concepts 4 exam 4
A nurse assesses a client with early-onset multiple sclerosis. Which clinical manifestation should the nurse expect to find? -hyperresponsive reflexes -excessive somnolence -nystagmus -heat intolerance
nystagmus
The client diagnosed with Parkinson's disease is being discharged. Which statement made by the significant other indicates an understanding of the discharge instructions? -"all of my spouse's emotions will slow down now just like his body movements" -"my spouse may experience hallucinations until the medication starts working" -"I will schedule appointments late in the morning after his morning bath" -"it is fine if we don't follow a strict medication schedule on the weekends"
-"I will schedule appointments late in the morning after his morning bath"
A nurse is teaching a client with cerebellar function impairment. Which statement would the nurse include in this client's discharge teaching? -"connect a light to flash when your doorbell rings" -"label your faucet knobs with hot and cold signs" -"ask a friend to drive you to follow-up appointments" -"use a natural gas detector with an audible alarm"
-"ask a friend to drive you to follow-up appointments"
The nurse is teaching the daughter of a client who has middle-stage Alzheimer disease. The daughter asks "will the sertraline my mother is taking improve her dementia?" How would the nurse respond about the purpose of the drug? -"it will allow your mother to live independently for several more years" -"it is used to halt the advancement of Alzheimer disease but will not cure it" -"it will not improve her dementia but can help control emotional responses" -"it is used to improve short-term memory but will not improve problem solving"
-"it will not improve her dementia but can help control emotional responses"
A patient asks what smoking cigarettes has to do with low back pain. How should the nurse respond to this patient? -"smoking is a sedentary activity" -"smoking is linked to nutritional disorders" -"nicotine in cigarettes interferes with nutrients that supply the disk spaces" -"nicotine hinders the mobility of the vertebral spaces and interferes with nerve dysfunction"
-"nicotine in cigarettes interferes with nutrients that supply the disk spaces"
A patient with a seizure disorder asks the purpose of staying awake all night prior to having an electroencephalogram in the morning. What should the nurse explain to this patient? -"you will be expected to sleep during the test" -"most people with seizure disorders receive too much sleep" -"this is the only way to prove that you really have a seizure disorder" -"sleep deprivation can cause a seizure, which will be helpful during the test"
-"sleep deprivation can cause a seizure, which will be helpful during the test"
A nurse is teaching a client who experiences migraine headaches and is prescribed propranolol. Which statement would the nurse include in this client's teaching? -"take this drug only when you have symptoms indicating the onset of a migraine headache" -"take this drug as prescribed, even when feeling well, to prevent vascular changes associated with migraine headaches" -"this drug will relieve the pain during the aura phase soon after a headache has started" -"this drug will have no effect on your heart rate or blood pressure because you are taking it for migraines"
-"take this drug as prescribed, even when feeling well, to prevent vascular changes associated with migraine headaches"
Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best for this situation? -"this type of monitoring system is complex and it is managed by skilled staff" -"the monitoring system helps show whether blood flow to the brain is adequate" -"the ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure" -"this monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage"
-"the monitoring system helps show whether blood flow to the brain is adequate"
When teaching patients who are at risk for Bell's palsy because of previous herpes simplex infection, which information should the nurse include? -"you should call the doctor if pain or herpes lesions occur near the ear" -"treatment of herpes with antiviral agents will prevent development of Bell's palsy" -"medications to treat Bell's palsy work only if started before paralysis onset" -"you may be able to prevent Bell's palsy by doing facial exercises regularly"
-"you should call the doctor if pain or herpes lesions occur near the ear"
A client is diagnosed with myasthenia gravis. What should the nurse explain about this disease process? -"your nerve endings are worn out" -"your body does not recognize the neurotransmitter needed for movement" -"your body does not make enough of the neurotransmitter needed for movement" -"your nerves have lost their protective covering and impulses cannot reach body areas"
-"your body does not recognize the neurotransmitter needed for movement"
A patient who has numbness and weakness of both feet is hospitalized with Guillain-Barre syndrome. The nurse will anticipate that collaborative interventions at this time will include: -intubation and mechanical ventilation -insertion of an NG tube -administration of methylprednisolone -IV infusion of immunoglobulin
-IV infusion of immunoglobulin
A patient receives a definitive diagnosis of multiple sclerosis. What finding occurred to validate this diagnosis? -onset of double vision -loss of bowel and bladder control -MRI changes in two separate locations
-MRI changes in two separate locations
a patient with a history of seizures experiences lip smacking and daydreams during a seizure with no loss of consciousness. the nurse recognizes these clinical manifestations as associated with which type of seizure? -absence seizure -complex partial seizure -atonic seizure -myoclonic seizure
-absence seizure
Which prescribed intervention will the nurse implement first for a patient in the ER who is experiencing continuous tonic-clonic seizures? -give phenytoin (dilantin) 100 mg IV -monitor level of consciousness -administer lorazepam (ativan) 4 mg IV -obtain CT scan
-administer lorazepam (ativan) 4 mg IV
It is believed that a patient's migraine headaches are caused by vascular constriction. Which medication should the nurse expect to be prescribed for this patient? -citalopram (celexa) -imipramine (tofranil) -amlodipine (norvasc) -lamotrigine (lamictal)
-amlodipine (norvasc)
A patient has a ruptured aneurysm and subarachnoid hemorrhage. Which intervention will the nurse include in the plan of care? -apply intermittent pneumatic compression stockings -assist to dangle on edge of bed and assess for dizziness -encourage patient to cough and deep breathe every 4 hours -insert an oropharyngeal airway to prevent airway obstruction
-apply intermittent pneumatic compression stockings
A patient is admitted to a unit with a diagnosis of left middle cerebral artery acute ischemic stroke and is not eligible for thrombolytic therapy. The nurse recognizes that this patient is at a high risk for which complication? -delirium -aspiration -bronchospasm -palipitations
-aspiration
When the nurse is planning care for a hospitalized patient who is experiencing an acute episode of trigeminal neuralgia, an appropriate action to include is: -teach facial and jaw relaxation techniques -assess intake and output and dietary intake -apply ice packs for no more than 20 minutes -spend time at the bedside talking with the patient
-assess intake and output and dietary intake
A client with a stroke has damage to Broca's area. What intervention to promote communication is best for this client? -assess whether or not the client can write -communicate using yes-or-no questions -reinforce speech therapy exercises -remind the client not to use neologisms
-assess whether or not the client can write
During the period of spinal shock, the nurse should expect the client's bladder function to be which of the following? -spastic -normal -atonic -uncontrolled
-atonic
A patient is being prepared for a tensilon test. What should the nurse ensure is available prior to the beginning of this test? -oxygen -atropine sulfate -intravenous fluids -nasogastric suction
-atropine sulfate
What patient education is most important for the patient with trigeminal neuralgia prior to eating a meal? -avoid using a straw in beverages -avoid brushing your teeth for 2 hours after a meal -avoid iced beverages and ensure that food is soft and easy to chew -close the door to provide privacy for meals
-avoid iced beverages and ensure that food is soft and easy to chew
The nurse is performing a mental status examination on a male client diagnosed with subdural hematoma. This test assesses which of the following? -cerebellar function -intellectual function -cerebral function -sensory function
-cerebral function
The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first? -client with cerebral perfusion pressure of 72 mmHg -client who has a glasgow coma scale score of 12 -client with a PaCO2 of 36 mmHg who is on a ventilator -client who has a temperature of 102
-client who has a temperature of 102
A nurse is assessing reflexes in a patient with hyperactive reflexes. When the patient's foot is abruptly dorsiflexed, it continues to beat two to three times before settling into a resting position. How would the nurse document this finding? -rigidity -flaccidity -clonus -ataxia
-clonus
A client is in the ER reporting a brief episode during which he was dizzy, unable to speak, and felt like his legs were very heavy. Currently the client's neurologic examination is normal. Which drug should the nurse plan to administer? -alteplase -clopidogrel -heparin sodium -mannitol
-clopidogrel
A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and determines that which of the following results would verify the diagnosis? -cloudy CSF, decreased protein, and decreased glucose -cloudy CSF, elevated protein, and decreased glucose -clear CSF, elevated protein, and decreased glucose -clear CSF, decreased pressure, and elevated protein
-cloudy CSF, elevated protein, and decreased glucose
A patient with left-sided weakness that started 60 minutes earlier is admitted to the ER and diagnostic tests are ordered. Which test should be done first? -complete blood count (CBC) -chest radiograph -computed tomography (CT) scan -12 lead electrocardiogram
-computed tomography (CT) scan
The nurse suspects that a patient with photophobia is experiencing encephalitis. What observation of the patient's behavior caused the nurse to make this clinical decision? -closed the eyes -covered the ears with both hands -placed both hands in coat pockets -rubbed the thighs with both hands
-covered the ears with both hands
assessing vision and smell is done during what part of the neurological assessment? -glasgow coma scale -cranial nerve assessment -health concern assessment -babinski sign assessment
-cranial nerve assessment
A client is admitted with head trauma after a fall from a ladder. The client is being prepared for a supratentorial craniotomy with burr holes, and an IV infusion of mannitol (osmitrol) is instituted. The nurse concludes that this medication is given to: -lower blood pressure -prevent hypoglycemia -increase cardiac output -decrease fluid in the brain
-decrease fluid in the brain
The nurse is planning the care of a patient with Parkinson's disease. The nurse should be aware that treatment will focus on what pathophysiological phenomenon? -premature degradation of acetylcholine -decreased availability of dopamine -insufficient synthesis of epinephrine -delayed reuptake of serotonin
-decreased availability of dopamine
A client with myasthenia gravis is admitted in a cholinergic crisis. Signs of cholinergic crisis include: -decreased blood pressure and constricted pupils -increased heart rate and increased respirations -increased respirations and increased blood pressure -anoxia and absence of the cough reflex
-decreased blood pressure and constricted pupils
the nurse correlates which clinical manifestations to age-related changes of the nervous system? SATA: -decreased visual acuity -increased pain sensation -balance problems -dementia -decreased pain sensation
-decreased visual acuity -balance problems -decreased pain sensation
A patient with meningitis is prescribed a cooling blanket. What should the nurse explain as being the purpose of this device? -relieves pain -increases cerebral venous outflow -decreases oxygen demand in the brain -reduces transmission of the infection
-decreases oxygen demand in the brain
A patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find? -impulsive behavior -right sided neglect -hyperactive left sided tendon reflexes -difficulty comprehending instructions
-difficulty comprehending instructions
Which medication taken by a patient with restless leg syndrome should the nurse question? -ibuprofen -multivitamin -acetaminophen -diphenhydramine
-diphenhydramine
A 24 year old with a history of a fall last year and resultant T1 injury is admitted for severe headache and nasal congestion. On assessment, vital signs reveal bradycardia and hypertension. The nurse determines which of the following is the probable cause of his symptoms? -absence of deep tendon reflexes -distending bladder -overexertion
-distending bladder
the nurse monitors for which complication in the patient with bulbar ALS? -lower back pain -dementia -paresthesia -dysphagia
-dysphagia
After endotracheal suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14-17 mmHg. Which action should the nurse take? -document the increase in intracranial pressure -ensure that the patient's neck is in neutral position -notify the health care provider about the change in pressure -increase the rate of the prescribed propofol infusion
-ensure that the patient's neck is in neutral position
A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest? -subdural hematoma -subarachnoid hemorrhage -epidural hematoma -contusion
-epidural hematoma
The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client has now lost consciousness again. The nurse takes quick action, knowing this is compatible with: -skull fracture -concussion -subdural hematoma -epidural hematoma
-epidural hematoma
Which nursing intervention is a priority for a patient with cranial nerve impairment from guillain-barre syndrome? -perform sensory checks with the neurological examination below the level of the cervical spine -consult with the provider for initiation of continuous positive airway pressure for breathing -create a turning schedule with limited time in the side-lying position -establish effective communication using eye blinks or a communication board
-establish effective communication using eye blinks or a communication board
During assessment of the patient with a recurrence of trigeminal neuralgia, the nurse should: -examine the mouth and teeth thoroughly -have the patient clench and relax the jaw and eyes -identify trigger zones by lightly touching the affected side -gently palpate the face to compare skin temperature bilaterally
-examine the mouth and teeth thoroughly
A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? -blowing the nose -isometric exercises -coughing vigorously -exhaling during repositioning
-exhaling during repositioning
Because the CVA affected the left side of the client's brain, the nurse should anticipate that the client will most likely experience: -expressive aphasia -dyslexia -apraxia -agnosia
-expressive aphasia
The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? -hyperreflexia -positive reflexes -flaccid paralysis -reflex emptying of the bladder
-flaccid paralysis
A patient with a neck fracture at the C5 level is admitted to the ICU following initial treatment in the ER. During the initial assessment of the patient, the nurse recognizes the presence of spinal shock as: -hypotension, bradycardia, and warm extremities -involuntary spastic movements of the arms and legs -the presence of hyperactive reflex activity below the level of injury -flaccid paralysis and lack of sensation below the level of injury
-flaccid paralysis and lack of sensation below the level of injury
A patient reports feeling numbness and tingling of the left arm before experiencing a seizure. The nurse determines that this history is consistent with what type of seizure? -focal -atonic -absence -myoclonic
-focal
the nurse recognizes that patients with major changes in personality most likely have damage in which lobe of the brain? -frontal -occipital -parietal -temporal
-frontal
The nurse is preparing medications for a client with encephalitis. Which medication should the nurse question before administering? -furosemide (lasix) -phenytoin (dilantin) -docusate sodium (colace) -prochlorperazine (compazine)
-furosemide (lasix)
The nurse interrupts an unlicensed assistive personnel who is assisting a patient with Parkinson's disease with breakfast. Which observation caused the nurse to immediately intervene? -patient sitting out of bed in chair -head of the bed raised to 30 degrees -thickener added to liquid menu items -oral suction catheter equipment turned on
-head of the bed raised to 30 degrees
A nurse is caring for a patient diagnosed with Mnires diseases. While completing a neurologic examination on the patient, the nurse assesses cranial nerve VIII. The nurse would be correct in identifying the function of this nerve as what? -movement of the tongue -visual acuity -sense of smell -hearing and equilibrium
-hearing and equilibrium
A patient with GBS was admitted to the nursing unit with ascending motor paralysis. He has been a patient on your unit for 2 weeks. As the nurse provides teaching to the patient, how does the nurse describe the resolution of his paralysis? -in the reverse order of the onset of symptoms -in the lower extremities first followed by the breathing muscles -as evidenced by bladder and bowel control -one limb at a time
-in the reverse order of the onset of symptoms
The nurse is concerned that a patient's Alzheimer's disease is progressing. What finding did the nurse use to confirm this suspicion? -inability to recall the word for "car" -misplacement of health insurance cards -unable to find sweater in waiting room -leaving the practitioners office without taking prescriptions
-inability to recall the word for "car"
The nurse is caring for the client with increased intracranial pressure as a result of a head injury. The nurse would note which trend in vital signs if the intracranial pressure is rising? -increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure -increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure -decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure -decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure
-increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure
When obtaining a health history and physical assessment for a 36 year old female patient with possible multiple sclerosis, the nurse should: -assess for the presence of chest pain -inquire about urinary tract problems -inspect the skin for rashes or discoloration -ask the patient about any increase in libido
-inquire about urinary tract problems
The nurse is admitting a patient with a basilar skull fracture. The nurse notes ecchymosis around both eyes and clear drainage from the patient's nose. Which admission order should the nurse question? -keep the HOB elevated -insert nasogastric tube to low suction -turn patient side to side every 2 hours -apply cold packs intermittently to face
-insert nasogastric tube to low suction
A patient has been taking phenytoin (dilantin) for 2 years. Which action will the nurse take when evaluating for adverse effects of the medication? -inspect the oral mucosa -listen to the lung sounds -auscultate the bowel sounds -check pupil reaction to light
-inspect the oral mucosa
The nurse has administered prescribed IV mannitol (osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness? -blood pressure -intracranial pressure -oxygen saturation -hemoglobin and hematocrit
-intracranial pressure
A patient with Guillain-Barre syndrome asks the nurse what has caused the disease. In responding to the patient, the nurse explains that Guillain-Barre syndrome: -results from an acute infection and inflammation of the peripheral nerves -is due to an immune reaction that attacks the covering of the peripheral nerves -is caused by destruction of the peripheral nerves after exposure to a viral infection -results from degeneration of the peripheral nerves caused by viral attacks
-is due to an immune reaction that attacks the covering of the peripheral nerves
During the acute stage of meningitis, a 3 year old child is restless and irritable. Which of the following would be most appropriate to institute? -limiting conversation with the child -keeping extraneous noise to a minimum -allowing the child to play in the bathtub -performing treatments quickly
-keeping extraneous noise to a minimum
Which clinical manifestation serves as an early warning for a client who experiences migraines without aura? -vertigo -lethargy -visual disturbances -numbness of the tongue
-lethargy
which assessment data does the nurse recognize as the most sensitive indicator of increased ICP? -pupillary -respiratory -level of consciousness -cranial nerves
-level of consciousness
The nurse is planning care for a patient with meningitis. What teaching material should be prepared to explain the prescribed treatment for this disorder? -fluid restriction -low fat, low calorie diet -over the counter analgesics -long term antibiotic therapy
-long term antibiotic therapy
A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication would the nurse anticipate to prepare for administration? -atenolol -lorazepam -phenytoin -lisinopril
-lorazepam
The nurse is caring for a patient with an upper motor neuron lesion. What clinical manifestations should the nurse anticipate when planning the patient's neurologic assessment? -decreased muscle tone -flaccid paralysis -loss of voluntary control of movement -slow reflexes
-loss of voluntary control of movement
The nurse is admitting a patient experiencing photophobia and nuchal rigidity. For which diagnostic test should the nurse prepare this patient? -lumbar puncture -evoked potentials -CT scan with contrast -electroencephalogram
-lumbar puncture
Which diagnostic test is used to confirm the diagnosis of amyotropic lateral sclerosis? -electromyogram (EMG) -muscle biopsy -serum creatine kinase (CK) -pulmonary function test
-muscle biopsy
the nurse assesses the patient for which early finding in ALS? -bowel and bladder incontinence -respiratory distress -muscle cramps -paralysis
-muscle cramps
A patient with multiple sclerosis is admitted for treatment of clinical manifestations. What should the nurse expect to be prescribed for this patient? -corticosteroids -beta interferons -muscle relaxants -immunosuppressive agents
-muscle relaxants
During the edrophonium or Tensilon test, a short-acting AChE inhibitor is administered intravenously, and the provider observes the patient for improvement in which function? -level of consciousness -muscle strength -muscle tone -hearing
-muscle strength
The nurse is assessing the motor and sensory function of an unconscious client who sustained a head injury. The nurse should use which technique to test the client's peripheral response to pain? -sternal rub -nailbed pressure -pressure on the orbital rim -squeezing of the sternocleidomastoid muscle
-nailbed pressure
During a home visit the nurse is concerned that the patient with Alzheimer's disease is deteriorating. What patient observation caused the nurse to have this concern? -sitting in a chair watching a television program -staying away from the door leading to the back yard -no recognition of bowel incontinence during the visit -eating cheese and crackers placed on a table near the living room chair
-no recognition of bowel incontinence during the visit
A patient is brought into the ER following a motor vehicle accident in which he sustained head trauma. Preliminary assessment reveals a vision deficit in the patient's left eye. The nurse should associate this abnormal finding with trauma to which of the following cerebral lobes? -temporal -occipital -parietal -frontal
-occipital
After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about: -cerebral aneurysm clipping -heparin intravenous infusion -oral low dose aspirin therapy -tissue plasminogen activator
-oral low dose aspirin therapy
While cooking, your client couldn't feel the temperature of a hot oven. Which lobe could be dysfunctional? -frontal -occipital -parietal -temporal
-parietal
The nurse is doing an initial assessment on a patient newly admitted to the unit with a diagnosis of cerebrovascular accident. The patient has difficulty copying a figure that the nurse has drawn and is diagnosed with visual-receptive aphasia. What brain region is primarily involved in this deficit? -temporal lobe -parietal-occipital area -inferior posterior frontal areas -posterior frontal area
-parietal-occipital area
The nurse is admitting a patient to the unit who is diagnosed with a lower motor neuron lesion. What entry in the patient's electronic record is most consistent with this diagnosis? -patient exhibits increased muscle tone -patient demonstrates normal muscle structure with no evidence of atrophy -patient demonstrates hyperactive deep tendon reflexes -patient demonstrates an absence of deep tendon reflexes
-patient demonstrates an absence of deep tendon reflexes
After a change-of-shift report, which patient should the nurse assess first? -patient with myasthenia gravis who is reporting increased muscle weakness -patient with a bilateral headache described as "like a band around my head" -patient with seizures who is scheduled to receive a dose of phenytoin -patient with Parkinson's disease who has developed cogwheel rigidity of th
-patient with myasthenia gravis who is reporting increased muscle weakness
The nurse advises a patient with myasthenia gravis to: -perform physically demanding activities early in the day -anticipate the need for weekly plasmapheresis treatments -do frequent weight-bearing exercise to prevent muscle atrophy -protect the extremities from injury due to poor sensory perception
-perform physically demanding activities early in the day
A 24 year old patient is hospitalized with the onset of Guillain-Barre syndrome. During this phase of the patient's illness, the most essential assessment for the nurse to carry out is: -monitoring the cardiac rhythm continuously -determining the level of consciousness every 2 hours -evaluating sensation and strength of the extremities -performing constant evaluation of respiratory function
-performing constant evaluation of respiratory function
When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care? -apply an eye patch to the right eye -approach the patient from the right side -place needed object's at the patient's left side -teach the patient that the left visual deficit will resolve
-place needed object's at the patient's left side
A client is diagnosed with a stroke that affects the right hemisphere of the brain. A nurse, receiving report prior to the care of this client, should expect the client to have which symptom? -right hemiparesis -expressive aphasia -poor impulse control -marked anxiety when learning new tasks
-poor impulse control
A client's arterial pressure is 60 mmHg and intracranial pressure is 20 mmHg. Based on the client's cerebral perfusion pressure, what should the nurse anticipate for this client? -impending brain herniation -poor prognosis and cognitive function -probable complete recovery -unable to tell from this information
-poor prognosis and cognitive function
During morning care a patient with a seizure disorder asks why the room has suddenly turned green. What should the nurse do? -ask the patient to explain -prepare for a seizure to begin -turn on the overhead room lights -document visual hallucinations present
-prepare for a seizure to begin
A patient who is suspected of having an epidural hematoma is admitted to the ER. Which action will the nurse expect to take? -administer IV furosemide -prepare the patient for craniotomy -initiate high dose barbiturate therapy -type and crossmatch for blood transfusion
-prepare the patient for craniotomy
A patient has been experiencing a tonic-clonic seizure for five minutes. What should the nurse do first? -assess carotid pulse -prepare to insert an airway -provide rescue breathing -insert an intravenous access line
-prepare to insert an airway
The nurse assesses for which clinical manifestations in a patient admitted with myasthenia gravis? SATA: -ptosis -diplopia -hyperventilation -dysphagia -bitemporal headaches
-ptosis -diplopia -dysphagia
A patient with multiple sclerosis experiences exacerbations of new symptoms that last a few days and then disappear. Which type of multiple sclerosis is this patient most likely experiencing? -relapsing-remitting -primary progressive -progressive relapsing -secondary progressive
-relapsing-remitting
When providing patient teaching about plasmapheresis to a patient with myasthenia gravis, the nurse explains that the purpose of the procedure is which result? -reduce the levels of calcium and magnesium in the blood -remove excessive acetylcholinesterase from the plasma -deliver deficient proteins directly into the blood -remove ACh receptor antibodies from the blood
-remove ACh receptor antibodies from the blood
which action is the highest priority in the patient who presents with autonomic dysreflexia? -prepare for intubation -initiate vasopressors -remove the stimulus -place a temporary pacemaker
-remove the stimulus
A patient returns to the community clinic after being diagnosed with Parkinson's disease. What should the nurse expect to see documented in the patient's medical record to support this diagnosis? -rigidity with ambulation -unremarkable electroencephalogram -results of serum potassium and calcium levels -integrity of cerebral vessels after a cerebral angiogram
-rigidity with ambulation
A nurse receives a report on a client who had a left-sided stroke and has homonymous hemianopsia. What action by the nurse is most appropriate for this client? -assess for bladder retention and/or incontinence -listen to the client's lungs after eating or drinking -prop the clients right side up when sitting in a chair -rotate the client's meal tray when the client stops eating
-rotate the client's meal tray when the client stops eating
The nurse suspects that a patient is experiencing Parkinson's disease. What did the nurse assess to make this clinical determination? -photophobia -nuchal rigidity -slow movements -elevated body temperature
-slow movements
a patient is admitted for evaluation and treatment of generalized tonic-clonic seizures. which clinical manifestations does the nurse assess for in this type of seizure disorder? -persistent jerking movement of one half of the body -unilateral jerking movement of one extremity -muscle flaccidity followed by tremors of all extremities -stiffening of muscles of arms and legs, followed by jerking movements
-stiffening of muscles of arms and legs, followed by jerking movements
the nurse correlates which clinical manifestation to a secondary headache? -sudden severe onset -tense neck muscles -nausea -tingling scalp sensation
-sudden severe onset
A patient with Parkinson's disease has bradykinesia. Which action will the nurse include in the plan of care? -instruct the patient in activities that can be done while lying or sitting -suggest that the patient rock from side to side to initiate leg movement -have the patient take small steps in a straight line directly in front of the feet -teach the patient to keep the feet in contact with the floor and slide them forward
-suggest that the patient rock from side to side to initiate leg movement
A trauma patient was admitted to the ICU with a brain injury. The patient had a change in level of consciousness, increased vital signs, and became diaphoretic and agitated. The nurse should recognize which of the following syndromes as the most plausible cause of these symptoms? -adrenal crisis -hypothalamic collapse -sympathetic storm -cranial nerve deficit
-sympathetic storm
Which action will the nurse plan to take for a patient with multiple sclerosis who has urinary retention caused by a flaccid bladder? -encourage a decreased evening intake of fluid -teach the patient how to use the crede method -suggest the use of adult incontinence briefs for nighttime only -assist the patient to the commode every 2 hours during the day
-teach the patient how to use the crede method
A patient with a paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. When the nurse develops a plan of care for this problem, which nursing action will be most appropriate? -teaching the patient how to self-catheterize -assisting the patient to the toilet every 2-3 hours -use the crede method to empty the bladder -catheterization for residual urine after voiding
-teaching the patient how to self-catheterize
Problems with memory and learning would relate to which of the following lobes? -frontal -occipital -parietal -temporal
-temporal
The nursing students are learning how to assess the function of cranial nerve VIII. To assess the function of cranial nerve VIII the students would be correct in completing which of the following assessment techniques? -have the patient identify familiar odors with the eyes closed -assess papillary reflex -utilize the snellen chart -test for air and bone conduction (rinne test)
-test for air and bone conduction (rinne test)
A patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin? -the patient has dysphagia -the patient has atrial fibrillation -the patient reports that symptoms began with a severe headache -the patient has a history of brief episodes of right-sided hemiplegia
-the patient reports that symptoms began with a severe headache
Which stroke risk factor for a 48 year old male patient in the clinic is most important for the nurse to address? -the patient is 25 lb above the ideal weight -the patient drinks a glass of red wine with dinner daily -the patient's usual blood pressure is 170/94 mmHg -the patient works at a desk and relaxes by watching television
-the patient's usual blood pressure is 170/94 mmHg
While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take? -insert an oral airway during the seizure to maintain a patent airway -restrain the patient's arms and legs to prevent injury during the seizure -time and observe and record the details of the seizure and postictal state -avoid touching the patient to prevent further nervous system stimulation
-time and observe and record the details of the seizure and postictal state
The nurse correlates which rationale to the use of hyperventilation to decrease intracranial pressure in a patient after traumatic head injury? -to maximize oxygenation -to promote vasoconstriction -to decrease cerebral perfusion -to decrease ventilatory effort
-to promote vasoconstriction
The nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How would the nurse document this type of seizure? -atonic -myoclonic -absence -tonic-clonic
-tonic-clonic
A patient with Parkinson's disease is prescribed carbidopa/levodopa (sinemet). Which clinical manifestation should the nurse expect to be most affected with this medication? -tremors -mood instability -impaired balance -behavioral changes
-tremors
Which nursing action will be implemented first if a client has a generalized tonic-clonic seizure? -turn the client to one side -give lorazepam 2 mg IV -administer oxygen via nonrebreather mask -assess the client's level of consciousness
-turn the client to one side
A patient is being treated with carbidopa/levodopa (sinemet) for Parkinson's disease. Which information indicates a need for change in the medication or dosage? -shuffling gait -tremor at rest -cogwheel rigidity of limbs -uncontrolled head movement
-uncontrolled head movement
The nurse expects the assessment of a patient who is experiencing a cluster headache to include: -nuchal rigidity -unilateral ptosis -projectile vomiting -throbbing, bilateral facial pain
-unilateral ptosis
The nurse is preparing a client for discharge from the ER after experiencing a transient ischemic attack (TIA). Before discharge, which factor would the nurse identify as placing the client at high risk for stroke? -age greater than or equal to 75 -blood pressure greater than or equal to 160/95 -unilateral weakness during a TIA -TIA symptoms lasting less than a minute
-unilateral weakness during a TIA
During the change of shift report, a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have: -dysphasia -confusion -visual deficits -poor judgment
-visual deficits
