Ch 14 medsurge

22.A patient who has been experiencing recent seizure activity is preparing to have diagnostic testing performed. The health care provider has explained that the test will provide a graphic recording of the electrical conduction activities of the brain. The patient understands that which test will be performed? 1.ECG 2.MRI 3.PET 4.EEG

EEG

13.The nurse is caring for a patient who suffered a cervical spinal cord injury. What injury can most likely be anticipated? 1.Tetraplegia 2.Hemiplegia 3.Paraplegia 4.Paresthesia

Paraplegia

12.When teaching a patient with Parkinson's disease, which response would indicate the need for further education? 1."If I miss an occasional dose of the medication, it doesn't matter much." 2."I need to exercise at least some every day." 3."I need to be sitting straight up with my chin slightly tucked so I won't choke when I eat or drink." 4."I should eat a diet high in fiber and roughage to decrease my constipation."

1."If I miss an occasional dose of the medication, it doesn't matter much."

20.What nursing interventions should the nurse include in the plan of care for a patient who has had a stroke with right-sided hemiplegia and expressive aphasia? (Select all that apply.) 1.Allow the patient ample time to verbalize his needs. 2.Encourage self-help behaviors as much as possible, such as feeding. 3.Monitor the patient's neurologic status once a day. 4.Perform ROM to affected extremities every shift. 5.Implement the use of a communication board for the patient to use as needed.

1.Allow the patient ample time to verbalize his needs. 2.Encourage self-help behaviors as much as possible, such as feeding. 4.Perform ROM to affected extremities every shift. 5.Implement the use of a communication

8.A 76-year-old who has had Parkinson's disease for the past 6 years has now been admitted to a long-term care facility. The nurse doing the admission interview and assessment notices which characteristic sign of the disease? 1.Bradykinesia 2.Increased postural reflexes 3.Sensory loss 4.Intention tremor

1.Bradykinesia

2.A 35-year-old patient is being seen for complaints of headache, which she has experienced for the past month. Her health care provider wants to rule out a brain tumor. What diagnostic tests will be most helpful in formulating this diagnosis? (Select all that apply.) 1.Brain scan 2.PET scan 3.Lumbar puncture 4.Electroencephalography 5.MRI

1.Brain scan 2.PET scan 4.Electroencephalography 5.MRI

19.Which sign or symptom of late-stage increased intracranial pressure should the LPN/LVN be aware of? (Select all that apply.) 1.Increase in systolic blood pressure 2.Widening of pulse pressure 3.Bradycardia 4.Unequal pupils that react slowly to light 5.Tachycardia

1.Increase in systolic blood pressure 2.Widening of pulse pressure 3.Bradycardia

17.A right-handed patient has right-sided hemiplegia and aphasia from a stroke. What is the most likely location of the lesion? 1.Left frontal lobe 2.Right brainstem 3.Motor areas of the right cerebrum 4.Medial superior area of the temporal lobe

1.Left frontal lobe

15.During admission of a patient with a severe head injury to the emergency department, what is the highest priority assessment for the nurse? 1.Patency of airway 2.Presence of a neck injury 3.Neurologic status with the Glasgow Coma Scale 4.Cerebrospinal fluid leakage from the ears or nose

1.Patency of airway

5.The nursing assessment of an 80-year-old who has had a stroke found that she had difficulty swallowing. A videofluoroscopy with barium was performed to rule out aspiration. The rehabilitation team in the skilled nursing facility determined that she can eat a soft diet with one-to-one supervision. Which action is important to prevent aspiration? 1.Tipping the head toward the unaffected side while swallowing 2.Extending the head during swallowing 3.Mixing solids and liquids to facilitate swallowing 4.Encouraging the patient to drink with a straw to make swallowing easier

1.Tipping the head toward the unaffected side while swallowing

3.A nurse in the emergency department of her community hospital is teaching a group of high school students how to prevent head and spine injuries. What should the nurse include in the presentation? (Select all that apply.) 1.Use helmets for bicycles, motorcycles, and skateboarding. 2.Use helmets when participating in contact sports. 3.Never drive or ride with someone under the influence of alcohol or drugs. 4.Wear seatbelts and shoulder harnesses when driving or riding in a car. 5.Avoid diving in water less than 6 feet deep.

1.Use helmets for bicycles, motorcycles, and skateboarding. 2.Use helmets when participating in contact sports. 3.Never drive or ride with someone under the influence of alcohol or drugs. 4.Wear seatbelts and shoulder harnesses when driving or riding in a car.

14.The nursing care plan for a patient with increased intracranial pressure will include what as the most therapeutic position for the patient? 1.Keep the head of the bed flat. 2.Maintain the head of the bed at 30 degrees. 3.Increase the head of the bed's angle to 30 degrees with patient on left side. 4.Use a continuous-rotation bed to continuously change patient position.

2.Maintain the head of the bed at 30 degrees

7.A patient was involved in a snowmobile accident. On admission to the emergency department, he is receiving oxygen and is intubated. His Glasgow Coma Scale score is 6. About 10 minutes after arrival, he is noted to have a widened pulse pressure, increased systolic blood pressure, and bradycardia. Which finding indicates to the nurse that late-stage increased ICP is present? 1.Anisocoria 2.Supratentorial shift 3.Cushing's response 4.Medullary reflex

2.Supratentorial shift

1.A patient is admitted to the hospital with a diagnosis of transient ischemic attack (TIA). The patient asks the nurse to explain to him what a TIA is. Which statement by the nurse is most accurate? 1."A TIA is the result of permanent cerebrovascular insufficiency." 2."An episode of a TIA may last up to 2 days." 3."A TIA is often a precursor to a stroke." 4."A TIA generally occurs once and never occurs again."

3."A TIA is often a precursor to a stroke."

21.The nurse is caring for a patient with myasthenia gravis. The patient asks the nurse about the causes of the disease. Which response by the nurse is correct? 1."Myelin sheath breakdown has caused your myasthenia gravis." 2."Degeneration of the dopamine-producing neurons in the midbrain most commonly causes the disease." 3."Antibodies attacking the acetylcholine receptors, damaging them, and reducing their number is the most likely cause of myasthenia gravis." 4."Myasthenia gravis is usually caused by inflammation of cranial nerve VII."

3."Antibodies attacking the acetylcholine receptors, damaging them, and reducing their number is the most likely cause of myasthenia gravis."

18.A patient experiencing TIAs is scheduled for a carotid endarterectomy. The patient asks the nurse what this procedure is. The nurse correctly responds with which response? 1."This procedure promotes cerebral flow to decrease cerebral edema." 2."This procedure reduces the brain damage that occurs during a stroke." 3."This procedure helps prevent a stroke by removing atherosclerotic plaques obstructing cerebral blood flow." 4."This procedure provides a circulatory bypass around thrombotic plaques obstructing cranial circulation."

3."This procedure helps prevent a stroke by removing atherosclerotic plaques obstructing cerebral blood flow."

23.A patient has been diagnosed with Bell's palsy. This condition impacts which cranial nerve? 1.Cranial nerve V 2.Cranial nerve VI 3.Cranial nerve VII 4.Cranial nerve VIII

3.Cranial nerve VII

9.A 13-year-old student is admitted to the pediatric unit with possible meningitis. The nurse finds that the patient cannot extend her legs completely without experiencing extreme pain. The nurse correctly documents this as which sign? 1.Brudzinski's sign 2.Battle's sign 3.Kernig's sign 4.Cosgrow's sign

3.Kernig's sign

10.A patient is diagnosed with Bell's palsy as indicated by a feeling of stiffness and a drawing sensation of the face. What is important to teach her about the disease? 1.There is a heightened awareness of taste, so foods must be bland. 2.There may be an increased sensitivity to sound. 3.The eye is susceptible to injury if the eyelid does not close. 4.Drooling from increased saliva on the affected side may occur.

3.The eye is susceptible to injury if the eyelid does not close

25.What plan of care is considered beneficial for select patients who have experienced an ischemic stroke? 1.IV Tensilon in the first 3 hours 2.Anticholinesterase in the first 3 hours 3.Thrombolytic such as tPA in the first 3 hours 4.Intravenous immune globulin in the first 3 hours

3.Thrombolytic such as tPA in the first 3 hours

4.A 70-year-old with back pain is scheduled to have a myelogram in the morning to rule out a pathologic condition of the spine. In preparing him for the procedure, what statement by the nurse is accurate? 1."We will be assessing your mental status frequently after the procedure." 2."You will need to lie completely supine and still during the procedure." 3."You will be able to ambulate immediately after the test." 4."We will ask you if you have any numbness or tingling in your legs after the procedure."

4."We will ask you if you have any numbness or tingling in your legs after the procedure

11.The nurse is caring for a patient with a spinal cord injury who displays symptoms of autonomic dysreflexia. What intervention should the nurse implement first? 1.Sit the patient upright, if permitted. 2.Check for bladder distention. 3.Give nitroprusside (Nipride) as ordered. 4.Assess vital signs.

4.Assess vital signs

6.A 12-year-old has a history of generalized tonic-clonic seizures. The nurse educates the patient and his family by including which teaching points? 1.Most people feel normal immediately after the seizure. 2.It is important to place a tongue blade in his mouth during the seizure. 3.The tonic phase of the seizure usually lasts for 3 to 4 minutes. 4.It is not uncommon to lose consciousness during this type of seizure.

4.It is not uncommon to lose consciousness during this type of seizure

24.When reviewing the medical plan of treatment for a patient with Guillain-Barré syndrome, what therapies are considered to be most therapeutic? 1.Avonex and Betaseron 2.Thymectomy and Zarontin 3.Depakote and Zarontin 4.Plasmapheresis and intravenous immune globulin

4.Plasmapheresis and intravenous immune globulin

16.When caring for a patient who has undergone a craniotomy, what is the primary nursing intervention? 1.Preventing infection 2.Ensuring patient comfort 3.Avoiding need for secondary surgery 4.Preventing increased intracranial pressure

4.Preventing increased intracranial pressure