Chapter 20: Neurological Disorders My Nursing Test Banks

Chapter 20: Neurological Disorders

Test Bank

MULTIPLE CHOICE

1. Which of the following statements is true about Parkinson disease (PD)?

a.

Drinking large amounts of alcohol can relieve symptoms of essential tremor.

b.

Motor tremors and slow movement accompany severe cognitive impairment.

c.

Lewy body dementia (LBD) is the most common form of dementia.

d.

Older adults taking rasagiline (Azilect) must avoid eating foods containing tyramine.

ANS: D

Older adults taking rasagiline (Azilect) must avoid eating foods containing tyramine; interactions of rasagiline with tyramine can cause sudden, severe hypertension.

Drinking small amounts of alcohol can relieve symptoms of essential tremor, although heavy drinking should be avoided. The majority of persons with PD remain alert and intelligent, but motor difficulties in facial expression and speech can give a false impression of cognitive impairment. LBD, which can occur in some patients with PD symptoms, is the second most common form of dementia. It accounts for 15% to 20% of all dementias.

PTS:1DIF:RememberREF:10-11

TOP: Nursing Process: Assessment MSC: Physiological Integrity

2. An older man comes to the emergency department after falling at home, and he reports that he cannot walk without losing his balance. Which steps should the nurse implement for this patient?

a.

Arrange to transfer him immediately to the radiology department.

b.

Determine symptom onset or when he fell at home.

c.

Organize the reperfusion tissue plasminogen activator (tPA) infusion.

d.

Perform a comprehensive neurologic assessment.

ANS: B

The nurse determines when the symptoms first appeared or the time of the fall to determine whether sufficient time is left to administer reperfusion tPA; if indicated, tPA must be administered within 3 hours of symptom onset. A patient with clinical indicators of a stroke will need a computed tomographic (CT) scan to differentiate between a thrombotic stroke and a hemorrhagic stroke; the type of stroke will determine the therapeutic course. The time of symptom onset is a vital piece of information that must be determined before the patient is referred to the radiology department because tPA is usually administered in the radiology suite. Administering tPA can be contraindicated for this patient; therefore the preparation of this infusion is delayed until the type of stroke and the plan of care are determined. The nurse will not have enough time to complete a comprehensive assessment and thus will perform a focused assessment in preparation for the trip to radiology.

PTS:1DIF:ApplicationREF:22

TOP: Nursing Process: Implementation MSC: Physiological Integrity

3. Which of the following statements is true about dysarthria?

a.

Does not affect intelligence.

b.

Stems from severe rheumatoid arthritis.

c.

Physical therapy can be beneficial.

d.

Can affect the balance.

ANS: A

Dysarthria is a speech disorder caused by a weakness or incoordination of the speech muscles. It occurs as a result of central or peripheral neuromuscular disorders that interfere with the clarity of speech and pronunciation; it does not affect intelligence. It does not stem from rheumatoid arthritis. Occupational therapy can help. Dysarthria does not affect balance.

PTS:1DIF:UnderstandREF:16-17| 33-34

TOP: Nursing Process: Assessment MSC: Physiological Integrity

4. A new nurse in a long-term care facility is caring for a patient with PD. The nurse should note which one of the following actions related to PD that is observed during the assessment?

a.

Tremors during sleep

c.

Frequent blinking

b.

Cogwheel rigidity

d.

Fast movements

ANS: B

Patients with PD display slow movement, infrequent blinking, masked facies, and cogwheel rigidity. Patients with PD exhibit tremors at rest in their hands, arms, legs, feet, and jaw.

PTS:1DIF:UnderstandREF:32

TOP: Nursing Process: Assessment MSC: Physiological Integrity

5. An older adult arrives at the emergency department with a probable diagnosis of a hemorrhagic stroke. The nurse understands, based on the patients age, that the most likely cause is which one of the following?

a.

Intracranial hemorrhage

c.

Thrombosis

b.

Decreased cardiac output

d.

Uncontrolled hypertension

ANS: D

Hemorrhagic strokes are primarily caused by uncontrolled hypertension and less often by malformations of the blood vessels (e.g., aneurysms). Although the exact mechanism is not fully understood, it appears that chronic hypertension causes a thickening of the vessel wall, microaneurysms, and necrosis. When enough damage to the vessel accumulates, it is at risk for rupture. The spontaneous rupture may be large and acute or small with a slow leak of blood into the adjacent brain tissue. In many cases, blood ruptures or seeps into the ventricular system of the brain with damage to the affected tissue through necrosis or death of brain tissue.

Hemorrhagic strokes are more life threatening but occur less frequently than ischemic strokes. Decreased cardiac output does not cause this type of hemorrhage. A thrombosis is not related to this type of hemorrhage.

PTS:1DIF:UnderstandREF:3

TOP: Nursing Process: Assessment MSC: Physiological Integrity

6. After completing an admission assessment on a patient who recently suffered a stroke, the nurse should choose which of the following nursing diagnoses as a priority?

a.

Risk for inury

c.

Altered cerebral perfusion

b.

Altered thought process

d.

Decreased mobility

ANS: C

Altered cerebral perfusion is the priority diagnosis. Altered cerebral perfusion may be caused by an interruption in blood flow such as occlusive disorder, hemorrhage, cerebral vasospasm, or cerebral edema. It is important for the nurse to monitor cognitive status and vitals for patients experiencing altered cerebral perfusion. The patient is at risk for injury due to the effects of the stroke, however it is not the priority diagnosis. This patient may suffer from altered thought processes due to cerebral damage from the stroke; however, this is not the priority diagnosis. This patient may experience a decrease in mobility such as hemiparesis; however, it is not the priority diagnosis.

PTS:1DIF:AnalyzeREF:2-5

TOP: Nursing Process: Assessment MSC: Physiological Integrity

7. A home health nurse is completing an admission on a patient who recently experienced a transient ischemic attack (TIA). During the assessment, the patient begins to complain of a severe headache and numbness in his left arm. Which action should the nurse take next?

a.

Instruct the patient to take Tylenol.

b.

Ask whether patient suffers from migraine headaches.

c.

Reschedule the visit.

d.

Call 9-1-1.

ANS: D

The home health nurse should immediately call 9-1-1. Approximately 24% to 29% of those who have a TIA will have a stroke within 5 years after the event (Goldstein, 2011). Tylenol would not be advised. The nurse should not leave the patient until the patient is en route to the emergency department.

PTS:1DIF:AnalyzeREF:2-5| 29

TOP: Nursing Process: Assessment MSC: Physiological Integrity

8. The nurse in a rehabilitation center is caring for a patient who has new-onset stroke with right-side hemiparesis. Which intervention should the nurse implement when caring for this patient?

a.

Orders a two-person assist with a transfer.

b.

May need to incorporate repetition.

c.

Gives the patient a dry erase board.

d.

Raises all four side rails.

ANS: C

Right-side hemiparesis involves a left-side brain injury. The left side of the brain controls speaking and language. By giving the patient a dry erase board, he or she can communicate easier initially after the stroke. People who have this type of hemiparesis experience difficulty talking.

With only one side affected; the nurse should be able to transfer the patient alone. Patients with left-side hemiparesis have with short term memory, often repetition must be incorporated into patient care. The raising of all four side rails up would be considered a restraint.

PTS:1DIF:AnalyzeREF:4-5

TOP: Nursing Process: Assessment MSC: Physiological Integrity

9. The nurse is caring for a patient who has had a stroke. The nurse is concerned the patient will develop contractures. Which intervention should the nurse implement?

a.

Use tennis shoes while in bed.

b.

Turn the patient onto the affected side, resting on the shoulder.

c.

Use paraffin wax for hand soaks.

d.

Conduct passive range-of-motion movements to the affected extremities.

ANS: D

Conducting passive range-of-motion movements will help decrease the risk of contractures. Using tennis shoes in bed helps decrease foot drop. Turning the patient on the affected side, resting on the shoulder, can cause pain. Paraffin wax soaks are often used for sufferers of arthritis.

PTS:1DIF:AnalyzeREF:4-5

TOP: Nursing Process: Assessment MSC: Physiological Integrity

10. The nurse is caring for a patient diagnosed with PD. Which tool should the nurse use to gather information from the patients perspective?

a.

The Geriatric Depression Tool

b.

The Sickness Impact Profile (SIP)

c.

The Mini-Mental State Examination2nd edition (MMSE-2)

d.

The Montreal Cognitive Assessment Tool

ANS: B

The SIP is a useful tool that can be used by nurses to determine problems most troublesome from the patients perspective. The Geriatric Depression Tool measures depression, and the MMSE-2 and the Montreal Cognitive Assessment Tool measures cognitive ability.

PTS:1DIF:AnalyzeREF:13

TOP: Nursing Process: Assessment MSC: Physiological Integrity

MULTIPLE RESPONSE

1. Which of the following behavior modifications should the nurse instruct a patient to accomplish to help reduce the risk factors for an occurrence of a stroke. (Select all that apply.)

a.

Increase the intake of green, leafy vegetables.

b.

Stop smoking.

c.

Control blood pressure.

d.

Increase physical activity.

ANS: B, C, D

Stopping smoking, keeping blood pressure under control, and incorporating physical activities are all modifiable risk factors. Increasing the intake of green leafy vegetables does not, in itself, decrease the risk of stroke; however, they are part of a healthy diet if the patient is not taking an anticoagulant medication.

PTS: 1 DIF: Apply REF: 31 TOP: Nursing Process: Planning

MSC: Physiological Integrity

2. Which of the following are common side effects of PD and the medications used to treat it? (Select all that apply.)

a.

Skin irritation

c.

Dystonia

b.

Dyskinesias

d.

Nausea

ANS: B, C

Medication therapy is complicated and must be closely supervised. Hypotension, dyskinesias (involuntary movements), dystonia (lack of control of movement), hallucinations, sleep disorders, and depression are common side effects of both the disease and the medications used to treat it. Nausea is not a side effect of PD.

PTS:1DIF:UnderstandREF:11

TOP: Nursing Process: Assessment MSC: Physiological Integrity

SHORT ANSWER

1. _____________   _____________ is the result of a lesion in the part of the brain adjacent to the primary auditory cortex (Wernicke area).

ANS:

Fluent aphasia

Fluent aphasia is also known as sensory, posterior, or Wernicke aphasia. The person speaks easily with many long runs of words, but the content does not make sense. He or she has problems finding the correct word and often substitutes an incorrect word. The speech sounds are similar to what is sometimes referred to as jabberwocky, with unrelated words strung together or syllables repeated.

PTS:1DIF:UnderstandREF:14

TOP: Nursing Process: Assessment MSC: Physiological Integrity

2. Persons with _____________   _______________ usually understand others but speak very slowly and use a minimal number of words.

ANS:

Nonfluent aphasia

Patients often struggle to articulate a word and seem to have lost the ability to voluntarily control the movements of speech. Difficulties are experienced in communicating orally and in writing.

PTS:1DIF:UnderstandREF:14

TOP: Nursing Process: Assessment MSC: Physiological Integrity

3. _______________  __________________ is a motor speech disorder that affects the ability to plan and sequence voluntary muscle movements.

ANS:

Verbal apraxia

The muscles of speech are not paralyzed; rather, a disruption occurs in the brains transmission of signals to the muscles. When thinking about what to say, the person may be unable to speak at all or may struggle to say any words. In contrast, the person may be able to say many words or sentences correctly when not thinking about the words. Apraxia frequently occurs with aphasia.

PTS:1DIF:UnderstandREF:14

TOP: Nursing Process: Assessment MSC: Physiological Integrity

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