Chapter 21 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 21

Question 1

Type: MCSA

A patient comes to the clinic complaining of repetitive episodes of sudden severe pain on the right side of the face. The nurse anticipates additional testing for which disorder?

1. Trigeminal neuralgia

2. Parkinsons disease

3. Bells palsy

4. Myasthenia gravis

Correct Answer: 1

Rationale 1: The cause of trigeminal neuralgia is not known, but contributing factors are recent flulike illness, trauma or infection of the teeth or jaw, and arteriosclerotic changes of an artery close to the nerve. It is manifested by repetitive episodes of sudden severe pain on the affected side of the face.

Rationale 2: The facial symptom associated with Parkinsons disease is decreased facial movement resulting in a masklike presentation. Severe facial pain is not associated with Parkinsons disease.

Rationale 3: Bells palsy results in paralysis of one side of the face. Severe espisodic facial pain is not associated with Bells palsy.

Rationale 4: Myasthenia gravis results in drooping of the eyelid. Severe espisodic facial pain is not associated with myasthenia gravis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-1

Question 2

Type: MCSA

A patient has just been diagnosed with trigeminal neuralgia. What would the nurse teach this patient about treatment for this disorder?

1. Drugs used to treat seizure disorders are generally effective.

2. Drug therapy will begin with a trial of antiviral drugs.

3. The primary treatment focus will be on supporting respiratory function until the condition resolves.

4. Gargling with hot salt water will help reduce pain and keep tissues moistened.

Correct Answer: 1

Rationale 1: Trigeminal neuralgia is treated by a pharmacologic approach to pain control with anticonvulsants such as carbamazepine (Tegretol).

Rationale 2: There is no evidence that trigeminal neuralgia is a viral illness or that antiviral drugs are indicated.

Rationale 3: Respiratory support is not necessary to treat this condition.

Rationale 4: Contact with hot or cold substances is often a trigger that induces pain and should be avoided.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-1

Question 3

Type: MCMA

A 25-year-old female is diagnosed with tic douloureux. How should the nurse describe this disorder to the patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. This condition is also called Bells palsy.

2. You are the typical age for onset of this condition.

3. More women than men have this condition.

4. More testing will be necessary.

5. The treatment for this condition is to allow it to run its course, which is typically 5 to 7 days.

Correct Answer: 3,4

Rationale 1: The other name for this condition is trigeminal neuralgia.

Rationale 2: The condition generally begins after age 40, with the typical onset at 60 to 70 years in approximately 90% of patients.

Rationale 3: This condition affects twice as many women as men.

Rationale 4: Occurrence of this condition in people 20 to 40 years of age may indicate other diseases such as multiple sclerosis.

Rationale 5: This condition does not abate untreated. Pharmacotherapy is necessary. If pharmacotherapy is not successful, surgical treatments are considered.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-1

Question 4

Type: MCSA

A patient is in the emergency department following a head injury. The nurse would assess for which sign indicating early increased intracranial pressure?

1. Decreasing level of consciousness

2. Elevated diastolic blood pressure

3. Decreasing respiratory rate

4. Tachycardia

Correct Answer: 1

Rationale 1: The brain is very sensitive to the level of oxygenation. As the pressure inside the skull increases, hypoxia develops, which negatively affects the level of consciousness.

Rationale 2: A change in blood pressure is generally a widening pulse pressure that would include increased systolic blood pressure.

Rationale 3: A change in respiratory rate is a late sign of increased ICP.

Rationale 4: Bradycardia is the most common indicator of increased ICP.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-2

Question 5

Type: MCMA

A patient with increased intracranial pressure (ICP) is being repositioned. The nurse would incorporate which actions into this intervention?


Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Inform the patient regarding what is going to occur during the intervention.

2. Reposition the patient every 1 to 2 hours.

3. Accompany each repositioning with passive range-of-motion exercises.

4. Elevate the head of the bed to 30 degrees.

5. Manage the repositioning with slow, smooth, and gentle movements.

Correct Answer: 1,4,5

Rationale 1: Patients should always be informed about what is going to occur.

Rationale 2: Position changes should be done less frequently for patients with ICP because turning, skin care, and passive ROM exercises can elicit involuntary posturing, which also causes increased ICP.

Rationale 3: Turning alone can cause an increase of ICP. Care should be spaced over time to avoid this complication.

Rationale 4: The head of the bed should be elevated. The degree depends on the reaction of the patient to the position; 30 degrees is usually appropriate, but this can vary by patient.

Rationale 5: It is especially important that patients with increased ICP be repositioned slowly and with smooth, gentle movements, because rapid changes can cause the pressure to increase.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-2

Question 6

Type: MCSA

The nurse is caring for a patient with an intracranial pressure monitoring device. What is the priority nursing diagnosis (NDX) for this patient?

1. Risk for Infection

2. Ineffective Thermoregulation

3. Risk for Impaired Skin Integrity

4. Impaired Physical Mobility

Correct Answer: 1

Rationale 1: The priority NDX for this patient is related to infection. In some cases, such as this one, a risk diagnosis takes priority over actual diagnoses. This patient has an invasive monitoring device in the skull. Infection would be devastating.

Rationale 2: Ineffective Thermoregulation is a very important NDX for this patient, but it is not as important as another NDX.

Rationale 3: The patient does have a break in skin integrity, but this is not the priority NDX.

Rationale 4: The patient is likely to have impairment in physical mobility, but this is not the highest-priority NDX.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 21-2

Question 7

Type: MCSA

Decerebrate posturing is present in an unconscious patient following a motor vehicle accident. The nurse expects to see which position?

1. The arms and legs are hyperextended, and arms are hyperpronated.

2. The arms are folded over the chest and spasms are rhythmic.

3. The arms are pulled inward and the head is turned to the side.

4. The arms and legs have tonic-clonic seizure activity.

Correct Answer: 1

Rationale 1: Decerebrate posture is displayed by hyperextension of the arms and legs and hyperpronation of the arms. Decerebration is

considered a sign that the patient has a serious injury with a poor prognosis.

Rationale 2: In decerebrate posture, the arms are hyperextended.

Rationale 3: In decerebrate posture, the arms are hyperextended.

Rationale 4: Tonic-clonic movement is not present in decerebrate posturing.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-2

Question 8

Type: SEQ

A patient without a history of previous seizures experiences two tonic-clonic seizures in succession while the nurse is in the patients room. List in priority order the actions the nurse should take.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Turn the patient on his or her side.

Choice 2. Protect the patient from environmental harm.

Choice 3. Start oxygen via face mask.

Choice 4. Reorient the patient to time, person, and place.

Correct Answer: 1,2,3,4

Rationale 1: Nursing care of patients during a seizure should first focus on maintaining a patent airway. During a seizure, the tongue may fall back and obstruct the airway, the gag reflex may be depressed, and secretions may pool at the back of the throat. To open and maintain a patent airway, the patient should be turned on his or her side.

Rationale 2: After ensuring the airway is patent, the nurse should protect the patient from harm.

Rationale 3: After the clonic phase of seizure activity, if needed, oxygen can be administered by face mask.

Rationale 4: Consciousness returns gradually. It may take hours before the patient is fully aware and alert and reorientation to person, place, and time can be achieved.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-6

Question 9

Type: MCSA

Reviewing a patients report of laboratory test results (see accompanying box), the nurse realizes that which values are critical for the patient with a decreased level of consciousness?

1. Glucose and serum osmolality

2. Sodium and potassium levels

3. Sodium and white blood cell count

4. Glucose and white blood cell count

Correct Answer: 1

Rationale 1: Blood glucose is measured immediately when coma or decreased LOC is of unknown origin. When the glucose falls to less than 50 mg/dl, cerebral function declines rapidly and hypoglycemia should be suspected. Serum osmolality of less than 250 mOsm/kg H2O leads to cerebral edema and swelling, impairing consciousness.

Rationale 2: The sodium and potassium levels are normal.

Rationale 3: The sodium and white blood cell count are normal.

Rationale 4: The white blood cell count is normal.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-2

Question 10

Type: MCSA

The patient was an unrestrained front-seat passenger in a motor vehicle crash and struck his forehead on the inside of the windshield. Diagnostic testing in the emergency department reveals coupcontrecoup injury. The nurse identifies which area as the contrecoup injury?

1. The frontal area of the brain

2. The posterior or occipital part of the brain

3. Both the anterior and posterior areas of the brain

4. The midpoint of the brainstem

Correct Answer: 2

Rationale 1: The frontal area is the coup injury.

Rationale 2: The area directly opposite the original injury is where the contrecoup injury occurs.

Rationale 3: Only one of these areas is described as sustaining contrecoup injury.

Rationale 4: The brainstem may be injured due to shearing forces, but it would not be included in the coup-contrecoup designation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-3

Question 11

Type: MCSA

The patient sustains a subdural hematoma after falling. How would the nurse explain this injury to the patients family?

1. Bleeding has occurred between the skull and the covering of the brain.

2. Bleeding has occurred in the center of the brain.

3. Bleeding has occurred between the layers of the scalp.

4. Bleeding is occurring between the brain and its covering.

Correct Answer: 4

Rationale 1: Bleeding between the skull and the covering of the brain (dura) is termed epidural.

Rationale 2: Subdural hematoma does not occur in the center of the brain.

Rationale 3: Bleeding between the layers of the scalp creates a hematoma but is not described as subdural.

Rationale 4: A subdural hematoma occurs between the brain and the covering or dura.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-3

Question 12

Type: MCSA

The nurse anticipates that which medication will be ordered to halt status epilepticus in a patient?

1. Lorazepam (Ativan) IV

2. Oral glucose

3. Phenytoin (Dilantin) orally

4. Gabapentin (Neurontin) and lamotrigine (Lamictal)

Correct Answer: 1

Rationale 1: Lorazepam (Ativan) can be used IV to stop the seizure and is an appropriate treatment order.

Rationale 2: No drug would be given orally during status epilepticus, although glucose IV might be appropriate.

Rationale 3: The drug must be given IV in this situation, and phenytoin (Dilantin) could be an option if ordered IV.

Rationale 4: The drug therapy used to treat this event uses only one drug at a time.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-6

Question 13

Type: MCSA

Which nursing diagnosis is most applicable to a patient with new-onset seizures?

1. Anxiety

2. Self-Care Deficit

3. Activity Intolerance

4. Impaired Mobility

Correct Answer: 1

Rationale 1: Anxiety is related to fear of the unknown in the future as well as to loss of control.

Rationale 2: There is no indication that the patient will not be able to care for him- or herself.

Rationale 3: There is no evidence that the patient will be intolerant of activity.

Rationale 4: There is no evidence that the patient with new-onset seizures will experience an alteration of mobility.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 21-6

Question 14

Type: MCSA

The patient was riding in a car that hit a tree. The head hit the windshield, and then the brain rebounded within the skull toward the opposite side. This injury represents which mechanism of injury?

1. An acceleration-deceleration injury

2. A penetrating head injury

3. An acceleration injury

4. A deceleration injury

Correct Answer: 1

Rationale 1: In an acceleration-deceleration injury, two or more areas of the brain can be injured.

Rationale 2: Penetrating injury occurs when an object disrupts the integrity of the head and skull.

Rationale 3: An acceleration injury occurs when the head is rapidly moved forward such as when a car stops abruptly.

Rationale 4: A deceleration injury occurs when the head hits a stationary object such as a windshield, dashboard, or other object in a car.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-3

Question 15

Type: MCSA

Following a fall, a patient is brought to the emergency department. There was a brief loss of consciousness; the patient complains of headache, has vomited twice, has a dilated pupil on the same side as a hematoma over the temporal area, and is currently having a seizure. The nurse prepares to care for this patient based on which evaluation of this assessment?

1. This is an emergency situation likely involving an epidural hematoma and requires surgery.

2. This is a controlled situation once the seizure stops.

3. This is a serious situation in which a subdural hematoma is developing and requires surgery.

4. This is a typical situation seen with most patients who fall, and symptoms will subside with observation.

Correct Answer: 1

Rationale 1: Classic signs of an epidural hematoma include a loss of consciousness followed by a brief lucid period before rapid deterioration.

Rationale 2: Because this injury involves a skull fracture that tears an artery, the patient is bleeding uncontrollably into the head. The bleeding may continue until herniation occurs. The situation is not controlled.

Rationale 3: A subdural hematoma would be manifested by drowsiness, confusion, and enlargement of the ipsilateral pupil within minutes of the injury. Hemiparesis and changes in respiratory pattern may soon follow.

Rationale 4: The assessments as stated indicate that the patient will require immediate intervention, not simply observation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-3

Question 16

Type: MCSA

A patient is having a seizure that involves a blank stare, unresponsiveness to questions, and smacking of the lips. The seizure lasts less than a minute. How would the nurse categorize this seizure?

1. Absence seizure

2. Partial seizure

3. Tonic-clonic seizure

4. Status epilepticus seizure

Correct Answer: 1

Rationale 1: Absence (or petit mal) seizures involve a blank stare, unresponsiveness to questions, and abnormal behavior such as smacking of the lips.

Rationale 2: A partial seizure involves only one area of the brain. The symptoms displayed are reflective of the area affected and may be muscle contraction of a single body part if the motor cortex is affected. Sensory manifestations may be exhibited by hallucinations or abnormal sensations.

Rationale 3: Tonic-clonic seizures involve generalized contraction coupled with impairment of consciousness.

Rationale 4: Status epilepticus seizures are repetitive, with only very brief calm periods in between.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-6

Question 17

Type: MCSA

The patient is supine and the head is flexed to the chest without pain, resistance, or flexion of the hips or knees. The nurse is observing for which finding?

1. Dolls eyes reflex

2. Brudzinski sign

3. Babinski reflex

4. Kernigs sign

Correct Answer: 2

Rationale 1: In the dolls eyes reflex, the eyes move in the opposite direction in which the head is turned.

Rationale 2: The Brudzinski sign is elicited by placing the patient in a supine position and flexing the neck toward the chest. A positive result would be noted if the patient has pain or flexes the hip or knees in response to the neck flexion. A positive response indicates meningeal irritation.

Rationale 3: The Babinski reflex is the extensor plantar response. An abnormal response is dorsiflexion of the big toe and often a fanning of the other toes.

Rationale 4: To assess for Kernigs sign, the patient, in the supine position, flexes the hip and extends the leg. Bilateral pain in the hamstring area that prevents straightening of the leg is a positive sign of meningitis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-4

Question 18

Type: MCSA

Which neurologic assessment is being performed in the exhibit?

1. Kernigs sign

2. Babinski reflex

3. Brudzinski sign

4. Decorticate posturing

Correct Answer: 3

Rationale 1: To assess for Kernigs sign, the patient, in the supine position, flexes the hip and extends the leg.

Rationale 2: The Babinski reflex occurs when the big toe moves toward the top of the foot and the other toes fan out after the sole of the foot has been firmly stroked. This reflex is normal in younger children, but abnormal after the age of 2.

Rationale 3: To test for Brudzinski sign, the nurse flexes the patients head to the chest with the patient supine. If pain, resistance, or flexion of the hips or knees occurs, this indicates meningeal irritation.

Rationale 4: Patients with decorticate posturing present with the arms flexed or bent inward on the chest, the hands clenched into fists, the legs extended, and the feet turned inward.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-4

Question 19

Type: MCSA

The nurse is assessing the patient using the technique shown. What is considered a normal finding using this technique?

1. Pain only at the hip during flexion

2. Resistance in the hip joint

3. A clicking sound in the knee upon flexion

4. No pain or resistance in either joint

Correct Answer: 4

Rationale 1: Pain in the hip is not normal.

Rationale 2: Resistance in the hip is not normal.

Rationale 3: A clicking sound in the knee is not normal.

Rationale 4: This technique tests for Kernigs sign. There should be no pain or resistance when doing this maneuver.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-4

Question 20

Type: MCSA

A patient has experienced a subarachnoid hemorrhage and is at risk for increased intracranial pressure (ICP) due to the initiation of the vasodilatory cascade. The nurse plans care for this patient to avoid which primary initiating factor?

1. Vasoconstriction of cerebral vessels

2. Cerebral tissue ischemia

3. Decreased cerebral perfusion pressure

4. Cerebral edema

Correct Answer: 2

Rationale 1: Vasoconstriction of cerebral blood vessels is not a cause of ICP.

Rationale 2: The vasodilatory cascade is a series of events triggered by hypoxia, with the result being increased ICP.

Rationale 3: Depressed cerebral perfusion pressure (CPP) is a decrease in the pressure gradient that drives cerebral blood flow.

Rationale 4: Cerebral edema may be a result of the vasodilatory cascade but is not its cause.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-2

Question 21

Type: MCMA

A patient at risk for increased intracranial pressure (ICP) is likely to experience involuntary compensatory mechanisms. The nurse would monitor this patient for signs of which involuntary compensation?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Vasoconstriction of cardiac vessels

2. Vasodilation of the cerebral vessels

3. Decreased production of cerebral spinal fluid (CSF)

4. Decreased metabolic energy needs

5. Increased absorption of cerebral spinal fluid (CSF)

Correct Answer: 3,4,5

Rationale 1: Vasoconstriction of cardiac vessels is not a normal compensatory mechanism for ICP.

Rationale 2: Vasoconstriction of the cerebral blood vessels results as space becomes compressed.

Rationale 3: For the brain to maintain a normal ICP, attempts are made to compensate for changes in any of the three components within the brain. Initial mechanisms for ICP may include changing the volume of CSF by decreasing production.

Rationale 4: Autoregulation can help maintain adequate tissue perfusion by adjusting metabolic needs.

Rationale 5: For the brain to maintain a normal ICP, attempts are made to compensate for changes in any of the three components within the brain. Initial mechanisms for ICP may include changing the volume of CSF by increasing absorption.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-2

Question 22

Type: MCSA

A patient with a right temporal lobe hematoma is displaying Cheyne-Stokes respirations. How should this nurse interpret this assessment finding?

1. The next sign will likely be sluggish pupil reaction ipsilaterally.

2. This type of brain pathophysiology is usually self-limiting.

3. This patient requires surgical decompression of the brain.

4. There is no medical treatment appropriate for this symptomology.

Correct Answer: 3

Rationale 1: This patient is experiencing a symptom of uncal herniation. Cheyne-Stokes respiration is a late sign. Ipsilateral pupillary changes would have already occurred.

Rationale 2: Herniation syndromes are life-threatening neurologic emergencies that, left untreated, can progress rapidly to death.

Rationale 3: Urgent surgical intervention to decompress the brain is often the treatment of choice.

Rationale 4: Urgent medical treatment may correct the condition causing this symptomology.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-3

Question 23

Type: MCSA

A 2-year-old child fell and sustained a scalp laceration that will require suturing. The parents ask the nurse, How serious an injury is this? How should the nurse respond?

1. There is a lot of bleeding, but it is really a rather superficial injury.

2. From the description of the fall it doesnt appear serious, but the X-ray will tell us for sure.

3. Hell need a few stitches and a tetanus injection, but that should do it.

4. Children this age are really resilient, but you never know until the X-rays are read.

Correct Answer: 2

Rationale 1: Telling the parents that the wound is superficial without the benefit of radiological confirmation is inappropriate.

Rationale 2: Scalp lacerations account for a large number of emergency department visits and are usually not serious, but with any scalp laceration, the possibility of an underlying skull fracture must be addressed. An accurate history of the event surrounding the injury is very important. If there is any reason to suspect a skull fracture, a computerized tomography (CT) scan or a plain X-ray of the skull should be obtained.

Rationale 3: Stating that a few stitches and a tetanus injection are all that is needed is minimizing the potential extent of the injury.

Rationale 4: Stating that children are resilient is minimizing the parents concern.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-3

Question 24

Type: MCMA

Which observations by the nurse are representative of the symptomology of an epidural hematoma (EDH)?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. History of unconsciousness immediately after trauma

2. Muscle weakness on the side opposite the head injury

3. Rapid deterioration in level of consciousness

4. Period of lucidity prior to onset of symptoms

5. Dilated pupil on the same side as the injury

Correct Answer: 1,3,4,5

Rationale 1: The classic clinical presentation of EDH is characterized by an immediate posttraumatic period of unconsciousness, followed by a lucid interval, which can last from minutes to hours.

Rationale 2: Hemiparesis (muscle weakness) of the contralateral arm and leg (opposite side from the injury) may be present with an acute subdural hematoma.

Rationale 3: A rapid deterioration in the level of consciousness may occur unexpectedly.

Rationale 4: The classic clinical presentation of EDH is characterized by an immediate posttraumatic period of unconsciousness, followed by a lucid interval, which can last from minutes to hours.

Rationale 5: Possible signs and symptoms include an enlarging pupil on the same side as the injury (ipsilateral).

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-3

Question 25

Type: MCMA

A patient is recovering from a lumbar puncture, and the nurse is concerned that the patient may contract bacterial meningitis. The nurse should be alert for which common early symptoms?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Fever

2. Seizures

3. Rhinorrhea

4. Headache

5. Confusion

Correct Answer: 1,2,4,5

Rationale 1: Fever is a common and early symptom of meningitis.

Rationale 2: Seizures are a common and early symptom of meningitis.

Rationale 3: Patients with skull fractures may experience rhinorrhea, which is the leaking of cerebral spinal fluid via the nose.

Rationale 4: Headache is a common and early symptom of meningitis.

Rationale 5: Confusion is a common and early symptom of meningitis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-4

Question 26

Type: MCSA

A patient is being admitted for possible early-stage viral meningitis. The nurse would assess for which significant findings to help confirm the diagnosis?

1. A history of flulike symptoms resolving 5 days ago

2. Sluggish pupils bilaterally

3. Blood pressure of 100/62

4. A cervical lymph node palpable on physical examination

Correct Answer: 1

Rationale 1: The presence of systemic viral infections such as a flulike illness is significant and may indicate the original source of the viral invasion.

Rationale 2: Sluggish pupils are not associated with viral meningitis.

Rationale 3: Decreased blood pressure is not an early finding of meningitis.

Rationale 4: The presence of a palpable cervical lymph node would not raise suspicion of viral meningitis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-4

Question 27

Type: MCSA

A patient has been diagnosed with a grade 1 astrocytoma, an intra-axial brain tumor. The patient asks, What are my chances of surviving this thing? The nurses response is based on which information?

1. A grade 1 astrocytoma is a very aggressive form of this type of tumor.

2. It depends on whether the tumor metastasizes outside the brain.

3. Age is the greatest predictor of patient survival.

4. This type of tumor has a survival rate of 10 years.

Correct Answer: 3

Rationale 1: A grade 1 astrocytoma is not the most aggressive form of this cancer.

Rationale 2: Although astrocytomas may spread into surrounding normal brain tissue, it is rare for them to spread outside the brain and CSF system.

Rationale 3: The strongest predictor of survival with low-grade (grades 1 and 2) astrocytoma is age. One study reported a mean survival time of 8.5 years for adults less than 40 years of age; this contrasts with 4.9 years for adults 40 years of age and older.

Rationale 4: Approximately 75% of patients with this type of tumor die within 5 years.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-5

Question 28

Type: MCSA

A patient has had a surgical resection of an acoustic neuroma. The nurse would prioritize which postoperative assessment?

1. Timing how long it takes for tinnitus to return

2. Measuring urine output hourly

3. Determining the degree of hearing loss

4. Identifying damage to cranial nerves VII, IX, X, and XII

Correct Answer: 4

Rationale 1: Acoustic neuromas cause tinnitus. It is not expected to return after surgery.

Rationale 2: Decreased urine output is not an expected effect of this surgery. Hourly outputs may be ordered because the patient is being given intravenous fluids, but this measurement is not the highest priority.

Rationale 3: Acoustic neuromas usually are diagnosed when the patient experiences gradual hearing loss. Hearing loss would not continue to progress.

Rationale 4: Surgical resection of acoustic neuromas can cause damage to cranial nerves in proximity to the tumor. Damage to cranial nerves VII, IX, X, and XII is possible. Therefore, a thorough cranial nerve assessment is important, both preoperatively and postoperatively.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-5

Question 29

Type: MCSA

A patient has been diagnosed with a pituitary adenoma. Which assessment finding supports that it is a nonfunctioning form?

1. 20/60 vision using a Snellen chart

2. A round, moon-shaped face

3. A protruding lower jaw

4. Report of insomnia

Correct Answer: 1

Rationale 1: Nonfunctioning pituitary adenomas produce symptoms caused by pressure of the tumor on surrounding structures, such as the optic nerve. Frequently, visual loss is the presenting symptom, sometimes in the form of decreased acuity.

Rationale 2: Functioning pituitary adenomas produce endocrine symptoms such as a moon-shaped face.

Rationale 3: A protruding lower jaw is not associated with a nonfunctioning pituitary adenoma.

Rationale 4: Insomnia is not associated with a nonfunctioning pituitary adenoma.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-5

Question 30

Type: MCSA

A patient diagnosed with a benign brain tumor is scheduled for gamma knife surgery. How would the nurse explain this procedure?

1. A radioactive seed or capsule will be implanted into the tumor.

2. A robotic arm device will deliver multiple beams of radiation to the tumor.

3. This is the traditional method of delivering radiation to a tumor.

4. The gamma knife is a method of delivering a focused dose of radiation at your tumor.

Correct Answer: 4

Rationale 1: Brachytherapy is the surgical implantation of radioactive capsules, or seeds, directly into the tumor bed.

Rationale 2: Cyber knife radiosurgery is a radiosurgical system that consists of a robotic arm used to deliver multiple beams of radiation.

Rationale 3: The gamma knife is not the traditional method of delivering radiation to a tumor.

Rationale 4: Gamma knife radiosurgery is a system that uses focused radiation in a single dose.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-5

Question 31

Type: MCSA

A patient diagnosed with a brain tumor is reluctant to agree to a surgical excision of the lesion. How can the nurse best address the patients concerns?

1. Notifying the neurosurgeon of the patients concerns

2. Assuring the patient that the procedure is necessary

3. Providing detailed written information on the benefits of the proposed procedure

4. Asking the patient to be more specific about the concerns

Correct Answer: 4

Rationale 1: The neurosurgeon may be notified of the concern if it is outside the nurses scope of responsibility.

Rationale 2: Merely assuring the patient about the necessity of the procedure does not address the patients concerns.

Rationale 3: While written reinforcement of the information is appropriate, the patient needs personal involvement on the part of the nurse to address specific concerns.

Rationale 4: The nurse has a responsibility to help address the patients concerns, but this cannot be done until the nurse fully understands those concerns.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-5

Question 32

Type: MCSA

A patient has developed severe postsurgical muscle weakness in the lower extremities after the removal of a brain tumor. The nurse takes which initial intervention to minimize the patients risk of developing a deep vein thrombosis (DVT)?

1. Ask the patient questions to determine if there is a history of DVT.

2. Add regular leg massages to the patients care plan.

3. Instruct the patient to perform leg exercises at least twice daily.

4. Apply well-fitted antiembolism hose.

Correct Answer: 4

Rationale 1: Determining whether the patient has a history of DVT is not the priority intervention.

Rationale 2: Massaging the legs is not an appropriate nursing intervention and may result in serious injury to the patient.

Rationale 3: The patient with this level of muscle weakness is not capable of performing leg exercises.

Rationale 4: The use of antiembolism hose or pneumonic stockings is highly recommended, and they should be applied as soon as possible. The hose must fit correctly to be effective.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 21-5

Question 33

Type: FIB

A nurse is providing care to a patient with increased intracranial pressure following a closed head injury. The nurse would determine that adequate cerebral perfusion pressure exists if the CPP is at least ____.

Standard Text:

Correct Answer: 50

Rationale : A CPP of at least 50 is required for adequate cerebral perfusion. The preferred CPP is 60.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 21-6

Question 34

Type: MCMA

The nurse is planning a community education session regarding prevention of traumatic brain injury (TBI). The nurse would discuss which risk factors?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Age over 65

2. Male gender

3. Age under 18

4. High alcohol intake

5. Serving in the military

Correct Answer: 2,4,5

Rationale 1: The risk of TBI becomes higher at age 70.

Rationale 2: Males suffer twice as many TBIs as women.

Rationale 3: The age group with the highest risk is adults 18 to 25 years old.

Rationale 4: High alcohol intake is a risk factor for TBI.

Rationale 5: Military service increases the risk of TBI.

Global Rationale:

Cognitive Level:

Client Need:

Client Need Sub:

Nursing/Integrated Concepts:

Learning Outcome: 21-3

Question 35

Type: MCSA

A patient is being tested for bacterial meningitis. Which finding would the nurse evaluate as supporting that diagnosis?

1. The CSF is negative for glucose.

2. CSF is high in sodium.

3. The CSF is turbid in appearance.

4. The potassium level in the CSF is low.

Correct Answer: 3

Rationale 1: Glucose is present in the CSF in both viral and bacterial meningitis.

Rationale 2: The sodium level in CSF is not associated with meningitis.

Rationale 3: When bacteria are present in the CSF, the fluid is cloudy and turbid.

Rationale 4: The potassium level of the CSF is not associated with meningitis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21-4

 

Leave a Reply