Exam 2 DA & Practice Questions

Which is an example of low-energy trauma with reference to fractures? Falls Motor vehicle collisions Injury from contact sports Bicycle accident

Falls

The nurse would expect to carry out which actions while caring for a newly admitted seizure client? Select all that apply. Setting up suction equipment at the client's bedside Having oxygen available at the client's bedside Positioning the client on the right side to prevent aspiration Placing a nasogastric (NG) tube Placing the client on a ventilator

Setting up suction equipment at the client's bedside Having oxygen available at the client's bedside

Which is a clinical feature of a myasthenic crisis? Select all that apply. Tachycardia Sweating and excessive secretions Pale, cool skin Bradycardia Flaccid muscles

Tachycardia Pale, cool skin Flaccid muscles

The nurse recognizes that patients with major changes in personality most likely have damage in which lobe of the brain? A. Frontal B. Occipital C. Parietal D. Temporal

A. Frontal

Which type of fracture creates an external wound that exposes the fracture site? Complete Simple Compound Incomplete

Compound

Using plasmapheresis as a treatment option for Guillain-Barré is beneficial for what reason? It can be done on an outpatient basis, thereby reducing the need for hospitalization. It shortens length of hospitalization and can prevent the patient from needing mechanical ventilation if implemented in the first week of symptom presentation. It is cost effective because it doesn't require skilled nursing staff for administration. It carries no complications as it is not an invasive procedure.

It shortens length of hospitalization and can prevent the patient from needing mechanical ventilation if implemented in the first week of symptom presentation.

The nurse is performing an assessment for a patient with a cast experiencing pain at rest, pressure, and paresthesia of the distal extremity. What could cause these symptoms? Rhabdomyolysis Neurovascular compromise Hypovolemia Hypoxia

Neurovascular compromise

The nurse is assessing a patient who reports severe, unrelenting pain in and around the eye. The pain occurs around the same time for several weeks, more often at night. Which kind of headache is the patient most likely experiencing? Cluster headaches Migraine headaches Episodic tension headaches Chronic tension headaches

Cluster headaches

The majority of medications used in the treatment of Alzheimer's disease focus on which pharmacological pathway? Increasing enzyme action of acetylcholinesterase Increasing enzyme action of butylcholinesterase Increasing oxidative stress Increasing levels of acetylcholine

Increasing levels of acetylcholine

Clients with Alzheimer's disease are more at risk for which of the following? Select all that apply. Infection Falls Dysphagia Pneumonia Dehydration

Infection Falls Pneumonia Dehydration

The nurse is aware that the client with a brain tumor can be medically managed with which treatments? Select all that apply. Chemotherapy Radiation Surgery Bone marrow transplant Blood transfusion

Chemotherapy Radiation Surgery ???

What common complications should the nurse assess for in a client with a brain tumor? Select all that apply. Bleeding Seizures Venous thrombus embolism Decline in kidney function Cerebral edema

Bleeding Seizures Venous thrombus embolism Cerebral edema

The nurse correlates respiratory compromise in GBS with which pathophysiological process? A. Decreased protein in the CSF B. Progressive limb weakness C. Diaphragmatic weakness D. Decreased acetylcholine at the neuromuscular junction

C. Diaphragmatic weakness

Which immunosuppressant medication is used to treat myasthenia gravis (MG)? Select all that apply. Cyclophosphamide Azathioprine Pyridostigmine Mycophenolate mofetil Neostigmine

Cyclophosphamide Azathioprine Mycophenolate mofetil

The patient with MG needs to be educated about medications that should be avoided because they can increase weakness. Which medication should the patient avoid? A. Acetaminophen B. Prednisone C. Azathioprine D. Maalox

D. Maalox (contains Mag)

Which type of therapy might be needed to take care of a client diagnosed with Guillain-Barré syndrome with respiratory compromise? Dialysis Reverse isolation Mechanical ventilation Hyperbaric therapy

Mechanical ventilation

The health unit coordinator notifies the nurse that the CT scan report has been received. An abnormal mass has been noted on the report and a neurology consult is ordered by the admitting physician. The neurologist assesses Mary and based on the findings, schedules surgery for the next morning with the strong possibility of chemotherapy and/or radiation to follow. Of the daily prescriptions that Mary has been taking at home, which is the nurse most concerned about? Diuretic Bronchodilator Selective serotonin reuptake inhibitors (SSRIs) NSAIDs

NSAIDs (Before surgery, the nurse must compile an accurate list of medications the client takes, including prescriptions, over-the-counter drugs, vitamins, and supplements. The NSAIDs are most concerning as these medications may cause bleeding issues during surgery.)

What is a normal finding for the spinal fluid of a lumbar puncture? Cloudy fluid Protein > 50 mg/dL Specific gravity 1.007 Pressure 22 mm Hg

Specific gravity 1.007

A patient has impairment of lower extremity function and poor trunk control. Which part of the spinal cord is the patient most likely to have injured? Sacral region Cervical region Lumbar region Thoracic region

Thoracic region

The next day, the nurse is caring for Mary after the craniotomy. Her bed should be kept at what angle to prevent increased intracranial pressure? Completely flat 30 to 45 degrees 45 to 60 degrees 60 to 90 degrees

30 to 45 degrees (The client's bed should be kept at an angle of 30 to 45 degrees. This promotes venous outflow of blood from the head through the jugular veins to prevent increased intracranial pressure.)

The nurse is caring for the postoperative client after a craniotomy and would like to decrease intracranial pressure. At which angle should the nurse place the head of the bed? 15-30 degrees 30-45 degrees 45-60 degrees 60-75 degrees

30-45 degrees

The nursing diagnosis "ineffective peripheral tissue perfusion associated with deficient knowledge of aggravating factors" applies to which fracture patient with the highest risk of developing VTE? A. A 30-year-old female on oral contraceptives who smokes one pack of cigarettes per day B. A 40-year-old male who ambulates four times a day with a walker C. A 70-year-old diabetic female who attends rehabilitation once a day D. A 20-year-old male who smokes 10 cigarettes per day and ambulates with crutches

A. A 30-year-old female on oral contraceptives who smokes one pack of cigarettes per day

A patient with a history of seizures experiences lip smacking and daydreams during a seizure with no loss of consciousness. The nurse recognizes these clinical manifestations as associated with which type of seizure? A. Absence seizure B. Complex partial seizure C. Atonic seizure D. Myoclonic seizure

A. Absence seizure

Before the start of the semester, what type of meningitis can college-aged students be vaccinated against? A. Bacterial meningitis B. Viral meningitis C. Aseptic meningitis D. Fungal meningitis

A. Bacterial meningitis (S. pneumoniae)

While caring for Ms. Jordan, the nurse monitors for which manifestations of a cholinergic crisis? (Select all that apply.) A. Bradycardia B. Angioedema C. Diarrhea D. Increased heart rate E. Decreased saliva

A. Bradycardia C. Diarrhea

The nurse monitors for which common symptom of compartment syndrome? A. Passive pain at rest B. Pain with movement C. Pallor D. Paresthesia

A. Passive pain at rest

The nurse's role in the overall patient assessment process includes which of the following actions? (Select all that apply.) A. Patient education about the process B. Assessing for allergies to seafood C. Explaining CT scan test results D. Providing reassurance that all will be okay E. Checking renal function laboratory values

A. Patient education about the process B. Assessing for allergies to seafood E. Checking renal function laboratory values

A patient who has undergone a Tensilon test for the detection of myasthenia gravis (MG) has developed bradycardia. Which drug will be most beneficial for the patient? Atropine Neostigmine Pyridostigmine Mycophenolate mofetil

Atropine (Tensilon test used for detection of MG by administering edrophonium IV. Atropine is a muscarinic blocker that reverses the action of edrophonium)

The nurse recognizes which explanation as the pathophysiological basis for MG? A. There is an inadequate number of muscarinic receptors. B. Antibodies to AChRs block neuromuscular junction transmission. C. Thymomas are present in 80% of patients with MG. D. There is an abundance of ACh, which binds to viable receptors.

B. Antibodies to AChRs block neuromuscular junction transmission.

The nurse monitors which diagnostic results in the patient with bacterial encephalitis? (Select all that apply.) A. Isolation of CSF via polymerase chain reaction B. Gram stain and culture of CSF C. CT D. MRI E. EMG

B. Gram stain and culture of CSF C. CT D. MRI

Which clinical manifestations are included in a diagnosis of Parkinson's disease? (Select all that apply.) A. Flaccidity B. Total resistance to movement C. Bradykinesia D. Tremors E. Photophobia

B. Total resistance to movement C. Bradykinesia D. Tremors

The nurse is caring for a client who has had surgery to remove a brain tumor. The nurse would carefully assess the client for which potential complication? Select all that apply. Bleeding Decreased intracranial pressure Venous thromboembolism Congestive heart failure Seizures

Bleeding Venous thromboembolism Seizures

Zachary has undergone placement of an external fixator for an open displaced femur fracture. Immediately following surgery, he begins to exhibit dyspnea, pleuritic chest pain, anxiety, and tachycardia. The nurse suspects which complication? A. Pneumothorax B. Deep vein thrombosis C. Fat embolism D. Myocardial infarction

C. Fat embolism

The nurse recognizes that supplementation with which vitamin has been found to help with symptoms of Alzheimer's disease? A. Vitamin A B. Vitamin C C. Vitamin D D. Vitamin E

D. Vitamin E

Which assessment findings would provide an indication of increased intracranial pressure? Select all that apply. Oxygen saturation Decreased alertness Increased blood pressure Personality changes Swelling of the optic disc

Decreased alertness Personality changes Swelling of the optic disc

A patient taking a daily dose of ibuprofen reports a severe headache every day. Which intervention is most likely to help in relieving the patient's condition? Increasing the dose of ibuprofen Replacing ibuprofen with acetaminophen Providing IV hydration treatment Encouraging the patient to discontinue use of ibuprofen

Encouraging the patient to discontinue use of ibuprofen

Which confirms the diagnosis of Alzheimer's disease (AD)? Neuropsychiatric testing Written and oral testing Examination of the brain following death Examination of cerebrospinal fluid

Examination of the brain following death

As part of discharge planning for a client with Alzheimer's disease, which option would lead to improved outcomes for the client and family members? Use of feeding tube to maintain nutritional status and hydration Use of a bed check to maintain client safety Initiating bladder training Providing referral assistance for support groups and alternative care settings

Providing referral assistance for support groups and alternative care settings ???

The provider plans to implant a vagal nerve stimulator (VNS) to better control James's seizures. The family asks for more information. Which statement by the nurse is correct? The generator continuously stimulates the vague nerve, providing electrical shock. The generator is activated and programmed immediately in the operating room. The generator is implanted into a small pouch in the left chest below the clavicle. Access to the vagal nerve is then established via an incision in the armpit.

The generator is implanted into a small pouch in the left chest below the clavicle. (The generator of the VNS is implanted into a small pouch in the left chest below the clavicle. Access to the vagus nerve is established via an incision in the neck. Either postoperatively or within a 2-week period, the generator is activated and programmed specifically to the patient. The generator is either continuously stimulating the vagus nerve, or the patient carries a small handheld magnet with which he can activate the program with the presence of an aura; thus, a seizure can be minimized and extinguished.)

The nurse documents that a patient had an atonic seizure. What did the nurse observe? The patient experienced a brief contracture of muscles or muscle groups. The patient developed shallow breathing and periods of apnea. The patient had rhythmic jerking of all extremities. The patient experienced a severe fall to the ground with loss of consciousness.

The patient experienced a severe fall to the ground with loss of consciousness. (Atonic seizures result in sudden momentary loss of motor tone. At high risk of injury. May experience head drop or severe fall to the ground accompanied by brief loss of consciousness.)

The adult who has had his first complex partial seizure is asking the nurse when he can drive again. What is the best response to the client regarding this question? "The doctor usually lets clients drive upon discharge." "You will need to notify the Department of Motor Vehicles about your condition. Each state has different rules and regulations." "You will need to notify the national Department of Motor Vehicles about your condition. The rules are the same for every state." "I doubt you will ever drive again, but there are public transportation options that you can explore."

"You will need to notify the Department of Motor Vehicles about your condition. Each state has different rules and regulations."

What pathophysiological processes occur in the first stage, or the acute phase, of GBS? A. Peripheral nerve demyelination, edema, and inflammation B. Depolarization of the spinal nerves C. Destruction of the myelin-producing oligodendrocytes D. Regeneration of the myelin sheath

A. Peripheral nerve demyelination, edema, and inflammation

When educating a patient with migraine headaches, the nurse includes which interventions? (Select all that apply.) A. Practice a healthy lifestyle (cease smoking, alcohol in moderation, exercise) B. Avoid triggers C. Use techniques such as relaxation and stress reduction D. Stop taking medications if symptoms subside to decrease tolerance E. Eliminate all salt and caffeine from the diet

A. Practice a healthy lifestyle (cease smoking, alcohol in moderation, exercise) B. Avoid triggers C. Use techniques such as relaxation and stress reduction

The nurse assesses for which clinical manifestations in a patient admitted with MG? (Select all the apply). A. Ptosis B. Diplopia C. Hyperventilation D. Dysphagia E. Bitemporal headaches

A. Ptosis B. Diplopia C. Hyperventilation ????

The nurse recognizes that the stretching or tearing of a muscle or tendon occurs in which condition? A. Strains B. Dislocations C. Fractures D. Sprains

A. Strains

Which spinal cord injury complications are related to the respiratory system? Select all that apply. Bradycardia Atelectasis Venous pooling Impaired tissue perfusion Pneumonia

Atelectasis Pneumonia

After the nurse provides patient education to Ms. Jordan, the patient states that by taking her medications as instructed and planning frequent rest periods in her day, she should expect which outcome? A. She will succumb to her disease within 5 years. B. Her symptoms will be controlled, and she can consider the disease cured. C. She will be able to manage her disease and have quality of life. D. She will not develop any respiratory complications.

C. She will be able to manage her disease and have quality of life.

A patient reports a sharp, throbbing, and shocklike pain after brushing the teeth, smiling, or talking. Which medication is the most appropriate as first-line therapy? Baclofen Gabapentin Carbamazepine Oxcarbazepine

Carbamazepine (Short, throbbing, & shocklike pain after brushing the teeth, smiling, or talking is a symptom of trigeminal neuralgia. Carbamazepine is first line tx)

The nurse is caring for a patient who has a spinal injury. The patient reports difficulty in breathing. Which region of the spinal cord is injured? Sacral region Cervical region Lumbar region Thoracic region

Cervical region

Which client issues are priorities of nursing care for a client diagnosed with Alzheimer's disease? Select all that apply. Confusion Problems with coping Fluid and electrolyte imbalance Caregiver strain Mobility issues

Confusion Problems with coping Fluid and electrolyte imbalance Caregiver strain (Safety & Hydration are key)

The nurse recognizes which class of medications as most effective in the management of trigeminal neuralgia? A. Anticholinergics B. Antihistamines C. Antibiotics D. Antiepileptics

D. Antiepileptics

The nurse is caring for an older client who has been diagnosed with osteoporosis. The nurse explains to the client that vertebral compression fractures are common with osteoporosis and can result in which condition? Lordosis Scoliosis Spinosis Kyphosis

Kyphosis

The nurse is caring for a client with a metastatic brain tumor. What are the most common locations of the primary cancer? Select all that apply. Liver Lung Melanoma Renal Breast

Lung Melanoma Renal Breast

Which is true regarding the pathophysiology of myasthenia gravis (MG)? An inadequate amount of acetylcholine (Ach) is released. Acetylcholine (Ach) crosses the synaptic clefts and attaches to Ach receptors (AchR). T cells or T lymphocytes are produced by the thymus gland. Sensitivity to normal amounts of acetylcholine is diminished.

Sensitivity to normal amounts of acetylcholine is diminished.

Which neurotransmitters are inhibitory? Select all that apply. Acetylcholine Serotonin Dopamine Glutamate Gamma-aminobutyric acid

Serotonin Dopamine Gamma-aminobutyric acid (GABA)

Which are the best descriptions of the nucleus pulposus? Select all that apply. Shock absorbers Calloused material Firm Spongy material Fluid

Shock absorbers Firm Spongy material

Which surgical procedure is used to treat the patient with Parkinson's disease (PD)? Vagal nerve stimulator (VNS) Stereotactic pallidotomy Deep brain stimulation Partial corpus callosectomy

Stereotactic pallidotomy

Judy is starting on donepezil (Aricept) for a recent diagnosis of Alzheimer's disease. The nurse is providing medication education.What is important to include in the teaching as she begins this medication? monitor heart rate prevents free radical damage transdermal patch generally well-tolerated titrate dosing over several weeks provide finger foods large single-day calendar visible speak calmly using positive statements

Titrating dosing over several weeks (Donepezil (Aricept) inhibits acetylcholinesterase, improving acetylcholinergic function. Side effects include diarrhea, nausea, vomiting, and anorexia. It is important to monitor for weight loss and dehydration. Dosing is titrated over several weeks.)

What type of vitamin therapy may be used in the treatment of Alzheimer's disease? Vitamin D Vitamin E Ascorbic acid or vitamin C Vitamin B12

Vitamin E

Which statement by a nurse regarding a first-degree strain indicates a need for further learning? "The symptoms of a first-degree strain can last for several days." "A first-degree strain demonstrates minimal inflammation and pain." "A first-degree strain is also known as a moderate strain." "Range of motion remains unaffected in a first-degree strain."

"A first-degree strain is also known as a moderate strain."

A registered nurse (RN) is teaching nursing students about Guillain-Barré syndrome (GBS). Which statement of a nursing student indicates a need for further teaching? "It leads to flaccid paralysis." "It is not an autoimmune disease." "It leads to the destruction of the myelin between the nodes of Ranvier." "It is acute inflammatory demyelinating polyneuropathy."

"It is not an autoimmune disease."

The nurse is discharging a patient after surgery for a brain tumor who will be performing blood glucose monitoring at home. The patient asks why this is necessary. How should the nurse respond? "The tumor has caused you to become diabetic." "The medications to decrease swelling cause blood glucose levels to rise." "Having high blood glucose causes the tumor to grow back." "This is a healthy lifestyle choice."

"The medications to decrease swelling cause blood glucose levels to rise."

A patient has returned from the postanesthesia care unit after having surgery to have an external fixator placed for an open tibia fracture with extensive soft tissue damage. What should the nurse do immediately? A. Conduct a neurovascular assessment B. Elevate the extremity C. Perform pin site care D. Remove the dressing and assess the wound

A. Conduct a neurovascular assessment

What is used to diagnose a seizure disorder? (Select all that apply.) A. Electroencephalogram B. Lumbar puncture C. Metabolic panel D. Coagulation studies E. Electromyogram

A. Electroencephalogram B. Lumbar puncture C. Metabolic panel

What interprofessional team members are involved in the management of the patient with Parkinson's disease? (Select all that apply.) A. Oncologist B. Speech therapist C. Occupational therapist D. Interventional radiologist E. Physical therapist

B. Speech therapist C. Occupational therapist E. Physical therapist

The nurse identifies which pathophysiological finding in a third-degree sprain? A. Stretched muscle or tendon fibers B. Torn/ruptured ligaments C. Torn/ruptured muscle or tendon fibers D. Stretched ligaments

B. Torn/ruptured ligaments

James is a young man in his 20s whose been diagnosed with a seizure disorder. He had a tonic-clonic seizure when at a pizza restaurant with some college friends a couple of weeks ago. The seizure has been followed on an outpatient basis, but today he had another seizure at home and is brought to the emergency department.When James arrives, the nurse realizes he is in the postictal phase when observing which symptoms? Select all that apply. Confusion Alertness Disorientation Drowsiness Hunger

Confusion Disorientation Drowsiness (During the postictal phase, which lasts between 5 and 30 minutes, the client is in an altered state of consciousness. He may exhibit drowsiness, confusion, disorientation, nausea, hypoxia, and headache or migraine symptoms.)

The nurse notes that Mary has not had a bowel movement for three days. What priority action should be taken? Contact the healthcare provider for an order for a bowel prep. Contact the healthcare provider for an order for a stool softener. Increase the client's activity. Increase the client's fluid and fiber intake. Check Answer

Contact the healthcare provider for an order for a stool softener. (Straining to have a bowel movement is contraindicated post-surgery as it can increase intracranial pressure. A stool softener may help the client have a bowel movement without straining.)

Look at the image and determine which cranial nerve, when affected because of Guillain-Barré syndrome (GBS), affects this movement? Cranial nerve VII (facial nerve) Cranial nerve X (vagus) Cranial nerve XI (spinal accessory) Cranial nerve XII (hypoglossal)

Cranial nerve VII (facial nerve)

The autoimmune dysfunction in MG results from which process? A. An overabundance of acetylcholine (ACh) B. An inadequate amount of ACh C. An inadequate amount of serotonin D. Destruction of the postsynaptic membrane

D. Destruction of the postsynaptic membrane

Electromyography DECREASED NERVE CONDUCTION or EXAGGERATED NERVE CONDUCTION

DECREASED NERVE CONDUCTION (Electromyography results in GB reveal slowed nerve conduction velocity resulting from demyelination of the nerve cells during the disease process. GB is an autoimmune disease in which destruction of peripheral nerve endings leads to alterations in function. In other words, the patient's own nerves are attacked.)

What finding would the nurse expect to see in a client diagnosed with Guillain-Barré syndrome? Clonus Diarrhea Decreased nerve conduction on electromyography test results No reported abnormalities on lumbar puncture test results

Decreased nerve conduction on electromyography test results

A client diagnosed with Alzheimer's disease may initially present with which clinical manifestations? Select all that apply. Difficulty with vocabulary and fluency Problems with short-term memory Problems with perception Personality changes Word-finding difficulty

Difficulty with vocabulary and fluency Problems with short-term memory Problems with perception Personality changes ???

Which clinical manifestation should a nurse look for in a patient with myasthenia gravis (MG)? Facial pain Areflexia Diplopia Paralysis

Diplopia (Caused by extraocular muscle weakness which leads to double vision. Facial pain indicated TN, Areflexia & Paralysis would indicated GB)

The nurse is viewing an x-ray of a patient who has experienced a fracture. The image shows malalignment of bone fragments at the fracture site. What type of fracture should the nurse document? Oblique Spiral Displaced Depressed

Displaced

While caring of a patient who underwent surgical repair of a fracture, the nurse finds edema in the area where the surgery occurred. Which should the nurse assess next based on these findings? Elevated temperature Level of independence Distal pulses Loss of sensation

Distal pulses

Identify the postoperative nursing processes for a client who has had an orthopedic surgical revision for a fracture (open reduction internal fixation - ORIF) and has developed compartment syndrome. Additional Potential Complications Fat embolism syndrome Hypervolemia Ketoacidosis Respiratory distress Hypovolemia Venous thromboemboli

Fat embolism syndrome Respiratory distress Hypovolemia Venous thromboemboli Rationale: A client who has had ORIF is at risk for numerous complications, including but not limited to fat embolism syndrome, respiratory distress, hypovolemia, and venous thromboemboli. Development of hypervolemia and ketoacidosis would not typically occur.

The client's mother is asking what foods could be included in a ketogenic diet for her school-aged child. The nurse would explain a dietitian would work with the family, but which of the following types of foods would be included on the diet? High carbohydrate and low protein Low carbohydrate and high protein Low fat, high carbohydrate, and low protein High fat, low carbohydrate, and low protein

High fat, low carbohydrate, and low protein

The nurse is teaching a community group about carpal tunnel syndrome (CTS). What should be included in teaching? It is the most frequent compression neuropathy of the legs. This syndrome usually occurs in children. Men are four to five times more likely to get CTS than are women. Higher occurrences are seen in computer operators and construction workers.

Higher occurrences are seen in computer operators and construction workers.

Use of intravenous immunoglobulin (IVIG) therapy for the treatment of Guillain-Barré is thought to have what effect? Shortens recovery time by up to 75% because it blocks macrophage receptor activity Effective for long-term treatment protocols for patients who have long-term disability Helps to promote antibody production Inhibits complement binding

Inhibits complement binding

What is the area of the neurological system that cover the spinal cord and can become inflamed? Meninges Vertebrae Cerebrospinal fluid Blood-brain barrier

Meninges

A patient is diagnosed with myasthenia gravis (MG). The patient also has paralytic ileus and is unable to take oral medication. Which medication is most likely to benefit the patient? Neostigmine Azathioprine Cyclosporine Mycophenolate mofetil

Neostigmine (Short acting Acetylcholinesterase inhibitor administered IV when oral route is not available bc of surgery or other conditions like Crohn's disease, GI bleed, or paralytic ileus)

Mary, a 67-year-old female client, is admitted to the medical-surgical unit from the emergency department (ED). Her primary symptoms include severe headache in the morning for several days, muscle weakness, and changes in her vision. Her daughter brought her to the ED after she was unable to get out of bed. A CT scan has been completed, but the results have not been released upon her admission to the medical-surgical unit. The nurse begins the admission assessment. Based on the symptoms that Mary is reporting, which body system is the priority? Respiratory system Urinary system Neurological system Integumentary system

Neurological System (Though the nurse will do a thorough head-to-toe assessment of the client, the priority action based on the symptoms is to assess the neurological system.)

Identify the postoperative nursing processes for a client who has had an orthopedic surgical revision for a fracture (open reduction internal fixation - ORIF) and has developed compartment syndrome. Most Common Symptoms Pallor Paralysis Paresthesia Pulselessness Pain Pressure Pigment Paraplegia

Pallor Paralysis Paresthesia Pulselessness Pain Pressure Rationale: The most common symptoms of compartment syndrome are the "six Ps"; passive pain at rest, along with pressure, paresthesia, pallor, paralysis, and pulselessness. Pallor, paralysis, and pulselessness are considered to be late findings. Pigment and paraplegia are not symptoms.

Which is true regarding oligodendrogliomas? Select all that apply. They occur during middle age. They are more common in females than in males. They arise from the fatty covering that protects nerves. They arise from the cells that provide support and insulation to axons. They are found in the anterior lobe of the pituitary gland and lead to the hypersecretion of hormones.

They occur during middle age. They arise from the fatty covering that protects nerves. They arise from the cells that provide support and insulation to axons.

The nurse uses cryotherapy in the area of injury for a patient with a sprain. Which is the rationale behind the nurse's intervention? To reduce pain To promote healing To promote mobility To decrease bleeding

To decrease bleeding (Vasoconstriction)

Which describes the role of the speech therapist in terms of care provided for a patient with Parkinson's disease? To maximize independence in activities of daily living (ADLs) To evaluate the patient's ability to swallow To provide exercises that increase strength To promote home safety

To evaluate the patient's ability to swallow

The nurse would be prepared to monitor which lab values in a client who has undergone pituitary surgery and now has diabetes insipidus as a concern? Select all that apply. Urine specific gravity Serum sodium Urine osmolality Serum chloride Urine ketones

Urine specific gravity Serum sodium Urine osmolality

The nurse is assessing a patient who has increased intracranial pressure. Which assessment finding should remain stable? Vital signs Motor function Pupillary function Level of consciousness

Vital signs

Mary has been diagnosed with Alzheimer's disease and has difficulty swallowing medications. Based on this information, the provider orders rivastigmine (Exelon).Why would the provider order this for Mary? monitor heart rate prevents free radical damage transdermal patch generally well-tolerated titrate dosing over several weeks provide finger foods large single-day calendar visible speak calmly using positive statements

transdermal patch (Mary has swallowing issues, so it is preferable for her to take medications that are not taken orally, due to the potential for aspiration. Ravastigmine (Exelon) can be administered using a transdermal patch, so there's no need for Mary to swallow any medication.)

Which precautionary measure should a nurse take when administering pyridostigmine to a patient when treating myasthenia gravis (MG)? Monitoring the blood glucose level, which may fluctuate Administering the medication 30 to 60 minutes before a meal Checking if calcium and vitamin D supplements have been ordered Educating the patient about side effects of steroids

Administering the medication 30 to 60 minutes before a meal

A patient with diabetes who had an elective below-the-knee amputation returns to the unit for IV antibiotic care on postoperative day 3. On closer examination, the nurse notices the patient has a pillow under the residual limb. What should the nurse do in this situation? A. Leave the pillow in place to prevent dependent edema B. Remove the pillow to prevent contractures C. Remove the pillow to prevent VTE D. Leave the pillow to promote circulation

B. Remove the pillow to prevent contractures

What information from Mr. Smith's history may make him ineligible for magnetic resonance imaging (MRI)? A. History of cerebrovascular accident with residual hemiplegia B. History of cardiac dysrhythmias requiring pacemaker C. History of seizure disorders controlled by antiepileptic medications D. History of deep vein thrombosis requiring anticoagulant therapy

B. History of cardiac dysrhythmias requiring pacemaker (metal & MRI don't mix)

Because Zachary has lost a significant amount of blood, what complication should the nurse monitor for? A. Bradycardia B. Hypotension C. Metabolic alkalosis D. Hyperkalemia

B. Hypotension

Which assessment data does the nurse recognize as the most sensitive indicator of increased ICP? A. Pupillary B. Respiratory C. Level of consciousness D. Cranial nerves

C. Level of consciousness

Which interventions should the nurse implement for the patient with Parkinson's disease (PD)? Select all that apply. Elevate head of bed when eating and drinking. Arrange speech therapy for the patient. Teach the patient to take long steps while walking. Teach the patient to call the healthcare provider for medical compliance. Discuss and evaluate the patient's ability to drive.

Elevate head of bed when eating and drinking. Arrange speech therapy for the patient. Teach the patient to call the healthcare provider for medical compliance. Discuss and evaluate the patient's ability to drive.

Which findings are consistent with lumbar puncture results in a patient who has Guillain-Barré syndrome? Select all that apply. Elevated protein levels Normal cell count Moderate bacterial count Excess blood cells Hypocellular

Elevated protein levels Normal cell count

Which feature of a cholinergic crisis may a patient encounter if he or she has myasthenia gravis (MG)? Pale and cool skin Tachycardia Excessive secretions Flaccid muscles

Excessive secretions

Which statement best describes a strain? Dislocation injury Compression injury Ligament injury Muscle or tendon injury

Muscle or tendon injury

The nurse is caring for a patient after a stroke who is having difficulty processing visual information. What part of the patient's brain is most like involved? Frontal Parietal Temporal Occipital

Occipital

The nurse is caring for a client experiencing osteomyelitis secondary to an open fracture. Which complications should the nurse monitor for? Select all that apply. Tetanus Gas gangrene Thrombocytopenia Hypokalemia Disseminated intravascular coagulopathy

Tetanus Gas gangrene

In what stage of Guillain-Barré syndrome does remyelination and axonal regeneration begin? Sub-acute stage Acute stage Plateau stage Recovery stage

Recovery stage

The nurse is caring for a patient with this type of traction. What is the purpose? Relieve muscle spasms Extend the bone in preparation for amputation Bone stabilization Alignment for healing

Relieve muscle spasms Rationale: Skin traction utilizes a flexible harness, boot, or belt to secure the extremity when 5-10 lbs of weight is applied to relieve muscle spasms & maintain the length of the bone

The nurse observes a patient experiencing a partial seizure. Which behavior does the nurse document as automatism? Unilateral, rhythmic muscle movements Rhythmic jerkiness of all extremities Repetitive unconscious movements Visualizations or hallucinations

Repetitive unconscious movements (Involves lip smacking, chewing, or swallowing)

Mary tells the nurse "I think I look horrible; my head is half shaved and looks ridiculous. I don't think I'll leave my house until my hair grows back." What should the nurse recommend? That she shaves the rest of her head That she wears a scarf when she goes out That she should be grateful her tumor was removed That it's a common look and very stylish Check Answer

That she wears a scarf when she goes out (Parts of the head is often shaved for the surgical procedure, wearing head coverings can decrease heat loss from the head and improve self-confidence.)

Identify the postoperative nursing processes for a client who has had an orthopedic surgical revision for a fracture (open reduction internal fixation - ORIF) and has developed compartment syndrome. Fasciotomy: Treatment for compartment syndrome Recommended when there is a strong pulse in the affected limb Urgent procedure Helps to pressure from internal edema Includes the placement of three incisions Incision made into the dermal layer of the skin

Treatment for compartment syndrome Urgent procedure Helps to pressure from internal edema Rationale: When compartment syndrome is present, an immediate fasciotomy is indicated to relieve internal pressure from edema. The surgical procedure includes incisions on both the medial and lateral aspects of the extremity down through the fascia, relieving the compartment pressure.

While caring for a patient with a sprain, the nurse refrains from wrapping the dressing very tightly. Which outcome indicates an effective nursing intervention? The patient will have intact sensation. The patient will have decreased bleeding. The patient will have decreased swelling. The patient will not have vasoconstriction.

The patient will have intact sensation.

Which statement is accurate with regard to stages of Guillain-Barré syndrome (GBS)? Each stage lasts approximately 4 weeks. The plateau stage can last from a few days to a few weeks. The acute stage lasts for 48 to 72 hours. Four stages are seen in GBS clients, with the recovery stage lasting the shortest amount of time.

The plateau stage can last from a few days to a few weeks.

Which consists of 12 pairs of spinal nerves? Sacral region Lumbar region Cervical region Thoracic region

Thoracic region

The nurse is performing a community assessment and identifying risk factors for traumatic amputations. Which group would most benefit from this education? Those with congenital abnormalities Those with ligament deficiencies Those with industrial jobs requiring the use of power tools Those with osteoarthritis

Those with industrial jobs requiring the use of power tools

Which noninvasive study is done to assess the skull and spinal column for fractures, compression, stenosis, and malformation, and can identify areas of injury or trauma? Magnetic resonance imaging (MRI) X-ray Electromyography (EMG) Discogram

X-ray

Which procedure is best to diagnose spinal stenosis? X-ray studies Computed tomography (CT) Cerebral angiography Computed tomography angiography

X-ray studies

For each medication used to treat Alzheimer's disease, drag and drop the correct response related to the provided scenario.John's family is concerned about the side effects of medications commonly used to treat Alzheimer's disease. Based on these concerns, the provider orders memantine (Namenda).Why is this medication being ordered? monitor heart rate prevents free radical damage transdermal patch generally well-tolerated titrate dosing over several weeks provide finger foods large single-day calendar visible speak calmly using positive statements

generally well-tolerated (Memantine (Namenda) generally has few side effects compared with the other medications commonly used to treat Alzheimer's disease)

Michael voices concern to the nurse about his mother with early Alzheimer's disease. "She continually asks me what day it is. It's driving me nuts."What suggestion can the nurse give? monitor heart rate prevents free radical damage transdermal patch generally well-tolerated titrate dosing over several weeks provide finger foods large single-day calendar visible speak calmly using positive statements

large single-day calendar visible (Placing a clock and calendar in the client's home can prevent disorientation. It needs to be large and in an obvious location. When it shows a single day and time, it will not require interpretation. The nurse should provide orientation to time and date for the client as cognition declines.)

The nurse is preparing to administer galantamine (Razadyne) to Daniel, who has recently been diagnosed with Alzheimer's disease.What should the nurse do before administering the medication? monitor heart rate prevents free radical damage transdermal patch generally well-tolerate titrate dosing over several weeks provide finger foods large single-day calendar visible speak calmly using positive statements

monitor heart rate (Most medications used in the treatment of Alzheimer's disease may cause bradycardia, so the client's heart rate should be monitored before administering. If the client's heart rate is too low, you should review the provider's order or contact the healthcare provider for further instruction.)

The provider has added vitamin E to Thomas's medication administration record. Medical history reveals that he has hypothyroidism, heart failure, and Alzheimer's disease.What health benefit will this medication provide? monitor heart rate prevents free radical damage transdermal patch generally well-tolerated titrate dosing over several weeks provide finger foods large single-day calendar visible speak calmly using positive statements

prevents free radical damage (Vitamin E is an antioxidant, and inclusion of an antioxidant in a treatment plan for Alzheimer's disease clients will help to prevent tissue damage from oxygen radicals. Clinical comorbidities associated with Alzheimer's disease and its treatment—hypothyroidism and heart failure especially—involve tissue damage, so the addition of vitamin E to prevent damage from free radicals would be significant.)

Lou has Alzheimer's disease and frequently gets loud and frustrated. During a visit to the clinic, he begins to get frustrated with the nurse and starts yelling.How should the nurse respond? monitor heart rate prevents free radical damage transdermal patch generally well-tolerated titrate dosing over several weeks provide finger foods large single-day calendar visible speak calmly using positive statements

speak calmly using positive statements (Speak calmly using positive statements and reassurance when the patient is agitated. The client may require frequent reminders to control anger outbursts. A calm approach and tone decrease escalation of the client's agitation is most therapeutic and helpful.)

The client's mother has heard a certain type of diet can improve seizure control. Although usually used with children, the doctor believes a ketogenic diet may be effective for James. When asked by the mother to explain a ketogenic diet, what information would you provide? "A ketogenic diet is high in protein, but low in carbohydrates and fats." "A ketogenic diet is high in carbohydrates and fats, but low in protein." "A ketogenic diet is high in fat and low in carbohydrates and protein." "A ketogenic diet is a balanced diet with equal values of fat, carbohydrates, and protein."

"A ketogenic diet is high in fat and low in carbohydrates and protein." (A ketogenic diet can help improve metabolic seizure control, primarily in children. The diet is high in fat (80%-90%) and low in carbohydrates and protein. The parents should work with a dietitian to formulate meal plans when helping a child implement this diet.)

How would the nurse explain to the client the difference between a strain and a sprain? "A sprain is the tearing of a muscle, tendon, or ligament; a strain is the stretching of a muscle, tendon, or ligament." "A sprain is stretching of a muscle, tendon, or ligament; a strain is the tearing of a muscle, tendon, or ligament." "A sprain is the stretching or tearing of a muscle or tendon; a strain is the stretching or tearing of a ligament." "A sprain is the stretching or tearing of a ligament; a strain is the stretching or tearing of a muscle or tendon."

"A sprain is the stretching or tearing of a *ligament*; a strain is the stretching or tearing of a *muscle or tendon*."

The nurse enters the room before breakfast to draw blood for a bedside glucose test. Mary is confused about why this test is necessary. What is the best explanation the nurse can provide? "Because the steroid you are receiving can elevate your glucose, the nurses will be monitoring your blood sugar while you are in the hospital. We will help you learn more about doing your own blood sugar testing if it is necessary when you go home." "Anyone who has had a craniotomy will have to monitor the blood sugar the rest of his or her life. We will teach you how to do this before you leave the hospital." "Because the IV fluids contain dextrose, which is a type of sugar, the nurses must monitor your blood sugar while you are in the hospital." "You might have to monitor your sugar after you are discharged. You can ask your healthcare provider the next time they visit."

"Because the steroid you are receiving can elevate your glucose, the nurses will be monitoring your blood sugar while you are in the hospital. We will help you learn more about doing your own blood sugar testing if it is necessary when you go home." (Steroids are used postoperatively for neurosurgery clients to treat and prevent further local cerebral edema. However, steroids may cause elevated blood glucose. Some clients may receive insulin until the levels go back to normal when the steroids are discontinued. This is not a permanent condition. The elevated blood glucose levels are not related to IV fluids that contain glucose. Referring the client to ask the healthcare provider does not position you as a client advocate._

A nurse is teaching about nursing actions for caring for patients with Guillain-Barré syndrome (GBS). Which statement indicates a need for further teaching? "Do not keep the patient in a single position." "Do not offer any kind of diversions to the patient." "Establish methods of communication, and provide a method to call the nurse." "Discuss the use of analgesics or nonopioids with the healthcare provider."

"Do not offer any kind of diversions to the patient."

The nurse is teaching about the interventions provided before a cerebral angiography procedure. Which statement indicates the need for further teaching? "I must advise the patient to be well hydrated and to drink plenty of fluids." "I must inform the patient that it takes 60 to 120 minutes for the procedure." "I will ensure that the procedure is started only after the patient gives informed consent." "I will inform the patient not to worry if he or she feels warmth when the IV contrast is administered."

"I must advise the patient to be well hydrated and to drink plenty of fluids."

The nurse is discussing treatment with a patient who has a brain tumor and is receiving chemotherapy. Which statement made by the patient indicates a need for further teaching? "I should wear a hat while going out." "I should stop taking glucocorticoids when I feel normal." "I should rinse my mouth with alcohol-free mouthwash." "I should consult the primary healthcare provider when a dose of antiepileptic medication is missed."

"I should stop taking glucocorticoids when I feel normal." (rapid withdrawal can cause adrenal crisis. Needs to be tapered)

The nurse is teaching a patient about seizure management. Which statement made by the patient indicates effective teaching? Select all that apply. "I should wear a medic alert bracelet." "I should refrain from driving." "I should monitor my blood glucose levels daily." "I should take short and deliberate steps while walking." "I should apply sunscreen and skin emollients while going out in sunlight."

"I should wear a medic alert bracelet." "I should refrain from driving."

The nurse is teaching a patient about seizure management. Which statement by the patient about this image demonstrates understanding? "I should wear this all of the time." "If I don't have it on, I can tell people I have a seizure disorder." "I only need to wear this when I leave the house." "This will help me if I get pulled over when driving."

"I should wear this all of the time." (Important bc it facilitates prompting necessary interventions in the event of a seizure)

The nurse is providing client teaching regarding the use of phenytoin and is aware the client requires further teaching when the client makes which statement? "I know that I must follow my medication regimen." "If I feel ill, it is okay for me to stop taking this medication." "I should refill my prescription before it runs out." "I should have regular dental checkups."

"If I feel ill, it is okay for me to stop taking this medication."

James has been prescribed phenytoin (Dilantin). The nurse is providing client teaching regarding this medication. Which statement demonstrates understanding? "I understand the medication will turn my urine orange." "It is important for me to have regular dental checkups." "I will not have to have any blood work to check the level of medicine in my blood with this medicine." "If I run out of medicine, it is OK not to take it for a couple of days until I can get my prescription filled." Check Answer

"It is important for me to have regular dental checkups." (The client teaching has been noted as effective when James states it is important to have regular dental checkups. A side effect of phenytoin is gingival hyperplasia, enlargement of the gum tissue in the mouth. This condition can lead to gum and tooth issues and should be monitored by a dentist. James should also understand that he cannot stop taking the medication for any reason. He should have plans in advance to have the prescription refilled before running out. He will have regularly scheduled lab work ordered to check phenytoin levels.)

A patient recently obtained a fracture and is asking the nurse about nonsurgical management of bone fractures. Which statements by the nurse are correct? Select all that apply. "Nonsurgical management of bone fractures can be achieved with the help of splints." "External fixation is a form of nonsurgical management of bone fractures." "Nonsurgical management of bone fractures can be achieved with the help of casts." "Open reduction with internal fixation is a form of nonsurgical management of bone fractures." "Closed reduction is a form of nonsurgical management of bone fractures."

"Nonsurgical management of bone fractures can be achieved with the help of splints." "Nonsurgical management of bone fractures can be achieved with the help of casts." "Closed reduction is a form of nonsurgical management of bone fractures."

The nurse is teaching about myasthenia gravis (MG) with a newly diagnosed patient. Which statement by the patient indicates a need for further teaching? "The symptoms include localized skeletal muscle weakness, ptosis, diplopia, and fatigue." "Penicillamine is used in the treatment of MG." "Serological tests and electromyography are used in the diagnosis of MG." "Plasmapheresis is an additional therapy used in the treatment of MG."

"Penicillamine is used in the treatment of MG." (Used in tx of Rheumatoid Arthritis. Can worsen or induce MG)

The nurse is caring for a patient who has recurrent tension headaches. Which is the most appropriate instruction for the nurse to give the patient about a headache diary? "Document activities performed throughout the day." "Document lifestyle and food habits." "Record the date and time when the headache occurs." "Record the medications taken for pain relief."

"Record the date and time when the headache occurs."

The nurse is caring for a client who is considering the implantation of a vagal nerve stimulator (VNS) to treat and control seizures. The nurse knows the client understands the purpose of the VNS when she makes which statement? "Electrodes are placed in deep brain structures and programmed to activate when the seizure activity is sensed." "I will be admitted to the hospital for at least a week to have the VNS implanted." "The VNS will either fire continuously or I may have to carry a magnet to activate the stimulator when I feel the presence of an aura." "The connection between the right and left hemisphere of the brain will be severed."

"The VNS will either fire continuously or I may have to carry a magnet to activate the stimulator when I feel the presence of an aura."

The charge nurse asks the student nurse to gather supplies to set up suction for a seizure client who is going to be admitted to the nursing unit. The student nurse asks why this equipment is needed. How should the charge nurse respond? "The client may not be able to protect the airway after the seizure and suctioning may be required." "The healthcare provider ordered it, so we are required to do it." "It will be available if the client wishes to use the equipment." "The client may have aspirated before coming to the hospital and the nursing staff may need to suction out the aspirate."

"The client may not be able to protect the airway after the seizure and suctioning may be required."

The nurse is preparing to give the client who had a craniotomy an oral stool softener. The client's wife asks why the client needs this medication and says the client rarely has problems with constipation. What is the nurse's best response? "The doctor ordered the medicine, so the client needs to receive it." "The client needs to avoid straining to have a bowel movement." "If the client does not want to take the stool softener, it is fine with me." "At times a client gets constipated, and the doctor wants to prevent that."

"The client needs to avoid straining to have a bowel movement."

The nurse is caring for a patient who is prescribed carbamazepine for complex partial seizures. Which is the most appropriate information for the nurse to teach the patient? "The medication must be chewed." "The medication may cause blurred vision." "Weight gain is a side effect of the medication." "The medication may cause sedation."

"The medication may cause blurred vision." (Monitor for visual changes)

The nurse is discharging a patient after surgery for a brain tumor who will be performing blood glucose monitoring at home. The patient asks why this is necessary. How should the nurse respond? "The tumor has caused you to become diabetic." "The medications to decrease swelling cause blood glucose levels to rise." "Having high blood glucose causes the tumor to grow back." "This is a healthy lifestyle choice."

"The medications to decrease swelling cause blood glucose levels to rise." (Glucocorticoids)

The client with a brain tumor is being discharged from the hospital. The nurse is explaining that the blood glucose must be monitored for a period of time after discharge. The client states, "Do I now have diabetes to deal with also?" What would be the nurse's best response? "It is difficult to tell at this time; your glucose has been high during your hospital stay. We will have to wait and see." "The steroids you have been taking can cause hyperglycemia. When the steroids are finished, blood sugar typically will return to normal." "I cannot answer your question. You must talk to your healthcare provider about your concerns." "Yes, you are diabetic and will have to check your blood sugar four times a day for the rest of your life."

"The steroids you have been taking can cause hyperglycemia. When the steroids are finished, blood sugar typically will return to normal."

A nurse is teaching about second-degree sprains. Which statement indicates a need for further teaching? "It can also be considered as a moderate sprain." "It prevents a patient from ambulating due to joint instability." "It leads to increased swelling, ecchymosis, pain, and altered weight-bearing mobility." "It results from a significantly moderate amount of tearing in the ligament fibers."

*"It prevents a patient from ambulating due to joint instability."

Arrange in order the actions a nurse should take for a patient who has hemorrhagic shock due to a traumatic amputation: - Prepare the patient for surgery to repair the severed extremity. - Notify the primary healthcare provider. - Immediately assess the wound for active hemorrhaging. - Place a pressure bandage or tourniquet and monitor for effectiveness. - Obtain a complete blood count (CBC) and type and crossmatch for immediate blood transfusion according to the primary healthcare provider's orders.

- Immediately assess the wound for active hemorrhaging. - Place a pressure bandage or tourniquet and monitor for effectiveness. - Notify the primary healthcare provider. - Obtain a complete blood count (CBC) and type and crossmatch for immediate blood transfusion according to the primary healthcare provider's orders. - Prepare the patient for surgery to repair the severed extremity.

Due to Mr. Smith's complaints of persistent headaches, the nurse assesses for other signs of increased intracranial pressure. Which finding may also be associated with increased intracranial pressure? A. Change in level of consciousness B. Tachycardia C. Diaphoresis D. Hypotension

A. Change in level of consciousness

Mr. Smith keeps his appointment with his neurologist. Upon his arrival, the first part of the assessment process is to complete a comprehensive history and physical examination. Mr. Smith has no significant health history. He exercises regularly, has a healthy diet, and drinks alcohol in moderation. The neurologist next obtains a thorough history of Mr. Smith's chief complaint of headaches, which have been frequent and severe for several weeks and unrelieved with aspirin or Tylenol. There does not seem to be a precipitating event such as diet or exercise, but after close questioning, it seems eating certain foods may be connected. The neurologist continues with the neurological assessment. The nurse recognizes which parameter as an important component of the neurological examination for Mr. Smith? A. Cranial nerve assessment B. Glasgow Coma Scale assessment C. Assessing the Babinski sign D. Assessing cerebral perfusion pressure

A. Cranial nerve assessment

The nurse correlates which diagnostic result for an older adult with a suspected pathologic fracture? A. Decreased bone density B. Increased osteocytes C. Hypertension D. Coagulopathy

A. Decreased bone density

The nurse correlates which of the following critically low laboratory results with a traumatic amputation? A. Hemoglobin (Hgb): 7.0 g/dL B. Glucose: 60 mg/dL C. BUN: 10 mg/dL D. WBC: 4,000 103/mm3

A. Hemoglobin (Hgb): 7.0 g/dL

The nurse prioritizes which nursing diagnosis in the patient immediately after arthroscopic surgical repair of the medial meniscus injury? A. High risk for ineffective airway clearance associated with general anesthesia B. High risk for ineffective breathing associated with intubation C. Self-care deficit associated with pain, edema, and immobility D. Pain associated with inflammation

A. High risk for ineffective airway clearance associated with general anesthesia

Ms. Jordan has been taking prednisone 20 mg daily for management of her MG. What side effects should she be monitored for during her hospitalization? (Select all that apply.) A. Hyperglycemia B. Weight gain C. Cardiomegaly D. Heart failure E. Insomnia

A. Hyperglycemia B. Weight gain E. Insomnia ????

During her hospitalization, Ms. Jordan receives plasmapheresis treatments. Following the plasmapheresis treatments, the nurse monitors Ms. Jordan for which complications? (Select all that apply.) A. Hypotension B. Stevens-Johnson syndrome C. Galactorrhea D. Hypocalcemia E. Hypoglycemia

A. Hypotension D. Hypocalcemia

The nurse correlates which responses as associated with the sympathetic nervous system? (Select all that apply.) A. Increased heart rate B. Decreased respiratory rate C. Increase in peristalsis D. Dilated bronchioles E. Decreased heart rate

A. Increased heart rate D. Dilated bronchioles

The nurse correlates which clinical manifestation to a secondary headache? A. Sudden severe onset B. Tense neck muscles C. Nausea D. Tingling scalp sensation

A. Sudden severe onset (then evaluated for clinical manifestations of meningitis, CSF leak ( esp w/ hx of lumbar puncture or epidural), cerebral aneurysm, cerebral aneurysm rupture, or brain tumor)

Deep Tendon Reflexes AREFLEXIA or CLONUS

AREFLEXIA (Absence of reflexes (areflexia) is seen in patients who have GB.)

Following the surgical procedure for an open displaced femur fracture, what action does the nurse frequently perform? A. ROM exercises B. Neurovascular assessments C. Dressing changes D. Pain assessments

B. Neurovascular assessments

The nurse caring for a client who is post status epilepticus is aware that status epilepticus can be caused by which conditions? Select all that apply. Anaphylactic reaction to medication Abrupt withdrawal of anticonvulsive medications Myocardial infarction Acute drug withdrawal Head trauma

Abrupt withdrawal of anticonvulsive medications Acute drug withdrawal Head trauma

Which is true regarding acetylcholine? Select all that apply. The activity of acetylcholine is triggered by acetylcholinesterase. Acetylcholine diffuses across the synapse and binds to muscarinic acetylcholine receptors on the parasympathetic end organ. Acetylcholine crosses the synapse to bind to nicotinic receptors of the membrane of the postganglionic neurons. Acetylcholine is the substance released into the synapse when an action potential is conducted down the axon of the preganglionic autonomic neuron. Acetylcholine is a neurotransmitter synthesized by sympathetic neurons.

Acetylcholine diffuses across the synapse and binds to muscarinic acetylcholine receptors on the parasympathetic end organ. Acetylcholine crosses the synapse to bind to nicotinic receptors of the membrane of the postganglionic neurons. Acetylcholine is the substance released into the synapse when an action potential is conducted down the axon of the preganglionic autonomic neuron.

Which nursing actions should a nurse take for a patient who has undergone amputation? Select all that apply. Place a pillow under the remaining portion of the lower extremity. Administer analgesics as per the order. Apply ice for at least an hour on the site. Apply a rigid cast or splint. Encourage intake of additional protein- and carbohydrate-rich foods.

Administer analgesics as per the order. Apply a rigid cast or splint. Encourage intake of additional protein- and carbohydrate-rich foods.

Which intervention should the nurse implement for the patient with increased intracranial pressure following a brain tumor resection? Administer stool softeners. Position the patient in a supine position at all times. Apply sequential compression devices. Encourage the patient to use a non-alcohol containing mouth wash.

Administer stool softeners. (Rationale: The nurse must administer stool softeners when caring for patients with increased intracranial pressure. This helps decrease Valsalva and straining, which can further increase intracranial pressure. Cn use compression devices, but not immediately after surfery)) devices)

The registered nurse (RN) is providing postsurgical care for a patient with a brain tumor. Which nursing action helps to prevent cerebral edema? Administering glucocorticoids to the patient Positioning the patient's head at a 15° angle Applying a sequential compression device to the patient Administrating benzodiazepines to the patient

Administering glucocorticoids to the patient

Which should a nurse keep in mind when caring for a patient with a traumatic amputation? Select all that apply. Apply a tourniquet to the remaining limb. Salvage surgery may be ordered for the patient by the primary healthcare provider. A coagulation panel, complete blood count (CBC), and serum lactate baseline level should be established. The Phalen test may be performed on the patient . The Steinman test may be performed on the patient .

Apply a tourniquet to the remaining limb. Salvage surgery may be ordered for the patient by the primary healthcare provider. A coagulation panel, complete blood count (CBC), and serum lactate baseline level should be established.

Which nursing action helps in preventing venous thromboembolism in a patient who is postcraniotomy? Administering stool softeners to the patient Instructing the patient to use a soft toothbrush Elevating the patient's head of the bed to a 45-degree angle Applying a sequential compression device to the patient

Applying a sequential compression device to the patient

A nurse is taking care of an athlete who has a first-degree sprain in the ankle. Which action by the nurse indicates a need for further training? Advising the patient to rest the injured extremity up to 72 hours Applying ice for at least 60 minutes at a stretch only for the first 24 hours after injury Applying a compression dressing Elevating the affected area

Applying ice for at least 60 minutes at a stretch only for the first 24 hours after injury

Which client presentation is indicative of a clinical diagnosis of Guillain-Barré syndrome? Bilateral pitting edema of the lower extremities Areflexia Nasal congestion Petechiae

Areflexia

Which should the nurse do to assess for when performing this on the patient with meningitis? (Kernig's Sign) Assess the patient's ability to move the head sideways. Assess the patient for involuntary flexion of the hips. Assess the movement of the eyes on the affected side. Assess the patient for pain behind the knee.

Assess the patient for pain behind the knee.

During the edrophonium or Tensilon test, a short-acting AChE inhibitor is administered intravenously, and the provider observes the patient for improvement in which function? A. Level of consciousness B. Muscle strength C. Muscle tone D. Hearing

B. Muscle strength

Identify the postoperative nursing processes for a client who has had an orthopedic surgical revision for a fracture (open reduction internal fixation - ORIF) and has developed compartment syndrome. Nursing Actions Begin total parenteral nutrition Assist with dressing removal Prepare client for fasciotomy Place the client in high semi-Fowler's position Prepare to administer antibiotics Begin preoperative teaching

Assist with dressing removal Prepare client for fasciotomy Begin preoperative teaching Rationale: As compartment syndrome is considered a medical emergency, you should be prepared to assist the orthopedic surgeon with removal of surgical dressing. Additionally, you should anticipate that the client will undergo a fasciotomy to relieve pressure in the compartment and begin preoperative teaching for this procedure. Maintaining the client in a high semi-Fowler's position is not required. TPN would only be indicated if there were additional comorbidities that warrant this intervention. Antibiotics will not correct the problem.

The nurse asked a family member of a client with seizures if the client exhibited automatisms with the most recent seizure. The family member asked for clarification on what the term automatisms meant. How should the nurse respond? Automatisms are odors, visualizations, and/or hallucinations that occur just prior to the beginning of the seizure. Automatisms are symptoms such as drowsiness, confusion, and disorientation that occur immediately after the seizure. Automatisms are repetitive unconscious movements such as chewing or lip smacking. Automatisms are the tonic/clonic movement seen in some types of seizures.

Automatisms are repetitive unconscious movements such as chewing or lip smacking.

Which method allows for a definitive diagnosis of Alzheimer's disease? Computed tomography scan of the brain Microscopic observation of neurofibrillary tangles Autopsy Review of client history and symptomology

Autopsy

The nurse monitors the heart rate of a client with Alzheimer's disease before giving treatment medication because of which potential complication? Premature atrial contractions Atrial fibrillation Bradycardia Atrial flutter

Bradycardia

Which sign is included in the triad of symptoms referred to as Cushing's triad? Tachypnea Ptosis Narrowing pulse pressure Bradycardia

Bradycardia

When caring for a patient with increased intracranial pressure (ICP), the nurse should be monitoring for which high-risk complication? Hypertensive crisis Brainstem herniation Cardiac dysrhythmias Stroke

Brainstem herniation (Cerebral Perfusion pressure -> secondary injury to brain via cytotoxic & anoxic injury -> herniation of brain)

Which action is critical when administering a pyridostigmine 60-mg tablet to a patient with MG? A. Administer with milk and crackers to minimize gastrointestinal distress. B. Administer 2 hours after meals because food slows gastric absorption. C. Administer 30 to 60 minutes before meals to optimize the strength of the chewing and swallowing muscles. D. Administer with orange juice because vitamin C facilitates gastric emptying.

C. Administer 30 to 60 minutes before meals to optimize the strength of the chewing and swallowing muscles.

The nurse recognizes that the patient with Parkinson's disease is at risk for which complication? A. Excessive dry mouth due to autonomic dysfunction B. Facial twitching secondary to seizure activity C. Orthostatic hypotension due to involvement of the sympathetic nervous system D. Flaccid extremities related to the increased levels of dopamine

C. Orthostatic hypotension due to involvement of the sympathetic nervous system

The nurse recognizes which as the probable cause of Alzheimer's disease? A. Exposure to environmental toxins B. CNS trauma C. Unknown D. Chronic hypertension

C. Unknown

Which etiologic agents might lead to the development of Guillain-Barré syndrome? Select all that apply. Campylobacter jejuni Epstein-Barr virus Pediculosis Mycoplasma pneumoniae H. pylori

Campylobacter jejuni Epstein-Barr virus Mycoplasma pneumoniae

Which is true regarding a compression fracture? It occurs around the shaft of the bone. It occurs at a 45° angle across the cortex of the bone. It occurs as a result of overstretching and tearing of a tendon or ligament. It occurs as a result of excessive force along the axis of cancellous bone.

It occurs as a result of excessive force along the axis of cancellous bone.

The nurse anticipates which as the next step in the assessment process after the neurological examination? A. MRI B. Evoked potentials C. Lumbar puncture D. CT scan

D. CT scan

The nurse monitors Zachary for which signs of rhabdomyolysis? A. Bloody urine and abdominal pain B. Anuria, nausea, and severe flank pain C. Low serum myoglobin, fever, and severe headaches D. Elevated serum myoglobin, tea-colored urine, and severe flank pain

D. Elevated serum myoglobin, tea-colored urine, and severe flank pain

Which nursing intervention is a priority for a patient with cranial nerve impairment from GBS? A. Perform sensory checks with the neurological examination below the level of the cervical spine. B. Consult with the provider for initiation of continuous positive airway pressure for breathing. C. Create a turning schedule with limited time in the side-lying position. D. Establish effective communication using eye blinks or a communication board.

D. Establish effective communication using eye blinks or a communication board. (Rationale: Due to cranial nerve involvement, patient with GBS will have difficulty speaking. The voice may be low or raspy with difficulty articulating due to cranial nerve involvement. The other interventions are not associated with cranial nerve impairment.)

The nurse is performing discharge instructions with Mary and discussing the steroids she will be taking after discharge. What educational point is most important? Take the steroids with a full glass of milk. Do not stop the steroids abruptly. They must be tapered. Only take the steroids at bedtime. The need to take the steroids for the rest of her life.

Do not stop the steroids abruptly. They must be tapered. (It is important to provide clear direction to the client regarding the importance of tapering the steroid dose as ordered. Rapid withdrawal of glucocorticoids can cause an adrenal crisis.)

Which lifestyle changes are most appropriate for the nurse to teach to the patient in order to prevent headaches? Select all that apply. Drink an adequate amount of fluids. Perform gentle exercises of the neck. Eliminate triggers from the diet. Establish consistent sleep habits. Eat as little as possible on the days you have headaches.

Drink an adequate amount of fluids. Perform gentle exercises of the neck. Eliminate triggers from the diet. Establish consistent sleep habits.

In which phase of migraine headache does the patient experience confusion and exhaustion? During the premonitory phase Prior to the migraine After the patient experiences auras During the postdromal phase

During the postdromal phase

In which state of a seizure is a patient most likely to have compromised airway and decreased level of consciousness? After a seizure episode During the preictal state During the postictal state Between seizure episodes

During the postictal state (Compromised airway secondary to decreased LOC following a seizure)

CSF - Cerebrospinal Fluid with Normal Cell Count and DECREASED PROTEIN or ELEVATED PROTEIN

ELEVATED PROTEIN (CSF results for a patient with GB would reveal increased protein levels and a normal cell count.)

Which are symptoms of the acute phase of Guillain-Barre syndrome (GBS)? Select all that apply. Edema Inflammation Remyelination Axonal regeneration Peripheral nerve demyelination

Edema Inflammation Peripheral nerve demyelination

The nurse is caring for a patient with viral meningitis who asks what could have caused this. What should the nurse include with the answer? Lumbar puncture Intraventricular catheter Traumatic injury Lack of immunization against mumps

Lack of immunization against mumps

Which are major ascending tracts of the spinal cord? Select all that apply. Tectospinal tract Fasciculus gracilis Spinoreticular tract Medial reticulospinal tract Posterior spinocerebellar tract

Fasciculus gracilis Spinoreticular tract Posterior spinocerebellar tract

The nurse expects to find the client receiving chemotherapy for a brain tumor exhibiting which signs and symptoms? Select all that apply. Fatigue Weight gain Mucositis Hair loss Reddening of skin

Fatigue Mucositis Hair loss

A patient comes to the emergency department and is being ruled out for meningitis. What symptoms would cause the provider to question this? Select all that apply. Fever and headache Flashing lights Nuchal rigidity Opisthotonos Uncontrolled yawning

Fever and headache Nuchal rigidity Opisthotonos

Which is true regarding a cholinergic crisis? It is caused by lack of anticholinesterase medication. It is an exacerbation of myasthenic gravis weakness that provokes an acute episode of respiratory failure. It is characterized by a clinical feature such as tachycardia. It is caused by an excessive intake of anticholinesterase medication.

It is caused by an excessive intake of anticholinesterase medication.

After assessing a patient with a fracture, the nurse documents a grade II open fracture. Which manifestations in the patient support the nurse's documentation? Select all that apply. Intact vasculature Fragments of broken bone Significant wound contamination Minimal injury to the soft tissues Severe damage to the blood vessels

Fragments of broken bone Significant wound contamination

The computed tomography reports of a patient show a glioma located near the brainstem. Which grade of brain tumor does the patient have? Grade I Grade II Grade III Grade IV

Grade IV (Most aggressive & lethal glioma near brain stem)

Respiratory Impairment INCREASED or DECREASED

INCREASED (Due to ascending paralysis, the patient with GB is at risk for increased respiratory impairment, which may require intubation and mechanical ventilation assistance. As the paralysis travels up the body and reaches the core and chest wall muscles, respiratory function becomes impaired. For instance, when paralysis reaches the diaphragm, the muscles do not move properly to help inflate and deflate the lungs.)

Level of consciousness and cognitive level IMPAIRED or INTACT

INTACT (The client's level of consciousness and cognitive function remain intact throughout the course of the illness despite the physical limitations.)

Which is true regarding the parasympathetic nervous system? It is referred to as the "rest and digest" portion of the nervous system. It is referred to as the "flight or fight" system. It regulates involuntary functions of the body. It elevates heart rate, blood pressure, and respiratory rate.

It is referred to as the "rest and digest" portion of the nervous system.

Which teaching points should the nurse include when educating James's parents about caring for a client with seizures? Select all that apply. If possible, turn the client on the left side during or immediately after a seizure to reduce the risk of aspiration. Attempt to restrain the client to reduce the risk of injury during the seizure. Do not force any object into the mouth during the seizure. Offer the client a drink of water immediately following the seizure. Document specifics of the seizure activity to report to the client's healthcare provider.

If possible, turn the client on the left side during or immediately after a seizure to reduce the risk of aspiration. Do not force any object into the mouth during the seizure. Document specifics of the seizure activity to report to the client's healthcare provider. (The person should be turned on his left side during or immediately after the seizure to reduce the risk of aspiration. The person should be protected from harm without being restrained, and should not be offered any drink or food immediately after the seizure. Parents should document specifics of the seizure, including date, time, duration of the seizure, description of the seizure, and sequence of the seizure progression. The parent should also document any observations during the preictal and postictal phases and share these observations with the healthcare provider.)

The nurse is assisting in a lumbar puncture and the spinal fluid is pink. Before assuming there is a problem, what should the nurse question? If the patient is on blood thinners If the procedure was traumatic If the specimen was contaminated If the patient's laboratory values are normal

If the procedure was traumatic

Which interventions should the nurse implement when caring for the patient with bacterial meningitis? Select all that apply. Ensure the patient is in a supine position except during meals. Ensure the room is brightly lit and pleasant. Implement droplet precautions. Keep the patient warm at all times. Teach the patient to take full course of antibiotics.

Implement droplet precautions. Teach the patient to take full course of antibiotics.

Which is true regarding percutaneous rhizotomy to treat trigeminal neuralgia? Select all that apply. In this process, a needle is inserted through the cheek into the foramen ovale. In this process, a lesion forms, which interrupts pain transmission to the brain. In this process, nerve fibers are damaged or destroyed. In this process, a shredded fluorocarbon resin pad is placed between the vessels and the nerve. In this process, patients may experience permanent facial numbness.

In this process, a needle is inserted through the cheek into the foramen ovale. In this process, nerve fibers are damaged or destroyed. In this process, patients may experience permanent facial numbness. (In this procedure, a needle is inserted through the cheek into the foramen ovale. The nerve fibers are damaged or destroyed by radiofrequency, glycerol injection, or balloon compression. Patients will have permanent facial numbness in the region supplied by the branch.)

What is the primary reason clients with Alzheimer's disease are at high risk for safety concerns? Inability to remember long-term events in their life Inability to answer questions and difficulty with finding appropriate words Heightened ability to perform answers to mathematical questions Inability to accurately assess their surroundings

Inability to accurately assess their surroundings

After a conversation with a provider, a patient asks what a psychogenic nonepileptic attack disorder (PNES) is. How should the nurse explain it? It does not involve abnormal electrical discharges. It is provoked by other disorders and conditions. It is a chronic disorder. It is an uncontrolled, sudden, excessive discharge of electrical activity.

It does not involve abnormal electrical discharges. (The client with PNES appears to be having an epileptic seizure, but there are no abnormal electrical discharges. Psychogenic nonepileptic attack disorder (PNES) is classified as a conversion disorder by the American Psychiatric Association)

The clinical manifestations of encephalitis are the same as those of meningitis. Which characteristic feature helps identify encephalitis? It involves pathogens that invade the central nervous system. It involves the cerebrum, brainstem, and cerebellum. It can be a life-threatening emergency leading to increased cranial pressure, coma, and death. It is diagnosed by examining the cerebrospinal fluid.

It involves the cerebrum, brainstem, and cerebellum.

The nurse would expect to place the client who just had a seizure in which position? Right-lying (lateral) Left-lying (lateral) Supine Supine with head elevated 15 degrees

Left-lying (lateral)

Which is a first-line medication used in the immediate treatment of seizures and status epilepticus? Select all that apply. Propofol Phenytoin Lorazepam Midazolam Levetiracetam

Lorazepam Midazolam (These are both benzos & need to be administered immediately following as first line meds in tx of a seizure & status epilepticus)

James's seizure stops after 7 minutes. He is not intubated but is placed on a ventilator and transferred to the intensive care unit. Which medications may the nurse request from the provider in case he has additional seizures? Select all that apply. Lorazepam (Ativan) Midazolam (Versed) Phenytoin (Dilantin) Levetiracetam (Keppra) Propofol (Diprivan)

Lorazepam (Ativan) Midazolam (Versed) Phenytoin (Dilantin) Levetiracetam (Keppra) Propofol (Diprivan) (Benzodiazepines including lorazepam and midazolam are first-line medications for seizures. At times a loading dose of anticonvulsants is used. If the client does not respond, high doses of propofol may be used or a pentobarbital coma may be induced.)

The nurse is developing a plan of care for a patient with Alzheimer's disease recently admitted to a nursing home. What priority goals should the nurse consider? Select all that apply. Maintain patient safety Socialization with residents Improve the quality of life Perform ADLs independently Independently take medications

Maintain patient safety Improve the quality of life

The nurse enters the room and finds James is having a seizure. The episode has lasted more than 5 minutes. What is the nurse's priority action? Observe the length and sequence of the seizure. Maintain the airway and prepare for intubation. Deliver the evening dose of oral phenytoin early. Confirm that the wall suction is functioning properly.

Maintain the airway and prepare for intubation. (Status epilepticus is seizure activity lasting greater than 5 minutes or two or more seizures without full recovery of consciousness. Airway, breathing, circulation (ABC) interventions must be initiated immediately. Clients are intubated and arterial blood gases are monitored)

Mary's treatment includes the use of antiepileptic medications for the prevention of seizures until her brain swelling decreases. What instructions should the nurse include? She cannot drive a vehicle while on these medications. The medications cause severe hypotension and she should rise slowly. A side effect includes hallucinations when taken with alcohol. Many antiepileptic medications require serum therapeutic levels be drawn.

Many antiepileptic medications require serum therapeutic levels be drawn. (Some antiepileptic medications may require serum medication levels to ensure that they are maintained at therapeutic levels. Most states restrict driving after a seizure occurs but not until then.)

Anticholinergics are used to reduce tremors and drooling associated with Parkinson's disease (PD). Which side effect of this drug contraindicates it for older patients? Memory impairment Urinary frequency Nausea and vomiting Disorders of impulse control

Memory impairment

The nurse if reviewing the spinal fluid report for a patient. The report shows that the glucose level is low. What is a reason for this finding? Meningitis Cerebral edema Diabetes Severe infection

Meningitis (Glucose decreases in case of meningitis)

The nurse is caring for a patient with a history of lung cancer. After presenting to the clinic with headaches, the provider obtains this image. What type of tumor is most likely the cause? Primary Gliomas Oligodendrogliomas Metastatic

Metastatic (Rationale: Metastatic disease is most commonly caused by primary cancer types that have spread: lung, melanoma, renal, breast, and colorectal cancer, although other types of cancer may also produce metastases to the CNS. Not Primary - Primary brain tumors originate from brain cells, brain meninges, nerves, and glands. Not Gliomas: Gliomas are primary tumors that generally originate in the cerebrum. Not Oligodendrogliomas - Oligodendrogliomas arise from oligodendrocytes, whose main functions are to provide support and insulation to axons in the central nervous system (CNS).)

The nurse is reviewing the pathophysiology of neurological conditions. Which disease is demonstrated by this image? Myasthenia gravis Parkinson's disease Guillain-Barré syndrome Trigeminal neuralgia

Myasthenia gravis (In MG, circulating anti-Ach receptor antibodies bind w/ the AchR, resulting in complement-mediated destruction of receptor sites)

Which nursing intervention is essential while caring for a patient with myasthenia gravis (MG)? Keeping the head of the bed in a lowered position Providing meals when medications are at trough levels Offering soft foods and thickened liquids per the order of the speech therapist Encouraging the patient to refrain from taking breaks by keeping him or her involved in activities of daily living (ADLs)

Offering soft foods and thickened liquids per the order of the speech therapist

Which is most likely responsible for headache that has been going for a prolonged period of time? Meningitis Brain tumor Cerebral aneurysm Opiate dependence and withdrawal

Opiate dependence and withdrawal

Compartment Syndrome Assessments Absence of pain Pain upon ambulation when assisted by physical therapist (PT) Passive pain at rest Numbness in operative extremity Minimal hair growth compared to the other leg Pressure at the surgical site

Passive pain at rest Numbness in operative extremity Pressure at the surgical site Rationale: Passive pain at rest may cause the nurse to suspect the development of compartment syndrome. Paresthesia may also indicate compromised vascular perfusion to the affected limb. Pressure at the surgical site indicates inflammation and is an early symptom of compartment syndrome. Absence of pain and pain upon ambulation when assisted by PT are expected findings after this type of procedure. Minimal hair growth can be affected by factors other than surgical intervention.

The nurse is caring for a client with a blunt trauma and tissue injury to the lower extremity. Which signs could develop in a client with compartment syndrome? Increased pain in the affected extremity upon ambulation Numbness in the toes of the affected extremity Passive pain at rest in the affected extremity Absence of pain in the affected extremity

Passive pain at rest in the affected extremity

The nurse is caring for four patients with different types of fractures. Which patient requires deep breathing exercises with the use of incentive spirometry? Patient 1: Rib; RR 24 Patient 2: Mandibular; Risk for aspiration Patient 3: Humerus; receiving IV pain meds Patient 4: Phalanges; in a cast

Patient 1

Which patient is most likely to experience atonic seizures? Patient A: 13 yr old experiencing lip smacking, confusion, & limping the last 1-3 minutes Patient B: 4 yr old experiencing unconsciousness, sudden loss of movement, & head drop due to fall Patient C: 10 yr old experiencing slight hand movements, lip smacking, inattentiveness that last 5-10 seconds Patient D: 27 year old experiencing spatial disorientation, & inability to speak

Patient B

A patient reports difficulty in breathing and chest pain during deep breathing. On assessment, the nurse finds tachycardia, abnormal breath sounds, and bluish coloration of the skin. Which condition can be suspected in the patient? Pulmonary embolism Fat embolism syndrome Compartment syndrome Neurovascular compromise

Pulmonary embolism

Which characteristic should the nurse monitor for in case James has another tonic-clonic seizure? Twitching with a brief loss of consciousness Twitching with no loss of consciousness Phases of rhythmic jerking of extremities and loss of consciousness Twitching where the client may or may not lose consciousness

Phases of rhythmic jerking of extremities and loss of consciousness (A tonic-clonic seizure exhibits phases of rhythmic jerking of extremities and loss of consciousness. An absence seizure is defined as a generalized seizure with brief loss of consciousness. A myoclonic seizure is defined as a generalized seizure with no loss of consciousness. An atonic seizure is a seizure where the client may or may not lose consciousness.)

A patient with inflamed meningitis due to herpes simplex virus infection shows a white blood cell count of 15,000 cells per mm3. Which other manifestations are likely to be observed in the patient? Select all that apply. Photophobia Opisthotonos Hemiparesis Vasogenic edema Personality changes

Photophobia Opisthotonos (NOT Vasogenic edema -> that's with Brain Tumors)

The nurse is caring for a patient in the skilled nursing facility with the condition here. Who should be included as a part of the collaborative team? Select all that apply. Physical therapist Patient and family Occupational therapist Security guard Speech therapist

Physical therapist Patient and family Occupational therapist Speech therapist

The nurse is caring for a patient with tonic-clonic seizures. Which action of the nurse is most likely to benefit the patient? Encouraging the patient to eat finger foods Placing the patient in a left recumbent position Placing a clock and calendar in the patient's room Encouraging the patient to participate in self-care activities

Placing the patient in a left recumbent position (Reduces aspiration risk)

Which diagnostic test is used to diagnose cancer with rapidly dividing cancer cells? Electroencephalogram Computed axial tomography Positron emission tomography Computed tomographic perfusion scan

Positron emission tomography

Which finding is used to diagnose the presence of Parkinson's disease (PD)? Electroencephalogram (EEG) Magnetic resonance imaging (MRI) Cerebrospinal fluid (CSF) testing Presence of tremors and muscular rigidity

Presence of tremors and muscular rigidity

The nurse is caring for a client with a recent lower extremity injury. During the physical assessment, the nurse should include which components during inspection and palpation of the injury? Select all that apply. Pulselessness Pallor Reflexes Sensation Movement

Pulselessness Pallor Sensation Movement

Which laboratory finding of cerebrospinal fluid (CSF) indicates the presence of Guillain-Barré syndrome? Pressure: 15 mm Hg Protein: 53 mg/dL Color: cloudy, turbulent Specific gravity: 1.007

Protein: 53 mg/dL (Normal level of protein in CSF is 15-50 mg/dL. When CSF is tested, elevated protein & normal cell count will show to indicate GB)

Which is not seen in Cushing's triad? Rapid heart rate Increase in systolic pressure Decrease in diastolic pressure Alterations in respiratory rate

Rapid heart rate

The nurse is performing an assessment on a patient with Guillain-Barré syndrome. What priority assessments should the nurse perform? Select all that apply. Respiratory assessment with vital capacity measurement Tactile fremitus Pain assessment Diaphragmatic excursion Motor sensory assessment

Respiratory assessment with vital capacity measurement Pain assessment Motor sensory assessment

The nurse is caring for a client post-open reduction internal fixation surgery. Which complications should the nurse monitor for? Select all that apply. Respiratory distress Fat embolism syndrome Elevated blood urea nitrogen and creatinine Elevated serum potassium Hypovolemia

Respiratory distress Fat embolism syndrome Hypovolemia

The nurse is caring for a client in the emergency department with a severe sprain to the left ankle. The nurse should include which information in the discharge teaching? Select all that apply. Rest the injury. Use a compression wrap to the injury. Apply heat for 20 minutes every hour for the first 24 hours. Decrease oral intake. Elevate the extremity.

Rest the injury. Use a compression wrap to the injury. Elevate the extremity.

The nurse is caring for a client who was involved in a crush injury of the lower extremity and experiencing severe flank pain and the presence of dark, tea-colored urine. The nurse is aware of the potential for which serious complication? Pulmonary embolism Rhabdomyolysis Compartment syndrome Fat embolism

Rhabdomyolysis

Antidiuretic Hormone SIADH or DI

SIADH (A patient who has GB with an affected cranial nerve X (CN X) may be at risk for SIADH or increased secretion of antidiuretic hormone because CN X is related to autonomic function.)

Initial progression SYMMETRICAL ASCENDING MOTOR WEAKNESS or SYMMETRICAL DESCENDING MOTOR WEAKNESS

SYMMETRICAL ASCENDING MOTOR WEAKNESS (The client with GBS develops symmetrical ascending motor weakness and paralysis that usually starts in the feet and extends to the trunk and arms. When the condition improves, symptoms usually first disappear from the trunk and arms before descending.)

As the nurse educates Mary and her family prior to the procedure, which topic specific to a postoperative client after neurosurgery should be included? Seizures Venous thromboembolism Infection Falls Check Answer

Seizures (All these topics are relevant for any surgery, but the risk for seizures is most relevant for a neurosurgery client. He or she may be placed on antiepileptic medications post-surgery to prevent the onset of seizures.)

The home healthcare nurse is caring for an elderly patient with Alzheimer's disease (AD). Which intervention should the nurse implement for the patient? Provide the patient with semi-soft diet. Encourage the patient to take an afternoon nap. Provide the patient with a different schedule every day. Speak calmly using positive statements.

Speak calmly using positive statements.

Which intervention should the nurse implement for a patient who experienced a seizure? Restrain the patient's movements. Assist the patient to a supine position. Suction the oral airway. Encourage the patient to drink water.

Suction the oral airway. (Compromised airway after seizure activity secondary to decreased LOC. Airway patency must be maintained)

A patient has difficulty ambulating due to joint instability caused by a third-degree sprain. Which treatment is most beneficial for the patient ? Surgical repair of the affected area Providing rest to the injured area for four days Providing compression with the help of an Ace wrap Applying ice bags to the affected area for 30 minutes

Surgical repair of the affected area

Which vital signs can be observed in a patient with excessive bleeding that leads to hemorrhagic shock? Select all that apply. Bradypnea Chest pain Tachycardia Low blood pressure Elevated temperature

Tachycardia Low blood pressure

The nurse is caring for a patient undergoing chemotherapy for a brain tumor. Which is the most important nursing intervention for this patient? Encourage use of sunscreen lotion. Provide nutritional supplements. Teach importance of frequent handwashing. Encourage use of skin emollients.

Teach importance of frequent handwashing. (Rationale: The nurse must teach the patient to wash hands frequently. This helps prevent secondary infections which can be life threatening to the immune compromised patient. Nutritional supplements also important to overcome fatigue, but handwashing more important)

Which diagnostic test is useful in distinguishing a myasthenic crisis from a cholinergic crisis? Repetitive nerve stimulation (RNS) Tensilon test Chest computed tomography (CT) scan Serological test

Tensilon test

Which statements would the nurse include in the client and family teaching about the postictal phase of seizures? Select all that apply. The postictal phase occurs after the seizure. The client in the postictal phase may exhibit automatisms such as lip smacking, rhythmic muscle movements, or chewing. The client may exhibit confusion and disorientation during the postictal phase. The postictal phase can last from 5-30 minutes. The postictal phase client may state seeing visualizations, hallucinations, or smell odors that are not present.

The postictal phase occurs after the seizure. The client may exhibit confusion and disorientation during the postictal phase. The postictal phase can last from 5-30 minutes.

Which type of surgery is usually performed for a patient with myasthenia gravis (MG)? Microvascular decompression Thymectomy Percutaneous rhizotomy Sterotactic radiosurgery

Thymectomy

Which is true regarding traction for treating fractures? Select all that apply. Cervical traction is an example of skin traction. Traction can be used in conjunction with surgical/nonsurgical management of fractures. Buck's traction is an example of skeletal traction. Skeletal traction involves the use of pins, tongs, screws, and wires to surgically secure the bone and weight application to provide realignment. Traction involves the use of weights and forces to reduce the fracture and relieve muscle spasms.

Traction can be used in conjunction with surgical/nonsurgical management of fractures. Skeletal traction involves the use of pins, tongs, screws, and wires to surgically secure the bone and weight application to provide realignment. Traction involves the use of weights and forces to reduce the fracture and relieve muscle spasms.

The nurse is caring for a client with a femoral shaft fracture. Which types of fracture may the client have? Select all that apply. Transverse Greenstick Comminuted Compound Displaced

Transverse Comminuted Compound

The nurse is performing this assessment (Babinski Sign) and finds it is positive. What could be the neurological condition causing this? None; this is a normal finding. Traumatic brain injury Increased intracranial pressure Cerebral infection

Traumatic brain injury

Which intervention should the nurse implement for the patient admitted to the intensive care unit with encephalitis? Restrict the patient's water intake. Position the patient's bed next to a window. Allow the family to visit and talk to the patient. Turn and reposition the patient every 2 hours.

Turn and reposition the patient every 2 hours.

Which assessment finding corresponds with the first stage of Parkinson's disease (PD)? Upper extremity tremors Muscle rigidity Shuffling gait Postural instability

Upper extremity tremors

The nurse is discharging a patient with this appliance. What should the nurse include with the teaching? Use a plastic hanger to reach under this device if your skin itches. Use a hairdryer on cool settings if it gets wet. Trim or break off any rough edges that are irritating your skin. Rest the heel of your foot on a pillow or bed.

Use a hairdryer on cool settings if it gets wet.

Cranial nerve involvement VII or II

VII (Cranial nerve VII (facial nerve) is most commonly affected, and the patient may have difficulty with facial expressions. Additionally, cranial nerves IX (glossopharyngeal), X (vagus), XI (spinal accessory), and XII (hypoglossal) may also be involved, causing dysphagia.)

Which assessment should the nurse be most concerned about for the patient with increased intracranial pressure (ICP) following a brain tumor resection? Quarter-sized dried blood on skull dressing Vomiting Low grade temperature Decreased urine output

Vomiting

Jonathan has Alzheimer's disease and continues to lose weight. He comes to the clinic today with his daughter who says "I don't know what to do, it's like he forgets to eat."What suggestion can the nurse give? monitor heart rate prevents free radical damage transdermal patch generally well-tolerated titrate dosing over several weeks provide finger foods large single-day calendar visible speak calmly using positive statements

provide finger foods (The client may forget to eat without reminders and assistance secondary to cognitive changes. Finger foods may be easier for the client to manage and may increase caloric intake.)