Medical-Surgical Nursing Exam 1 (questions) - Jersey College
6.3 mg -- The nurse gives 10% (6.3 mg) over 1 minute.
A 154-pound woman has been prescribed tPA (0.9 mg/kg) for an ischemic stroke. The nurse knows to give how many mg initially?
Growth is slow and symptoms are caused by compression rather than tissue invasion.
A 37-year-old mother of three has just been diagnosed with a grade I meningioma. As part of patient education, the nurse tells the patient that:
Trigeminal neuralgia
A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. He reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder?
Carotid endarterectomy
A 76-year-old client is brought to the clinic by his daughter. The daughter states that her father has had two transient ischemic attacks (TIAs) in the past week. The physician orders carotid angiography, and the report reveals that the carotid artery has been narrowed by atherosclerotic plaques. What treatment option does the nurse expect the physician to offer this client to increase blood flow to the brain?
wick
A _______ may be inserted in the canal to keep it open and facilitate medication administration.
cerumen (ear wax)
A brown, waxlike substance secreted by ceruminous glands is called?
Even, unlabored respirations
A client is hospitalized with Guillain-Barré syndrome. Which nursing assessment finding is most significant?
"Remain prone for 2 to 3 hours."
A nurse is preparing a client for lumbar puncture. The client has heard about post-lumbar puncture headaches and asks how to avoid having one. The nurse tells the client that these headches can be avoided by doing which of the following after the procedure?
Benign Paroxysmal Positional Vertigo (BPPV)
Brief episodes of vertigo (< 1 min.) assoc. w/position change; result of degen. of the utricular otoconia
35 mm
How long is the eustacian tube?
Aural Rehabilitation
intervention aimed at minimizing and alleviating the communication difficulties associated with hearing loss ? Can be used if hearing loss is permanent or untreatable or if the patient elects not to be treated.
tympanogram
measures middle ear muscle reflex to sound stimulation and compliance of the tympanic membrane by changing the air pressure in a sealed ear canal ?
>55-70 dB
moderately severe hearing loss in decibels ?
endolymphatic sac decompression
procedure that equalizes pressure int the endolymphatic space. A shunt or a drain is inserted in the endolymphatic sac through a postauricular incision. What is this procedure called?
Malignant external otitis
rare, progressive infection that effects the external auditory canal, surrounding tissue, and skull
tinnitus
roaring, buzzing, or hissing sound in one or both ears is called?
acoustic neuromas
slow-growing, benign tumors of cranial nerve VIII, usually arising from the Schwann cells of the vestibular portion of the nerve. What are these tumors called?
2-4 weeks
usual duration of coma ?
Restricting fluid intake and hydration
A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client?
An intracerebral hematoma
A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as?
An intracerebreal hematoma
A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as?
6 weeks
After ear surgery, how long should the patient keep the ears dry?
presbyopia
An aging client is brought to the eye clinic by the son. The son states he has seen his parent holding reading materials at an increasing distance to focus properly. What age-related changes does this indicate?
stapedotomy
An alternative procedure to stapedectomy. A small opening is created in the fixed stapes footplate with a small drill or laser. This allows for transmission of sound waves or placement of prosthesis ?
"An implanted lens has replaced the need for corrective glasses."
An elderly client is scheduled for cataract surgery and asks the nurse, "Will I need to wear pop-bottle lenses after surgery?" Which is the most appropriate response from the nurse?
Anaplastic astrocytoma Cerebral metastasis from other sites Glioblastoma
An older adult patient exhibiting clinical manifestations of a brain tumor is admitted to the hospital for testing. What tumor types does the nurse know are commonly seen in the older adult?
brain tumor
An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client?
blurred distance vision
An ophthalmologist diagnoses a patient with myopia. The nurse explains that this type of impaired vision is a refractive error characterized by:
pars tensa
Approximately 80% of the tympanic membrane is composed of all three layers and is called the ___________.
Bradycardia Hypertension Bradypnea
At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing's triad? Select all that apply.
T6
Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels?
Raise the head of the bed and place the patient in a sitting position.
Autonomic dysreflexia is an acute emergency that occurs with spinal cord injury as a result of exaggerated autonomic responses to stimuli. Which of the following is the initial nursing intervention to treat this condition?
VIII Vestibucochlear
Balance and equilibrium are functions of the ________ nerve.
Speak slowly and in short sentences.
Because of the pain in her facial muscles and jaws a young female client with Bell's palsy is upset because she is unable to communicate properly. What advice can be given to the client to improve her speech?
low bone mass and osteoporosis.
Bone density testing in clients with post-polio syndrome has demonstrated
70-20 mm H2O
CSF pressure with the patient in a lateral recumbent position is normally ____-_____ mm H2O.
24 hours
Cerebral edema peaks at which time point after intracranial surgery?
TRUE
Conductive hearing loss such as from otosclerosis or otitis media, when performing the Weber test the sound lateralizes toward the affected ear T/F?
Glossopharyngeal
Cranial nerve IX is also known as which of the following?
IX and X
Cranial nerves for gag reflex?
0
DTRs indicated by a score of ____ means that the patient did not have a response.
low sodium diet
Diet for patient with Meniere's disease?
1+
Diminished or hypoactive DTRs are indicated by a score of ______.
HCTZ - hydrochlorothiazide
Diuretic that can be used for a patient with Meniere's disease?
Administer atropine to control the side effects of edrophonium.
During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do?
myopia
During a routine eye examination, a patient complains that she is unable to read road signs at a distance when driving her car. What should the patient be assessed for?
degeneration of the organ of Corti
During a routine physical examination, the nurse practitioner notes that a 72-year-old patient has a significant loss of ability to discriminate words. The patient also states that he has noticed that he has trouble hearing high-frequency sounds. The nurse suspects that the patient has an age-related change in his ears known as:
Gingival hyperplasia
During assessment of a patient who has been taking dilantin for seizure management for 3 years, the nurse notices one of the side effects that should be reported. What is that side effect?
Glutamate
Excessive levels of which neurotransmitter has been implicated in amyotrophic lateral sclerosis (ALS)?
eustacian tube
Helps to equalize pressure in the ear ?
Aspirin
High doses of which medication can produce bilateral tinnitus?
cotton ball with vaseline
How can patients prevent water from entering the ear?
squeeze a muscle or apply firm but gentle pressure to the nail bed
How does the nurse assess for pain on a patient with an altered LOC?
every 15 minutes
How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)?
1 mm
How wide is the eustacian tube?
toxic or metabolic
If a patient is comatose but pupillary light reflexes are preserved, what type of disorder is suspected?
gently irrigate the canal with warm water
If the tympanic membrane cannot be visualized because of cerumen, the cerumen may be removed how?
>90
Profound hearing loss in decibels ?
-otalgia (ear pain) -fever -hearing loss
S/S of acute otitis media (3)
CN II
The nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse testing when using the chart?
Bone
Weber test just does ____ conduction.
hearing balance and equilirium
What are the two functions of the ears?
Providing palliative care
Which is a component of the nursing management of the client with variant Creutzfeldt-Jakob disease (vCJD)?
Cholesteatoma
benign tumor, an ingrowth of skin that causes persistently high pressure in the middle ear, which causes hearing loss and neurologic disorders and destroys structures. What is it called?
Audiometry confirms a client's chronic progressive hearing loss. Further investigation reveals ankylosis of the stapes in the oval window, a condition that prevents sound transmission. This type of hearing loss is called a:
conductive hearing loss
Serous otitis media
fluid in the middle ear without evidence of infection is called? Often due to eustacian tube dysfunction or blockage.
presbycusis
hearing loss associated with old age is called ?
tympanotomy, myringotomy
incision into the eardrum for inserting tubes is known by 2 names; what are they?
Risk for injury related to neurologic deficit
A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority?
Edrophonium (Tensilon)
A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The physician suspects myasthenia gravis. Which drug will be used to test for this disease?
Ishihara
A client comes to the eye clinic for a routine check-up. The client tells the nurse he thinks he is color blind. What screening test does the nurse know will be performed on this client to assess for color blindness?
Inner ear
A client complains of vertigo. The nurse anticipates that the client may have a problem with which portion of the ear?
Muscle weakness Sensory loss Aphasia Visual changes
A client diagnosed with a brain tumor is exhibiting focal symptoms. Which assessment findings are the nurse likely to note? Select all that apply.
dysarthria.
A client diagnosed with a stroke is having difficulty forming words during communication. This would be appropriately documented as
Reorient the client while gently holding their arms.
A client experiences a seizure while hospitalized for appendicitis. During the postictal phase, the client is yelling and swings a closed fist at the nurse. Which is the appropriate action by the nurse?
Assess for a halo sign
A client has been admitted for observation after a closed head injury. There is clear fluid leaking from the client's nose. How would the nurse assess if this drainage is CSF?
Form words that are understandable or comprehend spoken words
A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to perform which action?
initiate seizure precautions
A client has been diagnosed with a frontal lobe brain abscess. Which nursing intervention is appropriate?
amsler grid
A client has been referred to an ophthalmologist for suspected macular degeneration. The nurse knows to prepare what test for the physician to give the client?
Streptococcus pneumoniae
A client has meningitis and cultures are being done to determine the cause. Which of the following is most likely to be identified as the causative factor?
hyperopia
A client has noticed recently having clearer vision at a distance than up close. What is the term used to describe this client's visual condition?
Astereognosis
A client has sustained a head injury to the parietal lobe and cannot identify a familiar object by touch. The nurse knows that this deficit is
Take daily weights.
A client has sustained a traumatic brain injury with involvement of the hypothalamus. The nurse is concerned about the development of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus?
encourage the client to drink liberal amounts of fluids.
A client has undergone a lumbar puncture as part of a neurological assessment. The client is put under the care of a nurse after the procedure. Which important postprocedure nursing intervention should be performed to ensure the client's maximum comfort?
Respiratory dysfunction
A client has undergone surgery for a spinal cord tumor that was located in cervical area. The nurse would be especially alert for which of the following?
vitamins A and C
A client having an eye exam asks the nurse what she can do to help prevent cataracts. What dietary recommendations should a nurse give to a client to prevent cataracts?
Helicopod
A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term?
Keep the client's neck in a neutral position (no flexing).
A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP?
A small amount of yellow drainage at the left pin insertion site
A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the physician?
Have the client lie on the back and lift the leg, keeping it straight.
A client is admitted reporting low back pain. How will the nurse best determine if the pain is related to a herniated lumbar disc?
hypoxia
A client is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for:
Left-sided cerebrovascular accident (CVA)
A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings?
Neurovascular system
A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop. The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment?
"You have some fluid that has collected in your middle ear but no infection."
A client is diagnosed as having serous otitis media. When describing this condition to the client, which of the following would be most accurate?
occipital
A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain?
tonometry; intraocular pressure
A client is having a routine eye examination. The procedure being performed is done by using an instrument to indent or flatten the surface of the eye. This is known as ________ and it is routinely done to test for ________.
TIA
A client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what?
Proper instillation of prescribed ear drops
A client is newly diagnosed with otitis externa. Which information should the nurse teach the client before the client leaves the clinic?
increased urine output
A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant?
Shivering - Shivering can increase intracranial pressure by increasing vasoconstriction and circulating catecholamines. Shivering also increases oxygen consumption. A capillary refill of 2 seconds, urine output of 100mL/hr, and cool, dry skin are expected findings.
A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?
Withhold anticonvulsant medications for 24 to 48 hours before the exam
A client is scheduled for standard EEG testing to evaluate a possible seizure disorder. Which nursing intervention should the nurse perform before the procedure?
convert glycogen to glucose for immediate use.
A client is waiting in a triage area to learn the medical status of family members following a motor vehicle accident. The client is pacing, taking deep breaths, and handwringing. Considering the effects in the body systems, the nurse anticipates that the liver will:
"Although the required position may not be comfortable, it will make the procedure safer and easier to perform."
A client preparing to undergo a lumbar puncture states he doesn't think he will be able to get comfortable with his knees drawn up to his abdomen and his chin touching his chest. He asks if he can lie on his left side. Which statement is the best response by the nurse?
Contrast will be given and a rapid sequence of radiographs will be taken.
A client suspected of having a distortion of cerebral arteries and veins is scheduled for a cerebral angiography. What would the nurse tell the client about the upcoming test?
frequent neuro checks
A client tells the nurse that they have transient ischemic attacks. The client reports having undergone a carotid artery surgery. In such a case, what important assessments should be performed by the nurse?
Hemiplegia, seizures, and decreased level of consciousness (LOC)
A client undergoes cerebral angiography for evaluation after an intracranial computed tomography scan revealed a subarachnoid hemorrhage. Afterward, the nurse checks frequently for signs and symptoms of complications associated with this procedure. Which findings indicate spasm or occlusion of a cerebral vessel by a clot?
"Usually the incisional pain is mild and controlled by the prescribed medication for the first 24 hours."
A client undergoing mastoid surgery asks the nurse about the pain following the surgery. Which response by the nurse is appropriate?
Logroll the client from side to side.
A client was undergoing conservative treatment for a herniated nucleus pulposus, at L5 - S1, which was diagnosed by magnetic resonance imaging. Because of increasing neurologic symptoms, the client undergoes lumbar laminectomy. The nurse should take which step during the immediate postoperative period?
Client has cerumen in the ear.
A client who has been fitted with a hearing aid comes for a follow-up evaluation. During the visit, the client states, "I've noticed that I still don't seem to hear well enough. The hearing aid doesn't seem to make the sounds louder." Which of the following might the nurse determine as the possible cause?
raccoon's eyes and Battle sign.
A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:
Daily aspirin
A client who is at high-risk for a cerebrovascular accident has medication ordered to lower their cholesterol and to prophylactically anticoagulate them. What specific agent might be diagnosed for this client?
turning the client's head suddenly while holding the eyelids open.
A client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client's oculocephalic (doll's eye) response by:
Autonomic dysreflexia
A client with a T4 level spinal cord injury (SCI) is complaining of a severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect?
look for signs of increased ICP
A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family?
C5
A client with a spinal cord injury has full head and neck control when the injury is at which level?
increased intraocular pressure (IOP).
A client with an inflammatory ophthalmic disorder has been receiving repeated courses of a corticosteroid ointment, one-half inch in the lower conjunctival sac four times a day as directed. The client reports a headache and blurred vision. The nurse suspects that these symptoms represent:
Techniques to control blood sugar within normal ranges
A client with diabetes is hospitalized with a TIA. When planning this client's discharge teaching the nurse knows to include which of the following?
tell the physician
A client with glaucoma has been given a prescription for a mydriatic drug. What is a priority action of the nurse?
perimetry test
A client with multiple sclerosis is being seen by a neuroophthalmologist for a routine eye exam. The nurse explains to the client that during the examination, the client will be asked to maintain a fixed gaze on a stationary point while an object is moved from a point on the side, where it can't be seen, toward the center. The client will indicate when the object becomes visible The nurse further explains that the test being performed is called a:
Muscle biopsy
A client with muscle weakness and an abnormal gait is being evaluated for muscular dystrophy. Which test or finding confirms muscular dystrophy?
Antibodies are removed from the plasma.
A client with myasthenia gravis is admitted with an exacerbation. The nurse is educating the client about plasmapherisis and explains this in which of the following statements?
"Many people with developmental disabilities resulting from neurologic damage also have epilepsy."
A client with newly diagnosed seizures asks about stigma associated with epilepsy. The nurse will respond with which of the following statements?
Be forthright and inform others about the hearing deficit.
A client you are caring for has a hearing loss. The client tells you he is self-conscious about his hearing loss. What advice should the nurse give a self-conscious client with hearing loss to protect his self-esteem?
TRUE
A cochlear implant is an auditory prosthesis used for people with profound sensorineural hearing loss bilaterally who do not benefit from conventional hearing aids. T/F ?
-Visual disturbances -Sudden numbness -Confusion
A community health nurse is conducting a workshop for unlicensed care providers who work in a chain of long-term care facilities. The nurse is teaching the participants about the signs and symptoms of stroke. What signs and symptoms should the nurse identify? Select all that apply.
seborrheic dermatitis
A flaky scaliness on or behind the auricle usually indicates _____________________ and can be present on the scalp and facial structures as well
"A concussion is a blow to the head that jars the brain, resulting in diffuse and microscopic injury to the brain."
A mother brings her 6-year-old to the emergency department (ED) after the child fell off a bike. The physician diagnoses a concussion. The mother asks the nurse what a concussion is. What should the nurse's response be?
External auditory canal erythema
A nures is performing an otoscopic examination on a client. Which finding would the nurse document as abnormal?
Increased intracranial pressure
A nurse assesses a patient who has been diagnosed with having a pituitary adenoma that is pressing on the third ventricle. The nurse looks for the associated sign/symptom. What is that sign/symptom?
40 dB in the range of 500 to 2,000 Hz.
A nurse is asked to assess a patient's need for a hearing aid. The nurse knows that a general guideline to determine need would be a hearing loss of:
she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube.
A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean him from sedation therapy. A nurse needs further assessment data to determine whether:
Administer stool softeners.
A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP?
chewing
A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis?
Bradycardia and hypertension
A nurse is caring for a patient who is exhibiting signs and symptoms of autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient?
"Emotional lability is common after a stroke, and it usually improves with time."
A nurse is instructing the spouse of a client who suffered a stroke about the use of eating devices the client will be using. During the teaching, the spouse starts to cry and states, "One minute he is laughing, and the next he's crying; I just don't understand what's wrong with him." Which statement is the best response by the nurse?
Lamictal (lamotrigine)
A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication?
improved quality of life
A nurse is providing care to a client who has been diagnosed with metastatic brain cancer. When developing the client's plan of care, which outcome would the nurse most likely identify?
expressive aphasia, defects in the right visual fields, problems with abstract thinking
A nurse is providing care to a client who has had a stroke. Which symptoms are consistent with right-sided hemiplegia?
cardio embolic
A nurse is reading a journal article about stroke and the underlying causes associated with this condition. The nurse demonstrates understanding of the information when identifying which subtype of stroke as being due to atrial fibrillation?
Thrombolytic therapy has a time window of only 3 hours.
A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following?
Moderate amounts of low-fat dairy products
A nurse is teaching about ischemic stroke prevention to a community group and emphasizes that control of hypertension, which is the major risk factor for stroke, is key to prevention. Ways to control hypertension include the Dietary Approaches to Stop Hypertension (DASH) diet. This diet includes which of the following?
close his or her eyes and stand erect.
A nurse is working in a neurologist's office. The physician orders a Romberg test. The nurse should have the client:
"A secondary headache is associated with an organic cause, such as a brain tumor."
A nurse is working on a neurological unit with a nursing student who asks the difference between primary and secondary headaches. The nurse's correct response will include which of the following statements?
a motor cortex tumor
A nurse knows that a patient exhibiting seizurelike movements localized to one side of the body most likely has what type of tumor?
ptosis
A nurse notices that a client's left upper eyelid is drooping. The nurse has observed:
Damage to the hair cells inside the cochlea.
A nurse practitioner explains to a patient recently diagnosed with noise-induced hearing loss that the basic altered physiology in the ear is the result of:
Instill a few drops of warmed mineral oil to cover the insect.
A nurse practitioner in an emergency room receives a telephone call from a mother whose 4-year-old child has a mosquito stuck in his external ear canal. Which of the following is the best information the nurse could give the mother?
An obese woman with a history of atrial fibrillation and type 2 diabetes
A nurse who provides care at a community clinic is in contact with a diverse group of patients. Which of the following individuals most clearly displays risk factors for stroke?
Decerebrate
A nurse working in the neurologic intensive care unit admits from the emergency department a patient with an inoperable brain tumor. Of the two choices of posturing exhibited in the above image, which one demonstrates a deeper and more severe dysfunction?
Sounds travel through the external and middle ears.
A nursing instructor is preparing a class on air and bone conduction of sound. When describing the transmission of sounds by air conduction, which of the following would the instructor include?
It is referred to as endolymphatic hydrops.
A nursing instructor is teaching pre-nursing students in a pathophysiology class. What would the instructor teach the students about Ménière's disease?
"I am trying to quit smoking and have a patch on."
A patient arrives to have an MRI done in the outpatient department. What information provided by the patient warrants further assessment to prevent complications related to the MRI?
irrigates the wound to remove debris
A patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the physician sutures the wound?
V
A patient comes to the emergency department with severe pain in the face that was stimulated by brushing the teeth. What cranial nerve does the nurse understand can cause this type of pain?
Nuchal rigidity Positive Kernig's sign Positive Brudzinski's sign Photophobia
A patient diagnosed with meningitis would be expected to exhibit which of the following clinical manifestations? Select all that apply.
To prevent a stroke by removing atherosclerotic plaques blocking cerebral flow
A patient diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose?
Vasopressin
A patient had a small pituitary adenoma removed by the transsphenoidal approach and has developed diabetes insipidus. What pharmacologic therapy will the nurse be administering to this patient to control symptoms?
-Administering mannitol -Maintaining the partial pressure of carbon dioxide (PaCO2) within a range of 30 to 35 mm Hg -Elevating the head of the bed 30 degrees -Provide supplemental oxygen is SpO2 is less than 92%
A patient has had a large ischemic stroke and is hospitalized in the neurologic intensive care unit. What interventions will be provided for this patient to decrease intracranial pressure? Select all that apply.
This is significant for poor neurologic outcomes.
A patient having an acute stroke with no other significant medical disorders has a blood glucose level of 420 mg/dL. What significance does the hyperglycemia have for this patient?
Parkinson's disease
A patient is admitted to the hospital for management of an extrapyramidal disorder. Included in the physician's admitting orders are the medications levodopa, benztropine, and selegiline. The nurse knows that most likely, the client has a diagnosis of:
70 mm Hg
A patient is admitted to the hospital with an ICP reading of 20 mm Hg and a mean arterial pressure of 90 mm Hg. What would the nurse calculate the CPP to be?
dysfuction of the vagus nerve.
A patient is being tested for a gag reflex. When the nurse places the tongue blade to the back of the throat, there is no response elicited. What dysfunction does the nurse determine the patient has?
Noncontrast CT
A patient is brought to the emergency department with a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for?
Originated within the brain tissue.
A patient is diagnosed with an aggressive, primary malignant brain tumor. The nurse is aware that the glioma:
Astrocytoma Ependymoma Medulloblastoma
A patient is diagnosed with an intracerebral tumor. The nurse knows that the diagnosis may include which of the following? Select all that apply.
21 mm Hg or higher
A patient is suspected of having glaucoma. What reading of IOP would demonstrate an increase resulting from optic nerve damage?
BUN and creatinine
A patient is to have an angiography done using fluorescein as a contrast agent to determine if the patient has macular edema. What laboratory work should the nurse monitor prior to the angiography?
cerebral aneurysm
A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom?
cerebellum
A patient recently noted difficulty maintaining his balance and controlling fine movements. The nurse explains that the provider will order diagnostic studies for the part of his brain known as the:
It allows for stabilization of the cervical spine along with early ambulation.
A patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit from the application of the halo device?
Lioresal (Baclofen)
A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem?
brain stem
A patient who has suffered a stroke is unable to maintain respiration and is intubated and placed on mechanical ventilator support. What portion of the brain is most likely responsible for the inability to breathe?
Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone.
A patient with Bell's palsy says to the nurse, "It doesn't hurt anymore to touch my face. How am I going to get muscle tone back so I don't look like this anymore?" What interventions can the nurse suggest to the patient?
Semisolid food with thick liquids
A patient with Parkinson's disease is undergoing a swallowing assessment because she is experiencing difficulties when swallowing. What consistency is most appropriate for this patient, to reduce the risk of aspiration?
Riluzole
A patient with amyotrophic lateral sclerosis (ALS) asks if the nurse has heard of a drug that will prolong the patient's life. The nurse knows that there is a medication that may prolong the life by 3 to 6 months. To which medication is the patient referring?
350 to 375 mL.
A potential complication of a hemorrhagic stroke is interference with the ability of the arachnoid villi to absorb CSF. Therefore, fluid in the ventricles increase beyond the amount that is usually absorbed daily, which is:
frontal lobe
A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?
To ensure correct application of antibiotic ointment, gently drag tip of tube along lower lid while squeezing ointment on to lid.
A young client is being seen by a pediatric ophthalmologist due to a recent skateboarding accident that resulted in trauma to the right cornea, and is now at risk of developing an infection. Which nursing intervention would be contraindicated for a client at risk for infection?
Menieres Disease
Abnormal inner ear fluid balance caued by malabsoption of he endolymphatic sac or blockage of the endolymphatic duct. This disease is called?
retinal detachment
After a fall at home, a client hits their head on the corner of a table. Shortly after the accident, the client arrives at the ED, unable to see out of their left eye. The client tells the nurse that symptoms began with seeing spots or moving particles in the field of vision but that there was no pain in the eye. The client is very upset that the vision will not return. What is the most likely cause of this client's symptoms?
evaluation of the corneal reflex response.
After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway and attends to the client's immediate needs, then prepares to perform an initial neurologic assessment. The nurse should perform an:
Side-lying, to facilitate drainage of oral secretions
After a seizure, the nurse should place the patient in which of the following positions to prevent complications?
Elevating the head of the bed to 30 degrees
After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client?
Pituitary carcinoma
After a transsphenoidal adenohypophysectomy, a client is likely to undergo hormone replacement therapy. A transsphenoidal adenohypophysectomy is performed to treat which type of cancer?
taste - food will taste different until the nerve is healed
After an ear procedure, what change in the senses will the patient experience?
Performing a lumbar puncture
After striking his head on a tree while falling from a ladder, a client is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention should the nurse question?
-Decreased muscle mass -Increased sensitivity to heat and cold -Reduced papillary responses
Age-related changes in the neurologic system must be carefully assessed. Which of the following changes does the nurse expect to find in some degree depending on the patient's age and medical condition? Select all that apply.
conductive
During assessment of a patient with a hearing loss, the nurse notes a defect in the tympanic membrane. The nurse documents this disturbance as a loss known as:
Sensorineural loss.
During his annual physical examination, a retired airplane mechanic reports noticeable hearing loss. The nurse practitioner prescribes a series of hearing tests to confirm or rule out noise-induced hearing loss, which is classified as a:
cranial nerves IX and X.
During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates:
Respiratory irregularities Slow bounding pulse Widened pulse pressure
Elevated ICP is most commonly associated with head injury. Which of the following are clinical signs of increased ICP that a nurse should evaluate? Select all that apply.
facial nerve paralysis.
If untreated, squamous cell carcinoma of the external ear can spread through the temporal bone, causing ?
3+
Increased response of DTRs are indicated by a score of ______.
Decerebrate. It indicates deeper and more severe dysfunction than does decorticate posturing; implies brain patholog; poor prognostic sign.
Is decerebrate or decorticate posturing worse? Why?
20/200
Legally blind Central vision loss is ________ or worse in better eye ?
-Eye opening -Verbal response -Motor response
Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply.
Constriction of peripheral blood vessels Increased blood pressure Increased heart rate
Loud, persistent noise has been found to have which of the following effects on the body? Select all that apply.
Increased blood pressure
Loud, persistent noise has what effect on the body?
intensity
Loudness of sound is known as _________.
flaccid muscles
Lower motor neuron lesions cause ?
>25-40 dB
Mild hearing loss in decibels ?
constricts pupil
Miotic eye solutions are often ordered in the treatment of glaucoma. Which is the best nursing rationale for the use of this medication?
>40-55 dB
Moderate hearing loss in decibels ?
Acetylcholine (ACh)
Myasthenia gravis occurs when antibodies attack which receptor sites?
-diuretic agents: ethancrynic acid, fuosemide, acetazolamide -chemotherapeutic (antineoplastic) agents: cisplatin, nitrogen mustard, carboplatin -antimalarial agents: quinine, choroquine -anti-inflammatory agents: salicylates (aspirin), indomethacin -chemicals: alcohol, arsenic -aminoglycoside antibiotic agents: amikacin, gentamicin kanamycin, netlimicin, neomycin, streptomycin, tobramycin -other antibiotic agents: erythromycin, minocycline, polymyxin B, vancomycin -metals: gold, mercury, lead
Name Selected Ototoxic Substances & examples
frequency, pitch, and intensity
Name three characteristics that are important when evaluating hearing.
Weber and Rinne tests
Name two tests used to assess a patient's hearing ability.
-Diabetes mellitus -Loop diuretics (e.g., Lasix) -Bacterial meningitis -Gentamicin
Nursing assessment of hearing loss in an older adult client includes evaluation of age-related changes, as well as a history of current illnesses and medications. Which of the following factors are associated with ototoxic effects? Select all that apply.
acute angle-closure
On ocular examination, the health care provider notes severely elevated IOP, corneal edema, and a pupil that is fixed in a semi-dilated position. The nurse knows that these clinical signs are diagnostic of the type of glaucoma known as:
200 mm H2O
Pressures of more than ____mm H2O are considered abnormal.
vestibular nerve sectioning
Procedure that provides the greatest success rate in eliminating the attacks of vertigo. It can be performed by a translabyrinthine approach or in a manner that can conserve hearing, depending on the degree of hearing loss. Cutting the nerve prevents the brain from receiving input from the semicircular canals. What is it called?
mastoidectomy
Removal of diseased bone, mastoid air cells, and cholesteatoma to create a noninfected, healthy ear. What is this procedure called?
The Weber Test
Results of this test are used to determine whether the patient has conductive hearing loss or sensorineural hearing loss. Which test?
-family history of sensorineural impairment -congential malformations of the cranial structure (ear) -low birth weight (<1500g) -use of ototoxic medications (e.g., gentamycin, loop diuretics) -recurrent ear infections -bacterial meningitis -chronic exposure to loud noises (jobs, hobbies) -perforation of the tympanic membrane
Risk factors for hearing loss (8) ?
-pain and tenderness -discharge -edema -erythema -pruritus -hearing loss -feelings of fullness in the ear
S/S of external otitis (7)
>70-90 dB
Severe hearing loss in decibels ?
>15-25 dB
Slight hearing loss in decibels ?
ossiculoplasty
Surgical repair of an ossicle (small bone) of the middle ear is called ?
auricle (pinna)
The _______ collects the sound waves and directs vibrations in to the external auditory canal.
perilymph
The bony labyrinth surrounds and protects the membranous labyrinth, which is bathed in a fluid called ___________.
Transmits motor impulses from the brain to the spinal cord
The brain stem holds the medulla oblongata. What is the function of the medulla oblongata?
Vesstibular
The clinical manifestations of motion sickness are caused by an overstimulation in what system?
comatose
The critical care nurse is giving report on a client they are caring for. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the on-coming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate?
MRI
The diagnosis of multiple sclerosis is based on which test?
tympanic membrane
The external ear is separated from the middle ear by a disk-shaped structure called the ________________________.
annulus
The fibrous border that attaches the eardrum to the temporal bone ?
5 mm
The largest speculum that the ear canal can accommodate ____mm.
0-15 dB
The normal hearing in decibels ?
frequency
The number of sound waves emanating from a source per second, measured as cycles per second, or Hertz.
ADLs
The nurse caring for a client with Ménière's disease needs to assist with what when the client is experiencing an attack?
"I will stretch daily as directed by the physical therapist."
The nurse has been educating a client newly diagnosed with MS. Which statement by the client indicates an understanding of the education?
refrain from eating or drinking for now.
The nurse has completed evaluating the client's cranial nerves. The nurse documents impairment of the right cervical nerves (CN IX and CN X). Based on these findings, the nurse should instruct the client to ?
Basilar skull fracture
The nurse in the emergency department is caring for a patient brought in by the rescue squad after falling from a second-story window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of?
traction with weights and pulleys
The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury?
Apply warm packs to the affected area.
The nurse is advising a client with multiple sclerosis on methods to minimize spasticity and contractures. Which of the following techniques would the nurse instruct the client to perform?
Headache, nuchal rigidity
The nurse is assessing a client with meningitis. Which of the following signs would the nurse expect to observe?
The power of the lens to accommodate will be decreased
The nurse is assessing an older client's vision. The nurse integrates knowledge of which of the following during the assessment?
"Who is the president of the United States?"
The nurse is assessing the client's mental status . Which question will the nurse include in the assessment?
Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes.
The nurse is assisting with administering a Tensilon test to a patient with ptosis. If the test is positive for myasthenia gravis, what outcome does the nurse know will occur?
ischemic
The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has?
Approximately 60% to 75% of clients recover completely.
The nurse is caring for a client diagnosed with Guillain-Barre syndrome. His spouse asks about recovery rates. The nurse can correctly relate which of the following?
Administer medications at exact intervals ordered.
The nurse is caring for a client hospitalized with a severe exacerbation of Myasthenia Gravis. When administering medications to this client what is a priority nursing action?
Pulse and blood pressure
The nurse is caring for a client immediately after a spinal cord injury. Which assessment finding is essential when caring for a client in spinal shock with injury in the lower thoracic region?
retinal angiography
The nurse is caring for a client ordered for multiple eye screening. Following which procedure will the nurse instruct the client on a yellow coloring to the skin and urine as being normal?
Absence of brainstem reflexes Apnea Coma
The nurse is caring for a client who is being assessed for brain death. Which are cardinal signs of brain death? Select all that apply.
Coma Apnea Absence of brainstem reflexes
The nurse is caring for a client who is being assessed for brain death. Which are cardinal signs of brain death? Select all that apply.
The stimulation can increase intracranial pressure (ICP) or trigger a seizure.
The nurse is caring for a client with a cerebral aneurysm. Why does the nurse limit the interaction of visitors or family members with the client who has an aneurysm?
Insertion of a nasogastric (NG) tube
The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question?
Increased ICP is 12 mm Hg.
The nurse is caring for a client with a ventriculostomy. Which assessment finding demonstrates effectiveness of the ventriculostomy?
Explaining hospice care and services
The nurse is caring for a client with an inoperable brain tumor. What teaching is important for the nurse to do with these clients?
observing the client's response to painful stimuli
The nurse is caring for a comatose client. The nurse knows she should assess the client's motor response. Which method may the nurse use to assess the motor response?
burr holes
The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for?
"I was brushing my teeth."
The nurse is caring for a patient in the emergency department with an onset of pain related to trigeminal neuralgia. What subjective data stated by the patient does the nurse determine triggered the paroxysms of pain?
0 to 10 mm Hg
The nurse is caring for a patient in the neurologic ICU who sustained head trauma in a physical altercation. What would the nurse know is an optimal range of ICP for this patient?
Rapid, jerky, involuntary movements
The nurse is caring for a patient with Huntington's disease in the long-term care facility. What does the nurse recognize as the most prominent symptom of the disease that the patient exhibits?
Administer corticosteroids as ordered.
The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the priority nursing intervention?
The nurse should not move or manipulate the patient's head while assessing for bleeding or swelling.
The nurse is completing the physical assessment of a patient suspected of a neurologic disorder. The patient reports to the nurse that he has recently suffered a head trauma. In such a case, which of the following precautions should the nurse take for the patient? Select all that apply.
Applies gentle pressure bilaterally on the bridge of the nose to the inner canthus of each eye
The nurse is demonstrating how to perform punctal occlusion. Which activities does the nurse perform?
High in protein and low in carbohydrate
The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient?
Edema to the head with bruising of the mastoid process
The nurse is evaluating the transmission of a report from a paramedic unit to the emergency room. The medic reports that a client is unconscious with edema of the head and face and Battle's sign. What clinical picture would the nurse anticipate?
auditory nerve
The nurse is instructing a client on the benefits of a cochlear implant. The client asks, "How am I able to interpret sound?" The nurse credits which of the following as significant in the production of hearing?
CN I
The nurse is performing an assessment of cranial nerve function and asks the patient to cover one nostril at a time to see if the patient can smell coffee, alcohol, and mint. The patient is unable to smell any of the odors. The nurse is aware that the patient has a dysfunction of which cranial nerve?
Ptosis and diplopia
The nurse is performing an initial assessment on a client who is admitted to rule out myasthenia gravis. Which of the following findings would the nurse expect to observe?
Air-conducted sound heard longer than bone-conducted sound
The nurse is performing the Rinne test on a client with a sensorineural hearing loss. Which of the following would the nurse expect?
Young age Male gender Substance abuse
The nurse is planning to provide education about prevention in the community YMCA due to the increase in numbers of spinal cord injuries (SCIs). What predominant risk factors does the nurse understand will have to be addressed? Select all that apply.
LASIK involves working with the cornea on a deeper level.
The nurse is preparing a presentation for a local community group comparing photorefractive keratectomy and LASIK refractive surgeries. Which of the following would the nurse include?
"Have you experienced any viral infections in the last month?"
The nurse is taking health history from a client admitted to rule out Guillain-Barre syndrome. An important question to ask related to the diagnosis is which of the following?
A progressive, bilateral loss of hearing
The nurse is teaching a class on diseases of the ear. What would the nurse teach the class is the most characteristic symptom of otosclerosis?
The nurse would stand laterally to the client, opposite side to where the physician is standing.
The nurse is working in the emergency department when a physician asks for help as the client is performing a Romberg test. In which position would the nurse stand to be most helpful?
Hearing loss, vertigo, tinnitus
The nurse is working in the triage section of a walk-in clinic. Which triad of common symptoms, when placed together, indicate Ménière's disease?
Once symptoms occur, they will always be present.
The nurse on a cruise ship is assessing clients for motion sickness. Which of the following is a common misconception?
Right-sided paralysis.
The nurse practitioner is able to correlate a patient's neurologic deficits with the location in the brain affected by ischemia or hemorrhage. For a patient with a left hemispheric stroke, the nurse would expect to see:
pulls the tissue near the cheek downward to instill medication.
The nurse realizes that a client understands how to correctly instill ophthalmic medications when the client:
Coumadin
The nurse reviews the patient's drug regimen for treatment of a brain tumor. She explains to the patient why one of the following drugs would not be prescribed, even though it might have therapeutic benefits. Which drug would not be prescribed for this patient?
VIII
The nurse who is employed in a neurologist's office is performing a history and assessment on a client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of cranial nerve:
"There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive."
The parents of a client intubated due to the progression of Guillain-Barré syndrome ask whether their child will die. What is the best response by the nurse?
Blocks conduction of the vestibular pathways
The physician suggests that a client use meclizine as treatment for his motion sickness. The nurse explains the rationale for this drug based on an understanding of which of the following as the drug's action?
cerebral angiography
The physician's office nurse is caring for a client who has a history of a cerebral aneurysm. Which diagnostic test does the nurse anticipate to monitor the status of the aneurysm?
CN VIII
The provider orders the Romberg test for a patient. The nurse tells the patient that the provider wants to evaluate his equilibrium by assessing which cranial nerve?
VIII for Rom Test
The provider orders the Romberg test for a patient. The nurse tells the patient that the provider wants to evaluate his equilibrium by assessing which cranial nerve?
pars flaccida
The remaining 20% of the tympanic membrane that lacks the middle layer is called ?
An absence seizure
The school nurse notes a 6-year-old running across the playground with his friends. The child stops in midstride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child?
Ineffective airway clearance: Apply suction as indicated Disturbed sleep pattern: Provide back rubs to the client Interrupted family process: Encourage the family to join a support group
The statements presented here match nursing interventions with nursing diagnoses. Which statements are appropriate for a client who has suffered a head injury? Select all that apply.
-Impaired swallowing: Provide a pureed diet. -Disturbed sensory perception: Stand on the client's unaffected side. -Impaired verbal communication: Repeat words and instructions.
The statements presented here match nursing interventions with nursing diagnoses. Which statements are true for a client with a stroke? Select all that apply.
eye muscle movement
The trochlear nerve controls which function?
decibel (dB)
The unit for measuring loudness, the pressure exerted by sound. Hearing loss is measured using this unit.
opthalmoscopy
There are four major types of ophthalmic procedures to complete a glaucoma examination. If the health care provider wants to inspect the optic nerve, the nurse would prepare the patient for:
Rinne test
This hearing test is done by shifting the stem of a vibrating tuning fork between two positions: 2 inches from the opening of the ear canal and against the mastoid bone. As the position changes, the patient is asked to indicate which tone is louder or when the tone is no longer available. What is it called?
Weber test
This test for hearing uses bone conduction to test lateralization of sound. What is it called?
acute otitis media
This type of ear infection is most often seen in children ?
NSAIDS
To avoid the side effects of corticosteroids, which medication classification is used as an alternative in treating inflammatory conditions of the eyes?
"Have you noticed a change in your memory?"
To help assess a client's cerebral function, a nurse should ask:
backward
To straighten the ear canal in an adult for examination, the nurse practitioner would grasp the auricle and pull it:
Valium (diazepam)
Tranquilizers to help control vertigo? Used in patients with Meniere's disease.
-Glycerin -mineraloil -½ strength H2O2, or peroxide in glycerol
What can you use to soften earwax/cerumen and irrigate the ear canal? (3)
antihistamines
What classification of medications can be used in vertigo?
pearly grey
What color is NORMAL for the tympanic membrane?
organ of corti (spiral organ)
What is located in the cochlea of the inner ear?
It helps to conduct sound vibration.
What is the function of the tympanic membrane?
Glioma
What is the most common type of brain neoplasm?
Glossopharyngeal nerve
What is the name of cranial nerve IX?
2+
What is the normal DTR response score?
Ionizing radiation
What is the only known risk factor for brain tumors?
20-20,000 Hz
What is the range of human hearing?
the cerebellum
What part of the brain controls and coordinates muscle movement?
There are no activity restrictions after this procedure
What patient education for post mastoid surgery would be incorrect? -Avoid getting water in the ear. -Constant throbbing pain may be a sign of infection. -Call for assistance to ambulate to prevent injury. -There are no activity restrictions after this procedure.
-No attempt should be made to remove the object -Protect object from jarring -Use metal shield
When an impaled object is in the eye, which of the following steps should be taken to ensure that no further damage occurs? Select all that apply.
10 to 20 mm Hg.
When assessing the pressure of the anterior chamber of the eye, a nurse normally expects to find a pressure of:
Tactile agnosia
When caring for a client diagnosed with a brain tumor of the parietal lobe, the nurse expects to find:
Body temperature
When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?
fourth ventricle
Which anatomic part supplies cerebrospinal fluid to the subarachnoid space and down the spinal cord on the dorsal surface?
severe hypertension, slow heart rate, pounding headache, sweating
Which are characteristics of autonomic dysreflexia?
Intracranial hemorrhage Major abdominal surgery within 10 days
Which are contraindications for the administration of tissue plasminogen activator (t-PA)? Select all that apply.
temporal
Which cerebral lobe contains the auditory receptive areas?
The client with Huntington disease.
Which client should the nurse assess for degenerative neurologic symptoms?
neglect of the left side
Which clinical manifestation would be exhibited by a client following a hemorrhagic stroke of the right hemisphere?
Creutzfeldt-Jakob disease
Which condition is a rare, transmissible, progressive fatal disease of the central nervous system characterized by spongiform degeneration of the gray matter of the brain?
Otosclerosis
Which condition is characterized by the formation of abnormal spongy bone around the stapes?
Subdural Hematoma
Which condition occurs when blood collects between the dura mater and arachnoid membrane?
subdural hematoma
Which condition occurs when blood collects between the dura mater and arachnoid membrane?
Presbycusis
Which condition refers to hearing loss associated with degenerative changes?
transcranial doppler
Which diagnostic test may be performed to evaluate blood flow within intracranial blood vessels?
Homonymous hemianopsia
Which disturbance results in loss of half of the visual field?
Widened pulse pressure
Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury?
-Administering prescribed antipyretics -Maintaining aseptic technique with an intraventricular catheter -Frequent oral care
Which interventions are appropriate for a client with increased intracranial pressure (ICP)? Select all that apply.
Multiple sclerosis
Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of small patches of demyelination in the brain and spinal cord?
intracranial hemorrhage
Which is a contraindication for the administration of tissue plasminogen activator (t-PA)?
Spatial-perceptual deficits
Which is indicative of a right hemisphere stroke?
stapedectomy
Which is not a surgical procedure used in the treatment of Ménière's disease?
Parietal
Which lobe of the brain is responsible for spatial relationships?
cholinergics
Which medication classification increases aqueous fluid outflow in the client with glaucoma?
Levodopa
Which medication is the most effective agent in the treatment of Parkinson disease?
Monitoring the patency of an indwelling urinary catheter
Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?
Apply an eye patch to the right eye.
Which nursing intervention is appropriate for a client with double vision in the right eye due to MS?
clonus
Which occurs when reflexes are hyperactive when the foot is abruptly dorsiflexed?
Phenobarbital (Luminal)
Which of the following drugs may be used after a seizure to maintain a seizure-free state?
Muscle spasticity
Which of the following is a manifestation of an upper motor neuron lesion?
Polymerase chain reaction (PCR)
Which of the following is standard test for early diagnosis of herpes simplex virus (HSV)-1 encephalitis?
Uncontrolled hypertension
Which of the following is the chief cause of intracerebral hemorrhage (ICH)?
Change in level of consciousness (LOC)
Which of the following is the earliest sign of increasing intracranial pressure (ICP)?
Pyridostigmine bromide (Mestinon)
Which of the following is the first-line therapy for myasthenia gravis (MG)?
cornea
Which of the following is the main refracting surface of the eye?
Coumadin
Which of the following medications needs to be withheld for 5 to 7 days prior to cataract surgery?
Acetylcholine
Which of the following neurotransmitters are deficient in myasthenia gravis?
scleral buckle
Which of the following surgical procedures involves taking a piece of silicone plastic or sponge and sewing it onto the sclera at the site of a retinal tear?
Tensilon test
Which of the following tests confirms the diagnosis of myasthenia gravis (MG)?
Aura
Which phase of a migraine headache usually lasts less than an hour?
Surgical reconstruction of the middle ear bones
Which phrase defines ossiculoplasty?
Avoiding flexion of the neck with use of a cervical collar
Which positions is used to help reduce intracranial pressure (ICP)?
Psychosis, disorientation, delirium, insomnia, and hallucinations
Which set of symptoms characterize Korsakoff syndrome?
Conductive hearing loss may occur.
Which statement is consistent with acute otitis media?
Laser-assisted stromal in situ keratomileusis (LASIK)
Which surgical procedure involves flattening the anterior curvature of the cornea by removing a stromal lamella layer?
papilledema
Which term refers to swelling of the optic disc due to increased intracranial pressure?
aphakia
Which term refers to the absence of the natural lens?
Rinne
Which test uses a tuning fork shifted between two positions to assess hearing?
air conduction
Which type of conduction should be longer for sensiorneural hearing loss? Air or Bone?
Positive Brudzinski sign
Which well-recognized sign of meningitis is exhibited when the client's neck is flexed and flexion of the knees and hips is produced?
complications
While caring for clients who have suffered neurologic deficits from causes such as cerebrovascular accident and closed head injury, an important nursing goal that motivate nurses to offer the best care possible is preventing:
Severe headache and early change in level of consciousness
While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:
autonomic dysreflexia
You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides?
