nurs 220 exam #3

a 37 year old female is intoxicated and fractured her leg when you apply a splint she looks at you and withdraws her legs then Grunts in pain

8 (eye2 opens to pain, verbal 2 confused convo but able to answer questions, motor 4 obeys commands for movement)

A 24 year old female overdosed on an unknown substance. She is staring off into space, babbling, when you apply painful stimulus she cries out in comprehensibly but does not pull away

9 (eye2 reaction to pain, verbal 2 incomprehensible speech, motor 5 localizes)

A patient's mean arterial pressure is 82 and ICP is 15. What is the patient's cerebral perfusion pressure? A. 67 mmHg B. 100 mmHg C. 52 mmHg D. 30 mmHg

A The MAP is 82. When you calculate the equation: CPP= 82-15, you get 67 mmHg as the CPP.

The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? 1. An oral anticoagulant medication. 2. A beta blocker medication. 3. An anti-hyperuricemic medication. 4. A thrombolytic medication.

1

The client diagnosed with myasthenia gravis is being discharged home. Which intervention has priority when teaching the client's significant others? 1. Discuss ways to help prevent choking episodes. 2. Explain how to care for a client on a ventilator. 3. Teach how to perform passive range-of-motion exercises. 4. Demonstrate how to care for the client's feeding tube.

1

The client diagnosed with a gunshot wound to the head assumes decorticate posturing when the nurse applies painful stimuli. Which assessment data obtained three (3) hours later would indicate the client is improving? 1. Purposeless movement in response to painful stimuli. 2. Flaccid paralysis in all four extremities. 3. Decerebrate posturing when painful stimuli are applied. 4. Pupils that are 6 mm in size and nonreactive on painful stimuli.

1

The client diagnosed with a mild concussion is being discharged from the emergency department. Which discharge instruction should the nurse teach the client's significant other? 1. Awaken the client every two (2) hours. 2. Monitor for increased intracranial pressure. 3. Observe frequently for hypervigilance. 4. Offer the client food every three (3) to four (4) hours.

1

A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement? 1. Administer a stool softener b.i.d. 2. Encourage the client to cough hourly. 3. Monitor neurological status every shift. 4. Maintain the dopamine drip to keep BP at 160/90.

1

In assessing a client with a T12 SCI, which clinical manifestations would the nurse expect to find to support the diagnosis of spinal shock? 1. No reflex activity below the waist. 2. Inability to move upper extremities. 3. Complaints of a pounding headache. 4. Hypotension and bradycardia.

1

The charge nurse is making assignments. Which client should be assigned to the new graduate nurse? 1. The client diagnosed with aseptic meningitis who is complaining of a headache and the light bothering his eyes. 2. The client diagnosed with Parkinson's disease who fell during the night and is complaining of difficulty walking. 3. The client diagnosed with a cerebrovascular accident whose vitals signs are P 60, R 14, and BP 198/68. 4. The client diagnosed with a brain tumor who has a new complaint of seeing spots before the eyes.

1

The client diagnosed with Guillain-Barré syndrome asks the nurse, "Will I ever get back to normal? I am so tired of being sick." Which statement is the best response by the nurse? 1. "You should make a full recovery within a few months to a year." 2. "Most clients with this syndrome have some type of residual disability." 3. "This is something you should discuss with the health-care team." 4. "The rehabilitation is short and you should be fully recovered within a month."

1

The client diagnosed with Parkinson's disease is prescribed carbidopa/levodopa (Sinemet). Which intervention should the nurse implement prior to administering the medication? 1. Discuss how to prevent orthostatic hypotension. 2. Take the client's apical pulse for one (1) full minute. 3. Inform the client that this medication is for short-term use. 4. Tell the client to take the medication on an empty stomach.

1

The client diagnosed with septic meningitis is admitted to the medical floor at noon. Which health-care provider's order would have the highest priority? 1. Administer an intravenous antibiotic. 2. Obtain the client's lunch tray. 3. Provide a quiet, calm, and dark room. 4. Weigh the client in hospital attire.

1

The client is diagnosed with ALS. Which client problem would be most appropriate for this client? 1. Disuse syndrome. 2. Altered body image. 3. Fluid and electrolyte imbalance. 4. Alteration in pain.

1

The client is diagnosed with a closed head injury and is in a coma. The nurse writes the client problem as "high risk for immobility complications." Which intervention would be included in the plan of care? 1. Position the client with the head of the bed elevated at intervals. 2. Perform active range-of-motion exercises every four (4) hours. 3. Turn the client every shift and massage bony prominences. 4. Explain all procedures to the client before performing them.

1

The client is diagnosed with myasthenia gravis. Which intervention should the nurse implement when administering the anticholinesterase pyridostigmine (Mestinon)? 1. Administer the medication 30 minutes prior to meals. 2. Instruct the client to take with eight (8) ounces of water. 3. Explain the importance of sitting up for one (1) hour after taking medication. 4. Assess the client's blood pressure prior to administering medication.

1

The client is in the terminal stage of ALS. Which intervention should the nurse implement? 1. Perform passive ROM every two (2) hours. 2. Maintain a negative nitrogen balance. 3. Encourage a low-protein, soft-mechanical diet. 4. Turn the client and have him cough and deep breathe every shift.

1

The client is prescribed phenytoin (Dilantin), an anticonvulsant, for a seizure disorder. Which statement indicates the client understands the discharge teaching concerning this medication? 1. "I will brush my teeth after every meal." 2. "I will check my Dilantin level daily." 3. "My urine will turn orange while on Dilantin." 4. "I won't have any seizures while on this medication."

1

The client newly diagnosed with multiple sclerosis (MS) states, "I don't understand how I got multiple sclerosis. Is it genetic?" On which statement should the nurse base the response? 1. Genetics may play a role in susceptibility to MS, but the disease may be caused by a virus. 2. There is no evidence suggesting there is any chromosomal involvement in developing MS. 3. Multiple sclerosis is caused by a recessive gene, so both parents had to have the gene for the client to get MS. 4. Multiple sclerosis is caused by an autosomal dominant gene on the Y chromosome, so only fathers can pass it on.

1

The client with end-stage ALS requires a gastrostomy tube feeding. Which finding would require the nurse to hold a bolus tube feeding? 1. A residual of 125 mL. 2. The abdomen is soft. 3. Three episodes of diarrhea. 4. The potassium level is 3.4 mEq/L.

1

The client with myasthenia gravis is prescribed the cholinesterase inhibitor neostigmine (Prostigmin). Which data indicate the medication is effective? 1. The client is able to feed self independently. 2. The client is able to blink the eyes without tearing. 3. The client denies any nausea or vomiting when eating. 4. The client denies any pain when performing ROM exercises.

1

The client with myasthenia gravis is undergoing plasmapheresis at the bedside. Which assessment data warrant immediate intervention? 1. The client's BP is 94/60 and AP is 112. 2. Negative Chvostek's and Trousseau's signs. 3. The serum potassium level is 3.5 mEq/L. 4. Ecchymosis at the vascular site access.

1

The home health nurse is caring for a 28-year-old client with a T10 SCI who says, "I can't do anything. Why am I so worthless?" Which statement by the nurse would be the most therapeutic? 1. "This must be very hard for you. You're feeling worthless?" 2. "You shouldn't feel worthless—you are still alive." 3. "Why do you feel worthless? You still have the use of your arms." 4. "If you attended a work rehab program you wouldn't feel worthless."

1

The male client diagnosed with multiple sclerosis states he has been investigating alternative therapies to treat his disease. Which intervention is most appropriate by the nurse? 1. Encourage the therapy if it is not contraindicated by the medical regimen. 2. Tell the client only the health-care provider should discuss this with him. 3. Ask how his significant other feels about this deviation from the medical regimen. 4. Suggest the client research an investigational therapy instead.

1

The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical-surgical unit. Which task should not be assigned to the UAP? 1. Feed the 69-year-old client diagnosed with Parkinson's disease who is having difficulty swallowing. 2. Turn and position the 89-year-old client diagnosed with a pressure ulcer secondary to Parkinson's disease. 3. Assist the 54-year-old client diagnosed with Parkinson's disease with toilet-training activities. 4. Obtain vital signs on a 72-year-old client diagnosed with pneumonia secondary to Parkinson's disease.

1

The nurse asks the male client with epilepsy if he has auras with his seizures. The client says, "I don't know what you mean. What are auras?" Which statement by the nurse would be the best response? 1. "Some people have a warning that the seizure is about to start." 2. "Auras occur when you are physically and psychologically exhausted." 3. "You're concerned that you do not have auras before your seizures?" 4. "Auras usually cause you to be sleepy after you have a seizure."

1

The nurse enters the room as the client is beginning to have a tonic-clonic seizure. What action should the nurse implement first? 1. Note the first thing the client does in the seizure. 2. Assess the size of the client's pupils. 3. Determine if the client is incontinent of urine or stool. 4. Provide the client with privacy during the seizure.

1

The nurse is assessing the client diagnosed with meningococcal meningitis. Which assessment data would warrant notifying the HCP? 1. Purpuric lesions on the face. 2. Complaints of light hurting the eyes. 3. Dull, aching, frontal headache. 4. Not remembering the day of the week.

1

The nurse is caring for a client diagnosed with meningitis. Which collaborative intervention should be included in the plan of care? 1. Administer antibiotics. 2. Obtain a sputum culture. 3. Monitor the pulse oximeter. 4. Assess intake and output.

1

The nurse on the rehabilitation unit is caring for the following clients. Which client should the nurse assess first after receiving the change-of-shift report? 1. The client with a C6 SCI who is complaining of dyspnea and has crackles in the lungs. 2. The client with an L4 SCI who is crying and very upset about being discharged home. 3. The client with an L2 SCI who is complaining of a headache and feeling very hot. 4. The client with a T4 SCI who is unable to move the lower extremities.

1

The nurse writes the client problem of "altered sexual functioning" for a male client diagnosed with multiple sclerosis (MS). Which intervention should be implemented? 1. Encourage the couple to explore alternative ways of maintaining intimacy. 2. Make an appointment with a psychotherapist to counsel the couple. 3. Explain daily exercise will help increase libido and sexual arousal. 4. Discuss the importance of keeping physically calm during sexual intercourse.

1

The occupational health nurse is concerned about preventing occupation-related acquired seizures. Which intervention should the nurse implement? 1. Ensure that helmets are worn in appropriate areas. 2. Implement daily exercise programs for the staff. 3. Provide healthy foods in the cafeteria. 4. Encourage employees to wear safety glasses.

1

Which assessment intervention should the nurse implement specifically for the diagnosis of Guillain-Barré syndrome? 1. Assess deep tendon reflexes. 2. Complete a Glasgow Coma Scale. 3. Check for Babinski's reflex. 4. Take the client's vital signs.

1

Which client would the nurse identify as being most at risk for experiencing a CVA? 1. A 55-year-old African American male. 2. An 84-year-old Japanese female. 3. A 67-year-old Caucasian male. 4. A 39-year-old pregnant female.

1

Which discharge instruction should the nurse implement for the client newly diagnosed with myasthenia gravis (MG)? 1. Identify specific measures to help avoid fatigue and undue stress. 2. Instruct the client to pad bony prominences, especially the sacral area. 3. Discuss complementary therapies to help manage pain. 4. Explain the possibility of having a splenectomy to help control the symptoms.

1

Which statement by the female client diagnosed with myasthenia gravis indicates the client needs more discharge teaching? 1. "I will not have any menstrual cycles because of this disease." 2. "I should avoid people who have respiratory infections." 3. "I should not take a hot bath or swim in cold water." 4. "I will drink at least 2,500 mL of water a day."

1

The client is diagnosed with Huntington's chorea. Which interventions should the nurse implement with the family? Select all that apply. 1. Refer to the Huntington's Chorea Foundation. 2. Explain the need for the client to wear football padding. 3. Discuss how to cope with the client's messiness. 4. Provide three (3) meals a day and no between-meal snacks. 5. Teach the family how to perform chest percussion.

1, 2, 3

The nurse is preparing a client diagnosed with rule-out meningitis for a lumbar puncture. Which interventions should the nurse implement? Select all that apply. 1. Obtain an informed consent from the client or significant other. 2. Have the client empty the bladder prior to the procedure. 3. Place the client in a side-lying position with the back arched. 4. Instruct the client to breathe rapidly and deeply during the procedure. 5. Explain to the client what to expect during the procedure.

1, 2, 3, 5

The client diagnosed with myasthenia gravis is admitted with an acute exacerbation. Which interventions should the nurse implement? Select all that apply. 1. Assist the client to turn and cough every two (2) hours. 2. Place the client in a high or semi-Fowler's position. 3. Assess the client's pulse oximeter reading every shift. 4. Plan meals to promote medication effectiveness. 5. Monitor the client's serum anticholinesterase levels.

1, 2, 4

The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply. 1. Position the client to prevent shoulder adduction. 2. Turn and reposition the client every shift. 3. Encourage the client to move the affected side. 4. Perform quadriceps exercises three (3) times a day. 5. Instruct the client to hold the fingers in a fist.

1, 3

The client has been newly diagnosed with epilepsy. Which discharge instructions should be taught to the client? Select all that apply. 1. Keep a record of seizure activity. 2. Take tub baths only; do not take showers. 3. Avoid over-the-counter medications. 4. Have anticonvulsant medication serum levels checked regularly. 5. Do not drive alone; have someone in the car.

1, 3, 4

The client diagnosed with Guillain-Barré syndrome is admitted to the rehabilitation unit after 23 days in the acute care hospital. Which interventions should the nurse implement? Select all that apply. 1. Refer client to the physical therapist. 2. Include the speech therapist in the team. 3. Request a social worker consult. 4. Implement a regimen to address pain control. 5. Refer the client to the Guillain-Barré Syndrome Foundation.

1, 3, 4, 5

The nurse is admitting a client diagnosed with multiple sclerosis. Which clinical manifestation should the nurse assess? Select all that apply. 1. Muscle flaccidity. 2. Lethargy. 3. Dysmetria. 4. Fatigue. 5. Dysphagia.

1, 3, 4, 5

The nurse in the neurointensive care unit is caring for a client with a new C6 SCI who is breathing independently. Which nursing interventions should be implemented? Select all that apply. 1. Monitor the pulse oximetry reading. 2. Provide pureed foods six (6) times a day. 3. Encourage coughing and deep breathing. 4. Assess for autonomic dysreflexia. 5. Administer intravenous corticosteroids.

1, 3, 5

A 17 year old male overdosed on narcotics. He looks around with an unfocused gaze, mumbles when you ask him questions, and pulls away from painful stimulus. What is his glascoma scale

10 (eye3, speech 3 verbal, motor 4 withdraws)

A 21 year old male is extremely intoxicated . When you attempt to insert a nasal airway he slaps your hand away. Curses at you, and then set up. When you remove the air way he lies down on the stretcher what is his Glasgow Coma Scale

11 (eye opening 1 none, verbal 5 oriented motor, 5 purposeful movement to painful stimulus)

And 30 year old male was found on the sidewalk outside a homeless shelter when you applied painful stimuli he opens his eyes tells you to go away and then he pushes your hand away

12 (eye2, verbal5, motor5)

A 64 year old male looks at you when you speak to him when you ask him the date he says blue, he has left sided weakness when he grips your fingers

13 (eye4, verbal3, motor6)

An 85 year old male is in a nursing home and walking around his room and greet you when you answer. He speaks clearly but his answers are confusing and rambling

14 (eye4, verbal 4 confused, motor 6 obeys commands)

A 56 year old male rubs his abdomen and tells you it really hurts he tells you that he wants to go to the hospital and you help him walk to the stretcher what is his Glascow Coma Scale

15

A 6 year old male fell 6 feet from a tree. He is awake and has the ability to move all of his extremities. When you ask what happened he tells you that he sell and then begins to tell you about his pet dog

15 perfect

The 29-year-old client who was employed as a forklift operator sustains a traumatic brain injury secondary to a motor-vehicle accident. The client is being discharged from the rehabilitation unit after three (3) months and has cognitive deficits. Which goal would be most realistic for this client? 1. The client will return to work within six (6) months. 2. The client is able to focus and stay on task for 10 minutes. 3. The client will be able to dress self without assistance. 4. The client will regain bowel and bladder control.

2

The 34-year-old male client with an SCI is sharing with the nurse that he is worried about finding employment after being discharged from the rehabilitation unit. Which intervention should the nurse implement? 1. Refer the client to the American Spinal Cord Injury Association (ASIA). 2. Refer the client to the state rehabilitation commission. 3. Ask the social worker about applying for disability. 4. Suggest that the client talk with his significant other about this concern.

2

The client diagnosed with ALS asks the nurse, "I know this disease is going to kill me. What will happen to me in the end?" Which statement by the nurse would be most appropriate? 1. "You are afraid of how you will die?" 2. "Most people with ALS die of respiratory failure." 3. "Don't talk like that. You have to stay positive." 4. "ALS is not a killer. You can live a long life."

2

The client diagnosed with Guillain-Barré syndrome is on a ventilator. Which intervention will assist the client to communicate with the nursing staff? 1. Provide an erase slate board for the client to write on. 2. Instruct the client to blink once for "no" and twice for "yes." 3. Refer to a speech therapist to help with communication. 4. Leave the call light within easy reach of the client.

2

The client diagnosed with Parkinson's disease (PD) is being admitted with a fever and patchy infiltrates in the lung fields on the chest x-ray. Which clinical manifestations of PD would explain these assessment data? 1. Masklike facies and shuffling gait. 2. Difficulty swallowing and immobility. 3. Pill rolling of fingers and flat affect. 4. Lack of arm swing and bradykinesia.

2

The client diagnosed with a closed head injury is admitted to the rehabilitation department. Which medication order would the nurse question? 1. A subcutaneous anticoagulant. 2. An intravenous osmotic diuretic. 3. An oral anticonvulsant. 4. An oral proton pump inhibitor.

2

The client diagnosed with multiple sclerosis is having trouble maintaining balance. Which intervention should the nurse discuss with the client? 1. Discuss obtaining a motorized wheelchair for the client. 2. Teach the client to stand with the feet slightly apart. 3. Encourage the client to narrow his or her base of support. 4. Explain the need to balance activity with rest.

2

The client diagnosed with multiple sclerosis is scheduled for a magnetic resonance imaging (MRI) scan of the head. Which information should the nurse teach the client about the test? 1. The client will have wires attached to the scalp and lights will flash off and on. 2. The machine will be loud and the client must not move the head during the test. 3. The client will drink a contrast medium 30 minutes to one (1) hour before the test. 4. The test will be repeated at intervals during a five (5)- to six (6)-hour period.

2

The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care? 1. Potential for injury. 2. Powerlessness. 3. Disturbed thought processes. 4. Sexual dysfunction.

2

The client is diagnosed with meningococcal meningitis. Which preventive measure would the nurse expect the health-care provider to order for the significant others in the home? 1. The Haemophilus influenzae vaccine. 2. Antimicrobial chemoprophylaxis. 3. A 10-day dose pack of corticosteroids. 4. A gamma globulin injection.

2

The client with ALS is admitted to the medical unit with shortness of breath, dyspnea, and respiratory complications. Which intervention should the nurse implement first? 1. Elevate the head of the bed 30 degrees. 2. Administer oxygen via nasal cannula. 3. Assess the client's lung sounds. 4. Obtain a pulse oximeter reading.

2

The client with a cervical fracture is being discharged in a halo device. Which teaching instruction should the nurse discuss with the client? 1. Discuss how to correctly remove the insertion pins. 2. Instruct the client to report reddened or irritated skin areas. 3. Inform the client that the vest liner cannot be changed. 4. Encourage the client to remain in the recliner as much as possible.

2

The health-care provider scheduled a lumbar puncture for a client admitted with rule-out Guillain-Barré syndrome. Which preprocedure intervention has priority? 1. Keep the client NPO. 2. Instruct the client to void. 3. Place in the lithotomy position. 4. Assess the client's pedal pulse.

2

The nurse caring for the client diagnosed with Guillain-Barré syndrome writes the client problem "impaired physical mobility." Which long-term goal should be written for this problem? 1. The client will have no skin irritation. 2. The client will have no muscle atrophy. 3. The client will perform range-of-motion exercises. 4. The client will turn every two (2) hours while awake.

2

The nurse enters the room of a client diagnosed with acute exacerbation of multiple sclerosis and finds the client crying. Which statement is the most therapeutic response for the nurse to make? 1. "Why are you crying? The medication will help the disease." 2. "You seem upset. I will sit down and we can talk for awhile." 3. "Multiple sclerosis is a disease that has good times and bad times." 4. "I will have the chaplain come and stay with you for a while."

2

The nurse is assessing a client experiencing motor loss as a result of a left-sided cere- brovascular accident (CVA). Which clinical manifestations would the nurse document? 1. Hemiparesis of the client's left arm and apraxia. 2. Paralysis of the right side of the body and ataxia. 3. Homonymous hemianopsia and diplopia. 4. Impulsive behavior and hostility toward family.

2

The nurse is conducting a support group for clients diagnosed with Parkinson's disease and their significant others. Which information regarding psychosocial needs should be included in the discussion? 1. The client should discuss feelings about being placed on a ventilator. 2. The client may have rapid mood swings and become easily upset. 3. Pill-rolling tremors will become worse when the medication is wearing off. 4. The client may automatically start to repeat what another person says.

2

The nurse is developing a plan of care for a client diagnosed with aseptic meningitis secondary to a brain tumor. Which nursing goal would be most appropriate for the client problem "altered cerebral tissue perfusion"? 1. The client will be able to complete activities of daily living. 2. The client will be protected from injury if seizure activity occurs. 3. The client will be afebrile for 48 hours prior to discharge. 4. The client will have elastic tissue turgor with ready recoil.

2

The public health nurse is giving a lecture on potential outbreaks of infectious meningitis. Which population is most at risk for an outbreak? 1. Clients recently discharged from the hospital. 2. Residents of a college dormitory. 3. Individuals who visit a third world country. 4. Employees in a high-rise office building.

2

The rehabilitation nurse caring for the client with an L1 SCI is developing the nursing care plan. Which intervention should the nurse implement? 1. Keep oxygen via nasal cannula on at all times. 2. Administer low-dose subcutaneous anticoagulants. 3. Perform active lower extremity ROM exercises. 4. Refer to a speech therapist for ventilator-assisted speech.

2

The resident in a long-term care facility fell during the previous shift and has a lacer- ation in the occipital area that has been closed with Steri-Strips. Which signs/ symptoms would warrant transferring the resident to the emergency department? 1. A 4-cm area of bright red drainage on the dressing. 2. A weak pulse, shallow respirations, and cool pale skin. 3. Pupils that are equal, react to light, and accommodate. 4. Complaints of a headache that resolves with medication.

2

The unlicensed assistive personnel (UAP) is attempting to put an oral airway in the mouth of a client having a tonic-clonic seizure. Which action should the primary nurse take? 1. Help the UAP to insert the oral airway in the mouth. 2. Tell the UAP to stop trying to insert anything in the mouth. 3. Take no action because the UAP is handling the situation. 4. Notify the charge nurse of the situation immediately.

2

Which assessment data should the nurse expect to observe for the client diagnosed with Parkinson's disease? 1. Ascending paralysis and pain. 2. Masklike facies and pill rolling. 3. Diplopia and ptosis. 4. Dysphagia and dysarthria.

2

Which diagnostic test is used to confirm the diagnosis of ALS? 1. Electromyogram (EMG). 2. Muscle biopsy. 3. Serum creatine kinase (CK). 4. Pulmonary function test.

2

Which intervention should the nurse implement for the client diagnosed with systemic sclerosis (scleroderma)? 1. Instill artificial tears four (4) times a day. 2. Apply moisturizers to the skin frequently. 3. Instruct the client on how to apply braces. 4. Encourage the client to decrease smoking.

2

Which ocular or facial signs/symptoms should the nurse expect to assess for the client diagnosed with myasthenia gravis? 1. Weakness and fatigue. 2. Ptosis and diplopia. 3. Breathlessness and dyspnea. 4. Weight loss and dehydration.

2

Which statement best describes the scientific rationale for alternating a nonnarcotic antipyretic and a nonsteroidal anti-inflammatory drug (NSAID) every two (2) hours to a female client diagnosed with bacterial meningitis? 1. This regimen helps to decrease the purulent exudate surrounding the meninges. 2. These medications will decrease intracranial pressure and brain metabolism. 3. These medications will increase the client's memory and orientation. 4. This will help prevent a yeast infection secondary to antibiotic therapy.

2

Which statement by the client supports the diagnosis of Guillain-Barré syndrome? 1. "I just returned from a short trip to Japan." 2. "I had a really bad cold just a few weeks ago." 3. "I think one of the people I work with had this." 4. "I have been taking some herbs for more than a year."

2

The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply. 1. Maintain the head of the bed at 60 degrees of elevation. 2. Administer stool softeners daily. 3. Ensure that pulse oximeter reading is higher than 93%. 4. Perform deep nasal suction every two (2) hours. 5. Administer mild sedatives.

2, 3, 5

A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? 1. Prepare to administer recombinant tissue plasminogen activator (rt-PA). 2. Discuss the precipitating factors that caused the symptoms. 3. Schedule for a STAT computed tomography (CT) scan of the head. 4. Notify the speech pathologist for an emergency consult.

3

An 81 year old male is pulseless a nap nick is lying supine in bed with dried blood in his nose and ears

3

The 30-year-old female client is admitted with complaints of numbness, tingling, a crawling sensation affecting the extremities, and double vision which has occurred two (2) times in the month. Which question is most important for the nurse to ask the client? 1. "Have you experienced any difficulty with your menstrual cycle?" 2. "Have you noticed a rash across the bridge of your nose?" 3. "Do you get tired easily and sometimes have problems swallowing?" 4. "Are you taking birth control pills to prevent conception?"

3

The client diagnosed with Guillain-Barré syndrome is having difficulty breathing and is placed on a ventilator. Which situation warrants immediate intervention by the nurse? 1. The ventilator rate is set at 14 breaths per minute. 2. A manual resuscitation bag is at the client's bedside. 3. The client's pulse oximeter reading is 85%. 4. The ABG results are pH 7.40, PaO2 88, PaCO2 35, and HCO3 24.

3

The client diagnosed with PD is being discharged on carbidopa/levodopa (Sinemet), an antiparkinsonian drug. Which statement is the scientific rationale for combining these medications? 1. There will be fewer side effects with this combination than with carbidopa alone. 2. Dopamine D requires the presence of both of these medications to work. 3. Carbidopa makes more levodopa available to the brain. 4. Carbidopa crosses the blood-brain barrier to treat Parkinson's disease.

3

The client diagnosed with Parkinson's disease is being discharged. Which statement made by the significant other indicates an understanding of the discharge instructions? 1. "All of my spouse's emotions will slow down now just like his body movements." 2. "My spouse may experience hallucinations until the medication starts working." 3. "I will schedule appointments late in the morning after his morning bath." 4. "It is fine if we don't follow a strict medication schedule on weekends."

3

The client diagnosed with an acute exacerbation of multiple sclerosis is placed on high-dose intravenous injections of corticosteroid medication. Which nursing intervention should be implemented? 1. Discuss discontinuing the proton pump inhibitor with the HCP. 2. Hold the medication until after all cultures have been obtained. 3. Monitor the client's serum blood glucose levels frequently. 4. Provide supplemental dietary sodium with the client's meals.

3

The client has sustained a severe closed head injury and the neurosurgeon is deter- mining if the client is "brain dead." Which data support that the client is brain dead? 1. When the client's head is turned to the right, the eyes turn to the right. 2. The electroencephalogram (EEG) has identifiable waveforms. 3. There is no eye activity when the cold caloric test is performed. 4. The client assumes decorticate posturing when painful stimuli are applied.

3

The client is admitted to the intensive care department (ICD) experiencing status epilepticus. Which collaborative intervention should the nurse anticipate? 1. Assess the client's neurological status every hour. 2. Monitor the client's heart rhythm via telemetry. 3. Administer an anticonvulsant medication by intravenous push. 4. Prepare to administer a glucocorticosteroid orally.

3

The client is diagnosed with ALS. As the disease progresses, which intervention should the nurse implement? 1. Discuss the need to be placed in a long-term care facility. 2. Explain how to care for a sigmoid colostomy. 3. Assist the client to prepare an advance directive. 4. Teach the client how to use a motorized wheelchair.

3

The client is scheduled for an electroencephalogram (EEG) to help diagnose a seizure disorder. Which preprocedure teaching should the nurse implement? 1. Tell the client to take any routine antiseizure medication prior to the EEG. 2. Tell the client not to eat anything for eight (8) hours prior to the procedure. 3. Instruct the client to stay awake for 24 hours prior to the EEG. 4. Explain to the client that there will be some discomfort during the procedure.

3

The client who just had a three (3)-minute seizure has no apparent injuries and is oriented to name, place, and time but is very lethargic and just wants to sleep. Which intervention should the nurse implement? 1. Perform a complete neurological assessment. 2. Awaken the client every 30 minutes. 3. Turn the client to the side and allow the client to sleep. 4. Interview the client to find out what caused the seizure.

3

The client with a C6 SCI is admitted to the emergency department complaining of a severe pounding headache and has a BP of 180/110. Which intervention should the emergency department nurse implement? 1. Keep the client flat in bed. 2. Dim the lights in the room. 3. Assess for bladder distention. 4. Administer a narcotic analgesic.

3

The client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first? 1. Notify the health-care provider immediately. 2. Prepare to administer an antihistamine. 3. Test the drainage for presence of glucose. 4. Place 2 × 2 gauze under the nose to collect drainage.

3

The home health nurse is caring for the client newly diagnosed with multiple sclerosis. Which client issue is of most importance? 1. The client refuses to have a gastrostomy feeding. 2. The client wants to discuss if she should tell her fiancé. 3. The client tells the nurse life is not worth living anymore. 4. The client needs the flu and pneumonia vaccines.

3

The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? 1. The assistant places a gait belt around the client's waist prior to ambulating. 2. The assistant places the client on the back with the client's head to the side. 3. The assistant places a hand under the client's right axilla to move up in bed. 4. The assistant praises the client for attempting to perform ADLs independently.

3

The nurse arrives at the site of a one-car motor-vehicle accident and stops to render aid. The driver of the car is unconscious. After stabilizing the client's cervical spine, which action should the nurse take next? 1. Carefully remove the driver from the car. 2. Assess the client's pupils for reaction. 3. Assess the client's airway. 4. Attempt to wake the client up by shaking him.

3

The nurse educator is presenting an in-service on seizures. Which disease process is the leading cause of seizures in the elderly? 1. Alzheimer's disease. 2. Parkinson's disease. 3. Cerebral vascular accident (stroke). 4. Brain atrophy due to aging.

3

The nurse is assessing the client diagnosed with bacterial meningitis. Which clinical manifestations would support the diagnosis of bacterial meningitis? 1. Positive Babinski's sign and peripheral paresthesia. 2. Negative Chvostek's sign and facial tingling. 3. Positive Kernig's sign and nuchal rigidity. 4. Negative Trousseau's sign and nystagmus.

3

The nurse is caring for clients on a medical-surgical floor. Which client should be assessed first? 1. The 65-year-old client diagnosed with seizures who is complaining of a headache that is a "2" on a 1-to-10 scale. 2. The 24-year-old client diagnosed with a T10 spinal cord injury who cannot move his toes. 3. The 58-year-old client diagnosed with Parkinson's disease who is crying and worried about her facial appearance. 4. The 62-year-old client diagnosed with a cerebrovascular accident who has a resolving left hemiparesis.

3

The nurse is caring for the following clients on a medical unit. Which client should the nurse assess first? 1. The client with ALS who is refusing to turn every two (2) hours. 2. The client with abdominal pain who is complaining of nausea. 3. The client with pneumonia who has a pulse oximeter reading of 90%. 4. The client who is complaining about not receiving any pain medication.

3

The nurse is caring for the following clients. Which client would the nurse assess first after receiving the shift report? 1. The 22-year-old male client diagnosed with a concussion who is complaining someone is waking him up every two (2) hours. 2. The 36-year-old female client admitted with complaints of left-sided weakness who is scheduled for a magnetic resonance imaging (MRI) scan. 3. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale score of 6. 4. The 62-year-old client diagnosed with a cerebrovascular accident (CVA) who has expressive aphasia.

3

The son of a client diagnosed with ALS asks the nurse, "Is there any chance that I could get this disease?" Which statement by the nurse would be most appropriate? 1. "It must be scary to think you might get this disease." 2. "No, this disease is not genetic or contagious." 3. "ALS does have a genetic factor and runs in families." 4. "If you are exposed to the same virus, you may get the disease."

3

The wife of the client diagnosed with septic meningitis asks the nurse, "I am so scared. What is meningitis?" Which statement would be the most appropriate response by the nurse? 1. "There is bleeding into his brain causing irritation of the meninges." 2. "A virus has infected the brain and meninges, causing inflammation." 3. "This is a bacterial infection of the tissues that cover the brain and spinal cord." 4. "This is an inflammation of the brain parenchyma caused by a mosquito bite."

3

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? 1. A blood glucose level of 480 mg/dL. 2. A right-sided carotid bruit. 3. A blood pressure of 220/120 mm Hg. 4. The presence of bronchogenic carcinoma.

3

Which assessment data would make the nurse suspect that the client has amyotrophic lateral sclerosis? 1. History of a cold or gastrointestinal upset in the last month. 2. Complaints of double vision and drooping eyelids. 3. Fatigue, progressive muscle weakness, and twitching. 4. Loss of sensation below the level of the umbilicus.

3

Which intervention should the nurse take with the client recently diagnosed with amyotrophic lateral sclerosis (Lou Gehrig's disease)? 1. Discuss a percutaneous gastrostomy tube. 2. Explain how a fistula is accessed. 3. Provide an advance directive. 4. Refer to a physical therapist for leg braces.

3

Which is a common cognitive problem associated with Parkinson's disease? 1. Emotional lability. 2. Depression. 3. Memory deficits. 4. Paranoia.

3

Which nursing task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel? 1. Teach Credé's maneuver to the client needing to void. 2. Administer the tube feeding to the client who is quadriplegic. 3. Assist with bowel training by placing the client on the bedside commode. 4. Observe the client demonstrating self-catheterization technique.

3

Which statement by the female client indicates that the client understands factors that may precipitate seizure activity? 1. "It is all right for me to drink coffee for breakfast." 2. "My menstrual cycle will not affect my seizure disorder." 3. "I am going to take a class in stress management." 4. "I should wear dark glasses when I am out in the sun."

3

Which surgical procedure should the nurse anticipate the client with myasthenia gravis undergoing to help prevent the signs/symptoms of the disease process? 1. There is no surgical option. 2. A transsphenoidal hypophysectomy. 3. A thymectomy. 4. An adrenalectomy.

3

The client is diagnosed with an SCI and is scheduled for a magnetic resonance imaging (MRI) scan. Which question would be most appropriate for the nurse to ask prior to taking the client to the diagnostic test? 1. "Do you have trouble hearing?" 2. "Are you allergic to any type of dairy products?" 3. "Have you eaten anything in the last eight (8) hours?" 4. "Are you uncomfortable in closed spaces?"

4

The 29-year-old client is admitted to the medical floor diagnosed with meningitis. Which assessment by the nurse has priority? 1. Assess lung sounds. 2. Assess the six cardinal fields of gaze. 3. Assess apical pulse. 4. Assess level of consciousness.

4

The 45-year-old client is diagnosed with primary progressive multiple sclerosis and the nurse writes the nursing diagnosis "anticipatory grieving related to progressive loss." Which intervention should be implemented? 1. Consult the physical therapist for assistive devices for mobility. 2. Determine if the client has a legal power of attorney. 3. Ask if the client would like to talk to the hospital chaplain. 4. Discuss the client's wishes regarding end-of-life care.

4

The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first? 1. Administer a nonnarcotic analgesic. 2. Prepare for STAT magnetic resonance imaging (MRI). 3. Start an intravenous infusion with D5W at 100 mL/hr. 4. Complete a neurological assessment.

4

The client admitted with rule-out Guillain-Barré syndrome has just had a lumbar puncture. Which intervention should the nurse implement postprocedure? 1. Monitor the client for hypotension. 2. Apply pressure to the puncture site. 3. Test the client's cerebrospinal fluid. 4. Increase the client's fluid intake.

4

The client diagnosed with ALS is prescribed an antiglutamate, riluzole (Rilutek). Which instruction should the nurse discuss with the client? 1. Take the medication with food. 2. Do not eat green, leafy vegetables. 3. Use SPF 30 when going out in the sun. 4. Report any febrile illness.

4

The client diagnosed with Guillain-Barré syndrome is on a ventilator. When the wife comes to visit she starts crying uncontrollably, and the client starts fighting the ventilator because his wife is upset. Which action should the nurse implement? 1. Tell the wife she must stop crying. 2. Escort the wife out of the room. 3. Medicate the client immediately. 4. Acknowledge the wife's fears.

4

The client diagnosed with myasthenia gravis is admitted to the emergency department with a sudden exacerbation of motor weakness. Which assessment data indicate the client is experiencing a cholinergic crisis? 1. The serum assay of circulating acetylcholine receptor antibodies is increased. 2. The client's symptoms improve when administering a cholinesterase inhibitor. 3. The client's blood pressure, pulse, and respirations improve after IV fluid. 4. The Tensilon test does not show improvement in the client's muscle strength.

4

The client has been diagnosed with a cerebrovascular accident (stroke). The client's wife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge? 1. Obtain a rubber mat to place under the dinner plate. 2. Purchase a long-handled bath sponge for showering. 3. Purchase clothes with Velcro closure devices. 4. Obtain a raised toilet seat for the client's bathroom.

4

The client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority? 1. Assess neurological status. 2. Monitor pulse, respiration, and blood pressure. 3. Initiate an intravenous access. 4. Maintain an adequate airway.

4

The client is being evaluated to rule out ALS. Which signs/symptoms would the nurse note to confirm the diagnosis? 1. Muscle atrophy and flaccidity. 2. Fatigue and malnutrition. 3. Slurred speech and dysphagia. 4. Weakness and paralysis.

4

The client is being evaluated to rule out myasthenia gravis and being administered the Tensilon (edrophonium chloride) test. Which response to the test indicates the client has myasthenia gravis? 1. The client has no apparent change in the assessment data. 2. There is increased amplitude of electrical stimulation in the muscle. 3. The circulating acetylcholine receptor antibodies are decreased. 4. The client shows a marked improvement of muscle strength.

4

Which type of precautions should the nurse implement for the client diagnosed with septic meningitis? 1. Standard Precautions. 2. Airborne Precautions. 3. Contact Precautions. 4. Droplet Precautions.

4

The client with multiple sclerosis is prescribed the muscle relaxant baclofen (Lioresal). Which statement by the client indicates the client needs more teaching? 1. "This medication may cause drowsiness so I need to be careful." 2. "I should not drink any type of alcohol or take any antihistamines." 3. "I will increase the fiber in my diet and increase fluid intake." 4. "I stopped taking the medication because I can't afford it."

4

The intensive care nurse is caring for a client with a T1 SCI. When the nurse elevates the head of the bed 30 degrees, the client complains of lightheadedness and dizziness. The client's vital signs are T 99.2 ̊F, P 98, R 24, and BP 84/40. Which action should the nurse implement? 1. Notify the health-care provider ASAP. 2. Calm the client down by talking therapeutically. 3. Increase the IV rate by 50 mL/hour. 4. Lower the head of the bed immediately.

4

The male client is sitting in the chair and his entire body is rigid with his arms and legs contracting and relaxing. The client is not aware of what is going on and is making guttural sounds. Which action should the nurse implement first? 1. Push aside any furniture. 2. Place the client on his side. 3. Assess the client's vital signs. 4. Ease the client to the floor.

4

The nurse and a licensed practical nurse (LPN) are caring for a group of clients. Which nursing task should not be assigned to the LPN? 1. Administer a skeletal muscle relaxant to a client diagnosed with low back pain. 2. Discuss bowel regimen medications with the HCP for the client on strict bedrest. 3. Draw morning blood work on the client diagnosed with bacterial meningitis. 4. Teach self-catheterization to the client diagnosed with multiple sclerosis.

4

The nurse caring for a client diagnosed with Parkinson's disease writes a problem of "impaired nutrition." Which nursing intervention would be included in the planof care? 1. Consult the occupational therapist for adaptive appliances for eating. 2. Request a low-fat, low-sodium diet from the dietary department. 3. Provide three (3) meals per day that include nuts and whole-grain breads. 4. Offer six (6) meals per day with a soft consistency.

4

The nurse is admitting a client with the diagnosis of Parkinson's disease. Which assessment data support this diagnosis? 1. Crackles in the upper lung fields and jugular vein distention. 2. Muscle weakness in the upper extremities and ptosis. 3. Exaggerated arm swinging and scanning speech. 4. Masklike facies and a shuffling gait.

4

The nurse is assessing a 48-year-old client diagnosed with multiple sclerosis. Which clinical manifestation warrants immediate intervention? 1. The client has scanning speech and diplopia. 2. The client has dysarthria and scotomas. 3. The client has muscle weakness and spasticity. 4. The client has a congested cough and dysphagia.

4

The nurse is discussing psychosocial implications of Huntington's chorea with the adult child of a client diagnosed with the disease. Which psychosocial intervention should the nurse implement? 1. Refer the child for genetic counseling as soon as possible. 2. Teach the child to use a warming tray under the food during meals. 3. Discuss the importance of not abandoning the parent. 4. Allow the child to talk about the fear of getting the disease.

4

The nurse is enjoying a day at the lake and witnesses a water skier hit the boat ramp. The water skier is in the water not responding to verbal stimuli. The nurse is the first health-care provider to respond to the accident. Which intervention should be implemented first? 1. Assess the client's level of consciousness. 2. Organize onlookers to remove the client from the lake. 3. Perform a head-to-toe assessment to determine injuries. 4. Stabilize the client's cervical spine.

4

The nurse is planning care for a client experiencing agnosia secondary to a cerebrovas- cular accident. Which collaborative intervention will be included in the plan of care? 1. Observe the client swallowing for possible aspiration. 2. Position the client in a semi-Fowler's position when sleeping. 3. Place a suction setup at the client's bedside during meals. 4. Refer the client to an occupational therapist for evaluation.

4

The nurse is planning the care for a client diagnosed with Parkinson's disease. Which would be a therapeutic goal of treatment for the disease process? 1. The client will experience periods of akinesia throughout the day. 2. The client will take the prescribed medications correctly. 3. The client will be able to enjoy a family outing with the spouse. 4. The client will be able to carry out activities of daily living.

4

The nurse researcher is working with clients diagnosed with Parkinson's disease. Which is an example of an experimental therapy? 1. Sterotactic pallidotomy/thalamotomy. 2. Dopamine receptor agonist medication. 3. Physical therapy for muscle strengthening. 4. Fetal tissue transplantation.

4

The wife of a client diagnosed with myasthenia gravis is crying and shares with the nurse she just doesn't know what to do. Which response is the best action by the nurse? 1. Discuss the Myasthenia Foundation with the client's wife. 2. Refer the client to a local myasthenia gravis support group. 3. Ask the client's wife if she would like to talk to a counselor. 4. Sit down and allow the wife to ventilate her feelings to the nurse.

4

Which assessment data should the nurse assess in the client diagnosed with Guillain-Barré syndrome? 1. An exaggerated startle reflex and memory changes. 2. Cogwheel rigidity and inability to initiate voluntary movement. 3. Sudden severe unilateral facial pain and inability to chew. 4. Progressive ascending paralysis of the lower extremities and numbness.

4

Which collaborative health-care team member should the nurse refer the client to in the late stages of myasthenia gravis? 1. Occupational therapist. 2. Recreational therapist. 3. Vocational therapist. 4. Speech therapist.

4

Which priority client problem should be included in the care plan for the client diagnosed with Guillain-Barré syndrome? 1. High risk for injury. 2. Fear and anxiety. 3. Altered nutrition. 4. Ineffective breathing pattern.

4

Which sign/symptom should the nurse expect to assess in the client who is in the recovery stage of Guillain-Barré syndrome? 1. Decreasing deep tendon reflexes. 2. Drooping of the eyelids has resolved. 3. A positive Babinski's reflex. 4. Descending increase in muscle strength.

4

A 20 year old female sell 20 feet while rock climbing when you apply a sternal rub she extends her arms and legs and butt shows no other response

4 (eye1, verbal1, motor2)

A 28 year old female with a closed head injury moans and bends her arms towards her chest. She points her toes when you attempt to splint a extremity fracture. What is her gcs

6 (eye1, verbal 2 incomprehensible speech, motor 3 abnormal flexion decorticate posture)

A 44 year old female fell off a roof. She answers your commands within comprehensible sounds. When you pinch her trapezoid her eyes do not open but she moves her legs what is her Glasgow Coma Scale

7(eye1 no response, verbal 2 incomprehensible sounds, motor 4 withdraws from pain but not purposefully)

Benzodiazepines are indicated in the treatment of cases of delirium that have which cause

Alcohol withdrawal

Which patient may face the greatest risk of developing delirium

An older patient who takes multiple medications to treat various health problems

A patient's blood pressure is 152/96 and ICP is 20. What is the patient's cerebral perfusion pressure? A. 115 mmHg B. 20 mmHg C. 95 mmHg D. 56 mmHg

C The MAP is 115. When you calculate the equation: CPP= 115-20, you get 95 mmHg as the CPP.

A patient's blood pressure 92/56 and ICP 6. What is the patient's cerebral perfusion pressure and how do you interpret this finding? A. 82 mmHg, normal B. 56 mmHg, low C. 62 mmHg, normal D. 108 mmHg, high

C The MAP is 68. When you calculate the equation: CPP=68-6, you get 62 mmHg as the CPP. Remember a normal CPP is 60-100 mmHg.

A patient's blood pressure is 110/74 and ICP is 8. What is the patient's cerebral perfusion pressure? A. 94 mmHg B. 56 mmHg C. 98 mmHg D. 78 mmHg

D The MAP is 86. When you calculate the equation: CPP= 86-8, you get 78 mmHg as the CPP.

Which nursing intervention is most appropriate when caring for patients with dementia

Give simple directions focusing on one thing at a time

Which statement by the wife of a patient with Alzheimer's disease demonstrates an accurate understanding of her husband's medication regimen?

I'm really hoping this medication will slow down his mental losses

When providing community healthcare teaching regarding the early warning signs of Alzheimer's disease which signs should the nurse advise family members to report (select all that apply)

Losing sense of time difficulty performing familiar tasks problems with performing basic calculations becoming lost in usual familiar environment

The nurse who administered a dose of risperidone to a patient with delirium should assess for what intended effect of the medication

Lying quietly in bed

A patient's blood pressure is 80/42 and ICP 22. What is the patient's cerebral perfusion pressure and how do you interpret this finding? A. 33 mmHg, low B. 30 mmHg, normal C. 48 mmHg, low D. 64 mmHg, normal

The MAP is 55. When you calculate the equation: CPP=55-22, you get 33 mmHg as the CPP. Remember a normal CPP is 60-100 mmHg.