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Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)

Chapter 39: Concepts of Care for Patients With Problems of the Central Nervous System: The Brain Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse is teaching the daughter of a client who has middle-stage Alzheimer disease. The

daughter asks, “Will the sertraline my mother is taking improve her dementia?” How would the nurse respond about the purpose of the drug? a. “It will allow your mother to live independently for several more years.” b. “It is used to halt the advancement of Alzheimer disease but will not cure it.” c. “It will not improve her dementia but can help control emotional responses.” d. “It is used to improve short-term memory but will not improve problem solving.” ANS: C

Drug therapy is not effective for treating dementia or halting the advancement of Alzheimer disease. However, certain psychoactive drugs may help suppress emotional disturbances and manage depression, psychoses, or anxiety. Drug therapy will not allow the client with middle-stage dementia to safely live independently. DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Alzheimer disease, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 2. A client with early-stage Alzheimer disease is admitted to the hospital with chest pain. Which

nursing action is most appropriate to manage this client’s dementia? a. Provide animal-assisted therapy as needed. b. Ensure a structured and consistent environment. c. Assist the client with activities of daily living (ADLs). d. Use validation therapy when communicating with the client. ANS: B

The client who has early Alzheimer disease (AD) does not require assistance with ADLs or validation therapy. While animal-assisted therapy may be helpful, some health care agencies do not allow this intervention. Therefore, the most appropriate action is to provide a structured and consistent environment while the client is hospitalized to prevent worsening of the client’s symptoms. DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Alzheimer disease, Nursing Interventions MSC: Client Needs Category: Psychosocial Integrity 3. The nurse observes a client with late-stage Alzheimer disease eat breakfast. Afterward the

client states, “I am hungry and want breakfast.” What is the nurse’s best response? a. “I see you are still hungry. I will get you some toast.” b. “You ate your breakfast 30 minutes ago.” c. “It appears you are confused this morning.” d. “Your family will be here soon. Let’s get you dressed.” ANS: A

Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)

Use of validation therapy with clients who have late-stage Alzheimer disease involves acknowledgment of the client’s feelings and concerns. This technique has proved more effective in later stages of the disease because reality orientation only increases agitation. The other statements do not validate the client’s concerns. DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Alzheimer disease, Therapeutic communication MSC: Client Needs Category: Psychosocial Integrity 4. The nurse cares for a client with middle-stage (moderate) Alzheimer disease. The client’s

caregiver states, “She is always wandering off. What can I do to manage this restless behavior?” What is the nurse’s best response? a. “This is a sign of fatigue. The client would benefit from a daily nap.” b. “Engage the client in scheduled activities throughout the day.” c. “It sounds like this is difficult for you. I will consult the social worker.” d. “The provider can prescribe a mild sedative for restlessness.” ANS: B

Several strategies may be used to cope with restlessness and wandering. One strategy is to engage the client in structured activities. Another is to take the client for frequent walks. Daily naps and a mild sedative will not be as effective in the management of restless behavior. Consulting the social worker does not address the caregiver’s concern. DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Alzheimer disease, Client safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 5. The nurse prepares to discharge a client with early to moderate Alzheimer disease. Which

statement to maintain client safety would the nurse include in the discharge teaching for the caregiver? a. “Provide periods of exercise and rest for the client.” b. “Place a padded throw rug at the bedside.” c. “Provide a highly stimulating environment.” d. “Install safety locks on all outside doors.” ANS: D

Clients with early to moderate Alzheimer disease have a tendency to wander, especially at night. If possible, alarms would be installed on all outside doors to alert family members if the client leaves. At a minimum, all outside doors should have safety locks installed to prevent the client from going outdoors unsupervised. The client would be allowed to exercise within his or her limits, but this action does not ensure his or her safety. Throw rugs are a slip and fall hazard and would be removed. A highly stimulating environment would likely increase the client’s confusion. DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Alzheimer disease, Safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 6. The nurse is teaching a family caregiver about how best to communicate with the client who

has been diagnosed with Alzheimer disease. Which statement by the caregiver indicates a need for further teaching?

Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files) a. b. c. d.

“I will avoid communicating with the client to prevent agitation.” “I should use simple, short sentences and one-step instructions.” “I can try to use gestures or pictures to communicate with the client.” “I will limit the number of choices I provide for the client.”

ANS: A

Communication with the client is important to provide cognitive stimulation. Using short simple sentences, using gestures and pictures, and limiting choices provided for the client will help promote communication. DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Alzheimer disease, Therapeutic communication MSC: Client Needs Category: Psychosocial Integrity 7. The nurse teaches assistive personnel (AP) about how to care for a client with early-stage

Alzheimer disease. Which statement would the nurse include? a. “If she is confused, play along and pretend that everything is okay.” b. “Remove the clock from her room so that she doesn’t get confused.” c. “Reorient the client to the day, time, and environment with each contact.” d. “Use validation therapy to recognize and acknowledge the client’s concerns.” ANS: C

Clients who have early-stage Alzheimer disease would be reoriented frequently to person, place, and time. The AP would reorient the client and not encourage the client’s delusions. The room would have a clock and white board with the current date written on it. Validation therapy is used with late-stage Alzheimer disease. DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Alzheimer disease, Staff teaching MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 8. The primary health care provider prescribes donepezil for a client diagnosed with early-stage

Alzheimer disease. What teaching about this drug will the nurse provide for the client’s family caregiver? a. “Monitor the client’s temperature because the drug can cause a low grade fever.” b. “Observe the client for nausea and vomiting to determine drug tolerance.” c. “Donepezil will prevent the client’s dementia from progressing as usual.” d. “Report any client dizziness or falls because the drug can cause bradycardia.” ANS: D

Donepezil is a cholinesterase inhibitor that may temporarily slow cognitive decline for some clients but does not alter the course of the disease. The family caregiver would want to monitor the client’s heart rate and report any incidence of dizziness or falls because the drug can cause bradycardia. It does not typically cause fever or nausea/vomiting. DIF: Remembering TOP: Integrated Process: Teaching/Learning KEY: Alzheimer disease, Drug therapy, Caregiver health teaching MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 9. After teaching the wife of a client who has Parkinson disease, the nurse assesses the wife’s

understanding. Which statement by the client’s wife indicates that she correctly understands changes associated with this disease?

Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files) a. b. c. d.

“His masklike face makes it difficult to communicate, so I will use a white board.” “He should not socialize outside of the house due to uncontrollable drooling.” “This disease is associated with anxiety causing increased perspiration.” “He may have trouble chewing, so I will offer bite-sized portions.”

ANS: D

Because chewing and swallowing can be problematic, small frequent meals and a supplement are better for meeting the client’s nutritional needs. A masklike face and drooling are common in clients with Parkinson disease. The client would be encouraged to continue to socialize and communicate as normally as possible. The wife should understand that the client’s masklike face can be misinterpreted and additional time may be needed for the client to communicate with her or others. Excessive perspiration is also common in clients with Parkinson disease and is associated with the autonomic nervous system’s response. DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Parkinson disease, Signs and symptoms MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 10. The nurse plans care for a client with Parkinson disease. Which intervention would the nurse

include in this client’s plan of care? a. Restrain the client to prevent falling. b. Ensure that the client uses incentive spirometry. c. Teach the client pursed-lip breathing techniques. d. Keep the head of the bed at 30 degrees or greater. ANS: D

Elevation of the head of the bed will help prevent aspiration. The other options will not prevent aspiration, which is the greatest respiratory complication of Parkinson disease, nor do these interventions address any of the complications of Parkinson disease. Pursed-lip breathing increases exhalation of carbon dioxide; incentive spirometry expands the lungs. The client should not be restrained to prevent falls. Other less restrictive interventions should be used to maintain client safety. DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Parkinson disease, Complication prevention MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 11. A nurse teaches assistive personnel (AP) about how to care for a client with Parkinson

disease. Which statement would the nurse include as part of this teaching? “Allow the client to be as independent as possible with activities.” “Assist the client with frequent and meticulous oral care.” “Assess the client’s ability to eat and swallow before each meal.” “Schedule appointments early in the morning to ensure rest in the afternoon.”

a. b. c. d.

ANS: A

Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)

Clients with Parkinson disease do not move as quickly and can have functional problems. The client would be encouraged to be as independent as possible and provided time to perform activities without rushing. Although oral care is important for all clients, instructing the UAP to provide frequent and meticulous oral is not a priority for this client. This statement would be a priority if the client was immune-compromised or NPO. The nurse would assess the client’s ability to eat and swallow; this would not be delegated. Appointments and activities would not be scheduled early in the morning because this may cause the client to be rushed and discourage the client from wanting to participate in activities of daily living. DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Parkinson disease, Staff teaching MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 12. A client diagnosed with Parkinson disease will be starting ropinirole for symptom control.

Which statement by the client indicates a need for further teaching? a. “This drug should help decrease my tremors and help me move better.” b. “I need to change positions slowly to prevent dizziness or falls.” c. “I should take the drug at the same time each day for the best effect.” d. “I know the drug will probably make help me prevent constipation.” ANS: D

Although ropinirole is a dopamine agonist and mimics dopamine to promote movement, it does not work to prevent constipation. This class of drugs can cause orthostatic hypotension and should be taken at the same time every day. DIF: Understanding TOP: Integrated Process: Nursing Process: Evaluation KEY: Parkinson disease, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 13. A nurse is teaching a client who experiences migraine headaches and is prescribed

propranolol. Which statement would the nurse include in this client’s teaching? a. “Take this drug only when you have symptoms indicating the onset of a migraine headache.” b. “Take this drug as prescribed, even when feeling well, to prevent vascular changes associated with migraine headaches.” c. “This drug will relieve the pain during the aura phase soon after a headache has started.” d. “This drug will have no effect on your heart rate or blood pressure because you are taking it for migraines.” ANS: B

Propranolol is a beta-adrenergic blocker which is prescribed as prophylactic treatment to prevent the vascular changes that initiate migraine headaches. Heart rate and blood pressure will also be affected, and the client would monitor these side effects. The other responses do not discuss appropriate uses of this drug. DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Migraine headache, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files) 14. The nurse assesses a client who has a history of migraines. Which symptom would the nurse

identify as an early sign of a migraine with aura? a. Vertigo b. Lethargy c. Visual disturbances d. Numbness of the tongue ANS: C

Early warning of impending migraine with aura usually consists of visual changes, flashing lights, or diplopia. The other symptoms are not associated with an impending migraine with aura. DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Migraine headache, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 15. The nurse obtains a health history on a client prior to administering prescribed sumatriptan

succinate for migraine headaches. Which condition would alert the nurse to withhold the medication and contact the primary health care provider? a. Bronchial asthma b. Heart disease c. Diabetes mellitus d. Rheumatoid arthritis ANS: B

Sumatriptan succinate effectively reduces pain and other associated symptoms of migraine headache by binding to serotonin receptors and triggering cranial vasoconstriction. Vasoconstrictive effects are not confined to the cranium and can cause coronary vasospasm in clients with heart disease, hypertension, or Prinzmetal angina. The other conditions would not affect the client’s treatment. DIF: Applying TOP: Integrated Process: Nursing Process: Analysis KEY: Migraine headache, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 16. The nurse assesses a client with a history of epilepsy who experiences stiffening of the

muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How would the nurse document this type of seizure? a. Atonic b. Myoclonic c. Absence d. Tonic-clonic ANS: D

Seizure activity that begins with stiffening of the arms and legs, followed by loss of consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure. An atonic seizure presents as a sudden loss of muscle tone followed by postictal confusion. A myoclonic seizure presents with a brief jerking or stiffening of extremities that may occur singly or in groups. Absence seizures present with automatisms, and the client is unaware of his or her environment. DIF: Remembering

Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files) TOP: Integrated Process: Communication and Documentation KEY: Epilepsy, Assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 17. The nurse witnesses a client begin to experience a tonic-clonic seizure and loss of

consciousness. What action would the nurse take first? a. Start fluids via a large-bore catheter. b. Administer IV push diazepam. c. Turn the client’s head to the side. d. Prepare to intubate the client. ANS: C

The nurse would turn the client’s head to the side to prevent aspiration and allow drainage of secretions. Anticonvulsants are administered on a routine basis if a seizure is sustained. If the seizure is sustained (status epilepticus), the client must be intubated and would be administered oxygen, 0.9% sodium chloride, and IV push lorazepam or diazepam. DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Seizure, Aspiration precautions MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 18. A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication

would the nurse anticipate to prepare for administration? Atenolol Lorazepam Phenytoin Lisinopril

a. b. c. d.

ANS: B

Initially, intravenous lorazepam or diazepam is administered to stop motor movements. This is followed by the administration of phenytoin. Atenolol, a beta blocker, and lisinopril, an angiotensin-converting enzyme inhibitor, are not administered for seizure activity. These drugs are typically administered for hypertension and heart failure. DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation KEY: Epilepsy, Drug therapy MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 19. After teaching a client who is diagnosed with new-onset epilepsy and prescribed phenytoin,

the nurse assesses the client’s understanding. Which statement by the client indicates a correct understanding of the teaching? a. “To prevent complications, I will drink at least 2 L of water daily.” b. “This medication will stop me from getting an aura before a seizure.” c. “I will not drive a motor vehicle while taking this medication.” d. “Even when my seizures stop, I will continue to take this drug.” ANS: D

Discontinuing antiepileptic drugs can lead to the recurrence of seizures or status epilepticus. The client does not need to drink more water and can drive while taking this medication. The drug will not stop an aura before a seizure. DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Epilepsy, Drug therapy

Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files) MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 20. After teaching a cl...