Nursing 204 - Study Questions - Week 3
A nurse plans care for a client with Parkinson disease. Which intervention would the nurse include in this client's plan of care? A. Ambulate the client in the hallway twice a day. B. Ensure fluid intake of at least 3L/day. C. Teach the client pursed-lip breathing techniques. D. Keep the head of the bed at 30 degrees or greater.
D
A client will be receiving plasmapheresis for treatment of Guillain-Barre' syndrome (GBS). Which posttreatment test will the nurse anticipate to be ordered? A. Electrolyte panel B. Electroencephalogram (EEG) C. Lumbar puncture D. Urinalysis
A
A client with Parkinson disease (PD) is being discharged home with his wife. To ensure success with the management plan, which discharge action is most effective? A. Involving the client and his wife in developing a plan of care B. Setting up visitations by a home health nurse C. Telling his wife what the client needs D. Writing up a detailed plan of care according to standards
A
A client with early-stage Alzheimer's disease is admitted to the surgical unit for a biopsy. Which client problem is the priority? A. Potential for injury related to chronic confusion and physical deficits B. Risk for reduced mobility related to progression of disability C. Potential for skin breakdown related to immobility and/or impaired nutritional status D. Lack of social contact related to personality and behavior changes
A
A client with severe muscle spasticity has been prescribed tizanidine (Zanaflex, Sirdalud). The nurse instructs the client about which adverse effect of tizanidine? A. Drowsiness B. Hirsutism C. Hypertension D. Tachycardia
A
A client with trigeminal neuralgia is admitted for a percutaneous stereotactic rhizotomy in the morning. The client currently reports pain. What does the nurse do next? A. Administers pain medication as requested B. Ensures that the client has nothing by mouth (NPO) C. Ensures that the preoperative laboratory work is complete D. Performs a preoperative assessment
A
Which statement correctly illustrates the commonality between Guillain-Barré syndrome (GBS) and myasthenia gravis (MG)? A. The client's respiratory status and muscle function are affected by both diseases. B. Both diseases are autoimmune diseases with ocular symptoms. C. Both diseases exhibit exacerbations and remissions of their signs and symptoms. D, Demyelination of neurons is a cause of both diseases.
A
A nurse assesses a client with Alzheimer's disease who is recently admitted to the hospital. Which psychosocial assessment would the nurse complete? A. Assess religious and spiritual needs while in the hospital. B. Identify the client's ability to perform self-care activities. C. Evaluate the client's reaction to a change of environment. D. Ask the client about relationships with family members.
C
A nurse assesses a patient with spinal cord injury at level T5. The patient's blood pressure is 184/95, and the patient presents with a flushed face and blurred vision. What action would the nurse take first? A. Initiate oxygen via a nasal cannula. B. Place the patient in a supine position. C. Palpate the bladder for distention D. Administer a prescribed beta-blocker.
C
A nurse assesses patient at a community center. Which patient is at greatest risk for lower back pain? A. A 24 year old female who is 25 weeks pregnant B. A 36 year old male who uses ergonomic techniques C. A 45 year old male with osteoarthritis D. A 53 year old female who uses a walker
C
The nurse is caring for a client postoperatively after an anterior cervical diskectomy and fusion. Which assessment finding is of greatest concern to the nurse? A. Neck pain is at a level 7 on a 0-to-10 scale. B. Serosanguineous fluid oozes onto the neck dressing. C. The client is reporting difficulty swallowing secretions. D. The client has numbness and tingling bilaterally down the arms.
C
The nurse is caring for a client with Guillain-Barré syndrome (GBS) who is receiving intravenous immunoglobulin (IVIG). Which assessment finding warrants immediate evaluation? A. Chills B. Generalized malaise C. Headache with stiff neck D. Temperature of 99° F (37° C)
C
A patient in the family practice clinic has restless leg syndrome. Routine laboratory work reveals WBC 8,000, magnesium level 0.8, and sodium 138. What action by the nurse is best? A. Advise the patient to restrict fluids. B. Assess the patient for signs of infection. C. Have the patient add table salt to food. D. Instruct the patient to take a magnesium supplement.
D
A client has just returned from cerebral angiography. Which symptom does the client display that causes the nurse to act immediately? A. Bleeding B. Increased temperature C. Severe headache D. Urge to void
A
A client has received preoperative teaching from the nurse for a microdiskectomy. Which statement by the client indicates a correct understanding of the nurse's instruction? A. "I can go home the day of the procedure." B. "I can go home 48 hours after the procedure." C. "I'll have a drain in place after the procedure." D. "I'll need to wear special stockings after the procedure."
A
A client is admitted into the emergency department (ED) with frontal-temporal pain, preceded by a visual disturbance. The client is upset and thinks it is a stroke. What does the nurse suspect may be occurring? A. Classic migraine B. Meningitis C. Stroke D. West Nile virus
A
A client is admitted with bacterial meningitis. Which nursing intervention is the highest priority for this client? A. Assessing neurologic status at least every 2-4 hours B. Decreasing environmental stimuli C. Managing pain through drug and nondrug methods D. Strict monitoring of hourly intake and output
A
A client is being discharged to home with progressing stage I Alzheimer's disease. The family expresses concern to the nurse about caring for their parent. What is the priority for best continuity of care? A. Assigning a case manager B. Ensuring that all family questions are answered before discharge C. Providing a safe environment D. Referring the family to the Alzheimer's Association
A
A client is being evaluated for signs associated with myasthenic crisis or cholinergic crisis. Which symptoms lead the nurse to suspect that the client is experiencing a cholinergic crisis? A. Abdominal cramps, blurred vision, facial muscle twitching B. Bowel and bladder incontinence, pallor, cyanosis C. Increased pulse, anoxia, decreased urine output D. Restlessness, increased salivation and tearing, dyspnea
A
A client is scheduled for an electroencephalogram (EEG) in the morning. Which instruction does the nurse give the client? A. "Do not take any sedatives 12-24 hours before the test." B. "Please do not have anything to eat or drink after midnight." C. "You may bring some music to listen to for distraction." D. "You will need to have someone to drive you home."
A
A client newly diagnosed with Parkinson disease (PD) is being discharged. Which instruction is best for the nurse to provide to the client's spouse? A. Administer medications promptly on schedule to maintain therapeutic drug levels. B. Complete activities of daily living for the client. C. Provide high-fiber, high-carbohydrate foods. D. Speak loudly for better understanding.
A
A client presents to the clinic with a migraine and is lying in a darkened room with a wet cloth on the head after receiving treatment. In preparation for dismissal home, what does the nurse do next? A. Allow the client to remain undisturbed. B. Assess the client's vital signs. C. Remove the cloth because it can harbor microorganisms. D. Turn on the lights for a neurologic assessment.
A
A client's spouse expresses concern that the client, who has Guillain-Barré syndrome (GBS), is becoming very depressed and will not leave the house. What is the nurse's best response? A. "Contact the Guillain-Barré Syndrome Foundation International for resources. Here is their contact information." B. "Try inviting several people over so the client won't have to go out." C. "Let your spouse stay alone. Your spouse will get used to it." D. "This behavior is normal."
A
A nurse assesses a patient who demonstrates a positive Romberg's sign with eyes closed but not eyes open. Which condition does the nurse associate with his finding? A. Difficulty with proprioception. B. Peripheral motor disorder. C. Impaired cerebellar function. D. Positive pronator drift.
A
A nurse assesses a patient who is recovering from anterior cervical discectomy and fusion. Which complication would alert the nurse to urgently communicate with the healthcare provider? A. Auscultated stridor B. Weak pedal pulses C. Difficulty swallowing D. Inability to shrug shoulders
A
A nurse delegates care for a client with Parkinson disease to an unlicensed assistive personnel (UAP). Which statement would the nurse include when delegating the client's care? A. "Allow the client to be as independent as possible with activities." B. "Assist the client with frequent and meticulous oral care." C. "Assess the client's ability to eat and swallow before each meal." D. "Schedule appointments early in the morning to ensure rest in the afternoon."
A
After teaching a patient with a spinal cord injury, the nurse assesses the patient's understanding. Which patient statement indicates a correct understanding of how to prevent respiratory problems at home? A. "I will use my incentive spirometer every 2 hours while I'm awake." B. "I will drink thinned fluids to prevent choking." C. "I will take cough medicine to prevent excessive coughing." D. "I will position myself on my ride side so I don't aspirate."
A
An older patient is hospitalized with GBS. A family member tells the nurse that the patient is restless and seems confused. What action by the nurse is best? A. Assess the patient's oxygen saturation B. Check the medication list for interactions C. Place the patient on a bed alarm D. Put the patient on safety precautions
A
The nurse encourages a ventilated client with advanced Guillain-Barré syndrome (GBS) to communicate by which simple technique? A. Blinking for "yes" or "no" B. Moving lips to speak C. Using sign language D. Using a laptop to write
A
The nurse is caring for a client who is scheduled to have a transcranial Doppler (TCD). What does this diagnostic test evaluate? A. Cerebral vasospasm B. Cerebrospinal fluid C. Evoked potentials D. Intracranial pressure
A
The nurse is caring for a client with advanced Alzheimer's disease. Which communication technique is best to use with this client? A. Assuming that the client is not totally confused B. Providing the client with several options to choose from C. Waiting for the client to express a need D. Writing down instructions for the client
A
The nurse is performing a neurologic assessment on an 81-year-old client. Which physiologic change does the nurse expect to find because of the client's age? A. Decreased coordination B. Increased sleeping during the night C. Increased touch sensation D. Nightly confusion
A
The nurse is reviewing the history of a client who has been prescribed topiramate (Topamax) for prevention of migraines. The nurse plans to contact the primary care provider (PCP) if the client has which condition? A. Bipolar disorder B. Diabetes mellitus C. Glaucoma D. Hypothyroidism
A
The nurse prepares to assess a client with diabetes mellitus for sensory loss. Which equipment is the best choice for the nurse use to perform this assessment? A. Cotton-tipped applicator B. Glucometer C. Hammer D. Safety pin
A
The nurse's friend fears that something is wrong with his grandmother, saying that she is becoming extremely forgetful and disoriented and is beginning to wander. What is the nurse's best response? A. "Have you taken her for a check-up?" B. "She has Alzheimer's disease." C. "That is a normal part of aging." D. "You should look into respite care."
A
The nursing instructor asks a nursing student to compare Bell's palsy and trigeminal neuralgia. Which statement by the nursing student is correct? A. "Difficulty chewing may occur in both disorders." B. "Both are disorders of the autonomic nervous system." C. "Facial twitching occurs in both disorders." D. "Both disorders are caused by the herpes simplex virus, which inflames and irritates cranial nerve V."
A
The spouse of the client with Alzheimer's disease is listening to the home health nurse explain the client's drug regimen. Which statement by the spouse indicates an understanding of the nurse's instruction? A. "Donepezil (Aricept) will treat the symptoms of Alzheimer's disease." B. "Memantine (Namenda) is indicated for treatment of early symptoms of Alzheimer's disease. C. "Rivastigmine (Exelon) is used to treat depression." D. "Sertraline (Zoloft) will treat the symptoms of Alzheimer's disease."
A
The wife of a client with Alzheimer's disease mentions to the home health nurse that, although she loves him, she is exhausted caring for her husband. What does the nurse do to alleviate caregiver stress? A. Arranges for respite care B. Provides positive reinforcement and support to the wife C. Restrains the client for a short time each day, to allow the wife to rest D. Teaches the client improved self-care
A
Which change in the cerebrospinal fluid (CSF) indicates to the nurse that a client may have bacterial meningitis? A. Cloudy, turbid CSF B. Decreased white blood cells C. Decreased protein D. Increased glucose
A
Which client will the neurologic unit charge nurse assign to a registered nurse who has floated from the labor/delivery unit for the shift? A. Adult client who has just returned from having a cerebral arteriogram and needs vital sign checks every 15 minutes. B. Older adult client who was just admitted with a stroke and needs an admission assessment. C. Young adult client who has had a lumbar puncture and reports, "Light hurts my eyes." D. Middle-aged client who has a possible brain tumor and has questions about the scheduled magnetic resonance imaging.
A
The nurse is developing a teaching plan for a client with a history of low back pain. Which instructions does the nurse plan to include in teaching the client about preventing low back pain and injury? Select all that apply. A. "Do not wear high-heeled shoes." B. "Keep weight within 50% of ideal body weight." C. "Begin a regular exercise program." D. "When lifting something, the back should be straight and the knees bent." E. "Standing for long periods of time will help to prevent low back pain."
A, C, D
An emergency room nurse initiates care for a patient with cervical spinal cord injury who arrives via emergency medical services. What action would the nurse take first? A. Assess level of consciousness B. Obtain vital signs C. Administer oxygen therapy D. Evaluate respiratory status
D
In the emergency department (ED), which is the nursing priority in assessing the client with a spinal cord injury? A. Indication of allergies B. Level of consciousness C. Loss of sensation D. Patent airway
D
A nurse is teaching a client who experiences migraine headaches and is prescribed a beta-blocker. Which statement would the nurse include in this client's teaching? A. "Take this drug only when you have prodromal symptoms indicating the onset of a migraine headache." B. "Take this drug as prescribed, even when feeling well, to prevent vascular changes associated with migraine headaches." C. "This drug will relieve the pain during the aura phase soon after a headache has started." D. "This medication will have no affect on your heart rate or blood pressure because you are taking it for migraines."
B
A nurse is teaching a patient with MS who is prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which statement would the nurse include this patient's discharge teaching? A. "Take warm baths to promote muscle relaxation." B. "Avoid crowds and people with colds." C. "Relying on a walker will weaken your gate." D. "Take prescribed medications when symptoms occur."
B
A nurse obtains a health history on a client prior to administering prescribed sumatriptain (Imitrex) for migraine headaches. Which condition would alert the nurse to hold the medication and contact the healthcare provider? A. Bronchial asthma B. Prinzmetal's angina C. Diabetes mellitus D. Chronic kidney disease
B
A nurse plans care for a patient who has a hypoactive response to a f deep tendon reflexes. Which intervention would the nurse include in this patient's plan of care? A. Check bath water temperature with a thermometer. B. Provide the patient with assistance when ambulating. C. Place elastic support hose on the patient's legs. D. Assess the patient's feet for wounds each shift.
B
A nurse teaches a patient who is recovering from a cervical spinal fusion. Which statement would the nurse include in this patient's postoperative instructions? A. "Only lift items that are 10lbs or less." B. "Wear your brace whenever you are out of bed." C. "You must remain in bed for 3 weeks after surgery." D. "You are prescribed medications to prevent rejection."
B
A nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. What action would the nurse take first? A. Start fluids via a large-bore catheter. B. Turn the client's head to the side. C. Administer IV push diazepam. D. Prepare to intubate the client.
B
An older client presents to the clinic after a ground level fall at home. What statement by the client indicates the need for more injury prevention education? A. "I always take my medicine as directed." B. "I only eat little snacks so I don't gain weight." C. "I will make sure I drink enough water." D. "I make sure to get as much sleep as I used to."
B
The nurse admits a client with suspected Eaton-Lambert syndrome. The nurse anticipates that the primary health care provider (PHCP) will request which test to confirm the diagnosis? A. Doppler study B. Electromyography (EMG) C. Magnetic resonance imaging (MRI) D. Tensilon test
B
The nurse admits a client with suspected myasthenia gravis (MG). The nurse anticipates that the primary health care provider (PHCP) will request which medication to aid in the diagnosis of MG? A. Atropine B. Edrophonium chloride (Tensilon) C. Methylprednisolone (Solu-Medrol) D. Ropinirole (Requip)
B
A client newly diagnosed with myasthenia gravis (MG) is being discharged, and the nurse is teaching about proper medication administration. Which statement by the client demonstrates a need for further teaching? A. "It is important to post my medicine schedule at home, so my family knows my schedule." B. "I can continue to take over-the-counter drugs like before." C. "An extra supply of medicine must be kept in my car." D. "Wearing a watch with an alarm will remind me to take my medicine."
B
A client receiving propranolol (Inderal) as a preventative for migraine headaches is experiencing side effects after taking the drug. Which side effect is of greatest concern to the nurse? A. Dry mouth B. Slow heart rate C. Tingling feelings D. Warm sensation
B
A client returns to the neurosurgical floor after undergoing an anterior cervical diskectomy and fusion (ACDF). What is the nurse's first action? A. Administer pain medication. B. Assess airway and breathing. C. Assist with ambulation. D. Check the client's ability to void.
B
A client with a T6 spinal cord injury who is on the rehabilitation unit suddenly develops facial flushing and reports a severe headache. Blood pressure is elevated, and the heart rate is slow. Which action does the nurse take first? A. Check for fecal impaction. B. Help the client sit up. C. Insert a straight catheter. D. Loosen the client's clothing.
B
A female client with newly diagnosed migraines is being discharged with a prescription for sumatriptan (Imitrex). Which comment by the client indicates an understanding of the nurse's discharge instructions? A. "Birth control is not needed while taking sumatriptan." B. "I must report any chest pain right away." C. "St. John's wort can also be taken to help my symptoms." D. "Sumatriptan can be taken as a last resort."
B
The nurse has just received change-of-shift report about a group of clients on the neurosurgical unit. Which client does the nurse attend to first? A. Adult postoperative left craniotomy client whose hand grip is weaker on the right B. Middle-aged adult client who had a cerebral aneurysm clipping and is becoming increasingly confused C. Older adult client who had a carotid endarterectomy and is unable to state the day of the week D. Young adult client involved in a motor vehicle crash (MVC) who is yelling obscenities at the nursing staff
B
The nurse has just received report on a group of clients. Which client does the nurse assess first? A. Client who was in a car accident and has a Glasgow Coma Scale score of 14 B. Client who had a cerebral arteriogram and has a cool, pale leg C. Client who has a headache after undergoing a lumbar puncture D. Client who has expressive aphasia after a left-sided stroke
B
The nurse has received report on a group of clients. Which client requires the nurse's attention first? A. Adult who is lethargic after a generalized tonic-clonic seizure B. Young adult who has experienced four tonic-clonic seizures within the past 30 minutes C. Middle-aged adult with absence seizures who is staring at a wall and does not respond to questions D. Older adult with a seizure disorder who has a temperature of 101.9° F (38.8° C)
B
The nurse is about to administer a contrast medium to the client undergoing diagnostic testing. Which question does the nurse first ask the client? A. "Are you in pain?" B. "Are you taking ibuprofen daily C. "Are you wearing any metal?" D. "Do you know what this test is for?"
B
The nurse is reviewing the medication history of a client diagnosed with myasthenia gravis (MG) who has been prescribed a cholinesterase (ChE) inhibitor. The nurse contacts the primary health care provider (PHCP) if the client is taking which medication? A. Acetaminophen (Tylenol) B. Diazepam (Valium) C. Furosemide (Lasix) D. Ibuprofen (Motrin)
B
The nurse is teaching a client, newly diagnosed with migraines, about trigger control. Which statement made by the client demonstrates good understanding of the teaching plan? A. "I can still eat Chinese food." B. "I must not miss meals." C. "It is okay to drink a few wine coolers." D. "I need to use fake sugar in my coffee."
B
Which is the most effective way for a college student to minimize the risk for bacterial meningitis? A. Avoid large crowds. B. Get the meningococcal vaccine. C. Take a high dose vitamin C daily. D. Take prophylactic antibiotics.
B
Which task does the nurse plan to delegate to the unlicensed assistive personnel (UAP) caring for a group of clients in the neurosurgical unit? A. Assist the health care provider in performing a lumbar puncture on a confused client B. Attend to the care needs of a client who has had a transcranial Doppler study C. Educate a client about what to expect during an electroencephalogram (EEG) D. Prepare a client who is going to radiology for a cerebral arteriogram
B
The nurse is caring for a client diagnosed with partial seizures after encephalitis, who is to receive carbamazepine (Tegretol). The nurse plans to monitor the client for which adverse effects? Select all that apply. A. Alopecia B. Headaches C. Dizziness D. Diplopia E. Increased blood glucose
B, C, D
A client has Guillain-Barré syndrome. Which interdisciplinary health care team members does the nurse plan to collaborate with to help prevent pressure ulcers related to immobility in this client? Select all that apply. A. Certified hospital chaplain B. Family members C. Dietitian D. Occupational therapist (OT) E. Social worker
B, C, D, E
A client has been admitted with new-onset status epilepticus. Which seizure precautions does the nurse put in place? Select all that apply. A. Bite block at the bedside B. Intravenous access (IV) C. Continuous sedation D. Suction equipment at the bedside E. Siderails raised
B, D, E
The nurse is performing a rapid neurologic assessment on a trauma client. Which assessment findings are normal? Select all that apply. A. Decerebrate posturing B. Glasgow Coma Score (GCS) 15 C. Lethargy D. Minimal response to stimulation E. Pupil constriction to light
B, E
A client admitted with cerebral edema suddenly begins to have a seizure while the nurse is in the room. What does the nurse do first? A. Administer phenytoin (Dilantin). B. Draw the client's blood. C. Establish an airway. D. Start an intravenous (IV) line.
C
A client arrives in the emergency department with new-onset ptosis, diplopia, and dysphagia. The nurse anticipates that the client will be tested for which neurologic disease? A. Bell's palsy B. Guillain-Barré syndrome (GBS) C. Myasthenia gravis (MG) D. Trigeminal neuralgia
C
A client has Parkinson's disease (PD). Which nursing intervention best protects the client from injury? A. Discouraging the client from activity B. Encouraging the client to watch the feet when walking C. Monitoring the client's sleep patterns D. Suggesting that the client obtain assistance in performing activities of daily living (ADLs)
C
A client has been diagnosed with Primary Progressive MS (PPMS) and the nurse is providing education at the clinic. What statement by the client indicates the need for more teaching? A. "I can alternate wearing my eye patch between eyes for double vision." B. "I should keep my home clutter free so I don't fall." C. "It's important I work out in the afternoon so my muscles are warmed up." D. "I always keep my medications in the same place."
C
A client is admitted with an exacerbation of Guillain-Barré syndrome (GBS), presenting with dyspnea. Which intervention does the nurse perform first? A. Calls the Rapid Response Team (RRT) to intubate B. Instructs the client on how to cough effectively C. Raises the head of the bed to 45 degrees D. Suctions the client
C
A client is being discharged with paraplegia secondary to a motor vehicle crash and expresses concern over the ability to cope in the home setting after the injury. Which is the best resource for the nurse to provide for the client? A. Hospital library B. Internet C. National Spinal Cord Injury Association D. Provider's office
C
A client on the neurosurgical floor who had a lumbar laminectomy is confused, agitated, and complaining of difficulty breathing. The client is normally alert and oriented. The nurse notices a pinpoint rash over the client's chest. What condition is the nurse concerned has occurred? A. Autonomic dysreflexia B. CSF leak C. Fat embolism syndrome D. Paralytic ileus
C
A nurse asks a patient to take deep breaths during an EEG. The patient asks, "Why are you asking me to do this?" How would the nurse respond? A. "Hyperventilation causes vascular dilation of cerebral arteries, which decreases electrical activity in the brain." B. "Deep breathing helps you to relax and allows the EEG to obtain a better waveform." C. "Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity." D. "Deep breathing will help you to blow off carbon dioxide and decreases intracranial pressures."
C
A nurse delegates care for a client with early-stage Alzheimer's disease to an unlicensed assistive personnel (UAP). Which statement would the nurse include when delegating this clients care? A. " If she is confused, play along and pretend that everything is okay." B. "Remove the clock from her room so that she doesn't get confused." C. "Reorient the client to day, time, and environment with each contact." D. "Use validation therapy to recognize and acknowledge the client's concerns."
C
A nurse is caring for a patient with a history of renal insufficiency who is scheduled for a computer tomography scan (CT) of the head with contrast medium. Which priority intervention would the nurse implement? A. Educate the patient about strict bedrest after the procedure. B. Place an indwelling urinary catheter to closely monitor output. C. Obtain a prescription for intravenous fluids. D. Contact the provider to cancel the procedure.
C
A nurse is caring for a patient with paraplegia who is scheduled to participate in a rehabilitation program. The patient states, "I do not understand the need for rehabilitation; the paralysis will not go away and it will not get better." How would the nurse respond? A. "If you don't want to participate in the rehab program, I'll let the provider know." B. "Rehab has helped many patients with your injury. You should give it a chance." C. "The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability." D. "When new discoveries are made regarding paraplegia, people in rehab will benefit first."
C
A nurse is caring for an 83 year old patient who is experiencing age-related sensory perception changes. Which intervention would the nurse include in this patient's plan of care? A. Provide a call button that requires only minimal pressure to activate. B. Write the date on the patient's white board to promote orientation. C. Ensure that the path to the bathroom is free from clutter. D. Encourage the patient to season food to stimulate nutritional intake.
C
A nurse is preparing a patient for a Tensilon test. What action by the nurse is most important? A. Administering anxiolytics B. Having a ventilatory nearby C. Obtaining atropine sulfate D. Sedating the patient
C
A nurse is teaching a patient with cerebellar function impairment. Which statement would the nurse include in this patient's discharge teaching? A. "Connect a light to flash when your door bell rings." B. "Label your facet knows with hot and cold signs." C. "Ask a friend to drive you to your follow-up appointments." D. "Use a natural gas detector with an audible alarm."
C
A nurse plans care for a patient with lower back pain from a work-related injury. Which intervention would the nurse include in this patient's plan of care? A. Encourage the patient to stretch the back by reaching toward the toes. B. Massage the affected area with ice twice a day. C. Apply a heating pad for 10 minutes at least four times daily. D. Advise the patient to avoid warm baths or showers.
C
A nurse prepares to teach a patient who has experienced damage to the left temporal lobe of the brain. What action would the nurse take when providing education about newly prescribed medications to this patient? A. Help the patient identify each medication by its color. B. Provide written materials with large print size. C. Sit on the patient's right side and speak into the right ear. D. Allow the patient to use a white board to ask questions.
C
A nurse teaches an 80 year old patient with diminished touch sensation. Which statement would the nurse include in this patient's teaching? A. "Place soft rugs in your bathroom to decrease pain in your feet." B. "Bathe in warm water to increase your circulation." C. "Look at the placement of your feet when walking." D. "Walk barefoot to decrease pressure ulcers from your shoes."
C
A patient is admitted with Guillain-Barre syndrome (GBS). What assessment takes priority? A. Bladder control B. Cognitive perception C. Respiratory system D. Sensory functions
C
A patient with GBS is admitted to the hospital. The nurse plans caregiving priority to interventions that address which priority patient problem? A. Anxiety B. Low fluid volume C. Inadequate airway D. Potential for skin breakdown
C
After teaching a patient who is scheduled for magnetic resonance imaging (MRI), the nurse assess the patient's understanding. Which patient statement indicates a correct understanding of the teaching? A. "I must increase my fluids because of the dye used for the MRI." B. "My urine will be radioactive so I should not share a bathroom." C. "I can return to my usual activities immediately after the MRI." D. "My gage reflex will be tested before I can eat or drink anything."
C
In assessing a client with back pain, the nurse uses a paper clip bilaterally on each limb. What is the nurse assessing? A. Gait B. Mobility C. Sensation D. Strength
C
The home health nurse is checking in on a client with dementia and the client's spouse. The spouse confides to the nurse, "I am so tired and worn out." What is the nurse's best response? A. "Can't you take care of your spouse?" B. "Establishing goals and a daily plan can help." C. "Make sure you take some time off and take care of yourself too." D. "That's not a very nice thing to say."
C
The nurse is administering the intake assessment for a newly admitted client with a history of seizures. The client suddenly begins to seize. What does the nurse do next? A. Documents the length and time of the seizure. B. Forces a tongue blade in the mouth. C. Positions the client on the side. D. Restrains the client.
C
The nurse is assessing a client with a neurologic condition who is reporting difficulty chewing when eating. The nurse suspects that which cranial nerve has been affected? A. Abducens (CN VI) B. Facial (CN VII) C. Trigeminal (CN V) D. Trochlear (CN IV)
C
The nurse is caring for a client in the emergency department (ED) whose spinal cord was injured at the level of C7 1 hour prior to arrival. Which assessment finding requires the most rapid action? A. After two fluid boluses, the client's systolic blood pressure remains 80 mm Hg. B. Cardiac monitor shows a sinus bradycardia at a rate of 50 beats/min. C. The client's chest moves very little with each respiration. D. The client demonstrates flaccid paralysis below the level of injury.
C
The nurse is caring for a client with a spinal cord injury resulting from a diving accident, who has a halo fixator and an indwelling urinary catheter in place. The nurse notes that the blood pressure is elevated and that the client is reporting a severe headache. The nurse anticipates that the primary health care provider will prescribe which medication? A. Dopamine hydrochloride (Inotropin) B. Methylprednisolone (Solu-Medrol) C. Nifedipine (Procardia) D. Ziconotide (Prialt)
C
The nurse is providing instructions to a client with a spinal cord injury about caring for the halo device. The nurse plans to include which instructions? A. "Avoid using a pillow under the head while sleeping." B. "Begin driving 1 week after discharge." C. "Keep straws available for drinking fluids." D. "Swimming is recommended to keep active."
C
The nurse is providing medication instructions for a client for whom phenytoin (Dilantin) has been ordered for treatment of epilepsy. The nurse instructs the client to avoid which beverage? A. Apple juice B. Grape juice C. Grapefruit juice D. Prune juice
C
The nurse is teaching a client newly diagnosed with multiple sclerosis (MS). Which statement by the client indicates a correct understanding of the pathophysiology of the disease? A. "I will die early." B. "I will have gradual deterioration with no healthy times." C. "Parts of my nervous system have plaques." D. "This was caused by getting too many x-rays as a child."
C
Which client diagnosed with neurologic injury is typically at highest risk for depression? A. Older man with a mild stroke B. Older woman with a seizure C. Young man with a spinal cord injury D. Young woman with a minor closed head injury
C
Which cranial nerve allows a person to feel a light breeze on the face? A. I (olfactory) B. III (oculomotor) C. V (trigeminal) D. VII (facial)
C
Which information is most important for the nurse to communicate to the primary care provider (PCP) about a client who is scheduled for CT angiography? A. Allergy to penicillin B. History of bacterial meningitis C. Poor skin turgor and dry mucous membranes D. The client's dose of metformin (Glucophage) held today
C
Which nursing intervention is best for preventing complications of immobility when caring for a client with spinal cord problems? A. Encouraging nutrition B. Frequent ambulation C. Regular turning and repositioning D. Special pressure-relief devices
C
The nurse has just received report on a group of clients on the neurosurgical unit. Which client is the nurse's first priority? A. Client whose deep tendon reflexes have become hyperactive B. Client who displays plantar flexion when the bottom of the foot is stroked C. Client who consistently demonstrates decortication when stimulated D. Client whose Glasgow Coma Scale (GCS) has changed from 15 to 13.
D
The nurse learns that the pathophysiology of GBC includes segmental demyelination. The nurse understands that this causes what? A. Delayed afferent nerve impulses B. Paralysis of affected muscles C. Parathesia in upper extremities D. Slowed nerve impulse transmission
D
To prevent the leading cause of death for clients with spinal cord injury, collaboration with which component of the primary health care team is a nursing priority? A. Nutritional therapy B. Occupational therapy C. Physical therapy D. Respiratory therapy
D
A client has returned to the unit after a thymectomy and is extubated. The client begins to report chest pain. What does the nurse do next? A. Calls the Rapid Response Team for immediate intubation B. Gives sublingual nitroglycerin (Nitrostat) C. Increases the intravenous (IV) rate D. Informs the surgeon immediately
D
A client is admitted with a spinal cord injury at the seventh cervical vertebra secondary to a gunshot wound. Which nursing intervention is the priority for this client's care? A. Auscultating bowel sounds every 2 hours B. Beginning a bladder retraining program C. Monitoring nutritional status D. Positioning the client to maximize ventilation potential
D
A client who has just undergone spinal surgery must be moved. How does the nurse plan to move this client? A. Getting the client up in a chair B. Keeping the client in the Trendelenburg position C. Lifting the client in unison with other health care personnel D. Log rolling the client
D
A client with dementia and Alzheimer's disease is discharged to home. The client's daughter says, "He wanders so much, I am afraid he'll slip away from me." What resource does the nurse suggest? A. Alzheimer's Wandering Association B. Lost Family Members Tracking Association C. National Alzheimer's Group D. Safe Return Program
D
A client with myasthenia gravis is admitted with generalized fatigue, a weak voice, and dysphagia. Which client problem has the highest priority? A. Inability to tolerate everyday activities related to severe fatigue B. Inability to communicate verbally related to vocal weakness C. Inability to care for self-related to muscle weakness D. Potential for aspiration related to difficulty with swallowing
D
A client with new-onset Bell's palsy is being dismissed from the hospital. Which statement made by the client demonstrates a need for further teaching by the nurse? A. "I'll need artificial tears at least four times a day." B. "I will eat a soft diet." C. "My eye must be taped or patched at bedtime." D. "Narcotics will be needed for pain relief."
D
A family member of a client with a recent spinal cord injury asks the nurse, "Can you please tell me what the real prognosis for recovery is? I don't feel like I'm getting a straight answer." What is the nurse's best response? A, "Every injury is different, and it is too soon to have any real answers right now." B. "Only time will tell." C. "The Health Insurance Portability and Accountability Act requires that I obtain the client's permission first." D. "Please request a meeting with the health care provider. I will help set that up."
D
A nurse assesses a patient who is recovering from a discectomy 6 hours ago. Which assessment finding would the nurse address first? A. Sleepy but arouses to voice. B. Dry and cracked oral mucosa. C. Pain present in lower back. D. Bladder palpated above pubis.
D
A nurse assesses a patient with a neurologic disorder. Which assessment finding would the nurse identify as a late manifestation of amyotrophic lateral sclerosis (ALS)? A. Dysarthria B. Dysphagia C. Muscle weakness D. Impairment of respiratory muscles
D
A nurse assesses a patient's recent memory. Which patient statement confirms that the patient's remote memory is intact? A. "A young girl wrapped in a shroud fell asleep on a bed of clouds." B. "I was born on April 3, 1967, in Johnstown Community Hospital." C. "Apple, chair, and pencil are the words you just stated." D. "I ate oatmeal with wheat toast and orange juice for breakfast."
D
A nurse cares for a patient who presents with an acute exacerbation of MS. Which prescribed mediation would the nurse prepare to administer? A. Baclofen (Lioresal) B. Interferon beta-1b (Betaseron) C. Dantrolene sodium (Dantrium) D. Methylprednisolone (Medrol)
D
