final 49, 50, 52
A patient began experiencing manifestations of a stroke at 0800 hours. By which time should thrombolytic medications be provided to reverse stroke symptoms? 1. 0900 hours 2. 1250 hours 3. 1400 hours 4. 1660 hours
2
A patient arrives in the emergency department at 0200 exhibiting the manifestations of a stroke. The patient reports going to bed at 2100 and being negative for symptoms. If the CT reveals an ischemic stroke related to a blood clot, for which reason is tPA therapy withheld? 1. The therapy is based on the time the patient went to bed. 2. The patient's symptoms have progressed too quickly. 3. The total effects of ischemia are not currently known. 4. The patient is negative for any symptoms related to intracranial pressure (ICP).
1
A patient in the plateau stage of GBS is frustrated because there has been no improvement in manifestations for 5 days. Which explanation does the nurse provide to the patient? 1. The manifestations can last up to 2 weeks. 2. The manifestations can last up to 3 weeks. 3. The manifestations can last up to 6 months. 4. The manifestations can last up to 24 months.
1
A patient is recovering from a stroke. The family reports to the nurse that the patient alternates between periods of crying for no given reason to periods of laughing inappropriately. Which condition does the nurse suspect the patient is exhibiting? 1. Pseudobulbar effect 2. Psychotic events 3. Bipolar disorder 4. Mood swings
1
A patient presents with vertigo, tinnitus, and sensorineural hearing loss and is diagnosed with labyrinthitis. Which patient teaching does the nurse reinforce with this patient? 1. Instruct to not turn the head quickly. 2. Emphasize the importance of taking antihistamines. 3. Use proper methods for cleaning the ear. 4. Hearing will return with rest and medication.
1
The nurse is assisting the registered nurse (RN) in providing care for a patient who is recovering from a stroke. Which assigned intervention by the RN will the nurse question? 1. Observe the patient performing active range of motion (ROM) on the affected side. 2. Assist with maintaining correct body alignment for comfort. 3. Support affected extremities with pillows to prevent dislocation. 4. Follow the physical therapist's (PT's) recommendations for being up in a bedside chair.
1
The nurse is aware that children can be at risk for an embolic stroke. Which condition is least likely to cause a child to have a stroke? 1. Contact sport trauma 2. Sickle cell disease 3. Hyperlipidemia 4. Congenital heart defect
1
The nurse is collecting information from a patient in the HCP's office. The patient is exhibiting symptoms associated with Bell palsy. Which population group does the nurse recognize as being at greatest risk for the condition? 1. Women in the third trimester of pregnancy 2. Patients who have experienced a stroke 3. Patients who have a history of sun exposure 4. Men with history of excessive alcohol abuse
1
The nurse reviews information with a patient and family members about the patient's recent diagnosis of amyotrophic lateral sclerosis (ALS). Which comment by a family member indicates a need for clarification? 1. "When the heart muscle is affected, death will occur shortly." 2. "We need to remember that mental functioning is intact." 3. "A feeding tube and ventilator may need to be considered later." 4. "We need to do some research to see if this is a familial risk."
1
A patient with otitis media is experiencing severe ear pain. Which nonpharmacological measures does the nurse apply to help relieve this patient's discomfort? (Select all that apply.) 1. Offer a massage. 2. Apply heat to the area. 3. Offer liquid or soft diet. 4. Apply an ice pack to the area. 5. Dim the lights and reduce environmental noise.
1, 2, 3
The nurse is providing care for a patient with a sensorineural hearing loss. Which prescribed medications does the nurse question before administering medications to this patient? (Select all that apply.) 1. Gentamicin 2. Furosemide 3. Indomethacin 4. Acetaminophen 5. Warfarin sodium
1, 2, 3
The nurse is teaching a patient with MG how to recognize a cholinergic crisis. Which manifestations does the nurse include in this teaching? (Select all that apply.) 1. Diarrhea 2. Salivation 3. Vomiting 4. Difficulty speaking 5. Increased bronchial secretions
1, 2, 3, 5
A mother of three young children has a 3-year history of MG and recently stopped helping in the children's classrooms because of fatigue. Which advice does the nurse give to help the patient best cope with the problem? 1. "You need to realize that you may not be able to do the things you used to do." 2. "Time your medication so its action peaks during the time you need the most energy." 3. "Get plenty of sleep the night before you help to give you the stamina you need." 4. "Take your medication after you finish helping, and you may have a better energy level."
2
A patient arrives at the emergency department and states, "Something is wrong. I just don't feel right." Which objective data causes the nurse to suspect the patient is experiencing some type of stroke? 1. Symptoms have been increasing in severity for several days. 2. Ataxia is present when the patient attempts to ambulate. 3. The patient was diagnosed with hypertension managed with medication. 4. The patient appears upset and cries easily throughout assessment.
2
A patient diagnosed with Guillain-Barré syndrome (GBS) asks how the disease developed since the patient rarely has an illness. Which nursing response is the most accurate? 1. "No one knows an exact cause." 2. "It may be an autoimmune reaction to a virus." 3. "It most often occurs as a result of a bacterial infection." 4. "It is usually hereditary. Does anyone in your family have it?"
2
The nurse is visiting the home of a patient diagnosed with visual impairment related to macular degeneration. Which observation indicates to the nurse the patient is adjusting to the condition? 1. The patient is in nightclothes in the middle of the afternoon. 2. The patient is moving about in the apartment without problems. 3. The patient's refrigerator contains only condiments, eggs, and milk. 4. The patient has stacks of unopened mail on the kitchen table.
2
A patient is admitted from the emergency department to the hospital unit following the diagnosis of an ischemic stroke. The patient did not qualify for tPA therapy. The nurse is aware that which poststroke condition places the patient at greatest risk for deep vein thrombosis (DVT)? 1. The inability to be mobile and move independently 2. Hypercoagulability related to the admitting diagnosis 3. Testing that identified the cause of the stroke as ischemic 4. Laboratory tests indicating hyperlipidemia with high-density lipoprotein (HDL) at 200
2
A patient is diagnosed with Ménière disease. Which therapeutic measures does the nurse expect the HCP to prescribe? 1. A minimum of 8 hours of sleep nightly to prevent fatigue 2. A salt-restricted diet and prescribed antihistamines and vasodilators 3. Prophylactic antiemetic medications prescribed for nausea and vomiting 4. Meclizine, tranquilizers, and vagal blockers prescribed to prevent symptoms
2
A patient is scheduled for a thymectomy. For which peripheral nervous system disorder does the nurse plan care for this patient? 1. MS 2. MG 3. GBS 4. ALS
2
A patient reports to the nurse an inability to rest or sleep due to a long-term condition causing a constant urge to move the legs called restless legs syndrome (RLS). The patient expresses a need for some type of relief. Which suggestion by the nurse is most likely to help the patient? 1. Elimination of alcohol, tobacco, and caffeine 2. Pramipexole or ropinrole medication therapy 3. Using a vibrating pad (Relaxis) approved by the Food and Drug Administration (FDA) 4. Routine sleep habits and regular exercise program
2
A patient with acute angle glaucoma and a fractured femur that is scheduled for surgery is prescribed the preoperative medications morphine 10 mg intramuscularly (IM) and atropine 0.4 mg IM. Which action does the nurse take? 1. Hold the morphine. 2. Contact the physician. 3. Give medications as ordered. 4. Collect data on patient's pain.
2
An adolescent patient is diagnosed by the HCP with keratitis from a herpes simplex infection of the eye. Which patient teaching does the nurse reinforce as a method for pain management? 1. The importance of finishing all the prescribed antiviral medication 2. Wearing sunglasses indoors and outdoors to decrease effects of photophobia 3. Disposing of all eye cosmetics that were used at the time of becoming infected 4. Refraining from using contact lenses until all signs of inflammation are gone
2
The nurse is assisting in the evaluation of the effectiveness of teaching for a patient who has severe visual impairment. Which statement by the patient indicates additional teaching is needed? 1. "I can do all my self-care if no one moves my hygiene items." 2. "Cooking is still impossible and I am just eating cold foods." 3. "My family helped move everything out of my pathways." 4. "I have someone come weekly for cleaning and laundry."
2
The nurse is assisting with care of patients diagnosed with neuromuscular disorders. Which complication does the nurse recognize as a medical emergency? 1. Evidence of severe muscle wasting 2. Indications of the development of pneumonia 3. Interruption of skin integrity over bony prominences 4. Difficulty maintaining weight due to difficulty swallowing
2
The nurse is caring for a patient experiencing an acute exacerbation of multiple sclerosis (MS). Which pathophysiological change does the nurse recognize as causing the manifestations of MS? 1. Myelin buildup in the central nervous system 2. Demyelination and destruction of nerve fibers 3. Gamma aminobutyric acid (GABA) deficiency 4. Reduced acetylcholine receptors with impaired nerve impulse transmission
2
The nurse is collecting data from a patient with diabetes mellitus. The patient's medical history reveals multiple episodes of hyperglycemia requiring medical management. The patient tells the nurse, "I just got new glasses, but I still do not see very well." Which condition does the nurse suspect? 1. Preproliferative retinopathy 2. Background retinopathy 3. Proliferative retinopathy 4. Incomplete retinal detachment
2
The nurse is collecting information from a patient who reports difficulty seeing the print in the newspaper. The patient is 50 years of age and does not have any condition that requires medical management. Which vision condition does the nurse suspect the patient is experiencing? 1. Myopia 2. Presbyopia 3. Astigmatism 4. Emmetropia
2
The nurse is conducting hearing tests in a neighborhood clinic. The nurse is concerned about the number of young adult patients who exhibit signs of sensorineural hearing loss. For which reason does the nurse suspect this type of hearing loss in this population? 1. High exposure to ototoxic drugs 2. Prolonged exposure to loud noise 3. Trauma from physical contact sports 4. Increased incidences of meningitis
2
The nurse is preparing a patient with MG to undergo plasmapheresis. Which laboratory tests does the nurse verify and place on the medical record before the procedure? 1. Urine analysis, urine protein, blood urea nitrogen (BUN), and creatinine 2. Complete blood count, platelets, and clotting studies 3. Creatinine phosphokinase, blood type, and electrolytes 4. Electrolytes, BUN, creatinine, and albumin
2
The nurse is providing care for a patient being treated for trigeminal neuropathy. The nurse is concerned about the patient's nutritional status because of an inability to eat without experiencing severe pain. Which patient behavior indicates the nurse's interventions are successful? 1. The patient can sip cool or warm beverages through a straw. 2. The patient can eat multiple small, soft, lukewarm meals daily. 3. The patient's weight remains 10 pounds below the target weight. 4. The patient's pain is managed with postprandial pain medication.
2
The nurse is reinforcing teaching provided to a patient recovering from a stapedectomy. Which patient statement indicates teaching has been effective? 1. "I will avoid airplane travel for 6 months." 2. "I will cough or sneeze with my mouth open." 3. "I will gently blow my nose with both sides open." 4. "I will keep the ear moist by packing it with cotton balls."
2
The nurse is reinforcing teaching provided to a patient with open-angle glaucoma. What is most important for the nurse to include in the patient teaching? 1. Regardless of treatment, peripheral vision will be eventually lost. 2. Compliance with drug therapy is essential to prevent loss of vision. 3. Damage to the eye caused by glaucoma is reversible in early stages. 4. Eye pain is experienced until the optic nerve atrophies, causing blindness.
2
The nurse is providing care for a patient with expressive aphasia. Which intervention does the nurse expect to find in the patient's plan of care? (Select all that apply.) 1. Speak loudly. 2. Use a picture board. 3. Obtain an interpreter. 4. Provide pencil and paper. 5. Speak slowly and clearly.
2, 4
A patient comes into the emergency department with unilateral paralysis, aphasia, and inability to follow directions. Which emergency management by the health care provider (HCP) is unexpected by the nurse? 1. Maintenance of oxygen therapy to a saturation of at least 94 percent 2. Careful monitoring of changes in the patient's level of consciousness 3. Scheduling laboratory tests, electrocardiogram (ECG), and computerized tomography (CT) scan to be performed within 45 minutes 4. Immediate treatment for temperature greater than 99.6°F
3
A patient is diagnosed with otosclerosis and is scheduled for a stapedectomy. Which postoperative finding does the nurse report to the health care provider (HCP) or the registered nurse (RN) immediately? 1. The patient remains positioned with the surgical ear positioned upward. 2. The side rails of the bed are up in response to the patient feeling dizzy. 3. The patient received an antiemetic for nausea, but vomits after the medication. 4. The earplug placed in the surgical ear is found on the floor next to the patient's bed.
3
A patient who is prescribed neostigmine for newly diagnosed MG asks how the medication works. Which response does the nurse provide to the patient? 1. "It is a muscle relaxant to prevent the cramping in your muscles." 2. "It provides potassium to your muscles so that they will contract better." 3. "It makes more neurotransmitters available so that your muscles can contract." 4. "It reduces the inflammation in your nerves so that they transmit signals better."
3
A patient with trigeminal neuralgia is admitted to the hospital for diagnostic testing and possible surgery. Which intervention is appropriate for this patient? 1. Provide tissues for the patient to deal with drooling. 2. Provide frequent mouth care with a firm toothbrush. 3. Provide soft foods at body temperature at mealtimes. 4. Provide a fan in the room to keep the room well ventilated.
3
The HCP is preparing to discharge a patient from the hospital after a stroke. The patient is insistent on being sent to a rehabilitation center. The nurse is aware that the patient must meet which qualification to go to rehabilitation? 1. The determination to live alone and independently 2. The willingness to commit to long-term therapy 3. The ability to participate in intensive therapy 4. The acceptance of financial responsibility
3
A patient with acute ear pain and drainage comes into the community clinic. Which diagnostic tests does the nurse expect to be performed prior to beginning treatment for this patient? (Select all that apply.) 1. Biopsy 2. Audiometric testing 3. Complete blood count (CBC) 4. Rinne and Weber tests 5. Culture of ear discharge
3, 4, 5
The caregiver of a patient with macular degeneration voices being increasingly frustrated because of food spills on the patient's clothing. Which explanation does the nurse give to help the caregiver understand what the patient is experiencing? 1. "The patient's vision is blurred." 2. "There is total blindness in one eye occurring." 3. "The central vision is gone and only peripheral vision remains." 4. "There are black dots in the field of vision that cause confusion."
3
The nurse in an HCP's office is assisting with the removal of impacted cerumen from the ear canal of an older adult patient. The patient presented with decreased hearing and a sensation of fullness. Which reason does the nurse identify as the most likely cause of the patient's condition? 1. Improper cleaning of the ear canal 2. The presence of hair growth in the ear canal 3. Dryness of secretions from shrinking ear canal glands 4. Exposure to dirt and dust in the working environment
3
The nurse is assisting with the care of a patient being prepared for emergency intervention for a detached retina. If the nurse asks the patient about the ability to maintain a reclining position for 16 hours, which procedure is planned for this patient? 1. Laser surgery 2. Cryopexy 3. Pneumatic retinopexy 4. Scleral buckling
3
The nurse is assisting with the care of a patient diagnosed with postpolio syndrome. The nurse asks the registered nurse (RN) to explain the source of the disease. Which answer by the RN is correct? 1. The syndrome begins with the contraction of polio. 2. The disease is common among third-world travelers. 3. The patient must first have had a poliovirus infection. 4. The syndrome leads to development of great debilitation.
3
The nurse is assisting with the care of a patient following an ischemic stroke who does not qualify for tPA therapy. The patient's current blood pressure is 190/110 mm Hg. For which reason will the patient's hypertension remain untreated? 1. The elevated blood pressure will create collateral circulation in the brain. 2. Therapeutic blood pressure needs to exceed 220/120 mm Hg to be effective. 3. Permissive hypertension is being therapeutically used to salvage brain tissue. 4. Hypertension will move the clot to an area of the brain treatable by tPA.
3
The nurse is collecting up-to-date data from a patient who was diagnosed with MS 15 years ago. The patient has a good understanding of the disease and manages to maintain a relatively high level of functioning. Which statement by the patient prompts the nurse to seek additional information? 1. "I am very careful to avoid sick people and crowds in the winter." 2. "I have been attending a special yoga class for people with MS." 3. "I love to work in my flower beds during the summer months." 4. "I find that I do much better if I let other people run errands for me."
3
The nurse is preparing to assist a patient with eating who is recovering from a stroke. Which intervention is appropriate? 1. Have the patient sip liquids in small amounts with a straw. 2. Place the patient in a semi-Fowler's position to promote swallowing. 3. Check the patient's mouth periodically for presence of pocketed food. 4. Instruct the patient to swallow numerous times to clear food from the mouth.
3
The nurse is preparing to assist the HCP with the incision of a carbuncle in the ear canal of a patient. Which specific manifestation does the nurse associate with the patient's diagnosis? 1. Necrotic tissue spreading toward the auricle 2. An absence of protective earwax in the canal 3. Several hair follicles that have formed an abscess 4. Fungus in the ear canal causing an infection
3
The nurse is providing care for a patient after surgery for treatment of trigeminal neuropathy. Which nursing intervention will the nurse initiate for this patient? 1. Protect the patient's face from any movement of air. 2. Place eye patches bilaterally while the patient sleeps. 3. Check the eye on the surgery side for corneal sensation. 4. Provide a soft diet with food served at room temperature.
3
The nurse is providing care for a patient diagnosed with a cerebral aneurysm and subarachnoid hemorrhage. Which statement by the patient indicates a need for additional information? 1. "The doctors are going to do studies to see if I can have surgery." 2. "I know that I will be on some restrictions to prevent a rebleed." 3. "No strenuous activity until this condition is cured by surgery." 4. "It is very important to take my blood pressure medicine."
3
The nurse is providing care for a patient diagnosed with an ischemic stroke on the left side of the brain. The nurse notices that the patient does not easily locate items placed at the bedside. In which area does the nurse place items for easy location? 1. On the left side 2. Directly in front 3. One the right side 4. As the patient wants
3
The nurse is providing care for a patient recovering from a right hemisphere infarct who now exhibits unilateral neglect. Which nursing intervention is most important at promoting safety for this patient? 1. Encourage the patient to turn her plate for ease in self-feeding. 2. Place the call light and phone on the patient's left side. 3. Teach the patient to purposefully check the location of the left limbs. 4. Provide stimuli of all senses on the patient's affected side.
3
The nurse is providing care for an older adult client. The nurse notices the patient appears to be having difficulty understanding her and asks that questions and comments be repeated. If the nurse suspects presbycusis, which action does the nurse take to promote better hearing for the patient? 1. Ask the patient if he is having difficulty hearing. 2. Sit closer to and directly in front of the patient. 3. Speak to the patient in a lower tone of voice. 4. Use a slightly louder and slower talking rate.
3
The patient is diagnosed with a cerebral vascular accident that has the slowest rate of recovery and the highest probability of causing extensive neurologic deficits. For which type of stroke does the nurse plan care for this patient? 1. Thrombotic stroke 2. Cerebral aneurysm 3. Subarachnoid hemorrhage (SAH) 4. Reversible ischemic neurologic deficit (RIND)
3
A patient with MS has been prescribed baclofen to relax muscles. Which information is included in the nurse's teaching about this drug? (Select all that apply.) 1. "Avoid crowds while on this medication." 2. "Take a calcium supplement while on this medication." 3. "Report any shortness of breath or other respiratory problems." 4. "Avoid driving or operating machinery until the effects of the drug are known." 5. "Prevent constipation by increasing fluids and fiber-rich foods; use suppositories when necessary."
3, 4, 5
The nurse is collecting data from a patient with a detached retina. Which findings does the nurse expect in this patient? (Select all that apply.) 1. Severe pain 2. Blurred vision 3. Flashing lights 4. Loss of peripheral vision 5. Loss of acuity in the affected eye
3, 4, 5
The nurse is involved in a blood pressure clinic in the community, and an individual with possible stroke symptoms is brought for evaluation. Which findings in the FAST (Face, Arms, Speech, and Time) assessment indicate the need to call emergency personnel? (Select all that apply.) 1. The patient sways when asked to stand still with eyes closed. 2. The patient is unable to follow directions during the assessment. 3. The patient is unable to repeat a stated phrase exactly as it was stated. 4. The patient's face shows signs of uneven symmetry when asked to smile. 5. When asked to close the eyes and hold arms straight in front, one arm drifts downward.
3, 4, 5
A patient comes into the emergency department with symptoms of a stroke. Which medication does the nurse expect to be given to the patient if diagnostic testing confirms an ischemic stroke? 1. Heparin 2. Clopidogrel 3. Warfarin 4. Tissue-type plasminogen activator (tPA)
4
The nurse in the emergency department is assisting with the care of a patient with a penetrating wound to the eye. The patient keeps crying out and asking that the uninjured eye be uncovered. Which answer by the nurse provides understanding? 1. "It is less stressful if you cannot see anything about the other eye." 2. "Covering your uninjured eye will keep anything from getting into it." 3. "Being able to see will allow you to look around and get more upset." 4. "Covering the uninjured eye stops ocular movement in the injured one."
4
The nurse is collecting data from a patient who is diagnosed with MG. Which data is most important for the nurse to obtain? 1. Ascertain if the patient's needs are being met by an adequate support system. 2. Ask what amount of activity causes fatigue and muscle weakness to occur. 3. Determine baseline muscle strength through the use of appropriate techniques. 4. Monitor the patient's respiratory function and the ability to swallow effectively.
4
The nurse is providing care for a patient diagnosed with a stroke resulting in language disorder. Which type of disorder does the nurse recognize if the patient raises an arm in response to the nurse's direction to stick out his tongue? 1. Dysarthria 2. Expressive aphasia 3. Dysphasia 4. Receptive aphasia
4
The nurse is providing care for a school-age patient at a community clinic. The patient exhibits redness and crusting exudate on the lids and corners of each eye, and reports pain and itching. A culture was taken of the exudate and antibiotic drops were prescribed. Which action does the nurse take if the eye culture returns as positive for Neisseria gonorrhoeae? 1. Review the importance of medication administration with the patient's parent. 2. Mail the patient's household literature about prevention of infecting family members. 3. Ask a family member to bring the patient back to the clinic for a follow-up evaluation. 4. Notify the HCP and RN about a possible situation involving sexual abuse of a minor.
4
The nurse is reinforcing teaching provided to a patient with primary open-angle glaucoma (POAG) about symptoms to report. Which patient statement regarding symptoms indicates a correct understanding of the teaching? 1. "Hypotension and bradycardia" 2. "Fever and reddened conjunctiva" 3. "Loss of central vision and dizziness" 4. "Headache and seeing halos around lights"
4
The nurse is reviewing the medical records of patients in an HCP's practice. Which patient does the nurse recognize as the greatest risk for a stroke? 1. A postmenopausal patient who has type 2 diabetes mellitus (DM) controlled by diet 2. An overweight male with a 15-year smoking history, who is treated for hypertension 3. A young adult born with a heart defect causing ventricle fibrillation 4. An older female patient who has osteoporosis, a femur fracture, and hyperlipidemia
4
The nurse is visiting the home of a patient who is being treated for Bell palsy. Which statement by the patient indicates that care instructions need to be reviewed by the nurse? 1. "I find that I can eat better with a facial sling in place." 2. "Gentle massage of the effected muscles reduces discomfort." 3. "I follow the physical therapy exercises exactly as prescribed." 4. "Alternating heat and cold therapy is helping the swelling."
4
