MS3 Exam 1 TB

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Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1241

Chapter 66: Management of Patients with Neurologic Dysfunction

1. A patient is being admitted to the neurologic ICU following an acute head injury that has resulted in
cerebral edema. When planning this patients care, the nurse would expect to administer what priority
medication?

A) Hydrochlorothiazide (HydroDIURIL)

B) Furosemide (Lasix)

C) Mannitol (Osmitrol)

D) Spirolactone (Aldactone)

Ans: C

Feedback:

The osmotic diuretic mannitol is given to dehydrate the brain tissue and reduce cerebral edema. This
drug acts by reducing the volume of brain and extracellular fluid. Spirolactone, furosemide, and
hydrochlorothiazide are diuretics that are not typically used in the treatment of increased ICP resulting
from cerebral edema.

2. The nurse is providing care for a patient who is unconscious. What nursing intervention takes highest
priority?

A) Maintaining accurate records of intake and output

B) Maintaining a patent airway

C) Inserting a nasogastric (NG) tube as ordered

D) Providing appropriate pain control

Ans: B

Feedback:

Maintaining a patent airway always takes top priority, even though each of the other listed actions is
necessary and appropriate.

3. The nurse is caring for a patient in the ICU who has a brain stem herniation and who is exhibiting an
altered level of consciousness. Monitoring reveals that the patients mean arterial pressure (MAP) is 60
mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurses most appropriate
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1242

action?

A) Position the patient in the high Fowlers position as tolerated.

B) Administer osmotic diuretics as ordered.

C) Participate in interventions to increase cerebral perfusion pressure.

D) Prepare the patient for craniotomy.

Ans: C

Feedback:

The cerebral perfusion pressure (CPP) is 55 mm Hg, which is considered low. The normal CPP is 70 to
100 mm Hg. Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage. As
a result, interventions are necessary. A craniotomy is not directly indicated. Diuretics and increased
height of bed would exacerbate the patients condition.

4. The nurse is caring for a patient who is postoperative following a craniotomy. When writing the plan of
care, the nurse identifies a diagnosis of deficient fluid volume related to fluid restriction and osmotic
diuretic use. What would be an appropriate intervention for this diagnosis?

A) Change the patients position as indicated.

B) Monitor serum electrolytes.

C) Maintain NPO status.

D) Monitor arterial blood gas (ABG) values.

Ans: B

Feedback:

The postoperative fluid regimen depends on the type of neurosurgical procedure and is determined on an
individual basis. The volume and composition of fluids are adjusted based on daily serum electrolyte
values, along with fluid intake and output. Fluids may have to be restricted in patients with cerebral
edema. Changing the patients position, maintaining an NPO status, and monitoring ABG values do not
relate to the nursing diagnosis of deficient fluid volume.

5. A patient with a documented history of seizure disorder experiences a generalized seizure. What nursing
action is most appropriate?

A) Restrain the patient to prevent injury.


Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1243

B) Open the patients jaws to insert an oral airway.

C) Place patient in high Fowlers position.

D) Loosen the patients restrictive clothing.

Ans: D

Feedback:

An appropriate nursing intervention would include loosening any restrictive clothing on the patient. No
attempt should be made to restrain the patient during the seizure because muscular contractions are
strong and restraint can produce injury. Do not attempt to pry open jaws that are clenched in a spasm to
insert anything. Broken teeth and injury to the lips and tongue may result from such an action. If
possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward
and facilitates drainage of saliva and mucus.

6. A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of the
adverse of effects of this medication, the nurse should prioritize which of the following in the patients
plan of care?

A) Monitoring of pulse oximetry

B) Administration of a low-protein diet

C) Administration of thorough oral hygiene

D) Fluid restriction as ordered

Ans: C

Feedback:

Gingival hyperplasia (swollen and tender gums) can be associated with long-term phenytoin (Dilantin)
use. Thorough oral hygiene should be provided consistently and encouraged after discharge. Fluid and
protein restriction are contraindicated and there is no particular need for constant oxygen saturation
monitoring.

7. A nurse is admitting a patient with a severe migraine headache and a history of acute coronary
syndrome. What migraine medication would the nurse question for this patient?

A) Rizatriptan (Maxalt)

B) Naratriptan (Amerge)

C) Sumatriptan succinate (Imitrex)


Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1244

D) Zolmitriptan (Zomig)

Ans: C

Feedback:

Triptans can cause chest pain and are contraindicated in patients with ischemic heart disease. Maxalt,
Amerge, and Zomig are triptans used in routine clinical use for the treatment of migraine headaches.

8. The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing
diagnosis of ineffective cerebral tissue perfusion. What would be an expected outcome that the nurse
would document for this diagnosis?

A) Copes with sensory deprivation.

B) Registers normal body temperature.

C) Pays attention to grooming.

D) Obeys commands with appropriate motor responses.

Ans: D

Feedback:

An expected outcome of the diagnosis of ineffective cerebral tissue perfusion in a patient with increased
intracranial pressure (ICP) would include obeying commands with appropriate motor responses. Vitals
signs and neurologic status are assessed every 15 minutes to every hour. Coping with sensory
deprivation would relate to the nursing diagnosis of disturbed sensory perception. The outcome of
registers normal body temperature relates to the diagnosis of potential for ineffective thermoregulation.
Body image disturbance would have a potential outcome of pays attention to grooming.

9. A patient exhibiting an altered level of consciousness (LOC) due to blunt-force trauma to the head is
admitted to the ED. The physician determines the patients injury is causing increased intracranial
pressure (ICP). The nurse should gauge the patients LOC on the results of what diagnostic tool?

A) Monro-Kellie hypothesis

B) Glasgow Coma Scale

C) Cranial nerve function

D) Mental status examination


Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1245

Ans: B

Feedback:

LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma
Scale: eye opening, verbal response, and motor response. The Monro-Kellie hypothesis states that
because of the limited space for expansion within the skull, an increase in any one of the components
(blood, brain tissue, cerebrospinal fluid) causes a change in the volume of the others. Cranial nerve
function and the mental status examination would be part of the neurologic examination for this patient,
but would not be the priority in evaluating LOC.

10. While completing a health history on a patient who has recently experienced a seizure, the nurse would
assess for what characteristic associated with the postictal state?

A) Epileptic cry

B) Confusion

C) Urinary incontinence

D) Body rigidity

Ans: B

Feedback:

In the postictal state (after the seizure), the patient is often confused and hard to arouse and may sleep
for hours. The epileptic cry occurs from the simultaneous contractions of the diaphragm and chest
muscles that occur during the seizure. Urinary incontinence and intense rigidity of the entire body are
followed by alternating muscle relaxation and contraction (generalized tonicclonic contraction) during
the seizure.

11. A patient with increased ICP has a ventriculostomy for monitoring ICP. The nurses most recent
assessment reveals that the patient is now exhibiting nuchal rigidity and photophobia. The nurse would
be correct in suspecting the presence of what complication?

A) Encephalitis

B) CSF leak

C) Meningitis

D) Catheter occlusion

Ans: C
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1246

Feedback:

Complications of a ventriculostomy include ventricular infectious meningitis and problems with the
monitoring system. Nuchal rigidity and photophobia are clinical manifestations of meningitis, but are
not suggestive of encephalitis, a CSF leak, or an occluded catheter.

12. The nurse is participating in the care of a patient with increased ICP. What diagnostic test is
contraindicated in this patients treatment?

A) Computed tomography (CT) scan

B) Lumbar puncture

C) Magnetic resonance imaging (MRI)

D) Venous Doppler studies

Ans: B

Feedback:

A lumbar puncture in a patient with increased ICP may cause the brain to herniate from the withdrawal
of fluid and change in pressure during the lumbar puncture. Herniation of the brain is a dire and
frequently fatal event. CT, MRI, and venous Doppler are considered noninvasive procedures and they
would not affect the ICP itself.

13. The nurse is caring for a patient who is in status epilepticus. What medication does the nurse know may
be given to halt the seizure immediately?

A) Intravenous phenobarbital (Luminal)

B) Intravenous diazepam (Valium)

C) Oral lorazepam (Ativan)

D) Oral phenytoin (Dilantin)

Ans: B

Feedback:

Medical management of status epilepticus includes IV diazepam (Valium) and IV lorazepam (Ativan)
given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital)
are given later to maintain a seizure-free state. Oral medications are not given during status epilepticus.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1247

14. The nurse has created a plan of care for a patient who is at risk for increased ICP. The patients care plan
should specify monitoring for what early sign of increased ICP?

A) Disorientation and restlessness

B) Decreased pulse and respirations

C) Projectile vomiting

D) Loss of corneal reflex

Ans: A

Feedback:

Early indicators of ICP include disorientation and restlessness. Later signs include decreased pulse and
respirations, projectile vomiting, and loss of brain stem reflexes, such as the corneal reflex.

15. The neurologic ICU nurse is admitting a patient following a craniotomy using the supratentorial
approach. How should the nurse best position the patient?

A) Position the patient supine.

B) Maintain head of bed (HOB) elevated at 30 to 45 degrees.

C) Position patient in prone position.

D) Maintain bed in Trendelenberg position.

Ans: B

Feedback:

The patient undergoing a craniotomy with a supratentorial (above the tentorium) approach should be
placed with the HOB elevated 30 to 45 degrees, with the neck in neutral alignment. Each of the other
listed positions would cause a dangerous elevation in ICP.

16. A clinic nurse is caring for a patient diagnosed with migraine headaches. During the patient teaching
session, the patient questions the nurse regarding alcohol consumption. What would the nurse be correct
in telling the patient about the effects of alcohol?

A) Alcohol causes hormone fluctuations.

B) Alcohol causes vasodilation of the blood vessels.


Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1248

C) Alcohol has an excitatory effect on the CNS.

D) Alcohol diminishes endorphins in the brain.

Ans: B

Feedback:

Alcohol causes vasodilation of the blood vessels and may exacerbate migraine headaches. Alcohol has a
depressant effect on the CNS. Alcohol does not cause hormone fluctuations, nor does it decrease
endorphins (morphine-like substances produced by the body) in the brain.

17. A patient has developed diabetes insipidus after having increased ICP following head trauma. What
nursing assessment best addresses this complication?

A) Vigilant monitoring of fluid balance

B) Continuous BP monitoring

C) Serial arterial blood gases (ABGs)

D) Monitoring of the patients airway for patency

Ans: A

Feedback:

Diabetes insipidus requires fluid and electrolyte replacement, along with the administration of
vasopressin, to replace and slow the urine output. Because of these alterations in fluid balance, careful
monitoring is necessary. None of the other listed assessments directly addresses the major
manifestations of diabetes insipidus.

18. What should the nurse suspect when hourly assessment of urine output on a patient postcraniotomy
exhibits a urine output from a catheter of 1,500 mL for two consecutive hours?

A) Cushing syndrome

B) Syndrome of inappropriate antidiuretic hormone (SIADH)

C) Adrenal crisis

D) Diabetes insipidus

Ans: D
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1249

Feedback:

Diabetes insipidus is an abrupt onset of extreme polyuria that commonly occurs in patients after brain
surgery. Cushing syndrome is excessive glucocorticoid secretion resulting in sodium and water
retention. SIADH is the result of increased secretion of ADH; the patient becomes volume-overloaded,
urine output diminishes, and serum sodium concentration becomes dilute. Adrenal crisis is
undersecretion of glucocorticoids resulting in profound hypoglycemia, hypovolemia, and hypotension.

19. During the examination of an unconscious patient, the nurse observes that the patients pupils are fixed
and dilated. What is the most plausible clinical significance of the nurses finding?

A) It suggests onset of metabolic problems.

B) It indicates paralysis on the right side of the body.

C) It indicates paralysis of cranial nerve X.

D) It indicates an injury at the midbrain level.

Ans: D

Feedback:

Pupils that are fixed and dilated indicate injury at the midbrain level. This finding is not suggestive of
unilateral paralysis, metabolic deficits, or damage to CN X.

20. Following a traumatic brain injury, a patient has been in a coma for several days. Which of the following
statements is true of this patients current LOC?

A) The patient occasionally makes incomprehensible sounds.

B) The patients current LOC will likely become a permanent state.

C) The patient may occasionally make nonpurposeful movements.

D) The patient is incapable of spontaneous respirations.

Ans: C

Feedback:

Coma is a clinical state of unarousable unresponsiveness in which no purposeful responses to internal or


external stimuli occur, although nonpurposeful responses to painful stimuli and brain stem reflexes may
be present. Verbal sounds, however, are atypical. Ventilator support may or may not be necessary.
Comas are not permanent states.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1250

21. The nurse is caring for a patient with permanent neurologic impairments resulting from a traumatic head
injury. When working with this patient and family, what mutual goal should be prioritized?

A) Achieve as high a level of function as possible.

B) Enhance the quantity of the patients life.

C) Teach the family proper care of the patient.

D) Provide community assistance.

Ans: A

Feedback:

The overarching goals of care are to achieve as high a level of function as possible and to enhance the
quality of life for the patient with neurologic impairment and his or her family. This goal encompasses
family and community participation.

22. The nurse is providing care for a patient who is withdrawing from heavy alcohol use. The nurse and
other members of the care team are present at the bedside when the patient has a seizure. In preparation
for documenting this clinical event, the nurse should note which of the following?

A) The ability of the patient to follow instructions during the seizure.

B) The success or failure of the care team to physically restrain the patient.

C) The patients ability to explain his seizure during the postictal period.

D) The patients activities immediately prior to the seizure.

Ans: D

Feedback:

Before and during a seizure, the nurse observes the circumstances before the seizure, including visual,
auditory, or olfactory stimuli; tactile stimuli; emotional or psychological disturbances; sleep; and
hyperventilation. Communication with the patient is not possible during a seizure and physical restraint
is not attempted. The patients ability to explain the seizure is not clinically relevant.

23. The nurse is caring for a patient whose recent health history includes an altered LOC. What should be
the nurses first action when assessing this patient?

A) Assessing the patients verbal response


Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1251

B) Assessing the patients ability to follow complex commands

C) Assessing the patients judgment

D) Assessing the patients response to pain

Ans: A

Feedback:

Assessment of the patient with an altered LOC often starts with assessing the verbal response through
determining the patients orientation to time, person, and place. In most cases, this assessment will
precede each of the other listed assessments, even though each may be indicated.

24. The nurse caring for a patient in a persistent vegetative state is regularly assessing for potential
complications. Complications of neurologic dysfunction for which the nurse should assess include which
of the following? Select all that apply.

A) Contractures

B) Hemorrhage

C) Pressure ulcers

D) Venous thromboembolism

E) Pneumonia

Ans: A, C, D, E

Feedback:

Based on the assessment data, potential complications may include respiratory distress or failure,
pneumonia, aspiration, pressure ulcer, deep vein thrombosis (DVT), and contractures. The
pathophysiology of decreased LOC does not normally create a heightened risk for hemorrhage.

25. The nurse is caring for a patient with a brain tumor. What drug would the nurse expect to be ordered to
reduce the edema surrounding the tumor?

A) Solumedrol

B) Dextromethorphan

C) Dexamethasone
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1252

D) Furosemide

Ans: C

Feedback:

If a brain tumor is the cause of the increased ICP, corticosteroids (e.g., dexamethasone) help reduce the
edema surrounding the tumor. Solumedrol, a steroid, and furosemide, a loop diuretic, are not the drugs
of choice in this instance. Dextromethorphan is used in cough medicines.

26. The nurse is caring for a patient who sustained a moderate head injury following a bicycle accident. The
nurses most recent assessment reveals that the patients respiratory effort has increased. What is the
nurses most appropriate response?

A) Inform the care team and assess for further signs of possible increased ICP.

B) Administer bronchodilators as ordered and monitor the patients LOC.

C) Increase the patients bed height and reassess in 30 minutes.

D) Administer a bolus of normal saline as ordered.

Ans: A

Feedback:

Increased respiratory effort can be suggestive of increasing ICP, and the care team should be promptly
informed. A bolus of IV fluid will not address the problem. Repositioning the patient and administering
bronchodilators are insufficient responses, even though these actions may later be ordered.

27. A patient has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury.
As the patients ICP increases and condition worsens, the nurse knows to assess for indications of
approaching death. These indications include which of the following?

A) Hemiplegia

B) Dry mucous membranes

C) Signs of internal bleeding

D) Loss of brain stem reflexes

Ans: D

Feedback:
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1253

Loss of brain stem reflexes, including pupillary, corneal, gag, and swallowing reflexes, is an ominous
sign of approaching death. Dry mucous membranes, hemiplegia, and bleeding must be promptly
addressed, but none of these is a common sign of impending death.

28. A patient has experienced a seizure in which she became rigid and then experienced alternating muscle
relaxation and contraction. What type of seizure does the nurse recognize?

A) Unclassified seizure

B) Absence seizure

C) Generalized seizure

D) Focal seizure

Ans: C

Feedback:

Generalized seizures often involve both hemispheres of the brain, causing both sides of the body to
react. Intense rigidity of the entire body may occur, followed by alternating muscle relaxation and
contraction (generalized tonicclonic contraction). This pattern of rigidity does not occur in patients who
experience unclassified, absence, or focal seizures.

29. When caring for a patient with increased ICP the nurse knows the importance of monitoring for possible
secondary complications, including syndrome of inappropriate antidiuretic hormone (SIADH). What
nursing interventions would the nurse most likely initiate if the patient developed SIADH?

A) Fluid restriction

B) Transfusion of platelets

C) Transfusion of fresh frozen plasma (FFP)

D) Electrolyte restriction

Ans: A

Feedback:

The nurse also assesses for complications of increased ICP, including diabetes insipidus, and SIADH.
SIADH requires fluid restriction and monitoring of serum electrolyte levels. Transfusions are
unnecessary.

30. The nurse is admitting a patient to the unit who is scheduled for removal of an intracranial mass. What
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1254

diagnostic procedures might be included in this patients admission orders? Select all that apply.

A) Transcranial Doppler flow study

B) Cerebral angiography

C) MRI

D) Cranial radiography

E) Electromyelography (EMG)

Ans: A, B, C

Feedback:

Preoperative diagnostic procedures may include a CT scan to demonstrate the lesion and show the
degree of surrounding brain edema, the ventricular size, and the displacement. An MRI scan provides
information similar to that of a CT scan with improved tissue contrast, resolution, and anatomic
definition. Cerebral angiography may be used to study a tumors blood supply or to obtain information
about vascular lesions. Transcranial Doppler flow studies are used to evaluate the blood flow within
intracranial blood vessels. Regular x-rays of the skull would not be diagnostic for an intracranial mass.
An EMG would not be ordered prior to intracranial surgery to remove a mass.

31. A patient is recovering from intracranial surgery performed approximately 24 hours ago and is
complaining of a headache that the patient rates at 8 on a 10-point pain scale. What nursing action is
most appropriate?

A) Administer morphine sulfate as ordered.

B) Reposition the patient in a prone position.

C) Apply a hot pack to the patients scalp.

D) Implement distraction techniques.

Ans: A

Feedback:

The patient usually has a headache after a craniotomy as a result of stretching and irritation of nerves in
the scalp during surgery. Morphine sulfate may also be used in the management of postoperative pain in
patients who have undergone a craniotomy. Prone positioning is contraindicated due to the consequent
increase in ICP. Distraction would likely be inadequate to reduce pain and a hot pack may cause
vasodilation and increased pain.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1255

32. A patient is recovering from intracranial surgery that was performed using the transsphenoidal approach.
The nurse should be aware that the patient may have required surgery on what neurologic structure?

A) Cerebellum

B) Hypothalamus

C) Pituitary gland

D) Pineal gland

Ans: C

Feedback:

The transsphenoidal approach (through the mouth and nasal sinuses) is often used to gain access to the
pituitary gland. This surgical approach would not allow for access to the pineal gland, cerebellum, or
hypothalamus.

33. A patient is postoperative day 1 following intracranial surgery. The nurses assessment reveals that the
patients LOC is slightly decreased compared with the day of surgery. What is the nurses best response to
this assessment finding?

A) Recognize that this may represent the peak of post-surgical cerebral edema.

B) Alert the surgeon to the possibility of an intracranial hemorrhage.

C) Understand that the surgery may have been unsuccessful.

D) Recognize the need to refer the patient to the palliative care team.

Ans: A

Feedback:

Some degree of cerebral edema occurs after brain surgery; it tends to peak 24 to 36 hours after surgery,
producing decreased responsiveness on the second postoperative day. As such, there is not necessarily
any need to deem the surgery unsuccessful or to refer the patient to palliative care. A decrease in LOC is
not evidence of an intracranial hemorrhage.

34. A school nurse is called to the playground where a 6-year-old girl has been found unresponsive and
staring into space, according to the playground supervisor. How would the nurse document the girls
activity in her chart at school?

A) Generalized seizure
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1256

B) Absence seizure

C) Focal seizure

D) Unclassified seizure

Ans: B

Feedback:

Staring episodes characterize an absence seizure, whereas focal seizures, generalized seizures, and
unclassified seizures involve uncontrolled motor activity.

35. A neurologic nurse is reviewing seizures with a group of staff nurses. How should this nurse best
describe the cause of a seizure?

A) Sudden electrolyte changes throughout the brain

B) A dysrhythmia in the peripheral nervous system

C) A dysrhythmia in the nerve cells in one section of the brain

D) Sudden disruptions in the blood flow throughout the brain

Ans: C

Feedback:

The underlying cause of a seizure is an electrical disturbance (dysrhythmia) in the nerve cells in one
section of the brain; these cells emit abnormal, recurring, uncontrolled electrical discharges. Seizures are
not caused by changes in blood flow or electrolytes.

36. The nurse is caring for a patient who has undergone supratentorial removal of a pituitary mass. What
medication would the nurse expect to administer prophylactically to prevent seizures in this patient?

A) Prednisone

B) Dexamethasone

C) Cafergot

D) Phenytoin

Ans: D
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1257

Feedback:

Antiseizure medication (phenytoin, diazepam) is often prescribed prophylactically for patients who have
undergone supratentorial craniotomy because of the high risk of seizures after this procedure. Prednisone
and dexamethasone are steroids and do not prevent seizures. Cafergot is used in the treatment of
migraines.

37. A hospital patient has experienced a seizure. In the immediate recovery period, what action best protects
the patients safety?

A) Place the patient in a side-lying position.

B) Pad the patients bed rails.

C) Administer antianxiety medications as ordered.

D) Reassure the patient and family members.

Ans: A

Feedback:

To prevent complications, the patient is placed in the side-lying position to facilitate drainage of oral
secretions. Suctioning is performed, if needed, to maintain a patent airway and prevent aspiration. None
of the other listed actions promotes safety during the immediate recovery period.

38. A nurse is caring for a patient who experiences debilitating cluster headaches. The patient should be
taught to take appropriate medications at what point in the course of the onset of a new headache?

A) As soon as the patients pain becomes unbearable

B) As soon as the patient senses the onset of symptoms

C) Twenty to 30 minutes after the onset of symptoms

D) When the patient senses his or her symptoms peaking

Ans: B

Feedback:

A migraine or a cluster headache in the early phase requires abortive medication therapy instituted as
soon as possible. Delaying medication administration would lead to unnecessary pain.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1258

39. A nurse is collaborating with the interdisciplinary team to help manage a patients recurrent headaches.
What aspect of the patients health history should the nurse identify as a potential contributor to the
patients headaches?

A) The patient leads a sedentary lifestyle.

B) The patient takes vitamin D and calcium supplements.

C) The patient takes vasodilators for the treatment of angina.

D) The patient has a pattern of weight loss followed by weight gain.

Ans: C

Feedback:

Vasodilators are known to contribute to headaches. Weight fluctuations, sedentary lifestyle, and vitamin
supplements are not known to have this effect.

40. An adult patient has sought care for the treatment of headaches that have become increasingly severe
and frequent over the past several months. Which of the following questions addresses potential
etiological factors? Select all that apply?

A) Are you exposed to any toxins or chemicals at work?

B) How would you describe your ability to cope with stress?

C) What medications are you currently taking?

D) When was the last time you were hospitalized?

E) Does anyone else in your family struggle with headaches?

Ans: A, B, C, E

Feedback:

Headaches are multifactorial, and may involve medications, exposure to toxins, family history, and
stress. Hospitalization is an unlikely contributor to headaches.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1259

Chapter 67: Management of Patients with Cerebrovascular Disorders

1. A patient has had an ischemic stroke and has been admitted to the medical unit. What action should the
nurse perform to best prevent joint deformities?

A) Place the patient in the prone position for 30 minutes/day.

B) Assist the patient in acutely flexing the thigh to promote movement.

C) Place a pillow in the axilla when there is limited external rotation.

D) Place patients hand in pronation.

Ans: C

Feedback:

A pillow in the axilla prevents adduction of the affected shoulder and keeps the arm away from the
chest. The prone position with a pillow under the pelvis, not flat, promotes hyperextension of the hip
joints, essential for normal gait. To promote venous return and prevent edema, the upper thigh should
not be flexed acutely. The hand is placed in slight supination, not pronation, which is its most functional
position.

2. A patient diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy.
The nurse explains that this procedure will be done for what purpose?

A) To decrease cerebral edema

B) To prevent seizure activity that is common following a TIA

C) To remove atherosclerotic plaques blocking cerebral flow

D) To determine the cause of the TIA

Ans: C

Feedback:

The main surgical procedure for select patients with TIAs is carotid endarterectomy, the removal of an
atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in

patients with occlusive disease of the extracranial arteries. An endarterectomy does not decrease cerebral
edema, prevent seizure activity, or determine the cause of a TIA.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1260

3. The nurse is discharging home a patient who suffered a stroke. He has a flaccid right arm and leg and is
experiencing problems with urinary incontinence. The nurse makes a referral to a home health nurse
because of an awareness of what common patient response to a change in body image?

A) Denial

B) Fear

C) Depression

D) Disassociation

Ans: C

Feedback:

Depression is a common and serious problem in the patient who has had a stroke. It can result from a
profound disruption in his or her life and changes in total function, leaving the patient with a loss of
independence. The nurse needs to encourage the patient to verbalize feelings to assess the effect of the
stroke on self-esteem. Denial, fear, and disassociation are not the most common patient response to a
change in body image, although each can occur in some patients.

4. When caring for a patient who had a hemorrhagic stroke, close monitoring of vital signs and neurologic
changes is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke of
which the nurse should be aware?

A) Generalized pain

B) Alteration in level of consciousness (LOC)

C) Tonicclonic seizures

D) Shortness of breath

Ans: B

Feedback:

Alteration in LOC is the earliest sign of deterioration in a patient after a hemorrhagic stroke, such as
mild drowsiness, slight slurring of speech, and sluggish papillary reaction. Sudden headache may occur,
but generalized pain is less common. Seizures and shortness of breath are not identified as early signs of
hemorrhagic stroke.

5. The nurse is performing stroke risk screenings at a hospital open house. The nurse has identified four
patients who might be at risk for a stroke. Which patient is likely at the highest risk for a hemorrhagic
stroke?
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1261

A) White female, age 60, with history of excessive alcohol intake

B) White male, age 60, with history of uncontrolled hypertension

C) Black male, age 60, with history of diabetes

D) Black male, age 50, with history of smoking

Ans: B

Feedback:

Uncontrolled hypertension is the primary cause of a hemorrhagic stroke. Control of hypertension,


especially in individuals over 55 years of age, clearly reduces the risk for hemorrhagic stroke. Additional
risk factors are increased age, male gender, and excessive alcohol intake. Another high-risk group
includes African Americans, where the incidence of first stroke is almost twice that as in Caucasians.

6. A patient who just suffered a suspected ischemic stroke is brought to the ED by ambulance. On what
should the nurses primary assessment focus?

A) Cardiac and respiratory status

B) Seizure activity

C) Pain

D) Fluid and electrolyte balance

Ans: A

Feedback:

Acute care begins with managing ABCs. Patients may have difficulty keeping an open and clear airway
secondary to decreased LOC. Neurologic assessment with close monitoring for signs of increased
neurologic deficit and seizure activity occurs next. Fluid and electrolyte balance must be controlled
carefully with the goal of adequate hydration to promote perfusion and decrease further brain activity.

7. A patient with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure
(ICP). What nursing intervention would be most appropriate for this patient?

A) Range-of-motion exercises to prevent contractures

B) Encouraging independence with ADLs to promote recovery


Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1262

C) Early initiation of physical therapy

D) Absolute bed rest in a quiet, nonstimulating environment

Ans: D

Feedback:

The patient is placed on immediate and absolute bed rest in a quiet, nonstressful environment because
activity, pain, and anxiety elevate BP, which increases the risk for bleeding. Visitors are restricted. The
nurse administers all personal care. The patient is fed and bathed to prevent any exertion that might raise
BP.

8. A patient recovering from a stroke has severe shoulder pain from subluxation of the shoulder and is
being cared for on the unit. To prevent further injury and pain, the nurse caring for this patient is aware
of what principle of care?

A) The patient should be fitted with a cast because use of a sling should be avoided due to adduction
of the affected shoulder.

B) Elevation of the arm and hand can lead to further complications associated with edema.

C) Passively exercising the affected extremity is avoided in order to minimize pain.

D) The patient should be taught to interlace fingers, place palms together, and slowly bring scapulae
forward to avoid excessive force to shoulder.

Ans: D

Feedback:

To prevent shoulder pain, the nurse should never lift a patient by the flaccid shoulder or pull on the
affected arm or shoulder. The patient is taught how to move and exercise the affected arm/shoulder
through proper movement and positioning. The patient is instructed to interlace the fingers, place the
palms together, and push the clasped hands slowly forward to bring the scapulae forward; he or she then
raises both hands above the head. This is repeated throughout the day. The use of a properly worn sling
when the patient is out of bed prevents the paralyzed upper extremity from dangling without support.
Range-of-motion exercises are still vitally important in preventing a frozen shoulder and ultimately
atrophy of subcutaneous tissues, which can cause more pain. Elevation of the arm and hand is also
important in preventing dependent edema of the hand.

9. The patient has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make
the patients atmosphere more conducive to communication?

A) Provide a board of commonly used needs and phrases.

B) Have the patient speak to loved ones on the phone daily.


Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1263

C) Help the patient complete his or her sentences.

D) Speak in a loud and deliberate voice to the patient.

Ans: A

Feedback:

The inability to talk on the telephone or answer a question or exclusion from conversation causes anger,
frustration, fear of the future, and hopelessness. A common pitfall is for the nurse or other health care
team member to complete the thoughts or sentences of the patient. This should be avoided because it
may cause the patient to feel more frustrated at not being allowed to speak and may deter efforts to
practice putting thoughts together and completing a sentence. The patient may also benefit from a
communication board, which has pictures of commonly requested needs and phrases. The board may be
translated into several languages.

10. The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of a
stroke?

A) Facial droop

B) Dysrhythmias

C) Periorbital edema

D) Projectile vomiting

Ans: A

Feedback:

Facial drooping or asymmetry is a classic abnormal finding on a physical assessment that may be
associated with a stroke. Facial edema is not suggestive of a stroke and patients less commonly
experience dysrhythmias or vomiting.

11. The nurse is caring for a patient diagnosed with an ischemic stroke and knows that effective positioning
of the patient is important. Which of the following should be integrated into the patients plan of care?

A) The patients hip joint should be maintained in a flexed position.

B) The patient should be in a supine position unless ambulating.

C) The patient should be placed in a prone position for 15 to 30 minutes several times a day.

D) The patient should be placed in a Trendelenberg position two to three times daily to promote
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1264

cerebral perfusion.

Ans: C

Feedback:

If possible, the patient is placed in a prone position for 15 to 30 minutes several times a day. A small
pillow or a support is placed under the pelvis, extending from the level of the umbilicus to the upper
third of the thigh. This helps to promote hyperextension of the hip joints, which is essential for normal
gait, and helps prevent knee and hip flexion contractures. The hip joints should not be maintained in
flexion and the Trendelenberg position is not indicated.

12. A patient has been admitted to the ICU after being recently diagnosed with an aneurysm and the patients
admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate
into the patients plan of care?

A) Elevate the head of the bed to 45 degrees.

B) Maintain the patient on complete bed rest.

C) Administer enemas when the patient is constipated.

D) Avoid use of thigh-high elastic compression stockings.

Ans: B

Feedback:

Cerebral aneurysm precautions are implemented for the patient with a diagnosis of aneurysm to provide
a nonstimulating environment, prevent increases in ICP, and prevent further bleeding. The patient is
placed on immediate and absolute bed rest in a quiet, nonstressful environment because activity, pain,
and anxiety elevate BP, which increases the risk for bleeding. Visitors, except for family, are restricted.
The head of the bed is elevated 15 to 30 degrees to promote venous drainage and decrease ICP. Some
neurologists, however, prefer that the patient remains flat to increase cerebral perfusion. No enemas are
permitted, but stool softeners and mild laxatives are prescribed. Thigh-high elastic compression
stockings or sequential compression boots may be ordered to decrease the patients risk for deep vein
thrombosis (DVT).

13. A nurse is caring for a patient diagnosed with a hemorrhagic stroke. When creating this patients plan of
care, what goal should be prioritized?

A) Prevent complications of immobility.

B) Maintain and improve cerebral tissue perfusion.

C) Relieve anxiety and pain.


Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1265

D) Relieve sensory deprivation.

Ans: B

Feedback:

Each of the listed goals is appropriate in the care of a patient recovering from a stroke. However,
promoting cerebral perfusion is a priority physiologic need, on which the patients survival depends.

14. The nurse is preparing health education for a patient who is being discharged after hospitalization for a
hemorrhagic stroke. What content should the nurse include in this education?

A) Mild, intermittent seizures can be expected.

B) Take ibuprofen for complaints of a serious headache.

C) Take antihypertensive medication as ordered.

D) Drowsiness is normal for the first week after discharge.

Ans: C

Feedback:

The patient and family are provided with information that will enable them to cooperate with the care
and restrictions required during the acute phase of hemorrhagic stroke and to prepare the patient to
return home. Patient and family teaching includes information about the causes of hemorrhagic stroke
and its possible consequences. Symptoms of hydrocephalus include gradual onset of drowsiness and
behavioral changes. Hypertension is the most serious risk factor, suggesting that appropriate
antihypertensive treatment is essential for a patient being discharged. Seizure activity is not normal;
complaints of a serious headache should be reported to the physician before any medication is taken.
Drowsiness is not normal or expected.

15. A patient diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a
priority for the nurse?

A) Sit with the patient for a few minutes.

B) Administer an analgesic.

C) Inform the nurse-manager.

D) Call the physician immediately.

Ans: D
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1266

Feedback:

A headache may be an indication that the aneurysm is leaking. The nurse should notify the physician
immediately. The physician will decide whether administration of an analgesic is indicated. Informing
the nurse-manager is not necessary. Sitting with the patient is appropriate, once the physician has been
notified of the change in the patients condition.

16. A patient is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse
caring for this patient is aware that an absolute contraindication for thrombolytic therapy is what?

A) Evidence of hemorrhagic stroke

B) Blood pressure of 180/110 mm Hg

C) Evidence of stroke evolution

D) Previous thrombolytic therapy within the past 12 months

Ans: A

Feedback:

Thrombolytic therapy would exacerbate a hemorrhagic stroke with potentially fatal consequences.
Stroke evolution, high BP, or previous thrombolytic therapy does not contraindicate its safe and
effective use.

17. When caring for a patient who has had a stroke, a priority is reduction of ICP. What patient position is
most consistent with this goal?

A) Head turned slightly to the right side

B) Elevation of the head of the bed

C) Position changes every 15 minutes while awake

D) Extension of the neck

Ans: B

Feedback:

Elevation of the head of the bed promotes venous drainage and lowers ICP; the nurse should avoid
flexing or extending the neck or turning the head side to side. The head should be in a neutral midline
position. Excessively frequent position changes are unnecessary.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1267

18. A patient who suffered an ischemic stroke now has disturbed sensory perception. What principle should
guide the nurses care of this patient?

A) The patient should be approached on the side where visual perception is intact.

B) Attention to the affected side should be minimized in order to decrease anxiety.

C) The patient should avoid turning in the direction of the defective visual field to minimize shoulder
subluxation.

D) The patient should be approached on the opposite side of where the visual perception is intact to
promote recovery.

Ans: A

Feedback:

Patients with decreased field of vision should first be approached on the side where visual perception is
intact. All visual stimuli should be placed on this side. The patient can and should be taught to turn the
head in the direction of the defective visual field to compensate for this loss. The nurse should constantly
remind the patient of the other side of the body and should later stand at a position that encourages the
patient to move or turn to visualize who and what is in the room.

19. What should be included in the patients care plan when establishing an exercise program for a patient
affected by a stroke?

A) Schedule passive range of motion every other day.

B) Keep activity limited, as the patient may be over stimulated.

C) Have the patient perform active range-of-motion (ROM) exercises once a day.

D) Exercise the affected extremities passively four or five times a day.

Ans: D

Feedback:

The affected extremities are exercised passively and put through a full ROM four or five times a day to
maintain joint mobility, regain motor control, prevent development of a contracture in the paralyzed
extremity, prevent further deterioration of the neuromuscular system, and enhance circulation. Active
ROM exercises should ideally be performed more than once per day.

20. A female patient is diagnosed with a right-sided stroke. The patient is now experiencing hemianopsia.
How might the nurse help the patient manage her potential sensory and perceptional difficulties?
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1268

A) Keep the lighting in the patients room low.

B) Place the patients clock on the affected side.

C) Approach the patient on the side where vision is impaired.

D) Place the patients extremities where she can see them.

Ans: D

Feedback:

The patient with homonymous hemianopsia (loss of half of the visual field) turns away from the affected
side of the body and tends to neglect that side and the space on that side; this is called amorphosynthesis.
In such instances, the patient cannot see food on half of the tray, and only half of the room is visible. It is
important for the nurse to remind the patient constantly of the other side of the body, to maintain
alignment of the extremities, and if possible, to place the extremities where the patient can see them.
Patients with a decreased field of vision should be approached on the side where visual perception is
intact. All visual stimuli (clock, calendar, and television) should be placed on this side. The patient can
be taught to turn the head in the direction of the defective visual field to compensate for this loss.
Increasing the natural or artificial lighting in the room and providing eyeglasses are important in
increasing vision. There is no reason to keep the lights dim.

The public health nurse is planning a health promotion campaign that reflects current epidemiologic
21. trends. The nurse should know that hemorrhagic stroke currently accounts for what percentage of total
strokes in the United States?

A) 43%

B) 33%

C) 23%

D) 13%

Ans: D

Feedback:

Strokes can be divided into two major categories: ischemic (87%), in which vascular occlusion and
significant hypoperfusion occur, and hemorrhagic (13%), in which there is extravasation of blood into
the brain or subarachnoid space.

22. A patient who has experienced an ischemic stroke has been admitted to the medical unit. The patients
family in adamant that she remain on bed rest to hasten her recovery and to conserve energy. What
principle of care should inform the nurses response to the family?

A) The patient should mobilize as soon as she is physically able.


Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1269

B) To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks.

C) The patient should remain on bed rest until she expresses a desire to mobilize.

D) Lack of mobility will greatly increase the patients risk of stroke recurrence.

Ans: A

Feedback:

As soon as possible, the patient is assisted out of bed and an active rehabilitation program is started.
Delaying mobility causes complications, but not necessarily stroke recurrence. Mobility should not be
withheld until the patient initiates.

23. A patient has recently begun mobilizing during the recovery from an ischemic stroke. To protect the
patients safety during mobilization, the nurse should perform what action?

A) Support the patients full body weight with a waist belt during ambulation.

B) Have a colleague follow the patient closely with a wheelchair.

C) Avoid mobilizing the patient in the early morning or late evening.

D) Ensure that the patients family members do not participate in mobilization.

Ans: B

Feedback:

During mobilization, a chair or wheelchair should be readily available in case the patient suddenly
becomes fatigued or feels dizzy. The family should be encouraged to participate, as appropriate, and the
nurse should not have to support the patients full body weight. Morning and evening activity are not
necessarily problematic.

24. A patient diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse
knows that teaching for the patient and family needs to begin as soon as the patient is settled on the unit
and will continue until the patient is discharged. What will family education need to include?

A) How to differentiate between hemorrhagic and ischemic stroke

B) Risk factors for ischemic stroke

C) How to correctly modify the home environment


Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1270

D) Techniques for adjusting the patients medication dosages at home

Ans: C

Feedback:

For a patient with a hemorrhagic stroke, teaching addresses the use of assistive devices or modification
of the home environment to help the patient live with the disability. This is more important to the
patients needs than knowing about risk factors for ischemic stroke. It is not necessary for the family to
differentiate between different types of strokes. Medication regimens should never be altered without
consultation.

25. After a subarachnoid hemorrhage, the patients laboratory results indicate a serum sodium level of less
than 126 mEq/L. What is the nurses most appropriate action?

A) Administer a bolus of normal saline as ordered.

B) Prepare the patient for thrombolytic therapy as ordered.

C) Facilitate testing for hypothalamic dysfunction.

D) Prepare to administer 3% NaCl by IV as ordered.

Ans: D

Feedback:

The patient may be experiencing syndrome of inappropriate antidiuretic hormone (SIADH) or cerebral
salt-wasting syndrome. The treatment most often is the use of IV hypertonic 3% saline. A normal saline
bolus would exacerbate the problem and there is no indication for tests of hypothalamic function or
thrombolytic therapy.

26. A community health nurse is giving an educational presentation about stroke and heart disease at the
local senior citizens center. What nonmodifiable risk factor for stroke should the nurse cite?

A) Female gender

B) Asian American race

C) Advanced age

D) Smoking

Ans: C
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1271

Feedback:

Advanced age, male gender, and race are well-known nonmodifiable risk factors for stroke. High-risk
groups include people older than 55 years of age; the incidence of stroke more than doubles in each
successive decade. Men have a higher rate of stroke than that of women. Another high-risk group is
African Americans; the incidence of first stroke in African Americans is almost twice that as in
Caucasian Americans; Asian American race is not a risk factor. Smoking is a modifiable risk.

27. A family member brings the patient to the clinic for a follow-up visit after a stroke. The family member
asks the nurse what he can do to decrease his chance of having another stroke. What would be the nurses
best answer?

A) Have your heart checked regularly.

B) Stop smoking as soon as possible.

C) Get medication to bring down your sodium levels.

D) Eat a nutritious diet.

Ans: B

Feedback:

Smoking is a modifiable and highly significant risk factor for stroke. The significance of smoking, and
the potential benefits of quitting, exceed the roles of sodium, diet, and regular medical assessments.

28. The nurse is reviewing the medication administration record of a female patient who possesses
numerous risk factors for stroke. Which of the womans medications carries the greatest potential for
reducing her risk of stroke?

A) Naproxen 250 PO b.i.d.

B) Calcium carbonate 1,000 mg PO b.i.d.

C) Aspirin 81 mg PO o.d.

D) Lorazepam 1 mg SL b.i.d. PRN

Ans: C

Feedback:

Research findings suggest that low-dose aspirin may lower the risk of stroke in women who are at risk.
Naproxen, lorazepam, and calcium supplements do not have this effect.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1272

29. A nurse in the ICU is providing care for a patient who has been admitted with a hemorrhagic stroke. The
nurse is performing frequent neurologic assessments and observes that the patient is becoming
progressively more drowsy over the course of the day. What is the nurses best response to this
assessment finding?

A) Report this finding to the physician as an indication of decreased metabolism.

B) Provide more stimulation to the patient and monitor the patient closely.

C) Recognize this as the expected clinical course of a hemorrhagic stroke.

D) Report this to the physician as a possible sign of clinical deterioration.

Ans: D

Feedback:

Alteration in LOC often is the earliest sign of deterioration in a patient with a hemorrhagic stroke.
Drowsiness and slight slurring of speech may be early signs that the LOC is deteriorating. This finding is
unlikely to be the result of metabolic changes and it is not expected. Stimulating a patient with an acute
stroke is usually contraindicated.

30. Following diagnostic testing, a patient has been admitted to the ICU and placed on cerebral aneurysm
precautions. What nursing action should be included in patients plan of care?

A) Supervise the patients activities of daily living closely.

B) Initiate early ambulation to prevent complications of immobility.

C) Provide a high-calorie, low-protein diet.

D) Perform all of the patients hygiene and feeding.

Ans: A

Feedback:

The patient is placed on immediate and absolute bed rest in a quiet, nonstressful environment, because
activity, pain, and anxiety elevate BP, which increases the risk for bleeding. As such, independent ADLs
and ambulation are contraindicated. There is no need for a high-calorie or low-protein diet.

31. A preceptor is discussing stroke with a new nurse on the unit. The preceptor would tell the new nurse
which cardiac dysrhythmia is associated with cardiogenic embolic strokes?

A) Ventricular tachycardia
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1273

B) Atrial fibrillation

C) Supraventricular tachycardia

D) Bundle branch block

Ans: B

Feedback:

Cardiogenic embolic strokes are associated with cardiac dysrhythmias, usually atrial fibrillation. The
other listed dysrhythmias are less commonly associated with this type of stroke.

32. The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following
steps:

1. Change in pH

2. Blood flow decreases

3. A switch to anaerobic respiration

4. Membrane pumps fail

5. Cells cease to function

6. Lactic acid is generated

Put these steps in order in which they occur.

A) 635241

B) 352416

C) 236145

D) 162534

Ans: C

Feedback:

The ischemic cascade begins when cerebral blood flow decreases to less than 25 mL per 100 g of blood
per minute. At this point, neurons are no longer able to maintain aerobic respiration. The mitochondria
must then switch to anaerobic respiration, which generates large amounts of lactic acid, causing a
change in the pH. This switch to the less efficient anaerobic respiration also renders the neuron incapable
of producing sufficient quantities of adenosine triphosphate (ATP) to fuel the depolarization processes.
The membrane pumps that maintain electrolyte balances begin to fail, and the cells cease to function.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1274

33. As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for
benefit and for harm. The nurse should be cognizant of what contraindications for thrombolytic therapy?
Select all that apply.

A) INR above 1.0

B) Recent intracranial pathology

C) Sudden symptom onset

D) Current anticoagulation therapy

E) Symptom onset greater than 3 hours prior to admission

Ans: B, D, E

Feedback:

Some of the absolute contraindications for thrombolytic therapy include symptom onset greater than 3
hours before admission, a patient who is anticoagulated (with an INR above 1.7), or a patient who has
recently had any type of intracranial pathology (e.g., previous stroke, head injury, trauma).

34. After a major ischemic stroke, a possible complication is cerebral edema. Nursing care during the
immediate recovery period from an ischemic stroke should include which of the following?

A) Positioning to avoid hypoxia

B) Maximizing PaCO2

C) Administering hypertonic IV solution

D) Initiating early mobilization

Ans: A

Feedback:

Interventions during this period include measures to reduce ICP, such as administering an osmotic
diuretic (e.g., mannitol), maintaining the partial pressure of carbon dioxide (PaCO2) within the range of
30 to 35 mm Hg, and positioning to avoid hypoxia. Hypertonic IV solutions are not used unless sodium
depletion is evident. Mobilization would take place after the immediate threat of increased ICP has past.

35. The nurse is caring for a patient recovering from an ischemic stroke. What intervention best addresses a
potential complication after an ischemic stroke?
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1275

A) Providing frequent small meals rather than three larger meals

B) Teaching the patient to perform deep breathing and coughing exercises

C) Keeping a urinary catheter in situ for the full duration of recovery

D) Limiting intake of insoluble fiber

Ans: B

Feedback:

Because pneumonia is a potential complication of stroke, deep breathing and coughing exercises should
be encouraged unless contraindicated. No particular need exists to provide frequent meals and normally
fiber intake should not be restricted. Urinary catheters should be discontinued as soon as possible.

36. During a patients recovery from stroke, the nurse should be aware of predictors of stroke outcome in
order to help patients and families set realistic goals. What are the predictors of stroke outcome? Select
all that apply.

A) National Institutes of Health Stroke Scale (NIHSS) score

B) Race

C) LOC at time of admission

D) Gender

E) Age

Ans: A, C, E

Feedback:

It is helpful for clinicians to be knowledgeable about the relative importance of predictors of stroke
outcome (age, NIHSS score, and LOC at time of admission) to provide stroke survivors and their
families with realistic goals. Race and gender are not predictors of stroke outcome.

37. A nursing student is writing a care plan for a newly admitted patient who has been diagnosed with a
stroke. What major nursing diagnosis should most likely be included in the patients plan of care?

Adult failure to thrive


A)

B) Post-trauma syndrome
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1276

C) Hyperthermia

D) Disturbed sensory perception

Ans: D

Feedback:

The patient who has experienced a stroke is at a high risk for disturbed sensory perception. Stroke is
associated with multiple other nursing diagnoses, but hyperthermia, adult failure to thrive, and post-
trauma syndrome are not among these.

38. When preparing to discharge a patient home, the nurse has met with the family and warned them that the
patient may exhibit unexpected emotional responses. The nurse should teach the family that these
responses are typically a result of what cause?

A) Frustration around changes in function and communication

B) Unmet physiologic needs

C) Changes in brain activity during sleep and wakefulness

D) Temporary changes in metabolism

Ans: A

Feedback:

Emotional problems associated with stroke are often related to the new challenges around ADLs and
communication. These challenges are more likely than metabolic changes, unmet physiologic needs, or
changes in brain activity, each of which should be ruled out.

39. A rehabilitation nurse caring for a patient who has had a stroke is approached by the patients family and
asked why the patient has to do so much for herself when she is obviously struggling. What would be the
nurses best answer?

A) We are trying to help her be as useful as she possibly can.

B) The focus on care in a rehabilitation facility is to help the patient to resume as much self-care as
possible.

C) We arent here to care for her the way the hospital staff did; we are here to help her get better so she
can go home.

D) Rehabilitation means helping patients do exactly what they did before their stroke.

Ans: B
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1277

Feedback:

In both acute care and rehabilitation facilities, the focus is on teaching the patient to resume as much
self-care as possible. The goal of rehabilitation is not to be useful, nor is it to return patients to their
prestroke level of functioning, which may be unrealistic.

40. A patient with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue
plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the
patients cardiac and neurologic status, the nurse monitors the patient for signs of what complication?

A) Acute pain

B) Septicemia

C) Bleeding

D) Seizures

Ans: C

Feedback:

Bleeding is the most common side effect of t-PA administration, and the patient is closely monitored for
any bleeding. Septicemia, pain, and seizures are much less likely to result from thrombolytic therapy.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1278

Chapter 68: Management of Patients with Neurologic Trauma

1. The ED nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at
home. What physical assessment finding is suggestive of a basilar skull fracture?

A) Epistaxis

B) Periorbital edema

C) Bruising over the mastoid

D) Unilateral facial numbness

Ans: C

Feedback:

An area of ecchymosis (bruising) may be seen over the mastoid (Battles sign) in a basilar skull fracture.
Numbness, edema, and epistaxis are not directly associated with a basilar skull fracture.

2. A patient is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury
1 hours ago. Endotracheal intubation has been deemed necessary and the nurse is preparing to assist.
What nursing diagnosis should the nurse associate with this procedure?

A) Risk for impaired skin integrity

B) Risk for injury

C) Risk for autonomic dysreflexia

D) Risk for suffocation

Ans: B

Feedback:

If endotracheal intubation is necessary, extreme care is taken to avoid flexing or extending the patients
neck, which can result in extension of a cervical injury. Intubation does not directly cause autonomic
dysreflexia and the threat to skin integrity is a not a primary concern. Intubation does not carry the
potential to cause suffocation.

3. A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations
would the nurse expect in this patient?
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1279

A) Respiratory distress and projectile vomiting

B) Bradycardia and hypertension

C) Tachycardia and agitation

D) Third-spacing and hyperthermia

Ans: B

Feedback:

Autonomic dysreflexia is characterized by a pounding headache, profuse sweating, nasal congestion,


piloerection (goose bumps), bradycardia, and hypertension. It occurs in cord lesions above T6 after
spinal shock has resolved; it does not result in vomiting, tachycardia, or third-spacing.

4. The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain
injury. Which of the following clinical manifestations would suggest that the patient may be
experiencing increased brain compression causing brain stem damage?

A) Hyperthermia

B) Tachycardia

C) Hypertension

D) Bradypnea

Ans: A

Feedback:

Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic BP, and
widening pulse pressure. As brain compression increases, respirations become rapid, BP may decrease,
and the pulse slows further. A rapid rise in body temperature is regarded as unfavorable. Hyperthermia
increases the metabolic demands of the brain and may indicate brain stem damage.

5. A patient is brought to the ED by her family after falling off the roof. A family member tells the nurse
that when the patient fell she was knocked out, but came to and seemed okay. Now she is complaining of
a severe headache and not feeling well. The care team suspects an epidural hematoma, prompting the
nurse to prepare for which priority intervention?

A) Insertion of an intracranial monitoring device

B) Treatment with antihypertensives


Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1280

C) Emergency craniotomy

D) Administration of anticoagulant therapy

Ans: C

Feedback:

An epidural hematoma is considered an extreme emergency. Marked neurologic deficit or respiratory


arrest can occur within minutes. Treatment consists of making an opening through the skull to decrease
ICP emergently, remove the clot, and control the bleeding. Antihypertensive medications would not be a
priority. Anticoagulant therapy should not be ordered for a patient who has a cranial bleed. This could
further increase bleeding activity. Insertion of an intracranial monitoring device may be done during the
surgery, but is not priority for this patient.

6. The staff educator is precepting a nurse new to the critical care unit when a patient with a T2 spinal cord
injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. In addition to
monitoring the patient closely, what would be the nurses most appropriate action?

A) Prepare to transfuse packed red blood cells.

B) Prepare for interventions to increase the patients BP.

C) Place the patient in the Trendelenberg position.

D) Prepare an ice bath to lower core body temperature.

Ans: B

Feedback:

Manifestations of neurogenic shock include decreased BP and heart rate. Cardiac markers would be
expected to rise in cardiogenic shock. Transfusion, repositioning, and ice baths are not indicated
interventions.

7. An ED nurse has just received a call from EMS that they are transporting a 17-year-old man who has
just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type
of injury is what?

A) Sports-related injuries

B) Acts of violence

C) Injuries due to a fall

D) Motor vehicle accidents


Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1281

Ans: D

Feedback:

The most common causes of SCIs are motor vehicle crashes (46%), falls (22%), violence (16%), and
sports (12%).

8. A patient with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the
increased the risk of deep vein thrombosis (DVT). Which of the following would be included as an
appropriate nursing intervention to prevent a DVT from occurring?

A) Placing the patient on a fluid restriction as ordered

B) Applying thigh-high elastic stockings

C) Administering an antifibrinolyic agent

D) Assisting the patient with passive range of motion (PROM) exercises

Ans: B

Feedback:

It is important to promote venous return to the heart and prevent venous stasis in a patient with altered
mobility. Applying elastic stockings will aid in the prevention of a DVT. The patient should not be
placed on fluid restriction because a dehydrated state will increase the risk of clotting throughout the
body. Antifibrinolytic agents cause the blood to clot, which is absolutely contraindicated in this
situation. PROM exercises are not an effective protection against the development of DVT.

9. Paramedics have brought an intubated patient to the RD following a head injury due to acceleration-
deceleration motor vehicle accident. Increased ICP is suspected. Appropriate nursing interventions
would include which of the following?

A) Keep the head of the bed (HOB) flat at all times.

B) Teach the patient to perform the Valsalva maneuver.

C) Administer benzodiazepines on a PRN basis.

D) Perform endotracheal suctioning every hour.

Ans: C

Feedback:
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1282

If the patient with a brain injury is very agitated, benzodiazepines are the most commonly used sedatives
and do not affect cerebral blood flow or ICP. The HOB should be elevated 30 degrees. Suctioning
should be done a limited basis, due to increasing the pressure in the cranium. The Valsalva maneuver is
to be avoided. This also causes increased ICP.

10. A patient who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing
care should include which of the following?

A) Preparation for emergency craniotomy

B) Watchful waiting and close monitoring

C) Administration of inotropic drugs

D) Fluid resuscitation

Ans: B

Feedback:

Nondepressed skull fractures generally do not require surgical treatment; however, close observation of
the patient is essential. A craniotomy would not likely be needed if the fracture is nondepressed. Even if
treatment is warranted, it is unlikely to include inotropes or fluid resuscitation.

11. A patient who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What
aspect of the patients current health status is most likely to have precipitated this event?

A) The patient received a blood transfusion.

B) The patients analgesia regimen was recent changed.

C) The patient was not repositioned during the night shift.

D) The patients urinary catheter became occluded.

Ans: D

Feedback:

A distended bladder is the most common cause of autonomic dysreflexia. Infrequent positioning is a less
likely cause, although pressure ulcers or tactile stimulation can cause it. Changes in mediations or blood
transfusions are unlikely causes.

12. A patient is admitted to the neurologic ICU with a spinal cord injury. In writing the patients care plan,
the nurse specifies that contractures can best be prevented by what action?
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1283

A) Repositioning the patient every 2 hours

B) Initiating range-of-motion exercises (ROM) as soon as the patient initiates

C) Initiating (ROM) exercises as soon as possible after the injury

D) Performing ROM exercises once a day

Ans: C

Feedback:

Passive ROM exercises should be implemented as soon as possible after injury. It would be
inappropriate to wait for the patient to first initiate exercises. Toes, metatarsals, ankles, knees, and hips
should be put through a full ROM at least four, and ideally five, times daily. Repositioning alone will
not prevent contractures.

13. A patient with a head injury has been increasingly agitated and the nurse has consequently identified a
risk for injury. What is the nurses best intervention for preventing injury?

A) Restrain the patient as ordered.

B) Administer opioids PRN as ordered.

C) Arrange for friends and family members to sit with the patient.

D) Pad the side rails of the patients bed.

Ans: D

Feedback:

To protect the patient from self-injury, the nurse uses padded side rails. The nurse should avoid
restraints, because straining against them can increase ICP or cause other injury. Narcotics used to
control restless patients should be avoided because these medications can depress respiration, constrict
the pupils, and alter the patients responsiveness. Visitors should be limited if the patient is agitated.

14. A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the patient
complains of a severe throbbing headache. What should the nurse do first?

A) Check the patients indwelling urinary catheter for kinks to ensure patency.

B) Lower the HOB to improve perfusion.


Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1284

C) Administer analgesia.

D) Reassure the patient that headaches are expected after spinal cord injuries.

Ans: A

Feedback:

A severe throbbing headache is a common symptom of autonomic dysreflexia, which occurs after
injuries to the spinal cord above T6. The syndrome is usually brought on by sympathetic stimulation,
such as bowel and bladder distention. Lowering the HOB can increase ICP. Before administering
analgesia, the nurse should check the patients catheter, record vital signs, and perform an abdominal
assessment. A severe throbbing headache is a dangerous symptom in this patient and is not expected.

15. A patient is admitted to the neurologic ICU with a spinal cord injury. When assessing the patient the
nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury.
What should the nurse suspect?

A) Epidural hemorrhage

B) Hypertensive emergency

C) Spinal shock

D) Hypovolemia

Ans: C

Feedback:

In spinal shock, the reflexes are absent, BP and heart rate fall, and respiratory failure can occur.
Hypovolemia, hemorrhage, and hypertension do not cause this sudden change in neurologic function.

16. An elderly woman found with a head injury on the floor of her home is subsequently admitted to the
neurologic ICU. What is the best rationale for the following physician orders: elevate the HOB; keep the
head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion?

A) To decrease cerebral arterial pressure

B) To avoid impeding venous outflow

C) To prevent flexion contractures

D) To prevent aspiration of stomach contents


Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1285

Ans: B

Feedback:

Any activity or position that impedes venous outflow from the head may contribute to increased volume
inside the skull and possibly increase ICP. Cerebral arterial pressure will be affected by the balance
between oxygen and carbon dioxide. Flexion contractures are not a priority at this time. Stomach
contents could still be aspirated in this position.

17. A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding?

A) Absence of reflexes along with flaccid extremities

B) Positive Babinskis reflex along with spastic extremities

C) Hyperreflexia along with spastic extremities

D) Spasticity of all four extremities

Ans: A

Feedback:

During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all
reflexes are absent and the extremities are flaccid. When spinal shock subsides, the patient demonstrates
a positive Babinskis reflex, hyperreflexia, and spasticity of all four extremities.

18. A nurse is reviewing the trend of a patients scores on the Glasgow Coma Scale (GCS). This allows the
nurse to gauge what aspect of the patients status?

A) Reflex activity

B) Level of consciousness

C) Cognitive ability

D) Sensory involvement

Ans: B

Feedback:

The Glasgow Coma Scale (GCS) examines three responses related to LOC: eye opening, best verbal
response, and best motor response.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1286

19. The nurse is caring for a patient who is rapidly progressing toward brain death. The nurse should be
aware of what cardinal signs of brain death? Select all that apply.

A) Absence of pain response

B) Apnea

C) Coma

D) Absence of brain stem reflexes

E) Absence of deep tendon reflexes

Ans: B, C, D

Feedback:

The three cardinal signs of brain death upon clinical examination are coma, the absence of brain stem
reflexes, and apnea. Absences of pain response and deep tendon reflexes are not necessarily indicative of
brain death.

20. Following a spinal cord injury a patient is placed in halo traction. While performing pin site care, the
nurse notes that one of the traction pins has become detached. The nurse would be correct in
implementing what priority nursing action?

A) Complete the pin site care to decrease risk of infection.

B) Notify the neurosurgeon of the occurrence.

C) Stabilize the head in a lateral position.

D) Reattach the pin to prevent further head trauma.

Ans: B

Feedback:

If one of the pins became detached, the head is stabilized in neutral position by one person while another
notifies the neurosurgeon. Reattaching the pin as a nursing intervention would not be done due to risk of
increased injury. Pin site care would not be a priority in this instance. Prevention of neurologic injury is
the priority.

21. The ED is notified that a 6-year-old is in transit with a suspected brain injury after being struck by a car.
The child is unresponsive at this time, but vital signs are within acceptable limits. What will be the
primary goal of initial therapy?
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1287

A) Promoting adequate circulation

B) Treating the childs increased ICP

C) Assessing secondary brain injury

D) Preserving brain homeostasis

Ans: D

Feedback:

All therapy is directed toward preserving brain homeostasis and preventing secondary brain injury,
which is injury to the brain that occurs after the original traumatic event. The scenario does not indicate
the child has increased ICP or a secondary brain injury at this point. Promoting circulation is likely
secondary to the broader goal of preserving brain homeostasis.

22. A patient is admitted to the neurologic ICU with a suspected diffuse axonal injury. What would be the
primary neuroimaging diagnostic tool used on this patient to evaluate the brain structure?

A) MRI

B) PET scan

C) X-ray

D) Ultrasound

Ans: A

Feedback:

CT and MRI scans, the primary neuroimaging diagnostic tools, are useful in evaluating the brain
structure. Ultrasound would not show the brain nor would an x-ray. A PET scan shows brain function,
not brain structure.

23. A 13-year-old was brought to the ED, unconscious, after being hit in the head by a baseball. When the
child regains consciousness, 5 hours after being admitted, he cannot remember the traumatic event. MRI
shows no structural sign of injury. What injury would the nurse suspect the patient has?

A) Diffuse axonal injury

B) Grade 1 concussion with frontal lobe involvement

C) Contusion
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1288

D) Grade 3 concussion with temporal lobe involvement

Ans: D

Feedback:

In a grade 3 concussion there is a loss of consciousness lasting from seconds to minutes. Temporal lobe
involvement results in amnesia. Frontal lobe involvement can cause uncharacteristic behavior and a
grade 1 concussion does not involve loss of consciousness. Diagnostic studies may show no apparent
structural sign of injury, but the duration of unconsciousness is an indicator of the severity of the
concussion. Diffuse axonal injury (DAI) results from widespread shearing and rotational forces that
produce damage throughout the brainto axons in the cerebral hemispheres, corpus callosum, and brain
stem. In cerebral contusion, a moderate to severe head injury, the brain is bruised and damaged in a
specific area because of severe acceleration-deceleration force or blunt trauma.

24. An 82-year-old man is admitted for observation after a fall. Due to his age, the nurse knows that the
patient is at increased risk for what complication of his injury?

A) Hematoma

B) Skull fracture

C) Embolus

D) Stroke

Ans: A

Feedback:

Two major factors place older adults at increased risk for hematomas. First, the dura becomes more
adherent to the skull with increasing age. Second, many older adults take aspirin and anticoagulants as
part of routine management of chronic conditions. Because of these factors, the patients risk of a
hematoma is likely greater than that of stroke, embolism, or skull fracture.

25. A neurologic flow chart is often used to document the care of a patient with a traumatic brain injury. At
what point in the patients care should the nurse begin to use a neurologic flow chart?

A) When the patients condition begins to deteriorate

B) As soon as the initial assessment is made

C) At the beginning of each shift

D) When there is a clinically significant change in the patients condition


Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1289

Ans: B

Feedback:

Neurologic parameters are assessed initially and as frequently as the patients condition requires. As soon
as the initial assessment is made, the use of a neurologic flowchart is started and maintained. A new
chart is not begun at the start of every shift.

26. The nurse planning the care of a patient with head injuries is addressing the patients nursing diagnosis of
sleep deprivation. What action should the nurse implement?

A) Administer a benzodiazepine at bedtime each night.

B) Do not disturb the patient between 2200 and 0600.

C) Cluster overnight nursing activities to minimize disturbances.

D) Ensure that the patient does not sleep during the day.

Ans: C

Feedback:

To allow the patient longer times of uninterrupted sleep and rest, the nurse can group nursing care
activities so that the patient is disturbed less frequently. However, it is impractical and unsafe to provide
no care for an 8-hour period. The use of benzodiazepines should be avoided.

27. The nurse has implemented interventions aimed at facilitating family coping in the care of a patient with
a traumatic brain injury. How can the nurse best facilitate family coping?

A) Help the family understand that the patient could have died.

B) Emphasize the importance of accepting the patients new limitations.

C) Have the members of the family plan the patients inpatient care.

D) Assist the family in setting appropriate short-term goals.

Ans: D

Feedback:

Helpful interventions to facilitate coping include providing family members with accurate and honest
information and encouraging them to continue to set well-defined, short-term goals. Stating that a
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1290

patients condition could be worse downplays their concerns. Emphasizing the importance of acceptance
may not necessarily help the family accept the patients condition. Family members cannot normally plan
a patients hospital care, although they may contribute to the care in some ways.

28. The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should the nurse
identify as prominent risk factors for SCI? Select all that apply.

A) Young age

B) Frequent travel

C) African American race

D) Male gender

E) Alcohol or drug use

Ans: A, D, E

Feedback:

The predominant risk factors for SCI include young age, male gender, and alcohol and drug use.
Ethnicity and travel are not risk factors.

29. The school nurse has been called to the football field where player is immobile on the field after landing
awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse
perform?

A) Ensure that the player is not moved.

B) Obtain the players vital signs, if possible.

C) Perform a rapid assessment of the players range of motion.

D) Assess the players reflexes.

Ans: A

Feedback:

At the scene of the injury, the patient must be immobilized on a spinal (back) board, with the head and
neck maintained in a neutral position, to prevent an incomplete injury from becoming complete. This is a
priority over determining the patients vital signs. It would be inappropriate to test ROM or reflexes.

30. The nurse is caring for a patient whose spinal cord injury has caused recent muscle spasticity. What
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1291

medication should the nurse expect to be ordered to control this?

A) Baclofen (Lioresal)

B) Dexamethasone (Decadron)

C) Mannitol (Osmitrol)

D) Phenobarbital (Luminal)

Ans: A

Feedback:

Baclofen is classified as an antispasmodic agent in the treatment of muscles spasms related to spinal
cord injury. Decadron is an anti-inflammatory medication used to decrease inflammation in both SCI
and head injury. Mannitol is used to decrease cerebral edema in patients with head injury. Phenobarbital
is an anticonvulsant that is used in the treatment of seizure activity.

31. The nurse is planning the care of a patient with a T1 spinal cord injury. The nurse has identified the
diagnosis of risk for impaired skin integrity. How can the nurse best address this risk?

A) Change the patients position frequently.

B) Provide a high-protein diet.

C) Provide light massage at least daily.

D) Teach the patient deep breathing and coughing exercises.

Ans: A

Feedback:

Frequent position changes are among the best preventative measures against pressure ulcers. A high-
protein diet can benefit wound healing, but does not necessarily prevent skin breakdown. Light massage
and deep breathing do not protect or restore skin integrity.

32. A patient with a spinal cord injury has experienced several hypotensive episodes. How can the nurse
best address the patients risk for orthostatic hypotension?

A) Administer an IV bolus of normal saline prior to repositioning.

B) Maintain bed rest until normal BP regulation returns.


Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1292

C) Monitor the patients BP before and during position changes.

D) Allow the patient to initiate repositioning.

Ans: C

Feedback:

To prevent hypotensive episodes, close monitoring of vital signs before and during position changes is
essential. Prolonged bed rest carries numerous risks and it is not possible to provide a bolus before each
position change. Following the patients lead may or may not help regulate BP.

33. A nurse on the neurologic unit is providing care for a patient who has spinal cord injury at the level of
C4. When planning the patients care, what aspect of the patients neurologic and functional status should
the nurse consider?

A) The patient will be unable to use a wheelchair.

B) The patient will be unable to swallow food.

C) The patient will be continent of urine, but incontinent of bowel.

D) The patient will require full assistance for all aspects of elimination.

Ans: D

Feedback:

Patients with a lesion at C4 are fully dependent for elimination. The patient is dependent for feeding, but
is able to swallow. The patient will be capable of using an electric wheelchair.

34. The nurse is providing health education to a patient who has a C6 spinal cord injury. The patient asks
why autonomic dysreflexia is considered an emergency. What would be the nurses best answer?

A) The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel.

B) The suddenness of the onset of the syndrome tells us the body is struggling to maintain its normal
state.

C) Autonomic dysreflexia causes permanent damage to delicate nerve fibers that are healing.

D) The sudden, severe headache increases muscle tone and can cause further nerve damage.

Ans: A
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1293

Feedback:

The sudden increase in BP may cause a rupture of one or more cerebral blood vessels or lead to
increased ICP. Autonomic dysreflexia does not directly cause nerve damage.

35. The nurse caring for a patient with a spinal cord injury notes that the patient is exhibiting early signs and
symptoms of disuse syndrome. Which of the following is the most appropriate nursing action?

A) Limit the amount of assistance provided with ADLs.

B) Collaborate with the physical therapist and immobilize the patients extremities temporarily.

C) Increase the frequency of ROM exercises.

D) Educate the patient about the importance of frequent position changes.

Ans: C

Feedback:

To prevent disuse syndrome, ROM exercises must be provided at least four times a day, and care is
taken to stretch the Achilles tendon with exercises. The patient is repositioned frequently and is
maintained in proper body alignment whether in bed or in a wheelchair. The patient must be
repositioned by caregivers, not just taught about repositioning. It is inappropriate to limit assistance for
the sole purpose of preventing disuse syndrome.

36. Splints have been ordered for a patient who is at risk of developing footdrop following a spinal cord
injury. The nurse caring for this patient knows that the splints are removed and reapplied when?

A) At the patients request

B) Each morning and evening

C) Every 2 hours

D) One hour prior to mobility exercises

Ans: C

Feedback:

The feet are prone to footdrop; therefore, various types of splints are used to prevent footdrop. When
used, the splints are removed and reapplied every 2 hours.

37. A patient who is being treated in the hospital for a spinal cord injury is advocating for the removal of his
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1294

urinary catheter, stating that he wants to try to resume normal elimination. What principle should guide
the care teams decision regarding this intervention?

A) Urinary retention can have serious consequences in patients with SCIs.

B) Urinary function is permanently lost following an SCI.

C) Urinary catheters should not remain in place for more than 7 days.

D) Overuse of urinary catheters can exacerbate nerve damage.

Ans: A

Feedback:

Bladder distention, a major cause of autonomic dysreflexia, can also cause trauma. For this reason,
removal of a urinary catheter must be considered with caution. Extended use of urinary catheterization is
often necessary following SCI. The effect of a spinal cord lesion on urinary function depends on the
level of the injury. Catheter use does not cause nerve damage, although it is a major risk factor for UTIs.

38. A patient with spinal cord injury is ready to be discharged home. A family member asks the nurse to
review potential complications one more time. What are the potential complications that should be
monitored for in this patient? Select all that apply.

A) Orthostatic hypotension

B) Autonomic dysreflexia

C) DVT

D) Salt-wasting syndrome

E) Increased ICP

Ans: A, B, C

Feedback:

For a spinal cord-injured patient, based on the assessment data, potential complications that may develop
include DVT, orthostatic hypotension, and autonomic dysreflexia. Salt-wasting syndrome or increased
ICP are not typical complications following the immediate recovery period.

39. The nurse recognizes that a patient with a SCI is at risk for muscle spasticity. How can the nurse best
prevent this complication of an SCI?
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1295

A) Position the patient in a high Fowlers position when in bed.

B) Support the knees with a pillow when the patient is in bed.

C) Perform passive ROM exercises as ordered.

D) Administer NSAIDs as ordered.

Ans: C

Feedback:

Passive ROM exercises can prevent muscle spasticity following SCI. NSAIDs are not used for this
purpose. Pillows and sitting upright do not directly address the patients risk of muscle spasticity.

40. A patient is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care
for this patient, which of the following nursing diagnoses would the nurse prioritize in the immediate
care of this patient?

A) Risk for impaired skin integrity related to immobility and sensory loss

B) Impaired physical mobility related to loss of motor function

C) Ineffective breathing patterns related to weakness of the intercostal muscles

D) Urinary retention related to inability to void spontaneously

Ans: C

Feedback:

A nursing diagnosis related to breathing pattern would be the priority for this patient. A C4 spinal cord
injury will require ventilatory support, due to the diaphragm and intercostals being affected. The other
nursing diagnoses would be used in the care plan, but not designated as a higher priority than ineffective
breathing patterns.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1296

Chapter 69: Management of Patients with Neurologic Infections,


Autoimmune Disorders, and Neuropathies

1. A patient with possible bacterial meningitis is admitted to the ICU. What assessment finding would the
nurse expect for a patient with this diagnosis?

A) Pain upon ankle dorsiflexion of the foot

B) Neck flexion produces flexion of knees and hips

C) Inability to stand with eyes closed and arms extended without swaying

D) Numbness and tingling in the lower extremities

Ans: B

Feedback:

Clinical manifestations of bacterial meningitis include a positive Brudzinskis sign. Neck flexion
producing flexion of knees and hips correlates with a positive Brudzinskis sign. Positive Homans sign
(pain upon dorsiflexion of the foot) and negative Rombergs sign (inability to stand with eyes closed and
arms extended) are not expected assessment findings for the patient with bacterial meningitis. Peripheral
neuropathy manifests as numbness and tingling in the lower extremities. Again, this would not be an
initial assessment to rule out bacterial meningitis.

2. The nurse is planning discharge education for a patient with trigeminal neuralgia. The nurse knows to
include information about factors that precipitate an attack. What would the nurse be correct in teaching
the patient to avoid?

A) Washing his face

B) Exposing his skin to sunlight

C) Using artificial tears

D) Drinking large amounts of fluids

Ans: A

Feedback:

Washing the face should be avoided if possible because this activity can trigger an attack of pain in a
patient with trigeminal neuralgia. Using artificial tears would be an appropriate behavior. Exposing the
skin to sunlight would not be harmful to this patient. Temperature extremes in beverages should be
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1297

avoided.

3. The nurse is caring for a patient with multiple sclerosis (MS). The patient tells the nurse the hardest
thing to deal with is the fatigue. When teaching the patient how to reduce fatigue, what action should the
nurse suggest?

A) Taking a hot bath at least once daily

B) Resting in an air-conditioned room whenever possible

C) Increasing the dose of muscle relaxants

Avoiding naps during the day


D)

Ans: B

Feedback:

Fatigue is a common symptom of patients with MS. Lowering the body temperature by resting in an air-
conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower
can increase body temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can
cause drowsiness and fatigue. Planning for frequent rest periods and naps can relieve fatigue. Other
measures to reduce fatigue in the patient with MS include treating depression, using occupational
therapy to learn energy conservation techniques, and reducing spasticity.

4. A patient with Guillain-Barr syndrome has experienced a sharp decline in vital capacity. What is the
nurses most appropriate action?

A) Administer bronchodilators as ordered.

B) Remind the patient of the importance of deep breathing and coughing exercises.

C) Prepare to assist with intubation.

D) Administer supplementary oxygen by nasal cannula.

Ans: C

Feedback:

For the patient with Guillain-Barr syndrome, mechanical ventilation is required if the vital capacity falls,
making spontaneous breathing impossible and tissue oxygenation inadequate. Each of the other listed
actions is likely insufficient to meet the patients oxygenation needs.

5. A patient diagnosed with Bells palsy is being cared for on an outpatient basis. During health education,
the nurse should promote which of the following actions?
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1298

A) Applying a protective eye shield at night

B) Chewing on the affected side to prevent unilateral neglect

C) Avoiding the use of analgesics whenever possible

D) Avoiding brushing the teeth

Ans: A

Feedback:

Corneal irritation and ulceration may occur if the eye is unprotected. While paralysis lasts, the involved
eye must be protected. The patient should be encouraged to eat on the unaffected side, due to
swallowing difficulties. Analgesics are used to control the facial pain. The patient should continue to
provide self-care including oral hygiene.

6. The nurse is working with a patient who is newly diagnosed with MS. What basic information should
the nurse provide to the patient?

MS is a progressive demyelinating disease of the nervous system.


A)

B) MS usually occurs more frequently in men.

C) MS typically has an acute onset.

D) MS is sometimes caused by a bacterial infection.

Ans: A

Feedback:

MS is a chronic, degenerative, progressive disease of the central nervous system, characterized by the
occurrence of small patches of demyelination in the brain and spinal cord. The cause of MS is not
known, and the disease affects twice as many women as men.

7. The nurse is creating a plan of care for a patient who has a recent diagnosis of MS. Which of the
following should the nurse include in the patients care plan?

A) Encourage patient to void every hour.

B) Order a low-residue diet.

C) Provide total assistance with all ADLs.


Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1299

D) Instruct the patient on daily muscle stretching.

Ans: D

Feedback:

A patient diagnosed with MS should be encouraged to increase the fiber in his or her diet and void 30
minutes after drinking to help train the bladder. The patient should participate in daily muscle stretching
to help alleviate and relax muscle spasms.

8. A patient with metastatic cancer has developed trigeminal neuralgia and is taking carbamazepine
(Tegretol) for pain relief. What principle applies to the administration of this medication?

A) Tegretol is not known to have serious adverse effects.

B) The patient should be monitored for bone marrow depression.

C) Side effects of the medication include renal dysfunction.

D) The medication should be first taken in the maximum dosage form to be effective.

Ans: B

Feedback:

The anticonvulsant agents carbamazepine (Tegretol) and phenytoin (Dilantin) relieve pain in most
patients diagnosed with trigeminal neuralgia by reducing the transmission of impulses at certain nerve
terminals. Side effects include nausea, dizziness, drowsiness, and aplastic anemia. Carbamazepine
should be gradually increased until pain relief is obtained.

9. A male patient presents to the clinic complaining of a headache. The nurse notes that the patient is
guarding his neck and tells the nurse that he has stiffness in the neck area. The nurse suspects the patient
may have meningitis. What is another well-recognized sign of this infection?

A) Negative Brudzinskis sign

B) Positive Kernigs sign

C) Hyperpatellar reflex

D) Sluggish pupil reaction

Ans: B
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1300

Feedback:

Meningeal irritation results in a number of well-recognized signs commonly seen in meningitis, such as
a positive Kernigs sign, a positive Brudzinskis sign, and photophobia. Hyperpatellar reflex and a
sluggish pupil reaction are not commonly recognized signs of meningitis.

10. The nurse is developing a plan of care for a patient newly diagnosed with Bells palsy. The nurses plan of
care should address what characteristic manifestation of this disease?

A) Tinnitus

B) Facial paralysis

C) Pain at the base of the tongue

D) Diplopia

Ans: B

Feedback:

Bells palsy is characterized by facial dysfunction, weakness, and paralysis. It does not result in diplopia,
pain at the base of the tongue, or tinnitus.

The nurse caring for a patient diagnosed with Guillain-Barr syndrome is planning care with regard to the
11. clinical manifestations associated this syndrome. The nurses communication with the patient should
reflect the possibility of what sign or symptom of the disease?

A) Intermittent hearing loss

B) Tinnitus

C) Tongue enlargement

D) Vocal paralysis

Ans: D

Feedback:

Guillain-Barr syndrome is a disorder of the vagus nerve. Clinical manifestations include vocal paralysis,
dysphagia, and voice changes (temporary or permanent hoarseness). Hearing deficits, tinnitus, and
tongue enlargement are not associated with the disease.

12. The nurse is preparing to provide care for a patient diagnosed with myasthenia gravis. The nurse should
know that the signs and symptoms of the disease are the result of what?
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1301

A) Genetic dysfunction

B) Upper and lower motor neuron lesions

C) Decreased conduction of impulses in an upper motor neuron lesion

D) A lower motor neuron lesion

Ans: D

Feedback:

Myasthenia gravis is characterized by a weakness of muscles, especially in the face and throat, caused by
a lower neuron lesion at the myoneural junction. It is not a genetic disorder. A combined upper and
lower neuron lesion generally occurs as a result of spinal injuries. A lesion involving cranial nerves and
their axons in the spinal cord would cause decreased conduction of impulses at an upper motor neuron.

13. A patient with suspected Creutzfeldt-Jakob disease (CJD) is being admitted to the unit. The nurse would
expect what diagnostic test to be ordered for this patient?

A) Cerebral angiography

B) ABG analysis

C) CT

D) EEG

Ans: D

Feedback:

The EEG reveals a characteristic pattern over the duration of CJD. A CT scan may be used to rule out
disorders that may mimic the symptoms of CJD. ABGs would not be necessary until the later stages of
CJD; they would not be utilized as a diagnostic test. Cerebral angiography is not used to diagnose CJD.

14. To alleviate pain associated with trigeminal neuralgia, a patient is taking Tegretol (carbamazepine).
What health education should the nurse provide to the patient before initiating this treatment?

A) Concurrent use of calcium supplements is contraindicated.

B) Blood levels of the drug must be monitored.

C) The drug is likely to cause hyperactivity and agitation.


Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1302

D) Tegretol can cause tinnitus during the first few days of treatment.

Ans: B

Feedback:

Side effects of Tegretol include nausea, dizziness, drowsiness, and aplastic anemia. The patient must
also be monitored for bone marrow depression during long-term therapy. Skin discoloration, insomnia,
and tinnitus are not side effects of Tegretol.

15. A patient with herpes simplex virus encephalitis (HSV) has been admitted to the ICU. What medication
would the nurse expect the physician to order for the treatment of this disease process?

A) Cyclosporine (Neoral)

B) Acyclovir (Zovirax)

C) Cyclobenzaprine (Flexeril)

D) Ampicillin (Prinicpen)

Ans: B

Feedback:

Acyclovir (Zovirax) or ganciclovir (Cytovene), antiviral agents, are the medications of choice in the
treatment of HSV. The mode of action is the inhibition of viral DNA replication. To prevent relapse,
treatment would continue for up to 3 weeks. Cyclosporine is an immunosuppressant and antirheumatic.
Cyclobenzaprine is a centrally acting skeletal muscle relaxant. Ampicillin, an antibiotic, is ineffective
against viruses.

16. A middle-aged woman has sought care from her primary care provider and undergone diagnostic testing
that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the
woman to seek care?

A) Cognitive declines

B) Personality changes

C) Contractures

D) Difficulty in coordination

Ans: D
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1303

Feedback:

The primary symptoms of MS most commonly reported are fatigue, depression, weakness, numbness,
difficulty in coordination, loss of balance, spasticity, and pain. Cognitive changes and contractures
usually occur later in the disease.

17. A nurse is planning the care of a 28-year-old woman hospitalized with a diagnosis of myasthenia gravis.
What approach would be most appropriate for the care and scheduling of diagnostic procedures for this
patient?

A) All at one time, to provide a longer rest period

B) Before meals, to stimulate her appetite

C) In the morning, with frequent rest periods

D) Before bedtime, to promote rest

Ans: C

Feedback:

Procedures should be spaced to allow for rest in between. Procedures should be avoided before meals, or
the patient may be too exhausted to eat. Procedures should be avoided near bedtime if possible.

18. The nurse is caring for a patient who is hospitalized with an exacerbation of MS. To ensure the patients
safety, what nursing action should be performed?

A) Ensure that suction apparatus is set up at the bedside.

B) Pad the patients bed rails.

C) Maintain bed rest whenever possible.

D) Provide several small meals each day.

Ans: A

Feedback:

Because of the patients risk of aspiration, it is important to have a suction apparatus at hand. Bed rest
should be generally be minimized, not maximized, and there is no need to pad the patients bed rails or to
provide multiple small meals.

19. A 33-year-old patient presents at the clinic with complaints of weakness, incoordination, dizziness, and
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1304

loss of balance. The patient is hospitalized and diagnosed with MS. What sign or symptom, revealed
during the initial assessment, is typical of MS?

A) Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes

B) Flexor spasm, clonus, and negative Babinskis reflex

C) Blurred vision, intention tremor, and urinary hesitancy

D) Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs

Ans: C

Feedback:

Optic neuritis, leading to blurred vision, is a common early sign of MS, as is intention tremor (tremor
when performing an activity). Nerve damage can cause urinary hesitancy. In MS, deep tendon reflexes
are increased or hyperactive. A positive Babinskis reflex is found in MS. Abdominal reflexes are absent
with MS.

20. The nurse is developing a plan of care for a patient with Guillain-Barr syndrome. Which of the following
interventions should the nurse prioritize for this patient?

A) Using the incentive spirometer as prescribed

B) Maintaining the patient on bed rest

C) Providing aids to compensate for loss of vision

D) Assessing frequently for loss of cognitive function

Ans: A

Feedback:

Respiratory function can be maximized with incentive spirometry and chest physiotherapy. Nursing
interventions toward enhancing physical mobility should be utilized. Nursing interventions are aimed at
preventing a deep vein thrombosis. Guillain-Barr syndrome does not affect cognitive function or vision.

21. A 69-year-old patient is brought to the ED by ambulance because a family member found him lying on
the floor disoriented and lethargic. The physician suspects bacterial meningitis and admits the patient to
the ICU. The nurse knows that risk factors for an unfavorable outcome include what? Select all that
apply.

A) Blood pressure greater than 140/90 mm Hg


Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1305

B) Heart rate greater than 120 bpm

C) Older age

D) Low Glasgow Coma Scale

E) Lack of previous immunizations

Ans: B, C, D

Feedback:

Risks for an unfavorable outcome of meningitis include older age, a heart rate greater than 120
beats/minute, low Glasgow Coma Scale score, cranial nerve palsies, and a positive Gram stain 1 hour
after presentation to the hospital. A BP greater than 140/90 mm Hg is indicative of hypertension, but is
not necessarily related to poor outcomes related to meningitis. Immunizations are not normally relevant
to the course of the disease.

22. The critical care nurse is caring for 25-year-old man admitted to the ICU with a brain abscess. What is a
priority nursing responsibility in the care of this patient?

A) Maintaining the patients functional independence

B) Providing health education

C) Monitoring neurologic status closely

D) Promoting mobility

Ans: C

Feedback:

Vigilant neurologic monitoring is a key aspect of caring for a patient who has a brain abscess. This
supersedes education, ADLs, and mobility, even though these are all valid and important aspects of
nursing care.

23. A patient is being admitted to the neurologic ICU with suspected herpes simplex virus encephalitis.
What nursing action best addresses the patients complaints of headache?

A) Initiating a patient-controlled analgesia (PCA) of morphine sulfate

B) Administering hydromorphone (Dilaudid) IV as needed

C) Dimming the lights and reducing stimulation


Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1306

D) Distracting the patient with activity

Ans: C

Feedback:

Comfort measures to reduce headache include dimming the lights, limiting noise and visitors, grouping
nursing interventions, and administering analgesic agents. Opioid analgesic medications may mask
neurologic symptoms; therefore, they are used cautiously. Non-opioid analgesics may be preferred.
Distraction is unlikely to be effective, and may exacerbate the patients pain.

24. A patient is admitted through the ED with suspected St. Louis encephalitis. The unique clinical feature
of St. Louis encephalitis will make what nursing action a priority?

A) Serial assessments of hemoglobin levels

B) Blood glucose monitoring

C) Close monitoring of fluid balance

D) Assessment of pain along dermatomes

Ans: C

Feedback:

A unique clinical feature of St. Louis encephalitis is SIADH with hyponatremia. As such, it is important
to monitor the patients intake and output closely.

25. The nurse is caring for a 77-year-old woman with MS. She states that she is very concerned about the
progress of her disease and what the future holds. The nurse should know that elderly patients with MS
are known to be particularly concerned about what variables? Select all that apply.

A) Possible nursing home placement

B) Pain associated with physical therapy

C) Increasing disability

D) Becoming a burden on the family

E) Loss of appetite

Ans: A, C, D
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1307

Feedback:

Elderly patients with MS are particularly concerned about increasing disability, family burden, marital
concern, and the possible future need for nursing home care. Older adults with MS are not noted to have
particular concerns regarding the pain of therapy or loss of appetite.

26. You are the clinic nurse caring for a patient with a recent diagnosis of myasthenia gravis. The patient has
begun treatment with pyridostigmine bromide (Mestinon). What change in status would most clearly
suggest a therapeutic benefit of this medication?

A) Increased muscle strength

B) Decreased pain

C) Improved GI function

D) Improved cognition

Ans: A

Feedback:

The goal of treatment using pyridostigmine bromide is improvement of muscle strength and control of
fatigue. The drug is not intended to treat pain, or cognitive or GI functions.

27. The critical care nurse is admitting a patient in myasthenic crisis to the ICU. The nurse should prioritize
what nursing action in the immediate care of this patient?

A) Suctioning secretions

B) Facilitating ABG analysis

C) Providing ventilatory assistance

D) Administering tube feedings

Ans: C

Feedback:

Providing ventilatory assistance takes precedence in the immediate management of the patient with
myasthenic crisis. It may be necessary to suction secretions and/or provide tube feedings, but they are
not the priority for this patient. ABG analysis will be done, but this is not the priority.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1308

28. The nurse caring for a patient in ICU diagnosed with Guillain-Barr syndrome should prioritize
monitoring for what potential complication?

A) Impaired skin integrity

B) Cognitive deficits

C) Hemorrhage

D) Autonomic dysfunction

Ans: D

Feedback:

Based on the assessment data, potential complications that may develop include respiratory failure and
autonomic dysfunction. Skin breakdown, decreased cognition, and hemorrhage are not complications of
Guillain-Barr syndrome.

The nurse is teaching a patient with Guillain-Barr syndrome about the disease. The patient asks how he
29. can ever recover if demyelination of his nerves is occurring. What would be the nurses best response?

A) Guillain-Barr spares the Schwann cell, which allows for remyelination in the recovery phase of the
disease.

B) In Guillain-Barr, Schwann cells replicate themselves before the disease destroys them, so
remyelination is possible.

C) I know you understand that nerve cells do not remyelinate, so the physician is the best one to
answer your question.

D) For some reason, in Guillain-Barr, Schwann cells become activated and take over the
remyelination process.

Ans: A

Feedback:

Myelin is a complex substance that covers nerves, providing insulation and speeding the conduction of
impulses from the cell body to the dendrites. The cell that produces myelin in the peripheral nervous
system is the Schwann cell. In Guillain-Barr syndrome, the Schwann cell is spared, allowing for
remyelination in the recovery phase of the disease. The nurse should avoid downplaying the patients
concerns by wholly deferring to the physician.

30. A patient diagnosed with myasthenia gravis has been hospitalized to receive plasmapheresis for a
myasthenic exacerbation. The nurse knows that the course of treatment for plasmapheresis in a patient
with myasthenia gravis is what?
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1309

A) Every day for 1 week

B) Determined by the patients response

C) Alternate days for 10 days

D) Determined by the patients weight

Ans: B

Feedback:

The typical course of plasmapheresis consists of daily or alternate-day treatment, and the number of
treatments is determined by the patients response.

31. The nurse is discharging a patient home after surgery for trigeminal neuralgia. What advice should the
nurse provide to this patient in order to reduce the risk of injury?

A) Avoid watching television or using a computer for more than 1 hour at a time.

B) Use OTC antibiotic eye drops for at least 14 days.

C) Avoid rubbing the eye on the affected side of the face.

D) Rinse the eye on the affected side with normal saline daily for 1 week.

Ans: C

Feedback:

If the surgery results in sensory deficits to the affected side of the face, the patient is instructed not to rub
the eye because the pain of a resulting injury will not be detected. There is no need to limit TV viewing
or to rinse the eye daily. Antibiotics may or may not be prescribed, and these would not reduce the risk
of injury.

32. A patient diagnosed with Bells palsy is having decreased sensitivity to touch of the involved nerve.
What should the nurse recommend to prevent atrophy of the muscles?

A) Blowing up balloons

B) Deliberately frowning

C) Smiling repeatedly
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1310

D) Whistling

Ans: D

Feedback:

Facial exercises, such as wrinkling the forehead, blowing out the cheeks, and whistling, may be
performed with the aid of a mirror to prevent muscle atrophy. Blowing up balloons, frowning, and
smiling are not considered facial exercises.

33. A patient with diabetes presents to the clinic and is diagnosed with a mononeuropathy. This patients
nursing care should involve which of the following?

A) Protection of the affected limb from injury

B) Passive and active ROM exercises for the affected limb

C) Education about improvements to glycemic control

D) Interventions to prevent contractures

Ans: A

Feedback:

Nursing care involves protection of the affected limb or area from injury, as well as appropriate patient
teaching about mononeuropathy and its treatment. Nursing care for this patient does not likely involve
exercises or assistive devices, since these are unrelated to the etiology of the disease. Improvements to
diabetes management may or may not be necessary.

34. A patient diagnosed with MS has been admitted to the medical unit for treatment of an MS exacerbation.
Included in the admission orders is baclofen (Lioresal). What should the nurse identify as an expected
outcome of this treatment?

A) Reduction in the appearance of new lesions on the MRI

B) Decreased muscle spasms in the lower extremities

C) Increased muscle strength in the upper extremities

D) Decreased severity and duration of exacerbations

Ans: B

Feedback:
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1311

Baclofen, a g-aminobutyric acid (GABA) agonist, is the medication of choice in treating spasms. It can
be administered orally or by intrathecal injection. Avonex and Betaseron reduce the appearance of new
lesions on the MRI. Corticosteroids limit the severity and duration of exacerbations. Anticholinesterase
agents increase muscle strength in the upper extremities.

35. A 35-year-old woman is diagnosed with a peripheral neuropathy. When making her plan of care, the
nurse knows to include what in patient teaching? Select all that apply.

A) Inspect the lower extremities for skin breakdown.

B) Footwear needs to be accurately sized.

C) Immediate family members should be screened for the disease.

D) Assistive devices may be needed to reduce the risk of falls.

E) Dietary modifications are likely necessary.

Ans: A, B, D

Feedback:

The plan of care includes inspection of the lower extremities for skin breakdown. Footwear should be
accurately sized. Assistive devices, such as a walker or cane, may decrease the risk of falls. Bath water
temperature is checked to avoid thermal injury. Peripheral neuropathies do not have a genetic component
and diet is unrelated.

36. A 73-year-old man comes to the clinic complaining of weakness and loss of sensation in his feet and
legs. Assessment of the patient shows decreased reflexes bilaterally. Why would it be a challenge to
diagnose a peripheral neuropathy in this patient?

A) Older adults are often vague historians.

B) The elderly have fewer peripheral nerves than younger adults.

C) Many older adults are hesitant to admit that their body is changing.

D) Many symptoms can be the result of normal aging process.

Ans: D

Feedback:

The diagnosis of peripheral neuropathy in the geriatric population is challenging because many
symptoms, such as decreased reflexes, can be associated with the normal aging process. In this scenario,
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1312

the patient has come to the clinic seeking help for his problem; this does not indicate a desire on the part
of the patient to withhold information from the health care giver. The normal aging process does not
include a diminishing number of peripheral nerves.

37. A patient with MS has been admitted to the hospital following an acute exacerbation. When planning the
patients care, the nurse addresses the need to enhance the patients bladder control. What aspect of
nursing care is most likely to meet this goal?

A) Establish a timed voiding schedule.

B) Avoid foods that change the pH of urine.

C) Perform intermittent catheterization q6h.

D) Administer anticholinergic drugs as ordered.

Ans: A

Feedback:

A timed voiding schedule addresses many of the challenges with urinary continence that face the patient
with MS. Interventions should be implemented to prevent the need for catheterization and
anticholinergics are not normally used.

38. A patient with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action
should the nurse consequently perform?

A) Arrange for the patient to receive a low residue diet.

B) Position the patient upright during feeding.

C) Suction the patient following each meal.

D) Withhold liquids until the patient has finished eating.

Ans: B

Feedback:

Correct, upright positioning is necessary to prevent aspiration in the patient with dysphagia. There is no
need for a low-residue diet and suctioning should not be performed unless there is an apparent need.
Liquids do not need to be withheld during meals in order to prevent aspiration.

39. A 48-year-old patient has been diagnosed with trigeminal neuralgia following recent episodes of
unilateral face pain. The nurse should recognize what implication of this diagnosis?
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 1313

A) The patient will likely require lifelong treatment with anticholinergic medications.

B) The patient has a disproportionate risk of developing myasthenia gravis later in life.

The patient needs to be assessed for MS.


C)

D) The disease is self-limiting and the patient will achieve pain relief over time.

Ans: C

Feedback:

Patients that develop trigeminal neuralgia before age 50 should be evaluated for the coexistent of MS
because trigeminal neuralgia occurs in approximately 5% of patients with MS. Treatment does not
include anticholinergics and the disease is not self-limiting. Trigeminal neuralgia is not associated with
an increased risk of myasthenia gravis.

40. A patient presents at the clinic complaining of pain and weakness in her hands. On assessment, the nurse
notes diminished reflexes in the upper extremities bilaterally and bilateral loss of sensation. The nurse
knows that these findings are indicative of what?

A) Guillain-Barr syndrome

B) Myasthenia gravis

C) Trigeminal neuralgia

D) Peripheral nerve disorder

Ans: D

Feedback:

The major symptoms of peripheral nerve disorders are loss of sensation, muscle atrophy, weakness,
diminished reflexes, pain, and paresthesia (numbness, tingling) of the extremities. Trigeminal neuralgia
is a condition of the fifth cranial nerve that is characterized by paroxysms of pain in the area innervated
by any of the three branches, but most commonly the second and third branches of the trigeminal nerve.
Myasthenia gravis, an autoimmune disorder affecting the myoneural junction, is characterized by
varying degrees of weakness of the voluntary muscles. Guillain-Barr syndrome is an autoimmune attack
on the peripheral nerve myelin.

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