exam

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? 1. "I find that I can eat better with a facial sling in place." 2. "Gentle massage of the effected muscles reduces discomfort." 3. "I follow the physical therapy exercises exactly as prescribed." 4. "Alternating heat and cold therapy is helping the swelling."

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

The nurse is reinforcing teaching provided to a patient with primary open-angle glaucoma (POAG) about symptoms to report. Which patient statement regarding symptoms indicates a correct understanding of the teaching? 1. "Hypotension and bradycardia" 2. "Fever and reddened conjunctiva" 3. "Loss of central vision and dizziness" 4. "Headache and seeing halos around lights"

"Headache and seeing halos around lights"

A patient who is prescribed neostigmine for newly diagnosed MG asks how the medication works. Which response does the nurse provide to the patient? 1. "It is a muscle relaxant to prevent the cramping in your muscles." 2. "It provides potassium to your muscles so that they will contract better." 3. "It makes more neurotransmitters available so that your muscles can contract." 4. "It reduces the inflammation in your nerves so that they transmit signals better."

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

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? 1. "No one knows an exact cause." 2. "It may be an autoimmune reaction to a virus." 3. "It most often occurs as a result of a bacterial infection." 4. "It is usually hereditary. Does anyone in your family have it?"

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

The caregiver of a patient with macular degeneration voices being increasingly frustrated because of food spills on the patient's clothing. Which explanation does the nurse give to help the caregiver understand what the patient is experiencing? 1. "The patient's vision is blurred." 2. "There is total blindness in one eye occurring." 3. "The central vision is gone and only peripheral vision remains." 4. "There are black dots in the field of vision that cause confusion."

"The central vision is gone and only peripheral vision remains."

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? 1. "All family members are now at risk for the disease." 2. "You definitely need to have genetic testing for the disease." 3. "Your children need to be tested for a genetic connection."

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

A patient's Snellen chart findings are 20/60. Which explanation does the nurse provide to the patient regarding this finding? 1. "Your vision is better than normal." 2. "You must be at 60 feet to see what normal vision sees at 20 feet." 3. "You must be at 20 feet to see what normal vision sees at 60 feet." 4. "You are considered legally blind, even though with prescription glasses you'll be able to see.

"You must be at 20 feet to see what normal vision sees at 60 feet."

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?

. One the right side

A patient began experiencing manifestations of a stroke at 0800 hours. By which time should thrombolytic medications be provided to reverse stroke symptoms? 1. 0900 hours 2. 1250 hours 3. 1400 hours 4. 1660 hours

2. 1250 hours

The nurse is involved in a blood pressure clinic in the community, and an individual with possible stroke symptoms is brought for evaluation. Which findings in the FAST (Face, Arms, Speech, and Time) assessment indicate the need to call emergency personnel? (Select all that apply.) 1. The patient sways when asked to stand still with eyes closed. 2. The patient is unable to follow directions during the assessment. 3. The patient is unable to repeat a stated phrase exactly as it was stated. 4. The patient's face shows signs of uneven symmetry when asked to smile. 5. When asked to close the eyes and hold arms straight in front, one arm drifts

3, 4, 5

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? 1. The presence of amnesia about details before and after the injury 2. Changes in heart and respiratory rate, fever, and diaphoresis 3. Presence of head and scalp contusions with a single lesion 4. One-sided paralysis, extreme weakness, or pupil dilation

Changes in heart and respiratory rate, fever, and diaphoresis

The nurse is preparing to assist a patient with eating who is recovering from a stroke. Which intervention is appropriate? 1. Have the patient sip liquids in small amounts with a straw. 2. Place the patient in a semi-Fowler's position to promote swallowing. 3. Check the patient's mouth periodically for presence of pocketed food. 4. Instruct the patient to swallow numerous times to clear food from the mouth.

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

The nurse is reinforcing teaching provided to a patient with open-angle glaucoma. What is most important for the nurse to include in the patient teaching? 1. Regardless of treatment, peripheral vision will be eventually lost. 2. Compliance with drug therapy is essential to prevent loss of vision. 3. Damage to the eye caused by glaucoma is reversible in early stages. 4. Eye pain is experienced until the optic nerve atrophies, causing blindness.

Compliance with drug therapy is essential to prevent loss of vision.

A patient with acute angle glaucoma and a fractured femur that is scheduled for surgery is prescribed the preoperative medications morphine 10 mg intramuscularly (IM) and atropine 0.4 mg IM. Which action does the nurse take? 1. Hold the morphine. 2. Contact the physician. 3. Give medications as ordered. 4. Collect data on patient's pain

Contact the physician.

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? 1. Myelin buildup in the central nervous system 2. Demyelination and destruction of nerve fibers 3. Gamma aminobutyric acid (GABA) deficiency 4. Reduced acetylcholine receptors with impaired nerve impulse transmission

Demyelination and destruction of nerve fibers

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? 1. Partial 2. Chronic 3. Generalized 4. Traumatic

Generalized

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? 1. Rapid apical pulse 2. Increased systolic blood pressure (BP) 3. Shallow, even respirations 4. Narrowing pulse pressure

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? 1. Evidence of severe muscle wasting 2. Indications of the development of pneumonia 3. Interruption of skin integrity over bony prominences 4. Difficulty maintaining weight due to difficulty swallowing

Indications of the development of pneumonia

A patient presents with vertigo, tinnitus, and sensorineural hearing loss and is diagnosed with labyrinthitis. Which patient teaching does the nurse reinforce with this patient? 1. Instruct to not turn the head quickly. 2. Emphasize the importance of taking antihistamines. 3. Use proper methods for cleaning the ear. 4. Hearing will return with rest and medication

Instruct to not turn the head quickly.

A patient is diagnosed with bacterial encephalopathy. Which symptoms exhibited by the patient indicate late signs of the patient's diagnosis? 1. Short attention span and poor memory 2. Disorientation and difficulty following commands 3. Lack of involvement and lip smacking or chewing 4. Expressed fear about loud noises in the hallway

Lack of involvement and lip smacking or chewing

The nurse is collecting data from a patient who is diagnosed with MG. Which data is most important for the nurse to obtain? 1. Ascertain if the patient's needs are being met by an adequate support system. 2. Ask what amount of activity causes fatigue and muscle weakness to occur. 3. Determine baseline muscle strength through the use of appropriate techniques. 4. Monitor the patient's respiratory function and the ability to swallow effectively

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

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? 1. The elevated blood pressure will create collateral circulation in the brain. 2. Therapeutic blood pressure needs to exceed 220/120 mm Hg to be effective. 3. Permissive hypertension is being therapeutically used to salvage brain tissue. 4. Hypertension will move the clot to an area of the brain treatable by tPA.

Permissive hypertension is being therapeutically used to salvage brain tissue.

The nurse is preparing to administer eye medication as prescribed by the HCP after eye surgery for cataract removal. The HCP prescribes one drop with punctal occlusion. Which action will the nurse perform when administering this medication? 1. Have the nonmedicated eyelid held closed during medication administration. 2. Place the index finger on the corner of the eye and apply pressure against the nose bone. 3. Instruct the patient to squeeze the eye tightly shut once the drop is administered. 4. Tilt the head back, apply the drop, ask the patient to blink twice, and blot any leakage.

Place the index finger on the corner of the eye and apply pressure against the nose bone.

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? 1. Pseudobulbar effect 2. Psychotic events 3. Bipolar disorder 4. Mood swings

Pseudobulbar effect

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 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? 1. Make sure the call light is always within the patient's reach. 2. Perform active or passive range of motion (ROM) at least twice each shift. 3. Relocate environmental objects and pad the bedside rails. 4. Follow HCP's prescribed therapy for treatment of headache

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? 1. Maintenance of oxygen therapy to a saturation of at least 94 percent 2. Careful monitoring of changes in the patient's level of consciousness 3. Scheduling laboratory tests, electrocardiogram (ECG), and computerized tomography (CT) scan to be performed within 45 minutes 4. Immediate treatment for temperature greater than 99.6°F

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

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? 1. Bradykinesia 2. Muscle rigidity 3. Shuffling gait 4. Resting tremors

Shuffling gait

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? 1. The effectiveness of resting in a dark, quiet environment 2. Keeping a diary about episodes including pre- and post information 3. Determining if there may be a genetic connection to the headaches 4. Making note of preheadache visual, speech, or sensation disturbances

The effectiveness of resting in a dark, quiet environment

The nurse is conducting hearing acuity evaluation on a patient using the Rinne test. The test involves the use of a tuning fork. Which test result will be validated with the documentation "AC greater than BC"? 1. The patient hears the tuning fork twice as long when it is placed on the mastoid bone. 2. The patient is unable to hear the tuning fork when it is lifted away from the mastoid bone. 3. The patient continues to hear the tuning fork for twice as long when it is lifted from the mastoid bone. 4. The patient stops hearing the tuning fork when it is moved from in front of the ear and placed on the mastoid bone.

The patient continues to hear the tuning fork for twice as long when it is lifted from the mastoid bone.

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? 1. The patient has recently exhibited flu-like manifestations. 2. The patient lives in a home where a child has chickenpox. 3. The patient has been camping within the last few weeks. 4. The patient has experienced a stiff neck for 3 days.

The patient has been camping within the last few weeks

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? 1. Heparin 2. Clopidogrel 3. Warfarin 4. Tissue-type plasminogen activator (tPA)

Tissue-type plasminogen activator (tPA)

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? 1. Women in the third trimester of pregnancy 2. Patients who have experienced a stroke 3. Patients who have a history of sun exposure 4. Men with history of excessive alcohol abuse

Women in the third trimester of pregnancy

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? 1. "I am very careful to avoid sick people and crowds in the winter." 2. "I have been attending a special yoga class for people with MS." 3. "I love to work in my flower beds during the summer months." 4. "I find that I do much better if I let other people run errands for me."

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

The nurse is providing care for a patient with expressive aphasia. Which intervention does the nurse expect to find in the patient's plan of care? (Select all that apply.) 1. Speak loudly. 2. Use a picture board. 3. Obtain an interpreter. 4. Provide pencil and paper. 5. Speak slowly and clearly.

2 , 4

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? 1. Symptoms have been increasing in severity for several days. 2. Ataxia is present when the patient attempts to ambulate. 3. The patient was diagnosed with hypertension managed with medication. 4. The patient appears upset and cries easily throughout assessment.

2. Ataxia is present when the patient attempts to ambulate

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? 1. A postmenopausal patient who has type 2 diabetes mellitus (DM) controlled by diet 2. An overweight male with a 15-year smoking history, who is treated for hypertension 3. A young adult born with a heart defect causing ventricle fibrillation 4. An older female patient who has osteoporosis, a femur fracture, and hyperlipidemia

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

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? 1. Contact sport trauma 2. Sickle cell disease 3. Hyperlipidemia 4. Congenital heart defect

Contact sport trauma

During a physical examination of a patient, pupillary reflexes are checked. A light is shone into the right eye while it is observed. Pupillary reaction and pupil size are noted. Then a light is shone into the left eye as the right eye is still observed. Which response occurs during the second step of the test? 1. Direct response 2. Indirect response 3. Consensual response 4. Accommodation response

Consensual response

While checking a patient's pupils, the nurse notes that the left pupil constricts when a light is shone into the right eye. Which information does this finding suggest to the nurse? 1. Tropia present 2. Esotropia absent 3. Accommodation absent 4. Consensual response present

Consensual response present

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? 1. Help the patient make lists for tasks to be completed. 2. Make sure that all doors are locked where potential risk exists. 3. Monitor for signs or behaviors related to the patient's physical needs. 4. Regenerate interest in activities, acquaintances, or surroundings.

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

The nurse is collecting information from a patient who reports difficulty seeing the print in the newspaper. The patient is 50 years of age and does not have any condition that requires medical management. Which vision condition does the nurse suspect the patient is experiencing? 1. Myopia 2. Presbyopia 3. Astigmatism 4. Emmetropia

Presbyopia

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? 1. Thrombotic stroke 2. Cerebral aneurysm 3. Subarachnoid hemorrhage (SAH) 4. Reversible ischemic neurologic deficit (RIND)

Subarachnoid hemorrhage (SAH)

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? 1. Encourage the patient to turn her plate for ease in self-feeding. 2. Place the call light and phone on the patient's left side. 3. Teach the patient to purposefully check the location of the left limbs. 4. Provide stimuli of all senses on the patient's affected side.

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