Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition - Introduction to the Nervous System

Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition - Introduction to the Nervous System Related

Review Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition - Introduction to the Nervous System related questions and content

A client undergoes a scheduled electroencephalogram (EEG). Which post-procedure activity is most appropriate?

  • A. Measure the heart and the pulse rate.
  • B. Provide the client with caffeine-rich drinks.
  • C. Allow the client to wash hair and rest.
  • D. Measure the level of consciousness (LOC) of the client.
Correct Answer: C

Rationale: After an EEG, the nurse should ensure rest for the sleep-deprived client and allow the client to wash hair to remove the glue used to affix electrodes to the scalp. The client is advised not to take sedative drugs and caffeine-related drinks before the EEG; therefore, there is no reason to provide the client with them after the test. The nurse should not measure the LOC, the heart rate, or the pulse rate of the client unless advised by the health care provider.

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The nurse assists the health care provider (HCP) in completing a lumbar puncture (LP). Which should the nurse note as a concern?

  • A. The HCP maintains aseptic procedure.
  • B. The pressure is noted to be 90 mm H2O.
  • C. The cerebrospinal fluid (CSF) is cloudy in nature.
  • D. The HCP administers a drug by intrathecal injection.
Correct Answer: C

Rationale: The CSF is normally clear and colorless; therefore, CSF that is cloudy would be noted by the nurse as a concern. The HCP is correct to maintain aseptic procedure. At 90 mm H2O, the client's CSF fluid pressure falls within normal limits (between 80 and 100 mm H2O). Sometimes the HCP will administer medication via intrathecal injection during an LP, which should not be a cause for concern.

The nurse is caring for a client newly diagnosed with multiple sclerosis who is overwhelmed by learning about the disease. The client indicates understanding that there is a disruption in the covering of axons but does not remember what the covering is called. What should the nurse tell the client?

  • A. That it is not necessary to worry about the finer details of the disease.
  • B. That because there is so much to learn, there will be another meeting to discuss it again.
  • C. That the covering is called myelin and that it can be discussed further at the next meeting.
  • D. That the disease process requires more research.
Correct Answer: C

Rationale: Myelin is a fatty substance that covers some axons in the CNS and PNS. The nurse would be most correct in answering the question and then, if the client is tired, following up at the next meeting. It would also be appropriate to provide literature for the client to review at leisure. Discounting the client's need to know information about the disease process is belittling. Telling the client that more research needs to be done discounts the valuable information which is known.

The nurse is assessing the assigned client's level of consciousness during morning rounds. The nurse speaks the client's name, strokes the client's hand, and moves the client's shoulder. There is a delay, and then the client states, 'What do you want?' Which level of consciousness should the nurse document?

  • A. Conscious
  • B. Semicomatose
  • C. Somnolent
  • D. Stuporous
Correct Answer: C

Rationale: Somnolent or lethargy means that the client is drowsy or sleepy at inappropriate times. This is an improvement from the stuporous state, which includes arousing the client only with vigorous and repeated stimulation. A client that is conscious is alert and responds to stimulation immediately. A client is documented as semicomatose when the client only responds to superficial, relatively mild, painful stimuli.

The nurse scores the client's level of consciousness (LOC) using the Glasgow Coma Scale. Which score should indicate to the nurse that the client needs emergency attention?

  • A. A score of 9
  • B. A score of 11
  • C. A score of 12
  • D. A score of 15
Correct Answer: A

Rationale: A score of 9 indicates that the client needs emergency attention. Scores greater than or equal to 11 are considered within normal range.

A critical care nurse is documenting the assessment of a client. The client is status postresection of a brain tumor. The nurse documents that the client is flaccid on the left. This means that the client:

  • A. has an abnormal posture response to stimuli.
  • B. is not responding to stimuli.
  • C. is hyperresponsive on the left.
  • D. is hyporesponsive on the left.
Correct Answer: B

Rationale: Flaccidity is when the client has no motor response to stimuli. Flaccidity is a motor assessment.

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