week 9
The nurse is caring for a home health patient who had a spinal cord injury at C5 3 years ago. The nurse bases the plan of care on the knowledge that the patient will be able to:
feed self with setup and adaptive equipment.
A patient is in a coma after a serious motor vehicle accident. He has been diagnosed with asignificant neurologic impairment. He is demonstrating decorticate posturing. Anassessment of his positioning will reveal:
flexion of the arms, wrists, and fingers with adduction in the upper extremities.
An 83-year-old patient has had a stroke. He is right handed and has a history of hypertension and "little" strokes. He presents with right hemiplegia. To afford him the best visual field, the nurse should approach him:
from the left side.
The ______________ cranial nerve is responsible for the sense of smell.
olfactory
What is the first sign of Bell's palsy?
Inability to wrinkle forehead and pucker lips on affected side
A frantic family member is distressed about the flaccid paralysis of her son following a spinal cord injury several hours ago. What does the nurse know about this condition?
It is possibly a temporary condition and will clear.
The newly admitted patient to the emergency room 30 minutes ago after a fall off a ladder has gradually decreased in consciousness and has slowly reacting pupils, a widening pulse pressure, and verbal responses that are slow and unintelligible. What is the most appropriate position for the patient?
Neck placed in a neutral position.
A family member of a patient who has just suffered a tonic-clonic seizure is concerned about the patient's deep sleep. What is this behavior called?
Postictal period
After a seizure, the patient appears groggy and lethargic. These findings are consistent with which stage of the seizure?
Postictal period
When caring for a patient with a diagnosis of trigeminal neuralgia, an area for concern is:
activation of trigger points.
After performing the Glasgow coma scale test, the patient assessment reveals a score of 13. This score indicates:
normal neurologic functioning.
The nurse is aware that the characteristic gait of the person with Parkinson disease is a propulsive gait, which causes the patient to:
shuffle with arms flexed.
How would the nurse instruct a patient with Parkinson disease to improve activity level?
To walk with hands clasped behind back to help balance.
The nurse is aware that when assessing a patient by the FOUR score coma scale, the patient is assessed in four categories: eye response, brainstem reflexes, motor response, and respiration. How are these results reported?
As individual scores in each category
What is the nurse aware of when assessing a person with a craniocerebral injury?
Signs and symptoms may not occur until several days after the trauma.
What are surgical navigational systems?
Computerized devices that guide the surgeon
A patient who has recently been diagnosed with seizures asks if he will be allowed to drive again. What is the best response to his question?
"Once the seizures are under medical control for a period of time, you might be able to drive."
What is the nurse assessing when asking the patient, "Who is the president of the United States?" during a level of consciousness assessment?
Fund of knowledge
An assessment noting diplopia, vertigo, loss of joint sensation, and nystagmus is consistent with which disorder?
Multiple sclerosis
A patient, age 45, is to have a myelogram to confirm the presence of a herniated intervertebral disk. Which nursing action should be planned with respect to this diagnostic test?
Obtain an allergy history before the test.
The health care provider of a patient who has suffered a mild CVA has recorded in her notes that the patient is experiencing dysarthria. This refers to which occurrence?
Poorly articulated speech
A patient is in which stage of Alzheimer's disease when she demonstrates "sundowning"?
Second stage
What is the cranial nerve that supplies most of the organs in the thoracic and abdominal cavities and carries motor fibers to glands that produce digestive juices and other secretions?
Vagus nerve
The concept of proprioception refers to:
the sensation pertaining to spatial position and muscular activity stimuli originating from within the body.
While reviewing a cerebrospinal fluid test result, you note that the lab identified reduced glucose and chloride levels. Based upon your knowledge, you anticipate a diagnosis consistent with a:
varicella infection.