Exam 3

The most sensitive assessment finding to indicate increased ICP is: A. Level of consciousness B. Cranial nerve dysfunction C. Weakness on one side of the body D. Fixed and dilated pupil

A. Level of consciousness

What pathophysiologic processes occur in the first stage, or the acute phase, of GBS? A. Peripheral nerve demyelination, edema, and inflammation B. Depolarization of the spinal nerves C. Destruction of the myelin-producing oligodendrocytes D. Regeneration of the myelin sheath

A. Peripheral nerve demyelination, edema, and inflammation

Which intervention is typically the initial treatment of a metastatic spinal cord tumor? A. Radiation therapy B. Local chemotherapy into the cord C. Surgical decompression D. Corticosteroids

A. Radiation therapy

A fixed and dilated pupil is caused by compression of cranial nerve: A. II B. III C. IV D. VII

B. III

What class of drugs is the first line of treatment for status seizures?

Benzodiazepines

The nurse correlates respiratory compromise in GBS to which pathophysiological process? A. Decreased protein in the CSF B. Progressive limb weakness C. Diaphragmatic weakness D. Decreased acetylcholine at the neuromuscular junction

C. Diaphragmatic weakness

Which assessment data does the nurse recognize as the most sensitive indicator of increased ICP? A. Pupillary B. Respiratory C. Level of consciousness D. Cranial nerves

C. Level of consciousness

A patient with increased intracranial pressure (ICP) is sensitive to fluid-volume shifts. The nurse recognizes which approach as safest to reduce this patient's cerebral edema? 1. Mannitol 2. 3% sodium chloride 3. 0.9% normal saline 4. Packed red blood cells

2. 3% sodium chloride

In monitoring a patient with increased intracranial pressure (ICP) who is mechanically ventilated, the nurse correlates which arterial blood gas value to effective management of the increased ICP? 1. pH 7.32 2. PaCO2 32 mm Hg 3. PaO2 85 mm Hg 4. HCO3- 22 mEq/L

2. PaCO2 32 mm Hg

The nurse monitors for which clinical manifestation in the patient with neurogenic shock? 1. Tachycardia 2. Hypertension 3. Warm dry skin 4. Rapid shallow respirations

3. Warm dry skin

The latest blood pressure reading for a patient with a spinal cord injury is 210/140 mm Hg. What action should the nurse take first? 1. Palpating for bladder distention 2. Assessing for a bowel impaction 3. Remeasuring the blood pressure 4. Raising the head of the bed 45 degrees

4. Raising the head of the bed 45 degrees

A patient has arrived by ambulance at the emergency department after a cervical spinal cord injury. Which assessment is a priority for the nurse to perform at this time? 1. Mental status and blood pressure 2. Heart rate and rhythm 3. Muscle strength and reflexes 4. Respiratory pattern and airway

4. Respiratory pattern and airway

Which is the best position for the nurse to place a patient with increased intracranial pressure (ICP) and decreased intracranial compliance? 1. Flat 2. Prone 3. Side-lying with the neck flexed 4. Semi-Fowler's with the neck in a neutral position

4. Semi-Fowler's with the neck in a neutral position

A patient has a 4 cm spinal cord tumor located at T10. Which statement by the patient indicates the patient understands the treatment options? 1. "Surgery is the best treatment for this tumor." 2. "I will need radiation therapy before surgery." 3. "This tumor can be treated with chemotherapy." 4. "The only treatment for this tumor is stereotactic radiosurgery."

1. "Surgery is the best treatment for this tumor."

The nurse is reading the results of a single-fiber electromyography completed on a patient suspected of having myasthenia gravis. Which information would validate this patient's diagnosis? 1) Increased jitter 2) Nerve compression 3) Increased antibodies 4) Decreased muscle response

1) Increased jitter

A nurse is caring for a patient with leukemia who is neutropenic. Which intervention will the nurse implement to ensure this patient's safety? 1) Place patient in reverse isolation 2) Place patient in standard precaution isolation 3) Administer a prophylactic gram-negative antibiotic 4) Administer neutrophil colony-stimulating factor (N-CSF) as ordered

1) Place patient in reverse isolation

The nurse teaches a patient about computed tomography (CT scan) to diagnose a potential spinal cord disorder. Which patient statement indicates a correct understanding of the information presented? 1. "A CT scan allows my provider to visualize the bony structures of the spine." 2. "A CT scan allows my provider to monitor for soft tissue damage to my spine." 3. "A CT scan measures electrical impulse within muscle tissue in the spinal area." 4. "A CT scan measures pressure by injecting dye into my spinal canal."

1. "A CT scan allows my provider to visualize the bony structures of the spine."

Which statement by the patient with multiple sclerosis (MS) indicates the need for additional teaching? 1. "MS causes my nerves to die." 2. "There is no cure for MS." 3. "MS is caused by damage to the covering of the spinal cord." 4. "Physical therapy may help me with my MS."

1. "MS causes my nerves to die."

A patient has been experiencing a tonic-clonic seizure for 5 minutes. What should the nurse do first? 1. Assess carotid pulse. 2. Prepare to insert an airway. 3. Provide rescue breathing. 4. Insert an intravenous access line.

2. Prepare to insert an airway

A patient with amyotrophic lateral sclerosis is prescribed riluzole (Rilutek). What statement by the patient indicates that further teaching is needed about this treatment? 1. "This medication will cure my disease." 2. "This medication may delay the need to be on a ventilator." 3. "This medication works on nerve conduction." 4. "This medication may decrease the progression of my disease."

1. "This medication will cure my disease."

A patient in a barbiturate coma for increased intracranial pressure (ICP) has audible gurgling through the endotracheal tube. What should the nurse do first before suctioning this patient? 1. Administer 100% oxygen. 2. Elevate the head of the bed. 3. Interrupt sedative administration. 4. Place the head in a neutral position.

1. Administer 100% oxygen.

The nurse is planning care for a patient with Guillain-Barré syndrome (GBS). Which intervention will help with neuropathic pain? 1. Administer gabapentin 2. Turn and reposition every 2 hours 3. Apply sequential compression devices 4. Perform passive range-of-motion exercises several times a day

1. Administer gabapentin

A patient being evaluated for Guillain-Barré syndrome (GBS) presents with bilateral symmetrical muscle weakness and sensory changes of both feet and legs. The nurse correlates which key finding to this disease process? 1. Areflexia 2. Hyperreflexia 3. Hypothermia 4. Hyperanalgesia

1. Areflexia

A patient with neurogenic shock is demonstrating vagal stimulation. What should the nurse expect to be prescribed for this patient? 1. Atropine 2. Epinephrine 3. Phenylephrine 4. Norepinephrine

1. Atropine

A patient with progressively deteriorating lower extremity motor and sensory function is having a lumbar puncture. What finding suggests that this patient has Guillain-Barré syndrome (GBS)? 1. Elevated protein level 2. Elevated glucose level 3. Reduction in white blood cell count 4. Increased number of red blood cells

1. Elevated protein level

The nurse is caring for a patient with hypotension caused by neurogenic shock. What action should the nurse take to reduce the risk of developing orthostatic hypotension? 1. Raising the head of the bed slowly 2. Elevating the foot of the bed 30 degrees 3. Placing in the supine position with the head flat 4. Keeping the head of the bed elevated at 60 degrees

1. Raising the head of the bed slowly

The nurse teaches a patient who is prescribed carbamazepine (Tegretol) for the treatment of seizure activity. Which patient statement indicates a need for additional teaching? 1. "I will have blood drawn to monitor my liver function." 2. "I can crush the pill and eat it in applesauce because it is so big." 3. "I might experience blurred vision because of this medication." 4. "I will get up slowly if I experience dizziness while on this medication."

2. "I can crush the pill and eat it in applesauce because it is so big."

A patient with Guillain-Barré syndrome (GBS) is receiving plasmapheresis. The nurse monitors this patient for which complication of this treatment? 1. Septicemia 2. Flu-like symptoms 3. Aseptic meningitis 4. Acute renal failure

1. Septicemia

The nurse is planning discharge instructions for a patient recovering from surgery to debulk a brain tumor. What is the rationale for teaching the patient about self-monitoring of capillary blood glucose level? 1. Taking steroid medication 2. Risk for increased serum glucose as a result of radiation therapy 3. Interruption of glucose regulation in the brain 4. Alteration in oral intake from chemotherapy

1. Taking a steroid medication

The nurse recognizes that which disease process places the patient at the greatest risk for neurogenic shock? 1. Cerebral artery aneurysm 2. Cervical spine injury 3. Left embolic stroke 4. Epidural hematoma

2. Cervical spine injury

The nurse is caring for a patient with myasthenia gravis. Which assessment data provide the nurse with the earliest indication of the patient's potential respiratory deterioration? 1. Vital capacity 2. Pulse oximetry 3. Breath sounds 4. Arterial blood gas analysis

1. Vital capacity

A client is diagnosed with myasthenia gravis. What should the nurse explain about this disease process? 1) "Your nerve endings are worn out." 2) "Your body does not recognize the neurotransmitter needed for movement." 3) "Your body does not make enough of the neurotransmitter needed for movement." 4) "Your nerves have lost their protective covering and impulses cannot reach body areas."

2) "Your body does not recognize the neurotransmitter needed for movement."

The nurse is assisting the health-care provider with a bone marrow aspiration and biopsy on a patient who has leukemia. The patient also has thrombocytopenia. Upon completing of the test, which intervention is a priority for the nurse? 1) Make certain the patient understands the purpose of the test. 2) Hold pressure on the wound for approximately five minutes. 3) Label and refrigerate the specimen obtained by the physician. 4) Dispose of the equipment used, and clean the area properly.

2) Hold pressure on the wound for approximately five minutes.

Which statement by the patient recently diagnosed with a meningioma indicates understanding of the diagnosis? 1. "This is the worst type of brain tumor, and surgery is not an option." 2. "My tumor can be removed, but I can still have damage because of pressure in my brain." 3. "Even after the surgery, I will need chemotherapy to decrease the spread of the tumor." 4. "Radiation is never used on brain tumors because of possible nerve

2. "My tumor can be removed, but I can still have damage because of pressure in my brain."

A patient is diagnosed with myasthenia gravis. What information does the nurse include in an explanation of this disease process? 1. "Your nerve endings are no longer functional and that leads to muscle weakness." 2. "Your body has a disorder that destroys receptor sites at the neuromuscular junction, leading to decreased nerve conduction." 3. "Your body does not make enough of the neurotransmitter needed for movement." 4. "Your nerves have lost their protective covering and impulses are not as smooth."

2. "Your body has a disorder that destroys receptor sites at the neuromuscular junction, leading to decreased nerve conduction."

The nurse is caring for a patient admitted for treatment of a subarachnoid hemorrhage caused by a cerebral aneurysm who has a wide neck and tortuous vascular anatomy. The patient is hemodynamically stable with Glasgow Coma Scale of 14. Based on this data, the patient is most likely to have which procedure? 1. Aneurysm coiling 2. Aneurysm clipping 3. Reinforcing aneurysm wall 4. Evacuation of the hematoma

2. Aneurysm clipping

A patient is being prepared for a Tensilon test. What does the nurse ensure is available before the beginning of this test? 1. Oxygen 2. Atropine sulfate 3. Dexamethasone 4. Epinephrine

2. Atropine sulfate

The nurse is preparing a patient for insertion of an intraventricular catheter intracranial pressure (ICP) monitoring device. What is an advantage of this device? 1. Must be inserted in the operating room 2. Catheter tip located in the lateral ventricle 3. Less mechanical drift of the measurement over time 4. Lower rate of infection because of no fluid reservoir

2. Catheter tip located in the lateral ventricle

The nurse provides care to a patient who is admitted to confirm a suspected diagnosis of myasthenia gravis (MG). Which medication prescription does the nurse question for this patient? 1. Prednisone 2. Erythromycin 3. Edrophonium 4. Pyridostigmine

2. Erythromycin

A patient with myasthenia gravis is experiencing sweating and pallor. After administering edrophonium (Tensilon), which finding suggests the patient is experiencing a cholinergic crisis? 1. Improved muscle strength 2. Fasciculations 3. Strong hand grasps 4. Equal shoulder shrugs

2. Fasciculations

The nurse correlates which clinical manifestations to autonomic dysreflexia in a patient with a spinal cord injury? 1. Hypertension with tachycardia 2. Hypertension with bradycardia 3. Hypotension with bradycardia 4. Hypotension with tachycardia

2. Hypertension with bradycardia

In assessing a patient with increased intracranial pressure, the nurse notes that the patient's left pupil is larger than the right pupil. The nurse correlates the larger left pupil to compression of which cranial nerve? 1. Left optic nerve 2. Left oculomotor nerve 3. Right optic nerve 4. Right oculomotor nerve

2. Left oculomotor nerve

In providing care to a patient with multiple sclerosis who is developing speech difficulties, the nurse correlates this new finding to which factor? 1. Depression 2. Medications 3. Nerve regeneration 4. Mental status changes

2. Medications

A patient with neurogenic shock has a sustained heart rate of 38 beats per minute. Based on this observation, for what should the nurse prepare the patient? 1. Intravenous fluids 2. Pacemaker insertion 3. Cardiac catheterization 4. Arterial blood gas analysis

2. Pacemaker insertion

During morning care a patient with a seizure disorder asks why the room has suddenly turned green. What should the nurse do? 1. Ask the patient to explain. 2. Prepare for a seizure to begin. 3. Turn on the overhead room lights. 4. Document visual hallucinations.

2. Prepare for a seizure to begin.

The nurse correlates the new onset of back pain radiating down the left leg to which neurological disorder? 1. Meningitis 2. Spinal cord tumor 3. Multiple sclerosis 4. Amyotrophic lateral sclerosis

2. Spinal cord tumor

A patient with anemia caused by chemotherapy is prescribed synthetic erythropoietin. When teaching the patient about the therapeutic effect of this treatment, which is appropriate for the nurse to include? 1) Increase in platelets 2) Decrease in lymph fluid 3) Increase in red blood cells 4) Decrease in white blood cells

3) Increase in red blood cells

The nurse is caring for a patient with leukemia who is experiencing neutropenia as a result of chemotherapy. Which action should the nurse include in the plan of care for this patient? 1) Restrict fluid intake 2) Replace hand hygiene with gloves 3) Restrict visitors with communicable illnesses. 4) Insert an indwelling urinary catheter to prevent skin breakdown

3) Restrict visitors with communicable illnesses.

A patient with Guillain-Barré syndrome (GBS) asks how the illness develops. What should the nurse respond about the pathophysiology of the disorder? 1. "An infection destroys the nerve endings." 2. "An infection enters the spinal cord and erodes the nerves at the roots." 3. "The nerves are killed by infiltration of your body's white blood cells used to fight an infection." 4. "The covering of nerves that help conduct impulses is damaged."

4. "The covering of nerves that help conduct impulses is damaged."

A patient asks what smoking cigarettes has to do with low back pain. What is the best response to the patient? 1. "Nicotine in cigarettes decreases spinal blood flow." 2. "Nicotine is linked to nutritional disorders." 3. "Nicotine in cigarettes interferes with nutrients that supply the disk spaces." 4. "Nicotine hinders the mobility of the vertebral spaces and interferes with nervefunction."

3. "Nicotine in cigarettes interferes with nutrients that supply the disk spaces."

The nurse is reviewing orders written for a patient returning from surgery to remove a spinal cord tumor. Which order is the priority at this time? 1. Administer pain medications 2. Have the patient use the incentive spirometer 3. Administer dexamethasone (Decadron) 10 mg IVP now 4. Monitor urine output

3. Administer dexamethasone (Decadron) 10 mg IVP now

A patient recently diagnosed with amyotrophic lateral sclerosis is having difficulty with swallowing and has been choking and coughing excessively at mealtimes. The nurse implements which action first? 1. Initiating low-flow oxygen therapy 2. Suctioning the oropharynx 3. Auscultating breath sounds 4. Assessing neurological status

3. Auscultating breath sounds

In monitoring a trauma patient for shock, the nurse differentiates neurogenic shock from hypovolemic shock by correlating which parameters to neurogenic shock? 1. Tachycardia with increased afterload 2. Tachycardia with decreased afterload 3. Bradycardia with decreased afterload 4. Bradycardia with increased afterload

3. Bradycardia with decreased afterload

The nurse provides care to a patient diagnosed with myasthenia gravis (MG) who is prescribed corticosteroid therapy. Which data require immediate notification of the healthcare provider? 1. Insomnia 2. Weight gain 3. Hyperglycemia 4. Truncal obesity

3. Hyperglycemia

The nurse prioritizes which nursing diagnosis as the highest in the patient with Guillain-Barré syndrome (GBS)? 1. Risk for Aspiration related to related to loss of sensation in oropharynx secondary to progressive neuronal degeneration 2. Ineffective Airway Clearance related to decreased cough secondary to decreased acetylcholine at neuromuscular junction 3. Ineffective Breathing Pattern related to skeletal muscle weakness secondary to destruction of myelin sheath 4. Impaired Gas Exchange related to loss of respiratory muscle secondary to nerve root compression

3. Ineffective Breathing Pattern related to skeletal muscle weakness secondary to destruction of myelin sheath

A patient is diagnosed with spinal stenosis. The nurse recognizes which clinical manifestation that is caused by age-related loss of spinal muscle strength? 1. Fatigue 2. Constipation 3. Muscle spasm 4. Decreased stamina

3. Muscle spasm

A patient with multiple sclerosis experiences exacerbations of new symptoms that last a few days and then disappear. The nurse correlates these clinical manifestations to which type of multiple sclerosis? 1. Relapsing-remitting 2. Primary progressive 3. Progressive relapsing 4. Secondary progressive

3. Progressive relapsing

The nurse is caring for a patient in a barbiturate coma for increased intracranial pressure (ICP). What should the nurse assess to determine this patient's cerebral function? 1. Gag reflex 2. Glasgow Coma Scale 3. Pupillary size and reaction 4. Blood pressure and heart rate

3. Pupillary size and reaction

The nurse is caring for a patient who had a bone marrow transplant for the treatment of leukemia several weeks ago. The patient requires protective isolation. Which statement by the patient's family indicates understanding of this type of isolation? 1) "It will be important to restrict all visitors." 2) "We will encourage oral hygiene twice a day." 3) "You will have to administer all medications by IM injection." 4) "We will encourage meticulous hand washing among all visitors."

4) "We will encourage meticulous hand washing among all visitors."

A patient seeks treatment for progressively deteriorating motor and sensory function. What question is essential for the nurse to ask when completing this patient's health history? 1. "Have you been around any small children?" 2. "When was the last time you had anything to eat?" 3. "When was the last time you traveled out of the country?" 4. "Have you recently experienced any lung or stomach infections?"

4. "Have you recently experienced any lung or stomach infections?"

A patient with a seizure disorder asks the purpose of staying awake all night before having an electroencephalogram (EEG) in the morning. What should the nurse explain to this patient? 1. "You will be expected to sleep during the test." 2. "Most people with seizure disorders receive too much sleep." 3. "This is the only way to confirm that you really have a seizure disorder." 4. "Sleep deprivation can cause a seizure, which will be helpful during the test."

4. "Sleep deprivation can cause a seizure, which will be helpful during the test."

The nurse correlates which data as placing a patient at risk for experiencing a metabolic seizure? 1. Serum magnesium 3.2 mg/dL 2. Serum calcium 14 mg/dL 3. Serum potassium 3.2 mEq/L 4. Serum sodium 115 mEq/L

4. Serum sodium 115 mEq/L

The nurse notes that a patient with Guillain-Barré syndrome (GBS) sweats profusely. What should the nurse do about this finding? 1. Place on a cooling blanket. 2. Notify the healthcare provider. 3. Monitor body temperature every 2 hours. 4. Change linen and gown and keep comfortable.

4. Change linen and gown and keep comfortable.

The nurse monitors for which clinical manifestations in the patient diagnosed with a left temporal node brain tumor? 1. Sensory loss 2. Motor weakness 3. Expressive speech difficulty 4. Comprehensive speech difficulty

4. Comprehensive speech difficulty

The nurse is reviewing orders written for a patient with a new spinal cord injury. Which order does the nurse question? 1. Place on air mattress 2. Insert a nasogastric tube and attach to low intermittent suction 3. Insert indwelling urinary catheter; strict intake and output 4. Dexamethasone (Decadron) 10 mg IVP now and repeat in 4 hours

4. Dexamethasone (Decadron) 10 mg IVP now and repeat in 4 hours

The nurse is caring for a patient with multiple sclerosis. What actions does the nurse implement to increase venous return, prevent stiffness, and maintain muscle strength and endurance? 1. Administer interferon 2. Administer corticosteroids 3. Turn and reposition every 2 hours 4. Encourage range-of-motion exercises

4. Encourage range-of-motion exercises

The nurse correlates which clinical manifestation to a definitive diagnosis of multiple sclerosis? 1. Onset of double vision 2. Loss of bowel and bladder control 3. Numbness and tingling of one limb 4. Magnetic resonance imaging (MRI) changes in two separate locations

4. Magnetic resonance imaging (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? A. Absence seizure B. Complex partial seizure C. Atonic seizure D. Myoclonic seizure

A. Absence seizure

The Monroe-Kellie doctrine describes a fixed space or "box" occupied by the following components: A. Blood, water (tissue), CSF B. Blood, bone, CSF C. Bone, meninges, tissue (water) D. Bone, tissue (water), ventricles

A. Blood, water (tissue), CSF

A patient with a brain tumor has been admitted to the hospital due to changes in level of consciousness. The nurse correlates the action of which medication to the treatment of suspected increasing cerebral edema? A. Dexamethasone (Decadron) B. Phenytoin (Dilantin) C. Carbamazepine (Tegretol) D. Furosemide (Lasix)

A. Dexamethasone (Decadron)

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? A. In the reverse order of the onset of symptoms B. In the lower extremities first followed by the breathing muscles C. As evidenced by bladder and bowel control D. In one limb at a time

A. In the reverse order of the onset of symptoms

The nurse recognizes which explanation as the pathophysiological basis for MG? A. There are an inadequate number of muscarinic receptors. B. Antibodies to AChRs block neuromuscular junction transmission. C. Thymomas are present in 80% of patients with MG. D. There is an abundance of ACh, which binds to viable receptors.

B. Antibodies to AChRs block neuromuscular junction transmission.

A patient with a history of complex partial seizures has a phenytoin (Dilantin) level (free) of 3.1 mcg/mL. The nurse calls the patient and instructs the patient to take which action? A. Stop the medication and make an appointment for the following week with the provider. B. Continue the medication and make an appointment right away with the health-care provider. C. Take an extra dose now and continue with the current regimen. D. Skip the next dose and make an appointment right away with the health-care provider.

B. Continue the medication and make an appointment right away with the health-care provider.

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? A. Absence of deep tendon reflexes (DTRs) B. Distended bladder C. Respiratory distress D. Overexertion

B. Distended bladder

A patient is admitted with a C5 spinal cord injury. On admission, what is the highest nursing priority intervention? A. Assessing motor and sensory function B. Maintaining spinal cord precautions C. Assessing vital signs for symptoms of shock D. Preparing for an MRI scan

B. Maintaining spinal cord precautions

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? A. Level of consciousness B. Muscle strength C. Muscle tone D. Hearing

B. Muscle strength

The nurse correlates which rationale to the use of hyperventilation to decrease intracranial pressure in a patient after traumatic head injury? A. To maximize oxygenation B. To promote vasoconstriction C. To decrease cerebral perfusion D. To decrease ventilatory effort

B. To promote vasoconstriction

A patient is admitted to the neuroscience intensive care unit (NICU) after a TBI. If the goal of ICP monitor insertion is to measure ICP and drain CSF to control ICP, what device should the nurse anticipate being inserted? A. Intraparenchymal sensor B. Epidural sensor C. Intraventricular catheter D. Subarachnoid bolt

C. Intraventricular catheter

The nurse assesses the patient for which early finding in ALS? A. Bowel and bladder incontinence B. Respiratory distress C. Muscle cramps D. Paralysis

C. Muscle cramps

Which action is the highest priority in the patient who presents with autonomic dysreflexia? A. Prepare for intubation B. Initiate vasopressors C. Remove the stimulus D. Place a temporary pacemaker

C. Remove the stimulus

A 30-year-old male with a C-spine injury is placed in a halo vest for which of the following reasons? A. To decrease infection B. To prevent spinal shock C. To immobilize the spine D. To hasten wound healing

C. To immobilize the spine

The nurse monitors for which complication in the patient with bulbar ALS? A. Lower back pain B. Dementia C. Paresthesia D. Dysphagia

D. Dysphagia

Which nursing intervention is a priority for a patient with cranial nerve impairment from GBS? A. Perform sensory checks with the neurological examination below the level of the cervical spine. B. Consult with the provider for initiation of continuous positive airway pressure for breathing. C. Create a turning schedule with limited time in the side-lying position. D. Establish effective communication using eye blinks or a communication board.

D. Establish effective communication using eye blinks or a communication board.

The patient with MG needs to be educated about medications that should be avoided because they can increase weakness. Which medication should the patient avoid? A. Acetaminophen B. Prednisone C. Azathioprine D. Maalox

D. Maalox

When providing patient teaching about plasma- pheresis to a patient with MG, the nurse explains that the purpose of the procedure is which result? A. Reduce the levels of calcium and magnesium in the blood B. Remove excessive acetylcholinesterase from the plasma C. Deliver deficient proteins directly into the blood D. Remove ACh receptors antibodies from the blood

D. Remove ACh receptors antibodies from the blood

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? A. Persistent jerking movement of one half of the body B. Unilateral jerking movement of one extremity C. Muscle flaccidity followed by tremors of all extremities D. Stiffening of muscles of arms and legs, followed by jerking movements

D. Stiffening of muscles of arms and legs, followed by jerking movements