Brainiac
The nurse correlates which data as placing a patient at risk for experiencing a metabolic seizure?
A. Serum magnesium 3.2 mg/dL
B. Serum calcium 14 mg/dL
C. Serum potassium 3.2 mEq/L
D. Serum sodium 115 mEq/L
D. Serum sodium 115 mEq/L
Hyponatremia and hypernatremia are associated with metabolic seizures. This is a decreased sodium level; the normal range is 135 to 145 mEq/L.
The nurse assesses the patient for which early finding in ALS?
A. Bowel and bladder incontinence
B. Respiratory distress
C. Muscle cramps
D. Paralysis
C. Muscle cramps
Upper and lower neurons degenerate and die. Unable to function, muscles gradually weaken, atrophy, and twitch (fasciculate). Muscle weakness is an early sign of this progressive disease.
A patient is diagnosed with myasthenia gravis (MG). What information does the nurse include in an explanation of this disease process?
A. “Your nerve endings are no longer functional and that leads to muscle weakness.”
B. “Your body has a disorder that destroys receptor sites at the neuromuscular junction, leading to decreased nerve conduction.”
C. “Your body does not make enough of the neurotransmitter needed for movement.”
D. “Your nerves have lost their protective covering and impulses are not as smooth.”
B. “Your body has a disorder that destroys receptor sites at the neuromuscular junction, leading to decreased nerve conduction.”
In MG, circulating anti-AChR antibodies bind with the AChR, resulting in complement-mediated destruction of receptor sites.
In assessing a patient with increased intracranial pressure, the nurse notes that the patient’s left pupil is larger than the right pupil. The nurse correlates the larger left pupil to compression of which cranial nerve?
A. Left optic nerve
B. Left oculomotor nerve
C. Right optic nerve
D. Right oculomotor nerve
B. Left oculomotor nerve
Compression of the third cranial nerve (oculomotor) produces pupillary dilation on the same side as the cranial nerve compression or ipsilateral to the cranial nerve compression.
A patient being evaluated for Guillain-Barré syndrome (GBS) presents with bilateral symmetrical muscle weakness and sensory changes of both feet and legs. The nurse correlates which key finding to this disease process?
A. Areflexia
B. Hyperreflexia
C. Hypothermia
D. Hyperanalgesia
A. Areflexia
After the first few days of weakness, neurological assessment demonstrates diminished or absent deep tendon reflexes (areflexia). Areflexia is recognized as a key finding in GBS.
The nurse correlates the clinical finding of aphasia to damage to which cerebral artery?
A. Anterior cerebral artery
B. Basilar artery
C. Middle cerebral artery
D. Posterior cerebral artery
C. Middle cerebral artery
Decreased blood flow through the middle cerebral artery results in contralateral motor and sensory deficits, speech and language deficits, and aphasia.
A patient recently diagnosed with amyotrophic lateral sclerosis is having difficulty with swallowing and has been choking and coughing excessively at mealtimes. The nurse implements which action first?
A. Initiating low-flow oxygen therapy
B. Suctioning the oropharynx
C. Auscultating breath sounds
D. Assessing neurological status
C. Auscultating breath sounds
The priority is to assess the airway and breathing. Because motor weakness involves muscles of the face, mouth, and neck, maintaining an intact airway is compromised. Airway compromise is greater as the patient demonstrates weakened cough and impaired swallowing.
A patient with Guillain-Barré syndrome (GBS) asks how the illness develops. How should the nurse respond about the pathophysiology of the disorder?
A. “An infection destroys the nerve endings.”
B. “An infection enters the spinal cord and erodes the nerves at the roots.”
C. “The nerves are killed by infiltration of your body’s white blood cells used to fight an infection.”
D. “The covering of nerves that help conduct impulses is damaged.”
D. “The covering of nerves that help conduct impulses is damaged.”
In GBS, the patient’s own immune system begins to destroy the myelin that surrounds the peripheral nerves. Destruction occurs between the nodes of Ranvier that results in slowing of impulses or conduction block. There is infiltration of lymphocytes into the peripheral nervous system, which attracts macrophages; the macrophages penetrate the Schwann cells and invade the myelin, resulting in demyelination.
The nurse is preparing a patient for insertion of an intraventricular catheter intracranial pressure (ICP) monitoring device. What is an advantage of this device?
A. Must be inserted in the operating room
B. Catheter tip located in the lateral ventricle
C. Less mechanical drift of the measurement over time
D. Lower rate of infection because of no fluid reservoir
B. Catheter tip located in the lateral ventricle
The intraventricular catheter ICP monitoring device is considered the gold standard for ICP measurement because the catheter tip is located in the lateral ventricle. It allows measurement of ICP as well as drainage of cerebrospinal fluid (CSF).
The nurse monitors for which clinical manifestation in the patient diagnosed with trigeminal neuralgia?
A. Acute onset of pain
B. Impaired swallowing
C. Visual disturbances
D. Impaired extraocular movements
A. Acute onset of pain
Trigeminal neuralgia is a pain disorder, and the patient seeks medical attention for relief. It is not unusual for the patient to present to a primary care practitioner with a chief complaint of shocklike facial pain that is sharp and throbbing.
The nurse cares for a patient with increased intracranial pressure (ICP) due to edema. Which two actions should the nurse take to allow for venous flow and drainage?
A. Keep the head of bed flat.
B. Place the head in proper alignment.
C. Support the head with towel rolls.
D. Elevate the arms above the heart.
E. Elevate the foot of the bed.
B. Place the head in proper alignment.
This is correct. For patients with increased intracranial pressure (ICP) due to bleeding or edema, it is imperative to keep the head in proper alignment to allow venous flow or drainage of blood from the brain back to the heart. The nurse may need to provide support to the head to maintain proper alignment that facilitates venous outflow.
C. Support the head with towel rolls.
This is correct. For patients with increased intracranial pressure (ICP) due to bleeding or edema, it is imperative to keep the head in proper alignment to allow venous flow or drainage of blood from the brain back to the heart. The nurse may need to provide support to the head to maintain proper alignment that facilitates venous outflow.
A patient with amyotrophic lateral sclerosis is prescribed riluzole (Rilutek). What statement by the patient indicates that further teaching is needed about this treatment?
A. “This medication will cure my disease.”
B. “This medication may delay the need to be on a ventilator.”
C. “This medication works on nerve conduction.”
D. “This medication may decrease the progression of my disease.”
A. “This medication will cure my disease.”
This statement indicates the need for additional teaching because riluzole does not cure the disease. Because no cure exists, management focuses on slowing disease progression and managing clinical manifestations. Riluzole (Rilutek) is the first medication approved to slow disease progression.
The nurse prioritizes which nursing diagnosis as the highest in the patient with Guillain-Barré syndrome (GBS)?
A. Risk for aspiration related to related to loss of sensation in oropharynx secondary to progressive neuronal degeneration
B. Ineffective airway clearance related to decreased cough secondary to decreased acetylcholine at neuromuscular junction
C. Ineffective breathing pattern related to skeletal muscle weakness secondary to destruction of myelin sheath
D. Impaired gas exchange related to loss of respiratory muscle secondary to nerve root compression
C. Ineffective breathing pattern related to skeletal muscle weakness secondary to destruction of myelin sheath
In GBS, the patient’s own immune system begins to destroy the myelin that surrounds the peripheral nerves. Destruction occurs between the nodes of Ranvier that impairs saltatory (jumping) conduction and results in slowing of impulses or conduction block.
A patient with increased intracranial pressure (ICP) is sensitive to fluid-volume shifts. The nurse recognizes which approach as safest to reduce this patient’s cerebral edema?
A. Mannitol
B. 3% sodium chloride
C. 0.9% normal saline
D. Packed red blood cells
B. 3% sodium chloride
High-concentration sodium chloride solutions pull water from the interstitial spaces into the vascular space without the dramatic fluid shifts caused when osmotic diuretics are used.
The nurse cares for a patient with increased intracranial pressure (ICP) who has developed unilateral pupillary dilation and is unresponsive. What does the nurse suspect is the concern?
A. Oversedation
B. Decreased ICP
C. Increased ICP
D. Cerebral herniation
D. Cerebral herniation
Unresponsiveness, unilateral or bilateral pupillary dilation without reaction, contralateral hemiparesis, and Cushing’s triad are signs of cerebral herniation.
The nurse monitors for which clinical manifestations of increased intracranial pressure in the patient diagnosed with a brain tumor? Select all that apply.
A. Ataxia
B. Papilledema
C. Diarrhea
D. Vomiting
E. Headache
A. Ataxia
B. Papilledema
D. Vomiting
E. Headache
This is correct. Clinical manifestations of increased ICP include papilledema, headache, nausea and vomiting, decreased alertness, cognitive impairment, personality changes, ataxia, hemiparesis, abnormal reflexes, and cranial nerve palsies.
A patient with amyotrophic lateral sclerosis (ALS) is being prepared for discharge. What teaching would be essential for the family to receive before taking the patient home? Select all that apply.
A. Skin care
B. Aspiration precautions
C. Recognizing exacerbations
D. Lower extremity circulation
E. Strategies to lose weight
A. Skin care
This is correct. ALS is a progressive disease that leads to the inability to move. Complications include aspiration, difficulty swallowing, pressure injuries, speech problems, weight loss, paralysis, and tongue atrophy. Skin care to monitor for and prevent pressure injuries is important.
B. Aspiration precautions
This is correct. ALS is a progressive disease that leads to the inability to move. Complications include aspiration, difficulty swallowing, pressure injuries, speech problems, weight loss, paralysis, and tongue atrophy. Aspiration precautions are a high priority because of impaired swallowing.
D. Lower extremity circulation
This is correct. ALS is a progressive disease that leads to the inability to move. Complications include aspiration, difficulty swallowing, pressure injuries, speech problems, weight loss, paralysis, and tongue atrophy. Strategies to facilitate lower extremity circulation are important to prevent venous stasis and deep vein thrombosis development.
The nurse monitors for which clinical manifestations in the patient being evaluated for myasthenia gravis (MG)? Select all that apply.
A. Ptosis
B. Diplopia
C. Abdominal pain
D. Dysphagia
E. Epigastric pain
A. Ptosis
B. Diplopia
D. Dysphagia
This is correct. Ptosis; diplopia; difficulty with phonation, chewing, and swallowing (dysphagia); and trunk and limb weakness are clinical manifestations of MG.
In monitoring a trauma patient for shock, the nurse differentiates neurogenic shock from hypovolemic shock by correlating which parameters to neurogenic shock?
A. Tachycardia with vasoconstriction
B. Tachycardia with vasodilation
C. Bradycardia with vasodilation
D. Bradycardia with vasoconstriction
C. Bradycardia with vasodilation
The clinical manifestations of neurogenic shock include profound bradycardia, hypotension (vasodilation),, changes in level of consciousness, and metabolic acidosis.
The nurse correlates which rationale to the use of hyperventilation to decrease intracranial pressure in a patient after traumatic head injury?
A. To maximize oxygenation
B. To promote vasoconstriction
C. To decrease cerebral perfusion
D. To decrease ventilatory effort
B. To promote vasoconstriction
Hyperventilation decreases PaCO2 as more is exhaled with each breath. Decreased PaCO2 leads to vasoconstriction, which is an important factor in the management of increased intracranial pressure.
In monitoring a patient recovering from a craniotomy for treatment of a brain tumor, which assessment findings require the nurse to notify the surgeon? Select all that apply.
A. Heart rate 52 bpm
B. Temperature 99.2°F
C. Respiratory rate 10 and irregular
D. Urine output 200 mL over 4 hours
E. Systolic blood pressure 198 mm Hg
A. Heart rate 52 bpm
This is correct. For a patient with a brain tumor, decreased heart rate is a manifestation of Cushing’s triad, which occurs late in increased ICP that signals herniation syndrome, a medical emergency.
C. Respiratory rate 10 and irregular
This is correct. For a patient with a brain tumor, an irregular respiratory rate is a manifestation of Cushing’s triad, which occurs late in increased ICP that signals herniation syndrome, a medical emergency.
E. Systolic blood pressure 198 mm Hg
This is correct. For a patient with a brain tumor, increased intracranial pressure is a manifestation of Cushing’s triad, which occurs late in increased ICP that signals herniation syndrome, a medical emergency.
The nurse cares for a patient at home with advanced amyotrophic lateral sclerosis (ALS). Which complications should the nurse monitor for? Select all that apply.
A. Constipation
B. Deep vein thrombosis
C. Depression
D. Pneumonia
E. Gastric bleeding
A. Constipation
This is correct. Constipation occurs due to immobility.
B. Deep vein thrombosis
This is correct. Deep vein thrombosis and pulmonary embolism is a concern because of immobility.
C. Depression
This is correct. Depression is a concern because of living with a terminal illness.
D. Pneumonia
This is correct. Pneumonia is a result of aspiration, which is a high risk in ALS patients.
The nurse correlates which clinical manifestations to the patient diagnosed with Guillain-Barré syndrome (GBS)? What should the nurse expect to assess during the acute stage of this syndrome? Select all that apply.
A. Decreased level of consciousness
B. Hypotension
C. Difficulty breathing
D. Dysphagia
E. Numbness and tingling
B. Hypotension
C. Difficulty breathing
D. Dysphagia
E. Numbness and tingling
This is correct. Clinical manifestations of GBS include paresthesia and pain that involves the shoulders, back, buttocks, and upper legs; diminished or absent deep tendon reflexes; difficulty smiling or frowning; dysphagia; and autonomic dysfunction with possible cardiac dysrhythmias, paroxysmal hypotension, orthostatic hypotension, paralytic ileus, urinary retention, and potential syndrome of inappropriate secretion of antidiuretic hormone (SIADH).
A patient’s significant other asks the nurse what types of medication the patient will be on after discharge from an ischemic stroke. Which medications should the nurse talk about? Select all that apply.
A. Antihypertensives
B. Platelet inhibitors
C. Anticoagulants
D. Lipid-lowering medications
E. Anti-seizure medications
A. Antihypertensives
This is correct. Antihypertensives are used to reduce blood pressure to prevent long-term damage from excessive shear stress and reduce the chance for complications of hypertension, such as intracerebral hemorrhage.
B. Platelet inhibitors
This is correct. Platelet inhibitors are used to prevent platelet aggregation, reducing the risk of blood clot formation, which could cause cerebral blood vessel occlusion.
C. Anticoagulants
This is correct. Anticoagulants are used to prevent clotting in patients with disorders such as atrial fibrillation.
D. Lipid-lowering medications
This is correct. Lipid-lowering medications are used to reduce the production of cholesterol or the reabsorption of cholesterol, which leads to deposition in blood vessels and eventual blood vessel occlusion.
The nurse is monitoring a patient receiving rt-PA who develops a sudden headache. Which are the priority actions in evaluating this change in assessment? (Select all that apply.)
A. Decrease the rate of the rt-PA infusion.
B. Administer Tylenol for pain.
C. Stop the rt-PA infusion.
D. Notify the provider of the change.
E. Perform a neurologic assessment
C. Stop the rt-PA infusion.
D. Notify the provider of the change.
E. Perform a neurologic assessment
Development of a sudden headache is concerning for occurrence of an intracranial hemorrhage. Discontinuing the infusion, notifying the provider, and performing a neurologic assessment in rapid succession represent the expected nursing actions.