MEDSURG-E4

The nurse is conducting an initial screening to determine a patient's gross hearing acuity as part of a complete physical. Which test should the nurse include in the assessment?

Whisper voice

The nurse is caring for a patient experiencing an acute exacerbation of multiple sclerosis (MS). Which pathophysiological change leads to the symptoms of MS?

Demyelination and destruction of nerve fibers

The nurse is speaking with the family of a patient diagnosed with Guillain-Barré syndrome (GBS). They ask what could cause something like this. How should the nurse reply?

It may be an autoimmune reaction to a virus.

The nurse is preparing to assist the HCP with the incision of a carbuncle in the ear canal of a patient. Which symptoms are consistent with this diagnosis?

Several hair follicles that have formed an abscess

The nurse is caring for a patient scheduled for a computed tomography (CT) scan with contrast. Which actions does the nurse include in the preprocedural preparation? (Select all that apply.)

1. Check blood urea nitrogen (BUN) and creatinine levels. 2. Question the patient about allergies to dye, shellfish, or iodine. 4. Explain to the patient that a sensation of warmth may be felt when the dye is injected. 5. Tell the patient to report any nausea, itchiness, or difficulty breathing during the scan.

A patient with a spinal cord injury at T3-T4 experiences a sudden increase in BP and has cool, pale, gooseflesh skin on the lower extremities. Which action does the nurse perform while awaiting physician orders? (Select all that apply.)

1. Monitor BP every 5 minutes. 4. Check to see if the indwelling catheter is patent. 5. Perform a rectal examination to determine if impaction is present.

The nurse determines that a patient is experiencing common age-related changes in vision and hearing. Which findings does the nurse identify in the patient? (Select all that apply.)

1. Presbycusis 2. Yellowing of the lens 3. Distorted depth perception 4. Decreased lacrimal secretions

The nurse is using the FOUR tool to assess a patient's neurological functioning. In which areas does the nurse collect data when using this tool? (Select all that apply.)

1. Reflexes 2. Eye response 4. Motor movement 5. Breathing pattern

The nurse is involved in a BP clinic in the community, and an individual with possible stroke symptoms is brought for evaluation. Which findings in the FAST (face, arms, speech, and time) assessment indicate the need to call emergency personnel? (Select all that apply.)

3. The patient is unable to repeat a stated phrase exactly as it was stated. 4. The patient's face shows signs of uneven symmetry when asked to smile. 5. When asked to close the eyes and hold arms straight in front, one arm drifts downward.

A patient is diagnosed with Ménière disease. Which therapeutic measures does the nurse expect the HCP to prescribe?

A salt-restricted diet and prescribed antihistamines and vasodilators

A patient is admitted from the emergency department to the hospital following the diagnosis of an ischemic stroke. The patient did not qualify for tPA therapy. What findings indicate the patient may have developed a complication?

A warm, reddened area on the calf

The nurse is collection admission information for a patient who has a history of having a thymectomy. Which condition should the nurse inquire about?

MG

The nurse is hired by a family to provide care for a family member diagnosed with stage 2 Alzheimer disease. Which action related to safety is most important for the nurse to implement?

Make sure that all doors are locked where potential risk exists.

The nurse is reviewing the medical records of patients in an HCP's practice. Which patient does the nurse recognize as the greatest risk for a stroke?

An older female patient who has osteoporosis, a femur fracture, and hyperlipidemia

The nurse is assisting with care for a patient in the ICU with an extreme head injury and suspected brain herniation. What should the nurse anticipate for care?

Arranging for the family to be approached about possible organ donation

A patient arrives at the emergency department saying, "Something is wrong. I just don't feel right." Which observation causes the nurse to suspect the patient is experiencing a stroke?

Ataxia is present when the patient attempts to ambulate.

The nurse is caring for a patient at risk for primary open-angle glaucoma (POAG). Which finding is most concerning?

Headache and seeing halos around lights

The nurse is preparing a patient with MG to undergo plasmapheresis. Which laboratory tests should the nurse verify and place on the medical record before the procedure?

Complete blood count (CBC), platelets, and clotting studies

The nurse is reinforcing teaching provided to a patient with open-angle glaucoma. What is most important for the nurse to include in the patient teaching?

Compliance with drug therapy is essential to prevent loss of vision.

During an eye examination of a patient, a light is shone into the right eye while it is observed. Pupillary reaction and pupil size are noted. Then a light is shone into the left eye as the right eye is still observed. Which response occurs during the second step of the test?

Consensual response

While checking a patient's pupils, the nurse notes that the left pupil constricts when a light is shone into the right eye. Which information does this finding suggest to the nurse?

Consensual response present

A patient with acute-angle glaucoma and a fractured femur who is scheduled for surgery is prescribed an opioid prn and an anticholinergic as a preoperative medication. What action should the nurse take?

Contact the health-care provider (HCP).

A mother of two young children has a 1-year history of MS and recently stopped helping in the children's classrooms because of fatigue and weakness. What advice should the nurse give to help the patient best cope with the problem?

You may plan to be there for shorter visits so you can rest.

A patient is diagnosed with bacterial encephalopathy. Which symptoms exhibited by the patient indicate late signs of the patient's diagnosis?

Lethargy and seizures

The nurse enters the room of a patient who has recently experienced a stroke. The nurse discovers the patient lying flat and choking on saliva. What action should the nurse take first?

Elevate the head of the bed.

The nurse is working at a summer camp when one of the children comes to the nurse rubbing an eye and experiencing pain from getting sand in the eye. What should the nurse instruct the child after caring for them?

Do not rub your eye if it has something in it.

The nurse is preparing a patient for neurological testing. Symptoms of the patient include severe pain in the lower back from a suspected herniated disc. Which test should the nurse anticipate will be ordered?

Myelogram

The nurse is providing care for a patient with a cerebral aneurysm and subarachnoid hemorrhage. Which statement by the patient requires additional teaching?

No strenuous activity until this condition is cured by surgery.

The nurse asks an older adult patient to count backward from 100 in increments of three. The patient is challenged with the process and often pauses but performs this accurately. What should the nurse document that the patient shows?

Normal delay in problem solving

The nurse is assisting with the care of a patient following an ischemic stroke who does not qualify for tPA therapy. The patient's current BP is 190/110 mm Hg. For which reason will the patient's hypertension remain untreated?

Permissive hypertension is being therapeutically used to salvage brain tissue.

The nurse is assisting with the care of a patient being prepared for emergency intervention for a detached retina requiring the patient to maintain a reclining position for 16 hours, which procedure is planned for this patient?

Pneumatic retinopexy

The nurse is working in a college clinic when a student comes in and says, "I think I have a migraine. My head hurts, I cannot stand the bright light, and I feel sick to my stomach." What additional finding is most concerning?

Positive Brudzinski sign

The nurse performs a visual assessment on a patient and documents the findings using the acronym PERRLA. Which assessment finding does PERRLA indicate?

Pupils, equal, round, and reactive to light and accommodation

The nurse is providing care for a patient who had a stroke, resulting in a language disorder. The nurse asks the patient to stick out their tongue and they raise their arms. How should the nurse document this finding?

Receptive aphasia

The nurse is assisting with the care of a patient with a brain tumor who is exhibiting increased ICP. What safety action should the nurse take?

Relocate environmental objects and pad the bedside rails.

The nurse is collecting data from a patient with diabetes mellitus. The patient tells the nurse, "I just got new glasses, but I still do not see very well." What could be the cause?

Retinopathy

The nurse is assisting with a patient who was injured in an accident and experienced head injury. The RN records the patient as exhibiting decorticate posturing. Which condition does the nurse associate with the RN's finding?

Significant impairment of cerebral functioning

The nurse is providing care for an older adult client with presbycusis. What action should the nurse take?

Speak to the patient in a lower tone of voice.

The HCP is preparing to discharge a patient from the hospital after a stroke. The patient is insistent on being sent to a rehabilitation center. The nurse is aware that the patient must meet which qualification to go to rehabilitation?

The ability to participate in intensivetherapy

A patient has an injury resulting in major damage to the pinna of the right ear and is afraid that it may cause hearing loss. Which statement by the nurse will alleviate the patient's fear?

The impulses for hearing come from the middle and inner ear, not your outer ear.

The licensed practical nurse/licensed vocational nurse (LPN/LVN) is assigned to assist the registered nurse (RN) in providing care for a patient admitted for an infectious neurological disorder. Which reassessment finding is most concerning and should be reported to the RN?

The patient attempts to get out of bed to go to work.

The nurse is providing care for a patient being treated for trigeminal neuropathy. The nurse is concerned about the patient's nutritional status because of an inability to eat without experiencing severe pain. Which patient behavior indicates the nurse's interventions are successful?

The patient can eat multiple small, soft, lukewarm meals daily.

The nurse is conducting hearing acuity evaluation on a patient using the Rinne test. The nurse documents "AC greater than BC." How should this be interpreted?

The patient continues to hear the tuning fork for twice as long when it is lifted from the mastoid bone.

A patient is brought to the health-care provider's (HCP's) office with a headache, lethargy, nausea, vomiting, and a fever, which has developed over the past few days. The nurse begins collecting data about the possible causes of the symptoms. Which information supports a concern for encephalitis being the cause?

The patient has been camping within the last few weeks.

A patient's Snellen chart findings are 20/60. What does this information represent?

The patient must be at 20 feet to see what someone else can see at 60 feet.

The nurse is preparing to perform a Romberg test on a client. The nurse instructs the patient to stand with the feet together and eyes closed. After 20 seconds, the patient leans to one side and exhibits a swaying motion. Which conclusion can the nurse draw from these test results?

The test is positive and indicates cerebellar dysfunction.

A patient comes into the emergency department with symptoms of a stroke that began 2 hours ago. Diagnostic testing confirms an ischemic stroke is present. What medications should the nurse anticipate will be delivered?

Tissue-type plasminogen activator (tPA)

The nurse is preparing a patient for a fluorescein angiography. How should the nurse explain the purpose of this test?

To find leakage or damage to the blood vessels of the retina

A patient arrives in the emergency department at 0200 exhibiting signs and symptoms of a stroke. The patient went to bed at 2300 and was "feeling fine" but woke up at 0100 to go to the restroom and fell on the way there. The CT scan shows a hemorrhagic stroke. For what reason would tPA therapy be withheld?

tPA is not delivered for hemorrhagic stroke.