Exam (elaborations)
Neuro Exam 4
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Neuro Exam 4 Neuro Exam 4 Neuro Exam 4
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Neuro Exam 4A student nurse is assisting with an assessment of a client's level of consciousness using the Glasgow
Coma Scale. The student understands that which categories of client functioning are included in this
assessment? Select all that apply.
1. Eye opening
2. Reflex response
3. Best verbal response
4. Best motor response
5. Pupil size and reaction - verified answer 1. Eye opening
3. Best verbal response
4. Best motor response
Rationale:
Assessment of pupil size and reaction and reflex response are not part of the Glasgow Coma Scale.
The three categories included are eye opening, best verbal response, and best motor response. Pupil
assessment and reflex response is a necessary part of a total assessment of the neurological status
of a client but is not part of this particular scale.
Source: IGGY
A nurse caring for a client following craniotomy who has a supratentorial incision understands that
the client should most likely be maintained in which position?
1. Prone position
2. Supine position
3. Semi-Fowler's position
4. Dorsal recumbent position - verified answer 3. Semi-Fowler's position
Rationale:
In supratentorial surgery (surgery above the brain's tentorium), the client's head is usually elevated
30 degrees to promote venous outflow through the jugular veins. The client's head or the head of
the bed is not lowered in the acute phase of care after supratentorial surgery. An exception to this
position is the client who has undergone evacuation of a chronic subdural hematoma, but a health
care provider's (HCP) prescription is required for positions other than those involving head elevation.
Additionally, the health care provider's (HCP) prescription regarding positioning is always checked
and agency procedures are always followed.
Source: IGGY
,A client who is experiencing an inferior wall myocardial infarction has had a drop in heart rate into
the 50 to 56 beats/min range. The client is also complaining of nausea. The nurse interprets that
these symptoms are because of stimulation of which cranial nerve (CN)?
1. Vagus (CN X)
2. Hypoglossal (CN XII)
3. Spinal accessory (CN XI)
4. Glossopharyngeal (CN IX) - verified answer 1. Vagus (CN X)
Rationale:
The vagus nerve is responsible for sensations in the thoracic and abdominal viscera. It is also
responsible for the decrease in heart rate because approximately 75% of all parasympathetic
stimulation is carried by the vagus nerve. CN IX is responsible for taste in the posterior two thirds of
the tongue, pharyngeal sensation, and swallowing. CN XI is responsible for neck and shoulder
movement. CN XII is responsible for tongue movement.
Source: IGGY
A nurse is preparing to administer a prescribed antibiotic to a client with bacterial meningitis. The
nurse understands that the selection of an antibiotic to treat meningitis is based on which fact?
1. It has a long half-life.
2. It acts within minutes to hours.
3. It can be easily excreted in the urine.
4. It is able to cross the blood-brain barrier. - verified answer 4. It is able to cross the blood-brain
barrier.
Rationale:
A primary consideration regarding medications to treat bacterial meningitis is the ability of the
medication to cross the blood-brain barrier. If the medication cannot cross, it will not be effective.
The duration, onset, and excretion of the medication(options 1, 2, and 3) are also of general concern
but apply to all medications and not specifically to those that are used to treat meningitis.
Source: IGGY
A client has sustained damage to Wernicke's area in the temporal lobe from a brain attack (stroke).
Which should the nurse anticipate when caring for this client?
1. The client will be unable to recall past events.
2. The client will have difficulty understanding language.
3. The client will demonstrate difficulty articulating words.
,4. The client will have difficulty moving one side of the body. - verified answer 2. The client will
have difficulty understanding language.
Rationale:
Wernicke's area consists of a small group of cells in the temporal lobe the function of which is the
understanding of language. The hippocampus is responsible for the storage of memory (the client
will be unable to recall past events). Damage to Broca's area is responsible for aphasia (the client will
demonstrate difficulty articulating words). The motor cortex in the precentral gyrus controls
voluntary motor activity (the client will have difficulty moving one side of the body).
A nurse is assisting in the care of a client being discharged on phenytoin (Dilantin), 100 mg three
times daily, for seizure control. When providing client teaching about this medication, the nurse
should be sure to include which points? Select all that apply.
1. Break the capsules so they are easier to swallow.
2. Use a soft toothbrush while taking this medication.
3. If a dose is missed, just wait until the next one is due.
4. Alcohol should be avoided while taking this medication.
5. The medication may turn the client's urine pink, red, or brown.
6. Sore throat is a common side effect of the medication and is nothing to worry about. - verified
answer 2. Use a soft toothbrush while taking this medication.
4. Alcohol should be avoided while taking this medication.
5. The medication may turn the client's urine pink, red, or brown.
Rationale:
Phenytoin is an anticonvulsant that can cause gingival hyperplasia, as well as bleeding, swelling, and
tenderness of the gums. The client should use good oral hygiene, gum massage, and have regular
dental checkups. Alcohol interferes with the absorption of phenytoin, so it should be avoided.
Change in the color of the urine is a normal reaction. A sore throat, fever, glandular swelling, or any
skin reaction indicates hematological toxicity and needs to be reported.
Source: Kee Hayes
A nurse is reading the laboratory results for a client being treated with carbamazepine (Tegretol) for
prophylaxis of complex partial seizures. When evaluating the client's laboratory data, the nurse
determines that which value is consistent with an adverse effect of this medication?
1. Sodium level, 136 mEq/L
2. Platelet count, 350,000 cells/mm3
3. White blood cell count, 3200 cells/mm3
, 4. Blood urea nitrogen (BUN), 19 mg/dL - verified answer 3. White blood cell count, 3200
cells/mm3
Rationale:
Adverse effects of carbamazepine appear as blood dyscrasias, including aplastic anemia,
agranulocytosis, thrombocytopenia, and leukopenia. Other adverse effects include cardiovascular
disturbances, thrombophlebitis, dysrhythmias, and dermatological effects.
A nurse is speaking with a client taking phenytoin (Dilantin) for seizure control. The client states that
she has started using birth control pills to prevent pregnancy. Which would be an important point
for the nurse to emphasize to the client?
1. Oral contraceptives decrease the effectiveness of phenytoin.
2. Severe gastrointestinal side effects can occur when phenytoin and oral contraceptives are taken
together.
3. There is an increased risk of thrombophlebitis when phenytoin and oral contraceptives are taken
at the same time.
4. Phenytoin may decrease effectiveness of birth control pills, and additional measures should be
taken to avoid pregnancy. - verified answer 4. Phenytoin may decrease effectiveness of birth
control pills, and additional measures should be taken to avoid pregnancy.
Rationale:
Phenytoin enhances the rate of estrogen metabolism, which can decrease the effectiveness of some
birth control pills. The nurse should tell the client to alert the health care provider about the use of
birth control pills so that counseling may be provided about alternative birth control methods. The
other options are incorrect.
Source: Kee Hayes
A nurse is providing instructions to a client beginning medication therapy with divalproex sodium
(Depakote) for treatment of absence seizures. The nurse instructs the client that which represents
the most frequent side effect of this medication?
1. Tinnitus
2. Irritability
3. Blue vision
4. Nausea and vomiting - verified answer 4. Nausea and vomiting
Rationale:
The most frequent side effects of medication therapy with divalproex sodium (Depakote) are
gastrointestinal (GI) disturbances, such as nausea, vomiting, and indigestion. The items in the other
options are incorrect.
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