Neuro and Musculo Exam
1. You're assessing a patient's health history for risk factors associated with developing Guillain-Barre Syndrome. Select all the risk factors below: 1. Recent upper respiratory infection 2. Patient's age: 3 years old 3. Positive stool culture Campylobacter Jejuni 4. Hyperthermia 5. Epstein-Barr 6. Diabetes 7. Myasthenia Gravis * A. 1, 3, 5 B. 3, 5, 6 C. 1, 2, 3 D. 2, 4
A. 1, 3, 5
85. Which of the following patients are MOST at risk for developing heart failure? Select all that apply: 1. A 69 year old male with history of alcohol abuse and is recovering from myocardial infarction 2. A 55 year old female with a health history of asthma and hypoparathyroidism 3. A 30 year old male with a history of endocarditis and has severe mitral stenosis 4. A 45 year old female with lung cancer stage 2 5. A 58 year old female with uncontrolled hypertension and is being treated for influenza * A. 1, 3, 5 B. 2, 4, 5 C. 1, 3, 4 D. 2, 3, 4
A. 1, 3, 5
35. The client comes to the emergency department with weakness that has been progressing upward in both legs for two days. The nurse, suspecting Guillain-Barré syndrome, begins care by doing which of the following? Select all that apply. 1. Taking medical history, noting recent viral influenza 2. Giving the client orange juice for fatigue and low blood glucose 3. Assessing neurological and respiratory function 4. Evaluating for petit malseizures 5. Assessing vital signs * A. 1,3,5 B. 2,3,4 C. 1,2,4 D. 3,4,5
A. 1,3,5
27. Which medications below can help treat muscle spasms in a patient with multiple sclerosis? Select all that apply: 1. Propranolol 2. Isoniazid 3. Baclofen 4. Diazepam 5. Modafinil * A. 3 and 4 B. 1 and 5 C. 2 and 3 D. 1 only
A. 3 and 4
91. A 58-year-old female patient has superficial partial-thickness burns to the anterior head and neck, front and back of the left arm, front of the right arm, posterior trunk, front and back of the right leg, and anterior of the left leg. Using the Rule of Nines, calculate the total body surface are percentage that is burned? * A. 63% B. 81% C. 72% D. 54%
A. 63%
18. The patient has a blood pressure of 130/88 and ICP reading of 12. What is the patient's cerebral perfusion pressure, and how do you interpret this as the nurse? * A. 90 mmHg, normal B. 62 mmHg, abnormal C. 36 mmHg, abnormal D. 56 mmHg, normal
A. 90 mmHg, normal
98. A 35 y.o. Patient with RVF was assigned to the nurse. Which would be the priority assessment of the nurse? * A. Abdominal pain B. Anorexia C. Weight gain D. Fatigue
A. Abdominal pain
25. A patient with multiple sclerosis has issues with completely emptying the bladder. The physician orders the patient to take ______, which will help with bladder emptying. * A. Bethanechol B. Oxybutyin C. Avonex D. Amantadine
A. Bethanechol
33. A nurse is receiving a client in transfer from the emergency room who has a diagnosis of Guillain-Barre syndrome. The clients chief complaint is an ascending paralysis that has reached the level of the waist. The nurse plans to have which item available for emergency use? * A. Cardiac monitor and intubation tray B. Blood pressure cuff and flashlight C. Nebulizer and pulse oximeter D. Flashlight and incentive spirometer
A. Cardiac monitor and intubation tray
72. Mariel, a 25-year-old radio announcer came in for consult with the chief complaints of not being able to hear well and inability to discriminate sounds he is hearing. An otoscopic examination was done to her, which revealed that there is sensorineural loss. This condition is due to damage to what part of the ear? * A. Cochlea and auditory nerve B. Vestibular nerve and cochlea C. Middle ear and auditory nerve D. Outer ear and cochlea
A. Cochlea and auditory nerve
99. The nurse is caring for a 75 y.o. client with LVF. The nurse should be alerted when the patient experiences: * A. Confusion B. Crackles C. Pallor D. Tachycardia
A. Confusion
46. Which clinical indicator should the nurse expect a client with an exacerbation of multiple sclerosis to experience? * A. Double vision B. Resting tremors C. Flaccid paralysis D. Mental retardation
A. Double vision
42. The nurse is caring for a client with Parkinson's disease. Which of the following nursing interventions wouldld the nurse include in the plan of care? * A. Elevate the client's legs B. Offer the client the bedpan every two hours C. Encourage the client to sit in a reclining, soft chair without arms D. Instruct the client to eat a high-calcium diet
A. Elevate the client's legs
45. Which clinical indicator does the nurse expect a client with Parkinson's disease to exhibit? * A. Flattened affect B. Muscle flaccidity C. Tonic clonic seizures D. A change in pain tolerance
A. Flattened affect
70. A nurse finds Mr. Gubatan under the wreckage of his car. He is conscious, breathing satisfactorily, and lying on his back complain of pain in the back and an inability to move his legs. The nurse should first: * A. Leave Mr. Gubatan lying on his back with instruction not to move and then go seek additional help B. Gently raise Mr. Gubatan to a sitting position to see if the pain either diminishes or increase in intensity C. Roll Mr. Gubatan onto his abdomen, place a pad under his head, and cover him with any material available D. Gently lift Mr. Gubatan onto a flat piece of lumber and using any available transportation, rush him to the closest medical institution
A. Leave Mr. Gubatan lying on his back with instruction not to move and then go seek additional help
17. Which of the following is contraindicated in a patient with increased ICP? * A. Lumbar puncture B. Midline position of the head C. Hyperosmotic diuretic D. Barbiturates medications
A. Lumbar puncture
56. The nurse infuses phenytoin (Dilantin) with which of the following solutions to control seizures? * A. Normal Saline B. D5W C. Lactated Ringer's D. D5W 0.5 Normal Saline
A. Normal Saline
74. Which of the following is useful in correcting a sensorineural hearing loss? * A. Nothing, the damage is irreversible B. Myringotomy C. Stapedectomy D. Tympanolasty
A. Nothing, the damage is irreversible
100. The patient is receiving Digoxin to treat CHF. The nurse should monitor for the ff. laboratories. Which is the priority? * A. Potassium levels B. Magnesium levels C. Creatinine levels D. BUN levels
A. Potassium levels
68. A patient with Parkinson's disease is experiencing weight loss due to difficulty chewing and swallowing. Which meal option is the best for this client? * A. Scrambled eggs with a side of cottage cheese B. Grilled cheese with apple slices C. Baked chicken with bacon slices D. Tacos with refried beans
A. Scrambled eggs with a side of cottage cheese
64. The nurse is caring for a confused client who sustained a head injury resulting in a subdural hematoma. The client's blood pressure is 100/60 mmHg and he is unresponsive. Select the most effective position for the client as the nurse transport him to the operating room. * A. Semi - fowler's B. Trendelenburg C. High fowler's D. Supine
A. Semi - fowler's
63. A client is admitted a head Injury, to monitor hypothalamic function the nurse should monitor what parameters? * A. Temperature and urinal output. B. Gastric aspirate and BP. C. Heart rate and papillary responses. D. Respiratory rate and skin integrity.
A. Temperature and urinal output.
79. In instilling the eye drops you have to tilt the back slightly Claudia's head. Which of the following is the rationale for this nursing action? * A. To prevent any spill from the eye during procedure B. To keep any debris away from the lacrimal duct C. To facilitate the procedure D. To reach the conjunctival sac easily
A. To prevent any spill from the eye during procedure
7. You're developing discharge instructions to the parents of a child who experiences atonic seizures. What information below is important to include in the teaching? A. "This type of seizure is hard to detect because the child may appear like he or she is daydreaming." B. "Be sure your child wears a helmet daily." C. "It is common for the child to feel extremely tired after experiencing this type of seizure." D. "Avoid high fat and low carbohydrate diets."
B. "Be sure your child wears a helmet daily."
47. Which statement by a client with multiple sclerosis indicates to the nurse that the client needs further teaching? * A. "I use a straw to drink liquids" B. "I will take a hot bath to help relax my muscles" C. "I plan to use an incontinence pad when I go out." D. "I may be having a rough time now, but I hope tomorrow will be better."
B. "I will take a hot bath to help relax my muscles"
3. You're educating a patient about treatment options for Guillain-Barre Syndrome. Which statement by the patient requires you to re-educate the patient about treatment? * A. "Treatment available for this syndrome do not cure the condition but helps speed up recovery time." B. "Plasmapheresis or immunoglobin therapies are treatment options available for this syndrome but are most effective when given within 4 weeks of the onset of symptoms." C. "When I start plasmapheresis treatment a machine will filter my blood to remove the antibodies from my plasma that are attacking the myelin sheath." D. "Immunoglobin therapy is where IV immunoglobin from a donor is given to a patient to stop the antibodies that are damaging the nerves."
B. "Plasmapheresis or immunoglobin therapies are treatment options available for this syndrome but are most effective when given within 4 weeks of the onset of symptoms."
87. Select all the correct statements about educating the patient with heart failure: 1. It is important patients with heart failure notify their physician if they gain more than 6 pounds in a day or 10 pounds in a week 2. Patients with heart failure should receive an annual influenza vaccine and be up-to-date with the pneumonia vaccine 3. Heart failure patients should limit sodium intake to 2-3 grams per day 4. Heart failure is exacerbated by illness, too much fluid or sodium intake, and arrhythmias 5. Patient with heart failure should limit exercise because of the risks * A. 2, 3 B. 1, 2, 4 C. 2, 3, 4 D. 1, 4, 5
B. 1, 2, 4
8. You have a patient who has a brain tumor and is at risk for seizures. In the patient's plan of care you incorporate seizure precautions. Select below all the proper steps to take in initiating seizure precautions? 1. Oxygen and suction at bedside 2. Bed in highest position 3. Remove all pillows from the patient's head 4. Have restraints on stand-by 5. Padded bed rails 6. Remove restrictive objects or clothing from patients' body 7. IV access * A. 1, 3, 5 B. 1, 5, 6, 7 C. 1, 2, 3, 6 D. 2, 3, 4
B. 1, 5, 6, 7
24. During your discharge teaching to a patient with multiple sclerosis, you educate the patient on how to avoid increasing symptoms and relapses. You tell the patient to avoid: 1. Cold temperature 2. Infection 3. Overexertion 4. Salt 5. Stress * A. 1, 4, 5 B. 2, 3, 5 C. 2, 3, 4 D. 2 and 5 only
B. 2, 3, 5
86. Which of the following are NOT typical signs and symptoms of right-sided heart failure? Select all that apply: 1. Jugular venous distention 2. Persistent cough 3. Weight Gain 4. Crackles 5. Nocturia 6. Orthopnea * A. 1, 2, 4 B. 2, 4, 6 C. 4, 5, 6 D. 2, 3, 6
B. 2, 4, 6
28. A patient has right side brain damage from a stroke. Select all the signs and symptoms that occur with this type of stroke: 1. Right side hemiplegia 2. Confusion on date, time and place 3. Aphasia 4. Unilateral neglect 5. Aware of limitations 6. Impulsive 7. Short attention span 8. Agraphia * A. 1, 3, 4, 8 B. 2, 4, 6, 7 C. 3, 4, 7, 8 D. 1, 2, 4, 7
B. 2, 4, 6, 7
93. The most common cause of aspiration of food in adult is? * A. Vegetable B. Bolus of meat C. Softdrinks D. Bread
B. Bolus of meat
14. You're providing teaching to a group of patients with myasthenia gravis. Which of the following is NOT a treatment option for this condition? * A. Plasmapheresis B. Cholinesterase medications C. Thymectomy D. Corticosteroids
B. Cholinesterase medications
67. The physician orders 1 mg of benzatropine mesylate (Cogentin) po daily for Mr. Jones. Which findings suggest a favorable effect from this medication? * A. Decrease muscle rigidity B. Decreased tremors C. Decreased dizziness D. Decreased confusion
B. Decreased tremors
34. What does the nurse understand that clients with myasthenia gravis, Guillain-Barre syndrome, and amyotrophic lateral sclerosis share in common? * A. Progressive deterioration until death B. Deficiencies of essential neurotransmitters C. Increased risk for respiratory complications D. Involuntary twitching of small muscle groups
B. Deficiencies of essential neurotransmitters
10. The nurse is ordered to administer Lorazepam to a patient experiencing status epilepticus. As a precautionary measure, the nurse will also have what reversal agent on standby? * A. Narcan B. Flumazenil C. Calcium Chloride D. Idarucizumab
B. Flumazenil
39. In a client with a Cheyne stokes respiration, which of the following is the most appropriate nursing diagnosis? * A. Ineffective airway clearance B. Ineffective breathing pattern C. Impaired gas exchange D. Activity intolerance
B. Ineffective breathing pattern
6. A patient with a history of epilepsy is taking Phenytoin. The patient's morning labs are back, and the patient's Phenytoin level is 7 mcg/mL. Based on this finding, the nurse will? * A. Assess the patient for a rash B. Initiate seizure precautions C. Hold the next dose of Phenytoin D. Continue to monitor the patient
B. Initiate seizure precautions
16. External ventricular drains monitor ICP and are inserted where? * A. Subarachnoid space B. Lateral Ventricle C. Epidural space D. Right Ventricle
B. Lateral Ventricle
22. You're performing a head-to-toe assessment on a patient with multiple sclerosis. When you ask the patient to move the head and neck downward the patient reports an "electric shock" sensation that travels down the body. You would report your finding to the doctor that the patient is experiencing? * A. Romberg's Sign B. Lhermitte's Sign C. Uhthoff's Sign D. Homan's Sign
B. Lhermitte's Sign
71. Once admitted to hospital, the physician indicates that Mr. Gubatan is a paraplegic. The family asks the nurse what this means. The nurse explains that: * A. Upper extremities are paralyzed B. Lower extremities are paralyzed C. One side of the body is paralyzed D. Both lower and upper extremities are paralyzed
B. Lower extremities are paralyzed
65. Which clinical features of the disease should the nurse expect to serve during admission assessment? * A. Muscle flaccidity and lethargy B. Mask like face and shuffling gait C. Dry skin and drooling D. Swayback and muscle cramps
B. Mask like face and shuffling gait
61. Which of the following reduces cerebral edema by constricting cerebral veins? * A. Dexamethasone (decadron). B. Mechanical hyperventilation. C. Mannitol (Osmitrol) D. Ventriculostomy.
B. Mechanical hyperventilation.
15. You're a home health nurse providing care to a patient with myasthenia gravis. Today you plan on helping the patient with bathing and exercising. When would be the best time to visit the patient to help these task? * A. Mid-afternoon B. Morning C. Evening D. Before bedtime
B. Morning
78. You have observed presence of drainage in Claudia's eyes. Which of the following eye solutions would you use in cleaning her eyes? * A. Hydrochloric acid B. Normal saline solution C. Mineral water D. Soapsuds solutions
B. Normal saline solution
73. Which of the following is a predisposing factor for sensory hearing loss? * A. Serous otitis media B. Ototoxic agents C. Otosclerosis D. Perforation of the eardrum
B. Ototoxic agents
2. A 25-year-old presents to the ER with unexplained paralysis from the hips downward. The patient explains that a few days ago her feet were feeling weird and she had trouble walking and now she is unable to move her lower extremities. The patient reports suffering an illness about 2 weeks ago, but has no other health history. The physician suspects Guillain-Barre Syndrome and orders some diagnostic test. Which finding below during your assessment requires immediate nursing action? * A. The patient reports a headache B. The patient has a weak cough C. The patient has absent reflexes in the lower extremities D. The patient reports paresthesia in the upper extremities
B. The patient has a weak cough
82. Select the PRIORITY nursing responsibility for taking care of patient on Mannitol therapy like Renato. Monitoring of _________. * A. Respiratory rate B. Urine output C. Renal function D. Muscle function
B. Urine output
38. Which of the following is true with the triad seen in head injuries? * A. Narrowing of pulse pressure, Cheyne stokes respiration, Tachycardia B. Widening pulse pressure, irregular respiration, Bradycardia C. Hypertension, Kussmaul's respiration, Tachycardia D. Hypotension, irregular respiration, Bradycardia
B. Widening pulse pressure, irregular respiration, Bradycardia
12. A patient with myasthenia gravis will be eating lunch at 1200. It is now 1000 and the patient is scheduled to take Pyridostigmine. At what time should you administer this medication so the patient will have the maximum benefit for this medication? * A. As soon as possible B. 1 hour after the patient has eaten (at 1300) C. 1 hour before the patient eats (at 1100) To improve muscle strngth D. at 1200 right before the patient eats
C. 1 hour before the patient eats (at 1100)
21. A patient is suspected of having multiple sclerosis. The neurologist orders various test. The patient's MRI results are back and show lesion on the cerebellum and optic nerve. What signs and symptoms below would correlate with this MRI finding in a patient with multiple sclerosis? 1. Blurry vision 2. Pain when moving eyes 3. Dysarthria 4. Balance and coordination issues 5. "Pill rolling" of fingers 6. Heat intolerance 7. Dark spots in vision 8. Ptosis * A. 2, 3, 4, 7, 8 B. 1, 3, 5, 6 C. 1, 2, 3, 4, 7 D. 2, 4, 6, 7
C. 1, 2, 3, 4, 7
29. You're educating a group of nursing student about left side brain damage. Select all the signs and symptoms noted with this type of stroke? 1. Aphasia 2. Denial about limitations 3. Impaired math skills 4. Issues with seeing on the right side 5. Disoriented 6. Depression and anger 7. Impulsive 8. Agraphia * A. 1, 2, 3, 5, 8 B. 2, 4, 5, 6, 7 C. 1, 3, 4, 6, 8 D. 1, 2, 3, 7, 8
C. 1, 3, 4, 6, 8
30. In order for tissue plasminogen activator (tPA) to be most effective in the treatment of stroke, it must be administered? * A. 6 hours after the onset of stroke symptoms B. 3 hours before the onset of stroke symptoms C. 3 hours after the onset of stroke symptoms D. 12 hours before the onset of stroke symptoms
C. 3 hours after the onset of stroke symptoms
4. Which test below can be ordered to help the physician diagnose Guillain-Barre Syndrome? Select all that apply: 1. Edrophonium Test 2. Sweat Test 3. Lumbar puncture 4. Electromyography 5. Nerve Conduction Studies * A. 1, 3, 5 B. 2, 4, 5 C. 3, 4, 5 D. 2, 5
C. 3, 4, 5
97. Furosemide is administered intravenously to a client with heart failure. How soon after administration should the nurse begin to see evidence of the drug's desired effect? * A. 30-60 minutes B. 2-4 hours C. 5-10 minutes D. 6-8 hours
C. 5-10 minutes
49. The nurse is working in a busy emergency department on a hot summer day and four near drowning victims are admitted. Which near drowning victim should the nurse assess for signs of hypovolemia? * A. 72 years old rescued from a lake B. 2 year old rescued from a bath tub C. 50 year old rescued from the ocean D. 17 year old rescued from a backyard pool
C. 50 year old rescued from the ocean
31. A client with myasthenia gravis asks the nurse why the disease has occurred. What pathology underlies the nurse's reply? * A. A genetic defect in the production of acetylcholine B. An inefficient use of the neurotransmitter acetylcholine C. A decreased number of functioning acetyicholine receptor sites D. An inhibition of the enzyme AChE, leaving the end- plates folded
C. A decreased number of functioning acetyicholine receptor sites
52. The physician notes a sign of cholinergic crisis. Which of the following clinical manifestations should alert the nurse of this condition? * A. Restlessness, dyspnea and ineffective cough reflex B. Cyanosis and absence of swallowing reflex C. Abdominal cramps, diarrhea and excessive secretions D. Hypoxia, increased in blood pressure and heart rate
C. Abdominal cramps, diarrhea and excessive secretions
57. Phenytoin (Dilantin) has been prescribed for a client. Based on an understanding of medication, the nurse caring for the client should? * A. Maintain a Dilantin level of 30 to 50 g/ml B. Dilute IV Dilantin with 5% dextrose C. Administer good oral hygiene D. Give Intramuscularly
C. Administer good oral hygiene
62. A client with a closed head injury is confused, drowsy, and unequal pupils. Which of the following nursing diagnosis is most important at this time? * A. Altered level of cognitive function. B. High risk for injury. C. Altered cerebral tissue perfusion. D. Sensory perceptual alteration.
C. Altered cerebral tissue perfusion.
36. Andrea's respiration is described as waxing and waning. You know that this rhythm of respiration is defined as: * A. Blot's B. Kussmaul's C. Cheyne Stokes D. Eupnea
C. Cheyne Stokes
13. Which meal option would be the most appropriate for a patient with myasthenia gravis? * A. Roasted potatoes and cubed steak B. Hamburger with baked fries C. Clam chowder with mashed potatoes D. Fresh veggie tray with sliced cheese cubes
C. Clam chowder with mashed potatoes
37. What do you call the triad of sign and symptoms seen in a client with increasing ICP? * A. Virchow's Triad B. The Chinese Triad C. Cushing's Triad D. Charcot's Triad
C. Cushing's Triad
95. A client with congestive heart failure has digoxin (Lanoxin) ordered every day. Prior to giving the medication, the nurse assesses that the digoxin level is 1.2ng/mL and auscultates a one-minute apical pulse rate of 62. The nurse should: * A. Withhold the digoxin B. Withhold the dose and request an order for a potassium level C. Give the digoxin as ordered D. Notify the physician
C. Give the digoxin as ordered
44. When interviewing a client with a tentative diagnosis of Parkinson's disease, the nurse expects the client to report the onset of symptoms occurred. * A. Suddenly B. Overnight C. Gradually D. Irregularly
C. Gradually
26. A patient is receiving Interferon Beta treatment of multiple sclerosis. As the nurse you will stress the importance of? * A. Physical exercise to improve fatigue B. Low fat diet C. Hand hygiene and avoiding infection D. Reporting ideation of suicide
C. Hand hygiene and avoiding infection
41. Which of the following would the nurse assess in a client who has a degeneration of the neurons that synthesize and release dopamine? * A. Bradycardia and Hypotension B. Insomia and Mania C. Hand tremors and muscle rigidity D. Pupil dilation and dysuria
C. Hand tremors and muscle rigidity
11. An 8-year-old child, who is not responding to anti-seizure medications, is prescribe to start a ketogenic diet. This diet will include: * A. High carbohydrate and high fat B. Low fat, high salt and carbohydrate C. High fat and low carbohydrates D. High glucose, high fat and low carbohydrate
C. High fat and low carbohydrates
90. A patient is taking Digoxin. Prior to administration you check the patient's apical pulse and find it to be 61 bpm. Morning lab values are the following: K+ 3.3 and Digoxin level of 5ng/mL. Which of the following is the correct nursing action? * A. Hold this dose and administer the second dose at 1800 B. Administer the dose as ordered C. Hold the dose and notify the physician of the digoxin level D. Hold this dose until the patient's potassium level is normal
C. Hold the dose and notify the physician of the digoxin level
80. You accidentally touch Claudia's eyelid during eye drop instillation causing her to blink. What should have you done to prevent this from occurring? * A. Touch the inner side of the medicine cap B. Tilt back Claudia's head slightly C. Hold the dropper close to the eye but do not allow the medication to fall into the cornea D. Have Claudia look up and focus on something
C. Hold the dropper close to the eye but do not allow the medication to fall into the cornea
89. A patient with heart failure is taking Losartan and Spironolactone. The patient is having EKG changes that presents with tall peaked T-waves and flat p-waves. Which of the following lab results confirms these findings? * A. Na+ 135 B. BNP 560 C. K+ 8.0 D. K+ 1.5
C. K+ 8.0
43. The nurse is teaching a class on drugs used in the treatment of neurological disorders. Which of the following should the nurse include in the class? * A. Allergic reactions, hepatitis and bone marrow depression are common adverse reactions to anticonvulsants B. Antihistamines and antipsychotic drug decrease the effect of anticholinergric drugs C. Narrow-angle glaucoma is a contraindication in the use of anti-Parkinson drugs D. Cushing's syndrome occurs with short-term corticosteroid use
C. Narrow-angle glaucoma is a contraindication in the use of anti-Parkinson drugs
54. A nurse is caring for a client with Guillain-Barre syndrome. Which of the following is MOST important in the goal of care of the client during the acute phase? * A. Alleviating anxiety B. Maintaining a balance of rest and sleep C. Preventing complications D. Dealing with depression
C. Preventing complications
60. An adult has a medical diagnosis of increased intracranial pressure and is being cared for on the neurology unit. The nursing care plan includes elevating the head of the bed and positioning the clients head in proper alignment. The nurse recognizes that these actions are effectively because they act by: * A. Making it easier for the client to breathe. B. Preventing a valsalva maneuver. C. Promoting venous drainage. D. Increasing arterial pressure
C. Promoting venous drainage.
83. Decreased level of consciousness (LOC) is one of the results of IICP. Which of the following is NOT an early manifestation of decreased LOC? * A. Lethargy B. Comatose with no response to painful stimuli C. Restlessness D. Disorientation
C. Restlessness
96. The nurse is assessing a 59 y.o. Male patient with CHF who was just admitted to the Medical-. The nurse is assessing a 59 y.o. Male patient with CHF who was just admitted to the Medical-Surgical Unit. Which of the following is not a manifestation of LVF: * A. Difficulty breathing B. Patient experiences sensation of suffocation C. Sharp pain on the Upper Abdomen D. Patient assumes tripod position
C. Sharp pain on the Upper Abdomen
40. You know that apnea is seen in client's with Cheyne stokes respiration, APNEA is defined as: * A. Inability to breath in a supine position so the patient sits up in bed to breath B. The patient is dead, the breathing stops C. There is an absence of breathing for a period of time, usually 15 seconds or more D. A period of hypercapnia and hypoxia due to the cessation of respiration and effort inspite of normal respiratory functioning.
C. There is an absence of breathing for a period of time, usually 15 seconds or more
77. Which of the following is the rationale for instilling eye drops to patients who had eye surgery? * A. To help control the intra-ocular pressure B. To dilate the patient's pupils C. To treat an eye infection D. To constrict the patient's pupils
C. To treat an eye infection
69. The physician adds levodopa (Larodop) to Mr. Jones' regimen. Which precaution should the nurse give Mr. J the patient-teaching session before discharge? * A. Take a vitamin B6 tablet with each dose of Levodopa B. Eat high-protein meals C. Wear elastic stockings to help avoid orthostatic hypotension D. Take levodopa only on an empty stomach
C. Wear elastic stockings to help avoid orthostatic hypotension
5. You're teaching a group of nursing student about Guillain-Barre Syndrome and how it can affect the automatic nervous system. Which signs and symptoms verbalized by the student demonstrate they understood the autonomic involvement of this syndrome? Select all that apply: 1. Altered body temperature regulation 2. Inability to move facial muscles 3. Cardiac dysrhythmias 4. Orthostatic hypotension 5. Bladder distention * A. 1, 3, 5 B. 1, 2, 3, 4 C. 2, 4, 5 D. 1, 3, 4, 5
D. 1, 3, 4, 5
23. You're developing a plan care for a patient with multiple sclerosis who present with Uhthoff's Sign. What interventions will you include in the patient's plan of care? Select all that apply: 1. Avoid movements of the head and neck downward 2. Keep room temperature cool 3. Encourage patient to use warm packs and heating pads for symptoms 4. Educate the patient on three ways to avoid overheating during exercise * A. 3 and 4 B. 1, 2 and 3 C. 3 only D. 2 and 4
D. 2 and 4
9. You're patient is scheduled for an EEG (electroencephalogram). As the nurse you will: 1. Keep the patient nothing by mouth 2. Hold seizure medications until after the test 3. Allow the patient to have coffee, milk and juice only 4. Wash the patients' hair prior to the test 5. Administer a sedative prior to the test * A. 1, 3, 5 B. 3, 5, C. 1, 3 D. 2, 4
D. 2, 4
66. Mr. Jones symptoms are caused by: * A. Cerebral anorexia B. Congenital abnormalities in neuronal transmission in the brain C. An imbalance in glucose and adenosine triphosphate levels D. A decrease in dopamine producing cell
D. A decrease in dopamine producing cell
58. Following a grand mal seizure, the client is unconscious and unresponsive when the nurse tries to awaken the client. The nurse implements which of the following actions? * A. Calls the rapid response team B. Notifies the physician C. Administers the next dose of phenytoin (Dilantin) IV instead of by month D. Allow gradual awakening
D. Allow gradual awakening
92. In case of hospital evacuation, the nurse will evacuate the patients in the following order? * A. Bedridden-> Ambulatory-> Wheelchair bound B. Ambulatory-> Bedbound-> Wheelchair bound C. Wheelchair bound-> Bedridden-> Ambulatory D. Ambulatory-> wheelchair bound-> Bedbound
D. Ambulatory-> wheelchair bound-> Bedbound
75. One of your patients underwent tympanolasty. Which of the following interventions is the MOST APPROPRIATE after a tympanoplasty? * A. Applying ear drop as ordered by the physician B. Teaching the patient to avoid heavy physical activity for at least three weeks C. Rinsing the ear three times a day using hydrogen peroxide as ordered D. Avoiding the use of cotton in cleaning the ears
D. Avoiding the use of cotton in cleaning the ears
19. While positioning a patient in bed with increased ICP, it important to avoid? * A. Midline positioning of the head B. Placing the HOB at 30-35 degrees C. Preventing flexion of the neck D. Flexion of the hips
D. Flexion of the hips
88. Which of the following is a late sign of heart failure? * A. Shortness of breath B. Orthopnea C. Edema D. Frothy-blood tinged sputum
D. Frothy-blood tinged sputum
48. A young female diagnosed with multiple sclerosis (MS) has just discovered she is also pregnant. She and her husband have been trying to conceive for several years and are very excited. What client education should the nurse provide to the client concerning her disease and pregnancy? * A. Immediately report weakness that progresses upward in the extremities B. Report a change in level of consciousness, severe headache, or slow pulse C. Recognize that sore/stiff neck and pain when the neck is flexed are critical signs to report D. Immediately report spasticity, weakness, or visual changes
D. Immediately report spasticity, weakness, or visual changes
94. In which of the following positions should the nurse place a client with suspected heart failure? * A. Semi-sitting B. Lying on the right side C. Sitting almost upright D. Lying on the back with the head lowered
D. Lying on the back with the head lowered
51. A forty year old male is brought to the hospital complaining of extreme fatigue, difficulty swallowing, tremors and double vision. During assessment the nurse validated the presenting complaints and notes scanning speech, muscle weakness and painful sensation. From this information, the physician supports which of the following diagnosis? * A. Alzheimer's Disease B. Parkinson's disease C. Gullain-Barre Syndrome D. Multiple Sclerosis
D. Multiple Sclerosis
50. The nurse must establish and maintain an airway in a client who has experienced a near- drowning in the ocean. For which potential danger should the nurse assess the client? * A. Alkalosis B. Renal failure C. Hypervolemia D. Pulmonary edema
D. Pulmonary edema
32. The nurse is caring for a client with Guillain Barre Syndrome. Which of the following would indicate the client's condition is deteriorating? * A. Weakness and Paresthesia B. Pain and Muscle aches C. Urinary Retention D. Respiratory Infection
D. Respiratory Infection
59. During the open forum, one parent asks the nurse if she could send her child toa summer camp. Which of the following activities would the nurse decide is most important for the child to avoid? * A. Tennis B. Hiking C. Aquatic D. Rock Climbing
D. Rock Climbing
76. A patient came in with the chief complaints of ringing in the ears and a feeling of whirling around. The attending physician suspects Meniere's Syndrome. To arrive at a correct diagnosis, the patient must be manifesting these three symptoms: paroxysmal whirling vertigo, tinnitus; and _________. * A. Conductive hearing loss B. Bilateral symptoms C. Vomiting D. Sensorineural hearing loss
D. Sensorineural hearing loss
55. An elderly female client diagnosed with Alzheimer's Disease is brought to the hospital by her daughter because she could no longer recognize herself and others, is incontinent and manifests delusions and hallucinations. Based from the client's symptoms and abilities, at what stage of the disease can the nurse classify the client? * A. Stage 1 B. Stage 2 C. Stage 4 D. Stage 3
D. Stage 3
20. During the eye assessment of a patient with increased ICP, you need to assess the oculocephalic reflex. If the patient has brain stem damage what response will you find? * A. The eyes will move in the same direction as the head is moved side to side B. The eyes will move in the opposite direction as the head is moved side to side C. The eyes will roll back as the head is moved side to side D. The eyes will be in a fixed position as the head is moved side to side
D. The eyes will be in a fixed position as the head is moved side to side
84. Renato has been observed to manifest signs of disorientation. Which of the following occurs FIRST in the state of disorientation. Disorientation to _______. * A. Place B. Environment C. People D. Time
D. Time
81. Renato, was started on Mannitol therapy. What is the rationale for this treatment? * A. To prevent seizures B. To prevent dehydration C. To prevent serious fluid and electrolyte imbalance D. To increase the osmolality of the blood
D. To increase the osmolality of the blood
53. The nurse determines the risk for injury is the priority nursing diagnosis for a client with Parkinson's Disease. Safety is a major factor. The following nursing interventions help prevent any occurrence of falls EXCEPT: * A. Use of cane or walker B. Application of leg braces C. Clearing floors of rugs and loose carpets D. Use of memory devices
D. Use of memory devices
