POQ Unit 3 MS
A patient has a left temporal brain tumor. He smells an odor of ammonia prior to experiencing rapid rhythmic jerking movements. What is the odor of ammonia? a. The metastatic process of tumor growth b. The inhibition of serotonin and acetylcholine c. d. Chemical agent evoked by the tumor
An aura prior to the seizure activity
A patient is admitted to the intensive care unit with a subarachnoid bleed. Vital signs are: blood pressure 120/74 mm Hg, pulse 70 beats/min, and respirations 16 breaths/min. Several hours later, the patient has become belligerent, angry, threatening to the staff which is a change from his initial demeanor. Vital signs are now blood pressure (BP) 160/60 mm Hg, pulse 48 beats/min, and respirations 12 breaths/min. Most likely, what is going on with this patient?
Increasing intracranial pressure
A patient has been taking phenytoin (Dilantin) for a seizure disorder. He has recently run out of his medication and has not obtained a refill. What is the patient at risk for developing?
Status epilepticus
Mr. Marks, age 52, is being treated for Parkinson disease. You are aware that Parkinson disease results in muscle rigidity, tremor at rest, and postural instability. What occurs in the neurons that causes these symptoms?
There is an imbalance between dopamine and acetylcholine.
A client has just been diagnosed with a cerebral aneurysm. In planning discharge te aching for this client, what instructions should be delivered by the nurse to the client? a. Avoid heavy lifting. b. Avoid fiber in the diet. c. Take an antacid frequently. d. Take an herbal form of feverfew.
a
A client is being treated for increased intracranial pressure (ICP). The nurse should ensure that the client does not develop hypothermia because: a. shivering in hypothermia can increase ICP. b. hypothermia is indicative of severe meningitis. c. hypothermia is indicative of malaria. d. hypothermia can cause death to the client.
a
A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing: a. raccoon's eyes and Battle sign. b. nuchal rigidity and Kernig's sign. c. motor loss in the legs that exceeds that in the arms. d. pupillary changes.
a
A client who just experienced a suspected ischemic stroke is brought to the ED by ambulance. On what should the nurse's primary assessment focus? a. Cardiac and respiratory status b. Seizure activity c. Pain d. Fluid and electrolyte balance
a
A client with a new diagnosis of amyotrophic lateral sclerosis (ALS) is overwhelmed by his diagnosis and the known complications of the disease. How can the client best make known his wishes for care as his disease progresses? a. Prepare an advance directive. b. Designate a most responsible health care provider (MRP) early in the course of the disease. c. Collaborate with representatives from the Amyotrophic Lateral Sclerosis Association. d. Ensure that witnesses are present when he provides instruction.
a
A community health nurse is performing a home visit to a patient with amyotrophic lateral sclerosis (ALS). The nurse should prioritize assessments related to which of the following? a. Respiratory function b. Potential skin breakdown c. Cardiac function d. Cognition
a
A nurse and nursing student are caring for a client recovering from a lumbar puncture yesterday. The client reports a headache despite being on bedrest overnight. The physician plans an epidural blood patch this morning. The student asks how this will help the headache. The correct reply from the nurse is which of the following? a. "The blood will seal the hole in the dura and prevent further loss of cerebral spinal fluid." b. "The blood will replace the cerebral spinal fluid that has leaked out." c. "The blood can repair damage to the spinal cord that occurred with the procedure." d. "The blood provides moisture at the site, which encourages healing."
a
A nurse is assessing a client who has been in a motor vehicle collision. The client directly and accurately answers questions. The nurse notes a contusion to the client's forehead; the client reports a headache. Assessing the client's pupils, what reaction would confirm increasing intracranial pressure? a. unequal response b. equal response c. rapid response d. constricted response
a
A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following? a. Thrombolytic therapy has a time window of only 3 hours. b. A ruptured intracranial aneurysm must quickly be repaired. c. Intracranial pressure is increased by a space-occupying bleed. d. A ruptured arteriovenous malformation will cause deficits until it is stopped.
a
A patient admitted with a stroke is coming to the unit from the emergency department. The nurse assigned to care for the new patient knows that what assessment finding is indicative of a stroke? a. Difficulty speaking b. Increase in heart rate c. Facial edema d. Electrolyte imbalance
a
A patient is admitted to the hospital for management of an extrapyramidal disorder. Included in the physician's admitting orders are the medications levodopa, benztropine, and selegiline. The nurse knows that most likely, the client has a diagnosis of: a. Parkinson's disease. b. Huntington's disease. c. seizure disorder. d. multiple sclerosis
a
A patient presents in the emergency department with symptoms of a stroke. Which of the following is a thrombolytic medication that the physician might order to reverse the symptoms of the stroke? a. Tissue-type plasminogen activator b. Clopidogrel (Plavix) c. Warfarin (Coumadin) d. Heparin
a
A physician orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? a. Heparin sodium b. Dexamethasone (Decadron) c. Methyldopa (Aldomet) d. Phenytoin (Dilantin)
a
A typical spinal cord functions as a "highway" for sensory and descending motor neurons, providing conduction of impulses to and from the brain. The spinal cord is surrounded and protected by bony vertebrae, and ends between the: a. first and second lumbar vertebrae. b. first and second cervical vertebrae. c. first and second thoracic vertebrae. d. fourth and fifth thoracic vertebrae.
a
The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring? a. Increased ICP b. Exacerbation of uncontrolled hypertension c. Infection d. Increase in cerebral perfusion pressure
a
The school nurse notes a 6-year-old running across the playground with his friends. The child stops in midstride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child? a. An absence seizure b. A myoclonic seizure c. A partial seizure d. A tonic-clonic seizure
a
Which of the following, if left untreated, can lead to an ischemic stroke? a. Atrial fibrillation b. Cerebral aneurysm c. Arteriovenous malformation (AVM) d. Ruptured cerebral arteries
a
Which term describes the fibrous connective tissues that cover the brain and spinal cord? a. Meninges b. Dura mater c. Arachnoid mater d. Pia mater
a
You are assessing a patient who was prescribed levodopa 1 week ago. What would you assess for? a. Improvement in handwriting b. Drug-drug interactions with dopaminergic agents c. Stable mood d. Psoriasis
a
The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern? Select all that apply. a. Unequal pupils b. Pupil reaction quick c. Pinpoint pupils d. Absence of pupillary response e. Pupil reacts to light
acd
A client with meningitis has a history of seizures. Which should the nurse do to safely manage the client during a seizure? Select all that apply. a. Turn the client to the side. b. Physically restrain the client's movements. c. Inspect the oral cavity and teeth. d. Provide verbal reassurance.
ad
. While completing a health history on a client who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state? a. Epileptic cry b. Confusion c. Urinary incontinence d. Body rigidity
b
A 70-year-old woman is being treated at home for Parkinson's disease (PD), a health problem that she was diagnosed with 18 months ago. The nurse who is participating in the woman's care should be aware that her initial symptoms most likely consisted of: a. Increasing forgetfulness and confusion b. Tremors and muscle rigidity c. Visual disturbances and muscle weakness d. Fatigue and respiratory difficulties
b
A client experiences a seizure while hospitalized for appendicitis. During the postictal phase, the client is yelling and swings a closed fist at the nurse. Which is the appropriate action by the nurse? a. Place the client in wrist restraints. b. Reorient the client while gently holding their arms. c. Administer lorazepam per orders. d. Apply oxygen via nasal cannula.
b
A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis? a. Impaired physical mobility b. Ineffective breathing pattern c. Disturbed sensory perception (tactile) d. Dressing or grooming self-care deficit
b
A client scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the client for the MRI should prioritize what action? a. Withholding stimulants 24 to 48 hours prior to exam b. Removing all metal-containing objects c. Instructing the patient to void prior to the MRI d. Initiating an IV line for administration of contrast
b
A patient is transferred to a rehabilitation facility after a stroke. What is most likely the goal for rehabilitation? a. To cure any effects of the stroke b. To maximize remaining abilities c. To monitor neurological status d. To determine the extent of neurological deficits
b
A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom? a. Large artery thrombosis b. Cerebral aneurysm c. Cardiogenic emboli d. Small artery thrombosis
b
Which is the earliest sign of increasing intracranial pressure? a. Vomiting b. Change in level of consciousness c. Headache d. Posturing
b
A client diagnosed with Huntington's disease has developed severe depression. What would be most important for the nurse to assess for? a. Loss of bowel and bladder control b. Choreiform movements c. Suicidal ideations d. Emotional apathy
c
A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure? a. Jacksonian b. Absence c. Generalized d. Sensory
c
A client has tension headaches. The nurse recommends massage as a treatment for tension headaches. How does massage help clients with tension headaches? a. Reduces hypotension b. Increases appetite c. Relaxes muscles d. Relieves migraines
c
A client the nurse is caring for experiences a seizure. What would be a priority nursing action? a. Restrain the client during the seizure. b. Insert a tongue blade between the teeth. c. Protect the client from injury. d. Suction the mouth during the convulsion.
c
A client with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the client's cardiac and neurologic status, the nurse monitors the client for signs of what complication? a. Acute pain b. Septicemia c. Bleeding d. Seizures
c
A client with meningitis has a history of seizures. Which action by the nurse is appropriate while the client is actively seizing? a. Place a cooling blanket on the client b. Administer mannitol c. Turn the client to the side d. Insert oral airway
c
A patient diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose? a. To decrease cerebral edema b. To prevent seizure activity that is common following a TIA c. To prevent a stroke by removing atherosclerotic plaques blocking cerebral flow d. To determine the cause of the TIA
c
Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event? a. Seizure began at 1300 hours. b. The client cried out before the seizure began. c. Seizure was 1 minute in duration including tonic-clonic activity. d. Sleeping quietly after the seizure
c
A client is diagnosed with a brain tumor. As the nurse assists the client from the bed to a chair, the client begins having a generalized seizure. Which action should the nurse take first? a. Initiate the code team response. b. Put a padded tongue blade into the client's mouth and restrain his extremities. c. Record the type of seizure and the time that it occurred. d. Assist the client to the floor, in a side-lying position, and protect him with linens.
d
A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan? a. Disturbed sensory perception (visual) b. Dressing or grooming self-care deficit c. Impaired verbal communication d. Risk for injury
d
A nurse conducts the Romberg test on a client by asking the client to stand with the feet close together and the eyes closed. As a result of this posture, the client suddenly sways to one side and is about to fall when the nurse intervenes and saves the client from being injured. How should the nurse interpret the client's result? a. Positive Romberg test, indicating a problem with level of consciousness b. Negative Romberg test, indicating a problem with body mass c. Negative Romberg test, indicating a problem with vision d. Positive Romberg test, indicating a problem with equilibrium
d
Which topic is most important for the nurse to include in the teaching plan for a client newly diagnosed with Parkinson's disease? a. Involvement with diversion activities b. Enhancement of the immune system c. Establishing balanced nutrition d. Maintaining a safe environment
d
A patient is admitted with a fractured femur and possible head injury. Vital signs on admission were blood pressure (BP) 128/72 mmHg, pulse (P) 90/min, respirations (R) 16/min. Four hours after admission, the nurse is checking vital signs as part of her hourly assessment. Which of the following vital signs most likely indicate the presence of increased intracranial pressure?
BP 172/68, P 42, R 10
A client with a history of atrial fibrillation has experienced a TIA. In an effort to reduce the risk of cerebrovascular accident (CVA), the nurse anticipates the priority medical treatment to include which of the following? a. Cholesterol-lowering drugs b. Anticoagulant therapy c. Monthly prothrombin levels d. Carotid endarterectomy
b
A client is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this client's care, the nurse would expect to administer what priority medication? a. Hydrochlorothiazide b. Furosemide c. Mannitol d. Spirolactone
c
A client is experiencing dysphagia following a stroke. Which measure may be taken by the nurse to ensure that the client's diet allows for easy swallowing? a. Instruct the client to lie on the bed when eating. b. Offer liquids frequently and in large quantities. c. Help the client sit upright when eating and feed slowly. d. Allow optimum physical activity before meals to expedite digestion.
c
A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include honey thickened liquids. Which of the following is the priority nursing diagnosis for this client? a. Risk for Fluid Volume Deficit b. Risk for Electrolyte Imbalance c. Impaired Swallowing d. Altered Nutrition:Less Than Body Requirements
c
A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP? a. Encourage coughing and deep breathing. b. Position the client with the head turned toward the side of the brain tumor. c. Administer stool softeners. d. Provide sensory stimulation.
c
A physician orders aspirin, 325 mg P.O. daily for a client who has experienced a transient ischemic attack (TIA). The nurse should teach the client that the physician has ordered this medication to: a. control headache pain. b. enhance the immune response. c. prevent intracranial bleeding. d. reduce the chance of blood clot formation.
d
The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? a. High-Fowler's b. Prone c. Supine d. Semi-Fowler's
d
A nurse has been invited to speak to a support group for persons with movement disorders and their families. Which of the following statements by the nurse addresses the chronic nature of these diseases and the relevant drug therapies? a. "Drug therapy can consist of one or more drugs to eliminate the symptoms of these diseases." b."Drugs do not cure these disorders; they instead enhance quality of life." c. "Persons of all cultures are treated similarly and respond in similar ways to treatment." d. "Drugs used to treat these disorders always pose a risk of severe liver and kidney dysfunction."
B
You are bathing Ms. Jamison who is recovering from a stroke, and she suddenly begins to sob uncontrollably. Based on your knowledge of the stroke client, you realize that: a. mood swings and depression are very common with Neurologic problems b. she is probably having pain and cannot tell you c. she may be dissatisfied with your care d. she is probably embarrassed because she cannot care for herself
a
A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis? a. Risk for aspiration b. Risk for falls c. Risk for impaired skin integrity d. Decreased intracranial adaptive capacity
a
An osmotic diuretic, such as mannitol, is given to the patient with increased intracranial pressure (ICP) for which of the following actions? a. To dehydrate the brain and reduce cerebral edema b. To control fever c. To control shivering d. To reduce cellular metabolic demands
a
Thrombolytic therapy for the treatment of an ischemic stroke should be initiated within how many hours of the onset of symptoms to obtain the best functional outcome? a. 3 hours b. 6 hours c. 9 hours d. 12 hours
a
To meet the sensory needs of a client with viral meningitis, the nurse should: a. minimize exposure to bright lights and noise. b. promote an active range of motion. c. increase environmental stimuli. d. avoid physical contact between the client and family members.
a
What is the function of cerebrospinal fluid (CSF)? a. It cushions the brain and spinal cord. b. It acts as an insulator to maintain a constant spinal fluid temperature. c. It acts as a barrier to bacteria. d. It produces cerebral neurotransmitters.
a
A patient enters the emergency department with right-sided weakness and vision changes. All of the assessment findings listed below are reported to the ED physician. What assessment finding would be most important for determining the course of treatment for this patient? a. History of TIA 3 months ago b. Blood glucose 140 mg/dL c. Onset of symptoms occurred 60 minutes ago d. Blood pressure 148/92 mm Hg
c
A patient with Parkinson's disease is undergoing a swallowing assessment because she is experiencing difficulties when swallowing. What consistency is most appropriate for this patient, to reduce the risk of aspiration? a. Solid food with thin liquids b. Pureed food with water c. Semisolid food with thick liquids d. Thin liquids only
c
Which instructions should the nurse give a client who has been given a skeletal muscle relaxant for a herniated intervertebral disk? a. Avoid driving or operating equipment. b. Muscle relaxants are not known to cause drowsiness. c. Avoid physical exertion. d. Dizziness is an unexpected side effect.
a
On which understanding should a nurse base teaching of a patient who has experienced a TIA? a. A TIA is a medical emergency that requires immediate surgical intervention. b. A TIA is a forewarning that the patient is at risk for a cerebrovascular accident (stroke). c. A TIA is predictive that the patient will have a heart attack within 1 year. d. TIAs are not serious, and the patient should have no further problems.
b
The clinic nurse caring for a patient with Parkinson's disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. What common side effects of Sinemet would the nurse assess this patient for? a. Pruritus b. Dyskinesia c. Lactose intolerance d. Diarrhea
b
The nurse is assisting the physician in completing a lumbar puncture. Which would the nurse note as a concern? a. Physician maintains aseptic procedure. b. Cerebrospinal fluid is cloudy in nature. c. Client reports a piercing feeling. d. Client reports pressure relief in the head.
b
The nurse is caring for a client who is known to be at risk for cardiogenic embolic strokes. What dysrhythmia does this client most likely have? a. Ventricular tachycardia b. Atrial fibrillation c. Supraventricular tachycardia d. Bundle branch block
b
The nurse is caring for a client with dysphagia. Which intervention would be contraindicated while caring for this client? a. Assisting the client with meals b. Placing food on the affected side of the mouth c. Testing the gag reflex before offering food or fluids d. Allowing ample time to eat
b
The nurse is caring for a patient on the neurological unit who is in status epilepticus. What medication does the nurse anticipate being given to halt the seizure? a. IV phenobarbital b. IV diazepam c. IV lidocaine d. Oral phenytoin
b
Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura? a. Epidural b. Subdural c. Intracerebral d. Cerebral
b
A community health nurse is conducting a workshop for unlicensed care providers who work in a chain of long-term care facilities. The nurse is teaching the participants about the signs and symptoms of stroke. What signs and symptoms should the nurse identify? Select all that apply. a. Epistaxis (nosebleed) b. Confusion c. Sudden numbness d. Sudden ear pain
bce
A nurse is caring for a patient who has just been diagnosed with Parkinson disease. The patient does not understand how the medication ordered, carbidopa-levodopa, is going to help her condition. Which of the following is the correct response by the nurse? a. "This drug will change the immune processes in your body to help decrease the tissue damage." b. "Carbidopa-levodopa will delay the loss of muscle strength and limb function for several months." c. "Carbidopa-levodopa increases the activity of dopamine in your body, which will decrease your symptoms." d. "Your drug therapy will reduce excessive reflex activity causing your muscle spasms and will allow for muscle relaxation."
c
A client is scheduled for an EEG. The client asks about any diet-related prerequisites before the EEG. Which diet-related advice should the nurse provide to the client? a. Avoid eating food at least 8 hours before the test. b. Include an increased amount of minerals in the diet. c. Decrease the amount of minerals in the diet. d. Avoid taking sedative drugs or drinks that contain caffeine for at least 8 hours before the test.
d
Which of the following findings, based on the Cincinnati Prehospital Stroke Scale assessment tool, does NOT suggest a probability of an ischemic stroke? a. The patient sways when asked to stand still with eyes closed. b. The patient cannot repeat a stated phrase exactly as it was stated. c. The patient's right arm drifts downward when he holds both arms straight in front of him. d. The patient's face shows signs of symmetry when smiling.
d
A client was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first? a. Pupillary asymmetry b. Irregular breathing pattern c. Involuntary posturing d. Declining level of consciousness (LOC)
d
The school nurse has been called to the football field where player is immobile on the field after landing awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse perform? a. Ensure that the player is not moved. b. Obtain the player's vital signs, if possible. c. Perform a rapid assessment of the player's range of motion. d. Assess the player's reflexes.
a
Which term describes right-sided flaccidity (extreme weakness) in a patient who has had a on ischemic stroke on the left side of his brain? a. Contralateral hemiparesis b. Ipsilateral paraplegia c. Ipsilateral hemiparesis d. Contralateral quadriparesis
a
A clinic nurse is caring for a client diagnosed with migraine headaches. During the client teaching session, the client questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the client about the effects of alcohol? a. Alcohol causes hormone fluctuations. b. Alcohol causes vasodilation of the blood vessels. c. Alcohol has an excitatory effect on the CNS. d. Alcohol diminishes endorphins in the brain.
b
A fall during a rock climbing expedition this morning has caused a 28-year-old woman to develop an epidural hematoma. Immediate treatment is being organized by the emergency department team because this woman faces a risk of serious neurological damage as a result of: a. Decreased intravascular volume b. Increased intracranial pressure (ICP) c. Ischemic cerebrovascular accident (CVA) d. Brain tissue necrosis
b
A nurse is caring for a client diagnosed with a hemorrhagic stroke. When creating this client's plan of care, what goal should be prioritized? a. Prevent complications of immobility. b. Maintain and improve cerebral tissue perfusion. c. Relieve anxiety and pain. d. Relieve sensory deprivation.
b
The expected outcome for a patient taking levodopa as drug therapy for Parkinson's disease would be what? a. Decrease in sweating b. Decrease in rigidity c. Decrease in diarrhea d. Decrease in muscle twitching
b
The nurse is caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the potential complications of the disorder, what should the nurse keep always ready at the bedside? a. Nebulizer and thermometer b. Intubation tray and suction apparatus c. Blood pressure apparatus d. Incentive spirometer
b
The most important nursing priority of treatment for a patient with an altered LOC is to: a. Stabilize the blood pressure and heart rate to ensure adequate perfusion of the brain. b. Prevent dehydration and renal failure by inserting an IV line for fluids and medications. c. Maintain a clear airway to ensure adequate ventilation. d. Position the patient to prevent injury and ensure dignity.
c
What is the main purpose of the drugs used to treat Parkinson's disease? a. Substitute monoamine oxidase inhibitors for dopamine agonists b. Increase the actions of acetylcholine in the brain c. Make the COMT inhibitors work better d. Help adjust the balance of neurotransmitters
d
What safety actions does the nurse need to take for a client receiving oxygen therapy who is undergoing magnetic resonance imaging (MRI)? a. Securely fasten the client's portable oxygen tank to the bottom of the MRI table after the client has been positioned on the top of the MRI table b. Check the client's oxygen saturation level using a pulse oximeter after the client has been placed on the MRI table c. Note that no special safety actions need to be taken d. Ensure that no client care equipment containing metal enters the room where the MRI is located.
d
