exam 1 q/a

The client diagnosed with bacterial meningitis is admitted to the medical floor at noon. Which order would have the highest priority? A. Administer an IV antibiotic. B. Obtain the client's O2 saturation. C. Provide a quiet calm, and dark environment. D. Weigh the client in hospital attire.

A: Administer an IV antibiotic

The nurse notices a clear fluid draining from the nose of a patient who sustained a head injury 2 hours ago. This may indicate the presence of which of the following conditions? A. Cerebral contusion B. Basal skull fracture C. Brain tumor D. Sinus infection

B: basal skull fracture

Which of the following initial diagnostic tests is recommended to assess for a cerebral bleed? a. MRI b. Noncontrast CT c. CT with contrast d. Cerebral angiography

B: noncontrast CT

Which statement by the female client indicates that the client understands factors that may precipitate seizure activity? A. "It is all right for me to drink coffee with breakfast." B. "My menstrual cycle will not affect my seizure disorder." C. " I am going to take a class in stress management." D. "I should wear dark glasses when I am out in the sun."

C: "I am going to take a class in stress management."

Which interventions should the nurse's plan of care include to help prevent autonomic dysreflexia in a patient with SCI? A. Check for fecal impactions. B. Monitor blood pressure for hypotension. C. Check the urinary drainage system for any obstruction. D. Instruct the patient to wear a medic alert bracelet. E. Both A and C

C: Check the urinary drainage system for any obstruction ** checking for fecal impaction could trigger autonomic dysreflexia, must r/o other causes first

The nurse is planning care for a 28 year old female with a diagnosis of myasthenia gravis. What schedule would be most appropriate for the organization of diagnostic procedures for the patient? A. All at one time, in order to provide a longer rest period. B. Before meals, to stimulate her appetite. C. In the morning, with frequent rest periods. D. Before bedtime, to promote rest.

C: In the morning, with frequent rest periods

The nurse know that the signs and symptoms of meningeal irritation include all of the following EXCEPT: A. Nuchal rigidity and headache B. Kernig's and Brudzinski's signs C. Aphasia and motor weakness D. Photophobia

C: aphasia and motor weakness

A patient admitted to the emergency room has a history of a spinal cord tumor. Which of the following signs and symptoms should alert the nurse to the possibility of a spinal cord compression (SCC)? A. Seizures B. Headache C. Back pain D. Diplopia

C: back pain

A patient diagnosed with a stroke is experiencing slurred speech. The nurse would accurately document this finding as which of the following clinical manifestations of stroke? a. Aphasia b. Dysphasia c. Dysarthria d. Apraxia

C: dysarthria

A patient sustained a C6 SCI 4 hours ago. Which of the following nursing diagnoses is a priority? A. Urinary retention B. Risk for impaired skin integrity C. Ineffective breathing pattern D. Powerlessness

C: ineffective breathing pattern

In order to prevent the development of shoulder pain during recovery from a stroke, the nurse should: a. Avoid contact with the patient's weak arm whenever possible b. Avoid taking the patient's blood pressure on the affected arm c. Support the patient's weak arm on a pillow or table d. Let the patient's weak arm hang loose whenever possible

C: support the patient's weak arm on a pillow or table

The client diagnosed with a brain tumor was admitted to the intensive care unit with decorticate posturing. Which indicates that the client's condition is becoming worse? A. The client has purposeful movement with painful stimuli. B. The client has assumed adduction of the upper extremities. C. The client is aimlessly thrashing in the bed. D. The client has become flaccid and does not respond to stimuli.

D: Client has become flaccid and does not respond to stimuli

Which of the following will the nurse observe in the patient undergoing a tonic-clonic seizure? A. Jerking in one extremity that spreads gradually to adjacent areas B. Vacant staring and abrupt cessation of all activity C. Facial grimaces, patting motions, and lip smacking D. Loss of consciousness, body stiffening, and violent muscle contractions

D: Loss of consciousness, body stiffening, violent muscle contraction

A client is having a tonic-clonic seizure. What should the nurse do first? A. Elevate the head of the bed. B. Restrain the client's arms and legs C. Place a tongue blade in the client's mouth. D. Take measures to prevent injury.

D: Take measures to prevent injury

Which of the following would the nurse expect to document in the patient diagnosed with a right hemispheric stroke? a. Aphasia b. Slow, cautious behavior c. Right visual field defect d. Impulsive behavior

D: impulsive behavior

An 18 year old man is admitted with a closed head injury that he sustained in a motorcycle accident. He has been showing an upward trend in his ICP measurements. Which of the following nursing interventions should be the first action that the nurse takes? A. Administer 100 mg of IV pentobarbital as ordered. B. Increase the ventilator settings to a respiratory rate of 20 breaths/min. C. Administer 20 gm of IV mannitol as ordered. D. Reposition the patient to avoid neck flexion.

D: reposition patient to avoid neck flexion

While assessing a client with Parkinson's disease, the nurse identifies bradykinesia when the client exhibits which of the following? A. Muscle flaccidity B. Intention tremor C. Paralysis of the limbs D. Slow spontaneous movement

D: slow spontaneous movement

A 73 year old patient has been diagnosed with ischemic stroke following diagnostic studies. Which medication must be given within a 3 hour window of symptom onset to be effective in lysing a clot? a. Heparin b. Coumadin c. Plavix d. tPA

D: t-PA

Is the following statement true or false? The immediate nursing priority in the care of a patient presenting with a suspected stroke is assessment of motor function. A. True B. False

False ** Immediate assessment priorities: airway, breathing, circulation

87 year old male presents to the emergency room at 09:00. He went to bed at 21:00 the night before and woke up at 07:00 with right LE weakness and word finding difficulties. Pt with diagnosed with an ischemic stroke and was found to be in atrial fibrillation. Thrombolytic therapy was not initiated and pt was admitted to the stroke unit. HGB= 8.9, HCT= 29. PT, PTT WNL. He was started on a heparin gtt. PMH: cervical myelopathy (with residual right UE weakness), HTN, BPH, 36 pack year smoker What are the patient's risk factors? What did the provider choose not to administer thrombolytics? What is the likely cause of his stroke?

Risk factors: a-fib, HTN, smoker No thrombolytics: last known well 10 hr prior, out of 3-4.5 hr likely cause: untreated a-fib