MedSurg 3: Exam 2

The nurse is caring for a client in the rehab unit who had a right sided CVA with left-sided residual paralysis. Which is the most effective way to prevent plantar flexion? A. massage the clients ankles and feet regularly throughout the day B. place the clients feet against a firm footboard. C. have the client wear ankle high tennis shoes at intervals throughout the day D. Reposition the feet every 2 hours using pillows

C.

A nurse is caring for a client 4 hrs following evacuation of a subdural hematoma. which of the following assessments is the nurses priority? A. intracranial pressure B. serum electrolytes C. respiratory status D. temperature

C. ICP is important to assess but airway and breathing first

A nurse is caring for a pt who has had an evacuation of an epidural hematoma. The patients intracranial pressure is being monitored with an intraventricular catheter. Which information obtained by the nurse requires urgent communication with the healthcare provider? A. Mean arterial pressure 110mmHg B. Temp 99.4 degrees C. Intracranial pressure 21mmHg D. Pulse 100 beats/min

C. I think normal ICP needs to be under 15mmHg.

A nurse at a rehabilitative center is planning care for a patient who had a right CVA 3 weeks ago. Which of the following goals should the nurse include in the rehabilitation plan? A. pharmacological treatment for depression B. establish the ability to communicate effectively C. Improve left-sided motor function D. Anticipate the patient will have slow cautious movements

C. Right sided stroke=left sided paralysis

A nurse is assessing a patient follow a head injury following a brief loss of consciousness. Which of the following findings should the nurse report to the provider? A. Small drops of clear fluid in the ear canal B. Edematous bruise on the forehead C. Pupils 4 mm and reactive to light D. Glasgow coma scale score of 12

A.

The nurse is caring for a patient suspected of having a hemorrhagic stroke. The medical records indicate the client has a history of hypertension and cerebral aneurysm. Which of the following manifestations should the nurse expect? A. Report of severe headache followed by a sudden onset of neurological deficits B. Onset of symptoms over several hours C. Neurologic deficits that last less than 1 hour D. patient maintains consciousness

A.

The nurse is caring for a patient who has global aphasia. Which of the following actions should the nurse take? A. communicate with the patient about one idea at a time B. As the patient to multitask C. Limit questions to single yes and no responses D. Focus on a single form of communication

A.

The nurse is caring for a patient with a spinal cord injury newly admitted with a stage IV decubitus ulcer. Which clinical manifestations would the nurse expect if the patient were to develop autonomic hyperreflexia? A. bradycardia and hypertension B. respiratory distress and projectile vomiting C. tachycardia and agitation D. third-spacing and hyperthermia

A.

Which of the following explains the Monroe-Kellie Doctrine? A. An change in one skull component requires the change in another

A.

You are the clinic nurse caring for a patient with a recent diagnosis of myasthenia gravis. The patient has begun treatment with pyridostigmine bromide (Mestinon). What change in status would most clearly suggest a benefit of this medication. A. increased muscle strength B. improved GI function C. improved cognition D. Deceased pain

A.

Stupid Food Question: The nurse is providing teaching to the client about warfarin (Coumadin). The client should avoid which food items? A. Broccoli B. oranges C. turnips D. cabbage E. strawberries

A. C. D. You want to avoid foods with vitamin K because remember vitamin K is the antidote to warfarin And protamine sulfate (fish sperm) is the antidote to heparin. fun fact

Which of the following medications can be used as prevention in patient's at risk for thrombotic stroke? (Select all that apply) A. lovastatin B. warfarin C. Statins D. antiplatelet aggregates E. altoplase F. activase

A, B, C, D

The nurse is caring for a client who had a craniotomy 12 hours ago. The nurse plans to closely monitor for signs of increased ICP. which interventions will help monitor and maintain normal ICP? (Select all) A. monitor the neurological status using the Glasgow Coma Scale B. contact the healthcare provider if ICP >15mmHg C. stimulate the client with actie ROM exercises D. encourage the client to cough to expectorate secretions E. elevate the head of the bed to 30 degrees

A, B, E

A client is diagnosed with brain tumor of the parietal lobe. Based on the tumor's location, which assessment finding would the nurse most likely note? (Select all that apply) A. problems with mathematical calculations B. memory changes C. changing moods D. impaired reasoning E. difficulty reading

A, E

A nurse at a community health clinic is caring for a patient who reports a headache and stiff neck. Which of the following assessments should the nurse consider a priority. A. Evaluate the patient's neurological status B. Administer an oral analgesic C. obtain urine sample D. obtain a specimen for a complete blood count (CBC)

A.

A nurse is assessing a client who was involved in a motor-vehicle accident. Which of the following techniques should the nurse use to test cranial nerves IX and X? A. Gag reflex B. raise eyebrows C. Assess position of tongue D purse lips

A.

A nurse is caring for a patient who has an intracranial pressure (ICP) reading of 40 mmHg. Which of the following assessments should the nurse recognize as a late sign of increased ICP? (select all) A. hypotension B. decerebrate posturing C. Cheyne-Stokes respirations D. fixed pupils E. Tachycardia

B, C, D

the nurse on the oncology unit is caring for a patient with newly diagnosed metastatic brain cancer. The health care provider plans to discuss palliative care with the patient and family. The nurse will discuss palliative therapy with the family and knows this therapy consists of which of the following? (Select all) A. comfort measures only B. radiation C. surgery D. chemotherapy

B, C, D

The ICU nurse is caring for a patient who has cerebral edema and a new serum sodium level of 116 mEq/L and a decreasing level of consciousness. The patient begins complaining of a headache. Which of the following prescribed interventions will the nurse implement first? A. send patient for computed tomography (CT) B. Administer 5% hypertonic saline IV C. Draw for arterial blood gases (ABGs) D. Administer acetaminophen 650 mg orally

B.

The nurse is admitting a patient newly admitted with possible bacterial meningitis. The patient has a temperature of 101.8 degrees F and a severe headache. Which order should the nurse implement first? A. Apply a cooling blanket to lower the temperature B. Swab the nasopharyngeal mucosa for cultures C. administer prescribed antibiotics D. Place the patient om 2L/Nasal Cannula

B. Antibiotic therapy should be instituted rapidly inn bacterial meningitis, but cultures must be done before antibiotics are started. The patient's temperature can be addressed after this.

Which of these nursing actions for a patient with Guillain-Barré syndrome is most appropriate for the nurse to delegate to an experienced nursing assistant? A. Administer tube feedings B. Passive range of motion to extremities q4h C. Assessment for bladder distention q2h D. Artificial tear administration q2h

B. Assisting a patient with movement is included in UAP education and scope of practice. Remember bitches, administrations/assessments are all nurse stuff

The nurse is caring for a patient with a tumor in the cerebellum. Which intervention will the nurse plan to incorporate in the plan of care? A. mood stabilization B. fall prevention C. memory aids D. Aspiration precautions

B. Damage to the cerebellum can lead to: 1) loss of coordination of motor movement (asynergia), 2) the inability to judge distance and when to stop (dysmetria), 3) the inability to perform rapid alternating movements (adiadochokinesia), 4) movement tremors (intention tremor), 5) staggering, wide based walking (ataxic gait ...

Following a spinal cord injury a patient is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action? A. complete pin site care to reduce risk of infection B. reattach the pin to prevent further head trauma C. notify the neurosurgeon of the occurrence D. stabilize the head in a lateral position

C.

A male patient presents to the clinic complaining of a headache. The nurse notices the patient is guarding his neck and tells the nurse that he has stiffness in the neck area. What further assessment findings would support the nurses suspicion? (Of bacterial meningitis I assume) A. hyperpatellar reflexes B. Positive Kernig's Sign C. Negative Brudzinski's sign D. sluggish pupil response

B. Kernig's sign is inability to straighten the leg when the hip is flexed to 90 degrees. positive Brudzinski's sign also indicates bacterial meningitis,. This is when the neck is stiff and when flexed, the hips and knees also flex.

The nurse is caring for a patient with MS. The patient tells the nurse the hardest thing to deal with is the fatigue. When teaching the patient how to reduce fatigue, what action should the nurse suggest? A. Avoiding naps during the day B. Resting in an air-conditioned room whenever possible C. Taking a hot bath at least once a day D. Increasing the dose of muscle relaxants

B. Lowering the body temperature may relieve fatigue, however, extreme cold should be avoided. Hot baths and showers create fatigue. Muscle relaxants cause drowsiness and fatigue. Planning for frequent rest periods can actually relieve fatigue. Other measures to reduce fatigue include: treating depression, occupational therapy to learn energy conservation and reducing spasticity (stretching, positioning, splinting)

A nurse is caring for a patient who has right sided acoustic neuroma resulting in impaired cranial nerve VIII function. Which intervention will the nurse anticipate? A. apply an eye patch to the patient's right eye B. institute fall precautions C. avoid the use of warm water to wash the patient's face D. keep volume on TV muted

B. Nerve VIII is the acoustic nerve btw

What problem can a nurse expect from a patient with a positive Romberg test? A. Confusion B. Falls C. Aphasia D. Pain

B. The Romberg test is when the patient stands with feet together and closes their eyes and tries to remain balanced. Increased unsteadiness with eyes closed or loss of balance means they may have ataxia related to sensory function (vision)

A patient is experiencing a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize? A. Focal Seizure B. Unclassified Seizure C. Generalized Seizure D. Absence Seizure

C. The pattern of rigidity does not occur in patients with unclassified, absence or focal seizures. Generalized often involve both hemispheres of the brain, causing both sides of the body to react. Intense rigidity of entire body may occur followed by alternating relaxation and contraction

The nurse is caring for a patient with a stroke that is experiencing facial drooping on the right side and right-sides arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find? A. Right sided neglect B. Anosognosia C. Difficulty comprehending instructions D. Impulsive behavior

C. Right sided paralysis indicates a left sided stroke which will lead to difficulty with comprehension and use of language. Impulsive behavior and neglect are common with right sided stroke.

A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include? A. Encourage brief exercise before meals to promote appetite B. place the client with head reclined back to facilitate swallowing C. place food in the affected side of the mouth D. encourage the client to take small bites

D.

A patient with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform. A. arrange the patient to receive a low residue diet B. suction the patient following each meal C. withold liquids until patient has finished eating D. position the patient upright during feeding

D.

The nurse is assessing a pt with bacterial meningitis, the nurse obtains the following information. Which finding requires most immediate intervention. A. The patient is unable to flex the head forward B. The patients temperature 101.2 C. The patient has a positive Brudinski sign D. The patients blood pressure is 85/40 mmHg

D.

The nurse is caring for a patient with a spinal cord injury that is experiencing several hypotensive episodes. How can the nurse best address the patient's risk for orthostatic hypotension.? A. maintain bedrest until normal BP returns B. allow patient to initiate repositioning C. administer iv bolus of NS prior to position change D. monitor the patient's BP before and during position changes

D.

A nurse is caring for a patient diagnosed with lymphoma and has a known spinal cord tumor. The patient is exhibiting new onset back pain in the region of the tumor that increases when in the prone position. What complication should the nurse suspect? A. ineffective pain management B. this is a normal finding, the patient should reposition to lateral side C. Radiculopathy D. Tumor extension into the epidural space

D. Early signs of spinal cord compression are back pain that increases when in supine position and symmetrical extremity weakness.

Battle's Sign is a type of bruising. Where is it located? A. Around the eyes B. On the forehead C. Under the wiener D. Behind the ear

D. Battle's sign is a hematoma located behind the ear

A patient diagnosed with Bell's palsy is being cared for on an outpatient basis. During health education the nurse should promote which of the following actions? A. avoid brushing the teeth B. Avoid the use of analgesics C. Chewing on the affected side to prevent unilateral neglect D. applying a protective eye shield at night

D. Bell's palsy is a paralysis of usually one side of the face. Corneal irritation and ulceration can occur if the eye is not protected. Also, patient should chew on the unaffected side due to swallowing difficulties. Analgesics are used to control facial pain. Patient should continue to provide self care like oral hygiene.

A nurse is caring for a pt who is in status epilepticus. What medication would the nurse know may be given to halt the seizure immediately? A. PO phenytoin (Dilantin) B. IV phenobarbital (Luminal) C. PO lorazepam (Ativan) D. IV diazepam (Valium)

D. Management of status epilepticus includes administration of diazepam and lorazepam IV given slowly to halt seizure. Other medications like phenobarbital are given later for maintenance. And obvi don't give PO meds to someone having a seizure

The nurse suspects that a patient admitted for treatment of bacterial meningitis is experiencing increased ICP. Which of the following assessment findings by the nurse supports this suspicion? A. nuchal rigidity B. Photophobia C. Positive Kernig's sign D. Restlessness

D. The rest are common finding's in bacterial meningitis but for increased ICP it is restlessness and this question sucks Patients with bacterial meningitis also experienced phonophobia. Kernig's sign is tested by having pt flex hip and then extend the leg, if they cannot extend the leg fully it is a positive test

A nurse is caring for a client who has an epidural hematoma. Which of the following manifestations should the nurse expect? A. change in the level of consciousness that develops over 48 hrs B. Neurologic deficits that increase up to 2 weeks post-injury C. Cognitive perception that decreases over several months post-injury D. a lucid period followed by an immediate loss of consciousness

D. a SUBDURAL hematoma would be: A.

A client is being treated for transient ischemic attacks. The nurse will anticipate teaching about which of the following medications? A. IV heparin therapy B. warfarin sodium C. Tissue plasminogen activator TPA D. oral aspirin therapy

D. clients with TIA's are treated with antiplatelet medications (aspirin) and a stain and an antihypertensive. TPA is used for ACUTE ischemic stroke

A patient who has been experiencing numerous episodes of unexplained headaches and vomiting has subsequently been referred for testing to rule out a brain tumor. What characteristic of the patient's vomiting is most consistent with a brain tumor? A. The patient's emesis is blood-tinged. B. The patient's vomiting does not relieve his nausea. C. The patient's vomiting is unrelated to food intake. D. The patient's vomiting is accompanied by epistaxis.

c.