Module XIV_Neurosensory
b
A 23-year-old patient with a history of muscular dystrophy is hospitalized with pneumonia. Which nursing action will be included in the plan of care? a. Logroll the patient every 2 hours. b. Assist the patient with ambulation. c. Discuss the need for genetic testing with the patient. d. Teach the patient about the muscle biopsy procedure.
acd
A 27-year-old patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patients assigned room (select all that apply)? a. Side-rail pads b. Tongue blade c. Oxygen mask d. Suction tubing e. Urinary catheter f. Nasogastric tube
a
A 31-year-old woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which response by the nurse is accurate? a. MS symptoms may be worse after the pregnancy. b. Women with MS frequently have premature labor. c. MS is associated with an increased risk for congenital defects. d. Symptoms of MS are likely to become worse during pregnancy.
a
A 4-year-old child has just been diagnosed with pseudohypertrophic (Duchenne) muscular dystrophy. The management plan should include which action? a. Recommend genetic counseling. b. Explain that the disease is easily treated. c. Suggest ways to limit use of muscles. d. Assist family in finding a nursing facility to provide child's care
ebdac
A. Place in order the interventions the nurse would implement starting with the highestpriority intervention sequencing to the lowest-priority intervention for a child experiencing a generalized seizure. a. Monitor vital signs. b. Ease child to the floor. c. Evaluate postictal symptoms. d. Turn child to the side. e. Note onset of seizure.
abe
During assessment of the patient with fibromyalgia, the nurse would expect the patient to report which of the following (select all that apply)? a. Sleep disturbances b. Multiple tender points c. Cardiac palpitations and dizziness d. Multi-joint pain with inflammation and swelling e. Widespread bilateral, burning musculoskeletal pain
b
How much folic acid is recommended for women of childbearing age( to prevent 50% to 70% of cases of neural tube defects? a. 1.0 mg b. 0.4 mg c. 1.5 mg d. 2.0 mg
b
A high school teacher who has just been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, I cannot teach anymore, it will be too upsetting if I have a seizure at work. Which response by the nurse is best? 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.
a
A patient has been taking phenytoin (Dilantin) for 2 years. Which action will the nurse take when evaluating for adverse effects of the medication? a. Inspect the oral mucosa. b. Listen to the lung sounds. c. Auscultate the bowel tones. d. Check pupil reaction to light.
a
A patient reports feeling numbness and tingling of the left arm before experiencing a tonic-clonic seizure. The nurse determines that this history is consistent with what type of seizure? a. Focal b. Atonic c. Absence d. Myoclonic
a
After change-of-shift report, which patient should the nurse assess first? a. Patient with myasthenia gravis who is reporting increased muscle weakness b. Patient with a bilateral headache described as like a band around my head c. Patient with seizures who is scheduled to receive a dose of phenytoin (Dilantin) d. Patient with Parkinsons disease who has developed cogwheel rigidity of the arms
b
After the nurse has taught a 28-year-old with fibromyalgia, which statement by the patient indicates a good understanding of effective self-management? a. I am going to join a soccer team to get more exercise. b. I will need to stop drinking so much coffee and soda. c. I will call the doctor every time my symptoms get worse. d. I should avoid using over-the-counter medications for pain.
aef
An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Which interventions would be included in the child's postoperative care? (Select all that apply.) a. Observe closely for signs of infection. b. Pump the shunt reservoir to maintain patency. c. Administer sedation to decrease irritability. d. Maintain Trendelenburg position to decrease pressure on the shunt. e. Observe for signs of increased intracranial pressure. f. Monitor for abdominal distention.
a
Latex allergy is suspected in a child with spina bifida. Appropriate nursing interventions include which action? a. Avoid using any latex product. b. Use only nonallergenic latex products. c. Administer medication for long-term desensitization. d. Teach family about long-term management of asthma
a
The goal for the patient with muscular dystrophy is to keep the patient active for as long as possible. a. True b. False
d
The mother of a 1-month-old infant tells the nurse she worries that her baby will get meningitis like her oldest son did when he was an infant. The nurse would base her response on which statement? a. Meningitis rarely occurs during infancy. b. Often a genetic predisposition to meningitis is found. c. Vaccination to prevent all types of meningitis is now available. d. Vaccination to prevent Haemophilus influenzae type B meningitis has decreased the frequency of this disease in children.
a
The nurse is conducting a staff in-service on common problems associated with myelomeningocele. Which common problem is associated with this defect? a. Hydrocephalus b. Craniostenosis c. Biliary atresia d. Esophageal atresia
d
The nurse is conducting reflex testing on infants at a well-child clinic. Which reflex finding should be reported as abnormal and considered as a possible sign of cerebral palsy? a. Tonic neck reflex at 5 months of age b. Absent Moro reflex at 8 months of age c. Moro reflex at 3 months of age d. Extensor reflex at 7 months of age
ab
The nurse is evaluating the laboratory results on cerebral spinal fluid (CSF) from a 3-year-old child with bacterial meningitis. Which findings confirm bacterial meningitis? (Select all that apply.) a. Elevated white blood cell (WBC) count b. Decreased glucose c. Normal protein d. Elevated red blood cell (RBC) count e. Positive Gram stain
a
The nurse is planning a staff in-service on childhood spastic cerebral palsy. What characterizes spastic cerebral palsy? a. Hypertonicity and poor control of posture, balance, and coordinated motion b. Athetosis and dystonic movements c. Wide-based gait and poor performance of rapid, repetitive movements d. Tremors and lack of active movement
c
The nurse is reviewing prenatal vitamin supplements with an expectant client. Which supplement should be included in the teaching? a. Vitamin A throughout pregnancy b. Multivitamin preparations as soon as pregnancy is suspected c. Folic acid for all women of childbearing age d. Folic acid during the first and second trimesters of pregnancy
a
The nurse observes a patient ambulating in the hospital hall when the patients arms and legs suddenly jerk and the patient falls to the floor. The nurse will first a. assess the patient for a possible head injury. b. give the scheduled dose of divalproex (Depakote). c. document the timing and description of the seizure. d. notify the patients health care provider about the seizure.
d
The parents of a child with cerebral palsy ask the nurse whether any drugs can decrease their child's spasticity. The nurse's response should be based on which statement? a. Anticonvulsant medications are sometimes useful for controlling spasticity. b. Medications that would be useful in reducing spasticity are too toxic for use with children. c. Many different medications can be highly effective in controlling spasticity. d. Implantation of a pump to deliver medication into the intrathecal space to decrease spasticity has recently become available.
abe
Which assessment findings should the nurse note in a school-age child with Duchenne muscular dystrophy (DMD)? (Select all that apply.) a. Lordosis b. Gower sign c. Kyphosis d. Scoliosis e. Waddling gait
abd
Which clinical manifestations would the nurse prepare to assess if bacterial meningitis is confirmed? (Select all that apply.) a. Headache b. Photophobia c. Bulging anterior fontanel d. Seizures e. Poor muscle tone
d
Which information about a 60-year-old patient with MS indicates that the nurse should consult with the health care provider before giving the prescribed dose of dalfampridine (Ampyra)? a. The patient has relapsing-remitting MS. b. The patient walks a mile a day for exercise. c. The patient complains of pain with neck flexion. d. The patient has an increased serum creatinine level.
d
Which information about a 72-year-old 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 generalized tonic-clonic seizures. b. Patient experiences an aura before seizures. c. Patients most recent blood pressure is 156/92 mm Hg. d. Patient has minor elevations in the liver function tests.
c
Which is the initial clinical manifestation of generalized seizures? a. Being confused b. Feeling frightened c. Losing consciousness d. Seeing flashing lights
d
Which prescribed intervention will the nurse implement first for a patient in the emergency department who is experiencing continuous tonic-clonic seizures? a. Give phenytoin (Dilantin) 100 mg IV. b. Monitor level of consciousness (LOC). c. Obtain computed tomography (CT) scan. d. Administer lorazepam (Ativan) 4 mg IV.
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 patients 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
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 patients 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.