PrepU's Fall exam 1

The provider orders the Romberg test for a patient. The nurse tells the patient that the provider wants to evaluate his equilibrium by assessing which cranial nerve?

8

During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do?

Administer atropine to control the side effects of edrophonium.

The nurse is advising a client with multiple sclerosis on methods to minimize spasticity and contractures. Which of the following techniques would the nurse instruct the client to perform?

Apply warm packs to the affected area.

Which of the following terms is used to describe rapid, jerky, involuntary, purposeless movements of the extremities?

Chorea

Which of the following manifestations is inconsistent with the diagnosis of Guillain-Barr syndrome?

Cognitive decline

Cerebrospinal fluid (CSF) studies would indicate which of the following in a patient suspected of having meningitis? Select all that apply.

Decreased glucose Increased white blood cells Increased protein

Which of the following are sympathetic effects of the nervous system?

Dilated pupils

The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe?

Diplopia and ptosis

Which of the following safety actions will the nurse implement for a patient receiving oxygen therapy who is undergoing magnetic resonance imaging (MRI)?

Ensure that no patient care equipment containing metal enters the room where the MRI table is located.

A nurse is caring for a client with deteriorating neurologic status. The nurse is performing an assessment at the beginning of the shift that reveals a falling blood pressure and heart rate, and the client makes no motor response to stimuli. Which documentation of neuromuscular status is most appropriate?

Flaccidity

Which of the following cerebral lobes is the largest and controls abstract thought?

Frontal

A client with Guillain-Barre syndrome cannot swallow and has a paralytic ileus; the nurse is administering parenteral nutrition intraveneously. The nurse is careful to assess which of the following related to intake of nutrients?

Gag reflex and bowel sounds

A client has experienced an ischemic stroke that has damaged the frontal lobe of his brain. Which of the following deficits does the nurse expect to observe during assessment?

Limited attention span and forgetfulness

Which of the following is considered a central nervous system (CNS) disorder?

Multiple sclerosis

A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain?

Occipital

Which of the following is a component of the nursing management of the patient with new variant Creutzfeldt-Jakob disease (nvCJD)?

Providing supportive care

Which of the following cerebral lobes contains the auditory receptive areas

Temporal

The nurse is assisting with administering a Tensilon test to a patient with ptosis. If the test is positive for myasthenia gravis, what outcome does the nurse know will occur?

Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes.

A patient is actively hallucinating during an assessment. The nurse would be correct in documenting the hallucination as a disturbance in which of the following?

Thought content

A patient is scheduled for standard EEG testing to evaluate a possible seizure disorder. Nursing interventions prior to the procedure include which of the following?

Withholding antiseizure medications for 24 to 48 hours prior to the exam

Lower motor neuron lesions cause

flaccid muscle paralysis.

Which of the following is a nonmodifiable risk factor for ischemic stroke?

gender

To evaluate a client's cerebellar function, a nurse should ask:

"Do you have any problems with balance?"

A nurse and nursing student are caring for a client recovering from a lumbar puncture yesterday. The client reports a headache despite being on bedrest overnight. The physician plans an epidural blood patch this morning. The student asks how this will help the headache. The correct reply from the nurse is which of the following?

"The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid."

Which of the following terms refer to a method of recording, in graphic form, the electrical activity of the muscle?

Electromyogram

A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop. The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment?

Neurovascular system

A nurse is completing a neurological assessment and determines that the client has significant visual deficits. A brain tumor is considered. Considering the functions of the lobes of the brain, which area will most likely contain the neurologic deficit?

Occipital

A patient has difficulty interpreting his awareness of body position in space. Which lobe is most likely to be damaged?

Parietal

Laminectomy post op care plan

turn pt side to side using logroll technique

The nurse is caring for a client diagnosed with Guillain-Barre syndrome. His spouse asks about recovery rates. The nurse can correctly relate which of the following?

Approximately 60% to 75% of clients recover completely.

Which diagnostic test is used for early diagnosis of HSV-1 encephalitis?

Polymerase chain reaction (PCR)

Which neurotransmitter demonstrates inhibitory action, helps control mood and sleep, and inhibits pain pathways?

Serotonin

The initial symptoms of new variant Creutzfeldt-Jakob disease (vCJD) include which of the following?

anxiety, depression, and behavioral changes

The parents of a patient intubated due to the progression of Guillain-Barré syndrome ask if their child will die. What is the best response by the nurse?

"There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive."

A college student goes to the infirmary with a fever, headache, and a stiff neck. The nurse suspects the student may have meningitis and has the student transferred to the hospital. If the diagnosis is confirmed, what should the nurse institute for those who have been in contact with this student? (Select all that apply.)

Administration of ceftriaxone sodium (Rocephin) Administration of rifampin (Rifadin) Administration of ciprofloxacin hydrochloride (Cipro)

A 43-year-old female literature teacher with a neurologic deficit is feeling frustrated because since her stroke, she can no longer pronounce words without great difficulty. Which of the following is the client struggling with?

Dysarthria

A nurse is working in a neurologist's office. The physician orders a Romberg test. Which nursing action is correct?

Have the client close his eyes and stand erect.

The sympathetic and parasympathetic nervous systems have a direct effect on the circulatory system. Stimulation of the parasympathetic nervous system (PNS) causes which of the following?

Heartbeat to decrease

The nurse is performing a neurological assessment of a client who has sustained damage to the frontal cortex. Which of the following deficits will the nurse look for during assessment?

The inability to tell how a mouse and a cat are alike

A patient with fungal encephalitis receiving amphotericin B complains of fever, chills, and body aches. The nurse knows that these symptoms

may be controlled by the administration of diphenhydramine (Benadryl) and acetaminophen (Tylenol) approximately 30 minutes prior to administration of the amphotericin.

A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke?

severe headache

A female patient has undergone a lumbar puncture for a neurological assessment. The patient is put under the postprocedure care of a nurse. Which of the following important postprocedure nursing interventions should be performed to ensure maximum comfort to the patient?

Encourage a liberal fluid intake for the patient

The nurse is performing an initial assessment on a client admitted with a possible brain abscess. Which of the following would the nurse most likely find?

Headache that is worse in the morning

A patient has been diagnosed with a deficiency of the major neurotransmitter acetylcholine. Based on this information, the nurse knows to assess the patient for complications associated with:

Heart rate and rhythm.

The diagnosis of multiple sclerosis is based upon which of the following tests?

MRI

During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates:

cranial nerves IX and X.

A client preparing to undergo a lumbar puncture states he doesn't think he will be able to get comfortable with his knees drawn up to his abdomen and his chin touching his chest. He asks if he can lie on his left side. Which statement is the best response by the nurse?

"Although the required position may not be comfortable, it will make the procedure safer and easier to perform."

Which well-recognized sign of meningitis is exhibited when the patient's neck is flexed and flexion of the knees and hips is produced?

Positive Brudzinski sign

The nurse is caring for a patient in the emergency department with an onset of pain related to trigeminal neuralgia. What subjective data stated by the patient does the nurse determine triggered the paroxysms of pain?

"I was brushing my teeth."

The nurse has been educating a patient newly diagnosed with MS. Which of the following statements by the patient indicates an understanding of the education?

"I will stretch daily as directed by the physical therapist."

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate?

Alternatively patch one eye every 2 hours.

A patient who has suffered a stroke is unable to maintain respiration and so is intubated and placed on mechanical ventilator support. What portion of the brain is most likely responsible for the inability to breathe?

Brain stem

A client is hospitalized with Guillain-Barré syndrome. Which nursing assessment finding is most significant?

Even, unlabored respirations

A patient has been brought to the ED with altered LOC, high fever, and a purpura rash on the lower extremities. The family states the patient was complaining of neck stiffness earlier in the day. What action should the nurse do first?

Initiate isolation precautions.

A patient has been diagnosed with a frontal lobe brain abscess. Which of the following nursing interventions is appropriate?

Initiate seizure precautions.

A client is admitted to an acute care facility for treatment of a brain tumor. When reviewing the chart, the nurse notes that the client's extremity muscle strength is rated 1/5. Which assessment finding should the nurse anticipate?

Muscle contraction is palpable and visible.

The nurse is performing an initial nursing assessment on a client with possible Guillain-Barre syndrome. Which of the following findings would be most consistent with this diagnosis?

Muscle weakness and hyporeflexia of the lower extremities

The pre-nursing class is learning about the nervous system in their anatomy class. What part of the nervous system would the students learn is responsible for digesting food and eliminating body waste?

Parasympathetic

A client in a long-term nursing facility has severe dysphagia. Which of the following would best assist this client in preventing further complications?

Placement of a feeding tube

The nurse is caring for a patient diagnosed with a subarachnoid hemorrhage resulting from a leaking aneurysm. The patient is awaiting surgery. Which of the following nursing interventions would be appropriate for the nurse to implement? Select all that apply.

Provide a dimly lit environment. Elevate the head of bed 30 degrees. Administer Colace per order.

Which of the following is the first-line therapy for myasthenia gravis (MG)?

Pyridostigmine bromide (Mestinon)

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:

Severe headache and early change in level of consciousness

Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin?

Speeds nerve impulse transmission

A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. He reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder?

Trigeminal neuralgia

Medical management of arthropod-borne virus (arboviral) encephalitis is aimed at

controlling seizures and increased intracranial pressure.

A patient has been diagnosed with damage to Broca's area of the left frontal lobe. To document the extent of damage, the nurse would assess the patient's:

speech

A nurse is evaluating a client's cranial nerves during a routine examination. To assess the function of cranial nerve XII (hypoglossal), the nurse should assess the client's ability to:

stick out the tongue and move it rapidly from side to side and in and out.

During a routine physical examination to assess a client's deep tendon reflexes, a nurse should make sure to:

support the joint where the tendon is being tested.

A patient comes to the emergency department with severe pain in the face that was stimulated by brushing the teeth. What cranial nerve does the nurse understand can cause this type of pain?

v

A nurse is teaching a community group about modifiable and nonmodifiable risk factors for ischemic strokes. Which of the following is a risk factor that cannot be modified?

advance age

At what rate (in drops per minute) should a nurse start an I.V. infusion if the order is for 1 g of vancomycin (Vancocin) to be given in 180 ml of dextrose 5% in water over 60 minutes? The tubing delivers 15 drops/ml. Enter the correct number ONLY.

45

The most common cause of cholinergic crisis includes which of the following?

Overmedication

Which of the following is the priority nursing intervention for a patient in myasthenia crisis?

Assessing respiratory effort

Which of the following terms refers to the inability to coordinate muscle movements, resulting in difficulty walking?

Ataxia