reviewer
The following are the signs and symptoms of Parkinson's disease EXCEPT: * Intention tremors Drooling Aspiration Akinesia
Intention tremors
Nurse Joey has given a client with a leg cast instructions on a cast care at home. The nurse would evaluate that the client needs further instructions if the client makes which of the following statements? a) "I should avoid walking on wet, slippery floors." b) "I'm not supposed to scratch the skin underneath the cast." c) "It's ok to wipe dirt off the top of the cast with damp cloth." d) "If the cast gets wet, I can dry it within a hair dryer turned to the warmest setting."
"If the cast gets wet, I can dry it within a hair dryer turned to the warmest setting."
A client has fallen and sustained a leg injury. Which question would Nurse Nick ask the client to help determine if the injury caused a fracture? a) "Does discomfort fell like a cramp?" b) "Does the pain feel like the muscle was stretched?" c) "Is the pain a dull ache?" d) "Is the pain sharp and continuous?"
"Is the pain sharp and continuous?"
A client with osteoarthritis tells Nurse Eliang that she is concerning on the disease which will prevent her from doing her chores. Which suggestion should the nurse offer? a) "Do all your chores in the morning, when pain and stiffness are least pronounce." b) "Do all your chores after performing morning exercises to loosen up." c) "Pace yourself and rest frequently, especially after activities." d) "Do all your chores in the evening, when pain and stiffness are least pronounce."
"Pace yourself and rest frequently, especially after activities."
If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse would anticipate that the client has problems with: a. body temperature control. b. balance and equilibrium. c. visual acuity. d. thinking and reasoning
. body temperature control.
The nurse recognizes the presence of Cushing's triad in the patient with a. Increased pulse, irregular respiration, increased BP b. Decreased pulse, irregular respiration, increased pulse pressure c. Increased pulse, decreased respiration, increased pulse pressure d. Decreased pulse, increased respiration, decreased systolic BP
. Decreased pulse, irregular respiration, increased pulse pressure
A client with Parkinson's disease has begun therapy with Levodopa. The nurse determines that the client understands the action of the medication if he verbalizes that results may be apparent for: * 24 hours 1 week 1 5 to 7 days 2 to 3 weeks
2 to 3 weeks
A nurse assesses the patient's level of consciousness using the GlasgowComa Scale. Which score indicates severe impairment of neurologicfunctions? 6 12 9 3
3
A client with Myasthenia gravis reports the occurrence of difficulty chewing. The doctor prescribes pyridostigmine (Mestinon) to increase muscle strength for this activity. The nurse instructs the client to take the medication at what time in relation to meal * 1 hour ac 30 minutes ac 2 hours ac 30 minutes pc
30 minutes ac
The symptom of dizziness and vertigo are both subjective experiences.Which of the following is the most accurate description of the experienceof vertigo? A feeling that the environment is in motion Narrowed vision preceding fainting Light-headedness An episode of blackout
A feeling that the environment is in motion
The brain center responsible for balancing and coordination is: Cerebrum Midbrain Cerebellum Medulla oblongata
Cerebellum
The client reports that he has noticed progressively worsening hearingproblems over the last 5 years. Which one fo the following symptoms isnot a characteristic of sensorineural hearing loss? Ability to hear better in a noisy environment Inability to distinguish and understand speech Speaking more loudly than normal Greater loss of ability to hear highpitched sounds
Ability to hear better in a noisy environment
Parasympathetic impulses are mediated by the secretions of: Norepinephrine Epinephrine Acetylcholine All are correct.
Acetylcholine
Which of the following terms means inability to recognize objects througha particular sensory system? Agnosia Aphasia Ataxia Dementia
Agnosia
Mr. James is diagnosed with Parkinson's disease. The symptoms are caused by: * Congenital abnormalities in neonatal transmission in the brain An imbalance in dopamine and acetylcholine An imbalance in glucose and adenosine triphosphate levels Cerebral anoxia
An imbalance in dopamine and acetylcholine
What should patients who have seizure disorder be taught regarding theuse of seizure medications? Anti-epileptic medications should never be discontinued abruptly Pregnant women should reduce the dose of medication they are taking All anti-epileptic medications should be taken with food Children can build up a tolerance to the medication quickly
Anti-epileptic medications should never be discontinued abruptly
A client is treated in a physician's office for a sprained ankle after a fall. Radiographic examination has ruled out a fracture. Before sending the client home, the nurse plans to teach the client to avoid which of the following in the next 24 hours?cx a) Resting the foot. b) Applying the heating pad. c) Applying an elastic compression bandage. d) Elevating the ankle on a small pillow while sitting or lying down.
Applying the heating pad.
A child has just returned from surgery and has a hip spic cast. A priority nursing action at this time is to: a) Elevate the head of the bed. b) Abduct the hips using pillows. c) Assess circulatory status. d) Turn the child on the right side.
Assess circulatory status.
The client is for EEG this morning. Which of the following is not includedwhen preparing clienrt for the procedure? Render hair shampoo Instruct client to remain still during the procedure Exclude caffeine from his meal 5 respondents 10 Assess for claustrophpbia
Assess for claustrophpbia
What neuroglia is responsible for the maintenance of blood brain barrier? Oligodendrocytes Ependymal Astrocytes Microglia
Astrocytes
Which symptoms are often the presenting complaint from patients with MS? * Hyperactive reflexes Depression and sadness Heat intolerance Ataxia and paresthesia
Ataxia and paresthesia
Which of the following positions are employed to help reduce increasedintracranial pressure? Rotate the neck to the far right with neck support Avoid flexion of the neck with use of a cervical collar Place flat on bed without pillows Extreme hip flexion with pillow support
Avoid flexion of the neck with use of a cervical collar
Which of the following medications may be used to decrease spasticity in multiple sclerosis? * Lidocaine (Xylocaine) Hydrocortisone (Solucortef) Hydralazine (Apresoline) Baclofen (Lioresal)
Baclofen (Lioresal)
The Romberg test is used to assess: Muscle tone Muscle strength Biceps reflex Balance and coordination
Balance and coordination
A client is ambulatory and wearing a halo vest after cervical spine fracture. Nurse Nick tells the client to avoid which of the following because the client has a risk for injury? a) Bending at the waist b) Using a walker c) Wearing a rubber-soled shoes d) Scanning the environment
Bending at the waist
The nurse administers neostigmine to Mrs. Abelardo. The drug is prescribed to: * Increase synthesis of deficient neurotransmitters Block the action of cholinesterase Increase transmission of impulses to nerves Replace neurotransmitters
Block the action of cholinesterase
A client with a cataract would most likely complain of which symptoms? Blurred and hazy vision Eyestrain and headache when doing close work Eye pain and irritation that worsens at night Halos and rainbows around lights
Blurred and hazy vision
Nurse Nick is caring for an elderly female osteoporosis. When teaching the client, the nurse should include information about which major complication? a) Bone fracture b) Loss of estrogen c) Negative calcium balance d) Dowager's hump
Bone fracture
MS is an immune response against the component of the myelin sheath. There is progressive demyelination of the white matter of the brain, spinal cord, and optic nerve. The following are the signs and symptoms of multiple sclerosis EXCEPT: * Nystagmus Intention tremors Bradykinesia Scanning speech
Bradykinesia
A client newly diagnosed with epilepsy is being discharged from thehospital with a prescription of phenytoin (Dilantin). The nurse shouldadvise the client to: Brush teeth and gums and floss regularly Have BP checked monthly Take medication with a full glass of water Check stool color with each bowel movement
Brush teeth and gums and floss regularly
Nurse Nick is caring for a client being treated for fat embolus after multiple fractures. Which of the following data would the nurse evaluate as the most favorable indication of resolution of the fat embolus? a) Minimal dyspnea b) Clear chest radiograph c) Oxygen saturation of 85% d) Arterial oxygen level of 78 mmHg
Clear chest radiograph
A blow to the head has caused Julie to lose her balance. Which cranialnerve and what branch of that nerve are probably involved? CN 11, external CN 11, internal CN 8, vestibute CN 8, cochlea
CN 8, vestibute
A nurse is receiving a client from the ED with a diagnosis of GBS. The client's chief complaint is an ascending paralysis that has reached the level of the waist. The nurse plans to have which of the following items available for emergency use? * Nebulizer and pulse oximeter Cardiac monitor and intubation tray Flashlight with incentive spirometer BP cuff and flashlight
Cardiac monitor and intubation tray
.What is the purpose of the dendrite? Provides gap in peripheral nerve axons Carries impulses to the nerve cell body Carries impulses from the nerve cell body Helps to repair damage to peripheral axons
Carries impulses to the nerve cell body
The Babinski response is used to assess: Coordination Optical nerve damage Central nervous system disease Muscle strength
Central nervous system disease
The nurse is performing a mental status examination (MSE) on a maleclient diagnose with subdural hematoma. This test assesses which of thefollowing? Cerebral function Cerebellar function Sensory function Cognitive function
Cerebral function
What is the protective fluid of the central nervous system (CNS)? Limbic system Cerebrospinal fluid (CSF) Synaptic cleft Myelin sheath
Cerebrospinal fluid (CSF)
of the following should the nurse include in the plan of care of the client diagnosed with GBS? * Check ability to hear Check deep tendon reflex q shift Check bladder distention Check BP q 2H
Check bladder distention
The client with Myasthenia gravis is vomiting and complaining of abdominal cramps and diarrhea. The nurse also noted that the client is hypotensive and is experiencing facial muscle twitching. The nurse interprets these symptoms as: * Myasthenic crisis Systemic infection Systemic reaction to plasmapheresis Cholinergic crisis
Cholinergic crisis
Patient preparation for electroencephalography includes omitting for 24hours before the test, all of the following EXCEPT: Solid foods Stimulants Tranquilizers Coffee and tea
Coffee and tea
Which manifestation by a patient with GBS should the nurse report to the physician at once? * Muscle pain in the shoulder and thighs Urinary output of 50 mL during the last 2 hours last 2 hours Tingling sensation in the arms and hands Confusion and drowsiness
Confusion and drowsiness
Which of the following would be a priority goal for a client who hasundergone surgery for retinal detachment? Control pain Maintain normothermia Increase intraocular pressure Promote a low sodium diet
Control pain
A nurse while malling notices a group of people gathered around aperson lying on the floor having a seizure. The best immediate responsewould be to: Cradle the person's head in your lap Move the person to a place of safety Hold the person's arm down Place something in the patients mouth
Cradle the person's head in your lap
The most severe neurologic impairments are evidenced by the abnormalbody posturing defined as Decorticate Flaccid Rigid Decerebrate
Decerebrate
Mr. James, 65 year old and retired assembly line worker, is admitted to the hospital with a diagnosis of Parkinson's disease. Which of the following best describes Parkinson's disease? * An autoimmune response that destroys acetylcholine Loss of myelin sheath surrounding peripheral nerves A bleeding in the brainstem Degeneration of the substantia nigra
Degeneration of the substantia nigra
A nurse is caring for an older client who had a hip pinning following a fracture. In planning care, Nurse Nick avoids which of the following to minimize the chance for further injury? a) Side rails in the "up" position. b) Use of the nightlight in hospital room and bathroom. c) Call bell placed within the client's reach. d) Delays in responding to the call light but telling the client via the intercom system that someone will attend to his or her needs.
Delays in responding to the call light but telling the client via the intercom system that someone will attend to his or her needs.
A female client with brain tumor is scheduled for CT scan. What shouldthe nurse do when preparing for this test? Determine whether the client is allergic to iodine, contrast dye or shellfish Place a cap on the client's head 1 respondent 2 Immobilize neck before the client is moved into the stretcher Administer a sedative as ordered
Determine whether the client is allergic to iodine, contrast dye or shellfish
To decrease the risk of compartment syndrome, the client should be instructed to: a) Elevate his arm. b) Wriggle his fingers frequently. c) Take a mild analgesic. d) Take frequent deep breaths.
Elevate his arm.
Which test is most reliable in the confirmation of myasthenia gravis? * Stress test Glucose tolerance test Edrophonium (Tensilon) test Sweat Chloride test
Edrophonium (Tensilon) test
Which of the following tests furnishes the best diagnostic informationabout seizures? Cerebral angiogram Electroencephalogram Cerebral tomography Pneumoencephalogram
Electroencephalogram
A client age 20 is having a synthetic fiberglass cast placed on his arm for a fractured radius. 10 minutes after the cast is placed on his arm, he complains for a heat sensation under the cast. Nurse Joey should: a) Perform a neurovascular assessment of his fingers to make sure the cast is not too tight. b) Suspect an allergic reaction to the cast material and alert the doctor immediately. c) Explain that this is a normal thermal reaction that occurs while a synthetic cast is drying. d) Apply ice immediately because the water used to moisten the cast was too hot.
Explain that this is a normal thermal reaction that occurs while a synthetic cast is drying.
A client is demonstrating decerebrate posturing in response to pressurein the trapezius muscle. Decerebrate posturing is exhibited by: Extension of lower and flexion of upper extremities Flexion of upper and extension of lower extremities Flexion of lower and upper extremities Extension of upper and lower extremities
Extension of upper and lower extremities
Bruce has lost the ability to detect tastes on the tip of his tongue. Whatcranial nerve is involved? Facial Glossopharyngeal Hypoglossal Vagus
Facial
A patient with increased intracranial pressure demonstrates decorticateposturing. As a nurse, you will observe: Flexion of elbows, extension of the knees, plantar flexion of the feet Flexion of both upper and lower extremities Extension of elbows and knees, flexion of the wrists, plantar flexion of the feet Extension of upper extremities, flexion of lower extremities
Flexion of elbows, extension of the knees, plantar flexion of the feet
A client seeks treatment in the emergency room for a lower leg injury. There is visible deformity to the lower aspect of the leg and the injured leg appears shorter than the other leg. The area is painful, swollen and beginning to become ecchymotic. Nurse Nick interprets that this client experienced a: a) Confusion b) Fracture c) Sprain d) Strain
Fracture
Which lobe and specific area of the brain would be affected if one couldno longer cut designs from construction paper? Parietal Occipital Frontal Temporal
Frontal
A person's personality and judgment are controlled by that area of thebrain known as: Temporal lobe Frontal lobe Occipital lobe
Frontal lobe
The client returns six weeks later to have his cast removed. He should be instructed to call the doctor if; a) Full range of motion and strength don't return within 2-4 weeks. b) His wrist feels stiff and weak. c) His hand is swollen in the morning. d) His skin is very red, dry and mottled.
Full range of motion and strength don't return within 2-4 weeks.
Which type of seizure is usually preceded by an aura? Jacksonian (Focal motor) Petit mal (absence) Myoclonic Grand mal (Tonic-clonic)
Grand mal (Tonic-clonic)
Which of the following diseases is a chronic, degenerative progressive disease of the central nervous system characterized by the occurrence of small patches of demyelination in the brain and spinal cord? * Creutzfeldt- Jacob's disease Multiple sclerosis Guillan-Barre syndrome Parkinson's disease
Guillan-Barre syndrome
The RN is positioning a female client with increased ICP. Which of thefollowing positions would the nurse avoid? Head of bed elevated to 30 to 45 degrees Neck in neutral position Head midline Head turned to one side
Head turned to one side
Of the following terms, which refers to blindness in the right or left halvesof the visual fields of both eyes? Nystagmus Homonymous hemianopsia Diplopia Scotoma
Homonymous hemianopsia
client has been taking glucocorticoids to control rheumatoid arthritis. Nurse monitors the client for which adverse effect of this pharmacological therapy? a) Elevated serum potassium b) Decreased serum sodium c) Increased serum glucose d) Increased white blood cells
Increased serum glucose
ohn is experiencing problems in moving his tongue. His doctor tells himthe problems are due to a pressure on a cranial nerve. Which cranialnerve is involved? Hypoglossal Accessory Glossopharyngeal Vagus
Hypoglossal
The client has undergone cerebral angiography. Which of the followingcomplications should the nurse be most alert for? Hypertension Nausea and vomiting Hypotension Skin rashes
Hypotension
Neostigmine is producing its desired effect when the nurse observes: * Mild sedative effects without the patient "hang-over" symptoms Improved papillary and tactile stimulation response Increased self- care activity and decreased dysphagia Increased WBC and improved memory
Increased self- care activity and decreased dysphagia
A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse elevates the limb, applies an ice bag and administers an analgesic. The nurse interprets that this pain may be caused by: a) Infection under the cast. b) The anxiety of the client. c) Impaired tissue perfusion. d) The recent occurrence of the fracture. Correct1/1 Points
Impaired tissue perfusion.
Which nursing diagnosis takes highest priority for a client with Parkinson's crisis? * Imbalance nutrition less than body requirement Risk for injury 13 respondents 25 Impaired urinary elimination 1 respondent 2 Ineffective airway clearance
Ineffective airway clearance
Which of the following nursing diagnosis should be given the highest priority by the nurse in a client with GBS? Ineffective breathing pattern related to respiratory muscle weakness Ineffective sexuality pattern related to paralysis Activity Intolerance related to muscle weakness Ineffective coping related to body Wanges
Ineffective breathing pattern related to respiratory muscle weakness
Marta, 20 year old was diagnosed with seizure. She was discharged onPhenytoin therapy. As a nurse, you would teach her about hermedication: Instruct her to undergo complete blood count testing regularly Instruct her to take the drug on an empty stomach Stop taking her medication when she has had no seizures for at least two years Instruct her to avoid massaging her gums, since massage can precipitate bleeding
Instruct her to undergo complete blood count testing regularly
Which statement best explains the pathogenesis of MS? * Result of the circulating antibodies attacking the postsynaptic acetylcholine levels Degeneration of the lower cell bodies of the lower motor neurons in the gray matter It is a direct result of degenerative changes in the musculoskeletal system An immune-mediated response that is caused by the demyelinization of the myelin sheath of the white matter of the brain, spinal cord and optic nerve
It is a direct result of degenerative changes in the musculoskeletal system
The client's workup includes tonometry. Which of the followinginformation should the nurse give the client when preparing him for theprocedure? It is a painless procedure with no side effects Medication will be given to dilate the pupils prior to the procedure Oral pain medication will be given before the procedure Blurred or double vision may occur after the procedure
It is a painless procedure with no side effects
A client with possible rib fracture has never had a chest x-ray. Nurse Nick plans to tell the client which of the following about the procedure? a) The x-ray stimulates a small amount of pain. b) It is necessary to remove jewelry and any other metal objects from the chest area. c) The client will be ask to breathe in and out during the xray. d) The x-ray technologist will stand next to the client during x-ray.
It is necessary to remove jewelry and any other metal objects from the chest area.
A client with a fractured right ankle has short leg plaster cast applied in the emergency department. During discharge teaching, the nurse provides which information to the client to prevent complications? a) Keep the right ankle elevated above the heart level with pillows for 24 hours. b) Weight-bearing on the right leg is allowed once the cast feels dry. c) Expect burning and tingling sensations under the cast for 3 to 4 days. d) Trim the rough edges of the cast after it's dry.
Keep the right ankle elevated above the heart level with pillows for 24 hours.
A client has sustained a right tibial fracture and has just had a cast applied. Which instruction should Nurse Joey provide his cast care? a) Cover the cast with a blanket until the cast dries. b) Keep your right leg elevated above the heart level. c) Use a knitting needle to scratch inches inside the cast. d) A foul smell from the cast is normal.
Keep your right leg elevated above the heart level.
A female client develops signs and symptoms of increased ICP after acar accident. The nurse anticipates administration of which drugendotracheally before suctioning? Lidocaine (Xylocaine) Furosemide (Lasix) Phenytoin (Dilantin) Mannitol (Osmitrol)
Lidocaine (Xylocaine)
The most important nursing action during Mr. James confinement due to PD is: * Maintaining daily exercise program Discontinuing all over the counter medications Scheduling daily sessions with the speech therapist Scheduling routine home visits by the community health nurse
Maintaining daily exercise program
During a neurological assessment, the nurse asks the patient to repeat aseries of numbers. She is assessing: Memory Attention span Communication Thought processes
Memory
When evaluating the extent of the disease (PD), a nurse observes for which of the following symptoms? * Diplopia Hemiparesis Muscle rigidity Bulging eyeballs
Muscle rigidity
A 28 year old woman complains of extreme muscle weakness and says, "I have to rest even with just minimal talking." The nurse assess her for other symptoms of: * Parkinson's Disease Multiple sclerosis Guillain Barre Syndrome Myasthenia gravis
Myasthenia gravis
Mrs. Eisenhower told the nurse that she and her husband still plan to have two more children. She asked if the GBS will recur should she get pregnant. What would be the appropriate response by the nurse? * No, pregnant women have the immunity to the disease during pregnancy but it may occur anytime if she is not pregnant. Yes, the risk relapse is highest on the 3rd trimester No. Guillaine-Barre is one time disease that does not recur and will not affect future offspring Yes, the risk of relapse is highest in the first trimester
No, pregnant women have the immunity to the disease during pregnancy but it may occur anytime if she is not pregnant.
Sympathetic impulses are mediated by the secretion of: Norepinephrine Dopamine Serotonin Acetylcholine
Norepinephrine
Nurse Joey has conducted teaching with a client in an arm cast about signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that he or she should report which of the following early symptoms of compartment syndrome? a) Cold, bluish colored fingers. b) Numbness and tingling in the fingers. c) Pain that increases when the arm is dependent. d) Pain relieved only by oxycodone and aspirin (Percodan).
Numbness and tingling in the fingers.
The lobe of the cerebral cortex that is responsible for visual interpretationis the: Occipital lobe Temporal lobe Parietal lobe Frontal lobe
Occipital lobe
A client asks the nurse Eliang, "What's the difference between osteoarthritis and rheumatoid arthritis?" The nurse response is correct when she states: Osteoarthritis is a non-inflammatory joint disease. Rheumatoid arthritis is an inflammatory joint disease." b) "Osteoarthritis and Rheumatoid arthritis are very similar, but osteoarthritis affects the smaller joints and rheumatoid arthritis affects larger, weight bearing joints." c) "Osteoarthritis affects joints on both sides of the body, and rheumatoid arthritis is usually unilateral." d) "Osteoarthritis is more common on women, and rheumatoid arthritis is more common on men."
Osteoarthritis is a non-inflammatory joint disease. Rheumatoid arthritis is an inflammatory joint disease."
Which of the following refers to weakness of both legs and the lower partof the trunk? Paraparesis Hemiplegia Hemiparesis Paraplegia
Paraparesis
A client who has SCI still has use of the arms and has impaired motorand sensory function of the trunk, legs and pelvic organs. Which type ofclassification of SCI does the client have? Tetraplegia Quadriplegia Paraplegia Brown Sequard
Paraplegia
Which of the following diseases is associated with the decreased levels of dopamine due to destruction of pigmented neural cells in the substantia nigra in the basal ganglia of the brain? * Huntington's disease Multiple sclerosis Parkinson's disease Creutzfeldt- Jacob's disease
Parkinson's disease
Which of the following is not a function of neuroglia? secretion of CSF phagocytosis information processing support
information processing
Post-operative care should include measure to prevent dislocation of a client's new hip prosthesis. Which of the following interventions would achieve this objective? a) Keeping the affected leg in a position of adduction. b) Using pressure relief measures, other than turning to prevent pressure ulcers. c) Placing the leg in abduction. d) Keeping hip flexed by placing pillows under the patient's knee.
Placing the leg in abduction.
.Nurse Joey is assessing the casted extremity of a client. He would assess for which of the following signs and symptoms indicative of infection? a) Dependent edema b) Presence of the "hot spot" on the casts c) Presence of "cold spots" on the spots d) Diminished distal pulses
Presence of "cold spots" on the spots
The nurse is planning care for a client with MS. The client is concerned about weakness and the variability of the symptoms. Which of the following is the priority nursing care goal at this time? * ) Administer Baclofen (Lioresal) Increase protein and carbohydrates Provide rest between activities Reinforce need for bed rest
Provide rest between activities
A patient who has SCI exhibits pallor and goose pimples, and the BP is170/100 mm Hg. Which action should you perform immediately? Raise the head of the bed and empty bladder Reposition the patient supine and increase the rate of the IVF Take the patient's BP q 15 minutes until the physician arrives Turn the patient to the left side and insert an indwelling urinary catheter
Raise the head of the bed and empty bladder
During mealtime, the patient complained she can't swallow her food and shows increasing difficulty in speaking. The nurse should: * Place patient in sitting position and ask to extend neck slightly when swallowing Serve patient liquid foods only Refer to the physician Serve food later and administer neostigmine
Refer to the physician
A client with Guillain-Barre Syndrome asks the nurse what cause the disease. In formulating a response, the nurse incorporates the understanding that the theory of causation: * Relates to a previous Musculoskeletal injury Is a fungal infection Is unknown Relates to a previous CNS injury
Relates to a previous CNS injury
The nurse is planning care to a client with GBS. Which of the following is the highest priority? * Promote range of motion exercises Provide frequent mouth care and positioning Relieve pain Insert indwelling foley catheter
Relieve pain
Which of the following problems is a client with GBS should be given highest priority by the nurse? * Cardiovascular problems Respiratory problems Renal problems Neurologic problems
Respiratory problems
The nurse is teaching the client with MS on how to reduce fatigue. The nurse should tell the client to: * Increase the dose of muscle relaxant Rest in an air-condition room Take a hot bath Avoid naps during the day
Rest in an air-condition room
The nurse is caring for a client experiencing seizure while in bed. Whichof the following actions would be contraindicated? Loosening restrictive clothing Removing the pillow and raising padded side rails Positioning client on the left side if possible with the head flexed forward Restraining the client's hands
Restraining the client's hands
The nurse is reviewing the nursing diagnosis and a standardized care plan for the client with MS. The nurse validates which of the following nursing diagnoses before implementing the plan of care? * Risk for falls Impaired mobility Risk for seizures Self-care deficit
Risk for seizures
When a patient continues to experience muscular weakness despite treatment with neostigmine, Tensilon is ordered by the physician to: * Increase production of acetylcholine Increase effect of neostigmine Rule out cholinergic crisis Overcome developing resistance to anticholinesterase
Rule out cholinergic crisis
Which type of cells myelinate peripheral nerve fibers? Oligodendrocytes Schwann cells Satellite cells Astrocytes
Schwann cells
A nurse is caring for a client with a herniated lumbar intervertebral disc due to a fall. The nurse plan to place the client in which position to minimize pain? a) High fowler's position with foot placed flat on bed. b) Semi-fowler's positions with knees slightly rise. c) Semi-fowler's position with the foot placed flat on bed. d) Flat with knees rise.
Semi-fowler's positions with knees slightly rise.
A neurotransmitter that helps control mood and sleep is Enkephalin Serotonin Acetylcholine Dopamine
Serotonin
The client will be discharged home on the same day as the surgery. Whatinformation about her vision would be most important for the nurse toinclude in her discharge plan? She will need to relearn to judge distances accurately Cataract glasses correct vision by magnifying objects. She will need to wear her glasses only until her eye heals She will need to wear glasses or contact lenses to correct her vision
She will need to wear her glasses only until her eye heals
An elderly female is admitted with a fractured right femoral neck. Which clinical manifestation would Nurse Nick expect to find? a) Free movement of the right leg. b) Abduction of the right leg. c) Internal rotation of the right hip. d) Shortening of the right leg.
Shortening of the right leg.
A male client is for lumbar puncture. The client will be placed in whichposition? Side-lying with the legs pulled-up and head bent down onto chest Side-lying with a pillow under the abdomen Prone in a slight trendelenberg position Prone with a pillow under the abdomen
Side-lying with the legs pulled-up and head bent down onto chest
When teaching the client with ALS about the effects of Riluzone (Rilutek),the nurse explains that the expected outcome of the drug is to: Improve movement Cure the disease Prevent respiratory failure Slow disease progression
Slow disease progression
Which of the following nursing interventions would be most appropriatefor facilitating communication with a client who has a hearingimpairment? Ask only questions that the client can answer with a "yes" or "no" response. Speak loudly, shout if necessary Stand close to the patient and speak slowly and clearly Stand to one side of the client when speaking, to direct the voice directly into the client's ear
Stand close to the patient and speak slowly and clearly
Nurse Joy is performing a physical assessment and is testing the client'sreflexes. Which action would Nurse Joy take to assess pharyngealreflex? Ask the client to swallow 25 respondents Pull down on the client's lower eyelid Shine a light towards the bridge of the nose Stimulate the back of the throat with a tongue depressor
Stimulate the back of the throat with a tongue depressor
A client's leg is set in a long leg cast. Because of the long leg cast, the nurse should observe for signs that indicates compromised circulation like: a) Foul odor b) Swelling of the toes c) Drainage on the cast d) Increased temperature
Swelling of the toes
Which of the following may exacerbate multiple sclerosis: Stress ROM exercise Swimming Urinary retention
Stress
During a routine physical examination to assess a male client's deeptendon reflex, the nurse should make sure to: Tap the tendon softly and gently Hold the reflex hammer tightly Support the joint where the tendon is being tested Use the pointed end of the reflex hammer when striking the Achilles tendon
Support the joint where the tendon is being tested
Nurse Eliang is caring for a client with rheumatoid arthritis. The nurse knows that the client's symptoms will be most improved by: a) Taking a warm shower upon awakening. b) Applying ice packs to the joints. c) Taking two aspirin before going to bed. d) Going for an early morning walk.
Taking a warm shower upon awakening.
The nurse is teaching the client with MG about the prevention of myasthenic and cholinergic crisis. The RN tells the client that this is most effectively done by: * Taking mediations on time to maintain therapeutic blood levels Eating large, well-balanced meals Doing all chores early in the day while less fatigued Doing muscle-strengthening exercises
Taking mediations on time to maintain therapeutic blood levels
After testing confirms the diagnosis of ALS, the nurse prepares Mr. Gregfor discharge. Health teaching should include the following EXCEPT Use of leg braces, canes or walkers Teaching diaphragmatic breathing techniques Teaching the family how to perform Heimlich maneuver Avoiding fatigue and extreme cold
Teaching diaphragmatic breathing techniques
Which of the following will be included in your teaching prior to thediagnostic test in the preceding question? Tell the client that only a part of the scalp will be shaved Tell the client that the procedure is painless The client needs to rest for a couple of hours after the test Tell the client that a mild sedative will be given
Tell the client that the procedure is painless
What happens at the synapse? The nerve impulse is transmitted only from one neuron to another neuron. When a presynaptic cell releases excitatory neurotransmitters, the postsynaptic cell depolarizes enoughto generate an action potential. The synapse physically joins two neurons. The presynaptic terminal submits a nerve impulse through the synaptic cleft to the receptor site on the postsynaptic cell.
The presynaptic terminal submits a nerve impulse through the synaptic cleft to the receptor site on the postsynaptic cell.
The client's wife says that she does not understand what happened toher husband's eye. Which of the following explanations by the nursewould most accurately describe the pathology of retinal detachment? Retinal injury produces inflammation and edema, which increase intraocular increase The two layers of the retina separate, allowing fluid to enter between them tear in the retina permits the escape of vitreous humor from the eye The optic nerve is damaged when it is exposed to vitreous humor
The two layers of the retina separate, allowing fluid to enter between them
The nurse assesses a normal reflex when testing the plantar orBabinski's in an adult. What will she observe? No obvious response Toes bending downward Sudden dorsal flexion Toes flaring upward
Toes bending downward
A male client with Bell's palsy asks the nurse what has caused thisproblem. You will respond based on the understanding that the cause is: Unknown, but possibly include long term tissue malnutrition and cellular hypoxia Primary genetic in origin triggered by exposure to neurotoxins Primary genetic in origin, triggered by exposure to meningitis Unknown, but possibly include ischemia, viral infection or an autoimmune problem
Unknown, but possibly include ischemia, viral infection or an autoimmune problem
TThe normal adult produces about 150 ml of cerebrospinal fluid daily fromthe: Circle of Willis Ventricle Corpus callosum Dura mater
Ventricle
The nurse is assessing a 37-year-old client with multiple sclerosis. Which of the following symptoms would the nurse expect to find? * Absent deep tendon reflex (DTR) Tremors at rest Vision changes Flaccid muscles
Vission changes
SITUATION: The purpose of cast is to immobilize a body part, early wound healing and bone alignment. Nurse Joy is assigned in the orthopedic unit. Mr. Cruz is being discharged to home after the application of a plaster leg cast. Nurse Joey determines that the client understands proper care of the cast if Mr. Cruz states that he should: a) Void getting the cast wet. b) Cover the casted leg with warm blankets. c) Use the fingertips to lift and move the leg. d) Use a padded coat hanger end to scratch under the cast.
Void getting the cast wet.
The physician adds Levodopa (Larodopa) to Mr. James's regimen for PD. Which precaution should the nurse give in a discharge teaching to Mr. James? * Wear elastic stocking to help avoid orthostatic hypotension Take levodopa on an empty stomach 18 respondents 35 Eat high protein foods Take vitamin B6 with every dose of levodopa
Wear elastic stocking to help avoid orthostatic hypotension
A client had undergone fasciotomy to treat compartment syndrome of the leg. The nurse prepares to provide which type of wound care to the fasciotomy site? a) Dry sterile dressings b) Wet sterile saline dressings c) Hydrocolloid dressings d) One-half strength betadiene dressings
Wet sterile saline dressings
A female client with GBS has paralysis affecting the respiratory muscles and requires MV. When the client asks the nurse about the paralysis, how should you respond? * "It must be hard to accept the permanency of your paralysis." "You may have difficulty believing this but the paralysis caused by this disease is temporary." "You'll have to accept the fact that you're perfanently paralyzed. However, you won't have any sensory loss." "You'll 1st regain use of your legs and then your arms."
You may have difficulty believing this but the paralysis caused by this disease is temporary."
In Meniere's disease, diet modification is part f the client's treatment plan.The nurse would explain that the most frequently recommendedmodification is a severe headache a feeling of intra-ear fullness blurred vision nausea
a severe headache
Nurse Angela has an order to get the client to a chair on the first post-operative day following total knee replacement. The nurse plans to do which of the following to protect the knee joint? a) Apply a knee immobilizer before getting the client up and elevate the client's surgical leg while sitting. b) Apply a compression dressing and put ice on the knee while sitting. c) Lift the client to the bedside chair, leaving the continuous passive motion (CPM) machine in the place. d) Obtain a walker to minimize weight-bearing by the client on the affected leg.
a) Apply a knee immobilizer before getting the client up and elevate the client's surgical leg while sitting.
Nurse Eliang understands the joints most likely to be involved in a client with osteoarthritis are the: a) Hip and knees. b) Ankles and metatarsals. c) Fingers and metacarpals. d) Cervical spine and shoulder.
a) Hip and knees.
Nurse Angela is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be concerned especially with which of the following assessment findings? a) Temperature of 38.6 degree Celsius orally. b) Complains of discomfort during repositioning. c) Old bloody drainage outlined on the surgical dressing. d) Discomfort during coughing and deep-breathing exercises.
a) Temperature of 38.6 degree Celsius orally.
Which of the following values is considered normal for ICP? a. 0 to 15 mm Hg b. 25 mm Hg c. 35 to 45 mm Hg d. 120/80 mm Hg
a. 0 to 15 mm Hg
What is the priority nursing diagnosis for a patient experiencing a migraine headache? a. Acute pain related to biologic and chemical factors b. Anxiety related to change in or threat to health status c. Hopelessness related to deteriorating physiological condition d. Risk for Side effects related to medical therapy
a. Acute pain related to biologic and chemical factors
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? a. An oral anticoagulant medication. b. A beta-blocker medication. c. An anti-hyperuricemic medication. d. A thrombolytic medication
a. An oral anticoagulant medication.
The client with a brain attack (stroke) has residual dysphagia. When a diet order is initiated, the nurse avoids doing which of the following? a. Giving the client thin liquids b. Thickening liquids to the consistency of oatmeal c. Placing food on the unaffected side of the mouth d. Allowing plenty of time for chewing and swallowing
a. Giving the client thin liquids
An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first? a. Reposition the client to avoid neck flexion b. Administer 1 g Mannitol IV as ordered c. Increase the ventilator's respiratory rate to 20 breaths/minute d. Administer 100 mg of pentobarbital IV as ordered.
a. Reposition the client to avoid neck flexion
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor? a. Unequal pupil size b. Decreasing systolic blood pressure c. Tachycardia d. Decreasing body temperature
a. Unequal pupil size
A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? a. Urine output increases b. Pupils are 8 mm and nonreactive c. Systolic blood pressure remains at 150 mm Hg d. BUN and creatinine levels return to normal
a. Urine output increases
In the immediate postoperative period following scleral buckling, theclient's nursing care should include all of the following except providing meaningful stimuli encouraging deep breathing every 2 hours performing range-of-motion exercises applying pressure dressings to both eyes
applying pressure dressings to both eyes
The client asks the nurse, "What causes cataracts in old people?" Whichof the following statements should form the basis for the nurse'sresponse? Cataracts are believed to be result from eye injuries sustained early in life usually result from chronic systemic disease usually result from prolonged use of toxic substances are thought to be result of aging
are thought to be result of aging
To prevent circulatory complications after a total hip replacement, Nurse Angela should make sure that the client is: a) Turned from side-to-side every 3 hours. b) Exercising the ankles and other uninvolved joints. c) Ambulated as soon as the effects of anesthesia are gone. d) Permitted to be up in a chair as soon as the effects of anesthesia are gone.
b) Exercising the ankles and other uninvolved joints.
Nurse Angela develops a post-operative nursing care plan for a client; she knows that the client is at risk for developing complications associated with immobility. Which of the following is the most common post-operative complication of the THR surgery? a) Pneumonia b) Thromboembolism c) Hemorrhage d) Wound infection
b) Thromboembolism
Nurse caring for a client with a diagnosis of gout. Which of the following laboratory values would the nurse expect to note in the client? a) Calcium level of 9.0 mg/dl. b) Uric acid level of 8.6 mg/dl. c) Potassium level of 4.1 mEq/L. d) Phosphorous level of 3.1 mg/dl.
b) Uric acid level of 8.6 mg/dl.
A patient with an intracranial problem does not open his eyes to any stimulus, has no verbal response except moaning and muttering when stimulated, and flexes his arm in response to painful stimuli. The nurse records the patients GCS score as a. 6 b. 7 c. 9 d. 11
b. 7
The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid? a. Head midline b. Head turned to the side c. Neck in neutral position d. Head of bed elevated 30 to 45 degrees
b. Head turned to the side
A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? a. Vomiting continues b. Intracranial pressure (ICP) is increased c. The client needs mechanical ventilation d. Blood is anticipated in the cerebrospinal fluid (CSF)
b. Intracranial pressure (ICP) is increased
The nurse is caring for the male client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated? a. Loosening restrictive clothing b. Restraining the client's limbs c. Removing the pillow and raising padded side rails d. Positioning the client to side, if possible, with the head flexed forward
b. Restraining the client's limbs
The nurse is assigned to care for a female client with complete right-sided hemiparesis. The nurse plans care knowing that this condition: a. The client has complete bilateral paralysis of the arms and legs. b. The client has weakness on the right side of the body, including the face and tongue. c. The client has lost the ability to move the right arm but is able to walk independently. d. The client has lost the ability to move the left arm but is able to walk independently.
b. The client has weakness on the right side of the body, including the face and tongue.
patient recently started on phenytoin (Dilantin) to control simple complex seizures is seen in the outpatient clinic. Which information obtained during his chart review and assessment will be of greatest concern? a. The gums appear enlarged and inflamed. b. The white blood cell count is 2300/mm3. c. Patient occasionally forgets to take the phenytoin until after lunch. d. Patient wants to renew his driver's license in the next month.
b. The white blood cell count is 2300/mm3.
As the nurse completes the admission history, the client reports thatbefore the physician patched his eye, he saw many spots or "floaters." The nurse should explain to the client that these spots were cause by spasms of the retinal blood vessels traumatized by the detachment contamination of the aqueous humor blood cells released into the eye by the detachment pieces of the retina floating in the eye
blood cells released into the eye by the detachment
To prevent deformities of the knee joints in client with an exacerbation of arthritis Nurse Eliang should: a) Discourage use of the knee joint. b) Keep the client on a regimen of bed rest. c) Encourage motion of the joint within limits of pain. d) Immobilize the joint with pillows for a period of several weeks.
c) Encourage motion of the joint within limits of pain.
Nurse Eliang should know that a client with rheumatoid arthritis will most often have pain and limited movement of the joints a) When the room is cool b) After assistive exercise c) In the morning on awakening d) When the latex fixation test is positive
c) In the morning on awakening
Nurse Eliang is caring for a client with osteoarthritis. The nurse performs an assessment, knowing that which of the following is a critical manifestation associated with the disorders? a) Morning stiffness b) A decreased sedimentation rate c) Joint pain that diminishes after the rest d) Elevated antinuclear antibody levels
c) Joint pain that diminishes after the rest
After a total hip replacement surgery, Nurse Angela should make sure that the client is: a) Supine position b) Lateral position c) Orthopneic position d) Semi-fowler's position.
c) Orthopneic position
Nurse Angela is visiting an elderly client following a hip replacement. Which findings require further teaching? a) The client shares her apartment with the car. b) The client has grab bar near the commode. c) The client is sitting on a soft, low sofa. d) The client is wearing supportive shoes.
c) The client is sitting on a soft, low sofa.
You are providing care for a patient with an acute hemorrhage stroke. The patient's husband has been reading a lot about strokes and asks why his wife did not receive alteplase. What is your best response? a. "Your wife was not admitted within the time frame that alteplase is usually given." b. "This drug is used primarily for patients who experience an acute heart attack." c. "Alteplase dissolves clots and may cause more bleeding into your wife's brain." d. "Your wife had gallbladder surgery just 6 months ago and this prevents the use of alteplase."
c. "Alteplase dissolves clots and may cause more bleeding into your wife's brain."
Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? a. A blood glucose level of 480 mg/dl. . b. A right-sided carotid bruit. c. A blood pressure of 220/120 mmHg d. The presence of bronchogenic carcinoma
c. A blood pressure of 220/120 mmHg
Which of the following respiratory patterns indicate increasing ICP in the brain stem? a. Slow, irregular respirations b. Rapid, shallow respirations c. Asymmetric chest expansion d. Nasal flaring
c. Asymmetric chest expansion
Nurse Kristine is trying to communicate with a client with brain attack (stroke) and aphasia. Which of the following actions by the nurse would be least helpful to the client? a. Speaking to the client at a slower rate b. Allowing plenty of time for the client to respond c. Completing the sentences that the client cannot finish d. Looking directly at the client during attempts at speech
c. Completing the sentences that the client cannot finish
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg? a. Give the client a warming blanket b. Administer low-dose barbiturate c. Encourage the client to hyperventilate d. Restrict fluids
c. Encourage the client to hyperventilate
A white female client is admitted to an acute care facility with a diagnosis of cerebrovascular accident (CVA). Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for CVA? a. Caucasian race b. Female sex c. Obesity d. Bronchial asthma
c. Obesity
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? a. Prepare to administer recombinant tissue plasminogen activator (rt-PA). b. Discuss the precipitating factors that caused the symptoms. c. Schedule for A STAT computer tomography (CT) scan of the head. d. Notify the speech pathologist for an emergency consult.
c. Schedule for A STAT computer tomography (CT) scan of the head.
The client asks the nurse, "How does glaucoma damage my eyesight?"The nurse's reply should be based on the knowledge that chronic openangle glaucoma Is cause by decreased blood flow to the retina causes increased intraocular pressure results from chronic eye inflammation leads to detachment of retina
causes increased intraocular pressure
Nurse has performed nutritional teaching on a client with gout who is placed on a low-purine diet. Which selection by the client would indicate that teaching has been effective? a) Cabbage b) Apple c) Peach cobbler d) Spinach
d) Spinach
A nursing student is teaching a patient and family about epilepsy prior to the patient's discharge. For which statement should you intervene? a. "You should avoid consumption of all forms of alcohol." b. "Wear your medical alert bracelet at all times." c. "Protect your loved one's airway during a seizure" d. "It's OK to take over-the-counter medications."
d. "It's OK to take over-the-counter medications."
Which of the following describes decerebrate posturing? a. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers b. Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of the feet c. Supination of arms, dorsiflexion of feet d. Back arched; rigid extension of all four extremities
d. Back arched; rigid extension of all four extremities
When assessing the body function of a patient with increased ICP, the nurse should initially assess a. Corneal reflex testing b. Extremity strength testing c. Pupillary reaction to light d. Circulatory and respiratory status
d. Circulatory and respiratory status
The nurse is assessing the adaptation of the female client to changes in functional status after a brain attack (stroke). The nurse assesses that the client is adapting most successfully if the client: a. Gets angry with family if they interrupt a task b. Experiences bouts of depression and irritability c. Has difficulty with using modified feeding utensils d. Consistently uses adaptive equipment in dressing self
d. Consistently uses adaptive equipment in dressing self
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition? a. Widening pulse pressure b. Decrease in the pulse rate c. Dilated, fixed pupil d. Decrease in LOC
d. Decrease in LOC
A male client is having a tonic-clonic seizures. What should the nurse do first? a. Elevate the head of the bed. b. Restrain the client's arms and legs. c. Place a tongue blade in the client's mouth. d. Take measures to prevent injury.
d. Take measures to prevent injury.
The patient with migraine headaches has a seizure. After the seizure, which action can you delegate to the nursing assistant? a. Restrain the patient for protection. b. Perform neurologic checks. c. Document the seizure. d. Take the patient's vital signs.
d. Take the patient's vital signs.
During recovery from a cerebrovascular accident (CVA), a female client is given nothing by mouth, to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once each shift. This assessment evaluates: a. cranial nerves I and II. b. cranial nerves III and V c. cranial nerves VI and VIII d. cranial nerves IX and X.
d. cranial nerves IX and X.
What endocrine structure in the diencephalon secretes melatonin? thalamus hypothalamus epithalamus hyperthalamus
epithalamus
If the client experienced any symptom of glaucoma, it would most likelybe decreasing peripheral vision eye pain colored light flashes excessive lacrimation
eye pain
he client says, "The doctor told me that he'll remove the lens of my eye.What does the lens do, anyway?The nurse should explain that the lens of the eye holds rods and cones focuses lights rays onto the retina regulate the amount of lights entering the eye produces aqueous humor
focuses lights rays onto the retina
You just finished running and your heart rate is fast as is your breathing.Which part of the brain controls the basic body functions such as heartrate and blood pressure is the cerebellum spinal cord medulla oblongata Option 2
medulla oblongata
An essential aspect of the plan of care for the client following cataractremoval surgery would be to maintain a darkened environment prevent fluid volume excess increase cardiac activity promote safety
promote safety
The client asks the nurse why his eyes have to be patched. He finds theenforced blindness very frightening and rather disorienting. The nurse'sreply should be based on the knowledge that eye patches serve to reduce rapid eye movements decrease the irritation of light entering the damaged eye rest the eyes to promote healing protect the injured eye from the infection
reduce rapid eye movements
The nurse learns that the client uses timolol maleate (Timoptic) eyedrops. The nurse would understand that this beta-adrenergic blockerhelps control glaucoma by constricting the pupils improving ciliary muscles contractability dilating the canals of Schlemm reducing aqueous humor formation
reducing aqueous humor formation
Miotics are frequently used in the basic treatment of glaucoma. Thenurse should understand that miotics work by relaxing ciliary muscles paralyzing ciliary muscles constricting the intraocular vessels constricting the pupil
relaxing ciliary muscles
Glial cells found surrounding the cell bodies of peripheral neurons are ependymal cells astrocytes microglia satellite cells
satellite cells
The classic triad of symptoms associated with Meniere's disease isvertigo, hearing loss, and vomiting tinnitus and hearing loss nausea and headache headache and double vision
tinnitus and hearing loss
