Chapter 39: Concepts of Care for Patients
with Problems of the Central Nervous
System: The Brain
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse assesses a client who has a history of migraines. Which symptom would the
nurse identify as an early sign of a migraine with aura?
a. Vertigo
b. Lethargy
c. Visual disturbances
d. Numbness of the tongue
ANS: C
Early warning of impending migraine with aura usually consists of visual changes,
flashing lights, or diplopia. The other symptoms are not associated with an impending
migraine with aura.
DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment
KEY: Migraine headache, Assessment MSC: Client Needs
Category: Physiological Integrity: Physiological Adaptation
2. The nurse obtains a health history on a client prior to administering prescribed
sumatriptan succinate for migraine headaches. Which condition would alert the nurse
to withhold the medication and contact the primary health care provider?
a. Bronchial asthma
, b. Heart disease
c. Diabetes mellitus
d. Rheumatoid arthritis
ANS: B
Sumatriptan succinate effectively reduces pain and other associated symptoms of
migraine headache by binding to serotonin receptors and triggering cranial
vasoconstriction. Vasoconstrictive effects are not confined to the cranium and can
cause coronary vasospasm in clients with heart disease, hypertension, or Prinzmetal
angina. The other conditions would not affect the client’s treatment.
DIF: Applying TOP: Integrated Process: Nursing Process: Analysis
KEY: Migraine headache, Drug therapy MSC: Client Needs
Category: Physiological Integrity: Pharmacological and Parenteral Therapies
3. The nurse assesses a client with a history of epilepsy who experiences stiffening of the
muscles of the arms and legs, followed by an immediate loss of consciousness and
jerking of all extremities. How would the nurse document this type of seizure?
a. Atonic
b. Myoclonic
c. Absence
d. Tonic-clonic
ANS: D
Seizure activity that begins with stiffening of the arms and legs, followed by loss of
consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure.
An atonic seizure presents as a sudden loss of muscle tone followed by postictal
confusion. A myoclonic seizure presents with a brief jerking or stiffening of
extremities that may occur singly or in groups. Absence seizures present with
automatisms, and the client is unaware of his or her environment.
, DIF: Remembering TOP: Integrated Process: Communication and
Documentation KEY: Epilepsy, Assessment MSC: Client
Needs Category: Physiological Integrity: Physiological Adaptation
4. The nurse witnesses a client begin to experience a tonic-clonic seizure and loss of
consciousness. What action would the nurse take first?
a. Start fluids via a large-bore catheter.
b. Administer IV push diazepam.
c. Turn the client’s head to the side.
d. Prepare to intubate the client.
ANS: C
The nurse would turn the client’s head to the side to prevent aspiration and allow
drainage of secretions. Anticonvulsants are administered on a routine basis if a seizure
is sustained. If the seizure is sustained (status epilepticus), the client must be intubated
and would be administered oxygen, 0.9% sodium chloride, and IV push lorazepam or
diazepam.
DIF: Applying TOP: Integrated Process: Nursing Process: Planning and
Implementation KEY: Seizure, Aspiration precautions MSC: Client
Needs Category: Safe and Effective Care Environment: Management of Care
5. A nurse cares for a client who is experiencing status epilepticus. Which prescribed
medication would the nurse anticipate to prepare for administration?
a. Atenolol
b. Lorazepam
c. Phenytoin
d. Lisinopril
ANS: B
with Problems of the Central Nervous
System: The Brain
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse assesses a client who has a history of migraines. Which symptom would the
nurse identify as an early sign of a migraine with aura?
a. Vertigo
b. Lethargy
c. Visual disturbances
d. Numbness of the tongue
ANS: C
Early warning of impending migraine with aura usually consists of visual changes,
flashing lights, or diplopia. The other symptoms are not associated with an impending
migraine with aura.
DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment
KEY: Migraine headache, Assessment MSC: Client Needs
Category: Physiological Integrity: Physiological Adaptation
2. The nurse obtains a health history on a client prior to administering prescribed
sumatriptan succinate for migraine headaches. Which condition would alert the nurse
to withhold the medication and contact the primary health care provider?
a. Bronchial asthma
, b. Heart disease
c. Diabetes mellitus
d. Rheumatoid arthritis
ANS: B
Sumatriptan succinate effectively reduces pain and other associated symptoms of
migraine headache by binding to serotonin receptors and triggering cranial
vasoconstriction. Vasoconstrictive effects are not confined to the cranium and can
cause coronary vasospasm in clients with heart disease, hypertension, or Prinzmetal
angina. The other conditions would not affect the client’s treatment.
DIF: Applying TOP: Integrated Process: Nursing Process: Analysis
KEY: Migraine headache, Drug therapy MSC: Client Needs
Category: Physiological Integrity: Pharmacological and Parenteral Therapies
3. The nurse assesses a client with a history of epilepsy who experiences stiffening of the
muscles of the arms and legs, followed by an immediate loss of consciousness and
jerking of all extremities. How would the nurse document this type of seizure?
a. Atonic
b. Myoclonic
c. Absence
d. Tonic-clonic
ANS: D
Seizure activity that begins with stiffening of the arms and legs, followed by loss of
consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure.
An atonic seizure presents as a sudden loss of muscle tone followed by postictal
confusion. A myoclonic seizure presents with a brief jerking or stiffening of
extremities that may occur singly or in groups. Absence seizures present with
automatisms, and the client is unaware of his or her environment.
, DIF: Remembering TOP: Integrated Process: Communication and
Documentation KEY: Epilepsy, Assessment MSC: Client
Needs Category: Physiological Integrity: Physiological Adaptation
4. The nurse witnesses a client begin to experience a tonic-clonic seizure and loss of
consciousness. What action would the nurse take first?
a. Start fluids via a large-bore catheter.
b. Administer IV push diazepam.
c. Turn the client’s head to the side.
d. Prepare to intubate the client.
ANS: C
The nurse would turn the client’s head to the side to prevent aspiration and allow
drainage of secretions. Anticonvulsants are administered on a routine basis if a seizure
is sustained. If the seizure is sustained (status epilepticus), the client must be intubated
and would be administered oxygen, 0.9% sodium chloride, and IV push lorazepam or
diazepam.
DIF: Applying TOP: Integrated Process: Nursing Process: Planning and
Implementation KEY: Seizure, Aspiration precautions MSC: Client
Needs Category: Safe and Effective Care Environment: Management of Care
5. A nurse cares for a client who is experiencing status epilepticus. Which prescribed
medication would the nurse anticipate to prepare for administration?
a. Atenolol
b. Lorazepam
c. Phenytoin
d. Lisinopril
ANS: B
