Archer Neuro
- ANS-The nurse is preparing a staff in-service regarding sensorineural hearing loss. It would be
appropriate for the nurse to identify which factors cause this type of hearing loss? Select all that
apply.
A. Diabetes mellitus
B. Menieres disease
C. Excessive cerumen
D. Exposure to loud noise
E. Excessive fluid
Choice A is correct. This significantly elevated blood pressure and requires follow-up.
Vasoconstriction may occur with this medication, and thus, the client with a medical history of
coronary artery disease, uncontrolled hypertension, and a previous stroke should not take this
medication.
Choices B, C, and D are incorrect. The medication is indicated for migraine headaches, and a
headache would not be of significant concern. Flushing of the skin immediately after
administering this medication is a common effect. Nausea and abdominal cramping may be a
side-effect associated with this medication.
Additional Info
Sumatriptan is an abortive treatment for migraine headaches. This medication may be given
intranasally or subcutaneously. The drug commonly causes flushing after administration and is
expected. Recent myocardial infarction, peripheral vascular disease, and/or uncontrolled
hypertension are contraindications t - ANS-The nurse is caring for a client immediately following
the administration of prescribed sumatriptan. Which clinical finding would require follow-up by
the nurse?
A. Blood Pressure 189/98 mm Hg
B. Headache pain 4/10
C. Client's skin appears flushed
D. Reports of nausea
Choice C is correct. Calcium carbonate (Tums) should not be taken at the same time as
Phenytoin because taking them together can decrease the effects of phenytoin. Antacids
containing calcium carbonate reduce the bioavailability of phenytoin by reducing both the rate of
absorption and the amount of intake. Phenytoin is an anticonvulsant and not getting it at a
therapeutic dose may result in the client having a recurrent seizure. Clients should be cautioned
against the concomitant use of antacids/tums and phenytoin. If the client needs calcium
carbonate, he should be instructed to separate the times of intake of calcium carbonate and
phenytoin by at least two to three hours.
,Choice A is incorrect. Acetaminophen and phenytoin can be taken together without any concern
for therapeutic failure.
Choice B is incorrect. Ibuprofen and phenytoin can be taken together and do not cause the
therapeutic failure of phenytoin.
Choic - ANS-The nurse is educating a patient who is taking phenytoin. To make sure phenytoin
does not fail, which over-the-counter (OTC) medication should the nurse advise the patient not
to take at the same time?
A. Acetaminophen
B. Ibuprofen
C. Calcium carbonate
D. Ranitidine
Choice D is correct. Intractable pain is severe and unyielding pain that cannot be corrected with
medical treatments for the underlying cause. Pain management, rather than medical treatments,
is indicated for intractable pain.
Other commonly used pain management terms include:
Sensitization: Heightened pain and increased sensitivity to a receptor after the application of a
repeated noxious stimulus.
Allodynia: A painful response to a nonpainful stimulus.
Dysesthesia: A sudden and spontaneous or elicited abnormal response that is unpleasant.
Choice A is incorrect. Sensitization is not the eradication of all pain sensation after the
application of a repeated noxious stimulus. Sensitization is heightened pain and increased
sensitivity to a receptor after the use of a repeated noxious stimulus.
Choice B is incorrect. Allodynia is not a sudden and spontaneous or elicited abnormal response
that is unpleasant. Allodynia is - ANS-Select the pain or pain management term that is
accurately paired with its definition.
A. Sensitization: The eradication of all pain sensation subsequent to the application of a
repeated noxious stimulus.
B. Allodynia: A sudden and spontaneous or illicited abnormal response that is unpleasant.
C. Dysesthesia: A painful response to a nonpainful stimulus.
D. Intractable pain: Severe and unyielding pain that cannot be corrected with medical
treatments.
Explanation
Choice A is correct. A C6-C7 spinal cord injury (SCI) can still retain some ability to extend
shoulder, arms, and fingers with compromised dexterity in the hands and fingers. The client
showing that she can maneuver a wheelchair indicates that she has progressed in therapy.
Rehabilitation often will focus on learning to use the non-paralyzed portions of the body to
regain varying levels of autonomy. Upon successful treatment, survivors of injuries at the C6/C7
level may be able to drive a modified car with hand controls.
The C6 and C7 cervical vertebrae (and the C8 spinal nerve) form the lowest levels of the
cervical spine and directly impact the arm and hand muscles. The C6/C7 injury has the potential
to change everything below the top of the ribcage, resulting in quadriplegia or paraplegia.
,Physical therapy is an essential part of recovery. The patient will need to maintain any function
not lost by the - ANS-The nurse is evaluating the progress of a completely paraplegic female
client with a C6-C7 spinal cord injury. Which indicator signifies that the client is improving in
physical therapy?
A. The client can control the motorized wheelchair.
B. The client states she wants to stand up with assistance.
C. The client says she wants to move her toes.
D. The client says she regained her bladder control.
Explanation
Choice A is correct. A lumbar puncture (LP) reduces a client's cerebrospinal fluid volume and
pressure. As a result of this decreased volume and pressure, headache results. This
post-lumbar puncture headache is a common post-procedure complication, usually occurring
hours to one to two days following the procedure, with severity ranging from moderate to
severe. Hydration is a primary treatment for post-lumbar puncture headache. Increasing the
client's fluid intake would facilitate the restoration of the client's cerebrospinal fluid volume.
Choice B is incorrect. The administration of antihypertensive medications will not address the
issue at hand. Currently, the client is experiencing a post-lumbar puncture headache due to
decreased cerebrospinal fluid volume and pressure. Antihypertensive medications will not
increase the volume or pressure of the cerebrospinal fluid. If the antihypertensive medications -
ANS-A lumbar puncture was performed on a client for a myelogram. After the procedure, the
client complains of a severe headache. The most appropriate nursing intervention is:
A. Increase the client's oral fluid intake
B. Administer the prescribed antihypertensives to the client
C. Give the client roll lenses
D. Place a cool pack over the lumbar puncture site
Explanation
Choice A is correct. A tonic-clonic seizure requires a client to be placed on their side and have
their clothing loosened. Prompt intervention with benzodiazepines. In this case, prescribed
lorazepam is given to break the seizure.
Choices B and C are incorrect. Phenytoin and carbamazepine are anti-convulsants that are
used to prevent seizures.
Choice D is incorrect. Benztropine is an anticholinergic drug that is indicated for Parkinson's
disease. - ANS-The nurse is caring for a client experiencing a tonic-clonic seizure. Which of the
following medications should the nurse be prepared to administer?
A. Lorazepam
B. Phenytoin
, C. Carbamazepine
D. Benztropine
Explanation
Choice A is correct. Absent bowel sounds, gastric distention, bradycardia, hypotension, and
flaccid paralysis are concerning findings for spinal shock. When caring for a client following a
spinal cord injury, spinal shock is one of the many complications which may occur within 48
hours following the injury.
Choices B, C, and D are incorrect. This clinical data is not consistent with spinal shock. If spinal
shock is suspected, the client will develop hypotension and bradycardia. This shock would
depress reflexes, not cause hyperreflexia.
Additional Info
Spinal shock may occur immediately following a spinal cord injury or within 48 hours of the
insult.
The cause is thought to be the excessive amount of potassium in the extracellular space that
reduces neural transmission.
Manifestations associated with spinal shock include flaccid paralysis, absent bowel and bladder
control, and loss of reflex activity. - ANS-The nurse is caring for a client with a spinal cord injury.
Which client finding would require immediate follow-up?
A. Absent bowel sounds
B. Blood pressure 134/82
C. Pulse 92/minute
D. Hyperreflexia
Explanation
Choice A is correct. An increase in the Glasgow Coma Scale (GCS) is a favorable finding when
tPA is administered (intravenous alteplase) for an ischemic stroke. The highest score on a GCS
is 15.
Choices B, C, and D are incorrect. Intravenous alteplase is a potent thrombolytic indicated for
ischemic strokes and adversely may cause angioedema or severe bleeding. While slight
bleeding at the gum line is not necessarily a reason to stop the infusion, it is not a therapeutic
finding. Unintelligible speech would also be a consistent manifestation of a CVA that is not
therapeutic when tPA is administered. An increase in pulse and decrease in blood pressure
would suggest internal bleeding, which requires immediate follow-up by the nurse.
Additional Info
Alteplase is a thrombolytic indicated in the treatment of an ischemic stroke. To administer
alteplase, the nurse must ensure that all invasive procedures are c - ANS-The nurse is caring
for a client receiving intravenous (IV) alteplase for a cerebrovascular accident (CVA). The nurse
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