ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 66 : Management of Patients with Neurologic Dysfunction Questions
Question 1 of 5
A patient with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate?
Correct Answer: D
Rationale: Loosening restrictive clothing prevents injury during a seizure. Restraining or inserting an airway can cause harm, and high Fowlers is inappropriate during a seizure.
Question 2 of 5
A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the patients plan of care?
Correct Answer: C
Rationale: Phenytoin can cause gingival hyperplasia, making thorough oral hygiene essential. Pulse oximetry, low-protein diet, and fluid restriction are not related to phenytoin's adverse effects.
Question 3 of 5
A nurse is admitting a patient with a severe migraine headache and a history of acute coronary syndrome. What migraine medication would the nurse question for this patient?
Correct Answer: C
Rationale: Sumatriptan and other triptans can cause chest pain and are contraindicated in ischemic heart disease. All listed medications are triptans, but sumatriptan is specifically noted for this risk.
Question 4 of 5
The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing diagnosis of ineffective cerebral tissue perfusion. What would be an expected outcome that the nurse would document for this diagnosis?
Correct Answer: D
Rationale: Obeying commands with appropriate motor responses indicates improved cerebral perfusion. Other outcomes relate to sensory perception, thermoregulation, or body image, not perfusion.
Question 5 of 5
A patient exhibiting an altered level of consciousness (LOC) due to blunt-force trauma to the head is admitted to the ED. The physician determines the patients injury is causing increased intracranial pressure (ICP). The nurse should gauge the patients LOC on the results of what diagnostic tool?
Correct Answer: B
Rationale: The Glasgow Coma Scale assesses LOC via eye, verbal, and motor responses, making it ideal for monitoring ICP-related changes. Other options are not specific to LOC assessment.