Neuro Nclex (Assessment, stroke, headache, seizure)

Neuro Nclex (Assessment, stroke, headache, seizure) 4.5 (2 reviews) Students also studied Terms in this set (86) Science MedicineNeurology Save NCLEX Questions Parkinson Disease...20 terms SMathews926Preview Neurological NCLEX Questions 55 terms marissaxxcarol Preview Seizures NCLEX 12 terms murkacatPreview practic 21 terms lola The patient has been receiving scheduled doses of phenytoin (Dilantin) and begins to experience diplopia.The nurse immediately assesses the patient for which of the following?

• An aura
• Nystagmus or confusion
• Abdominal pain or cramping
• Irregular pulse or palpitations
• Diplopia is a sign of phenytoin toxicity. The nurse should assess for other signs

of toxicity, which include neurological changes such as nystagmus, ataxia, confusion, dizziness, or slurred speech.

• After teaching a patient about management of migraine

headaches, the nurse determines that the teaching has been effective when the patient says,

• "I will take the (Topamax) as soon as any headaches

start."

• "I should avoid taking aspirin and sumatriptan (Imitrex)

at the same time."

• "I will try to lie down someplace dark and quiet when

the headaches begin."

• "A glass of wine might help me relax and prevent

headaches from developing."

ANS: C

It is recommended that the patient with a migraine rest in a dark, quiet area.Topiramate (Topamax) is used to prevent migraines and must be taken for several months to determine effectiveness. Aspirin or other nonsteroidal anti- inflammatory medications can be taken with the triptans. Alcohol may precipitate migraine headaches.

• When a patient is experiencing a cluster headache, the

nurse will plan to assess for

• nuchal rigidity.
• projectile vomiting.
• unilateral eyelid swelling.
• throbbing, bilateral facial pain.

.ANS: C

Unilateral eye edema, tearing, and ptosis are characteristic of cluster headaches.Nuchal rigidity suggests meningeal irritation, such as occurs with meningitis.Although nausea and vomiting may occur with migraine headaches, projectile vomiting is more consistent with increases in intracranial pressure (ICP). Unilateral sharp, stabbing pain, rather than throbbing pain, is characteristic of cluster headaches.

• Which action will the nurse take when evaluating a

patient who is taking phenytoin (Dilantin) for adverse effects of the medication?

• Inspect the oral mucosa.
• Listen to the lung sounds.
• Auscultate the bowel tones.
• Check pupil reaction to light.

ANS: A

Phenytoin can cause gingival hyperplasia, but does not affect bowel tones, lung sounds, or pupil reaction to light.A patient reports a headache to the nurse. After reviewing the patient's history, the nurse finds that the patient has previously had a stroke. Which drug should be excluded from the patient's treatment regimen?

• Fluoxetine
• Propanolol

3Sumatriptan 4Amitriptyline

• A stroke is a medical condition characterized by poor blood flow to the brain.

Sumatriptan is a serotonin-receptor antagonist that acts by constricting the blood vessels. This drug may aggravate the patient's condition and should be excluded.Fluoxetine, propranolol, and amitriptyline do not affect blood vessels and are safe to include in the patient's treatment regimen.Which complaint made by the patient indicates that the individual may be suffering from a cluster headache?1"The pain is constant." 2"The pain is followed by nausea." 3"The pain disturbs my sleep at night." 4"The pain lasts for longer than eight hours.

• Cluster headaches usually occur at night and causes sleep disturbances.

Therefore, the patient's complaint about sleep-disturbing pain is a sign of a cluster headache. Constant pain is a characteristic of tension-type headaches. Migraine headaches are associated with nausea and vomiting; they usually exist for 4 to 72 hours.The primary health care provider diagnoses that a patient has a cluster headache. Which statements made by the patient support the health care provider's diagnosis?Select all that apply.1 "My cheeks also ache during the headache." 2 "I feel like my limbs are moving during the headache." 3 "I don't feel like sitting in one place during the headache." 4 "My skin appears pale during the headache." 5 "I have a strong desire to eat ice cream and chocolates during the headache." 1,3,4 A cluster headache is manifested by pain in the cheeks, gums, nose, and forehead. Cluster headache is also associated with restlessness and pallor (skin paleness). Feelings of limb movement and food cravings are clinical manifestations of migraine headache.A patient with a history of cluster headaches complains to the nurse that he or she does not have any pain relief even after taking analgesics. Which treatment will be beneficial for the patient?1Lithium therapy

• Melatonin therapy

3Deep brain stimulation 4Vagal nerve stimulation

• Refractory cluster headaches do not subside after taking medications such as

analgesics. Patients with refractory cluster headaches should be prescribed deep brain stimulation, invasive nerve block procedures, or ablative neurosurgical procedures. Lithium and melatonin therapies are used to treat nonrefractory cluster headaches. Vagal nerve stimulation is used to treat epilepsies.

A nurse is interviewing a patient who is seeking relief for frequent headaches. Which description is consistent with symptoms of a migraine headache?

• Extreme tenseness in the area of the neck and

shoulders.2Tears flow from one eye and nasal drainage occurs with the headache.

• The pain of the headache wakes the patient from sleep.

4The pain throbs and is synchronous with the patient's pulse.

• A migraine headache is caused by a series of neurovascular events that result

from some trigger stimulus. The pain usually is one-sided, throbbing in nature, and synchronous with the patient's pulse. Palpable tenseness in the neck and shoulders occurs with a tension headache. A cluster headache awakens the patient from sleep and involves tearing of one eye with nasal drainage on the same side.A white female client is admitted to an acute care facility with a diagnosis of cerebrovascular accident (CVA). Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for CVA?

• Caucasian race
• Female sex
• Obesity
• Bronchial asthma

Answer C. Obesity is a risk factor for CVA. Other risk factors include a history of ischemic episodes, cardiovascular disease, diabetes mellitus, atherosclerosis of the cranial vessels, hypertension, polycythemia, smoking, hypercholesterolemia, oral contraceptive use, emotional stress, family history of CVA, and advancing age. The client's race, sex, and bronchial asthma aren't risk factors for CVA.A male client is having a tonic-clonic seizures. What should the nurse do first?

• Elevate the head of the bed.
• Restrain the client's arms and legs.
• Place a tongue blade in the client's mouth.
• Take measures to prevent injury.

Answer D. Protecting the client from injury is the immediate priority during a seizure. Elevating the head of the bed would have no effect on the client's condition or safety. Restraining the client's arms and legs could cause injury.Placing a tongue blade or other object in the client's mouth could damage the teeth.For a male client with suspected increased intracranial

pressure (ICP), a most appropriate respiratory goal is to:

• prevent respiratory alkalosis.
• lower arterial pH.
• promote carbon dioxide elimination.
• maintain partial pressure of arterial oxygen (PaO2)

above 80 mm Hg Answer C. The goal of treatment is to prevent acidemia by eliminating carbon dioxide. That is because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP. Preventing respiratory alkalosis and lowering arterial pH may bring about acidosis, an undesirable condition in this case. It isn't necessary to maintain a PaO2 as high as 80 mm Hg; 60 mm Hg will adequately oxygenate most clients.The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use which plan to use which of the following to test the client's peripheral response to pain?

• Sternal rub
• Nail bed pressure
• Pressure on the orbital rim
• Squeezing of the sternocleidomastoid muscle

Answer B. Motor testing in the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response.Cerebral responses to pain are tested using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

A female client admitted to the hospital with a neurological problem asks the nurse whether magnetic resonance imaging may be done. The nurse interprets that the client may be ineligible for this diagnostic

procedure based on the client's history of:

• Hypertension
• Heart failure
• Prosthetic valve replacement
• Chronic obstructive pulmonary disorder

Answer C. The client having a magnetic resonance imaging scan has all metallic objects removed because of the magnetic field generated by the device. A careful history is obtained to determine whether any metal objects are inside the client, such as orthopedic hardware, pacemakers, artificial heart valves, aneurysm clips, or intrauterine devices. These may heat up, become dislodged, or malfunction during this procedure. The client may be ineligible if significant risk exists.A male client is having a lumbar puncture performed. The nurse would plan to place the client in which position?

• Side-lying, with a pillow under the hip
• Prone, with a pillow under the abdomen
• Prone, in slight-Trendelenburg's position
• Side-lying, with the legs pulled up and head bent

down onto chest.Answer D. The client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen and the head bent down onto the chest.This position helps open the spaces between the vertebrae.The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid?

• Head mildline
• Head turned to the side
• Neck in neutral position
• Head of bed elevated 30 to 45 degrees

Answer B. The head of the client with increased intracranial pressure should be positioned so the head is in a neutral midline position. The nurse should avoid flexing or extending the client's neck or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure down.A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that

this is cerebrospinal fluid if the fluid:

• Is clear and tests negative for glucose
• Is grossly bloody in appearance and has a pH of 6
• Clumps together on the dressing and has a pH of 7
• Separates into concentric rings and test positive of

glucose Answer D. Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.A male client with a spinal cord injury is prone to experiencing automatic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?

• Strict adherence to a bowel retraining program
• Keeping the linen wrinkle-free under the client
• Preventing unnecessary pressure on the lower limbs
• Limiting bladder catheterization to once every 12 hours

Answer D. The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours, and foley catheters should be checked frequently to prevent kinks in the tubing.Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.The nurse is caring for the male client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated?

• Loosening restrictive clothing
• Restraining the client's limbs
• Removing the pillow and raising padded side rails
• Positioning the client to side, if possible, with the head

flexed forward Answer B. Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising side rails in the bed, and placing the client on one side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible, protects the head from injury, and moves furniture that may injure the client. Other aspects of care are as described for the client who is in bed.