NCLEX - NERVOUS SYSTEM Day2 (Part 1)

A client with Alzheimer disease is found wandering in the middle of the street at 3 AM and is returned home by police. The community health nurse teaches the client's family members about measures to keep the client safe at home. What is the most important strategy for the nurse to include in the instruction to prevent wandering?

• Ensure that the family members never leave the client alone
• Install a door sensor to alert the family members if the client leaves the home
• Notify neighbors and local authorities of the client's tendency to wander
• Place a safe return bracelet on the client's nondominant hand

Answer explanation

Option 1: Ensure that the family members never leave the client alone

Option 2: Install a door sensor to alert the family members if the client leaves the home

Option 3: Notify neighbors and local authorities of the client's tendency to wander

Option 4: Place a safe return bracelet on the client's nondominant hand

Correct Option: 2

Explanation: Alzheimer disease (AD) is an irreversible, progressive form of dementia that destroys memory and cognitive functions. AD has a gradual onset and is often accompanied by neuropsychiatric symptoms (eg, agitation, aggression, delusions, hallucinations) as the disease progresses. Many clients experience worsening of these symptoms during the late afternoon and evening (ie, sundowning), which can cause them to wander. The most effective strategy to prevent wandering outside of the home is to make modifications that secure the environment. A preventive method to create a safe and secure environment for clients with AD is to install a door sensor to alert family members if the client leaves the home. Other interventions include providing an enclosed, safe area for wandering and maintaining a structured schedule to reduce confusion (Option 2). (Option 1) Clients with AD should not be left alone; however, it is impossible for any family member to watch the client every minute of the day. Clients with AD can easily leave the home while the family member is sleeping. (Option 3) Notifying neighbors and local authorities of wandering behaviors can be helpful if the client leaves the residence. However, this will not prevent wandering. (Option 4) Safe return or identification bracelets are important, but they will not prevent wandering.

The home health nurse teaches a client with dysphagia some strategies to help limit repeated hospitalizations for aspiration pneumonia. Which client statement indicates a need for further teaching?

• I should raise my chin slightly upward when swallowing food.
• I should sit upright for at least 30-40 minutes after every meal.
• I should swallow two times before taking another bite of food.
• I will avoid taking over-the-counter cold medications when sick.

Answer explanation

Option 1: I should raise my chin slightly upward when swallowing food.

Option 2: I should sit upright for at least 30-40 minutes after every meal.

Option 3: I should swallow two times before taking another bite of food.

Option 4: I will avoid taking over-the-counter cold medications when sick.

Correct Option: 1

Explanation: Aspiration pneumonia develops when aspirated material (eg, food, emesis, gastric reflux) causes an inflammatory response that promotes bacterial growth. Client conditions that increase the risk for aspiration pneumonia include cognitive changes (eg, dementia, head injury, stroke, sedation), difficulty swallowing (ie, dysphagia), compromised gag reflex, and tube feeding. Dysphagia increases the risk for aspiration of oropharyngeal secretions, gastric content, food, and/or fluid into the lungs. Positioning the chin slightly downward toward the neck (chin-tuck) when swallowing can be effective in clients with dysphagia because it facilitates closure of the epiglottis which helps prevent tracheal aspiration (Option 1). (Option 2) Sitting upright for at least 30-40 minutes after meals allows gravity to move food or fluid through the alimentary tract, which decreases gastroesophageal reflux and helps decrease aspiration risk. (Option 3) Swallowing twice before taking another bite of food helps the client clear food from the pharynx and aids in preventing food aspiration. (Option 4) Clients at risk for aspiration pneumonia should avoid over-the-counter cold medications due to anticholinergic properties, which can cause decreased saliva (ie, xerostomia) production, and dry mouth. Saliva is a lubricant that helps bind food together to facilitate swallowing.

The nurse is talking with a client who is scheduled for a lumbar puncture. Which of the following statements by the client would require follow-up?

• I will need to lie on my stomach during the procedure.
• I should go to the bathroom to urinate before the procedure.
• I understand that a needle will be inserted between the bones in my lower spine during the procedure.
• I may experience a sharp pain radiating down my leg during the procedure, but it should pass quickly.

Answer explanation

Option 1: I will need to lie on my stomach during the procedure.

Option 2: I should go to the bathroom to urinate before the procedure.

Option 3: I understand that a needle will be inserted between the bones in my lower spine during the procedure.

Option 4: I may experience a sharp pain radiating down my leg during the procedure, but it should pass quickly.

Correct Option: 1

Explanation: A lumbar puncture is a diagnostic procedure that involves insertion of a needle into the vertebral space to collect cerebrospinal fluid (CSF) for analysis of color, content, and pressure. The procedure is performed with the client in a sitting or left side-lying position with the knees drawn up (ie, fetal position), not the prone position (Option 1). These positions help widen the space between the vertebrae and allow easier insertion of the needle. (Option 2) The nurse should instruct the client to void before a lumbar puncture. (Option 3) A lumbar puncture requires a sterile needle to be inserted between the interspaces of L3-4 or L4-5. (Option 4) The client may experience pain radiating down the leg during the procedure, but it should be temporary.

Assessment of a client with a history of stroke reveals that the client understands and follows commands but answers questions with incorrect word choices. The nurse documents the presence of which communication deficit?

• Aphasia
• Apraxia
• Dysarthria
• Dysphagia

Answer explanation

Option 1: Aphasia

Option 2: Apraxia

Option 3: Dysarthria

Option 4: Dysphagia

Correct Option: 1

Explanation: Aphasia refers to impaired communication due to a neurological condition (eg, stroke, traumatic brain injury). The term aphasia is interchangeable with dysphasia, although aphasia is used more commonly. Receptive aphasia refers to impaired comprehension of speech and writing. A client with receptive aphasia may speak full sentences, but the words do not make sense. The nurse should speak clearly, ask simple "yes" or "no" questions, and use gestures and pictures to increase understanding. Expressive aphasia refers to impaired speech and writing. A client with expressive aphasia may be able to speak short phrases but will have difficulty with word choice (Option 1). The nurse should listen without interrupting and give the client time to form words. A client may have one type of aphasia or a combination of both, and the severity will vary with the individual. (Option 2) Apraxia refers to loss of the ability to perform a learned movement (eg, whistling, clapping, dressing) due to neurological impairment. (Option 3) Dysarthria is weakness of the muscles used for speech. Pronunciation and articulation are affected. Comprehension and the meaning of words are intact, but speech is difficult to understand (eg, mumble, lisp). (Option 4) Dysphagia refers to difficulty swallowing. The term dysphagia is often confused with dysphasia. Clients with motor deficits after a stroke may have dysphagia, which requires swallowing precautions to prevent aspiration.

The nurse is caring for a client who has a brain tumor. The client suddenly vomits but denies nausea. It would be a priority for the nurse to

• keep the head of the bed flat
• notify the health care provider
• document the amount of emesis
• administer antiemetic medication

Answer explanation

Option 1: keep the head of the bed flat

Option 2: notify the health care provider

Option 3: document the amount of emesis

Option 4: administer antiemetic medication

Correct Option: 2

Explanation: Increased intracranial pressure (ICP) is a life-threatening condition that decreases cerebral blood flow, which can result in brain ischemia, infarction, or herniation. Potential causes of increased ICP include head trauma, infections, hemorrhage, edema, and tumors. Clinical manifestations include unexpected vomiting without nausea, headaches, confusion, and drowsiness. If any of these manifestations are noted, the nurse should immediately notify the health care provider (Option 2). (Option 1) The head of the bed should be maintained at 30 degrees, not kept flat, for clients with suspected increased ICP to help drain cerebrospinal fluid and maintain adequate cerebral blood pressure. (Option 3) Documenting intake and output is important in determining the client's fluid status, but this can be safely delayed. (Option 4) Antiemetic medications are often ineffective when vomiting is caused by increased ICP. Vomiting will be reduced once ICP is decreased.

The nurse is providing a change-of-shift report for a client who experienced a traumatic brain injury and has a Glasgow Coma Scale (GCS) score of 10. It would be essential for the nurse to include that the client

• had a GCS score of 12 one hour ago
• is allergic to penicillin and vancomycin
• was unable to state the current year when asked
• has a blood pressure of 120/80 mm Hg and a pulse of 82/min

Answer explanation

Option 1: had a GCS score of 12 one hour ago

Option 2: is allergic to penicillin and vancomycin

Option 3: was unable to state the current year when asked

Option 4: has a blood pressure of 120/80 mm Hg and a pulse of 82/min

Correct Option: 1

Explanation: The Glasgow Coma Scale (GCS) quantifies the level of consciousness in a client with acute brain injury by measuring eye opening (alertness), verbal response (orientation), and motor response (eg, obeying a command or exhibiting other frontal lobe function). The maximum score on the GCS is 15, and the lowest is 3. The nurse should frequently assess the client's neurological status and note any changes. A numerical decline in the GCS score in 1 hour (eg, 12 to 10) is significant and should be conveyed during the change-of-shift report because it may indicate worsening of the client's condition (Option 1). (Option 2) Although it is important to be aware of allergies, it is essential to communicate a change in the client's current condition. The oncoming nurse can find allergy information in the electronic medical record if needed. (Option 3) Orientation to time is part of the GCS score. The total GCS score and a decline in the score are more indicative of the client's condition and are essential to include in the report. (Option 4) This client's vital signs are within normal limits. It would be more important to communicate evidence of Cushing's triad (bradycardia, bradypnea/Cheyne-Stokes respirations, and widening pulse pressure), which indicates increased intracranial pressure.

The daughter of an 80-year-old client recently diagnosed with Alzheimer disease (AD) says to the nurse, "I guess I can anticipate getting this disease myself at some point." What is an appropriate response by the nurse?

• Engaging in regular exercise decreases the risk of AD.
• Having a family history of AD is not a risk factor.
• Try not to worry about this now as you can't do anything to prevent AD.
• You should avoid aluminum cans and cookware to prevent AD.

Answer explanation

Option 1: Engaging in regular exercise decreases the risk of AD.

Option 2: Having a family history of AD is not a risk factor.

Option 3: Try not to worry about this now as you can't do anything to prevent AD.

Option 4: You should avoid aluminum cans and cookware to prevent AD.

Correct Option: 1

Explanation: The development of Alzheimer disease (AD) is related to a combination of genetic, lifestyle, and environmental factors. Clients with AD are usually diagnosed at age ≥65. Early-onset AD is a rare form of the disease that develops before age 60 and is strongly related to genetics. Children of clients with early-onset AD have a 50% chance of developing the disease. For late-onset AD, the strongest known risk factor is advancing age. Having a first-degree relative (eg, parent, sibling) with late-onset AD also increases the risk of developing AD (Option 2). Trauma to the brain has been associated with the development of AD in the future. Brain trauma may be prevented by wearing seat belts and sports helmets and taking measures to prevent falls. Research suggests that healthy lifestyle choices (eg, smoking cessation, avoiding excessive alcohol intake, exercising regularly, participating in mentally challenging activities) reduce the risk for developing AD (Options 1 and 3). (Option 4) Research has failed to confirm that exposure to aluminum products (eg, cans, cookware, antiperspirant deodorant) is related to the development of AD.

The nurse in the outpatient clinic is speaking with a client diagnosed with cerebral arteriovenous malformation. Which statement would be a priority for the nurse to report to the health care provider?

• I got short of breath this morning when I worked out.
• I have cut down on smoking to 1/2 pack per day.
• I haven't been feeling well, so I have been sleeping a lot.
• I took an acetaminophen in the waiting room for this bad headache.

Answer explanation

Option 1: I got short of breath this morning when I worked out.

Option 2: I have cut down on smoking to 1/2 pack per day.

Option 3: I haven't been feeling well, so I have been sleeping a lot.

Option 4: I took an acetaminophen in the waiting room for this bad headache.

Correct Option: 4

Explanation: An arteriovenous malformation (AVM) is a tangle of veins and arteries that is believed to form during embryonic development. The tangled vessels do not have a capillary bed, causing them to become weak and dilated. AVMs are usually found in the brain and can cause seizures, headaches, and neurologic deficits. Treatment depends on the location of the AVM, but blood pressure control is crucial. Clients with AVMs are at high risk for having an intracranial bleed as the veins can easily rupture because they lack a muscular layer around their lumen. Any neurologic changes, sudden severe headache, nausea, and vomiting should be evaluated immediately as these are usually the first symptoms of a hemorrhage (Option 4). (Option 1) The report of dyspnea may prompt further evaluation depending on the type of exercise performed, but it is not the priority. Clients with AVMs should be discouraged from engaging in heavy exercise as it increases blood pressure. (Option 2) Clients with AVMs should avoid smoking to prevent hypertension. This client needs education on smoking cessation, but it is not the priority. (Option 3) Reports of not feeling well and sleeping a lot may be related to the headache and possible hemorrhage, but this alone would not prompt a call to the health care provider.

A client comes to the emergency department with diplopia and recent onset of nausea. Which statement by the client would indicate to the nurse that this is an emergency?

• I am very tired, and it's hard for me to keep my eyes open.
• I don't feel good, and I want to be seen.
• I have not taken my blood pressure medicine in over a week.
• I have the worst headache I've ever had in my life.

Answer explanation

Option 1: I am very tired, and it's hard for me to keep my eyes open.

Option 2: I don't feel good, and I want to be seen.

Option 3: I have not taken my blood pressure medicine in over a week.

Option 4: I have the worst headache I've ever had in my life.

Correct Option: 4

Explanation: A ruptured cerebral aneurysm is a surgical emergency with a high mortality rate. Cerebral aneurysms are usually asymptomatic unless they rupture; they are often called "silent killers" as they may go undetected for many years before rupturing without warning signs. The distinctive description of a cerebral aneurysm rupture is the abrupt onset of "the worst headache of my life" that is different from previous headaches (including migraines). Immediate evaluation for a possible ruptured aneurysm is critical for any client experiencing a severe headache with changes in or loss of consciousness, neurologic deficits, diplopia, seizures, vomiting, or a stiff neck. Early identification and prompt surgical intervention help increase the chance for survival. (Options 1, 2, and 3) A change in level of consciousness, increased blood pressure, or a feeling of illness should be investigated but alone does not indicate an emergency.

The emergency department nurse receives a client with extensive injuries to the head and upper back. The nurse will perform what action to allow the best visualization of the airway?

• Head-tilt chin-lift in the supine position on a backboard
• Head-tilt chin-lift in the Trendelenburg position
• Jaw-thrust maneuver in semi-Fowler's position
• Jaw-thrust maneuver in the supine position on a backboard

Answer explanation

Option 1: Head-tilt chin-lift in the supine position on a backboard

Option 2: Head-tilt chin-lift in the Trendelenburg position

Option 3: Jaw-thrust maneuver in semi-Fowler's position

Option 4: Jaw-thrust maneuver in the supine position on a backboard

Correct Option: 4

Explanation: Critical situations involving trauma should follow ABC: Airway, Breathing, and Circulation. Airway assessment is particularly critical in clients with injuries to the head, neck, and upper back. Injury to the upper back should be treated as spinal trauma until the client has been cleared by an Advanced Trauma Life Support-qualified health care provider. Until the spine is appropriately assessed, the client should be placed on a backboard and stabilized. The nurse should use the jaw-thrust maneuver to avoid movement of an unstable spine. One provider should stabilize the cervical vertebra allowing the second provider to articulate the jaw independently of the spinal column. (Option 1) Although use of the backboard is appropriate, the head tilt chin-lift should not be used as it involves manipulation of the neck without proper stabilization. If the cervical vertebrae are fractured, the spinal cord could be badly damaged. (Option 2) The head-tilt chin-lift does not stabilize the alignment of the head and neck and can cause spinal cord damage. In addition, the Trendelenburg position causes the abdominal organs to shift toward the diaphragm, which increases the work of breathing. (Option 3) The jaw-thrust maneuver is appropriate, but stabilization of the spine is best performed in the supine position, such as on the flat, hard surface of a backboard.