CCC4 exam 1 practice quiz
the nurse is caring for a client diagnosed with Guillain-Barré Syndrome. What data gathered requires nursing actions?
- respiratory distress/failure - pain levels - sustain life and prevent complications - check vitals frequently - hypotension - cardiac arrhythmias
which of the following is most likely to be an age-related change in the nervous system?
- short term memory diminishes - the number of functioning dendrites decreases (slower impulse) - blood flow slows down - more susceptible to brain damage - body homeostasis is more difficult to maintain - pupils decrease in size
The LPN notices that a client is coughing each time they take a sip of liquid. The nurse will need to advocate for a swallowing study by speech therapy. what is the purpose of this study?
- speech study is done to determine the reflexes in the esophagus - ASSESS IF ITS SAFE TO GIVE THE CLIENT THEIR MEDS AND LIQUIDS BY MOUTH
the nurse is preparing to administer carbidopa/levodopa to a client whose current BP 78/50. What is the nurses priority action?
- Orthostatic hypotension is a risk factor for this drug - We would not want to administer it due to the low BP - Speak with provider
Which of the following signs of ICP are known as Cushings triad?
- Rising systolic pressure - Bradycardia - Widening pulse pressure
A client who has just started taking phenytoin asks the nurse if there are any adverse effects of this medication. What is the nurses best response?
- Somnolence (excessive sleepiness)
which s/s that would indicate the client is stuporous?
- abnormal breathing - unresponsive - pupils are wider or smaller than normal - pupils don't react or change with light
the nurse is caring for a client with trigeminal neuralgia. Which of the following findings is the priority for the nurse?
- cranial nerve disorder - PAIN MANAGEMENT - client complains of pain at littlest touch
a young adult is hospitalized with a seizure disorder. The client who is in a bed with padded rails, is found having a tonic-clinic seizure. Which of the following actions by the nurse would require further teaching?
- do not put anything in their mouth - do not restrain thwm
which nursing intervention will reduce the risk of increased intracranial pressure(ICP)
- general information: ICP above 200 requires treatment - prolonged elevation of ICP compromised brain tissue and affects neurons.
Drug therapy for seizure disorder typically includes which of the following?
Anti-convulsive ex: phenytoin
which medication will the nurse administer to a client who has experienced a thrombotic stroke 2 days ago.
Aspirin
Autonomic Dysreflexia can lead to...?
BP increase - at risk for severe hypertension and stroke
A client arrived in the ED following a bicycle accident in which the clients forehead hit the pavement. The nurse should place the client in what position?
Elevate head 20-30 degrees (semi-fowlers)
select a priority problem statement for a client with Parkinson's?
Fall prevention
a home care nurse is visiting with a client who has MS and reports severe fatigue. Which intervention would be appropriate in managing the client.
Frequent rest
which of the following symptoms is a significant indicator of a brain tumor?
Headache
Which of the following best describes an epidural hematoma?
Increase in ICP
The nurse is caring for a client whose injury has affected cranial nerve VIII. What is the function of this nerve?
It helps maintain body balance and hearing
What is a critical fact clients and families need to understand about treatments for Alzheimer's?
It is not curable, we are treating the symptoms
which baseline laboratory data should be established before a client is started on a tissue plasminogen activator or alteplase recombinant?
Looking at clotting factor - hemoglobin, hematocrit, and platelet
What is the priority intervention for a client having a tonic-clinic seizure?
Prevent injury
a nurse is caring for a client who has mild cognitive impairment from Alzheimer's causing the client to ask the same question repeatedly. Which of the following stages should the nurse identify as the clients current stage in the disease process?
Stage 3
during which phase of Guillain-Burre syndrome would the clients progress be described as not getting better, but not getting any worse?
Static Phase
the nurse observed that a client recovering with a stroke looks untidy and sad. The client says "i can't even find the strength to comb my hair" and bursts into tears. Which response by the nurse is best?
Tell me why...
the nurse notes in the documentation that a client with ICP is exhibiting signs of decerebrate posturing. The nurse expects to note which characteristics of this type of posturing?
arms are down and rigid, pronated out
a client with a spinal cord injury suddenly has an onset of excessively high BP. What should the nurse do first?
check the client for a distended bladder
a family member asks the nurse about whether there would be any long-term psychological effects from a clients mild traumatic brain injury.
everyone's reaction is different
the nurse is reinforcing teaching for a group of parents about the potential for febrile seizures in children. Which information should the nurse include?
high fever
a nurse is assigned to four clients. which client should the nurse see first?
most critical. Use ABCs
when evaluating a clients response to a painful stimulus, which of the following reactions would be most concerning?
no response would be the most concerning
what are the initial symptoms of Parkinson's?
pill-rolling tremors
what are the risk factors for a stroke/CVA?
smoking atherosclerosis drug use high BP high cholesterol sedentary lifestyle
a client is admitted to the hospital for observation with a head injury after a hit and run accident. The client is transported to the hospital by emergency medical services with a cervical collar. The nurse expects the collar will remain in place until which time?
the cervical collar remains on until the scans are done and the doctor reviews them.
a nurse is caring for a client who is experiencing auditory hallucinations. Which of the following responses should the nurse make first?
the nurse needs to recognize that this is something they are experiences so they might say "i do not hear what you are hearing"
The nurse anticipates that stool softeners will be given to a client prior to repair of cerebral aneurysm. Why would stool softeners be given to this client?
- to prevent straining when using the bathroom - prevent constipation
when providing information about coup-contrecoup brain injuries, the nurse should include which of the following statements.
-2 points of injury -nausea -hot spot on head- intracranial bleeding -headache
a nurse is modifying the diet of a client who has parkinson's and a prescription for Selegiline, a MAOI. Which of the following foods should the nurse eliminate from the clients diet.
-Aboid Tyramine -aged cheese, cured meats, dried fruit, alcohol, pickled or fermented foods
which of the following is an early sign of increased intracranial pressure?
-Headache -blurred vision -vomiting -changes in behavior - lack of energy
which nursing intervention is the priority when caring for a client during the acute phase of Guillain-Barre?
-assessment is the most important part during the acute stage -monitor the progression of paralysis -monitor ABGs -orthostatic hypertension and cardiac dysrhythmia
a client had a thrombotic cerebrovascular accident and now has flaccid hemiplegia of the right side. When the healthcare team begin rehab for this hospitalized client?
-begin treatment right away/upon admission to facility
a nurse is reinforcing teaching with the family of a client who has primary dementia. Which of the following manifestations of dementia should the nurse include in the teaching?
-difficulty performing ADLs -memory loss - FORGETFULNESS -wandering -confusion -repeating questions
a client who sustained a recent cervical spinal cord injury reports feeling flushed. The clients BP is 180/100. What is the priority action?
-empty bladder 1st -recheck the BP -then speak to supervisor if BP is still high
A 20-year-old client is admitted with a brain tumor. Which assessment made by the nurse is most critical to report to the child's health care provider.
-headache awaking is the key sign
a nurse is collecting data from an infant who hit her head when she fell off a dressing table. the nurse should identify which of the following as indicating increased intracranial pressure?
-high pitched cry -irritability -bulging fontanels -setting sun (eyes looking down)
A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first?
-make sure they are safe -LOC -stay with the person -DO NOT move them
A client in a group home has returned from the hospital following a transient ischemic (TIA). Which statement about stroke prevention indicates a client's understanding of health education provided by the nurse.
-native & african americans -hypertension and high cholesterol increases risk -stop drinkin & smokin -reduce sodium intake -increase exercise
a nurse is caring for a client who sustained a head injury in an accident. A focused exam reveals that one pupil is larger than the other. What should the nurse do first?
-notify the provider
the nurse is planning care for a client with a spinal injury who is to remind on complete bed rest. What should the nurse do to prevent the development of pressure ulcers?
-pressure mattress -repositioning every 2 hours -check sores on bony prominences
a client who is a paraplegic cannot feel the lower extremities and has been positioned on the side. The nurse should inspect which area for potential pressure point when the client is in a side lying position?
-the button and boney spots on the body -boney areas from hips and lower.
a client hospitalized for a head injury reports having the worst headache of his life. What should the nurse do next?
- report to the provider
a nurse visiting a client with Huntington's disease is asked if his offspring will also have this disease. Which response is appropriate?
-the children have a 50% chance of inheriting it -genetic testing can confirm it
a client has been treated at the emergency department for a concussion. At discharge the nurse is reinforcing teaching by explaining the s/s of a worsening condition. The nurse determines that the family needs further teaching if they state they will return to the ED.
- sx. of concussion - headaches & vomiting - if they have a headache that is described as the "worst headache of my life" -LOC -we MUST report to the provider right away -"I will need to come back should I get a headache"
which of the following findings are often observed with a basilar skull fracture?
- they are usually liner - seen in the base of the skull - must be diagnosis by the presence of CSF - we see ecchymosis (raccoon eyes) - battle sign presents around the ear
The nurse is caring for a client with a suspected head injury after a fall. Which of the following is a late sign of increased intracranial pressure?
- BRADYCARDIA - late sign
a nurse is reviewing the health record of a client who has a malignant brain tumor and notes the client has a positive Romberg sign. Which of the following actions should the nurse take to assess for this sign?
- Have the client stand with eyes closed and feet together - see if they sway - tests their balance
a client taking levodopa to control Parkinson's disease should be monitored for which following possible side effects?
- Orthostatic hypotension
some neurological disorders can result in bowel and bladder dysfunction. Which of the following would be included in a bowel training program?
- high fiber diet - good fluid intake - provide patient with privacy - establish a routine - restraining of the bladder
the nurse is caring for a client treated with Alteplase following a stroke. Which finding is the highest priority for the nurse?
- monitor VS for dysrhythmia, neuro checks, BLEEDING, precautions for 24hrs - not to be given with any other anticoagulants
What are the 3 categories measured by the Glasgow Coma Scale score?
- motor response - verbal response - eye response
a client with parkinson's has a nursing diagnosis of potential for injury. which of the following would be an expected outcome based on the nursing diagnosis?
-the client will not have any falls during stay -teach client that: meds may cause dizziness, levodopa will turn urine dark, liver function must be check with COMTs
what observations will the nurse document during the postictal period of a seizure?
-the length -LOC -ABC -Check for injury -vital signs
A nurse is assessing a client who has a seizure disorder. the client reports he thinks he is about to have a seizure. Which of the following should the nurse do?
-turn patient on their LEFT side -stay with client -head support
which intervention(s) below are beneficial in the prevention of neurological injuries?
-wearing a helmet and seat belt when driving/biking -alcohol and drug use put one at increased risk -swimming safety
What is the priority nursing intervention for the client with a spinal cord injury who is a quadriplegic?
Prevent over distension of the bladder
which symptom of myasthenia graves often occurs first?
Ptosis (drooping of upper eyelid)
an alert and oriented client comes to the ED after hitting his head in a motor vehicle accident. What should the nurse do first?
stabilize neck and spine
