Nervous System (LaCharity)

Which action should the nurse delegate to an experienced assistive personnel (AP) when caring for a patient with a thrombotic stroke who has residual left-sided weakness? SELECT ALL THAT APPLY A. Assisting the patient to reposition every 2 hours B. Reapplying pneumatic compression boots C. Reminding the patient to perform active range-of-motion exercises D. Assessing the extremities for redness and edema E. Setting up meal trays and assisting with feeding F. Using a lift to assist the patient up to a bedside chair

A. Assisting the patient to reposition every 2 hours B. Reapplying pneumatic compression boots C. Reminding the patient to perform active range-of-motion exercises E. Setting up meal trays and assisting with feeding F. Using a lift to assist the patient up to a bedside chair

All of the following nursing care activities are included in the care plan for 78yr old man with Parkinson disease who has been referred to the home health agency. Which activities will the nurse delegate to the assistive personnel (AP)? A. Checking for orthostatic changes in pulse and blood pressure B. Assessing for improvement in tremor after levodopa is given C. Reminding the patient to allow adequate time for meals D. Monitoring for signs of toxic reactions to anti-Parkinson medications E. Assisting the patient with prescribed strengthening exercises F. Adapting the patient's preferred activities to his level of function

A. Checking for orthostatic changes in pulse and blood pressure C. Reminding the patient to allow adequate time for meals E. Assisting the patient with prescribed strengthening exercises

A patient with a cervical spinal cord injury has been placed in fixed skeletal traction with a halo fixation device. When caring for this patient, the nurse may assign which action to the LPN? SELECT ALL THAT APPLY. A. Checking the patient's skin for pressure from the device B. Assessing the patient's neurologic status for changes C. Observing the halo insertion sites for signs of infection D. Cleaning the halo insertion sites for hydrogen peroxide E. Developing the nursing plan of care for the patient F. Administering oral medications as prescribed

A. Checking the patient's skin for pressure from the device C. Observing the halo insertion sites for signs of infection D. Cleaning the halo insertion sites for hydrogen peroxide F. Administering oral medications as prescribed

The nurse is mentoring a student nurse in the intensive care unit while caring for a patient with meningococcal meningitis. Which action by the student requires that the nurse intervene MOST rapidly? A. Entering the room without putting on a protective mask and gown B. Instructing the family that visits are restricted to 10 minutes C. Giving the patient a warm blanket when he says he feels cold D. Checking the patient's pupil response to light every 30 minutes

A. Entering the room without putting on a protective mask and gown

A patient with multiple sclerosis tells the assistive personnel after physical therapy that she is too tired to take a bath. What is the PRIORITY nursing concern at this time? A. Fatigue B. Impaired safety C. Decreased mobility D. Muscular weakness

A. Fatigue

The nurse is creating a teaching plan for a patient with newly diagnosed migraine headaches. Which key items will be included in the teaching plan? SELECT ALL THAT APPLY. A. Foods that contain tyramine, such as alcohol and aged cheese, should be avoided B. Drugs such as nitroglycerin and nifedipine should be avoided C. Abortive therapy is aimed at eliminating the pain during aura D. A potential side effect of medications is rebound headache E. Complementary therapies such as biofeedback and relaxation may be helpful F. Estrogen therapy should be continued as prescribed by the patient's health care provider

A. Foods that contain tyramine, such as alcohol and aged cheese, should be avoided B. Drugs such as nitroglycerin and nifedipine should be avoided C. Abortive therapy is aimed at eliminating the pain during aura D. A potential side effect of medications is rebound headache E. Complementary therapies such as biofeedback and relaxation may be helpful

The nurse is preparing to discharge a patient with chronic low back pain. Which statement by the patient indicates the need for additional teaching? A. I will avoid exercise because the pain gets worse B. I will use heat or ice to help control the pain C. I will not wear high-heeled shoes at home or work D. I will purchase a firm mattress to replace my old one

A. I will avoid exercise because the pain gets worse

The RN is supervising a senior nursing student who is caring for a patient with a right hemisphere stroke. Which action by the student nurse requires that the RN intervene? A. Instructing the patient to sit up straight and the patient responds with a puzzled look B. Moving the patient's food tray to the right side of his over-bed table C. Assisting the patient with passive range-of-motion exercises D. Combing the hair on the left side of the patient's head when the patient always combs his hair on the right side

A. Instructing the patient to sit up straight and the patient responds with a puzzled look

A 23yr old patient with a recent history of encephalitis is admitted to the medical unit with new-onset generalized tonic-clonic seizures. Which nursing activities included in the patient's care would be best to assign to an LPN under the nurse's supervision? SELECT ALL THAT APPLY A. Observing and documenting the onset and duration of any seizure activity B. Administering phenytoin 200 mg PO three times a day C. Teaching the patient about the need for frequent tooth brushing and flossing D. Developing a discharge plan that includes referral to the Epilepsy Foundation E. Assessing for adverse effects caused by new antiseizure medications F. Turning the patient to his/her side to avoid aspiration

A. Observing and documenting the onset and duration of any seizure activity B. Administering phenytoin 200 mg PO three times a day F. Turning the patient to his/her side to avoid aspiration

What is the PRIORITY nursing concern for a patient experiencing a migraine headache? A. Pain B. Anxiety C. Hopelessness D. Risk for brain injury

A. Pain

A patient who had a stroke needs to be fed. What instructions should the nurse give to the assistive personnel (AP) who will feed the patient? A. Position the patient sitting up in bed before he/she is fed B. Check the patient's gag and swallowing reflexes C. Feed the patient quickly because there are three more patients to feed D. Suction the patient's secretions between bites of food

A. Position the patient sitting up in bed before he/she is fed

The nurse is helping a patient with a spinal cord injury to establish a bladder retraining program. Which strategies may stimulate the patient to void? SELECT ALL THAT APPLY. A. Stroking the patient's inner thigh B. Pulling on the patient's pubic hair C. Initiating intermittent straight catheterization D. Pouring warm water over the patient's perineum E. Tapping the bladder to stimulate the detrusor muscle F. Reminding the patient to void in a urinal every hour while awake

A. Stroking the patient's inner thigh B. Pulling on the patient's pubic hair D. Pouring warm water over the patient's perineum E. Tapping the bladder to stimulate the detrusor muscle

Which nursing action will be implemented FIRST if a patient has a generalized tonic-clonic seizure? A. Turn the patient to one side B. Give lorazepam 2 mg IV C. Administer oxygen via a nonrebreather mask D. Assess the patient's level of consciousness

A. Turn the patient to one side

The nurse on the neurologic acute care unit is assessing the orientation of a patient with severe headaches. Which question would the nurse use to determine orientation? SELECT ALL THAT APPLY. A. When did you first experience the headache symptoms? B. Did the mayor of Cleveland run as a Democrat or Republican? C. What is your health care provider's name? D. What year and month is it? E. What is the color of your parents' house? F. What is the name of this health care facility?

A. When did you first experience the headache symptoms? C. What is your health care provider's name? D. What year and month is it? F. What is the name of this health care facility?

For which patient with severe migraine headaches would the nurse question a prescription for sumatriptan? A. 58yr old patient with gastroesophageal reflux disease B. 48yr old patient with hypertension C. 65yr old patient with mild emphysema D. 72yr old patient with hyperthyroidism

B. 48yr old patient with hypertension

Which patient should the charge nurse assign to a newly graduated RN who is orientating to the neurologic care unit? A. 28yr old newly admitted patient with a spinal cord injury B. 67yr old patient who had a stroke 3 days ago and has left-sided weakness C. 85yr old patient with dementia who is to be transferred to long-term care facility D. 54yr old patient with Parkinson disease who needs assistance with bathing

B. 67yr old patient who had a stroke 3 days ago and has left-sided weakness

Which patient should the charge nurse assign to the traveling nurse, new to neurologic nursing care, who has been on the neurologic unit for 1 week? A. 34yr old patient with newly diagnosed multiple sclerosis B. 68yr old patient with chronic amyotrophic lateral sclerosis (ALS) C. 56yr old patient with Guillain-Barre syndrome (GBS) in respiratory distress D. 25yr old patient admitted with a C4-level spinal cord injury

B. 68yr old with chronic myotrophic lateral sclerosis (ALS)

A patient with a spinal cord injury reports a sudden severe throbbing headache that started a short time ago. Assessment of the patient reveals increase BP (168/94 mm Hg) and decreased HR (48 beats/min), diaphoresis, flushing of the face and neck. What action should the nurse take FIRST? A. Administer the ordered acetaminophen B. Check the indwelling catheter tubing for kinks or obstruction C. Adjust the temperature in the patient's room D. Notify the HCP about the change in status

B. Check the indwelling catheter tubing for kinks or obstruction

The nurse is floated from the emergency department to the neurologic floor. Which action should the nurse delegate to the assistive personnel (AP) when providing nursing care for a client with a spinal cord injury? A. Assessing the client's respiratory status every 4 hours B. Checking and recording the client's vital signs every 4 hours C. Monitoring the client's nutritional status, including calorie counts D. Instructing the client how to turn, cough, and breathe deeply every 2 hours

B. Checking and recording the client's vital signs every 4 hours

The nurse is supervising a senior nursing student who will provide nursing care for a 63yr old man diagnosed with amyotrophic lateral sclerosis (ALS). Which statements by the student indicate accurate understanding of the disease process, assessment findings, and nursing care needed for this patient? SELECT ALL THAT APPLY A. Patient usually die within 10-15yrs of diagnosis B. Early symptoms include tripping, dropping things, and fatigue of extremities C. ALS always leads to changes in consciousness and confusion D. Nursing care for a patient with ALS includes decreasing risk for aspiration and falls E. There are no drugs and there is no cure for ALS F. The patient is likely to exhibit signs of depression G. The most common cause of death is respiratory tract infection H. Riluzole is a drug that can slow the progression of ALS

B. Early symptoms include tripping, dropping things, and fatigue of extremities D. Nursing care for a patient with ALS includes decreasing risk for aspiration and falls F. The patient is likely to exhibit signs of depression G. The most common cause of death is respiratory tract infection

The nurse has just admitted a patient with bacterial meningitis who reports a severe headache with photophobia and has a temperature of 102.6 degrees Fahrenheit orally. Which prescribed intervention should be implemented FIRST? A. Administer codeine 15 mg orally for the patient's headache B. Infuse ceftriaxone 2000 mg IV to treat infection C. Give acetaminophen 650 mg orally to reduce the fever D. Give furosemide 40 mg IV to decrease intracranial pressure

B. Infuse ceftriaxone 2000 mg IV to treat infection

The RN notes that a patient with myasthenia gravia has an elevated temperature (102.2 degrees Fahrenheit), an increased HR (120 beats/min), and a rise in BP (158/94 mm Hg) and is incontinent of urine and stool. What is the nurse's BEST action at this time? A. Administer an acetaminophen suppository B. Notify HCP immediately C. Recheck vitals in 1 hour D. Reschedule the patient's physical therapy

B. Notify HCP immediately

The nurse is preparing to admit a patient with a seizure disorder. Which action can be assigned to the LPN? A. Completing the admission assessment B. Setting up oxygen and suction equipment C. Placing a padded tongue blade at the bedside D. Padding the side rails before the patient arrives

B. Setting up oxygen and suction equipment

A patient who recently started taking phenytoin to control simple partial seizures is seen in the outpatient clinic. Which information obtained during the nurse's chart review and assessment will be of GREATEST concern? A. The gums appear enlarged and inflamed B. The WBC count is 2300/mm3 C. The patient sometimes forgets to take the phenytoin until the afternoon D. The patient wants to renew her driver's license in the next month

B. The WBC count is 2300/mm3

The critical care nurse is assessing a patient whose baseline Glascow Coma Scale (GCS) score in the emergency department was 5. The current GCS score is 3. What is the nurse's BEST interpretation of this finding? A. The patient's condition is improving B. The patient's condition is deteriorating C. The patient will need intubation and mechanical ventilation D. The patient's medication regime will need adjustments

B. The patient's condition is deteriorating

A 70yr old patient with alcoholism who has become lethargic, confused, and incontinent during the last week is admitted to the emergency department. His wife tells the nurse that he fell down the stairs about a month ago but that "he didn't have a scratch afterward." Which collaborative interventions will the nurse implement FIRST? A. Place the patient on the hospital alcohol withdrawal protocol B. Transport the patient to the radiology department for a CT scan C. Make a referral to the social services department D. Give the patient phenytoin 100 mg PO

B. Transport the patient to the radiology department for a CT scan

Which patient in the neurologic intensive care unit should the charge nurse assign to an RN who has been floated from the medical unit? A. 26yr old patient with a basilar skull fracture who has clear drainage coming out of the nose B. 42yr old patient admitted several hours ago with a headache and a diagnosis of a ruptured berry aneurysm C. 46yr old patient who was admitted 48hr ago with bacterial meningitis and has an IV antibiotic dose due D. 65yr old patient with an astrocytoma who has just returned to the unit after undergoing a craniotomy

C. 46yr old patient who was admitted 48hr ago with bacterial meningitis and has an IV antibiotic dose due

The nurse is providing care for a patient with an acute hemorrhagic stroke. The patient's spouse tells the nurse that he has been reading a lot about strokes and asks why his wife has not received alteplase. What is the nurse's BEST response? A. Your wife was not admitted within the time frame that alteplase is usually given B. This drug is used primarily for patients who experience an acute heart attack C. Alteplase dissolves clots and may cause more bleeding into your wife's brain D. Your wife just had gallbladder surgery 6 months ago, so we can't use alteplase

C. Alteplase dissolves clots and may cause more bleeding into your wife's brain

After a patient has a seizure, which action can the nurse delegate to the assistive personel (AP)? A. Documenting the seizure B. Performing neurologic checks C. Checking the patient's vital signs D. Restraining the patient for protection

C. Checking the patient's vital signs

The nurse is assessing a patient with a neurologic health problem and discovers a change in level of consciousness from alert to lethargic. What is the nurse's BEST action? A. Perform a complete neurologic assessment B. Assess the cranial nerve functions C. Contact the rapid response team D. Reassess the patient in 30 minutes

C. Contact the rapid response team

The nurse is preparing a nursing care plan for a patient with a spinal cord injury for whom problems of decreased mobility and inability to perform ADLs have been identified. The patient tells the nurse, "I don't know why we're doing all this. My life's over." Based on this statement, which additional nursing concern takes PRIORITY? A. Risk for injury B. Decreased nutrition C. Difficulty with coping D. Impairment of body image

C. Difficulty with coping

A patient with Parkinson disease has a problem with decreased mobility related to neuromuscular impairment. The nurse observes the assistive personnel (AP) performing all of these actions. For which action must the nurse intervene? A. Helping the patient ambulate to the bathroom and back to bed B. Reminding the patient not to look at his feet when he is walking C. Performing the patient's complete bathing and oral care D. Setting up the patient's tray and encouraging the patient to feed himself

C. Performing the patient's complete bathing and oral care

A patient with Guillain-Barre syndromeis to undergo plasmapheresis to remove circulating antibodies thought to be responsible for the disease. Which patient care action should the nurse delegate to the experienced assistive personnel (AP)? A. Observe the access site for ecchymosis or bleeding B. Instruct the patient that there will be three or four treatments C. Weigh the patient before and after procedure D. Assess the access site for bruit and thrill every 2-4hrs

C. Weigh the patient before and after procedure

After the nurse receives the change-of-shift report at 0700, which patient must the nurse assess FIRST? A. 23yr old patient with a migraine headache who reports severe nausea associated with retching B. 45yr old patient who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching C. 59yr old patient with Parkinson disease who will need a swallowing assessment before breakfast D. 63yr old patient with multiple sclerosis (MS) who has an oral temperature of 101.8 degrees Fahrenheit and flank pain

D. 63yr old patient with multiple sclerosis (MS) who has an oral temperature of 101.8 degrees Fahrenheit and flank pain

A nursing student is teaching a patient and family about epilepsy before the patient is discharged. For which statement should the nurse intervene? A. You should avoid consumption of all forms of alcohol B. Wear your medical alert bracelet at all times C. Protect you loved one's airway during a seizure D. It's OK to take OTC medications

D. It's OK to take OTC medications

A patient with a spinal cord injury at level C3 to C4 is being cared for by the nurse in the emergency department. What is the PRIORITY nursing assessment? A. Determine the level at which the patient has intact sensation B. Assess the level at which the patient has retained mobility C. Check blood pressure and pulse for signs of spinal shock D. Monitor respiratory effort and oxygen saturation level

D. Monitor respiratory effort and oxygen saturation level

An LPN, under the RN's supervision, is assigned to provide nursing care for a patient with Guillain-Barre syndrome (GBS). What observation should the LPN be instructed to report IMMEDIATELY? A. Reports of numbness and tingling B. Facial weakness and difficulty speaking C. Rapid HR of 102 beats/min D. Shallow respirations and decreased breath sounds

D. Shallow respirations and decreased breath sounds