NHI test #4 (Neuro)
The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further teaching if which statement is made? A. " I will use a straw for drinking" B. " I will drive only during the daytime" C. " I will use caution because the device alters balance" D. " I will wash the skin daily under the lambs wool liner of the vest"
B. " I will drive only during the daytime"
A 13-year-old female patient has been seen in a walk-in clinic following a blow to the head from a fall during basketball practice. Which statement by the parent indicates the need for further discharge teaching? A. "I need to wake her up every 2 or 3 hours for the first 24 hours." B. "I need to apply ice to the bump on her head for 20 minutes every hour for 72 hours." C. "I need to check her pupils frequently with a flashlight to be sure her pupils constrict." D. "I need to watch for any changes in the level of consciousness or vomiting for 48 hours."
B. "I need to apply ice to the bump on her head for 20 minutes every hour for 72 hours."
A patient who is to have computed tomography (CT scan) of the brain voices concern about the procedure. The LPN/LVN can best allay the patient's fears by making which statement? A. "CT scans use only a small amount of radioactive material injected into your brain." B. "The procedure is safe and painless; you will hear a clicking noise as the CT machine rotates." C. "You will probably be given something to make you drowsy and deaden the pain during the CT scan." C. "CT scanning is a new procedure, and since it involves the brain, I think the doctor can answer your questions better than I can."
B. "The procedure is safe and painless; you will hear a clicking noise as the CT machine rotates."
A patient has had a left-sided cerebrovascular accident (CVA). Which condition does the nurse expect the patient to have as a result of the CVA? A. Ataxia B. Aphasia C. Dyslexia D. Quadriplegia
B. Aphasia
The nurse is caring for a patient who suffered massive head trauma, and suspected increased intracranial pressure (ICP) from an automobile accident. Which cranial nerves are most appropriate to check at this time? A. CN I and CN II B. CN II and CN III C. CN III and CN IV D .CN IV and CN V
B. CN II and CN III
A clients with Parkinson's disease is experiencing tremors, rigidity, and bradykinesia. The nurse anticipates that the physician will prescribe which medication to control these symptoms? A. Phenytoin (Dilantin) B. Carbidopa-levodopa (Sinemet) C. Pyridostigmine (Mestinon) D. Warfarin (Coumadin)
B. Carbidopa-levodopa (Sinemet)
A client experiences an episode of Bell's palsy and complains about increasing clumsiness. The nurse should prepare the client for which diagnostic study(ies) to determine the cause of the assessment findings?(Select all that apply) A. Serum sodium level B. Cerebral angiography C. Lumbar puncture (LP) D. Oculovestibular reflex E. Electroencephalogram F. Computed tomography
B. Cerebral angiography C. Lumbar puncture (LP) F. Computed tomography
The nurse obtaining an admission history for a patient recovering from a CVA finds a medication history including aspirin (Ecotrin). What should alert the nurse to a possible adverse effect of this drug? A. Nausea B. Epistaxis C. Hyperactivity D. Abdominal distention
B. Epistaxis
The nurse observes the unlicensed assistive personnel positioning the client with increased intracranial pressure. Which position would require intervention by the nurse? A. Head midline B. Head turned to the side C. neck in neutral position D. head of bed elevated to 30 to 45 degrees
B. Head turned to the side
The nurse makes a home-care visit to a client with Bell's palsy. Which of statement by the client requires clarification by the nurse? A. I wear an eye patch at night B. I am staying on a liquid diet C. I wear dark glasses when I go out D. I have been gently massaging my face.
B. I am staying on a liquid diet
The client was seen and treated in the ER for a concussion. Before discharge, the nurse explains the signs and symptoms of worsening condition. The nurse determines that the family needs further teaching if they state they will return to the ED if the client experiences which sign and symptom? A. Vomiting B. Minor headache C. Difficulty speaking D. Difficulty awakening
B. Minor headache
The student nurse is caring for a patient with MG. The student demonstrates adequate learning when identifying which pathophysiologic factors regarding the disease? (Select all that apply.) A. The disease is an acute disorder. B. The cranial nerves are involved in the disease process. C. Muscle weakness is the major characteristic of the disorder. D. The etiology of the majority of cases of the disease is autoimmune. E.Progressive degeneration of the spinal cord occurs as the disease advances.
B. The cranial nerves are involved in the disease process. C. Muscle weakness is the major characteristic of the disorder. E.Progressive degeneration of the spinal cord occurs as the disease advances
A patient has recently been diagnosed with MS. The family asks the nurse about the common manifestations of the disease. The nurse is correct by identifying which as the most common clinical manifestation of the disease? A. Urinary incontinence B. Weakness of the limbs C. A loss of the sense of smell D. Decreased intellectual function
B. Weakness of the limbs
The LPN/LVN is talking with a patient, who has epilepsy, when he begins having a tonic-clonic (grand mal) seizure. Which assessment(s) should the LPN/LVN make? (Select all that apply.) A. What the patient had eaten prior to the seizure. B. What the patient was doing prior to the seizure. C. What time the seizure began and how long it lasted. D. Whether body movements are unilateral and symmetrical. E. Which direction the patient's eyes turned during the seizure.
B. What the patient was doing prior to the seizure. C. What time the seizure began and how long it lasted. D. Whether body movements are unilateral and symmetrical. E. Which direction the patient's eyes turned during the seizure
The nurse is assessing the patient's patellar reflex. The patient asks what the purpose of this exam is. Which response by the nurse is correct? A. "I am checking the conscious nerve response in your leg." B. "This assessment determines your hand-eye coordination." C. "Checking this reflex assesses involuntary muscular contractions." D. "The patellar reflex demonstrates large voluntary muscle coordination."
C. "Checking this reflex assesses involuntary muscular contractions."
The patient with trigeminal neuralgia asks the nurse if there is anything she can do to prevent future episodes of the disorder. Which response by the nurse is correct? A. "It is best if you speak with your physician about this condition." B. "Unfortunately, there is little you can do to prevent future episodes of pain." C. "Drinking very cold or hot liquids is frequently a trigger, so you should avoid both." D. "Surgery is the only form of treatment that will prevent this condition from recurring."
C. "Drinking very cold or hot liquids is frequently a trigger, so you should avoid both."
When teaching the patient with multiple sclerosis (MS) about how to best manage his disease, the nurse determines the patient requires further instruction when making which statement? A. "It is important that I attend all of my physical therapy sessions." B. "I should eat adequate fiber to prevent constipation." C. "It is a good idea for me to take a hot shower in the morning to relax my muscles." D. "The injections of interferon beta-1b (Betaseron) will help manage my symptoms."
C. "It is a good idea for me to take a hot shower in the morning to relax my muscles."
The nurse is providing patient teaching to a 23-year-old female who has recently been diagnosed with epilepsy. The nurse should educate the patient that seizures are most likely to occur at which time in the patient's menstrual cycle? A. At the time of ovulation B. 1 week after menstruation C. At the time of menstruation D. 1 week before menstruation
C. At the time of menstruation
Why should the nurse check with the physician to be sure that she knows a patient has MG when prescribing medications? A. Because the patient needs sublingual medications due to excessive salivation. B. Because when the patient is in remission, certain drugs should not be prescribed. C. Because the myasthenic patient can suffer from exaggerated and bizarre effects from a variety of drugs. D. Because the patient's MG medication, selegiline (Eldepryl), needs to be carefully monitored for patient reactions.
C. Because the myasthenic patient can suffer from exaggerated and bizarre effects from a variety of drugs
The post-head injury client opens eyes to sound, has no verbal response and localizes to painful stimuli when applied to each extremity. How should the nurse document the Glasgow Coma Scale (GCS) score? A. GCS= 3 B. GCS= 6 C. GCS= 9 D. GCS= 11
C. GCS= 9
The nurse is caring for a client who has undergone craniotomy with a supratentoral incision. The nurse should plan to place the client in which position post-op? A. Head of bed flat, head and neck midline B. Head of bed flat, head turned to the nonoperative side C. Head of bed elevated 30 to 45 degrees head and neck midline D. Head of bed elevated 30 to 45 degrees, head turned to the operative side
C. Head of bed elevated 30 to 45 degrees head and neck midline
Interventions to prevent which problem are the priority for a patient with myasthenia gravis (MG)? A. Accidental injury B. Uncontrolled pain C. Inability to maintain own airway D. Decreased functional ability and mobility
C. Inability to maintain own airway
For which condition would a patient most need to have medical alert identification? A. Poliomyelitis B. MS C. MG D. Cerebrovascular accident (CVA
C. MG
A client with trigeminal neuralgia asks a nurse what can be done to minimize the episodes of pain. The nurse's response is based on an understanding that the symptoms can be triggered by: A. infection or stress B. Excessive watering of the eyes or nasal stuffiness C. Sensations of pressure or extreme temperature D. Hypoglycemia and fatigue
C. Sensations of pressure or extreme temperature
The nurse is caring for the client who has suffered a spinal cord injury. The nurse further monitors the client for signs and symptoms of autonomic dysreflexia and suspects this complication if which sign and symptoms is noted? A. sudden tachycardia B. Pallor of face and neck C. Severe, throbbing headache D. Severe and sudden hypotension
C. Severe, throbbing headache
A client is being prepared for lumbar puncture (LP). The nurse assists the client into which of the following positions for the procedure? A. Prone, in slight Trendelenburg's position B. Prone, with a pillow under the abdomen C. Side-lying, with the legs pulled up and the head bent down onto the chest. D. Side-lying, with a pillow under the hip
C. Side-lying, with the legs pulled up and the head bent down onto the chest.
A patient is admitted to a rehabilitation facility following a brain injury that has resulted in dysphagia. While observing the patient and his wife, the nurse determines further instruction is necessary if which activity is performed? A. The patient sips from a cup rather than using a straw. B. The patient sits in his chair for 45 minutes after each meal. C. The patient tilts his head back when trying to swallow solid foods. D. The patient's wife places a teaspoon of food in the patient's mouth at a time.
C. The patient tilts his head back when trying to swallow solid foods.
The student nurse is assisting the nurse in turning a patient who is in cervical traction. What is most important for the LPN/LVN to instruct the student to do when assisting in turning the patient? A. Flex the knees and hips before turning the patient. B. Support the patient's head with a pillow so that his neck is flexed. C. Turn the patient slowly and as one unit to avoid twisting the spine. D. Place the patient's back in traction so that the spine will be kept slightly flexed.
C. Turn the patient slowly and as one unit to avoid twisting the spine
The nurse is caring for a patient who has undergone a lumbar puncture in order to run tests on the cerebrospinal fluid (CSF). The nurse knows which laboratory value is abnormal? A. Glucose 60 mg/100 mL B. Clear, colorless appearance C. White blood cells (WBCs) 100/mm3 D. Total protein 40 mg/100 mL
C. White blood cells (WBCs) 100/mm3
If a nurse fails another test her options for future careers would be which of the following? A) Only Fans here I come B) I always like Chick-fil-a and can def say "My pleasure" C) I will teach kindergarten and cut out shapes and colors D) I will be a Housewife or Husband to a wealthy person on deaths bed
D) I will be a Housewife or Husband to a wealthy person on deaths bed
The patient who had a laminectomy following a herniated lumbar disk is preparing to be discharged. Which statement by the patient indicates a need for additional discharge instructions? A. "I should try to maintain a normal weight." B. "It is best for me to do my back exercises twice a day." C. "I need to be sure not to twist or bend at the waist when lifting things." D. "I can take a four hour car ride, as long as I stay perfectly still.
D. "I can take a four hour car ride, as long as I stay perfectly still.
The nurse who is caring for a patient following a stroke performs passive range-of-motion exercises on the patient. The patient asks why these exercises are so important. Which response by the nurse is accurate? A. "This helps the patient believe she is making some progress." B. "This helps overcome mood swings and crying spells." C. "This helps prevent fatigue from worsening." D. "This helps to strengthen and retrain muscles."
D. "This helps to strengthen and retrain muscles."
A nurse analyzes the results of a Romberg test performed on a client with Parkinson's disease. Which finding during testing best indicates that the client has a positive Romberg test? A. Client marches in place B. Client stands quietly C. Client sways slightly D. Client begins to fall
D. Client begins to fall
The client with a cervical spine injury has Crutchfield tongs applied in the ER. The nurse should preform which essential action when caring for this client? A. Providing a standard bed frame B. Removing a standard bed frame C. Removing the weights if the client is uncomfortable D. Comparing the amount of prescribed weights with the amount in use
D. Comparing the amount of prescribed weights with the amount in use
The nurse is performing a "neuro check" on a patient who has demonstrated a decreased LOC. What is the best way to assess the patient's neuromuscular status? A. Measure the patient's vital signs. B. Test the reaction of the patient's pupils to light. C. Check the patient's response to the stimulus of pinching. D. Determine whether the patient is able to move his legs and arms
D. Determine whether the patient is able to move his legs and arms
A nurse would use which standardized tool as a guide in assessing a client with a head injury and increased intracranial pressure (ICP)? A. Snellen chart B. Pulse oximetry graph C. Visual Analogue Scale D. Glasgow Coma Scale
D. Glasgow Coma Scale
Following a viral respiratory infection, a patient develops symptoms of Guillain-Barré syndrome. What is most closely associated with this disorder? A. Emotional lability B. Hyperactive deep tendon reflexes C. Flapping tremors of the hands and feet D. Paresthesia and weakness of the lower extremities
D. Paresthesia and weakness of the lower extremities
When increased ICP is suspected, the nurse performs a complete neurologic assessment. What does the pupillary response indicate? A. High pressure can cause blurred vision. B. Hemorrhage can cause visual impairment. C. Pupil dilation is the first sign of increased ICP. D. Pupil changes can be caused by pressure on the ocular nerve.
D. Pupil changes can be caused by pressure on the ocular nerve.
A patient experienced injury to the spinal cord in the cervical region, with paralysis and loss of sensory perception in both legs and both arms. What term is used to describe this condition? A. Paraplegia B. Hemiplegia C. Homoplegia D. Quadriplegia
D. Quadriplegia
A patient has been diagnosed with a cerebral neoplasm. What are the symptoms of a cerebral neoplasm? A. Long-term memory loss and paralysis B. Loss of muscle strength and paresthesia C. Grand mal seizure activity and facial paralysis D. Severe headache that wakes patient and visual problems
D. Severe headache that wakes patient and visual problems
The client is having a lumbar puncture preformed. The nurse should place the client in which position for the procedure? A. Supine, in semi-fowlers B. Prone, in slight Trendelenburg C. Prone, with a pillow under the abdomen D. Side- laying with legs pulled up and chin to the chest
D. Side- laying with legs pulled up and chin to the chest
The client is admitted to the hospital for observation with a probable minor head injury after an automobile crash. The nurse expects the cervical collar will remain in place until which time? A. The client is taken for spinal x-rays B. The family comes to visit after surgery C. The nurse needs to provide physical care D. The health care provider reviews the x-rays
D. The health care provider reviews the x-rays
When rating a patient using the Glasgow Coma Scale, what would be appropriate for the LPN/LVN to ask the patient to do in order to test the patient's motor response? A. Roll his eyes in a circle. B. Take a deep breath and exhale. C. Describe the view from his window. D. Touch his nose with his left index finger.
D. Touch his nose with his left index finger.
The client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which of the following? A. Blowing the nose B. isometric exercises C. coughing vigorously D. exhaling during repositioning
D. exhaling during repositioning
The nurse is caring for a client with an increased intracranial pressure. ( ICP) Which change in vital signs would occur is ICP is rising? A. increasing temperature, increasing pulse, increasing respirations, and decreasing BP B. decreasing temperature, decreasing pulse, increasing respirations, decreasing BP C. decreasing temperature, increasing pulse, decreasing respirations, increasing BP D. increasing temperature, decreasing pulse, decreasing respirations, increasing BP
D. increasing temperature, decreasing pulse, decreasing respirations, increasing BP
The client has clear fluid leaking from the nose after a basilar skull fracture. The nurse determines that is is cerebrospinal fluid ( CSF) if the fluid meets which criteria? A. Is grossly bloody in appearance and has a pH of 6 B. Clumps together on the dressing and has a pH of 7 C. Is clear in appearance and tests negative for glucose D. separates into concentric rings and tests positive for glucose
D. separates into concentric rings and tests positive for glucose
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."
a. "You may have difficulty believing this, but the paralysis caused by this disease is temporary."
The client with a brain attack (stroke) has residual dysphagia. When a diet order is initiated, the nurse avoids doing which of the following? a. Giving the client thin liquids b. Thickening liquids to the consistency of oatmeal c. Placing food on the unaffected side of the mouth d. Allowing plenty of time for chewing and swallowing
a. Giving the client thin liquids
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 meningitis d. Primarily genetic in origin, triggered by exposure to neurotoxins
a. Unknown, but possibly includes ischemia, viral infection, or an autoimmune problem
The nurse is working on a surgical floor. The nurse must logroll a male client following: a. laminectomy. b. thoracotomy. c. hemorrhoidectomy. d. cystectomy.
a. laminectomy.
A female client has a neurological deficit involving the limbic system. Specific to this type of deficit, the nurse would document which of the following information related to the client's behavior. a. Is disoriented to person, place, and time b. Affect is flat, with periods of emotional lability c. Cannot recall what was eaten for breakfast today d. Demonstrate inability to add and subtract; does not know who is president
b. Affect is flat, with periods of emotional lability
A female client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test? a. Immobilize the neck before the client is moved onto a stretcher. b. Determine whether the client is allergic to iodine, contrast dyes, or shellfish. c. Place a cap over the client's head. d. Administer a sedative as ordered.
b. Determine whether the client is allergic to iodine, contrast
The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid? a. Head mildline b. Head turned to the side c. Neck in neutral position d. Head of bed elevated 30 to 45 degrees
b. Head turned to the side
The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use which plan to use which of the following to test the client's peripheral response to pain? a. Sternal rub b. Nail bed pressure c. Pressure on the orbital rim d. Squeezing of the sternocleidomastoid muscle
b. Nail bed pressure
A female client with amyotrophic lateral sclerosis (ALS) tells the nurse, "Sometimes I feel so frustrated. I can't do anything without help!" This comment best supports which nursing diagnosis? a. Anxiety b. Powerlessness c. Ineffective denial d. Risk for disuse syndrome
b. Powerlessness
The nurse is caring for the male client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated? a. Loosening restrictive clothing b. Restraining the client's limbs c. Removing the pillow and raising padded side rails d. Positioning the client to side, if possible, with the head flexed forward
b. Restraining the client's limbs
The nurse is assigned to care for a female client with complete right-sided hemiparesis. The nurse plans care knowing that this condition: a. The client has complete bilateral paralysis of the arms and legs. b. The client has weakness on the right side of the body, including the face and tongue. c. The client has lost the ability to move the right arm but is able to walk independently. d. The client has lost the ability to move the right arm but is able to walk independently.
b. The client has weakness on the right side of the body, including the face and tongue.
The nurse is teaching a female client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to: a. take a hot bath. b. rest in an air-conditioned room c. increase the dose of muscle relaxants. d. avoid naps during the day
b. rest in an air-conditioned room
During a routine physical examination to assess a male client's deep tendon reflexes, the nurse should make sure to: a. use the pointed end of the reflex hammer when striking the Achilles tendon. b. support the joint where the tendon is being tested. c. tap the tendon slowly and softly d. hold the reflex hammer tightly.
b. support the joint where the tendon is being tested.
Nurse Kristine is trying to communicate with a client with brain attack (stroke) and aphasia. Which of the following actions by the nurse would be least helpful to the client? a. Speaking to the client at a slower rate b. Allowing plenty of time for the client to respond c. Completing the sentences that the client cannot finish d. Looking directly at the client during attempts at speech
c. Completing the sentences that the client cannot finis
Nurse Maureen witnesses a neighbor's husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to opens the airway in this victim by using which method? a. Flexed position b. Head tilt-chin lift c. Jaw thrust maneuver d. Modified head tilt-chin lift
c. Jaw thrust maneuver
A white female client is admitted to an acute care facility with a diagnosis of cerebrovascular accident (CVA). Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for CVA? a. Caucasian race b. Female sex c. Obesity d. Bronchial asthma
c. Obesity
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 exercise b. Taking excess medication c. Omitting doses of medication d. Increasing intake of fatty foods
c. Omitting doses of medication
A female client admitted to the hospital with a neurological problem asks the nurse whether magnetic resonance imaging may be done. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the client's history of: a. Hypertension b. Heart failure c. Prosthetic valve replacement d. Chronic obstructive pulmonary disorder
c. Prosthetic valve replacement
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
c. promote carbon dioxide elimination.
The nurse is assessing the adaptation of the female client to changes in functional status after a brain attack (stroke). The nurse assesses that the client is adapting most successfully if the client: a. Gets angry with family if they interrupt a task b. Experiences bouts of depression and irritability c. Has difficulty with using modified feeding utensils d. Consistently uses adaptive equipment in dressing self
d. Consistently uses adaptive equipment in dressing self
A male client with a spinal cord injury is prone to experiencing automatic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? a. Strict adherence to a bowel retraining program b. Keeping the linen wrinkle-free under the client c. Preventing unnecessary pressure on the lower limbs d. Limiting bladder catheterization to once every 12 hours
d. Limiting bladder catheterization to once every 12 hours
A male client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure client safety? a. Speak loudly to the client b. Test the temperature of the shower water c. Check the temperature of the food on the delivery tray. d. Provide a clear path for ambulation without obstacles
d. Provide a clear path for ambulation without obstacles
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 visitors b. Providing positive feedback and encouraging active range of motion c. Providing information, giving positive feedback, and encouraging relaxation d. Providing intravaneously administered sedatives, reducing distractions and limiting visitors
d. Providing intravaneously administered sedatives, reducing distractions and limiting visitors
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 brain b. Meningitis during the last 5 years c. Back injury or trauma to the spinal cord d. Respiratory or gastrointestinal infection during the previous month.
d. Respiratory or gastrointestinal infection during the previous month.
A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority in this client's plan of care? a. Disturbed sensory perception (visual) b. Self-care deficient: Dressing/grooming c. Impaired verbal communication d. Risk for injury
d. Risk for injury
A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid: a. Is clear and tests negative for glucose b. Is grossly bloody in appearance and has a pH of 6 c. Clumps together on the dressing and has a pH of 7 d. Separates into concentric rings and test positive of glucose
d. Separates into concentric rings and test positive of glucose
A male client is having a lumbar puncture performed. The nurse would plan to place the client in which position? a. Side-lying, with a pillow under the hip b. Prone, with a pillow under the abdomen c. Prone, in slight-Trendelenburg's position d. Side-lying, with the legs pulled up and head bent down onto chest.
d. Side-lying, with the legs pulled up and head bent down onto chest.
A male client is having a tonic-clonic seizures. What should the nurse do first? a. Elevate the head of the bed. b. Restrain the client's arms and legs. c. Place a tongue blade in the client's mouth. d. Take measures to prevent injury.
d. Take measures to prevent injury.
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 meals b. Doing muscle-strengthening exercises c. Doing all chores early in the day while less fatigued d. Taking medications on time to maintain therapeutic blood levels
d. Taking medications on time to maintain therapeutic blood levels
The client has just undergone computed tomography ( CT) scanning with a contrast medium. Which statement by the client demonstrates an understanding of the post procedure care? A. " I should drink extra fluids for the remainder of the day." B. " I should not take any medications for atleast 4 hours." C. "I should eat lightly for the remainder of the day." D. " I should rest quietly for the remainder of the day."
A. " I should drink extra fluids for the remainder of the day."
The nurse is caring for a client who is in the chronic phase of brain attack (stroke) and has a right-sided hemiparesis. The nurse identifies the nursing diagnosis of Imbalanced Nutrition: less than body requirements, related to inability to feed self . Which of the following is a priority nursing intervention to help improve the client's nutrition? A. Assist the client to eat with the left hand to build strength. B. Provide a pureed diet that is easy for the client to swallow. C. Inform the client that a feeding tube will be placed if progress is not made D. Provide a variety of foods on the meal tray to stimulate the client's appetite.
A. Assist the client to eat with the left hand to build strength.
Which of the following conditions can increase the risk for torn vessels and contusion on the brain if an accident that involves brain injury occurs? A. Brain atrophy B. Hydrocephalus C. Heterotopic ossification D. Increased intracranial pressure (ICP)
A. Brain atrophy
The nurse is measuring the pressure of the CSF. Which statement accurately describes CSF? (Select all that apply.) A. CSF circulates within the subarachnoid space. B. CSF cushions and protects the brain and spinal cord. C. CSF normal pressure is 90 to 150 cm water pressure (cm H2O). D. CSF is reabsorbed by the arachnoid villi at the same rate at which it is formed. E. CSF is formed continuously within the ventricles of the brain as a filtrate from the blood.
A. CSF circulates within the subarachnoid space. B. CSF cushions and protects the brain and spinal cord. D. CSF is reabsorbed by the arachnoid villi at the same rate at which it is formed. E. CSF is formed continuously within the ventricles of the brain as a filtrate from the blood.
The nurse is providing teaching to a group of patients regarding CVA (stroke). The patients demonstrate an understanding of the teaching when listing which factors as being the possible cause of a stroke? (Select all that apply.) A. Cerebral thrombosis B. Cerebral encephalitis C. Cerebral hemorrhage D. Meningococcal meningitis E. Atherosclerosis of the arteries in the head and neck
A. Cerebral thrombosis C. Cerebral hemorrhage E. Atherosclerosis of the arteries in the head and neck
The nurse is assessing a patient who has a brain tumor. What assessment finding is most indicative of increased ICP in this patient? A. Decreasing level of consciousness (LOC) B. Elevated temperature C. Agitation and hostility D. Increasing blood pressure (BP)
A. Decreasing level of consciousness (LOC)
A nurse is providing medication to a client receiving Phenytoin (Dilantin). The nurse tells the client that: A. Good oral hygiene is needed, including brushing and flossing B. The daily medication dose should be taken before a scheduled serum drug level is drawn C. The medication dose may be self-adjusted, depending on side effects. D. Alcohol may be used in moderation while taking this medication
A. Good oral hygiene is needed, including brushing and flossing
After a head injury, the patient begins to have drainage from the nose. The nurse assesses the drainage by which method? A. Halo test B. Tinel sign C. Battle sign D. Babinski sign
A. Halo test
During the advanced stages of amyotrophic lateral sclerosis (ALS), which service would be most beneficial to the family and patient? A. Hospice services B. In-home physical therapy C. Pulmonary rehabilitation program D. Nursing visits from a home health care agency
A. Hospice Services
The nurse is assessing a patient admitted for a work-up to rule out ALS. Which symptoms are typically exhibited in a patient with ALS? (Select all that apply.) A. Muscle pain B. Slurred speech C. Muscle spasticity D. Decreased sensation E. Difficulty swallowing
A. Muscle pain B. Slurred speech C. Muscle spasticity E. Difficulty swallowing
A client recovering from a craniotomy complains of a "runny nose". Which of the following nursing actions should be immediately implemented? A. Notify the physician B. Provide the client with soft tissues C. Monitor the client for signs of a cold D. Tell the client to use soft tissues to soak up the drainage
A. Notify the physician
A client with a seizure disorder is being admitted to the hospital. Which should the nurse plan to implement for this client? Select all that apply A. Pad the bed's side rails B. place an airway by the bedside C. Place oxygen equipment at the bedside D. place suction equipment at the bedside E. Take a padded tongue blade to the wall at the head of the bed
A. Pad the bed's side rails B. place an airway by the bedside C. Place oxygen equipment at the bedside D. place suction equipment at the bedside
The nurse suspects that a 36-year-old patient recovering from a hypophysectomy (removal of the pituitary gland) has developed diabetes insipidus (DI). What sign or symptom is most indicative of DI? A. Polyuria B. Polyphagia C. Hypertension D. Hyperkalemia
A. Polyuria
The LPN/LVN discusses ways to prevent a stroke with a patient. Which measures should the nurse include in her teaching? (Select all that apply.) A. Proper treatment for hypertension B. Adequate treatment of atherosclerosis C. Avoiding the use of recreational drugs D. Encouraging the use of seat belts in vehicles E. Keeping serum cholesterol levels under control
A. Proper treatment for hypertension B. Adequate treatment of atherosclerosis C. Avoiding the use of recreational drugs E. Keeping serum cholesterol levels under control
During the acute stage of Guillain-Barré syndrome, what is the priority goal of nursing and medical treatment? A. Sustenance of life B. Promotion of rest C. Reduction of fever D. Prevention complications
A. Sustenance of life
Which patient is the nurse most concerned with developing a subdural hematoma following an injury that resulted with a blow to the head? A. The 76-year-old patient who is taking an anticoagulant B. The 16-year-old football player who suffered a concussion C. The 36-year-old patient who has a history of migraine headaches D. The 56-year-old patient who is taking an antihypertensive medication
A. The 76-year-old patient who is taking an anticoagulant
A patient who has epilepsy is to take phenytoin (Dilantin). What is an important teaching point that the LPN/LVN should include regarding this medication? A. The patient should have periodic drug levels drawn. B. The patient should regulate the dosage according to need. C. The patient should take the medication with juice containing vitamin C. D. The patient should take an extra dose of the medication before exercising.
A. The patient should have periodic drug levels drawn
A patient is bought in by ambulance with a suspected brain injury. What are the outward symptoms of head injury? (Select all that apply.) A. Tinnitus B. Diarrhea C. Ottorhea D. Battle sign E. Chvostek sign
A. Tinnitus C. Ottorhea D. Battle sign
The client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the vital signs, which immediate action should the nurse take? A. raise the head of bed and removed the noxious stimulus B. lower the head of bed and remove the noxious stimulus C. lower the head of bed and administer an antihypertensive agent D. remove the noxious stimulus and administer an antihypertensive agent
A. raise the head of bed and removed the noxious stimulus