HEHI FINAL Fall 2020 Review Questions
The nurse notices the family of a patient with severe post-stroke dysphagia giving the patient soda, though the patient has orders for thickened liquids. What is the greatest risk to the patient? a- aspiration pneumonia b- acidosis due to carbonation c- hyperglycemia d- dyspepsia due to altered stomach motility
A
When the nurse is caring for a client on the first postoperative day after a lobectomy, which assessment finding requires the most rapid action by the nurse? a- oxygen saturation 93% b- client has poor cough effort c- incision edges are red and swollen d- trachea deviates to the nonsurgical side
D
Which response would the nurse offer when a client undergoing brachytherapy for breast cancer asks what precautions need to be observed? a- there are no restrictions during brachytherapy b- all body fluid during therapy is treated as radioactive c- you should maintain contact isolation during your treatment d- visitors should be limited, particularly pregnant women and children
D
A client is admitted to the hospital with a tentative diagnosis of Guillian Barre syndrome. Which question by the nurse will elicit information consistent with this diagnosis? a- have you experienced an infection recently? b- is there a history of this disorder in your family? c- did you receive a head injury during the past year? d- what medications have you taken in the past several months?
A
A patient has undergone placement of a mechanical valve. A mechanical heart valve increases the risk of what kind of stroke? a- embolic stroke b- thrombotic stroke c- hemorrhagic stroke d- watershed stroke
A
A patient with severe carotid artery stenosis is about to undergo endarterectomy. Which of the following findings should be reported to the team immediately? a- platelet count of 60,000 b- hemoglobin of 14g/dL c- temperature of 98.9 d- carotid bruit auscultated on assessment
A
While in the playroom, a school-aged child exhibits twitching of the right arm and leg that almost immediately progresses to generalized tonic-clonic seizures with clenched jaws. Which action would the nurse take after moving the child to the floor? a- moving objects away from the child b- taking the other children to other rooms c- inserting a plastic airway into the child's mouth d- positioning a large pillow under the child's head
A
Which findings would the nurse expect when completing an admission physical for a client with diagnosis of Parkinson disease? SATA a- muscle rigidity b- blank facial expression c- leaning toward the affected side d- intention tremors with movement e- hyperextension of the affected extremity
A B
Which assessment finding indicates that a client has had a stroke? a- lopsided smile b- unilateral vision c- incoherent speech d- unable to raise right arm e- symptoms started 2 hours ago
A B C D
The nurse is preparing a patient with a stroke for fibrinolytic therapy. Which of the following would be a contraindication? SATA: a- allergy to TPA b- car accident with head bleed two months ago c- history of gall bladder removal 8 years ago d- patient is on beta blockers for HTN e- history of arteriovenous malformation
A B E
which clinical indicators would the nurse consider evidence of increase ICP? SATA a- vomiting b- irritability c- hypotension d- increased respirations e- decreased level of consciousness
A B E
A child with a seizure disorder has a generalized seizure shortly after admission to the hospital. Which nursing actions are most appropriate? SATA: a- assessing the time of the seizure b- taking the child's vital signs c- turning the child on the side d- pulling the padded side rails up e- initiating O2 therapy
A C D
10) A patient with carotid bruit is most likely to have which kind of stroke? a) Thrombotic b) Hemorrhagic c) Embolic d) TIA ???
A carotid bruit may indicate you have plaque buildup in your carotid artery. Plaque buildup in your carotid arteries can lead to carotid artery stenosis. This is a narrowing of your carotid artery. Thrombotic strokes occur when a blood clot forms in one of the blood vessels supplying the brain, often due to the narrowing or blockage caused by atherosclerosis (the buildup of plaques). While carotid plaques are not prone to breaking off and causing an embolic stroke, they can indicate the presence of plaques in the vessels of the brain, which can lead to thrombotic strokes.
A client who had a CVA begins to eat lunch. Which client behavior indicates the client may be experiencing left hemianopsia? a- the client asks to have food moved to the left side of the tray b- the client drops the coffee cup when trying to use the right hand c- the client ignored the food on the left side of the tray when eating d- the client reports not being able to use the right arm to help eat meals
C
The nurse notes splinter hemorrhage's and Janeway lesions on a patient's hands and feet. Which type of stroke is the patient at greatest risk for? a- thrombotic b- rupture of AVM c- embolic stroke d- subdural hemorrhage
C
A client with emphysema experiences a sudden episode of shortness of breath and is diagnosed with spontaneous pneumothorax. The client asks, "how could this have happened?" The nurse's response is based on which likely cause of the spontaneous pneumothorax? a- pleural friction rub b- tracheoesophageal fistula c- rupture of a subpleural bleb d- puncture wound of the chest wall
C
A patient presents with tracheal deviation to the left side. The nurse knows this is a sign of what underlying disorder? a- obstructive sleep apnea b- left ventricular hypertrophy due to valve stenosis c- tension pneumothorax of the right lung d- empyema secondary to pneumonia
C
The RN notices reddish linear streaks in the nail bed of the client. Which systemic condition would the RN suspect in the client based on these assessment findings? a- syphilis b- iron-deficiency anemia c- bacterial endocarditis d- COPD
C
Which of the following is not a risk factor for pleural effusion? a) CHF b) Cirrhosis c) IV drug use d) Renal failure e) Pneumonia
Anything that causes an increase in fluid volume will increase the risk for pleural effusion (water around the lungs). CHF and renal failure often result in fluid overload that can cause third spacing and fluid in the pleural space. Cirrhosis can increase risk for pleural effusion because decreased albumin in the blood will lead to decreased oncotic pressure. Lastly, pneumonia can affect the integrity of the lung parenchyma and lead to changes that would allow fluid into the pleural space.
The nurse is caring for a patient at high risk of pulmonary embolism due to venous insufficiency. Which of the following would be a sign of large pulmonary embolism? a- new wheezes on auscultation b- hypotension due to decreased left ventricular filling c- productive cough with purulent sputum d- absent breath sounds in the left lower lobe
B
The nurse is preparing a patient for lumbar puncture as a part of seizure workup. The patient asks what the purpose of a lumbar puncture is: a- the lumbar puncture can tell us which neurotransmitters are out of alignment b- the lumbar puncture will help us rule out meningitis c- the lumbar puncture will allow us to add fluid to your CSF, which will reduce your seizure threshold d- the lumbar puncture will help us determine your electrolyte levels
B
The nurse notices the family of a patient with severe post-stroke dysphagia giving the patient soda, though the patient has orders for thickened liquids. What is the best response? a- sternly condemn the family for endangering the patient's health b- ask the family about their understanding of the patient's dietary modification c- inform the family that only nursing staff my feed the patient d- teach the family how to administer soda via PEG tube
B
The nurse suspects increased ICP in a patient as evidence by Cushing's triad. Which of the following best describes the respiratory pattern in Cushing's Triad? a- persistent apnea unless the nurse performs a sternal rub b- periods of alternating hyperventilation and apnea c- kussmaul's respirations d- tachypnea with shallow respirations
B
What is the function of the water seal chamber on a closed chest drainage system for a client with hemothorax? a- collects drainage from the pleural space b- prevents reflux of air back into pleural space c- promotes drainage of blood from the pleural space d- controls level of suction applied to intrapleural space
B
Which clinical finding would the nurse expect to identify for a client with a new diagnosis of myasthenia gravis? a- tearing b- diplopia c- nystagmus d- exophthalmos
B
A patient arrives to the ER with unilateral facial drooping, prominent ptosis, and slurred speech. Which intervention should happen first? a) Give TPA to break up any clots: "time is tissue!" b) Get a non-contrast CT c) Get a contrast CT d) This patient does not need a CT, as they are experiencing Bell's Palsy and not a stroke
B) get non contrast CT When a patient arrives at the ER with facial drooping, a COMMON symptom in stroke, we MUST FIRST think about ruling out hemorrhagic stroke. The first intervention is going to be noncontrast CT. If the patient is having a hemorrhagic stroke, we will kill them by giving TPA (strong antithrombotic)... so CT comes first. Same reason we don't give a contrast CT first (dye in the brain is not conducive to helping patients recover). Lastly, even though this patient has symptoms that very well could be Bell's Palsy, we would be incompetent to not rule out stroke. Safety first! We need to rule out stroke and then if we know it is not a stroke, we could move towards Bell's Palsy diagnosis. The primary intervention with Bell's Palsy is always to rule out stroke.
When assessing a client, the nurse auscultates a murmur at the second intercostal space along the sternal border. Which valve does this sound reflect? a- aortic b- mitral c- pulmonic d- tricuspid
C
Which characteristic would a client who has been taught about myasthenia gravis identify as being common to both myasthenic and cholinergic crises? a- diarrhea b- salivation c- difficulty breathing d- abdominal cramping
C
Which complication would the nurse assess in both clients who have Parkinson and myasthenia gravis? a- cogwheel gait b- impaired cognition c- difficulty swallowing d- nonintention tremors
C
Which topic would be included in discharge teaching for a 22 year old client who has mitral valve replacement with a mechanical valve? a- daily aspirin use b- care of leg incisions c- anticoagulation therapy d- low fat and cholesterol diet
C
which finding would the nurse expect when assessing a client admitted for elective endovascular repair of a large aortic aneurysm? a- severe radiating abdominal pain b- pattern of visible peristaltic waves c- visible pulsating abdominal mass d- bilateral ankle swelling and redness
C
Which of the following patients is at highest risk of DVT if placed on bedrest? a) Cancer patient b) Epileptic patient c) Patient with current Bell's Palsy d) Patient with past history of Guillain-Barre
Cancer is a hypercoagulable state, so they would be at high risk of DVT if they were immobile. None of the other patients have increased risk of coagulation
A client asks the nurse what causes the sudden loss of vision common in persons with MS. What factor would the nurse include in the explanation? a- virus- induced iritis b- intracranial pressure c- close angled glaucoma d- optic nerve inflammation
D
A client experienced a tonic-clonic seizure. Which nursing intervention is the priority during the tonic-clonic stage of the seizure? a- go for additional help b- establish a patent airway c- turn the patient on their side d- protect the patient from injury
D
A client reports left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding? a- dull sound on percussion b- vocal fremitus on palpation c- rales with rhonchi on auscultation d- absence of breath sounds on auscultation
D
The nurse notes a patient who sustained a large stroke has profound mobility deficits and is unable to turn on their own. On assessment of the patient's sacral area, a red area blanches with palpation. What is this? a- stage I pressure injury b- stage II pressure injury c- venous stasis ulcer d- a warning sign of impending pressure injury
D
A patient with a hemothorax has a chest tube to drain fluid. What is the expected characteristic of the drainage? a) Sanguineous b) Frothy, pink c) Thick, black d) Semi sanguineous with some purulent streaks
a) Sanguineous Since a hemothorax is blood in the pleural space, the drainage should be blood. Frothy, pink sputum can sometimes be seen in advanced pulmonary edema.
17) A patient who experiences Guillain-Barre may require which of the following interventions? a) Tracheostomy b) Chest tube c) Aortic stent placement d) A wig for resulting alopecia
a) Tracheostomy Tracheostomies are needed for some patients with GBS due to loss of control of the diaphragm. Chest tubes are used for pneumothorax and hemothorax. Aortic stents are placed for dissection and aneurysms. Alopecia is common in patients receiving cancer treatment, not patients with GBS.
A patient with myasthenia gravis arrives at the ER complaining of difficulty breathing. What is the medication will the nurse administer first? a) Acetylcholinesterase Inhibitor (Edrophonium) b) Cholinergic medication (atropine) c) Serotonin antagonist (ondansetron) d) Selective serotonin uptake inhibitor (sertraline)
a) Acetylcholinesterase Inhibitor (Edrophonium) This is the Tensilon test! Although this question is sort of challenging, it gets to an important point of MG: it is a result of a deficiency of acetylcholine at the neuromuscular junction. If we block the enzyme that breaks this down (in other words, inhibit acetylcholinesterase) we will alleviate symptoms of a myasthenic crisis. If this does not work, then we can assume it was a cholinergic crisis, in which case we will give atropine, but this is only if the first method did not show improvement! Serotonin has nothing to do with MG, so c and d are wrong.
Which of the following can be symptoms associated with seizure? a) Altered consciousness b) Automatisms c) Diarrhea/incontinence d) Increased heart rate e) Decreased heart rate
a) Altered consciousness b) Automatisms c) Diarrhea/incontinence d) Increased heart rate e) Decreased heart rate Automatisms are common with complex partial seizures (focal seizure with impaired consciousness)
Which of the following are symptoms of stroke and NOT symptoms of Bell's Pasley? (SATA) a) Unilateral arm weakness b) Shortness of breath c) Facial drooping d) Changes in level of consciousness
a) Unilateral arm weakness d) Changes in level of consciousness Unilateral arm weakness, facial drooping, and changes in LOC are all associated with stroke. Facial drooping is the only symptom associated with Bell's Palsy. Shortness of breath is not associated with either disease process.
Why does cholinergic crisis have symptoms like increased salvation and bronchospasm? a) Because acetylcholine is the main neurotransmitter of the parasympathetic nervous system b) Because too much dopamine can lead to symptoms of mental illness c) Because increased ICP can cause changes to breathing pattern d) Because a seizure can do anything the brain can do
a) Because acetylcholine is the main neurotransmitter of the parasympathetic nervous system All of the answers above are true statements alone, but only 'a' applies to myasthenia gravis and cholinergic crisis. Decreased dopamine is seen in Parkinson's, and one of the treatments is to give levodopa which can have effects on behavior. Increased ICP is seen post-stroke an can cause irregular respiratory rate. Seizures could definitely cause salvation or bronchospasm, but seizures are not associated with cholinergic crisis/myasthenia gravis.
A patient undergoing chemotherapy has the following values on a CBC: RBC 2.7 WBC 115,000 Platelet 95,000 Based on the CBC results, what is this patient at risk for? (SATA) a) Bleeding b) Seizures c) Impaired ability to fight infection d) Fatigue
a) Bleeding d) Fatigue This patient has thrombocytopenia and anemia but has very high WBC. This patient is a bleeding risk and could be fatigued from the anemia. This patient is not at risk for seizure, and the increased white blood cells are a sign that there is an infection already, not an impaired ability to fend off infection (which would be indicated by LOW white blood cells)
Which of the following patients would have increased risk of stroke? SATA a) Cancer patient b) Patient who experienced TIA a year ago c) Tall, young male d) Patient with a mechanical tricuspid valve
a) Cancer patient b) Patient who experienced TIA a year ago Cancer causes a hypercoagulable state, therefore increased risk of clotting anywhere in the body (clots in brain will cause stroke). Patients who have prior TIA, though they have no lasting neurological deficit from the incident, they do have increased risk of stroke in the future. Tall, young males have a higher risk of spontaneous primary pneumothorax but nothing to do with stroke. Patients with mechanical valves have an increased risk of clotting and having emboli from the valve, however the tricuspid valve is on the right side of the heart so this would lead to increased risk of PE and not a stroke (of course ignoring the possibility of patent foramen ovale, since we are trying not to read into questions)
11) Which of the following risk factors contribute to thrombotic stroke? (SATA) a) Hyperlipidemia b) Diabetes c) Hypertension d) Smoking
a) Hyperlipidemia b) Diabetes c) Hypertension d) Smoking
Which of the following are symptoms consistent with pulmonary embolism? (SATA) a) Hypotension b) Hypertension c) Dyspnea d) Decreased breath sounds e) Headache
a) Hypotension c) Dyspnea Dyspnea is due to venous blockage, and the blockage reduces the amount of blood getting back to the left side of the heart (therefore reduced cardiac output and hypotension). Hypertension and headache are not associated with pulmonary embolism. The tricky one is decreased breath sounds! Since the lungs are still able to expand, there will still be normal breath sounds. Nothing is blocking the air from coming in! However, these patients have a problem of PERFUSION with their lungs! Airway=patent, Breathing=intact, Circulation=compromised! Leonard made this clear during the test review, so good to know
Which of the following are risk factors for embolic stroke? (SATA) a) Infective endocarditis b) Atrial fibrillation c) IV drug use d) Heart murmur e) Mechanical valve
a) Infective endocarditis b) Atrial fibrillation c) IV drug use d) Heart murmur e) Mechanical valve IV drug use can lead to infective endocarditis, therefore leading to septic emboli. Heart murmur could indicate aortic stenosis, which could lead to an embolism. A fib and mechanical valves are huge clotting risk, so embolism.
A nurse knows that she can give antihistamines to a patient before getting chemotherapy to do which of the following? a) Prevent a hypersensitivity reaction b) Help the patient sleep through the infusion c) Sedate the patient so they can access the central IV port d) To keep the patient from going into withdrawals
a) Prevent a hypersensitivity reaction Antihistamines are used in the setting of chemo patients to prevent a hypersensitivity reaction to the chemo drug. Although this can cause some sleepiness and sedation, this is not the primary purpose of giving the antihistamine
3) A patient experiencing a hemorrhagic stroke is likely to experience which of the following symptoms? a) Worst headache of their life b) Paresthesias of the feet bilaterally c) Severe xerostomia d) Smelling like "burnt toast"
a) Worst headache of their life Hemorrhagic strokes tend to present as the worst headache ever with very acute onset of symptoms. Paresthesias of the feet are not common with stroke (especially bilaterally, as stroke tends to have unilateral symptoms of the limbs). Severe xerostomia is maybe associated with treatment of some head and neck cancers, but nothing to do with acute symptoms of stroke. Smelling of burn toast or other odd smells can be an indication that someone is having an aura during the pre-ictal phase of a seizure, but strokes do not have pre-warning signs (wouldn't that be nice though?)
You are the nurse at an emergency department. Which patient do you attend to first? a) A post MI patient with endocarditis b) A patient with pericardial effusion who is showing new and worsening hypotension c) A patient with a pulsating abdominal mass d) A patient with pneumothorax
b) A patient with pericardial effusion who is showing new and worsening hypotension the most emergent is the patient with pericardial effusion and new hypotension, because this is likely cardiac tamponade, the EMERGENCY STATE of pericardial effusion. Endocarditis is seen often after heart attack as part of Dressler's syndrome. A pulsating abdominal mass could be an aortic aneurysm. Don't touch it!! But also, not an emergency unless it ruptures... in which case we can likely not save the patient anyways. A patient with a pneumothorax needs attention fast, but unless it is a tension pneumothorax, that patient is not an emergency above cardiac tamponade
Which of the following describes multiple sclerosis? a) A hereditary malformation of myelin in the central nervous system. b) An autoimmune disease that attacks myelin of the central nervous system. c) An autoimmune disease that attacks myelin of the peripheral nervous system. d) An idiopathic atrophy and death of both upper and lower neurons of the central nervous system.
b) An autoimmune disease that attacks myelin of the central nervous system 'B' describes multiple sclerosis. 'C' describes Guillan-Barre síndrome. 'D' describes ALS.
15) A patient is undergoing a lumbar puncture to diagnose meningitis. What should the nurse do to help the patient? (SATA) a) Help restrain the patient, so they do not move during the procedure b) Encourage fluid intake to replace the CSF c) Lie about the needle size so the patient experiences less anxiety d) Premedicate with pain medication
b) Encourage fluid intake to replace the CSF d) Premedicate with pain medication Although this may hurt, we don't hold patients down by force to do lumbar punctures. We also don't lie to patients who are afraid of procedures. A better approach is to assure them that the procedure will give us vital information so they will feel better soon, let them know we are doing everything we can to take care of them and that you will be with them during the procedure. Lumbar punctures often cause incredible headaches, which we can mitigate by premedicating with pain medicine. Also, we want them to hydrate to replace the CSF we took out.
32) Which of the following is the priority in the post-ictal phase of a tonic-clonic seizure? a) Make sure the patient does not go to sleep b) Ensure the patient is oxygenating/add oxygen c) Give insulin d) Draw blood to get to the lab for testing
b) Ensure the patient is oxygenating/add oxygen Patients may have sonorous respirations in the post-ictal phase. This is expected. We want to get the patients oxygen, because they were not breathing during the seizure. Hemodynamic stability is priority. Don't give insulin... if this was a DKA seizure then insulin would only make it worse. Also, the clonic seizures are very metabolically demanding and they will need to get glucose around their body. Drawing blood is not a priority.
A patient was part of a MVC and was brough to the ER. They have no injuries, but they were very scared by the accident and have a blood pressure of 210/145. What is the nurse concerned about? a) Hypoglycemia d/t increased metabolic need b) Hemorrhagic stroke s/t hypertensive crisis c) Development of Guillain-Barre d/t increased adrenaline d) Getting the patient albuterol
b) Hemorrhagic stroke s/t hypertensive crisis Hypertensive crisis can cause hemorrhagic stroke. There is no indication this patient has hypoglycemia. Guillain-Barre is caused by infection, not by stress or adrenaline. If the patient had asthma, then maybe albuterol would be important to protect the patency of the airway, but the question stem gives no indication that this patient is having difficulty breathing
A patient who is 3 days post-CVA suddenly shows changes in pupil reactivity, changes in their speech, and projectile vomiting. The nurse suspects which of the following: a) Ileus b) Increased ICP c) New onset of ischemic stroke d) Anxiety about being away from home
b) Increased ICP signs of increased ICP. They are: change in level of consciousness (confusion, agitation), pupillary changes, headache, vomiting without nausea, decreased motor function, changes in speech, "posturing", and seizure. Increased ICP is common in post-stroke patients. Although patients with ileus can have N/V, this has nothing to do with stroke. Another stroke, though likely to happen, would not be characterized by vomiting
Which of the following diseases are a disease involving incorrect amounts/action of a neurotransmitter? a) Multiple sclerosis b) Myasthenia Gravis c) Bell's Palsy d) Guillain-Barre
b) Myasthenia Gravis MS and GBS are diseases where the myelin is affected, and conduction is messed up. Bell's palsy involved conduction with the 7th cranial nerve. Myasthenia gravis (acetylcholine) and Parkinson's (dopamine) both involve inappropriate amounts of neurotransmitter.
What is the best action taken by a nurse caring for a patient with a chest tube connected to a collection system and suction? a) Make sure to strip the tube to dislodge any clots b) Notify the house officer for more than 70 mL of drainage in an hour c) Use wet-to-dry dressing over the insertion site so that the top layer is removed with each dressing change d) Nurses do not care for the chest tube; this is only don't by the respiratory team
b) Notify the house officer for more than 70 mL of drainage in an hour This is not a JP drain! Don't strip a chest tube because the lungs are too sensitive to pressure! If there is more than 70 mL of output in one hour, then someone needs to be notified (NHO means notify house officer). We would not want to use wet dressings on a wound going into the chest... at least not that I can think of! We want to keep this clean and dry.
Which of the following is false concerning seizures and epilepsy? a) Children who have febrile seizures have epilepsy. b) Partial seizure means that a person remains at least partially aware of their surroundings. c) Absence seizures are not a fall risk. d) Seizures lasting more than 5 minutes are a medical emergency.
b) Partial seizure means that a person remains at least partially aware of their surroundings A febrile seizure does not mean a child has epilepsy, and they are common in children. Partial seizures refer to only one hemisphere of the brain being involved, even if the patient loses consciousness. Absence seizures are unlikely to be a fall risk (focal seizures are also unlikely to be a fall risk). Status Epilepticus (a seizure for more than 5 minutes or multiple seizures without return to consciousness over 30 minutes) is a medical emergency. This is why it is so important to time seizures.
Which of the following patients it at risk for an unprovoked seizure? a) Patient in DKA b) Patient with brain tumor c) Patient with Na+ of 112 d) Patient in acute withdrawal from alcohol
b) Patient with brain tumor Unprovoked seizure means that it is likely not happen again, not that there was no cause. This means that a patient with a tumor that causes a seizure is likely to have another one, therefore unprovoked seizure. All of the other answers will DEFINITLY cause seizure, but they are all 'provoked' because they are unlikely to occur again if we fix the underlying problem.
A patient with ALS was not turned properly and now has an ulcer on their sacrum that extends into the subcutaneous tissue. What stage is this pressure ulcer? a) Stage 2 b) Stage 3 c) Stage 4 d) Unstageable
b) Stage 3 Dermal thickness wound is stage 2. Sub Q thickness is stage 3. Bone deep is stage 4. If it is a covered wound, it is unstageable until the top layer comes off and we can visualize the depth.
A patient comes to the ER complaining of new onset paralysis of their legs. They report that yesterday they could not feel their feet, and today they cannot stand. What action can the nurse reasonably expect? a) The patient will be sent home with an antibiotic. This is common for meningitis. b) The patient will be admitted to the hospital for respiratory support. This could be Guillain-Barre. c) The patient is having an abdominal aortic aneurysm dissection and needs to be rushed to surgery. d) The patient will need a non-contrast CT to rule out hemorrhagic stroke.
b) The patient will be admitted to the hospital for respiratory support. This could be Guillain-Barre. A patient with new onset paralysis would never be sent home without a workup, and this is not a common sign of meningitis (that would be nuchal rigidity, kernig's sign, brudzinski's sign, photophobia). This patient is showing signs of Guillain-Barre and will be admitted in case they need ventilation. A patient who had an aortic aneurysm at home would not live to the next day, as they would lose too much blood. This patient is not showing any signs of stroke, especially hemorrhagic stroke that is typically very acute onset.
A patient is having an ICP emergency and is exhibiting Cushing's Triad. Which of the following is NOT part of these symptoms? a) Increased systolic blood pressure b) Irregular respiratory pattern c) Acute onset hypoglycemia d) Bradycardia
c) Acute onset hypoglycemia Know Cushing's Triad. 1—HTN with widened pulse pressure (so increased systolic). 2— bradycardia. 3—irregular breathing pattern (specifically called Cheyne-Stoke's respirations).
You are working as a home health nurse and one of your ALS patients has a fever. A chest xray reveals that the patient has pneumonia. You know this is likely due to which symptom of ALS? a) Aphasia b) Dysarthria c) Dysphagia d) Dysphasia
c) Dysphagia This is due to dysphagia (or difficulty swallowing), not to be confused with dysphasia (or difficulty producing speech). Dysarthria also refers to difficulty speaking due to problems with motor function. Aphasia is not seen in ALS patients, but can be seen in post stroke patients. The two kinds of aphasia we need to know are Broca's (non-fluent, halted speech with retained understanding and meaning) and Wernicke's (word-salad speech that lacks meaning and understanding). Aphasia is caused by problems with the language center of the brain and can be caused by stroke or TBI.
A venous statis ulcer is typically found where? a) Sacrum b) Back of heels c) Lateral malleolus d) Bottom of foot
c) Lateral malleolus Sacrum and heels are typically pressure injuty sites. Bottom of the foot is more consistent with a diabetic foot ulcer. The lower leg is where venous stasis ulcers occur.
You hear the clicking sound of a mechanical valve when you auscultate the heart at the left sternal border in the 5th intercostal space. Which valve was replaced? a) Aortic b) Pulmonary c) Tricuspid d) Bicuspid
c) Tricuspid bicuspid is also known as mitral, so sneaky
Which of the following is incorrect patient education regarding TIA? a) "You had a clot in your brain." b) "The clot resolved on its own." c) "You will not have any long-term deficit from this incident." d) "There is no need for follow-up."
d) "There is no need for follow-up." While a, b, and c are true, this is falsely reassuring. The patient needs to have follow-up as the TIA increases the risk of stroke in the future.
A seizure patient describes their aura as lack of vision in right visual field of both eyes. How would you chart this? a) Anosognosia b) Ataxia c) Hemiplegia d) Hemianopsia
d) Hemianopsia Anosognosia is a lack of one's own deficits (seen in strokes, TBI). Ataxia is impaired balance and coordination (seen in stroke, parkinsons). Hemiplegia is paralysis of one side of the body (seen in stroke). Hemianopsia is loss of half of the visual field.
31) Which of the following is an incorrect action by the nurse during the ictal phase? a) Pad bed rails b) Put a pillow under the patient's head c) Time seizure d) Leave to go find help
d) Leave to go find help Don't leave a patient when they are having a seizure. Also, do not restrain them as this can cause harm. Hopefully you already had the bedrails padded, but if you didn't you can hurry to do that so they patient remains safe
Which of the following is true about stroke in the US? a) Hemorrhagic strokes are more common than ischemic strokes b) Thrombotic strokes can be caused by clots from atrial fibrillation c) DVT is a common cause of ischemic stroke d) Stroke is the leading cause of disability in older adults
d) Stroke is the leading cause of disability in older adults Ischemic stroke accounts for 90% of all strokes. A clot from afib would cause an embolic stroke (thrombotic strokes are caused by atherosclerosis inside of the brain). DVT will commonly cause pulmonary embolisms but are unlikely to cause stroke (if a patient has a patent foramen ovale, then there is a chance that a DVT causes stroke... still unlikely). Stroke is, indeed, the leading cause of disability in older adults
A patient with Parkinson's Disease is given levodopa to help with their symptoms. Which education point should the nurse include for the patient? a) This medication will increase your risk of seizures. b) You need to come into the clinic every month so we can give you this medication IV. c) This medication will cause you to lose your hair. d) This medication can lead to changes in behavior, such as increased risk of gambling and other addictions
d) This medication can lead to changes in behavior, such as increased risk of gambling and other addictions. Patients who increase their dopamine will also see increases in addictive behaviors and behaviors associated with schizophrenia (hallucinations, ideas of grandeur). Patients and caretakers should know to look out for these signs. Hair loss is common with chemo. Levodopa can be taken at home in a pill form (that is why we give levodopa so that it will cross the blood- brain barrier) levodopa relation to seizures?
Which of the following is true regarding patients who have past medical history of radical mastectomy? a) Do not insert an IV into the arm of the affected side. b) Do not take a blood pressure on the arm of the affected side. c) These patients have an increased risk of pleural effusion. d) Both A and B e) All of the above
e) All of the above These patients cannot have IV sticks or BP on the effected side because they have impaired lymph system (the radical mastectomy takes the entire breast, plus some muscle and lymph nodes). The fact that lymph structures have been removed also means they have an increased risk of pleural effusion on this side due to insufficient lymph drainage (then this lymph fluid, called chyle, needs a place to go and can go into the pleural space underneath the chest)
A patient is undergoing the tensilon test. The nurse knows this helps diagnose what condition?
myasthenia gravis
A patient comes into your clinic showing physical manifestations of Parkinson's Disease. This would include which of the following traits? (SATA) a) Pill rolling hand tick b) Expressionless face c) Irregular breathing pattern d) Shuffled gait e) Male pattern baldness
physical manifestations of Parkinson's bradykinesia (slow movements), mask-like facial expressions, pill-rolling tremor, shuffling gait, cogwheel rigidity, and difficulty swallowing/speaking. Irregular breathing is a sign of increased ICP
