NM yr 2

Meningitis symptoms

classic triad of headache, neck stiffness and fever -photophobia, vomiting, altered mental status +Kernigs

Which type of bone tumor occurs most commonly in elderly clients?

chondrosarcoma

A nurse evaluates the results of diagnostic tests on a client's cerebrospinal fluid (CSF). Which fluid results alert the nurse to possible viral meningitis? (Select all that apply.)

clear increased protein normal glucose

Which diagnostic procedure is used to detect muscle weakness?

electromyography

Wernicke's area

receptive language

Dysarthria

slurred speech

The nurse is caring for the client who is having difficulty walking. Which procedure should the nurse perform to test the cerebellar function of the client?

Have the client place the hands on the thighs, then quickly turn the palms up and then down.

Prostictal state

Drowsiness due to seizure

ORIF recovery

Elevate Ambulate 1st day Reposition

Severe LOC priority

Intubate

Infratentorial craniotomy position

Keep pt flat

Kernig's sign

a diagnostic sign for meningitis marked by the person's inability to extend the leg completely when the thigh is flexed upon the abdomen and the person is sitting or lying down

A 79-year-old male client has been transferred to the emergency department from a skilled nursing facility because of changes in orientation and level of consciousness due to a fall. The nurse records the most current set of vital signs as listed below:

administer bolus of saline Draw blood for a complete blood count (CBC). Check the client's blood glucose level. Prepare to intubate the client. Check pupil size and responsiveness. Assess and record the client's LOC.

Order the following terms describing level of consciousness from the least altered to the most altered.

alert confusion lethargy obdundation stupor coma

A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and suspects the presence of which problem?

altered breathing pattern

The nurse shows the client a picture of a baseball and asks the client to identify it and its characteristics. The client describes its color, size, and purpose but cannot identify it as a ball. How will the nurse document this finding?

anomia

The priority assessment for the comatose patient is:

assess airway patency

Which radiographic test is used to view the entire skeleton?

bone scan

global aphasia

inability to communicate

Alexia

inability to read

An appropriate nursing intervention to increase cerebral perfusion pressure for a patient with increased intracrainial pressure is:

limit endo trach suctioning to 15 sec

apraxia

limit of movements

When teaching a client about their disease process, which term would the nurse use to describe bone loss greater than normal but less than that caused by osteoporosis?

osteopenia

The nurse assesses a client admitted with suspected Guillain-Barré syndrome who reports numbness, which began in the hands and feet and now involves the arms, legs, and lower trunk. For which related clinical manifestations would the nurse assess in this client?

paresthesias and paralysis

Agnosia

the inability to recognize familiar objects.

Which diagnostic study would the health care provider use to investigate the cause of an inflamed joint and determine a client's response to anti-inflammatory medication therapy?

thermography

Cushing's triad

three classic signs—bradycardia, hypertension, and bradypnea—seen with pressure on the medulla as a result of brain stem herniation Widened pulse pressure

Which hormone increases the rate of protein synthesis?

thyroxine

A nurse performs an assessment of pain discrimination on an older adult patient. The patient correctly identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin. Which action would the nurse take next?

touch pin in same area on other hand

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply.

wrinkle-free linens preventing pressure repositioning

A nurse assesses a patient who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations would the nurse correlate with neurogenic shock? (Select all that apply.)

HR 34 urine output <30 decreased LOC

facial fx

Not nutritional

Which client condition is likely to improve significantly with the use of hearing aids?

Diminished sensitivity of the cochlea

ICP assessment

Pupils

During the first 24 hours after Activase (tPA), the primary concern is controlling the patient's:

blood pressure

coup head injury

-Stationary object hit by a moving object (struck in the head by a baseball) -Results in trauma on the side of the head that was struck

A patient is prescrived Phenytoin (Dilantil) for prevention of seizures following a head injury. Which of the following values represents a therapeutic serum blood level for this medication?

10-20

The best way to position a patient with increased intracranial pressure (ICP) is to:

30 degrees

A nurse is caring for four patients. Which patient does the nurse assess first for impaired cognition? 28-year-old patient 2 days post-open cholecystectomy 88-year-old patient 3 days post-hemorrhagic stroke 32-year-old patient with a 20 pack-year history of smoking 42-year-old patient with a serum sodium of 134 mEq/L (134 mmol/L)

88-year-old patient 3 days post-hemorrhagic stroke

You are the nurse on a medical unit taking care of a 50-year-old man. A.A. who was admitted 18 hours ago with peptic ulcer disease secondary to suspected chronic alchoholism. You enter A.A.'s room and find him having a generalized convulsive tonic-clonic seizure. After performing priority interventions, you contact the physician for orders. Among other medications ordered, the physician orders a phenytoin 15/mg/kg IV loading dose at a rate of 50/mg minute. The patient weighs 143 lbs. How many mg of phenytoin will you administer as the loading dose?

975

A client has a neurological deficit involving the limbic system. On assessment, which finding is specific to this type of deficit?

Affect is flat, with periods of emotional lability

A male client with a brain attack (cerebrovascular accident) is incontinent of urine. Which action would the nurse encourage to help the client reestablish bladder control?

Assume a standing position when voiding

Battle sign

Bruising behind an ear over the mastoid process that may indicate a basilar skull fracture. Watch for hemiparesis

indications for stroke

CT establish IV apply O2 perform NIH assessment

age-related bone loss

Cartilage degeneration

A vegetative state occurs when there is severe injury to the:

Cerebellum

T5 accident complication

Fever/cough

Dehydrated labs

Increased creatinine Increased BUN Increased hemoglobin (H&H)

Increased ICP displacement

Moved brain tissue Not intracranial fluid

A nurse is caring for a client with meningitis. Which laboratory values would the nurse monitor to identify potential complications of this disorder? Select all that apply.

Na level clotting factors

T5 nurse intervention for BP

Place in fowlers NOT bladder check

Which of the following respiratory patterns indicate increasing ICP in the brainstem?

Slow irregular respirations

Which intervention should the nurse include in a postoperative teaching plan for a client who underwent a spinal fusion and will be wearing a brace?

Tell the client to inspect the environment for safety hazards.

Which intervention and rationale would the nurse plan for a client admitted to the hospital with a right-sided brain attack (cerebrovascular accident)?

Use a hand roll and support the left arm on a pillow to prevent contractures

The unlicensed assistive personnel (UAP) reports to the registered nurse that a postoperative patient has a pulse of 132 beats/minute and a blood pressure of 168/90 mm Hg. What response by the nurse is most appropriate?

assess pain

Reflex activities concerned with heart reate and blood pressure are controlled by the:

brainstem

Which ophthalmic conditions can cause a client to have photophobia? Select all that apply. One, some, or all responses may be correct.

chalazion trachoma keratoconjunctivitis sicca

Which client's tears contain mucus strands?

dry eye syndrome

Glascow Coma Scale

eye opening, verbal response, motor response <8 severe 9-12 moderate 13-15 mild

Acute confusional states can be caused by which of the following? Select all that apply!

fevers head injury alcohol withdrawal

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists?

flaccid paralysis

Monroe-Kelly Hypothesis/Doctrine

•Doctrine: the cranial compartment is encased in a nonexpandable case of bone → the volume inside the cranium is fixed. •In an incompressible cranium, the blood, CSF, and brain tissue exist in a state of volume equilibrium, such that any increase in volume of one of the cranial constituents must be compensated by a decrease in volume of another. •ICP is generally measured in mm Hg to allow for comparison with MAP and to enable quick calculation of CPP. •7-15 mm Hg in adults who are supine (lower in children), with pressures over 20 mm Hg considered pathological

Which synovial joint movement is involved in turning a client's palm downward?

pronation

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply.

loosen clothing remove pillow and raise padded rails turn to side if possible

The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use which technique to test the client's peripheral response to pain?

nail bed pressure

A client with a cervical injury reports the sudden onset of a severe headache and nasal congestion. For which clinical manifestations would the nurse assess?

suprapubic distension

Which synovial joint movement is described as turning the sole away from the midline of the body?

eversion

Contraindications for beginning fibronolytic therapy include which of the following?

post major surgery 14 days platelets less than 100,000 blood glucose less than 50 serious head injury 4 weeks earlier INR over 1.7

After 3 months of rehabilitation after a craniotomy, a client still is having motor speech difficulty. Which would the nurse do to promote the client's use of speech?

respond to the client's efforts of speaking

21 on stroke scale

severe

A client with a neurological problem is experiencing hyperthermia. Which measures would be appropriate for the nurse to use in trying to lower the client's body temperature? Select all that apply.

tepid sponge bath tylenol fan hypothermia (cooling) blanket

neurogenic shock

Bradycardia Loss of tone hypotension Hypo w/o tachy