Neuro Test ch. 47,48,49,50
A patient with a spinal cord injury at T3-T4 experiences a sudden increase in BP and has cool, pale, gooseflesh skin on the lower extremities. Which action does the nurse perform while awaiting physician orders? (Select all that apply.) a) Perform a rectal examination to determine if impaction is present b) Check to see if the indwelling catheter is patent c) Place the patient in supine position. d) Place elastic stockings on the patient's legs e) Monitor BP every 5 minutes.
Answer: a, b, e
A patient is admitted from the emergency department to the hospital unit following the diagnosis of an ischemic stroke. The patient did not qualify for tPA therapy. The nurse is aware that which poststroke condition places the patient at greatest risk for deep vein thrombosis (DVT)? a. Hypercoagulability related to the admitting diagnosis b. Laboratory tests indicating hyperlipidemia with high-density lipoprotein (HDL) at 200 c. Testing that identified the cause of the stroke as ischemic d. The inability to be mobile and move independently
Answer: a. Hypercoagulability related to the admitting diagnosis
The nurse is planning care for a patient with a migraine headache. Which actions does the nurse include in this plan of care? (Select all that apply.) a) acetaminophen (Tylenol) b) A dark, quiet room c) Rest d) White noise e) Sumatriptan (imitrex)
Answer: b, c, e
The nurse is reviewing the medical records of patients in an HCP's practice. Which patient does the nurse recognize as the greatest risk for a stroke? a. A young adult born with a heart defect causing ventricle fibrillation b. An older female patient who has osteoporosis, a femur fracture, and hyperlipidemia c. An overweight male with a 15-year smoking history, who is treated for hypertension d. A postmenopausal patient who has type 2 diabetes mellitus (DM) controlled by diet
Answer: b. An older female patient who has osteoporosis, a femur fracture, and hyperlipidemia
A patient is brought to the emergency department after being hit by a baseball bat during a game. Which nursing intervention is immediately reported to the HCP or RN? a. One-sided paralysis, extreme weakness, or pupil dilation b. Changes in heart and respiratory rate, fever, and diaphoresis c. The presence of amnesia about details before and after the injury d. Presence of head and scalp contusions with a single lesion
Answer: b. Changes in heart and respiratory rate, fever, and diaphoresis
The nurse is providing care for a patient after surgery for treatment of trigeminal neuropathy. Which nursing intervention will the nurse initiate for this patient? a. Protect the patient's face from any movement of air. b. Check the eye on the surgery side for corneal sensation. c. Place eye patches bilaterally while the patient sleeps. d. Provide a soft diet with food served at room temperature
Answer: b. Check the eye on the surgery side for corneal sensation
The nurse is collecting data from a patient who is diagnosed with MG. Which data is most important for the nurse to obtain? a. Ask what amount of activity causes fatigue and muscle weakness to occur. b. Monitor the patient's respiratory function and the ability to swallow effectively c. Ascertain if the patient's needs are being met by an adequate support system. d. Determine baseline muscle strength through the use of appropriate techniques
Answer: b. Monitor the patient's respiratory function and the ability to swallow effectively
The nurse is caring for a patient with an acute brain injury. Which interventions does the nurse use to prevent increased intracranial pressure in this patient? (Select all that apply.) a) Encourage deep breathing and coughing b) Administer opioid analgesics for headache c) Keep head of bed elevated 30 degrees. d) Avoid hip flexion. e) Administer stool softeners
Answer: c, d, e
An older adult patient is experiencing the manifestation related to a neurocognitive disorder and is being transferred to a long-term care facility. Which condition will involve the nurse in reaching long-term goals related to this patient? a. Accepting the patient's attempts at independence b. Requesting hospitalization when symptoms worsen c. Suggesting the family attend a support group d. Considering the patient's input regarding care
Answer: c. Suggesting the family attend a support group
The nurse is providing care for a patient recovering from a right hemisphere infarct who now exhibits unilateral neglect. Which nursing intervention is most important at promoting safety for this patient? a. Place the call light and phone on the patient's left side. b. Provide stimuli of all senses on the patient's affected side. c. Teach the patient to purposefully check the location of the left limbs d. Encourage the patient to turn her plate for ease in self-feeding.
Answer: c. Teach the patient to purposefully check the location of the left limbs
The nurse is providing care for a female patient who is paralyzed from a C-4 spinal cord injury. The patient is turned and repositioned every 2 hours. Which action does the nurse take when repositioning the patient in a side-lying position a. Place the patient's call light within reach. b. Ask the patient if the new position is comfortable. c. Massage reddened or blanched areas on her back. d. Check that her breast is not compressed under her body.
Answer: d. Check that her breast is not compressed under her body.
The nurse is assisting with care of patients diagnosed with neuromuscular disorders. Which complication does the nurse recognize as a medical emergency? a. Interruption of skin integrity over bony prominences b. Difficulty maintaining weight due to difficulty swallowing c. Evidence of severe muscle wasting d. Indications of the development of pneumonia
Answer: d. Indications of the development of pneumonia
A patient is diagnosed with bacterial encephalopathy. Which symptoms exhibited by the patient indicate late signs of the patient's diagnosis? a. Expressed fear about loud noises in the hallway b. Short attention span and poor memory c. Disorientation and difficulty following commands d. Lack of involvement and lip smacking or chewing
Answer: d. Lack of involvement and lip smacking or chewing
The nurse is working in a college infirmary when a student comes in and states, "I think I have a migraine. My head hurts, I cannot stand the light, and I feel sick to my stomach." Which additional data collected by the nurse causes concern for a different diagnosis? a. A subnormal temperature b. Ill college roommate c. Positive Romberg test d. Positive Brudzinski's sign
Answer: d. Positive Brudzinski's sign
The nurse is assisting with the care of a patient with a brain tumor who is exhibiting ICP. Which nursing intervention is specifically initiated to provide safety for this patient? a. Follow HCP's prescribed therapy for treatment of headache b.Make sure the call light is always within the patient's reach. c.Perform active or passive range of motion (ROM) at least twice each shift d. Relocate environmental objects and pad the bedside rails.
Answer: d. Relocate environmental objects and pad the bedside rails.
A patient comes into the emergency department with unilateral paralysis, aphasia, and inability to follow directions. Which emergency management by the health care provider (HCP) is unexpected by the nurse? a. Careful monitoring of changes in the patient's level of consciousness b. Maintenance of oxygen therapy to a saturation of at least 94 percent c. Immediate treatment for temperature greater than 99.6°F d. Scheduling laboratory tests, electrocardiogram (ECG), and computerized tomography (CT) scan to be performed within 45 minutes
Answer: d. Scheduling laboratory tests, electrocardiogram (ECG), and computerized tomography (CT) scan to be performed within 45 minutes
A patient is brought to the health care provider's office with a headache, lethargy, nausea, vomiting, and a fever, which has developed over the past few days. The nurse begins collecting data about the possible causes of the symptoms. Which information indicates a possible cause for encephalitis? a. The patient has recently exhibited flu-like manifestations. b. The patient has experienced a stiff neck for 3 days. c. The patient lives in a home where a child has chickenpox. d. The patient has been camping within the last few weeks.
Answer: d. The patient has been camping within the last few weeks.
The nurse reviews information with a patient and family members about the patient's recent diagnosis of amyotrophic lateral sclerosis (ALS). Which comment by a family member indicates a need for clarification? a. "A feeding tube and ventilator may need to be considered later." b. "We need to do some research to see if this is a familial risk." c. "When the heart muscle is affected, death will occur shortly." d. "We need to remember that mental functioning is intact."
Answer: c. "When the heart muscle is affected, death will occur shortly."
A patient is distressed to learn that a sibling is diagnosed with both neurologic and cognitive manifestations of Huntington disease. When the patient asks the nurse how to determine the incidence of the disease, which answer is most appropriate? a. "Your children need to be tested for a genetic connection." b. "All family members are now at risk for the disease." c. "If you are not diagnosed by age 20, you are considered safe." d. "You definitely need to have genetic testing for the disease."
Answer: d. "You definitely need to have genetic testing for the disease."