medsurge test #3

a neurological deficit is best defined as a deficit of the...

.central and peripheral nervous systems with decreased, impaired, or absent functioning

a nurse is working with a patient to establish a bowel training program. based on the nurse's understanding of bowel function, they would suggest planning for bowel evacuation at which time?

after breakfast

a client who recently experienced a stroke tells the nurse that he has double vision. which nursing intervention is the most appropriate?

alternatively patch one eye every 2 hours

a patient with myasthenia gravis is admitted with an exacerbation. the nurse is educating the client about plasmapheresis and explains this in which of the following statements?

antibodies are removed from the plasma

the brain's ability to change the diameter if blood vessels to maintain cerebral flow is referred to as...

autoregulation

a nurse is assessing a client who will be discharged home after rehabilitation for a stroke. the nurse is questioning the client about his instrumental ADLs. which should the nurse address? a. grooming b. cooking c. bathing d. dressing

b. cooking

medical management of arthropod-borne virus (arboviral) encephalitis is aimed at...

controlling seizures and intracranial pressure

what is the primary medical management of arthropod-borne virus (arboviral) encephalitis?

controlling seizures and intracranial pressure

the nurse is performing an initial nursing assessment on a client with possible Guillian-Barre syndrome. which of the following would be most consistent with this diagnosis? a. hyporeflexia and skin rash b. fever and cough c. ptosis and muscle weakness of upper extremities d. muscle weakness and hyporeflexia of the lower extremities

d. muscle weakness and hyporeflexia of the lower extremities

abnormal flexion of the upper extremities and extension of the lower as neurologic function deteriorates and the patient becomes comatose is referred to as...

decortication

a client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. the physician suspects myasthenia gravis. which drug will be used to test for the disease?

edrophonium (tensilon)

the nurse is providing care for a patient who has limited mobility after a stroke. the nurse would assess for contractures by assessing the clients...

range of motion

a nurse is describing the concept of rehabilitation to a group of families who have members in need of these services. which statement would the nurse include in the description?

rehabilitation focuses on the persons abilities

a client with HSV encephalitis is receiving acyclovir. to ensure early intervention, the nurse monitors which lab values and urine output for which type of adverse reactions?

renal

the nurse is performing an initial assessment on a client admitted to rule out Guillain-Barre syndrome. on which of the following areas will the nurse focus most heavily?

respiratory

an abnormal episode of motor, sensory, autonomic, or psychic activity resulting from a sudden, abnormal, uncontrolled electrical discharge from cerebral neurons is referred to as what?

seizure

what position should be avoided when positioning a patient in bed in order to decrease the incidence of musculoskeletal complications?

semi-fowlers

what does it mean when an unconscious patient has fixed and dilated pupils?

the brain injury is at the level of the midbrain

a patient with Guillian-Barre syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. when the client asks the nurse about the paralysis, how should the nurse respond?

the paralysis caused by this disease is temporary

a nurse is teaching a client who was recently diagnosed with myasthenia gravis. which statement should the nurse include in her teaching?

this disease doesn't cause sensory impairment

a 45 year old client is admitted to the facility with excruciating paroxysmal facial pain. he reports that the episodes occur most often after feeling cold drafts and drinking cold drinks. based on the findings, the nurse determines that he is suffering from which disorder?

trigeminal neuralgia

when developing a plan of care for a patient with impaired physical mobility who must remain on complete bed rest, which of the following would the nurse most likely include to prevent external rotation of the hip?

trochanter roll

T of F: the earliest sign of increasing ICP is a change in LOC

true

T or F: nursing intervention when caring for a patient with ICP is to maintain the head of the bed at 30 degrees and maintain alignment of the head

true

myasthenia gravis occurs when antibodies attack which receptor sites?

acetylcholine

what tool would the nurse use to assess a patient's level of independent functioning?

functional independence measure

a client spend most of his time in a wheelchair. the nurse would be especially alert for the development of pressure ulcers in which area?

ischial tuberosity

what is the most frequently administered hyperosmotic agent used to reduce cerebral edema before intracranial surgery?

mannitol

what is the first treatment priority for a patient with an altered LOC?

obtain and maintain a patient airway

which condition is a rare, transmissible, progressive fatal disease of the central nervous system characterized by spongiform degeneration of the gray matter in the brain?

creutzfeldt-jakob disease

T or F: the cerebral perfusion pressure (CPP) must be maintained at 5mmHg to ensure adequate blood flow to the brain

false- 70 to 80mmHg

the patient is suddenly experiencing lower extremity weakness and dyskinesia. the client reports accompanying numbness and tingling episodes. which question will the nurse ask the client to help determine the cause of their symptoms?

have you had a recent illness?

a patient has been diagnosed with a frontal lobe brain abscess. which nursing intervention is appropriate?

initiate seizure precautions

using the GCS, the nurse gives a patient who is brain dead a score of...

3

a client has a neurological defect and will be transferred to a nursing home because family members are unable to care for the client at home. while receiving a bath, the client yells at the nurse, "you don't know what you're doing!" what is the best response by the nurse?

accept the clients behavior and do not take it personally

the nurse is admitting a client into the rehabilitation unit after an industrial accident. the client's nursing diagnosis includes disturbed sensory perception and the nurse identifies that he has decreased strength and dexterity. the nurse should know that this client may need what to accomplish self care?

appropriate assistive devices

which nursing intervention is the priority for a patient in myasthenic crisis?

assessing respiratory effort

which drug should be available to counteract the effect of edrophonium chloride?

atropine

for a patient who has a stroke, which nursing intervention can help prevent contractures in the lower legs?

attaching braces or splints to each leg and foot

bell palsy is a disorder of which cranial nerve?

facial (VII)

the nurse is caring for a client with Guillian-Barre syndrome. which assessment finding indicates the need for oral suctioning?

increased pulse rate, adventitious breath sounds

the nurse is assessing a patient at risk for the development of a pressure ulcer. what laboratory test will assist the nurse in determining the risk?

serum albumin

a client is on bed rest after sustaining injuries in a car accident. which nursing action helps prevent complications of immobility?

turning the client every two hours and providing a low-air-loss mattress