Nokea
A young male client visits a nurse with a complaint of chronic tension headaches. Which of the following is the most appropriate nursing instruction to manage the client?
- A. Instructing the client to monitor for signs of bruising or bleeding
- B. Suggesting eating and swallowing techniques that reduce the potential for aspiration
- C. Counseling on alternate therapies
- D. Advising the client to change sleeping positions frequently
Correct Answer: C
Rationale: Alternate therapies, such as relaxation techniques, can help manage tension headaches.
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There are ________ layers of meninges around the brain and spinal cord.
- A. one
- B. two
- C. three
- D. four
Correct Answer: C
Rationale: The brain and spinal cord are protected by three layers of meninges: the dura mater, arachnoid mater, and pia mater. These layers provide structural support, cushioning, and protection against physical injury. The dura mater is the outermost layer, the arachnoid mater is the middle layer, and the pia mater is the innermost layer. Therefore, three is the correct answer as it accurately describes the number of meningeal layers.
After talking with the health care provider, the patient asks what the blood-brain barrier does. What is the best description that the nurse can give the patient?
- A. Protects the brain from external trauma
- B. Protects against harmful blood-borne agents
- C. Provides for flexibility while protecting the spinal cord
- D. Forms the outer layer of protective membranes around the brain and spinal cord
Correct Answer: B
Rationale: The blood-brain barrier protects the brain against harmful substances in the blood.
What is the priority nursing diagnosis for a patient experiencing a migraine headache?
- A. Acute Pain related to biologic and chemical factors
- B. Anxiety related to change in or threat to health status
- C. Hopelessness related to deteriorating physiological condition
- D. Risk for Side Effects related to medical therapy
Correct Answer: A
Rationale: Migraine headaches are primarily characterized by severe pain, making Acute Pain the priority.
A patient says, I know I have a brain tumor despite the results of the magnetic resonance image (MRI). The radiologist is wrong. People who have brain tumors vomit, and yesterday I vomited all day. Which response by the nurse fosters cognitive restructuring?
- A. You do not have a brain tumor. The more you talk about it, the more it reinforces your illogical thinking.
- B. Let's see whether any other explanations for your vomiting are possible.
- C. You seem so worried. Let's talk about how you're feeling.
- D. We should talk about something else.
Correct Answer: B
Rationale: The correct answer is B because it encourages the patient to consider alternative explanations for their symptoms, which is key in cognitive restructuring. By exploring other possible reasons for the vomiting, the patient is guided to challenge their automatic assumption of having a brain tumor. This approach helps the patient to reevaluate their thoughts and beliefs in a more rational manner.
Choices A, C, and D are incorrect:
A: This response dismisses the patient's concerns without addressing the underlying irrational belief. It does not promote cognitive restructuring.
C: While acknowledging the patient's emotions is important, this response does not actively challenge the patient's irrational belief or encourage critical thinking.
D: Changing the subject does not address the patient's cognitive distortions and does not facilitate cognitive restructuring.
Which patient should be assigned to the traveling nurse, new to neurologic nursing care, who has been on the neurologic unit for 1 week?
- A. A 34-year-old patient newly diagnosed with multiple sclerosis (MS)
- B. A 68-year-old patient with chronic amyotrophic lateral sclerosis (ALS)
- C. A 56-year-old patient with Guillain-Barré syndrome (GBS) in respiratory distress
- D. A 25-year-old patient admitted with C4 level spinal cord injury (SCI)
Correct Answer: A
Rationale: A newly diagnosed MS patient would likely have stable conditions and be appropriate for a less experienced nurse.