Chapter 24: Care of Patients with Disorders of the Brain My Nursing Test Banks

Chapter 24: Care of Patients with Disorders of the Brain

MULTIPLE CHOICE

1. The nurse is caring for a patient who recently suffered a cerebrovascular accident (CVA). The family asks the nurse why their father had a seizure. What is the best response by the nurse?

a.

The seizure was most likely caused by brain cells being deprived of oxygen due to a blood clot in the brain.

b.

The stroke generated a toxin that excites the brain cells.

c.

The stroke causes an alteration in the cells adjacent to the blood clot.

d.

The stroke causes an increase in the depolarization of the brain cells due to the clot formation.

ANS: A

Thrombi from a CVA can occlude vessels, cutting off oxygen supply to cells of the brain and causing a seizure.

DIF: Cognitive Level: Application REF: 523 OBJ: 2 (theory)

TOP: Seizure: Etiology KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. The nurse is providing teaching to a patient newly diagnosed with simple partial seizure disorder. Which statement by the nurse is most accurate?

a.

Your seizures will typically only affect one side of your body.

b.

Simple partial seizures may result in an alteration of consciousness.

c.

The simple partial seizure may cause motor impairment to begin in all of your extremities.

d.

Simple partial seizures are not treatable.

ANS: A

Simple partial seizures only involve one side of the brain and one side of the body. Complex partial seizures may or may not result in an alteration in level of consciousness. Generalized seizures affect both sides of the body. Simple partial seizures may respond to treatment.

DIF: Cognitive Level: Application REF: 524 OBJ: 1 (theory)

TOP: Simple Partial Seizures KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

3. The anxious 20-year-old college student who just suffered his first seizure in his dorm room asks the nurse if he is now an epileptic. What is the nurses best response?

a.

No. All other causes of seizure activity must be ruled out before the diagnosis of epilepsy is made.

b.

Yes, but you may never have another seizure since it has just now manifested itself.

c.

No, but you should see a physician to get a prescription for a preventative antispasmodic.

d.

Yes. All seizures are considered to be epilepsy.

ANS: A

Epilepsy diagnosis is made after all other causes of seizure activity have proven negative. All seizures are not considered to be epilepsy.

DIF: Cognitive Level: Application REF: 523 OBJ: 1 (clinical)

TOP: Seizures vs. Epilepsy KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

4. The nurse instructs a person taking phenytoin (Dilantin) that periodic blood tests will be necessary. What is the physician monitoring for?

a.

Potassium depletion

b.

Liver damage

c.

Increased creatinine levels

d.

Increased sedimentation rates

ANS: B

Periodic blood tests are recommended for people taking phenytoin to monitor for liver damage.

DIF: Cognitive Level: Comprehension REF: 547 OBJ: 1 (clinical)

TOP: Phenytoin: Adverse Effects KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

5. The nurse is assessing a patient on IV phenytoin (Dilantin). Which assessment finding is the nurse concerned with?

a.

BP 138/86

b.

Frequent hiccups

c.

Irregular apical pulse

d.

Nausea and vomiting

ANS: C

IV phenytoin can cause cardiac arrhythmias and hypotension, especially if given faster than 50 mg/min.

DIF: Cognitive Level: Application REF: 526 | Clinical Cues

OBJ: 1 (theory) TOP: Phenytoin: Adverse Effects

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

6. The nurse is providing medication teaching to a patient with epilepsy who is taking an anticonvulsant medication. What should the nurse tell the patient to be sure to avoid?

a.

Taking alternative herbal remedies

b.

Drinking alcohol

c.

Using over-the-counter cold remedies

d.

Taking diet pills with ephedra

ANS: B

Alcohol interferes with the metabolism of anticonvulsants, increases lethargy, and may trigger seizures.

DIF: Cognitive Level: Application REF: 525 | Box 24-1

OBJ: 1 (theory) TOP: Epilepsy: Alcohol Use

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

7. The nurse reinforces the information given by the physician that endarterectomy as an intervention for stroke prevention is reserved for people who have carotid obstruction of more than:

a.

30%.

b.

40%.

c.

50%.

d.

60%.

ANS: D

Endarterectomy is reserved for people with carotid obstruction of more than 60%.

DIF: Cognitive Level: Comprehension REF: 527-528 OBJ: 4 (theory)

TOP: Endarterectomy: Guidelines KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

8. The dysarthric patient seated in the dining room of the long-term care facility yells, Poon! Poon! Poon! with increasing frustration. What is the nurses best response?

a.

Slow down, I cant understand what you are saying.

b.

Are you asking for a spoon?

c.

Not being able to speak is frustrating.

d.

If you tell me what you want, I will get it.

ANS: B

Attempting to interpret the dysarthric communication through questions that can be answered simply will reduce frustration.

DIF: Cognitive Level: Analysis REF: 531-532 OBJ: 4 (theory)

TOP: Stroke: Dysarthria KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity

9. The patient who suffered a CVA has developed agnosia. Which intervention by the nurse is most helpful?

a.

Telling the patient This is a spoon. You are to eat with it.

b.

Moving the patients hand with a toothbrush in repetitive motion to brush teeth

c.

Telling the patient The table edge is right in front of you.

d.

Providing an adaptive fork to enhance self-feeding

ANS: A

Identifying objects and their intended use is helpful to people with agnosia who can no longer recognize items. The other options are helpful to people with apraxia, hemianopsia, and altered coordination, respectively.

DIF: Cognitive Level: Analysis REF: 532 OBJ: 4 (theory)

TOP: Agnosia: Intervention KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

10. What intervention by the nurse would most encourage self-feeding in a patient who recently had a CVA with right-sided paralysis?

a.

Place finger foods on the left side of the plate.

b.

Support the right hand in holding an adaptive cup.

c.

Seat the patient in the dining room with other residents.

d.

Place large helpings of food in the center of the plate.

ANS: A

Finger foods on the nonparalyzed side encourage self-feeding. Privacy is more supportive to early efforts than being in a common dining room. Smaller helpings on the same side of the nonparalyzed limb are conducive to self-feeding.

DIF: Cognitive Level: Application REF: 539 OBJ: 4 (clinical)

TOP: Stroke: Self-Feeding KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

11. The nurse is aware that a key sign of a brain tumor is:

a.

morning nausea.

b.

difficulty reading.

c.

headache that awakens patient.

d.

increasing blood pressure.

ANS: C

A headache that awakens the patient is an early sign of a brain tumor. The other options are too nonspecific to be diagnostic.

DIF: Cognitive Level: Comprehension REF: 540 OBJ: 7 (theory)

TOP: Brain Tumor: Symptoms KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

12. The patient with brain tumorrelated hydrocephalus is to have a ventriculoperitoneal (V-P) shunt. The nurse explains that this surgical intervention will:

a.

redirect the cerebrospinal fluid from the ventricles to the peritoneum.

b.

stimulate ventricles to reabsorb excess cerebrospinal fluid.

c.

channel excess cerebrospinal fluid to the left atrium.

d.

provide a port from which excess cerebrospinal fluid can be aspirated.

ANS: A

The V-P shunt redirects the excess cerebrospinal fluid from the ventricles of the brain to the peritoneal space, where it is reabsorbed.

DIF: Cognitive Level: Comprehension REF: 541 OBJ: 3 (clinical)

TOP: Hydrocephalus: V-P Shunt KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

13. Following a craniotomy for the removal of a brain tumor, the patient exhibits nuchal rigidity, rash on the chest, headache, and a positive Brudzinski sign. What do these assessment findings indicate to the nurse?

a.

Intracranial bleeding

b.

Encephalitis

c.

Increasing intracranial pressure

d.

Meningitis

ANS: D

Nuchal rigidity, skin rash, headache, and a positive Brudzinski sign are indicative of meningitis.

DIF: Cognitive Level: Application REF: 542 OBJ: 10 (theory)

TOP: Meningitis: Signs KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

14. The nurse is caring for a patient with bacterial meningitis. What will the nurse include in the plan of care?

a.

A quiet environment with minimal stimulation

b.

Care using medical asepsis

c.

Limitation of oral fluids

d.

Distraction to reduce daytime naps

ANS: A

The environment is kept quiet with minimal stimulation to reduce the possibility of seizure. The care is done with general precautions. Fluid intake in encouraged, as are daytime naps to preserve energy.

DIF: Cognitive Level: Application REF: 543 OBJ: 10 (theory)

TOP: Meningitis: General Care KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

15. The patient reports intense intermittent headaches over the last 6 months that are preceded by specific symptoms. What symptom is the patient most likely experiencing?

a.

Nausea and vomiting

b.

Focal seizures

c.

Scotoma

d.

Fainting

ANS: C

The headaches are most likely migraines. Scotoma (spots before the eyes) are the typical prodromal symptom of a migraine headache.

DIF: Cognitive Level: Application REF: 545 OBJ: 11 (theory)

TOP: Migraine Headaches: Prodromal Symptoms

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

16. A patient was recently diagnosed as having Bells palsy. Which nursing intervention will the nurse include in the care plan for this patient?

a.

Medication for pain relief

b.

Protection of the eye on paralyzed side

c.

Precautions against aspiration

d.

Provision of a fan to cool the face

ANS: B

Protection of the eye with a shield or goggles is essential during period of paralysis. There is no pain or threat of aspiration. Cool air is a trigger for Bells palsy.

DIF: Cognitive Level: Application REF: 548 OBJ: 12 (theory)

TOP: Bells Palsy KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

17. The nurse is writing the care plan for a cerebrovascular accident (CVA) patient who has partial left-sided paralysis and is experiencing ataxia. Which intervention will be beneficial for this patient?

a.

Encourage the patient to ambulate as much as possible when she feels the energy to do so.

b.

Ensure the patient receives pureed foods and thickened liquids.

c.

Place the patients call light on the right side of the patient and remind her to call for assistance before getting up.

d.

Encourage the patient to use a communication board.

ANS: C

The patient with ataxia has experienced a loss of balance or poor coordination; therefore, placing the call light on this patients right side and reminding her to call for help will best address her high risk for falling. Pureed foods and thickened liquids are necessary for the patient with dysphagia, and a communication board would assist a patient with dysarthria or aphasia.

DIF: Cognitive Level: Application REF: 532 OBJ: 4 (theory)

TOP: Ataxia KEY: Nursing Process Step: Planning, Implementation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

18. The nurse on a rehabilitation unit is caring for a stroke patient who is experiencing homonymous hemianopsia. The patient asks if he is going to have any limitations when discharged from the hospital. The nurse anticipates the patient will be restricted from what activity?

a.

Ambulating independently

b.

Cooking on a stove

c.

Reading a book

d.

Driving a vehicle

ANS: D

Homonymous hemianopsia is blindness in part of the visual field of both eyes. Driving a vehicle may be very dangerous for this patient. With proper occupational therapy, the patient should be able to ambulate independently, cook, and read.

DIF: Cognitive Level: Application REF: 532 OBJ: 4 (theory)

TOP: Homonymous Hemianopsia KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

19. A patient diagnosed with a primary brain tumor asks the nurse if this is a common disease. Which response by the nurse is accurate?

a.

Brain tumors are very rare.

b.

About 40,000 people a year are diagnosed with a primary brain tumor.

c.

It doesnt really matter. We are just concerned with helping you.

d.

Almost all primary brain tumors are malignant.

ANS: B

About 200,000 new brain tumors are discovered each year in the United States with approximately 40,000 of those being primary tumors and the rest are metastatic tumors from a different site of origin. Many primary brain tumors are benign. Telling the patient his question doesnt really matter is non-therapeutic communication.

DIF: Cognitive Level: Application REF: 539 OBJ: 6 (theory)

TOP: Brain Tumors KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

MULTIPLE RESPONSE

20. The nurse is aware that seizures may be caused by: (Select all that apply.)

a.

stroke.

b.

cerebral tumor.

c.

hyperpyrexia.

d.

epilepsy.

e.

metabolic toxicity.

ANS: A, B, C, D, E

All options are potential causes of seizure.

DIF: Cognitive Level: Knowledge REF: 523 OBJ: 2 (theory)

TOP: Seizure: Etiology KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance

21. The nurse caring for an adult patient on the medical unit who has a seizure will document: (Select all that apply.)

a.

length of time of seizure.

b.

location of initiation of seizure.

c.

whether movements are unilateral or bilateral.

d.

familys reaction during the seizure.

e.

presence of incontinence.

ANS: A, B, C, E

The familys reaction to the seizure is not included in documentation of a seizure. All other options are significant observations to be included in the documentation of a seizure.

DIF: Cognitive Level: Comprehension REF: 526 | Focused Assessment

OBJ: 1 (theory) TOP: Seizure: Documentation

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

22. The nurse is aware that absence (petit mal) seizures are difficult to detect because: (Select all that apply.)

a.

there is no aura.

b.

the seizure appears to be a brief moment of absentmindedness.

c.

there is a loss of consciousness.

d.

the patient has no memory of the event.

e.

there are no postictal signs.

ANS: A, B, D, E

There is no loss of consciousness with a petit mal seizure. All other options are characteristics that make detection difficult.

DIF: Cognitive Level: Application REF: 524 OBJ: 1 (theory)

TOP: Absence Seizures: Characteristics KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance

23. The patient had a carotid ultrasound that showed a 40% obstruction following a transient ischemic attack (TIA). The nurse anticipates that the treatment will consist of: (Select all that apply.)

a.

diet modification.

b.

lifestyle alteration.

c.

aspirin for antiplatelet aggregation.

d.

daily doses of nitrates.

e.

endarterectomy.

ANS: A, B, C

Nitrates and endarterectomy are not initial treatment options for carotid obstruction below 60%.

DIF: Cognitive Level: Comprehension REF: 527-528 OBJ: 4 (theory)

TOP: TIA: Treatment KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

24. To help prevent aspiration while feeding a patient who has a right-sided paralysis, the nurse includes which interventions? (Select all that apply.)

a.

Place the patient in high Fowlers position.

b.

Instruct the patient to tilt the head and neck forward.

c.

Instruct the patient to drink liquids through a straw.

d.

Place food in the left side of the mouth.

e.

Avoid mixing foods with different textures.

ANS: A, B, D, E

Drinking through a straw rather than sipping from a cup increases the risk for aspiration. All other options will reduce the risk of aspiration in a stroke victim.

DIF: Cognitive Level: Application REF: 536-537 | Nursing Care Plan 24-1

OBJ: 4 (clinical) TOP: Stroke: Prevention of Aspiration

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

25. The nurse is completing a care plan for a stroke patient who is at risk for impaired physical mobility. Which interventions should the nurse include in the care plan? (Select all that apply.)

a.

Assist the patient to stand.

b.

Remind the patient to ambulate as much as possible.

c.

Ensure that the call bell is easily available.

d.

Coach the patient in active ROM.

e.

Reinforce the use of a walker or cane.

ANS: A, C, D, E

All options except reminding the patient to ambulate as much as possible are contributory to preventing falls.

DIF: Cognitive Level: Application REF: 537 | Nursing Care Plan 24-1

OBJ: 4 (theory) TOP: Stroke: Prevention of Falls

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

26. The nurse is educating a patient about his cluster headaches. The nurse is correct when stating that cluster headaches may be accompanied by which signs or symptoms? (Select all that apply.)

a.

Reddened conjunctiva

b.

Nasal congestion

c.

Ptosis

d.

Hypotension

e.

Sensitivity along trigeminal nerve

ANS: A, B, C, E

Cluster headaches may accompanied by hypertension rather than hypotension. All other options are signs and symptoms of a cluster headache.

DIF: Cognitive Level: Comprehension REF: 546 OBJ: 11 (theory)

TOP: Cluster Headache: Signs and Symptoms

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

27. The patient with a right-sided paralysis from a stroke becomes frustrated with attempting to self-feed. He throws the spoon at the nurse and begins to cry. What nursing actions would be best? (Select all that apply.)

a.

Retrieve the spoon and sit quietly for a few seconds.

b.

Touch the patient and inquire if he would rather have a high-protein milkshake for his meal.

c.

Remind the patient that such behavior is not acceptable.

d.

Add an intervention to the NCP for increased support with self-feeding.

e.

Complete an incident report.

ANS: A, B, C, D

An incident report would not be necessary unless the nurse or someone else was injured. All other options are supportive to the rehabilitation of the stroke patient.

DIF: Cognitive Level: Application REF: 537-538 | Nursing Care Plan 24-1

OBJ: 4 (theory) TOP: Stroke: Lability

KEY: Nursing Process Step: Planning, Implementation

MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

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