Chapter 23: Care of Patients with Disorders of the Brain |DeWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition
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Course
Medical Surgical Nursing
Institution
Medical Surgical Nursing
MULTIPLE CHOICE
1. The nurse is caring for a patient who recently suffered a cerebrovascular accident (CVA). Family members ask the nurse why their father had a seizure. Which response is best for the nurse to make?
a. “The seizure was most likely caused by brain cells being deprived of oxyge...
1. The nurse is caring for a patient who recently suffered a cerebrovascular accident (CVA).
Family members ask the nurse why their father had a seizure. Which response is best for
the nurse to make?
a. “The seizure was most likely caused by brain cells being deprived of oxygen due
to a blood clot in the brain.”
b. “The stroke generated a toxin that excites the brain cells.”
c. “The stroke causes an alteration in the cells adjacent to the blood clot.”
d. “The stroke causes an increase in the depolarization of the brain cells due to the
clot formation.”
ANS: A
Thrombi from a CVA can occlude vessels, cutting off oxygen supply to cells of the
brain and causing a seizure.
PTS:1 DIF: Cognitive Level: Comprehension REF: 524
OBJ:2 (theory) TOP: Seizure: Etiology
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. The nurse is providing teaching to a patient newly diagnosed with simple partial seizure
disorder. Which statement by the nurse is most accurate?
a. “Your seizures will typically only affect one side of your body.”
b. “Simple partial seizures may result in an alteration of consciousness.”
c. “The simple partial seizure may cause motor impairment to begin in all of your
extremities.”
d. “Simple partial seizures are not treatable.”
ANS: A
Simple partial seizures only involve one side of the brain and one side of the body.
Complex partial seizures may or may not result in an alteration in level of
consciousness. Generalized seizures affect both sides of the body. Simple partial
seizures may respond to treatment.
PTS:1 DIF: Cognitive Level: Application REF: 525
OBJ:1 (theory) TOP: Simple Partial Seizures
KEY: Nursing Process Step: Implementation
3. The nurse is caring for an anxious 20-year-old college student who just suffered his first
seizure in his dorm room. The patient asks the nurse if he is now an epileptic. What is the
nurse’s best response?
a. “No. All other causes of seizure activity must be ruled out before the diagnosis of
epilepsy is made.”
b. “Yes, but you may never have another seizure since it has just now manifested
itself.”
c. “No, but you should see a physician to get a prescription for a preventative
antispasmodic.”
d. “Yes. All seizures are considered to be epilepsy.”
ANS: A
Epilepsy diagnosis is made after all other causes of seizure activity have proven
negative. All seizures are not considered to be epilepsy.
PTS:1 DIF: Cognitive Level: Comprehension REF: 525
OBJ:1 (clinical) TOP: Seizures vs. Epilepsy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
4. The nurse instructs a person taking phenytoin (Dilantin) that periodic blood tests will be
necessary. The nurse explains that the laboratory checks will monitor for which potential
medication-induced change?
a. Potassium depletion
b. Liver damage
c. Increasing creatinine
d. Increasing sedimentation rates
ANS: B
Periodic blood tests are recommended for people taking phenytoin to monitor for liver
damage.
PTS:1 DIF: Cognitive Level: Comprehension REF: 549
OBJ:1 (clinical) TOP: Phenytoin: Adverse Effects
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
5. The nurse is assessing a patient on intravenous (IV) phenytoin (Dilantin). Which
assessment finding is most concerning to the nurse?
a. Blood pressure (BP) 138/92
b. Frequent hiccups
c. Irregular apical pulse
d. Nausea and vomiting
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