ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 42 : Care of Patients with Problems of the CNS: The Brain Questions
Question 1 of 5
A nurse assesses a client who is experiencing an absence seizure. For which clinical manifestations should the nurse assess? (Select all that apply.)
Correct Answer: A,D,E
Rationale: Absence seizures are characterized by brief lapses in attention, often with staring spells, lip smacking, or picking at clothing. Sudden loss of muscle tone is more typical of atonic seizures, and brief jerking of extremities is associated with myoclonic seizures.
Question 2 of 5
A nurse assesses a client who is at risk for secondary seizures. Which conditions place the client at risk? (Select all that apply.)
Correct Answer: A,B,C,D
Rationale: Clients at risk for secondary seizures include those with brain lesions from tumors or trauma, metabolic disorders, acute alcohol withdrawal, electrolyte disturbances, high fever, stroke, or substance abuse. Multiple sclerosis and chronic pulmonary disease are not typically associated with secondary seizures.
Question 3 of 5
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.)
Correct Answer: B,C,D
Rationale: Common complications of vagal nerve stimulation device implantation include hoarseness (most common), dyspnea, neck pain, and dysphagia. Bleeding is not a common complication, and seizures are not typically a post-procedure complication.
Question 4 of 5
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.)
Correct Answer: A,B
Rationale: Inflammation from meningitis can stimulate the hypothalamus, leading to excessive antidiuretic hormone production, causing syndrome of inappropriate antidiuretic hormone (SIADH); thus, sodium levels should be monitored. Systemic inflammatory response syndrome (SIRS) can lead to coagulopathy and disseminated intravascular coagulation, requiring monitoring of clotting factors. Other values are not specific to meningitis complications.
Question 5 of 5
A nurse assesses a client who has encephalitis. Which manifestations should the nurse recognize as signs of increased intracranial pressure (ICP), a complication of encephalitis? (Select all that apply.)
Correct Answer: B,D,E
Rationale: Increased ICP in encephalitis is indicated by dilated pupils, widened pulse pressure, bradycardia, irregular respirations, and less responsive pupils. Photophobia and headache are symptoms of encephalitis but not specific to increased ICP.