TBIs
SCIs
Miscellaneous
Alzheimer Disease
Miscellaneous
100
A patient is admitted to the emergency room with a fractured skull sustained in a motorcycle accident. The nurse notes fluid leaking from the patient's ears. The nurse knows this is a probable sign of which type of skull fracture?
A. Simple
B. Comminuted
C. Depressed
D. Basilar
D. Basilar
Basilar skull fractures are suspected when cerebrospinal fluid (CSF) escapes from the ears (CSF otorrhea) and/or the nose (CSF rhinorrhea).
100
An older adult patient has been brought to the emergency department (ED) after being found unconscious by a neighbor. What action should be the ED nurse's highest priority in the care of this patient?
A. Obtain a full set of vital signs.
B. Assess the patient's level of consciousness (LOC).
C. Maintain the patency of the patient's airway.
E. Establish IV access.
C. Maintain the patency of the patient's airway.
The first priority of treatment for the patient with altered LOC is to obtain and maintain a patent airway. IV access and thorough assessment are necessary but are superseded by the importance of obtaining and maintaining a patent airway.
100
The spouse of an older client experiencing delirium is at the client's bedside. The nurse is providing an update to the spouse regarding the client's plan of care. Which of the following responses indicates a need for further teaching?
A. "I am not worried. This sort of thing happens all the time to us 'old people.’”
B. "I brought an updated list of all the medications he takes at home to help you and the doctors determine what the cause of this could be."
C. "I am trying to stay positive. I know that most people return to normal, but it is hard to see them like this."
D. "I understand that these mental status changes are typically reversible once the cause has been reversed."
A. "I am not worried. This sort of thing happens all the time to us 'old people.’”
Delirium is not a normal response in older adults. Older adults (aged 65 years and older) may be at increased risk of developing delirium, but it should not be expected or determined normal.
100
When planning care for a client newly diagnosed with Alzheimer’s disease, the nurse should focus on:
A. Providing a safe, structured environment
B. Helping the client recognize physical limitations
C. Helping to reverse the disease
D. Preventing loss of cognitive functions
A. Providing a safe, structured environment
Preventing injury is an important goal of care for a client with Alzheimer’s disease and can be achieved by providing a safe, structured environment. Other care goals include establishing effective communication with the client and family to help them adjust to the client’s altered cognitive abilities, offering emotional support, teaching the client and family about the disease, and encouraging the client to exercise to help maintain mobility. Alzheimer’s disease cannot be reversed. Cognitive losses cannot be prevented because Alzheimer’s disease is an insidious, degenerative dementia that eventually causes disorientation; severe deterioration of memory, language, and motor ability; emotional lability; and physical and intellectual disability.
100
A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report?
A. Sciatic nerve pain
B. Herniation
C. Paresthesia
D. Paralysis
C. Paresthesia
When a client reports numbness and tingling in an area, the client is reporting a paresthesia. The nurse would document the experience as such or place the client’s words in parentheses. The nurse would not make a medical diagnosis of sciatic nerve pain or herniation. The symptoms are not consistent with paralysis.
200
A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care?
A. Symptoms will evolve over a period of 1 week.
B. Monitoring is needed as rapid neurologic deterioration may occur.
C. The crash cart with defibrillator is kept nearby.
D. Bleeding continues into the intracerebral area.
B. Monitoring is needed as rapid neurologic deterioration may occur
The nurse identifies that the CT scan suggests an epidural hematoma. A key component in planning care is the understanding that rapid neurologic deterioration occurs. Symptoms evolve quickly. A crash cart may be kept nearby, but this is not the key information. An intracerebral hematoma is bleeding within the brain, which is a different area of bleeding.
200
The school nurse has been called to the football field, where a player is laying immobile on the field after landing awkwardly on the 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 player's vital signs, if possible.
C. Perform a rapid assessment of the player's range of motion.
D. Assess the player's reflexes.
A. Ensure that the player is not moved.
At the scene of the injury, the client 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 client's vital signs. It would be inappropriate to test ROM or reflexes.
200
Your grandmother is 72 and is a feisty, independent matriarch to your family. She developed influenza and was quite ill for several days. Three days into her illness she became disoriented, confused and didn't recognize family members. As she is not improving, you take her to the local ED for treatment. What would you expect the physician to prescribe as treatment?
A. Treat the underlying condition
B. Antipsychotic medications
C. Admission to a psychiatric unit
D. No treatment is available
A. Treat the underlying condition
Delirium can result from high fever, head trauma, brain tumor, drug intoxication or withdrawal, metabolic disorders (e.g., liver or renal failure), or inflammatory disorders of the central nervous system (CNS), such as meningitis or encephalitis. Treating the underlying medical condition usually restores mental functions.
200
The family of a client with Alzheimer’s dementia who is admitted to a psychiatric unit awaiting placement to a long-term care facility indicates to the nurse an understanding of the prognosis when they state:
A. “We are investigating herbal and vitamin therapy.”
B. “Does another hospital have a better treatment?”
C. “We are waiting for this medicine to kick in so he can go back to his lodge.”
D. “What support resources are available for the long term?”
D. “What supports are available for the long term?”
This response indicates that the family members are aware that support will be required and that this is a long-standing, deteriorating condition. It is unlikely that a return to the client’s previous condition and living situation will evolve, because Alzheimer’s dementia is a progressive and deteriorating condition. Vitamin and herbal therapies are not a solution, and another care facility will not offer any miracle solutions.
200
A halo sign is indicative of which of the following complication of brain injury?
A. Cerebrospinal fluid (CSF) leak
B. Seizure
C. Cerebral edema
D. Ischemia
A. Cerebrospinal fluid (CSF) leak
A halo sign (a blood stain surrounded by a yellowish stain) may be seen on bed linens or on the head dressing and is highly suggestive of a CSF leak. A positive halo sign is not indicative of seizure, cerebral ischemia, or cerebral edema.
300
A fall during a rock climbing expedition this morning has caused a 28-year-old woman to develop an epidural hematoma. Immediate treatment is being organized by the emergency department team because this woman faces a risk of serious neurological damage as a result of:
A. Decreased intravascular volume
B. Increased intracranial pressure (ICP)
C. Ischemic cerebrovascular accident (CVA)
D. Brain tissue necrosis
B. Increased intracranial pressure (ICP)
The pathological effects of an epidural hematoma are primarily a result of the consequent increase in ICP. Blood loss, ischemia, and necrosis are not the primary sequelae of an epidural hematoma.
300
The nurse is caring for a female client who is newly paraplegic. The client and the client’s spouse ask the nurse about their reproductive options. Which suggestion by the nurse is most helpful?
A. Adoption is an option to complete your family but not put your life in jeopardy.
B. Conception is not impaired; the birth process is determined with the physician.
C. Birth via surrogate is best because your baby can be implanted in another woman.
D. Sterilization is best; it would be difficult to care for a baby in your condition.
B. Conception is not impaired; the birth process is determined with the physician.
The nurse’s role is to provide facts without inserting personal opinions. The fact is that the woman can conceive and bear children. Suggesting adoption, a surrogate, or sterilization is not appropriate. Providing information is appropriate.
300
A nurse is reviewing the medical record of a client who is experiencing delirium. Which of the following medications should the nurse identify as a cause of this disorder?
A. Amphetamines
B. Sertraline
C. Antihistamines
D. Benzodiazepines
D. Benzodiazepines
The nurse should identify that benzodiazepines can have an adverse effect of delirium. Benzodiazepines are central nervous system depressants used to treat insomnia, anxiety, and seizures.
300
The geriatrician has begun an 80-year-old female client on donepezil (Aricept) in order to treat her dementia of Alzheimer's type (DAT). Which of the following teaching points should the nurse provide to the client's husband about her new medication?
A. "Aricept won't cure your wife's dementia of Alzheimer's type, but it has the potential to slow down the progression of the disease."
B. "It's important to closely follow the administration schedule for this drug if it is to make your wife recover."
C. "This won't result in any improvements to her symptoms of dementia of Alzheimer's type, but it will make her much more compliant and easier to manage."
D. "Aricept will help your wife sleep much better at night and stay awake during the day."
A. "Aricept won't cure your wife's dementia of Alzheimer's type, but it has the potential to slow down the progression of the disease."
Cholinesterase inhibitors such as donepezil (Aricept) cannot cure DAT, but they can slow the progression of the disease and can stabilize symptoms. The drug does not directly affect sleep patterns.
300
Osmotic diuretics are an essential intervention for reducing cerebral edema. Which of the following drugs is most frequently prescribed for this situation?
A. Mannitol
B. Glucose
C. Glycerin
D. Hypertonic saline
A. Mannitol is considered the “gold standard” for reducing increased ICP.
400
While snowboarding, a client fell and sustained a blow to the head, resulting in a loss of consciousness. The client regained consciousness within an hour after arrival at the ED, was admitted for 24-hour observation, and was discharged without neurologic impairment. What would the nurse expect this client's diagnosis to be?
A. concussion
B. laceration
C. contusion
D. skull fracture
A. concussion
A concussion results from a blow to the head that jars the brain. It usually is a consequence of falling, striking the head against a hard surface such as a windshield, colliding with another person (e.g., between athletes), battering during boxing, or being a victim of violence. The force of the blow causes temporary neurologic impairment but no serious damage to cerebral tissue. There is generally complete recovery within a short time.
400
A client is admitted to the neurologic ICU with a spinal cord injury. When assessing the client 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. Autonomic Dysreflexia
C. Spinal shock
In spinal shock, the reflexes are absent, BP and heart rate fall, and respiratory failure can occur.
400
A nurse is caring for a client who has a spinal cord injury at the fourth cervical level. Which of the following mobility options should the nurse anticipate for this client?
A. Ultra-light wheelchairs
B. Hand controlled wheelchair
C. Manual wheelchair
D. Sip-and-puff device operated wheelchair
D. Sip-and-puff device operated wheelchair
400
A nurse is teaching clients at a senior center about the etiology of Alzheimer's disease. Which of the following statements by a client indicates the need for further teaching?
A. "The cause of Alzheimer's disease is still not fully known or understood."
B. "My child is at risk for developing Alzheimer's disease because they have trisomy 21."
C. "Since my parent suffered from Alzheimer's disease, I know that I am at an increased risk for developing the disease myself."
D. "I do not have to worry about this because I do not have Down syndrome and I have never had a stroke."
D. "I do not have to worry about this because I do not have Down syndrome and I have never had a stroke."
This is incorrect. While there can be other causes linked to Alzheimer's disease, such as trisomy 21, cerebrovascular diseases, and certain modifiable and non-modifiable risk factors, this does not mean the client without those risk factors will not develop AD.
400
A nurse is caring for a client who has urinary leakage due to nerve damage following a spinal cord injury. The nurse should identify that the client is experiencing which of the following types of urinary incontinence?
A. Stress incontinence
B. Urge incontinence
C. Reflex incontinence
D. Overflow incontinence
C. Reflex incontinence
500
A nurse is caring for a client who had a severe traumatic brain injury 3 weeks ago, remains unconscious, and is unlikely to recover. While bathing the client, the assistive personnel (AP) talks to him about current events. The client's partner asks the nurse why the AP talks to the client. Which of the following responses should the nurse make?
A. "I'm really not sure why the assistant is talking to him. Perhaps you should ask her."
B. "Although your partner is not responding to us, he might still be able to hear."
C. “Don’t let that concern you. She talks to all her clients, no matter what.”
D. "She is an excellent caregiver. She has many others to care for, but she takes the time to talk to your partner."
B. "Although your partner is not responding to us, he might still be able to hear."
Hearing is one of the last senses to fade in clients who are unconscious. The nurse should encourage the partner and the staff to talk to him about neutral topics like the weather and benign current events to provide minimally stressful sensory stimulation.
500
A client with quadriplegia is in spinal shock. What finding should the nurse expect?
A. Absence of reflexes along with flaccid extremities
B. Positive Babinski's reflex along with spastic extremities
C. Hyperreflexia along with spastic extremities
D. Spasticity of all four extremities
A. Absence of reflexes along with flaccid extremities
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 client will demonstrate positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities.
500
A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia?
A. Monitor for elevated blood pressure.
B. Provide analgesia for headaches.
C. Prevent bladder distention.
D. Elevate the client's head.
C. Prevent bladder distention.
500
A nurse is caring for a client who has dementia and has a prescription for levodopa. Which of the following types of dementia should the nurse identify that the client has?
A. Vascular dementia
B. Alzheimer disease
C. Lewy body dementia
D. Parkinson's disease
D. Parkinson's disease
The nurse should identify the client has Parkinson's disease dementia. Levodopa is a medication used to treat this type of dementia.
500
A nurse is reinforcing teaching to a client who has a spinal cord injury about sexual stimulation. Which of the following statements by the nurse should be included in the teaching?
A. "You must experiment with your body to find out what stimulation is enjoyable after your injury."
B. "Clients who have a spinal cord injury are not aroused by touch around the groin area."
C. "You will not be able to have an intimate relationship with anyone after a spinal cord injury."
D. "You should not feel undesirable after your injury. You are still nice-looking."
A. "You must experiment with your body to find out what stimulation is enjoyable after your injury."
It is important for clients to identify what type of stimulation can cause sexual excitement following their injury.