Ch.13 & Ch.14 Nursing
Which question is likely to elicit the most valid response from the patient who is being interviewed about a neurologic problem?
"Can you describe the sensations you are having?"
What Glasgow Coma Scale rating would a patient receive who opens the eyes spontaneously, but has incomprehensible speech and obeys commands for movement?
12
The nurse assures an anxious family member of a 92-year-old patient who is demonstrating signs of dementia that many causes of dementia are reversible and preventable. What is one example?
Hypotension
sensory aphasia or receptive aphasia
Inability to comprehend the spoken or written word.
Anomic Aphasia
Inability to name objects
Motor aphasia or expressive aphasia
Inability to speak or write using symbols of speech
Global aphasia
Inability to understand the spoken word or to speak
One of the housekeepers splashes a chemical in the eyes. What should be the first priority?
Irrigate with normal saline solution for 20 minutes
The nurse is aware that the drug t-PA (Activase), a tissue plasminogen activator, must be given in____hours of the onset of symptoms to have maximum benefit.
3 hours
The nurse is aware that the patient has 20/40 vision. This means that the patient can see at 20 feet what the normal eye can see at _______ feet.
40
The nurse would need to determine how this patient's visual impairment affects normal functioning.
The patient tells the nurse that he is legally blind. How would this information impact the nurse's plan of care for this patient?
What is the process when the lens of the eye changes its curvature to focus on the retina?
Accommodation
How would a nurse record the behavior when a patient with Alzheimer disease attempts to eat using a napkin rather than a fork?
Agnosia
When the newly blind male home health patient asks the nurse how he might get assistance, who might the nurse suggest he contact?
American Foundation for the Blind for a list of agencies
The nurse is aware that when assessing a patient by the FOUR score coma scale, the patient is assessed in four categories: eye response, brainstem reflexes, motor response, and respiration. How are these results reported?
As individual scores in each category
Which foods should the person who suffers from migraine headaches avoid? (Select all that apply.)
Caffeine
What does the nurse know about the stroke patient who has expressive aphasia?
Can understand the spoken word, but cannot speak
What does a tympanoplasty correct?
Conductive hearing loss
What is the cardinal sign of increased intracranial pressure in a brain injured patient?
Decrease in the level of consciousness
What is the nurse assessing when asking the patient, "Who is the president of the United States?" during a level of consciousness assessment?
Fund of knowledge
Diagnostic test used for neurologic injuries
MRI or CT
Which foods should the person who suffers from migraine headaches avoid? (Select all that apply.)
Marinated foods
What is the basic problem that prompts most of the early signs of Alzheimer disease?
Memory loss that disrupts daily life
The newly admitted patient to the emergency room 30 minutes ago after a fall off a ladder has gradually decreased in consciousness and has slowly reacting pupils, a widening pulse pressure, and verbal responses that are slow and unintelligible. What is the most appropriate position for the patient?
Neck placed in a neutral position
A patient, age 45, is to have a myelogram to confirm the presence of a herniated intervertebral disk. Which nursing action should be planned with respect to this diagnostic test?
Obtain an allergy history before the test.
What is a common mistake that hinders communication when communicating with the hearing impaired?
Overaccentuating words
What should the nurse do when the child arrives on the floor with the diagnosis of bacterial meningitis?
Place the child in respiratory isolation
Why are the drugs neostigmine (Prostigmin) and pyridostigmine (Mestinon) helpful to the person with myasthenia gravis?
Promotes nerve impulse transmission
As the result of a stroke, a patient has difficulty discerning the position of his body without looking at it. In the nurse's documentation, which would best describe the patient's inability to assess spatial position of his body?
Proprioception
What is the purpose of a "drug holiday" in the treatment of Parkinson disease?
Restart drugs at a lower dosage with favorable results
What is the nurse aware of when assessing a person with a craniocerebral injury?
Signs and symptoms may not occur until several days after the trauma
A patient with a spinal cord injury at T1 complains of stuffiness of the nose and a headache. The nurse notes a flushing of the neck and "goose flesh." What should be the primary nursing intervention based on these assessments?
Sit upright and check blood pressure
The 62-year-old home health patient who is recovering from eye surgery complains of a feeling of "grittiness" in the eye and is having blurred vision. The eyes are reddened and have stringy mucus. What do these complaints indicate?
Sjögren syndrome
A patient is in which stage of Alzheimer disease when she demonstrates "sundowning"?
Stage 2
Gently wipe nose with absorbent gauze
The newly admitted patient to the emergency room after a motorcycle accident has serosanguineous drainage coming from the nose. What is the most appropriate nursing response to this assessment?
Which symptom is specific to migraine headaches?
They are preceded by an aura
How would the nurse instruct a patient with Parkinson disease to improve activity level?
To walk with hands clasped behind back to help balance
What is the cranial nerve that supplies most of the organs in the thoracic and abdominal cavities and also carries motor fibers to glands that produce digestive juices and other secretions?
Vagus
Which foods should the person who suffers from migraine headaches avoid? (Select all that apply.)
Yogurt
The nurse is caring for a home health patient who had a spinal cord injury at C5 three years ago. The nurse bases the plan of care on the knowledge that the patient will be able to:
feed self with setup and adaptive equipment.
An 83-year-old patient has had a stroke. He is right-handed and has a history of hypertension and "little" strokes. He presents with right hemiplegia. To afford him the best visual field, the nurse should approach him:
from the left side.
Following a myelogram the nurse should include in the postprocedure care assessment for:
sensation in lower extremities.
The nurse is aware that the characteristic gait of the person with Parkinson disease is a propulsive gait, which causes the patient to:
shuffle with arms flexed.