Deck 48: Nursing Care of Patients With Central Nervous System Disorders

Question 1

The nurse is providing information to a patient with migraine headaches. Which information from the patient is least likely to be useful to the HCP when prescribing treatment?

A)The effectiveness of resting in a dark, quiet environment
B)Keeping a diary about episodes including pre- and postinformation
C)Determining if there may be a genetic connection to the headaches
D)Making note of preheadache visual, speech, or sensation disturbances

Answer 1

The effectiveness of resting in a dark, quiet environment

Question 2

The nurse is planning care for a patient with a migraine headache. Which actions does the nurse include in this plan of care? (Select all that apply.)

A)Rest
B)White noise
C)A dark, quiet room
D)Sumatriptan (Imitrex)
E)Acetaminophen (Tylenol)

Answer 2

Rest
A dark, quiet room
Sumatriptan (Imitrex)

Question 3

The nurse is caring for a patient with an acute brain injury. Which interventions does the nurse use to prevent increased intracranial pressure in this patient? (Select all that apply.)

A)Avoid hip flexion.
B)Administer stool softeners.
C)Keep head of bed elevated 30 degrees.
D)Encourage deep breathing and coughing.
E)Administer opioid analgesics for headache.

Answer 3

Avoid hip flexion.
Administer stool softeners.
Keep head of bed elevated 30 degrees.

Question 4

The nurse is providing care for a patient who was diagnosed with Parkinson disease 12 years prior. Which manifestation of the disease presents the nurse with the most likely risk for safety of this patient?

A)Bradykinesia
B)Muscle rigidity
C)Shuffling gait
D)Resting tremors

Question 5

The nurse is hired by a family to provide care for a family member diagnosed with stage 2 Alzheimer disease. Which action related to safety is most important for the nurse to implement?

A)Help the patient make lists for tasks to be completed.
B)Make sure that all doors are locked where potential risk exists.
C)Monitor for signs or behaviors related to the patient's physical needs.
D)Regenerate interest in activities, acquaintances, or surroundings.

Question 6

The nurse is working in a college infirmary when a student comes in and states, "I think I have a migraine. My head hurts, I cannot stand the light, and I feel sick to my stomach." Which additional data collected by the nurse causes concern for a different diagnosis?

A)A subnormal temperature
B)Ill college roommate
C)Positive Brudzinski's sign
D)Positive Romberg test

Question 7

The nurse is assisting with the care of a patient with a brain tumor who is exhibiting ICP. Which nursing intervention is specifically initiated to provide safety for this patient?

A)Make sure the call light is always within the patient's reach.
B)Perform active or passive range of motion (ROM) at least twice each shift.
C)Relocate environmental objects and pad the bedside rails.
D)Follow HCP's prescribed therapy for treatment of headache.

Question 8

The nurse is assisting with care for a patient in the ICU with an extreme head injury. The HCP reports that the patient has brain herniation. Which action does the nurse expect from the HCP?

A)Insertion of a shunt to reduce fluid volume in the skull
B)Emergency surgery to relieve pressure in the intracranial space
C)Medication to promote movement of fluid into the circulation system
D)Arranging for the family to be approached about possible organ donation

Question 9

The nurse suspects that a patient is experiencing increasing ICP. What observations cause the nurse to come to this conclusion? (Select all that apply.)

A)Headache
B)Rising temperature
C)Decreasing systolic pressure
D)Dilated pupil on affected side
E)Decreasing level of consciousness (LOC)

Question 10

The nurse is assisting with the care of a patient after a traumatic brain injury. The patient experiences a seizure and exhibits bilateral jerking of the extremities. Which type of seizure activity does the nurse recognize?

A)Partial
B)Chronic
C)Generalized
D)Traumatic

Question 11

The nurse is assisting the RN in providing care for a patient with a potential for ICP. Which manifestation does the nurse recognize as needing to be reported to the RN?

A)Rapid apical pulse
B)Increased systolic blood pressure (BP)
C)Shallow, even respirations
D)Narrowing pulse pressure

Question 12

A patient with a spinal cord injury at T3-T4 experiences a sudden increase in BP and has cool, pale, gooseflesh skin on the lower extremities. Which action does the nurse perform while awaiting physician orders? (Select all that apply.)

A)Monitor BP every 5 minutes.
B)Place the patient in supine position.
C)Place elastic stockings on the patient's legs.
D)Check to see if the indwelling catheter is patent.
E)Perform a rectal examination to determine if impaction is present.

Question 13

An older adult patient is experiencing the manifestation related to a neurocognitive disorder and is being transferred to a long-term care facility. Which condition will involve the nurse in reaching long-term goals related to this patient?

A)Suggesting the family attend a support group
B)Considering the patient's input regarding care
C)Accepting the patient's attempts at independence
D)Requesting hospitalization when symptoms worsen

Question 14

A patient is prescribed the dopamine agonist pramipexole (Mirapex) for Parkinson disease. Which instructions are important for the nurse to include when teaching about this medication? (Select all that apply.)

A)"Take it at noon each day."
B)"Increase fluids and fiber in your diet."
C)"Taking the medication with food may reduce nausea."
D)"You may experience sudden bouts of excessive sleepiness."
E)"Do not drive until the effects of this drug on you are fully known."

Question 15

The nurse is providing care for a patient on a medical unit with a history of seizure activity. The patient exhibits the manifestations of a generalized seizure, which does not respond to prescribed treatment. Seizure activity has been continuous for over 30 minutes. Which prescription does the nurse prepare for the HCP?

A)Gathering equipment needed for mechanical ventilation
B)Administering IV lorazepam or diazepam for seizure control
C)Setting up for administration of IV phenobarbital to induce coma
D)Making immediate arrangements to transfer the patient to the intensive care unit (ICU)

Question 16

A patient is brought to the health care provider's office with a headache, lethargy, nausea, vomiting, and a fever, which has developed over the past few days. The nurse begins collecting data about the possible causes of the symptoms. Which information indicates a possible cause for encephalitis?

A)The patient has recently exhibited flu-like manifestations.
B)The patient lives in a home where a child has chickenpox.
C)The patient has been camping within the last few weeks.
D)The patient has experienced a stiff neck for 3 days.

Question 17

A patient is diagnosed with bacterial encephalopathy. Which symptoms exhibited by the patient indicate late signs of the patient's diagnosis?

A)Short attention span and poor memory
B)Disorientation and difficulty following commands
C)Lack of involvement and lip smacking or chewing
D)Expressed fear about loud noises in the hallway

Question 18

The licensed practical nurse (LPN) is assigned to assist the registered nurse (RN) in providing care for a patient admitted for an inflammatory neurologic disorder. Which reassessment finding does the LPN report immediately to the RN?

A)The patient has a consistent temperature of 101.4°F rectally.
B)The patient attempts to get out of bed to go to work.
C)A pain level of 5 on a scale of 0 to 10 is verbally reported.
D)The patient is noticed to be changing position without assistance.

Question 19

A patient is distressed to learn that a sibling is diagnosed with both neurologic and cognitive manifestations of Huntington disease. When the patient asks the nurse how to determine the incidence of the disease, which answer is most appropriate?

A)"All family members are now at risk for the disease."
B)"You definitely need to have genetic testing for the disease."
C)"Your children need to be tested for a genetic connection."
D)"If you are not diagnosed by age 20, you are considered safe."

Question 20

A patient is brought to the emergency department after being hit by a baseball bat during a game. Which nursing intervention is immediately reported to the HCP or RN?

A)The presence of amnesia about details before and after the injury
B)Changes in heart and respiratory rate, fever, and diaphoresis
C)Presence of head and scalp contusions with a single lesion
D)One-sided paralysis, extreme weakness, or pupil dilation