Ignatavicius Chapter 038 Review Questions and Answers PDF

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Textbook review answers from review questions, case study, and safety priorities....

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Ignatavicius: Medical-Surgical Nursing, 10th Edition Chapter 38: Assessment of the Nervous System Answer Key – NCLEX Examination Challenges, Clinical Judgment Challenges, and Mastery Questions

Answer Key – NCLEX Examination Challenges

NCLEX  Examination Challenge 38-1 Health Promotion and Maintenance The nurse performs an initial neurologic assessment on an older client. Which assessment findings would the nurse expect to be the result of normal physiologic aging? Select all that apply. A. Decreased coordination B. Hearing loss C. Long term memory loss D. Recent memory loss E. Decreased balance control Answer: A, B, D, E Rationale: All of the choices can occur as a result of normal aging except for long term memory. Many older adults often reminisce about their earlier years and life events but often cannot recall what occurred the day before.

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NCLEX  Examination Challenge 38-2 Physiological Integrity During a client's neurologic assessment, the nurse finds that the client who is arousable only with vigorous or painful stimulation How does the nurse document this client's level of consciousness? A. Stuporous B. Lethargic C. Comatose D. Alert Answer: A Rationale: The client who is stuporous is only arousable with vigorous stimulation. The lethargic client (Choice B) is drowsy but is easily awakened. The comatose client (Choice C) is unconscious and not arousable.

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NCLEX  Examination Challenge 38-3 Physiological Integrity The nurse is teaching a client about what to expect immediately after a cerebral angiographic examination. Which statement by the client indicates a need for further teaching? A. “I’ll have a pressure dressing on my groin for a couple of hours.” B. “I'll have to keep my leg straight for a while after the procedure.” C. “The nurses will check circulation in my injected leg frequently.” D. “I can use heat on my groin to decrease any discomfort.” Answer: D Rationale: Ice is used to decrease swelling after the procedure. Heat could increase swelling and may cause the injection site to bleed due to vasodilation. Choices A, B, and C are part of expected postprocedure care after a cerebral angiogram.

Answer Key – Clinical Judgment Challenge 38-1 A 64-year old man awakened with an episode of new-onset weakness in his left leg and dizziness. His wife called their family nurse practitioner who recommended that she call 911 to take her husband to the closest emergency department (ED) for evaluation. By the time he was admitted to the ED, his condition improved. He stated that he had a headache, but otherwise felt fine now. The nurse collects this information based on admission assessment: Client History •

Has a history of hypertension for the last 15 years

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Has a history of diabetes mellitus Type 2 for the past 3 years which is controlled by diet

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Had a left total knee replacement 6 months ago

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Has been married for 42 years

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Has no children or other close family members in the area

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Has been independent with ADLs

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Works part-time for a large retail store in the area

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Reported height = 6 feet (1.83 meters)

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Current weight = 258 pounds (117 kilograms)

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Oral temperature = 98.6 degrees F (37 degrees C)

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Apical pulse = 84 BPM; respiratory rate = 20 breaths/minute

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Blood pressure = 180/98

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Reports a headache pain of 8/10 1. What assessment information in this client situation is the most important and immediate concern for the nurse? (Hint: Identify the relevant information first to help you determine what is most important.) • Episode of new-onset weakness and dizziness that resolved • History of hypertension and diabetes mellitus Type 2 • 258 pounds (117 kilograms) • BP = 180/98 • Report of severe headache 2. What client conditions are consistent with the most relevant information? (Hint: Think about priority collaborative problems that support and contradict the information presented in this situation.) • High blood pressure which may be causing headache • Severe headache pain • Short-term mobility problem • Potential for fall due to dizziness and left leg weakness episode • Obesity

Answer Key – Mastery Questions 1. The nurse is preparing to conduct a focused neurologic assessment for a client who had a traumatic brain injury. Which assessment finding is the immediate concern of the nurse? A. Disorientation B. Numbness in both arms C. Decreased level of consciousness D. Report of headache Answer: C

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Rationale: A decreased level of consciousness is the first sign of neurologic deterioration and can be lifethreatening more than the other changes in the client’s condition. Disorientation and headache are expected findings for a brain injury (Choices A and D). Numbness in the arms is not life-threatening Choice B). 2. The nurse is caring for a client following a cerebral angiography. Which assessment finding will the nurse report immediately to the primary health care provider? A. Discomfort at the injection site B. Bleeding from the injection site C. Fatigue and weakness D. Mild headache Answer: B Rationale: Discomfort is expected at the injection site (Choice A), but the client should not have bleeding from the site, which could be life-threatening. Fatigue, weakness, and a mild headache is not an immediate concern because these findings are not potentially life-threatening (Choice C and D).

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