NRS 221 W18 NURO NCLEX Questions from Presentations

Severe TBI - A client has been in the ICU for treatment of a traumatic head injury. Brain death has just been declared. Which assessment findings would the nurse anticipate? Select all that apply. *constricted pupils *apnea *presence of coma *loss of brainstem reflexes *normal temperature

*apnea *presence of coma *loss of brainstem reflexes *normal temperature

A physician order for mannitol (Osmitrol) has been written for a client with increased ICP. Which assessment finding would cause the nurse to question this order? *osmotic gap less than 10 *serum albumin low *the client is hypovolemic

*the client is hypovolemic

Crani - You are providing patient teaching for your patient who is scheduled for a craniotomy. Which possible complications should you include in your teaching? Select all that apply. 1. Seizures 2. Stroke 3. Nerve Damage 4. Loss of Mental Function

1. Seizures 2. Stroke 3. Nerve Damage 4. Loss of Mental Function

A patient has had a stroke, what is the maximum amount of time to start fibrinolytic therapy for it to be effective? 1. 1-2 hrs 2. 3-4.5hrs 3. 4-6 hrs 4. 10-24 hrs

2. 3-4.5hrs

Crani - A client presents with a meningioma and symptoms of increased intracranial pressure. Which manifestations should a nurse least expect to find on assessment of this client? 1. Headache 2. Vomiting 3. Pyrexia 4. Papilledema

3. Pyrexia

MS - Your patient has been diagnosed with MS. You are teaching her about how to reduce muscle spasticity. Which of the following statements, if made by the patient would indicate the need for further teaching? •1. Daily exercise, include weight bearing can help relieve spasticity •2. My stretching routine can help with the spasms •3. Taking Baclofen may help relieve these painful spasms in my legs •4. At the need of the day, taking a nice hot bath may relieve the muscle spasms

4. At the need of the day, taking a nice hot bath may relieve the muscle spasms Rationale - The patient with MS should never use hot water for a bath due to sensory deficits. All other answers can help with muscle spasms.

2. SCIin -Which of the following factors increases the risk of an incomplete spinal cord injury? Select all that apply. a. Male gender b. Underlying kidney disease c. African American or Asian ethnicity d. Age 16-30 e. Underlying arthritis

A. Male gender D. age 16-30 E. underlying arthritis.

HD - A college student is asking the nurse about his grandfather, who just received a diagnosis of Huntington's disease. The student wants to know if he will have the disease, too. What should the nurse tell the student? Select all that apply. A. "Huntington's disease affects men more than women." B. "Huntington's disease is an autosomal dominant disease." C. "Huntington's disease does not skip a generation." D. "Huntington's disease is a treatable disease." E. "There is a 75% chance you will have the disease."

B. "Huntington's disease is an autosomal dominant disease." C. "Huntington's disease does not skip a generation." Rationale: Huntington's disease, is an autosomal dominant genetic neurologic disease that affects descendants of an affected person at a 50% rate. Huntington's disease does not skip generations and affects men and women equally. Huntington's disease is genetically transmitted on chromosome 4, and death usually results from respiratory complications related to aspiration

SAH -The nurse is caring for the client with increased ICP. The nurse would note which trend in vital signs if the ICP is rising? A. Increasing temp, increasing pulse, increasing respirations, decreasing BP B. Increasing temp, decreasing pulse, decreasing respirations, increasing BP C. Decreasing temp, decreasing pulse, increasing respirations, decreasing BP D. Decreasing temp, increasing pulse, decreasing respirations, increasing BP

B. Increasing temp, decreasing pulse, decreasing respirations, increasing BP

AD - n clients with a cognitive impairment disorder, the phenomenon of increased confusion in the early evening hours is called: A.) aphasia B.) sundowning C.) agnosia D.) confabulation

B.) sundowning Rationale: Sundowning is a common phenomenon that occurs after daylight hours in a client with a cognitive impairment disorder. The other options are incorrect responses, although all may be seen in this client

SCIIn -Jeff, a 20 year old male, was rushed to the hospital after hitting shallow water while cliff jumping with friends. Once at the hospital an assessment by the doctor determined a diagnosis of an incomplete spinal cord injury. Emergency staff should administer which of the following medications first? a. Baclofen-Skeletal Muscle Relaxant b. Methylprednisolone- Corticosteroid c. Diazepam-Benzodiazepine d. Tizanidine-Centrally Acting Alpha II Adrenergic Agonist

B: The corticosteroid should be given first because it treats inflammation and can prevent further damage from occurring to the spine due to pressure.

SCI Compl -A client with a spinal cord injury who has been active in sports and outdoor activities talk almost obsessively about his past activities. In tears, he asks the nurse, "Why can't I stop talking about these things? I know those days are gone forever." Which of the following is the best response by the nurse? A. "Be patient. It takes time to adjust to such a massive loss." B. "Talking about the past is a form of denial. We have to help you focus on today." C. "Reviewing you losses is a way to help you work through your grief and loss." D. "It's a simple escape mechanism to go back and live again in happier times."

C. "Reviewing you losses is a way to help you work through your grief and loss." Rationale: Spinal cord injury represents a physical loss; grief is the normal response to this loss. Working through grief entails reviewing memories and eventually letting go of them. The process may take as long as two years.

HD -A 78 year-old patient with HD has developed contracture from muscle atrophy. The nurse is reviewing his information after he has been admitted to the long-term are facility. Which best describes an appropriate outcome for this patient? A. The patient will monitor for signs of skin breakdown as a result of the contractures. B. The patient will learn to reposition himself in bed and in his chair without help. C. The patient will participate in ROM exercises to reduce the effects of the contractures. D. The patient will verbalize the effects of his brain contractures on his ADL

C. The patient will participate in ROM exercises to reduce the effects of the contractures. Rationale: Huntington's disease is a progressive condition that can lead to muscle atrophy and potential contractures. The patient in this situation should be given a program of range of motion exercises in which he may need assistance. The nurse can help the patient to increase his range of motion and to prevent worsening of contractures by improving flexibility and reducing rigidity

SDH - A patient presents to the ER after an MVA, the skull x-ray and CTshow evidence of a depressed parietal fracture with a subdural hematoma. In planning care for the patient, the nurse anticipates that: A. the patient will receive life-support measures until condition stabilizes B. immediate burr holes will be made to decrease ICP C. patient will be closely monitored for changes in neurologic condition D. patient will be taken to surgery for a craniotomy to decrease ICP

C. patient will be closely monitored for changes in neurological condition

AD - Which of the following is not included in the care of plan of a client with a moderate cognitive impairment involving dementia of the Alzheimer's type? A.) Daily structured schedule B.) Positive reinforcement for performing activities of daily living C.) Stimulating environment D.) Use of validation techniques

C.) Stimulating environment Rationale: A stimulating environment is a source of confusion and anxiety for a client with a moderate level of impairment and, therefore, would not be included in the plan of care.

SAH - A client from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in ICP if the nurse observes the client doing which activity? A. Blowing their nose B. Isometric exercises C. Coughing vigorously D. Exhaling during repositioning

D. Exhaling during repositioning

MG - The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective? 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

ALS 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 Rationale: This comment best supports a nursing diagnosis of Powerlessness because ALS may lead to locked-in syndrome, characterized by an active and functioning mind locked in a body that can't perform even simple daily tasks.

GB A patient with Guillain-Barré syndrome asks the nurse what has caused the disease. In responding to the patient, the nurse explains that Guillain-Barré Syndrome: a. results from an acute infection and inflammation of the peripheral nerves. b. is due to an immune reaction that attacks the covering of the peripheral nerves. c. is caused by destruction of the peripheral nerves after exposure to a viral infection. d. results from degeneration of the peripheral nerve caused by viral attacks.

b. is due to an immune reaction that attacks the covering of the peripheral nerves. Rationale: Guillain-Barré syndrome is believed to result from an immunologic reaction that damages the myelin sheath of the peripheral nerves. Acute infection or inflammation of the nerves is not a cause. The peripheral nerves are not destroyed and do not degenerate.

.ALS - The nurse is providing medication instructions to a client diagnosed with amyotrophic lateral sclerosis who has been prescribed riluzole (Rilutek). Which statement indicates to the nurse that the client understands the instructions? a. "Riluzole should be taken with food." b. "I plan to take riluzole once daily." c. "I will call the health care provider if my pulse goes below 50." d. "I will need frequent checks of my liver enzymes."

d. "I will need frequent checks of my liver enzymes." Rationale: Riluzole (Rilutek) may cause liver toxicity, and liver enzymes will need to be checked frequently. This drug should be taken twice a day without food and when the stomach is empty. Riluzole may cause tachycardia, not bradycardia

MD - A 20-year-old patient with a 6-year history of muscular dystrophy is hospitalized with a respiratory tract infection. Which nursing action will be included in the plan of care? a. Logroll the patient every 1 to 2 hours. b. Teach the patient about the muscle biopsy procedure. c. Provide the patient with a pureed diet. d. Assist the patient with active range-of-motion (ROM) exercises

d. Assist the patient with active range-of-motion (ROM) exercises Rationale: The goal for the patient with muscular dystrophy is to keep the patient active for as long as possible. The patient would not be confined to bed rest and would not require logrolling. Muscle biopsies are necessary to confirm the diagnosis but would not be ordered for a patient who already had a diagnosis. There is no indication that the patient requires a pureed diet

MG -Which response to the Tensilon (edrophonium chloride) injection indicates the client has myasthenia gravis? a. The client has no apparent change in the assessment data. b. There is reduced amplitude of electrical stimulation in the muscle. c. The anti-acetylcholine receptor antibodies are present. d. The client shows a marked improvement of muscle strength

d. The client shows a marked improvement of muscle strength Edrophonium is administered during the test, if weakness is more severe the patient is overmedicated. Have the antidote, atropine Sulfate available prior to surgery and administer as prescribed.

GB - A 24-year-old patient is hospitalized with the onset of Guillain-Barré syndrome. During this phase of the patient's illness, the most essential assessment for the nurse to carry out is: a. monitoring the cardiac rhythm continuously. b. determining the level of consciousness q2hr. c. evaluating sensation and strength of the extremities. d. performing constant evaluation of respiratory function.

d. performing constant evaluation of respiratory function. Rationale: The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments will also be included in nursing care, but they are not as important as respiratory assessment

MSA nurse is discharging a patient with MS. The nurse should instruct the patient on which of the following? Select all that apply. •1. Avoiding consumption of shellfish •2. Avoiding extremes of temperature •3. Exercising vigorously every day •4. Including red meat in the patient's diet •5. Managing bowel and bladder symptoms •6. Practicing strategies for managing fatigue

•2. Avoiding extremes of temperature 5. Managing bowel and bladder symptoms •6. Practicing strategies for managing fatigue

LIS - All of the following functions are impaired in locked-in syndrome except: ○Fine motor control ○Eye movement - may have one or more movements ○Bowel and bladder incontinence oLower leg movement

○Eye movement - may have one or more movements

LIS - What is the priority treatment for Locked-In Syndrome? ○Anticonvulsants ○Physical therapy ○Treat the underlying cause ○Craniotomy

○Treat the underlying cause