ADC 2 Test 1

A 78 y/o Alzheimer's client is being treated for malnutrition and dehydration. The nurse decides to place him closer to the nurse's station because of his tendency to a. Forget to eat b. Not change his position often c. Exhibit acquire scent behavior d. Wander

Wander Rationale: a client with Alzheimer's disease is at risk for injury because of his tendency to wander. Placing him closer to the nurses station makes it easier to monitor him and better ensures his safety if he begins to wander. Placing the client closer to the nurse's station won't help the client remember to eat, change his position often or modify his behavior.

The wide, cerebrospinal fluid containing space is between the _____ mater and the pia mater and is called the _____ space. a. dura; subarachnoid b. pia; subdural c. arachnoid; subarachnoid d. arachnoid; subdural

arachnoid ; subarachnoid

A client with an inoperable brain tumor is brought to the hospital because the family can no longer care for him at home. As the nurse provides care for the client, family members express their disappointment at not being able to care for him at home according to his wishes. Which response by the nurse is best? a. "I understand: I take care of clients like this every day and don't know how you could do it at home" b. "Have you explored hospice care? I can ask the case manager to discuss this care option with you, if you are interested" c. "It's ok to bring the client back to the hospital to die" d. "Having family member with a terminal illness is very difficult"

"Have you explored hospice care? I can ask the case manager to discuss this care option with you, if you are interested" Rationale: The nurse should ask the family if they've explored hospice care. Hospice care offers many resources to the family so they can successfully care for the client at home. Options a, c and d don't address the family's concerns

Tim is 64 y/o dx. with cerebral aneurism. The physician orders hydralazine (Apresoline) 15 mg IV every 4 hours as needed to keep the systolic blood pressure under 140 mmHg. The label on the hydralazine vial reads "hydralazine 20 mg/ml". To administer the correct dose, how many milliliters of medication should the nurse draw up in the syringe? ___ ml

0.75 Rationale: The following formula is used to calculate drug dosage Dose on hand/quantity on hand = dose desired/X 20 mg/ml = 15 mg/X = 0.75 ml

Two days after a client undergoes repaired of a ruptured cerebral aneurism the physician prescribes mannitol (Osmitrol) 1.5 mg/kg to be infused over 60 minutes. The client weights 175 lbs. The nurse should administer how many milligrams of mannitol? a. 263 b. 120 c. 75 d. 60

120 Rationale: To determine the number of milligrams to administer, the nurse first must convert the clients weight form pounds to kilograms using the following conversion factor: 2.2 lb = 1 kg 2.2 lb/175lb = 1 kg/ X kg 2.2 x X kg = 175 lb X= 79.5 (rounded to 80) Then the nurse calculates the dosage by multiplying the clients weight times the desired dose: 80 kg x 1.5 mg/kg = 120 mg

The wave of depolarization that is propagated down an axon is known as the: a. Graded potential b. Resting potential c. Action potential d. Refractory period

Action potential

After striking his head on a tree while falling from a ladder, Carlos a young man is admitted to the emergency department. Pt is unconscious with non-reactive pupils. Which interventions will help with his current state? Select all that apply a. Administer a barbiturate b. Place him on mechanical ventilation c. Perform a lumbar puncture d. Elevate head of bed

Administer a barbiturate Place him on mechanical ventilation Elevate head of bed Rationale: the client's current history and assessment suggest that he may have increased ICP. After a head injury, barbiturates may be given to prevent seizures, mechanical ventilation may be required if breathing deteriorates and elevating the head of the bed may be used to reduce ICP. A lumbar puncture at this time should not be performed because it can quickly decompress the central nervous system and thereby cause additional damage.

One function of the optic chiasm is to: a. Adjust the refraction of light in the eye b. Allow for depth perception c. Transmit signals from the optic nerve to the cerebellum d. Prevent overlap of the visual field from each eye

Allow for depth perception

High doses of this medication can produce bilateral tinnitus? a. Promethazine b. Dramamine c. Antivert d. Aspirin

Aspirin Rationale: at high doses, aspirin toxicity can produce bilateral tinnitus. Atnivert and Dramamine is use for nausea and vomiting related to motion sickness. Antiemetics such as promethazine (Phenergan) suppositories help control the nausea and vomiting and the vertigo because of the antihistamine effect

A patient who is unable to speak despite having a clear concept of what is conceived (e.g., wanting coffee but unable to think of the word 'coffee') has most likely incurred damage to _____ area. a. Wernicke's b. Thalamus c. Hypothalamus d. Broca

Broca

_____ fills the ventricles and surrounds the brain and spinal cord, acting as a shock absorber, distributing nutritive materials, removing wastes, and providing a chemically stable environment. a. lymph b. interstitial fluid c. blood d. Cerebrospinal Fluid

Cerebrospinal Fluid

The nurse is caring for a client diagnosed with cerebral aneurysm who reports severe headache. Which action should the nurse perform? a. Sit with the client for a few minutes b. Administer an analgesic c. Inform the nurse manager d. Call the physician immediately

Call the physician immediately Rationale: the headache may be an indication that the aneurism is leaking. The nurse should notify the physician immediately. Sitting with the client is appropriate but only after the physician has been notified of the change in the client's condition. The physician will decide whether or not administration of an analgesic is indicated. Informing the nurse manager is not necessary.

65 y/o female is brought to the ER by ambulance after family member noticed sudden drooping of the left side of the mouth along with slurring of the speech. Patient has a past medical history remarkable for hypercholesterolemia, diabetes type II and hypertension. Treatment is initiated according to protocol. Impaired blood circulation to the brain due to a blocked or broken vessel is known as a ___________ a. Aneurysm b.Cerebrovascular Accident c. Meniere's disease d. Parkinson's Disease

Cerebrovascular Accident

A signal moves through the parts of a single neuron in what order? a. Dendrites, cell body, axon, axon terminals b. Axon terminals, axon, cell body, dendrites c. Cell body, dendrites, axon, axon terminals d. Axon, dendrites, axon terminals, cell body

Dendrites, cell body, axon, axon terminals

29 y/o professional boxer is brought to the hospital 2 days after a fight, the boxer refers loss of smell that started after the fight. Which of the following areas and cranial nerves might be affected? a. Sphenoid bone; vagus b. Nasal cavity; hypoglossal c. Cribriform plate; olfactory d. Frontal sinus; glossopharyngeal

Cribriform plate; olfactory

An auto mechanic accidentally has battery acid splashed in his eyes. His coworkers irrigate his eyes with water for 20 minutes, and then take him to the ER of a nearby hospital, where he receives emergency care for the corneal injury. The physician prescribes dexamethasone (Maxidex Ophthalmic Suspension) two drops of 0.1 % solution to be instilled initially into the conjunctival sacs of both eyes every hour, and polymyxin B sulfate (Neosporin Ophthalmic) 0.5% ointment to be placed in the conjunctival sacs of both eyes every 3 hours. Dexamethasone exerts its therapeutic effect by: a. Increasing the exudative reaction of ocular tissue b. Decreasing leukocyte infiltration at the site of ocular inflammation c. Inhibiting the action of carbonic anhydrase d.Producing a miotic reaction by stimulating and contracting the sphincter muscles of the iris

Decreasing leukocyte infiltration at the site of ocular inflammation Rationale: Dexamethasone exerts its therapeutic effect by decreasing leukocyte infiltration at the site of ocular inflammation. This reduces the exudative reaction of diseased tissue lessening edema redness and scarring. Dexamethasone and other anti-inflammatory agents don't inhibit the action of carbonic anhydrase or produce any type of miotic reaction

A 68-year-old man presents with a 3-month history of right arm tremor at rest. His movements have been slower and he has difficulty getting out of a chair. Physical examination reveals rigidity in the upper limbs. He walks with small steps and has limited ability to swing his arms. His facial expressions are limited. Which of the following neurotransmitters has low level in the condition mentioned above? a. Dopamine b. Serotonin c. Prolactin d. Acetylcholine

Dopamine

After a plane crash a patient is brought to the ER with severe burns and respiratory difficulty. The nurse helps to secure a patent airway and attends to the patients immediate needs, then prepares to perform a neurologic assessment. Because the patient is unstable and in critical condition this examination must be brief but should include: a. Evaluation of corneal reflex response b. Examination of the fundus of the eye c. Assessment of the client's gait d. Evaluation of bowel and bladder functions

Evaluation of corneal reflex response Rationale: during an acute crisis the examiner checks the corneal reflex response to rapidly assess brain stem function. Other components of the brief initial neurologic assessment usually include level of consciousness pupillary response and motor response in all arms and legs. If appropriate and if time permits the nurse also may assess sensory responses of the arms and legs. Emergency assessment does not include fundus examination unless the client has sustained direct eye trauma. The client shouldn't be moved unnecessarily until the extent of injuries is known, making gait evaluation impossible. Bowel and bladder functions aren't at this time vital so the nurse should delay their assessment.

Which of the following features should a nurse observe during an ophthalmic assessment? a. External eye appearance b. Intraocular pressure c. Internal eye function d. Visual acuity

External eye appearance Rationale: during an ophthalmic assessment the nurse should examine the external eye appearance and the pupil responses of the patient. A qualified examiner determines the internal eye function, the visual acuity and the intraocular pressure.

To assess clients cranial nerve function the nurse should: assess a. Hand grip b. Orientation to person, time and place c. Arm drifting d. Gag reflex

Gag reflex Rationale: the gag reflex is governed by the glossopharyngeal nerve, one of the cranial nerves. Hand grip and arm drifting are part of motor function assessment. Orientation is an assessment parameter related to a mental status examination

Equilibrium is sensed through: a. The tympanic membrane b. The oval window c. Auditory ossicles d. Hair cells

Hair cells

Blood pressure, rate and force of heartbeat, digestive tract motility, the rate and depth of breathing, and many other autonomic functions are controlled in the _____. a. Thalamus b. Medulla Oblongata c. Hypothalamus d. Fourth ventricle

Hypothalamus

The cranial nerves that are purely sensory nerves are: a. III, IV, VI, XI, and XII b. I, II, and III c. I,II,V,and VII d. I, II, and VIII

I, II, and VIII

Which best describes the pathway of circulation for cerebrospinal fluid? a. Lateral ventricles, third ventricle b.Lateral ventricles, third ventricle, fourth ventricle, fourth ventricle, central canal c. Central canal, fourth ventricle, third ventricle, lateral ventricles d. Fourth ventricle, third ventricle, lateral ventricles

Lateral ventricles, third ventricle, fourth ventricle, fourth ventricle, central canal

In vision, light passing through the ________ is refracted and projected onto the ________. a. Vitreous chamber, cornea b. Retina, lens c. Lens, retina d. Lens, cornea

Lens, retina

Merkel disks respond to _____. a. Light touch b. Deep pressure c. Vibration d. Pain

Light touch

A client comes to the emergency department complaining of headache, malaise, chills, fever and a stiff neck. Vital signs assessment reveals a temperature elevation, increased heart and respiratory rates and normal blood pressure. On physical examination the nurse notes confusion a petechial rash nuchal rigidity Brudzinski sign and Kerning's sign. What does Brudzinski sign indicate? a. Increase intracranial pressure (ICP) b. Cerebral edema c. Low cerebrospinal fluid (CSF) pressure d. Meningeal irritation

Meningeal irritation Rationale: Brudzinski sign indicates meningeal irritation as in meningitis. Other signs of meningeal irritation include nuchal rigidity and Kerning's sign. : Brudzinski sign does not indicate increased ICP, cerebral edema or low CSF pressure.

The _____ are a set of three connective tissue membranes that surround the CNS a. Ventricles b. Sulci c. Gyri d. Meninges

Meninges

A 68-year-old man presents with a 3-month history of right arm tremor at rest. His movements have been slower and he has difficulty getting out of a chair. Physical examination reveals rigidity in the upper limbs. He walks with small steps and has limited ability to swing his arms. His facial expressions are limited. Which of the following diagnoses match the described patient? a. Alzheimer's disease b. Depression c. Parkinson's Disease d. Raynaud disease

Parkinson's Disease

A client is admitted to an acute care facility after a motor vehicle accident, patient develops s/s of increased ICP. Patient is currently intubated and placed on mechanical ventilation to help reduce ICP. To prevent further rise in ICP caused by seizures, the nurse anticipates administering which drug parenterally? a. Phenytoin (Dilantin) b. Mannitol (Osmitrol) c. Lidocaine (Xylocaine) d. Furosemide (Lasix)

Phenytoin (Dilantin) Rationale: Phenytoin doesn't reduce ICP directly but may be used to abolish seizures, which can increase ICP. Although mannitol and furosemide may be given to reduce ICP they do not abolish seizures. Lidocaine can be administered via an endotracheal tube to minimize elevations in ICP caused by suctioning

Which diagnostic test distinguishes between conductive and sensorineural hearing loss? a. Audiometry b. Whisper test c. Weber test d. Rinne's test

Rinne's test Rationale: Rinne's test is useful for distinguishing between conductive and sensorineural hearing loss. The whisper test the patient with normal acuity can correctly repeat what was whispered. Audiometry is used to detect hearing loss. The Webber test uses bone conduction to test lateralization of sound

During a routine physical examination to asses a client's deep tendon reflexes, the nurse should make sure to: a. Use the pointed end of the reflex hammer when striking the Achilles tendon b. Support the joint where the tendon is being tested c. Tap the tendon very lowly and softly d. Hold the reflex hammer tightly

Support the joint where the tendon is being tested Rationale: to prevent the attached muscle from contracting the nurse should support the joint where the tendon is being tested. The nurse should use the flat not pointed end of the reflex hammer ehen striking the Achilles tendon. The pointed end is used to strike over small areas such as the thumb placed over the biceps tendon. Tapping the tendon slowly and softly wouldn't provoke a deep tendon reflex response. The nurse should hold the reflex hammer loosely not tightly between the thumb and fingers so it can swing in an arc.

A client is having tonic clonic seizures. What should the nurse do first? a. Elevate the head of the bed b. Restrain the client's arms and legs c. Place a tongue blade in the client's mouth d. Take measures to prevent injury

Take measures to prevent injury Rationale: Protecting the client form injury is the immediate priority during a seizure. Elevating the head of the bed would have no effect on the client's condition or safety. Restraining the client's arms and legs could cause injury. Placing a tongue blade or other object in the client's mouth could damage the teeth.

Why can spinal reflexes occur more quickly than premeditated actions? a. Reflexes utilize different motor neurons b. Reflex actions do not involve the central nervous system c.The signal for a spinal reflex is processed in the spinal cord rather than the cerebrum d. Sensory information travels faster during a reflex action

The signal for a spinal reflex is processed in the spinal cord rather than the cerebrum

_____ is a ringing or clicking sound in the ears in the absence of auditory stimuli. It can have many causes. a. Tinnitus b. Vertigo c. Tympanic rupture d. Hearing loss

Tinnitus

Vibrations are transferred through the ear in which order? a. Stapes, incus, malleus, tympanic membrane, cochlea b. Malleus, incus, stapes, tympanic membrane, cochlea c. Tympanic membrane, malleus, incus, stapes, cochlea d. Tympanic membrane, incus, stapes, malleus, cochlea

Tympanic membrane, malleus, incus, stapes, cochlea

A client is admitted for investigation of balance and coordination problems, including possible Meniere's disease. When assessing the client the nurse expects to note: a. Vertigo, tinnitus and hearing loss b. Vertigo, vomiting and nystagmus c. Vertigo, pain and hearing impairment d. Vertigo blurred vision and fever

Vertigo, tinnitus and hearing loss Rationale: Meniere's disease an inner ear disease is characterized by the symptom triad of vertigo tinnitus and hearing loss. The combination of vertigo vomiting and nystagmus suggests lybyrinthitis. Meniere's disease rarely causes pain blurred vision or fever.

Which of the following instructions regarding swimming should the nurse give to the patient who is recovering from otitis externa? a. Wear soft plastic earplugs b. Insert a loose cotton pledget in the external ear c. Avoid cold water d. Wear a scarf

Wear soft plastic earplugs Rationale: the nurse should advice the patient to wear soft plastic ear plugs to prevent trapping water in the ear while swimming. Wearing a scarf or inserting cotton does not kelp in preventing recurrence of the disorder. Avoiding cold water does not help to improve the patient's condition.

A patient who is able to speak but who chooses words at random and is unable to connect thought to language is likely to have damage to _____ area. a. Wernicke's b. Broca c. Cingulate gyrus d. Hypothalamus

Wernicke's

Which type of glaucoma presents an ocular emergency? a. Acute angle closure glaucoma b. Normal tension glaucoma c. Chronic open angle glaucoma d. Ocular hypertension

acute angle closure glaucoma Rationale: Acute angle closure glaucoma results in rapid progressive visual impairment. Normal tension glaucoma is treated with topical medication. Ocular hypertension is treated with topical medication. Chronic open angle glaucoma is treated initially with topical medication with oral medications added at a later time

Pacinian corpuscles are responsible for detecting _____. a. light touch b. deep pressure c. temperature d. pain

deep pressure

The tough, fibrous, double-layered, outermost meninge is the _____ a. dura b. pia c. arachnoid d. mass

dura

A client is hospitalized with Guillain-Barre syndrome. Which nursing assessment finding is most significant? a. Warm dry skin b. Urine output 40 ml/hr c. Soft nondistended abdomen d. Even unlabored respirations

even unlabored respirations Rationale: a characteristic feature of Guillain-Barre syndrome is ascending weakness, which usually begins in the legs and progress to the trunk arms and face. Respiratory muscle weakness is a particularly dangerous effect of this disease progression because it may lead to respiratory failure and death. Therefore although all of the options are pertinent assessment data those related to respiratory function and status are most significant.

A client with seizure disorder comes for a follow up routine checkup at the clinic. Upon reading the patients' medical record you observe that client currently takes phenytoin (Dilantin) to control seizures, the nurse assess for which common adverse drug effect? a. Excessive gum tissue growth b. Drowsiness c. Hypertension d. Tinnitus

excessive gum tissue growth Rationale: Phenytoin can lead to excessive gum tissue growth, known as gingival hyperplasia. However brushing the teeth two or three times daily helps control such growth. Some clients may require excision of excessive gum tissue every 6-12 months. Phenytoin may cause central nervous system stimulation leading to insomnia, nervousness and twitching it doesn't cause drowsiness. Other adverse reactions to phenytoin include hypotension, not hypertension and visual disturbances not tinnitus

The pharyngotympanic tube (Eustachian tube) connects the _____ to the _____________ a. middle ear; nasopharynx b. oropharynx; inner ear c. inner ear; nasopharynx d. outer ear; oropharynx

middle ear; nasopharynx

The physician determines that a client's chronic progressive hearing loss results from excess bone formation around the oval window, which impedes normal stapes movement and prevents sound transmission. What is the clinical term for this correctable middle ear disorder? a. Menieres disease b. Otosclerosis c. Prebycusis d. Otitis media

otosclerosis Rationale: the clinical term for this disorder is otosclerosis. Meniere's disease an inner ear disease that results from a labyrinth dysfunction causes severe vertigo sensorineural hearing loss and tinnitus. Presbycusis is progressive hearing loss associated with aging. Otitis media refers to a group of inflammatory middle ear conditions that may lead to life threatening mastoiditis or a brain abscess if not treated properly

Which of the following is a symptom related to vertigo? a. Spinning sensation b. Fainting c. Syncope d. Loss of consciousness

spinning sensation Rationale: vertigo is defined as the misperception or illusion of motion of the person or the surroundings. Most people with vertigo describe a spinning sensation or say they feel as though objects are moving around them.

Most of the neuronal death due to a stroke occurs several minutes or even hours after the stroke begins, allowing time for emergency treatment to have a major effect. True False

true

Which of the following terms refers to surgical repair of the tympanic membrane? a. Tympanotomy b. Myringotomy c. Occiculoplasty d. Tympanosplasty

tympanoplasty Rationale: tympanoplasty may be necessary to repair a scared eardrum. A tympanotomy is an incision into the tympanic membrane. A myringotomy is an incision into the tympanic membrane. An ossiculoplasty is a surgical reconstruction of the middle ear bones to restore hearing.

Which of the following manifestations is the most problematic for the patient diagnosed with Menieres disease? a. Hearing loss b. Diaphoresis c. Vertigo d. Tinnitus

vertigo Rationale: vertigo is usually the most troublesome complaint related to Meniere's disease. Other clinical manifestations include tinnitus diaphoresis and hearing loss