Nur 103 questions

Which descriptions is most suggestive of Parkinson disease

"Lately he seems to move far more slowly than he ever has in the past." -Parkinson disease is characterized by bradykinesia. It does not manifest as memory loss, increased appetite, or joint stiffness.

patient has gained 4 kg in the past 3 days. In milliliters, how much fluid retention does this equal?

- 4000 -1 kg=1000 ml

Which condition occurs when blood collects between the dura mater and arachnoid membrane?

- Subdural Hematoma

what finding would be for AKI

- client output 10 ml/hr- -most common sign is oliguria in AKI not flank pain or inability to void.

Peritoneal dialysis- what is important to be taught

- use Aseptic technique - Mask if RR infection present - Cath stabilized on abdomen above belt line. - cleaned with iodine not soap

he care team suspects an epidural hematoma. Based on the knowledge of the progression of this type of hematoma, the nurse prepares for which priority intervention?

-Emergency craniotomy - an extreme emergency. Marked neurologic deficit or respiratory arrest can occur within minutes. Treatment consists of making an opening through the skull to decrease ICP emergently, remove the clot, and control the bleeding.

Pancreatitis

-Pain on left side

A client with a neurologic deficit is feeling frustrated because it is very difficult to pronounce words since having a stroke. The client is struggling with:

-dysarthria. -Dysphasia is characterized by the compromised ability to put words together meaningfully. Ataxia is a dysfunction of the parts of the nervous system that coordinate movement. Dysphagia is difficulty with swallowing.

A client with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding?

Absence of reflexes along with flaccid extremities

Increased ICP is suspected. Appropriate nursing interventions would include which of the following?

Administer benzodiazepines on a PRN basis??? - sedative.. not sure thought sedatives were not supposed to be used?

head injury for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first

Alteration in level of consciousness (LOC)

The nurse is caring for a client who is rapidly progressing toward brain death. The nurse should be aware of what cardinal signs of brain death? Select all that apply.

Apnea Coma Absence of brain stem reflexes

What physical assessment finding is suggestive of a basilar skull fracture?

Bruising over the mastoid

When assessing a client who has experienced a spinal injury, the nurse notes diaphragmatic breathing and loss of upper limb use and sensation. At what level does the nurse anticipate the injury has occurred?

C5

A nurse should perform which intervention for a client with Cushing's syndrome?

Explain that the client's physical changes are a result of excessive corticosteroids.

thyroid nodule may be malignant.;usual test that will be ordered to establish a diagnosis. What is that test?

Fine-needle biopsy of the thyroid gland

anxiety, insomnia, weight loss, the inability to concentrate, and eyes feeling "gritty." Thyroid function tests reveal the following: thyroid-stimulating hormone (TSH) 0.02 U/ml, thyroxine 20 g/dl, and triiodothyronine 253 ng/dl. A 6-hour radioactive iodine uptake test showed a diffuse uptake of 85%.

Graves

Position for ICP

HOB 30 degrees

A client is admitted reporting low back pain. How will the nurse best determine if the pain is related to a herniated lumbar disc?

Have the client lie on the back and lift the leg, keeping it straight.

Which of the following symptoms are indicative of a rapidly expanding acute subdural hematoma? Select all that apply.

Hemiparesis Decreased reactivity of the pupils Bradycardia Coma

ACU after surgery for a tumor within the spine. The client complains of pain. When positioning the client for comfort and to reduce injury to the surgical site, the nurse will position to client in what position?

In a flat side-lying position

large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the physician sutures the wound?

Irrigates the wound to remove debris

What does the nurse administer to the patient that is considered the most effective drug currently given for the tremor of Parkinson's?

Levodopa

A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family?

Monitor for ICP

chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of small patches of demyelination in the brain and spinal cord?

Multiple sclerosis

A client with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. What is the nurse's best intervention for preventing injury?

Pad the side rails of the client's bed. - no opioids because it can depress respiration, constrict pupils.

The nurse is caring for a patient who sustained a major burn. What serious gastrointestinal disturbance should the nurse monitor for that frequently occurs with a major burn?

Paralytic ileus

The critical care nurse is admitting a client in myasthenic crisis to the ICU. The nurse should prioritize what nursing action in the immediate care of this client?

Providing ventilatory assistance

Liver Biopsy Positioning

Right side with pillow/towel against puncture site

disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan?

Risk for injury

A client who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the client's current health status is most likely to have precipitated this event?

The client's urinary catheter became occluded. -A distended bladder is the most common cause of autonomic dysreflexia.

What should the nurse identify as prominent risk factors for SCI? Select all that apply.

Young age Male gender Alcohol or drug use

A patient is ordered desmopressin (DDAVP) for the treatment of diabetes insipidus. What therapeutic response does the nurse anticipate the patient will experience?

decreased urine output

Which are characteristics of autonomic dysreflexia?

severe hypertension, slow heart rate, pounding headache, sweating

Lumbar puncture Positioning

side lying, chin to chest, legs curled to abd. After procedure lay on puncture site to prevent CSF leakage. - left side.