Exam 1 - Med Surg 2
The nurse is planning the care of a patient with Parkinsons disease. The nurse should be aware that treatment will focus on what pathophysiological phenomenon?
Decreased availability of dopamine
A nurse assesses a client with an injury to the medulla. Which clinical manifestations would the nurse expect to find? (Select all that apply.)
Decreased respiratory rate Impaired swallowing Inability to shrug shoulders Loss of gag reflex
A patient diagnosed with myasthenia gravis has been hospitalized to receive plasmapheresis for a myasthenic exacerbation. The nurse knows that the course of treatment for plasmapheresis in a patient with myasthenia gravis is what?
Determined by the patients response
.) A middle-aged woman has sought care from her primary care provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the woman to seek care?
Difficulty in coordination
During the performance of the Romberg test, the nurse observes that the patient sways slightly. What is the nurses most appropriate action?
Document successful completion of the assessment.
A nurse is caring for a client who is 6 hr postoperative following a transsphenoidal hypophysectomy. The nurse should test the client's nasal drainage for the presence of which of the following?
Glucose
A patient with amyotrophic lateral sclerosis (ALS) is being visited by the home health nurse who is creating a care plan. What nursing diagnosis is most likely for a patient with this condition?
Impaired verbal communication
The nurse is creating a plan of care for a patient who has a recent diagnosis of MS. Which of the following should the nurse include in the patients care plan?
Instruct the patient on daily muscle stretching.
A nurse is reviewing the trend of a patients scores on the Glasgow Coma Scale (GCS). This allows the nurse to gauge what aspect of the patients status?
Level of consciousness
A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect?
Loss of cognitive function
A patient is scheduled for a myelogram and the nurse explains to the patient that this is an invasive procedure, which assesses for any lesions in the spinal cord. The nurse should explain that the preparation is similar to which of the following neurologic tests?
Lumbar puncture
A nurse is planning care for a client who has acromegaly and is postoperative following a transsphenoidal hypophysectomy. Which of the following interventions should the nurse include in the plan?
Observe dressing drainage for the presence of glucose.
A patient with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this patient? Select all that apply.
Orthostatic hypotension Autonomic dysreflexia DVT
The staff educator is precepting a nurse new to the critical care unit when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the patient closely, what would be the nurse's most appropriate action?
Prepare for interventions to increase the patient's BP.
The staff educator is precepting a nurse new to the critical care unit when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the patient closely, what would be the nurses most appropriate action?
Prepare for interventions to increase the patients BP
After a subarachnoid hemorrhage, the patients laboratory results indicate a serum sodium level of less than 126 mEq/L. What is the nurses most appropriate action?
Prepare to administer 3% NaCl by IV as ordered.
A patient is admitted to the neurologic ICU with a spinal cord injury. When assessing the patient the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect?
Spinal shock
A family member brings the patient to the clinic for a follow-up visit after a stroke. The family member asks the nurse what he can do to decrease his chance of having another stroke. What would be the nurses best answer?
Stop smoking as soon as possible.
A family member brings the patient to the clinic for a follow-up visit after a stroke. The family member asks the nurse what he can do to decrease his chance of having another stroke. What would be the nurses best answer?
Stop smoking as soon as possible.
A 48-year-old patient has been diagnosed with trigeminal neuralgia following recent episodes of unilateral face pain. The nurse should recognize what implication of this diagnosis?
The patient needs to be assessed for MS.
The nurse is providing health education to a patient who has a C6 spinal cord injury. The patient asks why autonomic dysreflexia is considered an emergency. What would be the nurses best answer?
The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel.
A nurse is teaching a client who has multiple sclerosis and a new prescription for baclofen. Which of the following statements should the nurse include in the teaching?
"This medication can cause you to experience dizziness."
The public health nurse is planning a health promotion campaign that reflects current epidemiologic trends. The nurse should know that hemorrhagic stroke currently accounts for what percentage of total strokes in the United States?
13%
The nurse is preparing to provide care for a patient diagnosed with myasthenia gravis. The nurse should know that the signs and symptoms of the disease are the result of what?
A lower motor neuron lesion
A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding?
Absence of reflexes along with flaccid extremities
A patient with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this patient?
Absolute bed rest in a quiet, non-stimulating environment
A community health nurse is giving an educational presentation about stroke and heart disease at the local senior citizens center. What nonmodifiable risk factor for stroke should the nurse cite?
Advanced age
A client is admitted with a traumatic brain injury. What is the nurse's priority assessment?
Airway and breathing assessment
When caring for a patient who had a hemorrhagic stroke, close monitoring of vital signs and neurologic changes is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke of which the nurse should be aware?
Alteration in level of consciousness (LOC)
A patient with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased the risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring?
Applying thigh-high elastic stockings
A nurse is beginning a physical assessment ofa client who has a new diagnosis of multiple sclerosis. Which of the following findings should the nurse expect? (select all that apply.)
Areas of paresthesia Involuntary eye movements Ataxia
The nurse is reviewing the medication administration record of a female patient who possesses numerous risk factors for stroke. Which of the woman's medications carries the greatest potential for reducing her risk of stroke?
Aspirin 81 mg PO o.d.
The nurse is reviewing the medication administration record of a female patient who possesses numerous risk factors for stroke. Which of the woman's medications carries the greatest potential for reducing her risk of stroke?
Aspirin 81 mg PO o.d.
The nurse is conducting a focused neurologic assessment. When assessing the patients cranial nerve function, the nurse would include which of the following assessments?
Assessment of gag reflex
The nurse caring for a patient in ICU diagnosed with Guillain-Barr syndrome should prioritize monitoring for what potential complication?
Autonomic dysfunction
A patient with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the patients cardiac and neurologic status, the nurse monitors the patient for signs of what complication?
Bleeding
A patient with Cushing syndrome as a result of a pituitary tumor has been admitted for a transsphenoidal hypophysectomy. What would be most important for the nurse to monitor before, during, and after surgery?
Blood glucose
A 33-year-old patient presents at the clinic with complaints of weakness, incoordination, dizziness, and loss of balance. The patient is hospitalized and diagnosed with MS. What sign or symptom, revealed during the initial assessment, is typical of MS?
Blurred vision, intention tremor, and urinary hesitancy
A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient?
Bradycardia and hypertension
A patient who just suffered a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurses primary assessment focus?
Cardiac and respiratory status
The nurse is planning the care of a patient with a T1 spinal cord injury. The nurse has identified the diagnosis of risk for impaired skin integrity. How can the nurse best address this risk?
Change the patient's position frequently.
A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the patient complains of a severe throbbing headache. What should the nurse do first?
Check the patients indwelling urinary catheter for kinks to ensure patency.
A patient diagnosed with MS has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen (Lioresal). What should the nurse identify as an expected outcome of this treatment?
Decreased muscle spasms in the lower extremities
A patient diagnosed with MS has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen (Lioresal). What should the nurse identify as an expected outcome of this treatment?
Decreased muscle spasms in the lower extremities
A trauma patient in the ICU has been declared brain dead. What diagnostic test is used in making the determination of brain death?
Electroencephalography (EEG)
When caring for a patient who has had a stroke, a priority is reduction of ICP. What patient position is most consistent with this goal?
Elevation of the head of the bed
A patient is brought to the ED by her family after falling off the roof. A family member tells the nurse that when the patient fell she was knocked out, but came to and seemed okay. Now she is complaining of a severe headache and not feeling well. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention
Emergency craniotomy
The nurse is caring for a patient who is hospitalized with an exacerbation of MS. To ensure the patients safety, what nursing action should be performed?
Ensure that suction apparatus is set up at the bedside.
A nurse is caring for a patient who has an MRI scheduled. What is the priority safety action prior to this diagnostic procedure?
Ensuring that there are no metal objects on or in the patient
A patient with MS has been admitted to the hospital following an acute exacerbation. When planning the patients care, the nurse addresses the need to enhance the patients bladder control. What aspect of nursing care is most likely to meet this goal?
Establish a timed voiding schedule.
Splints have been ordered for a patient who is at risk of developing footdrop following a spinal cord injury. The nurse caring for this patient knows that the splints are removed and reapplied when?
Every 2 hours
A patient is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this patient is aware that an absolute contraindication for thrombolytic therapy is what?
Evidence of hemorrhagic stroke
A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod. For which common side effect would the nurse monitor?
Facial flushing
Whenmonitoring for possible secondary complications, including syndrome of inappropriate caring for a patient with increased ICP the nurse knows the importance of antidiuretic hormone (SIADH). What nursing interventions would the nurse most likely initiate if the patient developed SIADH?
Fluid restriction
A patient is admitted to the medical unit with an exacerbation of multiple sclerosis. When assessing this patient, the nurse has the patient stick out her tongue and move it back and forth. What is the nurse assessing?
Function of the hypoglossal nerve
A 13-year-old was brought to the ED, unconscious, after being hit in the head by a baseball. When the child regains consciousness, 5 hours after being admitted, he cannot remember the traumatic event. MRI shows no structural sign of injury. What injury would the nurse suspect the patient has?
Grade 3 concussion with temporal lobe involvement
The nurse is teaching a patient with Guillain-Barr syndrome about the disease. The patient asks how he can ever recover if demyelination of his nerves is occurring. What would be the nurses best response?
Guillain-Barr spares the Schwann cell, which allows for remyelination in the recovery phase of the disease.
The nurse is teaching a patient with Guillain-Barr syndrome about the disease. The patient asks how he can ever recover if demyelination of his nerves is occurring. What would be the nurses best response?
Guillain-Barr spares the Schwann cell, which allows for remyelination in the recovery phase of the disease.
A patient presents at the clinic complaining of pain and weakness in her hands. On assessment, the nurse notes diminished reflexes in the upper extremities bilaterally and bilateral loss of sensation. The nurse knows that these findings are indicative of what?
Guillain-Barr syndrome
The nurse is assessing a client who has symptoms of stroke. What are the leading causes of a stroke for which the nurse would assess for this client? (Select all that apply.)
Heavy alcohol intake Diabetes mellitus Elevated cholesterol Obesity Smoking Hypertension
The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the patient may be experiencing increased brain compression causing brain stem damage?
Hyperthermia
A nurse is planning the care of a 28-year-old woman hospitalized with a diagnosis of myasthenia gravis. What approach would be most appropriate for the care and scheduling of diagnostic procedures for this patient?
In the morning, with frequent rest periods
The nurse caring for a patient with a spinal cord injury notes that the patient is exhibiting early signs and symptoms of disuse syndrome. Which of the following is the most appropriate nursing action?
Increase the frequency of ROM exercises.
You are the clinic nurse caring for a patient with a recent diagnosis of myasthenia gravis. The patient has begun treatment with pyridostigmine bromide (Mestinon). What change in status would most clearly suggest a therapeutic benefit of this medication?
Increased muscle strength
A patient is admitted to the neurologic ICU with a spinal cord injury. In writing the patients care plan, the nurse specifies that contractures can best be prevented by what action ?
Initiating (ROM) exercises as soon as possible after the injury
A patient is admitted to the neurologic ICU with a spinal cord injury. In writing the patients care plan, the nurse specifies that contractures can best be prevented by what action?
Initiating (ROM) exercises as soon as possible after the injury
The nurse is participating in the care of a patient with increased ICP. What diagnostic test is contraindicated in this patients treatment?
Lumbar puncture
A patient is admitted to the neurologic ICU with a suspected diffuse axonal injury. What would be the primary neuroimaging diagnostic tool used on this patient to evaluate the brain structure?
MRI
The nurse is working with a patient who is newly diagnosed with MS. What basic information should the nurse provide to the patient?
MS is a progressive demyelinating disease of the nervous system.
A nurse is caring for a patient diagnosed with a hemorrhagic stroke. When creating this patients plan of care, what goal should be prioritized?
Maintain and improve cerebral tissue perfusion.
The nurse is caring for a patient who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of deficient fluid volume related to fluid restriction and osmotic diuretic use. What would be an appropriate intervention for this diagnosis?
Monitor serum electrolytes.
Following a spinal cord injury a patient is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action?
Notify the neurosurgeon of the occurrence.
A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. After raising the head of the bed, what action would the nurse take next?
Palpate the bladder for distention.
A hearing-impaired patient is scheduled to have an MRI. What would be important for the nurse to remember when caring for this patient?
Patient is likely unable to hear the nurse during test.
The nurse recognizes that a patient with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI?
Perform passive ROM exercises as ordered.
A patient is recovering from intracranial surgery that was performed using the transsphenoidal approach. The nurse should be aware that the patient may have required surgery on what neurological structure?
Pituitary gland
A patient has had an ischemic stroke and has been admitted to the medical unit. What action should the nurse perform to best prevent joint deformities?
Place a pillow in the axilla when there is limited external rotation.
A female patient is diagnosed with a right-sided stroke. The patient is now experiencing hemianopsia. How might the nurse help the patient manage her potential sensory and perceptional difficulties?
Place the patients extremities where she can see them.
The patient in the ED has just had a diagnostic lumbar puncture. To reduce the incidence of a post-lumbar puncture headache, what is the nurses most appropriate action?
Position the patient prone.
A patient with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform?
Position the patient upright during feeding.
The nurse is caring for a 77-year-old woman with MS. She states that she is very concerned about the progress of her disease and what the future holds. The nurse should know that elderly patients with MS are known to be particularly concerned about what variables? Select all that apply.
Possible nursing home placement Increasing disability Becoming a burden on the family
A patient with a new diagnosis of amyotrophic lateral sclerosis (ALS) is overwhelmed by his diagnosis and the known complications of the disease. How can the patient best make known his wishes for care as his disease progresses?
Prepare an advance directive
A patient with Guillain-Barr syndrome has experienced a sharp decline in vital capacity. What is the nurses most appropriate action?
Prepare to assist with intubation
Which assessment data should the nurse assess in the client diagnosed with Guillain-Barré syndrome?
Progressive ascending paralysis of the lower extremities and numbness.
The patient has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the patients atmosphere more conducive to communication?
Provide a board of commonly used needs and phrases.
The critical care nurse is admitting a patient in myasthenic crisis to the ICU. The nurse should prioritize what nursing action in the immediate care of this patient?
Providing ventilatory assistance
As a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for benefit and for harm. The nurse should be cognizant of what contraindications for thrombolytic therapy? Select all that apply.
Recent intracranial pathology Current anticoagulation therapy Symptom onset greater than 3 hours prior to admission
A patient scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the patient for the MRI should prioritize which of the following actions?
Removing all metal-containing objects
A nurse in the ICU is providing care for a patient who has been admitted with a hemorrhagic stroke. The nurse is performing frequent neurologic assessments and observes that the patient is becoming progressively more drowsy over the course of the day. What is the nurse's best response to this assessment finding?
Report this to the physician as a possible sign of clinical deterioration.
A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client's hips and sacrum. What actions would the nurse take? (Select all that apply.)
Reposition the client off of the reddened areas Apply a pressure-reducing mattress.
A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client's hips and sacrum. What actions would the nurse take? (Select all that apply.)
Reposition the client off of the reddened areas. Apply a pressure-reducing mattress.
A client who has multiple sclerosis reports increased severe muscle spasticity and tremors. What nursing action is most appropriate to manage this client's concern?
Request a prescription for an antispasmodic drug such as baclofen.
The nurse is caring for a patient with multiple sclerosis (MS). The patient tells the nurse the hardest thing to deal with is the fatigue. When teaching the patient how to reduce fatigue, what action should the nurse suggest?
Resting in an air-conditioned room whenever possible
he nurse is caring for a patient with multiple sclerosis (MS). The patient tells the nurse the hardest thing to deal with is the fatigue. When teaching the patient how to reduce fatigue, what action should the nurse suggest?
Resting in an air-conditioned room whenever possible
A patient is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 1 hours ago. Endotracheal intubation has been deemed necessary and the nurse is preparing to assist. What nursing diagnosis should the nurse associate with this procedure?
Risk for injury
A patient who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurses care of this patient?
The patient should be approached on the side where visual perception is intact.
A nurse on the neurologic unit is providing care for a patient who has spinal cord injury at the level of C4. When planning the patients care, what aspect of the patients neurologic and functional status should the nurse consider?
The patient will require full assistance for all aspects of elimination.
A patient who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the patients current health status is most likely to have precipitated this event?
The patients urinary catheter became occluded.
. A patient for whom the nurse is caring has positron emission tomography (PET) scheduled. In preparation, what should the nurse explain to the patient?
The test may result in dizziness or lightheadedness.
The nurse is admitting a patient to the unit who is scheduled for removal of anintracranial mass. What diagnostic procedures might be included in this patients admission orders? Select all that apply.
Transcranial Doppler flow study Cerebral angiography MRI
The nurse is developing a plan of care for a patient with Guillain-Barr syndrome. Which of the following interventions should the nurse prioritize for this patient?
Using the incentive spirometer as prescribed
A patient has developed diabetes insipidus after having increased ICP following head trauma. What nursing assessment best addresses this complication?
Vigilant monitoring of fluid balance
The nurse caring for a patient diagnosed with Guillain-Barr syndrome is planning care with regard to the clinical manifestations associated this syndrome. The nurses communication with the patient should reflect the possibility of what sign or symptom of the disease?
Vocal paralysis
A patient had a lumbar puncture performed at the outpatient clinic and the nurse has phoned the patient and family that evening. What does this phone call enable the nurse to determine?
Whether the patient has had any complications of the test
The nurse is performing stroke risk screenings at a hospital open house. The nurse has identified four patients who might be at risk for a stroke. Which patient is likely at the highest risk for a hemorrhagic stroke?
White male, age 60, with history of uncontrolled hypertension
A patient is scheduled for CT scanning of the head because of a recent onset of neurologic deficits. What should the nurse tell the patient in preparation for this test?
You will need to lie still throughout the procedure
A nurse is providing discharge teaching for a client who had a transsphenoidal hypophysectomy. Which of the following instructions should the nurse included? (select all that apply.)
eat a high‐fiber diet. Notify the provider of increased swallowing.
A nurse is caring for a client who has experienced a right‐hemispheric stroke. The nurse should expect the client to have difficulty with which of the following? (select all that apply.)
impulse control Moving the left side depth perception situational awareness
A nurse is assessing a client. Which of the following findings indicates that the client has experienced a left‐hemispheric stroke?
inability to recognize familiar objects
For a patient who had a right hemisphere stroke the nurse establishes a nursing diagnosis of
risk for injury related to denial of deficits and impulsiveness