Adult health exam 1 study material
bsence seizures, formerly referred to as petit mal seizures, are more common in children. They are characterized by a brief loss of consciousness, during which physical activity ceases. The person stares blankly; the eyelids flutter; the lips move; and slight movement of the head, arms, and legs occurs.
The school nurse notes a 6-year-old running across the playground with friends. The child stops in mid-stride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child?
Parkinson's disease
A 55-year-old female client presents at the walk-in clinic complaining of feeling like a mask is on her face. While doing the initial assessment, the nurse notes the demonstration of a pill-rolling movement in the right hand and a stooped posture. Physical examination shows bradykinesia and a shuffling gait. What would the nurse suspect is the causative factor for these symptoms?
Cerebellum
A client comes to the clinic for evaluation because of complaints of dizziness and difficulty walking. Further assessment reveals a staggering gait, marked muscle incoordination, and nystagmus. A brain tumor is suspected. Based on the client's assessment findings, the nurse would suspect that the tumor is located in which area of the brain?
generalized
A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure?
Pituitary carcinoma
After a transsphenoidal adenohypophysectomy, a client is likely to undergo hormone replacement therapy. A transsphenoidal adenohypophysectomy is performed to treat which type of cancer?
low bone mass and osteoporosis
Bone density testing in clients with post-polio syndrome has demonstrated
leathery and stupor
What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP?
decreased level of consciousness (LOC)
What is one of the earliest signs of increased ICP?
Osteoporosis
When educating a patient about the use of antiseizure medication, what should the nurse inform the patient is a result of long-term use of the medication in women?
143 lbs/2.2 = 65 kg. 65 kg x 1.5 = 97.5 grams.
client is receiving intravenous (IV) mannitol to prevent increased intracranial pressure. The order is for mannitol 1.5 grams per kg of body weight IV now. The client weighs 143 lbs (65 kg). How many grams will the nurse administer to the client? Enter the correct number ONLY.
Avoiding flexion of the neck with use of a cervical collar
which positions is used to help reduce intracranial pressure (ICP)?
laminectomy
A nurse is working on a surgical floor. The nurse must logroll a client following a:
Respiratory Dysfunction
A client has undergone surgery for a spinal cord tumor that was located in the cervical area. The nurse would be especially alert for which of the following?
hemorrhagic stroke
A client is diagnosed with a brain angioma. When teaching the client about the risks associated with this type of brain tumor, the nurse would educate about signs and symptoms associated with which condition?
shivering
A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?
To help confirm ALS, the physician typically orders EMG, which detects abnormal electrical activity of the involved muscles.
A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order:
3 indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response. A score of 15 indicates that the patient is fully responsive.
A nurse assesses the patient's level of consciousness using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function?
unequal response
A nurse is assessing a client who has been in a motor vehicle collision. The client directly and accurately answers questions. The nurse notes a contusion to the client's forehead; the client reports a headache. Assessing the client's pupils, what reaction would confirm increasing intracranial pressure?
a decrease in level of consciousness.
The initial sign of increasing intracranial pressure (ICP) includes
supine portion with head slightly elevated
The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the
Polydipsia Polyuria Disturbed sleep Impairment of visual field
The nurse is caring for a client who is currently under medical investigation for a pituitary adenoma. The nurse anticipates the client will likely report which symptoms that are consistent with this type of brain tumor? Select all that apply.
With a blood pressure of 175/45 mm Hg, it is evident that this client is experiencing progressively rising ICP, resulting from an advanced stage of the brain tumor. This blood pressure demonstrates a wide pulse pressure, meaning the difference between systolic and diastolic pressure is large. A heart rate of 42 bpm indicates the client is bradycardic.
The nurse is caring for a client who was diagnosed with a glioma 5 months ago. Today, the client was brought to the emergency department by his caregiver because he collapsed at home. The nurse suspects late signs of rising intracranial pressure (ICP) when which blood pressure and pulse readings are noted?
change in level of consciousness
Which is the earliest sign of increasing intracranial pressure?
Levodopa/Carbidopa
Which medication is the most effective agent in the treatment of Parkinson disease?
headache
Which of the following is an early sign of increasing intracranial pressure (ICP)?
aura
Which phase of a migraine headache usually lasts less than an hour?
Low level of dopamine
impaired balance and uncontrolled tremors of Parkinson's disease is correlated with which neurotransmitter?
supine position with the head slightly elevated.
the nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the
keep the head in neutral position
A male client who has undergone a cervical discectomy is being discharged with a cervical collar. Which of the following would be most appropriate to include the client's discharge plan?
tep 1: 2.2 lb / 1 kg = 132 lb / X kg 132 lb = 2.2 X 60 kg = X Step 2: 1 kg / 0.25 mg = 60 kg / X mg 15 mg = X
A client weighing 132 lb is brought to the emergency department in status epilepticus. The physician asks the nurse to prepare diazepam 0.25 mg/kg. How many milligrams will be given to this client?
related to impaired balance
A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase should the nurse add to complete the nursing diagnosis statement?
Photophobia and hypersensitivity to environmental stimuli are the common clinical manifestations of meningeal irritation and infection. Therefore, the nurse should provide a calm environment with less stressful stimuli.
to meet the sensory needs of a client with viral meningitis, the nurse should:
chewing
A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis?
The Monro-Kellie hypothesis states that, because of the limited space for expansion in the skull, an increase in any one of its components causes a change in the volume of the others.
A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following?
hearing loss usually occurs
A patient has recently been diagnosed with an acoustic neuroma. The nurse helps the patient understand that:
originated within the brain tissues
A patient is diagnosed with an aggressive, primary malignant brain tumor. The nurse is aware that the glioma:
Check the client's blood pressure Assess the client for headache Assess for presence of visual changes
The nurse is caring for a client who is postoperative from surgery for a brain tumor resection. The client has a visitor at the bedside who lowers the head of the bed below 30 degrees. The nurse assesses the client has decreased level of consciousness. What actions should the nurse take? Select all that apply.
Exposure to certain chemicals Having ionizing radiation
The nurse is providing a health promotion session on the risk factors for various health conditions. When discussing brain tumors, the nurse should include in the session which known risk factors for brain tumors? Select all that apply.
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 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?
Mannitol is an osmotic diuretic--> decreases the fluid content of the brain
the nurse explains to the client with projectile vomiting and severe headache that a medication is being prescribed to reduced edema surrounding the brain and lessen these symptoms. What medication is the nurse preparing to administer?
you must avoid coughing, sneezing, and blowing your nose
A client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize?
Ensure that the client is free of pain for meals. Plan meals for times when the client is rested. Provide the client with foods that he likes.
A client with an incurable brain tumor is experiencing nausea and vomiting and has little interest in eating. His family states, "We don't know how to help him." Which of the following would be appropriate for the nurse to suggest to help improve the client's nutritional intake? Select all that apply.
keep client on one side helps facilitate drainage of oral secretions provide verbal reassurance
A client with epilepsy is having a seizure. What intervention should the nurse do after the seizure?
Restricting fluid intake and hydration
A client with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client?
Intravenous immunoglobulin infusion may help you."
A client with post-polio syndrome displays fatigue and decreased muscle strength. How should the nurse best respond to the client?
magnetic resonance imaging (MRI)
A client with spinal cord compression from a tumor must undergo diagnostic testing. Which of the following is the most likely procedure for this client?
more than 200 ml/h
A nurse is assessing a patient's urinary output as an indicator of diabetes insipidus. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator?
increased intracranial pressure
A patient with a brain tumor is complaining of headaches that are worse in the morning. What does the nurse know could be the reason for the morning headaches?
Postures
Decorticate posture is the flexion and internal rotation of forearms and hands. Decerebrate posture is extension and external rotation indicates deeper and more severe dysfunction.
Benign tumors are usually slow growing but can occur in a vital area, where they can grow large enough to cause serious effects.
The nurse is seeing the mother of a client who states, "I'm so relieved because my son's doctor told me his brain tumor is benign." The nurse knows what is true about benign brain tumors?
How to facilitate tasks such as using both hands to hold a drinking glass
The nursing instructor gives their students an assignment of making a plan of care for a client with Huntington's disease. What would be important for the students to include in the teaching portion of the care plan?
