Show:
Assessment
Sign/Symptoms
Priority
Medications
Parkinson's
100
When assessing a patient with a traumatic brain injury, the nurse notes uncoordinated movement of the extremities. The nurse would document this as a. Ataxia b. Apraxia c. Anisocoria d. Anosognosia
Answer: A Rationale: Ataxia is a lack of coordination of movement, possibly caused by lesions of sensory or motor pathways, cerebellum disorders, or certain medications.
100
A patient who has a neurologic disease that affects the pyramidal tract is likely to manifest which of the following signs? a. Impaired muscle movement b. Decreased deep tendon reflexes c. Decreased level of consciousness d. Impaired sensation of touch, pain, and temperature
Answer: A. Rationale: Among the most important descending tracts are the corticobulbar and corticospinal tracts, collectively termed the pyramidal tract. These tracts carry volitional (voluntary) impulses from the cortex to the cranial and peripheral nerves. Dysfunction of the pyramidal tract is likely to manifest as impaired movement. Diseases affecting the pyramidal tract do not result in changes in LOC, impaired reflexes, or decreased sensation.
100
A 65-year-old woman was just diagnosed with Parkinson’s disease. The priority nursing intervention is a. Searching the Internet for educational videos b. Evaluating the home for environmental safety c. Promoting physical exercise and a well-balanced diet d. Designing an exercise program to strengthen and stretch specific muscles
Answer: C Rationale: Promotion of physical exercise and a well-balanced diet are major concerns of nursing care for patients with Parkinson’s disease.
100
A nurse is monitoring a client for adverse reactions to dantrolene (Dantrium). Which adverse reaction is most common? a. Excessive tearing b. Urine retention c. Muscle weakness d. Slurred speech
Answer: C Rationale: The most common adverse reaction to dantrolene is muscle weakness. The drug also may depress liver function or cause idiosyncratic hepatitis. Muscle weakness is rarely severe enough to cause slurring of speech, drooling, and enuresis. Although excessive tearing and urine retention are adverse reactions associated with dantrolene use, they aren’t as common as muscle weakness.
100
A 65-year-old woman was just diagnosed with Parkinson’s disease. The priority nursing intervention is a. Searching the Internet for educational videos b. Evaluating the home for environmental safety c. Promoting physical exercise and a well-balanced diet d. Designing an exercise program to strengthen and stretch specific muscles
Answer: C Rationale: Promotion of physical exercise and a well-balanced diet are major concerns of nursing care for patients with Parkinson’s disease.
200
When assessing the accessory nerve, the nurse would a. Assess the gag reflex by stroking the posterior pharynx. b. Ask the patient to shrug the shoulders against resistance. c. Ask the patient to push the tongue to either side against resistance. d. Have the patient say “ah” while visualizing elevation of soft palate.
Answer: B Rationale: The spinal accessory nerve is tested by asking the patient to shrug the shoulders against resistance and to turn the head to either side against resistance. The other options are used to test the glossopharyngeal and vagus nerves.
200
DAILY DOUBLE!! Which of the following characteristics of a patient’s recent seizure is congruent with a partial seizure? a. The patient lost consciousness during the seizure b. The seizure involved lip smacking and repetitive movements c. The patient fell to the ground and became stiff for 20 seconds d. The etiology of the seizure involved both sides of the patient’s brain
Answer: B Rationale: The most common complex partial seizure involves lip smacking and automatisms (repetitive movements that may not be appropriate). Loss of consciousness, bilateral brain involvement, and a tonic phase are associated with generalized seizure activity.
200
Which of the following nursing diagnoses is likely to be a priority in the care of a patient with myasthenia gravis (MG)? a. Acute confusion b. Bowel incontinence c. Activity intolerance d. Disturbed sleep pattern
Answer: C Rationale: The primary feature of MG is fluctuating weakness of skeletal muscle. Bowel incontinence and confusion are unlikely signs of MG, and although sleep disturbance is likely, activity intolerance is usually of primary concern.
200
The nurse is monitoring a male client for adverse reactions to atropine sulfate (Atropine Care) eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction? a. Tachycardia b. Increased salivation c. Hypotension d. Apnea
Answer: A Rationale: Systemic absorption of atropine sulfate can cause tachycardia, palpitations, flushing, dry skin, ataxia, and confusion. To minimize systemic absorption, the client should apply digital pressure over the punctum at the inner canthus for 2 to 3 minutes after instilling the drops. The drug also may cause dry mouth. It isn’t known to cause hypotension or apnea.
200
A nurse is talking to a client’s spouse about degenerative complications associated with Parkinson’s disease. The highest priority topic for the nurse to talk to the spouse about is the risk for a. Aspiration b. Emotional lability c. Impaired speech d. Self-care dependency
Answer: A Rationale: Parkinson’s disease is a chronic degenerative disease. Degenerative complications associated with Parkinson’s disease include aspiration, emotional lability, impaired speech, and self-care dependency.
300
DAILY DOUBLE!! When assessing motor function of a patient admitted with a stroke, the nurse notes mild weakness of the arm demonstrated by downward drifting of the arm. The nurse would most accurately document this finding as a. Athetosis b. Hypotonia c. Hemiparesis d. Pronator drift
Answer: D Rationale: Downward drifting of the arm or pronation of the palm is identified as a pronator drift. Hemiparesis is weakness of one side of the body; hypotonia defines a flaccid muscle tone; and athetosis is a slow, writhing, involuntary movement of the extremities.
300
Which of the following clinical manifestations would the nurse interpret as representing neurogenic shock in a patient with acute spinal cord injury? a. Bradycardia b. Hypertension c. Neurogenic spasticity d. Bounding pedal pulses
Answer: A Rationale: Neurogenic shock is due to the loss of vasmotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic innervation causes peripheral vasodilation, venous pooling, and a decreased cardiac output.
300
The nurse is providing care for a patient who has been diagnosed with Guillain-Barre syndrome. Which of the following assessments should the nurse prioritize? a. Pain assessment b. Glasgow Coma Scale c. Respiratory assessment d. Musculoskeletal assessment
Answer: C Rationale: Although all of the assessments are necessary in the care of patients with Guillain-Bare syndrome, the acute risk of respiratory failure neccessitates vigilant monitoring of the patient's respiratory status.
300
The patient has been receiving scheduled doses of phenytoin (Dilantin) and begins to experience diplopia. The nurse immediately assesses the patient for which of the following? a. An aura b. Nystagmus or confusion c. Abdominal pain or cramping d. Irregular pulse or palpitations
Answer: B Rationale: Diplopia is a sign of phenytoin toxicity. The nurse should assess for other signs of toxicity, which include neurologic changes, such as nystagmus, ataxia, confusion, dizziness, or slurred speech.
300
The nurse is teaching a client with Parkinson’s disease ways to prevent curvatures of the spine associated with the disease. To prevent spinal flexion, the nurse should tell the client to a. Periodically lie prone without a neck pillow b. Sleep only in dorsal recumbent position c. Rest in supine position with his head elevated d. Sleep on either side but keep his back straight
Answer: A Rationale: Periodically lying a prone position without a pillow will help prevent the flexion of the spine that occurs with Parkinson’s disease.
400
The nurse is caring for a patient admitted 1 week ago with an acute spinal cord injury. Which of the following assessment findings would alert the nurse to the presence of autonomic dysreflexia? a. Tachycardia b. Hypotension c. Hot, dry skin d. Throbbing headache
Answer: D Rationale: Autonomic dysreflexia is related to reflex stimulation of the sympathetic nervous system reflected by hypertension, bradycardia, throbbing headache, and diaphoresis.
400
The nurse is caring for a patient admitted with a spinal cord injury following a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following? a. Central cord syndrome b. Spinal shock syndrome c. Anterior cord syndrome d. Brown-Sequard syndrome
Answer: B Rationale: About 50% of people with acute spinal cord injury experience a temporary loss of reflexes, sensation, and motor activity that is known as spinal shock. Central cord syndrome is manifested by motor and sensory loss greater in the upper extremities. Anterior cord syndrome results in motor and sensory loss but not refelexes. Brown-Sequard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory function.
400
Which of the following measures should the nurse prioritize when providing care for a patient with a diagnosis of multiple sclerosis (MS)? a. Vigilant infection control and adherence to standard precautions b. Careful monitoring of neurologic vital signs and frequent reorientation c. Maintenance of a calorie count and hourly assessment of intake and output d. Assessment of blood pressure and monitoring for signs of orthostatic hypotension
Answer: A Rationale: Infection control is a priority in the care of patients with MS, since infection is the most common precipitator of an exacerbation of the disease. Decreases in cognitive function are less likely, and MS does not typically result in hypotension or fluid volume excess or deficit.
400
DAILY DOUBLE!! A bolus of mannitol (Osmitrol) is ordered for a client with a closed-head injury showing manifestations of increasing intracranial pressure. Prior to administration, assessment shows: urine output 40 mL/hr, apical heart rate 88/min, and the pupils equal and reactive. The client is sleepy but easily aroused. After administering mannitol to the client, which of the following should indicate to the nurse that the medication is having the desired effect? a. Urine output is 100 mL/hr b. Pupils are dilated c. Heart rate is 62/min d. Client is difficult to arouse
Answer: A Rationale: Mannitol is an osmotic diuretic used to increase urinary output and if effective, will result in decreased cerebral edema.
400
A male patient with a diagnosis of Parkinson’s disease (PD) has been admitted recently to a long-term care facility. Which of the following actions should the health care team take in order to promote adequate nutrition for this patient? a. Provide multivitamins with each meal b. Provide a diet that is low in complex carbohydrates and high in protein c. Provide small, frequent meals throughout the day that are easy to chew and swallow d. Provide the patient with a minced or pureed diet that is high in potassium and low in sodium
Answer: C Rationale: Nutritional support is a priority in the care of individuals with PD. Such patients may benefit from meals that are smaller and more frequent than normal and that are easy to chew and swallow. Multivitamins are not necessary at each meal, and vitamin intake, along with protein intake, must be monitored to prevent contraindications with medications. It is likely premature to introduce a minced or pureed diet, and a low carbohydrate diet is not indicated.
500
The nurse assesses that an 87-year-old woman with Alzheimer’s disease is continually rubbing, flexing, and kicking out her legs throughout the day. The night shift reports that this same behavior escalates at night, preventing her from obtaining her required sleep. The next step the nurse should take is a. Ask the physician for a daytime sedative for the patient b. Request for soft restraints to prevent her from falling out of her bed c. Ask the physician for a nighttime sleep medication for the patient d. Assess the patient more closely, suspecting a disorder such as restless leg syndrome
Answer: D Rationale: The severity of restless legs syndrome (RLS) sensory symptoms ranges from infrequent, minor discomfort (i.e., paresthesias, including numbness, tingling, and “pins and needles” sensation) to severe pain. The discomfort occurs when the patient is sedentary and is most common in the evening or at night. The pain at night can disrupt sleep and is often relieved by physical activity, such as walking, stretching, rocking, or kicking. In the most severe cases, patients sleep only a few hours at night, resulting in daytime fatigue and disruption of the daily routine. The motor abnormalities associated with RLS consist of voluntary restlessness and stereotyped, periodic, involuntary movements. The involuntary movements usually occur during sleep. Symptoms are aggravated by fatigue.
500
Which of the following signs and symptoms in a patient with a T4 spinal cord injury should alert the nurse to the possibility of autonomic dysreflexia? a. Headache and rising blood pressure b. Irregular respirations and shortness of breath c. Decreased level of conciousness or halluncinations d. Abdominal distension and absense of bowel sounds
Answer: A Rationale: Among the manifestations of autonomic dysreflexia are hypertension ( up to 300 mm HG systolic) and a throbbing headache. respiratory manifestations, decreased level of consiousness, and gastrointestinal manifestations are not characteristic.
500
DAILY DOUBLE!! When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is the highest priority? a. Impaired tissue integrity related to paralysis b. Impaired urinary elemination related to quadriplegia c. Compromised family coping related to the extent of trauma d. Ineffective airway clearance related to high cervical spinal cord injury
Answer: D Rationale: Maintaining a patent airway is the most important goal for a patient with a high cervical fracture. Although all of these are appropriate nursing diagnosis for a patieht with a spinal cord injury, respiratory needs are always the highest priority. Remember the ABCs.
500
A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning? a. phenytoin (Dilantin) b. mannitol (Osmitrol) c. lidocaine (Xylocaine) d. furosemide (Lasix)
Answer: C Rationale: Administering lidocaine via an endotracheal tube may minimize elevations in ICP caused by suctioning. Although mannitol and furosemide may be given to reduce ICP, they’re administered parenterally, not endotracheally. Phenytoin doesn’t reduce ICP directly but may be used to abolish seizures, which can increase ICP. However, phenytoin isn’t administered endotracheally.
500
DAILY DOUBLE!! The home health nurse is assessing a male client being treated for Parkinson disease with levodopa-carbidopa (Sinemet). The nurse observes that he does not demonstrate any apparent emotions when speaking and rarely blinks. Which intervention should the nurse implement? a. Perform a complete cranial nerve assessment b. Instruct the client that he may be experiencing medication toxicity c. Document the presence of these assessment findings d. Advise the client to seek immediate medical evaluation
Answer: C Rationale: A mask-like expression and infrequent blinking are common clinical features of Parkonsonism. The nurse should document the findings.