Chapter 13 and 14
What does the nurse know about the stroke patient who has expressive aphasia?
Can understand the spoken word, but cannot speak.
What does diabetes retinopathy result from?
Capillaries in retina hemorrhage
What are the two divisions of the nervous system?
Central and the peripheral
Which of the following techniques are necessary for safely feeding a hemiplegic patient?
Checking the affected side of mouth for food accumulation Offering small bites of food Adding a thickening agent to liquids
What is the most interior part of the eye?
Choroid
What is the reticular activating system (RAS) essential to?
Concentration Wakefulness Attention Introspection
4. What does a tympanoplasty correct?
Conductive hearing loss
What do miotic eye drops do for a patient with glaucoma?
Constrict the pupil and open the canal of Schlemm.
What factors must the nurse consider when assessing readiness to learn when teaching health promotion practices for the visually and hearing impaired?
Cultural beliefs Values Habits
What is the cardinal sign of increased intracranial pressure in a brain injured patient?
Decrease in the level of consciousness
What should the nurse do when assisting a blind person to walk in an unfamiliar hospital environment?
Describe the surroundings. Encourage the patient to ask for verbal cues. Place patient hand on nurse's shoulder or elbow.
When the patient in the emergency room complains of seeing flashing lights and a curtain down over his right eye, the nurse recognizes this as a symptom of which condition?
Detached retina
Which complaint made by a 64-year-old patient during a health interview would alert the nurse to the possibility of cataracts?
Difficulty driving at night
What should the nurse include in the plan of care following a tympanoplasty?
Elevating head of bed with operative side facing upward
Why is otitis media found more frequently in children 6 to 36 months?
Eustachian tubes in children are shorter and straighter.
Which may contribute to otitis media?
Exposure to cigarette smoke Allergies Upper respiratory infections
What is the nurse assessing when asking the patient, "Who is the president of the United States?" during a level of consciousness assessment?
Fund of knowledge
The newly admitted patient to the emergency room after a motorcycle accident has serosanguineous drainage coming from the nose. What is the most appropriate nursing response to this assessment?
Gently wipe nose with absorbent gauze.
6. Four hours after a stapedectomy, the patient complains that hearing has not improved at all. What knowledge would the nurse use to shape a response?
Hearing will not return until edema subsides.
The nurse assures an anxious family member of a 92-year-old patient who is demonstrating signs of dementia that many causes of dementia are reversible and preventable. What is one example?
Hypotension
What is the first sign of Bell's palsy?
Inability to wrinkle forehead and pucker lips on affected side
3. One of the housekeepers splashes a chemical in the eyes. What should be the first priority?
Irrigate with normal saline solution for 20 minutes.
The newly admitted patient to the emergency room 30 minutes ago after a fall off a ladder has gradually decreased in consciousness and has slowly reacting pupils, a widening pulse pressure, and verbal responses that are slow and unintelligible. What is the most appropriate position for the patient?
Neck placed in a neutral position.
_________________ is/are responsible for the transmission of impulses between synapses.
Neurotransmitters
A patient, age 45, is to have a myelogram to confirm the presence of a herniated intervertebral disk. Which nursing action should be planned with respect to this diagnostic test?
Obtain an allergy history before the test.
What is a common mistake that hinders communication when communicating with the hearing impaired?
Overaccentuating words
What should the nurse do when the child arrives on the floor with the diagnosis of bacterial meningitis?
Place the child in respiratory isolation.
What must a patient do following a left vitrectomy?
Position self in a face-down position for 4 to 5 days.
A family member of a patient who has just suffered a tonic-clonic seizure is concerned about the patient's deep sleep. What is this behavior called?
Postictal period
Why are the drugs neostigmine (Prostigmin) and pyridostigmine (Mestinon) helpful to the person with myasthenia gravis?
Promotes nerve impulse transmission.
What is the purpose of a "drug holiday" in the treatment of Parkinson disease?
Restart drugs at a lower dosage with favorable results.
A patient is in which stage of Alzheimer's disease when she demonstrates "sundowning"?
Second stage
What is the cranial nerve that supplies most of the organs in the thoracic and abdominal cavities and carries motor fibers to glands that produce digestive juices and other secretions?
Vagus Nerve
What are the three signs of Cushing response?
Widened pulse pressure Bradycardia Increased systolic blood pressure
1. The nurse is aware that the patient has 20/40 vision. This means that the patient can see at 20 ft what the normal eye can see at _______ ft.
b. 20
The nurse counsels the 16-year-old boy that playing his music at high volume can result in impairment in hearing related to:
damage of the fine hair cells in the organ of Corti.
The home health patient complains of tearing and a feeling of dryness in the right eye. The nurse assesses that the eyelid is turned inward and the sclera is red. The nurse documents the presence of a(n)_________________.
entropion
The total removal of an eye is a(n) ___________.
enucleation
The nurse will assess for _____________ when the older adult home health patient complains that the entire right side of his head hurts and he cannot chew without pain.
external otitis
The nurse is caring for a home health patient who had a spinal cord injury at C5 3 years ago. The nurse bases the plan of care on the knowledge that the patient will be able to:
feed self with setup and adaptive equipment.
An 83-year-old patient has had a stroke. He is right handed and has a history of hypertension and "little" strokes. He presents with right hemiplegia. To afford him the best visual field, the nurse should approach him:
from the left side
The nurse explains that a pneumatic retinopexy is a repair of a retinal detachment using a bubble of_________ to put pressure on the damaged retina.
gas
The nurse takes into consideration that the Weber test indicated a conductive hearing loss in a patient because the patient reported hearing the tone:
louder in his affected ear.
The waxy substance that covers the neuron fibers and increases the rate of transmission of impulses is the ________.
myelin
2. A ___________ is a diagnostic procedure used to identify lesions by observing the flow of radiopaque dye through the subarachnoid space.
myelogram
Involuntary rhythmic movement of the eyes, with oscillations that may be horizontal, vertical, or mixed movements, is called ___________________.
nystagmus
Progressive deafness caused by the ankylosis of the stapes is the condition of__________.
ostoclerosis
The nurse clarifies that the difference between a photorefractive keratectomy (PRK) and a laser in-situ keratomileusis (LASIK) is that a LASIK:
removes some internal layers of the cornea
Following a myelogram the nurse should include in the postprocedure care assessment for:
sensation in lower extremities.
The nurse is aware that the characteristic gait of the person with Parkinson disease is a propulsive gait, which causes the patient to:
shuffle with arms flexed.
The nurse explains that the triad of signs of Parkinson disease is: _______, rigidity, and bradykinesia.
tremor
What Glasgow Coma Scale rating would a patient receive who opens the eyes spontaneously, but has incomprehensible speech and obeys commands for movement?
12
The nurse is aware that the drug t-PA (Activase), a tissue plasminogen activator, must be given in hours of the onset of symptoms to have maximum benefit.
3 hours
What should a patient who has had a cataract repair avoid?
The lifting of heavy objects
As the result of a stroke, a patient has difficulty discerning the position of his body without looking at it. In the nurse's documentation, which would best describe the patient's inability to assess spatial position of his body?
Proprioception
What should the nurse remind the hearing aid wearer to do when the nurse hears a whistling hearing aid?
Reinsert the ear mold.
Which question is likely to elicit the most valid response from the patient who is being interviewed about a neurologic problem?
"Can you describe the sensations you are having?"
What should the nurse advise the 20 year old to do who has been put on cefaclor (Ceclor) for a resistant otitis media?
Avoid alcoholic beverages.
What is the process when the lens of the eye changes its curvature to focus on the retina?
Accommodation
How would a nurse record the behavior when a patient with Alzheimer's disease attempts to eat using a napkin rather than a fork?
Agnosia
When the newly blind male home health patient asks the nurse how he might get assistance, who might the nurse suggest he contact?
American Foundation for the Blind for a list of agencies
When the patient stares at the black dot on an Amsler grid, what should the nurse ask him to report?
Any distortion of the grid
A patient who had an enucleation of the right eye has been admitted PACU. What should the nurse include in the plan of care?
Apply pressure dressing over the right eye socket
What does the cataract treatment of phacoemulsification involve?
Breaking the cataract with ultrasound
Select all the conditions that may cause conductive hearing loss
Buildup of cerumen Foreign bodies Otosclerosis of external auditory canal Otitis media with effusion
Which is a sign of acute angle closure glaucoma (AACG)?
Large fixed pupil
What is the first nursing intervention step for the immediate care of a patient with a penetrating wound of the eye?
Lay the patient down flat.
How should the nurse advise a patient who has severe vertigo from labyrinthitis?
Lie immobile and hold the head in one position until the vertigo lessens
Which of the following are causes of cataracts?
Long-term use of corticosteroids Congenital from exposure to maternal rubella Diabetes mellitus Smoking
What are the effects of normal aging on the nervous system?
Loss of neurons Reduction of cerebral blood flow Lipofuscin Decrease in oxygen use
27. What is the basic problem that prompts most of the early signs of Alzheimer's disease?
Memory loss that disrupts daily life
What is the nurse aware of when assessing a person with a craniocerebral injury?
Signs and symptoms may not occur until several days after the trauma.
A patient with a spinal cord injury at T1 complains of stuffiness of the nose and a headache. The nurse notes a flushing of the neck and "goose flesh." What should be the primary nursing intervention based on these assessments?
Sit upright and check blood pressure.
The 62-year-old home health patient who is recovering from eye surgery complains of a feeling of "grittiness" in the eye and is having blurred vision. The eyes are reddened and have stringy mucus. What do these complaints indicate?
Sjögren syndrome
Why is the patient with suspected Guillain-Barre Syndrome (GBS) hospitalized immediately?
The disease can rapidly progress into respiratory failure
How would the nurse explain the purpose of photocoagulation to a diabetic patient with diabetic retinopathy?
The procedure will destroy new blood vessels, seal leaking vessels, and help prevent retinal edema.
Which symptom is specific to migraine headaches?
They are preceded by an aura
How would the nurse instruct a patient with Parkinson disease to improve activity level?
To walk with hands clasped behind back to help balance.
A patient has recently suffered a stroke with left-sided weakness and has problems with choking, especially when drinking thin liquids. What nursing interventions would be most helpful in assisting this patient to swallow safely?
Tuck chin when swallowing.
What would a nurse do when the patient arrives in the PACU after a left stapedectomy?
Turn the patient to his right side Leave the bed flat Medicate immediately on the complaint of nausea
The nurse is aware that when assessing a patient by the FOUR score coma scale, the patient is assessed in four categories: eye response, brainstem reflexes, motor response, and respiration. How are these results reported?
As individual scores in each category
What are surgical navigational systems?
Computerized devices that guide the surgeon
The nurse explains that the two divisions of the autonomic nervous system work to maintain homeostasis. Which is the first autonomic event?
Extremely stressful or frightening event
A frantic family member is distressed about the flaccid paralysis of her son following a spinal cord injury several hours ago. What does the nurse know about this condition?
It is possibly a temporary condition and will clear.
The surgical incision into the eardrum with either a knife or a heated wire loop to relieve pressure in the middle ear is a(n) ___________.
myringotomy
What is the first indication of macular degeneration?
The loss of central vision
2. The patient tells the nurse that he is legally blind. How would this information impact the nurse's plan of care for this patient?
The nurse would need to determine how this patient's visual impairment affects normal functioning.
Which foods should the person who suffers from migraine headaches avoid?
Yogurt Caffeine Marinated foods