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A diagnosis of a ruptured cerebral aneurysm has been made in a patient with manifestations of a stroke. The nurse anticipates which treatment option that would be considered for the patient?
- A. Hyperventilation therapy
- B. Surgical clipping of the aneurysm
- C. Administration of hyperosmotic agents
- D. Administration of thrombolytic therapy
Correct Answer: B
Rationale: Surgical clipping prevents further bleeding from a ruptured aneurysm
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To provide comfort to a client after a lumbar puncture, what step must the nurse take?
- A. Position the client flat for at least three hours or as directed by the physician.
- B. Keep the room well lighted and play some soothing music in the background.
- C. Help the client ambulate and perform a few light leg exercises.
- D. Provide some easy reading material to the client.
Correct Answer: A
Rationale: Flat positioning reduces the risk of post-lumbar puncture headache.
Nurse Peterson is reviewing her notes on various neurological conditions to prepare for an upcoming training session. She focuses on a chronic, degenerative, progressive disease of the central nervous system, notable for small patches of demyelination in the brain and spinal cord. Which disease is Nurse Peterson studying?
- A. Huntington's disease
- B. Parkinson's disease
- C. Creutzfeldt-Jakob's disease
- D. Multiple sclerosis
Correct Answer: D
Rationale: Multiple sclerosis is characterized by demyelination in the central nervous system, leading to a variety of neurological symptoms.
A patient with a spinal cord injury (SCI) complains about a severe throbbing headache that suddenly started a short time ago. Assessment of the patient reveals increased blood pressure (168/94) and decreased heart rate (48/minute), diaphoreses, and flushing of the face and neck. What action should you take first?
- A. Administer the ordered acetaminophen (Tylenol).
- B. Check the Foley tubing for kinks or obstruction.
- C. Adjust the temperature in the patient's room.
- D. Notify the physician about the change in status.
Correct Answer: B
Rationale: Checking the Foley tubing is critical as it could indicate autonomic dysreflexia, a life-threatening condition in SCI patients.
The healthcare provider is planning care for a patient diagnosed with multiple sclerosis (MS). Which of the following is the priority intervention?
- A. Advise the patient to drink liquids through a straw
- B. Monitor the patient's temperature to avoid overheating
- C. Teach the patient's family how to meet the patient's needs
- D. Encourage bed rest in order to conserve strength
Correct Answer: B
Rationale: Overheating can exacerbate MS symptoms, so monitoring temperature is a priority to prevent symptom flare-ups.
When assessing cranial nerve V (Trigeminal nerve), the nurse should:
- A. Test the sensation of the face and palpate the masseter muscles.
- B. Check the patient's ability to hear.
- C. Examine the patient's sense of smell.
- D. Assess the patient's swallowing ability.
Correct Answer: A
Rationale: Cranial nerve V (Trigeminal nerve) is responsible for facial sensation and mastication. Testing facial sensation and palpating the masseter muscles assess its function. Hearing, smell, and swallowing are assessed by other cranial nerves.