Seizures & Headaches
Surprise!
TIA, CVA, & Aneurysms
Neuromuscular Disorders
Pharmacology
100
A client the nurse is caring for experiences a seizure. What is the priority nursing action?
A) Restrain the client during the seizure.
B) Insert a tongue blade between the teeth.
C) Protect the client from injury.
D) Suction the mouth during the convulsion.
Correct Answer: C) Protect the client from injury.
The nursing action for a client experiencing a seizure should be to protect the client from being injured. To ensure this, the nurse should turn the client to one side and not restrain client's movements. Inserting a tongue blade between the teeth is not as important as protecting the client from injury. The mouth and the pharynx of the client should be suctioned only after the seizure.
100
The nurse will do these to detect which disorder
Meningitis
100
A client has just been diagnosed with a cerebral aneurysm. What discharge instruction should the nurse provide?
A) Avoid heavy lifting.
B) Avoid fiber in the diet.
C) Take an antacid frequently.
D) Take an herbal form of feverfew.
Correct Answer: A) Avoid heavy lifting.
A client with an aneurysm should be advised to avoid heavy lifting, extreme emotional situations, or straining of stools because these activities increase intracranial pressure and thereby headaches and potential rupture of aneurysm. Avoidance of fiber may lead to constipation and straining with stools and would not be recommended. There would not be a recommendation for antacids or feverfew in the discharge teaching.
100
A nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?
A. Sit with the client for a few minutes.
B. Administer an analgesic.
C. Inform the nurse manager.
D. Call the health care provider immediately.
D. Call the health care provider immediately.
The nurse should notify the health care provider immediately because the headache may be an indication that the aneurysm is leaking. Sitting with the client is appropriate but only after the health care provider has been notified of the change in the client's condition. The health care provider will decide whether or not administration of an analgesic is indicated. Informing the nurse manager isn't necessary.
100
A patient with epilepsy is being discharged with a new prescription for an anticonvulsant medication. Which statement by the patient indicates a need for further teaching?
A) "I will take this medication exactly as prescribed."
B) "I can stop taking the medication if I feel fine."
C) "I should avoid alcohol while on this medication."
D) "I will let my doctor know if I experience any side effects."
Correct Answer: B) "I can stop taking the medication if I feel fine."
Explanation: This statement indicates a misunderstanding of the importance of adherence to the prescribed anticonvulsant regimen. Patients with epilepsy often require lifelong treatment to prevent seizures, even if they feel well. Stopping the medication abruptly can lead to an increased risk of seizures.
200
A nurse is caring for a patient who has just experienced a generalized tonic-clonic seizure. Which of the following interventions should the nurse implement immediately after the seizure ends?
A) Offer the patient a glass of water to rehydrate.
B) Conduct a neurological assessment to determine any changes.
C) Place the patient in a prone position for comfort.
D) Restrain the patient to prevent further seizures.
B) Conduct a neurological assessment to determine any changes.
This is the correct answer because assessing the patient's neurological status after a seizure is crucial to determine if there are any new deficits or complications.
200
When evaluating the extent of Parkinson's disease, a nurse observes for which condition?
A. Bulging eyeballs
B. Diminished distal sensation
C. Increase dopamine levels
D. Muscle rigidity, stooped posture and resting tremors
D. Rationale: Parkinson's is characterized by the slowing of voluntary muscle movement. Muscular rigidity, and resting tremors.
200
A patient arrives in the emergency department with sudden onset of left-sided weakness and difficulty speaking. Which diagnostic test should the nurse anticipate being performed first to evaluate the patient for a stroke?
A) Chest Xray
B) Computed Tomography (CT) scan of the head
C) Electrocardiogram (ECG)
D) Carotid ultrasound
Correct Answer: B) A CT scan is typically the first imaging test performed in the emergency setting to quickly identify whether a stroke is ischemic or hemorrhagic. It helps rule out hemorrhagic stroke, which requires different management.
200
A client with an inoperable brain tumor says to the nurse, “I’m so afraid that I’m going to die alone.” What is the nurse’s best response?
A. "You sound frightened."
B. "You are not going to die."
C. "There is nothing to be afraid of."
D. "It won't be as bad as you think."
A. In this scenario, the nurse stating "You sound frightened" is an example of reflective technique; it focuses on the client's feelings and encourages verbalization. The other statements deny the client's feelings.
200
A patient receiving IV heparin therapy reports experiencing unusual bruising and bleeding from the gums. What is the most appropriate nursing intervention?
A) Continue heparin therapy and monitor the patient closely.
B) Discontinue heparin and notify the healthcare provider immediately.
C) Apply ice to the areas of bruising and bleeding.
D) Educate the patient on the normal side effects of heparin therapy.
Correct Answer: B) Discontinue heparin and notify the healthcare provider immediately.
Unusual bruising and bleeding from the gums are signs of potential heparin-induced bleeding, which requires immediate action. Discontinuing heparin and notifying the healthcare provider is crucial for patient safety.
300
A nurse is reviewing the pathophysiology of seizures with a student nurse. Which of the following statements accurately describes the underlying mechanisms that lead to seizure activity?
A) Seizures occur due to abnormal electrical discharges in the neurons of the brain.
B) Increased inhibitory neurotransmitter activity is primarily responsible for seizure onset.
C) A seizure may result from an imbalance between excitatory and inhibitory neurotransmitters.
D) Structural changes in the brain, such as lesions, can trigger seizures.
Correct Answer: A) This statement accurately describes that seizures result from abnormal electrical activity in the neurons of the brain.
300
A nurse is caring for a patient who has been prescribed warfarin (Coumadin) for the management of atrial fibrillation. Which of the following lab values should the nurse monitor regularly to ensure the safe use of this medication?
A) Platelet count
B) International Normalized Ratio (INR)
C) Complete blood count (CBC)
D) Activated partial thromboplastin time (aPTT)
B) International Normalized Ratio (INR)
Correct Answer: B) INR is essential for patients on warfarin to ensure that blood coagulation is within the therapeutic range, reducing the risk of bleeding or thromboembolic events.
300
A nurse is explaining the distinctions between a transient ischemic attack (TIA) and a cerebrovascular accident (CVA) to a patient. Which of the following statements by the patient demonstrates a correct understanding of these conditions? Select all that apply.
A) "A TIA is a brief episode of reduced blood flow to the brain, whereas a CVA causes lasting damage."
B) "Both TIA and CVA always result in permanent neurological damage."
C) "A TIA lasts longer than 24 hours, while a CVA lasts for a shorter duration."
D) "A TIA is often considered a warning sign for a future CVA."
Correct Answer: A & D.
This statement accurately reflects the difference between TIA and CVA: TIA is temporary, while CVA typically results in permanent neurological effects.
300
A client with CVA is prescribed medication to treat the disorder. The client wants to know what other measures may help reduce CVA. Which is an accurate suggestion for the client?
A. Increase body weight moderately
B. Reduce hypertension and high blood cholesterol
C. Increase intake of proteins and carbohydrates
D. Increase hydration and the intake of fluids
B. CVAs are prevented by reducing certain risk factors, such as hypertension, overweight, cardiac dysrhythmias like atrial fibrillation, and high blood cholesterol. Clients should not gain body weight. In addition, increased intake of proteins, carbohydrates, or fluids does not help reduce the risk of CVAs.
300
A nurse is educating a patient who has been prescribed sumatriptan for migraine management. Which of the following statements by the patient indicates a correct understanding of the medication's use?
A) "I should take sumatriptan as soon as I notice the headache starting."
B) "I can take sumatriptan with any over-the-counter pain medication."
C) "I can use sumatriptan daily to prevent migraines."
D) "It is okay to use sumatriptan when I have high blood pressure."
Correct Answer: A) This statement reflects the proper use of sumatriptan, as it is most effective when taken at the onset of a migraine.
400
A nurse is teaching a group of nursing students about the characteristics of different types of headaches. Which of the following statements correctly differentiates migraine headaches from tension-type headaches and cluster headaches?
A) "Migraines are usually bilateral and associated with muscle tightness."
B) "Migraine headaches often include aura and can cause nausea or vomiting."
C) "Cluster headaches typically last for several days and occur in a band-like pattern."
D) "Tension-type headaches are characterized by severe, unilateral pain around the eye."
Correct Answer: B) This statement accurately describes migraine headaches, which can include aura (visual disturbances) and often cause nausea or vomiting.
400
A client diagnosed with an ischemic stroke should be treated within the first 3 hours of symptom onset with which of the following?
A. Clopidogrel
B. Extended release dipyridamole
C. Tissue plasminogen activator (tPA)
D. Atorvastatin
C. Tissue plasminogen activator (tPA)
In 1996, the FDA approved the use of tissue plasminogen activator (tPA) for the treatment of acute ischemic stroke within the first 3 hours of symptom onset.
400
A nurse is assessing a patient who has experienced a stroke. Which of the following statements accurately differentiates between ischemic and hemorrhagic CVA?
A) "Ischemic CVA is caused by bleeding in the brain, while hemorrhagic CVA results from a blockage of blood flow."
B) "Ischemic CVA results from a blockage of blood flow, while hemorrhagic CVA is caused by bleeding in the brain."
C) "Both ischemic and hemorrhagic CVA result from blood clots."
D) "Ischemic CVA typically has a sudden onset, while hemorrhagic CVA develops gradually over time."
Correct Answer: B) "Ischemic CVA results from a blockage of blood flow, while hemorrhagic CVA is caused by bleeding in the brain."
This statement correctly differentiates the two types of CVAs: ischemic CVA is caused by a blockage (such as a clot), while hemorrhagic CVA is due to bleeding (such as from a ruptured vessel).
400
This is a rare, inherited disease that causes the progressive breakdown (degeneration) of nerve cells in the brain. It has a broad impact on a person's functional abilities and usually results in choriform movements and psychiatric disorders such as hallucinations, depression, and suicidal ideation.
A. Parkinson's Disease
B. Seizures
C. Huntington's disease
D. Multiple Sclerosis
C. Huntington's disease
400
The most effective drug to treat major symptoms associated with Parkinson's is:
A. Carbidopa Levodopa.
B. Selegiline (Eldepryl)
C. Benztropine (Cogentin)
D. MAO inhibitors.
A. Carbidopa Levodopa.
500
A nurse is educating a patient about potential triggers for migraines. Which of the following should the nurse include as common migraine triggers? (Select all that apply.)
A) Stress
B) Bright or flickering lights
C) Skipping meals
D) Regular exercise
E) Certain foods (e.g., aged cheese, chocolate)
F) Exposure to strong odors
Correct Answers: A, B, C, E, & F
500
The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client most at risk for this disease?
A. Meningitis or encephalitis during the last 5 years
B. Seizures or trauma to the brain within the last year
C. Back injury or trauma to the spinal cord during the last 2 years
D. Respiratory or gastrointestinal viral infection during the previous month
D. Respiratory or gastrointestinal infection during the previous month. Rationale: Guillain-Barré syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits. On occasion, the syndrome can be triggered by vaccination or surgery.
500
The nurse is educating a group of patients about the risk factors for cerebrovascular accidents (CVAs). Which of the following factors should the nurse include as significant risk factors for CVA? (Select all that apply.)
A) Hypertension
B) Smoking
C) Diabetes mellitus
D) Regular exercise
E) High cholesterol levels
F) Family history of stroke
Correct Answers: A, B, C, E, F
500
A nurse is educating a group of nursing students about the symptoms of Parkinson's disease. Which of the following symptoms should the nurse include in the discussion? (Select all that apply)
A. Tremors at rest
B. Bradykinesia
C. Numbness and tingling
D. Muscle rigidity
E. Fever
F. Hyperphonia
A, B, D
500
A nurse is assessing a client with Parkinson's disease. The nurse determines that the client's drug therapy is effective when the client exhibits what?
A. Decreased tremors
B. Decreased aggression
C. Improved level of intellectual functioning
D. Improved short term memory
A. Decreased tremors would indicate effective antiparkinsonism therapy. Intellectual dysfunction is not a manifestation associated with Parkinson's disease. Parkinson’s disease is not associated with aggression.