Prep U Exam 3

A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by: A. a positive edrophonium (Tensilon) test. B. Kernig's sign. C. a positive sweat chloride test. D. Brudzinski's sign.

A. a positive edrophonium (Tensilon) test.

A client was hit in the head with a ball and knocked unconscious. Upon arrival at the emergency department and subsequent diagnostic tests, it was determined that the client suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would the nurse expect this subdural hematoma to be classified? A. acute B. chronic C. subacute D. intracerebral

A. acute

While snowboarding, a fell and sustained a blow to the head, resulting in a loss of consciousness. The client regained consciousness within an hour after arrival at the ED, was admitted for 24-hour observation, and was discharged without neurologic impairment. What would the nurse expect this client's diagnosis to be? A. concussion B. laceration C. contusion D. skull fracture

A. concussion

A nurse is working in a neurologist's office. The physician orders a Romberg test. The nurse should have the client: A. touch his or her nose with one finger. B. close his or her eyes and stand erect. C. close his or her eyes and discriminate between dull and sharp. D. close his or her eyes and jump on one foot.

B. close his or her eyes and stand erect.

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: A. Weakness on one side of the body and difficulty with speech B. Severe headache and early change in level of consciousness C. Footdrop and external hip rotation D. Confusion or change in mental status

B. Severe headache and early change in level of consciousness Ch 67?

The nurse is seeing a client in the oncology outpatient clinic. The client has recently been diagnosed with grade I meningioma. The client asks, "Is there a cure for my condition?" How should the nurse respond? A. "For most clients, surgery is an effective treatment for this type of tumor." B. "Radiation and chemotherapy are good treatment options for this type of tumor." C. "You will need to speak to your doctor regarding questions about your prognosis." D. "This type of tumor is fast growing and difficult to treat."

A. "For most clients, surgery is an effective treatment for this type of tumor."

A client with Parkinson's disease asks the nurse what their treatment is supposed to do since the disease is progressive. What would be the nurse's best response? A. "Treatment aims at keeping you independent as long as possible." B. "Treatment really doesn't matter; the disease is going to progress anyway." C. "Treatment for Parkinson's is only palliative; it keeps you comfortable." D. "Treatment aims at keeping you emotionally healthy by making you think you are doing something to fight this disease."

A. "Treatment aims at keeping you independent as long as possible."

The school nurse notes a 6-year-old running across the playground with his friends. The child stops in midstride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child? A. An absence seizure B. A myoclonic seizure C. A partial seizure D. A tonic-clonic seizure

A. An absence seizure

During assessment of cognitive impairment, post-stroke, the nurse documents that the patient was experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe? A. Frontal B. Occipital C. Parietal D. Temporal

A. Frontal

Which of the following is the initial diagnostic in suspected stroke? A. Noncontrast computed tomography (CT) B. CT with contrast C. Magnetic resonance imaging (MRI) D. Cerebral angiography

A. Noncontrast computed tomography (CT) Ch 67?

A client on your unit is scheduled to have intracranial surgery in the morning. Which nursing intervention helps to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting? A. Restrict fluids before surgery. B. Administer prescribed medications. C. Administer preoperative sedation. D. Administer an osmotic diuretic.

A. Restrict fluids before surgery. Ch 67?

Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels? A. T6 B. S2 C. L4 D. T10

A. T6

A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following? A. Thrombolytic therapy has a time window of only 3 hours. B. A ruptured intracranial aneurysm must quickly be repaired. C. Intracranial pressure is increased by a space-occupying bleed. D. A ruptured arteriovenous malformation will cause deficits until it is stopped.

A. Thrombolytic therapy has a time window of only 3 hours. Ch 67?

A client with a suspected brain tumor is scheduled for a computed tomography (CT) scan. 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 dyes, or shellfish.

Which is a nonmodifiable risk factor for ischemic stroke? A. Atrial fibrillation B. Gender C. Hyperlipidemia D. Smoking

B. Gender Ch 67?

A male client is scheduled for an electroencephalogram (EEG). When the nurse caring for the client is preparing him for the test, the client states that during childhood he was mildly electrocuted but miraculously lived. Therefore, he is quite afraid of going through an EEG. In what ways can the nurse help dispel the client's fear regarding the test? A. Distract the client's attention from the test. B. Inform the client that he will not experience any electrical shock. C. Inform the client that he will experience only mild electrical shock. D. Encourage adequate water intake by the client.

B. Inform the client that he will not experience any electrical shock.

A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to: A. hold the client's arm still to keep him from hitting anything. B. carefully move the client to a flat surface and turn him on his side. C. allow the client to remain in the chair but move all objects out of his way. D. place an oral airway in the client's mouth to maintain an open airway.

B. carefully move the client to a flat surface and turn him on his side.

A client preparing to undergo a lumbar puncture states he doesn't think he will be able to get comfortable with his knees drawn up to his abdomen and his chin touching his chest. He asks if he can lie on his left side. Which statement is the best response by the nurse? A. "Lying on your left side will be fine during the procedure." B. "There's no other option but to assume the knee-chest position." C. "Although the required position may not be comfortable, it will make the procedure safer and easier to perform." D. "I'll report your concerns to the physician."

C. "Although the required position may not be comfortable, it will make the procedure safer and easier to perform."

A client with newly diagnosed seizures asks about stigma associated with epilepsy. The nurse will respond with which of the following statements? A. "In most people, epilepsy is usually synonymous with intellectual disability." B. "For many people with epilepsy, the disorder is synonymous with mental illnes." C. "Many people with developmental disabilities resulting from neurologic damage also have epilepsy." D. "Cases of epilepsy are often associated intellectual level."

C. "Many people with developmental disabilities resulting from neurologic damage also have epilepsy."

A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure? A. Prone, with the head turned to the right B. Supine, with the knees raised toward the chest C. Lateral recumbent, with chin resting on flexed knees D. Lateral, with right leg flexed

C. Lateral recumbent, with chin resting on flexed knees

A client with a traumatic brain injury is showing early signs of increasing intracranial pressure (ICP). While planning care for this client, what would be the priority expected outcome? A. Attains desired fluid balance B. Displays no signs or symptoms of infection C. Maintains a patent airway D. Demonstrates optimal cerebral tissue perfusion

C. Maintains a patent airway

The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly? A. Moving the head toward both sides B. Lightly tapping the lower portion of the neck to detect sensation C. Moving the head and chin toward the chest D. Gently pressing the bones on the neck

C. Moving the head and chin toward the chest

Which term will the nurse use when referring to blindness in the right or left half of the visual field in both eyes? A. Scotoma B. Diplopia C. Nystagmus D. Homonymous hemianopsia

D. Homonymous hemianopsia Ch 67?

A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? A. Dextrose 5% in water (D5W) B. Half-normal saline (0.45% NSS) C. One-third normal saline (0.33% NSS) D. Mannitol

D. Mannitol

A patient 3 days postoperative from a craniotomy informs the nurse, "I feel something trickling down the back of my throat and I taste something salty." What priority intervention does the nurse initiate? A. Give the patient some mouthwash to gargle with. B. Request an antihistamine for the postnasal drip. C. Ask the patient to cough to observe the sputum color and consistency. D. Notify the physician of a possible cerebrospinal fluid leak.

D. Notify the physician of a possible cerebrospinal fluid leak.

A client who has sustained a head injury to the parietal lobe cannot identify a familiar object by touch. The nurse knows that this deficit is which of the following? A. Visual agnosia B. Positive Romberg C. Ataxia D. Tactile agnosia

D. Tactile agnosia

Which statement(s) reflect nursing interventions for a client with post-polio syndrome? A. The nurse administers antiretroviral agents per order. B. The nurse plans patient activities for evening hours rather then morning hours C. The nurse must avoid the use of heat applications in the treatment of muscle and joint pain D. The nurse provides care aimed at slowing the loss of strength and maintaining the physical, psychological and social well being of the client

D. The nurse provides care aimed at slowing the loss of strength and maintaining the physical, psychological and social well being of the client

The spinal cord is composed of 31 pairs of spinal nerves. How many pairs of thoracic nerves are contained within the spinal column? A. Twelve B. Five C. One D. Eight

A. Twelve

The initial sign of increasing intracranial pressure (ICP) includes A. decreased level of consciousness. B. herniation. C. vomiting. D. headache.

A. decreased level of consciousness.

A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? A. Maintaining adequate hydration B. Administering prescribed antipyretics C. Restricting fluid intake and hydration D. Hyperoxygenation before and after tracheal suctioning

C. Restricting fluid intake and hydration

A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke? A. Numbness of an arm or leg B. Double vision C. Severe headache D. Dizziness and tinnitus

C. Severe headache Ch 67?

A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan? A. Disturbed sensory perception (visual) B. Dressing or grooming self-care deficit C. Impaired verbal communication D. Risk for injury

D. Risk for injury

A client with cerebral metastasis suddenly experiences a seizure for which phenytoin 10 mg/kg intravenously is ordered as an initial loading dose. The client weighs 165 pounds. How many milligrams of phenytoin should the client receive? ________ mg

750 mg

The physician's office nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm? A. Myelogram B. Electroencephalogram C. Echoencephalography D. Cerebral angiography

D. Cerebral angiography

The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important? A. Elevating the head of the bed to 30 degrees B. Monitoring for seizure activity C. Administering a stool softener D. Maintaining a patent airway

D. Maintaining a patent airway Ch 67?

The nurse is caring for a patient with an altered LOC. What is the first priority of treatment for this patient? A. Assessment of pupillary light reflexes B. Determination of the cause C. Positioning to prevent complications D. Maintenance of a patent airway

D. Maintenance of a patent airway

A client has a spinal cord injury. The home health nurse is making an initial visit to the client at home and plans on reinforcing teaching on autonomic dysreflexia. What symptom would the nurse stress to the client and his family? A. Slight headache B. Rapid heart rate C. Sweating D. Runny nose

C. Sweating

A 26 year-old female is resting after a 1-minute episode during which she lost consciousness while her muscles contracted and extremities extended. This was followed by rhythmic contraction and relaxation of her extremities. On regaining consciousness, she found herself to have been incontinent of urine. What has the woman most likely experienced? A. A myoclonic seizure B. A tonic-clonic seizure C. An absence seizure D. A complex partial seizure

B. A tonic-clonic seizure

Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting? A. The client will take the seizure medication at the same time daily. B. The client will remain free of injury if a seizure does occur. C. The client will verbalize an understanding of feelings that preempt seizure activity. D. The client will post emergency numbers on the refrigerator for ease of obtaining.

B. The client will remain free of injury if a seizure does occur.

A patient is exhibiting bradykinesia, rigidity, and tremors related to Parkinson's disease. The nurse understands that these symptoms are directly related to what decreased neurotransmitter level? A. Acetylcholine B. Dopamine C. Serotonin D. Phenylalanine

B. Dopamine

A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain? A. Frontal B. Occipital C. Temporal D. Parietal

B. Occipital

The community health nurse is conducting a home visit with a client who was discharged from hospital 3 days ago after surgical resection of a brain tumor and radiation therapy. The client is accompanied by his partner during the nurse's visit. During the visit, the client's partner becomes tearful. How should the nurse respond? A. "It is okay to say you give up. Are you worried you will not be able to continue to provide care for your partner?" B. "Many caregivers experience burnout. Are you experiencing symptoms depression and anxiety?" C. "Sometimes people are unhappy about the way they were treated in the hospital. Were you happy with the care your partner received in the hospital?" D. "Going through this experience with your partner has been very difficult for you, I'm sure. Can you tell me about your experience so far?"

D. "Going through this experience with your partner has been very difficult for you, I'm sure. Can you tell me about your experience so far?"

The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? A. High-Fowler's B. Prone C. Supine D. Semi-Fowler's

D. Semi-Fowler's Ch 67?

A client with a spinal cord injury is to receive methylprednisolone sodium succinate 100 mg intravenously twice a day. The medication is supplied in vials containing 125 mg per 2 mL. How many mL will constitute the correct dose? ___________ mL

1.6 mL

A patient had a carotid endarterectomy yesterday and when the nurse arrived in the room to perform an assessment, the patient states, "All of a sudden, I am having trouble moving my right side." What concern should the nurse have about this complaint? A. A thrombus formation at the site of the endarterectomy B. This is a normal occurrence after an endarterectomy and would not be a concern. C. Bleeding from the endarterectomy site D. Surgical wound infection

A. A thrombus formation at the site of the endarterectomy Ch 67?

The nurse is evaluating the transmission of a report from a paramedic unit to the emergency room. The medic reports that a client is unconscious with edema of the head and face and Battle's sign. What clinical picture would the nurse anticipate? A. Edema to the head and a blackened eye B. Edema to the head with a large scalp laceration C. Edema to the head with fixed pupils D. Edema to the head with bruising of the mastoid process

D. Edema to the head with bruising of the mastoid process

Which condition occurs when blood collects between the dura mater and arachnoid membrane? A. Intracerebral hemorrhage B. Epidural hematoma C. Extradural hematoma D. Subdural hematoma

D. Subdural hematoma

The nurse is seeing a client who is suspected of having a glioblastoma multiforme tumor. The nurse anticipates the client will require which diagnostic test to confirm the client has this form of brain tumor? A. Tissue biopsy B. Weber and Rinne test C. Audible bruit over the skull D. An increase in prolactin

A. Tissue biopsy

A critical care nurse is documenting her assessment of a client she is caring for. The client is status post-resection of a brain tumor. The nurse documents that the client is flaccid on the left. What does this mean? A. The client has an abnormal posture response to stimuli. B. The client is not responding to stimuli. C. The client is hyperresponsive on the left. D. The client is hyporesponsive on the left.

B. The client is not responding to stimuli.

A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP? A. Encourage coughing and deep breathing. B. Position the client with the head turned toward the side of the brain tumor. C. Administer stool softeners. D. Provide sensory stimulation.

C. Administer stool softeners.

A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report? A. Sciatic nerve pain B. Herniation C. Paresthesia D. Paralysis

C. Paresthesia

Which statement indicates appropriate nursing intervention for a client with post-polio syndrome? A. Administer antiretroviral agents B. Plan activities for evening hours rather than morning hours C. Avoid the use of heat applications in the treatment of muscle and joint pain D. Provide care aimed at slowing the loss of strength and maintaining overall well-being.

D. Provide care aimed at slowing the loss of strength and maintaining overall well-being.