Med Surg Exam 5
treatment for hemorrhagic stroke:
*concerned for increased intracranial pressure* -hypertension --> for perfusion BP goal 140-160 -hypovolemia --> make sure they are getting enough fluids -hemodilution -to decrease intracranial pressure HOB greater than 30 degrees - titanium clip --> clipping aneurysms -coils
unclassified (unknown) seizure:
-1/2 of all seizures are this type -occur for no known reason
preventative treatment for migraines:
-a pt starts on these when a migraine occurs more than 2x a week and is impacting quality of life -topiramate -beta blocker --> propranolol (at risk for bradycardia and hypotension) -calcium channel blockers --> nondihydropyridines
diagnosis of cataracts:
-absence of red reflex -should be diagnosed at annual eye exams
s/s left hemisphere stroke:
-aphasia -cautiousness -inability to discriminate words -quick to anger and frustration
cerebrovascular accident (CVA):
-brief interruption of cerebral blood flow -interruption in perfusion in part of the brain
treatment for ischemic stroke:
-carotid artery endarterectomy --> removal of plaque build up in artery -fibronylitic therapy aka tPA -mechanical embolectomy --> go through artery to remove embolism -BP goal systolic 120-140 to perfuse the brain
post ictal interventions:
-clients are fatigued after --> the greater the seizure the more likely they are to sleep after -assess airway #1 priority -assess MSK for injury #2 -neuro assessment --> 1-2 hrs after seizure we expect to see improvement -if post ictal state persists we need to seek medical attention -all for pt to rest -clean them up if they had incontinence during seizure -document frequency, duration, characteristics -notify HCP of seizure
potential complications of migraines:
-dehydration -AKI -social isolation -malnutrition -depression -facial paralysis from elective surgery
dementia vs delirium:
-delirium is acute temporary confusion -dementia is permanent; chronic and progressive
gonioscopy:
-determines if glaucoma is opened or closed angle -gets checked when youre diagnosed ---> this is not a routine part of an eye exam its only done if we suspect a complication
other treatment for migraines:
-external trigeminal nerve stimulator (E- TENS) --> interrupts signal of trigeminal nerve -botox injection--> temporarily paralyzes the nerves from signaling
diagnosis of macular degeneration:
-eye exam using amsler grid
risk factors for migraines:
-female -fatigues -foods: MSG, caffeine, alcohol, aged cheese, chocolate, foods with yeast, artificial sweeteners, nitrates -fluid retention
migraine w/ aura: 2nd phase
-headache accompanied by N/V -pain begins in temple and intensifies in severity over 1-2 hrs -peak of migraine stays and persists
abortive treatment for migraines:
-mild migraine: over the counter analgesics or NSAIDs (acetaminophen preferred) -severe migraines: sumatriptan
nursing interventions for retinal holes, tears, and detachment:
-monitor visual changes -loosely cover both eyes --> to protect the bad eye from the good eye -position supine after surgery on unaffected side -before surgery place clients on side of detachment -HOB slightly elevated -no bending, straining for BM, blowing nose, coughing, etc.
migraine w/ aura: 1st phase
-no headache -numbness, tingling of lips/tongue, acute confusion, aphasia, unilateral, weakness, drowsiness
status epilipticus:
-seizure lasting more than 5 minutes *medical emergency*
nursing actions for cataracts:
-teach s/s conjunctivitis--> persistent redness, drainage, increase pain
non-verbal communication nursing interventions for dementia:
-tone of voice and nonverbal communication is picked up easily by dementia patients -going down to patients eye level when talking to them -touch --> shoulder -be aware of your body language -maintain eye contact
which factors can trigger a clients migraine attacks? select all a. hormone fluctuations b. aphasia c. vertigo d. tingling sensations e. sleep problems
a. hormone fluctuations e. sleep problems
the nurse is planning a health teaching for a client who had a TIA to help prevent a major stroke. what teaching would the nurse include? select all a. seek a smoking cessation program if needed b. increase physical activity by exercising regularly c. monitor BP frequently to assess control d. take your prescribed antiplatelet agents e. if diabetic, work to achieve glucose control as needed f. eat health health diet every day if possible
a. seek a smoking cessation program if needed b. increase physical activity by exercising regularly c. monitor BP frequently to assess control d. take your prescribed antiplatelet agents e. if diabetic, work to achieve glucose control as needed f. eat health health diet every day if possible
a pt is admitted to the ED and is diagnosed w/ an ischemic stroke. which of the following would exclude the use of thrombolytic therapy for this pt? select all a. daily aspirin use b. onset of symptoms 2 hrs ago c. PT: 10 sec d. INR: 2 e. platelet count: 150,000
c. PT: 10 sec d. INR: 2
the client is admitted to the ICU experiencing status epilepticus. which collaborating nursing intervention should the nurse anticipate? a. assess the clients neuro status every hours b. monitor the clients vital signs every hr c. admin an anticonvulsant med by IVP d. prepare to admin a glucocorticosteroid orally
c. admin an anticonvulsant med by IVP
what would the nurse assess for as an initial s/s of parkinsons? a. aspiration of food b. akinesia c. pill rolling tremors d. forgetfulness
c. pill rolling tremors
a pt diagnosed w/ dementia is prescribed a med that inhibits acetylcholinestrase. which of the following accurately explains how this med benefits the pt? a. acetylcholine increase norepinephrine activity and decreased depression b, inhibition of acetylcholinestrase improves the pts motor function c. decreased levels of acetylcholine will well the pts anxiety d. acetylcholine is needed for memory and problem solving
d. acetylcholine is needed for memory and problem solving
a client visits the clinic with a migraine and is lying in a darkened room w/ a wet cloth of the head after receiving treatment/ what action would the nurse take next? a. turn on the lights for a neuro assessment b. assess the clients vitals c. remove the cloth because it can harbor microorganisms d. allow the client to remain undisturbed
d. allow the client to remain undisturbed
the 85 yr old client diagnosed with a stroke is complaining of a severe headache. which intervention should the nurse implement first? a. start an IV with D5W at 100 mL/ hr b. admin a nonnarcotic analgesic c. prepared for STAT MRI d. complete a neurological assessment
d. complete a neurological assessment
a hospitalized client w/ a diagnosis of delirium becomes disoriented and confused in her room at night. which of the following is the best nursing intervention to implement to reduce the disorientation and confusion? a. maintain a well-lit room during the night b. keep the television on during the night c. keep the radio on during the night d. ensure a low stimulating environment at night
d. ensure a low stimulating environment at night
the nurse is caring for a pt who has hemiplegia secondary to a stroke. what should the nurse do first when providing mouth care for this pt? a. use glycerin and lemon swabs to cleanse the mouth b. position the patient in the dorsal recumbent position c. apply petroleum jelly to the tongue and lips d. explain the the client what will be done
d. explain the the client what will be done
a nurse is caring for a client with a diagnosis of retinal detachment. the client suddenly complains of a burst of black spots in the eye. the nurse interprets this symptoms as indicating which of the following? a. the need to patch the affected eye b. the need to restrict fluid c. an expected finding d. hemmorhage d/t retinal detachement
d. hemmorhage d/t retinal detachement
which intervention would the nurse include when developing a plan of care for an older client with dementia? a. explain to the client the details of the regimen b. demonstrate interest in the clients various likes and dislikes c. be firm when dealing with the clients attitudes and behaviors d. provide consistency in carrying out nursing activities for the client
d. provide consistency in carrying out nursing activities for the client
the nurse is preforming an assessment on a client and notes that the client left eyelid is drooping. the nurse documents that the client is exhibiting which condition? a. arcus senilis b. dry eye syndrome c. halitosis d. ptosis
d. ptosis
when planning to help a pt dress who is weak of the right side, what should the nurse do first? a. keep the patient in an opened backed gown b. encourage the pt to dress independantly c. leave the right sleeve off and adjust the tie at the neck d. put the right sleeve of the gown of first
d. put the right sleeve of the gown of first
which goal would the nurse add the the plan of care for a forgetful oriented client who has dementia? a. restrict gross motor activity to prevent injury b. prevent further deterioration in the clients condition c. maintain scheduled activities through behavior modification d. rechannel the clients energies into more appropriate behaviors
d. rechannel the clients energies into more appropriate behaviors
the ED nurse would provide immediate care based on priority to the client with which condition? a. second degree burns b. blunt abdominal trauma c. closed fracture on the right arm d. repeated tonic-clonic seizures
d. repeated tonic-clonic seizures
the nurse is providing instructions to a client regarding home care following cataract removal of the left eye. the nurse teaches the client which info regarding positioning/ activity in the post op period? a. lower the head between the knees three times a day only b. bend below the waist whenever possible c. lean over to tie shoelaces twice a day only d. sleep on the right side
d. sleep on the right side
a client reports their head is throbbing rated 10/10, N/V, and pain. which nursing interventions would be most beneficial to the client? a. a room with a window for sunlight b. coffee, tea, and chocolate c. topiramate d. sumatriptan
d. sumatriptan
nursing interventions:
diet ed: avoid foods w/ MSG, caffeine, alcohol, aged cheese, chocolate, foods w/ yeast, artificial sweeteners, nitrates -headache/ migraine journal to keep track of aggravating factors -reduce stimulus --> dark quite room -fluids -antiemetics/ abortive migraine meds -monitor and trend vitals, pain, and BMP -complimentary alternative medicine --> yoga, massage, acupuncture, music
treatment for closed angle glaucoma:
osmotic diuretic
Transient Ischemic Attack (TIA):
presents the same clinical manifestations as a stoke but goes away and resolves within 24 hrs -health promotion and prevention of stroke is the priority
aura
there is not headache, visual disturbances, flashing lights, lines/ spots, shimmering or zig zag lines
surgical management for migraines:
trigeminal nerve resection -control facial expressions and part of their face will be completely paralyzed after the procedure
true or false: epilepsy is a disease
true
Epilepsy Pathophysiology:
unknown etiology; not from any other external/ internal causes -two or more seizures experienced by a person
fibrinolytic therapy for ischemic stroke from clots:
*we need to know their last known well time immediately* -tPA administered within 3 hrs of stroke onset -q 1 hr neuro checks because they can start to bleed in their brain as well American stroke association: 4.5 hrs except: -age older than 80 yrs old -taking anticoagulants -ischemia injury more than 1/3 of the brain supplies by the middle cerebral artery -baseline NIH stroke scale > 25 -hx of combined stroke and diabetes
clinical manifestations for middle stage dementia:
-2-3 yrs -may not remember names or faces -may not remember where they live or who their family is -difficulty managing finances -at risk for double dosing/ not taking meds -easily lost -impaired cognitive function -*most concerned for safety in this stage*
clinical manifestations late stage dementia:
-<1 yr -clients require total care -complete loss of identity -don't remember to swallow or go to the bathroom -may not remember how to walk/talk -agnosia --> inability to interpret sensations
labs for strokes:
-BG --> first lab because hypoglycemia and stoke can present similar -WBC --> infection can cause mental stat changes -BMP for electrolytes -check clotting factors to see if they are eligible for tPA: platelets, PT/ INR, aPTT, PTT normal pt: 11-12.5 normal INR: 0.8-1.1 with no anticoagulants PTT: 60-70 sec aPTT: 30 -40 sec
labs for migraines:
-BMP --> for electrolytes (some electrolyte imbalances can cause headaches) -CBC --> for infection
dx testing for stroke:
-CT #1 -CTA: for arteries in the brain -if CTs are negative: MRI/MRA -assessment tool: NIH stroke scale -ques us on all potential signs of a stroke, has specific images and words a client has to say, looks at every part of the brain for a deficit, the higher the # the poorer prognosis
hemorrhagic stroke risk factors:
-HTN --> we dont want them to take sympathomimetics -stress -genetics
Dementia Pathophysiology
-NOT a natural part of aging -memory loss, poor self care, underweight/ overweight, "short fuse"/ agitation, sundowning
causes of delirium in older adults:
-UTI -dehydration -meds -alcohol withdrawal -electrolyte imbalances
general nursing interventions for dementia:
-as much of a routine as the patient is able to do -maintain hygiene -nutrition support --> pts can sometimes lose/ gain wt -caregiver burden considerations -assess for abuse/ neglect
potential complications: seizures
-aspiration pneumonia -drowning -death -injury -anoxic brain injury --> seizure lasting more than 5 min -suicide/ depression -misuse of antiepileptic drugs/ abortive med
hemmorhagic stoke: pathophysiology
-bleeding in the brain -increased intracranial pressure -blood is not going where it needs to go to perfuse the brain -typically we will see a high BP -thunder clap: vessel bursting
causes of seizures:
-brain tumor -electrolyte imbalance -high fever -head injury -increased intracranial pressure -alcohol withdrawal/ substance abuse -heart dz: d/t build up of plaque in heart can also build up plaque in brain -stroke -hypoglycemia
macular degeneration pathophysiology:
-central vision loss -most common cause of vision loss in clients older than 65 -dry: age related -wet: cause from new blood vessel growth; can occur at any age
treatment for dementia:
-cholinestrase inhibitors (donepezil) --> keep acetylcholine from breaking down -NMDA (mematine) -take meds at bedtime -antidepressant meds --> to help stablize pts mood -antipsychotic --> for pts w/ vascular dementia that have psychosis
how to document a seizure as a nurse:
-describe how the presented -document time, frequency, and characteristics -cannot document what kind of seizure because thats a diagnosis
retinal holes, tears and detachment:
-detachment --> most significant; medical emergency; can lead to blindness -hole--> least significant
nursing interventions during seizure:
-ensure safety and free from injury -stay w/ them -put clients on their side (left side is best) -time -call for help -dont put anything in their mouth -suction if excessive gurgling/ saliva
desired outcomes for a seizure:
-free of injury -decreased incidence of seizures -adherence to treatment plan -take their meds -verabalize causes/ triggers -maintain autonomy/ independence
AVM stroke risk factors:
-genetics -male gender -family hx of AVMs
tonometry:
-how intraocular pressure is measured -normal 10-21 -pt w/ glaucoma: 21-30 -should be done during annual eye exam -clients who have glaucoma will have their pressure checked more often (every 3 months)
nursing interventions for glaucoma:
-how to admin eye drops and infection prevention -go to the eye docotr -use snellen eye chart -acute glaucome (closed) --> raise HOB 30 degrees -we dont want them to sneeze, strain to have a B<, or bend over
vascular dementia pathophysiology:
-impact on the vasculature of the brain causing permanent damage -decreased blood flow to the brain -affects the function that the particular part of the brain had -abrupt onset of symptoms
potential complications for parkinons:
-incontinence -skin breakdown -aspiration pneumonia -dementia -insomnia
Treatment of macular degeneration
-increase consumption of vitamin A --> gives pts hope -wet: phototherapy --> blood vessels in the eye are burned
glaucoma pathophysiology:
-increase intraoccular pressure d/t aqueous humor primary: no known cause associated (secondary): caused by something else (eye trauma, prednisone, diabetes)
potential complications for dementia:
-injury -depression -sundowning -aspiration pneumonia -UTI -skin breakdown -abuse/ neglect
seizure triggers:
-lack of sleep -stress -alcohol and recreational drug use -hormones -missed meds -sensitivity to light/ photosensitivity -OTC meds -nutritional deficiencies -illness
atypical migraine:
-lasts more than 72 hrs -sometimes called status migrainous (migraine lasting more than 72 hrs) -concerned for dehydration, malnutrition, poor personal hygiene, social isolation
non surgical treatment for parkinsons:
-levidopa/ carbidopa --> may cause dyskinesia -MAOI --> selegiline -central musinaric ---> only med to manage parkinsonism
sundowning:
-link in night and day --> when sun starts to set complete change in behavior -can be an increased amount of pacing at this time -usually happens around 2-4 pm
dx testing for parkinson's dz:
-lumbar puncture/ spinal tap --> CHF can show decreased dopamine pts are positioned in bed lying on their side in fetal position or on the edge of the bed leaning over a tray table, pts have to remain still so they dont obtain a spinal cord injury, after puncture position supine because if they are positioned upright they can get a spinal headache
Monoamine Oxidase Inhibitors (MAOIs): selegline
-med for parkinson's -inactivates norepinephrine and epinephrine increasing dopamine availability in the brain SE: -insomnia -hypertensive crisis when combined with tyramine food containing tyramine: aged cheese. red wine. aged/ smoked meats, chocolate, products that have yeast, avocados, caffienated bevs -admin first thing in the am
general nursing interventions for seizures:
-monitor vitals -safety -admin meds as ordered -promote pt to not engage in activity that could lead to a seizure -educate pt on why they had a seizure -avoid alcohol -avoid excessive fatigue -educate them to wear a medical alert bracelet -keep follow up appts -teach them is they feel s/s of seizure get to a safe place -dont take OTC/ herbal supplements without HCP approval --> these can lower seizure threshold -keep journal to document what they were doing B4 seizure to identify triggers
verbal communication nursing interventions for dementia:
-monosyllabic --> 1-2 syllable words -avoid abby talk in adult population -1 question/ statement at a time and simplify them -use "its time for" to get things done -avoid the statement "remember" -for time talk about things that happened earlier in life
Treatment of cataracts:
-most often surgery to remove or replace the lens -eye drops before and after surgery to not have an increase in intraocular pressure -before surgery explain med admin schedule -teach them not to bend over, sneeze, blow nose, strain to have a BM -not allowed to drive after surgery -have to wear dark glasses for 1st 24 hrs --> then when they are sleeping for the 1st weeks -mild pain/ a little itching is normal after surgery --> severe pain is NOT -dont rub eyes -sedentary lifestyle for a couple of weeks
migraine w/ out aura:
-no aura -usually have 1 of these 3 symptoms: n/v, photophobia (sensitivity to light), phonophobia (sensitivity to sound) -severe headache -pain aggravated by preforming physical activity -can have 4-72 hr time frame -more common in premenstrual times or times of hormonal fluctuations
desired outcomes for migraines:
-no migraines -reduced severity and duration -identify triggers
clinical manifestations of cataracts:
-opacity of lens -cloudy/ blurry vision -poor vision at night
seizure precautions:
-padded side rails -all 4 sides of the bed up for seizure precautions is not considered a restraint -possibly floor mat -yankaer suction -ambu bag and oxygen -bed in lowest position -check orders for abortive meds ---> check IV patency
potential complications for CVA:
-paralysis -loss of autonomy -stroke -pneumonia -PE -pain -contractures
dx testing for migraines:
-patient reported symptoms -MRI possible for tumor
clinical manifestations for parkinson's dz:
-pill rolling tremors -reports of freezing -bradykinesia--> slow movements progressing to akinesia no movement -shuffle gait -fatigue -mask like face -muscle rigidity -postural instability -difficulty speaking and swallowing -stage 1 is the start and stage 5 is the complete loss of independence
alzheimers dz: pathophysiology
-plaques and tangles in the brain (makes signals not able to pass) that cause changes -brain shrinks -will present in 3 stages: early, middle, and late
Parkinson's dz pathophysiology:
-progressive neurodegenerative dz -deficiency in dopamine affecting mobility resulting in: tremors, muscle rigidity, bradykinesia/ akinesia, and postural instability -more common in males -usually 50 + - primary: no known cause -secondary: parkinsonism
treatment for open angle glaucoma
-prostaglandin type: latanoprost (SE: increased tissue growth on eyelid and eyelash growth) -Beta blocker: timolol (SE: bradycardia and hypotension when misused -alpha agonist: brimonidine -carbonic anhydrase inhibitory: dorzolamide (is a sulfa med) all eye meds constrict the pupil to decrease intraocular pressure *AVOID*: anticholinergics surgical: laser iridotomy, trabeculectomy
Migraines Pathophysiology
-recurrent episodic attacks of head pain -can last 4-72 hrs -usually throbbing and unilateral -nausea, sensitivity to light, sound or head movement
desired outcome for CVA:
-returned to baseline --> best case -maintain independence -maintain quality of life -no further strokes
nursing interventions for parkinsons:
-safety -weighted utensils/ balance utensils -speech language pathology for pt who has difficulty swallowing, speaking, and cognition -use gait belt to help with walking --> keep head up and feet up we dont want them to shuffle -registered dietician for change in diet and to monitor weight loss -incontinence care -monitor bowel sounds -monitor for UTIs -monitor vitals because they are at risk for orthostatic hypotension -help them reposition to avoid skin breakdown -promote sleep and rest -monitor for aspiration --> check LS
nursing interventions for macular degeneration:
-scan the room fro safety -educate to increase vit A in diet -tred visual acuity -get assistance for menu options -large print items -transportation services because they eventually wont be able to drive
desired outcomes for dementia:
-slowed progression of dz --> maintaining ADLs and staying in the stage theyve been in -no injuries -maintain dignity -maintain max independence with assistance
surgical treatment for parkinsons:
-stereotactic pallidotomy --> probe goes into specific part of the brain that tremors are coming from and that part of the brain is burned and killed -deep brain stimulation (DBS): probe implanted in place and electrical activity applied to that area of the brain to decrease tremors
clinical manifestations of macular degeneration:
-straight lines that appear distorted -drusen body -difficulty reading and writing -increased injuries and falls
Risk factors for dementia:
-stroke --> vascular dementia -family hx -environmental factors (toxins, chemicals, hormones in food) -poor oral hygiene -uncontrolled seizures --> vascular dementia -head trauma
ischemic stroke: pathophysiology
-sudden blockage of cerebral artery; brain tissue suffers irreversible damage -oxygenated blood isnt going where it needs to fo from clot or plaque build up
clinical manifestations of glaucoma
-sudden loss of peripheral vision > 30 mmhg -headache -brow pain -acute --> severe sudden pain
treatment of retinal holes, tears, and detachment:
-surgery: scleral buckling, pneumatic retinopathy, photo coagulopathy (burning or retina back into place)
causes of retinal holes, tears, and detachment:
-trauma -eye surgery -age
ischemic stroke risk factors:
-tumors -blood clots -compression of blood vessels -CAD -genetics -hx of MI, VTE, DVT, stroke -*afib* --> huge risk -stress --> d/t increase in cortisol -prosthetic heart valves -DM
CVA clinical manifestations:
-unequal strength --> upper body 1st usually -sudden confusion -trouble speaking/ understanding -sudden numbness/ weakness in face, arms, or legs -facial drooping -sudden trouble seeing -sudden dizziness, trouble walking, loss of balance/ coordination -sudden severe headache w/ no know cause -hemonoxia: blindness can be half or inside/ outside halves
clinical manifestations for early stage dementia:
-up to 4 yrs -independent with ADLs -deny s/s -subtle change in behavior -decreased sense of smell -forget names/ misplace things -short term memory loss
seizure first aid:
1. stay with them until they are awake and alert after seizure 2. keep them safe --> move or guide them away from harm; DO NOT restrain 3. turn the person onto their side (left is best) if they are not awake and aware -keep airway clear -loosen tight clothing around neck -put something small and soft under the head
a client picked up their new prescription for prednisolone status post eye surgery. the order is prednisolone 1 drop to the R eye 4x a day for 30 days, a drop is 0.05 mL. a bottle contain 5 mL. how many bottles of prednisolone will the clients need for 30 days?
2
tonometry is preformed on a client w/ a suspected diqgnosis of glaucoma. the nurse determines that which results will support the suspected diagnosis? a. 30 mmHg b. 15 mmHg c. 20 mmHg d. 7 mmHg
a. 30 mmHg
a pt diagnosed w/ an acute ischemic stroke is to receive alteplase 0.9 mg/kg IV. the pt weight 187 Ibs. how many mg will be administered to the pt? a. 76.5 b. 88.6 c. 168.3 d. 156.2
a. 76.5 187/ 2.2 = 85 85 x 0.9 = 76.5
the nurse is caring for a client who is diagnosed w/ middle stage alzheimers. what assessment findings would the nurse expect? select all a. agnosia b. mild impaired cognition c. sleeping problems d. seizures e. wandering
a. agnosia c. sleeping problems d. seizures e. wandering
the nurse educator is providing a lecture on two major types of dementia. which statement indicated that the teaching has been effective? a. alzheimers is the most common type of dementia that typically affects people older than 65 b. medication memantine given with donepezil can reverse dementia d. alzheimers is an acute sudden condition e. vascular dementia can be divided into three stages
a. alzheimers is the most common type of dementia that typically affects people older than 65
which intervention would the nurse include in the plan of care for a client w/ dementia who wanders? select all a. assess and treat pain b. avoid loud music, television, and glaring lights c. have family members monitor client activity when possible d. use chemical or physical restraint at night to keep the client in bed de. place the client at the end of the hall to allow use of the hall wandering
a. assess and treat pain b. avoid loud music, television, and glaring lights c. have family members monitor client activity when possible
which interventions are most likely to promote maximum self-care for a pt recovering from a stroke? select all a. assist pt to track motor function and mobility levels b. provide adaptive equipment as indicated c. assess neurological function every shift d.encourage participation in ADLs e. educate pt on risks of repeat stroke
a. assist pt to track motor function and mobility levels b. provide adaptive equipment as indicated d.encourage participation in ADLs
which phase of severe unilateral throbbing headache with nausea and intolerance to light and sound involves double vision? a. aura phase b. headache phase c. prodromal phase d. termination phase
a. aura phase
which instruction would the nurse provide when assisting a client with parkinsons dz to ambulate? a. avoid leaning forward b. hesitate between steps c. rest when tremors are experiences d. keep arms close to the center of gravity
a. avoid leaning forward
the HCP is assessing a pt with parkinson's. which of the following findings would the HCP anticipate? select all a. bradykinesia b. daytime sleepiness c. kyphosis d. depression e. receptive aphasia f. exophthalamos
a. bradykinesia b. daytime sleepiness d. depression
the result of a clients vision test using a snellen chart is 20/50. the nurse understands this mens? a. can read at a distance of 20 ft what a client with normal vision can read at 50 ft b. can read at a distance of 50 ft what a client with normal vision can read at 20 ft c. has normal vision d. legally blind
a. can read at a distance of 20 ft what a client with normal vision can read at 50 ft
a client with parkinsons quickly develops akinesia while ambulating, increasing the risk for falls. which of the following suggestions should the nurse provide the client to alleviate this problem? a. consciously think about walking over imaginary lines on the floor b. stand erect and use a cane to ambulate c. lean forward and use a rolling walker d. use a wheelchair to move around
a. consciously think about walking over imaginary lines on the floor
the nurse is performing a neurological assessment on a client post right CVA. which finding if observed by the nurse warrants immediate attention? a. decrease in level of consciousness b. altered sensation to stimuli c. emotional lability d. loss of bladder control
a. decrease in level of consciousness
a client has glaucoma. the nurse reviews the clients medical record. expecting to note which of the following manifestations of this eye condition? select all a. decreased visual acuity b. severe eye pain c. headache d. photophobia e. increase accomodation
a. decreased visual acuity c. headache
which manifestation is an extrapyramindal side effects of chlorpromazine? select all a. drooling b.facial tics c. shuffling gait d. tongue rolling e. restless movements
a. drooling b.facial tics c. shuffling gait d. tongue rolling e. restless movements
which action would the nurse classify as priority when caring for a client with tonic-clonic seizures? a. ensuring patent airway b. admin IV fluids c. monitoring level of conciousness d. protecting the client from injury during seizures
a. ensuring patent airway
which information is important for the nurse to include in a teaching program for a client admitted to the hospital after having a tonic-clonic seizure and is being diagnosed with a seizure disorder? a. explain strategies a client may use to prevent physical trauma from occurring during a seizure b. teach the client to take anticonvulsant agents on an empty stomach c. teach the client that the symptoms and treatment of seizure disorders are similar regardless of the cause d. explain that sharing the knowledge of their illness with others is not necessary, because the meds will control the seizures
a. explain strategies a client may use to prevent physical trauma from occurring during a seizure
which factors can trigger a clients migraine attack? a. fatigue b. vertigo c. aphasia d. sleep problems e. tingling sensations d. hormonal fluctuations
a. fatigue d. sleep problems d. hormonal fluctuations
the nurse is interviewing a client w/ tentative diagnosis of parkinsons. which description would the nurse give to the client about the onset of symptoms? a. gradually b. overnight c. irregularly d. suddenly
a. gradually
after interacting w/ a client, the nurse believes the client is in the prodromal phase of a migraine. which statements made by the client led the nurse to reach this conclusion? select all a. i feel drowsy all the time b. I feel confused at this point in time c. i feel severe pain over my ear d. i feel throbbing pain in my head e. i feel weakness in the left side of my body
a. i feel drowsy all the time b. I feel confused at this point in time e. i feel weakness in the left side of my body
after interacting with a client, the nurse thinks the client is in the prodromal phase of a migraine. which statements made by the client led the nurse to conclusion? select all a. i feel drowsy all the time b. i feel severe pain over my ear c. i feel a throbbing pain in my head d. i feel confused at this point in time e. i feel weakness in the left side of my body
a. i feel drowsy all the time d. i feel confused at this point in time e. i feel weakness in the left side of my body
which comment made by a client w/ glaucoma indicates to the nurse that the client understands the home care instructions specific to this disorder? a. i will check the label on my nonprescription drugs b. i will take my eye drops until my vision clears c. i will limit my fluid intake d. i will change positions slowly
a. i will check the label on my nonprescription drugs
interventions for initial plan of care for a pt with suspected embolic stroke? select all a. identify last known well time b. obtain STAT CT of the head c. prepare to initiate alteplase within 4.5 hrs of symptom onset d. maintain BP of 120-140 e. preform neuro assessment
a. identify last known well time b. obtain STAT CT of the head c. prepare to initiate alteplase within 4.5 hrs of symptom onset d. maintain BP of 120-140 e. preform neuro assessment
a pt has a prescription for a seizure precautions and a nursing student develops a plan of care for the client. the RN reviews the plan w/ the student and instructs the student to reconsider planning for which of the following interventions? a. keeping all the lights on int he room at night b. monitoring the client closely while the client is showering c. pushing the lock-out button on the electric bed to keep the bed in the lowest position d. assisting the client to ambulate in the hallway
a. keeping all the lights on int he room at night
the HCP is assessing a pt admitted w/ a diagnosis of hemorrhagic stroke affecting the right cranial hemisphere. which assessment finding is consistent w/ this diagnosis? a. left sided flaccidity b. kernigs sign c. right sided spasticity d. bilateral babinski sign
a. left sided flaccidity
which assessment finding indicates that a client has had a stroke? select all a. lopsided smile b. unilateral vision c. incoherent speech d. unable to raise right arm e. symptoms started 2 hrs ago
a. lopsided smile b. unilateral vision c. incoherent speech d. unable to raise right arm e. symptoms started 2 hrs ago
the nurse is planning health teaching for a client starting donepezil for alzheimers. for which side effect will the nurse teach the family to monitor? a. low pulse rate b. elevated body temp c. low oxygen saturation d. high BP
a. low pulse rate d/t bradycardia side effect
the nurse is caring for a client who had a lumbar puncture. what priority action would the nurse preform to ensure client safety? a. monitor for increased intracranial pressure, such as decreased level of consciousness b. observe the needle insertion site for CSF leakage or infection c. give an analgesic for client report of headache if it is moderate or severe d. take vitals every hr after the procedure until the client is stable
a. monitor for increased intracranial pressure, such as decreased level of consciousness
which of the following interventions should be implemented for a pt immediately following recombinant tissue plasminogen therapy (tPA)? select all a. monitor vital signs and heart rhythm b. monitor blood glucose level c. provide pt education on plan of care d. administer aspirin e. assess neuro function hourly
a. monitor vital signs and heart rhythm b. monitor blood glucose level c. provide pt education on plan of care e. assess neuro function hourly
which finding would the nurse expect when completing an admission physical for a client with parkinson dz? select all a. muscle rigidity b. blank facial expression c. leaning toward the affected side d. intention tremors with movement d. hyperextension of the affected extremity
a. muscle rigidity b. blank facial expression
which findings would the nurse expect when completing an admission physical for a client with a diagnosis of parkinsons? select all a. muscle rigidity b. hyperextension of the affected exremity c. intentional tremors with movement d. blank facial expression e. leaning toward the affected side
a. muscle rigidity d. blank facial expression
which finding would support a clients diagnosis of parkinson dz? select all a. nonintentional tremors b. frequent bouts of diarrhea c. masklike facial expression d. hyperextension of the neck e. rigidity to passive movement
a. nonintentional tremors c. masklike facial expression e. rigidity to passive movement
the HCP is caring for a pt who has dysphagia after experiencing a stroke. which of the following info will be included when teaching the family how to assist the pt during meals? select all a. observe the pt for hoarseness and other vocal changes b. observe the pt for fatigue during meals c. maintain a distraction free environment during meals d.provide meals that are low in fat and low in calories e. give sips of water between bites of food f. place the food in the unaffected side of the mouth
a. observe the pt for hoarseness and other vocal changes b. observe the pt for fatigue during meals c. maintain a distraction free environment during meals f. place the food in the unaffected side of the mouth
Interventions for initial plan of care for a pt w/ suspected embolic stroke? Select all a. obtain a STAT CT scan of the head b. preform a neuro assessment c. prepare to initiate alteplase within 4 hrs of symptom onset d. maintain BP 180-200 e. advocate to keep the client in a quite, dark private room f. inform the UAP the client may urinate more with planned treament
a. obtain a STAT CT scan of the head b. preform a neuro assessment c. prepare to initiate alteplase within 4 hrs of symptom onset
the nurse notes during assessment and hx taking that an older adult client is exhibiting visual changes. the nurse determines that which finding requires the need for follow up? a. photophobia b. decreased visual acuity c. loss of peripheral vision d. decreased tolerance of glare
a. photophobia
the HCO is assessing a pt with parkinson's. which of the following assessments will the HCP anticipate? a. pill-rolling tremor when the hand is at rest b. an absence of stereognosis c. DTRs graded as a 1 d. twisting and protruding of the tongue
a. pill-rolling tremor when the hand is at rest
a nurse is preparing to discharge a client with alzheimers who will be cared for by her daughter from the hospital. when providing education on how to minimize behavioral problems at home, what should the nurse include? select all a. place safety locks on doors and gates b. arrange for day care programs to maintain interaction and provide respite care for the clients daughter c. encourage large family get togethers d. minimize clutter in all rooms of the house e. encourage the client to let the family do everything for her
a. place safety locks on doors and gates b. arrange for day care programs to maintain interaction and provide respite care for the clients daughter d. minimize clutter in all rooms of the house
it is 1600 on the dementia unit and an 87 yr old pt is becoming increasingly agitated because the staff will not let him leave to go meet his boss. what are the appropriate actions the nurse should take? select all a. place the pt on a chair alarm b. ignore the client, he will probably calm down on his own c. redirect the pt and offer him a puzzle to do in his room d.raise their voice and explain to the pt that he has no boss e. take the pt on frequent walks around the unit
a. place the pt on a chair alarm c. redirect the pt and offer him a puzzle to do in his room e. take the pt on frequent walks around the unit
the nurse is administering the intake assessment for a newly admitted client with a hx of seizures. the client suddenly begins to seize. what does the nurse do next? a. position the client on the side b. restrains the client c. forces a tongue blade in the mouth d. documents the length and time of the seizure
a. position the client on the side
the nurse is caring for a client with early stage alzheimers. which nursing action is most appropriate when caring for this client? a. provided a structured environment b. use validation therapy c. give cholinesterase inhibitor d. refer the client to the social worker
a. provided a structured environment
the wife of a pt recovering from a CVA tells the HCP "my husband acts as though i'm talking to him in a foreign language" the HCP will correctly document this communication disorder as which of the following? a. receptive aphasia b. expressive aphasia c.dysphasia d. dysarthria
a. receptive aphasia
which client need would the nurse prioritize while providing care for an older adult client with dementia? a. safety b. self esteem c. self actualization d. love and belonging
a. safety
a client has been admitted w/ new onset status epilepticus. which seizure precautions would the nurse implement? select all a. section equipment b. continuous sedation c. IV access d. bite block at bedside e. side rails raised
a. section equipment c. IV access e. side rails raised
a pt w/ a recent hx of a stroke if being discharged home. which instructions should be included in discharge education? select all a. seek help immediately if you have sudden weakness, visual changes, or altered level of consciousness b. make sure to take your prescribed meds c. consider participating in a physical/ occupational therapy programs d. make sure to attend all follow-up visits e. eat a diet low in saturated fat and high in sodium
a. seek help immediately if you have sudden weakness, visual changes, or altered level of consciousness b. make sure to take your prescribed meds c. consider participating in a physical/ occupational therapy programs d. make sure to attend all follow-up visits
the nurse is caring for a client with has parkinsons. what assessment findings would the nurse expect? select all a. stooped posture b. masklike facial expression c. drooling at times d. shuffled gait e. dysarthria f. muscle rigidity
a. stooped posture b. masklike facial expression c. drooling at times d. shuffled gait e. dysarthria f. muscle rigidity
which manifestations are associated w/ moderate dementia? select all a. sundowning b. hypervigilance c. increased inhibition d. exaggeration of premorbid traits e. inability to recognize family members
a. sundowning d. exaggeration of premorbid traits
the UAP is attempting to a put in an oral airway in the mouth of a client having a tonic-clonic seizure. which action should the primary nurse take? a. tell the UAP to stop trying to insert anything into the mouth b. tale no action because the UAP is handling the situation c. help the UAP inset the oral airway in the mouth d. notify the charge nurse of the situation immediately
a. tell the UAP to stop trying to insert anything into the mouth
which explanation would the nurse provide to a client about transient ischemic attacks (TIAs) a. temporary episodes of neurological dysfunction b. intermittent attacks caused by multiple small clots c. ischemic attacks that result in progressive neuro deterioration d. exacerbations of neurological dysfunction alternating with remissions
a. temporary episodes of neurological dysfunction
a pt tells the HCP, "yesterday i felt numbness in my right hand, my vision became blurry, and i felt like i was losing my balance, but after i laid down for about an hour is went away." what is the HCPs best response? a. this may be a warning sign of a stroke b. call us if this ever happens again c. were you drinking any alcohol at the time? d. did you feel any nausea at the time?
a. this may be a warning sign of a stroke
which outcome would be a priority for the nurse to incorporate in the plan of care for a client with a migraine? a. to decrease pain b. to decrease nausea c. to decrease vomiting d. to decrease light sensitivity
a. to decrease pain
a client is diagnosed w/ macular degeneration and asks the nurse to describe this condition. the nurse should include which info in response to the client? select all a. two types, atrophic (age related or dry) or exudative (wet exist) b. treatment aims to help the client maximize remaining vision c. mild blurring and disorientation occur d. it can be a age related problem e. it is caused by gradual blockage of retinal capillaries
a. two types, atrophic (age related or dry) or exudative (wet exist) b. treatment aims to help the client maximize remaining vision c. mild blurring and disorientation occur d. it can be a age related problem e. it is caused by gradual blockage of retinal capillaries
the nurse is assessing an older adult client with advanced parkinsons. which clinical manifestation alerts the nurse that the client is developing aspiration pneumonia? select all a. unilateral crackles b. weak, frequent cough c. temp 37.5 (99.5) d. o2 sat 93% e. RR 18
a. unilateral crackles b. weak, frequent cough c. temp 37.5 (99.5) d. o2 sat 93%
a nurse is teaching the UAP about how to communicate with a client who has receptive aphasia. which instruction would the nurse include? a. use simple short sentences and one-step commands b. work with speech language pathology for suggestions c. write sentences or works on a white board for the client d. speak loudly to ensure that the client can hear
a. use simple short sentences and one-step commands
seizure pathophysiology:
abnormal, sudden, excessive, uncontrolled electrical discharge of neurons within the brain that result in change of behavior: LOC, motor/ sensory ability, or behavior
desired outcomes for parkinsons:
active participation in ADLs
partial (simple/ focal) seizure:
affects one hemisphere of the brain -complex and simple
dx testing for alzheimers:
autopsy: only 100% way to tell is someone has alzheimers -neuroimaging (MRI) --> will not show anything until someone has significant alzheimers -psychological interview: MMSE--> mini mental stat exam BIMS--> brief interview for mental status MOCA --> montreal cognitive assessment tool
a client is being discharged home after treatment for a brain attack. what is the mnemonic that the nurse can teach the family and client to help recognize and act on another stroke? a. A-V-P-U b. F-A-S-T c. K-I-N-D d. P-Q-R-S-T
b. F-A-S-T F-facial drooping A-arm weakness S-speech difficulties T-time
the nurse is screening a group of potential new clients to determine which level of care they require. which of the following pts is most likely to be placed in the dementia unit? a. 70 yr old women who once forgot her name of her 16th great grandchild b. a 94 yr old man who has PTSH from WW2, and is disoriented to time, place, and events c. a 58 yrs old man who occasionally finds himself forgetting what day it is d. an 85 yr old women who needs minimal assistance w/ ADLs
b. a 94 yr old man who has PTSH from WW2, and is disoriented to time, place, and events
a nurse is working on a stroke unit. which of the following clients would be appropriate to receive tissue plasminogen activator (tPA) as treatment? a. a client with an arteriovenous malformation b. a client who has a blockage of a cerebral blood vessel c. a client who has a TIA d. a client who described hearing a thunder clap
b. a client who has a blockage of a cerebral blood vessel
which equipment would the nurse recommend to foster independence at home for an ambulatory client who has parkinsons? a. a trapeze above the bed b. a raised toilet seat c. side rails for the bed d. crutches for ambulation
b. a raised toilet seat
which factor is unique to vascular dementia when comparing assessment findings in clients with vascular dementia and dementia of alzheimers? a. memory impairment b. abrupt onset symptoms c. difficulty making decisions d. inability to use words to communicate
b. abrupt onset symptoms
A nurse is preparing to discharge a client with Alzheimer's who will be cared for by her daughter from the hospital. When providing education on how to minimize behavioral problems at home, what should the nurse include? Select all a. encourage the client to let her family do everything for her b. arrange for day-care programs to maintain interaction and provide respite care for the clients daughter c. encourage large family get together so the client can spend time with her other family members d. minimize clutter in all rooms e. place safety locks on doors and gates
b. arrange for day-care programs to maintain interaction and provide respite care for the clients daughter d. minimize clutter in all rooms e. place safety locks on doors and gates
a client is in the prodrome phase of a migraine. which manifestations will the nurse assess for? a. vomiting b. aura c. nausea d. headache
b. aura
the nurse is caring for a client with impaired vision. the nurse know the cranial nerve that controls visual acuity is which of the following? a. cranial nerve V b. cranial nerve II c. cranial nerve III d. cranial nerve VII
b. cranial nerve II (optic)
a client asks the nurse what causes parkinsons. which description of pathophysiology should the nurse provide in response to the client? a. reduced acetylcholine receptors at synapses b. degeneration of neurons of the basal ganglia c. breakdown of upper and lower neurons d. disintegration of the myelin sheath
b. degeneration of neurons of the basal ganglia
which IV med would the nurse anticipate the HCP will prescribe for a client who has a tonic-clonic seizure? a. naloxone b. diazepam c. ephinephrine HCI d. atropine
b. diazepam
a family of a client with parkinons tells the nurse that the client is having difficulty adjusting to the disorder and that they do not know what they should do. the nurse advises the family that which of the following is most therapeutic in assisting the client to cope with the dz? a. plan only a few activities for the client during the dat b. encourage and praise the client efforts to exercise and perform ADLs c. assist the client w/ ADLs as much as possible d. cluster activities at the end of the day when the client is restless and bored
b. encourage and praise the client efforts to exercise and perform ADLs
a client is admitted to the hospital w/ weakness in the right extremities, and speech that is slightly slurred. a diagnosis of a brain attack (CVA) is suspected. during the first 24 hrs after symptom onset, which action is priority? a. monitor bowels b. evaluate motor status c. assess the temp d. obtain a urinalysis
b. evaluate motor status
which nursing action has the highest priority during the first 24 hrs of a clients admission with right sided weakness, slight difficulty with speech, and vitals within normal limits? a. obtaining the clients temp trends b. evaluating the clients motor status c. obtaining the clients urine for urinalysis d. monitoring the clients BP for hypertension
b. evaluating the clients motor status
the nurse should instruct the client who had cataract surgery to contact the HCP if which of the following conditions develops? a. minor sweliing b. eye pain c. itching d. blurred vision
b. eye pain
which s/s are characteristics of alzheimers dz? select all a. ambivalence b. forgetfulness c. flight of ideas d. loose associations e. expressive aphasia
b. forgetfulness e. expressive aphasia
the nurse admits a client who is having controlled generalized tonic-clonic seizures. in planning for potential complications, which nursing intervention if of priority? a. maintain a quite environment b. have suction equipment available c. place bed in low position d. maintain side rails up at all times
b. have suction equipment available
the nurse is teaching a group of older adults about stroke prevention. which risk factors for stroke would the nurse include? select all a. female gender b. high BP c. previous stroke or TIA d. smoking e. use of oral contraceptives
b. high BP c. previous stroke or TIA d. smoking e. use of oral contraceptives
a pt is admitted to the mental health unit w/ a diagnosis of vascular dementia. which of the following described the brain alteration involved in this disorder? a. formation of beta- amyloid plaques b. hypoxic damage to brain tissue c. enlargement of the ventricles d. decreased choline acetyltransferase
b. hypoxic damage to brain tissue
a client with migraine headaches is admitted for electroencephalogram (EEG). which statement made by the client assures the nurse that preprocedure teaching has been effective? a. i will need to avoid milk until the test is complete b. i will need to avoid caffeine c. i will be able to take my zolpidem B4 the test d. i will have a headache after the test
b. i will need to avoid caffeine
a nurse is reading the chart for a client w/ alzheimers. the nurse notes that the clients is demonstrating aphasia. what is an expected finding? a. inability to find words b. inability to speak and understand c. loss of sensory comprehension d. inability to use words or objects correctly
b. inability to speak and understand
a client with parkinsons is being discharged home with his wife. to ensure success with the management plan, which discharge action is most effective? a. telling his wife what the client needs b. involving the client and his wife in developing a plan of care c. writing up a detailed plan of care according to standards d. setting up visitations by a home health nurse
b. involving the client and his wife in developing a plan of care
which action would the nurse take first when caring for a client who is admitted to the ED after experiencing a seizure? a. ask the emergency provider for a prophylactic anticonvulsant b. obtain a hx of seizure type and incidence c. ask the client to remove any dentures and eyeglasses d. observe the client for increased restlessness and agitation
b. obtain a hx of seizure type and incidence
a client completed alteplase infusion following thrombotic stroke. what nursing action is appropriate? a. insert an indwelling cath b. preform frequent neuro assessments c. notify radiology to schedule an MRI d.admin an antiplatelet agent
b. preform frequent neuro assessments
a pt arrives at the ED with slurred speech, right facial drooping, and right arm weakness. which of these actions by the HCP is priority? a. call the speech pathologist to the ED b. prepare the pt for a CT scan of the head c. transfer the pt to the neruo care unit d. prepare to admin a thrombolytic med
b. prepare the pt for a CT scan of the head
which finding for a client who has a diagnosis of paroxysmal atrial fib is most important to report quickly to the HCP? a. irregular heartbeat b. right arm weakness c. client report of palpations d. client report of lightheadedness
b. right arm weakness
a client w/ alzheimers was just admitted to the hospital. what are some strategies that the nurse can use to promote safety? select all a. four side rails up at all times b. sitters at the bedside as needed c. choosing a room close to the nurses station d. restraints applied at night e. toileting every 2 hrs
b. sitters at the bedside as needed c. choosing a room close to the nurses station e. toileting every 2 hrs
the nurse is caring for a client with vascular dementia. the nurse recognizes that which health problem is associated with this type of dementia? a. epilepsy b. stroke c. meningitis d. migraines
b. stroke
a nurse educator is preparing an educational session for nurses and UAPs on a medical unit to promote effective communication for clients with dementia. which intervention (s) should the nurse include in the educational session? select all a. allow family members to respond for the client whenever possible b. take cues from nonverbal aspects c. raise the volume of the voice when talking to the client d. ask open ended questions to promote therapeutic communication e. complete the sentences the client cannot finish
b. take cues from nonverbal aspects
a pt who has been prescribed antiparkinsonian medication carbidopa/ levidopa, asks the HCP "why am i getting these two medications?" how should the HCP respond? a. you will experience fewer side effects when you take both meds together b. the carbidopa prevents the breakdown of levidopa c. this drug combo is composed of two types of the same med d. the levodopa turns the carbidopa into dopamine when it reaches the brain
b. the carbidopa prevents the breakdown of levidopa
a client is admitted to the hospital with a tonic-clonic seizure after his seizures had been well controlled by phenytoin for 6 months. the client states "im so upset. i didnt think i was going to have any more seizures." which response would the nurse make to the client? a. did you forget to take your medication? b. you are worried about having more seizures? c. you must be under a lot of stress right now d. dont be concerned; your medication can be increased
b. you are worried about having more seizures?
myoclonic seizure:
brief jerking/ stiffness of muscles ; lasts a few seconds
when assisting a client who had a stroke to eat, the nurse can promote independence by taking which of the following actions? a. encourage the client to eat with other cleints who have also had a stroke b. sit the client in high fowlers for better visualization of the meal c. allow the client to participate as much as possible in eating d. odder a variety of textured foods
c. allow the client to participate as much as possible in eating
a nurse is getting a pts health hx. what questions are important to ask to differentiate alzheimers from other causes of impaired cognition? select all a. do you ever forget is the dishes in the dishwasher are clean or dirty? b. have you ever locked your keys in the car and needed to call for assistance? c. are you having any trouble preforming ADLs, and when did this begin? d. what can you tell me about your work history? e. have you noticed your memory declining over time?
c. are you having any trouble preforming ADLs, and when did this begin? d. what can you tell me about your work history? e. have you noticed your memory declining over time?
the nurse is reviewing the hx of a client who has been prescribed topiramate for prevention of migraines. the nurse plans to contact the HCP if the client has which condition? a. DM b. hypothyroidism c. bipolar disorder d. glaucoma
c. bipolar disorder d/t CNS related side effects from topiramate
a client asks the nurse " how does glaucoma damage my eyesight?" the nurse should explain to the client that chronic open angle glaucoma ______? a. results from chronic eye inflammation b. leads to detachment of the retina c. causes increase intraocular pressure d. is caused by decreased blood flow to the retina
c. causes increase intraocular pressure
a client is scheduled for an electroencephalogram (EEG). which instruction does the nurse give to the client before the test? a. you may bring some music to listen to for distraction b. please do not have anything to eat or drink after midnight c. do not take any sedative 12-24 hrs before the test d. you will need to have someone to drive you home
c. do not take any sedative 12-24 hrs before the test
a pt who is diagnosed with parkinson's states, "i cant tie my shoelaces anymore." the HCP recognizes that this pts problem is d/t a deficiency in which of these neurotransmitters? a. glutamate b. norepinephrine c. dopamine d. serotonin
c. dopamine
a pt diagnosed w/ alzheimers is demonstrating signs of impaired reasoning. the HCP suspects an alteration in which area of the brain? a. hippocampus b. amygdala c. frontal lobe d. occipital lobe
c. frontal lobe
the nurse is teaching a client, newly diagnosed w/ migraines about trigger control. which statement made by the client demonstrates food understanding of the teaching plan? a. i need to use fake sugar in my coffee b. i can still eat chinese food c. i should not miss any meals d. it is okay to drink a few wine coolers
c. i should not miss any meals missing meals can be a trigger for migraines
a female client w/ newly diagnosed migraines is being discharged with a prescription for sumatriptan. which statement by the client indicates an understanding of the nurses discharge instructions? a. birth control is not needed while taking sumatriptan b. sumatriptan can be taken as a last resort c. i will report any chest pain right away d. st johns wort can also be taken to help my symptoms
c. i will report any chest pain right away
which nursing intervention is most important for preventing injury to a client preparing to undergo electroconvulsive therapy (ECT) treatment? a. obtain baseline vitals b. evaluate swallowing abilities c. implement seizure precautions d. determine use of benzodiazepines
c. implement seizure precautions
in which position would a nurse maintain a client who has had experienced a subarachnoid hemorrhage? a. supine b. on the unaffected side c. in bed with the HOB elevated d. with sandbags on either side of the head
c. in bed with the HOB elevated
which info would the nurse include in the teaching plan for a pt who is prescribed sumatriptan for migraine headaches? a. it should be administered when headache is at its peak b. it should be administered by deep intramuscular injection c. is contraindicated in people with coronary artery dz d. injectable sumatriptan may be administered q 6 hrs PRN
c. is contraindicated in people with coronary artery dz
the nurse is teaching an older adult client about visual changes that occur w/ age. what statement does the nurse include? a. you will have to move reading materials closer to your eyes to focus b. when the sclera turns yellow, you have developed lover problems c. it may take your eyes longer to adjust in a darkened room d. most visual changes occur B4 age 40
c. it may take your eyes longer to adjust in a darkened room
a client experiences a CVA and is admitted to the hospital in a coma. what is the priority nursing care for this client? a. monitor vitals b. maintain fluid and electrolytes b. maintain fluid and electrolytes c. maintain an open airway 'd. monitor pupil response and equality
c. maintain an open airway
the home health nurse is checking on a client w/ dementia and the clients spouse. the spouse confides to the nurse " i am so tired and worn out" what is the nurses best response? a. establishing goals and a daily plan can help b. cant you take care of your spouse? c. make sure you take some time off and take care of yourself d. thats not a very nice thing to say
c. make sure you take some time off and take care of yourself
which intervention would be a priority for the nurse to include in the plan of care for a client with a gunshot wound who has severe hemiplegia associated with abnormal posturing and fixed dilated pupils? a. monitoring skin integrity b. monitoring bowel patterns c. monitoring respiratory rate d. monitoring nutritional status
c. monitoring respiratory rate
a client is admitted with a stroke. which tool does the nurse use to facilitate a focused neuro assessment of the client? a. intracranial pressure monitor b. mini-mental state examination (MMSE) c. national institutes of health stroke scale (NIHSS) d. glasgow coma score (GCS)
c. national institutes of health stroke scale (NIHSS)
the nurse enters the room as the client is beginning to have a tonic clonic seizure. what action should the nurse implement first? a. determine if the client is incontinent of urine and stool b. asses the size of the clients pupils c. note the first thing the client does in the seizure d. provide the client with privacy during the seizure
c. note the first thing the client does in the seizure
the nurse is caring for a client who has been diagnosed w/ alzheimers dz 5 yrs ago. which communication technique should be considered with this client? select all a. open ended questions allows for taking the conversational lead b. providing the client w/ several options to choose from c. recognize the clients non verbal cues d. sarcastic humor should be avoided e. limiting gestures as this can create distraction
c. recognize the clients non verbal cues d. sarcastic humor should be avoided
which mechanism of action would the nurse identify for levodopa therapy prescribed to a client diagnosed with parkinsons dz? a. blocks the effect of acetylcholine b. increases the production of dopamine c. restores the dopamine levels in the brain d. promotes the production of acetylcholine
c. restores the dopamine levels in the brain
the nurse is caring for a client with parkinsons. which is the priority nursing concern? a. impaired skin related to drooling b. decreased physical mobility related to stooped posture c. risk for injury related to gait disturbances d. pain related to headache
c. risk for injury related to gait disturbances
the RN is observing a nursing assistant ambulating a client with right sided weakness. the RN would determine that the UAP is preforming the procedure safely if the nurse observes the UAP is taking which of the following actions? a. standing behind the client b. standning on the left side of the client c. standing on the right side of the client d. standing in front of the client
c. standing on the right side of the client
which client statement indicates that the instructions to a client with a seizure disorder receiving phenytoin and phenobarbital are understood? a. i will not have any seizures with these meds b. these meds must be continued to prevent falls and injury c. stopping the meds can cause continuous seizures and i may die d. by my staying on the meds i will prevent postseizure confusion
c. stopping the meds can cause continuous seizures and i may die
a client is being provided w/ discharge instructions after having a cataract extraction and intraocular lens implant. which of the following activities should the nurse advise the client to avoid? a. eating a regular diet b. reading or watching TV for at least 12 hrs c. straining while having a bowel movement d. keep an eye patch over the affected eye for 24 hrs
c. straining while having a bowel movement
a client has undergone surgery for cataracts. the nurse instructs the client to call the physician for which of the following complications? a. gradual resolution of sclera redness b. eye pain relieved by acetaminophen c. sudden decrease in vision d. small amounts of dried matter on the eyelashes after sleep
c. sudden decrease in vision
the daughter of a pt diagnosed w/ alzheimers is complaining that her mother gets very agitated and restless suddenly in the evening. the nurse understands that what behavior is more likely that the patient is experiencing? a. agnosia b. depression c. sundowning d. alexia
c. sundowning
a client is to undergo gonioscopy. when the client asks what this test is for, what is the appropriate nursing response? a. this test creates a 3 dimensional view of the back of the eye b. retinal circulation is evaluated by this test c. the opthalmologist uses this test to determine if you have open- angle or closed-angle glaucoma d. this method of testing will determine if you have blood vessel changes d/t disease or drugs
c. the opthalmologist uses this test to determine if you have open- angle or closed-angle glaucoma
a client w/ glaucoma is concerned about surgery and asks the nurse if complete vision will return once the surgery is done. the nurse should make which response to the client? a. w/ most clients, vision loss returns approximately 4-6 wks after surgery b. you vision loss will never return and will only worsen c. the vision loss you have may not return but further loss can be prevented by adhering to treatment plan d. if you take you medications faithfully all of your vision will return
c. the vision loss you have may not return but further loss can be prevented by adhering to treatment plan
when planning care for a pt w/ parkinson's, which of these pt outcomes should receive priority in the pt plan of care? a. taking a vitamin supplement each day b. taking a daily walk around the neighborhood c. toileting and bathing independently d. working on a favorite hobby
c. toileting and bathing independently
a nurse is testing the function of a clients vestibulocohclear nerve (cranial nerve VIII). the nurse would gather which of the following items to preform the test? a. safety pin, hot and cold water in test tubes, cotton wisp b. snellen eye chart and opthalmoscope c. tuning fork and audiometer d. flashlight, pupil size chart, or millimeter ruler
c. tuning fork and audiometer
the nurse is preforming a neuro assessment and is checking the spinal accessory nerve (CN XI). the nurse should ask the client to perform which action to test this nerve? a. mimic the sounds the examiner makes b. open the moth and say ah for 30 sec c. turn the head to the side and resit the examiners attempt to push the face toward the midline d. swallow a sip of water several times during a 1 min period
c. turn the head to the side and resit the examiners attempt to push the face toward the midline
when reviewing the medical record of a pt diagnosed w/ alzheimers the HCP notes the patient is aphasic. which behavior supports this finding? a. diffuculty swallowing b. unable to recognize objects c. unable to speak d. difficulty with motor function
c. unable to speak
the night prior to an electroencephalogram (EEG), which preparation will a nurse instruct a client to preform? a. tak a laxative b. go to bed early c. wash the hair d. do not eat or drink after midnight
c. wash the hair
a client receiving propranolol as preventative therapy for a migraine is experiencing side effects after taking the drug which side effect is of greatest concern to the nurse? a. warm sensation b. tingling feelings c.slow heart rate d. dry mouth
c.slow heart rate
arteriovenous malformation (AVM): pathophysiology
clients are born w/ tangled blood vessels that can eventually burst -can be removed prophylactically
Cataracts Pathophysiology
clouding of the lens causes: -age (older more likely) -exposure to UV light -corticosteroids -alcohol -smoking
the nurse is caring for 4 client w/ eye concerns. which client who has family hx of an eye disorder does the nurse identify at risk for increased intraocular pressure? a. client with family hx of diabetic retinopathy b. client with family hx of anisocoria c. client with family hx of presbyopia d. client with family hx of glaucoma
d. client with family hx of glaucoma
a client recovering from a stroke reports double vision that is preventing the client from effectively completing ADLs. how would the nurse help the client compensate? a. approach the client on the affected side b. place objects in the clients filed of vision c. encourage turning the head from side to side d. cover the affected eye if possible
d. cover the affected eye if possible
which intervention would the nurse implement after determining that a client who sustained a CVA, needs assistance with eating for optimal nutrition? a. request that the clients food be pureed b. feed the client to conserve the clients energy c. have a family member assist the client with each meal d. encourage the client to participate in the feeding process
d. encourage the client to participate in the feeding process
a client admitted w/ cerebral edema suddenly begins to have a seizure while the nurse is in the room. what would the nurse do first? a. administer phenytoin b. draw the clients blood c. start an IV d. establish an airway
d. establish an airway
the nurse educator is preparing a session on neurodegenartive dz. which statement should be included about the difference between parkinsons and huntingtons? a. levedopa/ carbidopa improves functionality in pts with huntingtons dz while there is not an effect in clients with parkinsons b. parkinsons disease progresses quick while huntingtons is slow progressing c. parkinsons onset of age is 30-40 while huntingtons is later in life d. huntingtons dz is a rare genetic disorder affecting mobility and psychological function and parkinsons affects functionality due to lack of dopamine
d. huntingtons dz is a rare genetic disorder affecting mobility and psychological function and parkinsons affects functionality due to lack of dopamine
a client has been admitted w/ a diagnosis of a stroke. the nurse suspects that the client has had a right hemisphere stroke because the client exhibits which symptoms? a. quick to anger and frustration b. inability to discriminate words c. aphasia and cautiousness d. impulsiveness and smiling
d. impulsiveness and smiling
which instruction would the nurse include when teaching about hydrochlorothiazide given to a client diagnosed with a transient ischemic attack (TIA) related to hypertension? a. resume regular eating habits b. drink a protein supplement daily c. avoid eating foods high in insoluble fiber d. increase the intake of potassium rich foods
d. increase the intake of potassium rich foods
the nurse documents the following after observing a client with a tonic-clonic seizure: "0930 found client having jerky, involuntary movements of upper and lower extremities lasting 2 minutes, frothy saliva oozing from mouth, incontinent of urine." which statement best described the nurses documentation? the documentation a. should include the clients response and nursing interventions b. should just indicated that the client has a tonic clonic-seizure c. is lacking whether the client had an aura experience before the seizure d. is appropriate and describes the observations seen
d. is appropriate and describes the observations seen
which intervention would the nurse implement for a client w/ parkinsonism who takes an anticholinergic med for morning stiffness and tremors in the right arm who reports numbness in the left hand during a visit to the clinic? a. refer the client to the primary HCP, only is other neuro deficits are present b. ask the primary HCP to increase to increase the clients dosage of the anticholinergic c. stress the importance of having the client call the primary HCP as soon as possible d. make immediate arrangements for further medical evaluation by the clients primary HCP
d. make immediate arrangements for further medical evaluation by the clients primary HCP
the nurse should include which instruction in the teaching plan for a client who has had cataract surgery with an intraocular lens implant? a. cough and deep breathe at least q 2 hrs b. weak your eye patch and eye shield at all times c. use saline eye drops as needed d. no driving until your physician clears you
d. no driving until your physician clears you
a client is admitted w/ a suspected retinal detachment of the right eye. which position would be best for the client? a. supine b. high fowlers c. on the L side d. on the R side
d. on the R side
which nursing action is appropriate for a patient during the tonic-clonic stage of a seizure? a. go for additional help b. establish a patent airway c. restrain the client to prevent injury d. protect the clients head from injury
d. protect the clients head from injury
which measure should a nurse initially include in the plan of care for a client w. dysphagia d/t parkinsons? a. encouraging the client to drink fluids with meals b. placing food in the unaffected side of the clients mouth c. arrange for someone to feed the client d. providing the client with semisolid or soft food
d. providing the client with semisolid or soft food
during an interview with a pt diagnosed with parkinson's, which of the following speech patterns will the HCP anticipate? a. pressured and hurried b. clear and rythmic c. bubbly and spirited d. slow, slurred, and monotone
d. slow, slurred, and monotone
when obtaining the health hx of a pt w/ parkinson's, which of the following symptoms should the HCP anticipate the pt to report? a. my eyes have become very sensitive to light b. i used to be able to walk up the stairs w/out getting out of breath c. ive been getting really severe headaches lately d. sometimes i feel like my feet are glued to the floor
d. sometimes i feel like my feet are glued to the floor
which description of symptoms is consistent w/ dementia of the alzheimers type? a. symptom onset is fairly rapid b. symptoms will subside periodically c. symptoms are triggered by personal crisis d. symptoms reflect progressive disintegration
d. symptoms reflect progressive disintegration
a nursing instructor is observing a nursing student preform an otoscopic exam on an adult client. which of the following observations if made by the instructor indicates the correct assessment procedure? a. the nursing student uses a small speculum to decrease the discomfort of the exam b. the nursing student pulls the earlobe down and back before inserting the speculum c. the nursing student tilts the clients head forward and down before inserting the speculum d. the nursing student pulls the pinna up and back before inserting the speculum
d. the nursing student pulls the pinna up and back before inserting the speculum
which heath problem hx would increase an older adults risk for experiencing a CVA? a. glaucoma b. hypothyroidism c. continuous nervousness, tress d. transient ischemic attacks (TIAs)
d. transient ischemic attacks (TIAs)
which question is most useful when planning nursing care for a client with a tonic-clonic seizure at work and is admitted to the ED? a. is your job demanding or stressful most of the time? b. do you participate in any strenuous activities on a regular basis? c. does anyone in your family have a hx of CNS problems? d. were you aware of anything different or unusual just before your seizure began?
d. were you aware of anything different or unusual just before your seizure began?
a client who is using eye drops on both eyes develops a viral infection in one eye. what teaching will the nurse provide? a. wash your hands between eyes and put drops in the uninfected eye 1st b. don't touch the eyes with the dropper, and you can still use the drops in both eyes c.the other eye has likely already been infected w/ the virus d.you will need to use a separate bottle of drops for each eye
d.you will need to use a separate bottle of drops for each eye
nursing interventions for acute stoke state:
if stroke happens of the left side of the brain the right side is affected and vice versa -find out last known well time -neuro assessment q 1-2 hrs -help w/ transport to CT -finger stick BG -monitor BMP -med hx for anticoagulants -determine if they had HTN -for tPA: s/s bleeding--> decrease BP, increase HR
nursing interventions post CVA:
if they've returned to baseline: -prevention education of risk factors -DASH diet -alcohol and smoking cessation -med education -s/s stroke pain: -flaccid paralysis (no muscle tone) --> at risk for DVTs -spastic paralysis (tense contraction of muscles) -bedside swallow eval --> clients are at risk for dysphagia -psychosocial care for pt and family -discharge planning -caregiver burden --> assess for abuse/ neglect -adaptive equipment
what is a generalized seizure?
includes both hemispheres of the brain -tonic -clonic -tonic-clonic -myoclonic -atonic
tonic-clonic seizure:
jerking movements followed by stiffness of muscles ; can last several minutes and can by symmetrical or asymmetrical
surgical treatment for seizures:
lobectomy: removal of part of the brain; the function that the part of the brain had will no longer be there -vagus nerve stimulation: implanted device that stimulates the vagus nerve; has been found to stop seizures and from the brain sending abnormal signals
Cholinestrase inhibitors: doneprizil/ rivastigmine
med for alzheimers -prevent breakdown of acetylcholine SE: -bradycardia -GI side effects: N/V, dyspepsia, diarrhea -avoid NSAIDs and alcohol -decreased effect of anticholinergic meds -take at bedtime
N-Methyl-D-Aspartate (NMDA) Receptor Antagonist: memantine
med for alzheimers dz -blocks glutamine so there can be better calcium usage SE: dizziness, headache, increased confusion
dopamine replacement drug/ dopaminergic agents: levodopa/ carbidopa
med for parkinsonism levadopa is the precursor to dopamine and carbidopa allows levedopa to cross the blood brain barrier -promotes dopamine SE: -dyskinesia -N/V -orthostatic hypotension -psychosis/ depression -give several times a day before fine motor skills
pharmological treatment for seizures:
mostly medically managed -abortive meds: benzodiazapines (lorazepam/ diazepam) -preventative meds: phenobarbital, phenytoin, keppra, valporic acid; these are daily scheduled meds and therapeutic levels must be checked
labs for dementia
no labs that say it is dementia but check electrolytes and BG to see causes of mental stat changes
simple seizure:
pt is conscious, autonomic symptoms; possible aura or smell B4
clonic seizure:
rythmic jerking of body parts and relaxations; lasts 30 sec to several minutes
respite care:
short term relief from primary care givers
tonic seizure:
sudden increase in muscle tone; lasts 30 sec to several minutes
atonic seizure:
sudden loss of muscle tone
migraine w/ aura: 3rd phase
throbbing starts to shift to a dull pain -can be 4-72 hrs in length
dx testing for seizures:
to R/O other potential causes -EEG --> electroencephalogram; goal is to catch a seizure prep: no caffeine; take usual meds; dont put any hair products in -MRI -CT --> for swelling -SPECT/ PET scan
the nurse is preforming a neuro assessment on an 81 yr old client. which psychological change does the nurse expect to find because of the clients age? a. decreased coordination b. increased touch sensation c. nightly confusion d. increased sleeping during the night
a. decreased coordination
which of the following adverse effects should the HCO inquire about when assessing a pt who is receiving an anticholinergic med for the treatment of parkinsons? select all a. dry mouth b. urinary retention c. constipation d. dry eyes e.bradycardia f. bruising
a. dry mouth b. urinary retention c. constipation d. dry eyes
complex seizure:
LOC 1-3 min -most common in temporal seizure -absence seizure: pt appears to be zoned out
automatism:
non purposeful movement associated w/ seizures
labs for seizures:
only to rule out potential causes of seizures -BMP --> for electrolytes -BG --> to see if its caused by hypoglycemia -tox screens: from urine or blood ; alcohol levels can be checked and drugs -for epilepsy: therapeutic levels for each individual med
open vs. closed angle glaucoma:
open: 1-30 mmHg, *chronic* closed: *acute*, sudden massive increase in intraoccular pressure
