Neuro questions
A client is being monitored for transient ischemic attacks. This client is oriented, can open the eyes spontaneously, and follow commands. What is the Glasgow coma scale score?
15
A patient with Parkinson Disease is experiencing weight loss due to difficulty chewing and swallowing. Which meal option below is the best for this patient? A. Scrambled eggs with a side of cottage cheese B. Grilled cheese with apple slices C. Baked chicken with bacon slices D. Tacos with refried beans
A
A nurse is caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first? a. Client with a Glasgow Coma Scale score that was 10 and is now is 8 b. Client with a Glasgow Coma Scale score that was 9 and is now is 12 c. Client with a moderate brain injury who is amnesic for the event d. Client who is requesting pain medication for a headache
A
A nurse is providing community screening for risk factors associated with stroke. Which client would the nurse identify as being at highest risk for a stroke? a. A 27-year-old heavy cocaine user b. A 30-year-old who drinks a beer a day c. A 40-year-old who uses seasonal antihistamines d. A 65-year-old who is active and on no medications
A
A patient diagnosed with multiple sclerosis (MS) is prescribed baclofen (Gablofen). Which question will the healthcare provider ask when evaluating the effectiveness of the medication? a. "Has the stiffness in your muscles decreased?" b. "Did you have a bowel movement this morning?" c. "Are you feeling stronger and less fatigued today?" d. "Have you been able to urinate without difficulty?"
A
A patient with MS has been admitted to the hospital following an acute exacerbation. Whenplanning the patients care, the nurse addresses the need to enhance the patients bladder control.What aspect of nursing care is most likely to meet this goal? A) Establish a timed voiding schedule. B) Avoid foods that change the pH of urine. C) Perform intermittent catheterization q6h. D) Administer anticholinergic drugs as ordered.
A
A client in the emergency department is having a stroke and needs a carotid artery angioplasty with stenting. The client's mental status is deteriorating. What action by the nurse is most appropriate? a. Attempt to find the family to sign a consent. b. Inform the provider that the procedure cannot occur. c. Nothing; no consent is needed in an emergency. d. Sign the consent form for the client.
A
A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder? a. cardiovascular disease b. frequent UTIs c. farsightedness d. frequent upper respiratory infections
A
A nurse in an emergency department is assessing a client who reports sudden, severe eye pain with blurry vision. The provider determines that the client has primary angle-closure glaucoma. Which of the following medications should the nurse expect to administer? a. Osmotic diuretics via IV bolus b. Mydriatic ophthalmic drops c. Corticosteroid ophthalmic drops d. Epinephrine via IV bolus
A
A nurse is assessing a client who has a head injury following a motor-vehicle crash. The nurse should identify that which of the following findings indicates increasing ICP? a. restlessness b. dizziness c. hypotension d. fever
A
A physician orders a patient to take Benztropine (Cogentin). The patient has never taken this medication before and is due to take the first dose at 1000. What statement by the patient requires you to hold the dose and notify the physician? A. "I forgot to tell the doctor I take eye drops for my glaucoma." B. "I had a PET scan last week." C. "I take aspirin once day." D. "My hands are experiencing tremors at rest."
A
After the nurse instills atropine drops into both eyes for a client undergoing ophthalmic examination, which of the following instructions would be given to the client? a. wear dark glasses in bright light because the pupils are dilated b. avoid wearing your regular glasses when driving c. be careful because the blink reflex is paralyzed d. Be aware the pupils may be very small
A
The client is being discharged from the ambulatory care unit following cataract removal. The nurse provides instructions regarding home care. Which of the following, if stated by the client, indicates an understanding of the instructions? a. "I will wear my eye shield at night and my glasses during the day." b. "I will take Aspirin if I have any discomfort." c. "I will sleep on the side that I was operated on." d. "I will not lift anything if it weighs more that 10 pounds."
A
The client newly diagnosed with multiple sclerosis (MS) states, "I don't understand how I got multiple sclerosis. Is it genetic?" On which statement should the nurse base the response? 1. Genetics may play a role in susceptibility to MS, but the disease may be caused by a virus. 2. There is no evidence suggesting there is any chromosomal involvement in developing MS. 3. Multiple sclerosis is caused by a recessive gene, so both parents had to have the gene for the client to get MS. 4. Multiple sclerosis is caused by an autosomal dominant gene on the Y chromosome,so only fathers can pass it on.
A
The client with a brain attack (stroke) has residual dysphagia. When a diet order is initiated, the nurse avoids doing which of the following? a. Giving the client thin liquids b. Thickening liquids to the consistency of oatmeal c. Placing food on the unaffected side of the mouth d. Allowing plenty of time for chewing and swallowing
A
The daughter of an older adult client diagnosed with dry macular degeneration asks the nurse to explain the disorder. In formulating a response, the nurse would include which characteristics of this condition? a. atrophy and degeneration of outer pigmented layer of the retina b. scar formation between the retina and the choroid c. rapid and severe loss of vision d. separation of the retina from the choroids
A
The healthcare provider is planning care for a patient diagnosed with multiple sclerosis (MS). Which of the following is the priority intervention? 1) Advise the patient to drink liquids through a straw 2) Monitor the patient's temperature to avoid overheating 3) Teach the patient's family how to meet the patient's needs 4) Encourage bed rest in order to conserve strength
A
The nurse is caring for a client with an exacerbation of multiple sclerosis. Which medication(s) will the nurse expect to be prescribed to hasten recovery from the exacerbation? 1. Methylprednisolone (Solu-Medrol) intravenously 2. Carbamazepine (Tegretol) and phenytoin (Dilantin) by mouth 3. Phenytoin (Dilantin) intravenously, then tapered to oral route 4. Lioresal (Baclofen) by mouth and diazepam (Valium) intravenously
A
The nurse is caring for a patient who is hospitalized with an exacerbation of MS. To ensure the patients safety, what nursing action should be performed? A) Ensure that suction apparatus is set up at the bedside. B) Pad the patients bed rails. C) Maintain bed rest whenever possible. D) Provide several small meals each day
A
The nurse is teaching the client with MS about the use of corticosteroids for treatment. Which of the following statements, if made by the patient indicates correct understanding? A) I should watch for side effects such as euphoria and insomnia while taking this medication B) This medication will need to be administered for at least 2 weeks before I begin to see improvements in my condition C) The corticosteroids will reduce my chances of relapsing in the future D) I could see flu-like symptoms while taking this medication
A
The nurse should assess an older adult with macular degeneration for: a. Loss of central vision b. Loss of peripheral vision c. Total blindness d. Blurring of vision
A
Which of the following goals is collaboratively established by the client with Parkinson's disease, nurse, and physical therapist? a. To maintain joint flexibility b. To build muscle strength c. To improve muscle endurance d. To reduce ataxia
A
Which of the following is an expected outcome for a client with Parkinson's disease who has a pallidotomy improved? a. Functional ability b. Emotional stress c. Alertness d. Appetite
A
Which of the following nursing measures is not appropriate when providing oral hygiene for a client who has had a stroke? a. Placing the client on the back with a small pillow under the head b. Keeping portable suctioning equipment at the bedside c. Opening the client's mouth with a padded tongue blade. d. Cleaning the client's mouth and teeth with a toothbrush.
A
Which precaution is most important for the nurse to teach a 62-year-old client newly diagnosed with early-stage dry age-related macular degeneration? A. Quit smoking B. Quit drinking alcoholic beverages C. Eat more dark green, red, and yellow vegetables D. Wear dark glasses whenever he or she is outside or in bright interior lighting environments
A
You're caring for a patient with Parkinson's Disease that has tremors. Select the option that is INCORRECT about tremors experienced in this disease: a. The tremors are most likely to occur with purposeful movements b. A common term used to describe the tremors in the hands and fingers is called "pill-rolling". c. Tremors are one of the most common signs and symptoms of Parkinson's disease d. Tremors in this disease can occur in the hands, fingers, arms, legs and even the lips and tongue.
A
client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg, and respiratory irregularities. What action by the nurse takes priority? a. Call the provider or Rapid Response Team. b. Increase the rate of the IV fluid administration. c. Notify respiratory therapy for a breathing treatment. d. Prepare to give IV pain medication.
A
Which of the following statements made by a patient diagnosed with multiple sclerosis (MS) would alert the healthcare provider that the patient requires additional instruction about the disease? Select all that apply. 1. "A hot bath in the evenings will help relax my muscles and relieve pain." 2. "I will avoid foods that are high in fiber to prevent problems with my bowels." 3. "It's important for me to inspect my skin daily make sure there aren't any injuries." 4. "Use of stress reduction strategies can decrease the severity of my symptoms."
A, B
The client with a head injury is experiencing signs of increased intracranial pressure (ICP), and mannitol (Osmitrol) is prescribed. The nurse administering this medication expects which as an intended effects of this medication? Select all that apply. 1. Increased diuresis 2. Reduced intracranial pressure 3. Increased osmotic pressure of glomerular filtrate 4. Reduced tubular reabsorption of water and solutes 5. Reabsorption of sodium and water in the loop of Henle
A, B, C, D
A patient is suspected of having multiple sclerosis. The neurologist orders various test. The patient's MRI results are back and show lesions on the cerebellum and optic nerve. What signs and symptoms below would correlate with this MRI finding in a patient with multiple sclerosis? A. Blurry vision B. Pain when moving eyes C. Dysarthria D. Balance and coordination issues E. "Pill rolling" of fingers and hands G. Heat intolerance H. Dark spots in vision I. Ptosis
A, B, C, D, H
A spouse of a husband who has Parkinson's Disease explains to you that her husband experiences episodes while walking where he freezes and can't move. She asks what can be done to help with these types of episodes to prevent injury. Select all the options that are correct: A. Have the husband try to change direction of movement by moving in the opposite direction when the freeze ups occur. B. Use a cane with a laser point while walking. C. Have the husband try to push through the freeze ups. D. Encourage the husband to consciously lift the legs while walking (as with marching).
A, B, D
A nurse is working with many stroke clients. Which clients would the nurse consider referring to a mental health provider on discharge? (Select all that apply.) a. Client who exhibits extreme emotional lability b. Client with an initial National Institutes of Health (NIH) Stroke Scale score of 38 c. Client with mild forgetfulness and a slight limp d. Client who has a past hospitalization for a suicide attempt e. Client who is unable to walk or eat 3 weeks post-stroke
A, B, D, E
The nurse is caring for a 77-year-old woman with MS. She states that she is very concernedabout the progress of her disease and what the future holds. The nurse should know that elderlypatients with MS are known to be particularly concerned about what variables? Select all that apply. A) Possible nursing home placement B) Pain associated with physical therapy C) Increasing disability D) Becoming a burden on the family E) Loss of appetite
A, C, D
The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which medications might the nurse expect to provide discharge instructions (select all that apply)? A. Clopidogrel (Plavix) B. Enoxaparin (Lovenox) C. Dipyridamole (Persantine) D. Enteric-coated aspirin (Ecotrin) E. Tissue plasminogen activator (tPA)
A, C, D
The primary health care provider diagnoses that a patient has a cluster headache. Which statements made by the patient support the health care provider's diagnosis? Select all that apply. a. "My cheeks also ache during the headache." b. "I feel like my limbs are moving during the headache." c. "I don't feel like sitting in one place during the headache." d. "My skin appears pale during the headache." e. "I have a strong desire to eat ice cream and chocolates during the headache."
A, C, D
The nurse is admitting a client diagnosed with multiple sclerosis. Which clinical manifestation should the nurse assess?Select all that apply. 1. Muscle flaccidity. 2. Lethargy. 3. Dysmetria. 4. Fatigue. 5. Dysphagia.
A, C, D, E
The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that appl a. Avoid activities that require bending over b. Contact the surgeon if eye scratchiness occurs c. Place an eye shield on the surgical eye at bedtime d. Episodes of sudden severe pain in the eye are expected e. Contact the surgeon if a decrease in visual acuity occurs f. Take acetaminophen (Tylenol) for minor eye discomfort
A, C, E, F
A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. How should the nurse interpret this finding? a. The client is legally blind b. The client's vision is normal c. The client can read at a distance of 60 feet what a client what a client with normal vision can read at 20 feet d. The client can read only at a distance of 20 feet what a client with normal vision can read at 60 feet
A, D
The nurse is providing discharge instructions to a client with glaucoma. Which activities does the nurse instruct the client to avoid? (Select all that apply.) A. Bending over to tie shoes B. Sitting with legs elevated C. Sleeping on more than two pillows D. Blowing the nose frequently E. Lifting objects weighing more than 10 pounds
A, D, E
A patient with MS has developed dysphagia as a result of cranial nerve dysfunction. Whatnursing action should the nurse consequently perform? A) Arrange for the patient to receive a low residue diet. B) Position the patient upright during feeding. C) Suction the patient following each meal. D) Withhold liquids until the patient has finished eating.
B
A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? a. Vomiting continues b. Intracranial pressure (ICP) is increased c. The client needs mechanical ventilation d. Blood is anticipated in the cerebralspinal fluid (CSF)
B
A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak, and felt like his legs were very heavy. Currently the client's neurologic examination is normal. About what drug should the nurse plan to teach the client? a. Alteplase (Activase) b. Clopidogrel (Plavix) c. Heparin sodium d. Mannitol (Osmitrol)
B
A client with Parkinson's disease is taking benztropine mesylate (Cogentin) orally daily. In monitoring this client for medication side effects, the nurse should plan to focus the assessment on which item? 1. Pupil response 2. Voiding pattern 3. Prothrombin time 4. Respiratory status
B
A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action should the nurse implement based on this finding? a. Provide the client with materials on legal blindness. b. Instruct the client that he or she may need glasses when driving. c. Inform the client of where he or she can purchase a white cane with a red tip. d. Inform the client that it is best to sit near the back of the room when attending lectures.
B
A male client has just had a cataract operation without a lens implant. In discharge teaching, the nurse will instruct the client's wife to: a. Have her husband remain in bed for 3 days b. Allow him to walk upstairs only with assistance c. Keep the eye dressing on for one week d. Feed him soft foods for several days to prevent facial movement
B
A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the docusate sodium (Colace) because the client had a large stool earlier. What action by the supervising nurse is best? a. Have the student ask the client if it is desired or not. b. Inform the student that the docusate should be given. c. Tell the student to document the rationale. d. Tell the student to give it unless the client refuses.
B
After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse is best? a. Assess the client's magnesium level. b. Assess the client's sodium level. c. Increase the rate of the IV infusion. d. Provide oral care every hour.
B
Subjective data from a patient diagnosed with multiple sclerosis (MS) includes facial muscle spasms accompanied by stabbing pain. The patient states, "It gets worse during meals when I'm chewing food." The healthcare provider determines that these symptoms are most likely due to a lesion on which cranial nerve? a. VI b. V c. VII d. VIII
B
The nurse enters the room of a client diagnosed with acute exacerbation of multiple sclerosis and finds the client crying. Which statement is the most therapeutic response for the nurse to make? 1. "Why are you crying?The medication will help the disease." 2. "You seem upset. I will sit down and we can talk for awhile." 3. "Multiple sclerosis is a disease that has good times and bad times." 4. "I will have the chaplain come and stay with you for a while."
B
The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use which plan to use which of the following to test the client's peripheral response to pain? a. Sternal rub b. Nail bed pressure c. Pressure on the orbital rim d. Squeezing of the sternocleidomastoid muscle
B
The nurse is assigned to care for a female client with complete right-sided hemiparesis. The nurse plans care knowing that this condition: a. The client has complete bilateral paralysis of the arms and legs. b. The client has weakness on the right side of the body, including the face and tongue. c. The client has lost the ability to move the right arm but is able to walk independently. d. The client has lost the ability to move the right arm but is able to walk independently.
B
The nurse is caring for a client who was recently diagnosed with primary open-angle glaucoma (POAG). Which assessment finding is specific to this type of glaucoma? a. Client report of blurred vision b. Client report of "tunnel vision" c. Client report of ocular erythema d. Client report of halos around lights
B
The nurse is caring for a patient with multiple sclerosis (MS). The patient tells the nurse thehardest thing to deal with is the fatigue. When teaching the patient how to reduce fatigue, whataction should the nurse suggest? A) Taking a hot bath at least once daily B) Resting in an air-conditioned room whenever possible C) Increasing the dose of muscle relaxants D) Avoiding naps during the day
B
The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? a.Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure b.Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure c. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure d. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure
B
The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid? a. Head mildline b. Head turned to the side c. Neck in neutral position d. Head of bed elevated 30 to 45 degrees
B
The nurse is teaching a client about open-angle glaucoma management. Which statement by the client indicates a need for further instruction? A. "I must wait 10 to 15 minutes between different eyedrop medications." B. "I must press on the inside of my eye to prevent washout." C. "It is important to not skip a dose." D. "These eyedrops will not cure my glaucoma."
B
The nurse is working with a client during an annual physical examination. The client describes a new and rapid onset of signs of macular degeneration. The nurse's highest priority for this finding is to: a Schedule laser surgery. b Refer the client to an ophthalmologist. c Tell the client it is the result of aging. d Conduct an eye test.
B
Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23. What should be the nurse's initial action? a. Apply normal saline drops b. Note the time of day the test was done c. Contact the health care provider d. Instruct the client to sleep with the head of the bed flat.
B
What is the action of miotics in the client with glaucoma? A. Decrease the inflammatory process B. Enhance aqueous outflow C. Increase the production of vitreous humor D. Vasoconstrict the blood vessels in the eye
B
Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury? A. Insert an indwelling urinary catheter to straight drainage B. Schedule intermittent catheterization every 2 to 4 hours C. Perform a straight catheterization every 8 hours while awake D. Perform Crede's maneuver to the lower abdomen before the client voids.
B
Select all the TRUE statements about the pathophysiology of multiple sclerosis: A. "The dendrites on the neuron are overstimulated leading to the destruction of the axon." B. "The myelin sheath, which is made up of Schwann cells, is damaged along the axon." C. "This disease affects the insulating structure found on the neuron in the central nervous system." D. "The dopaminergic neurons in the part of the brain called substantia nigra have started to die."
B, C
The nurse is teaching a client with bladder dysfunction from multiple sclerosis (MS) about bladder training at home. Which instructions should the nurse include in the teaching plan? Select all that apply a. Restrict fluids to 1,000 mL/24 hr b. Drink 400 to 500 mL with each meal c. Drink fluids midmorning, midafternoon, and late afternoon d. Attempt to void at least every 2 hr e. Use intermittent catheterization as needed
B, C
32-year-old client recently diagnosed with multiple sclerosis is a full-time aerobics exercise instructor at a local fitness center. Which statements contain the correct information to give the client when answering her specific questions about lifestyle?Select all that apply. A) "Hyperbaric oxygen treatment is recommended prior to vigorous physical exercise." B) "You will tolerate exercise better in an air-conditioned room." C) "Acupuncture may benefit some of your symptoms." D) "Drinking cold water is recommended during exercise." E) "You will be able to maintain your exercise teaching schedule."
B, C, D
The nurse is performing preoperative teaching for an older adult client who will be having a cataract removed. Which instructions does the nurse include? (Select all that apply.) A. "You will need to wear a patch on your eye for several weeks after the surgery." B. "Several different types of eyedrops are requested after surgery, and they have to be taken several times a day for up to 4 weeks." C. "You will receive a medication to help you relax. Then you will receive some different eyedrops to dilate your pupils and paralyze the lens." D. "Bring sunglasses with you on the day of your procedure." E. "You might experience a lot of bruising and swelling around the eye."
B, C, D
The nurse is presenting a seminar about macular degeneration for a group of clients. Which of the following factors would the nurse include that increase the risk for this condition? (Select all that apply.) a Frequent infections b Nutritional status c Race d Age e Smoking
B, C, D, E
You're providing free education to a local community group about the signs and symptoms of Parkinson's Disease. Select all the signs and symptoms a patient could experience with this disease: A. Increased Salivation B. Loss of smell C. Constipation D. Tremors with purposeful movement E. Shuffling of gait F. Freezing of extremities G. Euphoria H. Coordination issues
B, C, E, F, H
During your discharge teaching to a patient with multiple sclerosis, you educate the patient on how to avoid increasing symptoms and relapses. You tell the patient to avoid: A. Cold temperatures B. Infection C. Overexertion D. Salt F. Stress
B, C, F
You're developing a plan of care for a patient with multiple sclerosis who presents with Uhthoff's Sign. What interventions will you include in the patient's plan of care? Select all that apply: A. Avoid movements of the head and neck downward B. Keep room temperature cool C. Encourage patient to use warm packs and heating pads for symptoms D. Educate the patient on three ways to avoid overheating during exercise
B, D
You're providing diet education to a patient with Parkinson's Disease. Which statement below demonstrates the patient understood your teaching? Select all that apply: A. "I will limit foods high in fiber like fruits and vegetables in my diet." B. "I will be sure to drink 2 Liter of fluid per day." C. "It is very common for me to experience diarrhea with this disease." D. "I will avoid taking Carbidopa/Levodopa with a protein rich meal."
B, D
n a patient with MS, which of the following will the healthcare expect to identify? Select all that apply. 1) Flaccid paralysis 2) Nystagmus 3) Resting tremors 4) Scanning speech 5) Seizures
B, D
The healthcare provider is teaching a group of patients diagnosed with multiple sclerosis (MS) about common bladder problems. Which of the following will the healthcare provider include? Select all that apply. 1. "Drinking caffeinated beverages can help you empty your bladder completely." 2. "MS may cause the bladder to contract and empty more often than usual." 3. "You should not attempt to urinate until you feel that your bladder is full." 4. "Drink 1.5 - 2 liters of water each day so your urine isn't too concentrated." 5. "Drinking lots of citrus juices will decrease the amount of bacteria in your urinary tract." 6. "Patients with MS are at increased risk of developing urinary tract infections."
B, D, F
A nurse is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assess neurologic status with the Glasgow Coma Scale. b. Check and document oxygen saturation every 1 to 2 hours. c. Cluster client care to allow periods of uninterrupted rest. d. Elevate the head of the bed to 45 degrees to prevent aspiration. e. Position the client supine with the head in a neutral midline position.
B, E
Which of the following is not a realistic outcome to establish with a client who has multiple sclerosis (MS)? The client will: 1. Develop joint mobility. 2. Develop muscle strength. 3. Develop cognition. 4. Develop mood elevation.
C
A 33-year-old patient presents at the clinic with complaints of weakness, incoordination,dizziness, and loss of balance. The patient is hospitalized and diagnosed with MS. What sign orsymptom, revealed during the initial assessment, is typical of MS? A) Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes B) Flexor spasm, clonus, and negative Babinskis reflex C) Blurred vision, intention tremor, and urinary hesitancy D) Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in bothlegs
C
A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. The nurse should first: a. Ask what medications the client is taking b. Complete a history and health assessment c. Identify the time of onset of the stroke d. Determine if the client is scheduled for any surgical procedures
C
A client diagnosed with multiple sclerosis has an acute onset of visual changes, fatigue, and leg weakness. The client says that the last time this happened, recovery occurred in a few weeks. Which classification of multiple sclerosis is the client experiencing? A Progressive-relapsing B Secondary-progressive C Relapsing-remitting D Primary-progressive
C
A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that a priority goal for this problem has been met? a. Chooses preferred items from the menu b. Eats 75% to 100% of all meals and snacks c. Has clear lung sounds on auscultation d. Gains 2 pounds after 1 week
C
A client had an embolectomy for an arteriovenous malformation (AVM). The client is now reporting a severe headache and has vomited. What action by the nurse takes priority? a. Administer pain medication. b. Assess the client's vital signs. c. Notify the Rapid Response Team. d. Raise the head of the bed.
C
A client has recently had cataract surgery. About which symptom does the nurse instruct the client to notify the health care provider? A. Increased tearing B. Itching of the eye C. Reduction in vision D. Swollen eyelid
C
A female client admitted to the hospital with a neurological problem asks the nurse whether magnetic resonance imaging may be done. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the client's history of: a. Hypertension b. Heart failure c. Prosthetic valve replacement d. Chronic obstructive pulmonary disorder
C
A nurse is assessing a client who had a right hemispheric stroke. Which of the following deficits should the nurse expect? a. Aphasia b. right sided neglect c. Impulsive behavior d. Inability to read
C
A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect? a. Hypoactive DTRs b. Ascending paralysis c. Intention tremors d. Increased lacrimation
C
A nurse is planning care for a lumbar puncture. Which of the following actions should the nurse plan to take? a. apply pressure dressing at the site for 8 hr. b. Restrict the client's fluid intake for 24 hr. c. Ensure that the client lies flat for up to twelve hours. d. Inform the client that neck stiffness is an expected outcome of the procedure.
C
A nurse is teaching a client who has Parkinson's disease and is prescribed carbidopa-levadopa. Which of the following client statements indicates an understanding of the teaching? a. "I should expect an increase in my blood pressure while taking this medication." b. "I should take this medication 2 hours after meals to increase absorption." c. "I should expect that this medication can cause me to be drowsy." d. "I should expect this medication to be effective within 48 hours."
C
A patient diagnosed with multiple sclerosis (MS) tells the healthcare provider, "I'm not sure if I'll be able to exercise anymore." Which of these is the most appropriate response? A. "It's important for you to conserve your strength by not being too active." B. "You should get a personal trainer to help you plan a fitness program." C. "Swimming or exercising in the water can be both enjoyable and beneficial." D. "Exercise often causes a relapse of the disease, so it should be avoided."
C
A patient is receiving Interferon Beta for treatment of multiple sclerosis. As the nurse you will stress the importance of? A. Physical exercise to improve fatigue B. Low fat diet C. Hand hygiene and avoiding infection D. Reporting ideation of suicide
C
A patient reports a headache to the nurse. After reviewing the patient's history, the nurse finds that the patient has previously had a stroke. Which drug should be excluded from the patient's treatment regimen? a. Fluoxetine b. Propanolol c. Sumatriptan d. Amitriptyline
C
A patient with Parkinson's Disease has slow movements that affects their swallowing, facial expressions, and ability to coordinate movements. As the nurse you will document the patient has: a. Akinesia b. Freeze up tremors c. Bradykinesia d. Pill-rolling
C
A white female client is admitted to an acute care facility with a diagnosis of cerebrovascular accident (CVA). Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for CVA? a. Caucasian race b. Female sex c. Obesity d. Bronchial asthma
C
After teaching a patient about management of migraine headaches, the nurse determines that the teaching has been effective when the patient says: a. "I will take the (Topamax) as soon as any headaches start." b. "I should avoid taking aspirin and sumatriptan (Imitrex) at the same time." c. "I will try to lie down someplace dark and quiet when the headaches begin." d. "A glass of wine might help me relax and prevent headaches from developing."
C
Benztropine mesylate (Cogentin) is prescribed for a client with a diagnosis of Parkinson's disease. What statement by the client indicates that the client needs additional information about the medication? 1. "I will avoid driving if I get drowsy or dizzy." 2. "I'll watch my urinary output and look for signs of constipation." 3. "I will sit in the sun for an hour a day to enhance medication effectiveness." 4. "I will call the health care provider (HCP) if I have difficulty swallowing or if I start vomiting."
C
During the first 24 hr after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's: a. Pulse b. Respirations c. Blood pressure d. Temperature
C
The 30-year-old female client is admitted with complaints of numbness, tingling, a crawling sensation affecting the extremities, and double vision which has occurred two(2) times in the month. Which question is most important for the nurse to ask the client? 1. "Have you experienced any difficulty with your menstrual cycle?" 2. "Have you noticed a rash across the bridge of your nose?" 3. "Do you get tired easily and sometimes have problems swallowing?" 4. "Are you taking birth control pills to prevent conception?
C
The client diagnosed with an acute exacerbation of multiple sclerosis is placed on high-dose intravenous injections of corticosteroid medication. Which nursing intervention should be implemented? 1. Discuss discontinuing the proton pump inhibitor with the HCP. 2. Hold the medication until after all cultures have been obtained. 3. Monitor the client's serum blood glucose levels frequently. 4. Provide supplemental dietary sodium with the client's meals.
C
The home health nurse has been discussing interventions to prevent constipation in a client with multiple sclerosis. The nurse determines that the client is using the information most effectively if the client reports which action? 1. Drinking a total of 1000 mL/day 2. Giving herself an enema every morning before breakfast 3. Taking stool softeners daily and a glycerin suppository once a week 4. Initiating a bowel movement every other day, 45 minutes after the largest meal of the day
C
The home health nurse is caring for the client newly diagnosed with multiple sclerosis. Which client issue is of most importance? 1. The client refuses to have a gastrostomy feeding. 2. The client wants to discuss if she should tell her fiancé. 3. The client tells the nurse life is not worth living anymore. 4. The client needs the flu and pneumonia vaccines.
C
The nurse has given instructions to a client with Parkinson's disease about maintaining mobility. Which action demonstrates that the client understands the directions? 1. Sits in soft, deep chairs to promote comfort. 2. Exercises in the evening to combat fatigue. 3. Rocks back and forth to start movement with bradykinesia. 4. Buys clothes with many buttons to maintain finger dexterity.
C
The nurse is developing a plan of care for the client scheduled for cataract surgery. The nurse documents which more appropriate nursing diagnosis in the plan of care? a. Self-care deficit b. Imbalanced nutrition c. Disturbed sensory perception d. Anxiety
C
The nurse is preparing to care for a client after a lumbar puncture. The nurse should plan to place the client in which best position immediately after the procedure? 1. Prone in semi-Fowler's position 2. Supine in semi-Fowler's position 3. Prone with a small pillow under the abdomen 4. Lateral with the head slightly lower than the rest of the body
C
The nurse is reviewing the care plan of a client with Multiple Sclerosis. Which of the following nursing diagnoses should receive further validation? 1. Impaired mobility related to spasticity and fatigue. 2. Risk for falls related to muscle weakness and sensory loss. 3. Risk for seizures related to muscle tremors and loss of myelin. 4. Impaired skin integrity related bowel and bladder incontinence.
C
The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing? 1. Flaccid paralysis of all extremities 2. Adduction of the arms at the shoulders 3. Rigid extension and pronation of the arms and legs 4. Abnormal flexion of the upper extremities and extension and adduction of the lower extremities
C
When a patient is experiencing a cluster headache, the nurse will plan to assess for a. nuchal rigidity. b. projectile vomiting. c. unilateral eyelid swelling. d. throbbing, bilateral facial pain.
C
When analyzing the cerebrospinal fluid of a patient diagnosed with multiple sclerosis (MS), which of the following results would the healthcare provider anticipate? a. Cloudy with increased turbidity b. Clear with decreased white blood cells c. Clear with increased proteins d. Pinkish with increased red blood cells
C
When assessing a patient diagnosed with multiple sclerosis (MS), which of the following would require immediate action by the healthcare provider? a. Paresthesia and tremor b. Nystagmus and diplopia c. Dysphagia and congested cough d. Fatigue and depression.
C
Which complaint made by the patient indicates that the individual may be suffering from a cluster headache? a. "The pain is constant." b. "The pain is followed by nausea." c. "The pain disturbs my sleep at night." d. "The pain lasts for longer than eight hours.
C
Which is a common cognitive problem associated with Parkinson's disease? 1. Emotional lability. 2. Depression. 3. Memory deficits. 4. Paranoia.
C
Which of the following is the most effective means of preventing plantar flexion in a client who has had a stroke with residual paralysis? a. Place the client's feet against a firm footboard. b. Reposition the client every 2 hr c. Have the client wear ankle-high tennis shoes at intervals throughout the day d. Massage the client's feet and ankles regularly
C
Which of the following procedures or assessments must the nurse perform when preparing a client for eye surgery? a. Obtaining informed consent with the client's signature and placing the forms on the chart. b. Clipping the client's eyelashes c. Verifying the client has been NPO since midnight, or at least 8 hours before surgery. d. Verifying the affected eye has been patched 24 hours before surgery
C
Which of these assessment findings should the healthcare provider expect to identify as an early clinical characteristic of multiple sclerosis? a. Muscle atrophy b. Dementia c. Vision loss d. Clonus
C
You're patient with Parkinson's Disease has been taking Carbidopa/Levodopa for several years. The patient reports that his signs and symptoms actually become worse before the next dose of medication is due. As the nurse, you know what medication can be prescribed with this medication to help decrease this for happening? A. Anticholinergic (Benztropine) B. Dopamine agonists (Ropinirole) C. COMT Inhibitor (Entacapone) D: Beta blockers (Metoprolol)
C
client with multiple sclerosis (MS) is receiving baclofen (Lioresal). The nurse determines that the drug is effective when it achieves which of the following? 1. Induces sleep. 2. Stimulates the client's appetite. 3. Relieves muscular spasticity. 4. Reduces the urine bacterial count.
C
he client diagnosed with Parkinson's disease is being discharged. Which statement made by the significant other indicates an understanding of the discharge instructions? 1. "All of my spouse's emotions will slow down now just like his body movements." 2. "My spouse may experience hallucinations until the medication starts working." 3. "I will schedule appointments late in the morning after his morning bath." 4. "It is fine if we don't follow a strict medication schedule on weekends."
C
Which medications below can help treat muscle spasms in a patient with multiple sclerosis? Select all that apply: A. Propranolol B. Isoniazid C. Baclofen D. Diazepam E. Modafinil
C, D
A health care provider has prescribed carbidopa-levodopa (Sinetmet) four times per day for a client with Parkinson's disease. The client wants "to end it all now that the Parkinson's disease has progressed." What should the nurse do? Select all that apply a. Explain that the new prescription for Sinemet will treat the depression b. Encourage the client to discuss feelings as the Sinemet is being administered c. Contact the health care provider before administering the Sinemet d. Determine if the client is on antidepressants or monoamine oxidase (MAO) inhibitors e. Determine if the client is at risk for suicide
C, D, E
During the early postoperative period, the client who had a cataract extraction complains of nausea and severe eye pain over the operative site. The initial nursing action is to: a. reassure the client that this is normal b. turn the client on his or her operative side c. administer the ordered pain medication and antiemetic d. call the physician
D
As the home health nurse you are helping a patient with Parkinson's Disease get dressed. What item gathered by the patient to wear should NOT be worn? A. Velcro pants B. Pull over sweatshirt C. Non-slip socks D. Rubber sole shoes
D
Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side/adverse effects to the medication. Which finding indicates that the client is experiencing an adverse effect? 1. Pruritus 2. Tachycardia 3. Hypertension 4. Impaired voluntary movements
D
A client in the intensive care unit is scheduled for a lumbar puncture (LP) today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. What action by the nurse is best? a. Ensure that informed consent is on the chart. b. Document these findings in the client's record. c. Give the prescribed preprocedure sedation. d. Notify the provider of the findings immediately.
D
A client tells the nurse about the vision being blurred and hazy throughout the entire day. The nurse should recommend that the client do which of the following? a. Purchase a pair of magnifying glasses b. Wear glasses with tinted lenses c. Schedule an appointment with an optician d. Schedule an appointment with an ophthalmologist
D
A client with a stroke is being evaluated for fibrinolytic therapy. What information from the client or family is most important for the nurse to obtain? a. Loss of bladder control b. Other medical conditions c. Progression of symptoms d. Time of symptom onset
D
A client with glaucoma asks the nurse if complete vision will return. The nurse makes which response to the client? a. Your vision will never return to normal b. Your vision loss is temporary and will return in about 3-4 weeks c. your vision loss will return as soon as the medications begin to work d. Although some vision has been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan.
D
A client with glaucoma is being assessed for new symptoms. Which symptom indicates a high priority need for reassessment of intraocular pressure? A. Burning in the eye B. Inability to differentiate colors C. Increased sensitivity to light D. Gradual vision changes
D
A male client is having a lumbar puncture performed. The nurse would plan to place the client in which position? a. Side-lying, with a pillow under the hip b. Prone, with a pillow under the abdomen c. Prone, in slight-Trendelenburg's position d. Side-lying, with the legs pulled up and head bent down onto chest.
D
A middle-aged woman has sought care from her primary care provider and undergonediagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely tohave prompted the woman to seek care? A) Cognitive declines B) Personality changes C) Contractures D) Difficulty in coordination
D
A nurse is caring for a client who is recovering from a stroke and has right-sided homonymous hemianopsia. To help the client adapt to the hemianopsia, the nurse should take which of the following actions? a. Check the client's cheek on the affected side after meals to be sure no food remains there. b. Encourage the client to sit upright with their head tilted slightly forward during meals. c. Provide the client with eating utensils that have large handles. d. Remind the client to look consciously at both sides of their meal tray.
D
A nurse is interviewing a patient who is seeking relief for frequent headaches. Which description is consistent with symptoms of a migraine headache? a. Extreme tenseness in the area of the neck and shoulders. b. Tears flow from one eye and nasal drainage occurs with the headache. c. The pain of the headache wakes the patient from sleep. d. The pain throbs and is synchronous with the patient's pulse.
D
A nurse receives a report on a client who had a left-sided stroke and has homonymous hemianopsia. What action by the nurse is most appropriate for this client? a. Assess for bladder retention and/or incontinence. b. Listen to the client's lungs after eating or drinking. c. Prop the client's right side up when sitting in a chair. d. Rotate the client's meal tray when the client stops eating.
D
The 45-year-old client is diagnosed with primary progressive multiple sclerosis and the nurse writes the nursing diagnosis "anticipatory grieving related to progressive loss." Which intervention should be implemented? 1. Consult the physical therapist for assistive devices for mobility .2. Determine if the client has a legal power of attorney. 3. Ask if the client would like to talk to the hospital chaplain. 4. Discuss the client's wishes regarding end-of-life care.
D
The 45-year-old client is diagnosed with primary progressive multiple sclerosis and the nurse writes the nursing diagnosis "anticipatory grieving related to progressive loss." Which intervention should be implemented? 1. Consult the physical therapist for assistive devices for mobility. 2. Determine if the client has a legal power of attorney. 3. Ask if the client would like to talk to the hospital chaplain. 4. Discuss the client's wishes regarding end-of-life care.
D
The client who had cataract surgery with a lens implant 1 week ago remarks to the home care nurse that after his daughter left to go to her home in another state yesterday, he combined all of his prescribed eyedrops together in one container so he had fewer drops to administer. What is the nurse's best response? A. "This is not a good idea because not all of the drugs are on the same schedule." B. "That is a good idea; just remember to not touch the dropper to your eye when giving yourself the drops." C. "Call your surgeon immediately and get new prescriptions because together these drugs can lower your blood pressure." D. "Call your surgeon immediately and get new prescriptions to use one at a time because these drugs cannot be mixed together."
D
The healthcare provider is planning care for a patient diagnosed with multiple sclerosis (MS). Which of the following is the priority intervention? a. Encourage bed rest in order to conserve strength b. Teach the patient's family how to meet the patient's needs c. Monitor the patient's temperature to avoid overheating d. Advise the patient to drink liquids through a straw
D
The nurse in a primary care provider's office is assessing several patients today. Which patient is most at risk for a stroke? A. A 92-year-old female who takes warfarin (Coumadin) for atrial fibrillation. B. A 28-year-old male who uses marijuana after chemotherapy to control nausea. C. A 42-year-old female who takes oral contraceptives and has migraine headaches. D. A 72-year-old male who has hypertension and diabetes mellitus and smokes tobacco.
D
The nurse is assessing a 48-year-old client diagnosed with multiple sclerosis. Which clinical manifestation warrants immediate intervention? 1. The client has scanning speech and diplopia. 2. The client has dysarthria and scotomas. 3. The client has muscle weakness and spasticity. 4. The client has a congested cough and dysphagia.
D
The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first? a. Client with cerebral perfusion pressure of 72 mm Hg b. Client who has a Glasgow Coma Scale score of 12 c. Client with a PaCO2 of 36 mm Hg who is on a ventilator d. Client who has a temperature of 102° F (38.9° C)
D
The nurse is creating a plan of care for a patient who has a recent diagnosis of MS. Which ofthe following should the nurse include in the patients care plan? A) Encourage patient to void every hour. B) Order a low-residue diet. C) Provide total assistance with all ADLs. D) Instruct the patient on daily muscle stretching.
D
The nurse is performing an assessment on a client with a diagnosis of thrombotic brain attack (stroke). Which assessment question would elicit data specific to this type of stroke? 1. "Have you had any headaches in the past few days?" 2. "Have you recently been having difficulty with seeing at nighttime?" 3. "Have you had any sudden episodes of passing out in the past few days?" 4. "Have you had any numbness or tingling or paralysis-type feelings in any of your extremities recently?"
D
When the nurse talks with a client with multiple sclerosis who has slurred speech, which nursing intervention is contraindicated? a. Encouraging the client to speak slowly b. Encouraging the client to speak distinctly c. Asking the client to repeat indistinguishable words d. Asking the client to speak louder when tired
D
Which goal is the most realistic for a client diagnosed with Parkinson's disease? a. To cure the disease b. To stop progression of the disease c. To begin preparations for terminal care d. To maintain optimal body function
D
the nurse caring for a client diagnosed with Parkinson's disease writes a problem of"impaired nutrition." Which nursing intervention would be included in the plan of care? 1. Consult the occupational therapist for adaptive appliances for eating. 2. Request a low-fat, low-sodium diet from the dietary department. 3. Provide three (3) meals per day that include nuts and whole-grain breads. 4. Offer six (6) meals per day with a soft consistency.
D
What is the expected outcome of thrombolytic drug therapy for stroke? a. Increased vascular permeability b. Vasoconstriction c. Dissolved emboli d. Prevention of hemorrhage
C
The nurse is instructing the client about postoperative care following cataract removal. What position should the nurse teach the client to use? a. Remain in a semi-fowler's position b. Position the feet higher than the body c. Lie on the operative side d. Place the head in dependent position
A
The nurse observes the client instill eyedrops. The client says, "I just try to hit the middle of my eyeball so the drops don't run out of my eye." The nurse explains to the client that this method may cause: a. Scleral staining b. Corneal injury c. Excessive lacrimation d. Systemic drug absorption
B
To decrease intraocular pressure following cataract surgery, the nurse should instruct the client to avoid: a. Lying supine b. Coughing c. Deep breathing d. Ambulation
B
Tonometry is performed on a suspected diagnosis of glaucoma. The nurse looks at the test results documented in the client's chart, knowing that which is the range for normal intraocular pressure? a. 2 to 7 mm Hg b. 10 to 21 mm Hg c. 22 to 30 mm Hg d. 31 to 35 mm Hg
B
What is a priority nursing assessment in the first 24 hr after admission of the client with a thrombotic stroke? a. Cholesterol level b. Pupil size and pupillary response c. Bowel sounds d. Echocardiogram
B
Which medication, if prescribed for the client with glaucoma, should the nurse question? a. Betaxolol (Betoptic) b. Atropine sulfate (Isopto Atropine) c. Pilocarpine hydrochloride (Isopto Carpine) d. Pilocarpine (Ocusert Pilo-20, Ocusert Pilo-40)
B
Which of the following is an initial sign of Parkinson's disease? a. Rigidity b. Tremor c. Bradykinesia d. Akinesia
B
Which of the following is not a typical clinical manifestation of multiple sclerosis (MS)? a. Double vision b. Sudden bursts of energy c. Weakness in the extremities d. Muscle tremors
B
Which of the following should the nurse provide as part of the information to prepare the client for tonometry? a. Oral pain medication will be given before the procedure b. It is a painless procedure with no adverse effects c. Blurred or double vision may occur after the procedure d. Medication will be given to dilate the pupils before the procedure
B
Which of the following techniques is not appropriate when the nurse changes a client's position in bed if the client has hemiparalysis? a. Rolling the client onto the side b. Sliding the client to move up in bed c. Lifting the client when moving the client up in bed d. Having the client help lift off the bed using a trapeze
B
Which term refers to the inability to coordinate muscle movements, resulting in difficulty walking? a. agnosia b. ataxia c. spasticity d. rigidity
B
The nurse is teaching a client about taking prophylactic warfarin sodium (Coumadin). Which statement indicates that the client understands how to take this drug? Select all that apply. a. "The drug's action peaks in two hours." b. "Maximum dosage is not achieved until 3 to 4 days after starting medications." c. Effects of the drug continue for 4 to 5 days after discontinuing medication." d. "Protamine sulfate is the antidote for warfarin." e. " I should have my blood levels tested periodically."
B, C, E
The nurse should conduct a focused assessment with the client with multiple sclerosis for risk of which of the following? Select all that apply a. Dehydration b. Falls c. Seizures d. Skin breakdown e. Fatigue
B, C, E
Which intervention should the nurse suggest too help a client with MS avoid episodes of urinary incontinence? a. Limit fluid intake to 1,000 mL/day b. Insert an indwelling urinary catheter c. Establish a regular voiding schedule d. Administer prophylactic antibiotics, as prescribed
C
Which of the following is not a realistic outcome to establish with a client who has MS? The client will develop: a. Joint mobility b. Muscle strength c. Cognition d. Mood elevation
C
Which of the following should the nurse include in the discharge plan for a client with MS who has an impaired peripheral sensation? Select all that apply a. Carefully test the temperature of bath water b. Avoid kitchen activities because of the risk of injury c. Avoid hot water bottles and heating pads d. inspect the skin daily for injury or pressure points e. Wear warm clothing when outside in cold temperatures
A, C, D, E
When communicating with a client who has aphasia, which of the following are helpful? Select all that apply a. Present one thought at a time b. Avoid writing messages c. Speak with normal volume d. Make use of gestures e. Encourage pointing to the needed object
A, C, D, E
A client is prescribed an eyedrop and an eye ointment for the right eye. How should the nurse best administer the medications? a. Administer the eyedrop first, followed by the eye ointment b. Administer the eye ointment first, followed by the eyedrop c. Administer the eyedrop, wait 15 minutes, and administer the eye ointment d. Administer the eye ointment, wait 15 minutes, and administer the eyedrop
A
After returning home, a client who has had cataract surgery will need to continue to instill eyedrops in the affected eye. The client is instructed to apply slight pressure against the nose at the inner canthus of the eye after instilling the eyedrops. The expected outcome of applying pressure is that the pressure: a. Prevents the medication from entering the tear duct b. Prevents the drug from running down the client's face c. Allows the sensitive cornea to adjust to the mediation d. Facilitates distribution of the medication over the eye surface
A
During the early postoperative period, a client who has undergone a cataract extraction complains of nausea and severe eye pain over the operative site. What should be the initial nursing action? a. Call the health care provider b. Reassure the client that this is normal c. Turn the client onto his or her operative side d. Administer the prescribed pain medication and antiemetic
A
In planning care for the client who has had a stroke, the nurse should obtain a history of the client's functional status before the stroke because a. The rehabilitation plan will be guided by it b. Functional status before the stroke will help predict outcomes c. It will help the client recognize physical limitations d. The client can be expected to regain most functional status
A
The clinic nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test? a. The right eye is tested, followed by the left eye, and then both eyes are tested b. Both eyes are assessed together, followed by an assessment of the right eye and then the left eye c. The client is asked to stand at a distance of 40 feet from the chart and is asked to read the largest line on the chart d. The client is asked to stand at a distance of 40 feet from the chart and to read the line that can be read 200 feet away by an individual with unimpaired vision
A
The nurse is performing a neurological assessment of a client who has sustained damage to the frontal cortex. Which of the following deficits will the nurse look for during assessment? a. The inability to tell how a mouse and cat are alike b. The inability to maintain steady balance for the Romberg test c. Absence of movements below the waist d. Intentional tumors
A
The nurse is assigned to care for a client with complete right-sided hemiparesis. Which characteristics are associated with this condition? Select all that apply a. The client is aphasic b. The client has weakness in the face and tongue c. To The client has weakness on the right side of the body d. The client has complete bilateral paralysis of the arms and legs e. The client has lost the ability to move the right arm but is able to walk independently f. The client has lost the ability to ambulate independently but is able to feed and bathe himself on herself without assistance
A, B, C
The nurse is preparing to administer eyedrops. Which interventions should the nurse take to administer the drops? Select all that apply a. Wash hands b. Put gloves on c. Place the drop in the conjunctival sac d. Pull the lower lid down against the cheek bone e. Instruct the client to squeeze the eyes shut after instilling the eyedrop f. Instruct the client to tilt the head forward, open the eyes, and look down
A, B, C, D
A client is having a cataract removed and will use eyeglasses after the surgery. The nurse should develop a teaching plan that includes which of the following? Select all that apply a. Images will appear to be one-third larger b. Look through the center of the glasses c. The changes will be immediate d. Use handrails when climbing stairs e. Stay out of the sun for 2 weeks
A, B, D
The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm and hand. Which of the following positions are appropriate? Select all that apply. a. Placing a pillow in a axilla so the arm is away from the body b. Inserting a pillow under the slightly flexed arm so the hand is higher than the elbow c. Immobilizing the extremity in a sling d. Positioning a hand cone in the hand so the fingers are barely flexed e. Keeping the arm at the side using a pillow
A, B, D
The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern? Select all that apply. a. unequal pupils b. pupil reactions quick c. pinpoint pupils d. absence of pupillary response e. pupils react to light
A, C, D
The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which of the following strategies should the nurse include in the teaching plan. Select all that apply a. Maintaining an upright position while eating b. Restricting the diet to liquids until swallowing improves c. Introducing foods on the unaffected side of the mouth d. Keeping distractions to a minimum. e. Cutting food into large pieces of finger food
A, C, D
The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply. a. avoid activities that require bending over b. contact the surgeon if eye scratchiness occurs c. Take acetaminophen for minor eye discomfort d. Expect episodes of sudden severe pain in the eye e. place an eye shield on the surgical eye at bedtime f. contact the surgeon if a decrease in visual acuity occurs
A, C, E, F
Which of the following is a potential complication following cataract surgery? Select all that apply a. Acute bacterial endophthalmitis b. Retrobulbar hemorrhage c. Rupture of the posterior capsule d. Suprachoroidal hemorrhage e. Vision loss
A, E
1. A client with MS lives with her daughter and 3 year old granddaughter. The daughter asks the nurse what she can do at home to help her mother. Which of the following measures would be most beneficial? a. Psychotherapy b. Regular exercise c. Daycare for the granddaughter d. Weekly visits by another person with MS
B
A client has a neurological deficit involving the limbic system. Which assessment finding is specific to this type of deficit? a. In disoriented to person, place, and time b. Affect is flat, with periods of emotional lability c. Cannot recall what was eaten for breakfast today d. Demonstrates inability to add and subtract; does not know who is the president of the United States
B
A client has had MS for 15 yr and has received various drug therapies. What is the primary reason why the nurse has found it difficult to evaluate the effectiveness of the drugs that the client has used? a. The client exhibits intolerance to many drugs b. The client experiences spontaneous remissions from time to time c. The client requires multiple drugs simultaneously d. The client endures long periods of exacerbation before the illness responds to a particular drug.
B
A client is ordered to undergo CT of the brain with IV contrast. Before the test, the nurse should complete which action first? a. Obtain a blood sample to evaluate BUN and creatinine concentrations b. Assess the client for medication allergies c. Obtain two large-bore IV lines d. Maintain the client NPO for 6 hours before the test.
B
A client was just admitted to the hospital to rule out a GI bleed. The client has brought several bottles of medications prescribed by different specialist. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication would the nurse identify as the cause of the client's complaint? a. Doxycycline (Vibramycin) b. Acetylsalicylic acid (asprin) c. Atropine sulfate (Isopto Atropine) d. Diltiazem hydrochloride (Cardizem)
B
A client who has been treated for chronic open-angle glaucoma (COAG) for 5 years asks the nurse, "How does glaucoma damage my eyesight?" the nurse's reply should be based on the knowledge that COAG: a. Results from chronic eye inflammation b. Causes increased intraocular pressure c. Leads to detachment of the retina d. Is caused by decreased blood flow to the retina
B
A client who has sustained a head injury to the parietal love cannot identify a familiar touch. The nurse knows that this deficit is which of the following? a. Visual agnosia b. Tactile agnosia c. Ataxia d. Positive Romberg
B
A client with Parkinson's disease is prescribed levodopa therapy. Improvement in which of the following indicates effective therapy? a. Mood b. Muscle rigidity c. Appetite d. Alertness
B
A client with Parkinson's disease needs a long time to complete morning care but becomes annoyed when the nurse offers assistance and refuses all help. Which action is the nurse's best initial response in this situation? a. Tell the client firmly that he or she needs assistance and help with the morning care b. Praise the client for the desire to be independent and give extra time and encouragement c. Tell the client that he or she is being unrealistic about the abilities and must accept the fact that he or she needs help d. Suggest to the client to at least modify the morning care routine if he or she insists on self-care
B
A client with a suspected brain tumor is scheduled for a computed tomography (CT) scan. What should the nurse do when preparing the client for this test? a. Immobilize the neck before the client is moved onto a stretcher. b. Determine whether the client is allergic to iodine, contrast dyes, or shellfish. c. Place a cap over the client's head d. Administer a sedative as ordered.
B
A client with glaucoma is to receive 3 gtt of acetazolamide (Diamox) in the left eye. What should the nurse do? a. Ask the client to close the right eye while administering the drug in the left eye b. Have the client look up while the nurse administers the eyedrops c. Have the client lift the eyebrows while the nurse positions the hand with the dropper on the client's forehead d. Wipe the eyes with a tissue following administration of the drops
B
At what time of day should the nurse encourage a client with Parkinson's disease to schedule the most demanding physical activities to minimize the effects of hypokinesia? a. Early in the morning, when the client's energy level is high b. To coincide with the peak action of drug therapy c. Immediately after a rest period d. When family members will be available
B
Betaxolol hydrochloride eyedrops have been prescribed for a client with glaucoma. Which nursing action is most appropriate related to monitoring for side/adverse effects of this medication? a. Monitoring temperature b. Monitoring blood pressure c. Assessing peripheral pulses d. Assessing blood glucose level
B
For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication? a. Speaking loudly and slowly b. Using a "picture board" for the client to point to pictures c. Writing directions so client can read them d. Speaking in short sentences
B
In preparation for cataract surgery, the nurse is to administer cyclopentolate (Cyclogyl) eyedrops. The nurse understands that which characterizes the medication action? a. Produces miosis of the operative eye b. Dilates the pupil of the operative eye c. Constricts the pupil of the operative eye d. Provides lubrication to the operative eye
B
The client with a cataract tells the nurse about being afraid of being awake during eye surgery. Which of the following responses by the nurse would be the most appropriate? a. "have you ever had any reactions to local anesthetics in the past?" b. "what is it that disturbs you about the idea of being awake?" c. "by using a local anesthetic, you won't have nausea and vomiting after the surgery." d. "there's really nothing to fear about being awake. You'll be given a medication that will help you relax"
B
The nurse is assisting a client who has new-onset vision loss to transition to home from the hospital. The client can see shadow and light in the right eye only. When at home, the client is at greatest risk for which of the following? a. Loss of sensory perception b. Injury from falls c. Denial of changes in vision d. Isolation from social activities
B
The nurse is assisting a client with a stroke who has homonymous hemianopia. The nurse should understand that the client will: a. Have a preference for foods high in salt b. Eat food on only half of the plate c. Forget the names of foods d. Not to be able to swallow liquids
B
The nurse is preparing a client with MS for discharge from the hospital to home. The nurse should tell the client: a. You will need to accept the necessity for a quiet and inactive lifestyle b. Keep active, use stress reduction strategies, and avoid fatigue c. Follow good health habits to change the course of the disease d. Practice using the mechanical aids that you will need when future disabilities arise
B
The nurse is to instill drops of phenylephrine hydrochloride (Neo-Synephrine) into the client's eye prior to cataract surgery. Which of the following is the expected outcome? a. Dilation of the pupil and blood vessels b. Dilation of the pupil and constriction of blood vessels c. Constriction of the pupil and constriction of blood vessels d. Constriction of the pupil and dilation of blood vessels
B
The nurse observes that when a client with Parkinson's disease unbuttons the shirt, the upper arm tremors disappear. Which statement best guides the nurse's analysis of this observation about the client's tremors? a. The tremors are probably psychological and can be controlled at will b. The tremors sometimes disappear with purposeful and voluntary movements c. The tremors disappear when the client's attention is diverted by some activity d. There is no explanation for the observation; it is a chance occurrence
B
A client has a history of macular degeneration. While the hospital, the priority nursing goal will be to: a. Provide education regarding community services for clients with adult macular degeneration (AMD) b. Provide health care related to monitoring the eye condition c. Promote a safe, effective care environment d. Improve vision
C
A client has been diagnosed with an acute episode of angle-closure glaucoma. The nurse plans the client's nursing care with the understanding that acute angle-closure glaucoma: a. Frequently resolves without treatment b. Is typically treated with sustained bed rest c. Is a medical emergency that can rapidly lead to blindness d. Is most commonly treated with steroid therapy
C
A client is being switched from levodopa to carbidopa-levodopa (Sinemet). The nurse should monitor for which of the following possible complications during medication changes and dosage adjustment? a. Euphoria b. Jaundice c. Vital sign fluctuation d. Signs and symptoms of diabetes
C
A client is experiencing mood swings after a stroke and often has episodes of tearfulness that are distressing to the family. Which is the best technique for the nurse to instruct family members to try when the client experiences a crying episode? a. Sit quietly with the client until the episode is over b. Ignore the behavior c. Attempt to divert the client's attention d. Tell the client that this behavior is unacceptable
C
A client uses timolol maleate (Timoptic) eyedrops. The expected outcome of this drug is to control glaucoma by: a. Constricting the pupils b. Dilating the canals of Schlemm c. Reducing aqueous humor formation d. Improving the ability of the ciliary muscle to contract
C
A client with multiple sclerosis (MS) is receiving baclofen (Lisoresal). The nurse determines that the drug is effective when it achieves which of the following? a. Induces sleep b. Stimulates the client's appetite c. Relieves muscular spasticity d. Reduces the urine bacterial count
C
A miotic medication has been prescribed for the client with glaucoma and the client asks the nurse about the purpose of the medication. Which response should the nurse provide to the client? a. "the medication will help dilate the eye to prevent pressure from occurring." b. "the medication will relax the muscles of the eyes and prevent blurred vision." c. "the medication causes the pupil to constrict and will lower the pressure in the eye." d. "the medication will help block the responses that are sent to the muscles in the eye."
C
One day after cataract surgery the client is having discomfort from bright light. The nurse should advise the client to a. Dim lights in the house and stay inside for one week b. Attach sun shields to existing eyeglasses when in direct sunlight c. Use sunglasses that wrap around the side of the face when in bright light d. Patch the affected eye when in bright light
C
The client has had a cataract removed. The nurse's discharge instructions should include which of the following? a. Keep the head aligned straight b. Utilize bright lights in the home c. Use an eye shield at night d. Change the eye patch as needed
C
The nurse develops a teaching plan for a client newly diagnosed with Parkinson's disease. Which of the following topics that the nurse plans to discuss is the most important? a. Maintaining a balanced nutritional diet b. Enhancing the immune system c. Maintaining a safe environment d. Engaging in diversional activity
C
The nurse has given instructions to a client with Parkinson's disease about maintaining mobility. Which action demonstrates that the client understands the directions? a. Sits in soft, deep chairs to promote comfort b. Exercises in the evening to combat fatigue c. Rocks back and forth to start movement with bradykinesia d. Buys clothes with many buttons to maintain finger dexterity
C
The nurse is admitting a client with glaucoma. The client brings prescribed eyedrops from home and insists on using them in the hospital. The nurse should: a. Allow the client to keep the eyedrops at the bedside and use as prescribed on the bottle b. Place the eyedrops in the hospital medication drawer and administer as labeled on the bottle c. Explain to the client that the physician will write a prescription for the eyedrops to be used at the hospital d. Ask the client's wife to assist the client in administering the eyedrops while the client is in the hospital
C
The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care? a. Avoid overuse of the eyes b. Decrease the amount of salt in the diet c. Eye medications will need to administer for life d. Decrease fluid intake to control the intraocular pressure
C
The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care? a. avoid overuse of the eye b. decrease the amount of salt in the diet c. eye medications will need to be administered for life d. decrease fluid intake to control the intraocular pressure
C
The nurse is observing a student nurse administer eyedrops. What should the nurse instruct the student to do? a. Move the dropper to the inner canthus b. Have the client raise the eyebrows c. Administer the drops in the center of the lower lid d. Have the client squeeze both eyes after administering the drops
C
When the nurse enters the client's room, the nurse perceives that the client is staring straight ahead. Which of the following is the best course of action for the nurse to take next? a. Hold an interdisciplinary meeting on the client's behalf promptly b. Consult with psychiatry c. Listen to the client and observe the body language d. Address the client by first name upon entering the room
C
A client with multiple sclerosis is experiencing bowel incontinence and is starting a bowel retraining program. Which strategy is not appropriate? a. Eating a diet high in fiber b. Setting a regular time for elimination c. Using an elevated toilet seat d. Limiting fluid intake to 1,000 mL/day
D
A new medication regimen is prescribed for a client with Parkinson's disease. At which time should the nurse make certain that the medication is taken? a. At bedtime b. All at one time c. Two hours before mealtime d. At the time scheduled
D
A nurse is teaching a client who had a stroke about ways to adapt to a visual disability. Which does the nurse identify as the primary safety precaution to use? a. Wear a patch over one eye b. Place personal items on the sighted side c. Lie in bed with the unaffected side toward the door d. Turn the head from side to side when walking
D
A short time after cataract surgery, the client has nausea. The nurse should first a. Instruct the client to take a few deep breaths until the nausea subsides b. Explain that this is a common feeling that will pass quickly c. Tell the client to call the nurse promptly if vomiting occurs d. Medicate the client with an antiemetic, as prescribed
D
After cataract removal surgery, the client is instructed to report sharp pain in the operative eye because this could indicate which of the following postoperative complications? a. Detached retina b. Prolapse of the iris c. Extracapsular erosion d. Intraocular hemorrhage
D
Carbidopa-levodopa (Sinemet) is prescribed for a client with Parkinson's disease. The nurse monitors the client for side/adverse effects to the medication. Which finding indicates that the client is experiencing an adverse effect? a. Pruritus b. Tachycardia c. Hypertension d. Impaired voluntary movements
D
During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates: a. Cranial nerves I and II b. Cranial nerves III and V c. Cranial Nerves VI and VIII d. Cranial nerves IX and X
D
The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? a. "We need to discourage him from wearing eyeglasses." b. "We need to place objects in his impaired field of vision." c. "We need to approach him from the impaired field of vision." d. "We need to remind him to turn his head to scan the lost visual field."
D
The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully? a. Gets angry with family if they interrupt a task b. Experiences bouts of depression and irritability c. Has difficulty with using modified feeding utensils d. Consistently uses adaptive equipment in dressing self
D
The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation should the nurse expect to note in the early stages of cataract formation? a. diplopia b. eye pain c. floating spots d. blurred vision
D
The nurse is performing as assessment on a client with a suspected diagnosis of cataract. What is the chief clinical manifestation that the nurse expects to note in the early stages of cataract formation? a. Diplopia b. Eye pain c. Floating spots d. Blurred vision
D
The nurse is providing instructions to a client who will be safe-administering eyedrops. To minimize systemic absorption of the eyedrops, the nurse should instruct the client to take which action? a. Eat before instilling the drops b. Swallow several times after instilling the drops c. Blink vigorously to encourage tearing after instilling the drops d. Occlude the nasolacrimal duct
D
The nurse should assess clients with chronic open-angle glaucoma (COAG) for: a. Eye pain b. Excessive lacrimation c. Colored light flashes d. Decreasing peripheral vision
D
The right hand of a client with multiple sclerosis trembles severely whenever she attempts a voluntary action. She spills her coffee twice at lunch and cannot get her dress fastened securely. Which is the best legal documentation in nurses' notes of the chart for this client assessment? a. Has an intention tremor of the right hand b. Right-hand tremor worsens with purposeful acts c. Needs assistance with dressing and eating due to severe trembling and clumsiness d. Slight shaking of right hand increases to severe tremor when client tries to button her clothes or drink from a cup
D
Which measure should the nurse teach the client with adult macular degeneration (AMD) as a safety precaution? a. Wear a patch over one eye b. Place personal items on the sighted side c. Lie in bed with the unaffected side toward the door d. Turn the head from side to side when walking
D
Which of the following clinical manifestations should the nurse assess when a client has acute angle-closure glaucoma? a. Gradual loss of central vision b. Acute light sensitivity c. Loss of color vision d. Sudden eye pain
D