neurological system

An unconscious patient with a traumatic head injury has a blood pressure of 126/72 mm Hg, and an intracranial pressure of 18 mm Hg. The nurse will calculate the cerebral perfusion pressure as ____________________.

72 mm Hg The formula for calculation of cerebral perfusion pressure is [(Systolic pressure + Diastolic blood pressure 2)/3] = intracranial pressure.

Which measure should the nurse prioritize when providing care for a patient with a diagnosis of multiple sclerosis (MS)? A. Vigilant infection control and adherence to standard precautions B. Careful monitoring of neurologic assessment and frequent reorientation C. Maintenance of a calorie count and hourly assessment of intake and output D. Assessment of blood pressure and monitoring for signs of orthostatic hypotension

A. Vigilant infection control and adherence to standard precautions

Which of these patients is most appropriate for the intensive care unit (ICU) charge nurse to assign to an RN who has floated from the medical unit? a. A 44-year-old receiving IV antibiotics for meningococcal meningitis b. A 23-year-old who had a skull fracture and craniotomy the previous day c. A 30-year-old who has an intracranial pressure (ICP) monitor in place after a head injury a week ago d. A 61-year-old who has increased ICP and is receiving hyperventilation therapy

a. A 44-year-old receiving IV antibiotics for meningococcal meningitis

After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a. A patient with right-sided weakness who has an infusion of tPA prescribed b. A patient who has atrial fibrillation and a new order for warfarin (Coumadin) c. A patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due d. A patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled

a. A patient with right-sided weakness who has an infusion of tPA prescribed

A 32-year-old patient has a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan? a. Applying intermittent pneumatic compression stockings b. Assisting to dangle on edge of bed and assess for dizziness c. Encouraging patient to cough and deep breathe every 4 hours d. Inserting an oropharyngeal airway to prevent airway obstruction

a. Apply intermittent pneumatic compression stockings

When admitting an acutely confused patient with a head injury, which action should the nurse take? a. Ask family members about the patients health history. b. Ask leading questions to assist in obtaining health data. c. Wait until the patient is better oriented to ask questions. d. Obtain only the physiologic neurologic assessment data.

a. Ask family members about the patients health history

A patient who sustained a spinal cord injury a week ago becomes angry, telling the nurse I want to be transferred to a hospital where the nurses know what they are doing! Which reaction by the nurse is best? a. Ask for the patients input into the plan for care. b. Clarify that abusive behavior will not be tolerated. c. Reassure the patient about the competence of the nursing staff. d. Continue to perform care without responding to the patients comments.

a. Ask for the patients input into the plan for care

When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority? a. Assessment of respiratory rate and depth b. Continuous cardiac monitoring for bradycardia c. Application of pneumatic compression devices to both legs d. Administration of methylprednisolone (Solu-Medrol) infusion

a. Assessment of respiratory rate and depth

A patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care? a. Assist with active range of motion. b. Observe for agitation and paranoia. c. Give muscle relaxants as needed to reduce spasms. d. Use simple words and phrases to explain procedures.

a. Assist with active range of motion

A patient found in a tonic-clonic seizure reports afterward that the seizure was preceded by numbness and tingling of the arm. The nurse knows that this finding indicates what type of seizure? a. Atonic b. Partial c. Absence d. Myoclonic

a. Atonic

A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse? a. Blood pressure 156/60, pulse 55, respirations 12 b. Blood pressure 130/72, pulse 90, respirations 32 c. Blood pressure 148/78, pulse 112, respirations 28 d. Blood pressure 110/70, pulse 120, respirations 30

a. Blood pressure 156/60, pulse 55, respirations 12

When teaching patients who are at risk for Bells palsy because of previous herpes simplex infection, which information should the nurse include? a. Call the doctor if pain or herpes lesions occur near the ear. b. Treatment of herpes with antiviral agents prevents Bells palsy. c. You may be able to prevent Bells palsy by doing facial exercises regularly. d. Medications to treat Bells palsy work only if started before paralysis onset.

a. Call the doctor if pain or herpes lesions occur near the ear

A patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Check the respiratory rate. b. Monitor the blood pressure. c. Send the patient for a CT scan. d. Obtain the Glasgow Coma Scale score.

a. Check the respiratory rate

A patient tells the nurse about using acetaminophen (Tylenol) several times every day for recurrent bilateral headaches. Which action will the nurse plan to take first? a. Discuss the need to stop taking the acetaminophen. b. Suggest the use of biofeedback for headache control. c. Teach the patient about magnetic resonance imaging (MRI). d. Describe the use of botulism toxin (BOTOX) for headaches.

a. Discuss the need to stop taking the acetaminophen

A patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care? a. Encourage family members to remain at the bedside. b. Apply soft restraints to protect the patient from injury. c. Keep the room well-lighted to improve patient orientation. d. Minimize contact with the patient to decrease sensory input.

a. Encourage family members to remain at the bedside

Which action should the nurse take when assessing a patient with trigeminal neuralgia? a. Examine the mouth and teeth thoroughly. b. Have the patient clench and relax the jaw and eyes. c. Identify trigger zones by lightly touching the affected side. d. Gently palpate the face to compare skin temperature bilaterally.

a. Examine the mouth and teeth thoroughly

A patient with mild dementia has a new prescription for donepezil (Aricept). Which nursing action will be most effective in ensuring compliance with the medication? a. Having the patients spouse administer the medication b. Setting the medications up weekly in a medication box c. Calling the patient daily with a reminder to take the medication d. Posting reminders to take the medications in the patients house

a. Having the patients spouse administer the medication

When administering a mental status examination to a patient, the nurse suspects depression when the patient responds with a. I dont know. b. Is that the right answer? c. Wait, let me think about that. d. Who are those people over there?

a. I don't know

While admitting a patient with a basal skull fracture, the nurse notes clear drainage from the patients nose. Which of these admission orders should the nurse question? a. Insert nasogastric tube. b. Turn patient every 2 hours. c. Keep the head of bed elevated. d. Apply cold packs for facial bruising.

a. Insert nasogastric tube

Which action will the nurse take when evaluating a patient who is taking phenytoin (Dilantin) for adverse effects of the medication? a. Inspect the oral mucosa. b. Listen to the lung sounds. c. Auscultate the bowel tones. d. Check pupil reaction to light.

a. Inspect the oral mucosa

An unconscious patient has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care? a. Keep the head of the bed elevated to 30 degrees. b. Position the patient with the knees and hips flexed. c. Encourage coughing and deep breathing to improve oxygenation. d. Cluster nursing interventions to provide uninterrupted rest periods.

a. Keep the head of the bed elevated to 30 degrees

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurance? Select all that apply a. Keeping the linens wrinkle-free under the client b. Preventing unnecessary pressure on the lower limbs c. Limiting bladder catheterization to once every 12 hours d. Turning and re positioning the client at least every 2 hours e. Ensuring that the client has a bowel movement at least once a week

a. Keeping the linens wrinkle-free under the client b. Preventing unnecessary pressure on the lower limbs d. Turning and re positioning the client at least every 2 hours Rationale: The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours, and urinary catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Ensuring a bowel movement once a week is much too infrequent. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

To evaluate the effectiveness of IV methylprednisolone (Solu-Medrol) given to a patient with a T4 spinal cord injury, which information is most important for the nurse to obtain? a. Leg strength and sensation b. Skin temperature and color c. Blood pressure and apical heart rate d. Respiratory effort and O2 saturation

a. Leg strength and sensation

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply a. Lossening restrictive clothing b. Restraining the client's limbs c. Removing the pillow and raising padded side rails d. Positioning the client to the side, if possible, with the head flexed forward e. Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist

a. Lossening restrictive clothing c. Removing the pillow and raising padded side rails d. Positioning the client to the side, if possible, with the head flexed forward Rationale: Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising padded side rails in the bed, and placing the client on 1 side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible, protects the head from injury; and moves the furniture that may injure the client

A 28-year-old woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which response by the nurse is accurate? a. MS symptoms may be worse after the pregnancy. b. Women with MS frequently have premature labor. c. Symptoms of MS are likely to become worse during pregnancy. d. MS is associated with a slightly increased risk for congenital defects.

a. MS symptoms may be worse after pregnancy

A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the spouse. Which action will the nurse take first? a. Obtain oxygen saturation. b. Check pupil reaction to light. c. Palpate the head for hematoma. d. Assess Glasgow Coma Scale (GCS).

a. Obtain oxygen saturation

When a patients intracranial pressure (ICP) is being monitored with an intraventricular catheter, which information obtained by the nurse is most important to communicate to the health care provider? a. Oral temperature 101.6 F b. Apical pulse 102 beats/min c. Intracranial pressure 15 mm Hg d. Mean arterial pressure 90 mm Hg

a. Oral temperature 101.6 F

When assessing a patient with Alzheimers disease (AD) who is being admitted to a long-term care facility, the nurse learns that the patient has had several episodes of wandering away from home. Which nursing action will the nurse include in the plan of care? a. Place the patient in a room close to the nurses station. b. Ask the patient why the wandering episodes have occurred. c. Have the family bring in familiar items from the patients home. d. Reorient the patient to the new living situation several times daily.

a. Place the patient in a room close to the nurses station

A 48-year-old man was just diagnosed with Huntington's disease. His 20-year-old son is upset about his father's diagnosis. How can the nurse best help this young man? a. Provide emotional and phychologic support b. Consult with a dietitian to provide nutritional support to slow the disease c. Encourage him to get diagnostic genetic testing done d. Tell him the chorea and psychiatric disorders can be treated with haloperidol (Haldol)

a. Provide emotional and phychologic support

When preparing to admit a patient who has been treated for status epilepticus in the emergency department, which equipment should the nurse have available in the room (select all that apply)? a. Siderail pads b. Tongue blade c. Oxygen mask d. Suction tubing e. Nasogastric tube

a. Siderail pads c. Oxygen mask d. Suction tubing

A hospitalized 24-year-old patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first? a. Start the ordered PRN oxygen at 6 L/min. b. Put a moist hot pack on the patients neck. c. Give the ordered PRN acetaminophen (Tylenol). d. Notify the patients health care provider immediately.

a. Start the ordered PRN oxygen at 6 L/min

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that the teaching is most effective? a. Taking medications as scheduled b. Eating large, well-balanced meals c. Doing muscle-strengthening exercises d. Doing all chores early in the day while less fatigued

a. Taking medications as scheduled Rationale: Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is important. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of excerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional stress

A patient with multiple sclerosis (MS) has urinary retention caused by a flaccid bladder. Which action will the nurse plan to take? a. Teach the patient how to use the Cred method. b. Decrease the patients fluid intake in the evening. c. Suggest the use of incontinence briefs for nighttime use only. d. Assist the patient to the commode every 2 hours during the day.

a. Teach the patient how to use the Cred method

The health care provider recommends a carotid endarterectomy for a patient with carotid atherosclerosis and a history of transient ischemic attacks (TIAs). The patient asks the nurse to describe the procedure. Which response by the nurse is appropriate? a. The carotid endarterectomy involves surgical removal of plaque from an artery in the neck. b. The diseased portion of the artery in the brain is removed and replaced with a synthetic graft. c. A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed. d. A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque.

a. The carotid endarterectomy involves surgical removal of plaque from and artery in the neck

The nurse is assigned to care for a client with complete right-0sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply a. The client is aphasic b. The client has weakness on the right side of the body c. the client has complete bilateral paralysis of the arms and legs d. The client has weakness on the right side of the face and tongue 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 or herself without assistance

a. The client is aphasic b. The client has weakness on the right side of the body d. The client has weakness on the right side of the face and tongue Rationale: Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic: unable to discriminate words and letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulation.

The charge nurse is observing a new staff nurse who is assessing a patient with a possible spinal cord lesion for sensation. Which action indicates a need for further teaching about neurologic assessment? a. The new nurse asks the patient, Does this feel sharp? b. The new nurse tests for light touch before testing for pain. c. The new nurse has the patient close the eyes during testing. d. The new nurse uses an irregular pattern to test for intact touch.

a. The new nurse asks the patient, Does this feel sharp?

When caring for a patient who has Guillain-Barr syndrome, which assessment data obtained by the nurse will require the most immediate action? a. The patient has continuous drooling of saliva. b. The patients blood pressure (BP) is 106/50 mm Hg. c. The patients quadriceps and triceps reflexes are absent. d. The patient complains of severe tingling pain in the feet.

a. The patient has continuous drooling of saliva

The nurse is assessing a patient who is being evaluated for a possible spinal cord tumor. Which finding by the nurse requires the most immediate action? a. The patient has new onset weakness of both legs. b. The patient complains of chronic severe back pain. c. The patient starts to cry and says, I feel hopeless. d. The patient expresses anxiety about having surgery.

a. The patient has new onset weakness of both legs

When caring for a patient who has had a head injury, which assessment information requires the most rapid action by the nurse? a. The patient is more difficult to arouse. b. The patients pulse is slightly irregular. c. The patients blood pressure increases from 120/54 to 136/62 mm Hg. d. The patient complains of a headache at pain level 5 of a 10-point scale.

a. The patient is more difficult to arouse

When admitting a patient with a possible coup-contracoup injury after a car accident to the emergency department, the nurse obtains the following information. Which finding is most important to report to the health care provider? a. The patient takes warfarin (Coumadin) daily. b. The patients blood pressure is 162/94 mm Hg. c. The patient is unable to remember the accident. d. The patient complains of a severe dull headache.

a. The patient takes warfarin (Coumadin) daily

A patient who has had a subarachnoid hemorrhage is being cared for in the intensive care unit. Which information about the patient is most important to communicate to the health care provider? a. The patients blood pressure is 90/50 mm Hg. b. The patient complains about having a stiff neck. c. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs). d. The patient complains of an ongoing severe headache.

a. The patients blood pressure is 90/50 mm Hg

The charge nurse observes an inexperienced staff nurse who is caring for a patient who has had a craniotomy for a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene? a. The staff nurse suctions the patient every 2 hours. b. The staff nurse assesses neurologic status every hour. c. The staff nurse elevates the head of the bed to 30 degrees. d. The staff nurse administers a mild analgesic before turning the patient.

a. The staff nurse assesses neurologic status every hour

When caring for a patient who experienced a T1 spinal cord transsection 2 days ago, which collaborative and nursing actions will the nurse include in the plan of care (select all that apply)? a. Urinary catheter care b. Nasogastric (NG) tube feeding c. Continuous cardiac monitoring d. Avoidance of cool room temperature e. Administration of H2 receptor blockers

a. Urinary catheter care c. Continuous cardiac monitoring d. Avoidance of cool room temperature e. Administration of H2 receptor blockers

The nurse obtains these assessment findings for a patient who has a head injury. Which finding should be reported rapidly to the health care provider? a. Urine output of 800 mL in the last hour b. Intracranial pressure of 16 mm Hg when patient is turned c. Ventriculostomy drains 10 mL of cerebrospinal fluid per hour d. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg

a. Urine output of 800 mL in the last hour

A patient with Parkinsons disease is admitted to the hospital for treatment of an acute infection. Which nursing interventions will be included in the plan of care (select all that apply)? a. Use an elevated toilet seat. b. Cut patients food into small pieces. c. Provide high protein foods at each meal. d. Place an arm chair at the patients bedside. e. Observe for sudden exacerbation of symptoms.

a. Use an elevated toilet seat b. Cut patients food into small pieces d. Place an arm chair at the patients bedside

Your client has fallen while getting up from the toilet. He states that he has bumped his head. You are concerned that he may have a concussion or closed head injury. Which of the following symptoms would support this? a. Vision changes, nausea, vomiting, and confusion b. PERRLA c. hypertension, bradycardia, and Cheyne- Strokes respiration d. alert and oriented X3, pain across buttocks that radiates down the leg, paresthesia

a. Vision changes, nausea, vomiting, and confusion

To assess the functioning of the trigeminal and facial nerves (CN V and VII), the nurse should a. apply a cotton wisp strand to the cornea. b. have the patient read a magazine or book. c. shine a bright light into the patients pupil. d. check for unilateral drooping of the eyelids.

a. apply a cotton wisp strand to the cornea

The nurse witnesses a patient with a seizure disorder as the patient suddenly jerks the arms and legs, falls to the floor, and regains consciousness immediately. It will be most important for the nurse to a. assess the patient for a possible head injury. b. give the scheduled dose of divalproex (Depakote). c. document the timing and description of the seizure. d. notify the patients health care provider about the seizure.

a. assess the patient for a possible head injury

A patient with a neck fracture at the C5 level is admitted to the intensive care unit. During initial assessment of the patient, the nurse recognizes the presence of neurogenic shock on finding a. hypotension, bradycardia, and warm extremities. b. involuntary, spastic movements of the arms and legs. c. hyperactive reflex activity below the level of the injury. d. lack of movement or sensation below the level of the injury.

a. hypotension, bradycardia, and warm extremities

When admitting a patient who has a tumor of the right frontal lobe, the nurse would expect to find a. judgment changes. b. expressive aphasia. c. right-sided weakness. d. difficulty swallowing.

a. judgement changes

When teaching a patient with myasthenia gravis (MG) about management of the disease, the nurse advises the patient to a. perform physically demanding activities in the morning. b. anticipate the need for weekly plasmapheresis treatments. c. do frequent weight-bearing exercise to prevent muscle atrophy. d. protect the extremities from injury due to poor sensory perception.

a. perform physically demanding activities in the morning

When developing a plan of care for a patient with dysfunction of the cerebellum, the nurse will include interventions to a. prevent falls. b. stabilize mood. c. enhance swallowing ability. d. improve short-term memory.

a. prevent falls

A patient with Bells palsy refuses to eat while others are present because of embarrassment about drooling. The best response by the nurse to the patients behavior is to a. respect the patients desire and arrange for privacy at mealtimes. b. teach the patient to chew food on the unaffected side of the mouth. c. offer the patient liquid nutritional supplements at frequent intervals. d. discuss the patients concerns with visitors who arrive at mealtimes.

a. respect the patients desire and arrange for privacy at mealtimes

A patient who is hospitalized with pneumonia is disoriented and confused 2 days after admission. Which information obtained by the nurse about the patient indicates that the patient is experiencing delirium rather than dementia? a. The patient was oriented and alert when admitted. b. The patients speech is fragmented and incoherent. c. The patient is disoriented to place and time but oriented to person. d. The patient has a history of increasing confusion over several years.

a. the patient was oriented and alert when admitted

When assessing a patient with newly diagnosed trigeminal neuralgia, the nurse will ask the patient about a. triggers that lead to facial pain. b. visual problems caused by ptosis. c. poor appetite caused by a loss of taste. d. weakness on the affected side of the face.

a. triggers that lead to facial pain

Epilepsy is diagnosed by which of the following tests: a. EEG b. ECG c. EKG d. LED

a.EEG

A patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. The nurse records the patients Glasgow Coma Scale score as a. 9. b. 11. c. 13. d. 15.

b. 11

A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115 mmol/L) and a decreasing level of consciousness (LOC) and complains of a headache. Which of these prescribed interventions should the nurse implement first? a. Draw blood for arterial blood gases (ABGs). b. Administer 5% hypertonic saline intravenously. c. Administer acetaminophen (Tylenol) 650 mg orally. d. Send patient for computed tomography (CT) of the head.

b. Administer 5% hypertonic saline intravenously

Following a head injury, an unconscious 32-year-old patient is admitted to the emergency department (ED). The patients spouse and children stay at the patients side and constantly ask about the treatment being given. What action is best for the nurse to take? a. Ask the family to stay in the waiting room until the initial assessment is completed. b. Allow the family to stay with the patient and briefly explain all procedures to them. c. Call the familys pastor or spiritual advisor to support them while initial care is given. d. Refer the family members to the hospital counseling service to deal with their anxiety.

b. Allow the family to stay with the patient and briefly explain all procedures to them

A patient seen at the health clinic with a severe migraine headache tells the nurse about having four similar headaches in the last 3 months. Which initial action should the nurse take? a. Refer the patient for stress counseling. b. Ask the patient to keep a headache diary. c. Suggest the use of muscle-relaxation techniques. d. Teach about the effectiveness of the triptan drugs.

b. Ask the patient to keep a headache diary

Which action will the nurse include in the plan of care when caring for a patient who is experiencing trigeminal neuralgia? a. Teach facial and jaw relaxation techniques. b. Assess intake and output and dietary intake. c. Apply ice packs for no more than 20 minutes. d. Spend time at the bedside talking with the patient.

b. Assess intake and output and dietary intake

Several weeks after a stroke, a patient has urinary incontinence resulting from an impaired awareness of bladder fullness. For an effective bladder training program, which nursing intervention will be best to include in the plan of care? a. Limit fluid intake to 1200 mL daily to reduce urine volume. b. Assist the patient onto the bedside commode every 2 hours. c. Perform intermittent catheterization after each voiding to check for residual urine. d. Use an external condom catheter to protect the skin and prevent embarrassment.

b. Assist the patient onto the bedside commode every 2 hours

After suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 16 mm Hg. Which action should the nurse take first? a. Document the increase in intracranial pressure. b. Assure that the patients neck is not in a flexed position. c. Notify the health care provider about the change in pressure. d. Increase the rate of the prescribed propofol (Diprovan) infusion.

b. Assure that the patients neck is not a flexed position

A patient is admitted to the hospital with left-sided paralysis. To differentiate between an ischemic and hemorrhagic stroke as well as to determine the location and size, the nurse anticipates that the physician will order a: a. cerebral arteriogram b. CT scan c. lumbar puncture d. EMG

b. CT scan

After noting that a patient with a head injury has clear nasal drainage, which action should the nurse take? a. Have the patient blow the nose. b. Check the nasal drainage for glucose. c. Assure the patient that rhinorrhea is normal after a head injury. d. Obtain a specimen of the fluid to send for culture and sensitivity.

b. Check the nasal drainage for glucose

A patient has a lesion that affects lower motor neurons. During assessment of the patients lower extremities, the nurse expects to find a. spasticity. b. flaccidity. c. loss of sensation. d. hyperactive reflexes.

b. Flaccidity

Which statement by a patient who is being discharged from the emergency department (ED) after a head injury indicates a need for intervention by the nurse? a. I will return if I feel dizzy or nauseated. b. I am going to drive home and go to bed. c. I do not even remember being in an accident. d. I can take acetaminophen (Tylenol) for my headache.

b. I am going to drive home and go to bed

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 respiration's, decreasing blood pressure b. Increasing temperature, decreasing pulse, decreasing respiration's, increasing blood pressure c. Decreasing temperature, decreasing pulse, increasing respiration's, decreasing blood pressure d. Decreasing temperature, increasing pulse, decreasing respiration's, increasing blood pressure

b. Increasing temperature, decreasing pulse, decreasing respiration's, increasing blood pressure Rationale: A change in vs may be a late sign of increased intracranial pressure. Trends include increasing temp. and bp and decreasing pulse and respirations. Respiratory irregularities also may occur.

Which intervention will the nurse include in the plan of care for a patient who has late-stage Alzheimers disease (AD)? a. Encourage the patient to discuss events from the past. b. Maintain a consistent daily routine for the patients care. c. Reorient the patient to the date and time every 2 to 3 hours. d. Provide the patient with current newspapers and magazines.

b. Maintain a consistent daily routine for the patients care

Following a thymectomy, a patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first? a. Auscultate the patients bowel sounds. b. Notify the patients health care provider. c. Administer the prescribed PRN antiemetic drug. d. Give the scheduled dose of prednisone (Deltasone).

b. Notify the patients health care provider

The spouse of a male patient with early stage Alzheimers disease (AD) tells the nurse, I am just exhausted from the constant worry. I dont know what to do. Which action is best for the nurse to take next (select all that apply)? a. Suggest that a long-term care facility be considered. b. Offer ideas for ways to distract or redirect the patient. c. Suggest that the spouse consult with the physician for antianxiety drugs. d. Educate the spouse about the availability of adult day care as a respite. e. Ask the spouse what she knows and has considered about dementia care options.

b. Offer ideas for ways to distract or redirect the patient. d. Educate the spouse about the availability of adult day care as a respite. e. Ask the spouse what she knows and has considered about dementia care options.

Which assessments will the nurse make to test a patients cerebellar function (select all that apply)? a. Assess for graphesthesia. b. Perform the finger-to-nose test. c. Observe arm movement with gait. d. Check ability to push against resistance. e. Determine ability to sense heat and cold.

b. Perform the finger-to-nose test c. Observe arm movement with gait

When the home health RN is planning care for a patient with a seizure disorder, which nursing action can be delegated to an LPN/LVN? a. Make referrals to appropriate community agencies. b. Place medications in the home medication organizer. c. Teach the patient and family how to manage seizures. d. Assess for use of medications that may precipitate seizures.

b. Place medications in the home medication organizer

The following orders are received for an unconscious patient who has just arrived in the emergency department after a head injury caused by an automobile accident. Which one should the nurse question? a. Obtain x-rays of the skull and spine. b. Prepare the patient for lumbar puncture. c. Send for computed tomography (CT) scan. d. Perform neurologic checks every 15 minutes.

b. Prepare the patient for lumbar puncture

A patient who has a head injury is diagnosed with a concussion. Which action will the nurse plan to take? a. Coordinate the transfer of the patient to the operating room. b. Provide discharge instructions about monitoring neurologic status. c. Transport the patient to radiology for magnetic resonance imaging (MRI) of the brain. d. Arrange to admit the patient to the neurologic unit for observation for 24 hours.

b. Provide discharge instructions about monitoring neurologic status

Which information about a 71-year-old patient is most important for the admitting nurse to report to the patients health care provider? a. Triceps reflex response graded at 1/5 b. Recent unintended weight loss of 20 pounds c. Patient complaint of chronic difficulty in falling asleep d. Orthostatic drop in systolic blood pressure of 10 mm Hg

b. Recent unintended weight loss of 20 pounds

When developing a plan of care for a hospitalized patient with moderate dementia, which intervention will the nurse include? a. Provide complete personal hygiene care for the patient. b. Remind the patient frequently about being in the hospital. c. Reposition the patient frequently to avoid skin breakdown. d. Place suction at the bedside to decrease the risk for aspiration.

b. Remind the patient frequently about being in the hospital

The nurse notes in the patients medical history that the patient has a positive Romberg test. Which nursing diagnosis is appropriate? a. Acute pain related to hyperreflexia and spasm b. Risk for falls related to dizziness or weakness c. Disturbed tactile sensory perception related to spinal cord damage d. Ineffective thermoregulation related to decreased vasomotor response

b. Risk for falls related to dizziness or weakness

Which action will the nurse in the outpatient clinic include in the plan of care for a patient with mild cognitive impairment (MCI)? a. Suggest a move into an assisted living facility. b. Schedule the patient for more frequent appointments. c. Ask family members to supervise the patients daily activities. d. Discuss the preventive use of acetylcholinesterase medications.

b. Schedule the patient for more frequent appointments

Which assessment information will the nurse collect to determine whether a patient is developing postconcussion syndrome? a. Muscle resistance b. Short-term memory c. Glasgow coma scale d. Pupil reaction to light

b. Short-term memory

A patient with Parkinsons disease has a nursing diagnosis of impaired physical mobility related to bradykinesia. Which action will the nurse include in the plan of care? a. Instruct the patient in activities that can be done while lying or sitting. b. Suggest that the patient rock from side to side to initiate leg movement. c. Have the patient take small steps in a straight line directly in front of the feet. d. Teach the patient to keep the feet in contact with the floor and slide them forward.

b. Suggest that the patient rock from side to side to initiate leg movement

A patient with paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. Which action will the nurse include in the plan of care? a. Educate on the use of the Cred method. b. Teach the patient how to self-catheterize. c. Catheterize for residual urine after voiding. d. Assist the patient to the toilet every 2 hours.

b. Teach the patient how to self-catheterize

When family members ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring for a patient, which response by the nurse is best? a. This type of monitoring system is complex and highly skilled staff are needed. b. The monitoring system helps show whether blood flow to the brain is adequate. c. The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure. d. This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage.

b. The monitoring system helps show whether blood flow to the brain is adequate

A patient is scheduled for a myelogram to confirm the presence of a herniated intervertebral disk. Which information obtained when admitting the patient is most important for the nurse to communicate to the health care provider before the procedure? a. The patient is anxious about the test. b. The patient has an allergy to shellfish. c. The patient had 4 ounces of apple juice 4 hours earlier. d. The patient has back pain when lying flat for long periods.

b. The patient has an allergy to shellfish

The nurse is caring for a patient with carotid artery narrowing who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a. The pulse rate is 104 beats/min. b. The patient has difficulty talking. c. The blood pressure is 142/88 mm Hg. d. There are fine crackles at the lung bases.

b. The patient has difficulty talking

Which equipment will the nurse obtain to assess vibration sense in a patient who has peripheral nerve dysfunction? a. Sharp pin b. Tuning fork c. Reflex hammer d. Calibrated compass

b. Tuning fork

A hospitalized patient complains of a moderate bilateral headache that radiates from the base of the skull. Which of these prescribed PRN medications should the nurse administer initially? a. lorazepam (Ativan) b. acetaminophen (Tylenol) c. morphine sulfate (Roxanol) d. butalbital and aspirin (Fiorinal)

b. acetaminophen (Tylenol)

A patient admitted to the emergency department is diagnosed with botulism, and an order for botulinum antitoxin is received. Before administering the antitoxin, it is most important for the nurse to a. obtain the patients temperature. b. administer an intradermal test dose. c. ask the patient about a history of egg allergies. d. document the presence of neurologic symptoms.

b. administer an intradermal test dose

A patient arrives at an urgent care center with a deep puncture wound after stepping on a nail that was lying on the ground. The patient reports having had a tetanus booster 7 years ago. The nurse will anticipate a. IV infusion of tetanus immune globulin (TIG). b. administration of the tetanus-diphtheria (Td) booster. c. intradermal injection of an immune globulin test dose. d. initiation of the tetanus-diphtheria immunization series.

b. administration of the tetanus-diphtheria (Td) booster

A patient is seen in the health clinic with symptoms of a stooped posture, shuffling gait, and pill rollingtype tremor. The nurse will anticipate teaching the patient about a. oral corticosteroids. b. antiparkinsonian drugs. c. the purpose of electroencephalogram (EEG) testing. d. preparation for magnetic resonance imaging (MRI).

b. antiparkinsonian drugs

The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. An appropriate nursing intervention to help the patient communicate is to a. have the patient practice facial and tongue exercises. b. ask simple questions that the patient can answer with yes or no. c. develop a list of words that the patient can read and practice reciting. d. prevent embarrassing the patient by changing the subject if the patient does not respond.

b. ask simple questions that the patient can answer with yes or no

A patient is admitted to the hospital with dysphasia and right-sided weakness that resolves in a few hours. The nurse will anticipate teaching the patient about a. alteplase (tPA). b. aspirin (Ecotrin). c. warfarin (Coumadin). d. nimodipine (Nimotop).

b. aspirin (Ecotrin)

A patient with a T1 spinal cord injury is admitted to the intensive care unit. The nurse will teach the patient and family that a. use of the shoulders will be preserved. b. full function of the patients arms will be retained. c. total loss of respiratory function may occur temporarily. d. elevations in heart rate are common with this type of injury.

b. full function of the patients arms will be retained

A patient is scheduled for a lumbar puncture. The nurse will plan to a. transfer the patient to radiology just before the procedure. b. help the patient to a side lying position before the procedure. c. place the patient on NPO status for 4 hours before the procedure. d. administer a sedative medication 30 minutes before the procedure.

b. help the patient to a side lying position before the procedure

When obtaining a health history and physical assessment for a patient with possible multiple sclerosis (MS), the nurse should a. assess for the presence of chest pain. b. inquire about any urinary tract problems. c. inspect the skin for rashes or discoloration. d. question the patient about any increase in libido.

b. inquire about any urinary tract problems

The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use which technique 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. nail bed pressure rationale: Nail bed pressure tests a basic motor and sensory peripheral response.

A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the effects of right brain damage, the nurse establishes a nursing diagnosis of a. impaired physical mobility related to right hemiplegia. b. risk for injury related to denial of deficits and impulsiveness. c. impaired verbal communication related to speech-language deficits. d. ineffective coping related to depression and distress about disability.

b. risk for injury related to denial of deficits and impulsiveness

The health care provider prescribes clopidogrel (Plavix) for a patient with cerebral atherosclerosis. When teaching about the new medication, the nurse will tell the patient a. to monitor and record the blood pressure daily. b. to call the health care provider if stools are tarry. c. that Plavix will dissolve clots in the cerebral arteries. d. that Plavix will reduce cerebral artery plaque formation.

b. to call the health care provider if stools are tarry

Neurologic testing of the patient indicates impaired functioning of the left glossopharyngeal nerve (CN IX) and the vagus nerve (CN X). Which action will the nurse include in the plan of care? a. Insert an oral airway. b. Withhold oral fluid or foods. c. Provide highly seasoned foods. d. Apply artificial tears every hour.

b. withhold oral fluid or foods

The earliest sign of a declining neurological condition is: a. Decreased reflexes b. Loss of ability to grasp with hand c. A decreased level of consciousness d. Pupils are equal and reactive

c. A decreased level of consciousness

A 58-year-old patient who began experiencing right-sided arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Obtain CT scan without contrast. b. Infuse tissue plasminogen activator (tPA). c. Administer oxygen to keep O2 saturation >95%. d. Use National Institute of Health Stroke Scale to assess patient.

c. Administer oxygen to keep O2 saturation >95% d. Use National Institute of Health stroke Scale to assess patient a. Obtain CT scan without contrast b. infuse tissue plasminogen activator (tPA)

Which of these nursing actions included in the care of a patient who has been experiencing stroke symptoms for 60 minutes can the nurse delegate to an LPN/LVN? a. Assess the patients gag and cough reflexes. b. Determine when the stroke symptoms began. c. Administer the prescribed clopidogrel (Plavix). d. Infuse the prescribed IV metoprolol (Lopressor).

c. Administer the prescribed clopidogrel (Plavix)

The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a patient with right-sided hemiplegia. Which intervention should be included in the plan of care? a. Provide a wide variety of food choices. b. Provide oral care before and after meals. c. Assist the patient to eat with the left hand. d. Teach the patient the chin-tuck technique.

c. Assist the patient to eat with the left hand

When caring for a patient who has had cerebral angiography, which nursing action will be included in the plan of care? a. Ask about headache and photophobia. b. Keep patient NPO until gag reflex returns. c. Check pulse and blood pressure frequently. d. Assess orientation to person, place, and time.

c. Check pulse and blood pressure frequently

A patient with a history of a T2 spinal cord injury tells the nurse, I feel awful today. My head is throbbing, and I feel sick to my stomach. Which action should the nurse take first? a. Assess for a fecal impaction. b. Give the prescribed antiemetic. c. Check the blood pressure (BP). d. Notify the health care provider.

c. Check the blood pressure (BP)

A patient who has right-sided weakness after a stroke is attempting to use the left hand for feeding and other activities. The patients wife insists on feeding and dressing him, telling the nurse, I just dont like to see him struggle. Which nursing diagnosis is most appropriate for the patient? a. Situational low self-esteem related to increasing dependence on others b. Interrupted family processes related to effects of illness of a family member c. Disabled family coping related to inadequate understanding by patients spouse d. Impaired nutrition: less than body requirements related to hemiplegia and aphasia

c. Disabled family coping related to inadequate understanding by patients spouse

A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering the medications, the patient says, I dont need the aspirin today. I dont have any aches or pains. Which action should the nurse take? a. Document that the aspirin was refused by the patient. b. Tell the patient that the aspirin is used to prevent aches. c. Explain that the aspirin is ordered to decrease stroke risk. d. Call the health care provider to clarify the medication order.

c. Explain that the aspirin is ordered to decrease stroke risk

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? a. Hyperreflexia b. Positive reflexes c. Flaccid paralysis d. Reflex emptying of the bladder

c. Flaccid paralysis Rationale: Resolution of spinal shock is occurring when there is return of refexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, and reflex emptying of the bladder.

The health care provider prescribes these interventions for a patient with possible botulism poisoning. Which one will the nurse question? a. Maintain NPO status. b. Obtain lumbar puncture tray. c. Give magnesium citrate 8 oz now. d. Administer 1500-mL tap water enema.

c. Give magnesium citrate 8 oz now

which nursing intervention is most appropriate when caring for patients with dementia? a. Avoid direct eye contact b. Lovingly call the patient "honey" or "sweetie" c. Give simple directions, focusing on one thing at a time. d. Treat the patient according to his or her age-related behavior

c. Give simple directions, focusing on one thing at a time.

Your patient is a 68-year-old man who is recovering from a right sided CVA. While doing your nursing assessment you note that he has an abnormal Babinski reflex. This would mean that: a. He experienced pain in the calf with foot dorsiflexion b. He curled his toes under when the bottom of the foot was stroked c. He fanned his toes out when the bottom of the foot was stroked d. His knee did not jerk when it was struck with a reflex hammer

c. He fanned his toes out when the bottom of the foot was stroked

A patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching? a. Recommendation to drink at least 3 to 4 L daily b. Need to avoid driving or operating heavy machinery c. How to draw up and administer injections of the medication d. Use of contraceptive methods other than oral contraceptives

c. How to draw up and administer injections of the medication

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. I will try to lie down someplace dark and quiet when the headaches begin

The community health nurse is developing a program to decrease the incidence of meningitis in adolescents and young adults. Which nursing action is most important? a. Vaccinate 11- and 12-year-old children against Haemophilus influenzae. b. Emphasize the importance of hand washing to prevent spread of infection. c. Immunize adolescents and college freshman against Neisseria meningitides. d. Encourage adolescents and young adults to avoid crowded areas in the winter.

c. Immunize adolescents and college freshman against Neisseria meningitides

During the morning change-of-shift report at the long-term care facility, the nurse learns that the patient with dementia has had sundowning. Which nursing action should the nurse take while caring for the patient? a. Provide hourly orientation to time of day. b. Move the patient to a quieter room at night. c. Keep blinds open during the daytime hours. d. Have the patient take a brief mid-morning nap.

c. Keep blinds open during the daytime hours

A 26-year-old patient with a T3 spinal cord injury asks the nurse about whether he will be able to be sexually active. Which initial response by the nurse is best? a. Reflex erections frequently occur, but orgasm may not be possible. b. Sildenafil (Viagra) is used by many patients with spinal cord injury. c. Multiple options are available to maintain sexuality after spinal cord injury. d. Penile injection, prostheses, or vacuum suction devices are possible options.

c. Multiple options are available to maintain sexuality after spinal cord injury

When the nurse is assessing a patient with myasthenia gravis, which action will be most important to take? a. Check pupillary size. b. Monitor grip strength. c. Observe respiratory effort. d. Assess level of consciousness.

c. Observe respiratory effort

When caring for a patient with left-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care during the acute period of the stroke? a. Apply an eye patch to the left eye. b. Approach the patient from the left side. c. Place objects needed for activities of daily living on the patients right side. d. Reassure the patient that the visual deficit will resolve as the stroke progresses.

c. Place objects needed for activities of daily living on the patients right side

A patient has an incomplete right spinal cord lesion at the level of T7, resulting in Brown-Squard syndrome. Which nursing action should be included in the plan of care? a. Assessment of the patient for left leg pain b. Assessment of the patient for left arm weakness c. Positioning the patients right leg when turning the patient d. Teaching the patient to look at the left leg to verify its position

c. Positioning the patients right leg when turning the patient

Which information about a patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse? a. Intracranial pressure of 15 mm Hg b. Cerebrospinal fluid (CSF) drainage of 15 mL/hour c. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg d. Cardiac monitor shows sinus tachycardia, with a heart rate of 126 beats/min

c. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg

A male patient with a diagnosis of Parkinson's disease (PD) has been admitted recently to a long-term care facility. Which action should the health care team take in order to promote adequate nutrition for this patient? a. Provide multivitamins with each meal b. Provide a diet that is low in complex carbohydrates and high in protein c. Provide small, frequent meals throughout the day that are easy to chew and swallow d. Provide the patient with a minced or pureed diet that is high in potassium and low in sodium

c. Provide small, frequent meals throughout the day that are easy to chew and swallow

A client with Guillain-Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness? a.Giving client full control over care decisions and restricting visitors b. Providing positive feedback and encouraging active range of motion c. Providing information, giving positive feedback, and encouraging relaxation. d. Providing intravenously administered sedatives, reducing distractions, and limiting visitors

c. Providing information, giving positive feedback, and encouraging relaxation rationale: The client with Guillain-Barre syndrome experiences fear and anxiety from the ascending paralysis and sudden onset of the disorder. The nurse can alleviate these fears by providing accurate information about the client's condition, giving expert care and positive feedback to the client, and encouraging relaxation and distraction. The family can become involved with selected care activities and provide diversion for the client as well.

A patient has a systemic BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? a. Elevate the head of the patients bed to 60 degrees. b. Document the BP and ICP in the patients record. c. Report the BP and ICP to the health care provider. d. Continue to monitor the patients vital signs and ICP.

c. Report the BP and ICP to the health care provider

A patient admitted with bacterial meningitis and a temperature of 102 F (38.8 C) has orders for all of these collaborative interventions. Which action should the nurse take first? a. Administer ceftizoxime (Cefizox) 1 g IV. b. Use a cooling blanket to lower temperature. c. Swap the nasopharyngeal mucosa for cultures. d. Give acetaminophen (Tylenol) 650 mg PO.

c. Swap the nasopharyngeal mucosa for cultures

While caring for a patient who has just been admitted with meningococcal meningitis, the RN observes all of the following. Which one requires action by the RN? a. The bedrails at the head and foot of the bed are both elevated. b. The patient receives a regular diet from the dietary department. c. The nursing assistant goes into the patients room without a mask. d. The lights in the patients room are turned off and the blinds are shut.

c. The nursing assistant goes into the patients room without a mask

The health care provider is considering the use of sumatriptan (Imitrex) for a patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider? a. The patient has at least 1 to 2 cups of coffee daily. b. The patient has had migraine headaches for 30 years. c. The patient has a history of a recent acute myocardial infarction. d. The patient has been taking topiramate (Topamax) for 2 months.

c. The patient has a history of a recent acute myocardial infarction

Which information about a patient with MS indicates that the nurse should consult with the health care provider before giving the prescribed dose of fampridine (Ampyra)? a. The patient has relapsing-remitting MS. b. The patient enjoys walking for relaxation. c. The patient has an increased creatinine level. d. The patient complains of pain with neck flexion.

c. The patient has an increased creatinine level

Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the health care provider before giving the aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient states, My symptoms started with a terrible headache. d. The patient has a history of brief episodes of right-sided hemiplegia.

c. The patient states, My symptoms started with a terrible headache

This same patient exhibits decorticate posturing that then begins to change to decerebrate posturing. This indicates that: a. The patient is slowly improving b. Is a normal sign of recovery following a stroke c. The patient's condition is deteriorating d. The hypothalamus and Cranial Nerve V are not working

c. The patient's condition is deteriorating

A 62-year-old patient is brought to the clinic by a family member who is concerned about the patients inability to solve common problems. To obtain information about the patients current mental status, which question should the nurse ask the patient? a. Where were you were born? b. Do you have any feelings of sadness? c. What did you have for breakfast? d. How positive is your self-image?

c. What did you have for breakfast?

When teaching the children of a patient who is being evaluated for Alzheimers disease (AD) about the disorder, the nurse explains that a. the most important risk factor for AD is a family history of the disorder. b. new drugs have been shown to reverse AD dramatically in some patients. c. a diagnosis of AD can be made only when other causes of dementia have been ruled out. d. the presence of brain atrophy detected by MRI confirms the diagnosis of AD in patients with dementia.

c. a diagnosis of AD can be made only when other causes of demetia have been ruled out

A long-term care patient with moderate dementia develops increased restlessness and agitation. The nurses initial action should be to a. reorient the patient to time, place, and person. b. administer the PRN dose of lorazepam (Ativan). c. assess for factors that might be causing discomfort. d. have a nursing assistant stay with the patient to ensure safety.

c. assess for factors that might be causing discomfort

A patient who has had a stroke has a new order to attempt oral feedings. The nurse should assess the gag reflex and then a. order a varied pureed diet. b. assess the patients appetite. c. assist the patient into a chair. d. offer the patient a sip of juice.

c. assist the patient into a chair

When the nurse applies a painful stimulus to the nail beds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as a. flexion withdrawal. b. localization of pain. c. decorticate posturing. d. decerebrate posturing.

c. decorticate posturing

During a neurologic assessment of the older adult, the nurse would expect to find: a. absent deep tendon reflexes b. poor cognitive function c. decreased sensation of touch and vibration sense d. decreased frequency of spontaneous wakening

c. decreased sensation of touch and vibration sense

After a 25-year-old patient has returned home following rehabilitation for a spinal cord injury, the home care nurse notes that the spouse is performing many of the activities that the patient had been managing during rehabilitation. The most appropriate action by the nurse at this time is to a. tell the spouse that the patient can perform activities independently. b. remind the patient about the importance of independence in daily activities. c. develop a plan to increase the patients independence in consultation with the patient and the spouse. d. recognize that it is important for the spouse to be involved in the patients care and support the spouses participation.

c. develop a plan to increase the patients independence in consultation with the patient and the spouse

The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include a. prophylactic clipping of cerebral aneurysms. b. heparin via continuous intravenous infusion. c. oral administration of low dose aspirin therapy. d. therapy with tissue plasminogen activator (tPA).

c. oral administration of low dose aspirin therapy

When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort and loose-sounding secretions, the initial intervention by the nurse should be to a. suction the patients oral and pharyngeal airway. b. administer oxygen at 7 to 9 L/min with a face mask. c. place the hands on the epigastric area and push upward when the patient coughs. d. encourage the patient to use an incentive spirometer every 2 hours during the day.

c. place the hands on the epigastric area and push upward when the patient coughs

When evaluating a patient with trigeminal neuralgia who has had a glycerol rhizotomy, the nurse will a. ask whether the patient is using an eye shield at night. b. determine whether the patient is doing daily facial exercises. c. question the patient about social activities with family and friends. d. remind the patient to chew food on the unaffected side of the mouth.

c. question the patient about social activities with family and friends

Propranolol (Inderal), a -adrenergic blocker that inhibits sympathetic nervous system activity, is prescribed for a patient. The nurse monitors the patient for a. dry mouth. b. constipation. c. slowed pulse. d. urinary retention.

c. slowed pulse

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. unilateral eyelid swelling

The nurse receives a verbal report that a patient has an occlusion of the left posterior cerebral artery. The nurse will anticipate that the patient may have a. dysphasia. b. confusion. c. visual deficits. d. poor judgment.

c. visual deficits

The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching? a. "I can sit down to put on my pants and shoes" b. "I try to exercise every day and rest when I'm tired" c. "My son removed all loose rugs from my bedroom" d. "I don't need to use my walker to get to the bathroom"

d. "I don't need to use my walker to get to the bathroom" Rationale: The client with Parkinson's disease should be instructed regarding safety measures in the home. The client should use his or her walker, as support to get to the bathroom because of bradykinesia. The client should sit down to put on pants and shoes to prevent falling. The client should exercise every day in the morning when energy levels are highest. The client should have all loose rugs in the home removed to prevent falling.

The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement? a. "I will wash my face with cotton pads." b. "I'll have to start chewing on my unaffected side." c. "I should rinse my mouth if toothbrushing is painful." d. "I'll try to eat my food either very warm or very cold"

d. "I'll try to eat my food either very warm or very cold" Rationale: Facial pain can be minimized by using cotton pads to wash the face and using room temp water. The client should chew on the unaffected side of the mouth, eat a soft diet, and take in foods and beverages at room temp. If brushing teeth triggers pain, an oral rinse after meals may be helpful instead.

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. "We need to remind him to turn his head to scan the lost visual field" Rationale: Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available

After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? a. A patient whose cranial x-ray shows a linear skull fracture b. A patient who has an initial Glasgow Coma Scale score of 13 c. A patient who lost consciousness for a few seconds after a fall d. A patient whose right pupil is 10 mm and unresponsive to light

d. A patient whose right pupil is 10 mm and unresponsive to light

Which of these prescribed interventions will the nurse implement first for a hospitalized patient who is experiencing continuous tonic-clonic seizures? a. Give phenytoin (Dilantin) 100 mg IV. b. Monitor level of consciousness (LOC). c. Obtain computed tomography (CT) scan. d. Administer lorazepam (Ativan) 4 mg IV.

d. Administer lorazepam (Ativan) 4 mg IV

The nurse is caring for a patient admitted with a spinal cord injury following a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following? a. Central cord syndrome b. Spinal shock syndrome c. Anterior cord syndrome d. Brown-Sequard syndrome

d. Brown-Sequard syndrome

The care plan for a patient who has increased intracranial pressure and a ventriculostomy includes the following nursing actions. Which action can the nurse delegate to nursing assistive personnel (NAP) who regularly work in the intensive care unit? a. Monitor cerebrospinal fluid color hourly. b. Document intracranial pressure every hour. c. Turn and reposition the patient every 2 hours. d. Check capillary blood glucose level every 6 hours.

d. Check capillary blood glucose level every 6 hours

The nurse is assessing the adaptation of a client to changes in functional status after a stroke. Which observation indicates to the nurse that the client is adapting most successfully? a. Get 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. Consistently uses adaptive equipment in dressing self Rationale: Clients are evaluated as coping successfully with lifestyle changes after a stroke if they make appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions. Options a and b are not adaptive behaviors; Option c indicates a not yet successful attempt to adapt

A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When admitting the patient, which clinical manifestation will the nurse expect to find? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided reflexes d. Difficulty in understanding commands

d. Difficulty in understanding commands

A patient is hospitalized with a possible seizure disorder. To determine the cause of the patients symptoms, the nurse will anticipate the need to teach the patient about which of these tests? a. Cerebral angiography b. Evoked potential studies c. Electromyography (EMG) d. Electroencephalography (EEG)

d. Electroencephalography (EEG)

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? a. Blowing the nose b. Isometric exercises c. Coughing vigorously d. Exhaling during repositioning

d. Exhaling during repositioning Rationale: Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure. Some of these activities include isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed opens glottis, which prevents intrthoracic pressure from rising.

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? a. Fluid is clear and tests negative for glucose b. Fluid is grossly bloody in appearance and has a pH of 6 c. Fluid clumps together on the dressing and has a pH of 7 d. Fluid separates into concentric rings and tests positive for glucose

d. Fluid separates into concentric rings and tests positive for glucose Rationale: Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose

After reviewing a patients cerebrospinal fluid analysis, which result will be most important for the nurse to communicate to the health care provider? a. Specific gravity 1.007 b. Protein 65 mg/dL (0.30 g/L) c. White blood cell (WBC) count 4/L d. Glucose 45 mg/dL (1.7 mmol/L)

d. Glucose 45 mg/dL (1.7 mmol/L)

A patient who has numbness and weakness of both feet is hospitalized with Guillain-Barr syndrome. The nurse will anticipate the need to teach the patient about a. intubation and mechanical ventilation. b. administration of IV corticosteroid drugs. c. insertion of a nasogastric (NG) feeding tube. d. IV infusion of immunoglobulin (Sandoglobulin).

d. IV infusion of immunoglobulin (Sandoglobulin)

A patient with Parkinsons disease has decreased tongue mobility and an inability to move the facial muscles. Which nursing diagnosis is of highest priority? a. Activity intolerance b. Self-care deficit: toileting c. Ineffective self-health management d. Imbalanced nutrition: less than body requirements

d. Imbalanced nutrition: less than body requirements

Which parameter is best for the nurse to monitor to determine whether the prescribed IV mannitol (Osmitrol) has been effective for an unconscious patient? a. Hematocrit b. Blood pressure c. Oxygen saturation d. Intracranial pressure

d. Intracranial pressure

. An elementary teacher who has just been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, I cannot teach anymore, it will be too upsetting if I have a seizure at work. Which response by the nurse is best? a. You may want to contact the Epilepsy Foundation for assistance. b. You might benefit from some psychologic counseling at this time. c. The Department of Vocational Rehabilitation can help with work retraining. d. Most patients with epilepsy are well controlled with antiseizure medications.

d. Most patients with epilepsy are well controlled with antiseizure medications

A patient with right-sided weakness that started 90 minutes earlier is admitted to the emergency department and all these diagnostic tests are ordered. Which test should be done first? a. Electrocardiogram (ECG) b. Complete blood count (CBC) c. Chest radiograph (Chest x-ray) d. Noncontrast computed tomography (CT) scan

d. Noncontrast computed tomography (CT) scan

Your client is being evaluated every 8 hours using the Glasgow Coma Scale. At 0800 your client's score is 13 and at 1600 the same client's score is 9. Your best intervention would be to: a. Document the score and report the improvement to the charge nurse b. Document the score and reevaluate in 4 hours c. Report the information at the end of the shift so that the next shift can continue to monitor for changes d. Notify the physician and charge nurse immediately

d. Notify the physician and charge nurse immediately

. Which of these nursing actions for a patient with Guillain-Barr syndrome is most appropriate for the nurse to delegate to an experienced nursing assistant? a. Nasogastric tube feeding q4hr b. Artificial tear administration q2hr c. Assessment for bladder distention q2hr d. Passive range of motion to extremities q8hr

d. Passive range of motion to extremities q8hr

A patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse plan to take? a. Administer IV furosemide (Lasix). b. Initiate high-dose barbiturate therapy. c. Type and crossmatch for blood transfusion. d. Prepare the patient for immediate craniotomy.

d. Prepare the patient for immediate craniotomy

The client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. Which past medical history finding makes the client most at risk for this disease? a. Menigitis or encephalitis during the last 5 years b. Seizures or trauma to the brain within the last year c. Back injury or trauma to the spinal cord during the last 2 years. d. Respiratory or gastrointestinal infection during the previous months

d. Respiratory or gastrointestinal infection during the previous months Rationale: Guillain-Barre syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits. on occasion, the syndrome can be triggered by vaccination or surgery

A patient with a stroke has progressive development of neurologic deficits with increasing weakness and decreased level of consciousness (LOC). Which nursing diagnosis has the highest priority for the patient? a. Impaired physical mobility related to weakness b. Disturbed sensory perception related to brain injury c. Risk for impaired skin integrity related to immobility d. Risk for aspiration related to inability to protect airway

d. Risk for aspiration related to inability to protect airway

Mrs. Jones complains of sudden loss of vision in her right eye. You notice that as she speaks her words are slurred and her mouth is drooping at the right corner. After 5 minutes all of her symptoms disappear. You suspect which of the following has occured: a. Concussion b. Seizure c. Herniated intravertebral disk d. TIA

d. TIA

Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia in order to prevent autonomic dysreflexia? a. Assist with selection of a high protein diet. b. Use quad coughing to assist cough effort. c. Discuss options for sexuality and fertility. d. Teach the purpose of a prescribed bowel program.

d. Teach the purpose of a prescribed bowel program

Which assessment finding in a patient who was admitted the previous day with a basilar skull fracture is most important to report to the health care provider? a. Bruising under both eyes b. Complaint of severe headache c. Large ecchymosis behind one ear d. Temperature of 101.5 F (38.6 C)

d. Temperature of 101.5 F (38.6 C)

A patient with sudden-onset right-sided weakness has a CT scan and is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patients speech is difficult to understand. b. The patients blood pressure is 144/90 mm Hg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin).

d. The patient has atrial fibrillation and takes warfarin (Coumadin)

. The nurse obtains all of the following information about a 65-year-old patient in the clinic. When developing a plan to decrease stroke risk, which risk factor is most important for the nurse to address? a. The patient has a daily glass of wine to relax. b. The patient is 25 pounds above the ideal weight. c. The patient works at a desk and relaxes by watching television. d. The patients blood pressure (BP) is usually about 180/90 mm Hg.

d. The patients blood pressure (BP) is usually about 180/90 mm Hg

When assessing a patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider? a. The patient has a positive Kernigs sign. b. The patient complains of having a stiff neck. c. The patients temperature is 101 F (38.3 C). d. The patients blood pressure is 86/42 mm Hg.

d. The patients blood pressure is 86/42 mm Hg

A patient has a new prescription for bromocriptine (Parlodel) to control symptoms of Parkinsons disease. Which information obtained by the nurse may indicate a need for a decrease in the dose? a. The patient has a chronic dry cough. b. The patient has four loose stools in a day. c. The patient develops a deep vein thrombosis. d. The patients blood pressure is 90/46 mm Hg.

d. The patients blood pressure is 90/46 mm Hg

A patient has a tonic-clonic seizure while the nurse is in the patients room. Which action should the nurse take? a. Insert an oral airway during the seizure to maintain a patent airway. b. Restrain the patients arms and legs to prevent injury during the seizure. c. Avoid touching the patient to prevent further nervous system stimulation. d. Time and observe and record the details of the seizure and postictal state.

d. Time and observe and record the details of the seizure and postictal state

When assessing a patient with a possible stroke, the nurse finds that the patients aphasia started 3.5 hours previously and the blood pressure is 170/92 mm Hg. Which of these orders by the health care provider should the nurse question? a. Infuse normal saline at 75 mL/hr. b. Keep head of bed elevated at least 30 degrees. c. Administer tissue plasminogen activator (tPA) per protocol. d. Titrate labetolol (Normodyne) drip to keep BP less than 140/90 mm Hg.

d. Titrate labetolol (Normodyne) drip to keep BP less than 140/90 mm Hg

Which information about a patient who is being treated with carbidopa/levodopa (Sinemet) for Parkinsons disease is most important for the nurse to report to the health care provider? a. Shuffling gait b. Tremor at rest c. Cogwheel rigidity of limbs d. Uncontrolled head movement

d. Uncontrolled head movement

To determine whether a new patients confusion is caused by dementia or delirium, which action should the nurse take? a. Assess the patient using the Mini-Mental Status Exam. b. Obtain a list of the medications that the patient usually takes. c. Determine whether there is positive family history of dementia. d. Use the Confusion Assessment Method tool to assess the patient.

d. Use the Confusion Assessment Method tool to assess the patient

To protect a patient from injury during an episode of delirium, the most appropriate action by the nurse is to a. secure the patient in bed using a soft chest restraint. b. ask the health care provider about ordering an antipsychotic drug. c. instruct family members to remain with the patient and prevent injury. d. assign a nursing assistant to stay with the patient and offer frequent reorientation.

d. assign a nursing assistant to stay with the patient and offer frequent reorientation

A 42-year-old patient who was adopted at birth is diagnosed with early Huntingtons disease (HD). When teaching the patient, spouse, and children about this disorder, the nurse will provide information about the a. use of levodopa-carbidopa (Sinemet) to help reduce HD symptoms. b. need to take prophylactic antibiotics to decrease the risk for pneumonia. c. lifestyle changes such as increased exercise that delay disease progression. d. availability of genetic testing to determine the HD risk for the patients children.

d. availability of genetic testing to determine the HD risk for the patients children

The day after having an ischemic stroke, a patient is to start oral fluids and food intake. Before feeding the patient, the nurse should first a. order a soft diet for the patient b. raise the HOB to a semi-sitting position c. evaluate the patient's ability to swallow small sips of ice water d. check the patient's gag reflex

d. check the patient's gag reflex

When administering a mental status examination to a patient with delirium, the nurse should a. medicate the patient first to reduce any anxiety. b. give the examination when the patient is well-rested. c. reorient the patient as needed during the examination. d. choose a place without distracting environmental stimuli.

d. choose a place without distracting environmental stimuli

During the neurologic assessment, the patient cooperates with the nurses directions to grip with the hands and to move the feet but is unable to respond orally to the nurses questions. The nurse will suspect a. a brainstem lesion. b. a temporal lobe lesion. c. injury to the cerebellum. d. damage to the frontal lobe.

d. damage to the frontal lobe

A patient who is seen in the outpatient clinic complains of restless legs syndrome. Which of the following over-the-counter medications that the patient is taking routinely should the nurse discuss with the patient? a. multivitamin (Stresstabs) b. acetaminophen (Tylenol) c. ibuprofen (Motrin, Advil) d. diphenhydramine (Benadryl)

d. diphenhydramine (Benadryl)

A 72-year-old patient is diagnosed with moderate dementia as a result of multiple strokes. During assessment of the patient, the nurse would expect to find a. excessive nighttime sleepiness. b. difficulty eating and swallowing. c. variable ability to perform simple tasks. d. loss of both recent and long-term memory.

d. loss of both recent and long-term memory

A 24-year-old patient is hospitalized with the onset of Guillain-Barr syndrome. During this phase of the patients illness, the most essential assessment for the nurse to carry out is a. monitoring the cardiac rhythm. b. determining level of consciousness. c. checking strength of the extremities. d. observing respiratory rate and effort.

d. observing respiratory rate and effort

After having a craniectomy and left anterior fossae incision, a patient has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to a. position the bed flat and log roll the patient. b. cluster nursing activities to allow longer rest periods. c. turn and reposition the patient side to side every 2 hours. d. perform range-of-motion (ROM) exercises every 4 hours.

d. perform range-of-motion (ROM) exercises every 4 hours

When the nurse is developing a rehabilitation plan for a patient with a C6 spinal cord injury, an appropriate patient goal is that the patient will be able to a. transfer independently to a wheelchair. b. drive a car with powered hand controls. c. turn and reposition independently when in bed. d. push a manual wheelchair on flat, smooth surfaces.

d. push a manual wheelchair on flat, smooth surfaces

A patient with a brainstem infarction is admitted to the nursing unit. The priority nursing assessment for the patient is a. reflex reaction time. b. pupil reaction to light. c. level of consciousness. d. respiratory rate and rhythm.

d. respiratory rate and rhythm

A patient with a left-sided brain stroke suddenly bursts into tears when family members visit. The nurse should a. use a calm voice to ask the patient to stop the crying behavior. b. explain to the family that depression is normal following a stroke. c. have the family members leave the patient alone for a few minutes. d. teach the family that emotional outbursts are common after strokes.

d. teach the family that emotional outbursts are common after strokes

A patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. The nurse anticipates the need to prepare the patient for a. surgical endarterectomy. b. transluminal angioplasty. c. intravenous heparin administration. d. tissue plasminogen activator (tPA) infusion.

d. tissue plasminogen activator (tPA) infusion

When performing a focused assessment on a patient with a lesion of the left posterior temporal lobe, the nurse will assess for a. sensation on the left side of the body. b. voluntary movement on the right side. c. reasoning and problem-solving abilities. d. understanding of written and oral language.

d. understanding of written and oral language

In which order will the nurse perform the following actions when caring for a patient with possible C6 spinal cord trauma who is admitted to the emergency department? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Infuse normal saline at 150 mL/hr. b. Monitor cardiac rhythm and blood pressure. c. Administer O2 using a non-rebreather mask. d. Transfer the patient to radiology for spinal computed tomography (CT). e. Immobilize the patients head, neck, and spine

e. Immobilize the patients head, neck, and spine c. Administer O2 using a non-rebreather mask b. Monitor cardiac rhythm and blood pressure a. Infuse normal saline at 150 mL/hr d. Transfer the patient to radiology for spinal computed tomography (CT)