Ch.13 & Ch.14 Nursing

Which question is likely to elicit the most valid response from the patient who is being interviewed about a neurologic problem?

"Can you describe the sensations you are having?"

What Glasgow Coma Scale rating would a patient receive who opens the eyes spontaneously, but has incomprehensible speech and obeys commands for movement?

12

The nurse assures an anxious family member of a 92-year-old patient who is demonstrating signs of dementia that many causes of dementia are reversible and preventable. What is one example?

Hypotension

sensory aphasia or receptive aphasia

Inability to comprehend the spoken or written word.

Anomic Aphasia

Inability to name objects

Motor aphasia or expressive aphasia

Inability to speak or write using symbols of speech

Global aphasia

Inability to understand the spoken word or to speak

One of the housekeepers splashes a chemical in the eyes. What should be the first priority?

Irrigate with normal saline solution for 20 minutes

The nurse is aware that the drug t-PA (Activase), a tissue plasminogen activator, must be given in____hours of the onset of symptoms to have maximum benefit.

3 hours

The nurse is aware that the patient has 20/40 vision. This means that the patient can see at 20 feet what the normal eye can see at _______ feet.

40

The nurse would need to determine how this patient's visual impairment affects normal functioning.

The patient tells the nurse that he is legally blind. How would this information impact the nurse's plan of care for this patient?

What is the process when the lens of the eye changes its curvature to focus on the retina?

Accommodation

How would a nurse record the behavior when a patient with Alzheimer disease attempts to eat using a napkin rather than a fork?

Agnosia

When the newly blind male home health patient asks the nurse how he might get assistance, who might the nurse suggest he contact?

American Foundation for the Blind for a list of agencies

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

Which foods should the person who suffers from migraine headaches avoid? (Select all that apply.)

Caffeine

What does the nurse know about the stroke patient who has expressive aphasia?

Can understand the spoken word, but cannot speak

What does a tympanoplasty correct?

Conductive hearing loss

What is the cardinal sign of increased intracranial pressure in a brain injured patient?

Decrease in the level of consciousness

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

Diagnostic test used for neurologic injuries

MRI or CT

Which foods should the person who suffers from migraine headaches avoid? (Select all that apply.)

Marinated foods

What is the basic problem that prompts most of the early signs of Alzheimer disease?

Memory loss that disrupts daily life

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 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.

What is a common mistake that hinders communication when communicating with the hearing impaired?

Overaccentuating words

What should the nurse do when the child arrives on the floor with the diagnosis of bacterial meningitis?

Place the child in respiratory isolation

Why are the drugs neostigmine (Prostigmin) and pyridostigmine (Mestinon) helpful to the person with myasthenia gravis?

Promotes nerve impulse transmission

As the result of a stroke, a patient has difficulty discerning the position of his body without looking at it. In the nurse's documentation, which would best describe the patient's inability to assess spatial position of his body?

Proprioception

What is the purpose of a "drug holiday" in the treatment of Parkinson disease?

Restart drugs at a lower dosage with favorable results

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

A patient with a spinal cord injury at T1 complains of stuffiness of the nose and a headache. The nurse notes a flushing of the neck and "goose flesh." What should be the primary nursing intervention based on these assessments?

Sit upright and check blood pressure

The 62-year-old home health patient who is recovering from eye surgery complains of a feeling of "grittiness" in the eye and is having blurred vision. The eyes are reddened and have stringy mucus. What do these complaints indicate?

Sjögren syndrome

A patient is in which stage of Alzheimer disease when she demonstrates "sundowning"?

Stage 2

Gently wipe nose with absorbent gauze

The newly admitted patient to the emergency room after a motorcycle accident has serosanguineous drainage coming from the nose. What is the most appropriate nursing response to this assessment?

Which symptom is specific to migraine headaches?

They are preceded by an aura

How would the nurse instruct a patient with Parkinson disease to improve activity level?

To walk with hands clasped behind back to help balance

What is the cranial nerve that supplies most of the organs in the thoracic and abdominal cavities and also carries motor fibers to glands that produce digestive juices and other secretions?

Vagus

Which foods should the person who suffers from migraine headaches avoid? (Select all that apply.)

Yogurt

The nurse is caring for a home health patient who had a spinal cord injury at C5 three 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.

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.

Following a myelogram the nurse should include in the postprocedure care assessment for:

sensation in lower extremities.

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.