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A nurse is preparing a client for discharge home who will bein the care of family members. The client is now incontinent because of astroke. What instructions regarding bladder training should be included in theteaching plan for this client’s family?
a.“Offer the client the commode or urinal every 2 hours.”
b. “Use a Foley catheter at night to prevent accidents.”
c. “Instruct the client to hold the urine as long aspossible to restore bladder tone.”
d. “Decrease the client’s oral fluid intake to 1 L per day.”
a. “Offer the client the commode or urinal every 2 hours.”
A client who experienced a minor hemorrhagic stroke from ananeurysm 1 week ago reports a severe headache accompanied by one episode ofnausea and vomiting. What conclusion can be drawn from this information?
a. The client is experiencing a transient vasospasm.
b. The client’s warfarin dose is inadequate.
c. The client is experiencing stroke-related psychologicalstress.
d. Theclient has manifestations of rebleeding.
A client is admitted to the trauma unit with a suspectedarterial bleed following a head injury. He lost consciousness at the time ofthe injury and has since experienced a period of lucidity followed by a rapiddecline in level of consciousness. As the nurse assesses his status, sherecognizes these are signs indicative of:
b. subdural hematoma
c. tentorial herniation
d. increased blood pressure
a. epidural hematoma
A nurse is caring for a client with a spinal cord injury whois receiving baclofen (Lioresal). Which of the following assessement findingswould indicate a therapeutic response from the medication?
a. Increased range of motion of all extremities
b.Decreased muscle spasms
c. Increased muscle tone and strength
d. Decreased nausea
b. Decreased muscle spasms
A client admitted to the intensive care unit with a brainattack becomes lethargic and unable to articulate words when speaking. What isthe nurse’s best action?
a. Document the finding and check blood pressure as the onlyactions.
b. Place the client in a supine position with a flat backrest and observe.
c. Assess the client’s white blood cell count anddifferential.
d.Elevate the back rest to 30 degrees and notify the health care provider.
The client has experienced a lower motor neuron injury andas a result has a flaccid bowel elimination pattern with infrequent passage ofhard, dry stool. What intervention would be most helpful in relieving thisclient’s constipation?
a. Pouring warm water over the perineum
c. Tapping the abdomen from left to right
d. Daily tap water enemas
b. Manual disimpaction
A nurse is preparing a client to undergo computed tomographyof the head with contrast medium. What follow-up care should the nurse beprepared to provide?
a. Pressure to the site of injection
d. Immobilization of the head for 4 hours
c. Fluid therapy
The nurse expects that management of the patient whoexperiences a brief episode of tinnitus, diplopia, and dysarthria with noresidual effects will include
a. prophylactic clipping of cerebral aneurysms.
b. heparin via continuous intravenous infusion.
c. oraladministration of low dose aspirin therapy.
d. therapy with tissue plasminogen activator (tPA).
c. oral administration of low dose aspirin therapy.
A patient with a stroke experiences right-sided arm and legparalysis and facial drooping on the right side. When admitting the patient,which clinical manifestation will the nurse expect to find?
a. Impulsive behavior
b. Right-sided neglect
c. Hyperactive left-sided reflexes
d.Difficulty in understanding commands
A client with a history of complex partial seizures presentsto the clinic for a follow-up visit. What manifestations of this type ofseizure disorder might the nurse observe in this client?
a. Blank staring
c. Sudden loss of muscle tone
d. Brief jerking of the extremities
Which statement indicates that the family has a goodunderstanding of the changes in motor movement associated with Parkinson’s disease?
a. “I can never tell what he’s thinking—he hides behind afrozen face.”
b. “She drools all the time just so I can’t take her outanywhere.”
c. “Ican offer smaller meals with bite-size portions and a liquid supplement.”
d. “I think this disease makes him nervous—he perspires allthe time.”
c. “I can offer smaller meals with bite-size portions and a liquid supplement.”
A patient admitted with a head injury has admission vitalsigns of temperature 98.6° F (37° C), blood pressure 128/68, pulse 110, andrespirations 26. Which of these vital signs, if taken 1 hour after admission,will be of most concern to the nurse?
a. Blood pressure 130/72, pulse 90, respirations 32
b. Blood pressure 148/78, pulse 112, respirations 28
c. Blood pressure 110/70, pulse 120, respirations 30
d.Blood pressure 156/60, pulse 60, respirations 14
Which nursing intervention is included in the care plan whenmanaging a patient with Gardner-Wells tongs?
a. place the Velcro binders securely around the patient'shead
b. donot remove the traction weights and ensure that they hang freely
c. ensure that an extra set of drill bits are available incase a new set of predrilled holes must be made into the patient's skull
d. apply a Halo vest whenever your patient is in the uprightposition
b. do not remove the traction weights and ensure that they hang freely
The intervention for promoting urination for clients withSCI that involves inhaling deeply, holding the breath, and bearing down as hardas possible is
a. quad cough
c. Crede's maneuver
d. rectal stretch
b. Valsalva maneuver
The nurse obtains all of the following information about a65-year-old patient in the clinic. When developing a plan to decrease strokerisk, which risk factor is most important for the nurse to address?
a. The patient has a daily glass of wine to relax.
b. The patient is 25 pounds above the ideal weight.
c. The patient works at a desk and relaxes by watchingtelevision.
d. Thepatient’s blood pressure (BP) is usually about 162/94 mm Hg.
A neurogenic bladder may be managed pharmacologically withmedications such as _______________ to stimulate bladder contraction or___________ to increase bladder capacity.
a. Flomore; Drinite
b. Flomax; Alfuzosin
d. saw palmetto; Hytrin
c. Urecholine; Detrol
When assessing a patient with a possible stroke, the nursefinds that the patient’s aphasia started 3.5 hours previously and the bloodpressure is 170/92 mm Hg. Which of these orders by the health care providershould the nurse question?
a. Infuse normal saline at 75 mL/hr.
b. Keep head of bed elevated at least 30 degrees.
c. Administer tissue plasminogen activator (tPA) perprotocol.
d.Titrate labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg.
What process causes brain damage resulting from increasedintracranial pressure related to cerebral edema?
a. Myelin degeneration from circulating enzymes released inareas of tissue damage
b. Decreased cerebral perfusion from hypotension and bloodloss
c. Axonal shearing and tearing from displacement of thebrain in the cranium
d.Cerebral tissue hypoxia and ischemia from compression of blood vessels
The client with trigeminal neuralgia is about to undergosurgery for pain relief. The client asks how this surgery can relieve the painassociated with the condition. What is the nurse’s best response?
a. “Asmall artery compressing the nerve will be relocated.”
b. “An incision is made into the nerve itself, and ananesthetic is applied to the area.”
c. “The surgeon will cut the connection between the cranialnerves to provide pain relief.”
d. “The surgeon will use an electrode to bypass theconduction of the trigeminal nerve.”
a. “A small artery compressing the nerve will be relocated.”
Which statement regarding the pathophysiology of myastheniagravis is true?
a. There is evidence of both central and peripheral nervoussystem disease.
b. The myelin sheath is destroyed by the immune system.
c.There is a defect in the transmission of nerve impulses to the skeletalmuscles.
d. Myasthenia gravis is caused by antibodies to dopaminereceptors.
c. There is a defect in the transmission of nerve impulses to the skeletal muscles.
Which of the following nursing diagnoses is a priority forthe client with autonomic dysreflexia?
a. Self-care Deficit related to spinal cord injury
b.Impaired Urinary Elimination related to neurogenic bladder
c. Impaired Physical Mobility related to paraplegia
d. Impaired Adjustment related to depression
b. Impaired Urinary Elimination related to neurogenic bladder
Long term sequelae of a traumatic brain injury oftenincludes
a. Poor concentration and memory dysfunction
b. Anger/stress management
c. Depression and boredom
d. Increased risk of Alzheimer's disease
e. Allof these
A client has been admitted to the hospital after having abrain attack. What predisposing factor in this client’s history places thisclient at risk for embolic stroke?
a. A history of seizures
b. A history of psychotropic drug use
c. Ahistory of atrial fibrillation
d. A history of cerebral aneurysm
c. A history of atrial fibrillation
Aspirin is ordered for a patient who is admitted with apossible stroke. Which information obtained during the admission assessmentindicates that the nurse should consult with the health care provider beforegiving the aspirin?
a. The patient has dysphasia.
b. The patient has atrial fibrillation.
c. Thepatient states, “My symptoms started with a terrible headache.”
d. The patient has a history of brief episodes ofright-sided hemiplegia.
c. The patient states, “My symptoms started with a terrible headache.”
The nurse is caring for a patient with carotid arterynarrowing who has just returned after having left carotid artery angioplastyand stenting. Which assessment information is of most concern to the nurse?
a. The pulse rate is 104 beats/min.
b. Thepatient has difficulty talking.
c. The blood pressure is 142/88 mm Hg.
d. There are fine crackles at the lung bases.
b. The patient has difficulty talking.
A patient with a head injury opens the eyes to a painfulstimulus, is cursing inappropriately, and attempts to remove a painfulstimulus. The nurse records the patient’s Glasgow Coma Scale score as
Patient receives a score of 2 for eye opening, a 3 forverbal response, and a 5 for motor response, totally 10.
The client with epilepsy develops stiffening of the musclesof the arms and legs, followed by an immediate loss of consciousness andjerking of all extremities. How should the nurse document this seizureactivity?
a. Generalized absence seizure
b.Generalized tonic-clonic seizure
c. Generalized atonic seizure
d. Generalized myoclonic seizure
b. Generalized tonic-clonic seizure
The client with deteriorating neurologic function is worriedabout her ability to provide care for her young children at home. What is thenurse’s best response?
a. “Canyou give me some more information about what worries you, so we can see ifthere is something we can do to make adjustments?”
b. “Asking for help can be difficult, but you have to doit.”
c. “Would you like to talk to a psychologist about adjustingto your changing status?”
d. “There are resources in our community that may help youwith some household tasks so you have energy to care for your children.”
a. “Can you give me some more information about what worries you, so we can see if there is something we can do to make adjustments?”
A nurse has instructed the client with myasthenia gravis totake drugs on time and to eat meals 45 to 60 minutes after taking theanticholinesterase drugs. The client asks why the timing of meals is soimportant. What is the nurse’s best response?
a.“This timing allows the drug to have maximum effect, so it is easier for you tochew, swallow, and not choke.”
The skeletal muscle weakness extends to the ability to chewand swallow. Clients who have myasthenia gravis are at risk for aspiration duringmeals. Timing the medication so that the majority of the meal is eaten when thedrugs have produced their peak effect enables the client to chew and swallowmore easily.
In order to deal with the most common problem ofHuntington's disease, the nurse should institute
a. adiet that includes foods that are easy to swallow
b. an exercise regimen to prevent contractures and footdrop
c. seizure precautions including padded side rails
d. communication signals for when altered mentation begins
a. a diet that includes foods that are easy to swallow
A nurse is assessing deep tendon reflexes in a client whosustained a spinal cord injury 5 days ago. The nurse can elicit a mild responseto a tap on the patella. What is the nurse’s interpretation of this finding?
a. It is too early to tell how extensive the injury is atthis time.
b. The injury has resulted in only temporary spinal corddysfunction.
c. There is a gradual response of all the nerves and muscles.
d. Thespinal shock phase of the injury is over.
When comparing disorders of the peripheral nervous system,which pathophysiologic feature is a hallmark of Guillain-Barré syndrome?
a. Antibodies to acetylcholine receptor sites develop.
b. The distal nerves degenerate and retract.
c. The immune system destroys the myelin sheath.
d.Nerve impulses are not transmitted to skeletal muscle.
A nurse is caring for a client with a history of epilepsywho suddenly begins to experience a tonic-clonic seizure and losesconsciousness. What would be the nurse’s best action?
a. Place an airway into the client’s mouth.
b. Restrain the client’s extremities.
c. Turnthe client’s head to the side.
d. Take the client’s blood pressure.
c. Turn the client’s head to the side.
Which diagnosis would be considered the priority nursingdiagnosis for the client with Guillain-Barré syndrome?
a. Anxiety related to powerlessness
b. Altered nutrition, less than body requirements, relatedto inability to swallow
c.Ineffective Breathing Pattern related to progressive muscle weaknessd. Risk for Injury & Impaired Skin Integrityrelated to immobility
c. Ineffective Breathing Pattern related to progressive muscle weakness
The client who has had a stroke combs her hair only on theright side of her head and washes only the right side of her face. What is thenurse’s interpretation of these actions?
a. The client has paralysis or contractures on the leftside.
b. Theclient is unaware of the existence of her left side.
c. The client’s visual perception of the left fields islimited.
d. The client has poor left-sided motor control.
b. The client is unaware of the existence of her left side.
The client is experiencing status epilepticus. Which of thefollowing drugs should the nurse have ready to administer?
The nurse is positioning the client with increasedintracranial pressure. Which of the following positions would the nurse avoid?
a. Head of bed elevated 30-45 degrees
b. Head midline
c. Headturned to the side
d. Neck in neutral position
c. Head turned to the side
A patient with Bell’s palsy refuses to eat while others arepresent because of embarrassment about drooling. The best response by the nurseto the patient’s behavior is to
a. offer the patient liquid nutritional supplements atfrequent intervals.
b.respect the patient’s desire and arrange for privacy at mealtimes.
c. discuss the patient’s concerns with visitors who arriveat mealtimes.
d. teach the patient to chew food on the unaffected side ofthe mouth.
b. respect the patient’s desire and arrange for privacy at mealtimes.
Immediately following a spinal cord injury, a client'sfamily asks the nurse, "Is the damage the client presents with in theemergency room as bad as it seems?" The most appropriate response by thenurse is
a."Because of the edema around the spinal cord, it is difficult to evaluatethe extent of the injury for up to one week."
b. "It is amazing what physical therapy can accomplishif he works hard."
c. "Probably not, because the client will probablyregain a lot of function."
d. "Unfortunately yes, the injury is exactly as itappears."
a. "Because of the edema around the spinal cord, it is difficult to evaluate the extent of the injury for up to one week."
The first symptom seen in the majority of clients withParkinson’s disease is:
a. flexed posture
d.tremor at rest
The early manifestations of amyotrophic lateral sclerosis(ALS) and multiple sclerosis (MS) are somewhat similar. What clinical featureof ALS distinguishes it from MS?
a.Impairment of respiratory muscles
d. Muscle weakness
a. Impairment of respiratory muscles
The client who has experienced status epilepticus treatedwith IV diazepam has been ordered to receive phenytoin to prevent a recurrence.What statement indicates that the client understands how to take this medication?
a. “This will stop me from getting an aura before aseizure.”
b. “I must drink at least 2 L of water daily.”
c. “I will not be able to be employed while taking thismedication.”
d.“Even when my seizures stop, I will still need to take this drug.”
A client who first experienced a symptoms related to aconfirmed thrombotic stroke 2 hours ago is brought to the intensive care unit.What drug should the nurse prepare to administer?
b. Heparin sodium
c.Tissue plasminogen activator
c. Tissue plasminogen activator
What alteration in laboratory data would the nurse expect tosee in a client with myasthenia gravis?
a. Elevated serum calcium level
b.Elevated acetylcholine receptor antibody levels
c. Decreased thyroid hormone level
d. Decreased complete blood count
b. Elevated acetylcholine receptor antibody levels
A client has multiple sclerosis (MS) of the relapsing-remittingtype. What clinical course of the disease should the nurse expect in thisclient?
a. Absence of active disease manifestations
b. Gradual neurologic worsening without remission
c. An absence of periods of remission
d.Attacks becoming increasingly frequent
For which client who experiences migraine headaches istreatment with sumatriptan succinate (Imitrex) contraindicated?
a. 40-year-old with diabetes mellitus
b. 60-year-old with chronic renal failure
c. 30-year-old with bronchial asthma
d.50-year-old with Prinzmetal’s angina
Your patient has been prescribed Sinemet(levodopa-carbidopa) for Parkinson's disease. You explain the mechanism ofaction of this medication by teaching your patient that
a.Sinemet is converted to dopamine and provides an exogenous form of dopaminereplacement.
b. Sinemet causes a release of dopamine from neurol storagesites and blocks the re-uptake of dopamine.
c. Sinemet counteracts the neurotransmitter acetylcholineand restores the natural balance of neurotransmitters in the CNS.
d. Sinemet inhibits dopamine breakdown, leading to increasedamounts of dopamine available in the CNS.
a. Sinemet is converted to dopamine and provides an exogenous form of dopamine replacement.
A client presents with an acute exacerbation of multiplesclerosis. Which drug should the nurse be prepared to administer?
d. Dantrolene sodium
Where are the most common sites of vertebral injury?
a. C1-2 and C4-6
b.C1-2, C4-6 and T11-L2
c. C1 and T11-12
d. C3 and T11-12
b. C1-2, C4-6 and T11-L2
An initial decline of how many points in your patient'sGlasgow Coma Scale is considered a significant change and requires immediatenotification of the MD?
When caring for a patient who was admitted 24 hourspreviously with a C5 spinal cord injury, which nursing action has the highestpriority?
a.Assessment of respiratory rate and depth
b. Application of pneumatic compression devices to both legs
c. Administration of a high dose methylprednisolone infusion
d. Continuous cardiac monitoring for bradycardia
a. Assessment of respiratory rate and depth
You are caring for a client who has just had neurosurgery.To assess for increased intracranial pressure, what would you include in yourassessment?
a. cranial nerves, motor function, and sensory function
b.level of consciousness, motor function, pupillary response, and vital signs
c. mental status, deep tendon reflexes, sensory function,and pupillary response
d. deep tendon reflexes, vital signs, and coordinatedmovements
b. level of consciousness, motor function, pupillary response, and vital signs
What is the rationale for asking questions about theclient’s level of activities of daily living during a neurologic assessment?
a. It has a direct relationship to inheritable neurologicdiseases that have know genetic factors
b. Ithelps establish a baseline for later comparison for improving or deterioratingneurologic status.
c. It determines whether the client can return to home afterrecovery from neurologic illness.
d. It helps to establish whether the client has dietary oroccupational hazards that contribute to neurologic dysfunction
b. It helps establish a baseline for later comparison for improving or deteriorating neurologic status.
Which symptom is associated with cluster headache?
a. Bilateral, bandlike pressure at the base of the skull
b.Ipsilateral periorbital pain & tearing
c. Unilateral, throbbing pulsatile temporal pain
d. Abrupt loss of consciousness
b. Ipsilateral periorbital pain & tearing
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