Question 1

A nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs,followed by an immediate loss of consciousness and jerking of all extremities.How should the nurse document this activity?

Accepted Answer

A)  Atonic seizure 
B)  Tonic-clonic seizure 
C)  Myoclonic seizure 
D)  Absence seizure

Question 2

A nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness.Which action should the nurse take?

Accepted Answer

A)  Start fluids via a large-bore catheter. 
B)  Turn the client's head to the side. 
C)  Administer IV push diazepam. 
D)  Prepare to intubate the client.

Question 3

A nurse assesses a client who is recovering from the implantation of a vagal nerve stimulation device.For which clinical manifestations should the nurse assess as common complications of this procedure? (Select all that apply.)

Accepted Answer

A)  Bleeding 
B)  Infection 
C)  Hoarseness 
D)  Dysphagia 
E)  Seizures

Question 4

A nurse evaluates the results of diagnostic tests on a client's cerebrospinal fluid (CSF).Which fluid results alerts the nurse to possible viral meningitis? (Select all that apply.)

Accepted Answer

A)  Clear 
B)  Cloudy 
C)  Increased protein level 
D)  Normal glucose level 
E)  Bacterial organisms present

Question 5

A nurse assesses clients on a medical-surgical unit.Which clients should the nurse identify as at risk for secondary seizures? (Select all that apply.)

Accepted Answer

A)  A 26-year-old woman with a left temporal brain tumor 
B)  A 38-year-old male client in an alcohol withdrawal program 
C)  A 42-year-old football player with a traumatic brain injury 
D)  A 66-year-old female client with multiple sclerosis 
E)  A 72-year-old man with chronic obstructive pulmonary disease

Question 6

A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis.Which question should the nurse ask?

Accepted Answer

A)  "Do you live in a crowded residence?" 
B)  "When was your last tetanus vaccination?" 
C)  "Have you had any viral infections recently?" 
D)  "Have you traveled out of the country in the last month?"

Question 7

A nurse plans care for a client with Parkinson disease.Which intervention should the nurse include in this client's plan of care?

Accepted Answer

A)  Ambulate the client in the hallway twice a day. 
B)  Ensure a fluid intake of at least 3 liters per day. 
C)  Teach the client pursed-lip breathing techniques. 
D)  Keep the head of the bed at 30 degrees or greater.

Question 8

A nurse plans care for a client with epilepsy who is admitted to the hospital.Which interventions should the nurse include in this client's plan of care? (Select all that apply.)

Accepted Answer

A)  Have suction equipment at the bedside. 
B)  Place a padded tongue blade at the bedside. 
C)  Permit only clear oral fluids. 
D)  Keep bed rails up at all times. 
E)  Maintain the client on strict bedrest.
F) Ensure that the client has IV access.

Question 9

A nurse delegates care for a client with early-stage Alzheimer's disease to an unlicensed assistive personnel (UAP).Which statement should the nurse include when delegating this client's care?

Accepted Answer

A)  "If she is confused, play along and pretend that everything is okay." 
B)  "Remove the clock from her room so that she doesn't get confused." 
C)  "Reorient the client to the day, time, and environment with each contact." 
D)  "Use validation therapy to recognize and acknowledge the client's concerns."

Question 10

A nurse is caring for a client with meningitis.Which laboratory values should the nurse monitor to identify potential complications of this disorder? (Select all that apply.)

Accepted Answer

A)  Sodium level 
B)  Liver enzymes 
C)  Clotting factors 
D)  Cardiac enzymes 
E)  Creatinine level

Question 11

A nurse assesses a client who is experiencing a cluster headache.Which clinical manifestations should the nurse expect to find? (Select all that apply.)

Accepted Answer

A)  Ipsilateral tearing of the eye 
B)  Miosis 
C)  Abrupt loss of consciousness 
D)  Neck and shoulder tenderness 
E)  Nasal congestion

Question 12

A nurse cares for a client who is experiencing status epilepticus.Which prescribed medication should the nurse prepare to administer?

Accepted Answer

A)  Atenolol (Tenormin) 
B)  Lorazepam (Ativan) 
C)  Phenytoin (Dilantin) 
D)  Lisinopril (Prinivil)

Exam 42: Care of Patients with Problems of the Central Nervous System: The Brain