MED SURGE FINAL

A patient in the plateau stage of GBS is frustrated because there has been no improvement in manifestations for 5 days. Which explanation does the nurse provide to the patient?

The manifestations can last up to 2 weeks.

The nurse is visiting the home of a patient who is being treated for Bell palsy. Which statement by the patient indicates that care instructions need to be reviewed by the nurse?

"Alternating heat and cold therapy is helping the swelling."

The nurse is collecting up-to-date data from a patient who was diagnosed with MS 15 years ago. The patient has a good understanding of the disease and manages to maintain a relatively high level of functioning. Which statement by the patient prompts the nurse to seek additional information?

"I love to work in my flower beds during the summer months."

A patient diagnosed with Guillain-Barré syndrome (GBS) asks how the disease developed since the patient rarely has an illness. Which nursing response is the most accurate?

"It may be an autoimmune reaction to a virus."

A patient is prescribed the dopamine agonist pramipexole (Mirapex) for Parkinson disease. Which instructions are important for the nurse to include when teaching about this medication? (Select all that apply.)

"Taking the medication with food may reduce nausea." "You may experience sudden bouts of excessive sleepiness." "Do not drive until the effects of this drug on you are fully known."

A mother of three young children has a 3-year history of MG and recently stopped helping in the children's classrooms because of fatigue. Which advice does the nurse give to help the patient best cope with the problem?

"Time your medication so its action peaks during the time you need the most energy."

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?

"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?

"You definitely need to have genetic testing for the disease."

A patient began experiencing manifestations of a stroke at 0800 hours. By which time should thrombolytic medications be provided to reverse stroke symptoms?

1250 hours

A patient is being admitted to a long-term care facility. Medical history includes a recent stroke with dysarthria. Which factor does the nurse consider when providing care for this patient?

A picture board will help the patient with word searching.

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 dark, quiet room Sumatriptan (Imitrex) rest

The nurse is providing care for a patient who is experiencing difficulty eating due to a neurologic dysfunction. Which action by the nurse will be least helpful in promoting adequate nutritional intake for this patient?

Allow the patient adequate time and privacy to self-feed.

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?

An older female patient who has osteoporosis, a femur fracture, and hyperlipidemia

The nurse is assisting with care for a patient in the ICU with an extreme head injury. The HCP reports that the patient has brain herniation. Which action does the nurse expect from the HCP?

Arranging for the family to be approached about possible organ donation

A patient arrives at the emergency department and states, "Something is wrong. I just don't feel right." Which objective data causes the nurse to suspect the patient is experiencing some type of stroke?

Ataxia is present when the patient attempts to ambulate

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.)

Avoid hip flexion. Administer stool softeners. Keep head of bed elevated 30 degrees.

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?

Changes in heart and respiratory rate, fever, and diaphoresis

The nurse is caring for a patient scheduled for a computed tomography (CT) scan with contrast. Which actions does the nurse include in the preprocedure preparation? (Select all that apply.)

Check blood urea nitrogen (BUN) and creatinine levels. Question the patient about allergies to dye, shellfish, or iodine. Explain to the patient that a sensation of warmth may be felt when the dye is injected.

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?

Check that her breast is not compressed under her body

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?

Check the eye on the surgery side for corneal sensation.

The nurse is preparing to assist a patient with eating who is recovering from a stroke. Which intervention is appropriate?

Check the patient's mouth periodically for presence of pocketed food.

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.)

Check to see if the indwelling catheter is patent. Perform a rectal examination to determine if impaction is present. Monitor BP every 5 minutes.

The nurse is preparing a patient with MG to undergo plasmapheresis. Which laboratory tests does the nurse verify and place on the medical record before the procedure?

Complete blood count, platelets, and clotting studies

The nurse is aware that children can be at risk for an embolic stroke. Which condition is least likely to cause a child to have a stroke?

Contact sport trauma

The nurse is caring for a patient experiencing an acute exacerbation of multiple sclerosis (MS). Which pathophysiological change does the nurse recognize as causing the manifestations of MS?

Demyelination and destruction of nerve fibers

An older adult patient is hospitalized for a respiratory infection. The nurses have been placing the patient's feet into high-top tennis shoes even while in bed. Which answer does the nurse make to a family member who asks about the purpose of the shoes?

Explain that without the proper foot position, it is impossible to stand.

The nurse is collecting data from a patient in the HCP's office. Which statement by the patient indicates that the patient is likely to be having problems with some activities of daily living (ADLs)?

I can barely lift my arms above my shoulders."

The nurse is assisting with the care of a patient after a traumatic brain injury. The patient experiences a seizure and exhibits bilateral jerking of the extremities. Which type of seizure activity does the nurse recognize?

Generalized

The nurse suspects that a patient is experiencing increasing ICP. What observations cause the nurse to come to this conclusion? (Select all that apply.)

Headache Rising temperature Dilated pupil on affected side Decreasing level of consciousness (LOC)

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)?

Hyper-coagulability related to the admitting diagnosis

The nurse is preparing a review of the neurologic system as part of a community health presentation. Which structures does the nurse identify as being part of the diencephalon? (Select all that apply.)

Hypothalamus thalamus

The nurse is assisting the RN in providing care for a patient with a potential for ICP. Which manifestation does the nurse recognize as needing to be reported to the RN?

Increased systolic blood pressure (BP)

The nurse is assisting with care of patients diagnosed with neuromuscular disorders. Which complication does the nurse recognize as a medical emergency?

Indications of the development of pneumonia

A patient who is prescribed neostigmine for newly diagnosed MG asks how the medication works. Which response does the nurse provide to the patient?

It makes more neurotransmitters available so that your muscles can contract."

A patient is diagnosed with bacterial encephalopathy. Which symptoms exhibited by the patient indicate late signs of the patient's diagnosis?

Lack of involvement and lip smacking or chewing

A patient is scheduled for a thymectomy. For which peripheral nervous system disorder does the nurse plan care for this patient?

MG

The nurse is hired by a family to provide care for a family member diagnosed with stage 2 Alzheimer disease. Which action related to safety is most important for the nurse to implement?

Make sure that all doors are locked where potential risk exists.

The nurse is providing care for a patient on a medical unit with a history of seizure activity. The patient exhibits the manifestations of a generalized seizure, which does not respond to prescribed treatment. Seizure activity has been continuous for over 30 minutes. Which prescription does the nurse prepare for the HCP?

Making immediate arrangements to transfer the patient to the intensive care unit (ICU)

The nurse is collecting data from a patient who is diagnosed with MG. Which data is most important for the nurse to obtain?

Monitor the patient's respiratory function and the ability to swallow effectively.

The nurse is providing care for a patient diagnosed with a cerebral aneurysm and subarachnoid hemorrhage. Which statement by the patient indicates a need for additional information?

No strenuous activity until this condition is cured by surgery."

The nurse asks an older adult patient to count backward from 100 in increments of three; the patient counts correctly until the nurse stops the process. Which reason does the nurse identify as a likely cause of long periods of hesitation during the process?

Normal delay in problem solving

The nurse is assisting the registered nurse (RN) in providing care for a patient who is recovering from a stroke. Which assigned intervention by the RN will the nurse question?

Observe the patient performing active range of motion (ROM) on the affected side.

The nurse is assisting with the care of a patient following an ischemic stroke who does not qualify for tPA therapy. The patient's current blood pressure is 190/110 mm Hg. For which reason will the patient's hypertension remain untreated?

Permissive hypertension is being therapeutically used to salvage brain tissue.

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?

Positive Brudzinski's sign

A patient reports to the nurse an inability to rest or sleep due to a long-term condition causing a constant urge to move the legs called restless legs syndrome (RLS). The patient expresses a need for some type of relief. Which suggestion by the nurse is most likely to help the patient?

Pramipexole or ropinirole medication therapy

The nurse will be accompanying a patient to the radiology department for the performance of a computerized axial tomography (CAT) scan with contrast. The patient is an older adult who has pain and exhibits signs of mild agitation. Which nursing care for the patient related to the examination is inappropriate?

Provide pain medication as soon as the test is done.

A patient with trigeminal neuralgia is admitted to the hospital for diagnostic testing and possible surgery. Which intervention is appropriate for this patient?

Provide soft foods at body temperature at mealtimes.

A patient is recovering from a stroke. The family reports to the nurse that the patient alternates between periods of crying for no given reason to periods of laughing inappropriately. Which condition does the nurse suspect the patient is exhibiting?

Pseudobulbar effect (patient yells out random things)

The nurse is providing care for a patient diagnosed with a stroke resulting in language disorder. Which type of disorder does the nurse recognize if the patient raises an arm in response to the nurse's direction to stick out his tongue?

Receptive Aphasia

The nurse is using the FOUR tool to assess a patient's neurologic functioning. In which areas does the nurse collect data when using this tool? (Select all that apply.)

Reflexes Eye response Motor movement Breathing pattern

The nurse suspects a patient is experiencing a sympathetic response. Which manifestations does the nurse expect the patient to exhibit? (Select all that apply.)

Relaxation of bladder Decrease in peristalsis Dilation of bronchioles

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?

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?

Scheduling laboratory tests, electrocardiogram (ECG), and computerized tomography (CT) scan to be performed within 45 minutes

While observing the neurologist complete a neurologic examination, the nurse notes that a patient has an absent left patellar reflex. Which possible areas of dysfunction does the nurse consider? (Select all that apply.)

Spinal cord Femoral nerve Quadriceps femoris muscle

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?

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?

Teach the patient to purposefully check the location of the left limbs.

The HCP is preparing to discharge a patient from the hospital after a stroke. The patient is insistent on being sent to a rehabilitation center. The nurse is aware that the patient must meet which qualification to go to rehabilitation?

The ability to participate in intensive therapy

The nurse is providing information to a patient with migraine headaches. Which information from the patient is least likely to be useful to the HCP when prescribing treatment?

The effectiveness of resting in a dark, quiet environment

The nurse is monitoring a patient who is 4 years of age who fell down a flight of steps. A Babinski response was not present during the initial assessment. The RN asks the nurse to recheck for a Babinski reflex and report abnormal responses. Which response will the nurse report to the RN?

The great toe extends and the other toes fan out.

The licensed practical nurse (LPN) is assigned to assist the registered nurse (RN) in providing care for a patient admitted for an inflammatory neurologic disorder. Which reassessment finding does the LPN report immediately to the RN?

The patient attempts to get out of bed to go to work.

The nurse is providing care for a patient being treated for trigeminal neuropathy. The nurse is concerned about the patient's nutritional status because of an inability to eat without experiencing severe pain. Which patient behavior indicates the nurse's interventions are successful?

The patient can eat multiple small, soft, lukewarm meals daily.

The nurse is assisting with the care of a patient admitted following a fall resulting in a head injury. Which finding prompts the nurse to inform the RN that the patient is experiencing a negative change in the level of consciousness?

The patient falls asleep in the middle of a sentence.

The nurse is assisting with the care of a patient diagnosed with post polio syndrome. The nurse asks the registered nurse (RN) to explain the source of the disease. Which answer by the RN is correct?

The patient must first have had a poliovirus infection.

The nurse is preparing to perform a Romberg test on a client. The nurse instructs the patient to stand with the feet together and eyes closed. After 20 seconds, the patient leans to one side and exhibits a swaying motion. Which conclusion does the nurse draw from these test results?

The test is positive and indicates cerebellar dysfunction.

The nurse is collecting information from a patient in the HCP's office. The patient is exhibiting symptoms associated with Bell palsy. Which population group does the nurse recognize as being at greatest risk for the condition?

Women in the third trimester of pregnancy

A patient arrives in the emergency department at 0200 exhibiting the manifestations of a stroke. The patient reports going to bed at 2100 and being negative for symptoms. If the CT reveals an ischemic stroke related to a blood clot, for which reason is tPA therapy withheld?

The therapy is based on the time the patient went to bed.

A patient comes into the emergency department with symptoms of a stroke. Which medication does the nurse expect to be given to the patient if diagnostic testing confirms an ischemic stroke?

Tissue-type plasminogen activator (tPA)

The nurse is preparing to collect data during the reassessment of a patient's neurologic status. Which equipment is unnecessary for this procedure?

cotton ball

The nurse is preparing a patient for neurologic testing. Which testing does the nurse expect if the patient expresses severe pain in the lower back aggravated by movement?

myelogram

The nurse is providing care for a patient diagnosed with an ischemic stroke on the left side of the brain. The nurse notices that the patient does not easily locate items placed at the bedside. In which area does the nurse place items for easy location?

right side

The nurse is providing care for a patient who was diagnosed with Parkinson disease 12 years prior. Which manifestation of the disease presents the nurse with the most likely risk for safety of this patient?

shuffling gait

The patient is diagnosed with a cerebral vascular accident that has the slowest rate of recovery and the highest probability of causing extensive neurologic deficits. For which type of stroke does the nurse plan care for this patient?

subarachnoid hemorrhage (SAH)

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?

the patient has been camping within the last few weeks.

The nurse is providing care for multiple patients. Which patient does the nurse decide to report immediately to the health care provider (HCP) or the registered nurse (RN)?

the patient who begins to exhibit lack of coordination and aphasia