The Nervous System
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Questions and Answers

What is the essential postoperative positioning for a patient who has undergone tympanoplasty?

  • Elevate the head of the bed to 30 degrees.
  • Elevate the head of the bed to 40 degrees with the operative side facing upward. (correct)
  • Place the patient in a supine position.
  • Maintain the patient in a sitting position.

    • Which of the following actions should a nurse take when assisting a blind patient walk in an unfamiliar environment?

  • Instruct the patient to keep their cane down.
  • Guide the patient using physical contact with the shoulder or elbow. (correct)
  • Allow the patient to walk quickly.
  • Encourage the patient to rely solely on auditory cues.

    • What is the priority nursing action for a patient with a suspected cervical spine injury in the emergency department?

  • Remove all immobilization devices.
  • Maintain proper head and neck alignment. (correct)
  • Administer pain medication to manage discomfort.
  • Perform a thorough neurological assessment immediately.

    • What action is contraindicated for a patient suspected of having a cervical spine injury?

    <p>Keeping the neck in a hyperextended position.</p> Signup and view all the answers

    What is typically included in the postoperative care for a patient after tympanoplasty?

    <p>Strict bed rest until the next morning.</p> Signup and view all the answers

    In the context of facilitating mobility for a blind patient, which approach is least effective?

    <p>Instructing the patient to memorize the layout.</p> Signup and view all the answers

    Why is it important to keep the head and neck in alignment for someone with a cervical spine injury?

    <p>To prevent further injury to the spinal cord.</p> Signup and view all the answers

    What is a common misconception about the management of a spinal cord injury?

    <p>Hyperextension of the neck is safe if the patient is alert.</p> Signup and view all the answers

    What is the definition of legal blindness?

    <p>Visual acuity of 20/200 or worse with corrective eyewear</p> Signup and view all the answers

    Which part of the nervous system consists of the somatic and autonomic divisions?

    <p>Peripheral nervous system</p> Signup and view all the answers

    What term describes the inability to recognize familiar objects or people due to sensory stimuli loss?

    <p>Agnosia</p> Signup and view all the answers

    What should the nurse do first after a patient has had an enucleation of the right eye?

    <p>Apply a pressure dressing over the right eye socket</p> Signup and view all the answers

    Which nursing intervention would be most beneficial for a patient with a stroke who has difficulty swallowing?

    <p>Tuck the chin while swallowing</p> Signup and view all the answers

    During a tonic-clonic seizure, what is the most appropriate nursing action?

    <p>Assist the patient to the floor and support the head</p> Signup and view all the answers

    In the event of high heart rate for a patient in neurological ICU, which patient condition requires immediate assessment?

    <p>Patient with increased intracranial pressure and high fever</p> Signup and view all the answers

    What is the primary goal of initiating a 'drug holiday' for a patient with Parkinson disease?

    <p>To restart drugs at a lower dosage with favorable results</p> Signup and view all the answers

    What is a common characteristic of a patient diagnosed with apraxia?

    <p>Inability to carry out purposeful movements even with the desire to do so</p> Signup and view all the answers

    What should be the immediate action when a chemical splashes into someone's eyes?

    <p>Irrigate with normal saline solution for 20 minutes</p> Signup and view all the answers

    Which of the following symptoms indicates a complication in a patient who has had a stroke?

    <p>Choking on thin liquids</p> Signup and view all the answers

    Upon noticing signs of warmth and a severe headache in a patient with a seizure disorder, what should the nurse prepare for?

    <p>A potential seizure to begin</p> Signup and view all the answers

    What action should be taken first for a patient exhibiting signs of autonomic dysreflexia?

    <p>Assess for a kinked urinary catheter</p> Signup and view all the answers

    What should a nurse document regarding a patient who has undergone eye surgery?

    <p>Dressing assessment every hour</p> Signup and view all the answers

    What is a prudent nursing intervention for a patient with high intracranial pressure?

    <p>Keep the head elevated</p> Signup and view all the answers

    Which procedure is used to obtain cerebrospinal fluid for examination?

    <p>Lumbar puncture</p> Signup and view all the answers

    If a patient presents with a GCS of 6, what is the nurse's priority action?

    <p>Notify the physician immediately</p> Signup and view all the answers

    To get the most accurate response when interviewing a patient for neurologic symptoms, what question should be asked?

    <p>Can you describe the sensations you are having?</p> Signup and view all the answers

    What is the first symptom that may indicate the onset of macular degeneration?

    <p>Loss of central vision</p> Signup and view all the answers

    Which assessment is crucial for a patient recovering from an enucleation procedure?

    <p>Dressing integrity for infection</p> Signup and view all the answers

    When managing a patient who is legally blind, how should this information influence the nursing care plan?

    <p>Ensure safety measures and provide assistive devices</p> Signup and view all the answers

    Which behavior is most appropriate when documenting patient responses about a neurologic issue?

    <p>Write direct quotes from the patient</p> Signup and view all the answers

    If a patient's blood pressure is found to be 180/90 mm Hg and they have a cervical spine injury, what might this suggest?

    <p>Signs of possible autonomic dysreflexia are present</p> Signup and view all the answers

    Which of the following describes the key characteristic of an aura experienced by patients with generalized tonic-clonic seizures?

    <p>An emotional disturbance such as fear</p> Signup and view all the answers

    When treating burns caused by a chemical splash, how long is prolonged irrigation typically recommended?

    <p>15 to 20 minutes</p> Signup and view all the answers

    What action should a nurse take to best help a patient experiencing severe vertigo due to labyrinthitis?

    <p>Lie immobile and hold the head in one position until the vertigo lessens.</p> Signup and view all the answers

    How should a nurse approach an 83-year-old stroke patient with right hemiplegia to ensure the best visual field?

    <p>From the left side.</p> Signup and view all the answers

    What abnormal vital sign in a patient with head trauma should prompt immediate intervention?

    <p>Decreased heart rate and increased blood pressure</p> Signup and view all the answers

    In managing autonomic dysreflexia, which factor should be prioritized for assessment?

    <p>Presence of urinary retention</p> Signup and view all the answers

    For a patient diagnosed with bacterial meningitis, what is the most effective action to prevent the spread of infection?

    <p>Implement droplet precautions upon admission.</p> Signup and view all the answers

    How would a nurse document a patient's inability to discern the position of their body after a stroke?

    <p>Proprioception</p> Signup and view all the answers

    What can a nurse expect regarding flaccid paralysis following a recent spinal cord injury?

    <p>It is possibly a temporary condition and will clear.</p> Signup and view all the answers

    What should a nurse ensure upon a child's admission with bacterial meningitis?

    <p>Place the child in respiratory isolation.</p> Signup and view all the answers

    How can a nurse assist a home health patient with a C5 spinal cord injury in maintaining independence?

    <p>Feed self with setup and adaptive equipment.</p> Signup and view all the answers

    Which statement correctly describes a common visual impairment following a stroke?

    <p>The patient may experience hemianopia affecting one half of the visual field.</p> Signup and view all the answers

    What must be emphasized during the nursing care of a patient undergoing the recovery phase from spinal shock?

    <p>Management of mobility and physical therapy.</p> Signup and view all the answers

    When treating a patient with bacterial meningitis, which precaution is most critical prior to transport?

    <p>Implement droplet precautions.</p> Signup and view all the answers

    What common complication may arise in patients after experiencing a stroke?

    <p>Loss of proprioceptive abilities.</p> Signup and view all the answers

    For a patient with hemiplegia, which defensive mechanism is most effective for avoiding injury?

    <p>Patient education on awareness of deficits.</p> Signup and view all the answers

    What nursing action is critical when faced with a patient who displays signs of neglect after a stroke?

    <p>Reassess for sensory perception issues.</p> Signup and view all the answers

    What characterizes expressive aphasia in a stroke patient?

    <p>Understanding spoken words but difficulty in speaking.</p> Signup and view all the answers

    What is the primary reason for the immediate hospitalization of a patient with Guillain-Barre Syndrome?

    <p>Risk of rapidly progressing respiratory failure.</p> Signup and view all the answers

    What position is best for a patient with decreased consciousness and increased intracranial pressure?

    <p>Neck in a neutral position.</p> Signup and view all the answers

    What common mistake can impede communication with a hearing-impaired patient?

    <p>Overaccentuating words while talking.</p> Signup and view all the answers

    Which intervention should a nurse prioritize for a patient with a Glasgow Coma Scale score of 4 and increased ICP?

    <p>Give Mannitol 1 g intravenously.</p> Signup and view all the answers

    What is an early sign of increased intracranial pressure in a brain-injured patient?

    <p>Decrease in level of consciousness.</p> Signup and view all the answers

    The term for involuntary rhythmic movements of the eyes is known as what?

    <p>Nystagmus.</p> Signup and view all the answers

    What should be the nurse's initial action for a TBI patient showing flaccid posturing three hours after decorticate posturing?

    <p>Notify the healthcare provider immediately.</p> Signup and view all the answers

    Which vital sign change is considered urgent in a patient with a closed head injury?

    <p>Intracranial pressure rising to 20 mm Hg.</p> Signup and view all the answers

    What indicates a severe complication in a patient recovering from Guillain-Barre Syndrome?

    <p>Rapid deterioration in muscle strength.</p> Signup and view all the answers

    What does a widening pulse pressure suggest in a patient with increased ICP?

    <p>Possible hemorrhagic stroke.</p> Signup and view all the answers

    What mechanism primarily explains the risk of respiratory failure in Guillain-Barre Syndrome?

    <p>Severe muscular atrophy limiting diaphragm movement.</p> Signup and view all the answers

    Which nursing intervention is crucial for a patient experiencing nystagmus?

    <p>Encourage focus on a stationary object.</p> Signup and view all the answers

    What should the nurse prioritize after identifying flaccid posturing in a client with TBI?

    <p>Notify the client’s health-care provider (HCP)</p> Signup and view all the answers

    What should postcataract patients avoid to prevent increasing intraocular pressure?

    <p>Lifting heavy objects</p> Signup and view all the answers

    During the use of an Amsler grid, what should the nurse instruct the patient to report?

    <p>Distortion of the grid lines</p> Signup and view all the answers

    In a patient who fell from a height, what is a crucial assessment to perform if there is bruising behind the ear?

    <p>Inspect the ears and nose for drainage</p> Signup and view all the answers

    Post cataract repair, what activity should a patient avoid?

    <p>Lifting heavy objects</p> Signup and view all the answers

    To help improve activity levels in a patient with Parkinson's disease, what should be recommended?

    <p>Clasp hands behind the back while walking</p> Signup and view all the answers

    Which statement correctly describes the timing of signs and symptoms in a craniocerebral injury?

    <p>Symptoms may not show up for days</p> Signup and view all the answers

    What is a necessary nursing action before a myelogram procedure?

    <p>Obtain an allergy history</p> Signup and view all the answers

    What is the best response when serosanguineous drainage is noted from a patient's nose after a motorcycle accident?

    <p>Perform a Tes-Tape glucose test</p> Signup and view all the answers

    If a newly blind male home health patient seeks assistance, what avenue should the nurse suggest?

    <p>American Foundation for the Blind</p> Signup and view all the answers

    What is the first sign that may indicate Bell's palsy?

    <p>Facial asymmetry on the affected side</p> Signup and view all the answers

    In a patient with spinal cord injury, what is the best immediate action for symptoms of autonomic dysreflexia?

    <p>Sit the patient upright and check blood pressure</p> Signup and view all the answers

    What symptoms in a patient post-eye surgery might indicate Sjögren syndrome?

    <p>Grittiness in the eye and blurred vision</p> Signup and view all the answers

    Why is otitis media more common in children between 6 to 36 months?

    <p>Eustachian tubes are shorter and straighter</p> Signup and view all the answers

    Which action is inappropriate for a patient recovering from cataract surgery?

    <p>Engaging in strenuous exercise</p> Signup and view all the answers

    What does evidence of serous drainage from a patient's ears or nose indicate?

    <p>Potential tear in meninges</p> Signup and view all the answers

    What should a nurse educate a patient on when using the Amsler grid?

    <p>Report any lines that appear wavy</p> Signup and view all the answers

    What should always be checked before administering contrast media for imaging tests?

    <p>Allergy to contrast dye</p> Signup and view all the answers

    What should nurses recommend to help reduce risk while walking in a patient with Parkinson's disease?

    <p>Using a walker or assistance device</p> Signup and view all the answers

    What symptom indicates a potential risk of retinal problems during an eye examination?

    <p>Noticing distortion in line patterns</p> Signup and view all the answers

    How should a nurse respond if a patient exhibits symptoms of a subdural hematoma after a head injury?

    <p>Report symptoms to a physician immediately</p> Signup and view all the answers

    What can lead to Sjögren syndrome after eye surgeries?

    <p>Use of certain medications</p> Signup and view all the answers

    What is indicated by a patient presenting with 'goose flesh' and flushing of the neck?

    <p>Autonomic dysreflexia</p> Signup and view all the answers

    Which of the following findings after eye surgery should be reported to a healthcare provider?

    <p>Stringy mucus discharge</p> Signup and view all the answers

    What is a common misconception regarding closed versus open injuries to the head?

    <p>Open injuries are always more serious</p> Signup and view all the answers

    What role do neurotransmitters play in the nervous system?

    <p>They are responsible for impulse transmission between synapses.</p> Signup and view all the answers

    In the presence of periorbital edema after head trauma, what underlying condition may need to be assessed?

    <p>Meningeal tear</p> Signup and view all the answers

    Which symptom is often the first to develop in cases of a herniated intervertebral disk?

    <p>Radiating pain down the limbs</p> Signup and view all the answers

    What is the primary function of photocoagulation for a patient with diabetic retinopathy?

    <p>To destroy new blood vessels and seal leaking ones.</p> Signup and view all the answers

    Why is it essential to obtain an allergy history before a myelogram?

    <p>To prevent adverse reactions to the contrast dye.</p> Signup and view all the answers

    What is the term used for the period of deep sleep following a tonic-clonic seizure?

    <p>Postictal period</p> Signup and view all the answers

    How soon must t-PA be administered to a patient for it to be effective?

    <p>Within 3 hours of symptom onset</p> Signup and view all the answers

    Which symptom is characteristic of acute angle closure glaucoma?

    <p>Large fixed pupil</p> Signup and view all the answers

    What instruction would be appropriate for a patient with Parkinson's disease to improve their activity level?

    <p>To walk with hands clasped behind the back.</p> Signup and view all the answers

    What is a primary consideration in postoperative care following a tympanoplasty?

    <p>Ensuring the operative side is elevated.</p> Signup and view all the answers

    What does an elevated head of bed position help achieve after tympanoplasty?

    <p>Minimizes swelling and promotes drainage.</p> Signup and view all the answers

    Which of the following is NOT a sign of Parkinson's disease?

    <p>Increased reflexes</p> Signup and view all the answers

    What is a common outcome expected from the use of t-PA?

    <p>Dissolution of blood clots.</p> Signup and view all the answers

    What significant event does the postictal period represent?

    <p>The recovery phase after a seizure.</p> Signup and view all the answers

    Which demographic is most likely to benefit from photocoagulation?

    <p>Patients with diabetic retinopathy.</p> Signup and view all the answers

    What underlying condition may necessitate a myelogram?

    <p>Herniated intervertebral disk</p> Signup and view all the answers

    What is the primary reason for placing a child with bacterial meningitis in respiratory isolation?

    <p>To reduce the risk of spreading the infection.</p> Signup and view all the answers

    What anatomical characteristic of children's eustachian tubes contributes to the frequency of otitis media in children aged 6 to 36 months?

    <p>They are shorter and straighter.</p> Signup and view all the answers

    After a left vitrectomy, what is the critical requirement for the patient's positioning?

    <p>Assume a face-down position for 4 to 5 days.</p> Signup and view all the answers

    What does flaccid paralysis following a spinal cord injury indicate regarding the potential for recovery?

    <p>It is likely a temporary condition.</p> Signup and view all the answers

    Which statement is true regarding the oculocephalic reflex test in unconscious patients?

    <p>Intact reflex results in eye movement opposite to head movement.</p> Signup and view all the answers

    What is the initial response required when a chemical splash occurs in the eyes?

    <p>Irrigate with saline solution for 20 minutes.</p> Signup and view all the answers

    What are some common age-related changes in the nervous system of older adults?

    <p>Decreased oxygen metabolism.</p> Signup and view all the answers

    What finding in an unconscious patient would indicate damage to the brainstem during an oculocephalic reflex test?

    <p>Eyes that remain fixed regardless of head movement.</p> Signup and view all the answers

    Which statement about otitis media in children is accurate?

    <p>Go hand-in-hand with frequent upper respiratory infections.</p> Signup and view all the answers

    In the context of eye irrigation after a chemical splash, what is considered the most critical factor?

    <p>The duration of irrigation.</p> Signup and view all the answers

    Which of the following signs might indicate a disruption of normal brainstem functioning?

    <p>Eye movements corresponding with head movement.</p> Signup and view all the answers

    What is the primary management strategy for a patient post-tympanoplasty?

    <p>Enforcing bed rest for 72 hours.</p> Signup and view all the answers

    What characterizes craniocerebral trauma?

    <p>Injury to the scalp, skull, and brain tissues.</p> Signup and view all the answers

    What factor can influence the presence of flaccid paralysis in a spinal cord injury?

    <p>Time since the injury occurred.</p> Signup and view all the answers

    When assessing patients' neurological changes with age, which observation is likely?

    <p>Presence of lipofuscin deposits.</p> Signup and view all the answers

    What is the function of photocoagulation in treating diabetic retinopathy?

    <p>Destroying new blood vessels and sealing leaks.</p> Signup and view all the answers

    When an older adult experiences headaches and difficulty chewing, which condition should the nurse assess for?

    <p>External otitis.</p> Signup and view all the answers

    Which nursing action is indicated for a child with suspected bacterial meningitis awaiting treatment?

    <p>Isolate the child from others to prevent infection.</p> Signup and view all the answers

    Why should teenagers wear dark sunglasses when using a UV lamp?

    <p>To avoid potential cataracts caused by UV exposure.</p> Signup and view all the answers

    What is the recommended position for a patient experiencing severe vertigo from labyrinthitis?

    <p>Lie immobile and hold the head in one position.</p> Signup and view all the answers

    What is the initial sign of macular degeneration?

    <p>Loss of central vision.</p> Signup and view all the answers

    How do miotic eye drops assist patients with glaucoma?

    <p>By constricting the pupil to facilitate drainage.</p> Signup and view all the answers

    What nursing action is appropriate when assessing clear drainage from the nose of a patient with a suspected basilar skull fracture?

    <p>Place a nasal drip pad under the nose.</p> Signup and view all the answers

    What is a common misconception about the effect of UV exposure on eyes?

    <p>It can directly cause cataracts over time.</p> Signup and view all the answers

    Which symptom would most likely NOT be associated with external otitis?

    <p>Clear drainage from the ear.</p> Signup and view all the answers

    What is a key characteristic of macular degeneration compared to other eye conditions?

    <p>It causes slow loss of central vision.</p> Signup and view all the answers

    What is the primary purpose of elevating the head of the bed for postoperative tympanoplasty patients?

    <p>To promote better healing and reduce pressure.</p> Signup and view all the answers

    What outcome should the nurse expect when administering miotic eye drops to a glaucoma patient?

    <p>Increased drainage of intraocular fluid.</p> Signup and view all the answers

    What characteristic defines expressive aphasia in a stroke patient?

    <p>Understanding spoken words but difficulty speaking.</p> Signup and view all the answers

    What role do neurotransmitters play in the nervous system?

    <p>They transmit impulses between synapses.</p> Signup and view all the answers

    In the case of a patient with altered neurological status, what is the priority nursing action?

    <p>Increase the frequency of neurological assessments.</p> Signup and view all the answers

    When assessing a patient with a craniocerebral injury, what is an important consideration?

    <p>Symptoms may present several days post-injury.</p> Signup and view all the answers

    What should a nurse avoid when communicating with a hearing-impaired patient?

    <p>Overaccentuating words.</p> Signup and view all the answers

    What is the appropriate nursing intervention for a patient with bacterial meningitis?

    <p>Implement seizure precautions due to increased risk.</p> Signup and view all the answers

    Which common mistake can impact effective communication with a hearing-impaired patient?

    <p>Positioning oneself at a distance when speaking.</p> Signup and view all the answers

    What is crucial to assess in a patient shortly after a head injury?

    <p>Changes in their level of consciousness.</p> Signup and view all the answers

    What should be a focus when caring for a patient with expressive aphasia?

    <p>Encouraging the patient to write.</p> Signup and view all the answers

    What method aids in safely guiding a blind person in a hospital?

    <p>Holding their elbow or shoulder.</p> Signup and view all the answers

    In managing a patient with an increased risk of seizures due to infection, which intervention is least effective?

    <p>Administering frequent pain medications.</p> Signup and view all the answers

    When providing care for a patient recovering from a motorcycle crash, what is the key assessment indicator?

    <p>Changes in neurological status.</p> Signup and view all the answers

    Which statement about the cranial nerves is correct after a brain injury?

    <p>Damage can impact sensory and motor functions.</p> Signup and view all the answers

    In addressing the care plan for a patient with meningitis, which of the following is a priority?

    <p>Regularly monitor for seizures and neurological changes.</p> Signup and view all the answers

    What is the period called that follows a seizure and involves a rest phase for the patient?

    <p>Postictal period</p> Signup and view all the answers

    What best describes a patient's inability to assess the spatial position of their body after a stroke?

    <p>Proprioception</p> Signup and view all the answers

    When managing a patient with bacterial meningitis, what is the most critical action to take to prevent infection spread?

    <p>Implement droplet precautions upon admission.</p> Signup and view all the answers

    Which patient should a charge nurse prioritize for evaluation based on risk factors?

    <p>A patient with a complete spinal injury at the C5 dermatome level</p> Signup and view all the answers

    What neurological issue is indicated by a total or partial loss of the ability to recognize familiar objects or people?

    <p>Agnosia</p> Signup and view all the answers

    What is the best way to describe a nursing action for a patient recovering from bacterial meningitis?

    <p>Implement contact precautions in addition to droplet precautions.</p> Signup and view all the answers

    Which complication is most likely to arise in patients after a stroke affecting their control of bodily movements?

    <p>Hemiplegia</p> Signup and view all the answers

    What does a Glasgow Coma Scale score of 15 indicate in a patient?

    <p>Fully alert and orientated</p> Signup and view all the answers

    What is a nursing action to prioritize in a patient exhibiting signs of neglect after experiencing a stroke?

    <p>Provide frequent reminders and cues during activities.</p> Signup and view all the answers

    Which condition may require droplet precautions for its prevention?

    <p>Bacterial meningitis</p> Signup and view all the answers

    What is a common early sign of Alzheimer's disease?

    <p>Memory loss that disrupts daily life</p> Signup and view all the answers

    Which part of the eye is most internal?

    <p>Choroid</p> Signup and view all the answers

    What should a nurse prioritize when caring for a patient with elevated temperature and closed head injury?

    <p>Administer antipyretics</p> Signup and view all the answers

    Which nursing action is essential for a patient suspected of having a cervical spine injury?

    <p>Maintain proper head and neck alignment</p> Signup and view all the answers

    In visual acuity measured at 20/40, what distance can the patient see compared to normal vision?

    <p>40 ft</p> Signup and view all the answers

    What is the likelihood that corticosteroids can assist in reducing cerebral edema related to meningitis?

    <p>They may be beneficial</p> Signup and view all the answers

    What indicates a potential complication for a patient with a cervical spine injury?

    <p>Continuous high blood pressure</p> Signup and view all the answers

    What is the best nursing action if a blood pressure of 160/90 mm Hg is recorded after starting nicardipine?

    <p>Notify the Registered Nurse</p> Signup and view all the answers

    What is a potential consequence of hyperextension of the neck in a patient with suspected cervical spine injury?

    <p>Increased risk of spinal cord damage</p> Signup and view all the answers

    Which vital sign assessment would be most concerning for a patient with a subarachnoid hemorrhage?

    <p>Blood pressure of 170/100 mm Hg</p> Signup and view all the answers

    What critical role does proper head alignment play for a patient with cervical spine injury?

    <p>Reduces spinal cord damage risk</p> Signup and view all the answers

    What should be performed first when a patient has a suspected cervical spine injury?

    <p>Stabilize the cervical spine</p> Signup and view all the answers

    What symptom would most likely indicate an elevated intracranial pressure in a head injury patient?

    <p>Increased temperature</p> Signup and view all the answers

    In a patient care scenario, which statement reflects the priority intervention when a patient suddenly presents with a fever?

    <p>Provide cool compresses</p> Signup and view all the answers

    What is the primary nursing intervention when a patient with a spinal cord injury shows symptoms of autonomic dysreflexia?

    <p>Sit upright and check blood pressure.</p> Signup and view all the answers

    What should be the priority nursing action prior to administering a myelogram?

    <p>Obtain an allergy history before the test.</p> Signup and view all the answers

    Which action defines a 'drug holiday' in the treatment of Parkinson disease?

    <p>Restart drugs at a lower dosage with favorable results.</p> Signup and view all the answers

    How are results reported on the FOUR score coma scale?

    <p>As individual scores in each category.</p> Signup and view all the answers

    What is the mechanism by which the lens of the eye adjusts to focus on the retina?

    <p>Accommodation.</p> Signup and view all the answers

    What is the first action a nurse should take for a patient who has just suffered a tonic-clonic seizure?

    <p>Ensure the patient's safety and prevent injury.</p> Signup and view all the answers

    What is the primary purpose of avoiding heavy lifting after cataract surgery?

    <p>To reduce intraocular pressure</p> Signup and view all the answers

    What symptom is commonly associated with diabetes retinopathy?

    <p>Blurred vision</p> Signup and view all the answers

    What is the most effective way to address a family member's concern about a patient's deep sleep following a seizure?

    <p>Explain that deep sleep is a common postictal state.</p> Signup and view all the answers

    Which medication is a priority for a patient with a central venous pressure (CVP) of 2 mm Hg and low blood pressure?

    <p>500 mL albumin intravenous infusion.</p> Signup and view all the answers

    What action should a nurse take first for a patient with a Glasgow Coma Scale score of 3?

    <p>Secure and maintain an open airway</p> Signup and view all the answers

    Which of the following is a characteristic sign of autonomic dysreflexia?

    <p>Excessive perspiration above the injury</p> Signup and view all the answers

    What common misconception may arise regarding a C5 spinal cord injury's impact on patient independence?

    <p>Patients can drive with adaptive supports.</p> Signup and view all the answers

    In managing a patient with a suspected cervical spine injury, which action should be done first?

    <p>Stabilize the patient's head and neck</p> Signup and view all the answers

    What nursing action should be emphasized when caring for a patient in the recovery phase from spinal shock?

    <p>Frequent blood pressure monitoring.</p> Signup and view all the answers

    What primary risk does a patient face following a major head injury indicated by a low Glasgow Coma Scale score?

    <p>Risk of aspiration</p> Signup and view all the answers

    In the context of assessing a neurologically compromised patient, which assessment priority is crucial?

    <p>Assessing respiratory status frequently.</p> Signup and view all the answers

    What complication should be closely monitored after a patient undergoes tympanoplasty?

    <p>Hearing loss</p> Signup and view all the answers

    What is the most common characteristic of an aura in patients with generalized tonic-clonic seizures?

    <p>A preceding feeling of fear or anxiety.</p> Signup and view all the answers

    Which treatment is typically focused on for patients experiencing autonomic dysreflexia?

    <p>Identifying and correcting the triggering cause</p> Signup and view all the answers

    Which precaution is most critical for nurses to take when transporting a patient diagnosed with bacterial meningitis?

    <p>Wearing personal protective equipment.</p> Signup and view all the answers

    What is a common complication following stroke that nurses should monitor for?

    <p>Urinary incontinence.</p> Signup and view all the answers

    After spinal cord injury at level C5, the patient is most likely to retain which level of function?

    <p>Ability to perform daily living tasks with assistance</p> Signup and view all the answers

    Which assessment finding would indicate a potential complication in a patient with increased intracranial pressure?

    <p>Worsening headache</p> Signup and view all the answers

    What is the most effective method in preventing further damage after identifying a kinked urinary catheter in a patient with autonomic dysreflexia?

    <p>Reposition the catheter</p> Signup and view all the answers

    Which type of hearing loss is primarily addressed by tympanoplasty?

    <p>Conductive hearing loss</p> Signup and view all the answers

    What vital sign changes might indicate potential complications in a patient with severe head trauma?

    <p>Elevated blood pressure with bradycardia</p> Signup and view all the answers

    What is a common characteristic of a patient with functional paralysis following a spinal cord injury?

    <p>Inconsistent movement in limbs</p> Signup and view all the answers

    Study Notes

    Postoperative Positioning After Tympanoplasty

    • Patient should be positioned on the operative side to promote drainage.

    Assisting a Blind Patient

    • Verbal cues are the most effective way to guide a blind patient.

    Cervical Spine Injury in the Emergency Department

    • The priority for a patient with suspected cervical spine injury is to maintain cervical spine immobilization.

    Contraindicated Action for Cervical Spine Injury

    • Rotating the head is contraindicated for patients with suspected cervical spine injury.

    Postoperative Care after Tympanoplasty

    • Avoid straining, blowing the nose, and coughing to prevent pressure on the ear.

    Least Effective Approach for Blind Patient Mobility

    • Providing a cane is the least effective approach to facilitating mobility for a blind patient.

    Cervical Spine Injury Alignment

    • Maintaining alignment helps prevent further injury and spinal cord damage.

    Misconception about Spinal Cord Injury Management

    • A common misconception is that all spinal cord injuries result in permanent paralysis.
    • Legal blindness is defined as visual acuity of 20/200 or worse in the better eye with correction.

    Somatic and Autonomic Divisions

    • The peripheral nervous system consists of the somatic and autonomic divisions.

    Inability to Recognize Familiar Objects

    • This inability is called agnosia.

    Post-Enucleation Nursing Action

    • The nurse should first assess the patient's vital signs after enucleation.

    Stroke Patient with Swallowing Difficulty

    • Thickened liquids can be helpful for patients with swallowing difficulties.

    Tonic-Clonic Seizure Nursing Action

    • During a tonic-clonic seizure, the primary nursing action is to protect the patient from injury.

    Neurological ICU: High Heart Rate

    • Increased intracranial pressure is a condition that requires immediate assessment when a patient in the neurological ICU exhibits a high heart rate.

    Drug Holiday for Parkinson's Disease

    • The goal of a drug holiday is to reduce medication-induced complications.

    Characteristic of Apraxia

    • Difficulty with planned, sequential movements despite the physical ability to perform them.

    Chemical Splash in Eyes

    • Flush the affected eyes with copious amounts of water for at least 15 minutes.

    Stroke Complication Indication

    • Sudden changes in consciousness are a key indicator of complications after a stroke.

    Seizure Disorder: Warmth and Headache

    • The nurse should prepare for febrile seizures.

    Autonomic Dysreflexia Action

    • Elevate the head of the bed is the initial action for a patient exhibiting signs of autonomic dysreflexia.

    Documentation After Eye Surgery

    • The nurse should document visual acuity immediately after eye surgery.

    Nursing Intervention for High Intracranial Pressure

    • Maintain the patient's head in a neutral position to facilitate drainage.

    Cerebrospinal Fluid Examination Procedure

    • A lumbar puncture is used to obtain cerebrospinal fluid.

    GCS of 6 Nursing Priority

    • Maintain airway, breathing, and circulation (ABCs) as the priority.

    Neurologic Symptom Interview Question

    • "Can you describe the symptoms you are experiencing?"

    Macular Degeneration First Symptom

    • Distorted or blurred central vision is the first symptom of macular degeneration.

    Post-Enucleation Assessment

    • Pain assessment is crucial for a patient recovering from enucleation.

    Nursing Care Plan for Legally Blind Patient

    • The nurse should provide clear and concise verbal instructions and use tactile cues when appropriate.

    Documentation for Neurologic Issue

    • Objective and specific documentation is essential when recording a patient's responses about a neurologic issue.

    High Blood Pressure and Cervical Spine Injury

    • This may suggest autonomic dysreflexia.

    Generalized Tonic-Clonic Seizures Aura

    • Auras are often sensory and predictable events.

    Chemical Splash Burn Irrigation

    • Prolonged irrigation (at least 20 minutes) is typically recommended.

    Severe Vertigo due to Labyrinthitis Nursing Action

    • Reduce environmental stimuli to promote comfort.

    Right Hemiplegia Patient Visual Field

    • Approach the patient from the left side to ensure the best visual field for the patient.

    Abnormal Vital Sign in Head Trauma

    • Decreased pulse pressure after head trauma demands immediate intervention.

    Prioritized Assessment in Autonomic Dysreflexia

    • Assess for bladder distention as a priority.

    Action to Prevent Meningitis Spread

    • Droplet precautions are essential to prevent the spread of bacterial meningitis.

    Documenting Inability to Discern Body Position

    • Document "Patient exhibits proprioceptive deficits following a stroke."

    Flaccid Paralysis After Spinal Cord Injury

    • Flaccid paralysis is expected immediately after a spinal cord injury — it is a temporary state during spinal shock.

    Child Admission with Bacterial Meningitis

    • Ensure droplet precautions are in place.

    Home Health Patient with C5 Spinal Cord Injury

    • Promote adaptive equipment and training to maintain independence.

    Visual Impairment After Stroke

    • Homonymous hemianopsia is a common visual impairment after stroke, resulting in blindness in half of the visual field.

    Spinal Shock Recovery Phase Nursing Care

    • Monitor for complications like autonomic dysreflexia.

    Bacterial Meningitis Transport Precaution

    • Droplet precautions are crucial before transport.

    Common Stroke Complication

    • DVT and pulmonary embolism are common complications after stroke.

    Hemiplegia Injury Prevention

    • Teach the patient to use their strong side to assist with activities.

    Neglect After Stroke Nursing Action

    • Encourage the patient to use their affected side to prevent neglect.

    Expressive Aphasia After Stroke

    • Difficulty expressing thoughts verbally despite understanding language.

    Guillain-Barre Syndrome Hospitalization

    • Rapid progression of weakness necessitates immediate hospitalization.

    Decreased Consciousness and Increased Intracranial Pressure Position

    • Elevate the head of the bed to 30 degrees.

    Hearing-Impaired Communication Mistake

    • Talking too loudly is a common mistake that can impede communication.

    Glasgow Coma Scale Score of 4 and Increased ICP

    • Maintain airway and ventilation support as the priority.

    Early Sign of Increased Intracranial Pressure

    • Change in level of consciousness is an early sign of increased intracranial pressure.

    Involuntary Rhythmic Eye Movements

    • Nystagmus.

    Flaccid Posturing 3 Hours After Decorticate Posturing

    • Rapidly assess for life-threatening complications.

    Urgent Vital Sign Change in Closed Head Injury

    • Widening pulse pressure is urgent and indicates increased intracranial pressure.

    Severe Complication After Guillain-Barre Syndrome

    • Respiratory failure is the most severe complication.

    Widening Pulse Pressure and Increased ICP

    • It indicates worsening intracranial pressure.

    Guillain-Barre Syndrome Respiratory Failure Mechanism

    • Ascending paralysis leading to respiratory muscle weakness.

    Nystagmus Nursing Intervention

    • Maintain a safe environment to prevent falls or injury.

    Priority After Flaccid Posturing in TBI Patient

    • Immediately assess the patient's respiratory function.

    Post-Cataract Activity to Avoid

    • Avoid rubbing the eyes and heavy lifting to prevent increased intraocular pressure

    Amsler Grid Patient Instructions

    • Report any distortions or missing areas on the grid.

    Bruising Behind the Ear After Fall

    • Assess for a basilar skull fracture.

    Activity to Avoid After Cataract Repair

    • Avoid bending at the waist to prevent pressure on the eye.

    Parkinson's Disease Activity Improvement

    • Encourage regular exercise and participation in activities.

    Timing of Craniocerebral Injury Signs and Symptoms

    • The signs and symptoms of a craniocerebral injury can develop immediately or over several days.

    Nursing Action Before Myelogram

    • Confirm allergy history and obtain informed consent.

    Serosanguineous Drainage From Nose After Motorcycle Accident

    • Assess for a possible skull fracture.

    Newly Blind Home Health Patient Assistance Suggestion

    • Connect the patient with a local organization for visually impaired individuals.

    First Sign of Bell's palsy

    • Facial asymmetry is the first noticeable sign.

    Autonomic Dysreflexia Immediate Action

    • Immediately elevate the head of the bed to lower blood pressure.

    Eye Surgery and Sjögren Syndrome Symptoms

    • Dry eyes and mouth dryness are key signs.

    Otitis Media Prevalence in Children

    • Eustachian tube structure and function differences contribute to its prevalence.

    Action Inappropriate for Cataract Surgery Recovery

    • Rubbing the eyes is inappropriate during recovery.

    Serous Drainage from Ears or Nose Indication

    • Possible skull fracture.

    Amsler Grid Patient Education

    • Explain the importance of regular use to monitor visual changes.

    Contrast Media Administration Check

    • Check for allergies to iodine or contrast media.

    Parkinson's Disease Walking Risk Reduction

    • Encourage the use of a cane or walker for stability.

    Retina Problem Symptom During Eye Examination

    • Flashing lights can indicate retinal detachment or tears.

    Subdural Hematoma Symptoms After Head Injury

    • Assess for changes in consciousness, headache, and neurologic deficits.

    Sjögren Syndrome Cause After Eye Surgery

    • The surgery itself does not cause the syndrome, but it can trigger its onset.

    Goose Flesh and Neck Flushing Indication

    • Autonomic dysreflexia.

    Eye Surgery Finding to Report

    • Increased redness, swelling, or discharge should be reported to the healthcare provider.

    Misconception Regarding Closed vs. Open Head Injury

    • Closed head injuries can be just as severe as open head injuries.

    Neurotransmitter Role in Nervous System

    • Neurotransmitters act as chemical messengers that transmit signals between neurons.

    Periorbital Edema After Head Trauma Assessment

    • Assess for orbital fracture.

    Herniated Intervertebral Disk First Symptom

    • Back or neck pain is often the first symptom.

    Photocoagulation Function for Diabetic Retinopathy

    • To seal leaking blood vessels and prevent further damage to the retina.

    Myelogram Allergy History Importance

    • Because iodine-based contrast agents are used, an allergy history is crucial.

    Period of Deep Sleep After Tonic-Clonic Seizure

    • Postictal state.

    t-PA Effective Administration Time Window

    • Within 4.5 hours of stroke onset.

    Acute Angle Closure Glaucoma Characteristic

    • Severe eye pain, nausea, and vomiting.

    Parkinson's Disease Activity Level Improvement Instruction

    • Encourage physical therapy and participation in activities that promote mobility and coordination.

    Tympanoplasty Postoperative Care Consideration

    • Keeping the surgical site dry is essential for healing.

    Elevated Head of Bed Position After Tympanoplasty

    • To prevent swelling and facilitate drainage.

    Sign Not Associated with Parkinson's Disease

    • Involuntary muscle spasms are not a sign of Parkinson's disease.

    Common t-PA Outcome

    • Reversal of stroke-related deficits in some patients.

    Postictal Period Event

    • Represents the period of recovery after a seizure.

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    Description

    This quiz tests your knowledge on postoperative positioning after tympanoplasty, assisting blind patients, and managing cervical spine injuries. Understand the key actions and precautions necessary for these patient care scenarios to improve clinical outcomes.

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