Final Test Quizlet #3
Which clinical manifestations would suggest hydrocephalus in a neonate? A. Bulging fontanel and dilated scalp veins B. Closed fontanel and high-pitched cry C. Constant low-pitched cry and restlessness D. Depressed fontanel and decreased blood pressure
A
A hospitalized patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first? A. Start the prescribed PRN O2 at 6 L/min. B. Put a moist hot pack on the patient's neck. C. Give the ordered PRN acetaminophen (Tylenol). D. Notify the patient's health care provider immediately.
A
A patient has been taking phenytoin (Dilantin) for 2 years. Which action should the nurse take when evaluating possible adverse effects of the medication? A. Inspect the oral mucosa. B. Listen to the lung sounds. C. Auscultate the bowel sounds. D. Check pupil reaction to light.
A
A patient tells the nurse about using acetaminophen (Tylenol) several times every day for recurrent bilateral headaches that are present on wakening. Which action should the nurse plan to take first? A. Discuss the need to stop taking the acetaminophen. B. Suggest the use of biofeedback for headache control. C. Describe the use of botulism toxin (Botox) for headaches. D. Teach the patient about magnetic resonance imaging (MRI).
A
The nurse observes a patient ambulating in the hospital hall. The patient's arms and legs suddenly jerk and the patient falls to the floor. What action should the nurse take first? A. Assess the patient for a possible injury. B. Give the scheduled divalproex (Depakote). C. Document the timing and description of the seizure. D. Notify the patient's health care provider about the seizure.
A
What is the priority nursing intervention when a child is unconscious after a fall? A. Establish an adequate airway B. Perform neurologic assessment C. Monitor intercranial pressure D. Determine whether a neck injury is present
A
Which nursing intervention is appropriate when caring for a child who has experienced a seizure? A. Describe and record the seizure activity observed. B. Restrain the child when seizure occurs to prevent bodily harm. C. Place a tongue blade between the teeth if they become clenched. D. Suction the child during a seizure to prevent aspiration.
A
An infant diagnosed with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Which interventions should be included in the child's postoperative care? (Select all that apply.) Observe closely for signs of infection Pump the shunt reservoir to maintain patency Administer sedation to decrease irritability Maintain Trendelenburg position to decrease pressure on the shunt Maintain an accurate record of intake and output Monitor for abdominal distention
A, E, F
A high school teacher who has been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, "I cannot teach any more. It will be too upsetting if I have a seizure at work." How should the nurse respond to specifically address the patient's concern? A. "You might benefit from some psychologic counseling." B. "Epilepsy usually can be well controlled with medications." C. "You will want to contact the Epilepsy Foundation for assistance." D. "The Department of Vocational Rehabilitation can help with work retraining."
B
The Glasgow Coma Scale consists of an assessment of what functions? A. Pupil reactivity and motor response. B. Eye opening and verbal and motor responses. C. Level of consciousness and verbal response. D. Intracranial pressure (ICP) and level of consciousness.
B
The health care provider is considering the use of sumatriptan (Imitrex) for a 54-yr-old male patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider? A. The patient drinks 1 to 2 cups of coffee daily. B. The patient had a recent acute myocardial infarction. C. The patient has had migraine headaches for 30 years. D. The patient has taken topiramate (Topamax) for 2 months.
B
The nurse has received report on four children. Which child should the nurse assess first? A. A school-age child in a coma with stable vital signs. B. A preschool child with a head injury and decreasing level of consciousness. C. An adolescent admitted after a motor vehicle accident who is oriented to person and place. D. A toddler in a persistent vegetative state with a low-grade fever.
B
What action should the nurse include in completing a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS)? A. Assess for the presence of chest pain. B. Inquire about urinary tract problems. C. Inspect the skin for rashes or discoloration. D. Ask the patient about any increase in libido.
B
Which finding should the nurse expect when assessing a patient who is experiencing a cluster headache? A. Nuchal rigidity B. Unilateral ptosis C. Projectile vomiting D. Bilateral facial pain
B
A hospitalized patient reports a bilateral headache (4/10 on the pain scale) that radiates from the base of the skull. Which prescribed PRN medication should the nurse administer initially? A. lorazepam (Ativan) B. acetaminophen (Tylenol) C. morphine sulfate (MS Contin) D. butalbital and aspirin (Fiorinal)
B The patient's symptoms are consistent with a tension headache, and initial therapy usually involves a nonopioid analgesic such as acetaminophen, which is sometimes combined with a sedative or muscle relaxant. Lorazepam may be used in conjunction with acetaminophen but would not be appropriate as the initial monotherapy. Morphine sulfate and butalbital and aspirin would be more appropriate for a headache that did not respond to a nonopioid analgesic.
A 22-yr-old patient seen at the health clinic with a severe migraine headache tells the nurse about having similar headaches recently. Which initial action should the nurse take? A. Teach about the use of triptan drugs. B. Refer the patient for stress counseling. C. Ask the patient to keep a headache diary. D. Suggest the use of muscle-relaxation techniques.
C
A woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. How should the nurse respond? A. "MS symptoms will be worse after the pregnancy." B. "Women with MS frequently have premature labor." C. "Symptoms of MS are likely to improve during pregnancy." D. "MS is associated with an increased risk for congenital defects."
C
The nurse should determine that teaching about migraine headaches has been effective when the patient says which of the following? A. "I can take the (Topamax) as soon as a headache starts." B. "A glass of wine might help me relax and prevent a headache." C. "I will lie down someplace dark and quiet when the headaches begin." D. "I should avoid taking aspirin and sumatriptan (Imitrex) at the same time."
C
What is the initial clinical manifestation of generalized seizures? A. Being confused B. Feeling frightened C. Losing consciousness D. Seeing flashing lights
C
Which type of seizure involves both hemispheres of the brain? A. Focal B. Partial C. Generalized D. Acquired
C
While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take? A. Insert an oral airway during the seizure to maintain a patent airway. B. Restrain the patient's arms and legs to prevent injury during the seizure. C. Time and observe and record the details of the seizure and postictal state. D. Avoid touching the patient to prevent further nervous system stimulation.
C
Clinical manifestations of increased intracranial pressure (ICP) in infants are: (Select all that apply.) Low-pitched cry Sunken fontanel Drowsiness Irritability Distended scalp veins Increased blood pressure
C, D, E
The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. What is the most essential part of the nursing assessment to detect early signs of a worsening condition? A. Posturing B. Vital signs C. Focal neurologic signs D. Level of consciousness
D
The nurse is performing a Glasgow Coma Scale (GCS) on a school-age child with a head injury. The child opens eyes spontaneously, obeys commands, and is oriented to person, time, and place. Which is the score the nurse should record? A. 8 B. 11 C. 13 D. 15
D
Which information about a patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consult with the health care provider before administration of the medication? A. Patient has tonic-clonic seizures. B. Patient experiences an aura before seizures. C. Patient's most recent blood pressure is 156/92 mm Hg. D. Patient has slight elevations in liver function test results.
D
