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 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 2 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 3 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.
Question 4 of 5
A nurse is teaching a client who experiences migraine headaches and is prescribed a beta blocker. Which a nurse should the nurse needs in this clients teaching?
Correct Answer: B
Rationale: Beta blockers are prescribed as prophylactic treatment to prevent the vascular changes that initiate migraine headaches. Heart rate and blood pressure will also be affected, and the client should monitor these side effects. The other responses do not discuss appropriate uses of the medication.
Question 5 of 5
A client experiences a seizure with jerking of the arms and legs, followed by an immediate loss of consciousness and jerkings of all extremities. How should the nurse document this activity?
Correct Answer: B
Rationale: The described seizure, characterized by jerking of arms and legs followed by loss of consciousness and generalized jerking, is a tonic-clonic seizure. 'Anotic' and 'myclonicic' are not recognized seizure types, and the correct term is tonic-clonic.