A patient is scheduled for an iodine-based diagnostic exam. Which patient condition requires the nurse to contact the health care provider immediately?
Allergy to seafood
For patients undergoing iodine-based diagnostic exams, the nurse must notify the provider immediately if the patient is allergic to shellfish, as shellfish contain iodine. Short-term memory loss, allergy to codeine, and claustrophobia would not affect the patient's ability to undergo iodine-based diagnostic testing.
A patient is admitted to the emergency department with frontal-temporal pain, preceded by a visual disturbance. The patient is upset and thinks it is a stroke. What does the nurse suspect may be occurring?
Classic migraine
The patient's symptoms match those of a classic migraine. Symptoms of a cluster headache include intense, unilateral pain occurring in the fall or spring and lasting 30 minutes to 2 hours. A tension headache is characterized by neck and shoulder muscle tenderness and bilateral pain at the base of the skull and in the forehead. Symptoms of a stroke include sudden, severe headache with unknown cause, facial drooping, sudden confusion, and sudden difficulty walking or standing.
What migraine medication should be avoided by a patient diagnosed with Prinzmetal's angina?
Rizatriptan
Rizatriptan is a triptan preparation and should be avoided in patients diagnosed with Prinzmetal's angina. Ibuprofen, verapamil, and acetaminophen are not contraindicated.
Which characteristic feature may be associated with the patient in stage I of Alzheimer's disease?
Decreased sense of smell
The symptoms associated with stage I of Alzheimer's disease include decreased sense of smell. The other features such as loss of facial recognition [Agnosia], loss of motor and verbal skills, and general and focal neurologic deficits are associated with the severe stage [Stage III] of Alzheimer's disease
A patient is frequently seen in the emergency department for severe headaches that typically involve unilateral, pulsating pain accompanied by nausea and sensitivity to light that begin when the patient has stress persisting for 2-3 days. Which type of headache does the nurse suspect in this patient?
Common migraine
Common migraines occur without an aura, which this patient does not have, and have symptoms typical of those described for this patient. Classic migraines have an aura preceding headache symptoms. Cluster headaches involve brief, intense, unilateral pain. Tension headaches involve muscles of the neck.
What finding is consistent with a status migrainous?
Headache lasting longer than 72 hours
Status migrainous is a headache that lasts longer than 72 hours. Sudden onset of headaches is associated with cluster headaches. Ischemic infarct would be noted in migrainous infarction. Neurologic symptoms that do not reverse are consistent with migrainous infarction.
What is the priority of care for the patient experiencing a migraine?
Pain management
The priority for care of the patient having a migraine is pain management. Prevention, safety, and diagnosis are important, but are not the priority.
When the patient is asked to stand with eyes closed, the patient sways back and forth. When the patient's eyes are opened, the swaying stops. Which term does the nurse use to document this finding?
Positive Romberg sign
Swaying with the eyes closed, but not open, is a positive Romberg sign. Dysarthria is difficulty speaking. Pronator drift occurs with muscle weakness when the arm on the weak side tends to fall, or "drift," with the palm pronating [turning inward] after the patient has closed the eyes and held the arms perpendicular to the body with the palms up for 15-30 seconds. Touch discrimination occurs when the patient identifies an object based on touch.
A patient with Alzheimer's disease is completely bedridden, has lost all motor and verbal skills, and cannot recognize family members. The nurse documents that the patient is in which stage of the disease?
III
A patient with stage III Alzheimer's disease is completely bedridden, totally dependent in activities of daily living, has lost motor and verbal skills, has generalized neurologic deficits, and has lost facial recognition. Those in stage I have mild cognitive impairments and symptoms. Those in stage II experience impairment of all cognitive functions, but still exhibit some functional abilities. There are only three classifiable stages of Alzheimer's disease.
Which test used for assessing the neurologic system involves the use of a contrast agent?
Cerebral angiography
Cerebral angiography uses a contrast medium to visualize blood circulation to the brain. EMG, EEG, and LP do not require the use of a contrast medium. EMG and EEG are electrical diagnostic tests. Lumbar puncture involves the aspiration of cerebrospinal fluid by inserting a needle into the arachnoid space.
The nurse assesses a patient who is suffering from dementia and metabolic disorders. Which diagnostic test will be most beneficial to assess the patient's condition?
Positron emission tomography [PET]
PET is an advanced technique and is most useful in determining the function of the brain, specifically glucose, and oxygen metabolism and cerebral blood flow. This test also detects metabolic abnormalities associated with dementia or other diseases. Cerebral angiography and a CT scan are not helpful in determining brain function. An MRI can also be used, but is not as efficient as a PET scan.
The nurse is preparing a diet plan for a patient with migraine headache. Which of these foods must be excluded from the chart? Select all that apply.
Meats
Fresh Breads
Smoked fishes
There are many food items that may trigger a migraine attack. The intake of meat increases the risk of migraine because it is a rich source of nitrates. The fresh breads are considered as a food with yeast; so patients with migraine should avoid consumption. The smoked fishes are also known to be a causative risk for migraine attack. Leafy vegetables and grapefruit would not trigger a migraine attack.
Which factors should the nurse identify as probable causes of worsening dementia? Select all that apply.
Impaired renal function
Impaired hepatic function
Impaired vision and hearing
Impaired renal and hepatic function has adverse effects on the central nervous system causing neurological and psychiatric disturbances and worsening dementia. Impaired vision and hearing will also worsen dementia. A static environment and an increase in blood supply do not affect dementia, although sudden environmental changes and decreased blood supply to the brain can worsen dementia.
A patient with a history of migraine headaches presents to the emergency room with vertigo and numbness of the lips. The patient reports seeing flashing lights. What phase of a migraine is the patient likely experiencing?
Prodrome phase
The prodrome phase of a migraine headache is when the patient develops an aura and experiences visual disturbances such as flashing lights and double vision, along with numbness or tingling of the lips. The second phase of the migraine is accompanied with nausea and vomiting; the third phase is when the throbbing pain begins to dull. The termination phase is when the intensity of the headache decreases.
Which antiepileptic medications are used in the treatment of migraine headaches? Select all that apply.
Divalproex
Topiramate
Divalproex and topiramate are both antiepileptic drugs used to treat migraine headaches. Butalbital, almotriptan, and dihydroergotamine are not antiepileptic medications.
What medications are indicated for prevention of migraine headaches? Select all that apply.
Ibuprofen
Verapamil
Propranolol
Ibuprofen, verapamil, and propranolol are all indicated for the prevention of migraine headaches. Eletriptan and sumatriptan are used for the treatment of severe headaches.
Which approaches are required to manage patients with Alzheimer's disease? Select all that apply.
Cognitive stimulation
Reminiscence therapy
Promoting communication
Cognitive stimulation and memory training help patients with Alzheimer's disease to reinforce desirable cognitive function and facilitate memory. Reminiscence therapy involves reminding the patient about memories of pleasant experiences. Promoting communication helps in better interaction with the patient. Environment relaxation may not be useful since the patient cannot recall their surroundings. Self-management such as enhanced physical activity should be encouraged in Alzheimer's patients.
Which assessment findings support the nurse's suspicion that a patient is in the third stage of Alzheimer's disease? Select all that apply.
Loss of facial recognition
Totally dependent regarding activities of daily living [ADLs]
Loss of facial recognition is observed in the late or severe stage of Alzheimer's disease, and patients become totally dependent regarding ADLs because they completely lose cognition. Decreased sense of smell is observed in the first or early stage of the disease. Wandering and trouble sleeping along with an increasing dependence on others for ADLs are characteristics of the middle or moderate stage of the disease.
Which information is most important for the nurse to communicate to the health care provider about a patient who is scheduled for cerebral angiography?
Poor skin turgor and dry mucous membranes
An assessment of poor skin turgor and dry mucous membranes indicates dehydration; to prevent contrast-induced nephropathy, angiography should not be done until the patient is hydrated. Allergy to penicillin, history of bacterial meningitis, and withheld metformin will need to be reported, but none indicate the need to intervene before the surgery.
In assessing the potential presence of bone erosion or dislocation in a patient, the nurse expects the provider to order which imaging assessment?
Skull x-ray
Plain skull x-rays are used to determine bony fractions, erosions, or dislocations. CT scans are used to evaluate neurologic problems such as edema or shifts of brain structure. Cerebral angiography is used to visualize cerebral circulation. MRI is used to determine abnormal brain anatomy.
A Glasgow Coma Scale is ordered on a patient. The nurse observes these signs and symptoms upon initial assessment: opens eyes to sound; localizes pain; confused conversation. What does the nurse record as this patient's Glasgow Coma Scale score?
12
The patient's Glasgow Coma Scale score is 12 because the patient receives 3 points for opening eyes in response to sound out of a possible 4, a score of 5 on motor response to localized pain out of a possible 6, and a score of 4 for verbal response of confused conversation out of 5. To score 15, the patient must respond with no deficiencies. A score of 8 would represent a near coma state.
While reviewing the results of a patient's lumbar puncture, the nurse notes the pressure was identified as greater than 25 cm H2O. Which interpretation of this finding is correct?
The level requires immediate surgical intervention
Cerebrospinal pressure that is greater than 20 cm H2O indicates increased pressure and possible intracranial hemorrhage. The finding is not low, normal, or slightly elevated.
What medications may be prescribed to a patient with mild migraine headaches? Select all that apply.
Naproxen
Acetaminophen
Naproxen and acetaminophen are the drugs indicated for mild migraine headaches. Rizatriptan, sumatriptan and ergotamine with caffeine are indicated for severe migraine headaches.
For the patient taking beta blockers or calcium channel blockers for migraine headache management, which teaching point should the nurse include in the treatment plan?
"Take your pulse rate daily and report bradycardia."
Calcium channel blockers and beta blockers can slow the heart rate significantly. The patient should monitor his or her pulse rate daily. The drugs do not cause muscle pain, nor do they deplete potassium, so there is no need to increase potassium intake or report muscle pain. Fluid does not need to be restricted to a level of less than 500 mL per day.
The nurse is assessing the verbal response of a patient on a Glasgow scale. What score does the nurse determine when the patient makes incomprehensible sounds?
2
The nurse gives a 2 rating for verbal response on the Glasgow Scale for the patient who makes incomprehensible sounds. The patient with no verbal response is rated as 1. The patient who uses inappropriate words while speaking is rated as 3. The patient who indulges in a confused conversation is rated as 4.
A patient is being discharged to home with progressing stage I Alzheimer's disease. The family expresses concern to the nurse about caring for their parent. What is the priority for best continuity of care?
Assigning a case manager
Whenever possible, the patient and family should be assigned a case manager who can assess their needs for health care resources and facilitate appropriate placement throughout the continuum of care. Ensuring all questions are answered and providing a safe environment are necessary for family support, but are not relevant for continuity of care. Referring the family to the Alzheimer's Association is necessary for appropriate resource referral, but is not relevant for continuity of care.
A patient with Parkinson disease is being discharged home with his wife. To ensure the success of the management plan, which discharge action is most effective?
Involving the patient and his wife in developing a plan of care
Involving the patient and spouse in developing a plan of care is the best way to ensure success. Home health nurse visitations are generally helpful, but may not be needed for this patient. Instructing the spouse about the patient's needs and providing the spouse with a written plan of care do not reinforce the spouse's involvement and buy-in with the management plan.
The nurse has just received change-of-shift report about a group of patients on the neurosurgical unit. Which patient does the nurse attend to first?
Middle-aged adult patient who had a cerebral aneurysm clipping and is increasingly stuporous
A change in level of consciousness [LOC] is an early indication that central neurologic function has declined; the neurologic status of this patient should be assessed and the health care provider notified about the change in status. The other patients are not the nurse's first priority. The young adult who is post-MVC does need to be assessed, but the patient's behavior does not indicate a decline in neurologic function. The postoperative left craniotomy patient and the older adult do need to be assessed, but these patients' neurologic assessment indicates better function.
A patient with a neurologic disorder has undergone a cerebral angiography. Which interventions does the nurse perform immediately after the procedure? Select all that apply
Check vital signs
Apply an ice pack to the site.
Keep the extremity immobilized.
Check pulses distal to the injection site
Cerebral angiography is performed to assess the circulation in the brain and the presence of a blockage in the blood vessels. Following the procedure, vital signs should be checked to assess the patient's stability. Ice packs should be applied to the site to prevent bleeding and reduce pain. The extremity should be immobilized to decrease the risk of bleeding. The pulses distal to the injection site should be checked. An absence of pulse indicates blockage of the blood vessels. The pressure dressing should be maintained for 2 hours to prevent bleeding.
A patient with dementia and Alzheimer's disease is discharged to home. The patient's daughter says, "He wanders so much, I am afraid he'll slip away from me." What resource does the nurse suggest?
Safe Return Program
The family should enroll the patient in the Safe Return Program, a national, government-funded program of the Alzheimer's Association that assists in the identification and safe, timely return of those with dementia who wander off and become lost. The Lost Family Members Tracking Association, National Alzheimer's Group, and Alzheimer's Wandering Association do not exist.
The nurse questions an order for a triptan preparation for migraine management when it is ordered for which patient?
50-year-old with a history of transient ischemic attacks
Triptans are contraindicated in patients with actual or suspected ischemic heart disease, cerebrovascular ischemia, hypertension, or peripheral vascular disease. Endometriosis, ulcerative colitis, or a history of breast cancer are not contraindications for triptan medications and should not be a cause of concern for the nurse.
A patient is scheduled for an electroencephalogram. What does the nurse teach the patient prior to the test?
Avoid central nervous system depressants.
The patient should avoid central nervous system depressants or stimulants prior to the test. The patient need not maintain NPO status the night before the test; food intake does not affect the results. However, the patient is asked to avoid caffeine-containing fluids on the day of the test as they interfere with the test results. During a positron emission tomography [PET] scan, the patient may be blindfolded and earplugs inserted during the test.
A 60-year-old woman presents to the emergency department with a new onset of headaches. The patient has had a migraine for 72 hours with photophobia. What diagnostic test does the nurse prepare the patient for?
Magnetic resonance imaging [MRI]
Magnetic resonance imaging is indicated to rule out stroke in a female patient older than 50 with migraine headaches and visual symptoms. Cardiac enzymes and an echocardiogram are not indicated. An electroencephalogram is not indicated at this time.
A patient with Parkinson's disease is scheduled for stereotactic pallidotomy. What are the steps in the correct order of their occurrence during the procedure?
Perform magnetic resonance imaging.
Place a stereotactic head frame.
Give intravenous sedation.
Insert an electrode into the target area.
Pass electric stimulation through the electrode.
The first step to be performed in stereotactic pallidotomy is to perform magnetic resonance imaging to identify the target area. The second step is to place a stereotactic head frame on the patient. Then intravenous sedation should be given as the third step. In the fourth step, an electrode should be inserted into the target area. Finally, electric stimulation should be passed through the electrode to access the patient's reaction for reduction of tremor and rigidity.
What medications are used for severe headaches? Select all that apply.
Rizatriptan
Dihydroergotamine
Rizatriptan and dihydroergotamine are both used for severe headaches. Butalbital, propranolol, and isometheptene are not indicated for severe headaches.
A patient with a history of migraines informs the nurse that she is trying to get pregnant. What teaching is priority?
The importance of stopping the prescribed sumatriptan
Sumatriptan should be stopped because the safety of use of this medication by pregnant women is not known. It is important to inform the patient that the pregnancy may be a trigger for migraines, but that is not the priority. Information on alternative and complementary pain relief should be provided in addition to the priority instruction to discontinue sumatriptan. Migraines may last longer than 24 hours, which is not an indication to call the health care provider.
Which statement is not applicable for Huntington's disease?
It is associated with an increased amount of dopamine levels.
Dementia is related to the obstruction of neurons, and it may be associated with excessive amounts of dopamine found within the cerebral cortex and limbic systems. Huntington's disease is a hereditary disorder transmitted as an autosomal dominant trait at the time of conception. The main symptoms of the disease are progressive mental and behavioral status changes leading to dementia and choreiform movements in the limbs, trunk, and facial muscles.
A patient newly diagnosed with Parkinson disease is being discharged. Which instruction is best for the nurse to provide to the patient's spouse?
Administer medications promptly on schedule to maintain therapeutic drug levels
Administering medications promptly on schedule is a correct statement. The patient should be encouraged to do as much as possible on his own. Slow speech rather than loud speech, and small, frequent meals are more effective for the patient with Parkinson disease.
A male patient is diagnosed with Huntington's disease. Which is the most appropriate advice that would help when the patient's wife asks about having children in the future?
You should avoid having biological child.
Huntington's disease is a single gene disorder caused by a mutation in the HD gene located on chromosome 4. The defective gene with one copy even with a single parent [either male or female] may cause this disease in the biological child. Therefore, couples should avoid having biological child if either parent is diagnosed. The advice of having a biological child without any risk may not be provided by the nurse to the patient. No treatment or cure has been found for this disease; therefore, providing vaccination to the biological child is not a solution. The patient receiving treatment with compliance may also not make the biological child safe from the disease.
Which assessment findings are consistent with cluster headaches? Select all that apply.
Ptosis
Rhinorrhea
Ptosis and rhinorrhea are assessment findings consistent with cluster headaches. Aphasia, drowsiness, and flashing lights are findings consistent with the prodromal phase of a migraine headache.
What actions does the nurse perform to assess the sensory function of a patient with a spinal cord problem? Select all that apply.
A cold reflex hammer is used to distinguish temperature.
The patient identifies sharp and dull touch in random sequence.
The patient is shown the object before the assessment.
Two places on the same extremity are touched with two objects.
The sensory function assessment is done to assess the patient's sensation of pain and temperature. A cold reflex hammer or a warm hand is used to distinguish temperature. The patient is asked to identify the touch of a sharp object such as a paper clip and the touch of a dull object such as a cotton-tipped applicator. The patient is shown the object before the assessment begins, so that the patient is aware of the object. The nurse tests the touch discrimination in a patient by touching two places on the same extremity with two objects at the same time. The patient is asked to identify the locations that were touched. During the test, the patient is expected to close the eyes and identify the location and object that was used.
The nurse is teaching a patient newly diagnosed with migraines about trigger control. Which statement made by the patient demonstrates good understanding of the teaching plan?
"It is okay to drink a few wine coolers.
Missing meals is a trigger for many people suffering from migraines. The patient should not skip any meals until the triggers are identified. Monosodium glutamate [MSG]-containing foods, alcohol, and artificial sweeteners are triggers for many people suffering from migraines and should be eliminated until the triggers are identified.
Which drug is prescribed to a patient to decrease the chorea associated with Huntington disease [HD]?
Tetrabenazine
The choreiform movements such as rapid, jerky movements in the limbs, trunk, and facial muscles are associated with HD. These symptoms may be decreased by the intake of tetrabenazine. Drugs such as felbamate and gabapentin may be prescribed for seizures. Rizatriptan is beneficial to treat headaches.
What tool is ideal to test cognitive changes related to Alzheimer's disease?
Mini-Mental State Examination
The Mini-Mental State Examination is widely used to effectively assess the cognitive changes related to Alzheimer's disease. It assesses five areas: orientation, registration, attention and calculation, recall, and speech-language. Brudzinski's and Kernig's signs are used in the diagnosis of meningitis. There is no such test as the Huntington's test.
A patient is intubated and cannot talk. What is the best possible Glasgow Coma score for this patient?
11t
As the patient cannot talk, the verbal response score will be 1, while the patient's motor response score would be 6 and the eye opening score would be 4. Therefore, the best possible normal score for this patient is 11t [t indicates that the patient cannot talk]. Scores of 5t and 7t indicate a comatose state. A 15t score is not possible as the verbal response is absent.
A patient has received contrast medium. Which teaching does the nurse provide to avoid any neurologic health problems after the procedure?
"Drink at least 1000-1500 mL of water today."
Drinking an adequate amount of water helps flush the contrast out of the body. Bedrest and practicing memory drills are not effective precautions after the use of contrast medium. Sunlight does not affect contrast medium.
Which question does the nurse ask a patient when assessing the patient's long-term memory?
"Where did you attend high school?"
Assessment of long-term memory is best assessed by asking the patient questions from their long-term past. The only question that meets this definition is, "Where did you attend high school?" The other three questions evaluate short-term memory.
Which assessment strategy does the nurse use to assess the function of cranial nerve VII?
Asks the patient to raise the eyebrows and grimace or puff the cheeks.
CN VII controls facial expressions and symmetry of the facial features. CN VI moves the eyes in all six directions. CN IX [glossopharyngeal nerve] controls swallow and gag reflexes and supplies some taste. CN XII allows skeletal movement of the tongue.
What is the goal of abortive therapy in migraine headaches?
Alleviating pain during the aura phase
The goal of abortive therapy in migraine headaches is to alleviate pain during the aura phase. Abortive therapy is not meant to identify triggers, prevent reoccurrence, or decrease pain during the second phase
A patient with Parkinson disease is undergoing a stereotactic pallidotomy. The patient has no reduction of tremor and rigidity on receiving a mild electrical stimulation on the target area within pallidum. Which intervention would be beneficial in this situation?
Repositioning the probe
Stereotactic pallidotomy is the option when drugs cannot effectively manage the symptoms of Parkinson disease. In this surgery, the target area within the pallidum receives a mild electrical stimulation when an electrode or cylindrical rod is inserted into it. If the patient shows no response in reduction for tremor and rigidity, then the probe is repositioned. The patient is monitored for 1 hour in the postanesthesia care unit once the surgery is performed. A lesion is made for the tissue destruction, once the probe is positioned at the ideal location. A burr hole is made into the cranium for the insertion of the electrode into the target area.
Which teams are involved in the care of a patient with Huntington's disease? Select all that apply.
Dietitian
Family members
Speech-language pathologist [SLP]
Physical and occupational therapists
The dietitian plans meals based on the SLP's recommendations and the patient's likes and dislikes. The family members work with the health care team to provide care for the patient. The SLP helps with communication, swallowing, and drooling. The physical and occupational therapists determine exercise conditioning and assistive devices. Pharmacists are not included in the care team for the patient with Huntington's disease.
Which statements by a student nurse regarding the drugs used to treat Parkinson's disease indicate effective learning? Select all that apply.
"Benztropine should be avoided in older patients."
"Entacapone should not be taken with cheese and red
wine."
"Apomorphine causes orthostatic hypotension and drowsiness."
Anticholinergic drugs such as benztropine should be avoided in older patients because they can cause side effects such as acute confusion, urinary retention, constipation, dry mouth, and blurred vision. Monamine oxidase type B [MAO-B] inhibitors [MAOIs] such as entacapone and rasagiline mesylate should not be taken with food and beverages that contain tyramine to prevent severe headache and life-threatening hypertension. Dopamine agonists such as apomorphine and pramipexole are associated with adverse effects such as orthostatic [postural] hypotension, hallucinations, and sleeplessness. Sinemet should be given before meals to increase absorption and transport across the blood-brain barrier. Apomorphine should not be taken with cheese and red wine to avoid severe headaches and life-threatening hypertension.
Which symptoms define the manifestations of the prodrome phase of migraine headache? Select all that apply.
Aura
Visual disturbances
Unilateral weakness
In the first, or prodrome, phase of migraine, the patient may experience an aura; visual disturbances such as flashing lights, lines, or spots; and unilateral weakness. Nausea occurs in the second and third phases. Tinnitus is not a symptom of migraine. During the third phase, pain changes from throbbing to dull.
A patient was prescribed a drug after complaining about unilateral, pulsating headache that was aggravated by routine physical activities, especially in the presence of light, and lasted for 2 days. Which drug in the prescription makes the patient complain about rebound headache after administration?
Frovatriptan
Frovatriptan relieves migraine headache by its vasoconstrictive effect on the cranial arteries, the basilar artery, and the blood vessels of the dura mater. This drug has a potential side effect of causing rebound headache. In this condition, another headache occurs after the initial migraine is relieved. The other drugs such as verapamil, topiramate, and divalproex are associated with adverse effects such as confusion, drowsiness, and dizziness, respectively.
What interventions should the nurse follow while taking care of a patient with Parkinson's disease? Select all that apply.
Give extra time for response to questions
Monitor for side effects of prescribed medications.
Collaborate with physical and occupational therapists
The nurse should follow certain interventions while taking care of a patient with Parkinson's disease. The patient should be given enough time to respond after being asked a question. Side effects of medications are common and should be monitored. The nurse should collaborate with physical and occupational therapists to keep the patient as mobile and as independent as possible. The patient should be provided high-protein, high-calorie foods to maintain body weight. The nurse should monitor the patient while eating and swallowing to avoid aspiration.
A patient experiences frequent headaches, and the nurse suggests that the patient maintain a headache diary. What is the primary purpose the nurse would recommend keeping a headache diary? Select all that apply.
To determine the effectiveness of the prescribed drugs
To assess headache symptoms and identify the type of headache
To identify the presence of any unusual changes associated with the headache
Headache diaries or journals allow the patient to document each headache to help the healthcare provider determine the type of headache on the basis of the patient's symptoms, determine the effectiveness of prescribed drugs, and identify any unusual changes associated with the headaches. A headache diary is not intended as a creative release or to take the patient's mind off the headache symptoms.
A patient has come to the emergency department following a motor vehicle crash. In which order does the nurse perform the following actions to determine the patient's level of consciousness [LOC]?
Ask questions in a normal voice.
Ask
questions in a loud voice.
Shake the patient gently.
Use painful or vigorous stimuli.
In order to determine LOC, the nurse should first ask the patient some questions in a normal voice. It helps in determining if the patient is alert or lethargic. If the patient does not respond, then questions should be repeated in a loud voice. If there is no response, the nurse should then shake the patient gently. If patient is unresponsive, some vigorous or painful stimuli [e.g., supraorbital pressure, trapezius muscle squeeze] can be used. If patient does not respond to any of the stimuli, it suggests that the patient is unconscious and emergency interventions are needed.
In assessing a patient who is unconscious, what care does the nurse take when applying painful stimuli using the sternal rub?
Use the sternal rub if the patient does not respond to mandibular pressure
The sternal rub should be used when the patient does not respond to mandibular pressure. Sternal rub is not applied for more than 20 to 30 seconds and is not applied to older adults or patients who bruise easily because the tissue in the area of the sternum is tender and bruises easily. The nurse should first apply supraorbital pressure to determine response to painful stimuli. If the patient does not respond, a trapezius muscle squeeze should be attempted. On failure to respond to this, the nurse applies mandibular pressure. The sternum rub is the last effort to obtain response to painful stimuli.
While reviewing a patient's chart from the previous shift, the nurse reads the phrase, "The patient continues to demonstrate decorticate posturing." From this entry, what does the nurse expect the patient to exhibit?
Clenched fists and arms bent in toward the body, with wrists and fingers held on the chest
Decorticate posturing is an indication of brain deterioration and is manifested by the classic signs of clenched fists and arms bent in toward the body. Tonic-clonic activity describes a jerking motion. Patients experiencing decorticate activity would not be able to respond to questions by blinking and will have movement below the waist.
The results of a patient's lumbar puncture indicate that the patient's protein level is 150 mg/dL. The nurse suspects that the patient may have which condition?
Viral infection
Protein levels of 50-200 mg/dL are indicative of a viral infection. A protein level greater than 500 mg/dL is indicative of a bacterial infection or Guillain-Barré syndrome. A protein level less than 15 mg/dL is indicative of meningismus. Protein levels of 45-100 mg/dL are indicative of a paraventricular tumor.
The wife of a patient with Alzheimer's disease mentions to the home health nurse that although she loves him, she is exhausted caring for her husband. What does the nurse suggest to alleviate caregiver stress?
Arranges for respite care
Respite care can give the wife some time to reenergize and will provide a social outlet for the patient. Providing positive reinforcement and support is encouraging, but does not help the wife's situation. Restraints are almost never appropriate and are used only as an absolute last resort. The patient with Alzheimer's disease typically is unable to learn improved self-care.
The nurse is using auditory-evoked potentials to assess a patient. What is this technique meant to detect?
High-frequency hearing loss
Auditory-evoked potentials [also called brainstem auditory evoked response] are used to assess high-frequency hearing loss, diagnose any damage to the acoustic nerve and auditory pathways in the brainstem, and detect acoustic neuromas. Visual-evoked potentials detect loss of vision from optic nerve damage. Somatosensory-evoked potentials measure response from stimuli to the peripheral and can detect nerve or spinal cord damage or nerve degeneration from degenerating diseases.
Which time frame accurately describes the typical duration of a cluster headache?
1-2 hours
Cluster headaches are brief, lasting 30 minutes to 2 hours, and are classified as the most common chronic short-duration headache with pain lasting less than 4 hours. Time frames of longer than 4 hours would not describe a cluster headache.
How does the nurse test pain and temperature sensation in the patient? Select all that apply.
Test for one sensation is sufficient.
Test for pain sensation
with the help of sharp or dull objects.
Test for temperature sensation with the help of a cold reflex hammer.
As pain and temperature sensations are transmitted by the same nerve endings, testing for one sensation is sufficient. To test for pain sensation, dull and sharp objects are randomly used. If the patient correctly identifies the stimulus, further testing is required. Temperature sensation can be tested by using either a cold reflex hammer or the warm touch of a hand. Testing all parts of the extremities is not necessary unless a spinal injury has occurred.
Which statement accurately describes the benefits of oxygen therapy for cluster headaches?
It decreases cerebral blood flow and inhibits activity of carotid bodies
Oxygen reduces cerebral blood flow and inhibits activity of the carotid bodies, decreasing vasoactive responses. Although oxygen therapy would increase oxygen saturation, this does not alleviate the headache. Ptosis is not relieved by oxygen therapy; it is due to pressure on nerves. Oxygen administration may decrease the heart rate and improve cardiac output, but this outcome is independent from reducing cluster pain.
A patient receiving sumatriptan for migraine headaches is experiencing adverse effects after taking the drug. Which adverse effect is of greatest concern to the nurse?
Chest tightness
Triptan drugs are contraindicated in patients with coronary artery disease because they can cause arterial narrowing. Patients taking triptan drugs should report angina or chest discomfort to prevent cardiac injury associated with myocardial ischemia. Skin flushing, tingling feelings, and a warm sensation are common adverse effects with triptan medications and are not indications to avoid using this group of drugs.
In assessing a patient using a reflex hammer, the nurse places a thumb in the patient's antecubital space and strikes it with the hammer. The patient's forearm and wrist rise. The nurse notes an appropriate response of which reflex?
Biceps
The biceps reflex is assessed by placing the thumb in the antecubital space and striking the thumb with a reflex hammer. The brachioradialis reflex is assessed by striking the upper wrist area with hammer while holding the elbow. The patellar reflex is assessed by striking the knee with a hammer. The triceps reflex is assessed by striking the elbow while gripping the forearm.
What is the nurse's best response to a patient with moderate Alzheimer's disease who asks the nurse to find her daughter?
"Tell us more about what she looks like."
A patient with moderate dementia may have difficulty in recalling people's faces and names, which increases the importance of effectively communicating with the patient. Gently gathering information about the daughter by asking questions that require a "yes" or "no" answer will help in identifying the patient's daughter. Any other responses given by the nurse such as promising to call the daughter later, telling the patient that the daughter went home, or that the daughter is not feeling well would only serve to confuse the patient.
A patient with a history of migraines will begin therapy with triptan drugs. Which information does the nurse include in patient teaching? Select all that apply
"Begin the drug therapy as soon as migraine symptoms develop."
"Report chest pain immediately."
"Female patients should use a form of birth control."
"Flushing and a feeling of being hot are to be expected."
Migraine drug therapy should begin as soon as symptoms of migraine are noted. Chest pain may indicate angina and should be reported immediately. Triptan drugs may not be safe for pregnant women and some form of contraception should be used. Common side effects to expect are flushing, tingling, and a hot sensation; these annoying sensations tend to subside after the patient's body gets used to the therapy. The concurrent use of SSRI antidepressants with triptan therapy is contraindicated. Discoloration of body fluids does not occur with triptan drugs.
A patient is experiencing cluster headaches involving ipsilateral tearing of the eye with ptosis and rhinorrhea. What does the nurse teach this patient about managing this disorder?
Wear sunglasses during periods of attacks
To prevent photophobia, patients should be taught to wear sunglasses and to sit facing away from windows during headache attacks. They should avoid alcohol during headache attacks, but alcohol does not precipitate headaches during times of remission. Medications, such as triptans, beta-blockers, and calcium channel blockers, are used to treat cluster headaches. Ptosis may become permanent, although the other symptoms usually abate.
The nurse is teaching a patient about preparing for an electroencephalogram [EEG]. Which instruction by the nurse is correct?
"Wake at 2:00 the morning of the EEG and remain awake until time for the test.
The patient undergoing an EEG must be sleep-deprived and should wake at 2:00 or 3:00 in the morning, and stay awake for the remainder of the morning. The patient should wash his or her hair on the morning of the EEG and should avoid caffeine or other CNS stimulants or depressants. The electrical activity of the brain is recorded, but current does not pass through the brain.
A patient is ordered to undergo a brain biopsy. In which order does the patient undergo the steps of the procedure?
A CT scan or MRI is performed.
A local anesthetic is injected into the scalp.
A small hole is drilled through the skull.
A hollow needle is inserted into the site of the lesion.
A CT scan or MRI is performed before a brain biopsy. This procedure involves injection of a local anesthetic into the scalp, drilling a small hole through the skull, and inserting a hollow needle into the site of the lesion. The brain biopsy samples are then analyzed under a microscope to identify abnormalities.
How would the nurse promote communication with a patient who is in the last stage of Alzheimer's disease?
Provide instruction with pictures
The nurse should promote communication with the patient in the last stage of Alzheimer's disease by providing instructions with pictures. The nurse should ask the patient direct questions, not indirect questions. The nurse should use clear gestures to help communicate with the patient. To facilitate easy and effective communication, the nurse should never assume that the patient is confused.
The nurse is assessing the cerebral motor integrity of a patient with muscle weakness. Arrange the steps of the assessment in the order in which they are performed
Ask
the patient to close the eyes.
Hold the arms perpendicular to the body.
Keep the palms up for 15 to 30 seconds.
The arm on the weak side falls with the palm pronating.
The patient is first asked to close the eyes. Then the arms are held perpendicular to the body with the palms up for 15 to 30 seconds. The arm on the weak side falls with the palms pronating or turning inwards. This pronator drift is caused when there is a cerebral or brainstem problem affecting the muscles.
A patient with Parkinson disease [PD] has bilateral limb involvement, masklike face, and slow, shuffling gait. Which stage of Parkinson disease does the nurse suspect in this patient?
Mild stage
The diagnosed manifestations in the patient such as bilateral limb involvement, masklike face, and slow, shuffling gait are the key features of the mild stage of PD. The initial stage includes manifestations such as unilateral limb involvement and hand and arm trembling in the patient. The severe disability stage of PD includes akinesia and rigidity in the patient. The postural instability and increased gait disturbances are considered as manifestations of the moderate disease stage of PD.
The primary health care provider prescribes tetrabenazine for the treatment of Huntington's disease [HD]. Which side effect of the drug is most important for the patient and family to be aware of before beginning the medication?
Depression
Tetrabenazine is prescribed to decrease chorea associated with HD. In some patients, it may increase the risk for suicidal ideation and depression. Sleeplessness is associated with tetrabenazine. Nausea and vomiting are common side effects of any drug used in the treatment of neurogenetic disorders. Patients using tetrabenazine suffer from decreasing appetite.
The nurse is assessing an older adult patient with a neurologic disorder. Which questions does the nurse ask to test the patient's remote memory? Select all that apply.
What is the name of the city where you were born?
"What is your date of birth?"
"What are the names of the schools you attended?"
In order to test a patient's remote, or long-term, memory, the nurse should ask about anything from the past, such as the date or city of the patient's birth, or the names of schools that the patient attended. This information can be verified from either hospital records or by checking with other family members. Asking about the name of the patient's health care provider or present home address is beneficial to test the patient's recent memory.
A patient has undergone single-photon emission computed tomography [SPECT]. Which instruction does the nurse give the patient?
"Return to your usual activity."
Patients who have undergone SPECT can return to their usual activities immediately after the test. Ice packs may be used by patients who have undergone cerebral angiography. Asking the patient to call if they have itching may be a typical instruction for a contact allergy, but not in this situation. The head of the bed should be kept flat for patients who have undergone a lumbar puncture.
A patient has chorea, poor balance, explosive speech, and dysphagia. Altered mental status such as poor judgment, and memory loss with dementia was also reported. The nurse instructs the patient's family to report early signs of depression in the patient after the drug administration. Which drug is prescribed for the patient?
Tetrabenazine
The manifestations of the patient are characteristic of Huntington's disease [HD]. It is a single gene disorder caused by a mutation in the HD gene located on chromosome 4. The patient may be prescribed Tetrabenazine for HD treatment, and this drug may cause depression as a side effect. The other drugs such as sinemet, amantadine, and rivastigmine may not be associated with depression. Sinemet is a levodopa-carbidopa combination and indicated in Parkinson Disease [PD] patients. Amantadine is an antiviral drug with anti-Parkinson effects. Rivastigmine is a cholinesterase inhibitor that is used in patients with PD having dementia.
A patient is prescribed dihydroergotamine for relief of a migraine headache. What medications should the nurse assess the patient for prior to giving this medication?
Sumatriptan
Patients taking dihydroergotamine should not take it within 24 hours of taking a triptan drug, such as Sumatriptan. Ibuprofen, verapamil, and propranolol will not affect the administration of dihydroergotamine.
A female patient with newly diagnosed migraines is being discharged with a prescription for sumatriptan. Which comment by the patient indicates an understanding of the nurse's discharge instructions?
"I must report any chest pain right away."
Chest pain must be reported immediately with the use of sumatriptan. Sumatriptan must be taken as soon as migraine symptoms appear. Remind the patient to use contraception [birth control] while taking the drug because it may not be safe for women who are pregnant. Triptans should not be taken with selective serotonin reuptake inhibitors [SSRIs] or St. John's wort, an herb used commonly for depression.
What nursing intervention is priority for a patient experiencing a migraine headache?
Pain management
Pain management is a priority intervention when caring for a patient with a migraine headache. Reduction of stimuli is important, but pain reduction is more important. Determining the trigger is important, but not the priority. Prevention of further headaches is not important at this time.
A patient is undergoing an assessment of the reflexes. What do hyperactive reflexes possibly indicate?
Tetanus
Hyperactive reflexes may indicate tetanus or an upper motor neuron disease. It may result from a spinal cord injury. Asymmetrical reflexes may indicate a disease process, including seizures. Abnormalities in motor functions can be an indicative of multiple sclerosis. Reflex activity is not affected by meningitis; the main symptoms of this disease include high fever and headache.
What instructions should the nurse provide to the family members of a patient with Alzheimer's disease? Select all that apply.
Reminisce about pleasant experiences from the past
Keep environmental distractions and noise to a minimum.
Remove or cover any abstract painting or wallpaper when the patient becomes frightened.
In Alzheimer's disease, the family members of the patient should reminisce about pleasant experiences from the past to improve the patient's memory and help in recall. Environmental distracters and noises should be minimized to reduce disturbance to the patient. If the patient becomes frightened when seeing any abstract painting or wallpaper, the family members should remove or cover it to reduce patient's fear. The family members should keep familiar items in the patient's room to help the patient's memory. Pictures of family members and close friends with names should be shown to help the patient's memory.
The nursing instructor asks the student nurse caring for a patient with Alzheimer's disease who has been prescribed donepezil how the drug works. Which response by the nursing student best explains the action of donepezil?
It delays the destruction of acetylcholine by acetylcholinesterase.
By delaying the destruction of acetylcholine, donepezil improves cholinergic neurotransmission in the central nervous system [CNS], thus delaying the onset of cognitive decline in some patients. Donepezil is not a serotonin reuptake inhibitor. It is a cholinesterase inhibitor and does not work on the protein beta amyloid, nor does it work on dopamine receptors.
The nurse is preparing a patient for a cerebral angiography. What actions does the nurse take? Select all that apply.
Determine if the patient is allergic to shellfish or iodine
Notify the health care provider if the patient is at risk for nephropathy
Check the patient's creatinine level
before the procedure
An iodine contrast agent is used for the procedure, so the nurse must determine if the patient is allergic to shellfish or iodine. The nurse assesses the patient for the risk of contrast-induced nephropathy; risk factors include pre-existing renal disease, diabetic nephropathy, heart failure, or dehydration. The patient's creatinine level is checked before the procedure because patients with a creatinine level greater than 1.5 mg/dL are at risk for contrast-induced nephropathy. The patient is not sedated, but given medication for relaxation. The head is immobilized and the patient is asked to avoid body movements during the procedure.
Which clinical manifestation should the nurse assess for in a patient in the prodrome phase of migraine headache?
Food craving
The manifestation of food craving appears in the prodrome phase of migraine headache. The patient with fatigue and developing muscle pain is a manifestation of the postprodrome phase. The appearance of double vision is associated with the aura phase.
A patient has been diagnosed with Huntington disease [HD]. The nurse is teaching the patient and her parents about the genetic aspects of the disease. Which statement made by the parents demonstrates a good understanding of the nurse's teaching?
"If she has children, she'll pass the gene on to her kids."
An autosomal dominant trait with high penetrance, such as HD, means that a person who inherits just one mutated allele has an almost 100% chance of developing the disease. Only one defective gene is needed to inherit HD. The patient could have inherited it from her father or mother. If the patient inherited the gene from her mother, she would live a longer life than other people with the disease. If she inherited the gene from her father, her life would be shorter. Additional testing is not necessary. If the patient has HD, then the patient has the gene.
A patient with Alzheimer's disease may have dysfunction of some parts of the brain. Which change may be noticed when there is impairment of the frontal lobe?
Inability to make decisions
An inability to make decisions may be due to impairment of the frontal lobe. Temporal and parietal dysfunction may cause apraxia, that is, an inability to use words or objects correctly. Aphasia is an inability to speak or understand. Anomia is an inability to find words.
A patient presents to the emergency department complaining of a headache and vomiting. What phase of migraine is the patient experiencing?
Second phase
A patient in the second phase of a migraine tends to have nausea and vomiting with a headache. The first phase [prodrome] is usually when the aura precedes the headache. In the third phase, the headache becomes dull. The termination phase is when the intensity decreases.
What medications should the nurse assess for after a patient has developed a rebound headache? Select all that apply.
Eletriptan
Sumatriptan
Isometheptene
Ergotamine with caffeine
Eletriptan, sumatriptan, isometheptene, and ergotamine with caffeine can all cause rebound headaches in patients that have taken these medications for a migraine. Ibuprofen and acetaminophen are not associated with rebound headaches.
A patient arrives at a hospital with a caretaker who reports loss of memory and thinking skills. Which medication is likely to be helpful?
Memantine
Memantine is indicated for advanced Alzheimer's disease [AD] and has been shown to slow the pace of deterioration. This drug helps maintain a patient's functioning ability for a bit longer than other therapies and has been shown to enhance memory and thinking skills in some patients. Sertraline and paroxetine are selective serotonin reuptake inhibitors used to treat depression in patients with AD. Amitriptyline is a tricyclic antidepressant and should not be used in AD patients due to its anticholinergic effect, especially in older adults.
A patient with severe symptoms of Parkinson disease is prescribed sinemet. Which instruction does the nurse include while teaching the patient's family about the drug administration?
Give the drug before the meals.
Sinemet may be the initial drug of choice for the patient with severe symptoms of Parkinson disease. The patient who is prescribed sinemet must take the drug before meals to increase absorption and transport across the blood-brain barrier. The other instructions such as taking the drug before sleeping, after meals, or after waking up in the morning may not be beneficial for administration of sinemet.
Which drug would be prescribed to reduce depression in a patient with Alzheimer's disease?
Paroxetine
Paroxetine is an antidepressant drug, which is used in the treatment of depression in patients with Alzheimer's disease. Donepezil is a cholinesterase inhibitor, which acts on the acetylcholinesterase enzyme. It helps to slow the onset of cognitive decline in some patients. Memantine is an N-methyl-aspartate receptor antagonist, which helps improve memory and thinking skills. Amitriptyline is a tricyclic antidepressant drug, but it is avoided in patients with Alzheimer's disease because of its anticholinergic effects.
A patient presents to the emergency department with a severe migraine headache. What lab value is consistent with a known trigger for migraine headaches?
Blood sugar of 60 mg/dL
A blood sugar of 60 would indicate that the migraine might have come from hypoglycemia. The hCG level indicates that there is no pregnancy, which would not affect migraines. The potassium of 3.5 mEq/L is normal. Hypoglycemia is a known trigger of migraines. The elevated white blood cell count would not likely affect migraines.
A nurse is teaching a patient scheduled to undergo an electroencephalogram [EEG]. Which action of the patient implies a good understanding about the instructions?
Avoids any caffeine-containing beverages on the day of the test
Caffeine-containing fluids should be avoided as they may interfere with the test results. The patient's hair should be thoroughly washed with shampoo and water to avoid false results due to contamination. Central nervous system stimulants and depressants must be avoided; these agents alter brain activity and lead to incorrect information.