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The nurse is collecting data from a patient in the HCP's office. Which statement by the patient indicates that the patient is likely to be having problems with some activities of daily livings? (ADLs)
" I can barely lift my arms above my shoulders."
The nurse suspects a patient is experiencing a parasypathetic response. Which manifestations does the nurse expect the patient to exhibit? SATA
-Decrease in heart rate to normal -increase in salivary gland secretion
The nurse is planning care for a patient with a migraine headache. Which actions does the nurse include in this plan of care. SATA
-a dark, quiet room -sumatriptan (imitrex) -rest -acetaminophen (tylenol)
What are nonmodifiable risk factors for stroke?SATA
-age -gender
Which are sympathetic responses? SATA
-increased heart rate -dilated pupils -relaxed urinary bladder -dilated bronchioles
What are the warning signs of a stroke?SATA
-sudden numbness on one side -sudden dizziness, and -sudden severe headache
What are the symptoms of cholinergic crisis? SATA
-urination -vomiting -lacrimation
A patient began experiencing manifestations of a stroke at 0800 hours. By which time should thrombolytic medications be provided to reverse stroke symptoms? a. 0900 hours b. 1250 hours c. 1400 hours d. 1660 hours
1250 hours
A patient is being admitted to a long-term care facility. Medical history includes a recent stroke with dysarthria. Which factor does the nurse consider when providing care for this patient?
A picture board will help the patient with word searching
What nursing intervention is most important for the patient with myasenthia gravis?
Allow frequent rest periods
The nurse is providing care for a patient who is experiencing difficulty eating due to neurologic dysfunction. Which action by the nurse will be least helpful in promoting adequate nutritional intake for this patient?
Allow the patient adequate time and privacy to self feed.
The nurse is reviewing the medical records of patients in an HCPs practice. Which patient does the nurse recognize as the greatest risk or a stroke?
An older female patient who has osteoporosis, a femur fracture, and hyperlypidima
Which of the following nursing interventions should be included in the plan of care for a patient at risk for foot drop?
Apply high tip tennis shoes?
A patient arrives at the emergency department and states,"Something is wrong. I just dont feel right." Which objective data causes the nurse to suspect the patient is experiencing some type of stroke?
Ataxia is present when the patient attempts to ambulate
The nurse is providing care for a patient after surgery for treatment of trigeminal neuralgia. Which nursing intervention will the nurse initiate for this patient?
Check the eye on the surgery side for corneal sensation
What does the FOUR score tool evaluate?
Coma
The nurse is preparing a patient with MG to undergo plasmapheresis. Which laboratory tests does the nurse verify and place on the medical record before the procedure?
Complete blood count, platelets, and clotting studies
The nurse is preparing to collect data during the reassessment of a patients neurologic status. Which equipment is necessary for this procedure?
Cotton Ball
The nurse is caring for a patient experiencing an acute exacerbation of multiple sclerosis (MS). Which pathophysiological change does the nurse recognize as causing the manifestations of MS?
Demyelination and destruction of nerve fibers
The nurse is caring for a patient scheduled for a computed tomography (CT) scan with contrast. Which actions does the nurse not include in the preprocedure preparation?
Determine if the patient has aneurysm clips of metal pins in the body
The nurse is assisting with the care of a patient after a traumatic brain injury. The patient experiences a seizure and exhibits bilateral jerking of the extremities. Which type of seizure activity does the nurse recognize?
Generalized
To protect from aspiration, what intervention should be carried out first following a stroke?
Have a swallowing evaluation done
A patient is admitted from the emergency department to the hospital unit following the diagnosis of an ischemic stroke. The patient did not qualify for tPA therapy. The nurse is aware that a post stroke condition places the patient at greatest risk for deep vein thrombosis (DVT)?
Hyper-coagulability related to the admitted diagnosis
The nurse is collecting up-to-date data from a patient who was diagnosed with MS 15 years ago. The patient has a good understanding of the disease and manages to maintain a relatively high level of functioning. Which statement by the patient prompts the nurse to seek additional information?
I love to work in my flower beds during the summer months.
The nurse is assisting with care of patients diagnosed with neuromuscular disorders. which complication does the nurse recognize as a medical emergency?
Indications of the development of pneumonia
A patient is diagnosed with bacterial encephalopathy. Which symptoms exhibited by the patient indicate late signs of the patients diagnosis?
Lack of involvement and lip smacking or chewing
Symptoms of multiple sclerosis are caused by damage to which structures?
Myeline sheath
The nurse is providing care for a patient diagnosed with cerebral aneurysm and subarachnoid hemorrhage. Which statement by the patient indicates a need for additional information?
No strenuous activity until this condition is cured by surgery
Which cranial nerve controls pupil restriction?
Occulomotor
A patient is admitted to the surgical unit following removal of a brain tumor. Which nursing intervention takes priority?
Pad side rails on the bed
A patient reports to the nurse with an inability to rest or sleep due to long term condition causing a constant urge to move the legs called restless legs syndrome (RLS). The patient expresses a need for some type of relief. Which suggestion by the nurse is most likely to help the patient?
Pramipexole or ropinrole medication therapy
Which assessment should take priority in a patient with a cervical spine injury who suddenly exhibits a spike in blood pressure?
Preforming a bladder scan
A patient with trigeminal neuralgia is admitted to the hospital for diagnostic testing and possible surgery. Which intervention is appropriate for this patient?
Provide soft foods at body temperature at mealtimes
Which speech and language deficit is a patient experiencing who is unable to comprehend all language? 1.Receptive dyphasia 2.Expressive dyphasia 3.Receptive aphasia 4.Expressive aphasia
Receptive aphasia
The nurse is assisting with the care of a patient with a brain tumor who is exhibiting ICP. Which nursing intervention is specifically initiated to provide safety for this patient
Relocate environmental objects and pad the bedside rails
Which assessment takes priority in the patient with guillian barre syndrome
Respiratory rate and depth
The nurse is providing care for a patient who was diagnosed with parkinson disease 12 years prior. Which manifestation of the disease presents the nurse with the most likely risk for safety of this patient?
Shuffling gait
The patient is diagnosed with a cerebral vascular accident that has the slowest rate of recovery and the highest probability of causing extensive neurologic deficits. For which type of stroke does the nurse plan care for this patient?
Subarachnoid hemorrhage (SAH)
An older adult patient is experiencing the manifestation related to a neurocognitive disorder and is being transferred to a long-term care facility. Which condition will involve the nurse in reaching long-term goals related to this paitent?
Suggesting the family attend a support group
The nurse is providing care for a patient recovering from a right hemisphere infarct who now exhibits unilateral neglect. Which nursing intervention is most important at promoting safety for this patient?
Teach the patient to purposefully check the location of the left limbs
The licensed practical nurse (PN) is assigned to assist the registered nurse (RN) in providing care for a patient admitted for an inflammatory neurologic disorder. Which reassessment finding does the LPN report immediately to the RN?
The patient attempts to get out of bed to go to work
The nurse is assisting with the care of a patient admitted following a fall resulting in a head injury. Which finding prompts the nurse to inform the RN that the patient is experiencing a negative change in the level of conciousness?
The patient falls asleep in the middle of a sentence
A patient is brought to the health care providers office with a headache, lethargy, nausea, vomiting, and a fever which has developed over the past few days. The nurse begins collecting data about the possible causes of the symptoms. Which information indicates a possible cause for encephalitis?
The patient has been camping within the last few weeks
The nurse is providing care for multiple patients. which patient does the nurse decide to report immediately to the health care provider or the registered nurse (RN)?
The patient who begins to exhibit lack of coordination and aphasia
The nurse is preparing to perform a Romberg test on a client. The nurse instructs the patient to stand with the feet together and eyes closed. After 20 seconds the patient leans to one side and exhibits a swaying motion. Which conclusion does the nurse draw from these test results?
The test is positive and indicates cerebellar dysfunction.
Which cranial nerve contributes to the control of heart rate and blood pressure?
Vagus
The nurse is collecting information from a patient in the HCPs office. The patient is exhibiting symptoms associated with bell palsy. Which population group does the nurse recognize as being at greatest risk for condition?
Women in the third trimester of pregnancy
A patient with late stage 2 Alzheimer dementia is throwing half-eaten food from the meal tray onto the floor. Which response by the nurse is best?
offer alternative foods and stay with the patient during mealtime
A patient comes into the emergency department with unilateral paralysis, aphasia, and inability to follow directions. Which emergency management by the health care provider is unexpected by the nurse?
scheduling laboratory tests, electrocardiogram(ECG) and computerized tomography (CT) scan to be preformed within 45 minutes
A patient is distressed to learn that a sibling is diagnosed with both neurologic and cognitive manifestations of huntington disease. When the patient asks the nurse how to determine the incidence of the disease, which answer is most appropriate?
you definitely need to have genetic testing for the disease
