Exam (elaborations)
Archer Neuro (1).
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Archer NeuroExplanation
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 D is correct. This patient is showing symptoms consistent with Wernicke's aphasia,
which refers to a lesion in the left posterior superior temporal lobe/language area of the brain. It
is characterized by the ability to produce verbal language but mix similar sounding words so that
speech is often incomprehensible. Reading, writing, oral comprehension, and repetition are
affected.
Choice A is incorrect. Broca's aphasia refers to a lesion in the anterior language area of the
brain (motor speech cortex). Verbal comprehension remains intact, but the patient is usually
unable to form words at all and has difficulty with writing and repetition.
Choice B is incorrect. Global aphasia is the most common and severe type of aphasia due to a
large lesion that damages both the anterior and posterior language areas of the brain. Speech,
comprehension, repetition, reading, and writing are absent or severely impa - ANS-The nurse is
assessing a patient with suspected neurological issues. The patient's speech is delivered with
normal rhythm but filled with words that do not form any meaningful statements. The patient is
also unable to write or repeat back words and does not appear to understand the nurse's
instructions or questions. The nurse would recognize these symptoms as:
,A. Broca's aphasia
B. Global aphasia
C. Expressive aphasia
D. Wernicke's aphasia
Explanation
Choice B is correct. One of the major goals during a seizure is injury prevention. Caregivers
should be taught about injury prevention precautions. The wife should ensure that the furniture
is moved out of the way when her husband seizes, improving his safety.
Choice A is incorrect. There is a chance for the client to urinate while having a seizure.
However, the wife does not have any control over his urinary incontinence unless the client
wears incontinence aids. The priority should be placed on injury prevention, not urinary
incontinence.
Choice C is incorrect. Self-limiting seizures are not life-threatening. The wife need not call 911
unless the seizure lasts longer than 5 minutes. Status Epilepticus is defined as a single seizure
lasting more than five minutes or two or more seizures occurring within a five-minute period
without the person returning to normal between them. The wife should be educated - ANS-The
nurse gives discharge instructions to a client who sustained a brain injury from a motor vehicle
accident. His wife is concerned regarding her husband having seizures at home. Which
statement from the wife indicates that she understood the nurse's teaching?
A. "I will make sure that my husband does not wet himself."
B. "I will clear all furniture that might injure him when he has a seizure."
C. "I will call 911 once he has a seizure lasting about 3 minutes."
D. "I will ensure he sleeps well after a seizure."
Explanation
Choice D is correct. The client is manifesting signs of increased intracranial pressure. This
situation warrants immediate medical intervention to decrease the ICP. The nurse needs to
notify the physician immediately.
Choice A is incorrect. A fixed and dilated pupil signifies an increase in ICP. Reducing
environmental stimuli is not an appropriate intervention at the time.
Choice B is incorrect. There is no need to reassess after ten minutes as this warrants immediate
attention from the healthcare team.
Choice C is incorrect. Checking the client's blood pressure is unnecessary. - ANS-The nurse is
caring for a post-stroke client when suddenly she notes that the client has a fixed and dilated
pupil. What would be the most appropriate action by the nurse?
A. Reduce environmental stimuli.
B. Reassess after ten minutes.
C. Check the client's blood pressure.
D. Notify the physician.
Explanation
,Choices A, C, and F are correct. Chronic Pain is characterized by typical vital signs (Choice A),
whereas acute pain is characterized by increased pulse, blood pressure, and respiratory rate
(Choice C). In chronic pain, pupils can be healthy or dilated, and the client can be withdrawn
and depressed. In chronic pain, the parasympathetic nervous system is activated. In acute pain,
the sympathetic nervous system is activated. Therefore, the presentation includes the features
of sympathetic activation. Pulse, blood pressure, and respiratory rate are increased. The pupils
are dilated; the client can be restless and show pain behaviors such as guarding the painful
area and crying. Somatic pain originates from the bones, the skin, and the muscles (Choice F)
and somatic pain is a type of nociceptive pain, rather than neuropathic pain.
It is essential to understand the terminology of pain based on:
Onset and dura - ANS-You are teaching a student nurse about various types of pain. The
student nurse should realize which of the following types of pain are accurately paired with one
of their signs or symptoms?
Select all that apply.
A. Chronic pain: The vital signs are normal.
B. Chronic pain: The sympathetic nervous system is activated.
C. Acute pain: The pulse, blood pressure, and respiratory rate are increased.
D. Acute pain: The parasympathetic nervous system is activated.
E. Somatic pain: A type of neuropathic pain.
F. Somatic pain: Pain sensation originates from the bones, skin, and muscles.
G. Visceral pain: A type of neuropathic pain.
H. Visceral pain: The vital signs are normal
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 D is correct. Minimizing and challenging the client's report of pain/pain intensity is in
violation of the American Nurses Association's standards of care about pain/pain management.
Specifically, the American Nurses Association's Standards of Professional Performance for Pain
Management Nursing. For example, nurses are mandated to document pain as expressed by
the client regardless of what the nurse believes to be true and accurate.
Choice A is incorrect. Minimizing and challenging the client's report of pain/pain intensity is not
often necessary if the client has a history of substance abuse; this expression and reporting of
pain must be considered valid and accurate. Nurses are mandated to document pain as
expressed by the client regardless of what the nurse believes to be accurate.
Choice B is incorrect. Minimizing and challenging the client's report of pain/pain intensity is not
often necessa - ANS-Minimizing and challenging the client's report of pain and pain intensity is:
A. Often necessary if the client has a history of substance abuse.
B. Often necessary if the client has a history of drug seeking behavior.
C. Contrary to and in violation of the Nightingale oath.
D. Contrary to and in violation of the American Nurses Association's standard of care.
Explanation
Choice A is correct. Patients who are at risk for aspiration should be encouraged to swallow with
their chin down. The nurse would need to intervene and give direct instructions about the proper
way to chew and swallow to prevent aspiration. The risk for aspiration is applied when any
patient has increased chances of secretions, solids, or fluids entering the tracheobronchial
passages. Following physician orders for and ensuring the patient's food is at the ordered
consistency is crucial. Nursing assistants and other ancillary personnel who may feed the client
should be instructed on the proper way to feed, which includes allowing the patient to take
his/her time and to make sure all food is swallowed before offering another bite. Fluids should
be held until the end of the meal, when possible.
Choices B, C, and D are incorrect. None of these require immediate nursing intervention.
NCSBN Client Need Topic - ANS-A nursing assistant is feeding a patient with Parkinson's
disease who is on aspiration precautions. Which action would require immediate intervention by
the nurse?
A. The nursing assistant reminds the client to keep his head back when he chews and swallows.
B. The nursing assistant maintains the thickened liquid diet as ordered by the physician.
C. The nursing assistant waits for the patient to finish swallowing before offering another bite.
D. The nursing assistant does not offer fluids until the end of the meal.
Explanation
Choice A is correct. Kernig's sign is positive if pain occurs upon extension of the knee. When
meninges are inflamed (meningitis), movement of the spinal cord or nerves against the inflamed
meninges results in pain. With the patient placed supine and hip flexed at 90 degrees, an
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