away, hold head in lap if on the floor
Position client to provide patent airway
Be prepared to suction oral secretion
Turn client to the side to decrease risk of aspiration
Loosen clothing
Do not attempt to open the jaw or insert anything in airway

Document onset and duration of seizure and findings

Question 7

First action for a seizure- First medication to give

Answer 7

Ativan (lorazepam)
Rapid acting for seizures 4mg
- give IV push
For prolonged seizures

Question 8

Carbamazepine

Answer 8

For partial seizure disorder

• partial seizure involves only one cerebral hemisphere

Carbamazepine (brand name: Tegretol) is an anticonvulsant medication commonly used in the management of partial seizures, as well as other types of seizures such as generalized tonic-clonic seizures. It is also used to treat certain types of nerve pain and mood disorders like bipolar disorder.

Question 9

A nurse is caring for an adolescent client who is receiving carbamazepine for partial seizure disorder. Which of the following statements by the client’s parent is the nurse’s priority?

A: “He take a 2-hour nap every day after school”
B: “He says he feels sick to his stomach after taking this medication”
C: “He has so many new bruises on his body.”
D: “He says his mouth is always dry.”

Answer 9

C: “He has so many new bruises on his body.”

Bruising can be a sign of a potential side effect of carbamazepine known as thrombocytopenia, which is a decrease in platelet count. Thrombocytopenia can increase the risk of bleeding and bruising.

Question 10

A nurse is caring for an adolescent client who is receiving carbamazepine (Tegretol) for partial seizure disorder. Which of the following statements by the client’s parent should indicate to the nurse an immediate need for further evaluation?

A: “He takes a 2-hour nap every day after school”
B: “Sometimes, it seems like he is so out of it when I speak to him.”
C: “We had to have his glasses changed three times in the last 6 months.”
D: “The rash he had seems to have gone away after I used the hydrocortisone cream.”

Answer 10

C: “We had to have his glasses changed three times in the last 6 months.

Toxic levels of carbamazepine can cause diplopia/double vision, profound headaches, and vertigo. The increased levels impact secretion of ADH.

Question 11

Phenytoin for seizure disorder

Answer 11

Initial goal is to control seizure using one medication.
Has a narrow therapeutic range
- performed on a routine schedule to ensure compliance
Some antiepileptic medications cause oral gum overgrowth. Routine oral hygiene and dental visits can minimize this adverse effect.
Avoid oral contraceptives, as this medication decreases their effectiveness. Warfarin should also not be given with this medication, as phenytoin can decrease absorption and increase metabolism of oral anticoagulants.

Question 12

A nurse is providing teaching to a client who has seizures and a new prescription for phenytoin. Which of the following information should the nurse provide?

A: Phenytoin turns urine blue
B: Alcohol increases the chance of phenytoin toxicity
C: Avoid flossing the teeth to prevent gum irritation
D: Take an antacid with the medication if indigestion occurs

Answer 12

B: Alcohol increases the chance of phenytoin toxicity

Phenytoin is metabolized in the liver, and alcohol consumption can increase the metabolism of phenytoin, leading to lower-than-therapeutic levels of the medication in the blood. This can result in breakthrough seizures.

Question 13

A nurse is teaching a client who has a new prescription for phenytoin to treat a seizure disorder. Which of the following adverse effects should the nurse instruct the client to report immediately to the provider?

A. Tender, bleeding gums.
B. Increased facial hair.
C. Constipation.
D. Skin rash.

Answer 13

D. Skin rash

ATI book reference : stop medication if skin rash develops

Question 14

A nurse is providing discharge instructions to a female client who has a prescription for phenytoin. Which of the following information should the nurse include?

A. Consider taking oral contraceptives when on this medication
B. Watch for receding gums when taking this medication
C. Take the medication at the same time every day
D. Provide a urine sample to determine therapeutic levels of the medication

Answer 14

C. Take the medication at the same time every day

Take medications at the same time every day to enhance effectiveness.

Question 15

Left sided hemisphere stroke

Answer 15

• Right-sided neglect
• Right visual field deficit
• Left gaze preference
• Right hemisensory loss

left cerebral hemisphere of the brain is responsible for language, mathematical skills, and analytical thinking.

Question 16

Clinical manifestations of left sided hemisphere stroke

Answer 16

— Aphasia
▪ Expressive
▪ Receptive
▪ Global
— Apraxia
▪ unable to perform simple commands
— Agraphia
▪ writing difficulty
— Alexia
▪ reading difficulty
— Agnosia
▪unable to recognize difficulty objects
— Affect
▪ difficulty controlling emotions, anger, depression

Question 17

Right hemispheric stroke

Answer 17

• Left-sided neglect
• Left visual field deficit
• Right gaze preference
• Left hemisensory loss

Question 18

Clinical manifestations of right sided hemispheric stroke

Answer 18

— Spatial-perceptual alterations
▪ Incorrect perception of self and illness
▪ Loss of depth perception
▪ Unilateral neglect
— Homonymous hemianopsia
▪ Loss of visual field in one or both eyes
— Motor manifestations (most obvious effects)
▪ Impairment of respiratory function, speech,
swallowing, gag reflex, mobility, self-care abilities
— Akinesia (absence of movement)
— Hemiplegia
— Hypotonia
— Hypertonia
— Hyporeflexia
— Hyperreflexia

Question 19

The nurse would expect to find what clinical manifestation in a patient admitted with a left-sided stroke?

a. Impulsivity
b. Impaired speech
c. Left-side neglect
d. Short attention span

Answer 19

b. Impaired speech

(Clinical manifestations of left-sided brain damage include right hemiplegia, impaired
speech/language, impaired right/left discrimination, and slow and cautious performance.
Impulsivity, left-sided neglect, and short attention span are all manifestations of right-sided brain
damage.)

Question 20

Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)?

a. Overestimation of physical abilities
b. Difficulty judging position and distance
c. Slow and possibly fearful performance of tasks
d. Impulsivity and impatience at performing tasks

Answer 20

c. Slow and possibly fearful performance of tasks

(Patients with a left-sided stroke (right hemiplegia) commonly are slower in
organization and performance of tasks and may have a fearful, anxious response to a stroke.
Overconfidence, spatial disorientation, and impulsivity are more commonly associated with a
right-sided stroke.

Question 21

A nurse is caring for a client who has dysphagia following a stroke, When assisting the client at mealtime, which of the following actions should the nurse plan to take?
A. Encourage the client to use a straw.
B. Provide oral care before meals.
C. Instruct the dient to tilt their head back to facilitate swallowing.
D. Schedule physical therapy directly before meals.

Answer 21

B. Provide oral care before meals.

Question 22

A nurse is instructing a client’s family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include?

A. Encourage brief exercise before meals to promote appetite.
B. Place food in the affected side of the mouth.
C. Encourage the client to take small bites.
D. Place the client with the head reclined back to facilitate swallowing

Answer 22

C. Encourage the client to take small bites.

Question 23

A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the following are expected findings? Select all that apply.

a. impulse control difficulty
b. left hemiplegia
c. loss of depth perception
d. aphasia
e. lack of situational awareness

Answer 23

a. impulse control difficulty
b. left hemiplegia
c. loss of depth perception
e. lack of situational awareness

Question 24

Which intervention is most appropriate when communicating with a patient with aphasia after a stroke?

a. Present several thoughts at once so that the patient can connect the ideas.
b. Ask open-ended questions to provide the patient the opportunity to speak.
c. Finish the patient’s sentences to minimize frustration associated with slow speech.
d. Use simple, short sentences accompanied by visual cues to enhance comprehension.

Answer 24

d. Use simple, short sentences accompanied by visual cues to enhance comprehension.

When communicating with a patient with aphasia, the nurse should present one
thought or idea at a time. Ask questions that can be answered with a “yes,” “no,” or simple word.

Question 25

Safe feeding for patient after stroke

Answer 25

• Place food on the unaffected side of the mouth.
• Position client in high-Fowler’s during and at least for 30 minutes after feeding.
• Monitor for choking and pocketing of food.
• Do not use straw for liquids (risk of aspiration)
• RN should provide initial feeding

Question 26

Several weeks after a stroke, a 50-yr-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention should be planned to begin 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.

Answer 26

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

Question 27

The nurse is planning psychosocial support for the patient and family of the patient who suffered a stroke. What factor will most likely have the greatest impact on positive family coping with the situation?

A. Specific patient neurologic deficits
B. The patient’s ability to communicate
C. Rehabilitation potential of the patient
D. Presence of complications of a stroke

Answer 27

C. Rehabilitation potential of the patient

Although a patient’s neurologic deficit might initially be severe after a stroke, the ability of the patient to recover is most likely to positively impact the family’s coping with the situation.

Question 28

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.

Answer 28

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

Patients who have left-sided brain stroke are prone to emotional outbursts that are not necessarily related to the emotional state of the patient.

Question 29

A nurse is caring for a client following a CVA and observes the client experiencing severe dysphagia. The
nurse notifies the provider. Which of the following nutritional therapies will likely be prescribed?

A. NPO until dysphagia subsides
B. Supplements via nasogastric tube
C. Initiation of total parenteral nutrition
D. Soft residue diet

Answer 29

Supplements via ng tube

Supplements via nasogastric tube provide enteral nutrition for clients who are at risk for aspiration caused by a diminished gag reflex or difficulty swallowing. This nutritional therapy will likely be prescribed.

Question 30

A patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. Health records show a history of several transient ischemic attacks (TIAs). What should the nurse anticipate for this patient?

a. Surgical endarterectomy.
b. Transluminal angioplasty.
c. Intravenous heparin drip administration.
d. Tissue plasminogen activator (tPa) infusion.

Answer 30

d. Tissue plasminogen activator (tPa) infusion.

tPA is a thrombolytic agent used to dissolve blood clots and is typically administered within a few hours of symptom onset in eligible patients to improve outcomes following an ischemic stroke. This intervention aims to restore blood flow to the affected area of the brain and potentially minimize long-term disability.

Question 31

A nurse is teaching a client who has a new prescription for sumatriptan (Imitrex) tablets to treat migraine headaches. Which of the following instructions should the nurse include?

A. Repeat dose in 1 hour for unrelieved headache.
B. Chew the tablet well before swallowing.
C. If you experience chest pain, call your physician immediately.
D. Take daily to prevent headaches

Answer 31

C. If you experience chest pain, call your physician immediately.

Choice C reason: If you experience chest pain, call your physician immediately. This instruction is correct because chest pain is a serious and potentially life-threatening side effect of sumatriptan. Chest pain may indicate a heart attack or coronary artery spasm, which require immediate medical attention.

Question 32

A nurse is caring for a client who is postprocedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? SA

A. Use the glasgow coma scale when assessing the client
B. Assist the pt to a supine position
C. Admin an opioid med
D. Encourage the client to increase fluid intake
E. Instruct the pt to perform deep breathing and coughing exercises.

Answer 32

B. Assist the pt to a supine position
C. Admin an opioid med
D. Encourage the client to increase fluid intake

Question 33

A nurse in a clinic is caring for a client who has frequent migraine headaches. The client asks about foods that can cause headaches. The nurse should recommend that the client avoid which of the following foods?
A. Baked salmon
B. Salted cashews
C. Frozen strawberries
D. Fresh asparagus

Answer 33

B. Salted cashews

Nuts contain tyramine, which can trigger migraine headaches.

Question 34

4. A nurse is providing discharge instructions to a client who has a new diagnosis of migraine headaches. Which of the following instructions should the nurse include?

A. Use music therapy for relaxation with the onset of the headache.
B. Increase physical activity when a headache is present.
C. Drink beverages that contain artificial sweeteners to prevent headaches.
D. Apply a cool cloth to the face during a headache.

Answer 34

D. Apply a cool cloth to the face during a headache.

A cool cloth placed over the client’s eyes provides comfort and can relieve pain.

Question 35

A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding?

a. Impulse control difficulty
b. Poor judgement
c. Inability to recognize familiar objects
d. Loss of depth perception

Answer 35

c. Inability to recognize familiar objects

This is known as agnosia which can be visual, tactile, smell.

Question 36

The patient with diabetes mellitus had a right-sided stroke. Which nursing intervention should the nurse plan to provide for this patient?

a. Safety measures
b. Patience with communication
c. Mobility assistance on the right side
d. Place food in the left side of patient’s mouth.

Answer 36

a. Safety measures

A patient with a right-sided stroke has spatial-perceptual deficits, tends to minimize
problems, has a short attention span, is impulsive, and may have impaired judgment. Safety is
the biggest concern for this patient. Hemiplegia occurs on the left side of this patient’s body.

Question 37

A nurse is caring for a client who has A Fib and is receiving heparin. Which of the following findings is the nurse’s priority?

A. The client’s ECG tracing shows irregular heart rate without P waves.
B. The client has an aPTT of 80 seconds.
C. The client experiences sudden weakness of one arm and leg.
D. The client’s urine output is cloudy and odorous.

Answer 37

C. The client experiences sudden weakness of one arm and leg.

Sudden weakness or numbness of the face and one arm or leg and can indicate that the client is at greatest risk for stroke; therefore, this is the nurse’s priority finding. In addition to these findings, the client may appear confused, have slurred speech, loss of balance, dizziness, or sudden severe headache.

Question 38

Surgery for a stroke

Answer 38

Carotid artery angioplasty with stenting
Stenting - a very small hollow tube, or catheter, is advanced from a blood vessel in the groin to the carotid arteries. Once the catheter is in place, a balloon may be inflated to open the artery and a stent is placed.

Question 39

The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse?

A. The pulse rate is 102 beats/min.
B. The patient has difficulty speaking.
C. The blood pressure is 144/86 mm Hg.
D. There are fine crackles at the lung bases

Answer 39

B. The patient has difficulty speaking.

Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual because of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure; the nurse should have the patient take some deep breaths.

Question 40

A female patient who had a stroke 24 hours ago has expressive aphasia. The nurse identifies the nursing diagnosis of impaired verbal communication. An appropriate nursing intervention to help the patient communicate is to

Answer 40

ask questions that the patient can answer with “yes” or “no.”

Communication will be facilitated and less frustrating to the patient when questions that require a “yes” or “no” response are used.

Question 41

A left-handed patient with left-sided hemiplegia has difficulty feeding himself. Which intervention should the nurse include in the plan of care?

A. Provide a wide variety of food choices.
B. Provide oral care before and after meals.
C. Assist the patient to eat with the right hand.
D. Teach the patient the “chin-tuck” technique

Answer 41

C. Assist the patient to eat with the right hand.

Question 42

The nurse enters the room as the client is beginning to have a tonic-clonic seizure.
What action should the nurse implement first?

A. Note the first thing the client does in the seizure.
B. Assess the size of the client’s pupils.
C. Determine if the client is incontinent of urine or stool.
D. Provide the client with privacy during the seizure.

Answer 42

A. Note the first thing the client does in the seizure.

I think it is D.

Question 43

Keeping the previous question in mind, the patient is now experiencing characteristics of a tonic-clonic seizure. The seizure started at 1402 and it is now 1408, and the patient is still experiencing a seizure. The nurse should?

A. Continue to monitor the patient
B. Suction the patient
C. Initiate the emergency response system
D. Restrain the patient to prevent further injury

Answer 43

C. Initiate the emergency response system

Tonic-clonic seizures should last about 1-3 minutes. If the seizure lasts MORE than 5 minutes, the patient needs medical treatment FAST to stop the seizure….this is known as status epilepticus

Question 44

For stroke patients- Prevent complications of immobility

Answer 44

Encourage range of motion exercises every 2 hr
- active for unaffected extremities
- passive for affected

Question 45

A nurse is caring for a client who has right-sided paralysis from a stroke. Which of the following interventions should the nurse implement to prevent footdrop?

A. Place sandbags to maintain right plantar flexion.
B. Position soft pillows against the bottom of the feet.
C. Apply a protective boot to the right ankle.
D. Splint the right lower extremity to maintain proper alignment.

Answer 45

C. Apply a protective boot to the right ankle.

Question 46

Post lumbar puncture nursing actions

Answer 46

Monitor the puncture site.
The client should remain lying for several hours to ensure that the site clots and to decrease the risk of a post-lumbar puncture headache, caused by CSF leakage
- Encourage the client to lie flat in bed.
- Provide fluids for hydration, and administer pain medication.
- Prepare the client for an epidural blood patch to seal the hole in the dura if the headache persists.

Question 47

A nurse is teaching a client who has a new prescription for phenytoin. The nurse should instruct the client to monitor for and report which of the following adverse effects of this medication?

Anxiety
Skin Rash
Diarrhea
Metallic Taste

Answer 47

Skin Rash

These rashes can range from mild to severe and may indicate a potentially dangerous condition known as Stevens-Johnson syndrome or toxic epidermal necrolysis. Therefore, any skin changes should be reported promptly to the healthcare provider for further evaluation and management.

Question 48

Migraine headache- Patient care

Answer 48

Pain management.
Maintain a cool, dark, quiet environment.
Elevate the head of the bed to 30°.
Administer medications as prescribed (may include analgesics and antiemetics).

Question 49

Sumatriptan

Answer 49

Causes a vasoconstriction effect
This helps prevent pain signals from entering the brain and other migraine symptoms
Reduces throbbing of the head

Question 50

Client education for Migranes

Answer 50

Keep a diary to record headache patterns and triggers.
Report changes in headache intensity, or new visual or neurologic disturbances.
Remain in a cool, dark, quiet environment.
Elevate the head of the bed as desired.
Females (sex assigned at birth) over age 50 are at increased risk for cardiovascular disease and stroke.

Question 51

A nurse in a clinic is teaching a client who has a history of migraine headaches about a
new prescription for zolmitriptan. Which of the following statements by the client indicates understanding of the teaching?

A. “This medication will relieve my symptoms by causing my blood vessels to dilate.”
B. “I should take this medication daily to prevent the headache from occurring.”
C.”I should expect facial flushing when I take this medication.”
D.”This medication will lower my sensitivity to food triggers.”

Answer 51

C.”I should expect facial flushing when I take this medication.”

Question 52

Patient teaching after stroke

Answer 52

*Assess the ability to understand speech by asking the client to follow simple commands.
*Avoid using yes/no questions (in expressive aphasia).
*Provide the client with alternate forms of communication; a communication board, computer, mobile device, picture board of commonly requested items/needs.
*For expressive and receptive aphasia, speak slowly and clearly, use one-step commands.
*Collaborate with speech language pathologist (SLP) for communication concerns.