N380 Exam 2: NEURO

The patient's spinal cord injury is at T4. What is the highest-level goal of rehabilitation that is realistic for this patient to have? a. Indoor mobility in manual wheelchair b. Ambulate with crutches and leg braces c. Be independent in self-care and wheelchair use d. Completely independent ambulation with short leg braces and canes

C

What is most important action for a patient who has a suspected cervical spinal injury? A. Apply a soft foam cervical collar. B. Perform a neurologic check. C. Place the patient on a firm surface. D. Assess function of cranial nerves IX and X.

C

When planning care for a patient diagnosed with Parkinson disease (PD), which of these patient outcomes should receive priority in the patient's plan of care? A. Taking a daily walk around the neighborhood B. Working on a favorite hobby C. Toileting and bathing independently D. Taking a vitamin supplement each day

C

Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)? A. Overestimation of physical abilities. B. Difficulty judging position and distance. C. Slow and possibly fearful performance of tasks. D. Impulsivity and impatience at performing tasks.

C

A 19-year-old man is admitted to the emergency department with a C6 spinal cord injury after a motorcycle crash. Which medication should the nurse anticipate that she will administer first? A. Enoxaparin (Lovenox) B. Metoclopramide (Reglan) C. IV immunoglobulin (Sandoglobulin) D. Methylprednisolone sodium succinate (Solu-Medrol)

D

A 62-year-old patient who has Parkinson's disease is taking bromocriptine (Parlodel). Which information obtained by the nurse may indicate a need for a decrease in the dose? a. The patient has a chronic dry cough. b. The patient has four loose stools in a day. c. The patient develops a deep vein thrombosis. d. The patient's blood pressure is 92/52 mm Hg.

D

A 74-year-old man who has right-sided extremity paralysis related to a thrombotic stroke develops constipation. Which action should the nurse take first? A. Assist the patient to the bathroom every 2 hours. B. Provide incontinence briefs to wear during the day. C. Administer a bisocodyl (Dulcolax) rectal suppository every day. D. Arrange for several servings per day of cooked fruits and vegetables.

D

A nursing intervention is indicated for the patient with hemiplegia is a. the use of a footboard to prevent plantar flexion b. immobilization of the affected arm against the chest with a sling c. positioning the patient in bed with each joint lower than the joint proximal to it d. having the patient perform passive ROM of the affected limb with the unaffected limb

D

A patient is admitted to the hospital with a C4 spinal cord injury after a motorcycle collision. The patient's blood pressure is 83/49 mm Hg and pulse is 39 beats/minute. He remains orally intubated. What is the cause of this pathophysiologic response? A. Increased vasomotor tone after the injury B. A temporary loss of sensation and flaccid paralysis below the level of injury C. Loss of parasympathetic nervous system innervation resulting in vasoconstriction D. Loss of sympathetic nervous system innervation resulting in peripheral vasodilation

D

Following a T2 spinal cord injury, the patient develops paralytic ileus. While this condition is present, what should the nurse anticipate that the patient will need? a. IV fluids b. Tube feedings c. Parenteral nutrition d. Nasogastric suctioning

D

In counseling patients with spinal cord lesions regarding sexual function, how should the nurse advise a male patient with a complete lower motor neuron lesion? a. He is most likely to have reflexogenic erections and may experience orgasm if ejaculation occurs. b. He may have uncontrolled reflex erections but orgasm and ejaculation are usually not possible. c. He has a lesion with the greatest possibility of successful psychogenic erection with ejaculation and orgasm. d. He will probably be unable to have either psychogenic or reflexogenic erections and no ejaculation or orgasm.

D

In planning community education for prevention of spinal cord injuries, what group should the nurse target? a. Older men b. Teenage girls c. Elementary school-age children d. Adolescent and young adult men

D

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness (LOC). Which nursing diagnosis do they determine has the highest priority for the patient? A. Impaired physical mobility related to weakness B. Disturbed sensory perception related to brain injury C. Risk for impaired skin integrity related to immobility D. Risk for aspiration related to inability to protect airway

D

The female patient has been brought to the ED with a sudden onset of a severe headache that is different from any other headache she has had previously. When considering the possibility of a stroke, which type of stroke should the nurse know is most likely occurring? A. TIA B. Embolic stroke C. Thrombotic stroke D. Subarachnoid hemorrhage

D

The nurse in a primary care provider's office is assessing several patients today. Which patient is most at risk for a stroke? A. A 92-year-old female who takes warfarin (Coumadin) for atrial fibrillation. B. A 28-year-old male who uses marijuana after chemotherapy to control nausea. C. A 42-year-old female who takes oral contraceptives and has migraine headaches. D. A 72-year-old male who has hypertension and diabetes mellitus and smokes tobacco.

D

The nurse is admitting a client with the diagnosis of Parkinson's disease. Which assessment data support this diagnosis? A. Crackles in the upper lung fields and jugular vein distention. B. Muscle weakness in the upper extremities and ptosis. C. Exaggerated arm swinging and scanning speech. D. Masklike facies and a shuffling gait.

D

The nurse is planning the care for a client diagnosed with Parkinson's disease. Which would be a therapeutic goal of treatment for the disease process? A. The client will experience periods of akinesia throughout the day. B. The client will take the prescribed medications correctly. C. The client will be able to enjoy a family outing with the spouse. D. The client will be able to carry out activities of daily living.

D

The priority intervention in the emergency department for the patient with a stroke is a. intravenous fluid replacement b. administration of osmotic diuretics to reduce cerebral edema c. initiation of hypothermia to decrease the oxygen needs of the brain d. maintenance of respiratory function with a patent airway and oxygen administration

D

When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is the highest priority? A. Impaired tissue integrity due to paralysis B. Impaired urinary elimination due to quadriplegia C. Ineffective coping due to the extent of trauma D. Ineffective airway clearance due to high cervical spinal cord injury

D

Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia in order to prevent autonomic dysreflexia? a. Assist with selection of a high protein diet. b. Use quad coughing to assist cough effort. c. Discuss options for sexuality and fertility. d. Teach the purpose of a prescribed bowel program.

D

You are caring for a patient admitted 1 week earlier with an acute spinal cord injury. Which assessment finding alerts you to the presence of autonomic dysreflexia? A. Tachycardia B. Hypotension C. Hot, dry skin D. Throbbing headache

D

In which order will the nurse perform the following actions when caring for a patient with possible C6 spinal cord trauma who is admitted to the emergency department? a. Infuse normal saline at 150 mL/hr. b. Monitor cardiac rhythm and blood pressure. c. Administer O2 using a non-rebreather mask. d. Transfer the patient to radiology for spinal computed tomography (CT). e. Immobilize the patient's head, neck, and spine.

E, C, B, A, D

A female patient who had a stroke 24 hours ago has expressive aphasia. The nurse identifies the nursing diagnosis of impaired verbal communication. An appropriate nursing intervention to help the patient communicate is to a.ask questions that the patient can answer with "yes" or "no." b.develop a list of words that the patient can read and practice reciting. c.have the patient practice her facial and tongue exercises with a mirror. d.prevent embarrassing the patient by answering for her if she does not respond.

a

A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate? a."The obstructing plaque is surgically removed from an artery in the neck." b."The diseased portion of the artery in the brain is replaced with a synthetic graft." c."A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed." d."A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque."

a

Computed tomography (CT) of a 68-year-old male patient's head reveals that he has experienced a hemorrhagic stroke. What is the priority nursing intervention in the emergency department? A. Maintenance of patient's airway. B. Positioning to promote cerebral perfusion. C. Control of fluid and electrolyte imbalances. D. Administration of tissue plasminogen activator (tPA)

a

Four days following a stroke, a patient is to start oral fluids and feedings. Before feeding the patient, the nurse should first a. check the patient's gag reflex b. order a soft diet for the patient c. raise the head of the bed to sitting position d. evaluate the patient's ability to swallow small sips of ice water

a

A 63-year-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? Select all that apply. a. Obtain computed tomography (CT) scan without contrast. b. Infuse tissue plasminogen activator (tPA). c. Administer oxygen to keep O2 saturation >95%. d. Use National Institute of Health Stroke Scale to assess patient.

a, b, c, d

The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a.The pulse rate is 102 beats/min. b.The patient has difficulty speaking. c.The blood pressure is 144/86 mm Hg. d.There are fine crackles at the lung bases.

b

The nurse would expect to find what clinical manifestation in a patient admitted with a left-sided stroke? A. Impulsivity B. Impaired speech C. Left-side neglect D. Short attention span

b

The physician orders alteplase (Activase) for a 58-year-old man diagnosed with an acute ischemic stroke. Which nursing action is most appropriate? A. Administer the medication by an IV route at 15 mL/hr for 24 hours. B. Insert two or three large-bore IV catheters before administering the medication. C. If gingival bleeding occurs, discontinue the medication and notify the physician. D. Reduce the medication infusion rate for a systolic blood pressure above 180 mm Hg.

b

To promote communication during rehabilitation of the patient with aphasia, an appropriate nursing intervention is to a. use gestures, pictures, and music to stimulate patient responses b. talk about activities of daily living (ADLs) that are familiar to the patient c. structure statements so that patient does not have to respond verbally d. use flashcards with simple words and pictures to promote language recall

b

Which information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the health care provider? a.The patient complains of having a stiff neck. b.The patient's blood pressure (BP) is 90/50 mm Hg. c.The patient reports a severe and unrelenting headache. d.The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).

b

A 47-year-old patient will attempt oral feedings for the first time since having a stroke. The nurse should assess the gag reflex and then a.order a varied pureed diet. b.assess the patient's appetite. c.assist the patient into a chair. d.offer the patient a sip of juice.

c

A 68-year-old patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin? a.The patient has dysphasia. b.The patient has atrial fibrillation. c.The patient reports that symptoms began with a severe headache. d.The patient has a history of brief episodes of right-sided hemiplegia.

c

A 72-year-old patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't have a fever." Which action should the nurse take? a.Document that the aspirin was refused by the patient. b.Tell the patient that the aspirin is used to prevent a fever. c.Explain that the aspirin is ordered to decrease stroke risk. d.Call the health care provider to clarify the medication order.

c

A carotid endarterectomy is being considered as a treatment for a patient who has had several TIAs. The nurse explains to the patient that this surgery a. is used to restore blood to the brain following an obstruction of a cerebral artery b. involves intracranial surgery to join a superficial extracranial artery to an intracranial artery c. involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke d. is sued to open a stenosis in a carotid artery with a balloon and stent to restore cerebral circulation

c

The nurse explains to the patient with a stroke who is scheduled for angiography that this test is used to determine the a. presence of increased ICP. b. site and size of the infarction. c. patency of the cerebral blood vessels. d. presence of blood in the cerebrospinal fluid.

c

A 66-year-old female is admitted to Silverstein 9 s/p a hemorrhagic stroke. The nurse performs a muscle strength exam revealing that the left upper extremity moves against gravity with some resistance and the left lower extremity can move purposefully, but not against gravity or resistance. The nurse requests that the patient extends her arms outward at shoulder level with palms facing up. The nurse observes that the left upper extremity floats downward after 3 seconds. Which of the following statements accurately reflects the nurse's assessment? A. Positive LUE pronator drift, LUE 4/5, LLE 2/5 B. Negative LUE pronator drift, LUE 4/5, LLE 2/5 C. Positive LUE pronator drift, LUE 4/5, LLE 1/5 D. Positive LUE pronator drift, LUE 4/5, LLE 3/5

A

A newly admitted patient who has suffered a right sided brain stroke has a nursing diagnosis of disturbed visual sensory perception related to homonymous hemianopsia. Early in the care of the patient, the nurse should a. place objects on the right side within the patient's field of vision b. approach the patient from the left side to encourage the patient to turn the head c. place objects on the patient's left side to assess the patient's ability to compensate d. patch the affected eye to encourage the patient to turn the head to scan the environment

A

The nurse is assessing a patient who is being evaluated for a possible spinal cord tumor. Which finding by the nurse requires the most immediate action? a. The patient has new onset weakness of both legs. b. The patient complains of chronic severe back pain. c. The patient starts to cry and says, "I feel hopeless." d. The patient expresses anxiety about having surgery.

A

When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority? a. Assessment of respiratory rate and depth b. Continuous cardiac monitoring for bradycardia c. Application of pneumatic compression devices to both legs d. Administration of methylprednisolone (Solu-Medrol) infusion

A

The healthcare provider is assessing a patient with a diagnosis of Parkinson disease (PD). Which of the following findings would the healthcare provider anticipate? Select all that apply. A. Kyphosis B. Depression C. Daytime sleepiness D. Bradykinesia E. Exophthalmos F. Receptive aphasia

A, B, C, D

The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which medications might the nurse expect to provide discharge instructions (select all that apply)? A. Clopidogrel (Plavix) B. Enoxaparin (Lovenox) C. Dipyridamole (Persantine) D. Enteric-coated aspirin (Ecotrin) E. Tissue plasminogen activator (tPA)

A, C, D

When caring for a patient who experienced a T1 spinal cord transsection 2 days ago, which collaborative and nursing actions will the nurse include in the plan of care (select all that apply)? a. Urinary catheter care b. Nasogastric (NG) tube feeding c. Continuous cardiac monitoring d. Avoidance of cool room temperature e. Administration of H2 receptor blockers

A, C, D, E

Common psychosocial reactions of the stroke patient to the stroke include (select all that apply) a. depression. b. disassociation. c. intellectualization. d. sleep disturbances. e. denial of severity of stroke.

A, D, E

A 73-year-old patient with Parkinson's disease has a nursing diagnosis of impaired physical mobility related to bradykinesia. Which action will the nurse include in the plan of care? a. Instruct the patient in activities that can be done while lying or sitting. b. Suggest that the patient rock from side to side 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 keep the feet in contact with the floor and slide them forward.

B

A female patient has left-sided hemiplegia following an ischemic stroke that she experienced 4 days earlier. How should the nurse best promote the health of the patient's integumentary system? A. Position the patient on her weak side the majority of the time. B. Alternate the patient's positioning between supine and side-lying. C. Avoid the use of pillows in order to promote independence in positioning. D. Establish a schedule for the message of areas where skin breakdown emerges.

B

A patient is admitted to the emergency department with a spinal cord injury at the level of T2. Which finding is of most concern to the nurse? a. SpO2 of 92% b. Heart rate of 42 bpm c. Blood pressure of 88/60 mm Hg d. Loss of motor and sensory function in arms and legs

B

A patient who has been taking bromocriptine (Parlodel) and benztropine (Cogentin) for Parkinson's disease is experiencing a worsening of symptoms. The nurse will anticipate that patient may benefit from a. complete drug withdrawal for a few weeks. b. use of levodopa (L-dopa)-carbidopa (Sinemet). c. withdrawal of anticholinergic therapy. d. increasing the dose of bromocriptine.

B

A patient with a T1 spinal cord injury is admitted to the intensive care unit. The nurse will teach the patient and family that a. use of the shoulders will be preserved. b. full function of the patient's arms will be retained. c. total loss of respiratory function may occur temporarily. d. elevations in heart rate are common with this type of injury.

B

A patient experiencing TIAs is scheduled for a carotid endarterectomy. The nurse explains that this procedure is done to a. decrease cerebral edema. b. reduce the brain damage that occurs during a stroke in evolution. c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow. d. provide a circulatory bypass around thrombotic plaques obstructing cranial circulation.

C

A patient has an incomplete right spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which nursing action should be included in the plan of care? a. Assessment of the patient for left leg pain b. Assessment of the patient for left arm weakness c. Positioning the patient's right leg when turning the patient d. Teaching the patient to look at the left leg to verify its position

C

The nurse caring for a client diagnosed with Parkinson's disease writes a problem of "impaired nutrition." Which nursing intervention would be included in the plan of care? A. Consult the occupational therapist for adaptive appliances for eating. B. Request a low-fat, low-sodium diet from the dietary department. C. Provide three (3) meals per day that include nuts and whole-grain breads. D. Offer six (6) meals per day with a soft consistency.

4. The client's energy levels will not sustain eating for long periods. Offering frequent and easy-to-chew (soft) meals of small proportions is the preferred dietary plan.

A patient is admitted to the hospital with a left hemiplegia. To determine the size and location and to ascertain whether a stroke is ischemic or hemorrhagic, the nurse anticipates that the health care provider will request a a. CT scan b. lumbar puncture c. cerebral arteriogram d. positron emission tomography (PET)

A

A patient who sustained a spinal cord injury a week ago becomes angry, telling the nurse "I want to be transferred to a hospital where the nurses know what they are doing!" Which reaction by the nurse is best? a. Ask for the patient's input into the plan for care. b. Clarify that abusive behavior will not be tolerated. c. Reassure the patient about the competence of the nursing staff. d. Continue to perform care without responding to the patient's comments.

A

A patient with a neck fracture at the C5 level is admitted to the intensive care unit. During initial assessment of the patient, the nurse recognizes the presence of neurogenic shock on finding a. hypotension, bradycardia, and warm extremities. b. involuntary, spastic movements of the arms and legs. c. hyperactive reflex activity below the level of the injury. d. lack of movement or sensation below the level of the injury.

A

Computed tomography (CT) of a 68-year-old male patient's head reveals that he has experienced a hemorrhagic stroke. What is the priority nursing intervention in the emergency department? A. Maintenance of patient's airway. B. Positioning to promote cerebral perfusion. C. Control of fluid and electrolyte imbalances. D. Administration of tissue plasminogen activator (tPA)

A

During the acute phase of a stroke, the nurse assesses the patient's vital signs and neurologic status every 4 hours. A cardiovascular sign that the nurse would see as the body attempts to increase cerebral blood flow is a. hypertension b. fluid overload c. cardiac dysrhythmias d. S3 and S4 heart sounds

A

During the patient's process of grieving for the losses resulting from spinal cord injury, what should the nurse do? a. Help the patient to understand that working through the grief will be a lifelong process. b. Assist the patient to move through all stages of the mourning process to acceptance. c. Let the patient know that anger directed at the staff or the family is not a positive coping mechanism. d. Facilitate the grieving process so that it is completed by the time the patient is discharged from rehabilitation.

A

For a 65-year-old female patient who has lived with a T1 spinal cord injury for 20 years, which health teaching information should you emphasize? A. A mammogram is needed every year. B. Bladder function tends to improve with age. C. Heart disease is not common in persons with spinal cord injury. D. As a person ages, the need to change body position is less important.

A

Four days following a stroke, a patient is to start oral fluids and feedings. Before feeding the patient, the nurse should first a. check the patient's gag reflex b. order a soft diet for the patient c. raise the head of the bed to sitting position d. evaluate the patient's ability to swallow small sips of ice water

A

How is urinary function maintained during the acute phase of spinal cord injury? a. An indwelling catheter b. Intermittent catheterization c. Insertion of a suprapubic catheter d. Use of incontinent pads to protect the skin

A

Priority Decision: A patient is admitted to the emergency department with a possible cervical spinal cord injury following an automobile crash. During admission of the patient, what is the highest priority for the nurse? a. Maintaining a patent airway b. Maintaining immobilization of the cervical spine c. Assessing the patient for head and other injuries d. Assessing the patient's motor and sensory function

A

Priority Decision: The patient was in a traffic collision and is experiencing loss of function below C4. Which effect must the nurse be aware of to provide priority care for the patient? a. Respiratory diaphragmatic breathing b. Loss of all respiratory muscle function c. Decreased response of the sympathetic nervous system d. GI hypomotility with paralytic ileus and gastric distention

A

The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical-surgical unit. Which task should not be assigned to the UAP? A. Feed the 69-year-old client diagnosed with Parkinson's disease who is having difficulty swallowing. B. Turn and position the 89-year-old client diagnosed with a pressure ulcer secondary to Parkinson's disease. C. Assist the 54-year-old client diagnosed with Parkinson's disease with toilet-training activities. D. Obtain vital signs on a 72-year-old client diagnosed with pneumonia secondary to Parkinson's disease.

A

The nurse decides that learning has been effective when the patient with Parkinson's makes which of the following statements: A. I should report any burning when I void. B. I may feel depressed, but this should only be reported if it lasts more than 6 months. C. I am going to start Sinemet in the early stages of my disease process. D. It is best for me to watch my feet while I walk to maintain balance.

A

The nurse observes a student nurse assigned to initiate oral feedings for a 68-year-old woman with an ischemic stroke. The nurse should intervene if she observes the student nurse: A. giving the patient 8 ounces of ice water to swallow. B. telling the patient to perform a chin tuck before swallowing. C. assisting the patient to sit in a chair before feeding the patient. D. assessing cranial nerves IX and X before the patient attempts to eat.

A

The nurse performs discharge teaching for a 34-year-old male patient with a T2 spinal cord injury resulting from a construction accident. Which statement, if made by the patient to the nurse, indicates that teaching about recognition and management of autonomic dysreflexia is successful? A. "I will perform self-catheterization at least six times per day." B. "A reflex erection may cause an unsafe drop in blood pressure." C. "If I develop a severe headache, I will lie down for 15 to 20 minutes." D. "I can avoid this problem by taking medications to prevent leg spasms."

A

The patient with diabetes mellitus has had a right-sided stroke. Which nursing intervention should the nurse plan to provide for this patient related to expected manifestations of this stroke? A. Safety measures B. Patience with communication C. Mobility assistance on the right side D. Place food in the left side of patient's mouth

A

To evaluate the effectiveness of IV methylprednisolone (Solu-Medrol) given to a patient with a T4 spinal cord injury, which information is most important for the nurse to obtain? a. Leg strength and sensation b. Skin temperature and color c. Blood pressure and apical heart rate d. Respiratory effort and O2 saturation

A

Which clinical manifestation do you interpret as representing neurogenic shock in a patient with acute spinal cord injury? A. Bradycardia B. Hypertension C. Neurogenic spasticity D. Bounding pedal pulses

A

Which condition is transmitted through wound contamination, causes painful tonic spasms or seizures, and can be prevented by immunization? a. Tetanus b. Botulism c. Neurosyphilis d. Systemic inflammatory response syndrome

A

Which intervention should you perform in the acute care of a patient with autonomic dysreflexia? A. Urinary catheterization B. Administration of benzodiazepines C. Suctioning of the patient's upper airway D. Placement of the patient in the Trendelenburg position

A

Which is most important to respond to in a patient presenting with a T3 spinal injury? A. Blood pressure of 88/60 mm Hg, pulse of 56 beats/minute B. Deep tendon reflexes of 1+, muscle strength of 1+ C. Pain rated at 9 D. Warm, dry skin

A

Which modifiable risk factors for stroke would be most important for the nurse to include when planning a community education program? A. Hypertension B. Hyerlipidemia C. Alcohol consumption D. Oral contraceptive use

A

Which signs and symptoms in a patient with a T4 spinal cord injury should alert you to the possibility of autonomic dysreflexia? A. Headache and rising blood pressure B. Irregular respirations and shortness of breath C. Decreased level of consciousness or hallucinations D. Abdominal distention and absence of bowel sounds

A

Which syndrome of incomplete spinal cord lesion is described as cord damage common in the cervical region resulting in greater weakness in upper extremities than lower? a. Central cord syndrome b. Anterior cord syndrome c. Posterior cord syndrome d. Cauda equina and conus medullaris syndromes

A

A patient with Parkinson's disease is admitted to the hospital for treatment of pneumonia. Which nursing interventions will be included in the plan of care (select all that apply)? a. Use an elevated toilet seat. b. Cut patient's food into small pieces. c. Provide high-protein foods at each meal. d. Place an armchair at the patient's bedside. e. Observe for sudden exacerbation of symptoms.

A, B, D

Which of the following might be seen in a patient who has been on long-term Levadopa therapy? A. Hypotension B. Hallucinations C. Respiratory distress D. Sleep alterations E. Confusion F. Depression

A, B, D, E, F

A patient with a diagnosis of Parkinson disease (PD) has been prescribed levodopa. Which of the following statements will the healthcare provider include when teaching the patient about this medication? Select all that apply. A. "Let us know if you notice if the medication begins to lose its effectiveness." B. "If you experience nausea, you may take your medication with a high protein meal." C. "It may take a few months for you to experience the full effects of the medication." D. "Call our office if you notice the development of a tic or facial grimace." e. "This medication will reverse the disease process and give you a normal life."

A, C, D

A 70-year-old patient is admitted after falling from his roof. He has a spinal cord injury at the C7 level. What findings during the assessment identify the presence of spinal shock? a. Paraplegia with a flaccid paralysis b. Tetraplegia with total sensory loss c. Total hemiplegia with sensory and motor loss d. Spastic tetraplegia with loss of pressure sensation

B

A patient with a metastatic tumor of the spinal cord is scheduled for removal of the tumor by a laminectomy. In planning postoperative care for the patient, what should the nurse recognize? a. Most cord tumors cause autodestruction of the cord as in traumatic injuries. b. Metastatic tumors are commonly extradural lesions that are treated palliatively. c. Radiation therapy is routinely administered following surgery for all malignant spinal cord tumors. d. Because complete removal of intramedullary tumors is not possible, the surgery is considered palliative.

B

A patient with paraplegia has developed an irritable bladder with reflex emptying. What will be most helpful for the nurse to teach the patient? a. Hygiene care for an indwelling urinary catheter b. How to perform intermittent self-catheterization c. To empty the bladder with manual pelvic pressure in coordination with reflex voiding patterns d. That a urinary diversion, such as an ileal conduit, is the easiest way to handle urinary elimination

B

A patient with paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. Which action will the nurse include in the plan of care? a. Educate on the use of the Credé method. b. Teach the patient how to self-catheterize. c. Catheterize for residual urine after voiding. d. Assist the patient to the toilet every 2 hours.

B

A week following a spinal cord injury at T2, a patient experiences movement in his leg and tells the nurse that he is recovering some function. What is the nurse's best response to the patient? a. "It is really still too soon to know if you will have a return of function." b. "That could be a really positive finding. Can you show me the movement?" c. "That's wonderful. We will start exercising your legs more frequently now." d. "I'm sorry but the movement is only a reflex and does not indicate normal function."

B

For a patient who is suspected of having a stroke, one of the most important pieces of information that the nurse can obtain is a. time of the patient's last meal. b. time at which stroke symptoms first appeared. c. patient's hypertension history and management. d. family history of stroke and other cardiovascular diseases.

B

One month after a spinal cord injury, which finding is most important for you to monitor? A. Bladder scan indicates 100 mL. B. The left calf is 5 cm larger than the right calf. C. The heel has a reddened, nonblanchable area. D. Reflux bowel emptying.

B

The Emergency Department (ED) charge nurse receives a call that a stroke alert patient will arrive via ambulance in 5 minutes. The nurse knows that the best practice guidelines to manage an acute ischemic stroke patient is to: A. obtain a Head CT within 1 hour upon arrival and alert Neurosurgery for possible craniotomy for decompression. B. obtain a Head CT within 30 minutes of arrival and administer tPA within 3 hours of symptom onset if the patient meets qualifications of tPA administration. C. obtain a MRI of the Brain within 30 minutes of arrival and administer tPA within 3 hours of symptom onset if the patient meets qualifications of tPA administration. D. call interventional radiology to schedule a cerebral angiogram and administer tPA 4 hours after symptom onset.

B

The client diagnosed with Parkinson's disease (PD) is being admitted with a fever and patchy infiltrates in the lung fields on the chest x-ray. Which clinical manifestations of PD would explain these assessment data? A. Masklike facies and shuffling gait. B. Difficulty swallowing and immobility. C. Pill rolling of fingers and flat affect. D. Lack of arm swing and bradykinesia.

B

The nurse is conducting a support group for clients diagnosed with Parkinson's disease and their significant others. Which information regarding psychosocial needs should be included in the discussion? A. The client should discuss feelings about being placed on a ventilator. B. The client may have rapid mood swings and become easily upset. C. Pill-rolling tremors will become worse when the medication is wearing off. D. The client may automatically start to repeat what another person says.

B

The nurse would expect to find what clinical manifestation in a patient admitted with a left-sided stroke? A. Impulsivity B. Impaired speech C. Left-side neglect D. Short attention span

B

The patient is diagnosed with Brown-Séquard syndrome after a knife wound to the spine. Which description accurately describes this syndrome? a. Damage to the most distal cord and nerve roots, resulting in flaccid paralysis of the lower limbs and areflexic bowel and bladder b. Spinal cord damage resulting in ipsilateral motor paralysis and contralateral loss of pain and sensation below the level of the lesion c. Rare cord damage resulting in loss of proprioception below the lesion level with retention of motor control and temperature and pain sensation d. Often caused by flexion injury with acute compression of cord resulting in complete motor paralysis and loss of pain and temperature sensation below the level of injury

B

The physician orders alteplase (Activase) for a 58-year-old man diagnosed with an acute ischemic stroke. Which nursing action is most appropriate? A. Administer the medication by an IV route at 15 mL/hr for 24 hours. B. Insert two or three large-bore IV catheters before administering the medication. C. If gingival bleeding occurs, discontinue the medication and notify the physician. D. Reduce the medication infusion rate for a systolic blood pressure above 180 mm Hg.

B

To promote communication during rehabilitation of the patient with aphasia, an appropriate nursing intervention is to a. use gestures, pictures, and music to stimulate patient responses b. talk about activities of daily living (ADLs) that are familiar to the patient c. structure statements so that patient does not have to respond verbally d. use flashcards with simple words and pictures to promote language recall

B

Two days following a spinal cord injury, a patient asks continually about the extent of impairment that will result from the injury. What is the best response by the nurse? a. "You will have more normal function when spinal shock resolves and the reflex arc returns." b. "The extent of your injury cannot be determined until the secondary injury to the cord is resolved." c. "When your condition is more stable, MRI will be done to reveal the extent of the cord damage." d. "Because long-term rehabilitation can affect the return of function, it will be years before we can tell what the complete effect will be."

B

What is the most common early symptom of a spinal cord tumor? A. Urinary incontinence B. Back pain that worsens with activity C. Paralysis below the level of involvement D. Impaired sensation of pain, temperature, and light touch

B

When a 74-year-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling-type tremor, the nurse will anticipate teaching the patient about A. oral corticosteroids. B. antiparkinsonian drugs. C. magnetic resonance imaging (MRI). D. electroencephalogram (EEG) testing.

B

When a 74-year-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling-type tremor, the nurse will anticipate teaching the patient about a. oral corticosteroids. b. antiparkinsonian drugs. c. magnetic resonance imaging (MRI). d. electroencephalogram (EEG) testing.

B

While giving discharge instructions, the nurse instructs the family of a patient with Parkinson's to watch for all of the following complications EXCEPT: A. Constipation B. Hypertension C. Excessive sweating D. Depression

B

You are caring for a patient admitted with a spinal cord injury after a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. What is this condition? A. Central cord syndrome B. Spinal shock syndrome C. Anterior cord syndrome D. Brown-Séquard syndrome

B

What are the goals of rehabilitation for the patient with an injury at the C6 level (select all that apply)? A. Stand erect with leg brace B. Feed self with hand devices C. Drive an electric wheelchair D. Assist with transfer activities E. Drive adapted van from wheel chair

B, C, D, E

A 68-year-old patient with a spinal cord injury has a neurogenic bowel. Beyond the use of bisacodyl (Dulcolax) suppositories and digital stimulation, which measures should the nurse teach the patient and the caregiver to assist the patient with bowel evacuation (select all that apply)? A. Drink more milk. B. Eat 20-30 g of fiber per day. C. Use oral laxatives every day. D. Drink 1800 to 2800 mL of water or juice. D. Establish bowel evacuation time at bedtime.

B, D,

A 22-year-old female with paraplegia after a spinal cord injury tells the home care nurse that bowel incontinence occurs two or three times each day. Which action by the nurse is most appropriate? a. Take magnesium citrate (Citroma) every morning with breakfast. b. Teach the patient to gradually increase intake of high-fiber foods. c. Assess bowel movements for frequency, consistency, and volume. d. Instruct the patient to avoid all caffeinated and carbonated beverages.

C

A 25-year-old male patient who is a professional motocross racer has anterior spinal cord syndrome at T10. His history is significant for tobacco, alcohol, and marijuana use. What is the nurse's priority during rehabilitation? A. Prevent urinary tract infections. B. Monitor the patient every 15 minutes. C. Encourage him to verbalize his feelings. D. Teach him about using the gastrocolic reflex.

C

A 26-year-old patient with a T3 spinal cord injury asks the nurse about whether he will be able to be sexually active. Which initial response by the nurse is best? a. Reflex erections frequently occur, but orgasm may not be possible. b. Sildenafil (Viagra) is used by many patients with spinal cord injury. c. Multiple options are available to maintain sexuality after spinal cord injury. d. Penile injection, prostheses, or vacuum suction devices are possible options.

C

A 65-year-old woman was just diagnosed with Parkinson's disease. The priority nursing intervention is a. searching the Internet for educational videos. b. evaluating the home for environmental safety. c. promoting physical exercise and a well-balanced diet. d. designing an exercise program to strengthen and stretch specific muscles.

C

A 72-year-old patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't have a fever." Which action should the nurse take? A. Document that the patient refused the aspirin. B. Tell the patient that the aspirin is used to prevent a fever. C. Explain that the aspirin is ordered to decrease stroke risk. D. Call the health care provider to clarify the medication order.

C

A patient diagnosed with Parkinson disease (PD) is prescribed levodopa. The medication therapy can be considered effective when the healthcare provider assesses improvement in which of the following? A. Appetite B. Hearing C. Urinary frequency D. Visual acuity

C

A patient with Parkinson's disease has decreased tongue mobility and an inability to move the facial muscles. The nurse recognizes that these impairments commonly contribute to the nursing diagnosis of a. disuse syndrome related to loss of muscle control. b. self-care deficit related to bradykinesia and rigidity. c. impaired verbal communication related to difficulty articulating. d. impaired oral mucous membranes related to inability to swallow.

C

A patient with a C7 spinal cord injury undergoing rehabilitation tells you he must have the flu because he has a bad headache and nausea. What is your initial action? A. Call the physician. B. Check the patient's temperature. C. Take the patient's blood pressure. D. Elevate the head of the bed to 90 degrees.

C

A patient with a history of a T2 spinal cord injury tells the nurse, "I feel awful today. My head is throbbing, and I feel sick to my stomach." Which action should the nurse take first? a. Assess for a fecal impaction. b. Give the prescribed antiemetic. c. Check the blood pressure (BP). d. Notify the health care provider.

C

A patient with a spinal cord injury has spinal shock. The nurse plans care for the patient based on what knowledge? a. Rehabilitation measures cannot be initiated until spinal shock has resolved. b. The patient will need continuous monitoring for hypotension, tachycardia, and hypoxemia. c. Resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder. d. The patient will have complete loss of motor and sensory functions below the level of the injury but autonomic functions are not affected.

C

A patient with a stroke has a right sided hemiplegia. The nurse prepares family members to help control behavior changes seen with this type of stroke by teaching them to a. ignore undesirable behaviors manifested by the patient b. provide directions to the patient verbally in small steps c. distract the patient from inappropriate emotional responses d. supervise all activities before allowing the patient to pursue them independently

C

A patient with right hemisphere stroke has a nursing diagnosis of unilateral neglect related to sensory perceptual deficits. During the patient's rehabilitation, it is important for the nurse to a. avoid positioning the patient on the affected side b. place all objects for care on the patient's unaffected side c. teach the patient to care consciously for the affected side d. protect the affected side from injury with pillows and supports

C

A patient with right-sided hemiplegia and aphasia resulting from a stroke most likely has involvement of the a. brainstem. b. vertebral artery. c. left middle cerebral artery. d. right middle cerebral artery.

C

A thrombus that develops in a cerebral artery does not always cause a loss of neurologic function because a. the body can dissolve the atherosclerotic plaques as they form b. some tissues of the brain do not require constant blood supply to prevent damage c. circulation through the circle of Willis may provide blood supply to the affected area of the brain d. neurologic deficits occur only when major arteries are occluded by thrombus formation around an atherosclerotic plaque

C

After a 25-year-old patient has returned home following rehabilitation for a spinal cord injury, the home care nurse notes that the spouse is performing many of the activities that the patient had been managing during rehabilitation. The most appropriate action by the nurse at this time is to a. tell the spouse that the patient can perform activities independently. b. remind the patient about the importance of independence in daily activities. c. develop a plan to increase the patient's independence in consultation with the patient and the spouse. d. recognize that it is important for the spouse to be involved in the patient's care and support the spouse's participation.

C

An appropriate food for a patient with a stroke who has mild dysphagia is a. fruit juices b. pureed meat c. scrambled eggs d. fortified milkshakes

C

Bladder training in a male patient who has urinary incontinence after a stroke includes a. limiting fluid intake. b. keeping a urinal in place at all times. c. assisting the patient to stand to void. d. catheterizing the patient every 4 hours.

C

Coexisting dementia and depression are identified in a patient with Parkinson's disease. The nurse anticipates that the greatest improvement in the patient's condition will occur with administration of a. antipsychotic drugs. b. anticholinergic agents. c. dopaminergic agents and antidepressant drugs. d. selective serotonin reuptake inhibitor (SSRI) agents.

C

During the initial treatment with Levodopa for patients with Parkinson's disease, nursing interventions should include: A. monitor for suicidal ideation. B. increase foods high in vitamin B, such as bananas and liver. C. provide safety to prevent falls. D. observe for extrapyramidal symptoms (EPS).

C

In promoting health maintenance for prevention of strokes, the nurse understands that the highest risk for the most common type of stroke is present in a. African Americans b. women who smoke c.individuals with hypertension and diabetes d. those who are obese with high dietary fat intake

C

Priority Decision: During assessment of a patient with a spinal cord injury, the nurse determines that the patient has a poor cough with diaphragmatic breathing. Based on this finding, what should be the nurse's first action? a. Institute frequent turning and repositioning. b. Use tracheal suctioning to remove secretions. c. Assess lung sounds and respiratory rate and depth. d. Prepare the patient for endotracheal intubation and mechanical ventilation.

C

The client diagnosed with PD is being discharged on carbidopa/levodopa (Sinemet), an antiparkinsonian drug. Which statement is the scientific rationale for combining these medications? A. There will be fewer side effects with this combination than with carbidopa alone. B. Dopamine D requires the presence of both of these medications to work. C. Carbidopa makes more levodopa available to the brain. D. Carbidopa crosses the blood-brain barrier to treat Parkinson's disease.

C

The client diagnosed with Parkinson's disease is being discharged. Which statement made by the significant other indicates an understanding of the discharge instructions? A. "All of my spouse's emotions will slow down now just like his body movements." B. "My spouse may experience hallucinations until the medication starts working." C. "I will schedule appointments late in the morning after his morning bath." D. "It is fine if we don't follow a strict medication schedule on weekends."

C

The health care provider has ordered IV dopamine (Intropin) for a patient in the emergency department with a spinal cord injury. The nurse determines that the drug is having the desired effect when what is observed in patient assessment? a. Heart rate of 68 bpm b. Respiratory rate of 24 c. Blood pressure of 106/82 mm Hg d. Temperature of 96.8°F (36.0°C)

C

The incidence of ischemic stroke in patients with TIAs and other risk factors is reduced with administration of a. furosemide (Lasix) b. lovastatin (Mevacor) c. daily low dose aspirin d. nimodipine (Nimotop)

C

The neurologic functions that are affected by a stroke are primarily related to a. the amount of tissue area involved b. the rapidity of onset of symptoms c. the brain area perfused by the affected artery d. the presence or absence of collateral circulation

C

The nurse explains to the patient with a stroke who is scheduled for angiography that this test is used to determine the a. presence of increased ICP. b. site and size of the infarction. c. patency of the cerebral blood vessels. d. presence of blood in the cerebrospinal fluid.

C

The nurse is planning psychosocial support for the patient and family of the patient who suffered a stroke. What factor will most likely have the greatest impact on positive family coping with the situation? A. Specific patient neurologic deficits B. The patient's ability to communicate C. Rehabilitation potential of the patient D. Presence of complications of a stroke

C

The student nurse reviews diagnostic criteria for Parkinson's Disease with the clinical instructor. Which of the following group of symptoms warrants further workup for Parkinson's Disease? A. Tremors, Incontinence & Insomnia B. Bradykinesia, Cognitive Decline, Lateral Nystagmus C. Postural Instability, Rigidity and Depression D. Loss of smell, Emotional Instability & Apathy

C

What causes an initial incomplete spinal cord injury to result in complete cord damage? a. Edematous compression of the cord above the level of the injury b. Continued trauma to the cord resulting from damage to stabilizing ligaments c. Infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites d. Mechanical transection of the cord by sharp vertebral bone fragments after the initial injury

C

What is the classic manifestation of a spinal cord tumor? A. Sudden onset of excruciating pain, worse at night B. Radiating pain down one leg C. Gradual onset of radicular pain, worse when lying down D. Positive Brudzinski's sign

C

When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort and loose-sounding secretions, the initial intervention by the nurse should be to a. suction the patient's oral and pharyngeal airway. b. administer oxygen at 7 to 9 L/min with a face mask. c. place the hands on the epigastric area and push upward when the patient coughs. d. encourage the patient to use an incentive spirometer every 2 hours during the day.

C

Which intervention should the nurse delegate to the LPN when caring for a patient following an acute stroke? a. assess the patient's neurologic status b. assess the patient's gag reflex before beginning feeding c. administer ordered antihypertensives and platelet inhibitors d. teach the patient's caregivers strategies to minimize unilateral neglect

C

Which is a common cognitive problem associated with Parkinson's disease? A. Emotional lability B. Depression. C. Memory deficits. D. Paranoia.

C

Without surgical stabilization, what method of immobilization for the patient with a cervical spinal cord injury should the nurse expect to be used? a. Kinetic beds b. Hard cervical collar c. Skeletal traction with skull tongs d. Sternal-occipital-mandibular immobilizer brace

C

A 76-year-old patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease. Which information is most important for the nurse to report to the health care provider? a. Shuffling gait b. Tremor at rest c. Cogwheel rigidity of limbs d. Uncontrolled head movement

D

A patient comes to the emergency department immediately after experiencing numbness of the face and an inability to speak, but while the patient awaits examination, the symptoms disappear and the patient request discharge. The nurse stresses that it is important for the patient to be evaluated primarily because a. the patient has probably experienced an asymptomatic lacunar stroke b. the symptoms are likely to return and progress to worsening neurologic deficit in the next 24 hours c. neurologic deficits that are transient occur most often as a result of small hemorrhages that clot off d. the patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebral vascular disease

D

A patient is admitted to the intensive care unit (ICU) with a C7 spinal cord injury and diagnosed with Brown-Séquard syndrome. What would you most likely find on physical examination? A. Upper extremity weakness only B. Complete motor and sensory loss below C7 C. Loss of position sense and vibration in both lower extremities D. Ipsilateral motor loss and contralateral sensory loss below C7

D

A patient's wife asks the nurse why her husband did not receive the clot busting medication (tPA) she has been reading about. Her husband is diagnosed with a hemorrhagic stroke. What should the nurse respond? a. He didn't arrive within the time frame for that therapy b. Not every is eligible for this drug. Has he had surgery lately? c. You should discuss the treatment of your husband with your doctor d. The medication you are talking about dissolves clots and could cause more bleeding in your husband's head

D

After learning about rehabilitation for his spinal cord tumor, which statement shows the patient understands what rehabilitation is and can do for him? A. "I want to be rehabilitated for my daughter's wedding in 2 weeks." B. "Rehabilitation will be more work done by me alone to try to get better." C. "I will be able to do all my normal activities after I go through rehabilitation." D. "With rehabilitation, I will be able to function at my highest level of wellness."

D

At 3:00pm, a 73-year-old male with a past medical history of a pulmonary embolism presents to the Emergency Department. Upon assessment, the triage nurse notes the patient has a left facial droop, a unilateral arm drift, and difficulty repeating "Today is a sunny day." The patient's spouse stated that the patient is on warfarin sodium (Coumadin). The provider orders a Head CT which revealed an ischemic stroke. Which of the following would the nurse question as a contraindication of tPA administration? A. Appendectomy one week prior B. Symptom onset at 9:00am C. INR of 3.1 D. Blood pressure 165/100

D

Information provided by the patient that would help differentiate a hemorrhagic stroke from a thrombotic stroke includes a. sensory disturbance b. a history of hypertension. c. presence of motor weakness. d. sudden onset of severe headache.

D

Of the following patients, the nurse recognizes that the one with the highest risk for a stroke is a(n) a. obese 45-year-old Native American. b. 35-year-old Asian American woman who smokes. c. 32-year-old white woman taking oral contraceptives. d. 65-year-old African American man with hypertension.

D

The nurse can assist the patient and the family in coping with the long term effects of a stroke by a. informing family members that the patient will need assistance with almost all ADLs b. explaining that the patient's prestroke behavior will return as improvement progresses c. encouraging the patient and family members to seek assistance from family therapy or stroke support groups d. helping the patient and family understand the significance of residual stroke damage to promote problem solving and planning

D

The nurse is caring for a patient recently diagnosed with Parkinson's disease. The nurse knows the first sign of Parkinson's disease is most often which of the following? A. Rigidity B. Drooling C. Shuffling gait D. Tremor

D

The nurse is teaching a senior citizen's group about signs and symptoms of a stroke. Which statement by the nurse would provide accurate information? A. "Take the person to the hospital if a headache lasts for more than 24 hours." B. "Stroke symptoms usually start when the person is awake and physically active." C. "A person with a transient ischemic attack has mild symptoms that will go away." D. "Call 911 immediately if a person develops slurred speech or difficulty speaking."

D

The nurse researcher is working with clients diagnosed with Parkinson's disease. Which is an example of an experimental therapy? A. Stereotactic pallidotomy/thalamotomy. B. Dopamine receptor agonist medication. C. Physical therapy for muscle strengthening. D. Fetal tissue transplantation.

D

The patient arrives in the emergency department from a motor vehicle accident, during which the car ran into a tree. The patient was not wearing a seat belt, and the windshield is shattered. What action is most important for you to do? A. Determine if the patient lost consciousness. B. Assess the Glasgow Coma Scale (GCS) score. C. Obtain a set of vital signs. D. Use a logroll technique when moving the patient.

D

What is one indication for early surgical therapy of the patient with a spinal cord injury? a. There is incomplete cord lesion involvement. b. The ligaments that support the spine are torn. c. A high cervical injury causes loss of respiratory function. d. Evidence of continued compression of the cord is apparent.

D

When the nurse is developing a rehabilitation plan for a patient with a C6 spinal cord injury, an appropriate patient goal is that the patient will be able to a. transfer independently to a wheelchair. b. drive a car with powered hand controls. c. turn and reposition independently when in bed. d. push a manual wheelchair on flat, smooth surfaces.

D

Which intervention is most appropriate when communicating with a patient suffering from aphasia following a stroke? A. Present several thoughts at once so that the patient can connect the ideas. B. Ask open-ended questions to provide the patient the opportunity to speak. C. Finish the patient's sentences to minimize frustration associated with slow speech. D. Use simple, short sentences accompanied by visual cues to enhance comprehension.

D

Which nursing diagnosis is of highest priority for a patient with Parkinson's disease who is unable to move the facial muscles? a. Activity intolerance b. Self-care deficit: toileting c. Ineffective self-health management d. Imbalanced nutrition: less than body requirements

D

Which patient should be assigned to the experienced registered nurse on a neurologic floor? A. Patient with trigeminal neuralgia reporting facial pain rated at 10 B. Patient with Bell's palsy with unilateral facial droop C. Patient after surgical removal of a spinal cord tumor who is scheduled for discharge tomorrow D. Patient with traumatic injury to the cervical spinal cord who was admitted today from the emergency department

D

A 40-year-old patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan? a.Apply intermittent pneumatic compression stockings. b.Assist to dangle on edge of bed and assess for dizziness. c.Encourage patient to cough and deep breathe every 4 hours. d.Insert an oropharyngeal airway to prevent airway obstruction.

a

A newly admitted patient who has suffered a right sided brain stroke has a nursing diagnosis of disturbed visual sensory perception related to homonymous hemianopsia. Early in the care of the patient, the nurse should a. place objects on the right side within the patient's field of vision b. approach the patient from the left side to encourage the patient to turn the head c. place objects on the patient's left side to assess the patient's ability to compensate d. patch the affected eye to encourage the patient to turn the head to scan the environment

a

A patient is admitted to the hospital with a left hemiplegia. To determine the size and location and to ascertain whether a stroke is ischemic or hemorrhagic, the nurse anticipates that the health care provider will request a a. CT scan b. lumbar puncture c. cerebral arteriogram d. positron emission tomography (PET)

a

After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a.A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed b.A 50-year-old patient who has atrial fibrillation and a new order for warfarin (Coumadin) c.A 40-year-old patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due d.A 30-year-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled

a

During the acute phase of a stroke, the nurse assesses the patient's vital signs and neurologic status every 4 hours. A cardiovascular sign that the nurse would see as the body attempts to increase cerebral blood flow is a. hypertension b. fluid overload c. cardiac dysrhythmias d. S3 and S4 heart sounds

a

For a patient who had a right hemisphere stroke the nurse establishes a nursing diagnosis of a.risk for injury related to denial of deficits and impulsiveness. b.impaired physical mobility related to right-sided hemiplegia. c.impaired verbal communication related to speech-language deficits. d.ineffective coping related to depression and distress about disability.

a

The nurse observes a student nurse assigned to initiate oral feedings for a 68-year-old woman with an ischemic stroke. The nurse should intervene if she observes the student nurse: A. giving the patient 8 ounces of ice water to swallow. B. telling the patient to perform a chin tuck before swallowing. C. assisting the patient to sit in a chair before feeding the patient. D. assessing cranial nerves IX and X before the patient attempts to eat.

a

The patient with diabetes mellitus has had a right-sided stroke. Which nursing intervention should the nurse plan to provide for this patient related to expected manifestations of this stroke? A. Safety measures B. Patience with communication C. Mobility assistance on the right side D. Place food in the left side of patient's mouth

a

Which modifiable risk factors for stroke would be most important for the nurse to include when planning a community education program? A. Hypertension B. Hyerlipidemia C. Alcohol consumption D. Oral contraceptive use

a

The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which medications might the nurse expect to provide discharge instructions? Select all that apply. A. Clopidogrel (Plavix) B. Enoxaparin (Lovenox) C. Dipyridamole (Persantine) D. Enteric-coated aspirin (Ecotrin)E. Tissue plasminogen activator (tPA)

a, c, d

Common psychosocial reactions of the stroke patient to the stroke include... select all that apply a. depression. b. disassociation. c. intellectualization. d. sleep disturbances.e. denial of severity of stroke.

a, d, e

A diagnosis of a ruptured cerebral aneurysm has been made in a patient with manifestations of a stroke. The nurse anticipates that treatment options that would be evaluated for the patient include a. hyperventilation therapy b. surgical clipping of the aneurysm c. administration of hyperosmotic agents d. administration of thrombolytic therapy

b

A female patient has left-sided hemiplegia following an ischemic stroke that she experienced 4 days earlier. How should the nurse best promote the health of the patient's integumentary system? A. Position the patient on her weak side the majority of the time. B. Alternate the patient's positioning between supine and side-lying. C. Avoid the use of pillows in order to promote independence in positioning. D. Establish a schedule for the message of areas where skin breakdown emerges.

b

A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. The nurse will anticipate teaching the patient about a.alteplase (tPA). b.aspirin (Ecotrin). c.warfarin (Coumadin). d.nimodipine (Nimotop).

b

Several weeks after a stroke, a 50-year-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention will be best to include in the initial plan for an effective bladder training program? a.Limit fluid intake to 1200 mL daily to reduce urine volume. b.Assist the patient onto the bedside commode every 2 hours. c.Perform intermittent catheterization after each voiding to check for residual urine. d.Use an external "condom" catheter to protect the skin and prevent embarrassment.

b

The home health nurse is caring for an 81-year-old who had a stroke 2 months ago. Based on information shown in the accompanying figure from the history, physical assessment, and physical therapy/occupational therapy, which nursing diagnosis is the highest priority for this patient? a.Impaired transfer ability b.Risk for caregiver role strain c.Ineffective health maintenance d.Risk for unstable blood glucose level

b

or a patient who is suspected of having a stroke, one of the most important pieces of information that the nurse can obtain is a. time of the patient's last meal. b. time at which stroke symptoms first appeared. c. patient's hypertension history and management. d. family history of stroke and other cardiovascular diseases.

b

A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a.Monitor the blood pressure. b.Send the patient for a computed tomography (CT) scan. c.Check the respiratory rate and effort. d.Assess the Glasgow Coma Scale score.

c

A male patient who has right-sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activities. The nurse observes that when the patient's wife is visiting, she feeds and dresses him. Which nursing diagnosis is most appropriate for the patient? a.Interrupted family processes related to effects of illness of a family member b.Situational low self-esteem related to increasing dependence on spouse for care c.Disabled family coping related to inadequate understanding by patient's spouse d.Impaired nutrition: less than body requirements related to hemiplegia and aphasia

c

A patient experiencing TIAs is scheduled for a carotid endarterectomy. The nurse explains that this procedure is done to a. decrease cerebral edema. b. reduce the brain damage that occurs during a stroke in evolution. c. prevent a stroke by removing atherosclerotic plaques blocking cerebral blood flow. d. provide a circulatory bypass around thrombotic plaques obstructing cranial circulation.

c

A patient with a stroke has a right sided hemiplegia. The nurse prepares family members to help control behavior changes seen with this type of stroke by teaching them to a. ignore undesirable behaviors manifested by the patient b. provide directions to the patient verbally in small steps c. distract the patient from inappropriate emotional responses d. supervise all activities before allowing the patient to pursue them independently

c

A patient with right hemisphere stroke has a nursing diagnosis of unilateral neglect related to sensory perceptual deficits. During the patient's rehabilitation, it is important for the nurse to a. avoid positioning the patient on the affected side b. place all objects for care on the patient's unaffected side c. teach the patient to care consciously for the affected side d. protect the affected side from injury with pillows and supports

c

A patient with right-sided hemiplegia and aphasia resulting from a stroke most likely has involvement of the a. brainstem. b. vertebral artery. c. left middle cerebral artery. d. right middle cerebral artery.

c

A thrombus that develops in a cerebral artery does not always cause a loss of neurologic function because a. the body can dissolve the atherosclerotic plaques as they form b. some tissues of the brain do not require constant blood supply to prevent damage c. circulation through the circle of Willis may provide blood supply to the affected area of the brain d. neurologic deficits occur only when major arteries are occluded by thrombus formation around an atherosclerotic plaque

c

After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about a.cerebral aneurysm clipping. b.heparin intravenous infusion. c.oral low-dose aspirin therapy. d.tissue plasminogen activator (tPA).

c

An appropriate food for a patient with a stroke who has mild dysphagia is a. fruit juices b. pureed meat c. scrambled eggs d. fortified milkshakes

c

Bladder training in a male patient who has urinary incontinence after a stroke includes a. limiting fluid intake. b. keeping a urinal in place at all times. c. assisting the patient to stand to void. d. catheterizing the patient every 4 hours.

c

During the change of shift report a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have a.dysphasia. b.confusion. c.visual deficits. d.poor judgment.

c

In promoting health maintenance for prevention of strokes, the nurse understands that the highest risk for the most common type of stroke is present in a. African Americans b. women who smoke c.individuals with hypertension and diabetes d. those who are obese with high dietary fat intake

c

The factor related to cerebral blood flow that most often determines the extent of cerebral damage from a stroke is the a. amount of cardiac output. b. oxygen content of the blood. c. degree of collateral circulation. d. level of carbon dioxide in the blood.

c

The incidence of ischemic stroke in patients with TIAs and other risk factors is reduced with administration of a. furosemide (Lasix) b. lovastatin (Mevacor) c. daily low dose aspirin d. nimodipine (Nimotop)

c

The neurologic functions that are affected by a stroke are primarily related to a. the amount of tissue area involved b. the rapidity of onset of symptoms c. the brain area perfused by the affected artery d. the presence or absence of collateral circulation

c

The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a left-handed patient with left-sided hemiplegia. Which intervention should be included in the plan of care? a.Provide a wide variety of food choices. b.Provide oral care before and after meals. c.Assist the patient to eat with the right hand. d.Teach the patient the "chin-tuck" technique.

c

The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? a.Assess the patient's gag and cough reflexes. b.Determine when the stroke symptoms began. c.Administer the prescribed short-acting insulin. d.Infuse the prescribed IV metoprolol (Lopressor).

c

The nurse is planning psychosocial support for the patient and family of the patient who suffered a stroke. What factor will most likely have the greatest impact on positive family coping with the situation? A. Specific patient neurologic deficits B. The patient's ability to communicate C. Rehabilitation potential of the patient D. Presence of complications of a stroke

c

When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care? a.Apply an eye patch to the right eye. b.Approach the patient from the right side. c.Place objects needed on the patient's left side. d.Teach the patient that the left visual deficit will resolve.

c

Which intervention should the nurse delegate to the LPN when caring for a patient following an acute stroke? a. assess the patient's neurologic status b. assess the patient's gag reflex before beginning feeding c. administer ordered antihypertensives and platelet inhibitors d. teach the patient's caregivers strategies to minimize unilateral neglect

c

Which of the following is the best treatment for acute ischemic stroke? a. heparin b. LMWH c. Alteplase d. Eptifibatiee. Warfarin

c

Which sensory-perceptual deficit is associated with left-sided stroke (right hemiplegia)? A. Overestimation of physical abilities. B. Difficulty judging position and distance. C. Slow and possibly fearful performance of tasks. D. Impulsivity and impatience at performing tasks.

c

Which stroke risk factor for a 48-year-old male patient in the clinic is most important for the nurse to address? a.The patient is 25 pounds above the ideal weight. b.The patient drinks a glass of red wine with dinner daily. c.The patient's usual blood pressure (BP) is 170/94 mm Hg. d.The patient works at a desk and relaxes by watching television.

c

A 56-year-old patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for a.surgical endarterectomy. b.transluminal angioplasty. c.intravenous heparin administration. d.tissue plasminogen activator (tPA) infusion.

d

A 58-year-old patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should a.use a calm voice to ask the patient to stop the crying behavior. b.explain to the family that depression is normal following a stroke. c.have the family members leave the patient alone for a few minutes. d.teach the family that emotional outbursts are common after strokes.

d

A 73-year-old patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find? a.Impulsive behavior b.Right-sided neglect c.Hyperactive left-sided tendon reflexes d.Difficulty comprehending instructions

d

A 74-year-old man who has right-sided extremity paralysis related to a thrombotic stroke develops constipation. Which action should the nurse take first? A. Assist the patient to the bathroom every 2 hours. B. Provide incontinence briefs to wear during the day. C. Administer a bisocodyl (Dulcolax) rectal suppository every day. D. Arrange for several servings per day of cooked fruits and vegetables.

d

A nursing intervention is indicated for the patient with hemiplegia is a. the use of a footboard to prevent plantar flexion b. immobilization of the affected arm against the chest with a sling c. positioning the patient in bed with each joint lower than the joint proximal to it d. having the patient perform passive ROM of the affected limb with the unaffected limb

d

A patient admitted with possible stroke has been aphasic for 3 hours and his current blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse question? a.Keep head of bed elevated at least 30 degrees. b.Infuse normal saline intravenously at 75 mL/hr. c.Administer tissue plasminogen activator (tPA) per protocol. d.Administer a labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg.

d

A patient comes to the emergency department immediately after experiencing numbness of the face and an inability to speak, but while the patient awaits examination, the symptoms disappear and the patient request discharge. The nurse stresses that it is important for the patient to be evaluated primarily because a. the patient has probably experienced an asymptomatic lacunar stroke b. the symptoms are likely to return and progress to worsening neurologic deficit in the next 24 hours c. neurologic deficits that are transient occur most often as a result of small hemorrhages that clot off d. the patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebral vascular disease

d

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a.The patient's speech is difficult to understand. b.The patient's blood pressure is 144/90 mm Hg. c.The patient takes a diuretic because of a history of hypertension. d.The patient has atrial fibrillation and takes warfarin (Coumadin).

d

A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first? a.Complete blood count (CBC) b.Chest radiograph (Chest x-ray) c.12-Lead electrocardiogram (ECG) d.Noncontrast computed tomography (CT) scan

d

A patient's wife asks the nurse why her husband did not receive the clot busting medication (tPA) she has been reading about. Her husband is diagnosed with a hemorrhagic stroke. What should the nurse respond? a. He didn't arrive within the time frame for that therapy b. Not every is eligible for this drug. Has he had surgery lately? c. You should discuss the treatment of your husband with your doctor d. The medication you are talking about dissolves clots and could cause more bleeding in your husband's head

d

Information provided by the patient that would help differentiate a hemorrhagic stroke from a thrombotic stroke includes a. sensory disturbance. b. a history of hypertension. c. presence of motor weakness. d. sudden onset of severe headache.

d

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness (LOC). Which nursing diagnosis do they determine has the highest priority for the patient? a.Impaired physical mobility related to weakness b.Disturbed sensory perception related to brain injury c.Risk for impaired skin integrity related to immobility d.Risk for aspiration related to inability to protect airway

d

Of the following patients, the nurse recognizes that the one with the highest risk for a stroke is a(n) a. obese 45-year-old Native American. b. 35-year-old Asian American woman who smokes. c. 32-year-old white woman taking oral contraceptives. d. 65-year-old African American man with hypertension.

d

Of the following patients, the nurse recognizes that the one with the highest risk for stroke is a(n): A. obese 45-year old Native American. B. 35-year-old Asian American woman who smokes. C. 32-year-old white woman taking oral contraceptives. D. 65-year-old African American man with hypertension.

d

The female patient has been brought to the ED with a sudden onset of a severe headache that is different from any other headache she has had previously. When considering the possibility of a stroke, which type of stroke should the nurse know is most likely occurring? A. TIA B. Embolic stroke C. Thrombotic stroke D. Subarachnoid hemorrhage

d

The nurse can assist the patient and the family in coping with the long term effects of a stroke by a. informing family members that the patient will need assistance with almost all ADLs b. explaining that the patient's prestroke behavior will return as improvement progresses c. encouraging the patient and family members to seek assistance from family therapy or stroke support groups d. helping the patient and family understand the significance of residual stroke damage to promote problem solving and planning

d

The nurse in a primary care provider's office is assessing several patients today. Which patient is most at risk for a stroke? A. A 92-year-old female who takes warfarin (Coumadin) for atrial fibrillation. B. A 28-year-old male who uses marijuana after chemotherapy to control nausea. C. A 42-year-old female who takes oral contraceptives and has migraine headaches. D. A 72-year-old male who has hypertension and diabetes mellitus and smokes tobacco.

d

The nurse is teaching a senior citizen's group about signs and symptoms of a stroke. Which statement by the nurse would provide accurate information? A. "Take the person to the hospital if a headache lasts for more than 24 hours." B. "Stroke symptoms usually start when the person is awake and physically active." C. "A person with a transient ischemic attack has mild symptoms that will go away." D. "Call 911 immediately if a person develops slurred speech or difficulty speaking."

d

The priority intervention in the emergency department for the patient with a stroke is a. intravenous fluid replacement b. administration of osmotic diuretics to reduce cerebral edema c. initiation of hypothermia to decrease the oxygen needs of the brain d. maintenance of respiratory function with a patent airway and oxygen administration

d

When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral atherosclerosis a.to monitor and record the blood pressure daily. b.that Plavix will dissolve clots in the cerebral arteries. c.that Plavix will reduce cerebral artery plaque formation. d.to call the health care provider if stools are bloody or tarry.

d

Which intervention is most appropriate when communicating with a patient suffering from aphasia following a stroke? A. Present several thoughts at once so that the patient can connect the ideas. B. Ask open-ended questions to provide the patient the opportunity to speak. C. Finish the patient's sentences to minimize frustration associated with slow speech. D. Use simple, short sentences accompanied by visual cues to enhance comprehension.

d