ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 37 : Caring for Clients With Central and Peripheral Nervous System Disorders Questions
Question 1 of 5
The nurse is caring for a client who continues to have increasingly high intracranial pressure. Which complication is expected unless intracranial pressure is resolved?
Correct Answer: C
Rationale: Unless intracranial pressure is resolved, the brain will shift to the lateral side or herniate downward through the foramen magnum. Inflammation occurs from damage to the brain but will reach a maximum. Blood vessels do not dilate as a result of intracranial pressure. Peripheral edema is not a concern.
Question 2 of 5
Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting?
Correct Answer: B
Rationale: All of the goals are appropriate, but the most important goal is the long-term goal to remain free of injury if a seizure occurs. Nursing interventions associated can include notifying someone of not feeling well, lowering self to a safe position, protecting head, turning on a side, etc. Also, the client may be at a risk for injury because, once a seizure begins, the client cannot implement self-protective behaviors. An established plan is important in the care of a seizure client. The other options are acceptable goals for nursing care.
Question 3 of 5
The nurse is caring for a client with head trauma. Which assessment finding(s) would indicate an increasing intracranial pressure (ICP) in this client? Select all that apply.
Correct Answer: D,F
Rationale: Elevated systolic blood pressure with widening pulse pressure is consistent with Cushing's triad, which occurs late in increasing ICP. Other signs of Cushing's triad include bradycardia and irregular breathing. Stiff neck is not a symptom associated with ICP. Generalized pain is not significant with ICP unless related to complaint of headache (especially upon awakening). Glasgow Coma Scale of 15 and brisk pupil response are normal findings.
Question 4 of 5
The nurse is caring for a client with bacterial meningitis. Which assessment finding(s) is most important in determining nursing care for this client? Select all that apply.
Correct Answer: A,C
Rationale: The cerebral spinal fluid (CSF) will be cloudy if bacterial meningitis is the causative agent. Purpura indicates a serious complication of bacterial meningitis (disseminated intravascular coagulation) is occurring and may place the client at risk for amputation of those parts. Pain and stiffness of the extremities is not indicative of meningitis. A rise in RBCs, WBCs, and ADH would be expected.
Question 5 of 5
A client adopted at birth recently discovers that Huntington disease is prevalent in the biological family history. The nurse is providing education to the client about the condition. Which statement(s) should the nurse include in the teaching? Select all that apply.
Correct Answer: A,B,C
Rationale: In teaching the client about Huntington disease, the nurse will explain to the client that people with the disease can participate in most physical activities in the early stages, but that the disease eventually causes hallucinations, delusions, impaired judgment, and increased intensity of abnormal movements. The nurse will go on to inform the client that medications for Huntington disease can decrease immune cells and immune protection. There are no specific diagnostic tests for this disorder, and it is transmitted genetically; thus, the nurse will leave out these statements in the teaching.