exam one MedsurgII
Increases the outflow of aqueous humor by constricting the pupil but this could also make it difficult to see in the dark (pupil dilation is needed when lighting is low)
miotics
A client with post-polio syndrome displays fatigue and decreased muscle strength. How should the nurse best respond to the client?
"Intravenous immunoglobulin infusion may help you." Explanation: There is no specific treatment for post-polio syndrome; however, the infusion of IV immunoglobulin has been shown to help with the physical pain and weakness.
May be used to decrease agitation in the setting of head injury because it has a rapid onset, short acting and allows for accurate neurological
Diprivan
The nurse is caring for a male client with benign prostatic hyperplasia who is taking tamsulosin (Flomax). When performing a neurologic assessment the nuse notes that the pupils do not dilate in the dark. Which of the following actions would the nurse do next?
Document the finding in the chart Principle: Alpha-antagonists (tamsulosin, [Flomax]) can impair pupil dilation (mydriasis)
A nurse is caring for a client with lower back pain who is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should place the client in which position?
Head of the bed elevated 45 degrees Explanation: After a myelogram, positioning depends on the dye injected. When a water-soluble dye such as metrizamide is injected, the head of the bed is elevated to a 45-degree angle to slow the upward dispersion of the dye. The prone and supine positions are contraindicated when a water-soluble contrast dye is used. The client should be positioned supine with the head lower than the trunk after an air-contrast study.
Which type of benign tumor of the eyelids is characterized by superficial, vascular capillary lesions that are strawberry-red in color?
Hemangioma Explanation: Hemangiomas are vascular capillary tumors that may be bright, superficial, strawberry-red lesions or bluish and purplish deeper lesions.
Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure?
Herniation Explanation: Herniation refers to the shifting of brain tissue from an area of high pressure to an area of lower pressure. Autoregulation is an ability of cerebral blood vessels to dilate or constrict to maintain stable cerebral blood flow despite changes in systemic arterial blood pressure. Cushing's response is the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased ICP. The Monro-Kellie hypothesis is a theory that states that, due to limited space for expansion within the skull, an increase in any one of the cranial contents causes a change in the volume of the others.
A male client who has undergone a cervical discectomy is being discharged with a cervical collar. Which of the following would be most appropriate to include the client's discharge plan?
Keeping the head in a neutral position Explanation: After a cervical discectomy, the client typically wears a cervical collar. The client should be instructed to keep his head in a neutral position and wear the collar at all times unless the physician has instructed otherwise. The front part of the collar is removed for shaving and the neck should be kept still while the collar is open or off.
A nurse is assisting during a lumbar puncture. How should the nurse position the client for this procedure?
Lateral recumbent, with thighs flexed Explanation: To maximize the space between the vertebrae, the client is placed in a lateral recumbent position with the thighs flexed toward the chin as much as possible. The needle is inserted between L4 and L5.
A 70 year old Caucasian female complains of having a loss of vision in the center of her sight. The clinical manifestation suggests which of the following disorders?
Macular degeneration Principle: The macula is the area of the retina that provides central vision; damage (macular degeneration) results in central vision loss
The nurse is caring for a patient with Ménière's disease who is hospitalized with severe vertigo. What medication does the nurse anticipate administering to shorten the attack?
Meclizine (Antivert) Explanation: Pharmacologic therapy for Ménière's disease consists of antihistamines, such as meclizine, which shortens the attack
A patient is diagnosed with an aggressive, primary malignant brain tumor. The nurse is aware that the glioma:
Originated within the brain tissue. Explanation: The most aggressive type of malignant brain tumor is a glioma, which originates within the brain tissue.
Which of the following is a late symptom of spinal cord compression?
Paralysis Explanation: Later symptoms include evidence of motor weakness and sensory deficits progressing to paralysis. Early symptoms associated with spinal cord compression include bladder and bowel dysfunction (urinary incontinence or retention; fecal incontinence or constipation).
Which lobe of the brain is responsible for spatial relationships?
Parietal Explanation: The parietal lobe is essential to a person's awareness of body position in space, size and shape discrimination, and right-left orientation.
Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels?
T6 Explanation: Any patient with a lesion above T6 segment is informed that autonomic dysreflexia can occur and that it may occur even years after the initial injury.
Which cerebral lobe contains the auditory receptive areas?
Temporal Explanation: The temporal lobe plays the most dominant role of any area of the cortex in cerebration. The frontal lobe, the largest lobe, controls concentration, abstract thought, information storage or memory, and motor function
What would the nurse correctly identify as the structure that responds to light through constriction and dilation.
The pupil is the structure that responds to light by constricting and dilating.
The nurse is seeing a client who is suspected of having a glioblastoma multiforme tumor. The nurse anticipates the client will require which diagnostic test to confirm the client has this form of brain tumor?
Tissue biopsy Explanation: Glioblastoma multiforme is the most common and aggressive malignant brain tumor. In most cases, a tissue biopsy, which can be obtained at the time of surgical removal, is needed to confirm the diagnosis.
What is a possible sign of hyperperfusion syndrome following a carotid endarterectomy
Unilateral headache that improves upon sitting
A nurse is performing a neurologic assessment on the client and notes a positive Romberg test. This test for balance is related to which of the following cranial nerves?
VIII Explanation: CN VIII is the acoustic nerve. It has to do with hearing, air and bone conduction, and balance.
The provider orders the Romberg test for a patient. The nurse tells the patient that the provider wants to evaluate his equilibrium by assessing which cranial nerve?
VIII Explanation: Cranial nerve VIII (acoustic) can be checked to assess equilibrium status.
A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by:
a positive edrophonium (Tensilon) test. Explanation: A positive edrophonium test confirms the diagnosis of myasthenia gravis. After edrophonium administration, most clients with myasthenia gravis show markedly improved muscle tone.
decreases aqueous humor production
alpha 2 receptor stimulation effect on ciliary body of eye
can impair pupil dilation (mydriasis)
alpha antagonist
Signs of neurogenic shock include
bradycardia, decreased blood pressure and cardiac output, peripheral vasodilation and venous pooling
Clinical manifestations of pulmonary embolism consist of:
chest pain, cough, dyspnea, hypoxemia, tachycardia, tachypnea, petechiae and restlessness
The nurse has documented a client diagnosed with a head injury as having a Glasgow Coma Scale (GCS) score of 7. This score is generally interpreted as
coma. Explanation: The GCS is a tool for assessing a client's response to stimuli. A score of 7 or less is generally interpreted as a coma. The lowest score is 3 (least responsive/deep coma); the highest is 15 (most responsive). A GCS between 3 and 8 is generally accepted as indicating a severe head injury. No category is termed "least" responsive.
During assessment for cranial nerve functions, the client closes the eyes and begins to fall to one side. Which cranial nerve alteration causes this response?
cranial nerve VIII Explanation: Nerve receptors for balance are found both in the vestibule and semicircular canals. They transmit information about motion through the vestibular nerve, which joins with the cochlear nerve to form the eighth cranial nerve (formally called the auditory or acoustic nerve).
What is Acute otitis media is marked by
unilateral otalgia, fever, hearing loss, bulging red tympanic membrane or otorrhea if the tympanic membrane perforates
An excessive increase in this hormone will result in decrease in serum sodium levels (hyponatremia)
vasopressin
A client is admitted with generalized abdominal pain, nausea, vomiting, and hypotension. The client has not passed stool in over 1 week and has been in pain for the past 4 days. Which type of pain would you expect the client to be experiencing?
visceral Explanation: Visceral pain arises from internal organs such as the heart, kidneys, and intestine that are diseased or injured. Visceral pain usually is diffuse, poorly localized, and accompanied by autonomic nervous system symptoms such as nausea, vomiting, pallor, hypotension, and sweating.
A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as?
An intracerebral hematoma Explanation: Intracerebral hemorrhage (hematoma) is bleeding within the brain, into the parenchyma of the brain. It is commonly seen in head injuries when force is exerted to the head over a small area (e.g., missile injuries, bullet wounds, stab injuries). A subdural hematoma (SDH) is a collection of blood between the dura and the brain, a space normally occupied by a thin cushion of cerebrospinal fluid. After a head injury, blood may collect in the epidural (extradural) space between the skull and the dura.
Decreases the production of aqueous humor and systemic effects could be observed (bradycardia and hypotension)
Beta blockers
A client with myasthenia gravis is admitted with an exacerbation. The nurse is educating the client about plasmapheresis and explains this in which of the following statements?
Antibodies are removed from the plasma. Explanation: Plasmapheresis is a technique in which antibodies are removed from plasma and the plasma is returned to the client. The other three choices are appropriate treatments for myasthenia gravis, but are not related to plasmapheresis.
The nurse is caring for a client who had a mastoidectomy today and is aware of the rare post op complication from this procedure. Based on this understanding the nurse must perform which of the following assessments?
Assess cranial nerve VII Principle: Facial nerve injury is a rare complication of mastoid surgery and cranial nerve VII should be assessed
A patient diagnosed with a tumor in the cerebellar region would expect to have changes in which of the following?
Balance and coordination Explanation: If a tumor is present in the cerebellar area, the nurse might expect to see changes in balance and coordination.
Are released from the adrenal medulla
Catecholamines; epi and noepi
The nurse reviews the patient's drug regimen for treatment of a brain tumor. She explains to the patient why one of the following drugs would not be prescribed, even though it might have therapeutic benefits. Which drug would not be prescribed for this patient?
Coumadin Explanation: Although deep vein thrombosis and pulmonary embolism occur in about 15% of patients and cause significant morbidity, anticoagulants are not prescribed due to the risk for CNS hemorrhage.
The nurse is caring for a client with Guillain-Barre Syndrome. The client complains of dysphagia. Which of the following actions is most important for the nurse to assess?
Cranial nerve IX & X Principle: Bulbar paralysis is manifested by dysphagia and puts the client at risk for aspiration
A nurse is performing an otoscopic examination on a client. Which finding would the nurse document as abnormal?
External auditory canal erythema Explanation: An erythematous external auditory canal would be considered an abnormal finding. The tympanic membrane is normally pearly gray and translucent. The umbo, which is located in the center of the eardrum, extends from the superior manubrium.
Administering _______ placing the PT in an upright position, identifying and relieving the noxious stimulus (insert a foley, manual disimpaction, remove, painful stimulus)
Hydralazine
Loud, persistent noise has what effect on the body?
Increased blood pressure Explanation: Loud, persistent noise has been found to cause constriction of peripheral blood vessels, increased blood pressure, increased heart rate, and increased gastrointestinal motility.
A client with a brain tumor experiences projectile vomiting. The nurse integrates understanding of this occurrence as resulting from which of the following?
Irritation of the medullary vagal centers Explanation: Vomiting associated with a brain tumor is usually the result of irritation of the vagal centers in the medulla
A nurse conducted a history and physical for a newly admitted patient who states, "My arms are too short. I have to hold my book at a distance to read." The nurse knows that the patient is most likely experiencing:
Loss of accommodative power in the lens. Explanation: Presbyopia is a refractive change that occurs with age. The lens of the eye loses accommodative power.
The nurse is assisting with the administration of a caloric stimulation test. Which client response would the nurse document as an expected response?
Nystagmus Explanation: A caloric stimulation test assesses vestibular reflexes of the inner ear that control balance. Warm or cool water or air is instilled into the external meatus of the ear separately. Nystagmus, a quivering movement of the eyes, is the expected response. Slight dizziness may be experienced but is not the expected response. Headache and double vision is not the expected response.
Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch?
Spasticity Explanation: Spasticity is often associated with weakness, increased deep tendon reflexes, and diminished superficial reflexes.
The nurse is preparing to administer t-PA to a client with an ischemic stroke. Which of the following assessment findings is a contraindication for this medication?
A blood pressure of 220/130 Principle: t-PA (given within 60 minutes) stimulates fibrinolysis in the setting of an ischemic stroke but could cause hemorrhage if the blood pressure is too high, the client is taking warfarin, received heparin in the last 48 hours or the platelet count is less than 100,000/mm3
Which of the following findings require the nurse to notify the physician prior to a cerebral angiography?
A weak bilateral dorsalis pedis pulse of 1+ Renal function and pulses must be noted prior to cerebral angiography since contrast medium is used
A 75-year-old client had surgery for a hip fracture yesterday. The client is under stress because of the pain, the medications, sleep deprivation, and hospital surroundings. Which nursing intervention to treat the client's pain should the nurse question when ordered by the doctor?
Advil for pain management Explanation: NSAIDs such as Advil increase the risk of gastrointestinal (GI) toxicity in individuals >60 years of age and should be assessed further before administration.
A patient is diagnosed with an intracerebral tumor. The nurse knows that the diagnosis may include which of the following? Select all that apply.
Astrocytoma Ependymoma Medulloblastoma Explanation: Glial tumors, the most common type of intracerebral brain neoplasm, are divided into many categories, including astrocytomas, ependymomas, and medulloblastomas.
A client with a brain tumor is receiving dexamethasone (Decadron). The nurse would monitor the client for which of the following clinical manifestations? Answer Options * Black tarry stools Hypotension Hypoglycemia Decreased appetite
Black tarry stools Principle: Corticosteroid use could result in gastrointestinal hemorrhage
When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?
Body temperature Explanation: It is important to monitor the client's body temperature closely because hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures.
A client is diagnosed with a brain angioma. When teaching the client about the risks associated with this type of brain tumor, the nurse would educate about signs and symptoms associated with which condition?
Brain angiomas (masses composed largely of abnormal blood vessels) are found either in the brain or on its surface. Because the walls of the blood vessels in angiomas are thin, affected clients are at risk for hemorrhagic stroke.
A client who complained of a severe headache with blurred vision quickly loses consciousness in one hour. Which of the following findings is consistent with the clinical presentation?
Cerebral aneurysm Principle: An acute severe headache with loss of consciousness, nuchal rigidity and visual disturbances could suggest a cerebral aneurysm
When caring for a client who has a decrease in cerebral perfusion pressure, which of the following assessment findings require immediate attention?
Cerebral perfusion pressure of 35 mmHg Principle: A decrease in cerebral perfusion pressure could trigger vasodilation and result in an increase in intracranial pressure and lower perfusion pressures
A nurse is caring for a client with a cervical disk herniation. Which of the following clinical manifestations is the client likely to experience?
Cervical disk herniation is typically accompanied by pain, paresthesias, and stiffness
Which of the following is the role of the nurse toward a patient who is to undergo eye examinations and tests?
Ensuring that the patient receives eye care to preserve his or her eye function and prevent further visual loss Explanation: Although nurses may not be directly involved in caring for patients who are undergoing eye examinations and tests, it is essential that they ensure that patients receive eye care to preserve their eye function and/or prevent further visual loss.
Bell palsy is a disorder of which cranial nerve?
Facial (VII) Explanation: Bell palsy is characterized by facial dysfunction, weakness, and paralysis. Trigeminal neuralgia, a disorder of the trigeminal nerve, causes facial pain. Ménière syndrome is a disorder of the vestibulocochlear nerve. Guillain-Barré syndrome is a disorder of the vagus nerve.
A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?
Lung auscultation and measurement of vital capacity and tidal volume Explanation: In Guillain-Barré syndrome, polyneuritis commonly causes weakness and paralysis, which may ascend to the trunk and involve the respiratory muscles. Lung auscultation and measurement of vital capacity, tidal volume, and negative inspiratory force are crucial in detecting and preventing respiratory failure — the most serious complication of polyneuritis.
Which of the following is a disorder due to a lesion in the basal ganglia?
Parkinson's disease Explanation: Disorders due to lesions of the basal ganglia include Parkinson's disease, Huntington's disease, and spasmodic torticollis.
A client with a T4-level spinal cord injury (SCI) reports severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp and suspects autonomic dysreflexia. What is the first thing the nurse will do?
Place the client in a sitting position. Explanation: The nurse immediately places the client in a sitting position to lower blood pressure. Next, the nurse will do a rapid assessment to identify and alleviate the cause, and then check the bladder and bowel. The nurse will examine skin for any places of irritation. If no cause can be found, the nurse will give an antihypertensive as ordered and continue to look for cause. He or she watches for rebound hypotension once cause is alleviated. Antiembolic stockings will not decrease the blood pressure.
A nurse is caring for a client with severe myopia. The nurse would educate the client on the signs and symptoms of which of the following potential complications?
Retinal detachment Principle: Severe myopia increases the risk for retinal detachment
A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as:
Severe TBI. Explanation: A score of 13 to 15 is classified as mild TBI, 9 to 12 is moderate TBI, and 3 to 8 is severe TBI. A score of 3 indicates severe impairment of neurologic function, deep coma, brain death, or pharmacologic inhibition of the neurologic response; a score of 8 or less typically indicates an unconscious patient; a score of 15 indicates a fully alert and oriented patient.
The nurse is caring for a client with a closed head injury. The client is lethargic and complains of a headache. Which of the following clinical manifestations suggests a worsening head injury.
Signs of a head injury that's worsening includes changes in level of consciousness, worsening headache, abnormal pupil response, vomiting, weakness, slurred speech or irritability
Which condition occurs when blood collects between the dura mater and arachnoid membrane?
Subdural hematoma Explanation: A subdural hematoma is a collection of blood between the dura mater and the brain, a space normally occupied by a thin cushion of fluid. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with displacement of surrounding structures. An epidural hematoma is bleeding between the inner skull and the dura, compressing the brain underneath. An extradural hematoma is another name for an epidural hematoma.
Which of the following is the treatment of choice for acoustic neuromas?
Surgery Explanation: Surgical removal of acoustic tumors is the treatment of choice because these tumors do not respond well to radiation or chemotherapy. There would be no need for palliation.
Acoustic neuromas are benign tumors of which of the following cranial nerves?
VIII Explanation: Acoustic neuromas are slow-growing, benign tumors of cranial nerve VIII, usually arising from the Schwann cells of the vestibular portion of the nerve.
Miotics (pilocarpine) do what?
increase the outflow of aqueous humor by constrictiing the pupil but this could also make it difficult to see in the dark (pupil dilation is needed when lighting is low)
A nurse knows that, for a patient with an ischemic stroke, tPA is contraindicated if the blood pressure reading is higher than:
185 mm Hg/110 mm Hg Explanation: Elevated blood pressure (systolic >185; diastolic >110 mm Hg) is a contraindication to tPA.
When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes?
30-degree head elevation Explanation: For clients with increased intracranial pressure (ICP), the head of the bed should be elevated to 30 degrees to promote venous outflow. Trendelenburg's position is contraindicated because it can raise ICP. Flat or neutral positioning is indicated when elevating the head of the bed would increase the risk of neck injury or airway obstruction. A side-lying position isn't specifically a therapeutic treatment for increased ICP.
Bone density testing in clients with post-polio syndrome has demonstrated
low bone mass and osteoporosis. Explanation: Bone density testing in clients with post-polio syndrome has demonstrated low bone mass and osteoporosis. Thus, the importance of identifying risks, preventing falls, and treating osteoporosis must be discussed with clients and their families.
Which symptoms may a client with Ménière disease report before an attack?
A full feeling in the ear Explanation: Clients with Ménière disease experience symptoms of headache and a full feeling in the ear before an attack
Has diuretic effects, contains sulfa; monitor electrolytes and avoid use in PTs with sulfa allergies
Acetazolamide
The nurse is assisting the client in planning care during exacerbations of Ménière's disease. Which diet would the nurse identify as appropriate at this time?
A low-sodium diet Explanation: Treatment for Ménière's disease is related to reducing fluid production in the inner ear, facilitating its drainage, and treating the symptoms that accompany the attack. A low-sodium and sodium-free diet lessens edema.
The nurse is teaching a class on diseases of the ear. What would the nurse teach the class is the most characteristic symptom of otosclerosis?
A progressive, bilateral loss of hearing Explanation: A progressive, bilateral loss of hearing is the characteristic symptom of otosclerosis. Tinnitus appears as the loss of hearing progresses; it is especially noticeable at night, when surroundings are quiet, and may be quite distressing to the client.
A client with quadriplegia is in spinal shock. What finding should the nurse expect?
Absence of reflexes along with flaccid extremities Explanation: During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the client will demonstrate positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities.
Which of the following neurotransmitters are deficient in myasthenia gravis?
Acetylcholine Explanation: A decrease in the amount of acetylcholine causes myasthenia gravis
An otherwise healthy 45 year old female is admitted to the hospital with a chief complaint of vertigo. The client has an order for meclizine (Antivert) q 12 hours as needed. Which action should the nurse take next?
Administer the meclizine (Antivert) as ordered Principle: Antihistamines (meclizine [Antivert]) may be used to treat vertigo or disturbances in balance
The nurse is preparing to start a 48-year old male with Parkinson's disease (PD) on a dopamine agonist. The nurse knows that dopamine has which of the following effects?
Affects movement Principle: Dopamine is typically inhibitory and affects behavior and fine movement
The nurse should monitor for which manifestation in a client who has had LASIK surgery?
After LASIK surgery, symptoms of central islands and decentered ablations can occur that include monocular diplopia or ghost images, halos, glare, and decreased visual acuity.
It is important for the nurse to educate clients newly diagnosed with Ménière disease to avoid which foods in their diet? Select all that apply.
Alcohol High-salt foods Monosodium glutamate Caffeine Explanation: Alcohol, high salt, monosodium glutamate, and caffeine can worsen symptoms of Ménière disease by affecting fluid levels in the inner ear.
Which disease includes loss of motor neurons in the anterior horns of the spinal cord and motor nuclei of the lower brain stem?
Amyotrophic lateral sclerosis (ALS) is a disease of unknown cause in which there is a loss of motor neurons in the anterior horns of the spinal cord and the motor nuclei of the lower brain stem.
The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following?
Cardiogenic emboli Explanation: Aneurysms, hemorrhages, and malformations are all examples of a hemorrhagic stroke. An embolism can block blood flow, leading to ischemia.
A client comes to the clinic for evaluation because of complaints of dizziness and difficulty walking. Further assessment reveals a staggering gait, marked muscle incoordination, and nystagmus. A brain tumor is suspected. Based on the client's assessment findings, the nurse would suspect that the tumor is located in which area of the brain?
Cerebellum Explanation: Findings such as ataxic or staggering gait, dizziness, marked muscle incoordination, and nystagmus suggest a cerebellar tumor.
The nurse is assessing the pupils of a patient who has had a head injury. What does the nurse recognize as a parasympathetic effect?
Constricted pupils Explanation: Constricted pupils are a parasympathetic effect;
The nurse is assessing the throat of a client with throat pain. In asking the client to stick out the tongue, the nurse is also assessing which cranial nerve?
Cranial nerve XII Explanation: Assessment of the movement of the tongue is cranial nerve XII .
Which condition is a rare, transmissible, progressive fatal disease of the central nervous system characterized by spongiform degeneration of the gray matter of the brain?
Creutzfeldt-Jakob disease Explanation: Creutzfeldt-Jakob disease causes severe dementia and myoclonus. Multiple sclerosis is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of small patches of demyelination in the brain and spinal cord. Parkinson disease is associated with decreased levels of dopamine due to destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain. Huntington disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary dancelike movements and dementia.
When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following?
Decerebrate Explanation: Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The described posturing results from cerebral trauma and is not normal. The patient has no motor function, is limp, and lacks motor tone with flaccid posturing.
A client with a spinal cord injury says he has difficulty recognizing the symptoms of urinary tract infection (UTI). Which symptom is an early sign of UTI in a client with a spinal cord injury?
Fever and change in urine clarity Explanation: Fever and change in urine clarity as early signs of UTI in a client with a spinal cord injury. Lower back pain is a late sign. A client with a spinal cord injury may not experience a burning sensation or urinary frequency.
After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know whether the client has a cervical spinal injury. Until such an injury is ruled out, the nurse should restrict this client to which position?
Flat, except for logrolling as needed Explanation: When caring for the client with a possible cervical spinal injury who's wearing a cervical collar, the nurse must keep the client flat to decrease mobilization and prevent further injury to the spinal column. The client can be logrolled, if necessary, with the cervical collar on.
The nurse is assessing a client who was brought to the emergency department due to a severe headache with sudden onset, lowered level of consciousness and slurred, non-sensical speech. The client completed chemotherapy and radiation treatment for a glioma-type brain tumor 6 months ago. The client has been taking low molecular weight heparin since completing treatment. The nurse should be prepared to provide care for which possible problem?
Intracerebral hemorrhage Explanation: Clients receiving anticoagulant agents, such as low molecular weight heparin, must be closely monitored because of the risk of central nervous system hemorrhage, also known as an intercerebral hemorrhage. Both deep vein thrombosis and pulmonary embolism would be prevented or mitigated by the use of anticoagulant medications such as low molecular weight heparin. The nurse should always consider the risk of these latter problems, however, because the client is clearly at risk for impaired coagulation. Spinal metastasis can result in spinal cord compression, which is considered a medical emergency requiring immediate treatment. In this case, the nurse would observe reports of back pain, extremity weakness, ataxia and/or paralysis.
A client comes to the emergency department, reporting that a bee has flown into his ear and is stuck. The client reports a significant amount of pain. Which of the following would be most appropriate to use to remove the bee?
Mineral oil Explanation: An insect in the ear canal can be dislodged by instilling mineral oil, which kills the insect and allows removal. Irrigation is contraindicated because the insect would swell
A client who has a pituitary adenoma would report which symptoms related to the presence of this type of tumor? Select all that apply.
Morning headaches Chiasmal syndrome Polydipsia Anorexia Common symptoms reported in association with the diagnosis of a pituitary adenoma include headaches in the morning, and changes in the visual field resulting from pressure on the optic nerves, optic chiasm and optic tracts. It is the pressure on the optic chiasm that can lead to a condition called chiasmal syndrome, which is correlated with pituitary adenomas. Polydipsia is just one of the symptoms of diabetes insipidus that accompanies the presence of this type of tumor. Low appetite resulting from the pressure of the tumor can lead to anorexia.
A nurse is caring for a client with Parkinson's disease who takes levodopa routinely. He has a temperature of 103 degrees Fahrenheit, increased muscle rigidity, and a decreased level of consciousness. Which of the following is true? These clinical manifestations are consistent with
Neuroleptic malignant syndrome. Principle: Neuroleptic malignant syndrome is charecterized by high fever, rigidity and stupor
... The nurse is assisting the eye surgeon in completing an examination of the eye. Which piece of equipment would the nurse provide to the physician to examine the optic disc under magnification?
Ophthalmoscope Explanation: The nurse is correct to provide an ophthalmoscope to the surgeon for examination of the optic disc.
The nurse is caring for a client who is currently under medical investigation for a pituitary adenoma. The nurse anticipates the client will likely report which symptoms that are consistent with this type of brain tumor? Select all that apply.
Polydipsia Polyuria Disturbed sleep Impairment of visual field Explanation: Pressure from a pituitary adenoma may be exerted on the optic nerves, optic chiasm, optic tracts, hypothalamus, or the third ventricle. Headache is a common symptom; there can also be visual dysfunction including loss of visual field, the development of diabetes insipidus including symptoms such as excessive thirst and urination. Sleep disturbances are reported and result from the development of diabetes insipidus.
An aging client is brought to the eye clinic by the son. The son states he has seen his parent holding reading materials at an increasing distance to focus properly. What age-related changes does this indicate?
Presbyopia Explanation: Refractive changes, such as presbyopia, occur in older adults where the lens cannot readily accommodate aging. In such cases, the client is observed holding reading materials at an increasing distance to focus properly.
During the recovery phase of a neurologic deficit, assessment tools may be used to help identify a client's level of functioning. Which tool is used to measure performance in activities of daily living (ADL)?
The Barthel Index Explanation: On The Barthel Index, each performance ADL item is rated with a given number of points assigned to each level or ranking. A higher number is associated with a greater likelihood of being able to live at home with a degree of independence following discharge from hospital.
The nurse receives an order to screen a client who has diminished hearing in the right ear for conductive hearing loss. Following the Weber test, the nurse observes that the sound is better in the affected ear. How should the nurse interpret this finding?
The client could have excess cerumen in the right ear Principle: When assessing unilateral hearing loss with the Weber test, sound is heard better in the affected ear with conductive deafness and in the unaffected ear with sensorineural deafness
The nurse received the report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?
The client has cerebral spinal fluid (CSF) leaking from the ear. Explanation: Otorrhea means leakage of CSF from the ear. The client with a basilar skull fracture can create a pathway from the brain to the middle ear due to a tear in the dura. As a result, the client can have cerebral spinal fluid leak from the ear. The nurse may assess clear fluid in the ear canal.
Which statement describes the pathophysiology of post-polio syndrome?
The exact cause is unknown, but aging or muscle overuse is suspected. Explanation: The exact cause of post-polio syndrome is not known but researchers suspect that with aging or muscle overuse the neurons that were not destroyed originally by the poliovirus are unable to continue generating axon sprouts. The exact cause of post-polio syndrome is not known.
The nurse is working in the emergency department when a physician asks for help as the client is performing a Romberg test. In which position would the nurse stand to be most helpful?
The nurse would stand laterally to the client, opposite side to where the physician is standing. Explanation: The Romberg test is used to evaluate a person's ability to sustain balance. The client stands with the feet together and arms extended. In the event that the client begins to sway (an abnormal result), the nurse is most helpful to stand on the lateral side of the client, opposite side to where the physician is standing to ensure that the client does not fall.
The nurse is seeing the mother of a client who states, "I'm so relieved because my son's doctor told me his brain tumor is benign." The nurse knows what is true about benign brain tumors?
They can affect vital functioning. Explanation: Benign tumors are usually slow growing but can occur in a vital area, where they can grow large enough to cause serious effects.
A client has a history of hearing loss and is returning for an annual hearing examination. During client education, the nurse explains that hearing involves which areas of the ear?
all sections Explanation: Sound is perceived because of a chain reaction involving all three areas of the ear.
When administering timolol (Timoptic) to a client with glaucoma, the nurse should hold the medication if the client admits to which of the following?
asthma Principle: Beta-blockers are contraindicated in the setting of asthma, chronic obstructive pulmonary disease, or heart failure since bronchodilation is inhibited and the heart rate is decreased
Nursing management of the client with acute symptoms of benign paroxysmal positional vertigo includes
bed rest. Explanation: Bed rest is recommended for clients with acute symptoms. Canalith repositioning procedures may be used to resolve attacks of vertigo, and clients with acute vertigo may be medicated with meclizine for 1 to 2 weeks. The Epley procedure is not recommended for clients with acute vertigo. The Dix-Hallpike test is an assessment test used to evaluate for benign paroxysmal positional vertigo.
A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should:
emonstrate eyedrop instillation. Explanation: Eyedrop instillation is a critical component of self-care for a client with glaucoma. After demonstrating eyedrop instillation to the client and family, the nurse should verify their ability to perform this measure properly.
Signs of autonomic dysreflexia include:
extreme hypertension, headache, diaphoresis above the lesion, nasal congestion and bradycardia and results from a noxious stimuli (full bladder, rectum or pain) following the resolution of spinal shock ;
If untreated, squamous cell carcinoma of the external ear can spread through the temporal bone, causing
facial nerve paralysis. Explanation: If untreated, squamous cell carcinomas of the ear can spread through the temporal bone, causing facial nerve paralysis and hearing loss.
Clinical manifestations of hyponatremia consist of :
headaches, seizures, lethargy, tachycardia, decrease in blood pressure, thready pulse, hyperactive bowel sounds and abdominal cramps
A client has noticed recently having clearer vision at a distance than up close. What is the term used to describe this client's visual condition?
hyperopia Explanation: Hyperopia is farsightedness. People who are hyperopic see objects that are far away better than objects that are close.
A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the health care provider in the emergency department. Which is the origin of the client's symptoms?
impaired cerebral circulation Explanation: TIAs involve the same mechanism as in the ischemic cascade, but symptoms are transient (< 24 hours) and there is no evidence of cerebral tissue infarction. The ischemic cascade begins when cerebral blood flow decreases to less than 25 mL/100 g/min and neurons are no longer able to maintain aerobic respiration. Thus, a TIA results directly from impaired blood circulation in the brain. Atherosclerosis, cardiac disease, hypertension, or diabetes can be risk factors for a TIA but do not cause it.
How do you treat autonomic dysreflexia
lacing the patient in an upright position, identifying and relieving the noxious stimulus (insert a foley, manual disimpaction, remove painful stimulus), administering hydralazine and educating the patient about the risk for AD for years after the injury above T6
helps to decrease fluid in the brain
osmotic diuretic
initiate inflammation and contribute to tissue swelling/pain and needed for renal blood flow
prostaglandins
Pituitary adenoma
Pituitary adenomas can increased production of several hormones including TSH, ACTH, growth hormone and prolactin.
A nurse is caring for an unconscious client who extends his elbows, pronates his arms, flexes his wrists and points his toes. Which of the following is true?
Joint extension or a lack of motor responses in the setting of a head injury typically suggest a poorer prognosis