Text Mode – Text version of the exam1) SITUATION: A 65 year old woman was admitted for Parkinson’s Disease. The charge nurse is going to make an initial assessment. One day, the patient complained of difficulty in walking. Your response would be

A. You will need a cane for supportB. Walk erect with eyes on horizonC. I’ll get you a wheelchairD. Don’t force yourself to walk

2) Nurse Carol is assessing a client with Parkinson’s disease. The nurse recognize bradykinesia when the client exhibits:

A. Intentional tremorB. Paralysis of limbsC. Muscle spasmD. Lack of spontaneous movement

3) Which of the following diseases is associated with decreased levels of dopamine due to destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain?

A. Parkinson’s diseaseB. Multiple sclerosisC. Huntington’s diseaseD. Creutzfeldt-Jakob’s disease

4) SITUATION: A 65 year old woman was admitted for Parkinson’s Disease. The charge nurse is going to make an initial assessment. The patient was prescribed with levodopa. What is the action of this drug?

A. Increase dopamine availabilityB. Activates dopaminergic receptors in the basal gangliaC. Decrease acetylcholine availabilityD. Release dopamine and other catecholamine from neurological

storage sites5) A shuffling gait is typically associated with the patient who has:

A. Parkinson’s diseaseB. Multiple sclerosisC. Raynaud’s diseaseD. Myasthenia gravis

6) SITUATION: A 65 year old woman was admitted for Parkinson’s Disease. The charge nurse is going to make an initial assessment. Which of the following is a characteristic of a patient with advanced Parkinson’s disease?

A. Disturbed visionB. ForgetfulnessC. Mask like facial expressionD. Muscle atrophy

7) SITUATION: A 65 year old woman was admitted for Parkinson’s Disease. The charge nurse is going to make an initial assessment. You are discussing with the dietician what food to avoid with patients taking levodopa?

A. Vitamin C rich foodB. Vitamin E rich foodC. Thiamine rich foodD. Vitamin B6 rich food

8) All of these nursing activities are included in the care plan for a 78-year-old man with Parkinson’s disease who has been referred to your home health agency. Which ones will you delegate to a nursing assistant (NA)? (Choose all that apply).

A. Check for orthostatic changes in pulse and bloods pressure.B. Monitor for improvement in tremor after levodopa (L-dopa) is given.C. Remind the patient to allow adequate time for meals.D. Monitor for abnormal involuntary jerky movements of extremities.E. Assist the patient with prescribed strengthening exercises.F. Adapt the patient’s preferred activities to his level of function.

9) Which of the following is the most common cause of dementia among elderly persons?

A. Parkinson’s diseaseB. Multiple sclerosisC. Amyotrophic lateral sclerosisD. Alzheimer’s disease

10) The nurse should instruct the patient with Parkinson’s disease to avoid which of the following?

A. Walking in an indoor shopping mallB. Sitting on the deck on a cool summer eveningC. Walking to the car on a cold winter day

D. Sitting on the beach in the sun on a summer day11) A patient with Parkinson’s disease has a nursing diagnosis of Impaired Physical Mobility related to neuromuscular impairment. You observe a nursing assistant performing all of these actions. For which action must you intervene?

A. The NA assists the patient to ambulate to the bathroom and back to bed.

B. The NA reminds the patient not to look at his feet when he is walking.

C. The NA performs the patient’s complete bath and oral care.D. The NA sets up the patient’s tray and encourages patient to feed

himself.12) Which of the following diseases is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of small patches of demyelination in the brain and spinal cord?

A. Multiple sclerosisB. Parkinson’s diseaseC. Huntington’s diseaseD. Creutzfeldt-Jakob’s disease

13) The nurse is teaching a client with Parkinson’s disease ways to prevent curvatures of the spine associated with the disease. To prevent spinal flexion, the nurse should tell the client to:

A. Periodically lie prone without a neck pillowB. Sleep only in dorsal recumbent positionC. Rest in supine position with his head elevatedD. Sleep on either side but keep his back straight

14) SITUATION: A 65 year old woman was admitted for Parkinson’s Disease. The charge nurse is going to make an initial assessment. The onset of Parkinson’s disease is between 50-60 years old. This disorder is caused by

A. Injurious chemical substancesB. Hereditary factorsC. Death of brain cells due to old ageD. Impairment of dopamine producing cells in the brain

15) A nurse is assigned to care to a client with Parkinson’s disease. What interventions are important if the nurse wants to improve nutrition and promote effective swallowing of the client?

A. Eat solid foodB. Give liquids with mealsC. Feed the clientD. Sit in an upright position to eat

16) The nurse is assessing a patient and notes a Brudzinski’s sign and Kernig’s sign. These are two classic signs of which of the following disorders?

A. Cerebrovascular accident (CVA)B. MeningitisC. Seizure disorderD. Parkinson’s disease

17) A nurse is caring for a client with Parkinson’s disease who has been taking carbidopa/levodopa (Sinemet) for a year. Which of the following adverse reactions will the nurse monitor the client for?

A. DykinesiaB. GlaucomaC. HypotensionD. Respiratory depression

18) Levodopa is ordered for a client with Parkinson’s disease. Before starting the medication, the nurse should know that:

A. Levodopa is inadequately absorbed if given with meals.B. Levodopa may cause the side effects of orthostatic hypotensionC. Levodopa must be monitored by weekly laboratory tests.D. Levodopa causes an initial euphoria followed by depression.

19) A client has been placed on levodopa to treat Parkinson’s disease. Which of the following is a common side effects of levodopa that the nurse should include in the client’s teaching plan?

A. PancytopeniaB. Peptic ulcerC. Postural hypotensionD. Weight loss

20) Mr. Perkson has a parkinson’s disease and he finds the resting tremor he is experiencing in his right hand very frustrating. The nurse advises him to:

A. Take a warm bathB. Hold an objectC. Practice deep breathing

D. Take diazepam as neededAnswers and Rationales

1. A. You will need a cane for support .Telling the client to walk erect neglects the clients complain of difficulty walking. Wheelchair is as much as possible not used to still enhance the client’s motor function using a cane. Telling the client not to force himself walk is non therapeutic. The client wants to talk and we should help her walk using devices such as cane to provide support and prevent injuries.

2. D. Lack of spontaneous movement . Bradykinesia is slowing down from the initiation and execution of movement.

3. A. Parkinson’s disease. In some patients, Parkinson’s disease can be controlled; however, it cannot be cured.

4. A. Increase dopamine availability. Levodopa is an altered form of dopamine. It is metabolized by the body and then converted into dopamine for brain’s use thus increasing dopamine availability. Dopamine is not given directly because of its inability to cross the BBB.

5. A. Parkinson’s disease . A shuffling gait from the musculoskeletal rigidity of the patient with Parkinson’s disease is common. Patients experiencing a stroke usually exhibit loss of voluntary control over motor movements associated with generalized weakness; a shuffling gait is usually not observed in stroke patient.

6. C. Mask like facial expression. Parkinson’s disease does not affect the cognitive ability of a person. It is a disorder due to the depletion of the neurotransmitter dopamine which is needed for inhibitory control of muscular contractions. Client will exhibit mask like facial expression, Cog wheel rigidity, Bradykinesia, Shuffling gait etc. Muscle atrophy does not occur in parkinson’s disease nor visual disturbances.

7. D. Vitamin B6 rich food . Vitamin b6 or pyridoxine is avoided in patients taking levodopa because levodopa increases vitamin b6 availability leading to toxicity.

8. A. Check for orthostatic changes in pulse and bloods pressure. , C. Remind the patient to allow adequate time for meals. , E. Assist the patient with prescribed strengthening exercises. NA education and scope of practice includes taking pulse and blood pressure measurements. In addition, NAs can reinforce previous teaching or skills taught by the RN or other disciplines, such as speech or physical therapists. Evaluation of patient response to medication and development and individualizing

the plan of care require RN-level education and scope of practice. Focus: Delegation

9. D. Alzheimer’s disease. Alzheimer;s disease, sometimes known as senile dementia of the Alzheimer’s type or primary degenerative dementia, is an insidious; progressive, irreversible, and degenerative disease of the brain whose etiology is still unknown. Parkinson’s disease is a neurologic disorder caused by lesions in the extrapyramidial system and manifested by tremors, muscle rigidity, hypokinesis, dysphagia, and dysphonia. Multiple sclerosis, a progressive, degenerative disease involving demyelination of the nerve fibers, usually begins in young adulthood and is marked by periods of remission and exacerbation. Amyotrophic lateral sclerosis, a disease marked by progressive degeneration of the neurons, eventually results in atrophy of all the muscles; including those necessary for respiration.

10. D. Sitting on the beach in the sun on a summer day . The patient with Parkinson’s disease may be hypersensitive to heat, which increases the risk of hyperthermia, and he should be instructed to avoid sun exposure during hot weather.

11. C. The NA performs the patient’s complete bath and oral care. The nursing assistant should assist the patient with morning care as needed, but the goal is to keep this patient as independent and mobile as possible. Assisting the patient to ambulate, reminding the patient not to look at his feet (to prevent falls), and encouraging the patient to feed himself are all appropriate to goal of maintaining independence. Focus: Delegation/supervision

12. A. Multiple sclerosis . The cause of MS is not known and the disease affects twice as many women as men.

13. A. Periodically lie prone without a neck pillow. Periodically lying in a prone position without a pillow will help prevent the flexion of the spine that occurs with Parkinson’s disease. Answers B and C flex the spine; therefore, they are incorrect. Answer D is not realistic because of position changes during sleep; therefore, it is incorrect.

14. D. Impairment of dopamine producing cells in the brain. Dopamine producing cells in the basal ganglia mysteriously deteriorates due to unknown cause.

15. D. Sit in an upright position to eat . Client with Parkinson’s disease are at a high risk for aspiration and undernutrition. Sitting upright promotes more effective swallowing.

16. B. Meningitis. A positive response to one or both tests indicates meningeal irritation that is present with meningitis. Brudzinski’s and Kernig’s signs don’t occur in CVA, seizure disorder, or Parkinson’s disease.

17. C. Hypotension . Hypotension, dizziness and lethargy are side effects of anti parkinson drugs like levodopa and carbidopa.

18. B. Levodopa may cause the side effects of orthostatic hypotension. Levodopa is the metabolic precursor of dopamine. It reduces sympathetic outflow by limiting vasoconstriction, which may result in orthostatic hypotension.

19. C. Postural hypotension20. B. Hold an object . The resting or non-intentional tremor may

be controlled with purposeful movement such as holding an object. A warm bath, deep breathing and diazepam will promote relaxation but are not specific interventions for tremor

Text Mode – Text version of the exam1) A nurse is putting together a presentation on meningitis. Which of the following microorganisms has noted been linked to meningitis in humans?

A. S. pneumoniaB. H. influenzaC. N. meningitisD. Cl. difficile

2) The mother brings a child to the health care clinic because of severe headache and vomiting. During the assessment of the health care nurse, the temperature of the child is 40 degree Celsius, and the nurse notes the presence of nuchal rigidity. The nurse is suspecting that the child might be suffering from bacterial meningitis. The nurse continues to assess the child for the presence of Kernig’s sign. Which finding would indicate the presence of this sign?

A. Flexion of the hips when the neck is flexed from a lying positionB. Calf pain when the foot is dorsiflexedC. Inability of the child to extend the legs fully when lying supineD. Pain when the chin is pulled down to the chest

3) Richard Barnes was diagnosed with pneumococcal meningitis. What response by the patient indicates that he understands the precautions necessary with this diagnosis?

A. “I’m so depressed because I can’t have any visitors for a week.”B. “Thank goodness, I’ll only be in isolation for 24 hours.”C. “The nurse told me that my urine and stool are also sources of

meningitis bacteria.”D. “The doctor is a good friend of mine and won’t keep me in

isolation.”4) A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which of the following nursing measures should the nurse do FIRST?

A. Institute seizure precautionsB. Assess neurologic statusC. Place in respiratory isolationD. Assess vital signs

5) A 4-month-old with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority?

A. Instituting droplet precautionsB. Administering acetaminophen (Tylenol)C. Obtaining history information from the parentsD. Orienting the parents to the pediatric unit

6) A client is admitted and has been diagnosed with bacterial (meningococcal) meningitis. The infection control registered nurse visits the staff nurse caring to the client. What statement made by the nurse reflects an understanding of the management of this client?

A. speech pattern may be alteredB. Respiratory isolation is necessary for 24 hours after antibiotics are

startedC. Perform skin culture on the macular popular rashD. Expect abnormal general muscle contractions

7) Patrick, a healthy adolescent has meningitis and is receiving I.V. and oral fluids. The nurse should monitor this client’s fluid intake because fluid overload may cause:

A. Cerebral edemaB. DehydrationC. Heart failureD. Hypovolemic shock

8) You are mentoring a student nurse in the intensive care unit (ICU) while caring for a patient with meningococcal meningitis. Which action by the student requires that you intervene immediately?

A. The student enters the room without putting on a mask and gown.B. The student instructs the family that visits are restricted to 10

minutes.C. The student gives the patient a warm blanket when he says he feels

cold.D. The student checks the patient’s pupil response to light every 30

minutes.9) Which of these patients in the neurologic ICU will be best to assign to an RN who has floated from the medical unit?

A. A 26-year-old patient with a basilar skull structure who has clear drainage coming out of the nose

B. A 42-year-old patient admitted several hours ago with a headache and diagnosed with a ruptured berry aneurysm.

C. A 46-year-old patient who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due

D. A 65-year-old patient with a astrocytoma who has just returned to the unit after having a craniotomy10) You have just admitted a patient with bacterial meningitis to the medical-surgical unit. The patient complains of a severe headache with photophobia and has a temperature of 102.60 F orally. Which collaborative intervention must be accomplished first?

A. Administer codeine 15 mg orally for the patient’s headache.B. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection.C. Give acetaminophen (Tylenol) 650 mg orally to reduce the fever.D. Give furosemide (Lasix) 40 mg IV to decrease intracranial pressure.

11) A 5-month-old infant is admitted to the ER with a temperature of 6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:

A. Periorbital edemaB. Tenseness of the anterior fontanelC. Positive Babinski reflex

D. Negative scarf sign12) A client, age 22, is admitted with bacterial meningitis. Which hospital room would be the best choice for this client?

A. A private room down the hall from the nurses’ stationB. An isolation room three doors from the nurses’ stationC. A semiprivate room with a 32-year-old client who has viral

meningitisD. A two-bed room with a client who previously had bacterial

meningitis13) The nurse is assessing a patient and notes a Brudzinski’s sign and Kernig’s sign. These are two classic signs of which of the following disorders?

A. Cerebrovascular accident (CVA)B. MeningitisC. Seizure disorderD. Parkinson’s disease

14) The adolescent patient has symptoms of meningitis: nuchal rigidity, fever, vomiting, and lethargy. The nurse knows to prepare for the following test:

A. blood culture.B. throat and ear culture.C. CAT scan.D. lumbar puncture.

15) A patient’s chart indicates a history of meningitis. Which of the following would you not expect to see with this patient if this condition were acute?

A. Increased appetiteB. VomitingC. FeverD. Poor tolerance of light

16) Dexamethasone improves mortality in meningococcal meningitis

A. TrueB. False

17) The client with suspected meningitis is admitted to the unit. The doctor is performing an assessment to determine meningeal irritation and spinal nerve root inflammation. A positive Kernig’s sign is charted if the nurse notes:

A. Pain on flexion of the hip and kneeB. Nuchal rigidity on flexion of the neck

C. Pain when the head is turned to the left sideD. Dizziness when changing positions

18) A 4 year old girl is admitted with pneumococcal meningitis. She has just returned from a holiday to Disneyland, Florida, 2 days before. What are you going to treat her with:

A. ceftriaxoneB. amoxicillin and gentamicinC. benzylpenicillin and rifampicinD. cefotaxime and vancomycin

19) A client is admitted with a diagnosis of meningitis caused by Neisseria meningitides. The nurse should institute which type of isolation precautions?

A. Contact precautionsB. Droplet precautionsC. Airborne precautionsD. Standard precautions

20) Among children aged 2 months to 3 years, the most prevalent form of meningitis is caused by which microorganism?

A. Hemophilus influenzaeB. MorbillivirusC. Steptococcus pneumoniaeD. Neisseria meningitidis

Answers and Rationales1. D. Cl. difficile . Cl. difficile has not been linked to meningitis.2. C. Inability of the child to extend the legs fully when lying

supine . Kernig’s sign is the inability of the child to extend the legs fully when lying supine. This sign is frequently present in bacterial meningitis. Nuchal rigidity is also present in bacterial meningitis and occurs when pain prevents the child from touching the chin to the chest.

3. B. “Thank goodness, I’ll only be in isolation for 24 hours.” Patient with pneumococcal meningitis require respiratory isolation for the first 24 hours after treatment is initiated.

4. C. Place in respiratory isolation . The initial therapeutic management of acute bacterial meningitis includes isolation precautions, initiation of antimicrobial therapy and maintenance of optimum hydration. Nurses should take necessary precautions to protect themselves and others from possible infection.

5. A. Instituting droplet precautions. Instituting droplet precautions is a priority for a newly admitted infant with meningococcal meningitis. Acetaminophen may be prescribed but administering it doesn’t take priority over instituting droplet precautions. Obtaining history information and orienting the parents to the unit don’t take priority.

6. B. Respiratory isolation is necessary for 24 hours after antibiotics are started . After a minimum of 24 hours of IV antibiotics, the client is no longer considered communicable. Evaluation of the nurse’s knowledge is needed for safe care and continuity of care.

7. A. Cerebral edema. Because of the inflammation of the meninges, the client is vulnerable to developing cerebral edema and increase intracranial pressure. Fluid overload won’t cause dehydration. It would be unusual for an adolescent to develop heart failure unless the overhydration is extreme. Hypovolemic shock would occur with an extreme loss of fluid of blood.

8. A. The student enters the room without putting on a mask and gown. Meningococcal meningitis is spread through contact with respiratory secretions so use of a mask and gown is required to prevent spread of the infection to staff members or other patients. The other actions may not be appropriate but they do not require intervention as rapidly. The presence of a family member at the bedside may decrease patient confusion and agitation. Patients with hyperthermia frequently complain of feeling chilled, but warming the patient is not an appropriate intervention. Checking the pupil response to light is appropriate, but it is not needed every 30 minutes and is uncomfortable for a patient with photophobia. Focus: Prioritization

9. C. A 46-year-old patient who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due. This patient is the most stable of the patients listed. An RN from the medical unit would be familiar with administration of IV antibiotics. The other patients require assessments and care from RNs more experienced in caring for patients with neurologic diagnoses. Focus: Assignment.

10. B. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection. Untreated bacterial meningitis has a mortality are approaching 100%, so rapid antibiotic treatment is essential. The other interventions will help reduce CNS stimulation and irritation, and should be implemented as soon as possible. Focus: Prioritization

11. B. Tenseness of the anterior fontanel .Tenseness of the anterior fontanel indicates an increase in intracranial pressure. Periorbital edema is incorrect because periorbital edema is not associated with meningitis. Positive Babinski reflex is incorrect because a positive Babinski reflex is normal in the infant. Negative scarf sign is incorrect because it relates to the preterm infant, not the infant with meningitis.

12. B. An isolation room three doors from the nurses’ station . A client with bacterial meningitis should be kept in isolation for at least 24 hours after admission and, during the initial acute phase, should be as close to the nurses’ station as possible to allow maximal observation. Placing the client in a room with a client who has viral meningitis may cause harm to both clients because the organisms causing viral and bacterial meningitis differ; either client may contract the other’s disease. Immunity to bacterial meningitis can’t be acquired; therefore, a client who previously had bacterial meningitis shouldn’t be put at risk by rooming with a client who has just been diagnosed with this disease.

13. B. Meningitis. A positive response to one or both tests indicates meningeal irritation that is present with meningitis. Brudzinski’s and Kernig’s signs don’t occur in CVA, seizure disorder, or Parkinson’s disease.

14. D. lumbar puncture. Meningitis is an infection of the meninges, the outer membrane of the brain. Since it is surrounded by cerebrospinal fluid, a lumbar puncture will help to identify the organism involved.

15. A. Increased appetite. Loss of appetite would be expected.16. B. False 17. A. Pain on flexion of the hip and knee . Kernig’s sign is

positive if pain occurs on flexion of the hip and knee. The Brudzinski reflex is positive if pain occurs on flexion of the head and neck onto the chest.

18. D. cefotaxime and vancomycin. The USA has a high rate of penicillin resistant pneumococi and first line treatment should include vancomycin until sensitivities are known.

19. B. Droplet precautions . This client requires droplet precautions because the organism can be transmitted through airborne droplets when the client coughs, sneezes, or doesn’t cover his mouth. Airborne precautions would be instituted for a client infected with tuberculosis. Standard precautions would be instituted for a client when contact with body substances is likely. Contact

precautions would be instituted for a client infected with an organism that is transmitted through skin-to-skin contact.

20. A. Hemophilus influenzae . Hemophilus meningitis is unusual over the age of 5 years. In developing countries, the peak incidence is in children less than 6 months of age. Morbillivirus is the etiology of measles. Streptococcus pneumoniae and Neisseria meningitidis may cause meningitis, but age distribution is not specific in young children

1) The diagnostic work-up of a client hospitalized with complaints of progressive weakness and fatigue confirms a diagnosis of myasthenia gravis. The medication used to treat myasthenia gravis is:

A. Prostigmine (neostigmine)B. Atropine (atropine sulfate)C. Didronel (etidronate)D. Tensilon (edrophonium)

2) Karina a client with myasthenia gravis is to receive immunosuppressive therapy. The nurse understands that this therapy is effective because it:

A. Promotes the removal of antibodies that impair the transmission of impulses

B. Stimulates the production of acetylcholine at the neuromuscular junction.

C. Decreases the production of autoantibodies that attack the acetylcholine receptors.

D. Inhibits the breakdown of acetylcholine at the neuromuscular junction.3) Myasthenia gravis is due to ____ receptors being blocked and destroyed by antibodies.

A. EpinephrineB. NicotinicC. AcetylcholineD. Transient

4) A client with myasthenia gravis has been receiving Neostigmine (Prostigmin). This drug acts by:

A. Stimulating the cerebral cortexB. Blocking the action of cholinesteraseC. Replacing deficient neurotransmitters

D. Accelerating transmission along neural swaths5) The most significant initial nursing observations that need to be made about a client with myasthenia include:

A. Ability to chew and speak distinctlyB. Degree of anxiety about her diagnosisC. Ability to smile an to close her eyelidsD. Respiratory exchange and ability to swallow

6) In making a diagnosis of myasthenia gravis Edrophonium HCI (Tensilon) is used. The nurse knows that this drug will cause a temporary increase in:

A. Muscle strengthB. SymptomsC. Blood pressureD. Consciousness

7) Helen, a client with myasthenia gravis, begins to experience increased difficulty in swallowing. To prevent aspiration of food, the nursing action that would be most effective would be to:

A. Change her diet order from soft foods to clear liquidsB. Place an emergency tracheostomy set in her roomC. Assess her respiratory status before and after mealsD. Coordinate her meal schedule with the peak effect of her

medication, Mestinon8) Myasthenia gravis reflects a deficiency in communication by _______________ because receptors for this neurotransmitter have been destroyed.

A. acetylcholineB. norepinephrineC. GABAD. dopamine

9) While reviewing a client’s chart, the nurse notices that the female client has myasthenia gravis. Which of the following statements about neuromuscular blocking agents is true for a client with this condition?

A. The client may be less sensitive to the effects of a neuromuscular blocking agent.

B. Succinylcholine shouldn’t be used; pancuronium may be used in a lower dosage.

C. Pancuronium shouldn’t be used; succinylcholine may be used in a lower dosage.

D. Pancuronium and succinylcholine both require cautious administration.10) Which of the following is not an autoimmune disease?

A. Graves diseaseB. Myasthenia gravisC. Insulin-dependent diabetes mellitusD. Alzheimer’s disease

11) A client with myasthenia gravis ask the nurse why the disease has occurred. The nurse bases the reply on the knowledge that there is:

A. A genetic in the production acetylcholineB. A reduced amount of neurotransmitter acetylcholineC. A decreased number of functioning acetylcholine receptor sitesD. An inhibition of the enzyme ACHE leaving the end plates folded

12) The nurse is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by:

A. Eating large, well-balanced mealsB. Doing muscle-strengthening exercisesC. Doing all chores early in the day while less fatiguedD. Taking medications on time to maintain therapeutic blood levels

13) The nurse is caring for a client admitted with suspected myasthenia gravis. Which finding is usually associated with a diagnosis of myasthenia gravis?

A. Visual disturbances, including diplopiaB. Ascending paralysis and loss of motor functionC. Cogwheel rigidity and loss of coordinationD. Progressive weakness that is worse at the day’s end

14) Helen is diagnosed with myasthenia gravis and pyridostigmine bromide (Mestinon) therapy is started. The Mestinon dosage is frequently changed during the first week. While the dosage is being adjusted, the nurse’s priority intervention is to:

A. Administer the medication exactly on timeB. Administer the medication with food or mild

C. Evaluate the client’s muscle strength hourly after medicationD. Evaluate the client’s emotional side effects between doses

15) The initial nursing goal for a client with myasthenia gravis during the diagnostic phase of her hospitalization would be to:

A. Develop a teaching planB. Facilitate psychologic adjustmentC. Maintain the present muscle strengthD. Prepare for the appearance of myasthenic crisis

16) A female client has experienced an episode of myasthenic crisis. The nurse would assess whether the client has precipitating factors such as:

A. Getting too little exerciseB. Taking excess medicationC. Omitting doses of medicationD. Increasing intake of fatty foods

17) Jane, a 20- year old college student is admiited to the hospital with a tentative diagnosis of myasthenia gravis. She is scheduled to have a series of diagnostic studies for myasthenia gravis, including a Tensilon test. In preparing her for this procedure, the nurse explains that her response to the medication will confirm the diagnosis if Tensilon produces:

A. Brief exaggeration of symptomsB. Prolonged symptomatic improvementC. Rapid but brief symptomatic improvementD. Symptomatic improvement of just the ptosis

18) Toy with a tentative diagnosis of myasthenia gravis is admitted for diagnostic make up. Myasthenia gravis can confirmed by:

A. Kernigs signB. Brudzinski’s signC. A positive sweat chloride testD. A positive edrophonium (Tensilon) test

19) A physician diagnoses a client with myasthenia gravis, prescribing pyridostigmine (Mestinon), 60 mg P.O. every 3 hours. Before administering this anticholinesterase agent, the nurse reviews the client’s history. Which preexisting condition would contraindicate the use of pyridostigmine?

A. Ulcerative colitisB. Blood dyscrasia

C. Intestinal obstructionD. Spinal cord injury

20) The nursing assistant reports to you, the RN, that the patient with myasthenia gravis (MG) has an elevated temperature (102.20 F), heart rate of 120/minute, rise in blood pressure (158/94), and was incontinent off urine and stool. What is your best first action at this time?

A. Administer an acetaminophen suppository.B. Notify the physician immediately.C. Recheck vital signs in 1 hour.D. Reschedule patient’s physical therapy.

Answers and Rationales1. A. Prostigmine (neostigmine). Protigmine is used to treat clients

with myasthenia gravis. Atropine (atropine sulfate) is incorrect because it is used to reverse the effects of neostigmine. Didronel (etidronate)is incorrect because the drug is unrelated to the treatment of myasthenia gravis. Tensilon (edrophonium) is incorrect because it is the test for myasthenia gravis.

2. C. Decreases the production of autoantibodies that attack the acetylcholine receptors. Steroids decrease the body’s immune response thus decreasing the production of antibodies that attack the acetylcholine receptors at the neuromuscular junction

3. C. Acetylcholine 4. B. Blocking the action of cholinesterase5. D. Respiratory exchange and ability to swallow . Muscle

weakness can lead to respiratory failure that will require emergency intervention and inability to swallow may lead to aspiration

6. A. Muscle strength. Tensilon, an anticholinesterase drug, causes temporary relief of symptoms of myasthenia gravis in client who have the disease and is therefore an effective diagnostic aid.

7. D. Coordinate her meal schedule with the peak effect of her medication, Mestinon. Dysphagia should be minimized during peak effect of Mestinon, thereby decreasing the probability of aspiration. Mestinon can increase her muscle strength including her ability to swallow.

8. A. acetylcholine 9. D. Pancuronium and succinylcholine both require cautious

administration. The nurse must cautiously administer pancuronium, succinylcholine, and any other neuromuscular blocking agent to a client with myasthenia gravis. Such a client isn’t

less sensitive to the effects of a neuromuscular blocking agent. Either succinylcholine or pancuronium can be administered in the usual adult dosage to a client with myasthenia gravis.

10. D. Alzheimer’s disease 11. C. A decreased number of functioning acetylcholine

receptor sites 12. D. Taking medications on time to maintain therapeutic

blood levels. Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is important. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional stress.

13. D. Progressive weakness that is worse at the day’s end . The client with myasthenia develops progressive weakness that worsens during the day. Visual disturbances, including diplopia is incorrect because it refers to symptoms of multiple sclerosis. Ascending paralysis and loss of motor function is incorrect because it refers to symptoms of Guillain Barre syndrome. Cogwheel rigidity and loss of coordination is incorrect because it refers to Parkinson’s disease.

14. C. Evaluate the client’s muscle strength hourly after medication. Peak response occurs 1 hour after administration and lasts up to 8 hours; the response will influence dosage levels.

15. C. Maintain the present muscle strength. Until diagnosis is confirmed, primary goal should be to maintain adequate activity and prevent muscle atrophy

16. C. Omitting doses of medication. Myasthenic crisis often is caused by undermedication and responds to the administration of cholinergic medications, such as neostigmine (Prostigmin) and pyridostigmine (Mestinon). Cholinergic crisis (the opposite problem) is caused by excess medication and responds to withholding of medications. Too little exercise and fatty food intake are incorrect. Overexertion and overeating possibly could trigger myasthenic crisis.

17. C. Rapid but brief symptomatic improvement . Tensilon acts systemically to increase muscle strength; with a peak effect in 30 seconds, It lasts several minutes.

18. D. A positive edrophonium (Tensilon) test 

19. C. Intestinal obstruction . Anticholinesterase agents such as pyridostigmine are contraindicated in a client with a mechanical obstruction of the intestines or urinary tract, peritonitis, or hypersensitivity to anticholinesterase agents. Ulcerative colitis, blood dyscrasia, and spinal cord injury don’t contraindicate use of the drug.

20. B. Notify the physician immediately.The changes that the nursing assistant is reporting are characteristics of myasthenia crisis, which often follows some type of infection. The patient is at risk for inadequate respiratory function. In addition to notifying the physician, the nurse should carefully monitor the patient’s respiratory status. The patient may need incubation and mechanical ventilation. The nurse would notify the physician before giving the suppository because there may be orders for cultures before giving acetaminophen. This patient’s vital signs need to be re-checked sooner than 1 hour. Rescheduling the physical therapy can be delegated to the unit clerk and is not urgent. Focus: Prioritization

1) Which of the following signs of increased intracranial pressure (ICP) would appear first after head trauma?

A. Bradycardia.B. Large amounts of very dilute urine.C. Restlessness and confusion.D. Widened pulse pressure.

2) The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid?

A. Head mildlineB. Head turned to the sideC. Neck in neutral positionD. Head of bed elevated 30 to 45 degrees

3) Whether Mr Snyder’s tumor is benign or malignant, it will eventually cause increased intracranial pressure. Signs and symptoms of increasing intracranial pressure may include all of the following except:

A. Headache, nausea, and vomitingB. Papilledema, dizziness, mental status changesC. Obvious motor deficitsD. increased pulse rate, drop in blood pressure

4) For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to:

A. Prevent respiratory alkalosis.B. Lower arterial pH.C. Promote carbon dioxide elimination.D. Maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg

5) The nurse is teaching family members of a patient with a concussion about the early signs of increased intracranial pressure (ICP). Which of the following would she cite as an early sign of increased ICP?

A. Decreased systolic blood pressureB. Headache and vomitingC. Inability to wake the patient with noxious stimuliD. Dilated pupils that don’t react to light

6) Later signs of increased intracranial pressure (ICP) later include which of the following?

A. Projectile vomitingB. Increased pulse rateC. Decreased blood pressureD. Narrowed pulse pressure

7) A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood pressure is 90/60 mmHG and the ICP is 18 mmHg; therefore his cerebral perfusion pressure (CPP) is:

A. 52 mm HgB. 88 mm HgC. 48 mm HgD. 68 mm Hg

8) Which of the following types of drugs might be given to control increased intracranial pressure (ICP)?

A. BarbituratesB. Carbonic anhydrase inhibitorsC. AnticholinergicsD. Histamine receptor blockers

9) A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP.

To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning?

A. Phenytoin (Dilantin)B. Mannitol (Osmitrol)C. Lidocaine (Xylocaine)D. Furosemide (Lasix)

10) A nurse in the emergency department is observing a 4-year-old child for signs of increased intracranial pressure after a fall from a bicycle, resulting in head trauma. Which of the following signs or symptoms would be cause for concern?

A. Bulging anterior fontanel.B. Repeated vomiting.C. Signs of sleepiness at 10 PM.D. Inability to read short words from a distance of 18 inches.

11) A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning?

A. Phenytoin (Dilantin)B. Mannitol (Osmitrol)C. Lidocaine (Xylocaine)D. Furosemide (Lasix)

12) A male client is brought to the emergency department due to motor vehicle accident. While monitoring the client, the nurse suspects increasing intracranial pressure when:

A. Client is oriented when aroused from sleep, and goes back to sleep immediately.

B. Blood pressure is decreased from 160/90 to 110/70.C. Client refuses dinner because of anorexia.D. Pulse is increased from 88-96 with occasional skipped beat.

13) Kate with severe head injury is being monitored by the nurse for increasing intracranial pressure (ICP). Which finding should be most indicative sign of increasing intracranial pressure?

A. Intermittent tachycardia

B. PolydipsiaC. TachypneaD. Increased restlessness

Answers and Rationales1. C. Restlessness and confusion. The earliest sign of increased ICP

is a change in mental status. Bradycardia and widened pulse pressure occur later. The patient may void a lot of very dilute urine if his posterior pituitary is damaged.

2. B. Head turned to the side. The head of the client with increased intracranial pressure should be positioned so the head is in a neutral midline position. The nurse should avoid flexing or extending the client’s neck or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure down.

3. D. increased pulse rate, drop in blood pressure . As ICP increases, the pulse rate decreases and the BP rise. However, as ICP continues to rise, vital signs may vary considerably.

4. C. Promote carbon dioxide elimination. The goal of treatment is to prevent acidemia by eliminating carbon dioxide. That is because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP. Preventing respiratory alkalosis and lowering arterial pH may bring about acidosis, an undesirable condition in this case. It isn’t necessary to maintain a PaO2 as high as 80 mm Hg; 60 mm Hg will adequately oxygenate most clients.

5. B. Headache and vomiting . Headache and projectile vomiting are early signs of increased ICP. Decreased systolic blood pressure, unconsciousness, and dilated pupils that don’t reac to light are considered late signs.

6. A. Projectile vomiting . Projectile vomiting may occur with increased pressure on the reflex center in the medulla.

7. A. 52 mm Hg . CPP is derived by subtracting the ICP from the mean arterial pressure (MAP). For adequate cerebral perfusion to take place, the minimum goal is 70 mmHg. The MAP is derived using the following formula:

MAP = ((diastolic blood pressure x 2) + systolic blood pressure) / 3 MAP = ((60 x2) + 90) / 3 MAP = 70 mmHg To find the CPP, subtract the client’s ICP from the MAP; in this

case , 70 mmHg – 18 mmHg = 52 mmHg.

8. A. Barbiturates . Barbiturates may be used to induce a coma in a patient with increased ICP. This decreases cortical activity and cerebral metabolism, reduces cerebral blood volume, decreases cerebral edema, and reduces the brain’s need for glucose and oxygen. Carbonic anhydrase inhibitors are used to decrease ocular pressure or to decrease the serum pH in a patient with metabolic alkalosis. Anticholinergics have many uses including reducing GI spasms. Histamine receptor blockers are used to decrease stomach acidity.

9. C. Lidocaine (Xylocaine) . Administering lidocaine via an endotracheal tube may minimize elevations in ICP caused by suctioning. Although mannitol and furosemide may be given to reduce ICP, they’re administered parenterally, not endotracheally. Phenytoin doesn’t reduce ICP directly but may be used to abolish seizures, which can increase ICP. However, phenytoin isn’t administered endotracheally.

10. B. Repeated vomiting. Increased pressure caused by bleeding or swelling within the skull can damage delicate brain tissue and may become life threatening. Repeated vomiting can be an early sign of pressure as the vomit center within the medulla is stimulated. The anterior fontanel is closed in a 4-year-old child. Evidence of sleepiness at 10 PM is normal for a four year old. The average 4-year-old child cannot read yet, so this too is normal.

11. C. Lidocaine (Xylocaine) . Administering lidocaine via an endotracheal tube may minimize elevations in ICP caused by suctioning. Although mannitol and furosemide may be given to reduce ICP, they’re administered parenterally, not endotracheally. Phenytoin doesn’t reduce ICP directly but may be used to abolish seizures, which can increase ICP. However, phenytoin isn’t administered endotracheally.

12. A. Client is oriented when aroused from sleep, and goes back to sleep immediately.This suggests that the level of consciousness is decreasing.

13. D. Increased restlessness . Restlessness indicates a lack of oxygen to the brain stem which impairs the reticular activating system.

1) Which patient should be assigned to the traveling nurse, new to neurologic nursing care, who has been on the neurologic unit for 1 week?

A. A 34-year-old patient newly diagnosed with multiple sclerosis (MS)

B. A 68-year-old patient with chronic amyotrophic lateral sclerosis (ALS)

C. A 56-year-old patient with Guillain-Barre syndrome (GBS) in respiratory distress

D. A 25-year-old patient admitted with CA level spinal cord injury (SCI)2) A female client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?

A. “You may have difficulty believing this, but the paralysis caused by this disease is temporary.”

B. “You’ll have to accept the fact that you’re permanently paralyzed. However, you won’t have any sensory loss.”

C. “It must be hard to accept the permanency of your paralysis.”D. “You’ll first regain use of your legs and then your arms.”

3) A client with Guillain-Barré syndrome has been on a ventilator for three weeks, and can communicate only with eye blinks because of quadriplegia. The intensive care nursing staff sometimes have no time for this tedious communication process. The client’s family comes infrequently since they run a family-owned restaurant that does not close until visiting hours are over. How should the nurse respond to the family’s request for exemption from visiting hours?

A. Arrange for a volunteer to stay with the client during the day to provide for socialization needs and to facilitate communication with staff.

B. Explain to the family that consistency in enforcing rules is important to prevent complaints from the families of other clients.

C. Suggest that the family visit in shifts during the normal visiting hours, since the client needs to sleep at night.

D. Make an exception to visiting regulations because of the long-term nature of the client’s recovery and the need for family support.4) A male client is hospitalized with Guillain-Barre Syndrome. Which assessment finding is the most significant?

A. Even, unlabored respirationsB. Soft, non distended abdomenC. Urine output of 50 ml/hrD. Warm skin

5) Female client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. The nurse inquires during the nursing admission interview if the client has history of:

A. Seizures or trauma to the brainB. Meningitis during the last 5 yearsC. Back injury or trauma to the spinal cordD. Respiratory or gastrointestinal infection during the previous month.

6) A female client with Guillian-Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which of the following strategies would the nurse incorporate in the plan of care to help the client cope with this illness?

A. Giving client full control over care decisions and restricting visitorsB. Providing positive feedback and encouraging active range of motionC. Providing information, giving positive feedback, and encouraging

relaxationD. Providing intravaneously administered sedatives, reducing

distractions and limiting visitors7) A 40n year old male patient is complaining of chronic progressive and mental deterioration is admitted to the unit. The nurse recognizes that these characteristics indicate a disease that results in degeneration of the basal ganglia and cerebral cortex. The disease is called:

A. multiple sclerosisB. myasthenia gravisC. Huntington’s diseaseD. Guillain-Barre syndrome

8) A male client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?

A. pH, 5.0; PaCO2 30 mm HgB. pH, 7.40; PaCO2 35 mm HgC. pH, 7.35; PaCO2 40 mm HgD. pH, 7.25; PaCO2 50 mm Hg

Answers and Rationales1. B. A 68-year-old patient with chronic amyotrophic lateral

sclerosis (ALS) . The traveling is relatively new to neurologic nursing and should be assigned patients whose conditions are stable

and not complex. The newly diagnosed patient will need to be transferred to the ICU. The patient with C4 SCI is at risk for respiratory arrest. All three of these patients should be assigned to nurses experienced in neurologic nursing care. Focus: Assignment

2. A. “You may have difficulty believing this, but the paralysis caused by this disease is temporary.” The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs.

3. D. Make an exception to visiting regulations because of the long-term nature of the client’s recovery and the need for family support.The need for family support is vital to prevent discouragement and depression. A volunteer will not take the place of family. The need for family support is vital to prevent discouragement and depression, even at the risk of offending the families of other patients. Loss of a breadwinner during the lengthy recovery process may add financial problems for the family. Guillain-Barré syndrome is characterized by the onset of ascending paralysis, which may include respiratory muscles. Persons with Guillain-Barré syndrome may remain ventilator-dependent for weeks, but have full consciousness. The prognosis for recovery from Guillain-Barré syndrome is good, but is very much dependent upon the level of supportive care during the acute stage.

4. A. Even, unlabored respirations5. D. Respiratory or gastrointestinal infection during the

previous month. Guillain-Barré syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits. Occasionally, the syndrome can be triggered by vaccination or surgery.

6. C. Providing information, giving positive feedback, and encouraging relaxation. The client with Guillain-Barré syndrome experiences fear and anxiety from the ascending paralysis and sudden onset of the disorder. The nurse can alleviate these fears by providing accurate information about the client’s condition, giving expert care and positive feedback to the client, and encouraging relaxation and distraction. The family can become involved with selected care activities and provide diversion for the client as well.

7. C. Huntington’s disease. Huntington’s disease is a hereditary disease in which degeneration of the basal ganglia and cerebral

cortex causes chronic progressive chorea (muscle twitching) and mental deterioration, ending in dementia. Huntington’s disease usually strikes people ages 25 to 55.

8. D. pH, 7.25; PaCO2 50 mm Hg. In respiratory acidosis, ABG analysis reveals an arterial pH below 7.35 and partial pressure of arterial carbon dioxide (PaCO2) above 45 mm Hg. Therefore, the combination of a pH value of 7.25 and a PaCO2 value of 50 mm Hg confirms respiratory acidosis. A pH value of 5.0 with a PaCO2 value of 30 mm Hg indicates respiratory alkalosis.

1) Oral steroids may help reduce the symptoms of a Bell’s Palsy.

A. TrueB. False

2) A male client with Bell’s palsy asks the nurse what has caused this problem. The nurse’s response is based on an understanding that the cause is:

A. Unknown, but possibly includes ischemia, viral infection, or an autoimmune problem

B. Unknown, but possibly includes long-term tissue malnutrition and cellular hypoxia

C. Primary genetic in origin, triggered by exposure to meningitisD. Primarily genetic in origin, triggered by exposure to neurotoxins

3) Bell’s palsy is a form of facial paralysis caused by a dysfunction of the 8th cranial nerve.

A. TrueB. False

4) Failure of the eye to close properly can occur, which may result in damage to the cornea.

A. TrueB. False

5) When the nurse performs a neurologic assessment on Anne Jones, her pupils are dilated and don’t respond to light.

A. glaucomaB. damage to the third cranial nerveC. damage to the lumbar spine

D. Bell’s palsy6) The nurse is aware that Bell’s palsy affects which cranial nerve?

A. 2nd CN (Optic)B. 3rd CN (Occulomotor)C. 4th CN (Trochlear)D. 7th CN (Facial)

7) Which of the following diseases has not been directly linked with Bell’s palsy?

A. AIDSB. DiabetesC. Lyme diseaseD. Alzheimer’s disease

8) Bell’s palsy can be associated with arm and leg weakness and difficulty finding the right words.

A. TrueB. False

9) The nurse has given the male client with Bell’s palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs additional information if the client states that he or she will:

A. Exposure to cold and draftsB. Massage the face with a gentle upward motionC. Perform facial exercisesD. Wrinkle the forehead, blow out the cheeks, and whistle

10) Bell’s palsy is a disorder of which cranial nerve?

A. Facial (VII)B. Trigeminal (V)C. Vestibulocochlear (VIII)D. Vagus (X)

Answers and Rationales1. A. True . Oral steroids can improve outcome but need to be given

early after the onset of symptoms.2. A. Unknown, but possibly includes ischemia, viral infection,

or an autoimmune problem . Bell’s palsy is a one-sided facial paralysis from compression of the facial nerve. The exact cause is unknown, but may include vascular ischemia, infection, exposure to

viruses such as herpes zoster or herpes simplex, autoimmune disease, or a combination of these factors.

3. B. False. Bell’s palsy results from a dysfunction of the 7th or facial cranial nerve.

4. A. True . To try and avoid corneal damage the lid can be taped shut at night and eye drops used to lubricate the eye.

5. B. damage to the third cranial nerve . The third cranial nerve (oculomotor) is responsible for pupil constriction. When there is damage to the nerve, the pupils remain dilated and don’t respond to light. Glaucoma, lumbar spine injury, and Bell’s palsy won’t affect pupil constriction.

6. D. 7th CN (Facial) . Bells’ palsy is the paralysis of the motor component of the 7th caranial nerve, resulting in facial sag, inability to close the eyelid or the mouth, drooling, flat nasolabial fold and loss of taste on the affected side of the face.

7. D. Alzheimer’s disease8. B. False . These signs indicate a stroke and if present the patient

needs urgent medical attention.9. A. Exposure to cold and drafts . Prevention of muscle atrophy

with Bell’s palsy is accomplished with facial massage, facial exercises, and electrical stimulation of the nerves. Exposure to cold or drafts is avoided. Local application of heat to the face may improve blood flow and provide comfort.

10. A. Facial (VII) . Bell’s palsy is characterized by facial dysfunction, weakness, and paralysis. Trigeminal neuralgia is a disorder of the trigeminal nerve and causes facial pain.Meniere’s syndrome is a disorder of the vestibulocochlear nerve. Guillain-Barre syndrome is a disorder of the vagus nerve.

1) The client with Alzheimer’s disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting:

A. AgnosiaB. ApraxiaC. AnomiaD. Aphasia

2) A client with Alzheimer’s disease is awaiting placement in a skilled nursing facility. Which long-term plans would be most therapeutic for the client?

A. Placing mirrors in several locations in the home

B. Placing a picture of herself in her bedroomC. Placing simple signs to indicate the location of the bedroom,

bathroom, and so onD. Alternating healthcare workers to prevent boredom

3) The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as:

A. Chronic fatigue syndromeB. Normal agingC. SundowningD. Delusions

4) Which age group has the highest rate of Alzheimer’s cases reported?

A. 85 and olderB. 74 to 84C. 65 to 74D. 55 to 65

5) A 75 year old client is admitted to the hospital with the diagnosis of dementia of the Alzheimer’s type and depression. The symptom that is unrelated to depression would be?

A. Apathetic response to the environmentB. “I don’t know” answer to questionsC. Shallow of labile effectD. Neglect of personal hygiene

6) The client with confusion says to the nurse, “I haven’t had anything to eat all day long. When are they going to bring breakfast?” The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response would be best for the nurse to make?

A. “You know you had breakfast 30 minutes ago.”B. “I am so sorry that they didn’t get you breakfast. I’ll report it to the

charge nurse.”C. “I’ll get you some juice and toast. Would you like something else?”D. “You will have to wait a while; lunch will be here in a little while.”

7) The nurse is caring for a client with stage III Alzheimer’s disease. A characteristic of this stage is:

A. Memory loss

B. Failing to recognize familiar objectsC. Wandering at nightD. Failing to communicate

8) The primary nursing intervention in working with a client with moderate stage dementia is ensuring that the client:

A. receives adequate nutrition and hydrationB. will reminisce to decrease isolationC. remains in a safe and secure environmentD. independently performs self care

9) During the evaluation of the quality of home care for a client with Alzheimer’s disease, the priority for the nurse is to reinforce which statement by a family member?

A. At least 2 full meals a day is eaten.B. We go to a group discussion every week at our community center.C. We have safety bars installed in the bathroom and have 24 hour

alarms on the doors.D. The medication is not a problem to have it taken 3 times a day.

10) Signs of Alzheimer’s include which of these symptoms?

A. Loss of memoryB. Increase in irritabilityC. RestlessnessD. All of the above

11) Which neurotransmitter has been implicated in the development of Alzheimer’s disease?

A. AcetylcholineB. DopamineC. EpinephrineD. Serotonin

12) Alzheimer’s is an INSIDIOUS disease. This means:

A. that it is terminalB. that is can be curedC. that it sneaks up on a person over timeD. that it only affects the elderlyE. none of the above

13) Edward, a 66 year old client with slight memory impairment and poor concentration is diagnosed with primary degenerative dementia of the

Alzheimer’s type. Early signs of this dementia include subtle personality changes and withdrawal from social interactions. To assess for progression to the middle stage of Alzheimer’s disease, the nurse should observe the client for:

A. Occasional irritable outbursts.B. Impaired communication.C. Lack of spontaneity.D. Inability to perform self-care activities.

14) Which of the following is not directly related with Alzheimer’s disease?

A. Senile plaquesB. Diabetes mellitusC. TanglesD. Dementia

15) Alzheimer’s is the most common form of which of these?

A. MalnutritionB. DementiaC. FatigueD. Psychosis

16) Which nursing intervention is most appropriate for a client with Alzheimer’s disease who has frequent episodes emotional lability?

A. Attempt humor to alter the client mood.B. Explore reasons for the client’s altered mood.C. Reduce environmental stimuli to redirect the client’s attention.D. Use logic to point out reality aspects.

17) Which of the following is the most common cause of dementia among elderly persons?

A. Parkinson’s diseaseB. Multiple sclerosisC. Amyotrophic lateral sclerosis (Lou Gerhig’s disease)D. Alzheimer’s disease

18) Rosana is in the second stage of Alzheimer’s disease who appears to be in pain. Which question by Nurse Jenny would best elicit information about the pain?

A. “Where is your pain located?”B. “Do you hurt? (pause) “Do you hurt?”

C. “Can you describe your pain?”D. “Where do you hurt?”

19) Rosana is in the second stage of Alzheimer’s disease who appears to be in pain. Which question by Nurse Jenny would best elicit information about the pain?

A. “Where is your pain located?”B. “Do you hurt? (pause) “Do you hurt?”C. “Can you describe your pain?”D. “Where do you hurt?”

20) How is Alzheimer’s diagnosed?

A. Mental-status testsB. Blood testsC. Neurological testsD. All of the above

21) The usual span of years that Alzheimer’s may progress in the patient is:

A. three to five yearsB. two to twenty yearsC. fifty to sixty yearsD. 6 months to one yearE. eight to ten years

22) Scientists believe that _________________ develop in the brain of an Alzheimer’s patient, and may be a cause of the disease.

A. cholesterolsB. tumorsC. ruptured blood vesselsD. plaques and tangles

23) To encourage adequate nutritional intake for a female client with Alzheimer’s disease, the nurse should:

A. stay with the client and encourage him to eat.B. help the client fill out his menu.C. give the client privacy during meals.D. fill out the menu for the client.

24) A 93 year-old female with a history of Alzheimer’s Disease gets admitted to an Alzheimer’s unit. The patient has exhibited signs of increased confusion

and limited stability with gait. Moreover, the patient is refusing to use a w/c. Which of the following is the most appropriate course of action for the nurse?

A. Recommend the patient remain in her room at all times.B. Recommend family members bring pictures to the patient’s room.C. Recommend a speech therapy consult to the doctor.D. Recommend the patient attempt to walk pushing the w/c for safety.

25) The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer’s disease. Which side effect is most often associated with this drug?

A. Urinary incontinenceB. HeadachesC. ConfusionD. Nausea

26) A patient with Stage One Alzheimers might exhibit these behaviors:

A. forgetting namesB. missing appointmentsC. getting lost while drivingD. all of the aboveE. none of the above

27) Which of the following diseases has not been directly linked with Bell’s palsy?

A. AIDSB. DiabetesC. Lyme diseaseD. Alzheimer’s disease

28) The symptom of dementia that involved a more confused state after dark is called:

A. dark retreatB. sundowningC. agitationD. dark reaction

29) Which of these is the strongest risk factor for developing the Alzheimer’s disease?

A. HeredityB. Age

C. Exposure to toxinsD. None of the above

30) The priority of care for a client with Alzheimer’s disease is

A. Help client develop coping mechanismB. Encourage to learn new hobbies and interestC. Provide him stimulating environmentD. Simplify the environment to eliminate the need to make chores

31) An elderly client with Alzheimer’s disease becomes agitated and combative when a nurse approaches to help with morning care. The most appropriate nursing intervention in this situation would be to:

A. Tell the client family that it is time to get dressed.B. Obtain assistance to restrain the client for safety.C. Remain calm and talk quietly to the client.D. Call the doctor and request an order for sedation.

32) Thomas Elison is a 79 year old man who is admitted with diagnosis of dementia. The doctor orders a series of laboratory tests to determine whether Mr. Elison’s dementia is treatable. The nurse understands that the most common cause of dementia in this population is:

A. AIDSB. Alzheimer’s diseaseC. Brain tumorsD. Vascular disease

33) A patient who has been admitted to the medical unit with new-onset angina also has a diagnosis of Alzheimer’s disease. Her husband tells you that he rarely gets a good night’s sleep because he needs to be sure she does not wander during the night. He insists on checking each of the medications you give her to be sure they are the same as the ones she takes at home. Based on this information, which nursing diagnosis is most appropriate for this patient?

A. Decreased Cardiac Output related to poor myocardial contractilityB. Caregiver Role Strain related to continuous need for providing careC. Ineffective Therapeutic Regimen Management related to poor

patient memoryD. Risk for Falls related to patient wandering behavior during the night

34) Physiologically, what happens to the brain as Alzheimer’s progresses?

A. Tissue swellsB. Fluid collectsC. Many cells dieD. Brain-stem atrophies

35) The nurse is aware that the following ways in vascular dementia different from Alzheimer’s disease is:

A. Vascular dementia has more abrupt onsetB. The duration of vascular dementia is usually briefC. Personality change is common in vascular dementiaD. The inability to perform motor activities occurs in vascular dementia

36) A 65 years old client is in the first stage of Alzheimer’s disease. Nurse Patricia should plan to focus this client’s care on:

A. Offering nourishing finger foods to help maintain the client’s nutritional status.

B. Providing emotional support and individual counseling.C. Monitoring the client to prevent minor illnesses from turning into

major problems.D. Suggesting new activities for the client and family to do together.

37) A nurse caring to a client with Alzheimer’s disease overheard a family member say to the client, “if you pee one more time, I won’t give you any more food and drinks”. What initial action is best for the nurse to take?

A. Take no action because it is the family member saying that to the client

B. Talk to the family member and explain that what she/he has said is not appropriate for the client

C. Give the family member the number for an Elder Abuse Hot lineD. Document what the family member has said

38) Alzheimer’s disease is the secondary diagnosis of a client admitted with myocardial infarction. Which nursing intervention should appear on this client’s plan of care?

A. Perform activities of daily living for the client to decease frustration.B. Provide a stimulating environment.C. Establish and maintain a routine.D. Try to reason with the client as much as possible.

39) As the manager in a long-term-care (LTC) facility, you are in charge of developing a standard plan of care for residents with Alzheimer’s disease.

Which of these nursing tasks is best to delegate to the LPN team leaders working in the facility?

A. Check for improvement in resident memory after medication therapy is initiated.

B. Use the Mini-Mental State Examination to assess residents every 6 months.

C. Assist residents to toilet every 2 hours to decrease risk for urinary intolerance.

D. Develop individualized activity plans after consulting with residents and family.40) The nurse would expect a client with early Alzheimer’s disease to have problems with:

A. Balancing a checkbook.B. Self-care measures.C. Relating to family members.D. Remembering his own name

Answers and Rationales1. B. Apraxia . Apraxia is the inability to use objects appropriately.

Agnosia is loss of sensory comprehension, anomia is the inability to find words, and aphasia is the inability to speak or understand .

2. C. Placing simple signs to indicate the location of the bedroom, bathroom, and so on. Placing simple signs that indicate the location of rooms where the client sleeps, eats, and bathes will help the client be more independent. Providing mirrors and pictures is not recommended with the client who has Alzheimer’s disease because mirrors and pictures tend to cause agitation, and alternating healthcare workers confuses the client.

3. C. Sundowning . Increased confusion at night is known as “sundowning” syndrome. This increased confusion occurs when the sun begins to set and continues during the night.

4. A. 85 and older5. C. Shallow of labile effect 6. C. “I’ll get you some juice and toast. Would you like

something else?”. The client who is confused might forget that he ate earlier. Don’t argue with the client. Simply get him something to eat that will satisfy him until lunch.

7. B. Failing to recognize familiar objects . In stage III of Alzheimer’s disease, the client develops agnosia, or failure to recognize familiar objects.

8. C. remains in a safe and secure environment. Safety is a priority consideration as the client’s cognitive ability deteriorates.. receiving adequate nutrition and hydration is appropriate interventions because the client’s cognitive impairment can affect the client’s ability to attend to his nutritional needs, but it is not the priority Patient is allowed to reminisce but it is not the priority. The client in the moderate stage of Alzheimer’s disease will have difficulty in performing activities independently

9. C. We have safety bars installed in the bathroom and have 24 hour alarms on the doors. We have safety bars installed in the bathroom and have 24 hour alarms on the doors. Ensuring safety of the client with increasing memory loss is a priority of home care. Note all options are correct statements. However, safety is most important to reinforce.

10. D. All of the above. Alzheimer’s sufferers also can’t learn new information and tend to repeat themselves.

11. A. Acetylcholine. A relative deficiency of acetylcholine is associated with this disorder. The drugs used in the early stages of Alzheimer’s disease will act to increase available acetylcholine in the brain. The remaining neurotransmitters have not been implicated in Alzheimer’s disease.

12. C. that it sneaks up on a person over time 13. B. Impaired communication. Initially, memory impairment

may be the only cognitive deficit in a client with Alzheimer’s disease. During the early stage of this disease, subtle personality changes may also be present. However, other than occasional irritable outbursts and lack of spontaneity, the client is usually cooperative and exhibits socially appropriate behavior. Signs of advancement to the middle stage of Alzheimer’s disease include exacerbated cognitive impairment with obvious personality changes and impaired communication, such as inappropriate conversation, actions, and responses. During the late stage, the client can’t perform self-care activities and may become mute.

14. B. Diabetes mellitus 15. B. Dementia. It is a collection of symptoms characterized by

decreasing intellectual and social abilities.16. C. Reduce environmental stimuli to redirect the client’s

attention. The client with Alzheimer’s disease can have frequent episode of labile mood, which can best be handled by decreasing a stimulating environment and redirecting the client’s attention. An over stimulating environment may cause the labile mood, which will

be difficult for the client to understand. The client with Alzheimer’s disease loses the cognitive ability to respond to either humor or logic. The client lacks any insight into his or her own behavior and therefore will be unaware of any causative factors.

17. D. Alzheimer’s disease . Alzheimer;s disease, sometimes known as senile dementia of the Alzheimer’s type or primary degenerative dementia, is an insidious; progressive, irreversible, and degenerative disease of the brain whose etiology is still unknown. Parkinson’s disease is a neurologic disorder caused by lesions in the extrapyramidial system and manifested by tremors, muscle rigidity, hypokinesis, dysphagia, and dysphonia. Multiple sclerosis, a progressive, degenerative disease involving demyelination of the nerve fibers, usually begins in young adulthood and is marked by periods of remission and exacerbation. Amyotrophic lateral sclerosis, a disease marked by progressive degeneration of the neurons, eventually results in atrophy of all the muscles; including those necessary for respiration.

18. B. “Do you hurt? (pause) “Do you hurt?” . When speaking to a client with Alzheimer’s disease, the nurse should use close-ended questions.Those that the client can answer with “yes” or “no”

19. B. “Do you hurt? (pause) “Do you hurt?” When speaking to a client with Alzheimer’s disease, the nurse should use close-ended questions.Those that the client can answer with “yes” or “no” whenever possible and avoid questions that require the client to make choices. Repeating the question aids comprehension.

20. D. D. All of the above. No single test identifies Alzheimer’s. Lab tests help rule out other disorders that may produce similar symptoms. Neurological and mental-status tests reveal cognitive-function deficits.

21. B. two to twenty years 22. D. plaques and tangles23. A. stay with the client and encourage him to eat. Staying

with the client and encouraging him to feed himself will ensure adequate food intake. A client with Alzheimer’s disease can forget how to eat. Allowing privacy during meals, filling out the menu, or helping the client to complete the menu doesn’t ensure adequate nutritional intake.

24. B. Recommend family members bring pictures to the patient’s room. Stimulation in the form of pictures may decrease signs of confusion.

25. D. Nausea . Nausea and gastrointestinal upset are very common in clients taking acetlcholinesterase inhibitors such as Exelon. Other side effects include liver toxicity, dizziness, unsteadiness, and clumsiness. The client might already be experiencing urinary incontinence or headaches, but they are not necessarily associated; and the client with Alzheimer’s disease is already confused.

26. D. all of the above 27. D. Alzheimer’s disease 28. B. sundowning 29. B. Age . Although some studies have shown an association

between certain modifiable lifestyle factors and a reduced risk for Alzheimer’s disease, the National Institutes of Health says that age is the strongest known risk factor where most people receive the diagnosis after age 60. An early onset familial form can also occur, although it is rare.

30. D. Simplify the environment to eliminate the need to make chores 

31. C. Remain calm and talk quietly to the client. Maintaining a calm approach when intervening with an agitated client is extremely important. Telling the client firmly that it is time to get dressed may increase his agitation, especially if the nurse touches him. Restraints are a last resort to ensure client safety and are inappropriate in this situation. Sedation should be avoided, if possible, because it will interfere with CNS functioning and may contribute to the client’s confusion.

32. B. Alzheimer’s disease . Alzheimer’s disease is the most common cause of dementia in the elderly population. AIDS, brain tumors and vascular disease are all less common causes of progressive loss of mental function in elderly patients.

33. B. Caregiver Role Strain related to continuous need for providing care. The husband’s statement about lack of sleep and anxiety over whether the patient is receiving the correct medications are behaviors that support this diagnosis. There is no evidence that the patient’s cardiac output is decreased. The husband’s statements about how he monitors the patient and his concern with medication administration indicate that the Risk for Ineffective Therapeutic Regimen Management and falls are not priorities at this time. Focus: Prioritization

34. C. Many cells die . Nerve cells change in certain parts of the brain, which causes brain cells to die. The loss of cells impairs thinking and judgment.

35. A. Vascular dementia has more abrupt onset . Vascular dementia differs from Alzheimer’s disease in that it has a more abrupt onset and runs a highly variable course. Personally change is common in Alzheimer’s disease. The duration of delirium is usually brief. The inability to carry out motor activities is common in Alzheimer’s disease.

36. B. Providing emotional support and individual counseling. Clients in the first stage of Alzheimer’s disease are aware that something is happening to them and may become overwhelmed and frightened. Therefore, nursing care typically focuses on providing emotional support and individual counseling. The other options are appropriate during the second stage of Alzheimer’s disease, when the client needs continuous monitoring to prevent minor illnesses from progressing into major problems and when maintaining adequate nutrition may become a challenge. During this stage, offering nourishing finger foods helps clients to feed themselves and maintain adequate nutrition.

37. B. Talk to the family member and explain that what she/he has said is not appropriate for the client . This response is the most direct and immediate. This is a case of potential need for advocacy and patient’s rights.

38. C. Establish and maintain a routine. Establishing and maintaining a routine is essential to decreasing extraneous stimuli. The client should participate in daily care as much as possible. Attempting to reason with such clients isn’t successful, because they can’t participate in abstract thinking.

39. A. Check for improvement in resident memory after medication therapy is initiated. LPN education and team leader responsibilities include checking for the therapeutic and adverse effects of medications. Changes in the residents’ memory would be communicated to the RN supervisor, who is responsible for overseeing the plan of care for each resident. Assessment for changes on the Mini-Mental State Examination and developing the plan of care are RN responsibilities. Assisting residents with personal care and hygiene would be delegated to nursing assistants working the LTC facility. Focus: Delegation

40. A. Balancing a checkbook. In the early stage of Alzheimer’s disease, complex tasks (such as balancing a checkbook) would be

the first cognitive deficit to occur. The loss of self-care ability, problems with relating to family members, and difficulty remembering one’s own name are all areas of cognitive decline that occur later in the disease process.