Health Challenges II - Midterm

What is a normal intraocular pressure?

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Contraindications of thrombolytic therapy include... 1. INR above 1.0 2. Recent intracranial patho 3. Symptom onset greater than 2 hours prior to admission 4. Current anticoagulant therapy 5. Symptom onset greater than 4.5 hrs prior to admission

2, 4 and 5. Recent intracranial pathology, current anticoagulant therapy, and symptom onset greater than 4.5 hours prior to admission. An INR above 1.7 would be contraindicative

The patho of an ischemic stroke includes the ischemic cascade which includes the following steps - in what order 1. Change in pH 2. Blood flow decreases 3. A switch to anaerobic respiration is made 4. Membrane pump fail 5. Cells cease to function 6. Lactic acid is generated

2. blood flow decreases 3. a switch to anaerobic respiration is made 6. lactic acid is generated 1. a change in pH 4. Membrane pump fail 5. Cells cease to function

When doing an initial assessment for his shift, the nurse finds that one of his clients is exhibiting signs of compartment syndrome. The nurse knows that the client can permanently lose function in the extremeity if the anoxic situation continues for longer than __ hours.

6 hours

The nurse witnesses a patient with a seizure disorder as he suddenly jerks his arms and legs, falls to the floor, and regains consciousness immediately. What type of seizure is demonstrated by this patient that the nurse must document? a. An atonic seizure b. A myoclonic seizure c. A complex partial seizure with automatisms d. A simple partial seizure with motor symptoms

ANS: A An atonic ("drop attack") seizure involves either a tonic episode or a paroxysmal loss of muscle tone and begins suddenly with the person falling to the ground. Consciousness usually returns by the time the person hits the ground, and normal activity can be resumed immediately.

5. A patient with a stroke caused by thrombosis of the middle cerebral artery experiences left-sided paralysis of the upper and lower extremities and facial drooping on the left side. When obtaining admission assessment data about the patient's clinical manifestations, it is most important for the nurse to assess which of the following? a. The patient's ability to follow commands b. The patient's visual fields c. The patient's left-sided reflexes d. The patient's emotional state

ANS: A Because the patient with a right-sided brain stroke may have difficulty with comprehension and use of language, it is important to obtain baseline data about the ability to follow commands.

6. The nurse records the following general survey of a patient: "The patient is a 68-year-old male Asian attended by his wife and two daughters. Alert and oriented. Does not make eye contact with the nurse and responds slowly, but appropriately, to questions. No apparent disabilities or distinguishing features." What additional information should be added to this general survey? a. Body movements b. Intake and output c. Reasons for contact with the health care system d. Comments of family members about his condition

ANS: A In addition to body movements, the general survey also describes the patient's general nutritional status. The other information will be obtained when doing the complete nursing history and examination but is not obtained through the initial scanning of a patient.

7. When caring for a patient with epilepsy who was hospitalized and successfully treated for status epilepticus, what is a precaution that the nurse should institute as part of the care? a. Placing oxygen and suction equipment at the bedside b. Assigning an assistant to stay with the patient at all times c. Keeping a tongue blade available to insert in case of a seizure d. Instructing the patient to stay in bed and call for assistance to go to the bathroom

ANS: A Oxygen and suction equipment should be available at the bedside for a patient who has epilepsy.

12. Which part of the stethoscope is best to use when the nurse is listening to low-pitched sounds? a. Bell b. Tube c. Diaphragm d. The largest area for auscultation

ANS: A The bell of the stethoscope is best to listen to low-pitched sounds. The diaphragm (or largest part) is best used when assessing for high-pitched sounds.

A hospitalized 24-year-old patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first? a. Notify the patient's physician immediately. b. Start the ordered as-needed oxygen at 9 L/min. c. Give the ordered as-needed acetaminophen (Tylenol). d. Put a moist hot pack on the patient's neck.

ANS: B Acute treatment for cluster headache is administration of 100% oxygen at 7 to 9 L/min. If the patient obtains relief with the oxygen, there is no immediate need to notify the physician.

A patient with Parkinson's disease tells the nurse that she is having increasing problems with constipation. The nurse explains that constipation occurring with Parkinson's disease is most often a result of which of the following factors? a. Advanced age b. Decreased physical activity c. Side effects of dopaminergic agents d. Diminished nerve conduction to the bowel

ANS: B Promotion of physical exercise and a well-balanced diet are major concerns for nursing care. Exercise for patients with Parkinson's disease can limit the consequences of decreased mobility, such as muscle atrophy, contractures, and constipation.

The nurse identifies the nursing diagnosis of impaired physical mobility related to bradykinesia for a patient with Parkinson's disease. To assist the patient to ambulate safely, what should the nurse do? a. Allow the patient to ambulate only with assistance. b. Teach the patient to rock back and forth to initiate leg movement. c. Have the patient take small steps in a straight line directly in front of the feet. d. Teach the patient to slide the feet forward with each step, always keeping the feet in contact with the floor.

ANS: B Rocking the body from side to side stimulates balance and improves mobility.

19. A patient with MS has a nursing diagnosis of urinary retention related to sensorimotor deficits. What is an appropriate nursing intervention for this problem? a. Decrease fluid intake in the evening. b. Teach the patient how to use the Credé manoeuvre. c. Suggest the use of incontinence briefs for nighttime use only. d. Assist the patient to the commode every 2 hours during the day.

ANS: B The Credé manoeuvre can be used to improve bladder emptying.

Neurological testing of the patient by the nurse indicates impaired functioning of the left glossopharyngeal nerve (cranial nerve IX) and the vagus nerve (cranial nerve X). Based on these findings, what should the nurse plan to do? a. Insert an oral airway. b. Withhold oral fluid or foods. c. Provide highly seasoned foods. d. Apply artificial tears to protect the cornea.

ANS: B The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex. A patient with impaired function of these nerves is at risk for aspiration.

26. A patient with left-sided hemiparesis arrives by ambulance at the emergency department. Which action should the nurse take first? a. Obtain the Glasgow Coma Scale score. b. Check the respiratory rate. c. Monitor the blood pressure. d. Send the patient for a CT scan.

ANS: B The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway.

11. To assess the functioning of the optic nerve (cranial nerve II), what should the nurse do? a. Apply a cotton wisp strand to the cornea. b. Perform a confrontational test for visual fields. c. Evaluate pupil response to light and accommodation. d. Ask the patient to follow a finger with the eyes as it is moved vertically, horizontally, and diagonally.

ANS: B The optic nerve is responsible for visual fields and visual acuity.

Which of the following is a clinical manifestation of myasthenia gravis (MG)? a. Bulging eyes b. Scotoma c. Unstable gait d. Hypertension

ANS: C A clinical manifestation of MG is unstable or unusual gait.

17. Which of the following is an age-related change in the nervous system? a. Increased efficiency of temperature-regulating mechanism b. Decreased size of ventricles in the brain c. Decrease in electrical activity d. Increase in deep-tendon reflexes

ANS: C A normal age-related change is a decrease in electrical activity. The temperature-regulating mechanism is decreased in efficiency in aging. The size of the ventricles increases with age. The deep-tendon reflexes either remain the same or decrease in aging.

28. Which one of the following manifestations would the nurse expect to assess on a patient with left-brain damage from a stroke? a. Left-sided hemiplegia b. Spatial-perceptual deficits c. Impaired speech-language d. Impaired time concepts

ANS: C A patient with left-brain damage will manifest impaired speech-language

4. Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the physician? a. The patient has atrial fibrillation. b. The patient has dysphasia. c. The patient states, "I suddenly developed a terrible headache." d. The patient has a history of brief episodes of right hemiplegia.

ANS: C A sudden-onset headache is typical of a subarachnoid hemorrhage and ruptured aneurysm; the physician should be notified immediately.

19. Which neurotransmitter is involved in emotions, moods, and regulating motor control? a. Serotonin b. Epinephrine c. Dopamine d. Substance P

ANS: C Dopamine is involved in emotions, moods, and regulating motor activity. Serotonin is also involved with moods and emotions but has no relevance to regulating motor control.

14. A patient with homonymous hemianopsia resulting from a stroke has a nursing diagnosis of disturbed sensory perception related to hemianopsia. What is an appropriate nursing intervention that will help the patient learn to compensate for the deficit during the rehabilitation period? a. Apply an eye patch to the affected eye. b. Approach the patient on the unaffected side. c. Place objects necessary for activities of daily living on the affected side. d. Teach the patient to exercise the eye muscles with full range of motion at least twice a day.

ANS: C During the rehabilitation period, placing objects on the affected side will encourage the patient to use the scanning technique to visualize the affected side.

9. On initial assessment of a patient hospitalized following a stroke, the nurse finds the patient's blood pressure to be 180/90 mm Hg. What should the nurse anticipate? a. IV fluids will be withheld until the blood pressure is within the normal range. b. Unless the blood pressure is lowered, the patient is at risk for another stroke. c. IV fluids will be administered to promote hydration to maintain cerebral perfusion. d. IV antihypertensive agents will be administered to maintain a mean arterial pressure of 140 mm Hg.

ANS: C Fluid intake should be 1500 to 2000 mL daily to maintain cerebral blood flow.

25. In order to assess a patient's receptive speech, what should the nurse do? a. Ask the patient where she is right now. b. Show the patient three items, and ask the patient to name them. c. Instruct the patient to close the eyes, ask if a stone sinks in water, and get her to point to the ceiling. d. Ask the patient the time of day, what month, and what year it is.

ANS: C Instructing the patient to close her eyes, asking if a stone sinks in water, and getting her to point to the ceiling is the assessment for receptive speech that the nurse would implement.

For which classification of drug that is used in the treatment of MS does the nurse know to teach the patient about the importance of restricting their sodium intake? a. Cholinergics b. Acetylcholinesterase c. Corticosteroids d. Anticholinergics

ANS: C Patient teaching with the administration of corticosteroids includes restricting salt intake, not stopping therapy abruptly, and being aware of drug interactions.

Twenty-four hours after admission, a patient with a stroke has progressive development of neurological deficits with increasing weakness and decreased level of consciousness. What is the primary goal of nursing management of the patient at this time? a. Protecting the skin from breakdown b. Monitoring for changes in neurological status c. Maintaining the patient's respiratory function d. Preventing joint contractures and muscle atrophy

ANS: C Protection of the airway is the priority of nursing care for a patient having an acute stroke.

A patient with MG is admitted to the hospital with severe weakness and acute respiratory insufficiency. The physician performs a Tensilon test to distinguish between myasthenic crisis and cholinergic crisis. During the test, it will be most important to monitor which of the following? a. Pupillary size b. Muscle strength c. Respiratory function d. Level of consciousness

ANS: C The Tensilon test in a patient with MG reveals improved muscle contractility after intravenous injection of the anticholinesterase agent edrophonium chloride (Tensilon); therefore, respiratory function must be monitored. (Anticholinesterase blocks the enzyme acetylcholinesterase.) This test also aids in the diagnosis of cholinergic crisis (secondary to overdose of anticholinesterase medication). In this condition, Tensilon does not improve muscle weakness but may actually increase it. Atropine, a cholinergic antagonist, should be readily available to counteract Tensilon effects when it is used diagnostically.

A patient has newly diagnosed multiple sclerosis (MS) and asks many questions about the disease. When teaching the patient about MS, what should the nurse explain? a. MS is an untreatable viral disease that destroys the basal ganglia in the brain. b. Nerve impulses travel too quickly over nerves that have lost their myelin coat, overloading the brain. c. An autoimmune process causes gradual destruction of the myelin sheath of nerves in the brain and spinal cord. d. In MS, antibodies are produced against acetylcholine receptors, resulting in blocked muscle contraction.

ANS: C The primary pathology in MS is an autoimmune process that leads to loss of the myelin sheath and results in decreased nerve transmission.

10. When assessing using mediated percussion, which finger of which hand will the nurse use on the patient's body? a. Middle finger of dominant hand b. Index finger of dominant hand c. Middle finger of nondominant hand d. Index finger of nondominant hand

ANS: C When performing mediated (indirect) percussion, the examiner uses the middle finger of the nondominant hand against the patient's body for percussion.

7. Which one of the following manifestations would the nurse expect to assess on a patient with right-brain damage from a stroke? a. Right-sided hemiplegia b. Slow performance, cautiousness c. Aware of deficits, depression d. Impulsive behaviour

ANS: D A patient with right-brain damage from a stroke would manifest impulsive behaviour, thus safety is a main priority of care.

A 28-year-old woman has had MS for 3 years and wants to have children before her disease becomes worse. When she asks about the risks associated with pregnancy, the nurse should explain which of the following information? a. The stress of pregnancy is likely to accelerate the course of the disease. b. She may experience an acute, long-lasting exacerbation of the disease during pregnancy. c. Because MS is genetically transmitted, she should consider the risks to future generations. d. MS has no apparent effect on pregnancy and lactation, but the risk for an exacerbation after the pregnancy is increased.

ANS: D During the postpartum period, women with MS are at greater risk for exacerbation of symptoms.

18. During the neurological assessment, the patient cooperates with the nurse's directions to grip with the hands and to move the feet, but does not respond to the nurse's questions. The nurse will suspect which of the following? a. A temporal lobe lesion b. Injury to the cerebellum c. A brainstem lesion d. Damage to the frontal lobe

ANS: D Expressive speech is controlled by Broca's area in the frontal lobe.

3. A patient is admitted to the orthopedic unit with a fractured right elbow following a skiing accident. During the initial nursing assessment, what information is related to the functional health pattern regarding the patient's fractured elbow and the treatment he has received? a. Activity-exercise b. Cognitive-perceptual c. Self-perception-self-concept d. Health perception-health management

ANS: D In a hospitalized patient, the health perception-health management pattern includes information about the patient's understanding of the onset and treatment of the current health problem.

During the acute phase of a patient with an ischemic stroke, the nurse monitors the patient's neurological status closely with the knowledge that following a stroke, increased intracranial pressure from cerebral edema is most likely to peak in which of the following time periods? a. 12 hours b. 24 hours c. 48 hours d. 72 hours

ANS: D Increased intracranial pressure from cerebral edema usually peaks in 72 hours and may cause brain herniation.

When teaching a patient with MG about management of the disease, the nurse advises the patient to do which of the following? a. Anticipate the need for weekly plasmapheresis treatments. b. Protect the extremities from injury due to poor sensory perception. c. Do frequent weight-bearing exercise to prevent muscle atrophy. d. Perform necessary physically demanding activities in the morning.

ANS: D Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then.

Following recovery from a stroke, a 68-year-old patient developed complex partial seizures with motor symptoms beginning in the right arm with progression to unconsciousness. The physician prescribes phenytoin (Dilantin) for control of the seizures. Which of the following statements by the patient indicates understanding of what self-care related to this drug includes? a. "I should use soft swabs rather than a toothbrush to clean my mouth." b. "If I have a seizure, I should call an ambulance to take me to the hospital." c. "I will take the medication at the beginning of the seizure before I lose consciousness." d. "As I start this medication, I will need to have my blood taken frequently to check the level of the drug."

ANS: D Serum levels of phenytoin may be checked to ascertain that a therapeutic level of the medication is achieved.

10. After experiencing a generalized tonic-clonic seizure in the classroom, a 25-year-old high school teacher is evaluated and diagnosed with idiopathic epilepsy. The patient cries when told of the diagnosis and tells the nurse that she can never go back to teaching after experiencing the seizure in front of her students. What is an appropriate nursing diagnosis for the patient? a. Anxiety related to loss of control during seizures b. Hopelessness related to diagnosis of chronic illness c. Disturbed body image related to new diagnosis of epilepsy d. Ineffective role performance related to misinformation about epilepsy

ANS: D The data indicate that the patient has ineffective role performance caused by inadequate information about the disease because most patients are able to control seizures with medication.

16. When reviewing the results of a patient's cerebrospinal fluid analysis obtained from a lumbar puncture, which of the following does the nurse identify as abnormal? a. pH 7.35 b. White blood cell count 4 cells/microlitre (0.004 cells/L) c. Protein 0.30 g/L (30 mg/dL) d. Glucose 1.7 mmol/L (30 mg/dL)

ANS: D The glucose level is low.

When obtaining a health history from a patient with a neurological problem, the nurse is likely to elicit the most valid response from the patient by asking the patient which of the following questions? a. "Do you ever have any nausea or dizziness?" b. "Does the pain radiate from your back into your legs?" c. "Do you have any sensations of pins and needles in your feet?" d. "Can you describe the sensations you are having in your chest?"

ANS: D The most useful and valid information is obtained through the use of open-ended questions that allow the patient to describe symptoms.

A 32-year-old patient has a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan? a. Encouraging the patient to cough and breathe deeply every 4 hours b. Inserting an oropharyngeal airway to prevent airway obstruction c. Assisting the patient to dangle on the edge of the bed and assessing for dizziness d. Applying intermittent pneumatic compression stockings

ANS: D The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for deep-vein thrombosis.

Completing a neurological assessment on a client the nurse exams cranial nerve VIII. What would be correct in identifying this nerve as what? Movement of tongue Visual acuity Sense of smell Hearing and equilibrium

Answer: Cranial nerve VIII is responsive for hearing and equilibrium. Tongue movement is cranial nerve XIII. Cranial nerve II is responsive for visual acuity. Cranial nerve I is responsive for sense of smell. To assess this cranial nerve (VIII) do a bone conduction test known as a rinne test

Name 3 common age related auditory changes

Drier cerumen, auditory nerve degeneration, atrophy of tympanic membrane

What is presbycusis?

Hearing loss caused by aging

Describe guidelines for caring for a patient with a recent hip replacement?

Hips should be kept in abduction by an abductor wedge or pillow. Hips should not flex more than 90 degrees and the head of the bed should not be elevated more than 60 degrees. Hips should be higher than the knees, so high seats are to be used.

If a patient is using drops for glaucoma, what would the nurse need to question?

History of heart or lung disease

Why might ocular pressure increase?

Increased production of aqueous humor

Describe the differences between macules, papules, vesicles and pustules.

Macules are flat, nonpalpable skin colour changes. Papules are elevated, solid palpable masses. Vesicles are circumscribed, elevated, palpable mass containing serous fluid and a pustule is a pus filled vesicle.

Before fluorescein is injected for angiography, what are two priorities for the nurse?

Obtain emesis basin and inform patient that skin may turn yellow

The client is given a medication that stimulates her parasympathetic system. What is an effect of the parasympathetic stimulation? Constricted pupils Dilated bronchioles Decreased peristaltic movement Relaxed muscular walls of the urinary bladder

Parasympathetic system results in constricted pupils, constricted bronchioles, increased peristaltic movement and contracted muscular walls of the urinary bladder.

What would a finding be in a patient with otosclerosis when examining the ear with an otoscope?

Schwartz sign, reddish blush of tympanic membrane

What is accomodation?

The shape of the lens is modified when a person changes from focusing on close to far objects

The nurse is doing an initial assessment of a client with cerebrovascular accident. The client has difficulty copying a figure the nurse has shown them. The nurse uses this technique for which type of of aphasia? Auditory - reception Visual - reception Expressive speaking Expressive writing

Visual receptive aphasia. Expressive aphasia is inability to express oneself and often results from frontal lobe damage. Auditory receptive aphasia is inability to understand what someone is saying and often results from temporal lobe damage.

What is otosclerosis?

a hereditary disorder causing progressive deafness due to overgrowth of bone in the inner ear, most common cause of hearing loss in young adults.

What is used to assess near vision problems?

jaegar chart

Presbyopia is...

normal aging change in which lens loses elasticity and flexibility occuring around age 40. inability to focus on close up objects

What is the normal finding when visualizing the tympanic membrane?

pearl-grey

A client that has difficulty understanding speech likely has...

sensorineural hearing loss