Complex Health - Questions for Exam #1

A stroke patient is having difficulty performing previously learned purposeful motor acts on a voluntary basis. What is this documented as?

Apraxia

What is a Stroke?

Hemorrhagic & Ischemic Stroke: The loss of oxygen to part of the brain. Hemorrhagic Stroke: Bleeding in the brain from a blood vessel. Ischemic Stroke: Blocked blood vessel in the brain.

What is the major risk factor for stroke?

Hypertension

What intervention would NOT be included in aspiration precautions for a patient in the Acute Phase of a Stroke? a) Raise HOB to 30 degrees b) Referral to Speech Therapy c) Have patient tuck their chin toward the chest when swallowing d) Thickened Fluids or Pureed Diet

a) Raise HOB to 30 degrees

A 33-year-old client presents at the clinic with reports of weakness, incoordination, dizziness, and loss of balance. The client is hospitalized and diagnosed with Multiple Sclerosis (MS). What sign or symptom, revealed during the initial assessment is typical of MS? a) Flexor spasm, clonus, and negative Babinski Reflex. b) Blurred vision, intention tremor, and urinary hesitancy. c) Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes. d) Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs.

b) Blurred vision, intention tremor, and urinary hesitancy.

A client sustained a Closed Head Injury in a fall from a tree that happened 2-hours ago. There is MRI evidence of a contusion. The client has just begun to regain consciousness and presents by opening eyes when asked, inappropriately responds to questions, and has purposeful movement to painful stimuli. Based on the GCS, the nurse should plan care for a client with which level of injury from this contusion? a) Mild b) Moderate c) Severe d) Extreme

b) Moderate (9 - 12)

A client presents to the emergency department with a head injury received from a fall at home. On admission, the client's Glasgow Coma Scale (GCS) score is 12. Within 20 minutes of arrival, the GCS is 8. What should the Nurse do first? a) Turn up the client's IV rate b) Prepare the Client for intubation c) Retake the client's BP d) Lower the Head of the Bed to 30 degrees

b) Prepare the Client for intubation

A client presents to the emergency department after sustaining a head injury in a MVA. The client is being prepped for diagnostic tests and possible surgery. To maintain the client's health and prevent further damage, what should the nurse be careful NOT to do? a) Log roll the client b) Remove clothing over the client's head c) Place an indwelling catheter d) Reduce fever using cooling blankets

b) Remove clothing over the client's head

A client with a TBI presents with a temperature of 98.2, BP of 83/51, PaO2 of 62 mmHg and a Glasgow Coma Scale (GCS) score of 11. Which of the following nursing interventions is the most appropriate to perform initially? a) Raise the Head of the Bed b) Hyperventilate the Patient c) Initiate fluid replacement with normal saline d) Manage the patient's temperature with a cooling blanket

c) Initiate fluid replacement with normal saline

Vagus nerve demyelinization, which may occur in Guillian-Barre Syndrome, is manifested by which of the following? a) Blindness b) Bulbar Weakness c) Tachycardia d) Inability to Swallow

c) Tachycardia

What education would the nurse include for the family of a client with a C2 level of injury? a) The client should retain movement of their upper extremities b) The client will not be able to eat solid foods c) The client will likely need a ventilator to breathe d) The client should be able to urinate on their own

c) The client will likely need a ventilator to breathe

A patient was recently diagnosed with Myasthenia Gravis (MG). Which statement should the nurse include in her teaching? a) You'll continue to experience muscle weakness and sensory deficits. b) You'll need to take edrophonium to treat the disease. c) This disease doesn't cause sensory impairment. d) The disease is a disorder of motor & sensory dysfunction.

c) This disease doesn't cause sensory impairment.

What is an expected patient outcome for a patient recovering from a Hemorrhagic Stroke? a) Residual Aphasia b) 1 to 4 Seizures c) Complains of Visual Changes d) Exhibits Absence of Vasospasm

d) Exhibits Absence of Vasospasm

The nurse determines that the client has a score of 24 using NHSS and recognizes that this score indicates: a) Minor Stroke b) Moderate Stroke c) Moderate to Severe Stroke d) Severe Stroke

d) Severe Stroke (21 - 42)