NEURO TEST 2 CVA/ MS/ ALS/ PD
The nurse is assigned to care for an adult client who had a stroke and is aphasic. Which interventions should the nurse use for communicating with the client? Select all that apply. 1. Face the client when talking. 2. Speak slowly and maintain eye contact. 3. Use gestures when talking to enhance words. 4. Avoid the use of body language when talking to the client. 5. Give the client directions using short phrases and simple terms. 6. Phrase what was said differently the second time, if there is a need to repeat it.
1235
A client with Parkinson's disease is developing dementia. Which action should the nurse plan to assist the client in maintaining self-care abilities? 1. Plan group activities. 2. Break down activities into small steps. 3. Change the time and day of bathing frequently. 4. Avoid playing music when the client is dressing.
2
The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further teaching if which statement is made? 1. "I will use a straw for drinking." 2. "I will drive only during the daytime." 3. "I will use caution because the device alters balance." 4. "I will wash the skin daily under the lamb's-wool liner of the vest."
2 The client should not drive because the device impairs the range of vision. The halo device alters balance and can cause fatigue because of its weight. The client should cleanse the skin daily under the vest or the device to protect the skin from ulceration and should use powder or lotions sparingly or not at all.
The nurse is preparing for the admission of a client with a diagnosis of early stage Alzheimer's disease. The nurse assists in developing a plan of care, knowing that which is a characteristic of early Alzheimer's disease? 1. Confusion 2. Wandering 3. Forgetfulness 4. Personality changes
3 In early Alzheimer's disease, forgetfulness begins to interfere with daily routines and may compromise client safety. The client has difficulty concentrating and difficulty learning new material. Options 1, 2, and 4 are characteristics of dementia that occur late as the disease progresses.
The nurse has given instructions to the client with Parkinson's disease about maintaining mobility. The nurse determines that the client understands the directions if the client states that he or she will perform which activity? 1. Sit in soft, deep chairs. 2. Exercise in the evening to combat fatigue. 3. Rock back and forth to start movement slowly. 4. Buy clothes with many buttons to maintain finger dexterity.
3 The client with Parkinson's disease should exercise in the morning, when energy levels are highest. The client should avoid sitting in soft, deep chairs because getting up from them can be difficult. The client can rock back and forth to initiate movement. The client should buy clothes with Velcro fasteners and slide-locking buckles to allow for easier dressing.
A client with a T4 spinal cord injury is to be monitored for autonomic dysreflexia (hyperreflexia). Which finding is indicative of this complication? 1. Pupil responses are brisk bilaterally. 2. Knee-jerk reaction is absent bilaterally. 3. One hundred mL of residual urine remains after the client voids. 4. The client complains of a headache, and the blood pressure is elevated.
4
An older gentleman is brought to the emergency department by a neighbor who heard him talking and wandering in the street at 3 am. The nurse should first determine which about the client? 1. His insurance status 2. Blood toxicology levels 3. Whether he ate his evening meal 4. Whether this is a change in his usual level of orientation
4
A client with Parkinson's disease "freezes" while ambulating, increasing the risk for falls. Which suggestion should the nurse include in the client's plan of care to alleviate this problem? 1. Use a wheelchair to move around. 2. Stand erect and use a cane to ambulate. 3. Keep the feet close together while ambulating and using a walker. 4. Consciously think about walking over imaginary lines on the floor.
4 Clients with Parkinson's disease can develop bradykinesia (slow movement) or akinesia (freezing or no movement). Having these individuals imagine lines on the floor to step over can keep them moving forward. Although standing erect and using a cane can help prevent falls, these measures will not help a person with akinesia move forward. Clients with Parkinson's disease should walk with a wide gait, not with the feet close together. A wheelchair should be used only when the client can no longer ambulate with assistive devices such as canes or walkers.
A client with Parkinson's disease is experiencing a parkinsonian crisis. The nurse should immediately place the client where? 1. In a bed with padded side rails, with limb restraints nearby 2. In a room near the nurses' station that is near the code cart 3. In a high-Fowler's position, with a nasogastric tube at the bedside 4. In a quiet, dim room with respiratory and cardiac support available
4 Parkinsonian crisis can occur with emotional trauma or sudden withdrawal of medications. The client exhibits severe tremors, rigidity, and bradykinesia. The client also displays anxiety, is diaphoretic, and has tachycardia and hyperpnea (tachypnea). The client should be placed in a quiet, dim room, and respiratory and cardiac support should be available.
The nurse administers an emergent dose of intravenous (IV) haloperidol to a patient with delirium who is combative and is putting herself and others at risk. Which priority instruction should she give the unlicensed assistive personnel immediately? "Please get a telemetry monitor and attach it to this patient." "Let's put a bed alarm under the patient's sheets right away." "Move everything away from the patient's bed, including the patient's phone and bedside table. "Please apply restraints to the patient's wrists and ankles and secure them to the immobile parts of the bed.
A
When assessing a patient diagnosed with multiple sclerosis (MS), which of the following would require immediate action by the healthcare provider? Choose 1 answer: Choose 1 answer: (Choice A) A Dysphagia and congested cough (Choice B) B Fatigue and depression (Choice C) C Paresthesia and tremor (Choice D) D Nystagmus and diplopia
A
A patient has been diagnosed as having dementia. Which symptom should the LPN/LVN expect? Patient tends to confabulate. Patient tends to have flight of ideas. Patient's speech tends to be slurred. Patient tends to be oriented to time, place, and person.
A Dementia is characterized by several cognitive deficits, memory in particular, and tends to be chronic. Confabulation is used to fill conversational gaps. Flight of ideas, slurred speech, and orientation to time, place, and person are not dementia symptoms.
12. The healthcare provider is assessing a patient with a diagnosis of Parkinson disease (PD). Which of the following findings would the healthcare provider anticipate? Select all that apply. A. Kyphosis B. Depression C. insomnia D. Bradykinesia E. Exophthalamos F. Receptive aphasia
ABD Rationale: Kyphosis is humpback due to the stooped posture, depression as this effects mood, slow rigid movements will be noted. Sleepiness is common not insomnia, bulging eyes is common in thyroid disorders and aphasia is common in stroke.
The nurse is providing teaching to a group of patients regarding CVA (stroke). The patients demonstrate an understanding of the teaching when listing which factors as being the possible cause of a stroke? (Select all that apply.) A Cerebral thrombosis B Cerebral encephalitis C Cerebral hemorrhage D Meningococcal meningitis E Atherosclerosis of the arteries in the head and neck
ACE
The nurse is caring for a patient recently diagnosed with AD. The nurse knows this patient's symptoms are caused by which changes in the brain? (select all that apply) A Neurofibrillary tangles B Development of gumma C Formation of aneurysms D Neuron loss in frontal and temporal lobes E Decreased production of neurotransmitters
ADE
1. An elderly patient who experiences nighttime confusion wanders from his room into the room of another patient. Which intervention will best decrease this patient's nighttime confusion? Administering a sedative at the hour of sleep Leaving a night-light on during the evening and night shifts Assigning a nursing assistant to sit with him until he falls asleep Allowing the patient to share a room with another elderly patient
B
The healthcare provider is planning care for a patient diagnosed with multiple sclerosis (MS). Which of the following is the priority intervention? Choose 1 answer: Choose 1 answer: (Choice A) A Encourage bed rest in order to conserve strength (Choice B) B Teach the patient's family how to meet the patient's needs (Choice C) C Advise the patient to drink liquids through a straw (Choice D) D Monitor the patient's temperature to avoid overheating
C
he LPN/LVN reads on a patient's chart that the patient is exhibiting the sundowning phenomenon. Which behavior should the nurse expect? On sunny days, the patient is disoriented. On cloudy days, the patient is disoriented. The patient becomes disoriented in the evening. The patient is very disoriented in the morning only.
C
A patient with Alzheimer disease (AD) has been prescribed oral donepezil 10 mg. The nurse should give priority to assessing the patient for which sign of an adverse effect of this drug? Skin rashes Cardiac dysrhythmias Decreased blood pressure Gastrointestinal (GI) bleeding
D
The healthcare provider is assessing a patient diagnosed with multiple sclerosis (MS). Which of the following will provide information about the patient's proprioceptive status? Choose 1 answer: Choose 1 answer: (Choice A) A Kernig sign (Choice B) B Chvostek's sign (Choice C) C Lhermitte's sign (Choice D) D Romberg sign
D
The nurse is planning care for a patient with dementia. Which would be an appropriate intervention to include in this patient's care plan? Speak loudly and slowly. Restrain the patient for safety. Involve the patient in new activities. Increase verbal and environmental cues.
D
The nurse who is caring for a patient following a stroke performs passive range-of-motion exercises on the patient. The patient asks why these exercises are so important. Which response by the nurse is accurate? "This helps the patient believe she is making some progress." "This helps overcome mood swings and crying spells." "This helps prevent fatigue from worsening." "This helps to strengthen and retrain muscles."
D
Which of these assessment findings should the healthcare provider expect to identify as an early clinical characteristic of multiple sclerosis (MS)? Choose 1 answer: Choose 1 answer: A Muscle atrophy B Dementia C Vision loss D Clonus
c
A client with a stroke (brain attack) has residual dysphagia. When a diet prescription is initiated, the nurse should avoid which action? 1. Giving the client thin liquids 2. Thickening liquids to the consistency of oatmeal 3. Placing food on the unaffected side of the mouth 4. Allowing plenty of time for chewing and swallowing
1 Before the client with dysphagia is started on a diet, the gag and swallow reflexes must have returned. The client is assisted with meals as needed and is given ample time to chew and swallow. Food is placed on the unaffected side of the mouth. Liquids are thickened to avoid aspiration.
The nurse is planning care for a client in spinal shock. Which action would be least helpful in minimizing the effects of vasodilation below the level of the injury? 1. Moving the client quickly as one unit 2. Using vasopressor medications, as prescribed 3. Applying compression stockings, as prescribed 4. Monitoring vital signs before and during position changes
1 Reflex vasodilation below the level of spinal cord injury places the client at risk of orthostatic hypotension, which may be profound. Actions to minimize this include measuring vital signs before and during position changes, use of a tilt table in early mobilization, and changing the client's position slowly. Venous pooling can be reduced by using compression stockings, if prescribed. Vasopressor medications are used as per protocol and as prescribed.
The nurse is caring for a client with a spinal cord injury. High-top sneakers on the client's feet will prevent the occurrence of which? 1. Foot drop 2. Plantar flexion 3. Pressure ulcers 4. Deep vein thrombosis
1
The healthcare provider is assessing an elderly patient who is disoriented to time and place. Which additional finding would support a diagnosis of delirium? Choose all answers that apply: Choose all answers that apply: (Choice A) A Sudden onset of symptoms (Choice B) B Attention is impaired (Choice C) C Slow and progressive course (Choice D) D Rambling and incoherent speech (Choice E) E Stable symptoms over time (Choice F) F Often linked to an identifiable cause
A B D F
10.The nurse identifies a problem of impaired physical mobility related to bradykinesia for a patient with Parkinson's disease. To assist the patient to ambulate safely, the nurse should a. allow the patient to ambulate only with assistance. b. instruct the patient to rock from side to side to initiate leg movement. c. have the patient take small steps in a straight line directly in front of the feet. d. teach the patient to keep the feet in contact with the floor and slide them forward.
B Rationale: Rocking the body from side to side stimulates balance and improves mobility. The patient should initially be ambulated with assistance but might not require continual assistance with ambulation. The patient should maintain a wide base of support to help with balance. The patient should lift the feet and avoid a shuffling gait.
14. Which of the following interventions is most appropriate for preventing excessive heel pressure? a. flexing the knees b. placing a doughnut-shaped cushion under the feet c. suspending the heels with a pillow d. rubbing lotion twice a day to the heels
C
A patient diagnosed with delirium sees the intravenous (IV) tubing and believes it to be a snake. How should the healthcare provider document this behavior? Choose 1 answer: Choose 1 answer: (Choice A) A Hallucination (Choice B) B Delusion (Choice C) C Confusion (Choice D) D Illusion
d The patient is experiencing an illusion, which is the misinterpretation of a real stimulus. A hallucination is a false sensory perception not associated with a real stimulus. A delusion is a false personal belief that is maintained in spite of evidence to the contrary. A patient who is confused would not believe the IV tubing is a snake.
The nurse is planning care for the client with hemiparesis of the right arm and leg. Where should the nurse plan to place objects needed by the client? 1. Within the client's reach, on the left side 2. Within the client's reach, on the right side 3. Just out of the client's reach, on the left side 4. Just out of the client's reach, on the right side
1
The LPN/LVN discusses ways to prevent a stroke with a patient. Which measures should the nurse include in her teaching? (Select all that apply.) A Proper treatment for hypertension B Adequate treatment of atherosclerosis C Avoiding the use of recreational drugs D Encouraging the use of seat belts in vehicles E Keeping serum cholesterol levels under control
ABCE
A 62-year-old woman is admitted to an assisted-living facility with symptoms of forgetfulness, irritability, difficulty following directions, and neglect of her personal hygiene. These would suggest which stage of AD? Late Early Moderate Moderate to severe
C
The patient with dementia presents to the clinic for a routine examination. The patient's daughter, who is her full-time caregiver, states to the nurse, "I just don't know how much longer I can go on caring for Mom full time. My kids feel neglected, my marriage is suffering, and I feel so run down." What is the best response by the nurse? "You must stay strong for your mother. You are all she has." "Your mother's dementia will improve once we correct the cause." "You should discuss the many medications available for treating and reversing dementia." "As your mother's condition continues to deteriorate, we should discuss alternative care resources."
D
1. The nurse has received report and is planning to inform the aide how best to communication with the client who has cognitive impairment. The best approach is? A Complete explanations with multiple details B Pictures or gestures instead of words C Stimulating words and phrases to capture the client's attention D Short words and simple sentences
D Rationale: Short words and simple sentences minimize client confusion and enhance communication. Complete explanations with multiple details and stimulating words and phrases would increase confusion in a client with short attention span and difficulty with comprehension. Although pictures and gestures may be helpful, they would not substitute for verbal communication.
The children of a patient diagnosed with Alzheimer disease (AD) tell the healthcare provider, "Our mother seems better during the day, but she gets very confused and agitated in the late afternoon and evenings." How should the healthcare provider document the patient's behavior? Choose 1 answer: Choose 1 answer: (Choice A) A Depression (Choice B) B Delirium (Choice C) C Sundowning (Choice D) D Psychosis
c
When reviewing the medical record of a patient diagnosed with Alzheimer disease (AD), the healthcare provider notes the patient is aphasic. Which behavior supports this finding? Choose 1 answer: Choose 1 answer: (Choice A) A Difficulty swallowing (Choice B) B Unable to recognize objects (Choice C) C Unable to speak (Choice D) D Difficultly with motor function
c -phasia" refers to speech. A patient who is aphasic is unable to speak.
The nurse observes that a client with Parkinson's disease has very little facial expression. The nurse attributes this piece of data to which information? 1. Masklike facies is a component of Parkinson's disease. 2. The client does not want her emotional reaction to the disease to show. 3. Clients with Parkinson's disease have diminished emotional involvement. 4. Clients with Parkinson's disease act very much like schizophrenics in that they have very little affect.
1
he nurse is caring for a client who sustained a spinal cord injury. While administering morning care, the client developed signs and symptoms of autonomic dysreflexia. Which is the initial nursing action? 1. Elevate the head of the bed. 2. Digitally examine the rectum. 3. Check the client's blood pressure. 4. Place the client in the prone position
1 Autonomic dysreflexia is a serious complication that can occur in the spinal cord of the injured client. Once the syndrome is identified, the nurse elevates the head of the client's bed and then examines the client for the source of noxious stimuli. The nurse also assesses the client's blood pressure, but the initial action is to elevate the head of the bed.
A client with a stroke (brain attack) is experiencing residual dysphagia. The nurse should remove which food items that arrived on the client's meal tray from the dietary department? 1. Peas 2. Scrambled eggs 3. Mashed potatoes 4. Cheese casserole
1 In general, flavorful, very warm, or well-chilled foods with texture stimulate the swallowing reflex. Moist pastas, casseroles, egg dishes, and potatoes are usually well tolerated. Raw vegetables; chunky vegetables such as diced beets; and stringy vegetables such as spinach, corn, and peas are commonly excluded from the diet of a client with a poor swallowing reflex.
7. A client arrives in the emergency department with a confirmed ischemic stroke and the plan is to administer tissue plasminogen activator (t-PA) administration. What is the priority nursing assessment? A Review current medications. B Complete the physical and history. C Determine time of onset of current stroke. D Coordinate for upcoming surgical procedures.
C Rationale: The time of onset of a stroke to t-PA administration is critical. Administration within 3 hours has better outcomes. A complete history is not possible in emergency care. Upcoming surgical procedures will need to be delay if t-PA is administered. Current medications are relevant, but onset of current stroke takes priority.
. Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? A A blood glucose level of 480 mg/dl. B A right-sided carotid artery blockage. C A blood pressure of 220/120 mmHg. D The presence of pulmonary carcinoma
C Rationale: Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a rupture blood vessel in the cranium. A blockage in the carotid artery would predispose a client to an embolic or ischemic stroke. High blood glucose levels could predispose a patient to ischemic stroke, but not hemorrhagic. Cancer is not a precursor to stroke.
The nurse is planning care for a patient with early AD. Interventions for which patient problems are appropriate for this patient's care plan? (select all that apply) A Pain B Airway patency issues C Nutritional deficiencies D Reduced cardiac output E Caregiver stress and fatigue
C E
11. When planning care for a patient diagnosed with Parkinson disease (PD), which of these patient outcomes should receive priority in the patient's plan of care? A. Taking a daily walk around the neighborhood B. Working on a favorite hobby C. Toileting and bathing independently D. Taking a vitamin supplement each day
C Rationale: continued independence and function is of most importance. Exercising, keeping busy and vitamins are less important priorities.
The nurse is caring for a client with a diagnosis of multiple sclerosis (MS) who has been prescribed amantadine. The client asks the nurse why the amantadine has been prescribed. Which response should the nurse make? 1. "It is prescribed to relieve fatigue." 2. "It is prescribed to decrease spasticity." 3. "It is prescribed to treat urinary retention." 4. "It is prescribed to relieve neuropathic pain."
1 Amantadine is used to relieve fatigue associated with the disease. The spasticity experienced by MS patients may respond to treatment with baclofen. Carbamazepine and gabapentin are used to relieve neuropathic pain. Urinary retention is treated with cholinergic drugs such as bethanechol.
A patient diagnosed with multiple sclerosis (MS) is admitted to the medical unit. When assessing the patient, which of the following will the healthcare expect to identify? Choose all answers that apply: Choose all answers that apply: (Choice A) A Seizures (Choice B) B Scanning speech (Choice C) C Resting tremors (Choice D) D Flaccid paralysis (Choice E) E Nystagmus( INVOLUNTARY EYE MOVEMENT)
B E Common findings can be remembered as the Charcot triad: nystagmus (and/or double vision), scanning speech (slow, hesitant pronunciation of words as syllables), and intention tremor.
A halo vest is applied to a client following a cervical spine fracture. The nurse reinforces instructions to the client regarding safety measures related to the vest. Which statement by the client indicates a need for further teaching? 1. "I will scan the room to see things." 2. "I will wear rubber-soled shoes for walking." 3. "I will use a walker for ambulating if I need to." 4. "I will bend at the waist, keeping the halo vest straight to pick up items."
4 The client with a halo vest should avoid bending at the waist because the halo vest is heavy and the client's trunk is limited in flexibility. It is helpful for the client to scan the environment visually because the client's peripheral vision is diminished from keeping the neck in a stationary position. Use of a walker and rubber-soled shoes may help prevent falls and injury, so these items are also helpful.
The healthcare provider is teaching a group of patients diagnosed with multiple sclerosis (MS) about common bladder problems. Which of the following will the healthcare provider include? Choose all answers that apply: Choose all answers that apply: (Choice A) A "MS may cause the bladder to contract and empty more often than usual." (Choice B) B "You should not attempt to urinate until you feel that your bladder is full." (Choice C) C "Drinking caffeinated beverages can help you empty your bladder completely." (Choice D) D "Drinking lots of citrus juices will decrease the amount of bacteria in your urinary tract." (Choice E) E "Drink 1.5 - 2 liters of water each day so your urine isn't too concentrated." (Choice F) F "Patients with MS are at increased risk of developing urinary tract infections
E F Drinking at least 1.5 - 2 liters of water each day will keep urine dilute. This will decrease bladder irritation. MS heightens a patient's risk of urinary tract infections. Patients should plan to void on a regular basis. Voiding at least every 2 hours will decrease urine stasis.
A client is admitted to the emergency department with a C4 spinal cord injury. The nurse performs which intervention first when collecting data on the client? 1. Taking the temperature 2. Observing for dyskinesia 3. Monitoring the respiratory rate 4. Checking extremity muscle strength
3 Because respiratory compromise is a leading cause of death in cervical spinal cord injury, respiratory assessment is the highest priority.
The nurse is collecting admission data on a client with Parkinson's disease. The nurse asks the client to stand with the feet together and the arms at the side and then to close the eyes. The nurse notes that the client begins to fall when the eyes are closed. Based on this finding, the nurse documents which in the client's record? 1. Positive Romberg's test 2. Negative Romberg's test 3. Positive Trousseau's sign 4. Negative Trousseau's sign
1 Romberg's test checks for cerebellar functioning related to balance. The client stands with the feet together and the arms at the side and then closes the eyes. Slight swaying is normal, but loss of balance indicates a problem and a positive Romberg's test. Trousseau's sign indicates a calcium imbalance.
A patient has had a left-sided cerebrovascular accident (CVA). Which condition does the nurse expect the patient to have as a result of the CVA? Ataxia Aphasia Dyslexia Quadriplegia
B Speech centers are located in the left hemisphere; processing is often affected by a left CVA. Although ataxia, dyslexia, or quadriplegia may also occur, the most specific to a left CVA is aphasia.
An 84-year-old client in an acute state of disorientation was brought to the emergency department by the client's daughter. The daughter states that this is the first time that the client experienced confusion. The nurse determines from this piece of information that which is unlikely to be the cause of the client's disorientation? 1. Hypoglycemia 2. Alzheimer's disease 3. Medication dosage error 4. Impaired circulation to the brain
2 Alzheimer's disease is a chronic disease with progression of memory deficits over time. The situation presented in the question represents an acute problem. Medication use, hypoglycemia, and impaired cerebral circulation require evaluation to determine if they play a role in causing the client's current symptom
A client has a halo vest that was applied following a C6 spinal cord injury. The nurse performs which action to determine whether the client is ready to begin sitting up? 1. Puts both of the client's hip joints through full range of motion 2. Compares the client's pulse and blood pressure when both flat and sitting 3. Loosens the vest to gather data on the client's ability to support his own trunk 4. Inspects the halo vest pin sites to monitor for purulent drainage, redness, and pain
2 Clients with cervical spinal cord injuries may lose control over peripheral vasoconstriction, causing postural (orthostatic) hypotension when upright. A drop of 15 mm Hg in the systolic pressure or 10 mm Hg in the diastolic pressure accompanied by an increase in heart rate when the head is elevated may indicate autonomic insufficiency that can cause dizziness or syncope in the upright position.
The nurse is reviewing the medical record of a client diagnosed with amyotrophic lateral sclerosis (ALS). Which initial sign/symptom of this disorder supports this diagnosis? 1. Muscle wasting 2. Mild clumsiness 3. Altered mentation 4. Diminished gag reflex
2 The initial manifestation of ALS is a mild clumsiness usually in the distal portion of one extremity. The client may complain of tripping and may drag one leg when the lower extremities are involved.
A client with spinal cord injury has experienced more than one episode of autonomic dysreflexia. The nurse should avoid which action that could trigger an episode of this complication? 1. Preventing pressure on the client's lower limbs 2. Rigidly adhering to a bowel retraining program 3. Allowing the client's bladder to become distended 4. Keeping the linen under the client free of wrinkles
3
The nurse is caring for a client with a diagnosis of multiple sclerosis who has been prescribed oxybutynin. The nurse evaluates the effectiveness of the medication by asking the client which question? 1. "Are you consistently fatigued?" 2. "Are you having muscle spasms?" 3. "Are you getting up at night to urinate?" 4. "Are you having normal bowel movements?"
3
The nurse is trying to communicate with a stroke (brain attack) client with aphasia. Which action by the nurse would be least helpful to the client? 1. Speaking to the client at a slower rate 2. Allowing plenty of time for the client to respond 3. Completing the sentences that the client cannot finish 4. Looking directly at the client during attempts at speech
3
A resident in a long-term care facility prepares to walk out into a rainstorm after saying, "My father is waiting to take me for a ride." An appropriate response by the nurse is which? 1. "I need you to sign a form before leaving." 2. "If you try to leave, I will need to restrain you." 3. "How old are you? Your father must no longer be living." 4. "I'm glad you told me that. Let's have a cup of coffee and you can tell me about your father."
4
The nurse is caring for a client with a diagnosis of brain attack (stroke) with anosognosia. To meet the needs of the client with this deficit, which action does the nurse plan? 1. Encourage communication. 2. Provide a consistent daily routine. 3. Promote adequate bowel elimination. 4. Increase the client's awareness of the affected side.
4
The nurse is collecting data on a client diagnosed with Parkinson's disease. Which finding indicates a serious complication of this disorder? 1. Shuffling and propulsive gait 2. Resting and pill-rolling tremors 3. Last bowel movement was 48 hours ago 4. Congested cough and coarse rhonchi heard during auscultation
4 Clients with Parkinson's disease are at risk for aspiration. A congested cough and coarse rhonchi may be present after a client aspirates. Although constipation is a problem for clients
The nurse is monitoring a client with a spinal cord injury for signs of spinal shock. Which sign is indicative of this complication of a spinal cord injury? 1. Hypertension 2. Tachycardia 3. Profuse diaphoresis 4. Areflexia below the level of injury
4 Spinal shock represents a temporary but profound disruption of spinal cord function, which occurs immediately after injury and is clinically evident within 30 to 60 minutes. It is a state of areflexia characterized by the loss of all neurological function below the level of injury. Flaccid paralysis, bradycardia, and hypotension occur. The body is unable to use either shivering or perspiring as a means of controlling body temperature.
During the advanced stages of amyotrophic lateral sclerosis (ALS), which service would be most beneficial to the family and patient? Hospice services Correct In-home physical therapy Pulmonary rehabilitation program Incorrect Nursing visits from a home health care agency
A ALS is a progressive disease with no known cure. The prognosis for most patients with ALS is death within about 3 years from the onset of symptoms. In the advanced stages of ALS, the patient and family would most benefit from the services offered by hospice. In-home physical therapy, home health care, and pulmonary rehabilitation are beneficial in the earlier stages of the disease.
8. The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? A An oral anticoagulant medication. B A beta-blocker medication. C An anti-hyperuricemic medication. D A thrombolytic medication.
A Rationale: Thrombi form secondary to atrial fibrillation, therefore, an anticoagulant would be anticipated to prevent thrombi formation; and oral (warfarin [Coumadin]) at discharge verses intravenous. Beta blockers slow the heart rate and lower the blood pressure. Anti-hyperuricemic medication is given to clients with gout. Thrombolytic medication might have been given at initial presentation but would not be a drug prescribed at discharge
The nurse is assessing a patient admitted for a work-up to rule out ALS. Which symptoms are typically exhibited in a patient with ALS? (Select all that apply.) A Muscle pain B Slurred speech C Muscle spasticity D Decreased sensation E Difficulty swallowing
ABCE Muscle pain and spasticity, slurred speech, and difficulty swallowing are all symptoms of ALS. Decreased sensation is not a symptom of ALS.
2. The nurse is caring for a client in the mild stage of dementia of the Alzheimer's type. The nurse would expect upon assessment the client has the ability to? A Remember the daily schedule B Recall past events C Cope with anxiety D Solve problems of daily living
B Rationale: Recent memory loss is the characteristic sign of cognitive difficulty in early Alzheimer's disease. The ability to recall past events is usually retained until the later stages of this disorder. Remembering daily schedules, coping with anxiety, and solving problems of daily living are areas that would pose difficulty in the early phase of Alzheimer's disease.
A patient experienced injury to the spinal cord in the cervical region, with paralysis and loss of sensory perception in both legs and both arms. What term is used to describe this condition? Paraplegia Hemiplegia Homoplegia Quadriplegia
D Injury to the spinal cord in the cervical region with paralysis and the loss of sensory perception in both legs and both arms is quadriplegia. Paraplegia is paralysis of both legs. Hemiplegia is paralysis of one half of the body. Homoplegia is not used to describe paralysis in the body.
A patient diagnosed with multiple sclerosis (MS) tells the healthcare provider, "I'm not sure if I'll be able to exercise anymore." Which of these is the most appropriate response? Choose 1 answer: Choose 1 answer: (Choice A) A "Exercise often causes a relapse of the disease, so it should be avoided." (Choice B) B "Swimming or exercising in the water can be both enjoyable and beneficial." (Choice C) C "It's important for you to conserve your strength by not being too active." (Choice D) D "You should get a personal trainer to help you plan a fitness program."
B
The nurse is monitoring a client with a spinal cord injury who is experiencing spinal shock. Which assessment will provide the nurse with the best information about recovery from the spinal shock? 1. Reflexes 2. Pulse rate 3. Temperature 4. Blood pressure
1 Areflexia characterizes spinal shock; therefore, reflexes should provide the best information. Vital sign changes are not consistently affected by spinal shock.
The nurse is preparing to care for a client with a diagnosis of brain attack (stroke). The nurse notes in the client's record that the client has anosognosia. The nurse plans care, knowing which is a characteristic of anosognosia? 1. The client has difficulty speaking. 2. The client neglects the affected side. 3. The client has difficulty swallowing. 4. The client experiences physical fatigue.
2 In anosognosia, the client neglects the affected side of the body. The client may neglect the affected side (often creating a safety hazard as a result of potential injuries) or state that the involved arm or leg belongs to someone else. Options 1, 3, and 4 are not associated with anosognosia.
The nurse is reinforcing instructions to the family of a stroke client who has homonymous hemianopsia about measures to help the client overcome the deficit. The nurse determines that the family understands the measures to use if they state that they will do which? 1. Place objects in the client's impaired field of vision. 2. Approach the client from the impaired field of vision. 3. Discourage the client from wearing his or her own eyeglasses. 4. Remind the client to turn the head to scan the lost visual field.
4 Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and performs client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses if they are available.
The client with spinal cord injury is prone to experiencing autonomic dysreflexia. The least appropriate measure to minimize the risk of autonomic dysreflexia is which action? 1. Strictly adhering to a bowel retraining program 2. Keeping the linen wrinkle-free under the client 3. Avoiding unnecessary pressure on the lower limbs 4. Limiting bladder catheterization to once every 12 hours
4 The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be performed every 4 to 6 hours, and indwelling bladder catheters should be checked frequently for kinks in the tubing. It is not appropriate to catheterize the client every 12 hours. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important.
Which of the following statements made by a patient diagnosed with multiple sclerosis (MS) would alert the healthcare provider that the patient requires additional instruction about the disease? Choose all answers that apply: Choose all answers that apply: (Choice A) A "A hot bath in the evenings will help relax my muscles and relieve pain." (Choice B) B "Use of stress reduction strategies can decrease the severity of my symptoms." (Choice C) C "Regular exercise can help reduce fatigue and help improve my sense of balance." (Choice D) D "I will avoid foods that are high in fiber to prevent problems with my bowels." (Choice E) E "It's important for me to inspect my skin daily make sure there aren't any injuries."
A D
13. A patient is suspected of having multiple sclerosis. The neurologist orders various test. The patient's MRI results are back and show lesions on the cerebellum and optic nerve. What signs and symptoms below would correlate with this MRI finding in a patient with multiple sclerosis?* • A. Blurry vision • B. Pain when moving eyes • C. Dysarthria • D. Balance and coordination issues • E. "Pill rolling" of fingers and hands • G. Heat intolerance • H. Dark spots in vision • I. Ptosis
A, B C, D, and H. If lesions are present on the optic nerves, optic neuritis can occurs which can lead to blurry vision, pain when moving the eyes, and dark spots in the vision. If cerebellar lesions are found, this can affect movement, speech, and some cognitive abilities. This would present as dysarthria (issues articulating words), and balance/coordination issue
A patient has recently been diagnosed with MS. The family asks the nurse about the common manifestations of the disease. The nurse is correct by identifying which as the most common clinical manifestation of the disease? Urinary incontinence Weakness of the limbs A loss of the sense of smell Decreased intellectual function
B
The nurse is collecting data on a client suspected of having Alzheimer's disease. The priority data should focus on which characteristics of this disease? Select all that apply. 1. Difficulty learning 2. Recent memory loss 3. Problems with concrete thinking 4. Difficulty in performing new tasks 5. Problems with hearing and discriminating the spoken word from other sounds
1 2 Dementia (difficulty learning and recent memory loss) is the hallmark of Alzheimer's disease. Recent memory loss (such as forgetting to turn off a stove after cooking) is one characteristic. Difficulty learning is another characteristic. Others include problems with abstract thinking, problems with speech (not hearing), and difficulty in performing familiar tasks.
6. Regular oral hygiene is an essential intervention for the client who has had a stroke. Which of the following nursing measures is appropriate when providing oral hygiene? A Placing the client on the back and flat. B Keeping portable suctioning equipment at the bedside. C Use a tongue blade to open the mouth when the client refuses D Cleaning the client's mouth only when cleared by occupational therapy.
B Rationale: Having suction available is safe and appropriate when providing oral care to clear the airway if necessary. stroke clients best position for oral care is side lying to assist with drooling and drainage of secretions, never force anything in the mouth when a client is refusing this is dangerous to the client as well as the caregiver, and nursing does not have to wait for clearance to perform oral care by OT.
Which of the following, if assessed in a patient, will the healthcare provider identify as a risk factor for the development of delirium? Choose all answers that apply: Choose all answers that apply: (Choice A) A Decreased social interactions (Choice B) B Organ failure (Choice C) C Administration of opioids (Choice D) D Decreased physical activity (Choice E) E Sleep deprivation (Choice F) F Infections
B C E F Sleep deprivation (common in hospitalized patients), organ failure, infections, and numerous drugs can put a patient at risk for delirium. Decreased social interaction can exacerbate delirium but will not cause delirium. Here's handy mnemonic to remember general risk factors for delirium: D = Dementia, E = Electrolyte disorders, L = Liver, lung, heart, kidney, brain, I = Infection, R = Rx (medications), I = Injury, pain, stress, U = Unfamiliar environment, M = Metabolic
A client is recovering at home after suffering a brain attack (stroke) 2 weeks ago. A home caregiver tells the home health nurse that the client has some difficulty swallowing food and fluids. Which nursing action would be appropriate? 1. Observe the caregiver feeding the client. 2. Observe the client feeding himself or herself. 3. Arrange for a home health aide to assist at mealtimes. 4. Instruct the caregiver to use a feeding syringe to feed the client.
2 It is not uncommon for a client to have difficulty swallowing after having a brain attack (stroke). Often the client has hemiplegia. The client's arm may be paralyzed, and the client has to learn to use an opposite arm to feed himself or herself. Using a different arm may require rehabilitation and retraining. Also a client may have partial paralysis of the mouth, tongue, or esophagus. To best assist the client, the nurse should first assess the situation by watching the client feed himself or herself. Perhaps the problem lies in the feeding technique, the type of feeding tool used, the types of foods being served, or a combination of problems. Having someone else feed the client may be necessary if the client is determined to be unable to feed himself or herself, but this action does not promote independence in the client. A feeding syringe is not recommended for feeding most clients.
A client with Parkinson's disease is embarrassed about the symptoms of the disorder and is bored and lonely. The nurse should plan which approach as therapeutic in assisting the client to cope with the disease? 1. Plan only a few activities for the client during the day. 2. Cluster activities at the end of the day when the client is most bored. 3. Encourage and praise perseverance in exercising and performing ADL. 4. Assist the client with activities of daily living (ADL) as much as possible.
3 The client with Parkinson's disease tends to become withdrawn and depressed and therefore should become an active participant in his or her own care to prevent this. Activities should be planned throughout the day to prevent daytime sleeping and boredom. The nurse gives the client encouragement and praises the client for perseverance. Activities such as exercise help prevent progression of the disease, and self-care improves self-esteem.
4. An elderly client diagnosed with Alzheimer's disease becomes agitated and combative when a nurse approaches to help with morning care. The most appropriate nursing intervention in this situation would be to: A tell the client firmly that it is time to get dressed. B obtain assistance to restrain the client for safety. C remain calm and talk quietly to the client. D call the doctor and request an order for sedation
C Rationale: Maintaining a calm approach when intervening with an agitated client is extremely important. Telling the client firmly that it is time to get dressed may increase his agitation, especially if the nurse touches him. Restraints are a last resort to ensure client safety and are inappropriate in this situation. Sedation should be avoided, if possible, because it will interfere with CNS functioning and may contribute to the client's confusion.
A patient diagnosed with dementia is prescribed a medication that inhibits acetylcholinesterase. Which of the following accurately explains how this medication benefits the patient? Choose 1 answer: Choose 1 answer: (Choice A) A Acetylcholine increases norepinephrine activity and decreases depression (Choice B) B Acetylcholine is needed for memory and problem solving (Choice C) C Decreased levels of acetylcholine will help decrease the patient's anxiety (Choice D) D Inhibition of acetylcholinesterase improves the patient's motor function
B Because acetylcholine is involved in cognitive functions like memory and problem solving, increased levels of acetylcholine will improve these functions.
3. An 82-year-old was admitted for a right hip fracture caused from a fall at home. The health care team is also concerned about a delirium. Which statement by the client's daughter best supports the diagnosis? A "Maybe it's just caused by aging. This usually happens by age 82." B "The changes in his behavior came on so quickly! I wasn't sure what was happening." C "Dad just didn't seem to know what he was doing. He would forget what he had for breakfast." D "Dad has always been so independent. He's lived alone for years since mom died."
B Rationale: Delirium is an acute process characterized by abrupt, spontaneous cognitive dysfunction. Cognitive impairment disorders (dementia or delirium) are not normal consequences of aging. Option C would be characteristic of someone with dementia. Although option D provides background data about the client, it is unrelated to the current problem of delirium.
15. A patient with a spinal cord injury (SCI) complains about a severe throbbing headache that suddenly started a short time ago. Assessment of the patient reveals increased blood pressure (168/94) and decreased heart rate (48/minute), diaphoresis, and flushing of the face and neck. What action should you take first? A Administer the ordered acetaminophen (Tylenol). B Check the Foley tubing for kinks or obstruction. C Adjust the temperature in the patient's room. D Notify the physician about the change in status.
B Rationale: B. These signs and symptoms are characteristic of autonomic dysreflexia, a neurologic emergency that must be promptly treated to prevent a hypertensive stroke. The cause of this syndrome is noxious stimuli, most often a distended bladder or constipation, so checking for poor catheter drainage, bladder distention, or fecal impaction is the first action that should be taken. Option C: Adjusting the room temperature may be helpful, since too cool a temperature in the room may contribute to the problem. Option A: Tylenol will not decrease the autonomic dysreflexia that is causing the patient's headache. Option D: Notification of the physician may be necessary if nursing actions do not resolve symptoms. Focus: Prioritization
5. A nurse is developing a plan of care for a client with a moderate cognitive impairment involving dementia of the Alzheimer's type. Which intervention would not be appropriate to include? A Daily structured schedule B Positive reinforcement for performing activities of daily living C Stimulating environment D Use of validation techniques
C Rationale: A stimulating environment is a source of confusion and anxiety for a client with a moderate level of impairment and, therefore, would not be included in the plan of care. The remaining options are all appropriate interventions for this client.
When teaching the patient with multiple sclerosis (MS) about how to best manage his disease, the nurse determines the patient requires further instruction when making which statement? "It is important that I attend all of my physical therapy sessions." "I should eat adequate fiber to prevent constipation." "It is a good idea for me to take a hot shower in the morning to relax my muscles." "The injections of interferon beta-1b (Betaseron) will help manage my symptoms."
C Heat often exacerbates the symptoms of MS, so a hot shower in the morning is not advisable. Physical therapy and exercise are important for maintaining muscle strength. Constipation can be prevented by eating adequate fiber. Biologic response modifier drugs help treat the symptoms of MS; there is currently no cure for the disease.
The student nurse is assisting the nurse in turning a patient who is in cervical traction. What is most important for the LPN/LVN to instruct the student to do when assisting in turning the patient? Flex the knees and hips before turning the patient. Support the patient's head with a pillow so that his neck is flexed. Turn the patient slowly and as one unit to avoid twisting the spine. Place the patient's back in traction so that the spine will be kept slightly flexed.
C One of the most important interventions when turning a patient in traction, or turning any patient with a spinal cord injury, is to logroll the patient in order to avoid twisting the vertebral column and further damaging the spinal cord. Nurses should always assist in turning a patient with a spinal cord injury; this intervention should never be delegated to assistive personnel.
