Exam 4- Med surg

A patient with a right lower leg fracture will be discharged home with an external fixation device in place. Which information will the nurse teach? A) "You will need to check and clean the pin insertion sites daily." B) "The external fixator can be removed for your bath or shower." C)" You will need to remain on bed rest until bone healing is complete." D) "You can remove the device while you are lying down."

A) "You will need to check and clean the pin insertion sites daily."

Which of the following describes the clinical manifestation of Guillain Barre Syndrome ? A) Ascending motor weakness B) Motor weakness on one side of the body C) Arm weakness greater than leg weakness D) Unilateral facial paralysis

A) Ascending motor weakness

A 32-year-old patient who has had an open reduction and internal fixation (ORIF) of left lower leg fractures continues to complain of severe pain in the leg 20 minutes after receiving the prescribed IV morphine. Pulses are faintly palpable and the foot is cool. Which action should the nurse take next? A) Notify the health care provider B) Assess the incision for redness C) Assist the patient to ambulate with crutches D) Administer an NSAID

A) Notify the health care provider

The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to make the client's atmosphere more conductive to communication? A) Provide a board of commonly used needs and phrases B) have the client speak to loved ones on the phone daily C) help the client complete their sentences as needed D) speak in a loud and deliberate voice to the client

A) Provide a board of commonly used needs and phrases

A client with suspected Parkinson disease is initially being assessed by the nurse. When is the best time to assess for the presence of a tremor? A) When the client is resting B) When the client is ambulating C) When the client is preparing their meal tray to eat D) When the client is participating in occupational therapy

A) When the client is resting

Which action will the nurse include in the plan of care for a patient with impaired functioning of the glossopharyngeal nerve (CN IX) and the vagus nerve (CN X)? A) Withhold oral fluid or foods B) Provide highly seasoned foods C) describe the smell of foods D) Apply artificial tears every hour

A) Withhold oral fluid or foods

A client exhibiting an uncoordinated gait has presented at the clinic. The nurse knows that what brain structure has the function of balance and coordination? A) cerebellar dysfunction B) A lesion in the pons C) Dysfunction in the medulla D) A hemorrhage in the midbrain

A) cerebellar dysfunction

The clinic nurse is caring for a client with a recent diagnosis of myasthenia gravis. The client has begun treatment with pyridostigmine brosmide (Mestimon). What change in status would most clearly suggest a therapeutic benefit of this medication? A) increased muscle strength B) Decreased pain C) Improved GI function D) Improved cognition

A) increased muscle strength

Assessment finding for a 65-year-old patient that alerts the nurse to the presence of osteoporosis is: A) measurable loss of height B) the presence of bowed legs C) the aversion of dairy products D) a statement about frequent falls

A) measurable loss of height

A 45-year-old patient has a dysfunction of the cerebellum. The nurse will plan interventions to: A) prevent falls B) stabilize mood C) avoid aspiration D) improve memory

A) prevent falls

Which of the following would be a likely cause of hemorrhagic stroke? A)prolonged hypertension B) Atrial fibrillation C) high fat diet D) sickle cell disease

A)prolonged hypertension

The physician has prescribed a somatosensory evoked responses (SERs) test for a client for whom the nurse is caring. The nurse is justified in suspecting that this client may have a history of what type of neurologic disorder? A) hypothalamic disorder B) Demyelinating disorder C) Brainstem deficit D) Diabetic neuropathy

B) Demyelinating disorder

The clinic nurse caring for a patient with Parkinsons disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. For what common side effect of Sinemet would the nurse assesses this patient? A) Pruritus B) Dyskinesia C) Lactose intolerance D) Diarrhea

B) Dyskinesia

A nurse is caring for a patient with Myasthenia gravis. Which of the following is most important to consider in planning care? A) Plan for a formal cognitive assessment B) Perform physically demanding tasks early in the day C) Limit fluid and food D) Monitor for increased tremor

B) Perform physically demanding tasks early in the day

Which of the following would you expect to find with your patient with a new diagnosis of Bell's Palsy? A) Intense facial pain rated an 8 on scale of 1-10 B) Unilateral facial paralysis and inability to close eye on affected side C) Progressive ascending weakness D) Loss of motor function on one side of the body and loss of sensory on the other

B) Unilateral facial paralysis and inability to close eye on affected side

The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration? A) generalized pain B) alteration in LOC C) tonic-clonic seizures D) shortness of breath

B) alteration in LOC

A patient has received TPA for treatment of their stroke. The nurse knows to assess for: A) elevated temperature B) bleeding C) altered lipid levels D) Jaundice

B) bleeding

After being hospitalized for 3 days with a right femur fracture, a 32-year-old patient suddenly develops shortness of breath and tachypnea. The patient tells the nurse, "I feel like I am going to die!" Which action should the nurse take first? A) obtain a chest x-ray B) check patient's pulse ox C) check patient's legs for swelling and tenderness D) reassure the patient that this is a normal finding

B) check patient's pulse ox

The nurse is planning care for a client with Parkinson disease. The nurse should be aware that treatment will focus on what pathophysiologic phenomenon? A) Premature degradation of acetylcholine B) decreased availability of dopamine C) insufficient synthesis of epinephrine D) delayed reuptake of serotonin

B) decreased availability of dopamine

A client has been admitted to the neurologic unit for the treatment of a newly diagnosed brain tumor. The client has just exhibited seizure activity for the first time. What is the nurse's priority response to this event? A) identify triggers B) implement precautions to ensure safety C) Teach the client's family about relationship of brain tumors and seizures D) Ensure the client is housed in a private room

B) implement precautions to ensure safety

A nurse is caring for a client who has suffered an unstable thoracolumbar fracture. What goal should the nurse prioritize during nursing care? A) preventing skin breakdown B) maintaining spinal alignment C) maximizing function D) preventing increased intracranial pressure

B) maintaining spinal alignment

A client scheduled for MRI has arrived at the radiology department. The nurse who prepares the client for the MRI should prioritize which action?

B) remove all metal-containing objects

A client diagnosed with a pituitary adenoma has arrived on the neurologic unit. When planning the client's care, the nurse should be aware that the effects of the tumor will primarily depend on what variable? A) Whether the tumor utilizes aerobic or anaerobic respiration B) the specific hormones secreted by the tumor C) the client's pre-existing health status D) Whether the tumor is primary or the result of a metastasis

B) the specific hormones secreted by the tumor

The nurse assessing a 54-year-old female patient with newly diagnosed trigeminal neuralgia will ask the patient about: A) visual problems caused by ptosis B) triggers leading to facial discomfort C) Poor appetite caused by loss of taste D) weakness on the affected area

B) triggers leading to facial discomfort

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

B.) Neck flexion produces flexion of the knees and hips

A client with a brain tumor has begun to exhibit signs of cachexia. What subsequent assessment should the nurse prioritize? A) Assessment of peripheral nervous function B) Assessment of cranial nerve function C) Assessment of nutritional status D) Assessment of respiratory status

C) Assessment of nutritional status

When caring for a client with an altered level of consciousness, the nurse is preparing to test cranial nerve VII. What assessment technique would most likely elicit a response from cranial nerve VII? A) Palpate trapezius muscle while client shrugs shoulders B) Administer the whisper or watch-tick test C) Observe for facial movement symmetry, such as a smile D) Note any hoarseness in the client's voice

C) Observe for facial movement symmetry, such as a smile

Which discharge instructions will the emergency department nurse include for a patient with a sprained ankle? A)Keep the ankle loosely wrapped with gauze B)Apply a heating pad C) Use pillows to elevate the ankle above the heart D) Gently move the ankle through the ROM

C) Use pillows to elevate the ankle above the heart

A young client is being treated for a femoral fracture suffered in a snowboarding accident. The nurse's most recent assessment reveals that the client is uncharacteristically confused. What diagnostic test should be performed on the client? A) electrolyte assessment B) electrocardiogram C) arterial blood gases D) abdominal ultrasound

C) arterial blood gases

Which assessment will the nurse make to monitor a patient's cerebellar function? A) assess for graphesthesia B) assess ability to speak C) perform finger-to-nose test D) Check ability to push against resistance

C) perform finger-to-nose test

A client diagnosed with transient ischemic stroke is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose? A) decrease cerebral edema B) prevent seizure activity that is common following a TPA C) to remove atherosclerosis plaques blocking the cerebral flow D) to determine the cause of the TPA

C) to remove atherosclerosis plaques blocking the cerebral flow

A patient is being evaluated for left middle cerebral artery ischemic stroke. The nurse explains to the patient's adult children that the deficits: A)Most likely will result in bilateral lower extremity weakness B) primarily will affect his vision C) usually results in long term confusion D) likely will affect his ability to speak

D) likely will affect his ability to speak

You suspect your patient is having a stroke. Which of the following tests should the nurse anticipate to do FIRST? A) MRI B) NIH stroke scale C) glasgow coma scale D) non-contrast CT

D) non-contrast CT

A nurse is planning the care of an older adult client who will soon be discharged home after treatment for a fractured hip. In an effort to prevent future fractures, the nurse should encourage what action? A) regular bone density testing B) a high-sodium diet C) use of corticosteroids as prescribed D) weight-bearing exercise

D) weight-bearing exercise

A middle-aged woman has sought care from her primary provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the woman to seek care? A.) cognitive decline B.) Personality changes C.) Contractures D.) Difficulty in coordination

D.) Difficulty in coordination

Which of the following neurologic conditions will most likely include the disease dementia?

Parkinson's disease

A client has just been diagnosed with Parkinson disease and the nurse is planning the client's subsequent care for the home setting. What nursing diagnosis should the nurse address when educating the client's family? A) Risk for infection B) Impaired spontaneous ventilation C) unilateral neglect D) Risk for injury

Risk for injury

A young man arrives in the emergency department with ankle swelling and severe pain after twisting his ankle playing basketball. Which of these prescribed collaborative interventions will the nurse implement first? a. Take the patient to have x-rays. b. Wrap the ankle and apply an ice pack. c. Administer naproxen (Naprosyn) 500 mg PO. d. Give acetaminophen with codeine (Tylenol #3).

b. Wrap the ankle and apply an ice pack.

During the neurologic assessment, the patient is unable to respond verbally to the nurse but cooperates with the nurse's directions to move his hands and feet. The nurse will suspect a. cerebellar injury. b. a brainstem lesion. c. frontal lobe damage. d. a temporal lobe lesion.

c. frontal lobe damage.