Exam 1 - quizzes 1 & 2, TA practice questions

A 38 yo male pt is flown to the neuro ICY after sustaining a traumatic head injury in a motor vehicle crash. He is intubated on arrival and has an initial GCS of 5 prior to intubation. After imaging is completed, a diffuse axonal injury is identified. Which of the following is the MOST important for the nurse to relay to the provider? A. A pupil which is large (~8mm) and non reactive to light B. A CN 1 palsy on cranial nerve exam C. No enteral access is available D. No response to verbal stimuli observed

A

A client with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform? A. Position the client upright during feeding B. Withhold liquids until the client has finished eating C. Suction the client following each meal D. Suction the client prior to each meal

A

A hospital client has experienced a seizure. In the immediate recovery period, what action best protects the client's safety? A. Place the client in a side-lying position B. Reassure the client and family members C. Administer anti anxiety medications as prescribed D. Pad the client's bed rails

A

A hospital pt has experienced a seizure. In the immediate recovery period, what action best protects the pt's safety? A. Place the pt in a side-lying position B. Pad the pt's bed rails C. Administer anti-anxiety medications as ordered D. Reassure the pt and family members

A

A nurse is caring for a pt with an external ventricular drain (EVD). The pt's vital signs are 100/36 (71), 93, 20, and 38.2 degrees C. The pt's ICP is measured as 15 mmHg. Which scheduled medication would the nurse hold and clarify with the provider? A. Metoprolol 25 mg B. Polyethylene glycol (miralax) 1 tbsp C. Acetaminophen 650 mg D. Levetiracetam (Keppra) 1000mg

A

A pt with MS has been admitted to the hospital following an acute exacerbation. When planning the pt's care, the nurse addresses the need to enhance the pt's bladder control. What aspect of nursing care is most likely to meet this goal? A. Establish a timed voiding schedule B. Avoid foods that change the pH of urine C. Administer anticholinergic drugs as prescribed D. Perform intermittent cauterization q6

A

A pt with a new diagnosis of amyotrophic lateral sclerosis (ALS) is overwhelmed by his diagnosis and the known complications of the disease. How can the pt best make known his wished for care as his disease progresses? A. Prepare an advanced directive B. Collaborate with representatives from the ALS Association C. Designate a most responsible health care provider (MRP) early in the course of the disease D. Ensure that witnesses are present when he provides instruction

A

The neurology floor nurse enters the room as a pt begins to experience a tonic-clinic seizure. After ensuring the pt's safety by placing them in the side-lying position and ensuring oxygen and suctioning are present at the bedside, the nurse begins timing the seizure. If seizure activity persists for longer than 5 minutes, which of the following medications should the nurse administer? A. Lorazepam (Ativan) 4mg IV B. Mannitol 17mg IV C. Phenytoin (Dilantin) 1.3g IV D. Dexamethasone 4mg IV

A

The nurse is caring for a client who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the client's respiratory effort has increased. What is the nurse's most appropriate response? A. Inform the care team and assess for further signs of possible increased ICP B. Administer bronchodilators as prescribed and monitor the client's LOC C. Increase the client's bed height and reassess in 30 minutes D. Administer a bolus of normal saline as prescribed

A

The nurse on the neuro unit reviews the plan of care for a pt that presents with a fever after a craniotomy due to an abscess. It is MOST important for the nurse to instruct the nursing assistant to do which of the following? A. Place a cooling blanket on the pt B. Check the pt every hour and notify me immediately if the pt presents with a headache C. Remember to keep the head of the bed flat D. Keep a padded tongue blade promptly available in case of seizures

A

A pt with a past medical history of atrial fibrillation and HTN presents to the ED with complaints of a severe headache, slurred speech, and numb right arm that began an hour ago. Which intervention should the nurse perform first? A. Administer tPA as the pt is most likely experiencing a stroke B. Perform a neurological assessment C. Transport the pt for a STAT CT scan D. Administer acetaminophen to provide pain relief from the headache

B

A pt with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a pt with this diagnosis? A. Pain upon ankle Dorsiflexion of the foot B. Neck flexion produces flexion of the knees and hips (Brudzinski's sign) C. Inability to stand with eyes closed and arms extended without swaying D. Numbness and tingling in the lower extremities

B

The charge nurse on the neuro unit admits 4 new pts. Which pt should the nurse be MOST concerned about? A. An 82 yo pt with a history of dementia who is oriented to person only B. A 53 yo pt who sustained a head injury is talking very slowly C. A 30 yo pt who had a motor vehicle accident is complaining of pain in their arm D. A 40 yo pt with a history of heavy alcohol use, whose last drink was 6 days ago, and reports an "odd tremor to his left hand"

B

The nurse is caring for a pt diagnosed with Parkinson disease. The pt is having increasing problems with rising from the sitting to the standing position. What should the nurse suggest to the client to use that will aid in getting from the sitting to the standing position as well as aid in improving bowel elimination? A. Sitting quietly on the toilet every 2 hours B. Use of a raised toilet seat C. Use of a bedpan D. Following the outlines bowel program

B

The nurse is participating in the care of a client with increased ICP. What diagnostic test is contraindicated in this client's treatment plan? A. MRI B. Lumbar puncture C. Venous Doppler studies D. CT scan

B

The nurse is providing care for a pt who is unconscious. What nursing intervention takes highest priority? A. Maintaining accurate records of intake and output B. Maintaining patent airway C. Inserting an NG tube as ordered D. Assessing for skin breakdown

B

The staff educator is precepting a nurse new to the critical care unit when a pt with a T2 spinal cord injury is admitted. The pt is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the client closely, what would be the nurse's most appropriate action? A. Place the client in the trendelenburg position B. Prepare for interventions to increase the pt's BP C. Prepare an ice bath to lower core body temp D. Prepare to transfuse packed red blood cells

B

When caring for a pt who had a hemorrhagic stroke, close monitoring of vital signs and neurologic changes is imperative. What is the earliest sign of deterioration in a pt with a hemorrhagic stroke of which the nurse should be aware? A. Generalized pain B. Alteration in LOC C. Tonic-clonic seizures D. Shortness of breath

B

When caring for a pt who has had a stroke, a priority is reduction of ICP. What pt position is most consistent with this goal? A. Head turned slightly to the right side B. Elevation of the head of the bed C. Position changes every 15 min while awake D. Extension of the neck

B

The nurse is caring for a pt who is rapidly progressing towards brain death. The nurse should be aware of what cardinal signs of brain death? SATA A. Absence of pain response B. Apnea C. Coma D. Absence of brain stem reflexes E. Absence of DTRs

B, C, D

As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for benefit and for harm. The nurse should be cognizant of what contraindications for thrombolytic therapy? SATA A. INR above 1.0 B. Recent intracranial pathology C. Sudden symptom onset D. Current anticoagulation therapy E. Symptom onset greater than 5 hours prior to administration

B, D, E

A nurse colleague from the hematology unit is floating to the neuro floor to assist due to a staffing shortage. Which of the following pts would be most appropriate to assign to the hematology nurse? A. A middle aged adult recently diagnosed with ALS who is awaiting discharge home B. A middle aged adult experiencing ascending paralysis currently at the level of the knees following recent influenza vaccination C. An older adult with progressive memory loss experiencing agitation and wandering during the early evening hours D. A college student recently admitted to the floor with a temp of 38.5C and a positive Brudzinski sign

C

A nurse in the ICY is caring for a pt currently ventilated due to respiratory failure secondary to myasthenic crisis. The pt is on a scheduled regimen of Mestinon and receiving plasmapheresis every other day for a total of 5 sessions. You note that the pt is unable to tolerate a decrease in her ventilator settings due to copious secretions which require frequent suctioning. What is the most appropriate intervention by the RN? A. Request the provider decrease the pt's maintenance IV fluid rate B. Advocate for additional plasmapheresis treatment as the pt is still symptomatic C. Discuss decreasing the pt's Mestinon dose with the provider D. Discuss increasing the pt's Mestinon dose with the provider

C

A nurse is caring for a pt with a spinal cord injury at C6. She notices on the monitor that his heart rate has dropped into the low 50s and he is newly hypertensive (168/79). What would be an appropriate intervention by the nurse? A. Lay the pt supine to assist with BP B. Administer the pt's scheduled propranolol C. Assess the pt's lower abdomen for bladder distention D. Hold the pt's requested PRN Tylenol

C

A nurse is preparing to discharge a pt with MS; which of the following statements by the pt would indicate further teaching is required? A. I will be sure to use the restroom at scheduled times B. I've arranged for a cane to be delivered to my home C. I can limit stress by taking hot baths to relax D. I will make sure to dress appropriately for the weather

C

A pt is admitted to the neuro ICU with a spinal cord injury. When assessing the pt, the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect? A. Epidural hemorrhage B. Hypovolemia C. Spinal shock D. Hypertensive emergency

C

A pt with Guillain-Barré syndrome has paralysis that has reached his abdomen. What is the nurse's most appropriate action? A. Administer bronchodilator as ordered B. Remind the pt of the importance the incentive spirometer C. Prepare to assist with intubation D. Administer supplemental oxygen by nasal cannula

C

Following a traumatic brain injury, a pt has been in a coma for several days. Which of the following statements is true of this pt's current LOC? A. The pt occasionally makes incomprehensible sounds B. The pt's current LOC will likely become a permanent state C. The pt may occasionally make non-purposeful movements D. The pt is incapable of spontaneous respirations

C

The ED nurse is caring for a pt who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture? A. Epistaxis B. Periorbital edema C. Bruising over mastoid process D. Unilateral facial numbness

C

The nurse is discharging home a pt who had a stroke. The pt has a flaccid right arm and leg and is experiencing urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common client response to change in body image? A. Uncertainty B. Confusion C. Depression D. Disassociation

C

The nurse is reviewing the medication administration record of a female pt who possesses numerous risk factors for stroke. Which of the woman's medications carries the greatest potential for reducing her risk of stroke? A. Lorazepam 1mg SL BID PRN B. Calcium carbonate 1000mg PO BID C. Aspirin 81mg PO daily D. Naproxen 250 PO BID

C

The nurse preceptor reviews care during the night shift for a pt scheduled for an EEG the following morning. Which of the following statements by the student nurse indicates the teaching was successful? A. I will remember to remove all pieces of jewelry and any metal objects from the pt B. I will withhold meals, and only offer water to the pt after 10pm today C. I will keep the pt awake overnight D. I will instruct the pt to eat breakfast early in the morning with some tea or small coffee

C

The nurse preceptor reviews medication orders for a pt diagnosed with a stroke. Which of the following statements by the student nurse indicated further teaching is necessary? A. This pt will take aspirin and clopidogrel at home to prevent the formation of new clots B. This pt will continue to take Hydrochlorothiazide to manage hypertension C. This pt should stop taking atorvastatin due to the increased risk for seizures D. This pt will restart losartan at home to manage hypertension

C

A client diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse? A. Inform the nurse manager B. Administer an analgesic C. Sit with the client for a few minutes D. Call the HCP immediately

D

A client has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the client's ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following? A. Hemiplegia B. Signs of internal bleeding C. Dry mucous membranes D. Loss of brain stem reflexes

D

A nurse delegates tasks to a UAP on a med-surg floor. Which task should not be assigned to the UAP? A. Ambulating a pt with Parkinson's disease experiencing a pill-rolling tremor, shuffling gait, and postural instability to the restroom B. Providing reorientation to a pt with Parkinson's disease experiencing dementia-like symptoms C. Obtaining vital signs on a pt with secondary pneumonia due to Parkinson's disease D. Feeding a pt with Parkinson's disease for the first time who is experiencing dysphagia

D

The nurse is providing health education to a pt who has a C6 spinal cord injury. The pt asks why autonomic dysreflexia is considered an emergency. What would be the nurse's best answer? A. The suddenness of the onset of the syndrome tells us the body is struggling to maintain its normal state B. The sudden, severe headache increases muscle tone and can cause further nerve damage C. Autonomic dysrefelxia causes permanent damage to delicate nerve fibers that are healing D. The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel

D

Which posture is this: arms are held out straight, toes pointed downward, head arched backward?

Decerebrate

Which posture is this: arms bent toward the body and wrists and fingers are flexed and held on the chest?

Decorticate