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 with an inoperable brain tumor. What is a major threat to this client?
Correct Answer: A
Rationale: Nursing management depends on the area of the brain affected, tumor type, treatment approach, and the client's signs and symptoms. If the tumor is inoperable or has expanded despite treatment, increased intracranial pressure (ICP) is a major threat. In this scenario, there are no indications that fluid volume either increasing or decreasing is an issue.
Question 2 of 5
An older client complains of a constant headache. A physical examination shows papilledema. Based on these symptoms, what condition would the nurse suspect?
Correct Answer: D
Rationale: Headache and papilledema are symptoms of a brain tumor, although these symptoms do appear less often in the older adult. Symptoms of epilepsy include seizure activity, whereas symptoms of trigeminal neuralgia would be pain in the jaws or facial muscles. Hypostatic pneumonia develops due to immobility or prolonged bed rest in older clients. The other options are not associated with papilledema or constant headache.
Question 3 of 5
The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased intracranial pressure (ICP). What neurologic sequelae might this client develop?
Correct Answer: A
Rationale: Neurologic sequelae in survivors include damage to the cranial nerves that facilitate vision and hearing. Sequelae to meningitis do not include damage to the vagal nerve, the olfactory nerve, or the facial nerve.
Question 4 of 5
The nurse is caring for a client hospitalized with a severe exacerbation of myasthenia gravis. When administering medications to this client, what is a priority nursing action?
Correct Answer: B
Rationale: The nurse must administer medications at the exact intervals ordered to maintain therapeutic blood levels and prevent symptoms from returning. Assessing the client's reaction, documenting medication and dose, and giving the client plenty of fluids are not the priority nursing action for this client.
Question 5 of 5
A client diagnosed with Huntington disease is on a disease-modifying drug regimen and has a urinary catheter in place. Which potential complication is the highest priority for the nurse while monitoring the client?
Correct Answer: C
Rationale: Because all disease-modifying drug regimens for Huntington disease can decrease immune cells and infection protection, it is most important for the nurse to assess for acquired infections such as urinary tract infections, especially if the client is catheterized. Severe depression is common and can lead to suicide. Symptoms of Huntington disease develop slowly and include mental apathy and emotional disturbances, choreiform movements (uncontrollable writhing and twisting of the body), grimacing, difficulty chewing and swallowing, speech difficulty, intellectual decline, and loss of bowel and bladder control. Assessing for these other conditions is appropriate but not as important as assessing for urinary tract infection in the client on a disease-modifying drug regimen with a urinary catheter in place.