RealizeIt 10-12

The nurse understand that which of the following are types of joints? Select all that apply Conduit Ball and socket Hinge Saddle Pivot

Moveable joints within the skeletal system include Hinge Joint, Ball and Socket, Pivot, Coldyloind, Saddle and Gliding Joints

Which statement by the client diagnosed with a fractured ulna indicates to the nurse the client needs further teaching? "I need to keep this immobilizer on when lying down only." "I need to take my pain medication before my pain is too bad." "I need to wiggle my fingers every hour to increase circulation." "I need to eat a high-protein diet to ensure healing."

"I need to keep this immobilizer on when lying down only." The immobilizer should be kept on at all times. This indicates the client does not understand the teaching and needs the nurse to provide more instruction. Protein is necessary for healing. By wiggling the fingers of the affected arm, the client can improve the circulation. Pain medication should be taken prior to perception of severe pain. Pain relief will require more medication if allowed to become severe.

The nurse is assessing a client in the day surgery unit who states, "I am really afraid of having this surgery. I'm afraid of what they will find." Which statement would be the best therapeutic response by the nurse? "Don't worry about your surgery. It is safe." "Tell me about your fears of having this surgery." "I understand how you feel. Surgery is frightening." "Tell me why you're worried about your surgery."

"Tell me about your fears of having this surgery." This statement focuses on the emotion which the client identified and is therapeutic.

A normal assessment finding of the musculoskeletal system is? Muscle and bone strength of 4. Angulation of bone toward midline Ulnar deviation and subluxation. No deformity or crepitation.

Normal spinal curvatures No muscle atrophy or asymmetry No joint swelling, deformity, or crepitation No tenderness on palpation of spine, joints, or muscles Full range of motion of all joints without pain or laxity Muscle strength of 5/5

A type of skin traction used preoperatively for the patient with a hip fracture to reduce muscle spasm is known as _________ Traction? Skeletal Kelly's Buck's Brad's

A type of skin traction used preoperatively for the patient with a hip fracture to reduce muscle spasm is known as Buck'sTraction?

The nurse caring for clients in a post anesthesia care unit understands that oliguria in the post-anesthesia period can be a sign of which of the following? Renal failure Urinary Tract Infection Opioid induced Hypovolemia

Oliguria (diminished output of urine) can be a sign of renal failure and is a less common, although more serious, problem after surgery. It may result from renal ischemia caused by inadequate renal perfusion

One of the greatest risks during the perioperative period is Inadequate nutrition IV site infection Surgical Site Infection (SSI) Accumulation of fluid in the wound

One of the greatest risks during the perioperative period is surgical site infection (SSI).

The nurse must obtain surgical consent forms for the scheduled surgery. Which client would not be able to consent legally to surgery? The 30-year-old client who does not understand English. The 80-year-old client who is not oriented to the day. The 16-year-old client who has a fractured ankle. The 65-year-old client who cannot read or write. I don't know O

A 16-year-old client is not legally able to give permission for surgery unless the adolescent has been given an emancipated status by a judge. This information was not given in the stem.

The PACU nurse administers Narcan, an opioid antagonist, to a postoperative client. Which client problem should the nurse include to the plan of care based on this medication? Potential for infection. Depressed respiratory pattern. Fluid and electrolyte imbalance. Alteration in comfort.

A client with respiratory depression treated with Narcan can have another episode within 15 minutes after receiving the drug as a result of the short half-life of the medication.

A short arm cast is often used to treat stable wrist fractures. The nurse understands this cast is apply from the distal palmer to the ________ ? Proximal forearm Proximal humerus Gluteal crease Distal humerus

A short arm cast is often used to treat stable wrist fractures. The nurse understands this cast is apply from the distal palmer to the proximal forearm.

A synapse is the structural and functional junction between? The spinal cord and the nerve Two neurons Grey and white matter A neuron and a muscle

A synapse is the structural and functional junction between two neurons. It is the point at which the nerve impulse is transmitted from one neuron to another. The nerve impulse also can be transmitted from neurons to glands or muscles.

When grading muscle strength, the nurse records a score of 3/5, which indicates? Active movement against full resistance without fatigue. A barely detectable flicker of contraction. No detection of muscular contraction. Active movement against gravity but not against resistance

Active movement against gravity but not against resistance Grade the strength of individual muscles or groups of muscles during contraction on a 5-point scale). Grade normal muscle strength with full resistance to opposition as a 5/5 bilaterally 0/5 No detection of muscular contraction 1/5 A barely detectable flicker or trace of contraction with observation or palpation 2/5 Active movement of body part with elimination of gravity 3/5 Active movement against gravity only and not against resistance 4/5 Active movement against gravity and some resistance 5/5 Active movement against full resistance without evident fatigue (normal muscle strength)

The nurse is caring for a client diagnosed with septic meningitis. Which health-care provider's order would have the highest priority? Weigh the client in hospital attire. Administer an intravenous antibiotic. Provide a quiet, calm, and dark room. Obtain the client's lunch tray.

Administer an intravenous antibiotic.

The nurse is caring for a client in acute pain as a result of surgery. Which intervention should the nurse implement? Use cryotherapy after heat therapy because it works faster. Use nonpharmacological methods to replace medications. Administer pain medication as soon as the time frame allows. Instruct family members to administer medication with the PCA.

Administer pain medication as soon as the time frame allows.

The health care provider has prescribed the following interventions for a patient who is taking azathioprine (Imuran) for systemic lupus erythematosus. Which order will the nurse question? Famotidine (Pepcid) 20 mg daily. Draw anti-DNA blood titer. Administer varicella vaccine. Naproxen (Aleve) 200 mg BID.

Administer varicella vaccine.

The nurse is an emergency department is triaging a patient with a severe head injury. Which of the following is of highest priority? Cerebrospinal fluid leakage from the ears or nose. Neurologic status with the Glasgow Coma Scale. Presence of a neck injury. Patency of airway.

Airway is always the first priority - no airway means no oxygenation.

The nurse caring for clients on an inpatient unit understands that airway obstruction is commonly caused by blockage of the airway by which of the following? Hypoventilation Atelectasis Bronchospasm Patients tongue

Airway obstruction is commonly caused by blockage of the airway by the patient's tongue. The base of the tongue falls backward against the soft palate and occludes the pharynx. It is most pronounced in the supine position and in the patient who is extremely sleepy after surgery.

The nurse is caring for a postoperative patient. Which problem should the nurse identify as priority for client who is one (1) day postoperative? Potential for infection. Potential for fluid volume excess. Potential for hemorrhaging. Potential for injury.

All clients who undergo surgery are at risk for hemorrhaging, which is the priority problem.

Which problem would be most appropriate for the nurse to identify for the client experiencing acute pain? Potential for injury. Alteration in comfort. Altered sensory input. Ineffective coping.

Alteration in comfort is addressing the client's acute pain

Neurons come in all shapes and sizes and share three characteristics. Which of the following are the three characteristics? Electricity Excitability Influence Impulsiveness Conductivity

Although neurons come in many shapes and sizes, they share three characteristics: (1) excitability, or the ability to generate a nerve impulse; (2) conductivity, or the ability to transmit an impulse; and (3) influence, or the ability to influence other neurons, muscle cells, or glandular cells.

Phase II and extended Observation are generally for which criteria of patient? 23 hours observation Ambulatory Care Outpatient Inpatient

Ambulatory surgery patients include those patients receiving Phase II and extended observation postoperative care

The nurse is teaching a patient newly diagnosed with amyotrophic lateral sclerosis (ALS). Which statement would be appropriate to include in the teaching? "This is a progressing disease that eventually results in permanent paralysis, though you will not lose any cognitive function." "You need to consider advance directives now, because you will lose cognitive function as the disease progresses." "Even though the symptoms you are experiencing are severe, most people recover with treatment." "ALS results from an excess chemical in the brain, and the symptoms can be controlled with medication."

Amyotrophic lateral sclerosis (ALS) is a rare progressive neuromuscular disorder characterized by loss of motor neurons. ALS usually leads to death 2 to 5 years after diagnosis, but a few patients may survive for more than 10 years

What would the nurse recognize as a possible difference in the assessment of a gerontologic patient? Decreased joint stiffness Increased fine motor dexterity Quicker reflex response Slowed reaction time

As a person ages the response time slows and the ability to "save" oneself from falling is less likely to actually work.

The client is taken to the emergency department with an injury to the left arm. Which intervention should the nurse implement first? Assess the nailbeds for capillary refill time. Remove the client's clothing from the arm. Call radiology for a STAT x-ray of the extremity. Prepare the client for the application of a cast.

Assess the nailbeds for capillary refill time. The nurse should assess the nailbeds for the capillary refill time. A prolonged time (greater than three [3] seconds) indicates impaired circulation to the extremity Show next question

The nurse is receiving a postoperative client transferred from the PACU to the surgical floor. Which action should the nurse implement first? Assess the client's vital signs. Listen to the report from the anesthesiologist. Attach the drain to 20 cm suction. Apply antiembolism hose to the client.

Assessing the client's status after transfer from the PACU should be the nurse's first intervention.

While obtaining subjective assessment data related to the musculoskeletal system, the nurse must ask a patient about other medical problems such as? Diabetes mellitus. Thyroid problems. Hypertension. Chronic bronchitis

Because certain illnesses are known to affect the musculoskeletal system directly or indirectly, question the patient about past medical problems, including tuberculosis, poliomyelitis, diabetes mellitus, parathyroid problems, hemophilia, rickets, soft tissue infection, and neuromuscular disability.

Which statement should the nurse identify as the expected outcome for a client experiencing acute pain? The client will use relaxation techniques. The client will participate in self-care activities. The client will have decreased use of medication. The client will repeat instructions about medications.

Clients experiencing acute pain will not be involved in self-care because of their reluctance to move, which increases the pain; therefore, participation indicates the client's pain is tolerable.

The nurse understands that clonus is which of the following? Part of a normal response A weak response to stimuli continued rhythmic contraction A sign of hyperreflexia

Clonus, an abnormal response, is a continued rhythmic contraction of the muscle with continuous application of the stimulus.

The nurse is caring for patients in a post-surgical care unit. The nurse understands that the common reasons post-surgical patients seek help after discharge include which of the following? Select all that apply Transportation Issues Unrelieved pain Wound issues Access own medical record Need for advice about drugs

Common reasons patients seek help after discharge include unrelieved pain, need for advice about drugs, and wound issues (e.g., drainage).

The nurse suspects a neurovascular problem based on assessment of which of the following? Exaggerated strength with movement. Increased redness and heat below the injury. Purulent drainage at the site of the open fracture Decreased sensation distal to the fracture site.

Decreased sensation is ominous sign of neurovascular occlusion.

The circulating nurse's primary responsibility for the care of the patient undergoing surgery is which of the following? Carrying out specific tasks related to surgical policies and procedures. Performing a preoperative history and physical assessment to identify patient needs. Ensuring that the patient has been assessed for safe administration of anesthesia. Developing an individualized plan of nursing care for the patient.

Developing an individualized plan of nursing care for the patient. Circulating, Nonsterile Activities • Reviews anatomy, physiology, and surgical procedure • Assists in preparing room, ensuring that supplies and equipment are available, in working order, and sterile (if required) • Maintains aseptic technique in all required activities • Monitors practices of aseptic technique in self and others • Checks mechanical and electrical equipment and environmental factors • Conducts a preprocedure verification process • Assesses patient's physical and emotional status • Confirms and implements ordered SCIP measures • Plans and coordinates intraoperative nursing care • Checks chart and relates pertinent data to team members • Helps with the application of monitoring devices and insertion of invasive lines and other devices • Assists with and ensures patient safety in transferring and positioning patient • Assists with induction of anesthesia • Monitors draping procedure • Participates in surgical time-out • Records intraoperative care • Prepares, records, labels, and sends blood, pathology, and any anatomic specimens to proper locations • Measures blood, urine output, and other fluid loss • Confirms, dispenses, and records drugs used, including local anesthetics • Coordinates all intraoperative activities with team members and other staff and departments • Maintains accurate count of sponges, needles, instruments, and medical devices that could be retained in the patient • Goes with patient to PACU • Gives hand-off report to PACU nurse with information relevant to care of patient

Then nurse is preparing to admit a client with septic meningitis. Which type of precautions should the nurse implement for the client diagnosed with septic meningitis? Airborne Precautions. Standard Precautions. Droplet Precautions. Contact Precautions.

Droplet Precautions are respiratory precautions used for organisms that have a limited span of transmission. Precautions include staying at least four (4) feet away from the client or wearing a standard isolation mask and gloves when coming in close contact with the client. Clients are in isolation for 24 to 48 hours after initiation of antibiotics.

The client admitted with a diagnosis of a fractured hip who is in Buck's traction is complaining of severe pain. Which intervention should the nurse implement? Turn the client on the affected leg using pillows to support the other leg. Raise the head of the bed to 45 degrees and the foot to 15 degrees. Adjust the patient-controlled analgesia (PCA) machine for a lower dose. Ensure the weights of the Buck's traction are off the floor and hang freely.

Ensure the weights of the Buck's traction are off the floor and hang freely. Weights from traction should be off the floor and hanging freely. Buck's traction is used to reduce muscle spasms preoperatively in clients who have fractured hips.

A patient is scheduled for an electromyogram (EMG). The nurse explains that this diagnostic test involves? Placement of skin electrodes to record muscle activity Insertion of small needles into certain muscles. Incision or puncture of the joint capsule. Administration of a radioisotope before the procedure.

Evaluates electrical potential associated with skeletal muscle contraction. Small-gauge needles are inserted into certain muscles. Needle probes are attached to leads that send information to EMG machine. Recordings of electrical activity of muscle are traced on audio transmitter and on oscilloscope and recording paper. Useful in providing information related to lower motor neuron dysfunction and primary muscle disease.

A sprain is excessive stretching of a muscle, its facial sheath, or a tendon. True False

False A sprain is an injury to the ligaments surrounding a joint, usually caused by a wrenching or twisting motion. A strain is an excessive stretching of a muscle, its fascial sheath, or a tendon.

Focal Seizures are classified into which of the following groups. Select all that apply. Complex Focal Tonic-Clinic Focal Seizures evolving Absence Simple Focal

Focal Seizures (Involve one hemisphere of brain) • Simple focal seizures (no impairment of awareness/consciousness) • Complex focal seizures (impairment of awareness/consciousness) • Focal seizures evolving to secondary generalized seizures

Fractures can be classified as __________ or __________. Select all that apply. closed open broken Partially open

Fractures can be classified as open or closed based on possible communication with the external environment.

The nurse is caring for a client who is suspected of having a brain tumor. The clients signs and symptoms include memory deficits, visual disturbances, weakness of right upper and lower extremities, and personality changes. The nurse recognizes that the tumor is most likely located which part of the brain? Occipital lobe. Frontal lobe. Parietal lobe. Temporal lobe.

Frontal lobe (unilateral) Unilateral hemiplegia, seizures, memory deficit, personality and judgment changes, visual disturbances.

Which of the following are three types of cartilage? Select all that apply Fibrous Rigid Hyaline Muscular Elastic

Hyaline cartilage, the most common, contains a moderate amount of collagen fibers. It is found in the trachea, bronchi, nose, epiphyseal plate, and articular surfaces of bones. Elastic cartilage, which contains both collagen and elastic fibers, is more flexible than hyaline cartilage. It is found in the ear, epiglottis, and larynx. Fibrous cartilage (fibrocartilage) consists mostly of collagen fibers and is a tough tissue that often functions as a shock absorber. It is found between the vertebral discs and also forms a protective cushion between the bones of the pelvic girdle, knee, and shoulder.

The nurse is caring for clients on a medical surgical unit. The nurse understands that which of the following is evidenced by signs of hypoperfusion to vital organs, especially the brain, heart and kidneys? Hypotension Hypokalemia Deep Vein Thrombosis Hypovolemia

Hypotension is evidenced by signs of hypoperfusion to the vital organs, especially the brain, heart, and kidneys.

The 26-year-old male client in the PACU has a heart rate of 110 and a rising temperature, and complains of muscle stiffness. Which interventions should the nurse implement? Select all apply Reposition the client on a warming blanket. Give a back rub to the client to relieve stiffness. Apply ice packs to the axillary and groin areas. Prepare to administer dantrolene, a smooth-muscle relaxant. Prepare an ice slush for the client to drink.

Ice packs should be applied to the axillary and groin areas for a client experiencing malignant hyperthermia. Dantrolene is the drug of choice for treatment.

If an injury occurs, immediate care focuses on which of the following? Select all that apply. Compressing the involved area Stopping activity and limiting movement Elevating the extremiity Walking it off Applying ice packs to injured area

If an injury occurs, immediate care focuses on (1) stopping the activity and limiting movement, (2) applying ice packs to the injured area, (3) compressing the involved area, (4) elevating the extremity, and (5) providing analgesia as needed

Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia? Loss of sensation at the lumbar (L5) dermatome. The blood pressure is within 20% of client's baseline Absence of the client's posterior tibial pulse. The client has a respiratory rate of eight (8).

If the effects of the spinal anesthesia move up rather than down the spinal cord, respirations can be depressed and even blocked.

A patient with acute osteomyelitis of the left femur is hospitalized for regional antibiotic irrigation. Which intervention will the nurse include in the initial plan of care? Positioning the left leg in flexion Immobilization of the left leg Quadriceps-setting exercises Assisted weight-bearing ambulation

Immobilization of the left leg Immobilization of the affected leg helps to decrease pain and reduce the risk for pathologic fracture. Weight-bearing exercise increases the risk for pathologic fractures. Flexion of the affected limb is avoided to prevent contractures.

An open fracture includes which of the following criteria? Select all that apply Soft tissue damage Bone is exposed Skin intact Crack in the bone Skin is broken

In an open fracture, skin is broken ad bone exposed, causing soft tissue injury.

In general, blood drainage from a surgical wound is expected to change color from ___________ to ___________ to _______________. sanguineous (red) to serous (clear yellow) to serosanguineous (pink). serous (clear yellow) to sanguineous (red) to serosanguineous (pink). serosanguineous (pink) to serous (clear yellow) to sanguineous (red). sanguineous (red) to serosanguineous (pink) to serous (clear yellow).

In general, drainage is expected to change from sanguineous (red) to serosanguineous (pink) to serous (clear yellow).

When a patient is admitted to the PACU, what are the priority interventions the nurse performs? Assess the surgical site, noting presence and character of drainage. Assess for airway patency and quality of respirations and obtain vital signs. Assess the amount of urine output and the presence of bladder distention. Review results of intraoperative laboratory values and medications received.

In the AHA guidelines AIRWAY is always the first assessment.

IV induction for general anesthesia is the method of choice for most patients because? Emergence is longer but with fewer complications. The patient is not intubated. The agents are nonexplosive. Induction is rapid and pleasant.

Induction is rapid and pleasant. General anesthesia is the technique of choice for patients who are having surgical procedures that are of significant duration, require skeletal muscle relaxation, require uncomfortable operative positions because of the location of the incision site, or require control of ventilation.

The nurse is interviewing a surgical client in the holding area. Which information should the nurse report to the anesthesiologist? Select all that apply. The client is experiencing anxiety. The client has had a chest x-ray which does not show infiltrates. The client has loose, decayed teeth. The client reports using herbs. The client smokes two (2) packs of cigarettes a day.

Loose teeth or caries need to be reported to the anesthesiologist so he or she can make provisions to prevent breaking the teeth and causing the client to possibly aspirate pieces. Smokers are at a higher risk for complications from anesthesia. Herbs—for example, St. John's wort, liquorice, and ginkgo—have serious interactions with anesthesia and with bodily functions such as coagulation.

Activities that the nurse might perform in the role of a scrub nurse during surgery include which of the following? Select all that apply. Checking electrical equipment. Maintaining accurate counts of sponges, needles, and instruments. Preparing the instrument table. Coordinating activities occurring in the operating room. Passing instruments to the surgeon and assistants.

Maintaining accurate counts of sponges, needles, and instruments. Passing instruments to the surgeon and assistants. Preparing the instrument table. Scrubbed, Sterile Activities • Reviews anatomy, physiology, and surgical procedure • Assists in preparing the operating room • Completes surgical hand antisepsis and gowns and gloves self and other members of surgical team • Prepares instrument table and arranges sterile equipment for functional use • Assists with draping procedure • Participates in surgical time-out procedure • Passes instruments to surgeon and assistants by anticipating their needs • Maintains accurate count of sponges, needles, instruments, and medical devices that could be retained in the patient • Monitors practices of aseptic technique in self and others • Keeps track of irrigation solutions used for calculation of blood loss • Accepts, verifies, and reports drugs used by surgeon and/or ACP, including local anesthetics

Manifestations of carpal tunnel syndrome include positive signs for which of the following? Tinel's signs and Phillip's sign Tanner's signs and Phalen's sign Tinel's signs and Phalen's sign Task's signs and Phelp's sign

Manifestations of CTS include a positive Tinel's sign and Phalen's sign. Tinel's sign can be elicited by tapping over the median nerve as it passes through the carpal tunnel in the wrist. A positive response is a sensation of tingling in the distribution of the median nerve over the hand. Phalen's sign can be elicited by allowing the wrists to fall freely into maximum flexion and maintain the position for longer than 60 seconds. A positive response is a sensation of tingling in the distribution of the median nerve over the hand. In late stages, atrophy of the thenar muscles around the base of the thumb results in recurrent pain and eventual dysfunction of the hand.

Migraine Headaches are characterized by a __________ throbbing pain? Circumoral Unilateral Repeated Bilateral

Migraine headache is a recurring headache characterized by unilateral throbbing pain.

Mild weakness of the arm is demonstrated by ________ __________ of the arm or pronation of the palm Upward swinging Hypertonia Downward drifting Sideways drift

Mild weakness of the arm is demonstrated by downward drifting of the arm or pronation of the palm

Patients at high risk for airway compromise in the PACU include those who? Select all that apply. Have a pre-existing lung disease Have a history of jaundice Older than 55 years Have a history of tobacco use Have undergone airway, thoracic or abdominal surgery Have had general anesthesia

Patients at high risk include those who (1) have had general anesthesia; (2) are older than 55 years of age; (3) have a history of tobacco use; (4) have pre-existing lung disease and/or sleep-disordered breathing; (5) are obese; (6) have co-morbidities (e.g., renal disease, diabetes, hypertension); or (7) have undergone airway, thoracic, or abdominal surgery.

The nurse is educating a client with a newly diagnosed neurological disease. Which of the following social effects should the nurse highlight as possible impacts? Depression Job loss Role changes Loss of self-esteem A solid steady relationship

Patients must deal with not only their disease but also the impact of the disease on their quality of life. Many patients have concerns regarding safety, mobility, self-care, and coping. Patients and their families often require psychosocial support, especially as the disease progresses and patients' disability gets worse.

Which of the following persons are at risk for repetitive strain injury (RSI)? Select all that apply Mail carrier Swimmer Dancer Grocery clerk Baseball player

Persons at risk for RSI include musicians, dancers, butchers, grocery clerks, vibratory tool workers, and those who frequently use a computer mouse and keyboard. Competitive athletes and poorly trained athletes may also develop RSI. Swimming, overhead throwing (e.g., baseball), weight lifting, gymnastics, tennis, skiing, and kicking sports (e.g., soccer) require repetitive motion.

The temporary impairment of gastric and bowel motility after surgery is known as which of the following? Constipation Postoperative nausea and vomiting Hiccups (singultus) Postoperative ileus (POI)

Postoperative ileus (POI), or the temporary impairment of gastric and bowel motility after surgery, results from the handling or reconstruction of the intestine during surgery and limited dietary intake before and after surgery.

The nurse caring for surgical patients understands that the planning for discharge of a surgical patient begins in which phase? postoperative Preoperative Intraoperative No planning is needed

Preparation for the patient's discharge is an ongoing process that begins during the preoperative phase.

The nurse is teaching a client about headaches and the importance of preventative treatment for migraine headaches. The nurse should assess which of the following prior to the initiation of preventative treatment? Select all that apply. Disability related to headache Cognitive ability Frequency Severity Nausea and vomiting

Preventive treatment is important in the management of migraine headaches. The decision to initiate preventive treatment is individually determined based on frequency, severity, and any disability related to headaches.

The nurse is education a group of student nurses about Primary Generalized Seizures. The nurse should include that seizures are classified into which of the following groups? Select all that apply Tonic-Clonic Absence Complex Focal Myoclonic Simple Focal

Primary Generalized Seizures (Involve both hemispheres of brain) • Tonic-clonic seizures • Absence seizures (simple or complex) • Typical • Atypical • Absence with special features • Myoclonic seizures • Tonic seizures • Atonic seizures (akinetic) • Clonic seizures Focal Seizures (Involve one hemisphere of brain) • Simple focal seizures (no impairment of awareness/consciousness) • Complex focal seizures (impairment of awareness/consciousness) • Focal seizures evolving to secondary generalized seizures Unknown (Events not clearly diagnosed into categories above)

Primary headaches are caused by another condition or disease. TrueFalse

Primary headache classifications include tension-type, migraine, and cluster headaches. Primary headaches are not caused by a disease or another medical condition.

The nurse is caring for a client with Parkinson's Disease. Which of the following should the nurse make a priority intervention? Promoting physical exercise and a well-balanced diet. Designing an exercise program to strengthen and stretch specific muscles. Searching the Internet for educational videos. Evaluating the home for environmental safety.

Promotion of physical exercise and a well-balanced diet are major concerns for nursing care. Exercise can limit the consequences of decreased mobility, such as muscle atrophy, contractures, and constipation.

Focal Seizures (Involve one hemisphere of brain) • Simple focal seizures (no impairment of awareness/consciousness) • Complex focal seizures (impairment of awareness/consciousness) • Focal seizures evolving to secondary generalized seizures

Restless legs syndrome (RLS), also called Willis-Ekbom disease, is a relatively common condition characterized by unpleasant sensory (paresthesia) and motor abnormalities of one or both legs.

The purpose of a Schwann cell is to? Myelinate the nerve fibers Aid in secretion of cerebral spinal fluid Regenerate the nerve Demyelinate the nerve fibers

Schwann cells myelinate the nerve fibers in the periphery.

The nurse has attended an educational session about Seizures. The nurse understands that seizures can be described as transient, uncontrolled electrical discharge of neurons in the brain that interrupts normal function. TrueFalse

Seizure is a transient, uncontrolled electrical discharge of neurons in the brain that interrupts normal function. Seizures may accompany a variety of disorders, or they may occur spontaneously without any apparent cause.

The nurse is admitting a client diagnosed with septic meningitis The nurse understand that septic meningitis is which of the following? "There is bleeding into his brain causing irritation of the meninges." "This is an inflammation of the brain parenchyma caused by a mosquito bite." "A virus has infected the brain and meninges, causing inflammation." "This is a bacterial infection of the tissues that cover the brain and spinal cord."

Septic meningitis refers to meningitis caused by bacteria; the most common form of bacterial meningitis is caused by the Neisseria meningitides bacteria.

The nurse is caring for a client admitted with a diagnosis of epidural hematoma. Which of the following nursing interventions should the nurse implement? Select all that apply. Maintain the head of the bed at 60 degree elevation Pulse oximetry to ensure a reading is greater than 93% Administer stool softeners daily Perform deep nasal suction every two (2) hours Administer mild sedatives for agitation

Stool softeners to prevent the Valsalva manoeuvre (can increase ICP), oxygen greater than 93% to ensure oxygenation to the brain (decreased can indicated increased ICP), mild sedatives can help with agitation but no strong narcotics as this can hide changes in the level of consciousness.

When scrubbing at the scrub sink, the nurse understands that good technique includes which of the following? Hold the hands higher than the elbows Scrub without mechanical friction. Scrub from elbows to hands. Scrub for a minimum of 10 minutes.

Surgical hand antisepsis is required of all sterile members of the surgical team (scrub nurse, surgeon, and assistant). When the procedure of scrubbing is the chosen method for surgical hand antisepsis (often for the first case of the day), your fingers and hands should be scrubbed first with progression to the forearms and elbows. The hands should be held away from surgical attire and higher than the elbows at all times to prevent contamination from clothing or detergent suds and water from draining from the unclean area above the elbows to the clean and previously scrubbed areas of the hands and fingers.

An external fixator is a device composed of metal pins that are inserted into the bone and attached to external rods to stabilize the fracture while it heals. True False

TRUE - An external fixator is a device composed of metal pins that are inserted into the bone and attached to external rods to stabilize the fracture while it heals.

The nurse is caring for a client complaining of a headache. The nurse understands there are common types of headaches. Name the common types of headache? Select all that apply. Tumors and hemorrhage headache Cluster headache Migraine headache Tension headache Study headache

Tension, migraine, and cluster headaches are by far the most common types of headaches, other types can occur. These headaches may be the first symptom of a more serious illness.

A tension-type headache is also called a __________ headache? Stress Cluster Occipital Migraine

Tension-type headache, also called stress headache, is the most common type of headache.

When testing a patients muscle strength the nurse should ask the patient to ___________ and ________ against resistance. Push and pull Bend and stretch Grasp and loosen Punch and kick

Test muscle strength by asking the patient to push and pull against the resistance of your arm as it opposes flexion and extension of the patient's muscle.

The PACU nurse is receiving the client from the OR. Which intervention should the nurse implement first? Monitor the pulse oximeter reading. Apply oxygen via nasal cannula. Assess the client's breath sounds. Take the client's blood pressure.

The airway should be assessed first. When caring for a client, the nurse should follow the ABCs: airway, breathing, and circulation.

Which statement would be an expected outcome for the postoperative client who had general anesthesia? The client will have a pulse oximetry reading of 97% on room air. The client will be able to distinguish sharp from dull sensations. The client will have a urine output of 30 mL per hour. The client will be able to sit in the chair for 30 minutes.

The anesthesia machine takes over the function of the lungs during surgery, so the expected outcome should directly reflect the client's respiratory status; the alveoli can collapse, causing atelectasis.

The body consists of _______ bones? 199 206 205 210

The body consist of 206 bones

The cerebrum has four lobes. Name the lobes. Select all that apply Temporal Frontal Basal Parietal Marginal Occipital

The cerebrum is composed of the right and left cerebral hemispheres and divided into four lobes: frontal, temporal, parietal, and occipital.

The nurse is caring for a client who is being admitted to rule out a brain tumor. Which of the following represents the classic triad of symptoms that supports a diagnosis of brain tumor? Abrupt loss of motor function, diarrhea, and changes in taste. Nervousness, metastasis to the lungs, and seizures. Headache, vomiting, and papilledema. Hypotension, tachycardia, and tachypnea.

The classic triad of symptoms suggesting a brain tumor includes a headache that is dull, unrelenting, and worse in the morning; vomiting unrelated to food intake; and edema of the optic nerve (papilledema), which occurs in 70% to 75% of clients diagnosed with brain tumors.

The nurse is preparing the care plan for a client with a fractured lower extremity. Which outcome is most appropriate for the client? The client will have no infection. The client will be turned every two (2) hours. The client will ambulate with assistance. The client will maintain function of the leg.

The client will maintain function of the leg. The expected outcome for a client with a fracture is maintaining the function of the extremity Ambulation with assistance is not the best goal. This is a nursing intervention, not a client goal. Infection is not the highest priority problem for a client with a fracture.

The direct energy source for muscle is which of the following? Adenosine Diphosphate (ADP) Glycogen Adenosine Triphosphate (ATP) phosphocreatine

The direct energy source for muscle fiber contractions is adenosine triphosphate (ATP).

The hypothalamus plays a primary role in the stress response by regulating the function of both the sympathetic and parasympathetic branches of the autonomic nervous system. Which is responsible for the fight or flight reaction? Parasympathetic Sympathetic

The hypothalamus plays a primary role in the stress response by regulating the function of both the sympathetic and parasympathetic branches of the autonomic nervous system. When an individual perceives a stressor, the hypothalamus sends signals that initiate both the nervous and endocrine responses to the stressor. It does this primarily by sending signals via nerve fibers to stimulate the sympathetic nervous system (SNS) and by releasing corticotropin-releasing hormone (CRH), which stimulates the pituitary to release adrenocorticotropic hormone (ACTH) SNS stimulation activates the mechanisms required for the "fight-or-flight" response that occurs throughout the body.

The nurse in the holding area of the surgery department is interviewing a client who requests to keep his religious medal on during surgery. Which intervention should the nurse implement? Tape the medal to the client and allow the client to wear the medal. Explain taking the medal to surgery is against the policy. Notify the surgeon about the client's request to wear the medal. Request the family member take the medal prior to surgery.

The medal should be taped and the client should be allowed to wear the medal because meeting spiritual needs is essential to this client's care.

During Phase I of the postoperative nursing assessment, vital signs monitored every ____________ minutes? 15 minutes 5 minutes 2 minutes 10 minutes

The most important aspect of the cardiovascular assessment is frequent monitoring of vital signs. They are usually monitored every 15 minutes in Phase I, or more often until stabilized, and then less frequently in Phase II.

The client is complaining of left shoulder pain. Which intervention should the nurse implement first? Ask if the client wants pain medication. Check the medication administration record (MAR). Assess the neurovascular status of the left hand. Administer the client's pain medication.

The nurse should first assess the client for potential complications to determine if this expected pain or pain requiring notifying the health-care provider.

The client is one day post- op following a left shoulder arthroscopy and is complaining of left shoulder pain. Which intervention should the nurse implement first? Administer the client's pain medication. Ask if the client wants pain medication. Check the medication administration record (MAR). Assess the neurovascular status of the left hand.

The nurse should first assess the client for potential complications to determine if this expected pain or pain requiring notifying the health-care provider.5

The nurse is completing a preoperative assessment on a male client who states, "I am allergic to codeine." Which intervention should the nurse implement first? Ask the client what happens when he takes the codeine. Apply an allergy bracelet on the client's wrist. Label the client's allergies on the front of the chart. Document the allergy on the medication administration record.

The nurse should first assess the events which occurred when the client took this medication because many clients think a side effect, such as nausea, is an allergic reaction.

The nurse is caring for an elderly client with a diagnosis of Alzheimer's Disease. The patient is continually rubbing, flexing and kicking their legs and these activities are worse at night. Which of the following is the most appropriate intervention/assessment? Ask the physician for a nighttime sleep medication for the patient. Assess the patient more closely, suspecting a disorder such as restless legs syndrome Ask the physician for a daytime sedative for the patient. Request soft restraints to prevent her from falling out of her bed.

The pain at night can disrupt sleep. Physical activity, such as walking, stretching, rocking, or kicking, often relieves the pain. In the most severe cases, patients sleep only a few hours at night, resulting in daytime fatigue and disruption of the daily routine.

The nurse is assessing a client with a closed head injury and notes there is clear draining from the nares. Which is the nurse's priory action for this finding? Notify the health-care provider immediately. Prepare to administer an antihistamine. Place a tissue under the nose to collect drainage Test the drainage for presence of glucose.

The presence of clear drainage form the nose could indicate there is a cerebrospinal leak and to differentiate this from normal nasal drainage the nurse will test the exudate for glucose. CSF is has high levels of glucose.

The nurse is caring for a patient admitted with a closed head injury. The nurse understands a priority intervention to be which of the following? Maintain an adequate airway. Assess neurological status. Initiate an intravenous access. Monitor pulse, respiration, and blood pressure.

The priority action for the nurse a patient with a closed head injury is maintenance of a patent airway.

The response (muscle contraction of the corresponding muscle) is measured on a 0 to 5 scale. The nurse records a response of 3 and understands this corresponds with which type of response? Normal response Brisk response clonus Hyperreflexia

The response (muscle contraction of the corresponding muscle) is measured on a 0 to 5 scale as follows: 0 = absent reflex, 1 = weak response, seen only with reinforcement, 2 = normal response, 3 = brisk response, 4 = hyperreflexia with non-sustained clonus, and 5 = hyperreflexia with sustained clonus.

Proper attire for the semirestricted area of the surgery department is which of the following? Street clothing. Street clothing with the addition of shoe covers. Surgical attire, head cover, and mask. Surgical attire and head cover.

The semirestricted area includes the surrounding support areas and corridors. Only authorized staff are allowed access to the semirestricted areas. All staff in the semirestricted area must wear surgical attire and cover all head and facial hair.

The standard neurologic examination helps determine the ___________, ___________ and ______________ of nervous system disease? Location Function Presence Nature

The standard neurologic examination helps determine the presence, location, and nature of nervous system disease.

The three types of muscle tissue are? Select all that apply Liver Skeletal Smooth Cardiac Rigid

The three types of muscle tissue are cardiac (striated, involuntary), smooth (nonstriated, involuntary), and skeletal (striated, voluntary) muscle. Cardiac muscle occurs only in the heart. Its spontaneous contractions propel blood through the circulatory system. Smooth muscle is found in the walls of hollow structures such as airways, arteries, gastrointestinal (GI) tract, urinary bladder, and uterus. Smooth muscle contraction is modulated by neuronal and hormonal influences. Skeletal muscle, which requires neuronal stimulation for contraction, accounts for about half of a human's body weight.

The nurse has attended a conference on Multiple Sclerosis. The nurse understands that which of the following are pathological characteristics of Multiple Sclerosis? Select all that apply. Genetic mutation Gliosis in the CNS Demyelination Chronic inflammation Antibodies attach acetylcholine receptors

Three pathologic processes characterize MS: chronic inflammation, demyelination, and gliosis in the CNS. The primary neuropathologic condition is an autoimmune process orchestrated by activated T cells.

Tonic-clonic seizure (formerly known as grand mal) is characterized by which of the following? No change in normal behavior A sudden, excessive jerk or twitch of the body or extremities Remain conscious and alert but experience unusual feelings or sensations that can take many forms Losing consciousness and falling to ground

Tonic-clonic seizure (formerly known as grand mal) is characterized by losing consciousness and falling to the ground if the patient is upright, followed by stiffening of the body (tonic phase) for 10 to 20 seconds and subsequent jerking of the extremities (clonic phase) for another 30 to 40 seconds. Cyanosis, excessive salivation, tongue or cheek biting, and incontinence may accompany the seizure.

A dislocation is the complete displacement or separation of the articular surfaces of the joint. It results from severe injury of the ligaments surrounding the joint. False True

True A dislocation is the complete displacement or separation of the articular surfaces of the joint. It results from severe injury of the ligaments surrounding the joint. A subluxation is a partial or incomplete displacement of the joint surface. The clinical manifestations of a subluxation are similar to those of a dislocation but are less severe.

Low urine output (800-1500mL) in the first 24 hours after surgery is excpected regardless of fluid intake. True False

Truev Low urine output (800 to 1500 mL) in the first 24 hours after surgery may be expected, regardless of fluid intake. This low output is caused by increased aldosterone and ADH secretion resulting from the stress of surgery; fluid restriction before surgery; and fluid loss through surgery, drainage, and diaphoresis.

When taking care of postoperative patient the nurse understand that two types of postoperative cognitive impairments seen in surgical patients are? postoperative cognitive dysfunction (POCD) and delirium postoperative cognitive dysfunction (POCD) and anxiety Depression and delirium Alcohol withdrawal delirium and anxiety

Two types of postoperative cognitive impairments seen in surgical patients are postoperative cognitive dysfunction (POCD) and delirium. POCD is a decline in the patient's cognitive function (e.g., memory, ability to concentrate) for weeks or months after surgery. POCD is seen primarily in the older surgical patient. Preexisting cognitive impairment, age, duration of anesthesia, intraoperative complications, and postoperative infections are related to the development of POCD. Any changes in mental status should be quickly and thoroughly investigated, as the causes may be life threatening.

The nurse is educating the spouse of a young adult male client who sustained a mild concussion playing football. Which of the following should the nurse teach as an intervention for the caretaker? Understand and monitor for increased intracranial pressure Wake the client up every 2 hours Observe frequently for any exaggerated startle response, trouble concentrating or any sleep problems (hypervigilance). Offer the client food and fluids every hour

Wake the client up every 2 hours Awakening the client every two (2) hours allows the identification of decreased in level of consciousness. The nurse should monitor for signs of increased intracranial pressure (ICP), the carer or the significant other, would not know what these signs and medical terms mean. Hypervigilance, increased alertness and super-awareness of the surroundings, is a sign of amphetamine or cocaine abuse, but it would not be expected in a client with a head injury. The client can eat food as tolerated, every hour does not affect the development of post-concussion syndrome, the signs of which are what should be taught to the significant other

Osteoporosis occurs most commonly in bones of which of the following? Select all that apply. Ribs Wrists Shoulder Spine Hips

Wrists Spine Hips

The nurse teaching a support group of women with rheumatoid arthritis (RA) about how to manage activities of daily living suggests they should protect the knee joints by sleeping with a small pillow under the knees. strengthen small hand muscles by wringing out sponges or washcloths. stand rather than sit when performing daily household and yard chores. avoid activities requiring repetitive use of the same muscles and joints.

avoid activities requiring repetitive use of the same muscles and joints.