Questions t1. C.docx PDF

Why is the Glasgow Coma Scale Used? - To quickly access the level of consciousness 2. A client with ICP has pressure of 12 mmHg. The nurse understands this pressure reflects which of the following? - A normal balance between brain tissue, blood and CSF 3. A nurse is caring for a client...

Why is the Glasgow Coma Scale Used? - To quickly access the level of consciousness 2. A client with ICP has pressure of 12 mmHg. The nurse understands this pressure reflects which of the following? - A normal balance between brain tissue, blood and CSF 3. A nurse is caring for a client with increased intracranial pressure knows that the best way to position the client is which of the following? - Elevate the head of the bed 30 degrees 4. The nurse is caring for a patient with a head injury who has clear nasal drainage. Which of the following actions should the nurse take? - Check the nasal drained for glucose 5. The nurse is caring for a client with a head injury. Which of the following assessments information requires most rapid action by the nurse? - The client is more difficult to rouse --- anything with change in LOC 6. Which of the following plays a role in alternating intracranial pressure? Select all that apply - Brain, cerebral fluid, blood 7. Which patient is MOST at risk for increased intracranial pressure? - A patient who is admitted with a traumatic brain injury 8. A patient who is experiencing a cerebral hemorrhage is at risk for developing and elevated intracranial pressure. What sign or symptom listed below is the earliest indicator the patient is experiencing this complication? - Restlessness 9. The patient has a blood pressure of 130/88 and intracranial pressure reading of 12. What is the patient's cerebral perfusion pressure and how should this value be interpreted? - CPP = MAP-ICP - MAP --- 130 + 2(88)/3= 102mmHg - [CPP = 102 -12 = 90mmHg, normal] CPP of 70-100 mmHg is normal  10. During the assessment of a patient who is experiencing increased intracranial pressure, you know the patient's arm are extended straight out, and toes are pointed downward. You will document this as: - Decerebrate posturing 11. While positioning a patient in bed with increased intracranial pressure, is important to avoid what the following: - Flexion of the neck and hips 12. Which of the following is considered a normal value of intracranial pressure? - 15 mmHg 13. A nurse is caring for a patient with increased intracranial pressure. Which intervention should the nurse avoid to prevent further increases intracranial pressure? - Suction the patient frequently to maintain a clear airway 14. Which of the following is not typically associated with signs of intracranial pressure? - A rise in pulse rate with a drop in blood pressure 15. What symptoms are associated with Cushing's triad? - Increase blood pressure, decrease heart rate, decrease respirations 16. The nurse is caring for a client with a T1 spinal cord injury. Which of the following information should the nurse include in the teaching plan for the client and the family? - Full function of the client's arms will be restrained 17. In plain or community education session for prevention of spinal cord, injuries, which group should the nurse target - Adolescent and young men 18. Which causes an initial incomplete, spinal cord injury to result in complete cord damage? - Infraction and necrosis of the cord caused by edema, hemorrhage, and metabolites 19. Two days following a spinal cord injury, a patient asked continuously about the extent of impairment that will result from the injury. What is the best response by the nurse? - The extent of your injury cannot be determined until the secondary injury to the cord is resolved - The rational behind this--- the oedema and necrosis of the site of injury are resolved in 72 hours to one week after the injury, it's not possible to determine how much cord damage is present from the initial injury. 20. A client has admitted to the hospital with SCI after an automobile accident. The nurse recognizes that the pathophysiology of the secondary SCI involves, which of the following? - Necrotic destruction of the cord from hemorrhage and edema 21. Without surgical stabilization, what method of immobilization for the patient with cervical spinal cord injury? Should the nurse expect to be used? - Skeletal traction with skull tongs 22. How was the urinary function maintained during the acute phase of a spinal cord injury? - An indwelling catheter --- bladder is hypotonic causing urinary retention 23. A week following a spinal cord injury at T2, a patient experiences movement in his leg and tells the nurse that he is recovering some function. What is the nurse's best response to the patient? - That could be a really positive finding. Can you show me the movement? 24. A patient with a C7 spinal cord injury, undergoing rehabilitation tells the nurse he must have the flu because he has had a bad headache and nausea. The nurse first priority too. - Take the patient's blood pressure 25. Which of the following clinical modification should the nurse interpret as a sign or symptom of neurogenic shock and a client with a cute spinal cord injury? - Bradycardia 26. The nurse is caring for a client admitted one week ago with acute spinal cord injury. Which of the following assessment findings would alert the nurse to the persistence of autonomic dysreflexia? - Throbbing headache 27. The nurse is planning care for a client with a C5 spinal cord injury. Which of the following nursing diagnosis is the highest priority? - Ineffective airway clearance caused by high cervical spinal cord injury 28. Which of the following signs of symptoms in a client with a T for spinal injury, should alert the nurse of the possibility of autonomic dyslexia? - Headache and rising blood pressure 29. Which of the following interventions would you expect to perform an acute care of a client with autonomic dyslexia? - Urinary catheterization 30. Which patient below is at most risk for developing a condition called autonomic dyslexia? - A 15-year-old patient with a spinal cord injury at C7 31. Your patient, who has a spinal cord injury at T3 states that they're experiencing a throbbing headache. What should a nurse do first? - Access the patient's blood pressure 32. A nurse is performing a bedside assessment on a patient with spinal cord injury at T6. The patient is restlessness, an extremely flush. The nurse assesses the patient's blood pressure and heart rate. The patient's blood pressure is 140/98 and the heart rate is 52. According to the patient's chart, their baseline blood pressure is 106/76 and heart rate is 72. What action should the nurse take first? - Position the patient upright position with legs lowered 33. You were providing in-service to a group of new nurses on the causes of autonomic dyslexia. Which of the following common causes should be included? - Distended, bladder, pressure injury on the scrotum, fecalimpaction, urinary track infection 34. After taking all the necessary steps for a patient who has developed autonomic dyslexia, what should the nurse access first as a possible cause of this condition? - bladder irrigation 35. A patient receiving treatment for a complete spinal cord injury at T4. As a nurse, you know to educate the patient on the signs of symptoms of autonomic dyslexia. What scientific symptoms will you include? - Headache, sweating, pale and cool above level of injury, hypertension, slow heart rate, and blurry vision 36. All the following statements are true regarding autonomic, dyslexia, except? - Autonomic dyslexia is a exaggerated reflex response by the parasympathetic nervous system that results in severe hypertension due to spinal cord injury 37. A patient is expected ligament injury to the spinal cord vertebrae. Which of the following diagnostic test are considered the gold standard for imaging? - MRI 38. A patient is admitted with spinal cord injury. The patient is experiencing severe hypotension and bradycardia. The patient diagnosed with neurogenic shock. Why is hypotension occurring in this patient? - The patient autonomic nervous system has lost the ability to regulate the diameter of the blood vessels and vasodilation is occurring 39. You're providing care to a patient with spinal cord injury at level T4. As the nurse you know which of the following is a safety priority? - Keep the patient spine immobilized 40. You know that Venus pooling from vasodilation and immobilization can lead to deep vein thrombosis period of patients goal following a spinal cord injury is that the patient will be free from the development of a DVT. All the following nursing interventions that can help meet this goal except: - Place a pillow underneath the knees 41. What possible sequence of responses is accessed in the eye component? - Spontaneous, to sound, to pressure, tone. 42. When accessing a patient you should: - Check, observe, stimulate, rate 43. When accessing a patient what is the reason for the CHECK steps in the assessment? - To identity factors that may interfere with the assessment 44. If when you approach the patient, they are awake and looking at you, how would you record this on GCS? - Spontaneous eye opening 45. You are assigned to a patient who has fallen through a plate glass door. As you approach the patient, you observed that their eyes are completely swollen and they're unable to open them. How would you record the eye component on the scale? - Eyes not testable (NT) 46. You were accessing the motor component of a patient's GCS. They're unable to obey commands, but can bend their elbow when their fingernail bed is stimulated. What do you do next? - Apply a trapezius pinch 47. A patient reacts to supraorbital notch pressure by moving their hand to their face. How would you record this response? - Localizing 48. Which of the following is contraindicated in a patient with increased intracranial pressure? - Lumbar puncture 49. Which patient is experiencing Cushing triad? - BP: 200/60, HR: 50, RR: 8 50. A client is being admitted to the neurological unit with a diagnosis of a C4 SCI. Which data should the nurse collect first. - Auscultation of lung sound 51. What is one indication for early surgical intervention in a patient with SCI? - Evidence of continued compression of the cord as evident 52. Which clinical modification would the nurse interpret as a medication of neurogenic shock in a patient with acute SCI? - Bradycardia 53. Which action will the home care nurse include in a patient with paraplegia to prevent autonomic dysreflexia? - Teach the purpose of the prescribed bowel program 54. How do generalized seizures differ from focal seizures? - Generalized seizures have bilateral synchronous epileptic discharges affecting the whole brain 55. Which type of seizure occurs in children, is also known as as a petit mal seizure, and consist of a staring spell that last for a few seconds - Typical absence 56. The patient is diagnosed with complex focal seizures. Which characteristics are related to complex focal seizures. - Physio-motor seizures with repetitive behaviour and lipsmacking, altered memory, sexual sensations, and disoriented, visual or auditory sensations, often involves behavioral, emotional, and cognitive functions with altered consciousness. 57. Which type of seizure is most likely to cause death for the patient - Tonic colonic status epileptics 58. A patient with a seizure disorder is being evaluated for surgical treatment of the seizures. The nurse recognizes what is one of the requirements for surgical treatment - An accurate trial of drug therapy that has been unsatisfactory results 59. The nurse finds a patient in bed having generalized tonic chronic seizure. During the seizure activity what action should the nurse take? - Focus on maintaining a pair patient's airway and preventing patient injury, the nurse should not place objects in the patient's mouth or restrain the patient 60. A client has a tonic chronic seizure while the nurse is in the client's room. Which of the following action should the nurse take? - Time, observe and document the details of the seizure and postictal state 61. An elementary school teacher who has just been diagnosed with epilepsy after having a generalized tonic clonic seizure tells a nurse, I cannot teach anymore, it will be too upsetting for the kids if I have a seizure at work. Which of the following responses by the nurse is the best. - Many new clients with epilepsy and well controlled with anti seizure drugs - Make sure to monitor their blood levels for therapeutic ranges 62. Which action will the nurse take when evaluating a client who is taking phenytoin for adverse effects of the medication? - Inspect the oral mucosa 63. A client found in tone, chronic seizure, reports afterwards that the seizure was proceeded by numbness and tingling in the arm. Which of the following types of seizures should the nurse document based on this finding? - Focal--- symptoms first before the seizure begins --- they are aware something is wrong. 64. The nurse is assessing a client at the health clinic who has symptoms of swooped posture, shuffling gate, and pill rolling type tremor. Which of the following topics should the nurse include in the plan of care? - Antiparkinsonian drugs 65. The nurse witness a client with a seizure disorder as a client suddenly jerks the arm and legs, falls to the floor and regains consciousness immediately - Assess the client for possible head injury 66. Which of the following prescribed interventions will the nurse expect to implement for a hospitalized client who is experiencing continuous, tonic, colonic seizures - Administer lorazepam 4mg IV 67. All the following are associated with Park disease except: - Uncontrolled head movements 68. The nurse is caring for a client with Parkinson's disease who is decreased tongue mobility, and inability to move the facial muscles. Which of the following nursing diagnosis is highest priority. - Imbalanced nutrition: less than body requirements related to insufficient dietary intake 69. As a nurse, you know that Parkinson's disease is the result of deteriorations of the \_\_\_\_\_\_ in the mid brain, resulting in depletion of the neurotransmitter \_\_\_\_ - Substantia nigra: dopamine 70. You were caring for a patient with Parkinson's disease. Select the statement about tumours that is incorrect. - Tremors are most likely to occur with purposeful movements 71. Well, assessing a patient with Parkinson's disease, you know that the patient's arm slightly jerks as you possibly move them towards the patient's body. This is known as: - Cogwheel rigidity 72. This type of seizure is considered a medical emergency impromptu treatment is necessary to prevent nerve damage and death - Satis epileptic-us 73. Seizures are divided into which classifications: - Generalized seizure and focal seizure 74. The nurse is teaching a female patient about the use of phenytoin for seizure control. The nurse tells a patient the following about taking oral conceptive with this medication - An alternative form of birth control should be used when taking phenytoin with oral contraceptives. 75. After a patient experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects. The nurse anticipates teaching about? - Oral low dose aspirin therapy 76. A 70-year-old patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the healthcare provider before giving the prescribed aspirin? - The patient reports that symptoms began with severe headache 77. When teaching your patient about clopidogrel the nurse will tell the patient with cerebral atherosclerosis? - To call the healthcare provider if the stool is black or Terry; this is because of bleeding 78. A 73 year old, patient experiences facial drooping on the right side and right sided arm and leg paralysis. When admitting the patient, which clinical magnification will the nurse expect to find? - Difficulty understanding instructions 79. A patient with carotid atherosclerosis ask the nurse to explain the erotic endarterectomy. Which response by the nurse is accurate? - The obstructing plaque is removed from the artery in the neck 80. A 56-year-old man arrives in the mercy department with hemiparesis and dysarthria that started two hours previously. His health record show a history of several transient Ischemic attacks. The nurse anticipates preparing the patient for? - Tissue plasminogen activator (tPA infusion) 81. A nurse is assessing a client with new onset of stroke-like symptoms the nurse is assessing 'S' in 'fast' this stands for which of the following? - Speech 82. The nurse is receiving report on a client who had a stroke. The outgoing nurse state, " keep your eye on him, he keeps trying to get out of his bed and making really poor impulsive decisions." The receiving nurse recognizes this is what kind of stroke? - Right hemisphere 83. A client who had a stroke is suffering from expressive aphasia. What interventions would most likely improve communication with this client? - Try to use 'yes' or 'no' questions 84. A patient CT scan shows damage to the cerebellum a week after the patient suffered a stroke. What assistance finding would. Correlate with the CT scan scan results? - Balance impairment 85. The classic triad of manifestations associated with Parkinson\'s disease is tremor, rigidity, and bradykinesia. What is a consequence related to rigidity? - Muscle soreness and pain 86. A patient with a tumour is being evaluated for Parkinson's disease. The nurse explains to the patient that Parkinson's disease can be confirmed by? - Relief of symptoms with administration of dopaminergic agents 87. A patient with Parkinson's disease has started on levodopa. What should the nurse explain about the drug? - It is a precursor of dopamine that is converted to dopamine in the brain 88. A patient with Parkinson's disease has started on carbidopa. What should the nurse explain about the drug? - It is an agent that's usually administered with levodopa to prevent the levodopa from being metabolize in the peripheral tissues before it reaches the brain and to reduce nausea 89. To reduce the risk of falls in a patient with Parkinson's disease, what should the nurse teach the patient to do? - Cautiously lift the toes when stepping, use a wide stance with the feet apart to promote more of a balanced gait. 90. A patient with Parkinson's disease who is having issues initiating movement, what initial intervention with the nurse consider? - Use of elevated toilet seat and rocking from side to side 91. What is strongly discouraged with people with Parkinson's disease to maneuver? - Canes and walkers as they are difficult for patients with Parkinson's disease, making it more prone to injury 92. For a client who is suspected to have a stroke, what is one of the most important pieces of information that the nurse can obtain? - Time at which the stroke symptoms first appear 93. A patient is admitted with uncontrolled arterial fibrillation. What type of stroke is this patient at most risk for? - Ischemic embolism 94. You see your patient's chart that has patient has 'apraxia'. What assessment findings in the morning assessment correlates with this condition? - The patient is unable to initiate movements 95. Your patient has hemiparesis of the right side and dysphasia when eating. It is important to: - Check for pocketing of food in the right cheek 96. In order for TPA to be most effective in the treatment of stroke. It must be a administered: - 3 to 4.5 hours after onset of symptoms 97. A patient's wife asked a nurse why her husband did not receive the clot-busting medication TPA she has been reading about. Her husband has been diagnosed with hemorrhagic stroke after arriving five hours after symptom onset. How would the nurse respond? - The medication you're talking about is a dissolve clots and it could cause more bleeding Helens Questions: - 1\. The nurse is teaching a patient with primary open angle for glaucoma about the disorder. Which of the following information should the nurse include in the teaching plan? - Aqueous Humor cannot drain from the eye, causing pressure damage to the optic nerve - 2\. What is a major symptom of open angle glaucoma? - Peripheral vision loss - 3\. Which of the following is a clinical modification of muscular degeneration? - Scotomas (blind spots) - 4\. A nurse working in a ear clinic conducted an ear assessment for a new patient. Which of the following would the nurse expect as a normal finding of a auditory system? - Pearl-grey tympanic membrane - 5\. Which of the following are common age related changes in the auditory system? select all that apply. - Drier cerumen - Auditory nerve degeneration - Atrophy of the tympanic membrane - 6\. A patient with Ménière's disease is prescribed a low-sodium diet. What is the rationale for this dietary recommendation? - To prevent fluid retention in the inner ear - 7\. What are the most common early symptoms of otosclerosis in adults? - Progressive conductive hearing loss - 8\. Which of the following is a classic triad of symptoms associated with Ménière's disease? - Tinnitus, hearing loss, and vertigo - 9\. A nurse is educating a patient with hearing aids about proper care. Which statement indicates the patient needs further teaching? - I will use alcohol to clean the hearing aids - 10\. Which of the following is a priority nursing intervention for a patient experiencing acute attack of vertigo? - Keep the patient in a dark, quiet environment - 11\. What is a key distinguishing feature of otitis media with effusion compared to acute otitis media? - OME involves fluid behind the eardrum without signs of infection - 12\. What symptom is most commonly observed in a child with acute otitis media? - High-pitched crying and ear tugging - 13\. What causes cerebral palsy? - Brain damage that happened before, during or after birth, an infection such as meningitis, head injury, and the cause is unknown - 14\. What differentiates communicating hydrocephalus from noncommunicating hydrocephalus? - Communicating hydrocephalus occurs due to impaired CSF absorption, while non communicating hydrocephalus involves a blockage within the ventricular system - 15\. Which symptom is most indicative of ruptured intracranial aneurysm ? - Sudden severe headache described as the :worst headache of my life. - 16\. Which of the following is the most appropriate nursing intervention for a patient with an unruptured intracranial aneurysm? - Maintain a calm and quiet environment to reduce blood pressure and stress. The nurse is explaining the difference between vertigo and Ménière's disease to a nursing student. What is the main difference between their pathologies? - Hearing loss