Quiz 1 -- chapter 36, 39, 45, 47, 53 and 54

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

"It prevents a patient from ambulating due to joint instability."Rationale: In a second-degree sprain, the joint remains intact and the ligament is not completely torn. However, a third-degree sprain prevents a patient from ambulating due to joint instability.Test Taking Tips:Look for the incorrect answer.

A patient has a mean arterial pressure (MAP) of 77 mm Hg. The cerebral perfusion pressure (CPP) is 61 mm Hg. What is the patient's intracranial pressure (ICP)? Record your answer using a whole number. Enter numeral only.

16 ICP is calculated by subtracting CPP from MAP. MAP-CPP=ICP. 77-61= 16 mm Hg

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

A, C, D a. The postictal phase occurs after the seizure. c. The client may exhibit confusion and disorientation during the postictal phase. d. The postictal phase can last from 5-30 minutes.

When the nurse assesses a patient regarding the auditory system, which is the most important question to ask? A. "Do you have any chronic illnesses that require you to take daily medication?" B. "Have you ever been told that you are tone deaf?" C. "Did you ever have a foreign body in your ear?" D. "Do you notice that you have wax in your ears?"

A. "Do you have any chronic illnesses that require you to take daily medication?"

What assessment data are most important in completing a history and physical examination of the eye? A. Family history, current state of health B. Record of daily food intake, obtaining an accurate weight of the patient C. Medications taken daily and occupation D. Use of sun protective glasses on a daily basis and immunization history

A. Family history, current state of health

The nurse recognizes which findings as expected changes in visual function associated with aging? A. Presbyopia, decrease in general color perception B. More narrowed field of vision, otosclerosis C. Decrease in general color perception, increased tear production D. Pupillary miosis, presbyopia

A. Presbyopia, decrease in general color perception

The nurse recognizes which actions as essential functions of the auditory system? (Select all that apply.) A. Transfer of sound waves through the auditory canal B. Vibration of the eardrum C. Warming air while it enters the outer ear D. Balance E. Secretion of cerumen

A. Transfer of sound waves through the auditory canal B. Vibration of the eardrum D. Balance E. Secretion of cerumen

The nurse implements which actions before the patient undergoes diagnostic studies of the ear? A. Verify the patient's understanding of the scheduled test B. Request that the nurse technician obtain consent for the test C. Reassure the patient that the ordered test should be completed D. Inform the patient that teaching for this procedure is the provider's responsibility

A. Verify the patient's understanding of the scheduled test

The nurse recognizes which action as most important to preventing eye trauma? A. Wearing protective goggles at home or work as indicated B. Keeping hands clean C. Refraining from looking directly into light sources D. Eating a well-balanced diet

A. Wearing protective goggles at home or work as indicated

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

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

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

Administer analgesics as per the order. Apply a rigid cast or splint. Encourage intake of additional protein- and carbohydrate-rich foods. Rationale: To prevent prostaglandin formation and promote movement, function, and participation in rehabilitation, the nurse should administer analgesics to the patient . Rationale: The nurse should apply a rigid cast/splint as it helps decrease edema by compressing the residual limb for a better fitting into the prosthesis. Rationale: To promote quick healing, the nurse should encourage the patient to consume additional protein- and carbohydrate-rich foods. Test Taking Tips: Consider priority actions for rehabilitation.

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

Apply a tourniquet to the remaining limb. Salvage surgery may be ordered for the patient by the primary healthcare provider. A coagulation panel, complete blood count (CBC), and serum lactate baseline level should be established. Rationale: When caring for a patient with traumatic amputations the nurse should apply a tourniquet to the remaining limb. This helps in stopping both arterial and venous bleeding. Rationale: To control hemorrhage, reattach limbs, or remove the damaged tissue, salvage surgery may be ordered for a patient with a traumatic amputation. Rationale: To start an immediate blood transfusion, a coagulation panel, CBC, and serum lactate baseline level should be established for a patient with traumatic amputation. Test Taking Tips: Consider priorities.

The nurse recognizes which action as the major function of the visual system? A. Differentiate colors B. Convert light into nerve signals for the brain to interpret C. Focus light onto the choroid D. Accommodate vision from light to dark

B. Convert light into nerve signals for the brain to interpret

Which findings are expected age-related changes in the auditory system? (Select all that apply.) A. Increase in frequency of ear infections B. Hearing acuity may decrease. C. The ability to hear high frequencies is lost first. D. The tympanic membrane loses elasticity. E. Increased flexibility of the stapes

B. Hearing acuity may decrease. C. The ability to hear high frequencies is lost first. D. The tympanic membrane loses elasticity.

The nurse recognizes which medication as ototoxic? A. Nonsalicylate pain medications B. Calcium channel blockers C. Antibiotics such as gentamicin D. Beta blockers

C. Antibiotics such as gentamicin

The nurse correlates which anatomical structure as the location of the sensory organs for hearing and equilibrium? A. Eustachian tube B. Ossicles C. Bony labyrinth D. Tympanic membrane

C. Bony labyrinth

Which is the most common examination used to assess a patient's auditory function? A. Examination using the tuning fork B. Assessment of all the cranial nerves C. Examination using the otoscope D. Evaluation of a written questionnaire

C. Examination using the otoscope

In assessing a patient's vision, the nurse recognizes which structures as key to the visual system? A. Uvea, lacrimal gland, macula B. Eyeball, cochlea, retina C. Fovea, retina, macula D. Rods, ciliary body, aqueous humor

C. Fovea, retina, macula

The nurse must consider all of these assessments prior to preparing a patient for diagnostic studies of the eye. Which intervention can be delegated to the technician on the team? A. Assessing the patient's past medical history B. Administering preprocedure medications C. Obtaining an accurate height and weight of the patient D. Reviewing current medications the patient is taking daily

C. Obtaining an accurate height and weight of the patient

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

Compound Rationale: When the bone pieces protrude through the skin and create an external wound that exposes the fracture site, it is known as a compound or open type of fracture. Test Taking Tips: Differentiate between fracture types.

The nurse should instruct the patient to perform which action to prevent possible ear trauma? A. Whisper when possible to prevent ear strain B. Select earbuds for electronic devices over external earphones C. Be cautious when taking oral medications D. Never use a cotton swab or other similar instrument in an attempt to remove wax

D. Never use a cotton swab or other similar instrument in an attempt to remove wax

The nurse prepares the patient for which common diagnostic evaluations during a visit to an eye care provider? A. Pupillary light test, ultrasound of the eye B. Test of peripheral vision, otoscope examination C. Test for presence of bacteria in the conjunctiva, pupillary light test D. Snellen eye chart examination, peripheral vision check

D. Snellen eye chart examination, peripheral vision check

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

Displaced Rationale: A displaced fracture indicates malalignment of bone fragments at the fracture site. Test Taking Tips: Do not confuse fracture types.

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

Falls Rationale: Falls are an example of low-energy trauma. Test Taking Tips: Differentiate between low-energy and high-energy.

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

Higher occurrences are seen in computer operators and construction workers. Rationale: Carpal tunnel syndrome (CTS) is found mostly in computer operators, construction workers, and others who have jobs requiring repetitive motions of the hands. Test Taking Tips: Risk factors for carpal tunnel syndrome include age, type of employment, and gender.

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

It occurs as a result of excessive force along the axis of cancellous bone. Rationale: A compression fracture occurs as a result of excessive force along the axis of cancellous bone that results in the bone collapsing on its own. Test Taking Tips: Do not confuse fracture types.

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

Neurovascular compromise Rationale: The presence of the 6 P's indicates neurovascular compromise, which can result in hemorrhage, compartment syndrome, infection, or permanent loss of function.Test Taking Tips:Consider the 6 P's.

Which patient is most likely to experience atonic seizures? Patient A Patient B Patient C Patient D

Patient B

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

Relieve muscle spasms Rationale: Skin traction utilizes a flexible harness, boot, or belt to secure the extremity while 5 to 10 lbs of weight is applied to relieve muscle spasms and maintain the length of the bone. Test Taking Tips: Do not confuse traction types.

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

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

The nurse is completing discharge teaching with the stroke client preparing for discharge. The client asks if the healthcare provider will continue the medications prescribed pre-stroke for hypertension and high cholesterol. What is the nurse's best response to this question? a. "High cholesterol and hypertension are risk factors for stroke. I would expect that the healthcare provider will continue treating these two conditions with medication after discharge." b. "Because you were taking these medications and still had a stroke, I doubt the healthcare provider will continue treating these conditions." c. "Ask the healthcare provider next time rounds are made. I am not able to answer that question for you." d. "Let's just wait and see what is ordered when your discharge paperwork is completed by the healthcare provider. I will address your questions at that time."

a. "High cholesterol and hypertension are risk factors for stroke. I would expect that the healthcare provider will continue treating these two conditions with medication after discharge."

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

a. "I should wear this all of the time."

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

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

Min is concerned that her pain level will worsen as she becomes more active. What would be an appropriate nurse response? a. "Your pain may increase, but you should strive for an active lifestyle." b. "Your pain should not increase when you add more activity in your life." c. "You cannot add pain medication to the medications that you take for osteoporosis." d. "You will find that your pain will decrease when you become more active."

a. "Your pain may increase, but you should strive for an active lifestyle." The client may find that when she increases her activity, her pain level increases. Exercises should include abdominal and back muscle strengthening and low-intensity, weight-bearing exercise such as walking. Regular exercise will improve posture and balance and strengthen muscle tone.

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

a. Administer stool softeners. this helps decrease valsalva and straining, which can further increase ICP

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

a. Administering glucocorticoids to the patient cerebral edema may occur due to the inflamed blood-brain barrier in a patient with a brain tumor post-surgery. the cerebral edema may be managed by increasing the dose of glucocorticoids as thee medications decrease the inflammatory process

The nurse performs and assessment on a patient and discovers the finding in the image. What does it represent? (image of bruising around both eyes) a. Basilar skull fracture b. Epidural hematoma c. Fracture in the middle fossa d. Fracture in the anterior fossa

a. Basilar skull fracture a late sign of a basilar fracture is bruising around the eyes (raccoons eyes) or the ears (battle's sign)

Which type of muscular dystrophy is most common in men and children? a. Becker MD b. Myotonic MD c. Duchenne MD d. Limb-girdle MD

a. Becker MD becker md is most common in males and in childhood

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

a. Bleeding b. Seizures c. Venous thrombus embolism e. Cerebral edema

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

a. Bleeding c. Venous thromboembolism e. Seizures

The nurse would expect the client admitted for a stroke to be monitored for cardiac status. Which methods would the nurse expect to see ordered for this purpose? Select all that apply. a. Cardiac enzymes per protocol b. Continuous electrocardiogram monitoring c. Baseline 12-lead electrocardiogram d. Cardiac catheterization e. Placement of cardiac pacemaker

a. Cardiac enzymes per protocol b. Continuous electrocardiogram monitoring c. Baseline 12-lead electrocardiogram

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

a. Chemotherapy b. Radiation c. Surgery

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

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

The nurse knows that close monitoring of serum electrolyte levels, especially sodium, is important because hyponatremia raises the risk of which stroke complication? a. Cumulative fluid imbalance b. Decreased cardiac output and arrhythmias c. Diabetes and liver dysfunction d. Acid-base imbalance and sepsis

a. Cumulative fluid imbalance

The nurse is talking with a client who is confused about modifiable and non-modifiable risk factors for osteoporosis. Which of these are examples of modifiable risk factors? Select all that apply. a. Diet b. Weight c. Gender d. Lifestyle e. Ethnicity

a. Diet b. Weight d. Lifestyle

After the healthcare provider completes a fracture risk assessment screening, Min is scheduled for outpatient diagnostic testing to further evaluate her risk for osteoporosis. Which diagnostic test will be used to evaluate her bone density? a. Dual-energy x-ray absorptiometry (DEXA) b. Quantitative computerized tomography (qCT) c. Serum biochemical markers d. X-ray of the pelvis

a. Dual-energy x-ray absorptiometry (DEXA) The client would be scheduled for a dual-energy x-ray absorptiometry (DEXA) scan, the established standard diagnostic exam used to diagnose osteoporosis and provide follow-up about the effectiveness of a prescribed treatment plan. The DEXA scan is noninvasive with no prep required prior to the test. The other diagnostic tests would not be used for assessment of osteoporosis; instead, they would be used for diagnostic management of the disease process.

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

a. Fatigue c. Mucositis d. Hair loss

The nurse also suggests that Min increase the amount of vitamin D that she consumes to improve absorption. What foods should the nurse suggest? Select all that apply. a. Fish b. Milk c. Cereals d. Liver e. Egg whites

a. Fish b. Milk c. Cereals d. Liver The recommended intake for vitamin D is 800 to 1,000 international units (IU), which can be ingested from dietary sources such as vitamin D-fortified milk, cereals, egg yolks, saltwater fish, and liver.

Min, a 55-year old postmenopausal Asian female, is visiting her healthcare provider for an annual physical. She is approximately 50 pounds overweight. Min states that she is a pack-a-day smoker and takes a daily multivitamin designed for women older than 50. When questioned by the healthcare provider, the client says she has never had bone mineral density testing.The nurse recognizes that that Min is at risk for osteoporosis because of which identified factors? Select all that apply. a. Gender b. Postmenopausal age c. Smoker d. Overweight e. Multivitamin use

a. Gender b. Postmenopausal age c. Smoker d. Overweight Female gender, age older than 50 years, being a smoker, and being overweight are all risk factors for developing osteoporosis. Daily use of a multivitamin that includes both calcium and vitamin D is important in preventing osteoporosis.

While reviewing the diagnostic test reports of a patient suspected of having a basilar skull fracture, the primary healthcare provider finds blood is collecting between the skull and the dura mater. Which is the patient most likely experiencing? a. Hematoma b. Battle's sign c. Fracture in the middle fossa d. Fracture in the anterior fossa

a. Hematoma hematoma is the condition in which blood collects in the space between the skull and the dura matter

After an extended hospital and rehabilitation stay, Tom is ready for discharge. What discharge instructions should the nurse include for Tom and his wife? Select all that apply. a. Identifying the symptoms of stroke b. The importance of smoking cessation c. Encouraging the use of salt substitutes d. Compliance with medications e. Following up with healthcare provider as directed

a. Identifying the symptoms of stroke b. The importance of smoking cessation d. Compliance with medications e. Following up with healthcare provider as directed Discharge instructions should include education about identification of stroke symptoms, since Tom is still at risk for having another stroke. Materials on smoking cessation should be provided, along with medication compliance and follow up appointments. Salt substitutes are not recommended.

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

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

The nurse suspects lower cranial nerve dysfunction in a patient with hemorrhagic stroke. Which diagnostic characteristic supports the nurse's suspicion? a. Impaired swallowing b. Impaired family coping c. Impaired physical mobility d. Impaired verbal communication

a. Impaired swallowing impaired swallowing is related to lower cranial nerve dysfunction or decreased LOC.

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

a. It does not involve abnormal electrical discharges.

The nurse knows that which interventions could be implemented for a stroke client at risk for aspiration? Select all that apply. a. Maintain the head of the bed at least 30 degrees or greater while eating or drinking. b. Ensure that the client is receiving the prescribed therapeutic food preparation. c. Ensure the client is supervised while eating or drinking, observing for signs of aspiration and choking. d. Advocating for evaluation of the client by a speech language pathologist. e. Allow the client to watch television and visit with visitors while eating and drinking.

a. Maintain the head of the bed at least 30 degrees or greater while eating or drinking. c. Ensure the client is supervised while eating or drinking, observing for signs of aspiration and choking. d. Advocating for evaluation of the client by a speech language pathologist.

The nurse is caring for a client who is receiving anticoagulants post-stroke. The nurse would implement which precautions for clients receiving anticoagulants? Select all that apply. a. Monitoring for presence of bleeding b. Using firm bristle toothbrush for oral hygiene c. Implementing fall precautions d. Monitoring for stroke-related weakness e. Taking temperature via rectal route for accuracy in reading

a. Monitoring for presence of bleeding c. Implementing fall precautions d. Monitoring for stroke-related weakness

Tom, a 75-year-old man, was at home watching television with his wife when he began displaying strange symptoms. His wife called 911 and stated, "Something is wrong with my husband. He won't answer me when I speak to him. He is staring straight ahead and drooling from his mouth. Please send an ambulance immediately!" The ambulance arrived and transported Tom to the local emergency department.The triage nurse performs an assessment when Tom arrives. What priority nursing action should be completed? a. Obtain a blood pressure. b. Draw a serum glucose level. c. Obtain a sterile urine specimen. d. Ask the patient about his home meds.

a. Obtain a blood pressure. Of the actions listed, the nurse should quickly obtain a blood pressure. With either an ischemic or hemorrhagic stroke, close monitoring of the blood pressure is a priority to ensure that it remains within prescribed limits. The nurse would need to know the client's home medications, but not before the client has been triaged and vital signs obtained. Lab work would be drawn and glucose would be part of the metabolic panel, but this is not the priority task.

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

a. Respiratory distress b. Fat embolism syndrome c. Elevated blood urea nitrogen and creatinine e. Hypovolemia

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

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

The nurse is caring for an unconscious client after a large ischemic stroke. Which assessment changes are most concerning? Select all that apply. a. Rising systolic blood pressure b. Bradycardia c. Equal and reactive pupils d. Irregular breathing pattern e. Hypotension

a. Rising systolic blood pressure b. Bradycardia d. Irregular breathing pattern e. Hypotension

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

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

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

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

The nurse is caring for a post-stroke client. As the client's recovery advances, what topics would the nurse include in her teaching? Select all that apply. a. Signs and symptoms of stroke b. Smoking cessation if applicable c. Use of salt substitutes that contain potassium d. Discharge medications e. Follow-up medical management

a. Signs and symptoms of stroke b. Smoking cessation if applicable d. Discharge medications e. Follow-up medical management

The nurse is preparing a community-based education program on risk factors for stroke. The nurse would include which modifiable risk factors in the presentation? Select all that apply. a. Smoking b. Obesity c. Vegetarian diet d. Hypercholesterolemia e. Advanced age

a. Smoking b. Obesity d. Hypercholesterolemia

Min is started on calcium but feels like the dose is too high. The nurse learns she is taking 1,200 mg each day in divided doses. What should the nurse suggest to Min? a. That dose is appropriate and should be continued. b. Decrease the dose by half. c. Clarify the dose with your provider. d. Increase the dose to 1,500 mg/day.

a. That dose is appropriate and should be continued. The recommended dose of calcium either via dietary consumption or via supplements varies by age; however, 1,200 mg/day is the recommended daily intake for adults 51 years of age or older.

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

a. They occur during middle age. c. They arise from the fatty covering that protects nerves. d. They arise from the cells that provide support and insulation to axons. oligodendrogliomas are slow-growing tumors that do not spread to surrounding tissue and are found in middle-aged patients. oligodendrogliomas occur in the cerebrum, arising from the fatty covering that protects nerves. oligodendrogliomas arise from oligodendrocytes and oligodendroglia. these cells provide support and insulation to axons in the central nervous system.

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

a. Transverse c. Comminuted d. Compound

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

a. Urine specific gravity b. Serum sodium c. Urine osmolality

While assessing a patient , the nurse observes uneven waist and shoulders. Which musculoskeletal disorder could cause this? a. scoliosis b. bone cancer c. osteomyelitis d. muscular dystrophy

a. scoliosis clinical manifestations of scoliosis are uneven waist and shoulders

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

b. "I should stop taking glucocorticoids when I feel normal." glucocorticoids are given to a patient with a brain tumor to reduce inflammation. the patient should consult their PCP before stopping the use of glucocorticoids, as rapid withdrawal can cause an adrenal crisis.

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

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

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

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

Min states she wants to lose weight and lead a healthier lifestyle. Which statement by the client requires additional teaching? a. "I can drink orange juice with Vitamin D added to help my body with the absorption of calcium." b. "My diet should focus on carbohydrates and fat with little protein." c. "I need to find an exercise activity to add to my life, along with a healthy diet to help manage my osteoporosis." d. "Along with a healthy diet, I should plan to take a multivitamin daily."

b. "My diet should focus on carbohydrates and fat with little protein." A balanced diet with adequate protein is important for bone formation. Proper calcium and vitamin D intake are important when managing osteoporosis, as is a healthy activity level.

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

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

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

b. "The medication may cause blurred vision."

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

b. "The medications to decrease swelling cause blood glucose levels to rise." glucocorticoids used for inflammation can cause glucose levels to rise

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

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

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

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

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

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

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

b. 30-45 degrees

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

b. Abrupt withdrawal of anticonvulsive medications d. Acute drug withdrawal e. Head trauma

The primary healthcare provider orders IV recombinant tissue plasminogen activator (rt-PA) therapy for a patient. Which is the most likely condition of the patient? a. Neurogenic shock b. Acute ischemic stroke c. Traumatic brain injury d. Increased intracranial pressure

b. Acute ischemic stroke IV rt-PA therapy is used in the treatment of acute ischemic stroke. It is the only FDA approved treatment for ischemic stroke

The nurse notes neglect, or inattention, to one side of the body in a patient who recently had a stroke. Which describes this condition in the patient? a. Apraxia b. Agnosia c. Battle's sign d. Hemianopia

b. Agnosia weakness or paralysis of extremities may be a chronic complication of stroke. Agnosia is the term indicating that the patient has neglect or has become inattentive toward one part of the body. this condition is known as hemiparesis.

Upon assessment, the nurse notes that Tom has weakness on the right side of his body. He has vomited numerous times since admission to the emergency department, has difficulty swallowing, and is drooling saliva from the right side of his mouth. He is attempting to speak but is unable to do so. Tom is exhibiting symptoms of which syndrome? a. Right middle cerebral artery syndrome b. Basilar artery syndrome c. Left middle cerebral artery syndrome d. Non-traumatic intracerebral hemorrhage syndrome

b. Basilar artery syndrome The symptoms the client is exhibiting are signs of basilar artery syndrome. The injury to the brain may be either on the same side or opposite side of the side of the body that is displaying symptoms. Nausea and vomiting are not usually found in either left or right middle cerebral artery syndrome.

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

b. Brainstem herniation increased ICP can severely decrease cerebral perfusion pressure, leading to secondary injury of the brain via cytotoxic and anoxic injury and herniation of the brain

The nurse is speaking with a female client in her 40s who has a family history of osteoporosis and wants to know what dietary changes can decrease her risk of developing the disorder. What nutrient deficiencies have been correlated with osteoporosis? Select all that apply. a. Magnesium b. Calcium c. Vitamin E d. Vitamin D e. Potassium

b. Calcium d. Vitamin D

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

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

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

b. Decreased alertness d. Personality changes e. Swelling of the optic disc

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

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

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

b. Left-lying (lateral)

The nurse receives the latest laboratory report. Which finding is most concerning for Tom? a. Normal potassium level b. Low sodium level c. Low protein level d. High INR level

b. Low sodium level Close monitoring of serum electrolytes, particularly sodium, is necessary to identify disorders of salt and water imbalance resulting in hyponatremia, which places patients who have suffered a stroke at high risk for cerebral edema and neurological deterioration.

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

b. Lung c. Melanoma d. Renal e. Breast

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

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

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

b. Placing the patient in a left recumbent position

Because of Tom's current condition, what action is a priority for the nurse? a. Begin nutritional supplement to prevent malnutrition b. Position to prevent aspiration c. Place antithrombotic devices to prevent clots d. Orient to person, place, and time

b. Position to prevent aspiration After a stroke, many clients experience swallowing dysfunction, which places them at risk for aspiration and subsequent pneumonia. Tom is at especially high risk because of his vomiting.

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

b. Rhabdomyolysis

Tom is admitted to the intensive care unit. The nurse receives the hand-off report from the emergency room nurse. Which priority assessments are appropriate for the nurse to perform? Select all that apply. a. Substance abuse assessment b. Serial neurological assessments every 1-2 hours c. Baseline neurological assessment d. Nutritional assessment e. Vital sign assessment every 1-2 hours

b. Serial neurological assessments every 1-2 hours c. Baseline neurological assessment e. Vital sign assessment every 1-2 hours Changes in level of consciousness and neurological status are early indicators of increased ICP. Neurological deterioration must be identified quickly in order to mitigate further brain injury. The nurse should obtain a baseline neurological assessment and monitor it regularly to identify change. Vital sign changes also indicate increased intracranial pressure (Cushing's Triad) and should be monitored closely.

Min tells the nurse she doesn't like any of the food and asks if there is another way to get vitamin D. What should the nurse suggest? a. Taking a multivitamin with vitamin D b. Sitting in the sun 15 minutes each day. c. Increasing the amount of table salt in her diet. d. Increasing weight-bearing exercises.

b. Sitting in the sun 15 minutes each day. Sunlight for 15 minutes per day also helps with vitamin D and calcium absorption.

The nurse is completing Tom's health history with his wife. Which of Tom's stroke risk factors are modifiable? Select all that apply. a. Age b. Smoking cigarettes c. Elevated cholesterol levels d. Race e. Weight

b. Smoking cigarettes c. Elevated cholesterol levels e. Weight Modifiable risk factors are risk factors that can be changed. The client could stop smoking, decrease his cholesterol level with diet, exercise, or medication, or lose weight by diet, exercise, or medication. The client cannot change his age or race.

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

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

Which populations have a high risk of osteoporosis? Select all that apply. a. Women younger than 50 b. Women of Asian descent c. Individuals with a family history of osteoporosis d. Individuals who are overweight e. Individuals who use tobacco

b. Women of Asian descent c. Individuals with a family history of osteoporosis d. Individuals who are overweight e. Individuals who use tobacco

Which are secondary risk factors for a patient with osteoporosis? Select all that apply. a. cigarette smoking b. cushing's disease c. steroid use d. gender e. down's syndrome

b. cushing's disease c. steroid use e. down's syndrome

A patient has undergone joint replacement. Which complications should the nurse monitor for? Select all that apply. a. myeloma b. hypotension c. spinal deformity d. hypovolemic shock e. deep vein thrombosis

b. hypotension d. hypovolemic shock e. deep vein thrombosis

A nurse is teaching a about total joint replacement (TJR). Which statement indicates a need for further teaching? a. it is also referred to as arthroplasty b. its replacement life span is 5-6 years c. its most commonly associated with the joints of the hip and knee d. its the surgical procedure designed to repair an articulating surface with a synovial joint

b. its replacement life span is 5-6 years the replacement life span is 10-15 years

A patient reports fever, swelling, and warmth at the site of swelling. Which musculoskeletal disorder should the nurse be concerned about? a. osteoporosis b. osteomyelitis c. paget's disease d. muscular dystrophy

b. osteomyelitis clinical manifestations of osteomyelitis are fever, swelling of the bone and warmth at the site of swelling

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

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

The nurse is explaining to the student nurse why it is important for the post-stroke client to maintain adequate blood pressure readings. What is the nurse's best explanation? a. "The client is able to rest more comfortably with blood pressure values in the normal range." b. "When blood pressure values are too low, the kidneys have to work harder. This situation creates stress on the kidneys." c. "After a stroke, cerebral autoregulation may not be working properly, and this intervention helps to protect the client's brain from ischemia caused by abnormally low systemic blood pressure." d. "If the blood pressure values are not within normal, the client must receive more medication to control the values."

c. "After a stroke, cerebral autoregulation may not be working properly, and this intervention helps to protect the client's brain from ischemia caused by abnormally low systemic blood pressure."

Min is upset by the new diagnosis and fearful of complications. What can the nurse tell her to provide some comfort? a. "Osteoporosis is genetic and you had no control over getting the disease." b. "Osteoporosis is curable and with proper treatment, you won't have residual effects." c. "Preventive lifestyle and medications can slow the progression of the disease." d. "Surgery is often a great alternative to living with the debilitating disease."

c. "Preventive lifestyle and medications can slow the progression of the disease." Prevention is the key modifying factor to incorporate into medical care for those at risk for osteoporosis. Weight loss and muscle-strengthening exercises to reduce the incidence of falls and fractures are highly recommended. A healthy lifestyle and avoidance of smoking and excessive alcohol intake are endorsed by the surgeon general for prevention of osteoporosis.

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

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

The nurse is seeing a client with osteoporosis who started on a bisphosphonate last month to treat osteoporosis. The client states "Ever since I started taking that medicine, my stomach has really been bothering me." What is the nurse's best response? a. "Are you taking the medication with food? Sometimes taking the medication when you haven't eaten can cause an upset stomach." b. "What time of day are you taking the medicine? Most individuals have fewer side effects if the medicine is taken at bedtime." c. "When have you been taking the medication? The best time to take this medication is first thing in the morning, on an empty stomach." d. "Are you having any other stomach issues? Gastrointestinal issues are very common with this drug." Next

c. "When have you been taking the medication? The best time to take this medication is first thing in the morning, on an empty stomach."

A client who has had a stroke is upset when told he cannot eat in his room without a staff member present. What is the best explanation that the nurse can give the client regarding this information? a. "This is the policy and unfortunately, I must enforce this rule." b. "If you ask your healthcare provider to change this order, I am sure they will make an exception." c. "You are at risk of choking and aspirating when you eat due to your stroke." d. "Why do you have a problem with this rule?"

c. "You are at risk of choking and aspirating when you eat due to your stroke."

The nurse notes an ECG rhythm on the monitor that may be the cause of Tom's stroke. Which rhythm leads the nurse to believe this? a. Ventricular tachycardia b. First degree AV block c. Atrial fibrillation d. Occasional PVCs

c. Atrial fibrillation Identification of rhythm disturbances such as atrial fibrillation is essential in determining potential causes of stroke. Atrial fibrillation is an irregular rhythm where clot formation is common.

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

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

The nurse is caring for a patient with traumatic brain injury. It is noted that there is clear fluid draining from the ears. After notifying the provider, what action should the nurse take? a. Pack ear canal with gauze. b. Turn the patient onto his or her side to allow for drainage. c. Collect the fluid using a loosely applied gauze. d. Suction the fluid using a suction catheter.

c. Collect the fluid using a loosely applied gauze. if clear fluid is draining from the ear or nose, it should not be stopped. it should be collected using loosely applied gauze

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

c. During the postictal state

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

c. Lorazepam d. Midazolam

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

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

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

c. Passive pain at rest in the affected extremity

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

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

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

c. Reflexes d. Sensation e. Movement

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

c. Repetitive unconscious movements

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

c. Suction the oral airway.

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

c. Teach importance of frequent handwashing. the nurse must teach the patient to wash hands frequently. This helps prevent secondary infections which can be life threatening to the immune compromised patient.

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

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

After the results of the DEXA scan, Min is started on a daily bisphosphonate. She states that she takes her daily medications at bedtime but has developed indigestion. What information should the nurse share with the client regarding this class of drug? a. Bedtime is an acceptable time to take the medication with a glass of milk. b. The medication should be taken at lunch with a large meal. c. The medication should be taken on an empty stomach first thing in the morning. d. The medication should be taken on an empty stomach 1 hour after a meal.

c. The medication should be taken on an empty stomach first thing in the morning. Most bisphosphonates should be taken first thing in the morning on an empty stomach since laying down can increase the esophagitis and GI upset.

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

c. Thrombocytopenia d. Hypokalemia

The nurse is teaching about home care for patients who have undergone joint replacement. Which statement indicates the need for further teaching? a. i should encourage the patient to use slip socks b. i should encourage the patient to use walking devices c. i should encourage the patient to sit with legs crossed d. i should encourage the patient to use a raised toilet seat and pull bar in the bathroom

c. i should encourage the patient to sit with legs crossed pt should avoid crossing leg over the midline to prevent hip abduction

A patient reports a stabbing heel pain that worsens when walking in the morning. What condition should the nurse consider? a. bunion b. pes planus c. plantar fasciitis d. morton's neuroma

c. plantar fasciitis the symptoms of plantar fasciitis are stabbing heel pain that is typically worsened with the first steps in the morning

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

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

The nurse is caring for a patient with a severe traumatic brain injury. What Glasgow Coma Score will the patient have? a. 15 b. 13 c. 9 d. 4

d. 4 severe brain injury if a score is less than or equal to GCS 8.

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

d. Applying a sequential compression device to the patient applying mechanical venous thromboembolism devices, such as SCD's, helps prevent venous thromboembolism in a patient after a craniotomy.

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

d. Grade IV according to the WHO classification system, a patient with a glioma located near the brainstem has a grade iv brain tumor. glioblastoma multiforme is a grade iv astrocytoma that is a most aggressive and lethal form of glioma

Tom goes for an emergency CT scan to check for intracranial hemorrhage. No intracranial hemorrhage is noted on the scan. The healthcare provider is evaluating Tom's eligibility for plasminogen activator (rt-PA) to dissolve the blood clot that is present. What would make Tom ineligible for rt-PA? a. He has type 2 diabetes controlled with oral agents. b. He has a history of a myocardial infarction (MI) 3 years ago. c. He has displayed stroke symptoms for 2 hours. d. He is taking warfarin (Coumadin) for with an INR of 2.0.

d. He is taking warfarin (Coumadin) for with an INR of 2.0. The client would not be eligible for rt-PA because of the warfarin, with an INR of 2.0. INR above 1.7 is an excluding factor for rt-PA. The combination of warfarin with the patient's INR of 2.0 and the rt-PA agent significantly increases his risk for brain hemorrhage. If the INR is 1.7 or below, the combination of warfarin and the rt-PA agent is a lower risk. Next

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

d. High fat, low carbohydrate, and low protein

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

d. Kyphosis

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

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

Which statement best describes a strain? a. Dislocation injury b. Compression injury c. Ligament injury d. Muscle or tendon injury

d. Muscle or tendon injury

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

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

A patient is experiencing severe hypotension after a spinal cord injury. Which medication should the nurse anticipate will be ordered? a. Lorazepam b. Atropine c. Mannitol d. Norepinephrine

d. Norepinephrine vasoactive infusions of norepinephrine (Levophed) or phenylephrine (neo-synephrine) are commonly used with neurogenic shock.

Which type of cerebral herniation syndrome is most likely to lead to stroke in the tissue surrounding the anterior cerebral artery? a. Uncal herniation b. Central herniation c. Tonsillar herniation d. Subfalcine herniation

d. Subfalcine herniation in a subfalcine herniation, brain tissue is shifted over and underneath the falx cerebri. there is risk of compression to the anterior cerebral artery, which may cause a stroke in the surrounding region of brain tissue

The nurse is providing client teaching to a client suspected to have osteoporosis who is scheduled for a dual-energy x-ray absorptiometry (DEXA) scan. What would be included in the nurse's client teaching? a. The DEXA scan requires a barium swallow. b. The client should have a family member or friend present to drive the client home at the end of the scan. c. The DEXA scan will require an overnight hospital stay the night before the procedure. d. The DEXA scan is noninvasive and requires no preparation.

d. The DEXA scan is noninvasive and requires no preparation.

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

d. The patient experienced a severe fall to the ground with loss of consciousness.

the nurse is caring for a patient with a history of lung cancer. after presenting to the clinic with headaches, the provider obtains this image. What type of tumor is most likely the cause? a. primary b. gliomas c. oligodendrogliomas d. metastatic

d. metastatic metastatic disease is most commonly caused by primary cancer types that have spread: lung, melanoma, renal, breast and colorectal cancer, although other types of cancer may also produce metastases to the CNS