complete final from Jacque
"Are you exposed to any toxins or chemicals at work?" "
"How would you describe your ability to cope with stress?" "What medications are you currently taking?" "Does anyone else in your family struggle with headaches?"
The patient scheduled for a Syme amputation is concerned about the ability to eventually stand on the amputated extremity. How should the nurse best respond to the patient's concern
"You will eventually be able to withstand full weight-bearing after the amputation."
An 82-year-old man is admitted for observation after a fall. Due to his age, nurse knows that the patient is at increased risk for what complication of his injury Hematoma
2 factors place older adults at increased risk for hematomas. dura becomes more adherent to the skull with increasing age. aspirin and anticoagulants as part of routine management
neurologic nurse is reviewing seizures with a group of staff nurses. How should this nurse best describe the cause of a seizure
A dysrhythmia in the nerve cells in one section of the brain
nurse is preparing to provide care for a patient diagnosed with myasthenia gravis. nurse should know that the signs and symptoms of the disease are a result of what
A lower motor neuron lesion weakness of muscles, especially in the face and throat, caused by a lower neuron lesion at the myoneural junction.
patient with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this patient
Absolute bed rest in a quiet, nonstimulating environment
nurse is caring for a patient who exhibits abnormal results of the Weber test and Rinne test. The nurse should suspect dysfunction involving what cranial nerve
Acoustic Abnormal hearing can correlate with damage to cranial nerve VIII acoustic
A nurse is caring for a patient who is being treated in the hospital for a spontaneous vertebral fracture related to osteoporosis. The nurse should address the nursing diagnosis of
Acute Pain Related to Fracture by implementing what intervention? Intermittent application of heat to the patient's back
patient with herpes simplex virus encephalitis has been admitted to the ICU. What medication would the nurse expect the physician to order for the treatment of this disease process
Acyclovir (Zovirax)
patient has just been diagnosed with Parkinson's disease and the nurse is planning the patient's subsequent care for the home setting. nursing diagnosis should the nurse
Address Risk for injury Individuals with Parkinson's disease face a significant risk for injury related to the effects of dyskinesia.
nurse is giving an educational presentation about stroke and heart disease at the local senior citizens center. What nonmodifiable risk factor for stroke should the nurse cite
Advanced age
The nurse is caring for a patient with Huntington disease who has been admitted to the hospital for treatment of malnutrition. What independent nursing action should be implemented in the patient's plan of care
Apply deep, gentle pressure around the patient's mouth to aid swallowing.and administer phenothiazines
patient diagnosed with Bell's palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions
Applying a protective eye shield at night Corneal irritation and ulceration may occur if the eye is unprotected. While paralysis lasts, the involved eye must be protected.
nurse in a busy emergency department provides care for many patients who present with contusions, strains, or sprains. Treatment modalities that are common to all of these musculoskeletal injuries include
Applying ice,Compression dressings, Resting the affected extremity Elevating the injured limb
Paramedics have brought an intubated patient to the RD following a head injury due to acceleration-deceleration motor vehicle accident. Increased ICP is suspected.
Appropriate nursing interventions would include which of the following Administer benzodiazepines on a PRN basis.
neurologic flow chart is often used to document the care of a patient with a traumatic brain injury. when should nurse begin to use a neurologic flow chart
As soon as the initial assessment is made
nurse is caring for a patient whose recent health history includes an altered LOC. What should be the nurse's first action when assessing this patient
Assessing the patient's verbal response
nurse is conducting a focused neurologic assessment. When assessing the patient's cranial nerve function, the nurse would include which of the following assessments
Assessment of gag reflex The gag reflex is governed by the glossopharyngeal nerve, one of the cranial nerves.
The nurse has implemented interventions aimed at facilitating family coping in the care of a patient with a traumatic brain injury. How can the nurse best facilitate family coping
Assist the family in setting appropriate short-term goals.
A preceptor is discussing stroke with a new nurse on the unit. The preceptor would tell the new nurse which cardiac dysrhythmia is associated with cardiogenic embolic strokes
Atrial fibrillation Cardiogenic embolic strokes are associated with cardiac dysrhythmias, usually atrial fibrillation.
The nurse caring for a patient in ICU diagnosed with Guillain-Barré syndrome should prioritize monitoring for what potential complication
Autonomic dysfunction potential complications that may develop include respiratory failure and autonomic dysfunction.
A nurse is caring for an adult patient diagnosed with a back strain. What health education should the nurse provide to this patient?
Avoid lifting more than one-third of body weight without assistance
The nurse is discharging a patient home after surgery for trigeminal neuralgia. What advice should the nurse provide to this patient in order to reduce the risk of injury
Avoid rubbing the eye on the affected side of the face.
patient has presented to the emergency department with an injury to the wrist. The patient is diagnosed with a third-degree strain. Why would the physician order an x-ray of the wrist
Avulsion fractures are associated with third-degree strains.
The nurse is caring for a patient whose spinal cord injury has caused recent muscle spasticity. What medication should the nurse expect to be ordered to control this
Baclofen (Lioresal) is classified as an antispasmodic agent in the treatment of muscles spasms related to spinal cord injury.
An older adult woman's current medication regimen includes alendronate . What outcome would indicate successful therapy? Increased bone mass
Bisphosphonates such as Fosamax increase bone mass and decrease bone loss by inhibiting osteoclast function
The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps:
Blood flow decreases ,A switch to anaerobic respiration ,Lactic acid is generated Change in pH Membrane pumps fail, Cells cease to function
Prior to discharge, when teaching the patient, the nurse should include information about which major complication of osteoporosis? Bone fracture
Bone fracture is a major complication of osteoporosis that results when loss of calcium and phosphate increases the fragility of bones.
A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient
Bradycardia and hypertension It occurs in cord lesions above T6 after spinal shock has resolved;
patient is admitted to the neurologic ICU with a suspected diffuse axonal injury. the primary neuroimaging diagnostic tool used on this patient to evaluate the brain structure
CT and MRI A PET scan shows brain function, not brain structure.
A patient with a brain tumor has begun to exhibit signs of cachexia. What subsequent assessment should the nurse prioritize
Cachexia is a wasting syndrome of weight loss, muscle atrophy, fatigue, weakness, and significant loss of appetite. Consequently, nutritional assessment is paramount.
A patient has been admitted to the medical unit for the treatment of Paget's disease. When reviewing the medication administration record, nurse should anticipate
Calcitonin, Bisphosphonates are the cornerstone of Paget therapy in that they stabilize the rapid bone turnover.
patient diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse
Call the physician immediately.A headache may be an indication that the aneurysm is leaking.
patient who just suffered a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurse's primary assessment focus
Cardiac and respiratory status
A nurse is planning discharge education for a patient who underwent a cervical diskectomy. What strategies would the nurse assess that would aid in planning discharge teaching
Care of the cervical collar
A nurse is teaching a patient with osteomalacia about the role of diet. What would be the best choice for breakfast for a patient with osteomalacia?
Cereal with milk, a scrambled egg, and grapefruit
patient exhibiting an uncoordinated gait has presented at the clinic. Which of the following is the most plausible cause of this patient's health problem
Cerebellar dysfunction The cerebellum controls fine movement, balance, position sense, and integration of sensory input.
nurse is planning the care of a patient with a T1 spinal cord injury. The nurse has identified the diagnosis of "risk for impaired skin integrity. nurse can best address this risk
Change the patient's position frequently.
A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the patient complains of a severe throbbing headache. What should the nurse do first
Check the patient's indwelling urinary catheter for kinks to ensure patency.
A patient is admitted through the ED with suspected St. Louis encephalitis. The unique clinical feature of St. Louis encephalitis will make what nursing action a priority
Close monitoring of fluid balance due to SIADH
nurse planning the care of a patient with head injuries is addressing the patient's nursing diagnosis of "sleep deprivation." What action should the nurse implement
Cluster overnight nursing activities to minimize disturbances.
While completing a health history on a patient has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state
Confusion
patient has been admitted to the hospital with a spontaneous vertebral fracture related to osteoporosis. the following nursing diagnoses must be addressed in the plan of care?
Constipation Related to Vertebral Fracture
mononeuropathy.
Damage to a single nerve
A patient's electronic health record notes that the patient has hallux valgus. What signs and symptoms would the nurse expect this patient to manifest?
Deviation of a great toe laterally
nurse is caring for a patient with a brain tumor. What drug would the nurse expect to be ordered to reduce the edema surrounding the tumor
Dexamethasone help reduce the edema surrounding the tumor
What should the nurse suspect when hourly assessment of urine output on a patient postcraniotomy exhibits a urine output from a catheter of 1,500 mL for two consecutive hours
Diabetes insipidus
patient is being admitted to the neurologic ICU with suspected herpes simplex virus encephalitis. What nursing action best addresses the patient's complaints of headache
Dimming the lights and reducing stimulation
nurse has created a plan of care for a patient who is at risk for increased ICP. The patient's care plan should specify monitoring for what early sign of increased ICP
Disorientation and restlessness Later signs include decreased pulse and respirations, projectile vomiting, and loss of brain stem reflexes, such as the corneal reflex.
student is writing a care plan for a newly admitted patient who has been diagnosed with a stroke. What nursing diagnosis should most likely be included in theplan of care
Disturbed sensory perception
During the performance of the Romberg test, the nurse observes that the patient sways slightly. What is the nurse's most appropriate action
Document successful completion of the assessment.
Dupuytren's disease
Dupuytren's contracture mainly affects the ring finger and pinky, and occurs most often in older men of Northern European descent.
A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding? Absence of reflexes along with flaccid extremities
During the period immediately following a spinal cord injury, spinal shock occurs.
A patient with suspected Creutzfeldt-Jakob disease (CJD) is being admitted to the unit. The nurse would expect what diagnostic test to be ordered for this patient
EEG
trauma patient in the ICU has been declared brain dead. What diagnostic test is used in making the determination of brain death
Electroencephalography (EEG)
When caring for a patient who has had a stroke, a priority is reduction of ICP. What patient position is most consistent with this goal
Elevation of the head of the bed
A patient, brought to the clinic by his wife and son, is diagnosed with Huntington disease. When providing anticipatory guidance, the nurse should address the future possibility of what effect of Huntington disease
Emotional and personality changes Huntington disease causes profound changes to personality and behavior. It is a nonmalignant disease
A nurse is caring for a patient who had a right below-the-knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. Which of the following measures will best achieve these goals
Encouraging the patient to turn from side to side and to assume a prone position
A patient is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 1½ hours ago.
Endotracheal intubation has been deemed necessary and the nurse is preparing to assist.
patient with a simple arm fracture is receiving discharge education from the nurse. What would the nurse instruct the patient to do
Engage in exercises that strengthen the unaffected muscles.
nurse is caring for a patient who is hospitalized with an exacerbation of MS. To ensure the patient's safety, what nursing action should be performed
Ensure that suction apparatus is set up at the bedside.Because of the patient's risk of aspiration, it is important to have a suction apparatus at hand.
A nurse is planning the care of an older adult patient with osteomalacia. What action should the nurse recommend in order to promote vitamin D synthesis?
Ensuring adequate exposure to sunlight
Splints are ordered for a patient who is at risk of developing footdrop following a spinal cord injury. nurse caring for this patient knows that the splints are removed and reapplied when
Every 2 hours
What should be included in the patient's care plan when establishing an exercise program for a patient affected by a stroke
Exercise the affected extremities passively four or five times a day.
nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of a stroke
Facial droop
patient diagnosed with Bell's palsy is having decreased sensitivity to touch of the involved nerve. What should the nurse recommend to prevent atrophy of the muscles Whistling
Facial exercises, such as wrinkling the forehead, blowing out the cheeks, and whistling, may be performed with the aid of a mirror to prevent muscle atrophy.
nurse is developing a plan of care for a patient newly diagnosed with Bell's palsy. The nurse's plan of care should address what characteristic manifestation of this disease
Facial paralysis
A patient is admitted to the medical unit with an exacerbation of multiple sclerosis. When assessing this patient, the nurse has the patient stick out her tongue and move it back and forth. What is the nurse assessing
Function of the hypoglossal nerve The hypoglossal nerve is the 12th cranial nerve. It is responsible for movement of the tongue
patient has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize
Generalized seizure
Radiographs of a boy's upper arm show that the humerus appears to be fractured on one side and slightly bent on the other. This diagnostic result suggests what
Greenstick are an incomplete fracture that results in the bone being broken on one side, while the other side is bent.
neurologic nurse is testing the function of a patient's cerebellum and basal ganglia. What action will most accurately test these structures
Guide the patient through the performance of rapid, alternating movements.
nurse is teaching a patient with Guillain-Barré syndrome about the disease. patient asks how he can ever recover if demyelination of his nerves is occurring. the nurse's best response
Guillain-Barré spares the Schwann cell, which allows for remyelination in the recovery phase of the disease."
patient has recently begun mobilizing during the recovery from an ischemic stroke. To protect the patient's safety during mobilization,nurse should perform what
Have a colleague follow the patient closely with a wheelchair.
.wear a cervical collar 24 hours a day during the acute phase of pain from a cervical disk herniation.
Hot, moist compresses applied to the back of the neck will increase blood flow
The orthopedic nurse should assess for signs and symptoms of Volkmann's contracture if a patient has fractured which of the following bones
Humerus
patient with amyotrophic lateral sclerosis is being visited by the home health nurse who is creating a care plan. What nursing diagnosis is most likely for a patient with this condition
Impaired verbal communication
A patient is having a "fight or flight response" after receiving bad news about his prognosis. What affect will this have on the patient's sympathetic nervous system
Increase in the secretion of sweat and dilated pupils.
nurse caring for a patient with a spinal cord injury notes that the patient is exhibiting early signs and symptoms of disuse syndrome. the most appropriate nursing action
Increase the frequency of ROM exercises.
A 35-year-old woman is diagnosed with a peripheral neuropathy. When making her plan of care, the nurse knows to include what in patient teaching
Inspect the lower extremities for skin breakdown.Footwear needs to be accurately sized. Assistive devices may be needed to reduce the risk of falls.
nurse is creating a plan of care for a patient who has a recent diagnosis of MS. Which of the following should the nurse include in the patient's care plan
Instruct the patient on daily muscle stretching.
nurse is caring for a patient who is in status epilepticus. What medication does the nurse know may be given to halt the seizure immediately
Intravenous diazepam (Valium) and lorazepam (Ativan) given slowly in an attempt to halt seizures immediately
Osteochondroma is the most common benign bone tumor.
It usually occurs as a large projection of bone at the end of long bones at the knee or shoulder.
patient for whom the nurse is caring has positron emission tomography (PET) scheduled. In preparation, what should the nurse explain to the patient
Key nursing interventions for PET scan include explaining the test and teaching the patient about inhalation techniques and the sensations
patient with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate
Loosen the patient's restrictive clothing.
nurse is assessing a patient with an acoustic neuroma who has been recently admitted to an oncology unit. What symptoms is the nurse likely to find during the initial assessment
Loss of hearing, tinnitus, and vertigo An acoustic neuroma is a tumor of the eighth cranial nerve, the cranial nerve most responsible for hearing and balance.
nurse is caring for a patient with an upper motor neuron lesion. What clinical manifestations should nurse anticipate when planning the patient's neurologic assessment
Loss of voluntary control of movement motor neuron lesions normally cause loss of voluntary control.
A patient is undergoing diagnostic testing for osteomalacia. Which of the following laboratory results is most suggestive of this diagnosis?
Low serum calcium and low phosphorus level
nurse is participating in the care of a patient with increased ICP. What diagnostic test is contraindicated in this patient's treatment
Lumbar puncture
nurse is working with a patient who is newly diagnosed with MS. What basic information should the nurse provide to the patient
MS is a progressive demyelinating disease of the nervous system.
nurse is caring for a patient diagnosed with a hemorrhagic stroke. When creating this patient's plan of care, what goal should be prioritized
Maintain and improve cerebral tissue perfusion.
neurologic ICU nurse is admitting a patient following a craniotomy using the supratentorial approach. How should the nurse best position the patient
Maintain head of bed (HOB) elevated at 30 to 45 degrees.
nurse is providing care for a patient who is unconscious. What nursing intervention takes highest priority
Maintaining a patent airway
A nurse is caring for a patient who has suffered an unstable thoracolumbar fracture. Which of the following is the priority during nursing care
Maintaining spinal alignment
A nurse is providing care for a patient who has osteomalacia. What major goal will guide the choice of medical and nursing interventions?
Maintenance of adequate levels of activated vitamin D
Triptans can cause chest pain and are contraindicated in patients with ischemic heart disease.
Maxalt, Amerge, and Zomig are triptans used in routine clinical use for the treatment of migraine headaches
The nurse is caring for a boy who has muscular dystrophy. When planning assistance with the patient's ADLs, what goal should the nurse prioritize
Maximizing the patient's level of function
patient has sustained a long bone fracture and the nurse is preparing the patient's care plan. Which of the following should the nurse include in the care plan
Monitor temperature and pulses of the affected extremity.
A patient with a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the patient's risk for orthostatic hypotension
Monitor the patient's BP before and during position changes.
The critical care nurse is caring for 25-year-old man admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this patient
Monitoring neurologic status closely Vigilant neurologic monitoring is a key aspect of caring for a patient who has a brain abscess.
During a patient's recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help patients and families set realistic goals. What are the predictors of stroke outcome
National Institutes of Health Stroke Scale (NIHSS) score LOC at time of admission Age
patient with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a patient with this diagnosis
Neck flexion produces flexion of knees and hips a positive Brudzinski's sign.
patient is brought to the ED by her family after falling off the roof. family member tells the nurse that when patient fell she was "knocked out," but came to and "seemed okay."
Now she is complaining of a severe headache not feeling well. team suspects epidural hematoma, prompting nurse to prepare forpriority intervention Emergency craniotomy
patient with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time.
Orthostatic hypotension Autonomic dysreflexia DVT
A patient with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. the nurse's best intervention for preventing injury
Pad the side rails of the patient's bed.
A patient with an inoperable brain tumor has been told that he has a short life expectancy. On what aspects of assessment and care should the home health nurse focus
Pain control,Management of treatment complications,Assistance with self-care Administration of treatments
patient is being given a medication that stimulates her parasympathetic system. Following administration of this medication, the nurse should anticipate what effect
Parasympathetic stimulation results in constricted pupils, constricted bronchioles, increased peristaltic movement, contracted muscular walls of the urinary bladder.
A patient who has undergone a lower limb amputation is preparing to be discharged home. What outcome is necessary prior to discharge
Patient can demonstrate safe use of assistive devices.
nurse is admitting a patient to the unit who is diagnosed with a lower motor neuron lesion. What entry in the patient's electronic record is most consistent with this diagnosis
Patient demonstrates an absence of deep tendon reflexes."
A myelogram is an x-ray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture.
Patient preparation for a myelogram would be similar to that for lumbar puncture
A patient with diabetes is attending a class on the prevention of associated diseases. What action should the patient perform to reduce the risk of osteomyelitis?
Perform meticulous foot care.
The nurse recognizes that a patient with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI
Perform passive ROM exercises as ordered.
patient, diagnosed with cancer of the lung, has just been told he has metastases to the brain. What change in status would nurse attribute to patient's metastatic brain disease
Personality changes
Difficulty copying a figure that the nurse has drawn would be considered visual-receptive aphasia, which involves the parietal-occipital area. Expressive aphasia, the inability to express oneself, is often associated with damage to the frontal area. Receptive aphasia, the inability to understand what someone else is saying, is often associated with damage to the temporal lobe area. 7. What term is used to describe the fibrous connective tissue that hugs the brain closely and extends into every fold of the brain's surface
Pia mater
Which of the following is the most appropriate nursing intervention to facilitate healing in a patient who has suffered a hip fracture
Place a pillow between the patient's legs when turning.
patient has had an ischemic stroke and has been admitted to the medical unit. What action should the nurse perform to best prevent joint deformities
Place a pillow in the axilla when there is limited external rotation.prevents adduction of the affected shoulder and keeps the arm away from the chest.
A hospital patient has experienced a seizure. In the immediate recovery period, what action best protects the patient's safety
Place the patient in a side-lying position.
patient in the ED has just had a diagnostic lumbar puncture. To reduce the incidence of a post-lumbar puncture headache, what is the nurse's most appropriate action
Position the patient prone.The lumbar puncture headache may be avoided if a small-gauge needle is used and if the patient remains prone after the procedure
patient with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform
Position the patient upright during feeding.Correct, upright positioning is necessary to prevent aspiration in the patient with dysphagia.
patient with lower back pain is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should prioritize what action
Positioning the patient with the head of the bed elevated 45 degrees DRINK PLENTY OF FLUIDS Will decrease headache
After a major ischemic stroke, a possible complication is cerebral edema. Nursing care during the immediate recovery period from an ischemic stroke should include which
Positioning to avoid hypoxia
After a subarachnoid hemorrhage, the patient's laboratory results indicate a serum sodium level of less than 126 mEq/L. What is the nurse's most appropriate action
Prepare to administer 3% NaCl by IV as ordered.
A patient who has had an amputation is being cared for by a multidisciplinary rehabilitation team. What is the primary goal of this multidisciplinary team
Promote the patient's highest possible level of function
The nurse caring for a patient diagnosed with Parkinson's disease has prepared a plan of care that would include what goal
Promoting effective communication
patient with diabetes presents to the clinic and is diagnosed with a mononeuropathy. This patient's nursing care should involve which of the following
Protection of the affected limb from injury
patient has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the patient's atmosphere more conducive to communication
Provide a board of commonly used needs and phrases.
critical care nurse is admitting a patient in myasthenic crisis to the ICU. The nurse should prioritize what nursing action in the immediate care of this patient
Providing ventilatory assistance
a member of the stroke team, nurse knows that thrombolytic therapy carries the potential for benefit and for harm. nurse should be cognizant of what contraindications for thrombolytic therapy
Recent intracranial pathology Current anticoagulation therapy Symptom onset greater than 3 hours prior to admission
A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, age-related changes. Of what phenomenon should the nurse be aware
Reduction in cerebral blood flow
Plasmapheresis
Removal of plasma from withdrawn blood by centrifuge. Collected cells are retransfused back into the donor. Fresh-frozen plasma or salt solution is used to replace withdrawn plasma.
A patient scheduled for MRI has arrived at the radiology department. The nurse who prepares the patient for the MRI should prioritize which of the following actions
Removing all metal-containing objects
nurse is caring for a patient with multiple sclerosis . patient tells the nurse the hardest thing to deal with is the fatigue. teaching the patient how to reduce fatigue, nurse suggest
Resting in an air-conditioned room whenever possible Fatigue is a common symptom of patients with MS.
What nursing diagnosis should the nurse associate with this procedure
Risk for injury If endotracheal intubation is necessary, extreme care is taken to avoid flexing or extending the patient's neck, which can result in extension of a cervical injury.
A patient presents at a clinic complaining of back pain that goes all the way down the back of the leg to the foot. The nurse should document the presence of what type of pain?
Sciatica
Primary brain tumors originate from cells and structures within the brain.
Secondary brain tumors are metastatic tumors that originate somewhere else in the body
patient with Parkinson's disease is undergoing a swallowing assessment because she has recently developed adventitious lung sounds. patient's nutritional needs should be met by
Semisolid food with thick liquids
Inform the surgeon of the possibility of a dural leak.
Serosanguineous drainage may indicate a dural leak. This constitutes a risk for meningitis,
A nurse is providing a class on osteoporosis at the local seniors' center. Which of the following statements related to osteoporosis is most accurate?
Slow discontinuation of corticosteroid therapy can halt the progression of the osteoporosis
Avulsion fractures
Small fracture near a joint that usually has a ligament or tendon attached
A nursing educator is reviewing the risk factors for osteoporosis with a group of recent graduates. What risk factor of the following should the educator describe?
Small frame, female gender, and Caucasian ethnicity
nurse is admitting a patient with a severe migraine headache and a history of acute coronary syndrome. What migraine medication would the nurse question for this patient
Sumatriptan succinate (Imitrex)
Following diagnostic testing, a patient has been admitted to the ICU and placed on cerebral aneurysm precautions. What nursing action should be included in patient's plan of care
Supervise the patient's activities of daily living closely.
nurse is caring for a patient with a bone tumor. The nurse is providing education to help the patient reduce the risk for pathologic fractures. the nurse teach the patient?
Support the affected extremity with external supports such as splints.
nurse is preparing health education for a patient who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education
Take antihypertensive medication as ordered.
nurse is caring for a patient recovering from an ischemic stroke. What intervention best addresses a potential complication after an ischemic stroke
Teaching the patient to perform deep breathing and coughing exercises
nursing students are learning how to assess function of cranial nerve VIII. To assess the function of cranial nerve VIII the students would be correct in completing which of the following assessment techniques
Test for air and bone conduction Rinne test Cranial nerve VIII is the acoustic nerve.
nurse is reviewing the trend of a patient's scores on the Glasgow Coma Scale . This allows the nurse to gauge what aspect of the patient's status Level of consciousness
The Glasgow Coma Scale (GCS) examines three responses related to LOC: eye opening, best verbal response, and best motor response.
Benefits of levodopa-carbidopa often diminish after 1 or 2 years of treatment.
The beneficial effects of levodopa therapy are most pronounced in the first year or two of treatment. Benefits begin to wane and adverse effects become more severe over time.
An orthopedic nurse is caring for a patient who is postoperative day one following foot surgery. What nursing intervention should be included in the patient's subsequent care?
The foot should be elevated in order to prevent edema.
An 80-year-old man in a long-term care facility has a chronic leg ulcer and states that the area has become increasingly painful in recent days.
The nurse notes that the site is now swollen and warm to the touch.
An ED nurse has just received a call from EMS that they are transporting a 17-year-old man who has just sustained a spinal cord injury (SCI).
The nurse recognizes that the most common cause of this type of injury is what Motor vehicle accidents
A patient is brought to the ER following a motor vehicle accident in which he sustained head trauma. Preliminary assessment reveals a vision deficit in the patient's left eye
The nurse should associate this abnormal finding with trauma to which of the following cerebral lobes Occipital
An older adult patient sought care for the treatment of a swollen, painful knee joint. Diagnostic imaging and culturing of synovial fluid resulted in a diagnosis of septic arthritis.
The nurse should prioritize which of the following aspects of care?Intravenous administration of antibiotics
male patient presents to the clinic complaining of a headache.nurse notes that patient is guarding his neck and tells the nurse that he has stiffness in the neck area.
The nurse suspects the patient may have meningitis. What is another well-recognized sign of this infection Positive Kernig's sign
nurse is caring for a patient diagnosed with Ménière's disease. While completing a neurologic examination on the patient, the nurse assesses cranial nerve VIII.
The nurse would be correct in identifying the function of this nerve as what Hearing and equilibrium Cranial nerve VIII acoustic is responsible for hearing and equilibrium.
Following a spinal cord injury a patient is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached.
The nurse would be correct in implementing what priority nursing action Notify the neurosurgeon of the occurrence.
patient with increased ICP has a ventriculostomy for monitoring ICP. nurse's most recent assessment reveals that patient is now exhibiting nuchal rigidity and photophobia.
The nurse would be correct in suspecting the presence of what complication Meningitis
male patient with a metastatic brain tumor is having a generalized seizure and begins vomiting. What should the nurse do first Turn the patient on his side.
The nurse's first response should be to place the patient on his side to prevent him from aspirating emesis
nurse admits a patient who has a fracture of the nose that has resulted in a skin tear and involvement of the mucous membranes of the nasal passages.
The orthopedic nurse is aware that this description likely indicates which type of fracture Compound
A patient is currently being stimulated by the parasympathetic nervous system. What effect will this nervous stimulation have on the patient's bladder
The parasympathetic nervous system makes the bladder contract.
Following a traumatic brain injury, a patient has been in a coma for several days. Which of the following statements is true of this patient's current LOC
The patient may occasionally make nonpurposeful movements.
48-year-old patient has been diagnosed with trigeminal neuralgia following recent episodes of unilateral face pain. The nurse should recognize what implication of this diagnosis
The patient needs to be assessed for MS.
A patient who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this patient
The patient should be approached on the side where visual perception is intact.
A patient diagnosed with MS should be encouraged to increase the fiber in his or her diet and void 30 minutes after drinking to help train the bladder.
The patient should participate in daily muscle stretching to help alleviate and relax muscle spasms.
patient diagnosed with a pituitary adenoma has arrived on the neurologic unit. When planning the patient's care, the nurse should be aware that the effects of the tumor will primarily depend on what variable
The specific hormones secreted by the tumor
The nurse is providing health education to a patient who has a C6 spinal cord injury. The patient asks why autonomic dysreflexia is considered an emergency.
The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel or lead to increased ICP.
A school nurse is assessing a student who was kicked in the shin during a soccer game. The area of the injury has become swollen and discolored.
The triage nurse recognizes that the patient has likely sustained what Contusion
A patient tells the nurse that he has pain and numbness to his thumb, first finger, and second finger of the right hand. nurse discovers patient is employed as a auto mechanic, and that the pain is increased while working.
This may indicate that the patient could possibly have what health problem Carpel tunnel syndrome
A patient presents at a clinic complaining of pain in his heel so bad that it inhibits his ability to walk. The patient is subsequently diagnosed with plantar fasciitis.
This patient's plan of care should include what intervention? Gently stretching the foot and the Achilles tendon
patient diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose
To remove atherosclerotic plaques blocking cerebral flow
nurse is admitting a patient to the unit who is scheduled for removal of an intracranial mass. What diagnostic procedures might be included in this patient's admission orders
Transcranial Doppler flow study,Cerebral angiography, MRI
An epidural hematoma is considered an extreme emergency. Marked neurologic deficit or respiratory arrest can occur within minutes
Treatment consists of making an opening through the skull to decrease ICP emergently, remove the clot, and control the bleeding.
The major symptoms of peripheral nerve disorders are loss of sensation, muscle atrophy, weakness, diminished reflexes, pain, and paresthesia of the extremities.
Trigeminal neuralgia is a condition of the fifth cranial nerve that is characterized by paroxysms of pain in the area innervated by any of the three branches, but most
Assessment is crucial to the care of patients with neurologic dysfunction. What does accurate and appropriate assessment require
Understanding of the tests used to diagnose neurologic disorders Knowledge of the anatomy of the nervous system
A nurse is preparing to discharge an emergency department patient who has been fitted with a sling to support her arm after a clavicle fracture. What should the nurse instruct the patient to do
Use the arm for light activities within the range of motion. Ans: D
The nurse is developing a plan of care for a patient with Guillain-Barré syndrome. Which of the following interventions should the nurse prioritize for this patient
Using the incentive spirometer as prescribed
patient has developed diabetes insipidus after having increased ICP following head trauma. What nursing assessment best addresses this complication
Vigilant monitoring of fluid balance Diabetes insipidus requires fluid and electrolyte replacement, along with the administration of vasopressin, to replace and slow the urine output
patient who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nurse should include the following
Watchful waiting and close monitoring
A patient who has been experiencing numerous episodes of unexplained headaches, vomiting has subsequently been referred for testing to rule out a brain tumor.
What characteristic of the patient's vomiting is most consistent with a brain tumor The patient's vomiting is unrelated to food intake.
A male patient presents at the free clinic with complaints of impotency. Upon physical examination, the nurse practitioner notes the presence of hypogonadism. What diagnosis should the nurse suspect
What diagnosis should the nurse suspect Prolactinoma
A patient presents at the clinic with complaints of morning numbness, cramping, and stiffness in his fourth and fifth fingers.
What disease process should the nurse suspect? Dupuytren's disease
A patient has come to the orthopedic clinic for a follow-up appointment 6 weeks after fracturing his ankle. Diagnostic imaging reveals that bone union is not taking place.
What factor may have contributed to this complication Inadequate immobilization
Diabetes insipidus is an abrupt onset of . During the examination of an unconscious patient, the nurse observes that the patient's pupils are fixed and dilated.
What is the most plausible clinical significance of the nurse's finding It indicates an injury at the midbrain level.
patient is postoperative day 1 following intracranial surgery. The nurse's assessment reveals that the patient's LOC is slightly decreased compared with the day of surgery. What is the nurse's best response to this assessment finding
What is the nurse's best response to this assessment finding Recognize that this may represent the peak of post-surgical cerebral edema. it tends to peak 24 to 36 hours after surgery
The nurse responds to the call light of a patient who has had a cervical diskectomy earlier in the day. The patient states that she is having severe pain that had a sudden onset.
What is the nurse's most appropriate action Call the surgeon to report the patient's pain.extrusion of the graft may have occurred, requiring reoperation.
A patient has been admitted to the neurologic unit for the treatment of a newly diagnosed brain tumor. The patient has just exhibited seizure activity for the first time.
What is the nurse's priority response to this event Implement precautions to ensure the patient's safety.
patient is recovering from intracranial surgery performed approximately 24 hours ago and is complaining of a headache that the patient rates at 8 on a 10-point pain scale.
What nursing action is most appropriate Administer morphine sulfate as ordered.
A nurse is caring for a patient who is 12 hours postoperative following foot surgery. The nurse assesses the presence of edema in the foot.
What nursing measure will the nurse implement to control the edema? Elevate the foot on several pillows.
patient who is being treated in the hospital for a spinal cord injury is advocating for the removal of his urinary catheter, stating that he wants to try to resume normal elimination.
What principle should guide the care team's decision regarding this intervention Urinary retention can have serious consequences in patients with SCIs.
patient diagnosed with MS has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen (Lioresal).
What should the nurse identify as an expected outcome of this treatment Decreased severity and duration of exacerbations
nurse educator is reviewing the assessment of cranial nerves. What should the educator identify as the specific instances when cranial nerves should be assessed
When level of consciousness is decreased With brain stem pathology In the presence of peripheral nervous system disease
The patient should undergo diagnostic testing for what health problem?
When osteomyelitis develops from the spread of an adjacent infection, no signs of septicemia are present, but the area becomes swollen, warm, painful, and tender to touch.
In spinal shock, all reflexes are absent and the extremities are flaccid.
When spinal shock subsides, the patient demonstrates a positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities.
A patient with suspected Parkinson's disease is initially being assessed by the nurse. When is the best time to assess for the presence of a tremor
When the patient is resting
patient had a lumbar puncture performed at the clinic and the nurse has phoned the patient and family that evening. What does this phone call enable the nurse to determine
Whether the patient has had any complications of the test
A patient has been admitted to the neurologic ICU with a diagnosis of a brain tumor. The patient is scheduled to have a tumor resection/removal in the morning.
Which of the following assessment parameters should the nurse include in the initial assessment Gag reflex
An adult patient has sought care for the treatment of headaches that have become increasingly severe and frequent over the past several months.
Which of the following questions addresses potential etiological factors
A patient with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased the risk of deep vein thrombosis (DVT).
Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring. Applying thigh-high elastic stockings
73-year-old man comes to the clinic complaining of weakness and loss of sensation in his feet and legs. Assessment of the patient shows decreased reflexes bilaterally.
Why would it be a challenge to diagnose a peripheral neuropathy in this patient Many symptoms can be the result of normal aging process.
A patient is scheduled for CT scanning of the head because of a recent onset of neurologic deficits. What should the nurse tell the patient in preparation for this test
You will need to lie still throughout the procedure."
The school nurse is giving a presentation on preventing spinal cord injuries . What should the nurse identify as prominent risk factors for SCI
Young age Male gender alcohol and drug use.
nurse is caring for a patient newly diagnosed with a primary brain tumor. The patient asks the nurse where his tumor came from. What would be the nurse's best response
Your tumor originated from cells within your brain itself."
patient is admitted to the neurologic ICU with a spinal cord injury. In writing the patient's care plan, the nurse specifies that contractures can best be prevented by what
action Initiating (ROM) exercises as soon as possible after the injury
patient has been admitted to the ICU after being recently diagnosed with an aneurysm and the patient's admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate into the patient's plan of care
action will the nurse incorporate into the patient's plan of care Maintain the patient on complete bed rest.
A patient with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In
addition to closely monitoring the patient's cardiac and neurologic status, the nurse monitors the patient for signs of what complication Bleeding
patient is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this patient's care, the nurse would expect to
administer what priority medication Mannitol (Osmitrol)
A nurse is reviewing the care of a patient who has a long history of lower back pain that has not responded to conservative treatment measures. The nurse should anticipate the
administration of what drug? Cyclobenzaprine Short-term prescription muscle relaxants cyclobenzaprine Flexeril are effective in relieving acute low back pain.
A gerontologic nurse is advocating for diagnostic testing of an 81-year-old patient who is experiencing personality changes. The nurse is aware of what factor that is known to
affect the diagnosis and treatment of brain tumors in older adults The effects of brain tumors are often attributed to the cognitive effects of aging.
A patient presents at the clinic complaining of pain and weakness in her hands. On assessment, the nurse notes diminished reflexes in the upper extremities bilaterally
and bilateral loss of sensation. The nurse knows that these findings are indicative of what Peripheral nerve disorder
and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency
and calls for assistance, recognizing that this patient is likely demonstrating symptoms of what complicationFat embolism syndrome
Due to the continuous involuntary movements, patients will have a ravenous appetite. Despite this ravenous appetite, patients usually become emaciated
and exhausted.As the disease progresses, patients experience difficulty in swallowing and thin liquids should be avoided.
An older adult patient experienced a fall and required treatment for a fractured hip on the orthopedic unit. Which of the following are contributory factors to the incidence of falls
and fractured hips among the older adult population Loss of visual acuity, Adverse medication effects, Slowed reflexes Muscle weakness
A 37-year-old man is brought to the clinic by his wife because he is experiencing loss of motor function and sensation. The physician suspects the patient has a spinal cord tumor
and hospitalizes him for diagnostic testing. In light of the need to diagnose spinal cord compression from a tumor, nurse will most likely prepare the patient for what test MRI
A patient who has experienced an ischemic stroke has been admitted to the medical unit. The patient's family in adamant that she remain on bed rest to hasten her recovery
and to conserve energy. What principle of care should inform the nurse's response to the family The patient should mobilize as soon as she is physically able.
nurse is caring for a patient in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the patient's mean
arterial pressure is 60 mm Hg with an intracranial pressure reading of 5 mm Hg. nurse's most appropriate action Participate in interventions to increase cerebral perfusion pressure.
patient has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the patient's ICP increases and condition worsens, the nurse knows to
assess for indications of approaching death. These indications include which of the following Loss of brain stem reflexes
A nurse is discussing conservative management of tendonitis with a patient. Which of the following may
be an effective approach to managing tendonitis? Intermittent application of ice and heat
A patient has come to the clinic for a routine annual physical. The nurse practitioner notes a palpable, painless projection of bone at the patient's shoulder. The projection appears to
be at the distal end of the humerus. The nurse should suspect the presence of which of the following?
nurse is caring for a patient with permanent neurologic impairments resulting from a traumatic head injury. When working with this patient and family, what mutual goal should
be prioritized Achieve as high a level of function as possible.
After spinal surgery, the bed is usually kept flat initially. The side-lying position is usually the most comfortable
because this position imposes the least pressure on the surgical site.
A patient is admitted to the neurologic ICU with a spinal cord injury. When assessing the patient the nurse notes there is a sudden depression of reflex activity in the spinal cord
below the level of injury. What should the nurse suspect Spinal shock In spinal shock, the reflexes are absent, BP and heart rate fall, and respiratory failure can occur.
A patient with MS has been admitted to the hospital following an acute exacerbation. When planning the patient's care, the nurse addresses the need to enhance the patient's
bladder control. What aspect of nursing care is most likely to meet this goal Establish a timed voiding schedule.
nurse is reviewing the pathophysiology that may underlie a patient's decreased bone density. What hormone will nurse identify as inhibiting bone resorption and promoting
bone formation? Calcitonin Calcitonin inhibits bone resorption and promotes bone formation,
A family member of a patient diagnosed with Huntington disease calls you at the clinic. She is requesting help from the Huntington's Disease Society of America. What kind of help
can this patient and family receive from this organization Information about this disease,Referrals,Public education
nurse is caring for a patient who is rapidly progressing toward brain death. nurse should be aware of what cardinal signs of brain death Apnea,Coma,Absence of brain stem reflexes
cardinal signs of brain death upon clinical examination are coma, the absence of brain stem reflexes, and apnea.
.A rehabilitation nurse is working with a patient who has had a below-the-knee amputation. The nurse knows the importance of the patient's active participation in self-
care. In order to determine the patient's ability to be an active participant in self-care, the nurse should prioritize assessment of what variable The patient's attitude
patient recovering from a stroke has severe shoulder pain from subluxation of the shoulder and is being cared for on the unit. To prevent further injury and pain, the nurse
caring for this patient is aware of what principle of care patient should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder.
patient exhibiting an altered level of consciousness (LOC) due to blunt-force trauma to the head is admitted to the ED. The physician determines the patient's injury is
causing increased intracranial pressure (ICP). The nurse should gauge the patient's LOC on the results of what diagnostic tool Glasgow Coma Scale
You are the clinic nurse caring for a patient with a recent diagnosis of myasthenia gravis. The patient has begun treatment with pyridostigmine bromide (Mestinon). What
change in status would most clearly suggest a therapeutic benefit of this medication Increased muscle strength
nurse has admitted a new patient to the unit. One of the patient's admitting orders is for an adrenergic medication. The nurse knows that this medication will have what effect on the
circulatory system Increased heart rate The term "adrenergic" refers to the sympathetic nervous system. Sympathetic effects include an increased rate and force of the heartbeat.
nurse is writing a care plan for a patient with brain metastases. nurse decides that an appropriate nursing diagnosis is anxiety related to lack of control over the health
circumstances. plan of care for patient, nurse should include what intervention patient will be encouraged to verbalize concerns related to the disease and its treatment.
nurse caring for a patient diagnosed with Guillain-Barré syndrome is planning care with regard to the clinical manifestations associated this syndrome. The nurse's
communication with the patient should reflect the possibility of what sign or symptom of the disease Vocal paralysis Guillain-Barré syndrome is a disorder of the vagus nerve
nurse is caring for a patient with ICP caused by a traumatic brain injury.the following clinical manifestations would suggest that the patient may be experiencing increased brain
compression causing brain stem damage Hyperthermia increases the metabolic demands of the brain and may indicate brain stem damage.
A young patient is being treated for a femoral fracture suffered in a snowboarding accident. The nurse's most recent assessment reveals that the patient is uncharacteristically
confused. What diagnostic test should be performed on this patient Arterial blood gases
32-year-old comes to the clinic complaining of shoulder tenderness, pain, and limited movement. Upon assessment nurse finds edema. MRI shows hemorrhage of the rotator
cuff tendons and the patient is diagnosed with impingement syndrome. the nurse should recommend in order to promote healing? Support the affected arm on pillows at night.
An older adult has encouraged her husband to visit their primary care provider, stating that she is concerned that he may have Parkinson's disease. Which of the wife's
descriptions of her husband's health and function is most suggestive of Parkinson's disease Lately he seems to move far more slowly than he ever has in the past."
A nurse is providing discharge teaching for a patient who underwent foot surgery. The nurse is collaborating with the occupational therapist and discussing the use of assistive
devices. On what variables does the choice of assistive devices primarily depend? Patient's general condition, balance, and weight-bearing prescription
nurse is providing care for a patient who has a recent diagnosis of Paget's disease. When planning this patient's nursing care, interventions should address what nursing
diagnoses? Impaired Physical Mobility Acute Pain Disturbed Auditory Sensory Perception Risk for Injury
nurse caring for an 80 year-old patient knows that she has a pre-existing history of dulled tactile sensation. The nurse should first consider what possible cause for this patient's
diminished tactile sensation Age-related neurologic changes
nurse is preparing to discharge a patient from the emergency department after receiving treatment for an ankle sprain. While providing
discharge education, the nurse should encourage which of the following Keep an elastic compression bandage on the ankle.
nurse in the ICU is providing care for a patient who has been admitted with a hemorrhagic stroke. nurse is performing frequent neurologic assessments and observes that the patient is becoming progressively more
drowsy over the course of the day. What is the nurse's best response to this assessment finding Report this to the physician as a possible sign of clinical deterioration.
The nurse is caring for a 77-year-old woman with MS. She states that she is very concerned about the progress of her disease and what the future holds. The nurse should know that
elderly patients with MS are known to be particularly concerned about what variables Possible nursing home placement, Increasing disability, Becoming a burden on the family
patient with a brain injury is very agitated, benzodiazepines are the most commonly used sedatives and do not affect cerebral blood flow or ICP. The HOB should be
elevated 30 degrees. Suctioning should be done a limited basis, due to increasing the pressure in the cranium. Valsalva maneuver is to be avoided. This also causes increased ICP.
A nurse is planning the care of an older adult patient who will soon be discharged home after treatment for a fractured hip. In an effort to prevent future fractures, the nurse should
encourage which of the following Regular bone density testing, A high-calcium diet,Use of falls prevention precautions Weight-bearing exercise
A patient who was diagnosed with Parkinson's disease several months ago recently began treatment with levodopa-carbidopa. The patient and his family are excited that he has
experienced significant symptom relief. The nurse should be aware of what implication of the patient's medication regimen
patient is scheduled for a myelogram and the nurse explains to the patient that this is an invasive procedure, which assesses for any lesions in the spinal cord. The nurse should
explain that the preparation is similar to which of the following neurologic tests Lumbar puncture
nurse is caring for a patient who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of "deficient fluid volume related to
fluid restriction and osmotic diuretic use." What would be an appropriate intervention for this diagnosis Monitor serum electrolytes.
nurse is caring for a patient who has suffered a hip fracture and who will require an extended hospital stay. The nurse should ensure that the patient does which of the
following in order to prevent common complications associated with a hip fracture Increase fluid intake and perform prescribed foot exercises.to prevent DVT
The health care team is caring for a patient with osteomalacia. It has been determined that the osteomalacia is caused by malabsorption. What is the usual treatment
for osteomalacia caused by malabsorption?Supplemental calcium and increased doses of vitamin D
The public health nurse is planning a health promotion campaign that reflects current epidemiologic trends. The nurse should know that hemorrhagic stroke currently accounts
for what percentage of total strokes in the United States 13%
nurse on the neurologic unit is providing care for a patient who has spinal cord injury at the level of C4. When planning the patient's care, what aspect of the patient's neurologic and
functional status should the nurse consider The patient will require full assistance for all aspects of elimination.
nurse is reviewing the medication administration record of a female patient who possesses numerous risk factors for stroke. Which of the woman's medications carries the
greatest potential for reducing her risk of stroke Aspirin 81 mg PO o.d.
nurse is providing care for a patient who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the patient
has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following The patient's activities immediately prior to the seizure.
nurse is caring for a patient who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the patient's respiratory effort
has increased. What is the nurse's most appropriate response Inform the care team and assess for further signs of possible increased ICP.
nurse is performing stroke risk screenings at a hospital. nurse has identified four patients who might be at risk for a stroke. Which patient is likely at the highest risk for a
hemorrhagic stroke White male, age 60, with history of uncontrolled hypertension
A 20 year-old is brought in by ambulance to the emergency department after being involved in a motorcycle accident. The patient has an open fracture of his tibia. The wound is
highly contaminated and there is extensive soft-tissue damage. How would this patient's fracture likely be graded Grade III
A patient is brought to the emergency department by ambulance after stepping in a hole and falling. While assessing him the nurse notes that his right leg is shorter than
his left leg; his right hip is noticeably deformed and he is in acute pain. Imaging does not reveal a fracture the following is the most plausible explanation for this patient's signs and symptoms Traumatic hip dislocation
nurse is collaborating with the interdisciplinary team to help manage a patient's recurrent headaches. What aspect of the patient's health history should the nurse
identify as a potential contributor to the patient's headaches The patient takes vasodilators for the treatment of angina.Vasodilators are known to contribute to headaches
A patient is being treated for a fractured hip and the nurse is aware of the need to implement interventions to prevent muscle wasting and other complications of
immobility. What intervention best addresses the patient's need for exercise Encouraging frequent use of the overbed trapeze
25-year-old man is involved in a motorcycle accident and injures his arm. The physician diagnoses the man with an intra-articular fracture and splints the injury. The nurse
implements the teaching plan developed for this patient. What sequela of intra-articular fractures should the nurse describe regarding this patient Post-traumatic arthritis
A nurse is caring for a patient who experiences debilitating cluster headaches. The patient should be taught to take appropriate medications at what point
in the course of the onset of a new headache As soon as the patient senses the onset of symptoms
A patient is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this patient, the following nursing diagnoses would the nurse prioritize
in the immediate care of this patient Ineffective breathing patterns related to weakness of the intercostal muscles
patient who has been on long-term phenytoin therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following
in the patient's plan of care Administration of thorough oral hygiene
. When caring for a patient with increased ICP the nurse knows the importance of monitoring for possible secondary complications, including syndrome of
inappropriate antidiuretic hormone What nursing interventions would the nurse most likely initiate if the patient developed SIADH Fluid restriction
nurse is performing a shift assessment on an elderly patient who is recovering after surgery for a hip fracture. The nurse notes that the patient is complaining of chest pain, has an
increased heart rate, and increased respiratory rate. The nurse further notes that the patient is febrile and hypoxic, coughing,
Acute compartment syndrome involves a sudden and severe decrease in blood flow to the tissues distal to an area of injury that results in ischemic necrosis if prompt, decisive
intervention does not occur. Removing or bivalving the cast is necessary to relieve pressure.
A 25-year-old female patient with brain metastases is considering her life expectancy after her most recent meeting with her oncologist. Based on the fact that the patient
is not receiving treatment for her brain metastases, what is the nurse's most appropriate action Ensuring that the patient receives adequate palliative care
A myelogram is an x-ray of the spinal physician has ordered a somatosensory evoked responses (SERs) test for a patient for whom the nurse is caring. The nurse is
justified in suspecting that this patient may have a history of what type of neurologic disorder Demyelinating disease
Prolactinoma most common pituitary adenoma. In men- impotence, small testicles, low testosterone,
low or inappropriately normal FSH/LH. Tx- dopamine agonists, cabergoline and bromocriptine, decrease prolactin and reduce size
nurse is collaborating with the physical therapist to plan the care of a patient with osteomyelitis. What principle should guide the
management of activity and mobility in this patient? Stress on the weakened bone must be avoided.
. An emergency department nurse is assessing a 17-year-old soccer player who presented with a knee injury. The patient's description of the injury indicates that his knee was struck
medially while his foot was on the ground. The nurse knows that the patient likely has experienced what injury Lateral collateral ligament injury
69-year-old patient is brought to the ED by ambulance because a family member found him lying on the floor disoriented and lethargic. The physician suspects bacterial
meningitis and admits the patient to the ICU. nurse knows that risk factors for an unfavorable outcome include what Heart rate greater than 120 bpm, Older age Low Glasgow Coma Scale
Neurologic signs and symptoms include headache, gait disturbances, visual impairment, personality changes, altered
mentation memory loss and confusion, focal weakness, paralysis, aphasia, and seizures.
A nurse is caring for a patient who is being assessed following complaints of severe and persistent low back pain. The patient is scheduled for diagnostic testing in the
morning. Which of the following are appropriate diagnostic tests for assessing low back pain? CT MRI Ultrasound X-ray
A middle-aged woman has sought care from her primary care provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is
most likely to have prompted the woman to seek care Difficulty in coordination
gerontologic nurse educator is providing practice guidelines to unlicensed care providers. Because reaction to painful stimuli is sometimes blunted in older adults, what
must be used with caution Hot or cold packs
older adult patient has fallen in her home and is brought to the emergency department by ambulance with a suspected fractured hip. X-rays confirm a fracture of the left femoral
neck. When planning assessments during the patient's presurgical care, the nurse should be aware of the patient's heightened risk of what complication Avascular necrosis
patient is recovering from intracranial surgery that was performed using the transsphenoidal approach. nurse should be aware that the patient may have required surgery on what
neurologic structure Pituitary gland The transsphenoidal approach through the mouth and nasal sinuses is often used to gain access to the pituitary gland.
nurse educator is discussing neoplasms with a group of recent graduates. The educator explains that the effects of neoplasms are caused by the compression and infiltration of
normal tissue. The physiologic changes that result can cause what pathophysiologic events increased ICP, Focal neurologic signs,Altered pituitary function,cerebral edema
An elite high school football player has been diagnosed with a shoulder dislocation. The patient has been treated and is eager to resume his role on his team, stating that he is
not experiencing pain. What should the nurse emphasize during health education The importance of adhering to the prescribed treatment and rehabilitation regimen
nurse is doing an initial assessment on a patient newly admitted to the unit with a diagnosis of cerebrovascular accident The patient has difficulty copying a figure that the
nurse has drawn and is diagnosed with visual-receptive aphasia. What brain region is primarily involved in this deficit Parietal-occipital area
nurse caring for a patient with Parkinson's disease notes that the patient has been taking levodopa and carbidopa for 7 years. what common side effect of Sinemet would the
nurse see. Dyskinesia Another complication of long-term dopaminergic medication use is neuroleptic malignant syndrome seen by severe rigidity, stupor, and hyperthermia
trauma patient was admitted to the ICU with a brain injury. The patient had a change in level of consciousness, increased vital signs, and became diaphoretic and agitated. The
nurse should recognize which of the following syndromes as the most plausible cause of these symptoms Sympathetic storm
A rehabilitation nurse caring for a patient who has had a stroke is approached by the patient's family and asked why the patient has to do so much for herself when she is
obviously struggling. What would be the nurse's best answer The focus on care in a rehabilitation facility is to help the patient to resume as much self-care as possible."
Patients that develop trigeminal neuralgia before age 50 should be evaluated for the coexistent of MS because trigeminal neuralgia
occurs in approximately 5% of patients with MS
nurse is caring for a patient with Paget's disease and is reviewing the patient's most recent laboratory values. Which of the following values is most characteristic
of Paget's disease? An elevated serum alkaline phosphatase level and a normal serum calcium level
nurse is planning the care of a 28-year-old woman hospitalized with a diagnosis of myasthenia gravis. What approach would be most appropriate for the care and scheduling
of diagnostic procedures for this patient In the morning, with frequent rest periods
Cranial nerves are assessed when level of patient in the OR goes into malignant hyperthermia due to an abnormal reaction to the anesthetic. The nurse knows that the area
of the brain that regulates body temperature is which of the following Hypothalamus
commonly the second and third branches of the trigeminal nerve. Myasthenia gravis, an autoimmune disorder affecting the myoneural junction, is characterized by varying degrees
of weakness of the voluntary muscles. Guillain-Barré syndrome is an autoimmune attack on the peripheral nerve myelin.
An elderly woman found with a head injury on the floor of her home is subsequently admitted to the neurologic ICU. What is the best rationale for the following physician
orders: elevate the HOB; keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion To avoid impeding venous outflow which increases ICP
nurse is caring for a patient with increased intracranial pressure . The patient has a nursing diagnosis of "ineffective cerebral tissue perfusion." What would be an expected
outcome that the nurse would document for this diagnosis Obeys commands with appropriate motor responses.
A patient presents to a clinic complaining of a leg ulcer that isn't healing; subsequent diagnostic testing suggests osteomyelitis. The nurse is aware that the most common
pathogen to cause osteomyelitis is what? S. aureus causes over 50% of bone infections. Proteus, Pseudomonas, and E. coli are also causes, but to a lesser extent.
The hypothalamus plays an important role in nurse is planning the care of a patient with Parkinson's disease. The nurse should be aware that treatment will focus on what
pathophysiological phenomenon Decreased availability of dopamine
A patient with a new diagnosis of amyotrophic lateral sclerosis (ALS) is overwhelmed by his diagnosis and the known complications of the disease. How can the
patient best make known his wishes for care as his disease progresses Prepare an advance directive.
patient with metastatic cancer has developed trigeminal neuralgia and is taking carbamazepine for pain relief. What principle applies to the administration of this med
patient should be monitored for bone marrow depression. Side effects include nausea, dizziness, drowsiness, and aplastic anemia. Carbamazepine should be gradually increased
When caring for a patient who had a hemorrhagic stroke, close monitoring of vital signs and neurologic changes is imperative. What is the earliest sign of deterioration in a
patient with a hemorrhagic stroke of which the nurse should be aware Alteration in level of consciousness (LOC)
nurse is performing a neurologic assessment of a patient whose injuries have rendered her unable to follow verbal commands. How should the nurse proceed with assessing the
patient's level of consciousness (LOC) Assess the patient's eye opening and response to stimuli.
nurse is caring for a patient diagnosed with an ischemic stroke and knows that effective positioning of the patient is important. Which of the following should be integrated into the patient's plan of care
patient's plan of care The patient should be placed in a prone position for 15 to 30 minutes several times a day.
patient who suffered a spinal cord injury is experiencing an exaggerated autonomic response. the patient's current health status is most likely to have precipitated this event
patient's urinary catheter became occluded.A distended bladder is the most common cause of autonomic dysreflexia
female patient is diagnosed with a right-sided stroke. patient is now experiencing hemianopsia. the nurse can help the patient manage her potential sensory and
perceptional difficulties Place the patient's extremities where she can see them.
patient diagnosed with myasthenia gravis has been hospitalized to receive plasmapheresis for a myasthenic exacerbation. nurse knows that the course of treatment for
plasmapheresis in a patient with myasthenia gravis is what Determined by the patient's response
surgical nurse is admitting a patient from postanesthetic recovery following the patient's below-the-knee amputation. The nurse recognizes the patient's high risk for
postoperative hemorrhage and should keep which of the following at the bedside A tourniquet
The nurse is caring for a patient who is scheduled for a cervical discectomy the following day. During health education, the patient should be made aware of what
potential complications Hematoma at the surgical site resulting in cord compression and neurologic deficit and recurrent or persistent pain after surgery.
patient with Guillain-Barré syndrome has experienced a sharp decline in vital capacity. What is the nurse's most appropriate action
prepare to assist with intubation.mechanical ventilation is required if the vital capacity falls, making spontaneous breathing impossible and tissue oxygenation inadequate.
nurse is caring for a patient who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to
prevent seizures in this patient Phenytoin
72-year-old man has been brought to his primary care provider by his daughter, who claims that he has been experiencing uncharacteristic lapses in memory. What
principle should underlie the nurse's assessment and management of this patient Thorough assessment is necessary because changes in cognition are always considered to be pathologic.
Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic BP, and widening pulse pressure. As brain compression increases, respirations become
rapid, BP may decrease, and the pulse slows further. A rapid rise in body temperature is regarded as unfavorable.
patient has just returned to the unit from the PACU after surgery for a tumor within the spine. The patient complains of pain. When positioning the patient for comfort and to reduce injury to the surgical site, the nurse will position to patient in what position
reduce injury to the surgical site, the nurse will position to patient in what position In a flat side-lying position
A patient with Parkinson's disease is experiencing episodes of constipation that are becoming increasingly frequent and severe. The patient states that he has been achieving
relief for the past few weeks by using OTC laxatives. How should the nurse respond let's explore other options, because laxatives can have side effects and create dependency."
A patient was fitted with an arm cast after fracturing her humerus. Twelve hours after the application of the cast, the patient tells the nurse that her arm hurts. Analgesics do not
relieve the pain. What would be the most appropriate nursing action Prepare the patient for opening or bivalving of the cast.
13-year-old was brought to the ED, unconscious, after being hit in the head by a baseball.the child regains consciousness, 5 hours after being admitted, he can't
remember the traumatic event. MRI shows no structural sign of injury. What injury would the nurse suspect the patient has Grade 3 concussion with temporal lobe involvement
Syme amputation
removal of part of the foot.
Six weeks after an above-the-knee amputation (AKA), a patient returns to the outpatient office for a routine postoperative checkup. During the nurse's assessment, the patient
reports symptoms of phantom pain. What should the nurse tell the patient to do to reduce the discomfort of the phantom pain Take opioid analgesics as ordered.
When caring for a patient with an altered level of consciousness, the nurse is preparing to test cranial nerve VII. What assessment technique would the nurse use to elicit a
response from cranial nerve VII Observe for facial movement symmetry, such as a smile.
nurse is assessing a patient who reports a throbbing, burning sensation in the right foot. patient states that the pain is worst during the day but notes that the pain is relieved with
rest. The nurse should recognize the signs and symptoms of what health problem? Morton's neuroma
nurse is assessing reflexes in a patient with hyperactive reflexes. When the patient's foot is abruptly dorsiflexed, it continues to "beat" two to three times before settling into a
resting position. How would the nurse document this finding Clonus When reflexes are very hyperactive, a phenomenon called clonus may be elicited
patient with diabetes has been diagnosed with osteomyelitis. nurse notes that the patient's right foot is pale and mottled, cool to touch, with a capillary refill of greater than 3
seconds. nurse should suspect what type of osteomyelitis? Osteomyelitis with vascular insufficiency
nurse caring for a patient in a persistent vegetative state is regularly assessing for potential complications. Complications of neurologic dysfunction for which the nurse
should assess include which of the following Contractures, Pressure ulcers, Venous thromboembolism,Pneumonia
A 33-year-old patient presents at the clinic with complaints of weakness, incoordination, dizziness, and loss of balance. The patient is hospitalized and diagnosed with MS. What
sign or symptom, revealed during the initial assessment, is typical of MS Blurred vision, intention tremor, and urinary hesitancy
nurse's assessment of a patient's knee reveals edema, tenderness, muscle spasms, and ecchymosis. The patient states that 2 days ago he ran 10 miles and now it "really hurts to
stand up." The nurse should plan care based on the belief that the patient has experienced what A second-degree strain
A family member brings the patient to the clinic for a follow-up visit after a stroke. The family member asks the nurse what he can do to decrease his chance of having another
stroke. What would be the nurse's best answer Stop smoking as soon as possible."
ED nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is
suggestive of a basilar skull fracture Bruising over the mastoid
A nursing diagnosis related to breathing pattern would be the priority for this patient. A C4 spinal cord injury will require ventilatory
support, due to the diaphragm and intercostals being affected.
The nurse is providing care for a patient who has had a below-the-knee amputation. The nurse enters the patient's room and finds him resting in bed with his residual limb
supported on pillow. What is the nurse's most appropriate action Explain the risks of flexion contracture to the patient.
patient returned to the unit after undergoing limb-sparing surgery to remove a metastatic bone tumor. The nurse providing postoperative care in the days following
surgery assesses for what complication from surgery? Delayed wound healing
A patient is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The patient has been placed in traction until his femur can be rodded in
surgery. For what early complications should the nurse monitor this patient Deep vein thrombosis,Compartment syndrome, Fat embolism
nurse is planning discharge education for a patient with trigeminal neuralgia. nurse knows to include information about factors that precipitate an attack.the nurse correct in teaching the patient to avoid
teaching the patient to avoid Washing his face
While assessing the patient at the beginning of the shift, the nurse inspects a surgical dressing covering the operative site after the patients' cervical diskectomy. The nurse notes
that the drainage is 75% saturated with serosanguineous discharge. What is the nurse's most appropriate action
An emergency department patient is diagnosed with a hip dislocation. The patient's family is relieved that the patient has not suffered a hip fracture, but the nurse explains
that this is still considered to be a medical emergency. the rationale for the nurse's statement Avascular necrosis may develop at the site of the dislocation if it is not promptly resolved.
When preparing to discharge a patient home, the nurse has met with the family and warned them that the patient may exhibit unexpected emotional responses. The nurse should teach
the family that these responses are typically a result of what cause Frustration around changes in function and communication
nurse is discharging home a patient who suffered a stroke. He has a flaccid right arm and leg and is experiencing problems with urinary incontinence.
the nurse makes a referral to a home health nurse because of an awareness of what common patient response to a change in body image Depression
A nurse is providing an educational class to a group of older adults at a community senior center. In an effort to prevent osteoporosis,
the nurse should encourage participants to ensure that they consume the recommended adequate intake of what nutrients? Calcium Vitamin D
The nurse is caring for a patient diagnosed with Parkinson's disease. The patient is having increasing problems with rising from the sitting to the standing position. What should
the nurse suggest to the patient to use that will aid in getting from the sitting to the standing position as well as aid in improving bowel elimination Use of a raised toilet seat
patient with a T2 spinal cord injury is admitted. patient is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the patient closely,
the nurse's most appropriate action Prepare for interventions to increase the patient's BP.Manifestations of neurogenic shock include decreased BP and heart rate.
A patient diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the patient and family needs to begin as soon as
the patient is settled on the unit and will continue until the patient is discharged. What will family education need to include How to correctly modify the home environment
A patient newly diagnosed with a cervical disk herniation is receiving health education from the clinic nurse. What conservative management measures should nurse teach the patient to implement
the patient to implement Sleep on a firm mattress rest for several days
A nurse is planning the care of a patient with osteomyelitis that resulted from a diabetic foot ulcer. The patient requires a transmetatarsal amputation. When planning
the patient's postoperative care, which of the following nursing diagnoses should the nurse most likely include in the plan of care Disturbed Body Image
ED is notified that a 6-year-old is in transit with a suspected brain injury after being struck by a car. child is unresponsive at this time, but vital signs are acceptable
the primary goal of initial therapy Preserving brain homeostasis and preventing secondary brain injury, which is injury to the brain that occurs after the original traumatic event.
In the course of a focused neurologic assessment, the nurse is palpating the patient's major muscle groups at rest and during passive movement. Data gleaned from
this assessment will allow the nurse to describe which of the following aspects of neurologic function Muscle tone
To alleviate pain associated with trigeminal neuralgia, a patient is taking Tegretol (carbamazepine). What education should the nurse provide to the patient before initiating
this treatment Blood levels of the drug must be monitored.Side effects of Tegretol include nausea, dizziness, drowsiness, and aplastic anemia.
patient is brought by ambulance to the ED after suffering what the family thinks is a stroke. nurse caring for this patient is aware that an absolute contraindication for
thrombolytic therapy is what Evidence of hemorrhagic stroke Thrombolytic therapy would exacerbate a hemorrhagic stroke with potentially fatal consequences
Which of the following patients should the nurse recognize as being at the highest risk for the development of osteomyelitis An elderly patient with an infected pressure
ulcer in the sacral area Patients who are at high risk of osteomyelitis include those who are poorly nourished, elderly, and obese
In a grade 3 concussion there is a loss of consciousness lasting from seconds to minutes. Temporal lobe involvement results in amnesia. Frontal lobe involvement can cause
uncharacteristic behavior and a grade 1 concussion doesn't involve loss of consciousness. duration of unconsciousness is an indicator of the severity of the concussion.
patient has returned to the postsurgical unit from the PACU after an above-the-knee amputation of the right leg. Results of the nurse's initial postsurgical assessment were
unremarkable but the patient has called out. nurse enters the room and observes copious quantities of blood at the surgical site. What should be the nurse's action Apply a tourniquet.
The school nurse has been called to the football field where player is immobile on the field after landing awkwardly on his head during a play. While awaiting an ambulance,
what action should the nurse perform Ensure that the player is not moved.
nurse is planning the care of a patient who has been recently diagnosed with a cerebellar tumor. Due to location of this patient's tumor, nurse should implement measures to prevent what complication
what complication Falls.A cerebellar tumor causes dizziness, an ataxic or staggering gait with a tendency to fall toward the side of the lesion, and marked muscle incoordination.
elderly patient is being discharged home. The patient lives alone and has atrophy of his olfactory organs. The nurse tells the patient's family that it is essential that the patient have
what installed in the home A smoke detector
The nurse in an extended care facility is planning the daily activities of a patient with postpolio syndrome. The nurse recognizes the patient will best benefit from physical therapy
when it is scheduled at what time In the morning as fatigue often increases in the afternoon and evening.
patient with Huntington disease has just been admitted to a long-term care facility. The charge nurse is creating a care plan for this patient. Nutritional management for a patient with Huntington disease should be informed by what principle
with Huntington disease should be informed by what principle The patient is likely to have an increased appetite.
nurse is writing a care plan for a patient admitted to the emergency department (ED) with an open fracture. The nurse will assign priority to what nursing diagnosis for a patient with an open fracture of the radius
with an open fracture of the radius Risk for Infection
clinic nurse is caring for a patient diagnosed with migraine headaches. During the patient teaching session, the patient questions the nurse regarding alcohol consumption. What
would the nurse be correct in telling the patient about the effects of alcohol Alcohol causes vasodilation of the blood vessels.
school nurse is called to the playground where a 6-year-old girl has been found unresponsive and "staring into space," according to the playground supervisor. How
would the nurse document the girl's activity in her chart at school Absence seizure