Question 1

The nurse is assessing a patient on intravenous (IV)phenytoin (Dilantin).Which assessment finding is most concerning to the nurse?

Accepted Answer

A)   Blood pressure (BP)  138/92
B)   Frequent hiccups
C)   Irregular apical pulse
D)   Nausea and vomiting C

Question 2

The nurse is providing medication teaching to a patient with epilepsy who is taking phenytoin (Dilantin).Which statement best indicates that the nurse's teaching has been successful?

Accepted Answer

A)   "I should decrease my alcohol intake to a single drink per day."
B)   "I should visit the dentist every 3 to 6 months while taking this medication."
C)   "I should take my antacid an hour after my Dilantin."
D)   "This medication may turn my urine orange." B

Question 3

The nurse 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?

Accepted Answer

A)   Ambulating independently
B)   Cooking on a stove
C)   Reading a book
D)   Driving a vehicle D

Question 4

Which nursing intervention best encourages self-feeding in a patient with right-sided paralysis after a CVA?

Accepted Answer

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.

Question 5

The nurse is caring for a patient who recently suffered a cerebrovascular accident (CVA).Family members ask the nurse why their father had a seizure.Which response is best for the nurse to make?

Accepted Answer

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."

Question 6

A patient was recently diagnosed as having Bell palsy.Which nursing intervention is most important for the nurse to include in the patient's care plan?

Accepted Answer

A)   Administer pain medication as needed.
B)   Administer artificial tears and aclyclovir.
C)   Implement aspiration precautions.
D)   Offer the patient a small fan to cool the face.

Question 7

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 is most beneficial for this patient?

Accepted Answer

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 patient's 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.

Question 8

Which condition(s)may cause seizures?

Accepted Answer

A)   Stroke
B)   Cerebral tumor
C)   Hyperpyrexia
D)   Epilepsy
E)   Metabolic toxicityF) Noune of above

Question 9

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

Accepted Answer

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."

Question 10

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 greater than what percentage?

Accepted Answer

A)   30%
B)   40%
C)   50%
D)   60%

Question 11

A patient diagnosed with a primary brain tumor asks the nurse if this is a common disease.Which response is most appropriate for the nurse to make?

Accepted Answer

A)   "Brain tumors are very rare."
B)   "About 40,000 people a year are diagnosed with a primary brain tumor."
C)   "It doesn't really matter. We are just concerned with helping you."
D)   "Almost all primary brain tumors are malignant."

Question 12

The nurse is caring for an adult patient with a history of seizures.In the event of a seizure,the nurse should document which information?

Accepted Answer

A)   Duration of seizure
B)   Location of initiation of seizure
C)   Description of movements
D)   Family's reaction during the seizure
E)   Presence of incontinence

Question 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?

Accepted Answer

A)   Intracranial bleeding
B)   Encephalitis
C)   Increasing intracranial pressure
D)   Meningitis

Question 14

The patient with a right-sided paralysis from a stroke becomes frustrated when attempting to self-feed.He throws the spoon at the nurse and begins to cry.What nursing action(s)is/are most appropriate at this time?

Accepted Answer

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.

Question 15

The nurse is caring for a patient with brain tumor-related hydrocephalus who is scheduled to undergo placement of a ventriculoperitoneal (V-P)shunt.Which information is most important for the nurse to include when explaining the purpose of the procedure?

Accepted Answer

A)   A V-P shunt redirects the cerebrospinal fluid (CSF)  from the ventricles to the peritoneum.
B)   A V-P shunt stimulates ventricles to reabsorb excess CSF.
C)   A V-P shunt channels excess CSF to the left atrium.
D)   A V-P shunt provides a port from which excess CSF can be aspirated.

Question 16

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?

Accepted Answer

A)   Nausea and vomiting
B)   Focal seizures
C)   Scotoma
D)   Fainting

Question 17

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?

Accepted Answer

A)   Assist the patient to stand.
B)   Remind the patient to ambulate as much as possible.
C)   Ensure that the call light is within reach.
D)   Coach the patient in active range-of-motion (ROM) .
E)   Reinforce the use of a walker or cane.

Question 18

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

Accepted Answer

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."

Question 19

The nurse is caring for a patient admitted with a transient ischemic attack (TIA).A carotid ultrasound reveals a 40% obstruction.The nurse anticipates that the treatment will likely consist of which factor(s)?

Accepted Answer

A)   Diet modification
B)   Lifestyle alteration
C)   Aspirin for antiplatelet aggregation
D)   Daily doses of nitrates
E)   Endarterectomy

Question 20

Which symptom is a key sign of a brain tumor?

Accepted Answer

A)   Morning nausea
B)   Difficulty reading
C)   A headache that awakens patient
D)   Increasing blood pressure

Exam 23: Care of Patients with Disorders of the Brain

The nurse is assessing a patient on intravenous (IV) phenytoin (Dilantin) .Which assessment finding is most concerning to the nurse?

The nurse is providing medication teaching to a patient with epilepsy who is taking phenytoin (Dilantin) .Which statement best indicates that the nurse's teaching has been successful?

The nurse 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?

Which nursing intervention best encourages self-feeding in a patient with right-sided paralysis after a CVA?

The nurse is caring for a patient who recently suffered a cerebrovascular accident (CVA) .Family members ask the nurse why their father had a seizure.Which response is best for the nurse to make?

A patient was recently diagnosed as having Bell palsy.Which nursing intervention is most important for the nurse to include in the patient's care plan?

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 is most beneficial for this patient?

Which condition(s) may cause seizures?